Mental Health Care "Reform" In My State: Out of the Hospital and Into Prison

Until about two years ago our community hosted a premier mental health care facility funded by the state. Often working in conjunction with the psychiatric wards of several hospitals, it provided a psychiatrist, medication, outpatient individual and/or group therapy, substance abuse counseling, crisis intervention, an ACT team, DBT (dialectical behavior training) classes and a case manager/social worker who helped connect the client with resources in the community and assistance programs when necessary. The facility also ran several group homes for the mentally challenged and the mentally ill who needed some assistance in everyday living.

Payment for these services was on a sliding scale--those with sufficient income paid the going rate for such services and those with less also paid a given percentage of their earnings. Homeless people and those living at shelters could walk in and be treated, often for free. Two pharmacies cooperated in discounting needed medication for those with a proven need, and the facility itself kept a storeroom full of free samples from drug salespeople, which they dispensed to the indigent. The group homes were accessible to those with some form of public assistance.

It wasn't perfect. Hospital stays typically last only until an acute crisis has passed and the medication has begun to work -- typically about two weeks. This is in accordance with the demands of insurance companies, which often will not cover mental illness or cover it only minimally, and in accordance with a philosophy which took root in the late 1960's and the 1970's. This philosophy postulated that institutionalization was an unmitigated evil and that all patients need to be free. In addition, new psychiatric medications have been developed that allow people who were previously completely impaired to function fairly normally in their homes and communities. The result has been the closing of thousands of state mental hospitals nationally. Our state currently has only one, which is always filled over capacity and has a waiting list months long.

The result has not been a success, however, in millions of cases. There are those whose illnesses are chronic and recurring, and who often forget when and how to take their medication when they are unsupervised. There are those who need consistent nursing care as well as psychiatric treatment. There are those who can function only within the structure of a hospital, which gives them the necessities for sustaining life-- necessities they are incapabable of providing for themselves--and also gives them social interaction with the staff and other patients as well as structure in their lives. There has always been a segment of the mentally ill population who thrive in an institutional setting.

And then, of course, there are those who do not have warm families or welcoming communities to go back to. There are many who are homeless or live temporarily in shelters. And there are those who, in the absence of mental hospitals, get in trouble and are committed to prison. When these prisoners are released, often still suffering acutely from their illness and having no resources for finding a place to live or getting employment, reoffend and go back to prison. Truly our society has simply replaced one form of institutionalization with another, much worse, form.

Short hospitals stays and deinstitutionalization, as well as the practice of locking up the mentally ill, of course, preceded the "reforms" our state has made in its mental health system. Still, they have destroyed the services that once made our community a model of enlightened mental health care.

It began when the state decided to cut the budget for mental health, proclaiming that it was eliminating the waste, fraud and inefficiency of the system. They also decided that privatization was the only road to success. The state government would now pay only the minimum possible and turn over the lion's share of the care of the mentally ill to private businesses. I don't like to point fingers, but the movers and shakers of this "reform" were mostly--but not exclusively--conservative Republicans.

Without state funds our premier mental health facility quickly closed. Five small for-profit agencies sprang up in their place. Three quickly went out of business. Those that remain have cherry-picked their services, providing only those that are most lucrative: psychiatrist, group and individual therapy. Their staffs and salaries are so small and the work load so heavy they have difficulty in retaining trained professionals, especially psychiatrists. In addition, the few services they do provide are far more costly for the patients. And even so, the state keeps demanding more and more paperwork to justify less and less funding.

Gone are the sliding scales, the discounted or free medications, the community support teams, the group homes, the crisis intervention. Gone are the services for the severely and chronically ill. Scarce are the social workers, who are not profitable (how can you make money helping people to find subsidized housing or get food stamps?) Gone are the homeless, the indigent who have no benefits, the shelter dwellers. Gone back to prison or the streets. Gone are the days when our community could point with pride at our effective, enlightened and advanced mental health care system.

Now when a politician brags about how he or she was instrumental in bringing about health care "reform" I know who not to vote for.