American Psychosis (30 page)

Especially impressive are studies showing the effectiveness of AOT and conditional release in reducing violent behavior among individuals with serious mental illnesses. A study in North Carolina reported that for mentally ill individuals with a history of
violence, AOT reduced violent episodes from 42% to 27% when the AOT was continued for at least 6 months. In a study in New York, AOT reduced the proportion of mentally ill individuals who “physically harmed others” from 15% to 8%. In a study in New Hampshire, conditional release of mentally ill individuals reduced violent episodes by half.
¹⁷

This raises the question of how many mentally ill individuals should be on some form of assisted treatment at any given time. Little research has been done on this questions other than estimates that approximately 10% of seriously mentally ill individuals are the most problematic (e.g., have repeated incarcerations, homelessness, repeated hospitalizations, etc.) and that 10% of those who are problematic, or 1%of the total, are a definite danger to themselves or to others. The National Institute of Mental Health estimates the total number of adults (ages 18 years and older) with severe mental illnesses (schizophrenia, severe bipolar disorder, and severe depression) in a year is 5.3% of the adult population, or about 12.3 million people. Multiplying that number by 1% gives us a total of approximately 123,000 seriously mentally ill adults who should be on some form of assisted treatment at any given time.
Table 8.1
provides a breakdown of this number by state. These numbers include those who are receiving treatment in hospitals or other institutions (e.g., jails, prisons, nursing homes) at any given time. The numbers will also vary, of course, depending on the definition used for severe mental illness.
¹⁸

Despite clear evidence of its effectiveness, AOT and conditional release are vastly underutilized. Six states—Massachusetts, Connecticut, Maryland, Tennessee, New Mexico, and Nevada—do not even have state laws permitting AOT, and most other states use it sparingly. Resistance to using any kind of involuntary treatment comes primarily from civil libertarians who appear oblivious to the fact that we routinely involuntarily confine and treat individuals with Alzheimer’s disease who also suffer from anosognosia. Logical thinking, however, is not the guiding principle of America’s mental health system, so we allow mentally ill individuals who are unaware of their illness to live on the streets or in jails rather than treating them, all in the name of protecting their civil rights. As our treatment system has developed over the last half-century, callousness apparently became confused with civil rights. The freedom to be insane is a cruel hoax, perpetrated on those who cannot think clearly by those who will not think clearly.

2. Lack of awareness of illness (anosognosia) must be considered when planning any mental illness treatment system and provision made for the implementation of some form of involuntary treatment, such as assisted outpatient treatment (AOT) or conditional release for approximately 1% of all individuals with severe mental illnesses who are living in our communities.

Table 8.1
Number of Adults With Severe Mental Illness Who Should be on Assisted Treatment at any Given Time*

*
According to the National Institute of Mental Health (NIMH), the number of adults with severe mental illness is 5.3% of the total adult population (age 18 years and older), or about 12.3 million individuals; this includes adults with schizophrenia, severe bipolar disorder, and severe depression. The number of adults who should be on assisted treatment is assumed to be 1% of the total number of adults with severe mental illness.

•
Misunderstanding Community Treatment

A second fundamental error of deinstitutionalization was a misunderstanding of what is meant by “community treatment.” As a universally used phrase, it is a tractable term and has been appropriated to cover a multitude of agendas. In its most elementary form, community treatment simply means having patients live anywhere but in the mental hospitals. It has been used this way by advocates who believe that mental hospitals are the ultimate iniquity. As one anti-hospital crusader phrased it, “When you have Buchenwald, you do not worry first about alternatives to Buchenwald.” Many civil rights lawyers have adopted this belief; as one noted in 1974: “They [the patients] are better off outside the hospital with no care than they are inside with no care. The hospitals are what really do damage to people.” Gorman also reflected this belief; when I asked him in the
1970s how he viewed the rapidly increasing numbers of mentally ill homeless persons, he replied: “No matter how bad it is for those people on the streets, it’s better than it was in the hospital.” Gorman even wrote a letter to the
New York Times
in 1984 suggesting that he “should be honored” for his role in emptying the state mental hospitals. Such thinking has been said to exhibit “a curious lack of regard for the fate of the individual.”
¹⁹

“Community treatment” has also been used by well-meaning social activists who viewed the community mental health center movement as a vehicle for treating social ills, as described in
Chapter 4
. Matthew Dumont, one of the NIMH psychiatrists who led this movement, looked back on it in a 1992 retrospective:

The community mental health movement, which once stirred imagination and idealism like the civil rights movement, the War on Poverty, and eventually the peace and ecology movements, has become a dead leaf blown into a blind alley, its occasional rustle causing the merest sidelong glance from passersby busy with other things.

Dumont claimed that the movement failed not because of any conceptual flaw but merely because “the money ran out.”
²⁰

Many observers have claimed that it was precisely this kind of thinking that led to the failure of deinstitutionalization in general and community treatment in particular. Community treatment became a catchword, a seductive call-to-arms for all true believers of the new program. And the emphasis was on
new
—shifting the treatment of literally hundreds of thousands of people from mental hospitals to the community had never been done before. The appeal of this newness was evident in Robert Felix’s reflections on the community mental health centers when he was interviewed in 1972; he said the program had great “sex appeal” and repeatedly characterized it as “creative,” “daring,” “innovative,” and “exciting.” Frank Ochberg, an NIMH psychiatrist, similarly recalled the new program as “dazzling.” Anthony Panzetta, one of the earliest and most thoughtful enthusiasts for community treatment, also noted this appeal:

One of the sacred words in the new psychiatry is innovation. It is a cleansing word because it suggests an out with the old and in with the new mentality. It is fresh, creative, experimental, free and good. . . . It is optimistic, egalitarian, and benevolent. In a word, it is sacred.

By 1975, however, some mental health professionals were beginning to question whether community treatment was more than a current fashion. In an article titled “Community Mental Health: A Noble Failure?” the authors observed: “The mental health profession, like American society in general, has little immunity to infatuation with fad.”
²¹

The misunderstanding of community treatment actually goes back to the origins of the National Institute of Mental Health. The original name of the institute was to have been the National Neuropsychiatric Institute, but early in 1946, when passage of its founding legislation was assured, Felix and his colleagues had the name changed to the National Institute of Mental Health. The change altered its essential function, from focusing on mental illnesses—diseases of the brain—to focusing on social problems thought to be relevant for mental health. Focusing on social problems inevitably led NIMH and its community mental health centers into political issues. Claudewell Thomas, an NIMH psychiatrist who directed the community mental health centers program in the 1970s, said in an interview that the sociopolitical focus of NIMH and the centers ultimately led to the demise of the centers program: “The political issue became manifest . . . and Republicans killed the program.” In retrospect, it is clear that the change in emphasis in community treatment from mental illness to mental health was a fatal flaw.
²²

3. Community treatment of mentally ill individuals will only be successful if carried out by community mental
illness
centers, not in community mental
health
centers. The change of one word is crucial to the success of any such program. Mental illness centers may be freestanding or integrated as part of medical centers.

Another important lesson that has been learned about community treatment during the past half-century of deinstitutionalization is that continuity of care, especially the continuity of caregivers, is very important. People with normally functioning brains find it difficult to get good medical and psychiatric care when that care is provided in constantly shifting venues with constantly shifting caregivers. For people whose brains are not functioning normally, such changes are extremely difficult and usually lead to treatment failure.