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The Human Cost of Deinstitutionalization
Winter 1993

For nearly seven years, Larry Hogue, a schizophrenic crack addict, has terrorized the residents of West 96th Street. Thousands of people with similar disorders live on the streets of New York, but negligent mental health policies and misguided legal decisions prevent officials from protecting the public or providing effective psychiatric care to those who desperately need it.

“I’m going to kill you,” Larry Hogue muttered to Lisa Lehr as she got out of her car on the night of January 5, 1992. Hogue, a mentally ill crack addict, was an all too familiar fixture on West 96th Street, where Lehr, a 54-year-old retired teacher and community activist, lives. With determined New York bravura, Lehr decided to ignore his threat, and quickly crossed the street to her apartment. When she looked out the window a few minutes later, she saw the burly Hogue smash a marble bench through the window of her car, bending its frame. Hogue then defecated in the back seat.

It was a typical night out for Larry Hogue. For years he had terrorized Lehr’s neighbors—vandalizing cars, setting fires, threatening elderly people and children, once even pushing a girl in front of an oncoming truck. Whenever the community sought the help of the authorities, their advice was always the same: Drop dead. Unless the community could produce a dead body on Hogue’s account, neither the mental health nor the criminal justice system was prepared to keep him off the street. As if to drive the point home, an employee in the Manhattan District Attorney’s Office once handed Lehr, who was leading a community effort to commit Hogue, a flyer for “Homicide Victims Support Groups.” The flyer was for her husband—in case Hogue got to her before the authorities decided what would be the reasonable thing to do with him.

However macabre this incident, it seems no more bizarre to the residents of West 96th Street than the normal procedures of New York’s mental health system. Hogue has been brought into psychiatric emergency rooms innumerable times over the years in a drug-induced psychotic state, only to be discharged within days to begin the cycle again.

West 96th Street’s as-yet-unsuccessful struggle to break that cycle has proven one of the more surreal forays into the bureaucratic morass. Lehr and her neighbors have encountered enough official blundering and callousness to make even the cynical New Yorker weep. More importantly, their efforts to commit Hogue have illuminated every facet of the therapeutic and social disaster known as “deinstitutionalization.” This was the process whereby the most venal instincts of state legislatures combined with civil-libertarian ideology run amok to destroy the system of care for mental patients. The mentally ill now enjoy a full panoply of legal rights. Unfortunately for them, these rights often prevent them from receiving effective treatment. As a result, thousands of increasingly violent mentally ill are being turned away from hospitals to wreak havoc on communities like the Upper West Side.

Nightmare on 96th Street
When Hogue first arrived in the neighborhood about seven years ago, he seemed relatively harmless. Residents, including Lehr, fed him and gave him blankets. But something was not right: Hogue was homeless, despite receiving a $36,000 annual tax-free pension from the Veterans Administration for a brain injury he suffered in Vietnam.

Hogue was addicted to crack. He was also schizophrenic, a condition one of his former doctors believes was aggravated by his war injury. As his addiction worsened, so did his madness. He developed certain signatures: garbage strewn on the sidewalks, an entire block of cars with gasoline-soaked rags stuck in their gas tanks and their side-view mirrors broken off, fires smoldering under cars and in the street.

Residents also learned that Hogue holds a grudge. The second time he broke Marilyn Boutwell’s car windows, she filed charges. Since then, she says, “he has threatened me with a lead pipe, and he has leapt out at me at night.” When a woman politely referred Hogue to a local soup kitchen instead of giving him money, he chased her into her building and began screaming and pounding on the windows in the vestibule when he was unable to get through.

Hogue often hurls himself into traffic. He jumps onto moving cars and pummels the windshields. In 1992 alone, he caused $10,000 in damage to the landmark Christian Science Church on 96th Street and Central Park West by hurling cinder blocks through its stained-glass windows. For three years, the church has requested relief from Mayor Dinkins’s “Action Center.” It has yet to receive a response.

Children and the elderly have been among his targets. Michael Oliver has seen Hogue “jump out from hiding and grab passing schoolchildren, screaming obscenities.” Oliver says they often flee into moving traffic. Many neighborhood children are now terrified to go outside; at least one is in therapy. Lehr has seen a club-wielding Hogue chase an elderly woman down the street.

In 1988, a 16-year-old girl was walking home from school when Hogue punched her in the stomach and pushed her in front of a Con Edison truck, which swerved in time to avoid hitting her. A jury found him guilty of reckless endangerment but acquitted him of attempted murder; he was sentenced to one year in prison. The girl and her family subsequently moved upstate.

Hogue has been arrested at least nine times in New York on charges including attempted murder, assault, robbery, weapons possession, and criminal mischief. He has been sentenced to prison six times since 1984; the one-year term was his longest.

Hogue has been an even more frequent, though always fleeting, presence in the mental health system. According to Robert Spoor, spokesman for the State Office of Mental Health, Hogue has been in and out of mental hospitals since 1972, but he has never been hospitalized for longer than six months. Usually the hospital releases him within 24 hours after the police bring him in. The city’s psychiatric emergency rooms are intimately familiar with him. On one occasion the police were turned away from six emergency rooms with Hogue restrained in their back seat.

By the time Hogue smashed Lisa Lehr’s car, her neighbors had organized their lives around him. Whoever first spotted the telltale garbage strewn over the street or the rags in the gas tanks would notify the neighbors that “Larry’s back,” so that people could stay off the streets until the police picked him up again.

When Lehr went to the 24th Precinct to file charges, she discovered that officers had “massive dossiers” on Hogue. Realizing that many of her neighbors must be among the victims, she began making calls. Within 48 hours, people were calling and writing her. “They had been in hiding and were only now coming out, because they said they did not want to be ’posthumous,’” she explains.

Soon after Lehr filed her complaint, Hogue again went out of control and was taken to the Manhattan Psychiatric Center, a state hospital on Ward’s Island. Heidi Higgins, one of the police officers who had picked Hogue up, organized a meeting at the hospital of Hogue’s medical team, nine of his victims, herself, and another police officer.

The meeting at Manhattan State, Lehr says, was “demoralizing and frightening.” The hospital staff told the victims, “Hogue is more violent than you think, but we can’t tell you what’s in his record.” Many of the community representatives were crying. “Why are you telling us this,” they pleaded, “without protecting us?” According to Linda Mayers, another resident of 96th Street, Hogue’s medical team answered that they were “unable to hold him because of his rights.” When the effect of the crack wears off, the hospital team claimed, “he becomes a model patient, and we have to release him.”

An agreement was reached at the meeting: If the hospital decided against involuntarily committing Hogue, it would notify the community and the District Attorney’s Office so that Hogue could be arrested on Lehr’s complaint immediately upon his discharge.

That evening, Lehr says, she received an unofficial phone call from one of Hogue’s caseworkers. The caseworker said she was terrified for the community, because Hogue was “homicidal” and the residents of West 96th Street were “all PIVs— potentially identifiable victims.” In her opinion, the medical team had portrayed Hogue as a model patient as a pretext for releasing him. In truth, she said, they simply did not want him on their ward. Having assuaged her conscience by passing along the information, the caseworker told Lehr, “Now we [the medical team] can sleep.”

On January 22, Manhattan State broke its promise: It released Hogue without notifying anyone. On February 1, Hogue was arrested after becoming violent. It took seven officers to pick him up and take him to Bellevue for evaluation. He was released on February 3 to police custody.

The same day, City Council President Andrew Stein wrote Richard Surles, the state commissioner of mental health, urging an in-depth review of Hogue’s case, followed by long-term treatment. The letter he received in reply from Robert Hettenbach, regional director of the State Office of Mental Health, speaks volumes about New York’s mental health system.

Hettenbach informed Stein that Hogue was in Manhattan Psychiatric Center from November 21, 1991, until January 22, 1992—a patently false statement, since he smashed Lehr’s car on January 5. Hettenbach further claimed that the hospital discharged Hogue to live with a relative in New Jersey, with after-care provided by the East Orange VA Hospital and a Narcotics Anonymous group—a fantasy scenario. Hogue’s brother in New Jersey reportedly has refused to have anything to do with him since Hogue allegedly attempted to burn his house down. Finally, Hettenbach wrote that there was no record of Hogue’s admission to Bellevue in early February. (In a subsequent interview, Hettenbach said he got his information from the central registry of the Office of Mental Health, a system he termed “quite accurate.”)

The letter’s conclusion is cruelly ironic: “We will continue to work with the community, police, and other agencies as needed to address Mr. Hogue’s complex service needs.”

On February 4, Hogue was arraigned on Lehr’s complaint. Bail was set at $2,000 on April 15. By that time, Assistant DA Paul Schechtman had become actively involved in the case. During pretrial negotiations in March and April, Schechtman had tried to persuade the VA hospital in the upstate town of Montrose to accept Hogue for three months in its inpatient drug rehabilitation program. Hogue was initially eager to enter the program, but later became recalcitrant. Montrose declared that it would accept him only on a voluntary basis.

Around the same time, one of Hogue’s former doctors also became involved in the effort to secure long-term treatment for him. As director of the emergency psychiatric room at St. Luke’s Hospital from 1977 to 1990, Dr. Michael Pawel saw Hogue at least a dozen times. Known on the wards as “Treat ’Em and Street ’Em” for his opposition to involuntary commitment, Pawel nevertheless wrote Montrose twice urging that Hogue be confined. Hogue was, in Pawel’s words, such “a mess” that “any competent doctor would know he was dangerous.”

On April 30, Hogue made bail, returned to West 96th Street, painted himself green, and went on a rampage. It took four police officers to calm him down and take him to St. Luke’s. This time, Schechtman explains, doctors determined that Hogue “presented himself as truly dangerous” and could be held involuntarily for sixty days. Schechtman secured Hogue’s transfer to Montrose. At the end of May, however, the VA doctors decided, according to Schechtman, that Hogue was no longer an “imminent danger to the community” and released him. Hogue eventually pled guilty to criminal mischief, served the remaining two months of an eight-month sentence, and left prison on Saturday, August 15.

The next day Lehr got a call from St. Luke’s. A hospital official told her that Hogue had just left the hospital after walking in and demanding money for drugs; he couldn’t cash his VA check until Monday. The official told Lehr that Hogue could not be held because he had entered voluntarily, but did offer Lehr some helpful advice: “Watch out, because the drugs will make him violent.”

The next morning, a camera crew from “60 Minutes” was waiting at Hogue’s bank. It filmed him cashing his benefit check, going to a crack-house to get high, and descending into complete psychosis. During that week, Hogue was picked up on Wednesday and released from St. Luke’s on Thursday, then picked up, straitjacketed, on Friday and released later the same day. When he was not traveling between 96th Street and St. Luke’s, Hogue roamed the neighborhood with a machete, screwdriver, and ice pick sticking out of his pockets.

On August 23, Andrea Kerzner-Torgovnik saw Hogue scrape the length of her car with a long knife. She filed charges. At his arraignment, according to police, Hogue threatened the judge, accused Schechtman of assassinating John Kennedy, and had to be put in restraints. Hogue was held at Bellevue until December 7, when a judge declared him competent to stand trial. At this writing, no trial date has been set.

Undoubtedly spurred by the media storm surrounding the case last summer, city, state, and federal officials have established an “Interagency Treatment Coordination Group” to resolve the Hogue problem. The list of agencies represented illustrates the labyrinth that the mental health system has become: the VA hospital at Montrose; the Visiting Nurses Service of New York City; the Manhattan DA; the State Office of Mental Health; the Office of Mental Health Bureau of Forensic Services; the City Department of Health; the City Department of Corrections; Project Help; the 24th Precinct; the City Department of Mental Health Forensic Psychiatry Clinic; the Department of Mental Health Crisis Assistance and Training Unit; St. Luke’s emergency room; Bellevue; the Health and Hospitals Corporation; and the City Department of Mental Health, Mental Retardation, and Alcoholism Services.

The Bureaucratic Muddle
There is an official and an unofficial explanation for why Hogue is continuously discharged from the hospital without receiving long-term care. These are matched by official and unofficial versions of Hogue himself. The official explanation was offered to Lehr and her neighbors at Manhattan State: Hogue is brought to the hospital after taking drugs and “decompensating” on the street; in the hospital, the crack clears from his system and he no longer poses a danger to himself or others; the law allows the involuntary retention of patients only if they are dangerous; therefore, when Hogue stabilizes, he must be discharged.

The farther one is from the fray, the more compelling this logic becomes. In Albany, it is all but irrefutable. Robert Spoor of the State Office of Mental Health insists that “when Hogue’s condition improves, the responsible thing is to allow him to leave.”

The official Hogue is a Jekyll-and-Hyde figure—docile when treated, a terror on the streets. But officially, even the Hyde component is not so troubling. “The charges against Hogue have always been misdemeanors,” Spoor points out. (In fact, Hogue has been charged with, though not convicted of, felonies.) Spoor adds that Hogue “has never done substantial harm.” When asked if he did not consider pushing a girl in front of a truck “substantial harm,” Spoor conceded that he did, but quickly countered with the rhetorical question of whether Hogue had ever been convicted of a felony.

The unofficial explanation surfaced in Lehr’s conversation with Hogue’s caseworker: Hogue is always discharged because he’s a pain in the neck. The unofficial Hogue is never a model patient. “You can’t turn your back on him because he will be climbing up the walls to dismantle the lights, or destroying furniture,” says Pawel, his former doctor. Pawel says the law provides ample authority to commit Hogue, who is “one of the very few who actually meet the standards for long-term commitment.” No one is using the available legal authority, however, because no one wants Hogue on his ward, according to Pawel. Not only is he disruptive, but because he is not going to get better, he is ungratifying to work with. Most importantly, he would ruin a hospital’s “stats.”

For budgetary reasons, hospitals are under pressure from the State Office of Mental Health to decrease their patient populations. When Albany issues a mandate to cut a hospital’s census, Pawel says, “it’s Hogue that’s going to get cut.”

The mental health system is particularly ill-equipped to treat “dual diagnosis” patients, those who suffer from both psychosis and addiction. Drug addiction is not included in the statutory definition of “mental disorder.” As a result, according to city Mental Health Commissioner Dr. Luis Marcos, mental health professionals feel “disempowered” to treat someone “just” because he is high. Drug treatment programs, meanwhile, turn away mentally ill patients, because the combination of street drugs and psychotropic medication can be lethal.

Dr. Gregory C. Bunt, director of the Mentally Ill Chemical Abusers program at the Manhattan Psychiatric Center, argues that current law makes it impossible to offer effective treatment to patients who suffer from both psychosis and addiction. (Bunt headed Hogue’s treatment team at Manhattan State in January 1992, but will not discuss the specifics of the case.) According to Bunt, New York’s treatment system offers only two options of care: commitment in a locked ward or release to the streets. Rehabilitating drug addicts, however, requires graduated levels of responsibility and freedom in order both to provide incentives and to test compliance.

Furthermore, mentally ill addicts need real long-term care—at least a year—in a residential program. But, Bunt says, even “a few extra weeks of treatment is considered ’long-term’” by judges who make commitment decisions.

There are programs for mentally ill substance abusers, but they are overcrowded and their patients are almost all either voluntary or probated from the criminal courts. According to Bunt, two factors inhibit civil judges from committing patients to such programs. First, judges know that “if they set a precedent, we will need to create the facilities.” Second, the commitment decision is unenforceable: If a patient “elopes” from a drug treatment program, a civil judge has no legal authority to order him back.

Additionally, the law prohibits commitment if there are “less restrictive alternatives available.” As Bunt explains, a judge feels compelled to release a clean, sober patient who assures him that he is not a danger and will seek outpatient drug treatment upon release—especially if he knows that committing the patient for a few more weeks will accomplish nothing. The judge cannot ensure, however, that such a patient remains true to his word.

The Deinstitutionalization Disaster
At the root of both explanations of the Hogue debacle lies the legal rule that a mentally ill patient can be committed only if he is a danger to himself or others. This “dangerousness” standard either compels (the official explanation) or provides a pretext for (the unofficial explanation) the discharge of the still-addicted, still-psychotic Hogue as soon as his symptoms abate. Yet though he may momentarily not be dangerous, Hogue’s release does him no service, since it is obvious that he desperately needs treatment.

How did we arrive at a point where hospitals not only refuse treatment to those most in need of it, but claim they are obligated to do so? The excesses of deinstitutionalization have resulted from the unhappy conjunction of two powerful forces: a civil libertarian ideology indifferent to social consequences, and the state’s eagerness to cut its mental health budget regardless of the human costs. Though their motives differed, the cost-cutters and the libertarians shared a common purpose: to evacuate, then close the door to, the state hospitals.

Deinstitutionalization was born out of revulsion at the often barbaric conditions of state hospitals at the end of World War II and optimism about new methods of treating mental illness. Proponents argued that recently discovered antipsychotic drugs would allow patients to lead normal lives outside institutions. But while some patients benefited from the reorientation of mental health policy, others were denied the only thing that could help them: intensive, long-term care.

The first major legislative initiative of the deinstitutionalization movement was the federal Community Mental Health Centers Act of 1963 (CMHC Act). The act provided seed money for a nationwide system of mental health centers that was intended to render state hospitals obsolete.

Deinstitutionalization proved irresistible to state governments, which embraced it as a way to save money. During hearings on the CMHC Act, the doctors who testified were questioned most often about the act’s supposed cure-all effect on states’ ballooning mental health budgets. Spending on hospitals had increased dramatically because of the unionization of hospital workers and the eight-hour working day. By discharging patients to the promised federally subsidized community health centers, states expected to reap significant savings. Subsequently enacted federal benefits such as Medicare, Medicaid, and Supplemental Security Income increased the incentive for states to discharge patients, because such benefits were only available to patients outside state hospitals.

The subsequent history of deinstitutionalization can be quickly summarized: Patients got dumped, and the community facilities that were supposed to care for them never materialized. Nationwide, only half of the two thousand community centers projected by the CMHC Act were ever built; New York State got 31 of the 100 that had been planned. The centers that were built decided early on that they preferred to treat what Dr. E. Fuller Torrey of the Public Citizen Health Research Group calls the “worried well”—people suffering from minor psychological problems or acute disorders such as depression—rather than those with chronic severe illness. The worried well were more responsive to treatment and better able to pay.

Untreated chronic patients, released in huge numbers during the 1960s and 1970s, drifted to SROs and welfare hotels. When the low-income housing stock dried up in the 1980s, the mentally ill migrated to the streets.

By the early 1970s, virtually all of the untoward consequences of deinstitutionalization were already well in evidence: a dramatic increase in the rate of violence by the mentally ill, disorder in local communities, the absence of community care, and an increased burden on the criminal justice system from what Torrey has called “the criminalization of psychosis.” Jails and prisons have become the asylum of last resort for seriously ill patients who are denied medical treatment.

Yet New York continued to empty its hospital beds. The state hospital population was cut from 80,000 in 1967 to 33,000 in 1975. Four years later, 16,000 former mental patients were living in New York City’s SROs and welfare hotels, receiving no medical care. By 1974, 28 percent of discharged patients were being readmitted within six months for failure to take their medication. Yet in 1977, the state’s Mental Hygiene Department reiterated its commitment to “letting its large institutions ’run down,’” with the intention of transferring the money saved to the counties. This “hospital dividend” never materialized.

To this day, Albany continues to empty its mental hospitals: According to Robert Spoor, spokesman for the State Office of Mental Health, the state plans to decrease the hospital census from the present 11,000 patients to 6,000 by the year 2000.

The dumping of patients is abetted by the diffusion of responsibility for their care. Torrey has written that the “convoluted array of federal, state, and local government programs [with fiscal responsibility for the seriously mentally ill] would make Rube Goldberg proud.” The splintering of authority is even worse in New York, he said in an interview, “because the state and the city don’t talk to each other.” Torrey added that the “biggest issue for the [State] Office of Mental Health is how to shift costs to the Federal Government.”

Lawsuits aimed at improving the conditions of mental hospitals have also created perverse incentives to dump patients onto the street. Since the 1970s, civil libertarians and advocates for the mentally ill have won a variety of consent decrees dictating minimum staff-to-patient ratios, standards for treatment, and financial liability for improper commitment. Regrettably but predictably, hospitals achieved the required staff-to-patient ratios not by hiring new staff but by indiscriminately discharging patients. They minimized the risk of lawsuits by not admitting patients in the first place.

Some of the doctors who pressed for deinstitutionalization in the early 1960s have since had second thoughts. In 1984, Dr. Robert Felix, who had been director of the National Institutes for Mental Health (NIMH) in 1963, acknowledged that “many of those patients who left the state hospitals never should have done so.” Dr. Bertram Brown, another former NIMH executive, admits that “the doctors did not believe that community care would cure schizophrenia.... We knew that there [were] not enough resources in the community to do the whole job, so that some people would be in the streets . . . and questions would be raised about the necessity to send them back to state hospitals.”

The Civil Libertarians
Most of the doctors who initially supported deinstitutionalization did so out of a humanitarian concern for mental patients who were suffering under atrocious conditions in state mental hospitals. But some theorists went much further: R.D. Laing, Erving Goffman, Herbert Marcuse, and Thomas Szasz taught that mental illness had no clinical reality, that psychosis was merely a “label” applied by society to certain “nonconformist” behaviors. “Where is the illness?” Szasz asked in a 1991 letter to the New York Times, and answered: “In the eye of the beholder—and the power of the definer.... ’Psychiatrists’ prefer to treat diseases that do not exist.”

The theories of Szasz and others were seized upon by civil liberties lawyers, who saw involuntary treatment of the mentally ill not as a paternalistic exercise of state power for a therapeutic end, but as a deprivation of liberty tantamount to incarceration.

“Mentally ill persons seemed particularly appropriate targets for a crusade against governmental power,” writes Dr. Paul Appelbaum of the University of Massachusetts Medical School, a critic of deinstitutionalization. “The state was depriving them of liberty—with ostensibly benevolent aims, yet in conditions that belied the goal of treatment.” The patient’s welfare was not necessarily the chief concern of the libertarians either, however. “Lawyers are doing what they think is right in terms of civil rights, whether it is good for the person or not,” the Times quoted Bruce Ennis, then a lawyer with the New York Civil Liberties Union (NYCLU), as saying in 1974.

The civil liberties bar succeeded in transforming the issue of commitment from a medical question into a legal one. The law had allowed involuntary commitment for patients “in need of treatment.” Civil libertarians argued that the patient’s “liberty interest” was of paramount importance: Unless someone was a danger to himself or others, he had a constitutional right to be left alone. In 1975, the U.S. Supreme Court accepted this argument, ruling that “dangerousness to self or others” was the only constitutionally permissible criterion for involuntary commitment.

Since commitment involves a deprivation of liberty, civil libertarians argued, patients who contest their commitment deserve procedural protections comparable to those afforded criminal defendants. Patients in commitment hearings now have the right to an attorney at public expense, the right to a jury if requested, a high standard of proof (“clear and convincing evidence”), and the right to cross-examine witnesses. Some patients have even successfully contested the introduction of their medical and criminal records on the grounds that such information is prejudicial.

Mental patients’ most controversial right is the right to refuse treatment: A doctor can medicate a patient over his objection only by convincing a judge that the patient is incompetent to make his own treatment decisions and that the requested course of treatment is necessary and medically sound. Dr. Gregory Bunt of the Manhattan Psychiatric Center calls the right to refuse treatment “a terrible, terrible law, which [does its] greatest disservice to the patients themselves. An untreated, uncontrollable patient infringes on the rights of other patients.”

All the state hospitals, and many other hospitals in the New York City region, have courtrooms on the premises for commitment and medication hearings. Patients in hospitals without courtrooms who wish to contest their doctors’ decisions must be transported to a hospital with a court, along with their medical team, their attorneys, and their hospital’s attorneys.

The impetus behind judicial oversight of medical decisions regarding the mentally ill is suspicion of medical authority. Robert Levy, an NYCLU attorney best known for his role in the “Billie Boggs” case (in which a mentally ill homeless woman challenged the city’s efforts to treat her), says that because “doctors are not independent evaluators,” treatment decisions with which the patient disagrees must be subject to judicial review. Levy likens psychiatrists to police investigators. “By virtue of making an investigation, they have a point of view.” That a psychiatrist’s “point of view” is based on medical expertise seems not to matter.

If doctors’ professional “biases” render their decisions suspect, certainly the judges who oversee those decisions suffer from no such handicap. In a recent court session at Bellevue, Judge Bruce Wright denied two doctors’ requests to administer antipsychotic medication over their patients’ objections. One of the patients was an old man who had lived on the streets around Columbia University for some thirty years. Because of paranoid delusions, he was refusing treatment for a festering ulceration from an earlier cancer operation. The other patient had repeatedly sent death threats to Joan Rivers and accosted her outside her studio. He had also threatened to kill people on his ward. Judge Wright needed to have the term “akathisia”—one of the most common side-effects of neuroleptic drugs— defined for him. Yet despite his obvious lack of medical knowledge, he was given the final say over the patients’ course of psychiatric treatment.

Patients’ lawyers often question the amount of time the treating doctor has spent with the patient. Yet the judge who makes the final decision has invariably spent far less time with the patient, and never one-on-one but only in the courtroom.

Doctors find the judicial process time-consuming and frustrating. The hearing and transportation to and from court can easily consume a day. Many doctors, according to Bunt, simply give up on the process: “They conclude, ’My judgment is not respected; it seems futile to go back and be made to look like an adversary.’”

A further paradox in the legal model of mental illness is that by making “dangerousness” the sole basis for involuntary commitment, the courts have placed commitment on the most medically tenuous ground possible. The prediction of dangerousness is “the most problematic [evaluation] in psychiatry,” according to Dr. John Monahan, a psychologist and professor at the University of Virginia Law School. No one has been more vocal in pointing out the shortcomings of the dangerousness standard than the civil libertarians themselves: Psychiatry’s record in predicting dangerousness, they correctly charge, has been weak. Furthermore, they argue, the standard is inconsistent with other principles of criminal justice: It is unconstitutional to confine dangerous but sane people until they have been charged with a criminal act.

In raising these objections, civil libertarians are arguing not for a more sensible standard of involuntary commitment, but for its outright abolition. Indeed, during the late 1960s and early 1970s, when New York’s mental health reform legislation was being drafted, the NYCLU fought to do away with commitment altogether. It lost that battle, but, as the Hogue case demonstrates, it has largely won the war.

Fixing the System
Both supporters and critics of deinstitutionalization agree that the present situation is untenable. Not surprisingly, however, they disagree on the solutions. Despite a quarter-century of failure, supporters of deinstitutionalization still say, in effect, “Give us a little more time and a lot more money.” The NYCLU’s Robert Levy will not even discuss the possibility of using commitment more aggressively to remove dangerous individuals from the street until society offers “meaningful services in the community.” Once the mentally ill “see that the services are helpful, they will accept them,” he says. “Until we build the centers, we can’t know how many will refuse.”

E. Fuller Torrey and his colleague Dr. Sidney M. Wolfe rebut this argument. They have written: “The state can make the [outpatient] psychiatric services as attractive and convenient as possible, as recommended by civil liberties lawyers, but there will still remain a sizable hard core of individuals who refuse treatment because they believe that nothing is wrong with them.... The part of their brain which allows a normal person to check beliefs against reality is damaged and the only way they will ever be treated is involuntarily.”

While it is unquestionable that better community services are needed, the argument that such services are all that is needed is not only false but dangerous, because it postpones confronting the real needs of a Larry Hogue and the community he is terrorizing. Hogue represents a significant minority of the mentally ill population for whom community treatment will never be feasible. These are the patients who, according to Dr. Paul Appelbaum, “decompensate rapidly on their own” by going off their medication, taking drugs, or both. Hogue’s history of violence and the severity of his drug problem make him an unacceptable risk for the community.

According to Dr. Pawel, no responsible community service provider would take Hogue. Father Tom McVean, program director of the highly regarded St. Francis residency program, agrees. Though St. Francis takes the most impaired of the chronically mentally ill, it does not admit patients who are also addicted to drugs, because they are so difficult to treat. Hogue would have to be sober for six months before the program would consider him.

Based on personal experience, Dr. Mark Irwin Klein, a professor of clinical psychiatry at the University of California’s Davis campus, rejects the argument that more money for community treatment centers is the answer for patients like Hogue. After completing his medical studies in the New York area, Klein went to Berkeley in 1974 to specialize in treating severely disturbed patients.

Unlike New York, Klein says, California in the 1970s had all the money and expertly staffed facilities the proponents of deinstitutionalization could have asked for. Nonetheless, Klein watched his patients go into a “downward spiral” as they learned to manipulate the system. They rejected placement in community facilities because they would have lost their eligibility for federal disability benefits. Instead, they lived on the streets, stopped taking their medication, and spent their benefit money on drugs or alcohol; when their money ran out, they typically would enter an acute-care hospital until the next check arrived. Today Klein sees many of his former patients wandering Berkeley’s Telegraph Avenue, still psychotic and addicted despite tens of thousands of dollars worth of sporadic treatment.

Years ago, Klein says, one rarely saw the combined disorders of mental illness and drug addiction. “Social Security has ruined patients,” Klein explains, by providing them with the money to buy drugs. He terms the current epidemic of drug addiction among the mentally ill “socially iatrogenic”—an iatrogenic disease being one caused by the treating doctor.

What Hogue and others like him need is a reconstruction of the “total-care institution” to provide true long-term care. Those who are so sick that they do not respond to less restrictive methods of treatment must be provided with institutional care, both for their own sake and for society’s. The total-care institution serves as a locus of care and responsibility. Food, shelter, clothing, and treatment are provided by a single authority. Klein says institutionalizing Hogue would “keep him out of harm’s way and prevent his further deterioration. When we find a real cure for schizophrenia, Hogue will be less deteriorated than if he were returned to the streets, and would be a better candidate for treatment.”

To call for a return to involuntary commitment triggers fears of the “warehousing” of patients in the “snake pits” of the past. It is highly unlikely, however, that such abuses would be repeated. The mental health reform movements, including the civil liberties battles, have changed society’s attitudes towards the mentally ill, and these new attitudes are reflected in regulations governing patient care. The oversight mechanisms currently in place are adequate to guard against negligence and abuse.

New York has 17 large hospitals upstate that have been all but mothballed, though none has actually been closed. These hospitals would be an excellent place to establish programs for mentally ill substance abusers. Such programs would be far less costly than conventional inpatient treatment, because their staffing requirements are lower. Bunt dismisses the likely objection that the upstate hospitals are too removed from the patient’s “community.” It is “leaving them in the community,” where they can obtain drugs, that constitutes “neglect,” Bunt says. Left to their own devices, “they will be devoured by their predators.”

The standard for commitment must be changed as well. Peter Rossi, emeritus professor of sociology at the University of Massachusetts, Amherst, suggests changing the law to allow the commitment of people who are acting “in a bizarre or aggressive manner, are incoherent, or are neglecting to care for themselves.” Such a change might ultimately require the Supreme Court to revisit its 1975 decision establishing the dangerousness standard. But in light of the accumulated evidence of nearly two decades of failed policy, there is reason to hope the court would let stand a more inclusive commitment law.

Changing the legal standard for commitment, however, will make little difference unless society can muster the will and the resources to provide long-term care for the seriously mentally ill. The Larry Hogue case “exemplifies the major difficulty of the mental health system: the belief that all patients can and should be released as soon as their symptoms abate,” says Dr. Paul Appelbaum. Pawel agrees: “We do not really have long-term care available to anyone. We need to reform health care to make it a treatment system. Now we legislate everyone not treatable out of the system.”

City Mental Health Commissioner Luis Marcos proposes giving the mental health system jurisdiction over drug addiction. The law should also be changed to give judges the legal authority to order patients back into drug treatment programs if they “elope.”

In addition, the problem of unsupervised government benefits going to mentally ill drug addicts urgently needs attention. A mechanism must be established whereby doctors or social workers who realize that a patient is regularly using his benefit money on drugs could initiate an administrative investigation without violating doctor-patient confidentiality. If the patient is found to be abusing his benefits, a conservator would be appointed to manage them.

The proposal for a return to the asylum will meet with two predictable objections: financial and ideological.

Cost comparisons generally show that institutional care is four times as expensive as community care. These figures, however, do not reflect the actual financial and social costs of the current system. The traditional gateway to the state hospital, the city emergency room, long ago reached a point of crisis saturation. Rather than treating a patient once and sending him through to a state hospital, the emergency room now sees him over and over: A recent study in the journal Hospital and Community Psychiatry documents a patient who has been hospitalized 120 times. The bottleneck into the state hospital system exhausts police resources as well. It is the police who transport the thousands of patients circulating rapidly and endlessly between the emergency room and the streets and who process them once they arrive at the hospital. And it is the police who must respond to the violence committed by people like Larry Hogue. Many of the mentally ill, moreover, end up in prison, a costly alternative to hospital care that restricts their freedom without helping their condition.

The most tragic cost, however, is borne by the residents of neighborhoods like the Upper West Side, who live in constant fear because their government is unable or unwilling to protect them. Lisa Lehr says Hogue’s lawyer has told her that Hogue is “furious about all the publicity that he’s been receiving.” “I’m terrified that when he comes out, he’s going to kill me,” Lehr says. “I weigh 120 pounds; he’s the one that’s got all the crack coursing through his system.” While Lehr may be tenacious enough to keep up the fight, many will no doubt follow the lead of the 16-year-old girl’s family and give up on New York City. In comparison to these immeasurable costs, even the most labor-intensive treatment seems a bargain.

Civil libertarians will no doubt continue to oppose institutionalization on ideological grounds, oblivious to the toll the current policy is taking both on local communities and on the mentally ill. Commenting on the Hogue case, the NYCLU’s Robert Levy blithely reminds the Upper West Side that “society can’t eliminate risk.”

David Rothman, director of the Center for Society and Medicine at Columbia University, takes a harsher approach, attacking the motives of those who favor institutionalization. He asks “whether the mental health system is capable of delivering humane care, let alone total supportive care. Where will the money come from? . . . From the community that had no empathy for [the mentally ill]?” “Apparently,” Rothman sniffs, “we underestimated the great number of our fellow citizens who can tolerate the daily sight of pain without flinching.”

Advocates like Levy and Rothman are increasingly out of touch, even with their natural political allies. The Upper West Side, after all, is a haven for progressive liberalism; it is only with great anguish and through bitter personal experience that its residents have come to criticize the excesses of organizations like the NYCLU. Given the horrors they have had to face, it is remarkable that they have any compassion left at all. Yet all of the community residents interviewed for this article expressed fear that Hogue was jeopardizing his own life by hurling himself into traffic. Andrea Kerzner-Torgovnik even worries that Hogue will cause her children to stigmatize all homeless people. “This bothers me, because the homeless need more sympathy.”

It is difficult to avoid the conclusion that part of what has driven the dogged pursuit of a failed policy is the belief that communities disintegrating under the burden of violence and chaos deserve their plight. The result has been utter madness: a system that disregards the community’s right to live free of violence and fear in favor of the “freedom” of potentially violent psychotics to refuse the therapeutic intervention they so desperately need.

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