HOW RELEASE OF MENTAL PATIENTS BEGAN - NYTimes.com

HOW RELEASE OF MENTAL PATIENTS BEGAN - NYTimes.com

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.''

Supply-Side Economics in One Lesson : The Freeman : Foundation for Economic Education

Supply-Side Economics in One Lesson : The Freeman : Foundation for Economic Education

As I explain in my course on macroeconomics, the term “supply-side” was intended to differentiate an economic way of thinking that did not depend on the Keynesian obsession with controlling aggregate demand. Supply-siders insisted that while there may be policy effects on the demand side, one cannot ignore the consequences of the changes such policies make to the incentives of suppliers and entrepreneurs.

For example, changes in marginal tax rates affect cooperation between suppliers and buyers. So increasing tax rates on “the rich” to transfer the same amount to “the poor” would have no effect in the Keynesian aggregate framework, because it does not change net taxes or disposable income in the household sector as a whole. But supply-siders know such policies change the incentives facing both groups—resulting in negative outcomes. Higher tax rates for “the rich” and unearned income for the poor—both reduce incentives to create additional effort or to be more productive.

In essence, supply-side economists hold that “supply matters, too,” whereas the dominant Keynesian approach ignores this aspect of the economy.

Supply-side economics also grew out of classical economists’ longer-term view of growth, because altering incentives now changes behavior, which changes economic growth potential. Whatever Keynes thought, in the long run, real economic growth is the prime determinant of well-being. But in the public discussion (or distortion) of supply-side economics, Keynesians largely bypass such issues and violate Hazlitt’s lesson, which he offers in the opening chapter of Economics in One Lesson:

The art of economics consists in looking not merely at the immediate but at the longer effects of any action or policy; it consists in tracing the consequences of that policy not merely for one group but for all groups.

Supply-side economics has built on this insight. But many economists today, following Keynes, fail to look carefully at Keynesianism’s long-term effects—not to mention immediate effects—such as the perverse consequences to all affected groups. Supply-side economics adds a corollary to Hazlitt’s definition, tracing not just the impact on all groups, but the impact over the many margins of choice that will be affected.

In Hazlitt’s opening chapter, he also points to an important reason why such basic principles are so often violated in politics:

Bad economists [who ignore his lesson] rationalize this intellectual debility and laziness by assuring the audience that it need not even attempt to follow the reasoning or judge it on its merits, because it is only “classicism” or “laissez-faire” or “capitalist apologetics” or whatever other term of abuse may happen to strike them as effective.

It’s the same story with supply-side economics, because the commonly used pejoratives—“trickle-down economics,” “tax giveaways for the rich,” and “voodoo economics” (and its “deja voodoo economics” variant)—reveal ways in which its opponents failed, often intentionally, to heed Hazlitt’s lesson.

And yet they have mastered the lesson that bad economics is often good politics. (One need only read The New York Times’s favorite economist to see why.)

Take the term “trickle-down economics,” which no supply-side economist ever used. The false assumption is that taxing high-income earners less only benefits those earners, except of course when the rich spend some of that income to buy goods and services from the rest of us. It also assumes a zero-sum trade-off out of total measured income: more for “the rich” has to be taken from everyone else. That narrative gets support from snapshot income-distribution figures in which a higher share of income to “the rich” is used to suggest they benefitted themselves at others’ expense.

When people, however rich or poor, get richer through voluntary arrangements, they do not hurt anyone except the envious. Everyone is better off. They benefit each other—as is the nature of market arrangements. And changes in the measured “percentage distribution” of income do not accurately represent the consequences to any given group.

If I create a massively successful software program, my measured real income will be greater, but all the buyers will also be better off because they face better options than before (using my cool software, which might even make everyone more productive long term). This holds true even if, at any point in time after buying the program, their share of total income is lower.

So redistribution fans’ campaigns to punish the rich by exploiting envy moves the debate away from the central question—are others helped or hurt? Worsening the productive incentives of high-income people induces them to do less for others, making people worse off than they might otherwise have been. On the other hand, if a rich person gets richer by rigging the political process—say by getting stimulus funds to build a boondoggle—that is certainly objectionable. But it is not a market failure at all. In fact, it’s Keynesian economics par excellence. And the solution is to get the government out of the theft-and-transfer business. (Using perceived unfairness as an excuse to tax high-income earners more heavily just glosses over the bad fiscal policies that make all the cronyism possible.)

“Tax giveaways to the rich” was another denigrating description of supply-side economics. That term emphasizes looking only at the short run, which is of course where politicians’ incentives all lie. Economic growth, however, is the most important variable in long-run determinants of well-being. To get robust economic growth, you need to improve productivity. To do that, you need to establish good incentives for rich and poor alike—and to improve incentives wherever possible.

Supply-siders focus on making productive incentives permanently better for everyone, and reducing tax rates and regulatory burdens does the most good for incentives. The immediate benefits will, it’s true, go to the people who own the assets affected by those changes. Present and anticipated gains will be capitalized into those assets’ prices. Those owners are mostly going to be wealthy people. But treating that fact as solely a “tax giveaway to the rich” ignores that what is primarily rewarded is doing more that others value, making those others better off. The greater economic output that results will benefit everyone. But the effects often take some time to come to fruition. That should be fine: Sound economics is always about wisely and productively creating the future. Living for the now is like thinking your credit card has no limit and you’re going to die tomorrow. Unfortunately, legislating for now, despite adverse consequences for the future, is often a good way to get votes.

Then there’s another term that suggests supply-siders don’t live in the real world. “Voodoo economics” implies that the analysis involves some bogus “magical” assumptions that could not possibly be true. This term was used to imply that lowering tax rates on those who are heavily taxed cannot possibly increase the tax revenue from them.

In particular, critics emphasize that estimates of labor supply elasticities (how much more people work in response to changes in take-home wages) are far too low to support large supply-side effects. But those estimates look only at the short run and do not incorporate the longer-term effects of permanently improved incentives on upward mobility, investment, formal and informal education, tax evasion and cheating, and other choices that will change.
Looking at long-term labor supply responses to incentives generates a very different picture than that for a smaller time slice. Nobel Prize-winning economist Edward Prescott found that long-term labor responses are far greater. With regard to supply-side incentives, he says: “I find it remarkable that virtually all of the large [nearly 30%] difference in labor supply between France and the United States is due to differences in tax systems.”

Further, supply-side opponents dramatically misrepresent the effects of reducing tax rates by focusing on near-term labor supply as if it is the only relevant variable. Behavior will change at other margins. Permanently lower tax rates might not produce great changes in the current year. But the lower rates mean workers who acquire higher-margin returns keep more of those gains than before. So they have a stronger incentive to invest and acquire those skills (through education, on-the-job training, etc.), increasing overall human capital. In parallel, employers can make capital investments to increase worker productivity. Better incentives will increase how many secondary workers there will be in households and how much they will work. And workers may have incentives to delay retirement, expanding the lifetime labor supply.

The lower rates, in short, reduce disincentives to engage in productive risk-taking by shrinking the tax penalty on those risks that pay off. They reduce the incentive for people to choose things they might desire less, simply because of tax deductibility—distortions which are greater the higher the tax rate. Lower tax rates also reduce tax evasion and tax cheating. They can even cause the in-migration of productive people from less-friendly tax and regulatory climates. Recognizing all the dimensions at which people’s actions will be affected paints a very different picture than the far more blinkered view supply-side opponents take. In addition to underestimating the effects of supply-side policies, this narrow view understates the costs of interventionist policies. When government policy distorts people’s choices, it causes a welfare cost to society—the difference between what people really want and what the distorted incentives created by government intervention led them to choose instead.

One cannot honestly prove that improvements in incentives do not expand productive behavior, benefitting others, because that contradicts one of the most basic economic realities. The embellished version of Hazlitt’s lesson (examine the effects of a policy on all groups… over all margins of choice that will be affected) suggests a basic test that should be applied to every political proposal, not just those related to supply-side economics.

In other words, whenever you see the truth being distorted or effects being ignored to “sell” you some political proposal, its backers either don’t know enough to competently evaluate their own positions or they are lying to you. And since the best way to demonstrate that a truly good idea advances the “general welfare” is to accurately present the whole truth, both possibilities tell you not to “buy” the political line that is being sold.

William F. Buckley, Jr. - National Review Online

Link: Ronald Reagan: A Relaxing View


Among other things, the war against Reagan, before he's even elected President.

Reagan and Alzheimers

What did he not know, and when did he not know it? New Ron Reagan book: My dad had Alzheimer’s while in office « Hot Air

Reagan’s doctors and Alzheimer’s specialists have been debunking this myth for years, but no matter how many times they try to explain that occasional memory lapses in an elderly person do not an Alzheimer’s diagnosis make, the narrative rolls on. And it’ll keep rolling, thanks to Ron Jr and the explosive never-before-revealed details in his new book which, per Paul Bedard of U.S. News, … seem not to add up.

Besides playing amateur doctor, Ron Reagan reveals, if true, brain surgery on his dad never before reported. He accurately reports that Reagan, after leaving the presidency, was bucked from a horse on July 4, 1989, while in Mexico. Ron tells of how his dad, after initially refusing medical help, was transported to a San Diego hospital. “Surgeons opening his skull to relieve pressure on the brain emerged from the operating room with the news that they had detected what they took to be probable signs of Alzheimer’s disease.” Several Reagan associates, however, say there was no surgery in San Diego.

What’s more there is no reporting about any San Diego operation on Reagan. News reports at the time of his fall say Reagan was flown to a hospital in Arizona, where he was treated for scrapes and bruises and released after five hours…

Ron Reagan doesn’t mention this, but says that Reagan visited the Mayo Clinic in 1990 for tests that “confirmed the initial suspicion of Alzheimer’s.” Reagan’s post-presidency history, documented in several archives like University of Texas, reveal no such visit. And Dr. John E. Hutton Jr. his doctor from 1984 through Reagan’s retirement, told the New York Times that Reagan didn’t show the tell-tale symptoms until 1993.

Obama a unifier, just like Reagan?

Apparently, that's what some are saying:

He was a college professor with strong political opinions--two marks against him right there--but even so he seemed to be a very smart man. Like all but 17 of America's college professors, he was an Obama supporter. He had noted my skepticism.

"But don't you see Obama has the potential to be a unifying force," he said. "He could bring the country together, the way Reagan did to win the Cold War."

Huh?

I spent a lot of time during the Reagan years in faculty lounges, on college campuses, with men and women just like this professor, and I don't remember Reagan as a unifying force. Just about everybody I knew hated him--really couldn't stand him, with a teeth-grinding, skin-crawling disdain. Even beyond the leafy lotus land of higher-ed, he was acknowledged by admirer and critic alike as a "polarizing presence." Weekend after weekend, protesters swelled our great cities and hoisted placards calling him either a psychopath or a buffoon (they could never decide which). His foremost political adversary, Tip O'Neill, said he "had ice water for blood." His landslide reelection victory in 1984 was impressive, but even then, at the zenith of his presidency, more than 40 percent of voters wanted to give him the boot. For that matter, his victory in 1984 wasn't as big as the victory recorded in 1972 by Richard Nixon. Now there was a unifying force.

Only in retrospect has Reagan been tagged as a twinkly, grandfatherly presence, a firm but gentle leader who transcended ideology and brought us together to defeat the Soviet Empire. Things didn't go so smoothly at the time. In his dealings with the Soviets, for example, Reagan was hampered at every step--first by liberals for being too rough, then by conservatives for being too soft. The firing of the air traffic controllers, the huge tax cuts of 1981, the huge tax hike of 1982 (in the middle of a recession!), the nuclear freeze movement, aid to the contras and to the mujahedeen, the "three million" homeless, budget cuts, the invasion of Grenada, the Iran-contra scandal and the subsequent calls for impeachment--the real story of the Reagan years is a story of endless contention, much of it bitter, wrenching, and, to a squeamish public, unpleasant to watch.