Care for the mentally ill sinks back 100 years

Walk the streets of any city in the U. S. and you will see them. Homeless, mentally ill people, filthy and dressed in rags, screaming obscenities at invisible assailants or mumbling to themselves, responding to voices only they hear. Pick up a newspaper in one of these cities and you are likely to read about violent crimes committed by untreated and unmedicated mental patients.
What’s going on here? Why is it that fully 50 percent of the homeless suffer from mental illness? Is there an epidemic of craziness going around? And how can we help the people who sadden, embarrass, repel or even frighten us when we meet them on the street?
A combination of factors is creating a storm of stigmatization, abuse and neglect that has set the humane treatment of the mentally ill back by at least a hundred years. The community mental health system, once charged with caring for people with chronic psychiatric problems, is in shambles. Managed care, introduced as the ideal solution to runaway health care costs, has frozen out even those who have insurance from needed long-term treatment. The “war on drugs” and welfare “reform” have also contributed to the crisis.
But first, some background. Diseases such as schizophrenia and manic depression (also known as bipolar disorder) are thought to be caused by a chemical imbalance in the brain. Will power and talk therapy cannot control the symptoms such as hearing voices and paranoia. But psychiatric medication can. It is not addictive nor does it render patients semi-conscious when properly dosed. While incurable, mental illness is very treatable, given the right resources.
At one time, the only “treatment” for people suffering these psychiatric ailments was years of confinement in private or state-run hospitals. But in the 1970s, inspired by the gains of the civil rights struggles of the era, the community mental health movement was born. It sought to free all but the sickest patients from institutions, to be treated in their communities, close to family and friends with access to medication and vocational rehabilitation. A system of group homes would house and care for patients in a family setting.
But the community mental health system has never been adequately funded. And things like long-term case management, day programs and substance abuse treatment, crucial to keeping patients on track, are cut again and again. For those lucky enough to find housing, it is always tenuous, due to a woeful lack of supervised living arrangements. This unstable state of affairs sets patients up to fail.
The privatization of healthcare has also been a disaster for the mentally ill. Managed care may provide some access to brief therapy, but the ongoing, multi-disciplinary treatment that works is hard to come by. In California patients and their families had to sue the mega-HMO Kaiser Permanente after it denied benefits to those who were deemed “too chronic.” And there are more restrictions and higher co-pays for mental health benefits, even though they cover physical brain disorders, much like multiple sclerosis or Parkinson’s disease.
Finally, so-called welfare reform has chipped away at access to disability income for people too impaired to work. Frequently these same people are denied benefits because they also have drug abuse problems. Add to this the failed war on drugs, with its focus on punishment rather than treatment on demand, and you have a public health nightmare.
In the midst of these callous retreats, jails are becoming the new psychiatric emergency rooms. Inmates who need specialized services typically languish in custody twice as long as others, often in solitary confinement. Once released, mentally ill offenders often have no follow-up psychiatric care in the community.
After twenty years as a psychiatric social worker, I took early retirement. I was fed up with constant budget cuts, a never-ending lack of resources and a dysfunctional system that discharges mentally ill patients to the streets. I concluded that no matter how humane, I could not be therapeutic.
What’s needed is a complete overhaul of this deplorable system of care for those who suffer from chronic and severe mental illness. Programs need to be funded, substance abuse treatment must be widely available and no one who is sick should have to survive on the streets. But these measures are not likely in a healthcare system based on profit, rather than human welfare. Replace capitalism with an economic system based on human needs? Now that would be therapeutic!
Sukey Wolf is a socialist feminist writer and therapist. She has a Master’s degree in clinical psychology and is currently writing a book on her experiences in the trenches.