Tuesday, November 04, 2014

Out of the Hospitals & Into the Jails?

Over on Saving Normal, psychiatrist-blogger Dr. Allen Frances has put up a thought provoking article called We Should All Be Ashamed.    Frances asserts that closing the state hospitals was the wrong thing to do : those patients now live on the streets and cycle through the jails.  We haven't freed them, he says, we've abandoned them.  Frances goes on to say that Dr. E. Fuller Torrey is right: our society needs laws that allow us to force those who need help into care and Representative Tim Murphy is right: we need to pass the Helping Families in Mental Health Crisis Act -- one that mandates states to have programs for involuntary outpatient commitment.  

Frances concludes:
Is there any possible way to get this train back on track? First, implementing Tim Murphy’s Helping Families in Mental Health Crisis Act (H.R. 3717) would be a good start. Second, Congress should abolish the IMD (Institution for the Treatment of Mental Disease) exclusion. In fact, I personally believe that the federal government should get out of the mental illness treatment business altogether. They have been in this business since the passage of the CMHC legislation in 1963 and it has been all downhill. Let’s give the responsibility – and the federal money—back to the states and then hold the governors accountable for the results. They cannot do worse than we are doing now. Third, there needs to be further modification of state involuntary treatment laws and increased use of assisted outpatient treatment (AOT) and conditional release so that the small number of seriously mentally ill individuals who need these kind of services can be treated before they end up homeless or incarcerated. These three steps alone would go a long ways toward improving the treatment system."

Over the years, we've see lots of controversy about these topics on Shrink Rap and as you know, we are working on a book called Committed: The Battle Over Forced Psychiatric Care, so an article like this catches my attention.  

Surf over to Saving Normal, read the whole thing, and I'll invite you to return and comment here, if you'd like. 


Joel Hassman, MD said...

Having worked in a State in-patient facility for about a year of time 4 years ago, let's have a brutal moment of candor here, state hospitals CANNOT return to the environment they were back in the 60's to 70s before being shut down, as they were run like near incarceration type settings. But also, we CANNOT allow forensic patients to be mixed with true psychiatric patients if the system does increase bed counts in the future.

The point is to learn and avoid mistakes, not just make them more esoteric and convoluted.

Hence why the need for healthy change should NOT be driven by politicians, but by clinicians.

Anonymous said...

I think the biggest problem with this post is that psychiatry is a human endeavor and will always be subject to bad actors. If we could guarantee that psychiatrists would always (or even almost always) act with restraint and wisdom, then making it easier to intervene in individual's lives and families might make sense.

I also think that there is a place for the mentally ill in jail. Allowing people to be responsible for their behavior (if they can legitimately take responsibility for it and prefer to do so) is a type of beneficence. They may still need psychiatric care, but they may prefer the structure and expectations of the prison system to those of long-term hospitalization.

I guess in summary I see the article you referred to as a new effort to allow psychiatrist to put their wishes in place of sick patients. It is true that sometimes we do know best and can see most clearly, but this will be abused by some unless the legal limitations stay in place. We do need to advocate for our patients, but we must avoid advocating for ourselves "on behalf of our patients".

Anonymous said...

The biggest problem with Allen Frances' piece is that it is built on a false premise. This issue has been debunked long time ago, but for some reason keeps being brought to light from time to to time by the advocates of coercive psychiatry,

" As Steven Raphael and Michael Stoll point out in Do Prisons Make Us Safer? (just published), mental-hospital patients tended to be white, female, and elderly, while prisoners are disproportionately black, male, and young.

Certainly, the jails have borne some of the brunt of de-institutionalization; the Los Angeles County jail has been described as the largest mental hospital in the nation. But Raphael and Stoll compute that fewer than 130,000 of the nation’s 2.3 million prison and jail inmates are the products of de-institutionalization; that’s about 10% of the growth in the system.

Yes, it’s important to provide better mental-health services to criminal-justice clients, and doing so will tend to reduce prison and jail headcounts. But de-institutionalization is not among the major sources of mass incarceration."

"But surely the civil libertarians got the bigger question right: locking people up for acting crazy is a pretty rotten thing to do, and I’m glad we mostly don’t do it anymore. There’s a revisionist tendency to add de-institutionalization to high-rise public housing on the liberal-good-intentions-gone-awry list. It should be resisted. And the notion that the current level of incarceration is somehow historically normal needs to have stake driven through its heart."

Anonymous said...

I think we should ashamed that there are people who advocate for force when many of these patients never had access to voluntary outpatient treatment, community support, food and housing, etc to begin with. How about instead of advocating for force + services, we actually provide these services to those in need and see what happens?

Making it easier to force treatment will come at a huge price. It will make even more people afraid to see a psychiatrist and agree to voluntary treatment.


Dinah said...

Real Psychiatry has a post up: http://real-psychiatry.blogspot.com/2014/11/the-shadow-state-hospital-system.html
Where he discusses state hospital beds. He notes that at it's max, there were 344 state beds per 100K people, and that Torrey suggests 50 per 100K. I don't think there is anyone suggesting that the good old days were good old days or that most of the people confined in state hospitals needed to be there. But certainly there were some people who would be better off with someplace to live for an extended period with nursing care, activities, on site docs, if the environment were clean, humane, uncrowded? And certainly there are people who need and want the respite of a hospital for a brief period who can't be admitted to one because we don't have enough hospital beds (state or private).

Anonymous said...

I just read RP's piece. It is full of the type of paternalism/justification of coercion that anti psychiatry activists like yours truly have come to detest.

Sure, "the system" should trust families' testimony more than the victim's, like families have never made up stuff to incarcerate a so called "loved one"...

A few days ago Pete Earley published a letter of some reader telling the story of how the system had failed a son. Buried in the letter was the reader's admission that they had exaggerated the son's symptoms to force him into so called "psychiatric care" and that as a result he stopped trusting them. The piece brought me tears but only because of the creepy personality of both the writer if the letter and Earley's who thought we should pity them instead of the innocent victim that suffered an unwanted psychiatric assault and ended up paying the ultimate price as a result.

With families like these, there is no question that protections against psychiatric assault should be even higher.

Anonymous said...


I have been following your comments in this site for a while and I think that you are still very naive when it comes to understanding psychiatry's role in society.

There are no "good psychiatrists" vs "bad psychiatrists" anymore than there are "bad cops" and "good cops" in the sense that the very existence of cops is to provide security and be the first line of enforcement of criminal laws. Then, sure, there are cops who do this job in nicer way than others - I am not talking about police corruption which is a different topic altogether- but if you think that you can do something that violates a criminal law and that a "good cop" will let you lose, you are mistaken.

The institutional influence and status of psychiatry comes from its coercive powers that the law bestows onto them. They have been given the legal authority to both define behavioral orthodoxy outside the criminal justice system (through the DSM process) and the power to enforce it through a variety of coercive provisions that includes not only involuntary drugging and involuntary commitment but the areas that are the domain of forensic psychiatry.

Anybody who gets into psychiatry as a profession needs to be a believer that his/her job is to enforce the version of "behavioral normality" that emanates from the DSM; otherwise, he/she will not last long. The cream of the crop among psychiatrists will be even given the task of being part of the DSM process in the future, but their job with respect to the DSM is fundamentally the same as the job of law enforcement with respect of criminal laws: enforcement.

Now, different psychiatrists take different approaches to achieve this goal, but you will not find a single psychiatrist in good standing with organized psychiatry, including the author of this blog, disputing the fact that psychiatrists need a God given right to lock up people as they see fit, even though they might disagree among themselves what "they see fit" means.

In that regard, if anything, we need to thank E Fuller Torrey for unmasking those psychiatrists who want to "play nice"; he says it as it is. As long as you see psychiatrists, the risk that they will lock you up will be there, regardless of how nice they are to you.

Anonymous said...

Sorry for another posting, but there is no edit button.

This is the story published by Pete Earley on the son that killed himself ,

"The hospital admitted him only after I exaggerated his symptoms. It was the beginning of his resentment toward me. He didn’t believe there was such a thing as mental illness. He was convinced that psychiatrists and pharmaceutical companies were in cahoots to dispense medicine and make huge profits."

You cannot make this stuff up!!

Anonymous said...


As one who agrees with alot of your positions (not everything), using the example of someone whose son committed suicide to make your case is not good form. And many of those parents are in a tough position as eloquently expressed by one particular parent on the MIA site. This person felt that drugs were a disaster for her kid but desperately needed help for him that she can't find due to the drugs or nothing approach of mental health care in the US.

P-K, as always, a great post. You always hit the nail on the head.


Anonymous said...


I respectfully disagree with you.

These stories in which some parent laments that the "system failed" their children and then turn out to be stories of involuntary psychiatric assaults - in which the victim paid the ultimate price out of despair because the victim couldn't take it anymore and takes his/her own life- or because the families turn over the furniture and the victim dies at the hands of the police are nothing but public lynchings of the victims by their "alleged loved ones".

With love ones like these, who needs enemies!!!

Retired APRN said...

The comments so far seem to have concentrated on compulsory involuntary treatment. Another aspect is that of people who desperately seek treatment but do not receive it, not to mention the present short-stay paradigm that discharges people before there is a chance for psychotherapy or psychotropic medicine to make any kind of significant difference.

Back in the old days of the 1970s I worked at a state psychiatric hospital in California. In the years I worked there, I was a staff nurse on the admissions unit and the forensic unit, a head nurse on a long-term treatment unit and a nurse practitioner in the psychiatric emergency room.

People could present themselves asking for treatment, be referred by clinics or other settings or be placed on 5150 holds for 72 hours. The hospital was structured in a way that provided good continuity of care where required. There were "cottage" programs for gradual reintroduction to the community for people who no longer needed the more restrictive hospital environment.

Those who could not re-enter the community could stay for longer periods while a board and care, adult foster home or other situation was sought. They could work, hang out at the canteen (where there was pretty good food), go to the barber shop or beauty salon or just chill outside. Of course there were also ancillary therapies like OT and RT, too.

What I am saying is that we should not rush to throw out the baby with the bath water.

The system was a bit paternalistic, but some people need more support than others. That's not such a bad thing. These are the people who these days are being mistreated in jails and prisons or living on the street, vulnerable to terrible abuse and mistreatment.

Mental illness does not discriminate; it can strike anyone. If I became ill, I'd much rather be in a paternalistic hospital than homeless and vulnerable.

Anonymous said...

When you've been a family member who has tried mutiple times to get treatment for your loved one in full blown psychosis but the hospital says they are not sick enough, or the crisis line says call back when he tries to hurt you, then you will begin to understand why families feel they have no choice but to stretch the truth just to get a family member admitted. When you are dealing with a broken system where the rules are illogical and designed to prevent treatment at every turn, you might take desperate measures such as these. Until you have walked in their shoes and truly understood the circumstances they were up against just to get treatment, you have no right to judge. Talk to some families who have done involuntary commitments and get educated. You have no idea what you are talking about.

Anonymous said...

Dinah, the comments on this blog and elsewhere on the internet should be a clue to you and to all the other pro-force psychiatry zealots out there that people who live with mental illnesses are never again going to wind up like Rosemary Kennedy or Zelda Fitzgerald. The only reason those psychiatric concentration camps lasted as long as they did was that families could completely hide their barbaric aggression and deception from public observation, scrutiny, and disgust. Those "good old days" are gone for good. Punitive tactics are costly and cruel for both the psychiatric inmate and society. Creating attractive, sustainable, and safe programs that are entirely voluntary is, by far, the cheapest public health and safety option available. If I or someone I knew was railroaded by their family and the quasi-carceral psychiatric system, getting justice by any means necessary would be a lifelong mission for me. Angry ex-patients would make the riots in Chicago and Detroit during the 1960's look like a fracas at Wal-Mart on Black Friday. Tim Murphy has the potential to become this century's Joe McCarthy. We need to stop his efforts to legalize second-class citizenship for people living with mental illnesses before it's too late.

Anonymous said...

I am a different anon but I couldn't have said things better than the previous anon, specially,

"Tim Murphy has the potential to become this century's Joe McCarthy. We need to stop his efforts to legalize second-class citizenship for people living with mental illnesses before it's too late."

These pro coercive psychiatry zealots forgot Louis Brandeis' observation that "sunlight is said to be the best of disinfectants".

Do you, or Torrey, honestly believe that in the age of the internet -that allows survivors to connect via Mad In America and similar websites- you can go back to the obscure times when people were forcibly incarcerated for life by their "alleged" loved ones with nobody noticing?

Using a psychiatric term, I think that you guys are deluded. You and those of your kind will be looked at by future generations with the same disdain and contempt we currently look at KKK members.