Who Cares for the Mentally Ill?
Hope, Marjorie, Young, James, The Nation
Who Cares for The Mentally Ill?
New York City Mayor Edward Koch's plan to hospitalize, against their will, some of the city's homless who are seriously mentally ill has generated a bewildering battle among lawyers, bureaucrats and assorted professionals. When Joyce Brown, the first street dweller to be involuntarily hospitalized, brought suit against the city, a state court granted her release request; the next day, an appellate court delayed it. Psychiatrists hired by the American Civil Liberties Union pitted their opinions against those of psychiatrists appearing for the city, while state and local officials accused each other of reneging on responsibility for the homeless mentally ill.
Most authorities contend that only a minority of the severely mentally ill need prolonged institutional care. But focusing on the right of mentally ill persons to live on the streets deflects attention from the basic issues. What of their right to comprehensive mental health services? To decent housing? Why is it that so many so-called street people are unwilling to do something as instinctive as come in from the cold? Psychologist Mel Roman observes, "The city's psychiatric wards are miserably overcrowded. Adding twenty-eight beds, as Koch has done, is no solution. Many shelters are dangerous and dehumanizing. More important, if these people had been given adequate mental health services and living supports in the first place, most would not be out on the streets. We need a preventive approach.'
Since colonial days the states have assumed fiscal responsibility for the mentally ill. In the 1960s, however, Federal aid enabled discharged patients to live in the community, and Medicaid began to cover some mentally ill people who could be cared for in nursing homes. States welcomed Federal funds but not the dilution of their power. Another new source of Federal funding and power was the 1963 Community Mental Health Centers Act, which President John Kennedy signed with great fanfare. This "bold new approach' was motivated by the same sense of national purpose as the Federal stand on civil rights--the belief that Washington had to set certain standards to protect citizens in the less enlightened states.
In 1955 state mental hospitals held 558,922 long-term patients; in 1984, approximately 114,000. The movement toward deinstitutionalization was spurred by the development of behavior-altering drugs; by court decisions upholding the rights of patients, including the right to refuse institutionalization unless there is a clear danger to self and others; and by the growing philosophy that most patients should be treated in the least restrictive setting, preferably their own communities.
However, state hospital administrators and employee unions had a vested interest in the status quo. Today there are nearly sixteen times as many mental patients in outpatient facilities as in state hospitals, yet roughly 70 percent of public funds allocated for mental health goes to the hospitals. Deinstitutionalization fosters short-term acute treatment, which is more costly than custodial care, but the fact remains--as James Stockdill, a division director at the National Institute of Mental Health (N.I.M.H.) points out--that few states have transferred state hospital savings to the communities.
The flip side of deinstitutionalization is the emergence of highly restrictive policies of admission to state facilities. Today thousands of mentally ill street people in New York City and elsewhere have never been in a state hospital. Some live outside of institutions because most states forbid involuntary commitment unless the person poses a clear danger to self or others. On the other hand, advocates of outpatient treatment report many cases in which patients, frightened by their inner turmoil, have clearly wanted admission but were denied it. The Central Ohio Psychiatric Hospital, for example, refuses patients not accompanied by an involuntary admission form, as well as those with an alcohol, drug or serious physical problem. …