[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

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     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.''

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