This month, we mark the 50th anniversary of the assassination of President John F. Kennedy. Less heralded is another significant anniversary that passed a few days ago: Oct. 31 was the 50th year of a profound shift in mental health policy - the last policy, as it turns out, that Kennedy signed before his untimely death.
This month, we mark the 50th anniversary of the assassination of President John F. Kennedy. Less heralded is another significant anniversary that passed a few days ago: Oct. 31 was the 50th year of a profound shift in mental health policy - the last policy, as it turns out, that Kennedy signed before his untimely death.
This policy, the Community Mental Health Centers Act of 1963, was designed to reduce costs of mental health treatment, increase access to effective community-based mental health services, and put an end to the horrific warehousing and abuses of the asylum system.
Unfortunately, the policy, which aimed to move the mentally ill safely out of institutions and asylums and into the community, where they might be treated more humanely at local outpatient centers and integrated into the community, failed miserably.
The results, particularly in a city like Houston, are everywhere: under overpasses, on street corners, in emergency rooms and in the overburdened Harris County Jail. We drive past these people every day, shutting our eyes, desperately hoping that, if we pretend they don't exist, the problem will go away.
How did we get here? The shift in policy began with the best of intentions. Kennedy's sister, Rosemary, suffered from mild mental retardation and severe mental illness; and had undergone a lobotomy, a horrific procedure in which part of her brain tissue was destroyed in a crude effort to end her symptoms. This personal connection, combined with exposés on mental asylum abuses, led Kennedy to a monumental policy decision: to move the mentally ill into the community by opening and funding Community Mental Health Centers where they could be treated.
Unfortunately, Kennedy's assassination took the major driver of comprehensive change, and the momentum began to falter. Funding went elsewhere, especially toward the Vietnam War and newly developed social safety-net programs such as Medicaid and Social Security disability benefits. As a result, the planned community mental health centers failed to materialize to any meaningful degree. States saved money by driving those with mental illness out of institutions. Many thrived, but the severely mentally ill often were left with nowhere to go, no social supports, and no outpatient care. Judicial decisions eventually guaranteed that no person with mental illness could be treated without personal consent. While requiring consent might be good in the abstract, a psychotic patient who thinks his doctor is a demon is hardly capable of informed consent. Soon, it was nearly impossible to rehospitalize those set out into the community. By the 1980s, homelessness had skyrocketed and the prison and jail population had grown exponentially, a huge percentage of both now psychotic.
What happens when we leave treatment up to those who are too ill to choose treatment? Do we let them languish in the streets and overburden our legal system? Even if that were humane, what are the costs? A visit to the emergency room costs much more than consistent care, and a year in jail costs more for a mentally ill inmate because of increased medical costs. Even being homeless costs the community. Then, there are the tragedies: mentally ill people who, unmedicated and alone, devastate communities with violent acts.
What can we do? We can save lives, those with mental illness as well as the possible victims of acts of violence - which are rare, but always devastating. We can drive down costs through consistent care instead of emergency care and prison-based care. We can invest in Assisted Outpatient Treatment and Assertive Community Treatment, recognizing that "treatment before tragedy" saves lives. We can learn who has a history of medication noncompliance and potential problems resulting from that, such as misdemeanor crimes and chronic homelessness, and monitor the treatment of those who are the most ill, mandating them to remain in treatment, the basis of Assisted Outpatient Treatment, in order to remain in the community. We can help those who recognize they are ill but need support find Assertive Community Treatment communities, where they get more support than in traditional community mental health. We can be the compassionate society we've always projected to the world, treating the poorest and sickest among us instead of leaving them to rot in the streets and in jails.
It's time to treat those who are most vulnerable instead of closing our ears and our hearts and pretending they don't exist.
