HOW RELEASE OF MENTAL PATIENTS BEGAN
By RICHARD D. LYONS
Published: October 30, 1984
THE policy that led to the release of most of the nation's mentally ill patients from the hospital to the community is now widely regarded as a major failure. Sweeping critiques of the policy, notably the recent report of the American Psychiatric Association, have spread the blame everywhere, faulting politicians, civil libertarian lawyers and psychiatrists.
But who, specifically, played some of the more important roles in the formation of this ill-fated policy? What motivated these influential people and what lessons are to be learned?
A detailed picture has emerged from a series of interviews and a review of public records, research reports and institutional recommendations. The picture is one of cost-conscious policy makers, who were quick to buy optimistic projections that were, in some instances, buttressed by misinformation and by a willingness to suspend skepticism.
Many of the psychiatrists involved as practitioners and policy makers in the 1950's and 1960's said in the interviews that heavy responsibility lay on a sometimes neglected aspect of the problem: the overreliance on drugs to do the work of society.
The records show that the politicians were dogged by the image and financial problems posed by the state hospitals and that the scientific and medical establishment sold Congress and the state legislatures a quick fix for a complicated problem that was bought sight unseen.
'They've Gone Far, Too Far'
In California, for example, the number of patients in state mental hospitals reached a peak of 37,500 in 1959 when Edmund G. Brown was Governor, fell to 22,000 when Ronald Reagan attained that office in 1967, and continued to decline under his administration and that of his successor, Edmund G. Brown Jr. The senior Mr. Brown now expresses regret about the way the policy started and ultimately evolved. ''They've gone far, too far, in letting people out,'' he said in an interview.
Dr. Robert H. Felix, who was then director of the National Institute of Mental Health and a major figure in the shift to community centers, says now on reflection: ''Many of those patients who left the state hospitals never should have done so. We psychiatrists saw too much of the old snake pit, saw too many people who shouldn't have been there and we overreacted. The result is not what we intended, and perhaps we didn't ask the questions that should have been asked when developing a new concept, but psychiatrists are human, too, and we tried our damnedest.''
Dr. John A. Talbott, president of the American Psychiatric Association, said, ''The psychiatrists involved in the policy making at that time certainly oversold community treatment, and our credibility today is probably damaged because of it.'' He said the policies ''were based partly on wishful thinking, partly on the enormousness of the problem and the lack of a silver bullet to resolve it, then as now.''
The original policy changes were backed by scores of national professional and philanthropic organizations and several hundred people prominent in medicine, academia and politics. The belief then was widespread that the same scientific researchers who had conjured up antibiotics and vaccines during the outburst of medical discovery in the 50's and 60's had also developed penicillins to cure psychoses and thus revolutionize the treatment of the mentally ill.
And these leaders were prodded into action by a series of scientific studies in the 1950's purporting to show that mental illness was far more prevalent than had previously been believed.
Finally, there was a growing economic and political liability faced by state legislators. Enormous amounts of tax revenues were being used to support the state mental hospitals, and the institutions themselves were increasingly thought of as ''snake pits'' or facilities that few people wanted.
One of the most influential groups in bringing about the new national policy was the Joint Commission on Mental Illness and Health, an independent body set up by Congress in 1955. One of its two surviving members, Dr. M. Brewster Smith, a University of California psychologist who served as vice president, said the commission took the direction it did because of ''the sort of overselling that happens in almost every interchange between science and government.''
''Extravagant claims were made for the benefits of shifting from state hospitals to community clinics,'' Dr. Smith said. ''The professional community made mistakes and was overly optimistic, but the political community wanted to save money.''
'Tranquilizers Became Panacea'
Charles Schlaifer, a New York advertising executive who served as secretary-treasurer of the group, said he was now disgusted with the advice presented by leading psychiatrists of that day. ''Tranquilizers became the panacea for the mentally ill,'' he said. ''The state programs were buying them by the carload, sending the drugged patients back to the community and the psychiatrists never tried to stop this. Local mental health centers were going to be the greatest thing going, but no one wanted to think it through.''
Dr. Bertram S. Brown, a psychiatrist and Federal official who was instrumental in shaping the community center legislation in 1963, agreed that Presidents Eisenhower, Kennedy and Johnson were to some extent misled by the mental health community and Government bureaucrats.
''The bureaucrat-psychiatrists realized that there was political and financial overpromise,'' he said.
Dr. Brown, then an executive of the National Institute of Mental Health and now president of Hahnemann University in Philadelphia, stated candidly in an interview: ''Yes, the doctors were overpromising for the politicians. The doctors did not believe that community care would cure schizophrenia, and we did allow ourselves to be somewhat misrepresented.''
''They ended up with everything but the kitchen sink without the issue of long-term funding being settled,'' he said. ''That was the overpromising.''
Dr. Brown said he and the other architects of the community centers legislation believed that while there was a risk of homelessness, that it would not happen if Federal, state, local and private financial support ''was sufficient'' to do the job.
Resources Vanished Quickly
The legislation sought to create a nationwide network of locally based mental health centers which, rather than large state hospitals, would be the main source of treatment. The center concept was aided by Federal funds for four and a half years, after which it was hoped that the states and local governments would assume responsibility.
''We knew that there were not enough resources in the community to do the whole job, so that some people would be in the streets facing society head on and questions would be raised about the necessity to send them back to the state hospitals,'' Dr. Brown said.
But, he continued, ''It happened much faster than we foresaw.'' The discharge of mental patients was accelerated in the late 1960's and early 1970's in some states as a result of a series of court decisions that limited the commitment powers of state and local officials.
Dr. Brown insists, as do others who were involved in the Congressional legislation to establish community mental health centers, that politicians and health experts were carrying out a public mandate to abolish the abominable conditions of insane asylums. He and others note - and their critics do not disagree - that their motives were not venal and that they were acting humanely.
In restrospect it does seem clear that questions were not asked that might have been asked. In the thousands of pages of testimony before Congressional committees in the late 1950's and early 1960's, little doubt was expressed about the wisdom of deinstitutionalization. And the development of tranquilizing drugs was regarded as an unqualified ''godsend,'' as one of the nation's leading psychiatrists, Dr. Francis J. Braceland, described it when he testified before a Senate subcommittee in 1963.
Dr. Braceland, a former president of the American Psychiatric Association who is a retired professor of psychiatry at Yale University, still maintains, however, that under the circumstances the widespread prescription of drugs for the mentally ill was and is a wise policy.
''We had no alternative to the use of drugs for schizophrenia and depression,'' Dr. Braceland said. ''Before the introduction of drugs like Thorazine we never had drugs that worked. These are wonderful drugs and they kept a lot of people out of the hospitals.''
Testimony to Congress
His point is borne out repeatedly by references in Congressional testimony, such as the following exchange at a House subcommittee hearing between Representative Leo W. O'Brien, Democrat of upstate New York, and Dr. Henry N. Pratt, director of New York Hospital in Manhattan, who appeared on behalf of the American Hospital Association.
Mr. O'Brien: ''Do you know offhand how much New York appropriates annually for its mental hospitals?''
Dr. Pratt: ''It is the vast sum of $400 million to $500 million.''
Mr. O'Brien: ''So you see that, through a real attempt to handle this problem at the community level, the possibility that this dead weight of $400 million to $500 million a year around the necks of the New York State taxpayers might be reduced considerably in the next 15 or 20 years?
Dr. Pratt: ''I do, indeed. Yes, sir.''
He then told the subcommittee that ''striking proof of the advantages of local short-term intensive care of the mentally ill was brought out'' in a Missouri study.
Dr. Pratt's testimony and the Missouri study were repeatedly cited in subsequent Congressional debates on the community centers bill by such politicians as Senator Hubert H. Humphrey of Minnesota and Representative Kenneth A. Roberts of Alabama.
The Missouri study, which compared a group of 412 patients in two intensive treatment centers with patients admitted to five mental hospitals, showed that the average stays for patients in the large hospitals were 237 days longer than for similarly diagnosed patients at the treatment centers.
But Dr. George A. Ulett of St. Louis, the psychiatrist who directed the study as head of Missouri's Division of Mental Diseases, now says the numbers cited, though correct, were misinterpreted. ''We did have dramatic numbers, but the initial success of the community centers in Missouri hinged on the large numbers of psychiatrists and support personnel who staffed the centers at that time,'' Dr. Ulett said.
The centers were two pilot projects that were given special staff and attention to demonstrate what could be accomplished, he said. By linking the community centers to large teaching hospitals in major cities and providing adequate funds for their maintenance it was possible to attract the quality of staff that all but guaranteed better results than the old state hospitals, he said.
''Unfortunately,'' he said, ''over the years the budgets were progressively reduced, the professional staffs were cut, and the program regressed to right back where it started.''
Dr. Frank R. Lipton and Dr. Albert Sabatini of Bellevue Psychiatric Hospital in Manhattan, who have done research on the problems of the homeless, say one of the major flaws in the concept of deinstitutionalization was the notion that serious, chronic mental disorders could be minimized, if not totally prevented, through care provided within the local community.
''This philosophical and ideological shift in thinking was not adequately validated, yet it became one of the major conceptual bases for moving the locus of care,'' they said in a recent study.
Value and Danger in Drugs
Some problems have actually been brought on for mental patients by long-term use of drugs. This condition has been considered by Dr. Loren Mosher of the Uniformed Services Medical University in Bethesda, Md., who says that from 15 percent to 40 percent of such mental patients develop uncontrollable movements of the mouth and neck that can only be cured by taking people off the drugs.
The consensus seems to be that the more intelligent approach to the overall problem is to realize both the limitations and value of the drugs, the importance of combining drug treatment with proper care - either in hospitals or local clinics, depending on the individual case - and that mental illness is a sociological fact that cannot be ignored simply out of a desire to save tax dollars.
Jack R. Ewalt, who directed the staff of the Joint Commission when it was founded in 1955, says now that he remains ''a great believer in the use of drugs, but they are just another treatment, not a magic.''
''Drugs can help people get back to the community,'' he said, ''but they have to have medical care, a place to live and someone to relate to. They can't just float around aimlessly.''
Dr. Ewalt said the 1963 act was supposed to have the states continue to take care of the mentally ill but that many states simply gave up and ceded most of their responsibility to the Federal Government.
''The result was like proposing a plan to build a new airplane and ending up only with a wing and a tail,'' Dr. Ewalt said. ''Congress and the state governments didn't buy the whole program of centers, plus adequate staffing, plus long-term financial supports.''
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