A rich fantasy life is said to be a good thing, but when that fantasy life becomes an vehicle for realizing visions of control and oppression should we celebrate it? One thing I will grant many of those who seek to take mental patients out of prisons and put them back into mental hospitals: prisons and jails should not be places where people with mental disorders are warehoused. Here, however, their mirage begins. They believe that their new asylums will not be snake pits like the old ones were. In support of this belief, they promote a false dichotomy — either we have mental institutions or we have nothing for the mentally ill. The third choice — funding community-based programs for the mentally ill — is a path they do not acknowledge. One thinks of the road not taken: do we follow the same hazardous trail, do we pass through a jungle that has already ruined the lives of many, or do we struggle to realize a third, more compassionate, path?
I often tell new people to the support group that if it were not for the medications, we would be committed for life in stark places. The meds let us go home, I say. There are some, however, who would send us back to the dismal day rooms, claiming that the present system has failed us. Indeed it has, but not because it is structurally unsound but because it has been constructed of cheap materials. Society has failed us by neglicting to provide sufficient capital for community mental health programs. These patient-friendly clinics let us live among our peers and live gainfully. The guarantee of coverage is key to their success. They fail where state governments have been too cheap to foot the bill. So mental patients end up where the money does flow: prisons and jails.
Proponents of mental hospitals — many are overworked psychiatrists and anxious family members — believe that the system is an absolute failure despite the fact that it has never been given a fair chance. Funding deficits created by Congress and state legislatures eager to funnel money to their major contributors instead of “parasites” like you and me stifle the Dream. New wave asylum advocates tell us horror stories about jails and prisons — and I do not deny these! — to bolster their contention that we need kinder, gentler mental institutions. Dr. Christine Montrose, a Rhode Island staff psychiatrist, promises:
Modern asylums would be nothing like the one in “One Flew Over the Cuckoo’s Nest.” They could be modeled on residential facilities for patients with dementia, who would have languished in the asylums of yore, but whose quality of life has improved thanks to neurological and pharmacological advancements.
Asylums for the severely mentally disabled would provide stability and structure. Vocational skills would be incorporated when possible, and each patient would have responsibilities, even if they were carried out with staff assistance. Staff members would be trained to address the needs of minimally verbal adults. Sensory issues often accompany severe intellectual disability, so rooms with weighted blankets, relaxing sounds and objects to squeeze would help patients calm themselves.
Facilities for chronically psychotic patients would have medication regimens and psychoeducation tailored to the needs of those living with mental illness.
Are mental institutions a better place than jails and prisons? Let’s number some of the ways that they have been known to fail.
Funding. Montrose declares group homes have failed because they have been underfunded. State legislatures routinely cut programs for the mentally ill, so what makes her believe that they will be any more likely to properly endow her new-wave mental institutions? Her use of underfunding of group homes as a reason for mental institutions only bolsters my contention that the problem lies not in the concept of community mental health care but in how much money Congress and the state have allocated to them. Mental hospitals are more expensive than group homes — which do work when they have the money to do their job — so no state government is going to create them in the first place if there is not incentive for them to do so.
The worst alternative is privatized state institutions. For profit concerns would undoubtedly want two things: more patients and a lower bottom line. The reborn mental institutions industry would certainly lobby for changes to standards which define what a danger to self or others entails. A cutter who is careful in her choice of spots to slice might find herself incarcerated. So might a man who mentioned his thoughts of death to a psychiatrist or an overeater. Such patients might never be declared “in remission”. Advocates often say that their strongest argument for mental hospitals is the number of homeless people. Privatized institutions, however, would discharge the more-expensive-to-maintain patients. The homeless would resume their places in refrigerator boxes.
Most advocates for mental hospitals do not want privatization. The issue is in the clutches of a reactionary Congress and the legislatures however. If we move back to more mental institutions, we may see moves in this unsafe direction.
Staff. Trained workers are the backbone of the mental hospital system that Montrose proposes. In her dreamland, trained staff will eliminate rough handling of mental patients. In reality, wards often end up being run for the convenience of the staff rather than the betterment of the patients. We may not see the return of the Utica Crib or the strait jacket, but I do not doubt that chemical straitjackets such as heavy doses of thorazine will be used again. A short step separates the infamous padded room from Montrose’s special rooms. Patients still complain of being strapped to gurneys at the slightest sign of rebellion or mania. Then there are those sadists who ignore the rules and punish patients more severely. This happens in contemporary mental hospitals and group homes, as in the example of the psychiatric wing of a Brooklyn hospital. Assaults on patients are rarely prosecuted.
So the next time you hear someone propose mental hospitals as an alternative to the violent jails, remember these facts and do not buy the sales pitch.
Isolation. In the 1950s, Life published a series of photos showing life in a Midwestern mental hospital. The gray images show people standing in bleak, undecorated rooms doing nothing. (Such pictures contribute to the erroneous belief that the mentally ill are lazy.) The grimness of the wards made them a difficult place for families and friends to visit. Many gave up. Was this good for the patients who could not venture into the outside world?
Overcrowding. Mental hospitals were almost by definition over-crowded. Patients slept in open wards. Diseases spread from bed to bed. Rapes and assaults by other inmates were common. One could, of course, build more hospitals to give each sufferer a private room. Would citizens want to see their taxes raised or redirected away from other purposes to build them is the question. Smart money says to doubt it.
Violence. New wave asylum advocates would have you believe that mental hospitals are not violent. As we have seen above, however, patients are threatened not only by other patients, but also by the staff members who are supposed to be looking after them.
Loss of freedom and voting rights It is a given that patients will lose their freedom when the State locks them up. But we forget that they will also lose their inalienable voting rights.
Length of incarceration. Jail terms end. You can get out on parole. When you are in a mental hospital, you stay as long as the staff says you have to stay.
One result of the legislative budgeting process was the tendency of medical professionals to keep patients even after they stopped being symptomatic so that the hospital could keep getting money for their “care”. The ACLU took up the case of Kenneth Donaldson, a Florida man, who was neither dangerous or receiving medical care. He spent 15 years locked up until the ACLU managed to convince a court to free him. Would this happen again? Do people never juggle the books and fudge budgets?
Loss of due process. The decision as to whether a patient is well enough to live in the community or not rests with her doctors. There is no appeal available. When you are accused of an infraction of the rules, it is the staff– not your peers — who determine your guilt and mete out any punishment.
Stigma. When patients cannot communicate with the outside world, they will not be able to tell their story. The result will be a narrowly informed electorate who will choose candidates who stand for draconian options. Stigma, as I have written elsewhere, is not just about prejudice, but control. The mental hospital is its epitome.
This table examines the three roads that we could take in dealing with the problem of the mentally ill who lack access to care. It tellingly upends many of the arguments that the new wavers make in defense of the claim that hospitals are superior to jails and also compares them to the third alternative, a well-funded community health program:
|Jails and Prisons||Mental Hospitals||Community
|Loss of Freedom||Yes||Yes||No|
|Loss of due process||No||Maybe||No|
(For the record, I support limited use of mental hospitals. But they must be vigorously regulated. Orderlies and other staff who are violent towards their charges must not only be disciplined, they should be prosecuted. The smaller the institutions, the easier they will be to regulate. Most patients should be served by community clinics.)
Mental hospitals will not be much — if any — better than jails. New Waver solutions favor the caretakers, the staff, and other family who just want to put the mentally ill out of sight without providing them with access to freedom, housing, and decent healthcare.
We live in reactionary times. The public is inclined to jump in panic at the mention of mental illness and elect lawmakers who are loathe grant the kind of assistance that we truly need while supporting draconian measures such as forced medication and more mental hospitals. We must not allow those who claim to speak for us to promote doing just “anything in the name of helping the mentally ill”; we must speak for ourselves. Community mental health programs are a realistic approach to the problems that face the mentally ill, including those most severely afflicted. We cannot afford lazy, disingenuous, and stigmatizing alternatives. They will be the end of our freedom and our recovery.