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Betraying the Most Vulnerable

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Betraying the Most Vulnerable

Civil libertarians and mental health advocates impose degradation on the seriously mentally ill. December 10, 2018
Health Care
Politics and law

As the death of George H. W. Bush brought admiring attention to the Americans with Disability Act, which he had signed into law, the New York Times detailed how mental health advocates have weaponized the ADA to force hospitals and adult homes to discharge mentally ill patients still in need of significant care. The result of these discharges has been increased degradation, death, homelessness, and incarceration among the mentally ill whom the advocates purport to represent.

The Times told the story of Abraham Clemente, a schizophrenia sufferer formerly housed in an adult home—a residence where mentally ill can get intensive care, in environments less restrictive than psychiatric hospitals—who was discharged in 2017 as a result of an ADA consent decree that New York State signed under pressure from civil-liberties advocates. The agreement, as the Times described it, “is meant to be a national model for the rights of the mentally ill to live independently.” Frontline’s cameras were rolling this year, when police found the 69-year-old Clemente living in his apartment with “maggot-infested scrambled eggs . . . strewn across the floor”; a cantaloupe “so spoiled, it seemed to be melting,” and feces “ground into the carpet.”

After being hospitalized, Clemente was readmitted to an adult home, and says he doesn’t want to leave. The Times detailed another mentally ill victim, a 34-year-old former adult-home resident also moved to independent living after the ADA consent decree. She “stopped taking her antipsychotic drug and began trying to solicit sex from passing drivers and swap alcohol for drugs with neighborhood children. . . . Eventually, facing eviction, she became homeless.”

Civil liberties and mental health advocates believe that institutional living is axiomatically bad, and independent living is definitively good, regardless of the severity of the mental illness and the limitations it imposes on the person suffering from it. In its 1999 Olmstead v. L. C. decision, the Supreme Court ruled that the ADA requires states to place people with mental disabilities in the “least restrictive settings . . . appropriate to the individual . . . taking into account the resources available.” (Emphasis in original.)

Extremists in the mental health community used Olmstead to push states to move thousands of mentally ill people out of adult homes and hospitals that provide intensive services and into independent living—largely ignoring the Court’s requirement that the discharges be “appropriate to the individual,” or that the states have the resources to provide non-institutional support. As the Times reported, “A few months before Mr. Clemente moved out of his adult home last year, the company that had been managing his health care warned the rest of his team that he was not interested in learning how to handle his medication. ‘At this time,’ the company said, ‘we cannot safely provide service to this member in a supported apartment.’ Mr. Clemente moved out anyway.”

New York State Office of Mental Health commissioner Ann Sullivan defends the rush to clear out institutions, which saves her department money. Her office claims that only about 10 percent of mentally ill people discharged failed to thrive, but the Office of Mental Health doesn’t monitor failures. Clinicians and others on the frontlines argue the rate of failure is as high as 50 percent. Sullivan told the Times, “I truly believe that stigma and discrimination have historically left too many individuals with serious mental illness living in institutions.” What she ignores is that closing hospitals does not reduce institutionalization; it simply shifts the burden of care to jails. Nationwide, more than 42 state psychiatric hospitals have shut their doors since the Olmstead decision, leaving many of the seriously mentally ill with nowhere to go. Ten times as many seriously mentally ill people are now incarcerated as hospitalized.

We need more asylums—in the best sense of the word—for the few people with the most serious mental illnesses who can’t function in the community. Creating more psychiatric beds will help reduce reliance on streets, jails, prisons, and morgues as our overflow valve. The first step in creating new beds: Washington should eliminate the obscure provision in Medicaid that prohibits giving states Medicaid funds for patients in state psychiatric hospitals and some adult homes. Until that happens, states should use the waiver process, recently announced by Health and Human Services Secretary Alex Azar, which could enable states to get Medicaid funds for short-term institutional care of the seriously mentally ill.

To prevent what happened to Abraham Clemente from happening to others, mental health advocates and civil libertarians should abandon ideology and embrace science. Being psychotic or delusional is not a “right” to be protected—it is an illness to be treated.  

Rachel Lerch/iStock

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