[Congressional Record (Bound Edition), Volume 145 (1999), Part 11] [Senate] [Pages 15539-15541] [From the U.S. Government Publishing Office, www.gpo.gov]DEINSTITUTIONALIZATION OF THE MENTALLY ILL Mr. MOYNIHAN. Mr. President, this past Friday (July 9, 1999), the Washington Post carried an excellent op-ed piece, ``Deinstitutionalization Hasn't Worked,'' by E. Fuller Torrey and Mary T. Zdanowicz. The authors are the president and executive director, respectively, of the Treatment Advocacy Center. They write about the continued stigma attached to mental illness. They write about barriers to treatment. Most important, they write about the aftermaths of deinstitutionalization, and the seemingly horrific effects this policy has had. In this morning's New York Times (July 12, 1999), Fox Butterfield writes about a Department of Justice report released yesterday which states that some 283,800 inmates in the nation's jails and prisons suffer from mental illness. (This is a conservative estimate.) As Butterfield puts it, ``. . . jails and prisons have become the nation's new mental hospitals.'' Over the past 45 years, we have emptied state mental hospitals, but we have not provided commensurate outpatient treatment. Increasingly, individuals with mental illnesses are left to fend for themselves on the streets, [[Page 15540]] where they victimize others or, more frequently, are victimized themselves. Eventually, many wind up in prison, where the likelihood of treatment is nearly as remote. This is a cautionary tale, instructive of what is possible and also what we ought to be aware of. I was in the Harriman administration in New York in the 1950s. Early in 1955, Harriman met with his new Commissioner of Mental Hygiene, Paul Hoch, who described the development of a tranquilizer derived from rauwolfia by Dr. Nathan S. Kline at what was then known as Rockland State Hospital (it is now the Rockland Psychiatric Center) in Orangeburg. The medication had been clinically tested and appeared to be an effective treatment of many patients. Dr. Hoch recommended that it be used system wide; Harriman found the money. That same year Congress created a Joint Commission on Mental Health and Illness with a view to formulating ``comprehensive and realistic recommendations'' in this area which was then a matter of considerable public concern. Year after year the population of mental institutions grew; year after year new facilities had to be built. Ballot measures to approve the issuance of general obligation bonds for building the facilities appeared just about every election. Or so it seemed. The discovery of tranquilizers was adventitious. Physicians were seeking cures for disorders they were just beginning to understand. Even a limited success made it possible to believe that the incidence of this particular range of disorders, which had seemingly required persons to be confined against their will or even awareness, could be greatly reduced. The Congressional Commission submitted its report in 1961; it was seen to propose a nationwide program of deinstitutionalization. Late in 1961 President Kennedy appointed an interagency committee to prepare legislative recommendations based on the report. I represented Secretary of Labor Arthur J. Goldberg on this committee and drafted its final submission. This included the recommendation of the National Institute of Mental Health that 2,000 ``community mental health centers'' (one for every 100,000 people) be built by 1980. A buoyant Presidential Message to Congress followed early in 1963. ``If we apply our medical knowledge and social insights fully,'' President Kennedy stated, ``all but a small portion of the mentally ill can eventually achieve a wholesome and a constructive social adjustment.'' A ``concerted national attack on mental disorders [was] now possible and practical.'' The President signed the Community Mental Health Centers Construction Act on October 31, 1963--his last public bill signing ceremony. He gave me a pen. The mental hospitals emptied out. The number of patients in state and county mental hospitals peaked in 1955 at 558,922 and has declined every year since then, to 61,722 in 1996. But we never came near to building the 2,000 community mental health centers. Only some 482 received Federal construction funds from 1963 to 1980. The next year, 1981, the program was folded into the Alcohol, Drug Abuse, and Mental Health block grant program, where it disappeared from view. Even when centers were built, the results were hardly as hoped for. David Musto has noted that the planners had bet on improving national mental health ``by improving the quality of general community life through expert knowledge [my emphasis], not merely by more effective treatment of the already ill.'' The problem was: there is no such knowledge. Nor is there. But the belief there was such knowledge took hold within sectors of the profession, which saw institutions as an unacceptable mode of social control. These activists subscribed to a redefining mode of their own, which they considered altruistic: mental patients were said to have been ``labeled,'' and were not to be drugged. So as the Federal government turned to other matters, the mental institutions continued to release patients, essentially to fend for themselves. There was no connection made: we're quite capable of that in the public sphere. Professor Frederick F. Siegel of Cooper Union observed: ``in the great wave of moral deregulation that began in the mid-1960s, the poor and the insane were freed from the fetters of middle-class mores.'' Soon, the homeless appeared. Only to be defined as victims of an insufficient supply of affordable housing. No argument, no amount of evidence has yet affected that fixed ideological view. I commend these two articles to my colleagues and ask that they be printed in the Record. The articles follow: [From the Washington Post, July 9, 1999] Deinstitutionalization Hasn't Worked ``We have lost effectively 93 percent of our state psychiatric hospital beds since 1955'' (By E. Fuller Torrey and Mary T. Zdanowicz) The White House Conference on Mental Health identified stigma and discrimination as the most important barriers to treatment for the mentally ill. For the most severely ill, there are more significant barriers to treatment, such as laws that prevent treating individuals until they become dangerous. These laws and our failure to treat individuals with schizophrenia and manic-depressive illness are, ironically, the leading causes of stigma and discrimination against those with mental illnesses. Stigma is created by the sort of headlines that result when a person is not being treated for mental illness and shoots two Capitol police officers to death, or pushes an innocent victim in front of a speeding subway train. Some 20 years of research has proven this point. A 1996 study published in the Journal of Community Psychology demonstrated that negative attitudes toward people with mental illnesses increased greatly after people read newspaper articles reporting violent crimes by the mentally ill. Henry J. Steadman, an influential public opinion researcher, wrote as far back as 1981: ``Recent research data on contemporary populations of ex-mental patients supports these public fears [of dangerousness] to an extent rarely acknowledged by mental health professionals. . . . It is [therefore] futile and inappropriate to badger the news and entertainment media with appeals to help destigmatize the mentally ill.'' Tipper Gore and the White House must tackle 30 years of failed deinstitutionalization policy if they hope to win the battle of mental illness stigma and solve the nation's mental illness crisis. Hundreds of thousands of vulnerable Americans are eking out a pitiful existence on city streets, underground in subway tunnels or in jails and prisons because of the misguided efforts of civil rights advocates to keep the severely ill out of hospitals and out of treatment. The images of these gravely ill citizens on our city landscapes are bleak reminders of the failure of deinstitutionalization. They are seen huddling over steam grates in the cold, animatedly carrying on conversations with invisible companions, wearing filthy, tattered clothing, urinating and defecating on sidewalks or threatening passersby. Worse still, they frequently are seen being carried away on stretchers as victims of suicide or violent crime, or in handcuffs as perpetrators of violence against others. All of this occurs under the watchful eyes of fellow citizens and government officials who do nothing but shake their heads in blind tolerance. The consequences of failing to treat these illnesses are devastating. While Americans with untreated severe mental illnesses represent less than one percent of our population, they commit almost 1,000 homicides in the United States each year. At least one-third of the estimated 600,000 homeless suffer from schizophrenia or manic-depressive illness, and 28 percent of them forage for some of their food in garbage cans. About 170,000 individuals, or 10 percent, of our jail and prison populations suffer from these illnesses, costing American taxpayers a staggering $8.5 billion per year. Moreover, studies suggest that delaying treatment results in permanent harm, including increased treatment resistance, worsening severity of symptoms, increased hospitalizations and delayed remission of symptoms. In addition, persons suffering from severe psychiatric illnesses are frequently victimized. Studies have shown that 22 percent of women with untreated schizophrenia have been raped. Suicide rates for these individuals are 10 to 15 times higher than the general population. Weak state treatment laws coupled with inadequate psychiatric hospital beds have only served to compound the devastation for this population. Nearly half of those suffering from these insidious illnesses do not realize they are sick and in need of treatment, because their brain disease has affected their self-awareness. Because they do not believe they are sick, they refuse medication. Most state laws today prohibit treating individuals over their objection unless they pose an immediate danger to themselves. In other words, an individual must have a finger on the trigger of a gun before any medical care will be prescribed. Studies have proved that outpatient commitment is effective in ensuring treatment compliance. While many states have some [[Page 15541]] form of assisted treatment on the books, the challenge remains in getting them to utilize what is at their disposal rather than tolerating the revolving-door syndrome of hospital admissions, readmissions, abandonment to the streets and incarceration that engulfs those not receiving treatment. Adequate care in psychiatric facilities also must be available. Between 5 and 10 percent of the 3.5 million people suffering from schizophrenia and manic-depressive illness require long-term hospitalization--which means hospitalization in state psychiatric hospitals. This critical need is not being met, since we have lost effectively 93 percent of our state psychiatric hospital beds since 1955. It is time to recognize that feel-good mental health policies have caused grave suffering for those most ill and that real solutions must be developed. The lives of millions of Americans depend on it. ____ [From the New York Times July 12, 1999] National Report--Prisons Brim With Mentally Ill, Study Finds (By Fox Butterfield) The first comprehensive study of the rapidly growing number of emotionally disturbed people in the nation's jails and prison has found that there are 283,800 inmates with mental illness, about 16 percent of the jail population. The report confirms the belief of many state, local and Federal experts that jails and prisons have become the nation's new mental hospitals. The study, released by the Justice Department yesterday, paints a grim statistical portrait, detailing how mentally ill inmates tend to follow a revolving door from homelessness to incarceration and then back to the streets with little treatment, many of them arrested for crimes that grow out of their illnesses. The report found that mentally ill inmates in state prisons were more than twice as likely to have been homeless before their arrests than other inmates, twice as likely to have been physically or sexually abused in childhood and far more likely to have been using drugs or alcohol. In another reflection of their chaotic lives, the study found that emotionally disturbed inmates had many more incarcerations than other inmates. More than three-quarters of them had been sentenced to jail or prison before, and have had served three or more prior sentences. One of the most striking findings in the study, and the one most likely to be disputed, is that mentally ill inmates in state prisons were more likely than other prisoners to have been convicted of a violent crime. Too, many emotionally disturbed inmates were arrested for little more than bizarre behavior or petty crimes, like loitering or public intoxication, but the report, by the Justice Department's Bureau of Justice Statistics, did not offer any breakdown on this category of convictions. Moreover, once incarcerated, emotionally disturbed inmates in state prisons spend an average of 15 months longer behind bars than others, often because their delusions, hallucinations or paranoia make hem more likely to get into fights or receive disciplinary reports. ``This study provides data to show that the incarceration of the mentally ill is a disastrous, horrible social issue,'' said Kay Redfield Jamison, a professor of psychiatry at the Johns Hopkins School of Medicine. ``There is something fundamentally broken in the system that covers both hospitals and jails,'' said Professor Jamison, the author of ``Night Falls Fast: Understanding Suicide,'' to be published later this year by Knopf. With the wholesale closings of public mental hospitals in the 1960's, and the prison boom of the last two decades, jails are often the only institutions open 24 hours a day and required to take the emotionally disturbed. The hospitals were closed at a time when new antipsychotic drugs made medicating patients in the community seem a humane alternative to long-term hospitalization. From a high of 559,000 in 1955, the number of patients in state hospitals dropped to 69,000 in 1995. But drugs work only when taken and many states failed to build a promised network of clinics to monitor patients. To compound the problem, for-profit hospitals began turning away the psychotic, who tend to be more expensive and stay longer than other patients, and are often without health insurance. At the same time, the number of jail and prison beds has quadrupled in the last 25 years, with 1.8 million Americans now behind bars. ``Jails have become the poor person's mental hospitals,'' said Linda A. Teplin, a professor of psychiatry and director of the psycho-legal studies program at Northwestern University. After years of inattention by the Government, the problem has generated a flurry of interest in the Clinton Administration, led by Tipper Gore and Attorney General Janet Reno, whose department is sponsoring a major conference on it next week. All previous estimates of the number of emotionally disturbed inmates have been based on research by Professor Teplin in the Cook County Jail in Chicago. She found that 9.5 percent of male inmates there had experienced a severe mental disorder like schizophrenia, manic depression or major depression, four times the rate in the general population. Professor Teplin said that while she welcomed the Justice Department count, it was open to question because the study relied on reports by the inmates themselves, who were asked whether they had a mental condition or had ever received treatment for a mental problem. People with emotional disorders often are not aware of them or do not want to report them, she said, so the Justice Department estimate of more than a quarter-million inmates with mental illness may actually be too low, Professor Teplin said. In addition, she said, the study was not conducted by mental health professionals using diagnostic tests, so it was impossible to tell what mental disorders the inmates suffered from, and whether they were severe illnesses, like schizophrenia, or generally less severe problems, like anxiety disorders. The study found that 53 percent of emotionally disturbed inmates in state prisons were sentenced for a violent crime, compared with 46 percent of other prisoners. Specifically, 13.2 percent of mentally ill inmates in prisons had been convicted of murder, compared with 11.4 percent of other prisoners, and 12.4 percent of mentally ill inmates had been convicted of sexual assault, compared with 7.9 percent of other prisoners. Advocates for the mentally ill have worked hard to show that emotionally disturbed people are no more violent than others, to try to lessen the stigma surrounding mental illness. But recent research, while confirming that mentally ill people may not be more violent than others, suggests that they can become violent in a number of conditions, including when they are off their medications or are taking drugs or alcohol. In another important finding, also subject to differing interpretations, the study found that reported rates of mental illness varied by race and gender, with white and female inmates reporting higher rates than black and male inmates. The highest rates of mental illness were among white female state prisoners, with an estimated 29 percent of them reporting emotional disorders, compared with 20 percent of black female prisoners. Overall, 22.6 percent of white state prisoners were identified as mentally ill, compared with 13.5 percent of black prisoners. Dr. Dorothy Otnow-Lewis, a psychiatrist, said the differences were a result of white psychiatrists ``being very bad at recognizing mental illness in minority individuals.'' Psychiatrists are more likely to dismiss aggressive behavior in men, particularly black men, as a result of their being bad, rather than being mad, said Dr. Lewis, who is a senior criminal justice fellow at the Center on Crime, Communities and Culture of the Soros Foundation. Michael Faenza, the president of the National Mental Health Association, said the study ``shows that the criminal justice system is just a revolving door for a person with mental illness, from the street to jail and back without treatment.'' Professor Jamison noted that jails and prisons are not conducive to treatment, even when it is available. ``Inmates get deprived of sleep,'' she said, ``and isolation can exacerbate their hallucinations or delusions.'' ____________________