RAEL JEAN ISAAC: FAILING THE MENTALLY ILL
Rael Jean Isaac interviews Clayton E. Cramer, author of My Brother Ron: A Personal and Social History of the Deinstitutionalization of the Mentally Ill, 2012, available from Amazon.
As terrible stories of random murders of innocents (for example, the mass shootings at the Batman showing in Aurora, Colorado) follow one another with frightening regularity, the media reaction is predictable–the fault lies in the availability of guns. Take away the public’s ability to buy guns and the problem will go away. The real problem is never addressed. It is the destruction of our mental health system, including the ability to commit seriously ill people for treatment before they become actively dangerous. It started over fifty years ago with a terrible idea. That terrible idea–that mental illness does not exist–can be traced to a man who died little more than a month ago, psychiatrist Thomas Stephen Szasz. Even now, when the consequences of radical deinstitutionalization should have become clear to everyone, the idea lives on. Last month’s issue of the Cato Institute’s online journal Cato Unbound, dedicated, so it says, to presenting each month “an essay on a big-picture topic by one of the world’s leading thinkers” was devoted to “Strategies of Psychiatric Coercion” by Thomas Szasz acolyte Jeffrey Schaler. Schaler employs the same rhetorical sleight of hand as his master: mental illness cannot exist because the mind cannot be diseased. Of course what is diseased in “mental illness” is the brain, which is as susceptible to malfunction as any other bodily organ.
The crew at Cato, who continue to make fools of themselves with this pernicious nonsense should read Clayton Cramer’s well-researched and heartfelt book, which weaves together two narratives. One focuses on the history of deinstitutionalization, which began in the 1960s and is still unfolding; Cramer does a very creditable job in explaining the various strands of ideas (including those of Szasz), advances in treatment and financial pressures that converged to empty hospitals and determine the way the seriously mentally ill subsequently fared. The other personalizes that history through the odyssey of his brother Ron through those same forty years as he–and his family–survive (sometimes barely) in the chaos. The humane, reliable community treatment for the mentally ill that was supposed to replace the institution never materialized and Ron’s family–which unlike many families never gave up–struggled for decades to navigate a hopelessly fragmented system where the “right to refuse treatment” far outweighed the right to receive it.
How could a literally mad idea–the bizarre conceit that the ancient, ongoing and universal scourge of mental illness did not in fact exist– become influential? How on earth could it become the foundation of public policy? The libertarian folks at Cato might take note that deinstitutionalization was in good part an achievement of the radical left. Szasz would have remained a fringe curiosity had the counter-culture and political radicals not taken up his notions (along with the similar misconceptions, on the political left, of R.D. Laing) as a way to flagellate existing institutions. The mentally ill became a group to be “liberated” along with blacks, Hispanics and Third World peoples. The mentally ill were an especially attractive cause because they were imprisoned, not in the invisible institutional complexes of law and custom but in the concrete brick and mortar of the asylum. While many have noted the radical egalitarianism of the adversary culture, what escaped notice is the way that denial of mental illness dissolved the most fundamental distinction of all: that between sanity and madness. For the most radical claim of the left was that all realities were equal. Indeed some countercultural intellectuals went so far as to invert the consensual order. The mad were sane, the sane mad. After all the mad rejected the unacceptable, irrational reality of a rotten social system, while those called sane conformed to the sick values of the culture.
It was thanks to the left that deinstitutionalization became a “progressive” idea to which those eager to cut costs could attach themselves. The Lanterman-Petris-Short Act of 1967, which inaugurated the wave of state legislation sharply restricting both the grounds for involuntary hospitalization and its length, passed both houses without a single dissenting vote. Conservative Republicans saw a way to save money, liberal Democrats a way to expand civil rights. The promise of saving money by doing good was irresistible.
While most of Cramer’s book is devoted to the deinstitutionalization disaster of the last forty years, Cramer also offers a concise history of treatment of the mentally ill from colonial times until the end of World War II.
I would take issue with Cramer on one important issue. He repeatedly refers to “well-intentioned and beautiful theories” behind deinstitutionalization. No doubt there were some who had good intentions. But for the most part deinstitutionalization was an ideological movement in which the mentally ill were pawns, their fate as individuals a matter of indifference. In fact Cramer shows this repeatedly. For example, he describes the conflicting agendas of those who brought the Wyatt v. Stickney suit in Alabama. Dr. Morton Birnbaum did indeed initiate that suit with the best of intentions, hoping to use “the right to treatment” (a notion he pioneered) to force states to adequately fund state hospitals. But the ACLU, his partner in the suit, saw it as a way to abolish mental illness commitment laws and shut down the hospitals, not improve care of the mentally ill. And so the ACLU refused to support Birnbaum in his subsequent suit to obtain Medicaid funding for those in state hospitals. Similarly, the civil libertarian attorneys who at state expense “represent” seriously mentally ill patients refusing treatment know full well that their clients need and will benefit from treatment but callously do their bit to throw them out into the streets.
A minor complaint. Given the amount of valuable information in the book, I wish it had included an index.
It is a pleasure to interview Clayton E. Cramer.
RJI: To me your mother emerges as the heroine in your brother’s story, and I found myself wishing you had told your reader more about her. Much of her life has centered on his care, and you write that continues to be the case now, when she is in her nineties. Can you tell us more about her perspective on what she has gone through? What kept her going in supporting your brother through very discouraging times? After all, at one time he almost killed her. Indeed you write that he thought he had done so.
Cramer: As I pointed out in the book, parents can remain committed to their children when everyone else has run out of energy, hope, and time. My mother has managed to keep going because, like most mothers, she is terribly committed to looking out for her children.
RJI :If you could construct an ideal system of care tailored to your brother’s condition, what would it be? Clearly you do not feel your brother should have been institutionalized for life. Do you feel there is a set of laws and services that would have enabled your brother to live a life without the roller coaster
Cramer: I’m not really sure what would have been the best situation for Ron. I do think that instead of short-term hospitalization (almost never for more than 17 days), he might have benefited from more long-term treatment. As I mention in the book, there is some evidence that early and more consistent treatment lessens the severity of schizophrenia and improves the chances of recovery. Unfortunately, the data on this is pretty incomplete.
RJI :You talk about the need for rebuilding the hospital system. But how is that going to happen given the way the anti-treatment philosophy has imbued government services? For example, I see that SAMHSA (Substance Abuse and Mental Health Law Administration) has just appointed Paolo Del Vecchio as head of its Center for Mental Health Services. He comes out of a consumer rights (largely right to refuse treatment) background and has publicly compared court ordered treatment to “a personal Holocaust.” The Treatment Advocacy Center notes that SAMSHA is almost totally silent on the subject of severe mental illness, not even mentioning schizophrenia and bipolar disease in its 41,000 word plan. Protection and Advocacy agencies, supposedly there to advocate for the mentally ill, in many cases have been taken over by anti-treatment activists. You don’t talk about these government agencies in your book. Are you concerned about them and what do you think can be done about the way government programs have been largely taken over by the anti-treatment movement?
Cramer: Oh, you are discouraging me when you tell me this. But I am not letting it stop me. A friend works at a research institute in Colorado. He is using some of my research in conversations he is having with legislators and the governor today and tomorrow concerning mental health law reform. This tragedy in Aurora last month has, unsurprisingly, concentrated the attention of governmental officials on this problem.
As part of my preparation for his meetings, I have identified some relatively minor changes in Colorado law that would have likely prevented this tragedy–and a lot of smaller tragedies that were only headlines in local news media there. I have also identified where the money will come from to reverse the decline of Colorado’s public mental health system. Every murder by a mentally ill offender turns into an enormous price tag for cleaning up the bodies, trying the killer, and then sending them to prison for decades. You can build a lot of mental hospitals, and provide a lot of both in-patient and out-patient care for what it costs to lock up murderers for the rest of their life.
RJI :What would you say to the people at the Cato Institute who refuse to accept the reality of mental illness because they are wedded to the notion of personal responsibility and see mental illness as something which undermines this principle? Who argue that mental illness is a psychiatric invention and people should be free to do whatever they want until they break the law at which point they should be punished to its full extent?
Cramer: I confess that I am always a bit mystified by the ideological purity that surrounds this. The Cato Institute has published papers by me on other subjects, and had me speak earlier this year concerning Stand Your Ground laws. I understand the motivation for an ideological approach; a purely pragmatic approach to public policy leads to the horrible situation where, as someone once observed, “A person who stands for nothing will stand for anything.”
The claims of people like Szasz and R.D. Laing, as beautiful as they are from an ideological standpoint, fail when tested against the real world. In my book, I point to an interview where Szasz takes great pride in having managed to get through his psychiatric residency without ever having to treat (or perhaps even meet) a psychotic. And then he went into the Navy, where by his own description, his job was to play a psychiatrist certifying that people who were pretending to be mentally ill were actually mentally ill. You can see how all this disconnect from real world problems might influence his thinking.
I think of myself as a recovering libertarian. There are any aspects of libertarian thought that are very attractive. But an ounce of experience is worth a pound of theory. I notice that a lot of libertarians that I know, because they have had family members or friends who suffered a mental illness breakdown, recognize that Szasz’s theories are wrong. They are outweighed on the truth scale by their own experiences.
RJI: You found through your brother’s experiences that community programs were often not what they advertised themselves to be and that the neglect that once characterized large institutions is now simply diffused into many small ones. Do you see any way to deal with this problem?
Cramer: Sadly, no. Neglect is part of human nature. At least in state institutions, there is no profit motive to neglect, and a centralized institution is a bit easier to keep inspected. Of course, traditional state mental hospitals, because of their remoteness, were sometimes forgotten by those seeking to keep state employees doing their jobs correctly. Whatever solution states come up with, no one should plan to fall asleep when it comes to watching what it is happening.
RJI: A major positive development of the last decade has been the passage of outpatient commitment laws which are a means to enforce medication compliance in the community, crucial because so many patients function relatively well when they take medication, and spiral downward without them. Yet even when these laws are passed, they are not necessarily enforced. You mention that in California such a law was passed but the counties can choose to participate and only one is doing so. Given the potential of these laws to at least minimize violence and the revolving door of hospital admissions, do you have any ideas for ways to motivate state mental health officials to make maximum use of them?
Cramer: The problem was that individual counties had the decision on this. The general public, unfortunately, has failed to make the connection between mental illness in the streets and violence. And this failure to make the connection is part of why there is so little willingness to do anything about the problem of mental illness in the streets. Mental health advocacy groups are trying very hard to eliminate the stigma of mental illness in the hopes of getting people to seek help and reduce prejudice against the mentally ill–but by making the false claim that the mentally ill are no more likely to be violent than the general population, they are reducing public interest in doing something about the problem of deinstitutionalized mentally ill people.
RJI Hoping to reduce the stigma of mental illness, many advocacy groups insist that the mentally ill are no more violent than other people. You speak openly about the problem of violence. What made you decide to do this?
Cramer: For one thing, because it is true. Most mentally ill people are not violent. They are generally more at risk of being victims than victimizers. But it is also true that the severely mentally ill are many times more violent than the general population (the exact number depends on the study). And this is a pretty recent phenomenon.
Into the 1940s, because the severely mentally ill were often hospitalized before they had committed very serious crimes, the arrest rates for the severely mentally ill were lower than for the general population. When studies of violence by the mentally ill start to be published in the 1970s, after deinstitutionalization has started, suddenly, the severely mentally ill are more violent than the general population. No surprise: now, by the time a person with a serious mental illness problem gets committed, it is often because they have committed aggravated assault, or murder. And sympathy from just about everyone declines because of that.
I speak about the problem of violence both because it is true, and because the average person won’t much care about that homeless guy begging on the street corner unless it affects the average person’s bottom line. And this affects the bottom line. In one sense, it isn’t fair. Most of those homeless people who freeze to death on the street in winter aren’t going to hurt anyone but themselves. But reminding the general public that this mental illness problem that underlies these random acts of mass murder that have become common, not just in the U.S., but in Canada and Europe over the last 30 years, is a way to get them care.
RJI As your brother’s experience shows, families are the most important resource mentally ill people have. Part of the tragedy of the current system is that it all too often rejects family input rather than involving the family. What can be done about this problem?
Cramer: Much of the problem that we face has been the hijacking of state legislative authority by the judiciary from the 1960s onward. States did not always make the best decisions about mental health law, but as bad as many state mental hospitals were in the 1950s, and even into the 1960s, at least their patients weren’t freezing to death on the streets. Before deinstitutionalization, family concerns worked in conjunction with the psychiatric profession and the legal system to hospitalize those who were in serious trouble. This is not
to say that the old system worked perfectly; no system works perfectly. But when family members and psychiatrists came to
the courts and said, “This relative has a serious problem,” there was a good chance of hospitalization. Not today.
Rael Jean Isaac is the co-author (with Virginia Armat) of Madness in the Streets: How Psychiatry and the Law Abandoned the Mentally Ill (The Free Press)
Rael Jean Isaac is the co-author (with Virginia Armat) of Madness in the Streets: How Psychiatry and the Law Abandoned the Mentally Ill (The Free Press)
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