Policies and Consequences: How America and Psychiatry Took the Detour to Erewhon

In 1964, my first postresidency position at the Public Health Service Hospital at Fort Worth, Texas, introduced me to the lives of people with severe mental illness and the psychiatrists who cared for them. I inherited 425 patients on ten wards. Each patient had been hospitalized for more than two years. The staff suggested I schedule a morning on one ward and afternoon on another so that I could visit each ward each week. The staff expected me to rewrite prescriptions, review charts, see patients with changed behaviors, and carry out required treatments. Two years later another doctor would take my place. I was about to become institutionalized.

Early Experiences

Using my experiences with ward meetings of staff and patients at Yale as a model, I agreed to start weekly visits with a large circle of patients and staff sitting and talking together for one hour. It was from these meetings that I learned what would occupy my career.

One patient, Mr. A., was in shackles, locked behind bars all day with fellow patients on his ward—unofficially called The Pit—and in a seclusion room each night. A frontal lobotomy, electroconvulsive therapy, antipsychotic drugs, and six years of hospitalization had extinguished his symptoms but not his outbursts requiring restraints. He and his fellow patients were not about to sit quietly for an hour. So I led other staff behind the bars to speak with the patients, each of us armed with a towel to clean the urine and food from the chairs. Mr. A. accepted an invitation to sit with us and was remarkably straightforward about his objections to his current situation. He wanted to live the life he knew before becoming mentally ill and would work toward a return to the community. He set our program agenda. We needed to create these needed transitional experiences by using existing hospital and community resources (1).

Within months of being given other choices, Mr. A. was living with fellow patients on an open self-care ward. Five days a week he took public transportation to a community-based vocational rehabilitation program. All that had changed in his treatment was a response to his needs for personal well-being. What had changed for him was the quality of life he saw in his future. I still view such changes as the core of the specific interventions that in subsequent years maintained many patients with severe mental illness in community jobs and housing (2).

At Southern Illinois University Medical School, we provided care over ten years to 180 patients with severe mental illness who were already living in the community or who came to us after discharge from a hospital. Most of the patients had been referred to us because other programs refused to accept them. In a 1999 publication in this journal, we reported our experiences (3). We found that patients in our program were succeeding in independent living and competitive employment and learning not to alienate others with expressions of their hallucinations or bizarre behaviors. There were no violent behaviors to report. When staff told patients that our assessments indicated that they should be hospitalized or should take medication, they complied, even though many had a history of physically resisting hospitalization and medication. With in-person services from on-call staff 24/7, supportive housing and employment, and access to court reviews, patients had alternatives to allowing symptoms and personal distress to escalate and complicate their illnesses. Most patients had lived in environments that escalated their frustrations. Symptoms without solutions had tormented parents and others. Patient-parent arguments spiraled out of control. Drugs of abuse worsened symptoms and prevented patients from seeing the life consequences of drug use. We provided deescalating environments. Mr. A. had summed up a reason for the changes these patients made in their lives: “You gave us hope.”

A Benefit From Social Policies

In the mid-1960s, psychiatry saw an opportunity to expand widely into communities (4). Early diagnosis and treatment and community supports would address mental illnesses and prevent and mend disabilities among individuals with more severe mental illness (5). New federal legislation provided funds for construction and initial staffing of local community mental health programs and for research and teaching of social-community psychiatry skills in university psychiatry departments. Psychiatry was gaining resources. For diseases there were new drugs, and for disabilities there was an array of interventions: social, psychological, housing, family counseling, vocational, patient-oriented case management, home visits, and medication supervision. Some academic centers pursued research in a broad range of life sciences to understand mental illness and how persons with severe mental illness could live successfully in communities. Some academics pursued a more limited range of inquiry in biological sciences to ground mental illnesses as diseases of the brain. Psychiatry was gaining the resources needed to understand both mental illness and the disabling effects of mental illness on patient well-being (6). The new science and resources to apply that science were giving psychiatry hope to share with patients.

The Reshaping of Psychiatry

In America at midcentury, psychoanalysis required many years of extended hours in offices with individual patients. Hospitals incarcerated, rather than treated, patients with chronic illness. In the 1960s and 1970s, community psychiatry interventions and new drugs were benefiting patients within days and weeks and maintaining previously hospitalized patients in communities (7). Research focused on brain mechanisms and drugs provided resources that enabled psychiatry’s hospital and community interventions (8). Psychoanalysis waned as psychiatrists gained skills and as the field of psychiatry devoted more time to understanding patients with acute and chronic illness as persons seeking personal well-being. Unfortunately, evolving social policies made psychiatry’s newly complementary community and neuroscience activities into competing interests.

Motivated by economics, states moved increasing numbers of patients from hospitals into communities that were unprepared to care for them. The developing community psychiatry programs struggled to keep patients from becoming homeless and rehospitalized. Before harmful federal funding shortfalls for the new community programs could be corrected, Reagan’s New Federalism terminated social-community psychiatry funding (9). Pharmaceutical and health insurance industry policies further undercut the expansions of psychiatry from offices into communities as well as the time that physicians could spend with patients. The survival of community-based services, research, and training became tenuous. Soon homelessness and arrest and incarceration replaced hospitalizations and community services.

In the 1980s, psychiatry became increasingly dependent on the pharmaceutical and insurance industries. Without federally funded community and social psychiatry activities, drugs became the most economical, medically indicated, and humane responses to serious mental illnesses. Financially sponsored activities, honoraria, contracts, and other financial inducements gave industry access to well-placed leaders in psychiatry. Abuses inevitably ensued. Academics were paid to promote drugs while federal agencies fined companies for misrepresenting these drugs to the public. Some leading academics received six- and seven-figure incomes from drug companies. Many authors of studies that guided the use of new drugs reported increasing conflicts of interests because of financial supports from drug companies. Head-to-head comparisons of drugs did not find that the new drugs were more effective than older drugs. Finally, the National Institute of Mental Health moved to refocus psychiatry’s nosology and clinical trials on the mechanisms of disease and treatment (10). Accomplishments in the neurosciences were being tarnished, but without federal funding, social psychiatry had become mortally wounded.

Without sufficient insurance reimbursement for spending time with patients beyond reviewing medications, most psychiatrists’ work on community streets, in homes, in community agencies, with police officers responding to calls, and in programs for the rehabilitation of persons with severe mental illness ended. Now trainees do not always learn how to work in and through groups to be effective when faced with overwhelming numbers of seriously ill patients and their problems with well-being. The structure of care for inpatients and for persons who live in the community creates its own environment. These environments do not always serve all patients’ needs to move beyond disabilities and find satisfying lives. It is here that psychiatrists need the flexibility and innovation learned from social-community psychiatry. Without experiences in social-community psychiatry, trainees are not exposed to patients’ real-life social and community burdens. Without this exposure, trainees can fail to develop the skills and flexibility to adapt current psychiatric resources to these situations or the skills to improvise, as I found necessary in my inpatient and community programs. Without federal or state funding for community-based services, communities cannot provide viable career options for tomorrow’s socially oriented psychiatrists. Remarkable advances in neuroscience cannot be effectively translated into improved patient care unless these advances are balanced by scientific developments relevant to the delivery of medicine’s traditional whole-patient care.

Tomorrow

Forced by social policies into providing office-based services, psychiatrists will not support patients in independent community living, go to patients to prevent rehospitalization, focus on personal and community well-being, and work to keep people with mental illness out of jails. Drugs and office-based psychotherapies, in and of themselves, are not therapies for persons with mental disabilities (2). They function as tools enabling interventions with socialization, supportive employment, case management, and so forth—tools that allow psychiatrists to create well-being for patients (1,3). For all too many patients with acute and chronic mental illness, drugs are becoming ways to manage symptoms while leaving patients desperate to restore lost well-being.

In retrospect, I believe that federal and commercial policies have made untenable psychiatry’s complementary developments and its uses of neurosciences and social sciences. Pressed by lost funding for social-community services, research, and training, psychiatry has accepted, not chosen, its current priorities. The 1980s federal defunding policies, followed by adverse insurance and pharmaceutical industry policies, have made psychiatry’s retreat toward becoming an applied neuroscience inevitable. These social policies, not psychiatry’s medical judgments, account for the fact that persons with mental illness today populate jails rather than hospital beds. A 2010 documentary on Utah’s mental health services reported that 40% of persons with severe mental illness in Utah would end up in jail at some point in their lives, many as repeat offenders (11). Salt Lake City police are trained to do case management of homeless persons with mental illness, but no rehabilitative psychiatric services are provided to them. Jail diversion programs based in the criminal justice system provide the only services these individuals receive. No psychiatrist trainees from the University of Utah are present to learn how to serve individuals with severe mental illness. In Utah, as nationally, the police have become psychiatry’s and society’s dirty workers (12). Fortunately, many police have, with responsibility and grace, accepted these burdens, which should not be theirs.

Has Erewhon Come to Stay?

In his 1872 novel Erewhon, Samuel Butler described a utopia where criminals are treated as patients in hospitals and the sick are jailed (13). In strange ways, these distortions have begun to appear in our society. Journalists, politicians, and pundits state uncategorically that persons with mental illness commit mass murders (14). In my experience, callous criminals, not the patients who were once neglected in large mental hospitals and are now neglected in jails, plan and organize the killing of others. I met callous criminals who were mentally ill. I never met a person who was made heartless by mental illness. I found that patients who might in desperation have stumbled into acts of violence were so symptomatic that they would have been committed to treatment by community outreach programs—the very programs that psychiatry lost with the termination of federal funding. I found patients desperately protesting the disabilities that had ensnared them in hopeless situations. Society’s policies have left persons with acute mental illness without adequate access to care and persons with mental disabilities in jails.

We lack the resources to find and return individuals with acute mental illness to states of well-being. We jail homeless people with severe mental illness. By use of labels in the news media and political arena, we propose persons who preplan and carry out cold-blooded murders as candidates for mental hospitals. It is tragic to think that violence might occur because psychiatry no longer has the resources to reach out to schools, agencies, and others in America’s communities. If America reflects the utopia described in Erewhon, psychiatry is not to blame. Legislators, industry, and local governments destabilized the needed academic research and training programs in community and social psychiatry and drove psychiatrists behind desks and into the arms of industry. Without a right to health care, patients’ rights keep patients living on the streets. The losses of hospital beds and community programs put street patients into jails. Psychiatry naïvely foresaw the dawning of one utopia but has lived to see another.

Conclusions

Society has subjected psychiatry’s patients to a sad social experiment that no Ethical Review Committee would allow medical investigators to pursue. These unacceptable experimental options—use of jails, medical errors, false claims for therapies, denials of health care access, and demoralizing conditions for the profession and its patients—are prevalent conditions today. Society chose and will choose the conditions affecting psychiatry. If psychiatry does not rise up in protest to defend publicly the needs of its patients, we will have no grounds to disparage society’s choices.