Emergency doctor to Trump: You are wrong, mental illness ...

 Much as it pains me to say it, President Trump is dead wrong about the issue of mental illness in the wake of mass shootings, stating that long-stay psychiatric hospitals, which are necessary for those with intents to harm themselves or others, were emptied out and closed in the 1960s for budgetary reasons.  It did happen, but it was called “deinstitutionalisation,” at the time. It occurred not primarily for cost-saving reasons, but largely because of  “a series of socio-political movements that campaigned for patient freedom.”

I first heard Mr. Trump say what he did about the costs of those closings last week at his New Hampshire rally as he addressed gun issues, the mentally ill, and the homeless problem:

Years ago, many cities and states, I remember it so well, closed mental institutions for budgetary reasons. They let those people out onto the street….[T]hey let really seriously mentally ill people out on the streets, and you see plenty of them today, even today.

Mr. Trump is also wrong in his proposed solution to the problem:

We’re going to have to give major consideration to building new facilities for those in need. We have to do it. And at the same time, we will be taking mentally deranged and dangerous people off of….the streets so we won’t have to worry so much about that….We don’t have those institutions anymore and people can’t get proper care. They’re seriously ill people and they’re on the streets.

Mr. Trump used very similar words on the tarmac Sunday as he was returning from Bedminster to Washington:

…I was talking about mental institutions. They closed so many — like 92 percent — of the mental institutions around this country over the years, for budgetary reasons. These are people that have to be in institutions for help. I’m not talking about as a form of a prison. I’m saying for help. And I think it’s something we have to really look at — the whole concept for mental institutions.  I remember, growing up, we had mental institutions. Then they were closed — in New York….And all of those people were put out on the streets. And I said — even as a young guy, I said, “How does that work? That’s not a good thing.” And it’s not a good thing. So I think the concept of mental institution has to be looked at.

Notice his emphasis on “mental institutions.”  Yes, we need to build mental institutions (long-stay psychiatric hospitals), but we also need to build basic housing units. Getting the people he’s talking about into them is not going to be easy.

Just as costs are not the cause of the problem of the homelessness of so many of the mentally ill, the building of facilities as he wants to do is not, in itself, the solution. Furthermore, there are beds available now or which could rapidly be made available, but getting the homeless into those beds is a near-impossibility as things now stand.

Mr. Trump is almost certain to say these things again.  But I want to weigh in here because I think that as the gun issue develops he is going to make addressing the homelessness of the mentally ill a big part of the debate.

It shouldn’t be.  I cannot think of a single instance of a mentally ill homeless person carrying out a mass shooting of the type we’ve seen lately.  I think all of these shooters lived in a private home of some kind with at least one close relative as did the three potential shooters apprehended this past weekend.

The hue and cry these days amongst politicians and pundits is to do something, anything, to get and keep guns out of the hands of dangerous mentally ill people. But it should be to get those people into institutions and to keep them there until they are no longer dangerous.  The three potential shooters apprehended this last weekend will go to jail, if convicted, and not into long-stay psychiatric hospitals where they probably belong.

Getting dangerous mentally ill now people living in private homes into institutions and getting dangerous mentally ill people now living on the street or under a bridge into institutions may be two sides of the same coin, but they should not be conflated.  Nor should gun control and institutionalization be conflated.

My purpose is to focus on the reinstitutionalization of the mentally ill and to leave gun control and things like Red Flag laws for another time or to others.

I’ll get into reinstitutionalization shortly, but let’s first look at how we got to this sorry state of affairs.

Taking actions in cases of dangerous mentally ill people living in private homes is not particularly difficult now.  Most, if not all, states have some variant of Florida’s Baker Act  “that enables families and loved ones to provide emergency mental health services and temporary detention for people who are impaired because of their mental illness, and who are unable to determine their needs for treatment.”  This temporary detention is usually done at the nearest hospital that has an inpatient psychiatric unit.

Police, judges, physicians, clinical psychologists, psychiatric nurses, mental health counselors, marriage and family therapists, or clinical social workers can also initiate the process, but big problems arise after 72 hours if it is determined that further treatment is required.

That is when deinstitutionalisation and Mr. Trump’s ideas come into play.

The lead-up to deinstitutionalisation was prompted, in the first instance, by the serendipitous discovery that certain drugs helped the mentally ill:

In 1949, John Cade…discover[ed] that lithium sedated people who experienced mania….[and, it has become]the standard treatment for the disorder….[and in a] French hospital….chlorpromazine, later named Thorazine, was….[accidentally found to be] the first drug [suitable for] treatment for schizophrenia—a development that encouraged doctors to believe that they could use drugs to manage patients outside the asylum, and thus shutter their institutions….[These discoveries] held out the hope that mental illness could be treated in the same way as pneumonia or hypertension: with a single pill.

Solving the problem of treating mental illness primarily with drugs is just another liberal magic bullet that ended up missing the target.  For example, large numbers of the mentally ill stop taking their medications often because the side effects of psychotropic drugs can be quite unpleasant.  And many manics and schizophrenic people prefer those states to the states they feel on medication.  Stigma, feelings of dependence, and like reasons inhibit others from taking their medications.

But that magic bullet also fit into and fed quite nicely other “virtuous” liberal concepts:

[After]…the development of psychiatric drugs….society accepted that the mentally ill needed to be treated instead of locked away….[and] federal funding such as Medicaid and Medicare went toward community mental health centers instead of mental hospitals….

[In 1955 there were just over 500,000]…patients in public mental health hospitals….[suffering from] schizophrenia, bipolar disorder…depression….organic brain diseases….mental retardation combined with psychosis, autism, or brain damage from drug addiction. Most patients were not expected to get better given the treatments at the time….[Later] community health centers [were] set up to treat those with less severe mental illnesses….[And] “One Flew Over the Cuckoo’s Nest”….a fictional story about abuses in a mental hospital….helped turn public opinion against electroshock therapy and lobotomies.

….[Then came] community-based mental health facilities….[providing] prevention, early treatment, and ongoing care….[that] would allow patients to remain close to their families and be integrated into society. But…75 percent of those in hospitals had no families….[and later Medicaid funded] health care for low-income families….[but it] did not pay for care in mental hospitals. As a result, states transferred those patients into nursing homes and hospitals to receive federal funding.

[In 1967 California’s…Lanterman-Petris-Short Act….limited a family’s right to commit a mentally ill relative without the right to due process….[but it] doubled the number of mentally ill people in California’s criminal justice system the following year. It also increased the number treated by hospital emergency rooms. Medicaid covered those costs.

[By 1977 community health centers….served 1.9 million patients….and] were designed to help those with less severe mental health disorders. As states closed hospitals, the centers became overwhelmed with those patients with more serious challenges.

So, where we find ourselves today is that, because of the above and other actions, dangerous mentally ill people living in private homes can be forced to be evaluated but they cannot be forced into non-existent long-term psychiatric institutions (except for the criminally insane), they cannot be forced into community centers, and they cannot be forced to take medications.

Any plan Mr. Trump comes up with will have to include the passage of a new set of laws that will overcome those realities.  Good luck with getting this Congress to do that!

Unlike in the movies, if Trump rebuilds the institutions, the potential patients don’t have to come.  Donald Trump, the developer extraordinaire, might be able to produce new institutions, but only the willing will come to them: Getting unwilling, dangerous mentally ill people into institutions is impossible under the current legal framework.

My college sociology class went on a field trip to a long-stay psychiatric hospital in the early 60s, and the place was grim, indeed, but not Bedlam.  In the early 1990s I was a case manager serving about 50 schizophrenics in a communal facility that was an improvement over the long-stay psychiatric hospital I had earlier visited, but any of my clients were free to move out to the street at any time.  Additionally, only one or two of my clients were potentially dangerous whether living in or out of the facility.

Deinstitutionalisation was and is another liberal notion gone horribly wrong. But it is just one of the reasons why major, mostly Democrat-run cities have huge, filthy encampments of indigent, mentally ill people living in the streets.  Reinstitutionalisation in new facilities for the placement and the keeping of the severe and the dangerous mentally ill is needed.  That will eliminate almost all of those encampments, but that will not happen before changes of attitudes occur and not before new laws replace bad, old laws.

Unfortunately, despite Mr. Trump’s notions, I don’t foresee those transformations materializing any time soon.  Moreover, someone needs to tell Mr. Trump that if he wishes to get guns out of the hands of the mentally ill, he must focus not on finding a way for the reinstitutionalization of the mentally ill living on the streets but on finding a way for the reinstitutionalization of the mentally ill living in private residences.