Who Wants to Be in an Institution?

To the editor:

Howard Husock’s article [“Dreams of My Uncle,” Spring 2017] makes important points about the history of the treatment of the mentally ill in relation to the crisis today. The inadequacy of most current programs of treatment and rehab to treat the mentally ill is measured by the number of afflicted people in jails and prisons. Several factors contribute to this state of affairs.

Involuntary treatment was embraced as a cause by civil rights advocates so that patients, whose capacity for judgment is woefully impaired by their illness, cannot be treated without their consent. Thus, the responsibility of society to care for those who cannot care for themselves has been neglected, and people who should receive care are denied it.

Deinstitutionalization, which was a humane—and, in most cases, successful—policy, has been subverted by several factors. Because the symptoms of mental disorders may persist despite the sufferer being of no danger to others, average citizens are fearful of people who may be doing well on adequate treatment, with the result that the success stories are lumped with people who should be restrained and treated. This fuels NIMBY reactions and makes providing community care a delicate endeavor.

Nevertheless, there are a host of successful programs, often in the nonprofit sector, working for state authorities, which receive little credit for their good work, because a successfully treated and integrated mentally ill individual is indistinguishable from an average person. In Massachusetts and Connecticut, the Vinfen program offers high-quality state-funded residential and rehab programs for persons with serious mental disorders. New York State and City also have robust, well-managed, state-funded programs that are quite effective within the limits of their funding. These programs and similar ones around the country attest to the success of community care, replacing the warehousing that was the standard in the nineteenth century.

Miles F. Shore

Professor of Psychiatry, Emeritus

Harvard Medical School

Howard Husock responds:

Miles Shore’s thoughtful and well-informed letter underscores a key point I sought to make: that a relatively small group of the mentally ill require intervention to treat them in asylum-type settings. In other words, we would not have to re-create anything like the scale of nineteenth- and twentieth-century mental institutions in order to provide successful treatment for those who might otherwise be a danger to themselves and others. To the extent that we “warehoused” such patients in earlier times, doing so may have been a humane response to the limited tools that psychiatry had at the time. Shore points toward a more limited system—but one that is practical to establish.

Stigma and Mental Illness

To the editor:

Stephen Eide, in opposition to your suggestions in your article [“Failure to Thrive,” Spring 2017], we accept whoever won’t “accept” being treated as unacceptable. Dr. Seager—a rabid “sanist”—is hoping for an outcome that bucks this nation’s pattern of gradually accepting more and more people. Our laws set limits on EVERYBODY’S power to remove the harmless people we just don’t like. The master class in our society (white, married, middle-class, able-normative, Christian, heterosexual) didn’t—and still doesn’t—like those laws, but they eventually had to obey them. Victims of legalized segregation will NEVER live by those unconstitutional laws, and Mad people will be the next group to disobey them.

Our arguments against your anti-Mad NIMBY-campaign couldn’t be stronger. The only coercion that ANYBODY endures should occur only after he has violated someone’s rights. Bigots DO NOT have a right to remove “weird” people from society just so that they can dodge the ego bruise of living alongside the Mad people who disgust them. Further, the state cannot force-psychiatrize people, just for the hell of it. Our SCOTUS has repeatedly ruled that Mad people have a right to live in the LEAST RESTRICTIVE setting. We don’t “fail” to thrive.

“Force first” mental health laws will ALWAYS be gratuitously paternalistic and cruel. They’re a legal monstrosity that forecloses people’s chances for the best possible quality of life. I WON’T BE COERCED INTO SECOND-CLASS CITIZENSHIP. Nor will any other Mad people. That’s not a dilemma. It’s justice, and it’s here to stay.

Pat Jones

Stephen Eide responds:

Pat Jones believes that mental health-care reform must begin with the recognition of the mentally ill as an oppressed minority. I reject this premise. The state asylum system that existed throughout the nineteenth and early twentieth centuries, though far from perfect, was designed by advocates who meant the best for people with mental illness. The same cannot be said for slavery or Jim Crow. After more than a half-century of deinstitutionalization, it makes no sense to accuse our mental health-care system of having a “force first” bias.

This letter itself may be seen as a reductio ad absurdum critique of Mayor de Blasio’s anti-stigma campaign. Someone who feels stigmatized feels oppressed. “Thrive NYC” uses more decorous language, but de Blasio would surely echo Pat Jones’s call for greater “acceptance” and say that the same thing goes for people with mild mental disorders and not just “Mad people.” But as difficult as this may be to understand for progressives still stuck in the 1960s, not every social-policy challenge boils down to fighting oppression. It is hard to reach a schizophrenic man who prefers to sleep on the streets because he believes that city homeless shelters are bugged by the FBI. The root of his problem is not an oppressive society but rather, severe mental illness.

The thousands of mentally ill people who are now incarcerated and homeless did not wind up in that condition because we failed to respect sufficiently their personal freedom. We are not going to make any progress on serious mental illness if we don’t recognize this challenge as principally a medical one. The overarching goal of mental health-care policy should be understood as treatment, not liberation, and the fact that we can’t even agree on that shows how far away we are from a solution.


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