American Psychosis (25 page)

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The other component of the emerging corrections-dominated psychiatric outpatient system is the courts. Traditionally, courts have adjudicated civil and criminal cases, determining guilt and meting out punishments as necessary. In 1997, in response to the increasing number of mentally ill individuals who were repeatedly charged with offenses, Florida’s Broward County created the first of what are now known as mental health courts. In such courts, mentally ill defendants are given the choice of either participating in a treatment program for their mental illness or going to jail. Legally, this is done by having the prosecutor hold the charges in abeyance, requiring a guilty plea, or obtaining a conviction but then suspending the sentence, all contingent on the person’s participation in the treatment program. The court then monitors the person’s compliance with the program by requiring regular court visits.
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Mental health courts have spread quickly because they have proven to be highly successful in decreasing arrests and incarcerations of mentally ill persons. There are now at least 300 such courts throughout the United States. Initially, they were just used for mentally ill individuals charged with misdemeanors but more recently have been used for individuals charged with nonviolent felonies and even violent felonies. The courts provide primary oversight for the treatment of a significant and rapidly increasing number of seriously mentally ill individuals and are thus a vital component of the new psychiatric outpatient system controlled by the criminal justice, rather than the traditional mental health, system.
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HOMELESS SHELTERS, NURSING HOMES, AND BOARD-AND-CARE HOMES

One of the salient characteristics of seriously mentally ill people in the United States is their peripatetic lives. Chris Falzone, a 28-year-old Californian with bipolar disorder, is not unusual in having “been in more than 60 facilities in 15 years. . . . He bounces from board-and-care homes to hospitals, from jail cells to the streets.” In 2000 in
San Francisco, 30% of mentally ill jail inmates had been homeless, and 88% had been psychiatrically hospitalized. This constant changing of venues is one factor that makes the psychiatric treatment system so ineffective and expensive. For example, a 2007 Los Angeles study of mentally ill people who regularly migrate between homeless shelters, jails, emergency rooms, and psychiatric hospitals estimated the annual cost per person to be between $35,000 and $150,000.
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Since the early 1980s, studies have consistently reported that at least one-third of homeless individuals are seriously mentally ill. A 2010 study estimated that there are approximately 650,000 homeless persons in the United States; thus, approximately 216,000 homeless individuals have serious mental illnesses. Los Angeles and San Francisco have vied for the dubious distinction of being the “homeless capital of America.” Los Angeles, with an estimated 48,000 homeless, appeared to win the award in 2005 when Mayor Antonio Villaraigosa visited Skid Row and commented: “I mean that almost looked like Bombay or something, except for more violence. . . . You see a complete breakdown of society.” Not to be outdone, San Francisco in 2008 claimed to have “the highest per capita number of homeless in the nation. . . . These days, the streets of San Francisco resemble the streets of Calcutta.” San Francisco had distinguished itself in 2003 when a prominent member of the American Psychiatric Association, attending the organization’s annual meeting, was knocked unconscious on the street by a homeless mentally ill man, an unintended but ironic comment on the failure of psychiatrists to provide treatment for such people.
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Homeless mentally ill people are prominent not only in large cities. In 2007 in Roanoke, Virginia, the homeless population was estimated to be 566, of which “70 percent were receiving mental health treatment or had in the past.” The number of mentally ill people being turned away from hospitals and ending up homeless had increased so markedly in Virginia by 2011 that a report by the state office of Inspector General coined a new term for it: “streeting.” In 2009 in Colorado Springs, “as many as two-thirds of the 400 chronically homeless people . . . are said to suffer severe mental illnesses.” State laws in most states also make it difficult to treat such people. For example, in Kennebec, Maine, a severely mentally ill homeless man dug a cave-like home for himself in a hillside beneath a downtown parking lot. He rejected all offers of help by police and mental health workers, and Maine law did not allow for involuntary treatment except under extreme circumstances. Finally, the overlying city parking lot began to sag because of his digging, and it was decided to arrest him because he was a threat to the parking lot, not because he was a threat to himself.
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Homeless mentally ill individuals are indeed threats to themselves, frequently being assaulted and otherwise victimized. In 2009 it was reported that 43 homeless people had been killed, “the highest level in a decade.” Such deaths now occur almost weekly, the vast majority of victims being mentally ill.

• April 25, 2011: Stephen McGuire, 61 years old, a Marine Corps veteran, homeless and diagnosed with bipolar disorder, was beaten to death in Indianapolis by four boys and one girl.

• May 1, 2011: Chantell Christopher, 36 years old, the mother of two, homeless and “suffering from profound mental illness,” was beaten to death in New Orleans. Her body was found in a crawlspace beneath the Pontchartrain Expressway, where she routinely slept.

• July 5, 2011: Kelly Thomas, 36 years old, homeless, and diagnosed with schizophrenia, was beaten to death by two policemen during a confrontation on the streets of Fullerton, California.

Our failure to protect such mentally ill people by ensuring that they receive treatment is a major miscarriage of our medical care system and a blot on our claims to be civilized.
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Nursing homes have continued to be heavily used for mentally ill individuals, allowing states to shift the cost of care from the state to federal Medicare and Medicaid. This is especially true in Illinois, California, Missouri, Louisiana, Ohio, and Vermont, which in 2005 had the highest percentage of nursing home admissions diagnosed with serious mental illnesses. In 2002, for the first time, the number of new nursing home admissions with mental illness as a primary diagnosis exceeded those with dementia as a primary diagnosis; by 2005 admissions with mental illness were 50% higher than those with dementia. The total number of mentally ill nursing home residents was estimated to be 560,000.
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Of special concern has been the rapid increase in young and middle-aged mentally ill individuals being admitted to nursing homes, thus mixing with elderly residents who have dementia. Nationally, there was a 41% increase in such admissions between 2002 and 2008, with predictable results. In one Illinois nursing home, a 21-year-old man with bipolar disorder and a history of violence raped a 69-year-old woman. In another Illinois nursing home, a 50-year-old man with a severe mental illness and a history of aggression beat to death his 77-year-old roommate, who had Alzheimer’s disease.
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Both Illinois nursing homes were for-profit homes, as are two-thirds of all nursing homes in the United States. According to a 2007 report, for-profit homes average 33% more deficiencies than nonprofit homes during state and federal inspections. From the states’ point of view, such deficiencies are of minor concern, as nursing homes allow states to save state money. For example, in 2002 in New York the annual state cost for a mentally ill patient in a state hospital was $120,000, but the state’s share of the cost for
the same patient in a nursing home was only $20,000; the federal government picked up the rest of the cost, and the for-profit nursing home made a handsome profit. This helps explain the cozy relationship between governors and the for-profit nursing home industry in several states, including Illinois and New York, as mentioned previously. In the latter, for example, after George Pataki had been elected governor in 1995, a “debt-retirement dinner” at an upscale New York restaurant raised an estimated $200,000 for the governor, “most of it from the nursing home industry.” Subsequently, Benjamin Landa, a prominent for-profit nursing home owner and major contributor to Pataki, was appointed to the state council that regulates nursing homes.
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The situation of mentally ill persons in board-and-care homes is at least as bad and may well be worse than nursing homes. Nobody knows for certain, because a large and unknown number of these homes are unlicensed and thus unregulated. Like nursing homes, some operators are caring and try to provide decent services for their mentally ill residents, but many others are not. The total number of mentally ill residents in these homes is variously estimated to be several hundred thousand but is really unknown.
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The disgraceful depths to which board-and-care homes can descend was illustrated in 2002 by a Pulitzer Prize-winning
New York Times
series by Clifford Levy. He described for-profit homes in New York in which the owners had misappropriated thousands of dollars from residents, homes with “squalid conditions,” and homes in which some residents had been raped and killed. At one home, 24 seriously mentally ill residents had been subjected to unnecessary prostate surgery, and others had been given unnecessary cataract and laser eye surgery, generating “tens of thousands of dollars in Medicaid and Medicare fees” for the physicians and the home owners. The ophthalmologist involved subsequently pleaded guilty to billings “for more than 10,000 services that were either improper, unnecessary or never conducted, ranging from cataract surgery to routine eye examinations. . . . He had billed for more than 400 procedures when he was actually out of the country.”
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The fact that abuses of this magnitude could occur for many years in board-and-care homes suggests that there is virtually no state oversight of these homes. And that is indeed the case. The Empire State Association of Adult Homes, the trade group for owners of for-profit board-and-care homes in New York City, was one of the earliest and most generous donors to Pataki’s campaign funds. After taking office, Pataki reduced the number of board-and-care home state inspectors in New York City from 25 to 5, reduced the staff of the Commission on Quality of Care for the Mentally Disabled in New York City from 15 to 3, and decided to not enforce a new law that would have required a report for every death occurring in a group home. As the chairman of the Commission on Quality of Care for the Mentally Disabled politely phrased it, Governor Pataki “didn’t believe in government interference with the private sector.”
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Sadly, the situation of largely unregulated board-and-care homes in New York State is far from unique. During the past decade, horrendous living conditions and abuses of the mentally ill resident have been described in many states. Most such exposés have been documented by the media rather than by state inspectors. For example, in 2004 in Kansas, an unlicensed board-and-care home was closed by federal prosecutors who accused the owners of forcing the mentally ill residents “to work on their farm and deciding who could wear clothes.” The owners had been billing Medicare for nude therapy, claiming that it was beneficial for schizophrenia. In Virginia, an exposé of the state’s board-and-care homes reported that “thousands of documents kept by state and local agencies reveal repeated sexual abuse, beatings, and other assaults.” In 2006 in Milwaukee, the
Journal Sentinel
published a series on the city’s board-and-care homes, many unlicensed, calling them “stealth mental hospitals.” It described “infestations by cockroaches, mice, and rats, backed-up toilets, insufficient heat, broken smoke detectors, dangling electrical wires, filthy carpeting, a lack of proper exits, [and] a host of structural defects.” In one home, a resident had been dead for 3 days before being found. In others, “building inspectors have found people begging on the streets for food because they don’t get enough from landlords who take their disability checks, leaving them with next to nothing.”
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A special problem in board-and-care homes, as in nursing homes, occurs when young individuals with serious psychiatric disorders are placed in homes with elderly residents. For example, in 2005 at a small board-and-care home in North Carolina, Tony Zichi, 25 years old, stabbed to death Ruth Terrell, age 84 years. Zichi, diagnosed with schizophrenia, had previously been evicted from seven other homes because of very violent behavior, yet he was placed in the home with four elderly women. Over a 10-month period in 2008 and 2009, four other mentally ill residents were beaten to death in North Carolina board-and-care homes, so the U. S. Department of Justice expanded its ongoing investigation into the state’s mental health programs. Similar problems have been prominent in Florida. In 2007, for example, 33-year-old Darryl McGee, diagnosed with schizophrenia and with 11 previous arrests, was admitted to a board-and-care home’s “locked Alzheimer’s ward with people twice his age.” For 4 months, “McGee terrorized the home’s elderly residents during drunken rages, beating elderly men and women . . . before he brutally raped a 71-year-old woman in her bedroom.” In an exposé of such incidents in the
Miami Herald
, it was noted that “Florida’s requirements to run a home for people with mental illnesses are among the lowest in the nation: a high school diploma and 26 hours of training—less than the state requirements for barbers, cosmetologists, and auctioneers.”
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