From the Asylum to Anarchy

Oct. 22, 1990

Shameful indifference to the plight of the mentally ill has left many of them wandering the streets and crowding the jails

By ANASTASIA TOUFEXIS--Reported by Elaine Shannon/Washington and Janice C. Simpson/New York

Mike hears voices inside his head and sees things that are not there. Frightening things, like snakes and abandoned babies. Sometimes, when the hallucinations become too vivid, Mike erupts in hostile words and angry gestures that frighten other people. Twenty-five years ago, Mike would probably have been locked away in a state mental hospital in some secluded locale. Today, however, he lives on a bench in Manhattan's Central Park.

Mike and thousands like him are stark evidence of America's brutal indifference to the mentally ill. The care meted out to the severely disturbed is a "disaster by any measure used," concludes a new report issued by the Public Citizen Health Research Group and the National Alliance for the Mentally Ill (NAMI). "Not since the 1820s have so many mentally ill individuals lived untreated in public shelters, on the streets and in jails." Up to 30% of the estimated 500,000 homeless in the U.S. suffer from serious mental disorders, mostly schizophrenia and manic depression, as do 10% of the 1 million people behind bars. With 3,600 psychotic inmates, the Los Angeles County jail is "the largest de facto mental institution in the nation," says the report. Countless other distressed people inhabit squalid apartments or transient hotels, without adequate food, clothing or medical care.

Federal officials say the report does not exaggerate. "We have 2.8 million people with serious mental illness, and only 1 in 5 is receiving adequate care," observes Dr. Lewis Judd, director of the National Institute of Mental Health. And the problem is sure to get worse. The majority of the sick live with their parents, whose average age is now between 50 and 60. When they die, many of their troubled children will land on the street. Baby boomers are moving through their 30s, the vulnerable years for late-onset schizophrenia. Moreover, the number of people with dementia as a result of AIDS is expected to increase dramatically.

How did things get so bad? During much of the first half of this century, large state hospitals were generally regarded as the best way to treat the mentally ill. Attitudes changed in the 1950s and '60s as tales of abuse in giant institutions multiplied. New drugs were introduced that helped control mental illness, and a concern for the civil rights of the disturbed led state legislatures to make it difficult to commit people to hospitals against their will.

Belief grew that the sick would fare better out of hospitals. Community clinics and halfway houses, it was argued, could provide needed care--and at less expense than large institutions. So the exodus began. In 1955, state institutions had 552,000 patients; today the number is 119,000.

But as the doors of the hospitals were swinging open, the fiscal gates were clanging shut. Few halfway houses were ever established, and many community centers shifted their focus to family counseling and treating drug abuse and alcoholism. Programs also came under attack from budget cutters. California's services, once held up as a model for the nation, are being slashed. The new state budget lops $73 million from a planned outlay of $520 million for the community-care system.

In Los Angeles, that means 12 out of 20 community mental-health centers must close. The city's remaining clinics will act only as crisis centers. Among the hard hit will be the Skid Row Mental Health Clinic, an innovative facility that, for example, provides bathrooms, washers and dryers and money management. The clinic, which serves 1,000 people a month, has had to reduce its 15-member psychiatric staff to five. The skeleton crew has little time for outreach--going into the streets and cajoling the mentally ill into accepting help. PET (for psychiatric emergency team) units used to respond to mental crises anytime. Now they rarely make calls after their normal 10-hour workday.

Across the U.S., mental-health care has become a shambles--fragmented and misfocused. One problem: the system is geared to episodic, not chronic, care. "We're spending about 70% of our mental-health dollars for hospital care," complains Leonard Stein, director of the Robert Wood Johnson Foundation's Mental Health Services Development Program. "What we're doing is waiting for people to have psychotic episodes and putting them in the hospital to take care of that, which we can do very well. But once the episode is over, that doesn't mean the person is cured." Patients are caught in a revolving door: discharged people have a 60% chance of being readmitted within two years.

What is needed, say advocates for the mentally ill, is comprehensive care, tailored to people's individual needs and aimed at building self-esteem and the skills to manage on their own. Numerous demonstration programs attest that the mentally disturbed can lead safe, productive and happy lives outside institutions. The key elements: monitored medication, specialized training and a stable and supportive environment in which to live.

One of the most successful programs is New York City's Fountain House, which began 42 years ago as a meeting place for former mental patients. In contrast to the sterile wards and decrepit housing in which so many of the sick have spent most of their lives, the sprawling complex's buildings are tastefully furnished and the grounds beautifully landscaped. Each day about 400 people visit the clubhouse, relieving the isolation that traps so many of the ill. In addition, Fountain House provides shelter for more than 200 people citywide in housing that ranges from small, supervised group homes to individual apartments.

The core of Fountain House, though, is its work program. Members perform almost all the chores at the complex, from tending the gardens to keeping the books. Those who do well are placed in part-time entry-level jobs at some 31 companies, including banks, law firms and ad agencies.

Other successes dot the country. In Madison, Wis., mental-health workers counsel landlords, employers and others who come into regular contact with the mentally ill. Philadelphia has experimented with groups in which patients receive support from their peers. This approach "provides people with a feeling that they can give as well as receive help," says Joe Rogers, president of the city's self-help group Project SHARE. But the impact of the model mental-health programs is far too limited. Fountain House, for example, can accept only 1 out of every 5 people who apply for membership.

More broadly based efforts are crucial. The Public Health/NAMI study ranks Vermont tops in the nation in caring for the mentally ill because of the strong quality of outpatient support services. Vermont helps its distressed residents apply for federal housing benefits and provides them with bridge money to pay the rent. Caseworkers literally move into the homes of people going through a psychotic episode.

Important to the Vermont approach is the belief that patients themselves must be involved in deciding about treatment. It is a far cry from the old ways. "I was locked away, and I was forcibly drugged," remembers William Montague, 36, who has been diagnosed as paranoid and schizophrenic. "I started getting my life together through living and working in the community and making decisions on my own, good and bad." Today Montague has his life together enough to work in a program that helps the homeless in Burlington.

It is to the U.S.'s shame that the William Montagues are so few. The solution is no mystery; only the will and resources are missing. "We know what needs to be done," says Project SHARE's Rogers. "We're just not doing it yet."

Copyright (c) TIME Magazine, 1995 TIME Inc. Magazine Company; (c) 1995 Compact Publishing, Inc.

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