(Article published in Street Speech by the Columbus Coalition for the Homeless)
According to the Substance Abuse and Mental Health Services Administration, 20 to 25% of the homeless population in the United States suffers from some form of severe mental illness. But since more than half of all homeless people are without any heath care insurance, most would not have been able to be diagnosed, and even of those who were diagnosed, many of them deny the diagnosis. Thus, we should amend the statistic to say that the amount of homeless that are mentally ill is unknown, but the number might reach as much as half.
Why you might ask are so many homeless also mentally ill? Isn’t this inhumane of society to let this segment of the population remain “out there” untreated and unprotected? The answer is not an easy one since the issues involved in the problem are complex. To begin to try and understand the situation we need to take a brief historical look at society’s view of mental illness in America.
In the mid-1800’s, and in some places, the early 1900’s, mentally ill men and women of all ages used to be confined either to prisons, where conditions were often abysmal, or poorhouses (tax-supported residential institutions where indigent people were sent. During these years in America the aim was not to provide treatment or even basic care for the mentally ill, but simply to remove them from society- an “out of sight, out of mind” mentality.
In prison patients were often treated like animals. They were shackled to the wall in dark, cramped cells with no heat or bathrooms. Little thought was given to whether they were adequately fed or clothed. Cells were rarely if ever cleaned so inmates were forced to live in their own waste.
The alternatives to prison for some mentally ill were poorhouses. Every county in Ohio established one or more poorhouses during the 19th century. Some were clean and had plenty of food. Others were filthy places where people often went hungry. It all depended on where you lived, and who was on the county board. In the 1920s, the federal government sent volunteers to examine more than 2,000 poorhouses around the country. A report concluded that conditions were shameful.
Activists for the mentally ill lobbied for more humane treatment and in the early nineteenth century. This led to the creation of a progressive environment which fostered the establishment of many public "lunatic asylums" throughout the country. These asylums (meaning a retreat or place of refuge or protection) gradually replaced cruder methods of coping with the mentally ill.
“The Ridges,” a mental hospital in Athens, Ohio, is an example of such a place. It operated from 1874 until 1993. It was called the Athens Lunatic Asylum, then renamed Athens Asylum for the Insane. Later it became the Athens State Hospital. It is representative of a style of mental hospital common at this time known as “Kirkbrides” (named after Dr. Thomas Story Kirkbride, an influential advocate of an asylum system) built on large plots of isolated land where patients took care of the land. Many Kirkbrides like the Athens State Hospital featured self- sustaining apple orchards, gardens, and dairy farms. Positive behavior was rewarded, and patients were expected to exercise self-control.
This new “moral treatment” approach was marked by a well-ordered daily routine in which patients followed a therapeutic regiment of work and leisure activities. It was believed crucial to place patients in a more natural environment away from the pollutants and hectic energy of urban centers. Abundant fresh air and natural light not only contributed to a healthy environment, but also served to promote a more cheerful atmosphere.
Patients were also encouraged to take part in recreations, games, and entertainments which would also engage their minds, make their stay more pleasant, and perhaps help foster and maintain social skills. The patients with the most self-control participated in recreational activities like boating, painting, dances, and picnics. Church services were also offered in the asylum chapel building. Most of the nurses who worked at the hospital also lived there in order to provide better 24 hour care for the patients.
Columbus too had a similar Kirkbride asylum completed in 1877 after the first hospital, called the Lunatic Asylum of Ohio, burned to the ground in 1868. The building was similar in appearance to the Athens State Hospital Kirkbride, although it was significantly larger. The institution closed in the late 1980s. Unfortunately, attempts at preservation of the historic structure failed and the Kirkbride was razed in 1991. The Ohio Department of Public Safety and Department of Transportation now call the former asylum grounds home.
The failure of the moral treatment method to produce permanent cures and eventual overcrowding (patient records show an increase from the original 200 hundred patients to nearly 2000 patients by the early 1900’s) led to the demise of this treatment approach.
In the early to mid-1900’s a new generation of asylum superintendents began advocating different forms of new and "better" treatments for patients. These included water treatments (consisted of patients being thrust into ice cold water for extended periods of time or wrapped and restrained by sheets that had been soaked in the ice water), shock therapy (also known as electroconvulsive therapy or ECT, used to induce a seizure in a patient for therapeutic effect), and the infamous lobotomy.
Around 1950, people from the medical field began to speak out against Dr. Freeman’s lobotomies, suggesting that there was no evidence to prove the procedure actually worked, and in some cases, resulted in death. The lobotomy was finally declared barbaric, and a new wave of psychotropic drugs, like Thorazine, replaced it. Although the heavy drugs administered in hospitals at this time weren’t perfect, they were far more humane than electric shock or radical brain surgery.
Psychiatric hospitals, as they were now called, gradually became notorious for poor living conditions, lack of hygiene, overcrowding, and ill-treatment and abuse of patients. Custodial care once again superseded humane treatment. Controlling a patient’s behavior by the administration of medication and the use of behavior modification techniques, like the use of restraints and seclusion rooms, were the norm. The 1975 movie, One Flew Over the Cuckoo’s Nest, depicts this era graphically.
I saw this first hand during my student nursing days when I did my psychiatric nursing rotation on the back ward of a state hospital. Drugged patients paced listlessly or lay on their beds staring off into space. Time was measured by the burning of cigarettes, and days were organized around the dispensing of scheduled medications and mealtimes. The lack of stimulation and activity was, I thought, like being in prison. The locked doors were another striking similarity. The objective was to limit the disturbing behaviors, not restore the patient to a productive life in the community.
It was not until the 1960’s that humane treatments began reappearing in psychiatric hospitals when class action lawsuits, patient advocacy groups and government agencies helped expose the poor conditions and treatment in state hospitals.
Around the same time, sociologists and others argued that long term hospitalization maintained or created dependency, passivity, exclusion and disability, causing people to become "institutionalized." There was an argument that community services would be cheaper. Anti-psychotic drugs made it possible to begin discharging large numbers of patients back into the community. Deinstitutionalization is the name given to the policy of moving severely mentally ill people out of large state institutions and then closing part or all of those institutions. It began in 1955 and escalated in the 60’s and early 70’s.
The 1980’s were the final days of the Ridges, as well as many other state mental hospitals all over America. The final patients left in 1993 (the buildings and grounds have been taken over by the Ohio University). However, because of inadequate housing and follow-up care, many of these patients became homeless or went to prison. We have come full circle.
The magnitude of deinstitutionalization of the severely mentally ill qualifies it as one of the largest social experiments in American history. Many consider it to be a major contributing factor to the current mental illness crisis. The most striking evidence of this crisis was the dramatic appearance of large numbers of obviously mentally ill people on city streets, people who were dirty, who wore torn or inappropriate clothing, who hallucinated and talked to themselves or shouted to others, and who in general acted in a strange or bizarre way. In many places, huge ghettos of discharged patients were created in areas of low-cost housing, proprietary homes, or deteriorating neighborhoods. It has been said that instead of "community psychiatry," reforms established a "psychiatric community."
The majority of those who would have been under continuous care in long-stay psychiatric hospitals are often paranoid and delusional to the point that they refuse help and do not believe they need it, which makes it difficult to treat them in the community. Community services were often uncoordinated and unable to meet complex needs and existing patients were often discharged without sufficient preparation or support.
This has led to two new syndromes: "falling between the cracks" and the "revolving door," the former indicating a total lack of follow-up and aftercare for discharged patients, and the latter their continued readmissions, usually due to noncompliance with treatment. Thus deinstitutionalization is part of a process sometimes called transinstutionalization- the transfer of institutional populations from hospitals to jails, nursing homes, and shelters.
Our society as a whole still grapples with the dilemma of what to do with its mentally ill members. Both long-term hospitalization and community mental health services have, in large measure, been a failure. This population remains vulnerable and at risk.
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