The national mental health provider shortage, especially of psychiatrists, continues unabated. More and more large mental health organizations are now joining the national vocal chorus highlighting this decade and a half (in my own estimate) crisis.
He details that all types of agencies in all service sectors are having enormous troubles recruiting and maintaining practitioners at all levels of expertise, training and professionals. This goes beyond the all too well known national shortage of psychiatrists. Psychologists, social workers, and counselors-therapists at all levels of training from bachelors to master’s level are increasingly hard to recruit and retain. One issue he highlighted I was less aware of, was that agencies now have significant retaining practitioners due to staffers leaving for other positions in other areas of work. Salaries again are touted as causing losses of staff on a continuing basis. I have this as social workers and psychologists, especially the younger ones to their professions, leave public mental health jobs for more lucrative positions, especially in federal systems.
Everyone seems to have heard about Rikers Island prison in New York City and its horrors, overcrowding, deaths etc. I suppose it does not help Rikers’ public image much since it has been mentioned in every episode of Law and Order for over 20 years on television. And I further suppose Harris County Jail has been happy to fly well under Rikers’ blip on the national consciousness radar.
Another acquaintance of mine in the Houston who is in government tells me the officials in the area governments are very sensitive to stories like this about their county jail and do not want it lumped together with other infamous jails such as Cook County (Chicago), Los Angeles, Phoenix, etc. And who can blame them? A quote from the article brought to me by my trusty Google Search New Bots hinted at this sensitivity: ” The Harris County sheriff’s office doesn’t want its jail to be the largest mental health facility in Texas anymore.”I must preface my coming complimentary remarks about Texas’ efforts in the state’s jail systems by stating that in my estimation, Texas is one of the several states in the country that is making huge and creditworthy reform efforts on many fronts in their entire state’s mental health care delivery system. The legislature formed a task force on mental health in 2014-5, and it actually DID something. It issued a very comprehensive report in a year’s time. It is a piece of landmark analysis and goals. And, to top it off, the state legislature in Texas started drafting and passing concrete reform legislation. They started talking about spending up to $500M initially in a few years to get the massive, multifaceted statewide effort underway. It was all the more amazing since the Texas state legislature was the same body that had a number of its legislators hide in motels across state lines in another state to avoid a politically contentious vote several years ago. It was the laughing stock of the country for a week or so as all kinds of media and Internet games and memes started about where the missing lawmakers were. Pseudo rewards were offered. Petitions were started by wags and satirists to rename the missing officials “Waldo.” Kinky Friedman the inimitable Texas satirist and sometime candidate for the Governorship had a field day. Molly Ivins, the late great political satirist of Texas, was said to have been sighted in the Legislature and her newspaper’s offices. It was great theater.
The Harris Co. Jail has a triaging setup that is situated RIGHT AT the front intake booking desk. A trained officer with a communicating wireless tablet can consult with a nearby consulting psychiatrist to start the referral process form evaluation and treatment within the jail complex. Harris Co. Jail has decided that it will not pursue a mental health “diversion” program like many other judicial systems have started. In point of fact, Texas has started dozens of pilot diversion programs in counties elsewhere in the state. This model is felt to fit better in smaller counties with much smaller local jail populations.
So rather than having the ‘diversion-referral process start in the courtroom, this process is situated at the receiving desk of the jail. The model is structured so that the staff, from the trained deputies to the consulting mental health providers (from counselors to psychiatric social workers and psychologists to the close-by psychiatrist) on down, have a more vertically integrated and functional system that makes sense. It can be activated for any arriving inmate right at the first contact within the jail. It is certainly a novel approach and should be studied and likely tried elsewhere.
The jail has its own inpatient unit, the Harris County Psychiatric Center, which has nearly 300 beds. This is filled all the time and has a waiting list from the rest of the jail’s population. The jail as a whole, has long known that 1 in 4 or its total population have mental illness and need medication based psychiatric treatment and management. Nationally, over 400,00 inmates have psychiatric illnesses needing ongoing treatment, a staggering number.
Texas’s and Harris County’s efforts are to be applauded, followed closely and studied. Hopefully, it is a sign of things to come.
Modern life, it seems, may bring to us at times, more than our share of tragedies. A person who has suffered and endured what I consider the most painful such loss in recent memory, is Dr. Craige Deeds Ph.D., a clinical psychologist in Virginia. He is also a Virginia state legislator who has dedicated himself more than ever, to the cause of reforming and improving mental health care delivery in Virginia. He lost his son in 2013 when his then schizophrenic son, committed suicide after trying to stab his father Dr. Deeds. Dr. Deeds had endeavored to hospitalize his son after that incident but somehow in the whole state, there were no beds for his sons, a circumstance I cast a very skeptical eye upon, with my own suspicions as to why none could be found at all. His son was treated for four days with medications in an ER and then had to be released when he had calmed and was no longer deemed dangerous. Four days later, he suicided.
Dr. Deeds faced this tragedy and turned his tragedy and sorrow into something positive which is about the only thing one can do. He redoubled his previous efforts in mental health legislation and singlehandedly almost has nudged the state of Virginia into enacting and putting into place several well thought out reforms, changes and additions to the state’s public mental health system. The first reform was a long needed statewide registry database of open psychiatric beds. This enabled mental health professionals and law enforcement officials and courts to place quickly acutely ill persons needing urgent inpatient psychiatric care, into hospital beds. One radical aspect of this law and change was that private psychiatric beds were mandated to be included. This prevented private psychiatric units from refusing involuntarily committed patients or unruly persons from being rejected out of hand for admission.
Dr. (State Senator for his second title) Deeds has labored mightily to take one broad, large, unwieldy state-wide system issue in Virginia’s broken system of public mental health services delivery after another. It can be easily said that he has done what no one else has done, and accomplished as a result of these efforts, more than any other single person in this country. I regard him personally with utmost respect as our present modern day personification of the great reformer, Dorothea Dix. One of the things that Dr. Deeds has done, has been to cross the political aisles in his state. He has brought the two feuding political parties together in a common effort and fashioned a new alliance that has passed a set of legislative advances for over 3 years since his efforts began to take off in 2014.
In a recent article entitled, “US: Care lacking at troubled Washington psychiatric hospital,” that appeared in many Northwest and national USA news sites and sources, the continuing troubles at Washington state’s Western State (psychiatric) Hospital were documented. Speaking as a psychiatrist that recognizes both the still present need for inpatient psychiatric beds and treatment, as well as the past history of state hospital abuses, I am again troubled by the travails of this hospital.
For the reader, I wish to add a little background. This hospital is very large, over 800 beds and serves a rather large if not huge area as big as some countries. It has had all kinds of troubles over the last several years. It almost lost its federal hospital accreditation a few years ago. Loss of such endorsement in the USA means that a hospital is not able to bill for services rendered to patients through the American-federal insurance entities of Medicare (for American elderly) and Medicaid (for the American poor, those on “welfare,” the derogatory term in the USA for aid to the poor).
The news detailed that this hospital will lose up to $53M in the coming financial year which runs from July 2018 until the end of June 2019. That, in turn, means that Washington State will have to make up that money to the hospital to keep it running. And for the wondering reader not well acquainted with the American health care system, such a public hospital can NOT close. Services of psychiatric care cannot stop for obvious reasons.
The article referenced above gives a good deal of the history behind this unfortunate development which I will not go into. I wish to give the reader some semblance of explanation of why this has happened. The reader will need to have a historical viewpoint. The problems of this hospital did not start a year or two back…They have been longstanding to say the least.
Like many state hospitals in the USA, Western is located out in the countryside, quite a distance, meaning usually up to a hundred or more miles from the nearest urban area. This means that the labor pool un its area, including its home city, has a quite small metropolitan area from which to draw employees for hire. And this state hospital like most, has to employ hundreds of health workers. My own state hospital of my employ has 1,200 employees!
As a corollary in our modern society that now is overwhelmingly city based with all the ‘amenities’ thereof, is a harder sell to prospective employees. Few persons want to uproot themselves and move to a much smaller city or town and give up the modern shopping centers and such.
Currently, salaries for the professional working class are moderately lower in state psychiatric hospital settings than comparable urban areas. For nurses, physicians, physician-psychiatrists, across the economic board. Western State Hospital has long had psychiatrist shortages and nurse shortages. A few years ago the hospital had to suddenly close wards totally a hundred beds or so. No psychiatrists to see the patients…The salary issues had prompted several, ?seven or so, to move themselves and their skills to a VA (Veteran’s Administration) hospital in another part of the state because the VA hospital pay was SO MUCH HIGHER. Western State could not compete.
Another issue that has hurt Western is that the hospital structure itself is housed in a building that is many decades old, some dating back to the late 1800’s. This circumstance is actually NOT all that unusual in the USA. Most of the American state hospitals originated in the state hospital building boom after 1870 or so. [My own state hospital’s main building just a connecting walkway away from the building I work in, was built in1875. It is a gorgeous building that fortunately has been masterfully maintained].
Washington state’s governor, Jay Inslee, has labored mightily for several years to help correct the situation. He has worked with the previously reluctant legislature to increase funding which still needs far more generosity on a permanent basis. Implicit in this last sentence is a hint. Psychiatric state hospitals in the USA have long been underfunded.
Worsening this chronic pattern has been that in the last 20 years or so since the first ‘recession’ of the dot com era’s origin in 1999, states’ tax intake has shrunk. With each wave of recession in the American economy, states in the federal union that is called the United States, have had to drastically tighten their budgets. Public healthcare including state psychiatric hospitals, highway construction funding, financial initiatives in public transit, and education have taken very significant hits.
The results have been the kinds of delayed consequences that are exemplified in Western State Hospital’s evolving plight resulting in its delayed de-accreditation. This slow train wreck in public state hospitals is developing at a number of other state psychiatric hospital systems. Few states are doing what it takes to rebuild, revamp and replaces their aging, falling down facilities. The solution in the majority of states especially in the Northeastern United States has been to close many facilities. This has had the predictable result of throwing hundreds of essential inpatient psychiatric beds into thin air. And this is where the huge increase in mentally ill came from that now occupy jails and are homeless on cities’ streets.
So another basis for the de-accreditation has been that the physical plant of Western is so old and faulty that buildings are not safe and are hazards to residents and employees’ well being.
Through the wonders of my trusty Google Search Bots, I was made aware of a book published by a regional university press. Upon linking to the press release for this book, I realized that in another less totally “connected” world in my past lifetime, I would have never known of this literary gem. This book, as fascinating and scholarly as it is, appealing to my personal historical interests and professional psychiatric mental health reform history, likely will have an undeserved narrow readership. But in my own literary zeal, I hope to support this author’s superb scholarship efforts in this field by calling attention to her wonderful book and read.
There exist dozens of books in print on the history of mental health reform, state hospitals, asylums, and so on. Additionally, there are many out of print books to be had by the student of mental health reform, thanks to the incredible networked of bookshops and sellers on the Internet. I have long been a student and collector (to my wife’s everlasting anti-hoarding tendencies) of antique and historical tomes on psychiatry, mental health, and psychoanalysis. In past decades when I first had my interest kindled in this scholarly effort by two mentors. These two far-sighted supervisors and teachers cultivated the awareness in me that many surprising answers and relevant insights could be gleaned from the acquaintance of the historical efforts of predecessors in our field and any area of human endeavor and understanding for that manner. To fuel my collecting and voracious reading appetite, I relied on one publishing and book reseller business in New York City (natch, where else?) as the only source for my dogged blood hound collector impulses. That business still exists, but sadly I utilized them far less often as their range of books seems narrow to me these days. But they still “cover” the field of psychiatric writers that I can find nowhere else so my loyalty to them persist.
This book serves as a scholarly, historical prod to this reader of mental health reform history because it is a unique book. It is not dry documentation of events as some books in this arena can be. Any area of historical review and retelling for a contemporary audience runs the high risk of taking the easy route of simply cataloging events. At least some of the history textbooks of my youth were such tediously boring examples. Like many youths of that era, I could not understand why anyone would want to study history. What saved me was experiencing the teaching of history of other countries and cultures in schools overseas. I was awakened to the rich stories of the Middle East and of the British Empire in different schools. I returned to the US at the end of my high school years and dove into America political history in the only history course before university studies that hooked me. I focused on two area, the Civil War and the formation of the American system of government in the Revolutionary period. These interests prepared me for looking at my profession of psychiatry in a historical manner that afforded me a much deeper appreciation for even the most routine daily efforts in my work with patients and systems.
One of the first lessons that are highlighted in Ms. Foote’s book is the lost refrain that mental reform is not a new current of our time. Every generation of reformers seems to suffer initially from the realization that their efforts often have been duplicated in past eras. The helpful grace of this intellect and psyche warming circumstance is that any contemporaneous effort can be buttressed by learning from the directions of past efforts and their successes and failures.
Another lesson that is more sobering is that past reforms led to acclaimed successes that were much celebrated. Politicians, reformers, and those who implemented the changes bourne out of the results of the reforms felt early on that changes they had all worked so hard to accomplish would go a long way toward solving the problems that initiated the zeal of reform.
But the efforts did not lead to lasting change. In the state mental hospital orbits, reality overtook even the best of intentions.
Ms. Foote weaves a masterful story of a period of years in the pre-deinstitutionalization era, up to the early 1950’s. This makes for a truly engaging and fascinating read. Many different tides of motivations and ideologies are described. They range from social reformers of the 1800’s such as national figures like Dorothea Dix to a more intimate portrayal of local Minnesotan figures that were unknown to me. One of the other historical tributaries for the unique critical mass reached in Minnesota in the post-WWII years, was that of the singular religious community in the state, largely not existing elsewhere in this country except for the Quaker communities who pioneered mental health reform as early as the 1700’s.
One notable feature of Ms. Foote’s book helps stories of patients’ lives to come alive as few other books I have read. The second chapter has vignette life stories of several patients all ably researched from superb sources that the author read herself in unique local venues in Minnesota.
Only one other book I have seen rivals this book as far as an unusual source of person based history which I find to be the most interesting kind…That other book with such storytelling power is “The Lives They Left Behind: Suitcases from a State Hospital Attic,” by writer by Darby Penney, psychiatrist-photographer Peter Stastny.
This book resulted from the NY State mental health commission finding a treasure trove of patients’ suitcases after their admissions to one of the closed state hospitals. The authors wrote a book on the actual lives of the patients whose belongings they found. The authors found descendants living in venues in NY state and interviewed them learning more of their lives, filling in the details accordingly, making for an incredible read.
Colorado’s problem has continued to balloon up so persistently that the article stated: “[the]State can’t keep up with monthly court orders for competency evaluation, which jumped from 146 to 215” swamping the entire state hospital bed capability. And as has happened in every other state, the regular emergent psychiatric admissions to the state’s public psychiatric hospitals were delayed, creating the all too familiar backups of patients in ERs statewide. And it must be remembered that almost all referrals for admission to state psychiatric hospitals are true emergencies.
Judge Marsha Pechman of Washington state began fining Washington in the fall of 2017 $1500 daily after she found the state in contempt for not being able to deliver adequate care for the ITP patients. Her fines later escalated as she found the CEO of the Western State Hospital and the state mental health agency in contempt, to over $50M in total fines last year. By the time Judge Pechman began to levy the fines against Washington, its statewide monthly judicial orders, mirroring Colorado’s almost exactly were averaging 291 in-jail evaluation orders.
The issue is that most states in the USA continue to be flooded with mandated admissions of inmates from state judicial systems for psychiatric evaluations. These types of admissions are variously termed ITPs or incompetent to proceed to trial patients and other arcane terms derived from states’ laws designations. Washington state has struggled mightily more than most states with this issue so much that a Washington state judge has fined the state over $50M in the past two years because of the delays in care for other patients who had ended up warehoused for weeks to months at a time in general hospitals all over the state.
The Governor of Washington, Jay Inslee, who has been working at a furious pace with the Washington state legislature, recently announced new plans to try to have regional, non-state hospital-based forensic evaluation centers in different parts of the state by 2022 to handle all the ITP case needs. This is innovative in that most states do not have such a system.
In decades past, states had “forensic centers” that were designated the proper facilities to handle such cases. In the states that had such, their capacities were usually not increased from levels of the 1960’s. One such notable and nationally recognized center was and still is Michigan’s Center for Forensic Psychiatry south of Ann Arbor Michigan. Another has been the infamous Massachusetts facility Bridgewater state hospital’s forensic unit. Its heyday has long passed, and it has been the site of repeated scandals for a good decade and is not such a good example…
Nationally some of the forensic facilities were phased out as such units were incorporated into state psychiatric hospitals’ physical plants. But overall, the bed needs were not increased to keep up with population growth for over 50 years, hence the ‘sudden’ swamping of these facilities in whatever form they existed nationally.
Additionally, the impetus of the legal system has been to increasingly become scrupulous about ensuring inmates’ rights are protected to assure access to mental health evaluation and treatment. Issues of below average intelligence, organic mental conditions and medical conditions affecting legal issues such as the ability to know right from wrong, judgment, impairment of any sort at the times of commission of crimes, were more readily identified than ever in the past.
Also, it likely has become the standard of practice in the world of legal defense representation, to adequately refer to such psychiatric review whenever there is a question such an issue may exist with any defendant.
All these factors have fed into the current national crisis of explosion of need for such forensic psychiatric services at all levels and not just in infamous trials involving serial killers or cases involving the rich and famous.
All states who currently fall short of providing these mandated services will have to face the coming necessities of funding for such services along with all the other inadequacies of social, educational and human services gutted over the last 30 years. How all this will play out will in no small part shape the political and social policy debates in this country for decades.
In my journey through my training centers becoming a psychiatrist, I was accidentally graced that my medical school and subsequent residency centers had medical libraries with superb historical collections. There are a number of other medical school libraries who have similar collections. At Michigan and then at Duke, I found myself spending empty hours reading histories of medicine and then psychiatry in the rarefied collections rooms. These left an indelible mark in my reading appetites that have lasted my entire professional life.
The past five decades of exposure and experience have faced me with the enormous shifts in practice models, the wrenching changes in mental health service delivery since the 1950’s, and continuing dilemmas posed by seductive national solutions that brought with them worsening problems. The overall shift in western mental health care has swung from outpatient care for the well-off seen by private practitioners, the subsequent mental health center movement for the general populace from the 1960’s through the 1980’s, and the even larger but mostly unseen segment of public inpatient psychiatric hospital care that dwarfed all other portions of the mental health care pie. This last “market” underwent the most severe changes of all. By the latter 1960’s the movement to close state psychiatric hospitals was underway fueled by the new sociologic analyses of authors like Erving Goffman and the emergence national awareness of the wretched, medieval conditions of state hospitals and wretched treatment of patients. Commitment laws came to be humanized with respect for patients’ rights to legal representation after the 1974 Supreme Court Wyatt vs. Stickney decision. De-institutionalization, the discharging of inpatients from state hospitals proceeded through the 1990’s, eventually emptying states’ psychiatric hospitals of roughly 4/5 of their beds, closing old hospitals in wholesale fashion.
Many figures played major roles in this profoundly important movement. R. D. Laing in the UK tried treating schizophrenic patients in more open, experimental settings. Typical of those times, whether in state hospitals or a number of private free-standing hospitals, patient governments were formed. Patients were encouraged and helped to make many personal and treatment decisions for themselves. The “therapeutic community” movement arose out of, and in parallel, grew from this non-authoritarian, more democratic hospital life. Hospitals were opened up to the community. Echoing rehabilitation practices of nearly a century before, patients were permitted to work and earn money. Social activities were begun with the return of art, dance, crafts, and musical pursuits.
One very influential source of the de-institutionalization movement in psychiatric hospital care came from Italy in the 1960’s. This piece of psychiatric history is little known in the USA.
The Italian psychiatrist who pioneered many of the components of radical change in public psychiatric hospitals was Dr. Franco Basaglia. His story is nothing short of fascinating. As is so often the case in the culture of Italian figures no matter what their field of endeavor, his crusade began to take shape in his younger years being exposed to different mass political movements and periods of social upheaval in Italy. He was born into the fascist periods of Italy before and through World War II. He absorbed radical social concepts from the communist and socialist movements of post-war Italy. These concepts guided him to become the effective psychiatric reformer that led to his national fame and regard. This kind of personal development would be viewed as heretical, treasonous and would prevent any achievement in this conservative America. But in Italy, Basaglia’s social-intellectual development made perfect sense.
Basaglia did all the things we think of radical in a wretched state hospital. He empowered patients, tore down fences, did away with tortuous physical treatment, had patients go into the community and so on. He did all this in a true backwater town on the northern border away from any and all big cities and centers of thought and social change. He worked for several years in isolation and obscurity. Then through a fascinating chain of fortuitous events, his efforts began to be noticed and the powerful beacons of the press and celebrity status quickly enveloped him, his work and his staff.
His efforts came quickly to be acclaimed and trumpeted nationally and internationally. His influence in Italy was far beyond that of any of America’s famous reformers such as Dorothea Dix, Nelly Bly, Erving Goffman, Laing and all the others. Italy responded with the national social change that has only been equaled in the Scandinavian countries, not France, nor the UK and especially not in the United States.
With a few years, a reform law was passed in Italy named after Basaglia. It set the national goal of the closure of ALL the public state psychiatric hospitals!
This was indeed fully accomplished, a feat that is beyond astounding in the annals of national social change. For several decades now in Italy, there have been no mass hospitalizations of the chronically mentally ill. There do not seem to be hundreds of thousands of “CMI” (chronically mentally ill) persons everywhere on the streets of Italy. Somehow Italy with all its frequent political crises, changes in governments, scandals, raucous politics and all the other tumult that seems par for the national life of Italy, has done what other western societies cannot care pretty well for the nation’s mentally ill.
Realizing what Basaglia accomplished forty years ago leaves this student of psychiatry, its history, and observer of our current national crises, sad for where we have been trapped by our own hobbling prejudices, resistance to social change and pattern of quickie formulas that led to the all too familiar conundrum of “unintended consequences,” and bigger and more complex messes with each year in mental health care delivery.