Twenty-six years ago this month, President John F. Kennedy, backed by a generation of young and innovative psychiatrists and psychologists, announced a plan to revamp the nation's mental-health system.
No longer would the mentally ill be sentenced to grim and indefinite stays in "the snake pits," as state mental hospitals had come to be known. The President wanted "a bold new approach." Community clinics were to be set up in virtually every neighborhood of every city and town across America to prevent mental disease where possible and to provide comprehensive, economical and humane psychological care for all those who needed it, whether rich or poor, homebound or homeless.
That was the dream. The reality has become something else altogether.
"For many, that dream was shattered years ago," said Murray Levine, a psychologist at the State University of New York at Buffalo who is author of a 1981 Oxford University Press book, "The History and Politics of Community Mental Health."
That fact was rudely brought home to mental-health workers last week after the brutal stabbing of a 36-year-old psychiatric social worker in Santa Monica. While Robbyn Panitch's death Tuesday at the hands of a deranged patient may well have been an isolated tragedy that could have happened any time, any place, it has caused professionals around the country to reflect once again on the woeful inadequacies of the U.S. mental-health care system.
Although tentative hopes were being expressed last week in Los Angeles that the Santa Monica killing might rivet public attention on the system's financial woes, many professionals are alarmed that public sentiment is already turning against the whole concept of treating the mentally ill in community settings.
A "backlash against the mentally ill" may well be developing in this country, warned Michael Dear, a USC geographer and planner who has studied the problems of the homeless, at least a third of whom are thought to be mentally ill.
After World War II, when soldiers returned with mental problems, there was a sense that "everyone could suffer," Dear said. People became more tolerant, more understanding.
Now, Americans are once again feeling threatened, particularly by the people on the streets. Efforts are already under way "to put them (the homeless mentally ill) back into asylums and into jails," he said.
Indeed, in a few states, particularly Florida, there has already been something of a boom in building new psychiatric facilities, mostly for profit. This is an example of the "backlash" in attitudes toward mental health that is probably the most frightening because it takes us back to where we were decades ago, Dear said.
Some bewildering legal battles have also begun to erupt over the civil rights of the mentally ill. Last year, for example, New York City's Mayor Edward Koch announced that he wanted to hospitalize, against their will, some of the city's homeless who are seriously deranged.
The plan set off a flurry of protests, but pro-hospitalization groups continue to put forth their battle cry that "patients are dying with their rights on"--meaning that severely mentally disturbed patients may be retaining their civil rights but they are doing so at the cost of their dignity and safety. Many are being forced to roam the streets and eat out of garbage cans simply because they cannot find a place in the normal world of home and work and school.
The idea of separating the mentally ill from the rest of the world dates back to 19th-Century France and England. By the time the system was picked up in America and fully established, insane asylums, as they came to be called, were overcrowded warehouses. Patients were prisoners of a hateful system that could, at its worst, sadistically torture its inmates and, at its best, simply forget about them.
What brought that system to an end, scholars now say, were several unrelated historical factors that did not begin until in the middle of the 20th Century. The first was legal. Revelations of mistreatment in mental hospitals, particularly in the South in the 1950s, led the courts to redefine the civil rights of the mentally ill, thus restricting the government's ability to institutionalize people against their will.
The second was philosophical. Emerging psychiatric treatment theories led physicians to believe that only a minority of the severely mentally ill needed prolonged institutional care. Some mental illnesses, in fact, could be better treated at home or in the community rather than in the unnatural confines of a hospital.
Part of the new thinking in psychiatry came about as a result of a development in the field of pharmacology. Researchers in the 1950s were developing and testing some of the first drugs designed to control human behavior. Although they could not cure mental diseases, these medicinal compounds could reduce symptoms, thereby allowing some mentally disturbed patients to live safely on their own.
The final and perhaps most important development in the community mental-health movement was economic. Medical planners and taxpayers began to see that treating people in clinics and doctors' offices rather than in hospitals would surely be far less costly proposition.
So, when Congress responded to President Kennedy's message by passing the Community Mental Health Centers Act, most states were ready, too, especially since the federal government was providing a number of financial incentives.
In many respects, the Kennedy plan worked. In 1955, state mental hospitals held more than 550,000 long-term patients; by 1984 only about 114,000. But in other respects, most experts now agree, the execution of the plan was a disaster.
There simply are not enough community services to accommodate all those would-be patients.
The whole thing was "unplanned and under-funded," Dear said.
One of the problems was that, for all the federal government's support for the idea, not enough of the money followed the patients from the hospitals to the clinics. Today, for example, there are nearly 16 times as many mental patients in outpatient facilities as in state hospitals, yet about 70% of public funds for mental health go to hospitals, largely to cover overhead expenses and other fixed costs.
Pertains to California
That has certainly been the case in California.
California was a "leader" in moving mental patients out of the state hospitals but it has not been so much of a leader in establishing community programs and keeping them going, said Michael S. Goldstein, associate professor of public health at ULCA, who has had to stop teaching courses on community mental health because of lack of interest among students in recent years.
"You look around today and see how many successful community mental-health programs there are today and you won't see many," said Neal Brown, head of community mental health at the National Institute of Mental Health in Washington.
"In L.A." Brown said, "there are only a handful. . . . That's pretty remarkable considering the size and population of the place. The track record isn't too good."
Some states have made the best of a bad situation. Wisconsin, Massachusetts and Ohio, for example, have provided generous support and strong leadership for mental-health programs for years. So have Rhode Island and Vermont and some of the other New England states.
"If you ask me why, it's hard to say," Brown said. "but I suspect it has something to do with leadership from the top, the governor on down. And also it has to do with a sense of community and community responsibility. A place like L.A. may just be too big to have any sense of community and all that entails."
Want Further Limits
Now the state and county governments want to limit services even more, another sign of the backlash that experts feared would happen.
Just this week, eight of Los Angeles County's 28 mental-health clinics are scheduled to close and others are being asked to cut services.
Even before the actions were proposed, Los Angeles County had been "known nationally . . . for having among the worst outpatient services for the mentally ill in the United States," according to a 1988 rating of state programs published by Ralph Nader's Public Citizen Health Research Group and the National Alliance for Mental Health.
"We're in a bad situation that's going to get worse," said Paul Schettler, a social worker who directs the San Pedro Mental Health Services, one of the clinics scheduled to close in that working-class harbor community.
The "spirit" of the South Bay Mental Health Service, "has been destroyed" by the cutbacks, said Terry S. Gock, a clinical psychologist and acting director of the clinic, which will not close but whose workers are feeling the strain of budget reductions. Under the conditions that now exist, Gock said, "People aren't going to want to go into public service any longer."
Implications Are Clear
What is worse, under the latest county budgetary guidelines, only the most severely ill patients will be able to get help. People who are only moderately depressed, those who have anxiety and panic disorders, even if they are severely dysfunctional, cannot be treated. Nor will court-referred criminals be treated any longer. The implications, Gock said, are quite clear: Sex offenders, spouse abusers, child abusers, rapists, are going to be out on the street or sent back to jail, which will be even more costly to the community.
Many mental-health professionals today blame Ronald Reagan for the disastrous state of California's mental-health-care system. When he was governor he cut state programs; when he was President he cut federal programs. But he was not alone. Other presidents and other governors, Democratic and Republican, have been less than receptive to mental-health issues in recent years, according to health analysts. And taxpayers also have to shoulder some of the blame. Proposition 13, the widely supported tax-saving measure of 1970s, for example, is as responsible for mental-health cuts in this state as are the actions of any administrator or lawmaker, said Dear of USC.
What is to be done about the problem is anyone's guess.
The California Alliance for the Mentally Ill, a family support group and lobbying organization, is pushing for more money, for more individualized therapy and rehabilitation. The group and its national affiliate is also lobbying heavily for more research on the biochemical underpinnings of mental disease.
Another group of mental-health professionals takes a dim view of this position, arguing that while some and indeed all forms of mental illness may have biological roots, there are still serious social or psychological issues that have to be taken into account.
"It is possible, for example, to identify women who are at high risk for postpartum depression . . . men who are likely to be child abusers . . . people in general who are susceptible to a variety of forms of mental illness," said Stephen E. Goldston, associate director of UCLA's preventive psychiatry center who spent 25 years working on preventive mental-health programs at the National Institute of Mental Health.
"There are the people, and I count myself among them, who would like to go back to the original dream that prevention is more desirable than treatment. Clearly, in some areas we need more research. But in many areas, we already know enough to at least begin to start tackling the problems. What we need to do now is get down to business."