TIME: Almanac 1993/TIME Almanac 1993.iso/time/102290/1022131.000

Text File | 1992-08-28 | 8KB | 172 lines

                r                                                              HEALTH, Page 58

From the Asylum to Anarchy


Shameful indifference to the plight of the mentally ill has left
many of them wandering the streets and crowding the jails

By ANASTASIA TOUFEXIS -- Reported by Elaine Shannon/Washington
and Janice C. Simpson/New York


    Mike hears voices inside his head and sees things that are
not there. Frightening things, like snakes and abandoned
babies. Sometimes, when the hallucinations become too vivid,
Mike erupts in hostile words and angry gestures that frighten
other people. Twenty-five years ago, Mike would probably have
been locked away in a state mental hospital in some secluded
locale. Today, however, he lives on a bench in Manhattan's
Central Park.

    Mike and thousands like him are stark evidence of America's
brutal indifference to the mentally ill. The care meted out to
the severely disturbed is a "disaster by any measure used,"
concludes a new report issued by the Public Citizen Health
Research Group and the National Alliance for the Mentally Ill
(NAMI). "Not since the 1820s have so  many mentally ill
individuals lived untreated in public shelters, on the streets
and in jails." Up to 30% of the estimated 500,000 homeless in
the U.S. suffer from serious mental disorders, mostly
schizophrenia and manic depression, as do 10% of the 1 million
people behind bars. With 3,600 psychotic inmates, the Los
Angeles County jail is "the largest de facto mental institution
in the nation," says the report. Countless other distressed
people inhabit squalid apartments or transient hotels, without
adequate food, clothing or medical care.

    Federal officials say the report does not exaggerate. "We
have 2.8 million people with serious mental illness, and only
1 in 5 is receiving adequate care," observes Dr. Lewis Judd,
director of the National Institute of Mental Health. And the
problem is sure to get worse. The majority of the sick live
with their parents, whose average age is now between 50 and 60.
When they die, many of their troubled children will land on the
street. Baby boomers are moving through their 30s, the
vulnerable years for late-onset schizophrenia. Moreover, the
number of people with dementia as a result of AIDS is expected
to increase dramatically.

    How did things get so bad? During much of the first half of
this century, large state hospitals were generally regarded as
the best way to treat the mentally ill. Attitudes changed in
the 1950s and '60s as tales of abuse in giant institutions
multiplied. New drugs were introduced that helped control
mental illness, and a concern for the civil rights of the
disturbed led state legislatures to make it difficult to commit
people to hospitals against their will.

    Belief grew that the sick would fare better out of
hospitals. Community clinics and halfway houses, it was argued,
could provide needed care -- and at less expense than large
institutions. So the exodus began. In 1955, state institutions
had 552,000 patients; today the number is 119,000.

    But as the doors of the hospitals were swinging open, the
fiscal gates were clanging shut. Few halfway houses were ever
established, and many community centers shifted their focus to
family counseling and treating drug abuse and alcoholism.
Programs also came under attack from budget cutters.
California's services, once held up as a model for the nation,
are being slashed. The new state budget lops $73 million from
a planned outlay of $520 million for the community-care system.

    In Los Angeles, that means 12 out of 20 community
mental-health centers must close. The city's remaining clinics
will act only as crisis centers. Among the hard hit will be the
Skid Row Mental Health Clinic, an innovative facility that, for
example, provides bathrooms, washers and dryers and money
management. The clinic, which serves 1,000 people a month, has
had to reduce its 15-member psychiatric staff to five. The
skeleton crew has little time for outreach -- going into the
streets and cajoling the mentally ill into accepting help. PET
(for  psychiatric emergency team) units used to respond to
mental crises anytime. Now they rarely make calls after their
normal 10-hour workday.

    Across the U.S., mental-health care has become a shambles
-- fragmented and misfocused. One problem: the system is geared
to episodic, not chronic, care. "We're spending about 70% of
our mental-health dollars for hospital care," complains Leonard
Stein, director of the Robert Wood Johnson Foundation's Mental
Health Services Development Program. "What we're doing is
waiting for people to have psychotic episodes and putting them
in the hospital to take care of that, which we can do very
well. But once the episode is over, that doesn't mean the
person is cured." Patients are caught in a revolving door:
discharged people have a 60% chance of being readmitted within
two years.

    What is needed, say advocates for the mentally ill, is
comprehensive care, tailored to people's individual needs and
aimed at building self-esteem and the skills to manage on their
own. Numerous demonstration programs attest that the mentally
disturbed can lead safe, productive and happy lives outside
institutions. The key elements: monitored medication,
specialized training and a stable and supportive environment in
which to live.

    One of the most successful programs is New York City's
Fountain House, which began 42 years ago as a meeting place for
former mental patients. In contrast to the sterile wards and
decrepit housing in which so many of the sick have spent most
of their lives, the sprawling complex's buildings are
tastefully furnished and the grounds beautifully landscaped.
Each day about 400 people visit the clubhouse, relieving the
isolation that traps so many of the ill. In addition, Fountain
House provides shelter for more than 200 people citywide in
housing that ranges from small, supervised group homes to
individual apartments.

    The core of Fountain House, though, is its work program.
Members perform almost all the chores at the complex, from
tending the gardens to keeping the books. Those who do well are
placed in part-time entry-level jobs at some 31 companies,
including banks, law firms and ad agencies.

    Other successes dot the country. In Madison, Wis.,
mental-health workers counsel landlords, employers and others
who come into regular contact with the mentally ill.
Philadelphia has experimented with groups in which patients
receive support from their peers. This approach "provides
people with a feeling that they can give as well as receive
help," says Joe Rogers, president of the city's self-help group
Project SHARE. But the impact of the model mental-health
programs is far too limited. Fountain House, for example, can
accept only 1 out of every 5 people who apply for membership.

    More broadly based efforts are crucial. The Public
Health/NAMI study ranks Vermont tops in the nation in caring
for the mentally ill because of the strong quality of
outpatient support services. Vermont helps its distressed
residents apply for federal housing benefits and provides them
with bridge money to pay the rent. Caseworkers literally move
into the homes of people going through a psychotic episode.

    Important to the Vermont approach is the belief that
patients themselves must be involved in deciding about
treatment. It is a far cry from the old ways. "I was locked
away, and I was forcibly drugged," remembers William Montague,
36, who has been diagnosed as paranoid and schizophrenic. "I
started getting my life together through living and working in
the community and making decisions on my own, good and bad."
Today Montague has his life together enough to work in a
program that helps the homeless in Burlington.

    It is to the U.S.'s shame that the William Montagues are so
few. The solution is no mystery; only the will and resources
are missing. "We know what needs to be done," says Project
SHARE's Rogers. "We're just not doing it yet."