American Psychosis (23 page)

Perhaps most discouraging of all at this time was evidence that no learning was occurring among public officials. Violent acts and homicides committed by mentally ill individuals were simply written off as random asteroids, events that just happen
from time to time and over which nobody has any control. This failure to learn from experience was demonstrated most dramatically by mentally ill individuals who had committed a violent crime and then were released without ongoing treatment, only to commit another violent crime.

1990: John Kappler, diagnosed with bipolar disorder, killed a random bicyclist in Massachusetts with his car. As a physician who practiced anesthesiology, he had tried to kill patients in 1975, 1980, and 1985. Although he responded well to antipsychotic medication, he was not mandated to take it.

1993: Jeanette Harper, diagnosed with psychosis, stabbed to death a 71-year-old woman in Virginia. In 1986 she had killed a man and had been found not guilty by reason of insanity. She was released from the hospital in 1990 and allowed to stop taking medication a year later.

1995: Gerald Barcella, diagnosed with bipolar disorder, bludgeoned to death his landlord in Washington State. Barcella had 47 previous arrests for violent offenses.

1997: Eugene Devor, diagnosed with schizophrenia, severely beat a female university student with a large stapler in Wisconsin. In 1979 he had beaten another female student with an ax, causing severe head injuries.

1998: Daniel Ellis, diagnosed with bipolar disorder, ran his car through a stop sign at 70 miles per hour in Iowa, killing a man. In 1993 Ellis had been convicted of kidnapping and attempting to kill a 3-year-old boy. Ellis was not taking his medication.

1999: Salvatore Garrasi, diagnosed with schizophrenia and not taking his medication, killed his wife in New York. In 1983 Garrasi, also not taking his medication, had killed his 10-year-old son “out of love.”
⁴⁰

There is an additional suggestion that homicides committed by mentally ill persons were increasing in the 1980s and 1990s. In 2000, the
New York Times
published a series on “rampage killers,” homicides in which multiple people had been killed but that were not associated with a domestic dispute or robbery. The articles identified 102 such incidents that had taken place between 1949 and 1999. Six such incidents occurred in the 1970s, 17 in the 1980s, and 73 in the 1990s. Many, but not all, of the “rampage killers” were known to be seriously mentally ill.
⁴¹

And that was how the century ended. In 1900, there had been almost 2,000 seriously mentally ill individuals per million population in state mental hospitals. In 2000, there were just under 200 seriously mentally ill individuals per million population in state mental hospitals. In the intervening years, the hospitals had overflowed with patients, reaching 3,388 per million in 1955. At that point, a new plan was adopted: Move the patients out of the hospitals and treat them in the community. Federal CMHCs were
created and tried but failed. As Andrew Scull aptly noted, the federal plans for treating patients in the community turned out to be “castles in the air, figments of their planners’ imagination.” In one sense, deinstitutionalization was never really tried; rather, what had happened had merely been depopulation of the hospitals. John Talbott, one of the few American psychiatrists to focus on this disaster, summarized it as follows:

With the knowledge that state hospitals required 100 years to achieve their maximum size, the precipitous attempt to move large numbers of their charges into settings that in fact did not exist must be seen as incompetent at best and criminal at worst.
⁴²

7
DIMENSIONS OF THE PRESENT DISASTER: 2000–2013

In the fall of 1941, Joseph Kennedy arranged for his daughter Rosemary to have a lobotomy. He did so because she had become psychotic, was behaviorally out of control, and was in danger of becoming pregnant. The operation was a disaster, leaving Rosemary profoundly brain damaged. Twenty years later, Jack Kennedy assumed the presidency and authorized a new mental health and retardation program to honor his sister, although he never publicly acknowledged her connection to these programs. The program involved closing state psychiatric hospitals, shifting outpatient care to federally funded community mental health centers, and preventing mental illnesses. As implemented, the new federal program effectively lobotomized both the existing and the emerging state mental health programs. The federal program has been a disaster, and the current chaotic, dysfunctional mental health system is, in one sense, Rosemary’s baby.

It is important to recognize that this failed federal mental health program was not merely a one-time disaster. By aborting the development of emerging state systems and replacing them with a potpourri of uncoordinated federal programs, it set in motion an ongoing disaster that continues today. With each passing decade, the situation has become progressively worse, and it will continue to do so until corrective action is taken.

THE GOOD NEWS

As described in the previous chapter, the federally initiated mental health disaster has not affected all individuals with mental illnesses. Many of those with less severe symptoms and with awareness of their need for medication have done reasonably well, especially if they live in areas where rehabilitative programs are available. The employment of mentally ill individuals by state or county mental health agencies has been especially successful. In approximately one-third of the states, there are active programs to train and employ mentally ill individuals as “peer counselors” in outpatient treatment teams,
substance abuse programs, and housing programs. Studies of the effectiveness of these “peer counselors” have been positive, and it is a promising line of employment for mentally ill individuals who are stable.
¹

Another generally positive development for mentally ill individuals has been the recent “recovery movement.” This movement focuses first on the needs and treatment goals of the patient, so that treatment becomes a shared endeavor between the patient and the treatment team. As characterized by one summary, “recovery requires reframing the treatment enterprise from the professional’s perspective to the person’s perspective.” The major problem, of course, is that many people with serious psychiatric disorders have anosognosia, meaning that they are not aware they are sick, because of their brain disorder. The concept of “recovery” is meaningless to them, because they believe they have nothing to recover from. The “recovery movement” thus is useful for some individuals with mental illnesses but not for many others. In large measure, “recovery” is simply a restatement of what should be the optimal relationship between a patient and doctor, and it is unclear at this point whether the movement is merely an anodyne of hope or a fad.
²

Unfortunately, both the employment of mentally ill individuals as peer counselors and the “recovery movement” have been partially discredited by the parallel “psychiatric survivor” movement. This consists of a small but vocal group of individuals who have more or less recovered from their previous mental illness and who profess four beliefs (although, of course, not every “survivor” agrees with all four): (1) psychiatric medications are extremely dangerous and best not taken at all; (2) no mentally ill person should ever be treated involuntarily; (3) electroconvulsive therapy (ECT) should never be used; and (4) serious psychiatric disorders are not physiological brain disorders but, rather, merely states of “emotional distress.” The “survivors” had their philosophical origin in their own experiences of having been mentally ill as well as in the writings of Thomas Szasz (
The Myth of Mental Illness
) and R. D. Laing; a few were also influenced by the antipsychiatry teachings of Scientology. They have organized themselves over the years into groups such as the Insane Liberation Front, the Network Against Psychiatric Assault, and the National Association of Psychiatric Survivors. By claiming to speak for all “psychiatric consumers,” they have discredited the others, especially regarding the issue of involuntary treatment, which is an essential treatment strategy needed for a small number of mentally ill individuals. By claiming that mental illness does not exist or is merely an “alternate reality,” this group has also discredited the recovery movement. I will return to the effect of the “survivor movement” on possible solutions to the mental illness problem in the final chapter.
³

* * *

The good news, therefore, is that one group of individuals with serious mental illnesses is doing reasonably well. Most of them are living on their own in the community and remain stable on their medication. Some are raising families and working. This group, however, is a minority. The majority of individuals with serious mental illnesses in the United States are experiencing the effects of the misguided federal decisions made half a century ago, and the situation grows worse with each passing year.

JAILS AND PRISONS AS THE NEW
PSYCHIATRIC INPATIENT SYSTEM

In 1955 there were 340 public (state and county) psychiatric beds in the United States per 100,000 population. In 2010 there were 14 beds per 100,000 population, and states are continuing to close additional beds. One study estimated that the minimum number of public psychiatric beds needed in the United States is 50 per 100,000 population, almost four times the number that currently exist.
⁴

The relationship between the decrease in public psychiatric beds and the subsequent increase of mentally ill persons in jails and prisons is very clear. In Atlanta following the closure of the Georgia Mental Health Institute, “the number of inmates [in the county jail] being treated for mental illness . . . increased 73.4 percent.” After the Northwest Georgia Regional Hospital closed, the administrator of the local county jail estimated that “prisoners with mental problems . . . increased by 60 percent.” Nationally, a 2010 survey reported that “there are now more than three times more seriously mentally ill persons in jails and prisons than in hospitals.” In states like Arizona and Nevada, the difference was more than ninefold. The three largest
de facto
psychiatric inpatient facilities in the country are the county jails in Los Angeles, Chicago, and New York. In fact, there is not a single county in the United States in which the public psychiatric inpatient unit holds as many mentally ill persons as the county jail holds.
⁵

How bad is the situation now? Recall that in the 1970s estimates of the number of seriously mentally ill persons in jails and prisons were around 5%. In the 1980s this had increased to around 10%, and in the 1990s, to around 15%. Estimates for 2007 to 2012 vary between 20% and 40%. Thus, 20% of Alabama prison inmates “were thought to be mentally ill”; 20% of prisoners in Michigan “had severe mental disabilities—and far more were mentally ill”; and 20% of jail inmates in the Denver metro area have “a serious mental illness.”
⁶

In Florida’s Broward County, “23 percent of the jail system’s population [are] on psychotropic drugs.” In Virginia the Roanoke County sheriff claimed that “between 25 percent and 30 percent of his inmates suffer from mental illness.” In the Corrections Center of Northeast Ohio, 25% of the inmates “were on psychotropic medications,” which cost “nearly half of the medical budget.” In Texas’s Harris County Jail, 25% of
inmates take psychotropic medications. In Massachusetts, 26% of all inmates in county jails have a “major mental illness.” And in Illinois 28% of the inmates in the Cook County Jail “are taking serious psychotropic medications.” Such estimates are consistent with a 2006 national survey by the Department of Justice that reported 24% of inmates in county jails had psychoses.
⁷

Other reports have been higher. In Boone County, Missouri, “at least 30 percent of the jail population” was said to be mentally ill. Similarly, in Stark County, Ohio, “roughly 30 percent of the jail population suffers from a mental illness.” At New York’s Riker’s Island Jail, “one in three prisoners . . . [is] mentally ill, and the number is climbing.” And in the Tennessee prison system, “nearly one of every three inmates is mentally ill.”
⁸

Alarmingly, there are even higher estimates. In Texas’s El Paso County Jail, 40% of the inmates are taking psychotropic medications. In Alabama’s Tuscaloosa County Jail, 40% of the inmates “receive some form of psychiatric care.” In Pennsylvania’s Erie County Jail, 44% of inmates “have a serious mental illness.” In Iowa’s Black Hawk County Jail, “more than 60 percent of the inmates . . . are mentally ill.” And in Mississippi’s Hinds County Jail, “about two-thirds of the 594 inmates . . . take anti-psychotic medication.”
⁹

* * *

The problems caused by the increasing number of mentally ill inmates in jails and prisons are legion. In Florida’s Orange County Jail, the average stay for all inmates is 26 days; for mentally ill inmates, it is 51 days. In New York’s Riker’s Island Jail, the average stay for all inmates is 42 days; for mentally ill inmates, it is 215 days. The main reason mentally ill inmates stay longer is that many find it difficult to understand and follow jail and prison rules. In one study, mentally ill jail inmates were twice as likely (19% vs. 9%) to be charged with facility rule violations. In another study in the Washington State prisons, mentally ill inmates accounted for 41% of infractions although they constituted only 19% of the prison population. In a county jail in Virginia, 90% of assaults on deputies were committed by mentally ill inmates.
¹⁰