Being mad is the first step
"Show Me The Money!" from Jerry Maguire (1996)
But before we can institute change, we need to understand how we got here.
The bottom line is that mental health care never has been funded sufficiently.
A look back at history—at the attempts of Dorothea Dix, Clifford Beers, and John Kennedy to enrich the lives of people with mental illness—is instructive. Together their efforts tell the story of what’s gone wrong in our approach to providing care for people with mental illness.
A series of detailed state investigations beginning in Massachusetts in the 1840’s led by Dorothea Dix examined how people with mental illness were treated. She found that towns contracted with local individuals to provide care for people with mental illnesses who could not care for themselves and who lacked family or friends to help them. Unregulated and underfunded, abuse was widespread. People were chained, naked, beaten with rods, and lashed into obedience.1
Ms. Dix’s research led her to lobby for a new system of care for people with mental illness and so the state mental hospital was born.
Over a 40-year period, Ms. Dix convinced the U.S. government to fund the building of 32 state psychiatric hospitals. Dix intended for state mental hospitals to provide humane treatment and ensure a quiet, orderly existence for people with mental illnesses. Surely this was a humane and virtuous goal.
But things got complicated very quickly, and state mental hospitals failed to provide the care Ms. Dix had envisioned. As Gerry Grob, Ph.D. details in his riveting book The Mad Among Us: A History of the Care of America’s Mentally Ill,2 as the state hospitals grew in size, complexity, and patient diversity, considerations of order and efficiency began to conflict with therapeutic goals. Additionally, although institutionalization was typically a last resort decision for families, wrongful commitments did happen. The personal liberty of patients was constrained, their behavior was over-regulated, and patient-staff relationships were turbulent.
The state mental hospitals were underfunded and understaffed.
Following a suicide attempt, Clifford Beers, a graduate of Yale, was hospitalized at both the Hartford Retreat and the Connecticut Hospital for the Insane. In 1907, disillusioned by his experiences at these institutions, he wrote A Mind That Found Itself. Beers accepted his diagnosis of manic depression, but was critical of the psychiatrists who had treated him. Their use of punitive measures, including straitjackets and seclusion and their lax system of supervision of brutal, untrained attendants angered him.
Beers did not reject the legitimacy of institutions. Rather his rejection was of the insensitive and brutal treatment of patients by staff. But others got involved, deflecting Beers’ central goal of improving institutions. State hospitals remained underfunded and understaffed.
By the mid-1950’s, the push for deinstitutionalization in favor of outpatient treatment began. Facilitated by the development of antipsychotic drugs such as Thorazine, the prevailing belief was that people with mental illness would have a better quality of life if they were treated in their communities rather than in hospitals. The Community Mental Health Centers Act of 1963, the last bill President Kennedy signed before his untimely death that year, closed most of the state hospitals and moved 560,000 people who had been living in state hospitals back into the community.
Though the goal of deinstitutionalization—improving the quality of treatment for people with mental illness—is not controversial, deinstitutionalization has been an abysmal failure largely because insufficient resources to support needed care have been allocated to communities. Rather than putting the requisite resources into the state hospitals as Beers had suggested, we threw the baby out with the bathwater.
Today there is a severe shortage of hospital beds for people with mental illness.3 People like Austin Deeds, son of Virginia Senator, R. Creigh Deeds, commit suicide after being released to their families because there are not enough hospital beds. Resources in the community are woefully inadequate. People with mental illness have no place to go for treatment. And so they live on our streets and sometimes in our prisons.
Dorothea Dix, Clifford Beers, and John Kennedy had the research expertise, personal experience, and political acumen to fix our sorry mental health system. Their goal was to make life better for people with mental illness. But the money needed to fulfill their quest of improving the quality of life for people with mental illness never existed.
In the 1996 movie, Jerry Maguire, Tom Cruise, has a moral epiphany and screams, “Show me the money.” He was talking about sports.
I’m talking about mental illness. Show me the money. What will it take to fix this problem?
2. Gerald N. Grob. The Mad Among Us: A History of the Care of America’s Mentally Ill, The Free Press, NY, 1994.