Shortchanging the Mentally Ill

...Shortchanging the Mentally 111 By Frank Leonard Once each year the President of the United States proclaims Mental Health Month, and the National Association for Mental Health uses the opportunity to present the bright side of things The leader of the mental health movement, it decided at least a decade ago that to talk about the ugly condition of our system of care for the mentally ill was to risk frightening or sickening potential supporters "This year's campaign theme 'accents the positive,' " says a leaflet sent out recently to state and local chapters Among the positive elements being emphasized is the drop in the census of the nation's state mental hospitals from 558,922 in 1955 to 475,761 m 1965, and the development of the community mental health centers approach The census drop has not been due to any inci eased commitment to the mentally ill, however It is a result of the more or less chance discovery of tranquilizmg drugs, which do not "cure ' mental illness and have often been called "chemical straight-jackets " When tranquilizers permit a patient to return to the community, there are few services there to help the relatives and friends who then Frank Leonard is a social worker and authoi of City Psychiatric, a no\el about mental institutions have to assume responsibility for his care If there are no relatives or friends, or if they refuse to help, the patient may have to go on welfare In New York City alone, 2,000 ex-patients a year do so New York spends only $1,200 a year to maintain an individual on welfare, about half the amount spent for his care in a state hospital The census decline is also deceptive in another way, for there has been a steady increase in the total number hospitalized at some time during the year, from 685,420 during 1955 to 762,750 during 1965 Yet there have been virtually no major improvements in the state mental hospital system in the last 10 years, aside from the massive use of tranquilizers that reduce the length of a patient's stay In a society characterized by affluence, and a rapid improvement in the living standard of the majority, it is possible for less privileged groups to make small advances while falling further behind relative to the others The position of the Negro poor is one example The mentally ill are in a similar position, especially those who must rely on state care Psychiatrist F Lewis Bartlet points out that in 1965 four states lowered their standards for doctors employed in their hospitals "Today," he says, "when American Psychiatric Association membership exceeds 14,000, there are fewer apa members working in state institutions than when the membership was 4,000 " Governor Ronald Reagan of California has demonstrated that gains of previous years can be wiped away with the stroke of a pen If a reduction of 3,700 employes in the State Department of Mental Hygiene is actually made, it seems likely that California s ratio of staff to patients—one index of patient care —will fall below the national average for the first time in 10 years Dr Harry C Solomon, in a 1958 apa presidential address, said, "I do not see how any reasonably objective view of our mental hospitals today can fail to conclude that they are bankrupt beyond remedy " Aftei eight years of "progress, Dr Daniel Blam, past president ot apa wrote in January 1966, "the gieat majority of patients in our public mental hospitals are not benefiting from the greatly improved treatment methods denved from new scientific knowledge Under the existing system of state mental hospitals, I doubt that two-thirds of oui patients ever will " In describing our jails in 1965, James V Bennett former dnector of the Federal Bureau of Prisons, told a Senate committee they were dirty, overcrowded and deplorable "The prisoner spends his time vegetating and degenerating" In 1966 it cost an average of $2,448 per prisoner per year to maintain him at that level Almost exactly the same amount was spent on each mental patient There are occasional scattered reports of brutality m state and municipal mental hospitals Several years ago, I saw brutality to old men and children used as a part of the customary pattern of patient control at Bellevue Psychiatric Hospital in New York City My own guess is that the amount of brutality in the system as a whole is underestimated, because of the difficulty of detection If a patient makes a complaint, it can conveniently be dismissed as "paranoia " Over-optimism about the development of community mental health centers must also be tempered with a note of realism There has been a good deal of talk about building and staffing 500 centers by 1970 and 2,000 by 1975?one for each 100,000 people The National Institute of Mental Health has sometimes used similar figures The concept is marvelous, and England is about a decade ahead of us in its implementation It is based on the belief that the mentally ill can be most successfully helped m their own communities, and that a single center should have total responsibility for care of the mentally ill within a small, clearly defined geographic area A variety of devices are used to keep full hospitalization to a minimum (The state hospital system has shown that hospitalization itself is often disabling ) The patient may come to the center only during the day, and sleep at home, for example, or he may sleep at the center and work at a job during the day The more ties that can be preserved with the home, job and community, the better the chance of limiting the disabling effects of the illness Ideally, the community mental health center system would eventually replace the state hospital system The cost ot developing the new system is quite high, though—not compared to space expenditures, but compared to the amounts we have been willing to spend in the past on the mentally ill The National Institute of Mental Health estimates the average cost of construction of one center at $1 3 million, or $2 6 billion for 2,000 centers The estimate for operating expenses is $1 2 million per year for one center, $2 4 billion per year for 2,000 centers President Johnson's budget for the 1967-68 fiscal year provides only $50 million for the construction of community mental health centers If the states matched this with $50 million, the total would still pay for construction of only eight centers At that rate, it would take 250 years to build 2,000 Staffing is an even more crucial problem than construction Karl Menmnger has said that you can cure people m a barn if you have the staff Without staff, fancy centers will be empty symbols or "professional hideouts" Community mental health centers alone will require 100,000 psychiatric nurses and 40,000 other professionals Yet the President's budget for 1967-68 allows 110 fewer fellowships in the mental health field than were given last year, when nearly 2,000 qualified applicants were turned down for lack of funds The Joint Commission on Mental Health and Illness, m its 1961 report, Action for Mental Health, pointed out the hopelessness of expecting the states to pay the bill for improvements in care foi the mentally ill "It is self evident that the states, for the most part, have defaulted on adequate care for the mentally ill, and have consistently done so for a century It is likewise evident that the states cannot afford the kind of money needed to catch up with modern standards of care without revolutionary changes in their tax structure " The Joint Commission said Federal contributions for mental health should double in five years (reaching $940 million annually) and triple m 10 years (reaching $1 75 billion annually) Six years later, annual Federal expenditures have still not reached $325 million The Federal laws under which the community mental health centeis program is proceeding require the states to bear the major costs for construction and staffing Applicants for Federal staffing grants for centers must demonstrate that they can take over the full cost of staffing after three years Early optimism has been generated by the fact that some states have been devoting sizable sums to their first few centers Many of these states, however, will eventually need 50-100 such centers Resources that were there for the first few will not be there for 40-90 more If the community mental health centers system is really to replace the state hospital system, the Federal government must accept the principle that it, and not the states, must supply most of the money It must then quickly begin to provide that money in meaningful amounts...