I was struck by a segment that aired January 29, 2014 on Chris Hayes All In show on MSNBC which displayed a graphic on the effects of deinstutionalizing people with mental illness. The process of releasing patients from mental health facilities began in the early 1970s as public attention was being drawn to how awful those institutions had become.
Rather than improving care, there were suggestions that people could be cared for much cheaper inside of the community rather than locked away in some hell-hole where they were simply warehoused out of sight and mind. Newly developed drugs provided better control for patients suffering from conditions like schizophrenia and bi-polar disorder. Instead of improving inpatient facilities, ensuring that programs were in place for patients released, and that those released would do well in the community, patients were essentially dumped out of institutions. To a large extent, they were on their own.
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Here's a clip from that segment that aired:
Deinstitutionalization escalated in 1981 when Ronald Reagan ended the federal governments role in the care of mentally ill individuals by establishing block grants for states (which later were subjected to a series of cuts). Mother Jones has a nice timeline of these events.
With dimishing federal block grants or seeing those block grants diverted elsewhere the burdens fell to states and local areas. The ones that took up the burden of providing community services often found those services the easiest to slash in a time when cutting taxes was a popular way to gain approval with the voters (especially in election years). Those with mental illness also didn't crowd into budget committee meetings demanding funding the way that other groups did when services that they used were the subject of proposed cuts. Year after year, community services were subjected to so many cuts that most programs simply vanished.
In the end, the Reagan promises of community care rather than institutional care evaporated into the ether as the mentally ill were left on their own and with little to no access to the treatment and medications that were promised as budget cuts took their toll year after year. Yet, the process gained momentum and as mental health facilities downsized or closed, the mentally ill were simply released into the community with hopes that they would keep their appointments, get their prescriptions filled, and take their meds as prescribed.
Mental illness, however, isn't like other diseases. It's cruel. Patients often feel "cured" when their symptoms abate because of the medications they take and they often discontinue those meds and stop going to their appointments. And when their symptoms return, the auditory and visual hallucinations they experience aren't tied to their illness, but blamed on outside forces. Those tinfoil hats that people with uncontrolled schizophrenia wear are to prevent "signals" from being beamed into their brains from those unknown outside forces.
Without oversight from family, friends, or a community program, missed appointments and untaken meds take their toll and the mentally ill soon enter a downward spiral where they lose their job because of their uncontrolled behavior, don't remember to pay their bills, and become homeless. Once on the street, opportunities for the safety net vanish since you need an address in order to even apply for benefits.
Even those whose families oversee their care and medication compliance often didn't get care because, without a job, they didn't have health insurance because they couldn't work, worked at a job without benefits or were not covered because their mental illness was "pre-existing" (and that is now no more thanks to the ACA). Those fortunate enough to have coverage ran into the disparity between coverage for physical illnesses and mental illness. Only with the ACA have we seen mental illness covered at the same level as physical illness.
It also became very difficult for the seriously mentally ill to qualify for disability and the Medicaid that comes with it that would cover their care. Republicans have successfully argued that there is cheating by applicants so the process, of course, has been made more torturous, difficult, and the end result is often denial of disability benefits. Even a person without a psychiatric disorder finds it nearly impossible to navigate the process or file an appeal.
Far too many of the mentally ill find themselves on the streets, homeless, and without a support system. Then they meet the police who often have no other option except arrest unless a serious psychiatric emergency exists (usually defined as "being a danger to ones self or others"). It's then that the mentally ill find themselves in the mental health care system of the last resort: jails and prison. And that's where I saw the magnitude of the problem first hand.
After the public hospital that Milwaukee County had run for many decades was closed to the loud cheers of "taxpayers", I found myself working at one of the few jobs available to displaced RNs, working at the 2000 inmate Milwaukee County House of Correction. Being very close to retirement, I was more fortunate than the hundreds of other nurses in the system, overcame my dismay at taking a transfer to a facility that had always had serious problems trying to recruit and keep RNs, and began the last 7 1/2 years of my career.
I was shocked to see such a large number of inmates with not only serious and untreated medical and dental problems, but with very serious and untreated mental health disorders. As hard as it was for people with diabetes, hypertension, or other medical problems to access care and medications when they had no insurance, it was even harder for those with mental health issues to access care and treatment. And it was worse now since the only public hospital had closed and the Mental Health Complex had been systematically downsized.
Jail and prison had become not only the health and dental care provider of last resort, but the last resort mental health provider. The demands were enormous, but resources were not. On my arrival, a doctor was available for 2 hours Monday through Friday, a dentist once a week, and a rotating series of psychiatrists were available an afternoon or two a week. Inmates got nursing care provided by a series of protocols rather than the actual care they needed.
A lawsuit eventually required additional resources be available, but what was available never met the enormous requirements for a population that hadn't been cared for except during incarceration. And the lack of community resources soon meant that many inmates would return to custody soon after they had been released, particularly those with mental health issues. I could tell plenty of horror stores.
Our safety net has been seriously broken with far too many of those falling through the cracks becoming not only out of sight and mind, but the victims of a "last resort" penal system which has become a literal dumping ground for people who aren't criminals. The expense, however, is easier to justify to a public hungry for tax cuts, but so fearful of whatever real or imagined boogeyman that the cost of prisons is an easy sell.
They're not getting their moneys worth, either, because the band-aids provided by the Last Resort for Care are only temporary fixes and not long term solutions. Instead of funding prisons that are literally exploding with populations of non-criminals, we should be funding community care and support programs to ensure that people have access to care and medications as well as housing.
These are people who could live good and productive lives as long as their underlying mental illness was controlled. Instead, they were tossed out of one institution under the guise of tax savings and "progress" only to be tossed into another, worse institution.
This cycle must end.
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February 4, 2014
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