The Case for Hospitalizing the Mentally Ill

It’s been fashionable among liberals in recent years to applaud the ‘60s move to “deinstitutionalize” the mentally ill--that is, turn them out of state hospitals and shield them against involuntary confinement.

Thus many well-meaning liberals reacted in alarm and opposition when New York City recently began trying to take its more disturbed homeless people off the streets and forcibly put them into Bellevue Hospital for treatment.

But as one who has been studying, and writing about, the homeless mentally ill for a long time--and as a fierce defender of individual liberty--I am not at all sure New York is wrong. In fact, with wet, colder weather upon us in Southern California, bringing with it the promise of a long and bitter winter for the homeless, this is a time for liberals, lawmakers and the mental-health Establishment to re-examine their supposedly humane position.

When the move began to empty the state’s mental hospitals, it did indeed seem like a sound and humanitarian concept, both to cost-cutting conservatives and to liberals upset at the imagined--and perhaps sometimes real--specter of innocent people incarcerated and brutalized in a state-run system of Cuckoo’s Nests.

The mentally ill would be “stabilized” with new wonder drugs like Thorazine and Stelazine, would be deinstitutionalized and reintroduced into normal community life with the support of a system of state-operated halfway houses.

The first part of the plan was quickly undertaken and soon accomplished. The result: Where there were 38,000 beds available in state mental hospitals in 1968, today there are only 4,000. But the much-ballyhooed system of halfway houses, where the mentally ill were to be professionally counseled, monitored and kept “stabilized” on drugs, was never even undertaken.

The result is that of the 35,000 homeless people wandering the streets of the Los Angeles area today, 30% to 50% are mentally ill to one degree or another. Dr. Roger Fair, chief of medical and psychiatric consulting services for the Los Angeles County Mental Health Department and founder of the Skid Row Mental Health Program, says 33% of the homeless mentally ill are seriously enough unbalanced as to be technically psychotic. Many hundreds of them are so disoriented and incapacitated with schizophrenia--an incurable disorder--and other diseases of the mind that they are wholly incapable of caring for themselves.

Some stay for short times in state-supported board-and-care facilities, but the great majority of them get no effective medical or psychiatric care there and soon are back on the streets, no better and often worse than before.

The dominant public reaction to the homeless is to write them off as threatening, ambitionless, smelly bums who have consciously made their beds, literally and figuratively, on the streets, under freeways, in doorways and even on the steps of City Hall--where one man recently died of exposure.

But the mentally ill among the homeless are not threats to us--they are victims, not victimizers. Many, perhaps most, do carry weapons--knives fashioned from mission utensils, sharpened screwdrivers, zip guns and radiator belts with bolts in them. But they carry these weapons in order to defend themselves. They live in constant fear, and with good reason. Statistics for the homeless indicate that anyone who lives on the streets for a year stands at least a 50% chance of being seriously injured by assault--or of being killed. The risk of injury among the mentally ill, especially those who get military retirement checks, or Social Security or disability benefit money, are much higher, of course, for they are routinely beaten and robbed.

The mentally disoriented and incapacitated women are easy and constant prey not only to thieves, muggers, drunks and drug addicts, but to rapists as well. I learned about one such victim, a beautiful and severely disoriented woman in her 20s, who was raped three times in a single week, twice by gangs.

The current mental-health laws affecting these people, passed in the well-intentioned fervor of the progressive ‘60s, don’t allow the mentally ill to be picked up for treatment even when they are completely out of touch with reality and completely unable to take care of themselves. The law allows someone to be held against his will only if he is adjudged an “immediate” threat to himself or to others. And even when the most severely ill person is picked up, he can usually be held for only 72 hours, or, far more rarely, for 30 days. There are no laws allowing for compulsory long-range institutional treatment, even for outpatient treatment.

In the rare cases when mentally ill people are picked up for confinement these days, they get acute treatment with anti-psychotic drugs and become stabilized enough to know just what to say in hearings, and thus are almost routinely released back to the streets, where they neglect to use their medications and lapse back into foggy helplessness.

All decent citizens want to protect innocent, mentally competent people from being locked up, but in light of what has evolved, it is time to rewrite these well-intentioned laws and make it easier to hold ill people for treatment. It’s time to have psychiatrists more involved and inexpert paraprofessionals less involved. It’s time for a new requirement; to avoid institutionalization, severely ill people must report regularly to mental-health centers so they can be monitored and required to stay on their medications.

It’s time as well to change the system. The Los Angeles County Mental Health Department, the biggest such system in the world, closes at 5 p.m. every weekday and shuts down on weekends. How does that effectively and humanely serve the needs on the streets?

To do less than consider these changes is to be less then well-meaning. While it is necessary to protect people’s rights, what good are those rights to people who are completely incompetent and helpless to help themselves? Would you defend the right of a 3-year-old child to run into a busy street? No more, I hope, that than you would you defend the right of a mentally-ill woman to be raped three times in a week.

By ignoring the helplessness of mentally ill people, we are, in the name of defending a principle, defending nothing more than their right to be constantly victimized on our mean streets.