Many people think that the era of closing large, state psychiatric hospitals and dumping the mentally ill on city streets is a thing of the past. Sadly, Oklahoma is proving them wrong and perpetuating the failure of deinstitutionalization and success of transinstitutionalization by downsizing Eastern State Hospital in Vinita.

Gravely ill Oklahomans, who were until recently provided appropriate psychiatric care, have now joined the hundreds of thousands of mentally ill Americans for whom deinstitutionalization has meant nothing more than a denial of treatment, abandonment to the streets and preventable imprisonment in jails and prisons… .

The primary blame lies not in Oklahoma City, however, but in Washington and in a decades-old federal policy established when severe mental illness was not universally recognized as a biologically based brain disease.

Most people think that the era of closing large, state psychiatric hospitals and dumping the mentally ill on the streets is a thing of the past. Florida is proving them wrong by threatening to close another 350 hospital beds for its most severely mentally ill citizens.

The primary blame lies not in Tallahassee, however, but in Washington. Because their illness prevents them from obtaining private insurance through employment, many people with severe mental illness rely on Medicaid to pay for their treatment. For every dollar Florida spends on Medicaid, the federal government reimburses more than 56 cents—unless the patient is between the ages of 21 and 65 and treatment is in a psychiatric hospital or other “Institution for Mental Diseases” (IMD)… .

States such as Florida fill the financing gap created by the IMD exclusion by relying on Medicaid's “Disproportionate Share Hospitals” (DSH) payments for hospitals providing care to a “disproportionate share” of poor or indigent patients. But Florida's DSH payments have been trimmed some $47 million per year from 1998 to 2002. Rather than picking up the entire tab for state psychiatric hospital care, Florida is proposing to close 350 beds that are used to treat the most severely ill.

Imagine a train wreck that scatters passengers across the landscape. Paramedics arrive and begin loading the injured onto stretchers. But when anyone screams out in pain, “No! Don't touch me!” the medics nod compassionately and leave that person sprawled amid the rocks and cactuses.

A similar scene has been unfolding on the urban landscape for the last 40 years. People with severe mental illness, tossed from state hospitals, have landed on public sidewalks and in wretched urban encampments. And no one helps them because they say they don't want help.

In 1945, Mike Gorman … embarked on a campaign, as he later put it, to wave “the reek and stench of our state mental hospitals under the public's nostrils.” In May 1946, Life magazine ran Albert Q. Maisel's withering report on the conditions in these institutions. In 1948 both Albert Deutsch's Shame of the States (like Maisel’s, accompanied by photos) and Gorman's Oklahoma Attacks Its Snake Pits were published. These journalists compared some psychiatric wards to Nazi extermination camps, which newsreel footage had freshly seared in public memory. Maisel compared state mental hospitals to concentration camps on the Belsen pattern.

Limiting ourselves for the present to this country—this rich, busy, idealistic, sympathetic, growing country—it is painful to face the fact that for the mentally ill we have much less demonstrated compassion, despite their oftentimes greater suffering, than for the more obviously physically ill. Let a man be taken to a hospital because he has a broken a leg, crying out with pain when he tries to walk, and he will be surrounded by nurses, physicians and technicians within a few hours, his suffering eased and his leg so held that it can begin to mend. But let a man's mind begin to wander or his memory to fail, his perceptions to become confused or his fear to overwhelm him, and he is likely to be conveyed in a dilatory fashion through the county jail to the courtroom and thence to the wards of what was once called the “asylum.” What happens after that few know, few care, and fewer do anything about it.

Much of Laing's appeal lay in his use of his psychiatric credentials to define the establishment as insane. The sane were mad, the mad sane, and psychiatrists the craziest of the lot. Sometimes Laing suggests there may be such a thing as mental illness after all. It is something from which psychiatrists suffer and that they project upon their patients … . And while in the 1960's all this seemed hyperbole typical of the times, the New Left's assault on the distinction between sanity and insanity would prove the most far-reaching and radical of its many inversions of assumptions underlying the social order.

Theories fashionable in sociology gave spurious academic respectability to the counterculture's denial of the boundary between sanity and insanity. So-called labeling theorists argued that it was the label, or stereotype, rather than the underlying behavior that lay at the root of a variety of social problems. Applied to mental patients, the theory argued that mental patients were just people who behaved a little differently, were stigmatized by labels, and put in institutions whose baleful influence then caused them to be unable to function independently.

Late in 1961 President Kennedy appointed an interagency committee to prepare legislative recommendations based on the report. I represented Secretary of Labor Arthur J. Goldberg on this committee and drafted its final submission. This included the recommendation of the National Institute of Mental Health that 2,000 “community mental health centers” (one for every 100,000 people) be built by 1980. A buoyant Presidential Message to Congress followed early in 1963. “If we apply our medical knowledge and social insights fully,” President Kennedy stated, “all but a small portion of the mentally ill can eventually achieve a wholesome and a constructive social adjustment.”

… The mental hospitals emptied out … . But we never came near to building the 2,000 community mental health centers … . Even when centers were built, the results were hardly as hoped for. 145 Cong. Rec. S8295-01 (July 12, 1999) (statement of Sen. Daniel Patrick Moynihan).

The recently released Surgeon General's Report on Mental Health is the equivalent of describing the maiden voyage of the Titanic without mentioning the iceberg. While the report criticizes private insurance companies for failing to provide “parity” in their coverage of mental illnesses, it is totally silent on the failure to provide parity in Medicaid, the federal government's insurance program.

For the most severely mentally ill, private insurance is essentially meaningless. Because of their illness, most are indigent, and private insurance is a luxury they cannot afford and are not in a position to obtain through employment.

(A) inpatient services which are provided in an institution (or distinct part thereof) which is a psychiatric hospital as defined … in this title or in another inpatient setting that the Secretary has specified in regulations;

(B) inpatient services which, in the case of any individual (i) involved active treatment which meets [certain specified] standards … , and (ii) a team, consisting of physicians and other personnel qualified to make determinations with respect to mental health conditions and the treatment thereof, has determined are necessary on an inpatient basis and can reasonably be expected to improve the condition, by reason of which such services are necessary, to the extent that eventually such services will no longer be necessary; and

(C) inpatient services which, in the case of any individual, are provided prior to (i) the date such individual attains age 21, or (ii) in the case of an individual who was receiving such services in the period immediately preceding the date on which he attained age 21,

(I) the date such individual no longer requires such services, or (II) if earlier, the date such individual attains age 22.

From the legislative history, it is clear that the community mental health center was represented to Congress as a facility capable of supplanting the state mental hospital … . However much mental health centers may accomplish in other ways, they will not accomplish the goal for which Congress established the program unless they can stem the flow of the mentally ill to the state hospitals.

The problem of providing special hospital care for the mentally ill entailed a number of complicating factors absent in the institutional provision for general patients. While the stay of the average general hospital patient could be measured in days, that of the mental patient had to be measured in years. The financial burden of adequate hospital provision for this class was a heavy one—too heavy for most localities to bear … . For these and other social, economic, and medical reasons, the state was recognized as the only public administrative unit able to provide adequate institutional facilities for the mentally sick.

The insane were usually supported at home, their illness making them one of the poor; only when they were uncontrollable, threatening the safety of relatives and neighbors, did towns seek alternatives. Those equipped with an almshouse put lunatics in an empty attic or cellar, to suffer alone. A community that lacked this option sometimes devised a special structure, which however rudimentary or elaborate, was invariably designed as a substitute household. Thus, officials in the early colonial period at times confined the violent insane in shacks and huts set up for the occasion on the commons. One local Pennsylvania court directed a village in 1676 to build “a little block-house” for a dangerous lunatic; unfit to live in another household, he would have a crude one of his own. Even more striking, the designers of the first hospital exclusively for the insane in the American colonies, opened at Williamsburg, Virginia, intended it for a last resort, when the family did not, or could not, take responsibility. The burgesses, concerned that “several persons of insane and disordered minds have frequently been found wandering in different parts of this colony,” established in 1769 a lunatic asylum. Although it might help to cure those not “quite desperate,” its primary task was to preserve the peace of the community, to keep the insane from roaming about. Accordingly, no insane would be admitted to Virginia's new institution if relatives or friends agreed to look after his welfare and behavior. When no one would take the charge, the asylum served as a surrogate household.

Jan Vorelissen, of Amesland, Complayning to ye Court that his son Erik is bereft of his naturall Senses and is turned quyt madd and yt, he being a poore man is not able to maintain him; Ordered: yt three or four persons be hired to build a little block-house at Amesland for to put in the said madman.

(1) aid could be provided so that the poor could remain in their own home; (2) their care could be auctioned off to the lowest bidders, that is, to the persons willing to undertake their support at the lowest cost to the community; (3) the support of all paupers could be contracted to a single individual at a fixed price; or (4) the community could support them in a public poorhouse.

Almost from the opening day of the Pennsylvania Hospital, the insane persons hospitalized there were regarded as great curiosities by the public. In 1762 it was noted that “the great crowds that invade the Hospital gave trouble and create so much disturbance” that special security precautions were instituted. According to hospital records, “the insane wing was such an object of public curiosity that the managers decided to charge an admission fee.” Five years later, the fee was increased to four pence to restrict “the Throng of people who are led by Curiosity to frequent the House on the first day of the week, to the great disturbance of the Patients.” Additional restrictions were instituted in 1784 and 1791.

For months, the dark videos with the homemade feel beamed out over the Web site: Bedraggled men beating each other to a pulp. A scruffy street person ramming his head into a wall. Another poor fellow ripping out his own tooth with a pair of pliers. But Bumfights.com offered only snippets. If you wanted a full dose of street mayhem, you had to pay for the full video—at $19.95 a pop. By some accounts, 300,000 copies were sold.

The results of two years of investigation were summed up in this manner:

Lincoln. A woman caged.

Medford. One idiotic subject chained, and one in a close stall for 17 years.

Concord. A woman from the hospital in a cage in the almshouse. In the jail, several, decently cared for in general, but not properly placed in prison

… .

Dedham. The insane disadvantageously placed in the jail. In the almshouse, two females in stalls, situated in the main building; lie in wooden bunks filled with straw; always shut up.

With the advent of psychotropic drugs and a shift in popular thinking about treatment, states began in the 1960's to relocate the mentally ill to what were supposed to be more humane settings in communities.

In large part, however, the motivation was money. Through new federal programs like Supplemental Security Income, Medicaid and Medicare, states could shift the financial burden of caring for the mentally ill to Washington. Nowhere was that embraced more than in New York, which had by far the largest psychiatric system of any state. In the 1950’s, it housed 93,000 people and spent a third of its budget on mental health.

The hospital system now has only 4,500 beds, and the state's current mental health budget is $2 billion, 2.4 percent of the state's overall $84.5 billion budget. And while the adult home system remains costly—roughly $600 million a year for housing and healthcare for 15,000 residents—most of that comes from federal coffers.

The federal money, in turn comes with many restrictions … .

For example, the homes—originally intended for the elderly who did not need full time care—are still classified only as residential facilities. That is largely so the federal government, through its aid programs, will foot most of the bill for treatment and services provided by outside professionals who visit the homes. If the state wanted to improve the homes by turning them into mental health facilities, thereby allowing them to provide better on-site and 24-hour care, it most likely would have to provide its own money.

Further, the group excluded is not congruent with appellees’ class. Among those excluded are the inmates of any other nonmedical “public institution,” such as a prison, other penal institution, and another publicly funded residential program the State may operate; persons residing in tuberculosis institution; and residents of a medical institution not certified as a Medicaid provider. Although not by the same subsection, Congress also chose to exclude from SSI eligibility persons afflicted with alcoholism or drug addiction and not under going treatment … and persons who spend more than a specified time out of the United States.

Indigent persons who need treatment in a hospital can count on Medicaid to pay for diseases of the heart, liver, blood and most other body organs. Medicaid will not cover the individual if he or she is between the ages of 21 and 65, has a disease in his or her brain and needs care in a psychiatric hospital.

Research over the past decade has clarified what is wrong with those diagnosed with severe mental illnesses. They have neurobiological disorders of their brains that affect their thinking and moods and that can be measured by changes in both brain structure and function … . Research on schizophrenia, schizoaffective disorder, manicdepressive disorder, autism, and severe forms of major depression, panic disorder and obsessive-compulsive disorder has also revealed a variety of functional disease-related changes in the brains of affected individuals. These include changes in the neurochemistry, metabolism, electrical activity, neurological function, and neuropsychological function of the brain.

In 1955, with a population of only 164 million, the United States had 558,239 patients in state and county psychiatric hospitals. By 1996, with a population that had increased to 265 million, the number of patients in state and county psychiatric hospitals had dropped to only 61,722. That is an effective deinstitutionalization rate of about 93 percent.

These systemic improvements can be considered as the next step in providing care: Community services, including supported residential and rehabilitation programs must be provided in one, integrated system. The model programs all more or less independently discovered what ingredients enable the chronically mentally ill to function in the community; now, finally, mental health authorities must fix responsibility and organize service delivery to meet patients’ needs. As Fuller Torrey emphasizes, responsibility for the mentally ill must be fixed at a single level of government, along with the financial resources to carry out those responsibilities.

The great forty years’ crusade of Dorothea Lynde Dix, begun in 1841, greatly stimulated the trend toward removing the insane from poorhouses and prisons to state hospitals.

Humanitarians and medical men united in support of the state care movement. A most important factor favorable to the movement was the absence of medical opposition.

Are such conditions [overcrowding, underpaid and overworked staff, inadequate psychiatrists, etc.] an inevitable part of a state care system? I certainly do not think so. In my considered opinion, there is nothing inherently bad in any system of governmentsponsored medicine, including state hospital psychiatry. I offer the “medical revolution” in the Federally operated veterans hospitals under General Omar Bradley as a classic proof of this point. There is no reason why first-rate psychiatry can't be practiced in our state hospitals—if the people demand it with sufficient force and if enough far-visioned men can be found to carry out the public will.

The availability of neuroleptic drugs also encouraged optimism that … former patients [could be maintained] in the community on the strength of a prescription. Yet, … studies had been published chronicling the limitations of the drugs. Brill and Patton, whose study of psychoactive drugs … was quoted by the Joint Commission [on Mental Illness and Health], emphasized that the drugs were much more effective in reducing “positive” symptoms of schizophrenia, such as delusions and hallucinations, than in the “negative” ones: “occupational inertia, vocational incapacity, and lack of initiative for constructive occupation.” Psychiatrists insufficiently appreciated, they observed, that defects in this area “are not an accidental and secondary problem but a primary and central one directly related to mental illness and especially schizophrenia.”