The Honorable Joseph R. Pitts: In your opinion, how has the legacy of deinstitutionalizing the mentally ill worked out over the past half-century?
Dr. Michael Welner: Let’s remember that when we speak of “de-institutionalization,” we speak of what we NOW think of as long term psychiatric hospitals. When they were originally developed, mental institutions as they were known catered to our society at an age in which psychiatry was far less invested in its science for those with serious and chronic mental illness. The role of mental institutions was custodial and at a time when those with chronic mental illness were as dehumanized as others were prejudiced.
In such an age of low oversight and the perception of chronic and seriously mentally ill as essentially hopeless cases (or at least, irrelevant to broader society), a more primitive psychiatry was treating with high doses of sedating antipsychotics like Thorazine, other sedating agents, or even lobotomy. Devaluing becomes conditioned as hopelessness begets abuses. And so custodial and experimental care were eventually exposed for their appalling inadequacy and lack of humanity. We must remember that this was the catalytic force of deinstitutionalization, not medical economics. But unanticipated progress followed, just as psychiatry was fleeing the institution model of care for the seriously mentally ill, primarily for how it stigmatized psychiatry.
Quantum leaps in psychiatric therapeutics have paralleled the exceptional civil rights sensitivity of contemporary America. Moreover, psychiatry has become ever more scrupulous about its scientific methodology, beginning with diagnosis and the DSM and continuing to therapeutics. Whereas therapeutic options and advances were substantial in the 1980s and 1990s, options still remained more limited. Now, a range of therapies from transcranial stimulation to light therapy to EMDR to genetics to omega-3 to naturopathic interventions are providing a broad range of therapeutic approaches to better defined chronic mental illnesses.
Therefore, it is my professional opinion that we are not confronting a question of, “What is the impact of deinstitutionalization,” but rather a more urgent query, “What is the impact of psychiatry’s advances now that institutions are no longer available?”
The impact has been huge. Those who were institutionalized who were released because those facilities closed, were never discharged because they were treated or healed, they were essentially evicted from where they otherwise needed to be, as if a renter were to be moved out by a condo developer. Those who languished in institutions under over-sedation or psychosurgery were given desperate and non-specific treatments, because that was all that was available. But they still needed treatment desperately in the first place that could not be provided to them in the community because of the dire nature of their illness. Those who were abused in mental institutions still belonged in institutions – they were mistreated, or neglected instead of being cared for the fragile and fractured minds they truly were.
And those who did not belong in institutions were not there because of 2014 psychiatric assessment skills, along with current hospital oversights, even the combination of those skills with unscrupulous families who committed them to settle scores. No. They were misunderstood because the psychiatry up to the 1970s really was adolescent compared to today. Ours is a far more rigorous science than ever before.
Unfortunately, the advent of demonstrably helpful solutions for serious mental illness – more effective, more tolerated, safer medicines that have impact on broader ranges of symptoms – coincides with deinstitutionalization. Thus, even with the tools to treat the people who were once appropriately committed and without hope, deinstitutionalization had created conditions in which a lack of access of beds, a lack of sufficient hospital days, and restrictive formularies compromised treatment.
For comparison purposes, let us consider a surgical hospital that diverted a number of procedures to ambulatory care. There are still core surgical procedures that require inpatient stays. And there are still complex surgical procedures that require lengthy hospitalizations. Psychiatry and serious mental illness is no different. Nor should the mandate that each psychiatrist embraces be different. No surgeon would send a patient home at high risk for complication, relapse, and medical calamity. No psychiatrist would rightfully wish to either. Yet in the current climate of deinstitutionalization, this is exactly what happens from hospitals and emergency rooms, with obvious impact.
For those who serious mental illness impacts or is accompanied by an unwillingness to get help, their deterioration is inevitable and tragic. Their destiny may be;
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In what has become one of the largest psychiatric hospitals in any area, the local jail or prison. It is telling and damning that only since deinstitutionalization have prisons become overwhelmed by mental health needs. What was anticipated to be a cost-saving measure is now the problem of those seeking to relive overcrowded prisons.
What was a civil rights triumph for those who fought hospitalization and commitment is now the bitter pill of criminalized mental illness. Bad as hospitals once were, jails are worse – especially jails overburdened and overcrowded with those with special mental health needs. Bad as institutionalization was, psychiatric hospitals now are better than many residential situations, let alone jail.
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Custody of overwhelmed families in hostile, dependent relationships in which little therapeutic benefit exists beyond material support. These situations are known for their violent outcomes, however uncommon the incidence of violence in the mentally ill.
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Homelessness. My work on a murder case involving a homeless man with serious and chronic mental illness on Hawaii’s Big Island exposed me to the little known local knowledge that the expanse, laid back mentality of the community, ability to hide as a paranoid individual, and the reliably temperate climate were responsible for attracting large numbers of homeless mentally ill from numerous states to Hawaii. Is that a mental health policy to serve the needs of the seriously mentally ill?
Psychiatric specialists no longer relate to chronic mental illness as hopeless and dehumanized, inscrutable puzzles to be treated in a safe and controlled environment. Treatment options are really that helpful and improved. All illnesses of those without intellectual deficiency are expected to improve to a degree that a person with even serious mental illness ought to be able to work toward as much quality of life, with as much life, as possible.
But first someone has to get well. Like the complex surgical patient, recovery may happen that the treatments take time to generate healing, are not guaranteed to work, may require multiple interventions over time, and monitoring for complications. Without the wherewithal for longer term psychiatric inpatient care, people who genuinely and definitely need help are just not getting the treatment that works, and the treatments that can save their lives from the many paths of quiet or not-so-quiet ruin. Psychiatric hospitals work and are essential for patients committed to their long-term care.
