Choices: Punishing or Aiding the Mentally Ill

"State hospitals began to realize that individuals who were there probably could do well in the community. It was well-intended, but what I believe happened over the past 50 years is that there's been such an evaporation of psychiatric therapeutic spaces that now we lack a sufficient number of psychiatric beds."
"When people are going back and forth from prisons to hospitals, that's a sign they might have benefited from longer-term treatment options."
"[Health care providers are] rather leery about these individuals because these people are, often at least according to the stereotype, high-cost patients who maybe are difficult to treat or noncompliant." 
"I think the stigma that we should be really focused on and worried about actually emerges out of our health care system more than from the public."
"[What is needed is] a continuum of care that ranges from outpatient care and transitional-type housing situations to inpatient care."
"Many times individuals who really do require intensive psychiatric care find themselves homeless or more and more in prison. Much of our mental health care now for individuals with serious mental illness has been shifted to correctional facilities."
Dominic Sisti, medical ethicist, University of Pennsylvania School of Medicine

"It took a lot of effort to move away from the practice of warehousing people."
"Locking people up long-term is no treatment [for mental illness] at all."
Jennifer Mathis, Bazelon Center

At Cook County, where a third of those incarcerated suffer from psychological disorders, officials are looking for ways to treat inmates less like prisoners and more like patients. 
Charles Rex Arbogast / AP

"No one seemed to care enough a generation ago, when so many [people with mental illness released from institutions to live on their own] became homeless." 
"Now that they're going to prison, well, these are horrendous tragedies, and if there were beds available, you wonder how many of these tragedies could be avoided."
Dr. E. Fuller Torrey, founder, Treatment Advocacy Center

Dr. Sisti, medical ethicist, co-authored a paper with the title "Bring Back the Asylum", published in 2015 in the journal JAMA (Journal of the American Medical Association). In that paper urging the necessity of restoring asylums to house and medically aid people with mental illness, rather than leaving them to end up homeless on the streets, committing petty and sometimes more serious crimes so they end up in prion, the paper's authors focused on the Worcester Recovery Center and Hospital in Massachusetts.

Using this state hospital that was opened in 2012, as an example of responsible medical intervention, it was pointed out the hospital has a range of treatments, therapy, and vocational training, working with an annual budget of $80 million, for the 320-private-room hospital. According to a Massachusetts state spokeswoman, the average length of stay for adolescents is 28 days while the average for continuing care (more intensive cases) worked out to 85 days' stay.

Those committed to urging legislators to reconsider the asylum as a modern-day intervention tool to help those in the community regain their mental equilibrium to resume their status as healthily functioning members of the community point out that this financial investment is well spent. The cost of housing a resident at modern state mental facilities is an annual $150,000, whereas good community care inclusive of housing, is estimated by experts to cost a reasonable $30,000 a year.

"The more you spend on these hospitals, the less is available for community care", insists David J. Rothman, historian at Columbia University in New York, co-author of an account of Willowbrook State School, shuttered after complaints of abuse in 1987. In the wake of a number of mass shootings in the United States of late, President Trump has issued a call to once again build and operate mental institutions.

The very thought of returning to the days when people with mental problems were mass institutionalized is anathema to Jennifer Mathis of the Bazelon Center whose function is to litigate on behalf of people with mental disabilities. Originally established in Europe at the turn of the 19th Century, the first therapeutic asylums were founded just as modern psychiatry came of age. Intended to provide for their inmates a protective environment as well as medical assistance, the ideal turned to nightmare.

The institutions and in particular state hospitals, became mass warehouses of society's unwanted. In some of these institutions only a single medical doctor would be held responsible for the health and welfare of hundreds of residents. Living conditions often deteriorated, to reflect squalid, abusive conditions. And then, by 1960 the first drugs able to blunt psychosis -- chlorpromazine -- was available to prescribing medical professionals allowing tens of thousands of people the opportunity to live independently.

The Community Mental Health Act was initiated in 1963 by President John F. Kennedy; unsurprising in light of the fact that one of his own sisters had been shuttered away in one of those grim institutions. That act was intended as a mechanism to put an end to institutional abuses, creating a system of community-based care. A  hoped-for best-case scenario where mental patients could be stabilized and live fairly secure, independent lives in the community.

Released from institutions, inmates were meant to move back into the neighbourhoods they were familiar with. Access to a doctor, therapists, at-home services and other assistance would be available as required. Theoretically, the money saved through hospital closures could then be used in support of independent living. State governments, however, failed to provide adequate care and the result was a swelling of homelessness through to the 1980s.

Such social initiatives went beyond the United States; its neighbour to the North which often looked at supposed advances in social management to the U.S., followed suit and the acute problem of the mentally unstable living on the streets of cities occurred in Canada as well. And the social phenomenon of people with mental disabilities increasingly ending up in prison, generally for non-violent offenses, began to take its toll. Experts estimate the presence of 100,000 inmates living with psychosis in the U.S. today.

And at the same time the number of public psychiatric beds available in the United States has plummeted to 11 per 100,000 people from 360 per 100,000; the number that prevailed in the 1950s. The Treatment Advocacy Center founded by Dr. Torrey lobbies for increased beds for people with severe mental illness, estimating that more than 90 percent of people with psychosis could be stabilize and discharged within weeks, with acute care.

When the Northville Psychiatric Hospital closed, many of the patients either had to leave southeast Michigan for hospitals elsewhere in the state or ended up in community programs that haven't always met their needs, an advocacy group says.

Paul Sancya/AP