American Psychosis (18 page)

Many centers pay little attention to former state hospital patients and hard-to-treat and seriously disturbed patients. . . . Some critics have suggested . . . that the recipients of services would do better if they were given the money that the services cost instead of the services.

Another critic castigated the CMHC program “for embodying the arrogance of social engineering by euphoric experts . . . [and] for being primarily an ambitious power play by federal mental health bureaucrats.” The National Institute of Mental Health, realizing that its prize program was in trouble, invoked a classic governmental ploy. Rather than trying to correct the existing program, it instead started a new program in 1977. It was called the Community Support Program (CSP) and initially made available $3.5 million ($12.6 million in 2010 dollars) in grants to states to coordinate services “for one particularly vulnerable population—adult psychiatric patients whose disabilities are severe and persistent.” The tasks designated under the CSP grants were precisely those things the CMHCs should have been doing.
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For the leadership of NIMH, however, it was too little, too late. In December 1977, Brown was fired by DHEW Secretary Joseph Califano. The firing was the result of accumulated minor departmental grievances combined with Brown’s having alienated leaders of American psychiatry, some of whom wanted his job. Brown had, ironically,
survived 8 years under Presidents Nixon and Ford, who disliked mental health, but he could not survive under President Carter, who was a strong mental health advocate. With the departure of Brown, the last of the architects of the CMHC program was gone, bringing to an end more than 30 years of an attempted federal solution to the nation’s mental illness problems.

ADDITIONAL LEGAL ACTIONS AND FISCAL INCENTIVES

During the 1970s, as the CMHC program spiraled slowly toward its inevitable demise, legal actions and fiscal incentives further complicated the nation’s mental illness treatment system. Both would play important roles in determining the fate of the patients who were being released from the state mental hospitals.

Legally, additional court cases reinforced earlier decisions promoting the discharge of patients from state hospitals and making it increasingly difficult to get patients admitted to the hospitals. In the 1971
Wyatt v. Stickney
ruling in Alabama, the court ruled that involuntarily hospitalized mental patients had a legal right to adequate treatment. The court also established standards for such treatment, including a minimum staff-to-patient ratio. The decision was hailed by many as an important step toward better care for the seriously mentally ill; in fact, it simply led to the discharge of many more patients, because a better staff-patient ratio could be achieved less expensively by discharging patients than by hiring more staff. A further impetus to deinstitutionalization came in 1975 from the
O’Connor v. Donaldson
case in Florida in which a court awarded $20,000 in compensatory damages to a patient who had been kept in a hospital for nearly 15 years without proper treatment. Making a state monetarily liable for inadequate hospital care was a strong incentive to discharge more patients. The most important court decision that made it much more difficult to get patients admitted to mental hospitals was the 1972
Lessard v. Schmidt
decision in Wisconsin. The judge ruled that being a danger to self or others was the only justification for involuntary hospitalization.

Most of these court cases were orchestrated by the American Civil Liberties Union (ACLU). Bruce J. Ennis, a leading ACLU lawyer and subsequent chair of the American Bar Association’s Commission on the Mentally Disabled, wrote at the time that “the goal [of legal efforts] should be nothing less than the abolition of involuntary hospitalization.” Lawyers such as Ennis viewed any involuntary psychiatric hospitalization as inherently bad. The popularity of Kesey’s 1961 book
One Flew over the Cuckoo’s Nest
had been reinforced by the 1967 movie
King of Hearts
, which featured psychiatric inmates in France released from their asylum by departing German soldiers at the end of World War II. The inmates were depicted as living happily ever after and being more sane than the departing soldiers. The movie ran for 5 consecutive years in Cambridge, Massachusetts, a bastion of civil liberties support.
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The major fiscal change related to mentally ill individuals during the 1970s was the federalization of the Supplemental Security Income (SSI) program for the aged, blind, and disabled. For many years, there had been state-operated welfare and disability programs, with federal supplements, in which states determined who would be eligible and what state payments would be. This resulted in eligibility standards and payment levels that varied considerably among states. In 1972 President Nixon decided to reform and standardize the welfare and disability system. SSI was created, which established standard federal eligibility requirements and a standard federal payment that states could supplement if they wished. SSI essentially reversed the historic state and federal roles for welfare. SSI was not targeted for mentally ill individuals and, in fact, specifically sought to exclude most of them by making ineligible any resident of a state mental hospital or other public institution. Nor is there evidence that any consultations took place between the Social Security Administration and the NIMH regarding what effect the SSI program might have on mentally ill individuals.

Following the implementation of the SSI program in January 1974, it soon became clear that SSI would be an enormous fiscal incentive for states to empty their state hospitals. In New York, for example, the annual state cost for a person in a state mental hospital was $13,835. If the person was discharged to live in a group home or boarding house, according to the calculations of social work expert Stephen Rose, then the maximum state costs, including all services, would be $4,600, because federal SSI would be paying the person’s living costs. Thus, for every person discharged from the hospital, the state saved more than $9,000 per year and also decreased state costs for running the hospitals. It would not take the states long to figure out the rules of the game.
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A QUIET DEATH AND BURIAL

In November 1980, Republican Ronald Reagan overwhelmingly defeated Jimmy Carter, who received less than 42% of the popular vote, for president. Republicans took control of the Senate (53 to 46), the first time they had dominated either chamber since 1954. Although the House remained under Democratic control (243 to 192), their margin was actually much slimmer, because many southern “boll weevil” Democrats voted with the Republicans.

One month prior to the election, President Carter had signed the Mental Health Systems Act, which had proposed to continue the federal community mental health centers program, although with some additional state involvement. Consistent with the report of the Carter Commission, the act also included a provision for federal grants “for projects for the prevention of mental illness and the promotion of positive mental health,” an indication of how little learning had taken place among the Carter Commission members and professionals at NIMH. With President Reagan and the
Republicans taking over, the Mental Health Systems Act was discarded before the ink had dried and the CMHC funds were simply block granted to the states. The CMHC program had not only died but been buried as well. An autopsy could have listed the cause of death as naiveté complicated by grandiosity.
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President Reagan never understood mental illness. Like Nixon, he was a product of the Southern California culture that associated psychiatry with Communism. Two months after taking office, Reagan was shot by John Hinckley, a young man with untreated schizophrenia. Two years later, Reagan called Dr. Roger Peele, then director of St. Elizabeths Hospital, where Hinckley was being treated, and tried to arrange to meet with Hinckley, so that Reagan could forgive him. Peele tactfully told the president that this was not a good idea. Reagan was also exposed to the consequences of untreated mental illness through the two sons of Roy Miller, his personal tax advisor. Both sons developed schizophrenia; one committed suicide in 1981, and the other killed his mother in 1983. Despite such personal exposure, Reagan never exhibited any interest in the need for research or better treatment for serious mental illness.
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Thus, by 1981, the CMHC movement had come and gone. In its brief existence, it had profoundly changed the treatment of mentally ill persons in the United States, although not in the direction Felix had envisioned. Felix had written that “mental hygiene must be concerned with more than the psychoses and with more than hospitalized mental illness.” He had created a program that, in fact, had been concerned with almost everything except psychoses and hospitalized mental illness.
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In 1963, when the Community Mental Health Centers Act had been signed, there had been a coherent, if flawed, mental illness treatment system, which had been run by the states for over a century. It consisted of state hospitals that were in poor shape but slowly improving, thanks to the availability of new medications. Deinstitutionalization was underway, with 10% of the 1955 peak patient census having already been placed in the community. Most states were opening state-funded outpatient treatment clinics, and according to a 1959 report, 20% of the clinic patients were diagnosed with “psychotic disorders.” States controlled the eligibility and payments for the state disability programs, more generous in some states, less generous in others. Most important, there was an established level of authority and accountability: the state legislature, the state department of mental health, and the governor were ultimately responsible even in states that passed along some program responsibility to the counties.
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Eighteen years later, when the CMHC program was effectively buried, the landscape for the treatment of mental illness had changed profoundly. States had been told that state hospitals would no longer be needed, because they would be replaced by the federally funded community mental health centers. According to Brian O’Connell,
executive director of the National Mental Health Association, “the state hospitals were downsized or closed and the states in many cases just washed their hands of the treatment of mental illness.” In setting up the CMHC program, federal officials had bypassed the state mental health authorities and sent the federal funds directly to local organizations. As Robert Rich noted in 1985: “There was no precedent for this new model of intergovernmental relations: bypassing the states and working directly with the localities. The federal government was going into the business of competing with [an] already established public sector program.”
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Whereas the original state treatment programs had been funded almost exclusively with state and local funds, the emerging treatment system included funding by federal Medicaid, Medicare, SSI, SSDI, block grants, food stamps, employment programs, housing, etc. In 1981, Murray Levine noted:

At present, 11 major federal departments and agencies are responsible for 135 programs that could provide service to the mentally disabled. The agencies control funds for direct clinical care, education, rehabilitation, employment, housing, and income support. There are federal programs to cover just about any need a mentally disabled individual might have. However, the agencies do not coordinate, do not cooperate, and tend to pursue their own priorities for program development.

State governors watched this proliferation of uncoordinated federal programs with increasing concern. At their annual meeting in 1977, they voted to express concern about the “lack of continuity of care caused by fragmented federal programs and compounded by complex and irrational federal regulations and guidelines.”
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The federal support of mental health programs was, of course, attractive to fiscally conservative state officials. The more patients who were discharged and the more state hospital beds that were shut down, the more state money was saved and the happier such conservative officials were. Simultaneously, civil rights lawyers were instituting lawsuits to further encourage states to empty the hospitals. The more patients who were discharged and the more state hospital beds shut down, the more state money was saved and the happier the civil rights lawyers were as well. This malformed marriage of fiscally conservative state officials and politically liberal civil rights lawyers produced a strong advocacy coalition guaranteeing that the existing deinstitutionalization policies would be continued into the future.

Of major concern, however, was that by 1981, all authority and responsibility for the mental illness treatment system had essentially disappeared. Authority that had been previously vested in the state legislatures, departments of mental health, and governors had become so diffused that it seemed to evaporate altogether. As noted in many reports, the mental illness treatment system had been essentially beheaded.

1974
: No state or local agency has sole responsibility for discharged patients; the agency, like the patient, is bewildered.

1977
: Responsibility for the mentally disabled in communities was generally fragmented and unclear. . . . Responsibility for their care and support frequently becomes diffused among several agencies and levels of government. . . . The roles and responsibilities of these agencies and specific actions to be taken by them for deinstitutionalization, however, have frequently not been clearly defined, understood, or accepted.