In his own clumsy and inarticulate way, President Donald Trump said something profound on Wednesday. Feb. 21 that both sides of the aisle have refused to say for over 50 years: deinstitutionalization created more problems than it solved. Our national mental health infrastructure has been decimated by years of wayward cultural upheaval and the idealism of starry-eyed utopians.
President Kennedy’s 1963 Community Mental Health Act was well-intentioned, if not effective- during the middle of the last century, psychiatric hospitals were overcrowded and often barbaric. The advent of psychotropic medication also contributed to the emptying of the asylums, as persons once wholly dependent on institutional care could enjoy a semblance of independence with the advent of drugs like Haldol. But state laws in the wake of Kennedy’s initiative drastically changed, making commitments to psychiatric facilities – both voluntary and involuntary – nearly impossible. Those hit hardest by these earnest civil liberty concerns were the severely mentally ill who clearly needed in-patient services but never acceded the high statutory benchmarks required for institutional care.
State Republican lawmakers saw an opportunity for cost savings, yanked funding, and the nation has never looked back. America emptied large portions of its asylums and psychiatric hospitals that now exist as mere ivy-covered anachronisms while many of their former inhabitants lie homeless on our city streets or festering in our prisons. Something needs to change, clearly- approximately one third of our nation’s incarcerated population is mentally ill, and mental illness plagues about a quarter of our homeless population. And, while it shouldn’t take a mass shooting to talk about this, President Trump had the unexpected temerity to address the issue directly.
An intellectually alluring combination of postmodernism and mid-twentieth century idealism has decimated our national mental health infrastructure. We’ve gone to fairly profound lengths as a culture to obscure the reality of mental illness – on one hand, the country is medicated beyond belief, awash in a sea of antidepressants and antipsychotics. Simultaneously, we seem so certain of mental illness’ illusory transience that we’ve legislatively made both voluntary and involuntary commitment to an institution nearly impossible.
What was supposed to replace the network of in-patient psychiatric care was “community mental health,” perhaps the most vacuous three-word euphemism in the lexicon of progressives in Washington. The theory of care has yielded a number of effects, largest among them the displacement of the severely ill. It may be unpleasant to see people suffering profound mental health challenges committed to the campus of a state institution, but for some it is a preferable intermittent fate to the unthinkable acts of violence that may follow.
Psychiatry does not enjoy the overwhelming evidentiary support as do specialties in the biological sciences, but the current stasis is unsustainable. There is no question that individuals like the Florida or Newtown shooters should not have had to be completely and utterly incapacitated for the civil commitment system to intervene.
The Florida shooter was reported to have gotten treatment from a “mental health clinic,” a half-baked alternative to serious inpatient care. Such clinics are often out-patient, community-based models of care without the capacity of integrative care that the psychiatric community has called for. The insistence upon letting a potentially dangerous individual like this shooter languish “in the community” when his behavior warranted an involuntary evaluation–if not full institutional commitment–is an example of idealism’s physical toll and pernicious cynicism. It’s also a fiscal rabbit hole: it’s easy for Democrats to claim that the problem is not that our mental health system is paradigmatically flawed, it’s that conservatives haven’t given enough funding to their unproven pet project.
Most every state still has state hospitals for cases like this, but civil rights actors have prevented their functional use in stemming the problem of severe psychiatric illness. No doubt some of those concerns were legitimate in their historical moment, but at present the dearth of inpatient beds has eradicated the bedrock of our mental health system. Making involuntary commitment or examination easier, and allowing institutional care to be more than just a last-ditch effort for those who are completely incapacitated would be an actionable step in improving mental health outcomes.