The Vanishing Mental-Health Safety Net
The first hospital my mom checked Aunt Terri into no longer exists. Neither does CPI, where she was taken later. In the 1950s, more than a half million people lived in U.S. mental institutions—one in 300 Americans. By the late ’70s, only 160,000 did, due to efforts by psychiatrists, philanthropists, and politicians to deinstitutionalize the mentally ill.
Today there’s one public psychiatric-care bed per 7,100 Americans—the same ratio as in 1850. The motives behind this trend were varied. Emptying the asylums was going to save money. And who needed hospitals with all the antipsychotic drugs on the market? Deinstitutionalization was going to restore citizens’ rights and protect them from deplorable conditions like those portrayed in movies like One Flew Over the Cuckoo’s Nest, conditions in which a sane person would go crazy and a crazy person was unlikely to be cured. Wouldn’t it be better if the mentally ill were treated at home, given support, therapy, and medication via community clinics? It sounded good, but the reality was quite different.
In 1961, a joint commission of the American Medical and American Psychiatric associations recommended integrating the mentally ill into society. This plan depended on the establishment of local facilities where mentally ill people could receive outpatient care. Congress passed a law providing funding for these “community mental health centers” in 1963, and states, under pressure from the patients’ rights movement, downsized their psychiatric hospitals faster than anyone had anticipated.
Between the Vietnam War, an economic crisis, and a lack of political will, adequate funding for community services never came through. In 1980, the Mental Health Systems Act was passed to fill the gap. But a year later, Ronald Reagan gutted the act, then decreased federal mental-health spending by 30 percent and shifted the burden to state and local governments. The crucial community services that the mentally ill were supposed to receive failed to materialize, and more and more people ended up on the streets. Collectively, states have cut $4.35 billion in public mental-health spending since 2009.
As of 2006, 1.3 million of America’s mentally ill were housed where they used to be until the late 1800s: in prisons. Between 1998 and 2006, the number of mentally ill people behind bars more than quadrupled. In some county jails, rates of inmates with mental illness have increased by nearly 50 percent in the past five years. It’s not uncommon for individual jails to report that 25 to 30 percent of their inmates are mentally ill or that their mentally ill population rises year after year.
“None of us are suggesting that we need to go back to 1930, when a psychiatrist could say, ‘I don’t like the sound of your voice, so I’m going to keep you in my facility—which I also happen to own—for three weeks,’ ” says Dr. Torrey. “You have to have a system of checks and balances.”
What Will Happen to Houston?
The pendulum, however, has now swung far past patients’ rights and well into the territory of wild neglect. The dismantling of the mental-health system has left those willing to undergo treatment with no options and rendered ineffective the laws intended to protect against dangerous scenarios. “Danger to self or others is defined too [stringently],” Dr. Torrey says. In the eight states where danger to self or others is the sole trigger for treatment, “you either have to be trying to kill your psychiatrist or trying to kill yourself in front of your psychiatrist” to receive assistance.
Regardless of what you think about commitment rules, the bottom line is that decent facilities need to exist. “A psych ward in a general hospital that’s set up to see people with eating disorders and depression” is not equivalent to a psychiatric-care facility, Dr. Torrey says. If my uncle Mark could have taken Houston to a well-staffed hospital with an open bed and properly administered antipsychotic medications, maybe his crime could have been not only predicted but also prevented.
“Hospitals are motivated to get people out as quickly as possible. We ignore the mentally ill until they commit a crime that lands them in prison,” says Robin Lipetzky, the chief public defender of Contra Costa County, near San Francisco Bay. “Over and over again, we see situations where the parents of those who commit these offenses … say they’ve been trying and trying to get treatment for their kids, and it’s just not available. And it’s usually young adults. There’s not enough out there in terms of resources for families.” She concedes that calculating the cost of treatment of the mentally ill is not so easy to do. “How do you put the price,” she asks, “on people losing their lives when [someone has] a psychotic break?”
Houston had already been incarcerated for 430 days the first time I visited him back in January 2013, costing the county $49,811 in jail expenditures. He received medication but no therapy. After I identified myself as a cousin who knew Aunt Annette and we settled into our visiting-booth chairs, he explained, without complaining, that he wasn’t exactly thriving there. He talked about his illness a little, how he’d had “some episodes” that had landed him in the most acute cells of the most serious of the jail’s three mental wards—“the dungeon,” which includes rooms with padded walls and no socializing and sometimes sick people yelling and screaming on all sides. “You would have a nervous breakdown,” he told me, “just standing in there for ten minutes.”
We did not talk about Uncle Mark or about how Houston had gruesomely killed him, or, as unspeakable as that was, that sometimes unchecked mental illness can lead to far worse tragedies, when access to guns meets delusions centered on a movie theater or a temple or a school.
The last time I saw Houston was in a courtroom at the end of February 2013. It was yet another hearing to set his trial date for April 5. He didn’t look at me, or at anybody, not even his mother, Marilyn. Houston kept his tortured-looking face pointed at his twitching thumbs, probably wondering, amid his delusions—despite antipsychotics, he still suspects people of being conniving extraterrestrials or robots—whether his NGI (not guilty by reason of insanity) plea will be accepted by a jury.
Ultimately, it was. Ultimately, Houston was not sentenced to prison but was moved to a psychiatric hospital in California. There he’ll remain for years, or maybe forever, occupying one more bed that won’t be available to one more person having trouble until it’s too late.