In the Winter 1993 issue of the City Journal, Heather Mac Donald wrote about Larry Hogue, a mentally ill crack addict who has terrorized the residents of West 96th Street for years. Since her article was published, Hogue has been committed to a mental hospital.
The City Journal invited several people who have been directly involved in Hogues case—from the neighborhood, Police Department, District Attorneys Office, mental hospitals, and government agencies—to comment on Mac Donalds article and to discuss reforming the care of the mentally ill in light of their needs and the needs of communities.
HEATHER MAC DONALD: Yesterday the Appellate Division of New Yorks Supreme Court committed Larry Hogue for six months of treatment in a state hospital. The courts decision is a testament to the persistence with which citizens of the Upper West Side have demanded that the state mental health system act responsibly.
It would be premature, however, to declare a turnaround in New Yorks mental health policy, which continues to be driven by a powerful conjunction of fiscal imperatives and ideological pressures that militate against long-term commitment of the seriously and violently mentally ill. That conjunction was depressingly in evidence after the recent fatal beating of an eighty-year-old woman by Christopher Battiste, a mentally ill homeless man, in the South Bronx. While city and state officials traded charges over the incident, the only reform proposal offered by the state was to accelerate the shifting of resources from institutional to community care.
The comments of State Mental Health Commissioner Richard Surles exemplified how blindly reflexive the commitment to community care has become. After listing the wondrous savings that will accrue to the state from further decreasing the hospital census, Surles admitted a slight catch in the plan: No community centers would have taken Battiste. He was too hostile, too dangerous, too unpredictable and too unmotivated, Surles said. He asked staffers at one of the few facilities that treat both drug abuse and mental illness if they would have accepted Battiste. They recommended prison or state hospital until he indicated more willingness to cooperate in his treatment. In the same breath, Surles advocates a policy of community treatment and acknowledges its infeasibility.
The solution to the problem of the Larry Hogues and the Christopher Battistes lies not in communities already deeply frayed by the homeless mentally ill, but in the reconstruction of the total care institutions for the long-term treatment of the seriously and violently mentally ill. For patients with serious drug-aggravated mental illness, intensive long-term treatment is the best hope for improvement. Sending such patients back into the community not only ignores their medical needs, but destroys the public life of the city as well.
WILLIAM GRINKEF, Center on Addiction and Substance Abuse, Columbia University, and former commissioner of the Human Resources Administration: The city and state governments have deliberately deemphasized the number of seriously mentally ill people on the streets of New York. It is a miracle that we havent had more violence, given the mentally ill population that is on our streets. Probably 10 to 20 percent of the mentally ill are people like Larry Hogue, and they should be institutionalized for a much longer period of time.
Eighty to 90 percent of the mentally ill population can function in the community, however, and we have to provide decent, ongoing, supervised care for them. The mental health establishment has failed to implement the policy of deinstitutionalization by failing to create enough community residences for the numbers of people who are being let out of institutions or who have never been institutionalized in the first place. If small community residences were created in a reasonable cross section of the city, a large part of the problem on the Upper West Side and in other neighborhoods would be alleviated.
FRED SIEGEL, City Journal: You are assuming that the legal reformers who fought for deinstitutionalization had as their intention a functioning community mental health system. But many acknowledged that they were never interested in community mental health. Bruce Ennis, who is quoted in Heather Mac Donalds article, fought for deinstitutionalization because he believed that it was the institutions that made the mentally ill sick in the first place. He didnt want community mental health facilities to take the place of the institutions, because he thought they would be a restraint on freedom.
WILLIAM GRINKER. Some of the ACLU lawyers have this attitude, but I think the responsible psychiatric mental health community always believed in community mental health facilities.
MYRON MAGNET, Fortune: There is a problem with the idea that mental patients will derive therapeutic benefits from living in the community. The community, the very thing which is supposed to be of benefit, is eroded by the presence of the mentally ill. This is happening on the Upper West Side, where our children go to school through a gauntlet of people who aggressively panhandle or make sexually frank comments.
AARON BILLER, Neighborhood in the 90s Block Association: I would like to tell you about a community residence that the Volunteers of America wanted to open on the Upper West Side, which may help you understand our opposition to these facilities. At first they wanted to put it on 95th Street, opposite a school. Our group asked them simple questions: What type of people would be living in the facility? Would they screen for pedophiles? We were told that they couldnt screen. We asked them if they could give priority to the mentally ill people living on our streets, and were told that the whole city was the catchment area—in other words, they were going to bring more mentally ill people into our community.
When we asked the Volunteers of America what they were going to do to ensure that patients take their antipsychotic medication, they said they had a nurse who came in four days a week. We said we thought compliance required a seven-day regimen—what did they do on the other three days? They said, we give them a packet of pills and tell them this is what they must take every day. We asked them what kind of supervision they had for the residents, because they dont have regular recreational activities. They didnt have an answer. Somebody from our group said, Oh, we have been to your facility. You have the guard there and he puts the TV on. And then the patients go out into the streets. Finally, we asked if they were doing anything about the fact that their clients have a very high rate of tuberculosis. There is a strain of tuberculosis prevalent in homeless people which is not treatable. They had no answer.
When the Volunteers of America opened a facility on 97th Street, they had everything so well planned that they had to go to one of the local churches and ask if they had a community supper program to which they could send their patients. They were told there was no room.
DR. MANUEL TRUJILLO, Bellevue Hospital Center: I have a recommendation for community organizations like Aaron Billers. Formulate the standards to which you are going to hold a community mental health center. Make sure that the local community-based mental health agencies are responsive to you and that you are represented on their boards. In the last ten years the associations of the families of the mentally ill have gotten tremendous power. They are helping to shape mental health policy. I think its time for communities to do the same thing.
HEATHER MAC DONALD: I would add that the victims of the excessive pursuit of deinstitutionalization are not just the middle class, but the poor as well. The dumping may have been greatest in minority districts that dont have the clout of the Upper West Side. They need representation too.
Another problem with community care is that the facilities are not responsible for the behavior of their patients off-site. A possible reform is to establish some accountability on the part of the service providers for their clients behavior in the community.
DR. MANUEL TRUJILLO: I would like to point out that for every person like Larry Hogue there are nine people who have been deinstitutionalized and are doing well. They are making progress and their quality of life is far better than before deinstitutionalization. On what basis can we deny these nine people their right to live in the community?
HEATHER MAC DONALD: I agree that for the majority of mental patients community care is the optimal solution. However, if we put our entire focus on community care, patients are not going to be carefully screened to determine who is likely to succeed in community centers and who should stay in the hospital. Hospitalization is just not on the agenda.
DR. MANUEL TRUJILLO: For high-risk patients we need a new social policy that makes it easier to retain them against their will in inpatient facilities. We also must get outpatient commitment enacted into law. Right now someone can be committed against his will only to an inpatient facility—that is, a hospital with 24-hour supervision. Typically, while a patient is in the hospital, he takes his medication and does well, but some patients go off their medication when they are released. The law has no ability to compel them to show up at an outpatient facility once a week, or once a day, for medication or evaluation. An outpatient law would make it possible for judges to do that.
HEATHER MAC DONALD: But will outpatient commitment work? There is already a law requiring an intensive case manager for mentally ill patients who have been released from hospitals—Hogue supposedly has one—but nobody follows up. Can you track down noncompliant patients in New York City and bring them before the judge? And again, how are you going to say to communities, Lets just try it. Chances are the patients are going to go off their medication, but dont worry, well find them.
WILLIAM GRINKER: Heather Mac Donalds article said that despite all the evidence that institutionalization is necessary for some patients, the state continues to let people out of the institutions and shrink the system. How should the standard for institutionalization be modified?
CHARLES GUNTHER, Deputy Inspector, New York Police Department: I think thats a very good question. I would like to offer my vantage point as commander of the 24th Precinct for two-and-a-half years. First, the complaints we got about quality-of-life issues crossed all economic boundaries. It wasnt as though wealthier people complained more about panhandlers or people urinating in front of their children.
Let me describe how the police used to respond to mentally ill cases. When I was a young officer and we got calls about people who were emotionally disturbed, we would ask them very basic questions, such as did they know where they were or what day of the week it was. If the answers werent acceptable, we would take them to a hospital for evaluation. A person could also be put in a hospital for psychiatric evaluation if someone came to us with a letter from a psychiatrist saying that the person was emotionally disturbed. Now we can only take someone off the street if he appears to be mentally ill and is conducting himself in a manner that is likely to result not just in injury but in serious injury to himself or others, or if we have a letter from the commissioner of the Department of Mental Health, Mental Retardation, and Alcoholism Services.
PAUL SHECTMAN, Manhattan District Attorneys Office: In April 1992, Larry Hogue was picked up by the police on the Upper West Side, his face painted green and sucking gas out of car tanks. He was brought to St. Lukes Hospital, where a psychiatrist said he was the single most dangerous person she had ever seen. He was then taken from there to the Veterans Administration Hospital at Montrose on an involuntary commitment order. He stayed there for two weeks, and then the hospital decided to release him. They told me he was not an imminent danger to himself or others because he wouldnt be dangerous until he went back onto the street the next day.
Given all the times the police arrested Hogue and brought him to psychiatric facilities because he was out of control on the streets, why didnt anyone take a case to court to determine whether he could be involuntarily committed for a longer period? That wasnt done until he appeared on 60 Minutes.
DR. MICHAEL PAWEL, August Aichorn Center: We did make the case. Hogue was always hospitalized by judges and he was always released by psychiatrists.
DR. MANUEL TRUJILLO: One of the problems is the ideological division within the psychiatric profession. When Larry Hogue came to Bellevue, I had problems with the first doctor assigned to the case because he was a follower of Thomas Szasz. He didnt even believe in the existence of mental illness. The second problem is that the doctor has to make a choice. He may have fifty patients in the emergency room waiting for beds. Should he go to court with a case when he knows he is going to lose? Paul Shectman is right: The only reason Larry Hogue is in the mental health system today is because he was the subject of a report on 60 Minutes. We cant get all our patients on 60 Minutes.
MARTIN BEGUN, New York City Department of Mental Health, Mental Retardation, and Alcoholism Services: There are psychiatrists on our staff at NYU who really believe that mental illness is just a lifestyle issue. But its not only the psychiatrists who are opposed to institutionalization. I have talked privately with dozens of judges in the Court of Appeals, the Appellate Division, and the Supreme Court. They are wedded to the philosophy that freedom is always better than incarceration. Unfortunately, in these cases involving the mentally ill there is a collision between civil liberties and human dignity. When I became chairman of the Mental Health Board, I leaned very heavily at first towards the civil liberties position. But I realized that I was indulging myself in an grandiose exercise in personal theorizing. Somewhere along the line we have got to separate out the very seriously disturbed and begin to treat them as a separate class of patients.
FRED SIEGEL: In effect, then, we are under the grip of a consensus among judges, the civil liberties bar, and parts of the mental health profession that was created twenty years ago and until recently seemed unshakable.
MARTIN BEGUN: In 1977, Dr. June Jackson, the commissioner of mental heath, and I wrote a report to the mayor in which we said the Hogues of the world would become an increasingly dominant part of our lives, our police system, our court system, and our mental health system.
New York State is currently decommissioning thirty beds a week in its mental hospitals. In 1970 we had 96,000 beds in the state system; today we have 11,100.
But we dont have fewer problems today. We have a much more volatile population. Years ago, when American psychiatry concluded that psychotropic drugs would allow people to be released from state institutions, they didnt know that most of the mentally ill who would be on the streets today would be multiply disabled—with drugs, alcohol, HIV, and tuberculosis as well as mental illness. Two-thirds of the mentally ill today are addicted to drugs or alcohol. But in New York State, the law does not allow the mental health system to treat drug and alcohol abuse. We are operating with a mental health system created in the 1960s and 1970s on the basis of assumptions that are no longer applicable in the 1990s. The system is outmoded and a failure.
DR. MICHAEL PAWEL: The mental health system will never be given the ability to commit substance abusers because it would be too expensive. Long-term care for anybody in any setting, whether its a prison, a nursing home, a child care facility, or a psychiatric hospital, is extremely expensive. There are 168 hours in a week, which means it takes five workers to fill one position on a 24-hour, seven-day-a-week basis. No matter how low the salaries are kept, it will still cost about $100,000 in overhead to care for one person.
WILLIAM GRINKER. The system is expensive, but we can do a lot better with the resources that already exist. We have a mental health system that refuses to see drug-addicted people and a drug-treatment system that refuses to see the mentally ill. We dont have to spend millions and millions of dollars to get these two systems to function interactively.
MARTIN BEGUN: The cost issue is a little bit bogus. It is my understanding that there are millions of dollars in state funding just sitting there because there arent enough mental health agencies equipped to treat mentally ill chemical abusers.
I have asked the city administration to permit the citys Department of Mental Health, Mental Retardation, and Alcoholism Services to change its name from alcoholism services to addiction services so that there will be one single coordinating agency for both mental health and addiction treatment. But it is a struggle just to get the name of the department changed.
Some of the opposition to using mental health resources more efficiently comes from the unions. I am not anti-union by a long shot, but the civil servants union has been a major stumbling block to doing anything creative or effective in the state system.
FRED SIEGEL: What are the unions afraid of?
MARTIN BEGUN: Losing jobs. After all, the state mental health system is the largest single bureaucracy in the state government. It has almost 46,000 employees and 27 hospitals. Most of the upstate hospitals are empty even though their budgets and staff sizes have remained constant. You can walk through the day room of Gowanda or St. Lawrence and see 12 staffers watching one patient looking at a TV camera.
FRED SIEGEL: What practical steps could be taken to integrate services for drug abusers with those for the mentally ill?
WILLIAM GRINKER. The most important step is to get the relevant agencies involved to sit down and work together. But its going to take a tremendous amount of will to bring them together. It will be hard to do without pressure from the community. As Dr. Trujillo suggested, communities need to understand how these bureaucracies work and get them to work together effectively.
MARTIN BEGUN: There are two bills before the State Legislature this year that for the first time may see the light of day. One is a piece of legislation that Dr. Luis Marcos, the citys commissioner of mental health, has fought for. It would give the mental health system jurisdiction to treat mental illness induced by drug and substance abuse. The ACLU opposed it at first, but Dr. Marcos and I met with them and were able to get their cooperation because they are now getting nervous about the Larry Hogue situation.
The other is a bill that would require the state government to reinvest some of the money saved by closing state facilities in community residences. In my judgment, by the way, the state is closing the wrong hospitals. About 10 of the 27 state hospitals are still open because of regional politics. They are in small towns in upstate New York where the hospital represents what a military base would: jobs. These hospitals are super institutions. They have state-of-the-art facilities and competent staff. Some of the staffers have made family careers there for four and five generations. St. Lawrence County has a facility that is like a resort. But these are the hospitals the state is closing. It should be decommissioning some of the hospitals in New York City which have become no more than holding pens.
FRED SIEGEL: What is the basis for these decisions?
MARTIN BEGUN: The city hospitals are being kept open because of the traditional assumption that a patient should be close to his family for visitation purposes. But it has been documented that very few families visit their relatives in mental hospitals. I have often made the argument to family groups that they would be happier if their relatives were in a first-class facility in upstate New York rather than in a crowded, miserable facility here in the city, and they have agreed.
DR. MICHAEL PAWEL: One of the reasons behind deinstitutionalization that has not been mentioned here is the issue of the funding source. Federal Medicaid funding gave a great impetus to deinstitutionalization because it is not available to state hospitals but is available to voluntary hospitals with psychiatric programs. In the late 1960s it suddenly became profitable for general hospitals like St. Lukes to develop psychiatric units because patients could pay with Medicaid. This was encouraged by the state because it pays only 25 percent of the cost of Medicaid but 100 percent of the cost of a state hospital. When you talk about moving people out of the Medicaid-funded general and acute care hospitals and into the state hospital system, you are talking about moving people onto the state bill. I dont think its realistic to expect that Albany will embrace this proposal.
I think we have to focus on creating community health care. Community groups can do a tremendous amount to foster responsible care for the mentally ill if they dont adopt a stance of unalterable opposition, but instead insist that certain standards—seven-day-a-week nursing, for example—be met. If these standards were set by the New York State Office of Mental Health (OMH), community service providers could demand that OMH give them the funds to meet those standards.
I also think there are some real lessons to be learned from the states Community Support System (CSS) program. Under the CSS heading, the state funded whatever programs for the mentally ill homeless the service providers thought were needed. All kinds of programs were spawned: Some hospitals developed emergency room follow-up programs, other groups created programs and services for people in shelters. It has been the most successful chapter in the deinstitutionalization story.
MARTIN BEGUN: The bad news is that when the Larry Hogue story broke, the state commissioner froze all the CSS money the state gives the city and decided to use the fund to take care of the severely mentally disabled like Larry Hogue. Instead of taking a look at the whole system and using some of the money they are saving by decommissioning hospitals, they took a remarkable program and turned off the funding, leaving everybody high and dry, so they could use the money to manage the crisis of the moment.
DR. MANUEL TRUJILLO: I think its wrong to present our problem with mental health as primarily one of cost. New York State has $2.5 billion to $3 billion to spend on this problem. The problem is a lack of coordination. Twenty to 30 percent of the money falls between the cracks in the system. I recently reviewed the records of twenty patients at Bellevue, each of whom had been admitted within the previous six or seven weeks to as many as 24 other facilities. I jokingly suggested to the commissioner that we should buy Pan Ams reservation system. Under the current system, I have no way of knowing what resources might be available that would fit a patients needs.
MYRON MAGNET: In all this talk about what this agency or that agency should do, we shouldnt be blinded to the enormity of the civic failure that has resulted from deinstitutionalization. Until someone can show us that deinstitutionalization really can work for communities, we have to judge that it has failed.
HEATHER MAC DONALD: Any policy that ignores its effects on citizens at large is bound to fail in the long term. The community has heretofore been wholly unrepresented in decisions regarding New Yorks mental health policies. Thanks to the efforts of communities like the Upper West Side, one can hope that sometime in the future such indifference to the concerns of citizens will end.
FRED SIEGEL: Judge David Bazelon, one of the first judges to set deinstitutionalization in motion, made an observation that summarizes much of what we have been saying. Deinstitutionalization, he said, was originally based on an argument for individuation, for not treating the mentally ill as a single category. The problem with deinstitutionalization as it has been practiced is that it treats people like a category, that it doesnt individuate. We need a policy that recognizes the variety of problems the mentally ill have and gives each patient the treatment suitable for his particular needs.