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Out of the psych ward, into the city streets

"Out of the psych ward, into the city streets" Continued...

Issue: "Debunking Darwinism," Nov. 22, 1997

The result was not so much deinstitutionalization as what Dr. Torrey terms trans-institutionalization, a phenomenon in which patients are discharged from mental institutions only to be transferred to the care of homeless shelters, nursing homes, public hospitals, and prisons. In fact, it is now common in many states to find former residents of psychiatric hospitals residing in the same buildings that they once knew as mental institutions, now shut down by the state and reopened as homeless shelters.

But a huge number of former mental patients wind up on the streets, due largely to inadequate provisions for continuing treatment and a series of court rulings that make involuntary commitment almost impossible. Dr. Torrey estimates that the number of homeless people who have serious mental illnesses exceeds 150,000, which is about 35 percent of the total homeless population in the United States. (If drug and alcohol abusers are included, the mentally ill make up a full 95 percent of the homeless population.) And the number of severely mentally ill persons incarcerated in the nation's prisons probably exceeds the number who are homeless.

Tragically, the vast majority of the mentally ill homeless-as well as many of those serving time for violent crime-could live a normal life with adequate treatment; 70 to 90 percent of those with serious mental illnesses respond positively to medication. But effective treatment of severely mentally ill outpatients requires follow-up supervision, since those who suffer from serious mental disorders often have a weak grasp of their condition and subsequently fail to see the need to take their medicine.

The chief reason for the cautious approach to mandatory treatment on the part of states and law-enforcement officials is the work over the past 30 years of civil-liberties advocates and judges who have put up virtually insuperable barriers to institutionalization and mandatory treatment. Court decisions that mandated strict guidelines for commitment were seized on by civil-liberties lawyers in order to force the discharge of psychiatric patients and to pressure institutions not to admit new patients, often with the express intent of closing down the state institutions.

Dr. Torrey proposes giving fiscal responsibility for the treatment of the severely mentally ill back to states in the form of block grants that ensure a minimum standard of follow-up care for released mental patients. At least one state has attempted reforms along the lines that Dr. Torrey proposes; during John Sununu's tenure as governor of New Hampshire in the mid-1980s, the state legislature passed legislation mandating "conditional discharge" of mental patients who have been hospitalized. Among the conditions: avoiding drugs and alcohol, continuing to take any needed medication, and agreeing to follow-up visits from certified psychiatric hospital staff. After a decade, the results have been impressive, including a sharp decline in the number of released psychiatric patients readmitted to hospitals and significantly improved stability in employment and housing.

The idea of greater fiscal responsibility at the local level is in keeping with the policy trend toward devolving federal powers and programs to the states, and Dr. Torrey has some sympathetic ears among the members of the GOP majority in Congress. But in order to carry out any plan that involves mandatory follow-up and treatment for persons with serious mental illnesses who wish to continue living in the community, legal reform will be necessary, and many civil libertarians oppose such changes. But Dr. Torrey has noticed less resistance to such ideas in the last few years. "After all," he says, "if you push the civil libertarians into a choice between mandatory outpatient commitment and reinstitutionalization, there is little doubt that most would choose the former."

Mr. Robertson is a writer in Washington.

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