MESSAGE
| DATE | 2023-07-21 |
| FROM | Ruben Safir
|
| SUBJECT | Subject: [Hangout - NYLXS] insanity
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wsj.com
Essay | It’s Time to Bring Back Asylums
David Oshinsky
15–18 minutes
The ongoing saga of the severely mentally ill in America is stirring
attention again in a sadly familiar way. In Los Angeles in early 2022, a
70-year-old nurse was murdered while waiting for a bus, and two days
later a young graduate student was stabbed to death in an upscale
furniture store where she worked. That same week in New York City, a
40-year-old financial analyst was pushed onto the subway tracks as a
train was arriving, killing her instantly.
All three assaults, random and unprovoked, were committed by unsheltered
homeless men with violent pasts and long histories of mental illness. In
New York, the perpetrator had warned a psychiatrist during one of his
many hospitalizations of his intention to commit that very crime.
Then came the chance encounter this May that led to the death of Jordan
Neely on a Manhattan-bound subway car. Homeless and schizophrenic, Neely
had spent most of his adult life in and out of emergency rooms,
psychiatric wards and prison. He had 42 prior arrests, mostly for
nuisance crimes, but also for assault. He’d recently pleaded guilty to
punching an elderly woman in the face, fracturing her eye socket.
What happened in the moments leading up to his death is still in
dispute. While a jury will decide whether another passenger’s chokehold
on Neely was second-degree manslaughter or an act of self-defense, the
attention the incident received speaks volumes about the public’s fear
of the aggressive and sometimes violent behavior of the mentally ill.
Most of all, Neely’s death highlights the failures of a mental health
system that allows profoundly disturbed people to slip through the
cracks.
On an average night, according to the U.S. Department of Housing and
Urban Development, close to 600,000 people in the country will be
homeless—a figure seen by many as an undercount. More than 40% will be
“unsheltered,” or “living in places not suitable for human habitation,”
and about 20% will be dealing with severe mental illness.
Experts sharply disagree about the contribution of homelessness to
rising crime rates. Some emphasize that the most of these crimes are
low-level victimless offenses, such as loitering or public urination.
But others note the disproportionately high level of all crimes,
including assaults and homicides, committed by those battling
homelessness and mental issues simultaneously.
Had Jordan Neely and the others been born a generation or two earlier,
they probably would not have wound up on the streets. There was an
alternative back then: state psychiatric hospitals, popularly known as
asylums. Massive, architecturally imposing, and set on bucolic acreage,
they housed close to 600,000 patients by the 1950s, totaling half the
nation’s hospital population. Today, that number is 45,000 and falling.
Asylums were created for humane ends. The very term implies refuge for
those in distress. The idea was to separate the insane, who were
innocently afflicted, from the criminals and prostitutes who were then
commonly referred to as the “unworthy poor.” Asylums were popular
because they provided treatment in isolated settings, far from
temptation, while relieving families of their most burdensome members.
But “insanity” in these years cast a very wide net. A typical asylum
included patients who were suffering from alcoholism, dementia,
depression and epilepsy, as well as such now defunct diagnoses as
“lunacy” and “melancholia.” The usual stay was marked in years, not
months, as evidenced by the rows of crosses in asylum graveyards.
Over time, the number of institutionalized patients far outpaced the
state’s willingness to support them. Funding and oversight disappeared.
And this, in turn, produced a flood of exposés—some embellished, others
sadly true—portraying these institutions as torture chambers where
icepick lobotomies, electric shock, sterilization and solitary
confinement turned humans into zombies.
A seemingly revolutionary solution soon appeared—a new drug with the
potential to treat psychotic disorders such as schizophrenia and bipolar
disorder. First marketed in 1955 under the brand name Thorazine, it
became the psychiatric equivalent of antibiotics and the polio vaccine.
Why keep patients locked away in sadistic institutions when they could
be successfully medicated close to home?
The promise of Thorazine coincided with a dramatic assault upon
traditional psychiatry led by radical critics such as Michel Foucault
and Thomas Szasz. Asylums existed to enslave those who ignored society’s
norms, they believed. Who could say with assurance that the people
locked away in these places were any more or less insane than the
authorities who put them there? It seemed a perfect fit for the 1960s,
appealing to emerging rights groups and a counterculture scornful of
elites. “If you talk to God, you are praying,” Szasz declared. “If God
talks to you, you are schizophrenic.”
In October 1963, President John F. Kennedy put his signature to the last
bill he would ever sign—the Community Mental Health Act. It aimed to
demolish the walled-off world of the asylum in favor of 1,500 local
clinics where patients could receive the drugs and therapies they
needed. Kennedy had a personal stake in the legislation: His sister,
Rosemary, had undergone an experimental lobotomy that left her severely
disabled. On paper, at least, deinstitutionalization seemed both more
humane and more likely to succeed. Then reality set in.
Closing the asylums was the easy part. Getting people to accept a mental
health clinic next to their local church or elementary school proved a
much tougher sell. Asylum inmates returned home to find their former
neighbors unprepared and often unwilling to help. Most of the clinics
never materialized. And the promise of Thorazine was blunted, in part,
by its nasty side effects. Surveys of those released from state asylums
found that close to 30% were either homeless or had “no known address”
within six months of their discharge. One critic likened it to “a
psychiatric Titanic.”
A few voices had predicted as much. In 1973, a Wisconsin psychiatrist
named Darold Treffert wrote an essay about the dangerous direction in
which his profession was headed. His colleagues had become so fixated on
guarding the patient’s civil liberties, he noted, that they had lost
sight of the patient’s illness. What worried him was the full-throated
endorsement of recent laws and court decisions that severely restricted
involuntary commitments. What purpose was served by giving people who
couldn’t take care of themselves the freedom to live as they wished? He
titled his piece, “Dying With Their Rights On.”
Treffert was referring to cases like Lessard v. Schmidt (1972), where a
federal court ruled that involuntary commitment must be limited to cases
involving the “extreme likelihood” that someone “will do immediate harm
to himself or others”—a very strict standard. Three years later, the
Supreme Court tightened things further by asserting that authorities had
been too cavalier in locking away the “harmless mentally ill.” In
O’Connor v. Donaldson, it declared: “Mere public intolerance or
animosity cannot constitutionally justify the deprivation of a person’s
physical liberty.”
Enter Joyce Brown, a 40-year-old woman who went by the street name
“Billie Boggs.” The year was 1987, and Brown was living atop a heating
vent on New York’s tony Upper East Side. It was a tense time for the
nation’s largest cities, with exploding crime rates, rampant crack
addiction, the AIDS crisis and thousands of homeless people camping in
parks, bus stations, subway tunnels and doorways. Under extreme
pressure, New York’s Mayor Edward Koch authorized the involuntary
commitment of those living unsheltered on the streets. Brown was the
first to be confined.
Little was known about her beyond her struggles with heroin and a
diagnosis of schizophrenia following her eviction from a New Jersey
shelter. Brown was more of a nuisance than a threat to the
neighborhood—stopping traffic, screaming at pedestrians, using the
sidewalk as her toilet. Social workers who periodically visited her
worried that she ate poorly, never bathed and lacked the clothing to
handle New York’s brutal weather. Some viewed her as self-negligent to
the point of being suicidal.
Taken to Bellevue Hospital, Brown was bathed, deloused and given
antipsychotic drugs. Four psychiatrists confirmed the diagnosis of
chronic schizophrenia. Bellevue contained a courtroom where patients
could challenge their confinement before a state-appointed judge. Most
were represented by a public defender, but the American Civil Liberties
Union took on Brown’s case, claiming that her confinement violated
federal court guidelines.
Ironically, Brown turned out to be her own best witness. Carefully
medicated, she testified thoughtfully enough to convince the judge that
the evidence before him was too ambiguous to merit the loss of her
liberty. But he surely was conflicted, writing: “There must be some
civilized alternatives other than involuntary hospitalization or the
street.”
Unfortunately, there weren’t. An appeals court reversed the decision to
free Brown, leading her to refuse all medication. Another trial was held
to determine whether antipsychotic drugs could be forced upon her, and
this time she prevailed. The city, weary of lawsuits, chose to discharge
her rather than to appeal.
Brown became an instant celebrity. She traveled the TV talk show circuit
as “the most famous homeless person in America” and even gave a lecture
of sorts at Harvard Law School. “I like the streets, and I am entitled
to live the way I want to live,” she explained. Offered a room at a
“residential hotel,” she quickly returned to the life that she knew
best, panhandling for drug money at the Port Authority Bus Terminal
before fading from public view. She died in 2005 at age 58.
The questions her case raised, however, are more relevant than ever. How
does a civilized society deal with severely mentally ill people who
refuse assistance? What constitutes the sort of behavior that requires
forced hospitalization? Is it time to bring back the asylum?
These issues are intertwined with a fundamental change brought about by
deinstitutionalization. Put simply, civil libertarians and disability
rights advocates have largely replaced psychiatrists as the arbiters of
care for the severely mentally ill. And a fair number of them, with the
best of intentions, seem to view the choices of those they represent as
an alternative lifestyle rather than the expression of a sickness
requiring aggressive medical care.
The enormous vacuum created by deinstitutionalization has been a
calamity for both the mentally ill and society at large. The role once
occupied by the asylum has been transferred to the institutions perhaps
least able to deal with mental health issues—prisons and jails. The
number of inmates in the U.S. in 1955 was 185,000; today, that figure is
1,900,000.
Unsurprisingly, the nation’s three largest mental health facilities are
the Los Angeles County Jail, the Cook County Jail in Chicago, and Rikers
Island in New York City. Approximately one quarter of their inmates have
been diagnosed with a serious mental disorder.
In this massive system, the mentally ill are less likely to make bail,
more likely to be repeat offenders and far more likely to be victimized
by other inmates. Given the sheer numbers, maintaining order in these
prisons and jails depends heavily on antipsychotic medication. It’s hard
to imagine a worse environment for the safety, much less the treatment,
of the mentally ill.
Meanwhile, state mental hospitals continue to shrink. Gone is the
laundry list of afflictions that marked asylum life in the 1950s. The
majority of the current patients are there “involuntarily”—people who
have been judged a danger to themselves or to others, who have been
found not guilty of a crime by reason of insanity, or who are being
evaluated for their competency to stand trial. Because so many
psychiatric beds have disappeared, the waiting period for admission can
take months, which means that inmates languish in jail without having
been convicted of a crime.
In the past decade, a growing number of scholars from across the
ideological spectrum have suggested a return to asylums. Among them is
Ezekiel Emanuel, a leading medical ethicist, who joined with two
colleagues in 2015 to recommend the building of “safe, modern and
humane” state institutions to end the revolving door of
homelessness-hospitalization-prison that passes for policy today.
The model they suggested is the Worcester Recovery Center in
Massachusetts, a facility for 320 long-term patients with private rooms
and “a recovery-inspired residential design.” Opened in 2012 on the
grounds of a long-abandoned state asylum, it cost $300 million to
complete, making it one of the most expensive non-road construction
projects in the state’s history.
There is little doubt of the need for it, and the early signs, including
surveys of recovery outcomes, are encouraging. Since the goal is to
serve patients, rather than to warehouse them, the price can be steep.
In 2015 Massachusetts spent $55,000 per prison inmate, with some
additional costs for those with serious mental health issues. Meanwhile,
the Worcester Recovery Center, with an annual budget of $60 million,
spent close to four times that sum per patient. How this will play out
in the long run, and how many other states will follow, remains to be
seen.
The very word “asylum” brings shivers to those old enough to remember
its abuses. It has a disturbing cultural legacy to confront in the
sadistic Nurse Ratched of “One Flew Over the Cuckoo’s Nest.” Bringing it
back in any form will face the twin obstacles of cost and image. But for
the most vulnerable among us, who exist in a world of peril to
themselves and to others, it is a far better option than the
alternatives of homelessness and incarceration.
David Oshinsky directs the Division of Medical Humanities at NYU Langone
Health. His books include “Bellevue: Three Centuries of Medicine and
Mayhem at America’s Most Storied Hospital” and “Polio: An American
Story,” which won the 2006 Pulitzer Prize for history.
***
Photo illustration caption: Clockwise from top left: A patient record
from a state mental hospital in Massachusetts; Bellevue Hospital in
1962; a sign at a protest following the death of Jordan Neely, May 5; a
New York subway train; a doctor examines a patient at a state mental
hospital in New York, 1937; a bottle of Thorazine, the antipsychotic
drug introduced in 1955; the Twin Towers jail in Los Angeles; nurses
restrain a patient at an asylum in Ohio, ca. 1946.
Source photographs for illustration: Max Denisov/Unsplash; Vlad
Hilitanu/Unsplash; Renan Kamikoga/Unsplash; Tim Gouw/Unsplash; Diego
Jimenez/Unsplash; Jerry Cooke/Getty Images; John Tlumacki/The Boston
Globe/Getty Images; ROBYN BECK/AFP/Getty Images; Spencer Platt/Getty
Images; Jack Harris/Associated Press; School of Pharmacy, University of
Wisconsin, Madison, Wisconsin/Smithsonian Institution; Alfred
Eisenstaedt/The LIFE Picture Collection/Shutterstock
--
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