Back in the late 1960s, the Ronald Reagan administration in California (he was governor for two terms before he was President -- and I only say that because it was so long ago now that many seem not to know or remember) began the process of dismantling the state public mental health care system that had existed in one form or another for a century.
Dismantling the public mental health care system nationally became part of an official consensus soon afterwards, and by the time Reagan entered the White House, the process was nearly complete.
Part of the rationale came from Nancy Reagan's adoptive father, a neurosurgeon who was convinced that mental illness -- as it was typically understood and treated -- was an illusion, a chimera. Mental health, in his view, was largely a matter of brain chemistry, and if chemistry went off track, it could be and should be treated with drugs, not warehousing in state mental institutions. In some cases of so-called mental illness, surgery might be necessary to repair or bypass damaged brain and nerve cells. There might be a genetic component to cases of Down's Syndrome (called "Mongolism" in those days) and Autism (sometimes seen as Idiot Savance) which couldn't be treated by any means.
His goal was to eliminate the mental health care system as it had long been operated. Like many others, he saw it as cruel, unnecessary, and the cause of more harm than help.
The ideal substitution would be for those encountering mental health issues to go to community clinics where their condition could be assessed by competent professionals and an appropriate course of medication or medication and surgery could be determined and prescribed. Those with genetic mental conditions that could not be treated would be assigned to board and care homes in their local communities rather than to giant State Institutions for the Feeble Minded.
It all seemed rational and reasonable. Many state institutions (as depicted in "The Snake Pit" for example) were terrible places, filled with suffering patients, indifferent or downright cruel staff, and from which it was too often nearly impossible to escape. The law enabled involuntary indefinite commitments, too often on the say-so of people who were unqualified to determine the mental condition of those who were committed. Getting out once committed could be a nightmare of bureaucracy and legal misconduct.
Treatment in these places was often non-existent or so inadequate as to be counterproductive.
Patient neglect was commonplace, medical malpractice was too common as well.
The community clinic approach to mental health care seemed far better given the liberationist tenor of the times and the rapid development of psychotropic drugs, some of which seemed to be better at treating common mental health conditions such as depression, anxiety and manic behavior than any course of psycho-therapy.
Placing those who could not be treated with medication in community board and care homes where a few to a dozen patients might live in comfort and be cared for compassionately seemed far better for the patients and their families than warehousing them by the hundreds or thousands at a central location.
The law cooperated by making the indefinite involuntary commitment no longer possible and by strictly controlling how and whether any involuntary commitment would henceforth take place.
State mental hospitals were largely shut down or turned into prisons for the "criminally insane." Patients were released to their own or their family's recognizance. Community clinics were slow to be established or non-existent. Board and care facilities were initially few and quite expensive. Drug treatments for mental illness were sometimes botched by physicians unfamiliar with the side effects of medications, by patients who refused medication, and by pharmaceutical manufacturers who produced quantities of unhelpful medications. Surgery was expensive and rare.
In fact, the expense and bother of this new system proved to be a barrier to the widespread availability of mental health care services once the state systems had been dismantled.
For many patients, there was simply no place to go. Even where there were clinics, being seen and treated at them could be daunting for people in fragile mental condition.
Literally what happened was that the police took over the "care" of a large portion of the mentally ill, and jails and prisons became the new "Snake Pits" for many people who might otherwise have benefited from treatment had it been available.
In many jurisdictions today, 30% or more of those in jail or prison suffer from mental illness, and their conditions are rarely treated. It has become commonplace to read about mentally ill individuals who are shot to death by police when they act out, or to see the horrifying results of the beatings they endure under from police under the guise of public safety.
What replaced the state mental health care system was better for some patients, much, much worse for others. Deadly for too many.
What's replaced the state mental health care system is a national and international disgrace and embarrassment, but for reasons of economy on the one hand, and official indifference to suffering on the other, nothing substantive is done about it. The situation in which a significant number of mentally ill individuals is shot to death by police every year, and a much larger number is jailed or imprisoned is taken for granted. This is the status quo, and there is little official interest in changing it.
Yet this status quo is barbaric compared to public mental health care provisions practically anywhere else in the developed world. It's outrageous and unacceptable, and yet it doesn't change.
The theme running through the current system is one of official abuse and neglect of the mentally ill, and the continual deaths of mentally ill individuals by police gun fire. I call them summary executions.
The shooting death in March of James Boyd of Albuquerque was one of the most egregious examples, but by no means was it the only one. The Boyd killing, however, caused such an outcry that instead of looking the other way or simply dismissing his death as "unfortunate but justified", officials in Albuquerque and elsewhere had to pay attention.
The people rose up and demanded better from their police and their civic administrations.
So far, they have yet to receive anything better. The killing goes on unabated, there is no improvement in mental health care provisions, and police and civic officials defy every call for reform. The status quo seems so entrenched that it often appears that nothing can be done to change it.
It's almost fifty years since shutting down state mental health care services became the standard operational practice. The results are plain enough: much death and destruction of those unlucky enough to be afflicted with mental illness, much death and destruction among families and communities, much imprisonment of the mentally ill, little or no care for the mentally ill, and a barbaric disregard for the well-being of individuals, communities and society.
That's where we are.
What then must we do?
That will be a topic for another post.
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