Treatment of the Mentally Ill

Since the beginning of the eighteenth century, societies around the world, the American society specifically, have come face to face with a growing problem that continues to exist within our midst to this very day. It can oftentimes be seen while driving past certain street corners, within homeless shelters, in the forms of men, women, or children wandering aimlessly about in a confused, perplexed daze; those roaming the streets in search of warmth, food, and a moment’s peace; or those who have been left without the care of families or friends completely on their own within overcrowded hospitals without hope of ever truly recovering. All waiting to die, waiting to live again, waiting for a resolution that perhaps will or will not come. Yet despite all this hardly anyone lifts a finger to help, hardly anyone casts a glance of pity in their direction, or and hardly anyone takes it upon themselves to restore the peace and safety, that which rightfully belongs to all, to the one who needs it most of all. These individuals we so callously walk past, harden our hearts to, and deafen our ears to are none other than those who have been classified as mentally ill; persons afflicted psychologically day in and day out without any chance of being truly helped by the country or families that vowed to care for them.

Over the years, efforts had been made to at first diminish this problem by simply approaching them Biblically as individuals who are “demon-possessed” and performing series of exorcisms so as to cleanse them of their condition. Oftentimes these poor beings endured being locked up and away in attics, cellars, or bedrooms in chains so that they might be out of the sights and minds of those who are kindred to them as their families had no idea how to help them. Then of course they moved from these cold, dreary rooms into those of insane asylums and mental institutes where they were exposed to harsher conditions such as abuse, terrible and ineffective treatments, and inhumane housing where they were forgotten and left to die alone. Now, not only are these people exposed to uncaring caretakers inside mental hospitals and cruel solitude, but there are many who fall through the cracks of a faulty system which does not even try to safeguard them like it ought to. Throughout the course of this essay what will be discussed are three concepts supporting the fact that there is a better way to treat those who suffer mental conditions both severe and minor: Institutionalization, Deinstitutionalization, and a solution that best combines the better elements of each of the aforementioned models of mental healthcare.

To begin with, let us discuss the concept and convention of what is widely known as Institutionalization; which is what the mental health reformation established so as to assist the families in the care of mentally impaired loved ones. Not very many know this, but the very first individual to innovate earlier concepts of Institutionalization was none other than Hippocrates; in 5th century B.C., he was affirmed in “treating mentally ill people with techniques not rooted in religion or superstition; instead he focused on changing a mentally ill patient’s environment or occupation, or administering certain substances as medications”; therefore paving a path to Institutionalization (Course, Module 2.1). Right away the first archetype seemed to do more good than harm in the beginning considering the fact that those who were enrolled in these hospitals had individuals who were available to care for them at all times. Through the “first half of the 20th century, according to Joel A. Dvoskin, “state hospitals provided care, housing, employment (usually unpaid), and social control of people deemed unable to meet life’s daily demands” such as those with mental illness, “alcoholism, mental retardation, advanced age, or chronic somatic illness, or a combination of these factors” (Dvoskin 1). G. Thornicroft refers to this early stage of Mental Health Services as “The Rise of the Asylum” which, according to Thornicroft’s research, “occurred between approximately 1880 and 1950 in many more economically developed countries” and “was marked by the construction and enlargement of asylums remote from the populations they served, offering mainly custodial containment and the bare necessities of survival to patients with a wide range of clinical disorders and abnormalities” (Thornicroft 6).

Research of history shows that before the establishment of Institutionalization, those who possessed the ailments of an un-well mind were simply placed in holding cells with those who were criminals and holed up in almshouses where they seemed to only grow worse and worse by the passing day as those who encountered them treated them as though they were less than human. Having witnessed these severe situations first hand, Sunday-school teacher and advocate Dorthea Dix made it known that the mentally ill “could be treated, and thus need not be relegated to the cellars of local jails”, supported the idea that they “were more like us than unlike”, and upheld the belief that if the mentally ill were “treated with kindness, encouraged to establish order in their lives, given the opportunity to work at productive trades, and provided with models of behavior, their mental illness might dissipate” (Appelbaum 511).

Another advocate that shared similar views with and preceded Dorthea Dix was Frenchman Philippe Pinel, who not only instituted what he called “traitement moral” at the Bicetre Hospital in Paris, but held hard and fast to the belief that “insane people did not need to be chained, beaten, or otherwise physically abused”, but on the contrary could be helped with “kindness and patience, along with recreation, walks, and pleasant conversation” (Trent Jr.1). Around the same time, another advocate of mental care reformation, William Tuke, an English Quaker “emphasized the rural quiet retreat where insane people could engage in reading, light manual labor, and conversation” and rejected the idea of “traditional medical intervention” (Trent Jr. 1). In fact, Dorthea Dix, along with a few other pioneers of mental health reformation, made it possible for “a network of state-operated hospitals” to come into existence and did in fact cause greater change in the field of mental health care, which lasted for quite a long time (Appelbaum 511).

However, this would not last forever, as nothing ever does in this imperfect, broken world. As time went on, the states “assumed wider responsibility for the mentally ill” and “the hospitals grew in size, absorbing the denizens of the jails and poorhouses”, these places soon evolved from places of serenity and care to places of desolation and chaos (Appelbaum 511). In the wake of the Civil War, public hospitals went under a great deal of stress in regards to the states’ “burdens created by waves of immigration” and were eventually forced to surrender the “goal of active treatment” (Appelbaum 511). These hospitals “continued to expand, but changed into enormous holding units, to which the mentally ill were sent and from which many never emerged”; as the mentally ill once again found their way to the bottom of the “list of social priorities”, they were “often treated with brutality” and at best “suffered from benign indifference to anything more than their needs for shelter and food” (Appelbaum 511). According to an article written by William F. May mental hospitals along with penal institutions soon became “symbols of death” and “subliminally associate[d] with the oblivion of death”; May confirms that the “mentally disturbed often receive notoriously poor treatment of their physical ailments” and that although “such neglect is remediable, institutionalization, whether good or bad, often tends to afflict the afflicted more subtly, by depriving them of community” or “’being present’ to others and letting others be present to oneself” (May 516-17).

In further discussion of this flawed method of care, Institutionalization is also shown to be ineffective in regards to the patient’s sense of autonomy. According to William F. May the institution “forces upon them a loss of name, identity, companionship, and acclaim—an extremity of deprivation of which the ordinary citizen has a foretaste in his complaints about the anonymous and impersonal conditions of the modern life” (May 517) Although it can be argued that many have “suffered a loss of community long before” admittance into a mental hospital and that the “institution may in fact provide [the patient] with more community that they have enjoyed for years”, the patient undergoes certain psychological situations that they most often did not have to face before (May 517). One of those situations would be fear of the unknown and unfamiliar. In his article studying the total institutions, May reveals that this form of care “gnaws—with its alien machines, rhythms, language, and routines—at the identity which a person precious maintained in the outside world” and claims that the patient’s capacity for “savoring [their] world is numbed” by the assorted procedures used to treat the ailment such as “diet, drugs, X-rays, surgery, nausea-inducing therapy, and sleeping potions” (May 517). Not only that, but when a patient is admitted into an institution, they find that their ability to communicate with their world “erodes as [they lose their] social role”, makes them feel “less secure in [their] dealings with fellows”, and “the procedures of the hospital remind [them] acutely of his loss by placing [them] in the hands of professionals—the nurse and the doctor—precisely those who seem unassailably secure in their own identities” (May 517). Needless to say, although Institutionalization was well and good in the beginning and does provide a bit of structure to the lives of the patients who reside in the mental hospitals, this model of care now requires a great deal of investigation and fine tuning before it can be considered a better option for treatment. If a method of care only works when the patient is being worn down and being stripped of all that they were familiar with, how effective is it really? If this method is considered an effective way of soothing the afflicted minds of the patients, honestly they would be much better off being holed up in some attic in the house where their families reside. Certainly they could suffer no worse damage to their already frayed minds than if they were admitted into a place they knew they had no hopes of escaping and being constantly reminded that they are the lesser, forgotten members of society. No, this cannot be, should not be. There must be a better way of treating these poor people than what is available now. Fortunately, there is.

Moving onto the next sub subject of mental health care, Deinstitutionalization, there emerges a seemingly superior method of caring for those who are mentally ill while preserving their sense of independence and personal rights that are granted to every individual at birth. As doctors, psychiatrists, and advocates began to further explore healthier alternatives to simply locking patients up in buildings and giving them medications that ultimately dull the senses, they slowly but surely began to consider possibilities of reintroducing mental patients back into a society they had once been exiled from as they were considered unable to function harmoniously with those who were considered “normal”. In his article, “Crazy in the Streets”, Paul S. Appelbaum reveals that after the end of World War II came about, a “new generation of psychiatrists, returning from the war, began to express their disquiet with the system as it was” and believed that “patients need not spend their lives sitting idly in smoky, locked wards” (Appelbaum 511). Furthermore, these “psychiatrists and their disciples, emphasizing the desirability of preparing pations for return to the community, began to introduce reforms into the state systems”, such as opening up the wards, allowing male and female patients to intermix, setting active treatment programs in motion, and screening patients before admitting them, particularly those who were elderly; ensuring that efforts were “made to divert them where possible to more appropriate settings” (Appelbaum 511). In addition to this, Appelbaum reveals the presence of new medicines that served to reverse effects of psychological illnesses and disorders were discovered, researched, developed, and introduced during this movement:

“In 1952, French scientists searching for a better antihistamine discovered chloropromazine, the first medication with the power to mute and even reverse the symptoms of psychosis. In traduced in this country in 1954 under the trade Thorazine (elsewhere the medication was called Largactil, a name that better conveys the enormous hope that accompanied its debut), the drug rapidly and permanently altered the treatment of severe mental illness. The ineffective treatments of the past, from bleedings and purgings, cold baths and whirling chairs, to barbiturates and lobotomies, were supplanted by a genuinely effective medication. Thorazine’s limitations and side-effects would become better known in the future; for now the emphasis was on its ability to suppress the most flagrant symptoms of psychosis.

Patients bedeviled by hallucinatory voices and ridden by irrational fears, who previously could have been managed only in inpatient units, now became tractable. They still suffered from schizophrenia, still manifested the blunted emotions, confused thinking, odd postures that the disease inflicts. But the symptoms which had made it impossible for them to live outside the hospital could, in many cases be controlled”

(Appelbaum 511-12).

According to this segment taken from his article, Appelbaum makes it abundantly clear that Deinstitutionalization was and is the most progressive and successful mental health reform movement by far; and with the combination of community-based care and this powerful new drug that helped regulate patients with mental conditions as severe as schizophrenia, this movement showed great promise in revolutionizing the overall mental health care system.

All those that were involved in the execution of multiple reforms and significant changes that occurred when Deinstitutionalization was introduced all believed in one common goal, belief, and mission: “all patients should be treated in the community or in short-term facilities” and that the “state hospitals should be closed” (Appelbaum 512). In referencing the Unite for Sight modules on the online course they offer, it is revealed what soon happened while advocates for Deinstitutionalization were lobbying for the shut-down of mental hospitals:

“Although large inpatient psychiatric hospitals are a fixture in certain countries, particularly in Central and Eastern Europe, the deinstitutionalization movement has been widespread, dramatically changing the nature of modern psychiatric are. The closure of state psychiatric hospitals in the United States was codified by the Community Mental Health Centers Act of 1963, and strict standards were passed so that only individuals ‘who posed an imminent danger to themselves or someone else could be committed to state psychiatric hospitals. By the mid-1960’s in the U.S., many severely mentally ill people had been moved from psychiatric institutions to local mental health homes or similar facilities. The number of institutionalized mentally ill patients fell from its peak of 560,000 in the 1950s to 130,000 by 1980. By 2000, the number of state psychiatric hospital beds per 100,000 people was 22, down from 339 in 1955. In place of institutionalized care, community-based mental health care was developed to include a range of treatment facilities, from community mental health centers and smaller supervised residential homes to community-based psychiatric teams”

(Course, Module 2.6-10).

Based off of the given statistics, one can see that this mental health reform movement was twice if not ten times more successful than that of Institutionalization. Not only were the numbers of patients reduced in the psychiatric hospitals, but the world now possesses new ways of treating, controlling, and perhaps even curing individuals of mental disorders so no one will have to be locked away out of sight and away from those who love and care about them. Furthermore, based off of the many efforts of the psychiatrists aforementioned, those diagnosed as mentally insane can be more involved in the world around them and, although they might still be living with their conditions, can still experience life to its fullest degree without having to worry about harming themselves or others.

Unfortunately, according to history and findings, Deinstitutionalization also proves to be somewhat deficient in some areas, therefore is not a completely fool-proof system of care for the mentally ill. The following excerpt taken from an article written by Joel A. Dvoskin entails such details of issues that were faced when the reforms of Deinstitutionalization were taking place:

“There was insufficient provision for the comprehensive needs of both discharged patients and future generations of people with serious mental illnesses. These needs—housing, social support, employment—were largely neglected in the early decades of deinstitutionalization. Treatment services were expanded but were often focused on those with less severe mental illnesses. In many ways, the decades since the massive deinstitutionalization of the 1960s and 1970s have been devoted to repairing the flaws of that era. Community support systems and supportive housing were gradually increased—although demand vastly outstrips supply in every state. The growth of the family movement and consumer empowerment movement brought new advocacy to the needs of those attempting to manage and recover from severe mental illness. The results of our nation's implementation of deinstitutionalization have been mixed. A recent study found that people with serious mental illness are dying 25 years earlier than the general population. Between one-fourth and one-third of America's 2.3 million homeless persons have a serious mental illness, such as schizophrenia, bipolar disorder, or major depression. Furthermore, 6% to 20% of the nation's more than 2 million incarcerated people are estimated to have a serious mental illness. The high prevalence of mental illness in local jails and state prisons eventually became known as the “criminalization” of mental illness” (Dvoskin 1-2).

Based off the information provided by the passage from his article, Dvoskin exposes a few of the main flaws of this mental health reformation, which include are found to include inadequate stipulations for those with severe mental illness and those diagnosed as slightly less than severe; an alarming amount of these patients going untreated, being imprisoned, becoming homeless, and simply not receiving the required treatment because, odds are, the patients decided not to take the recommended medication they were advised to take. A true testament of this imperfect approach to mental health care is that of a college professor, whom I interviewed and shall remain anonymous, and his own personal story of his brother who was diagnosed with schizophrenia and bipolar disorder:

“Person Anonymous: I have had many experiences over many years with a brother who has been mentally challenged undoubtedly but clinically diagnosed at one point being bipolar and another doctor even clinically diagnosed him as borderline schizophrenic.

My understanding of the chemical diagnosis [of schizophrenia] was that my brother had paranoid hallucinations of a kind that made him believe that he was being chased, he was being pursued, being an object of the police’s attention, things like that.

He might be very placid and able to engage in conversation normally…able to be lucid, even emotionally engaged. At other times he could be a raging maniac. So at times [he would physically be] attacking members of the family. He has physically attacked me before.

He’s been in and out of mental institutes on multiple occasions.

[He] was given some very powerful medications which he described as encasing his head in concrete

[The drugs] undermined his ability to think quickly and undermined rational thought. My personal opinion is that the drugs worked very powerfully on his mind in ways that were pernicious, dangerous, damaging and contributed to his descent into a disorderly mind that he has today.

Living on the street, being intentionally homeless and refusing to take his medication didn’t help him [with his condition]” (Anonymous).

Upon conducting this personal interview with this professor I had come to realize that the issues of the mentally afflicted are in fact real and cannot be ignored or written off as nothing. I also realized that unlike the reforms that fall under Deinstitutionalization, there are some cases in which the patient should have no say in their treatment whatsoever if their illness spirals out of control to the point where a patient becomes a danger to themselves and those around them. Autonomy is important, yes. Being able to hold onto who one is in society is important, yes. But when one’s personal rights and choices one makes based on those rights impedes on the well-being of one’s self and others around, how exactly does that solve anything?

Now that the advantages and disadvantages of both models of health care have been explored, if one is astute enough to see it, there is a viable solution to perfecting the system of mental health care to a point where no patient is left behind and each one will get the treatment they very much require in order to be fully functioning and contributing members of society. According to the evidence given to prove the effectiveness and ineffectiveness of both different approaches to reforming the mental health care system only one solution remains: taking the best elements of the two models, combining them, and ensuring that there are necessary provisions for executing this solution to the absolute best of state’s abilities. In other words, take the best ideas of the advocates and psychiatrists that came before and make it work for the modern world today: make the in-care institutions look like what they were intended for—healing, peace, and recovery; address mental issues as equally significant no matter how severe or slight the case, establish community-ties and creativity even within the confines of mental hospitals through group and individual activities that are enjoyable as well as constructive; employ individuals who care more about people instead of just receiving a check, approach each case differently because the “one-size-fits-all” theory does not apply to uniquely thinking and functioning beings, and most importantly grant autonomy to the point where each patient is treated with dignity and respect but expected to do all they can to help the care-givers help them get better. Interviewing Certified Nursing Assistant, Madame Anonymous proved that having outlets for the mentally unstable could in fact encourage healing. On the subject, M.A. stated that in one of the mental care facilities she worked in there were “little sessions, ice breakers of how they are feeling…we try to help them open up, talk about what is causing their meltdowns…and get them into a position where they are going to function with society…it’s a program where they can grow as a group but also individually” (Mme. Anon).

In conclusion to this essay, what has been revealed is that there really is no quick fix with mental patients. Although the two major approaches to the mental health care system have made significant advances in the field of diagnosing and treating mental illness, there are still a few issues that need resolving because no approach is really going to be perfect as human beings are really unpredictable beings with minds doctors are only just beginning to understand its inner workings. The solution aforementioned, a result of countless hours of research, just might very well have a higher chance of addressing the issues that remain. Hopefully one day it might come to pass, until then we will just have to hope for the best.

Works Cited

Interviews

• Anonymous. Personal interview. 06 Mar. 2014.

• Anonymous, Madame. Personal interview. 16 Mar. 2014.

Textbook Articles

• Applebaum, Paul S. “Crazy in the Streets.” On Moral Medicine: Theological Perspectives in Medical Ethics. Ed. M. Therese Lysaught and Joseph J. Kotva Jr. with Stephen E. Lammers and Allen Verhey. Grand Rapids, Michigan/Cambridge, U.K.: William B. Eerdman’s Publishing Company, 2012. 510-15.

• May, William F. “Afflicting the Afflicted.” On Moral Medicine: Theological Perspectives in Medical Ethics. Ed. M. Therese Lysaught and Joseph J. Kotva Jr. with Stephen E. Lammers and Allen Verhey. Grand Rapids, Michigan/Cambridge, U.K.: William B. Eerdman’s Publishing Company, 2012. 516-22.

Websites

• Dvoskin, Joel A., Bopp, James, Dvoskin, Jennifer L. “Institutionalization and Deinstitutionalization.” Encyclopedia of Psychology and Law. 2007. SAGE Publications. 17 Jul. 2011. Web. 13 April 2014. http://sage-ereference.com.ezproxy2.library.arizona.edu/view/psychologylaw/n151.xml or <joeldvoskin.com/Dvoskin_Bopp_Dvoskin_2007.pdf>.

• Thornicroft, G, Tansella, M. “What Are the Arguments for Community-Based Mental Health Care?.” World Health Organization Europe. Health Evidence Network. 29 August 2003. Web. 13 April 2014. http://www.euro.who.int/document/E82976.pdf.

• Course, Unite for Sight. “Mental Health Online Course.” Unite for Sight. Unite for Sight International Headquarters. Web. 13 April 2014. www.unitedforsight.org/mental-health/

• Trent Jr, James. “Moral Treatment.” Disability History Museum. Straight Ahead Pictures, Inc. Web. 13 April 2014. www.disabilitymuseum.org/dhm/edu/essay.html?id=19.