From Bedlam- When Dr. Kenneth Rosenberg trained as a psychiatrist in the late 1980s, the state mental hospitals, which had reached peak occupancy in the 1950s, were being closed at an alarming rate, with many patients having nowhere to go. There has never been a more important time for this conversation, as one in five adults – 40 million Americans – experience mental illness each year. Today, the largest mental institution in the United States is the Los Angeles County Jail, and the last refuge for many of the 20,000 mentally ill people living on the streets of Los Angeles is L.A. County Hospital. There, Dr. Rosenberg begins his chronicle of what it means to be mentally ill in America today, integrating his own moving story of how the system failed his sister, Merle, who had schizophrenia. As he says, “I have come to see that my family’s tragedy, my family’s shame, is America’s great secret.”
Dr. Rosenberg gives readers an inside look at the historical, political, and economic forces that have resulted in the greatest social crisis of the twenty-first century. The culmination of a seven-year inquiry, Bedlam is not only a rallying cry for change, but also a guidebook for how we move forward with care and compassion, with resources that have never before been compiled, including legal advice, practical solutions for parents and loved ones, help finding community support, and information on therapeutic options.
Cheryl Roberts, executive director of the Greenburger Center for Social and Criminal Justice, says “Asylums never went away; they just grew into two varieties: posh for the wealthy (in the form of a handful of fancy $100,000-plus a year mental institutions) and prisons for the poor.”
Jonathan Sherin, MD, PhD, director of Los Angeles County Department of Mental Health, doesn’t mince words. He says we did not get rid of asylums in Los Angeles in the 1960s with deinstitutionalization: we just substituted the local asylum for an ‘indoor” one called the Los Angeles County jail and an “outdoor” asylum called skid row. John Snook, director of the Treatment Advocacy Center, agreed that the dismantling of the asylum was really “trans-institutionalization”- transferring the fate of patients from asylums to streets and prisons. We still hospitalize people, they are “micro-hospitalizations”, says Snook, referring to the average length of stay of three to five days. “The state of California is a canary in the coal mine from day one,” he said, because it emptied out its hospitals early. In 1975, the city’s “containment” policy squeezed people with substance abuse disorders, mental illness, and other disabilities into a fifty-block radius skid row- helping it become what a Los Angeles Times reporter called “a dumping ground for hospitals, prisons, and other cities to get rid of people with nowhere else to go.
According to Dr. Edwin Fuller Torrey (an American psychiatrist and schizophrenia researcher. He is the Associate Director of Research at the Stanley Medical Research Institute and Founder of the Treatment Advocacy Center), the United States currently has just 2 to 3 percent of the psychiatric treatment beds that we had sixty years ago: “We have so few beds available for people with mental illness that there’s nowhere to put them.” Because emergency rooms are legally required to treat anyone who comes through the door, people with serious mental illness (SMI) often wind up staying there for days or even weeks at a time waiting for a psychiatric treatment bed. We see that all across the country.
What Dr. Sherin, Snook, and many other policy experts hold partly responsible for this mess is the IMD (Institutes for Mental Diseases) exclusion rule, enacted in 1965 as part of the Medicaid and Medicare legislation. “The IMD exclusion explicitly prohibited Medicaid from paying for patient care in state or private hospitals that specialize in mental health care. It prohibits federal Medicaid payments for services delivered to individuals aged twenty-two to sixty-four years residing in IMDs, defined as “hospitals, nursing homes, or other institutions with more than sixteen beds that are primarily engaged in providing diagnosis, treatment, or care of persons with ‘mental diseases’ other than dementia or intellectual disabilities. To repeat- no mental hospital with more than sixteen beds.”
ACMI is encouraged by some recent actions:
· One sign that America is waking up to our mental health crisis is the 21st Century Cures Act of 2016, which provided additional research and treatment reforms.
· The creation of a mental health czar position in the Department of Health and Human Services now occupied by Dr. Elinore McCance-Katz, MD, Ph.D.
· Dr. Elinore McCance-Katz, MD, PhD. has returned to SAMSHA with a priority to address Serious Mental Illness, something that had not been a priority at SAMSHA for years.
· SAMSHA focusing on evidence-based practices.
· The recent White House Mental Illness summit (see links below)
· Increased discussion about changes to the IMD exclusion
· The rise of celebrity candor about their personal experiences with mental illness.
In Arizona we are fortunate to have strong laws to help persons with SMI that do not have the insight to understand they are ill. We are often contacted by families from other states that do not have our strong laws.
Arizona will also lead the nation is providing a new level of care that is less restrictive than a level 1 psychiatric hospital, but more than community living. This level of care – secure residential treatment – will be a closely monitored program that will assist the chronically mentally ill in their recovery.
Below please find information mentioned in the Summit along with full video coverage and a transcript of President Donald J. Trump’s remarks.
- C-SPAN Coverage of White House Mental Health Summit
- Remarks by President Trump at the White House Mental Health Summit
- Secretary Alex Azar’s Remarks at the White House Mental Health Summit
U.S. Department of Housing & Urban Development (HUD)
- Request for Information: White House Council on Eliminating Regulatory Barriers to Affordable Housing
- Press Release: HUD Issues Request for Information on Eliminating Regulatory Barriers to Affordable Housing
Office of National Drug Control Policy (ONDCP)
- National Drug Control Policy Strategy: Establishes the Administration’s priorities for addressing the challenge of drug trafficking and use
- Federal Rural Resources Guide: A listing of Federal programs that can be used to address substance use disorder and opioid misuse in rural communities
- Community Assessment Tool: Provides a snapshot of county-by-county data about drug overdose deaths and socio-economic conditions in a county to help leaders build grassroots solutions for prevention, treatment and recovery
- School Resource Guide: Guide for teachers, administrators and staff about resources available to help educate and protect students from substance misuse
- Treatment Services Locator: Mentioned in the Federal Leaders Perspective Panel
- Google Drug Takeback: Mentioned in the Federal Leaders Perspective Panel
U.S. Department of Justice (DOJ)
- Press Release: Justice Department Awards More Than $333 Million to Fight Opioid Crisis
- Justice and Mental Health Collaboration Fact Sheet
- How to Reduce Repeat Encounters: A Brief for Law Enforcement Executives
- Overview of Law Enforcement-Mental Health Resources
- Resources and Publications to Improve State and Local Systems in Cross-System Collaboration
- Housing Assistance Grants for Victims of Human Trafficking