A now slightly dated article published July 4, 2016 in many papers authored by Lateshia Beachum of the Washington Post that I came across in the Walla Walla Union Bulletin of Washington state recorded the magnitude of the cut backs nationally in public state hospital beds psychiatric beds. While this has long been known as a trend occurring over at least the last five decades, this article startled even this observer by how many beds have been cut by state governments in just the last several years. The article was entitled, “Psychiatric bed count hits record low in state hospitals.”
The first sentence of the article hints at two of the main themes: “The number of psychiatric beds in state hospital has dropped to a historic lows, and nearly half of the beds that are available are filled with patient from the criminal justice system.”
Just yesterday I wrote briefly of the contrasts between New Hampshire and Vermont who face difficult state wide mental health service care delivery tasks.
Today I feel I have to return to a story, or rather a sad saga, of Central State Hospital in Virginia. Virginia since the tragedy of State Senator Craige Deeds’ son Gus who was variously reported as bipolar or schizophrenia, committed suicide two years ago. The circumstances were unbelievably tragic, sad and preventable if, in my view, public and/or private psychiatric inpatient facilities had done their duty [more on that rant later below]. In brief summary, young Gus was in his very early 20’s and had been repetitively psychotically mentally ill for a few years illustrating the typical early adult onset of these illnesses, especially schizophrenia. He became psychotic again and stabbed his father. He was taken by his father to a nearby hospital ER, a hospital without a psychiatric inpatient unit. He was held in the ER for some period of time [the reports vary from hours to a few days]. He had to be released under less than clear circumstances because a bed could not be found for him in ANY psychiatric inpatient unit in the state, which to me is the first bad tip off in this saga. He very shortly thereafter, while apparently still quite symptomatic and actively ill, suicided. As is well known, his father Sen. Deeds has thrown his considerable talents, knowledge, energies and influence into crafting exemplary legislation in Virginia to correct many cracks and deficiencies in their combined state system of psychiatric care. Of note is the lingering issue that his bill is still not law in Virginia.
Now to the current unfolding tale of woe, and goodness knows what else that is week by week it seems, unfolding out of Virginia’s Central State Hospital. There have been a series of near damning articles in multiple minor and major newspapers in Virginia detailing the trial of failures it appears that resulted in the death of a woman named Valerie Anderson now buried on the campus of Central State Hospital since she died there.
The accounts from the various media, best summarized in the article, “State fails to notify family woman dies at Central State Hospital,” which appeared in the July 3, 2016 edition of the Culpepper Star-Exponent, shows that this woman was likely chronically mentally psychotic, a neighborhood recurring disturbing presence and was arrested for misdemeanor trespassing May 14, and was jailed as she was poor and could post a $1,000 bond. She was reportedly evaluated and cleared because of unspecified behavior in jail, and transferred May 24, 2016 to Central State Hospital. All without notifying her family but there were real issues with this part as she was out of follow up treatment and no one seemed to know where her family resided or how to contact them. She then died under unclear circumstances at Central State Hospital May 26th. The family as time went on, found they could not contact her. No one who knew her knew where to look. Meanwhile, the hospital for various and sundry reasons apparently did not do due diligence in following up and trying to establish more information about her and to contact the family. It finally took the Richmond Times-Dispatch in June bringing a Freedom of Information lawsuit to secure, confirm and establish that this lady had died in the hospital. This was prompted as described in the article thusly: “The search for answers in Valerie Anderson’s death was launched in earnest last month after the spokeswoman for the Department of Behavioral health and Developmental Services and other state officials declined to provide any details related to the transfer of an inmate from Hampton Roads Regional Jail to Central State Hospital.”
“Among the information officials initially would not provide about the Central State Hospital death: the patient’s name, gender, and age’ when he or she was transferred to the hospital; when exactly he or she died; and when and why the person had been incarcerated.”
Further, “Later, they to The Times-Dispatch that the patient was female, had been arrested for trespassing; was evaluated and medically cleared on May 24 for admission to a state hospital following mental health crisis at the Portsmouth jail; and was transported Central the following. she was found dead the morning of May 26 by a hospital worker.”
The intrepid reporters for the Times-Dispatch, then armed with the scant information they were able to gain from their Freedom of Information suit, did gumshoe, old-fashioned journalistic ‘detective work.’ and examined Newport News court records, found the record of a Valerie Anderson trespassing charge. And of things in the newspaper “morgue file,” as they used to be called, they found a sticky note marked “Important,” that gave the date of May 25 as her transfer/admission to Central State, and of May 26 as the date of her death.
An instance of denial by hospital officials June 8, to the Times-Dispatch team working the story, prompted them to only dig further [my characterization of what appeared to happen] and her grave was located on the grounds of the hospital. The Times-Dispatch also then were the ones–get this folks!- to locate her family and notify them of her death. Unbelievable…
As it turns out Virginia DOES have good state laws and mandatory procedures for handling patient deaths in state institutions of any kind and they are detailed quite objectively in the above-cited article.There are well-defined time frames in which certain steps must be taken in order and that the steps must go up the state government’s chain of command in a certain order to the highest levels. But the article’s description of the halting effort the hospital made in its description of the events and refusals and declinations to give information makes for sad but also infuriating reading. To make matters worse, the family was rebuffed initially in their efforts to gain information regarding the fate of their mother. This makes for tough reading as the article details the obfuscating and self-justifying responses of the officials that were contacted.
I will end this story with a final slightly lengthy quote which I think emodies the then attitude of the protective state functionaries [a kinder word than I think the families or reporters would use] who were in a position to help the family and reporters: “Anderson had a personal Facebook page and was online frieds with her four children. But social media sites and internet search engines are not part of the process state workers use to locate family members [I would ask WHY NOT?] when someone dies in custody, according to Maria Reppas, spokeswoman for the Virigina Department of Behavioral health and Developmental Serivces…The facility does not take steps such as conducting Google searches or looking through Facebook sites to locate next of kind nor is it required to do so,” Reppas said in a email.
After the family learned through the newspapers’ reporters that their mother was indeed deceased and had been buried in the hospital cemetery, the daughter Jacqueline asked to visit her mother’s gravesite. The article states at its end that she was told she would have to make an appointment to do so.
I became aware of Bridgewater State Hospital during my college and medical school years in Ann Arbor, Michigan through two events in my student life back then.
First, I was able to see the famous documentary movie, “Titicut Follies,” almost accidentally at a university sponsored film festival in 1970 or so. The film was all the rage since it had been “banned in Boston” by the Supreme Court of Massachusetts. It was filmed in 1967 by the now acclaimed filmmaker Frederick Wiseman. I remember not knowing really anything about the movie, but going with friends to see this controversial movie. At that time, I had not settled on a future career in psychiatry. I was stunned at the content of the movie which showed deplorable conditions at a correctional center division of the state hospital located at Bridgewater Massachusted. After I finished medical school, I was
After I finished medical school, I was fortunate enough to land a six-month externship in forensic psychiatry at the Center for Forensic Psychiatry located on the grounds of Ypsilanti State Hospital south of Ann Arbor. This was a state hospital that had become famous in its own right. It was the subject and setting of a famous book, The Three Christs of Ypsilanti, by Milton Rokeach.
The book was ahead of its time, portraying the irony of three psychotic inpatients who shared a unit as well as the common delusion that each was Christ. The book was hit for years and required reading almost in every university in first-year classes in psychology. I had read the book as well and was fascinated by the premise of how these patients handled the dilemma of their common and contradictory claims.
Little did I know that my externship would bring me into contact with the late forensic psychiatrist, Dr. Ames Robey. Dr. Robey astutely had realized and discovered the identity of the “Boston Strangler” as one of the psychiatric inpatients at Bridgewater, Albert DiSalvo.
This brought Dr. Robey national fame and publicity though he had no interests in all media attention. As an aside, I also was able to work under Dr. Elissa Benedek MD, an early female forensic psychiatrist, who was also a child psychiatrist, and a few years later, became President of the American Academy of Child and Adolescent Psychiatry. She was a small bespectacled woman, calm, supportive and incredible teacher, and clinician.
So, these two experiences acquainted me serendipitously with Bridgewater State Hospital. Late last year, Bridgewater State hit the headlines again as stories of abuse, poor treatment, a group of deaths of three men in 2015 were reported in the Boston media. Within months, three guards at the facility were indicted of involuntary manslaughter and the Boston Globe had a documentary series of articles on the all too familiar, decades-old tale of sandals and substandard levels of care. I had actually assumed that Bridgewater State, by this time, had long been closed. Silly me. Like so many state psychiatric facilities, it was very much needed and like an old battleship kept in service for decades. The news about the hospital by April of this year just kept getting worse. To me, it was like somehow seeing an eerie reprise of the movie “Titicut Follies.” That goofy and weird feeling kept me following the news stories that have emerged in the last two months in the Boston Globe newspaper.
How did this hideous story come to be repeated nearly 45 years later? The Boston Globe reported on the slowly evolving, yet almost inevitable conditions that brought this tragic replay back to life in an article in April 2016, this past month at the time of this writing. The usual culprits of legislative neglect through decades of inadequate funding, lack of oversight and installation of a poor level of care, and a herculean task demanded of an institution not properly fueled for its job.
A once famous historical psychiatric institution forced into repeating its own tragic failings because of legislative “neglect” forced into a Kafka-esque re-run reinforcing all the negative stereotypes of a psychiatric institution. This has almost a psychotic quality, all its own, in which the observer, cannot tell reality from unreality…
Texas, like many states, has been struggling for the better part of the last two decades with its public mental health system’s needs. Like almost all other states in the United States, it has seen its share of declining state funding for state-wide mental health services. Ageing state hospitals for the acutely mentally ill, chronically mentally ill and developmentally disabled have been closed or downsized. Short-falls have gradually appeared in the provision of outpatient services recommended and hoped for, to supplement or replace those reduced state hospital beds.
Texas for a number of years has begun to experience the enormous increase in jail populations of the mentally ill, mirroring many other states, especially New York with its travails at Rikers Island, perhaps the country’s most famous metropolitan jail facility, serving New York City. Rikers Island has lamentably been in the tragedy borne headlines in the last few years with repeated suicides of mentally ill inmates, and lawsuits by families and repeated efforts at reform and improvement, recently occurring again by necessity under the mayoralty of Bill DeBlasio.
Harris County Jail, of Houston Texas, has become known as one of the largest “psychiatric” facilities in the country. Several years ago I recall that the Harris County Jail had to increase its psychiatrist staff roster from three psychiatrists to fifteen and add a number of psychiatric physician extenders and other staff to serve the needs of this swelling psychiatric segment of the inmate population. What happened in Harris County, encompassing metropolitan Houston, was not unique to the country’s correctional systems at all, but became known readily nationwide as one of the first such settings recognized for this tell-tale barometer of the deficiencies in any area’s public mental health service system. Harris County, on a personal note, is known quite well to me, as that extended area was where my father came from and is where I have my only sibling living all our adult lives.
A very recent article online written by Stephen M. Glazier, one of the nation’s leading mental health care executives and head of UTHealth Harris County Psychiatric Center of Houston, outlined one of the best-written definitions of the concept of psychiatric “continuum of care,” that I have ever read. His article appearing at TribTalk.org, “Bridging the Mental Health Treatment Gap,” on May 9, 2016, provided insight into Texas’ progressive efforts in just the last 1-2 years on improving the state’s mental health reform and care delivery efforts which have not received the recognition they deserve.
Mr. Glazier pointed out the common issue seen in many states who have had to face the need to close or replace aging state hospitals, and the multifaceted dilemmas of what to replace them with. He eloquently wrote of the concept of providing what he termed the middle range of less intensive residential and non-hospital based psychiatric services in the overall continuum from hospital to home or ultimate living placement for the mentally ill person. He delineated some key concepts and facts: 1) that Texas’ state psychiatric bed ratio has declined since 2001 from 13.4 beds per 100,000 persons to 10.9; and that, 2) even if Texas had ‘kept up’ with the growing mental health needs, the rapid growth population growth in the state of Texas, which has always been in the top five states in the US, the state’s level of services would still have fallen behind previous levels of beds per 100,000 population.
His idea is not a new one, that increased and nuanced provision of these middle ground “residential,” transitional psychiatric services, would to at least some degree, not only replace some state hospital beds, but reduce the spill-over, or “trans-institutionalizations,” (the new buzzword) that we are seeing as ever more rapidly increasing numbers of the seriously mentally ill, shift from non-existent state psychiatric hospital beds to jails, hospital ERs, and the streets and shelters, all never intended to serve this population. But Mr. Glazier’s description of what is needed in filling in the gaps in the continuum of care of the mentally ill is well worth reading.
On December 12, 2015 the newspaper, the major newspapers in North Caroline, Winston-Salem Journal p, The Durham Morning Herald, and the Raleigh News and Observer, all published as article, ” Researchers measure NC psychiatric bed shortage.” In this article, hard data confirmed what has been known for a number of years, the North Carolina, in spite of its unique and laudatory efforts, almost head and shoulders above most states in the US, still needs many more psychiatric beds. North Carolina is unique and to be regarded positively in its almost singular effort to spend hundreds of millions of dollars upgradings its entire state hospital physical plants over the last several years. Almost no other state in the Union is doing this in this time of tight state fiscal budgets, and the lingering slow recovery of the now nearly 10 years banking and housing bubble scandal-induced Great Recession. NC has closed one old hospital, the former John Umsted state hospital in the “institutional” town of Butner NC, just 20 miles or so NE of Durham and replaced it and the now closed famous Dorothea Dix Hospital of Raleigh named after the 19th century’s more famous mental health reformer, Dorothea Dix, with a new nearly 400 bed state hospital , Central Regional Hospital. NC has also nearly finished completing replacing the old “Cherry State Hospital,” in Goldsboro serving the eastern third of the state with another completely new facility.
As an historical and “tourist guide” type aside, the town of Butner is tiny and sprang up in the rattlesnake-infested pine forests north of Durham in WWII when Camp Butner was built by the Army as a major military training center and was the site of a 4000 bed Army hospital for wounded veterans from the ongoing War in Europe. It was the second largest such hospital during WWII on the East Coast. After the war, in 1947, the year I was born it was sold to NC for $1 on the condition it be utilized as a state hospital for the mentally ill. On a persona note, my own training psychoanalyst, who came to NC to help state psychiatry at UNC Medical School, was named its first psychiatric superintendent. Butner is currently also the 30 year site for the famous or infamous “Federal Correctional Facity” where some of the worst federal psychiatrically insane criminals have been housed and evaluated such as Ted Kazsinski, The “Unibombers,” Mark Chapman, John Hinkley and many others.
Once again the author finds himself balefully writing about the continuing appalling trends in mental health inpatient care nationally. However, I am moved to do only when I see a very good reference that I feel the reader interested in this vital topic, should be alerted to.
A recent article in the news blog, Vindy.com of November 24th, 2015 showed that it does not take a nationally prestigious paper or news sources to put out a superb summary and analysis of a subject pertinent to this topic. In an article entitled, “Mental health care in Ohio shifts from hospitals to jails,” written by Peter H. Milliken [email@example.com] in Youngstown Ohio, the issues were as clearly spelled out as I have ever seen.
That author started that “”in the past five decades, state-run psychiatric hospitals have been phased out with funds shifted into each community cereate outpatient care and support services for those afflicted with any of a number of mental illnesses.” He adds tellingly: “As in all complicated cases, the result has been a complicated stream of causes and effects,” and I would add ‘unintended effects’ that have marked ill conceived mental health reform efforts nationwide over the last 15-20 years. The three basic mistakes were 1) way too rapid closing of albeit aging state mental health hospitals and beds, 2) grossly inadequate replacement of those inpatient beds, the thinking being in the minds of frankly ignorant and misinformed ideology on the part of state level mental health planners and legislators, that the beds were not needed and should be “liberated” [my term] bourne out of the “de-institutionalization” misguided ideology arising in the 1950’s and 1960’s, and 3) the totally insufficient of funds to cover the community based needs as a result of the closure of inpatient, BOTH public and private.
The author gives an example of a state hospital closing 19 years before, the Woodside Hospital, and its surrounding county gradually absorbing what sounds like an inordinate number of extreme mental patients who had no place else to go. He states tellingly, “We’re in a crisis for state hospitals,…we have days when there are no hospital beds for our clients,” quoting Duane Piccririlli, executive director of Mahoning County, whose jail had to pick up the slack.
The article goes on to describe what happened in stark broad overview terms. The state of Ohio previously had 19 state hospitals but now has only six. Patient shifting as it is sometimes, called has occurred in a massive way from non-existent state hospital beds to jail beds. And it costs the state more in most studies to house such patients in jails than even so called “expensive” or “labor intensive care,” and the care if far poorer and more and more marked by preventable tragedies.
One of the sadly recurring, and enduring themes of so-called “mental health reform” in this country, is the inevitability of a number of problems as state hospital beds are foolishly cut in this country and staff positions are cut as well.
Today, September 22, 2015, the Raleigh News and Observer newspaper revealed and published some very disheartening and totally surprising news that illustrates yet another dilemma in the ever more difficult tasks in improving mental health care public services in this state, and, likely reflects the kinds of dilemmas that other states are and will be struggling with in facing up to their obligations in this area. The article is entitled: “NC budget cuts $110 million from regional mental health,” and can be read here.
The state hospital system in this country began as an attempt in various of the early 13 colonies and later the early states as humane, for the most part, attempts to house the mentally ill. Williamsburg VA, now the site of Eastern Virginia State Hospital and a similar facility established by the Quakers in Philadelphia were two of the earliest efforts. There was no effective treatment until the advent of ECT (electroconvulsive therapy in the 1940’s and 1050’s with its own then shortcomings and crude, barbaric techniques till refined later, and the advent of psychiatric medications starting with Thorazine, Valium Elavil etc., in the 1950’s.
By this time even the best efforts of Clifford Beers a man who had recurrent psychotic mental illness and wrote in the early 1900’s the first widely read autobiographical account of his onw psychosis which was a national sensation as it described basically for the first time for the public, the pain of being mentally ill, and Dorothea Dix the great crusader for the mentally ill the lattter half of the 1800’s, fell short of preventing the average state hospital from turning into a facility for containment, incarcertion, etc., of the mentally ill. The famous book ASYLUM was published in the fifties and cranked up the debate over “institutionalization” and debasing treatment of the patients in the average state hospital. This fueled, the movement to get patients out of state hospitals, then beginning to be thought of as cruel institutions and less as places of possible treatment or early rehabilitation. This book came on the national scene at the “right” time, caught the attention of the public, politicians, advocates and helped to state the partial dismantling of state hospitals nearly every where. Bed numbers were reduced from averages of a few thousand beds per hospital, as many state hospitals were indeed massive. Smaller was thought to be better and bed numbers through the second half of the 20th century over time came down to the hundreds. And this does not include the dozens of institutions that were outright closed, because of revelations of abuse, mistreatment, no treatment, subhuman conditions, and “warehousing.” The Comprehensive Mental Health Center Act of 1963 was enacted as one of the last major pieces of legislation of the JFK Presidency. Smaller treatment-oriented facilities were to be built all over the country by the hundreds, often to be linked up with major medical centers. One of the earliest community psychiatric hospitals so built was Marshall I. Pickens Hospital in Greenville SC next to Greenville Memorial Hospital. They both still exist today; GMH is the major teaching hospital because of its size and faculty, of the University of South Carolina at Columbia. The opening of Marshall Pickens Hospital was graced by the presence of no less than Hubert Humphrey in the early years of Lyndon Johnson’s administration after the assassination of President Kennedy.
As usual I always bow to my internal ethics and try to be as open and transparent as possible about the subject at hand, revealing attitudes, biases, views based on long term experience, and an almost “historical view” of the galloping phenomenon of “mental health care delivery reform” thankfully occupying the attention of the country finally. I am old enough to have practiced in the so called mental health age of oodles of resources, and have watched them atrophy, became extinct, go corrupt and get themselves prosecuted out of existence, lose funding for many many understandable reasons, lose their place of importance, watch the ever decreasing number of bright talented younger generations of “would have been social workers, psychiatrists, and psychologists” shy away from the training programs, and our numbers go down especially in child psychiatry. One could take an inflammatory demagogic view and see is as necessary to prevent th abuse and horrors that indeed happened for decades shuttered away out of the light of public review and knowledge and responsible accountability and oversight. But that approach has nearly led to the old saw of “throwing the baby out with the bathwater because something was wrong with the bathwater, too dirty, too hot, whatever. I have seen the inhumane past and still in more restricted corners, inhumane treatment of patients in poorly run state hospitals that made me so mad I thought i would bomb them into the ground they were so bad, but of course after evacuating the helpless patients. I have helped to de-accredite the abominations of such hospitals, a few but enough to see first hand the decades old cultures of isolated facilities with poor faculty, psychiatrists who could work no where else due to histories of alcoholism, just plain bad practitioners and all the rest. I have had close colleagues since my residency days who presided over the deserved federally mandated dismantling of closure of famous hellholes permitted to exist far too long and heard their stories of generations of horror stories.
But in the midst of all this, or in my case in the last quarter of my career, I still know and hold to the somewhat unpopular certitude that state psychiatric hospitals are needed, good ones and now more than every. One simply statistic is that out country’s population and mental health treatment burden has at least doubled if now tripled since World War II. And we have had new mental health phenomenon syndromes, traumatic brain injuries of unforeseen overwhelming magnitude outstripping the abilities of public and private psychiatric-neurological treatment worlds to receive, treat and comprehensively help them out of our IED head rattling new genre of injuries in the Middle Eastern conflicts we have had to enter, police and try to stabilize at little thanks from much of the rest of the concerned world with some exceptions.
State hospitals across the country have been marked for closure and destructions for decades with the trend accelerating greatly in the last 2o years or so. It was thought and expected the the monies saved from funding these “dinosaurs” would be responsibly shifted to the long known need for massive outpatient services for the CMI, chronically mentally ill for which the state hospitals had long existed and served, and served well in a surprising high number of hospitals. Remember the famous Meninnger family of three generations of nationally recognized humane psychiatrists practiced in a state public hospital, Topeka State in Kansas a venerable training and research facility itself.