Dr. Frances is former Chair and Professor Emeritus of Psychiatry at Duke University. He was the Chair of the DSM-IV Task Force. Mr. Ruffalo is Affiliate Assistant Professor of Psychiatry and Adjunct Instructor of Social Work at the University of South Florida. He is a psychoanalyst in private practice.
From our beginnings, psychiatry has functioned at the intersection of medicine and the broader society—serving not only to treat psychiatric disorders, but also to help prevent patients from harming themselves or others. When the father of modern psychiatry, Philippe Pinel (1745-1826), freed his patients from chains at the Salpêtrière asylum in Paris 220 years ago, he established a centuries-long precedent of attempting to appropriately balance the civil rights of the mentally ill with the occasional and carefully considered need for involuntary treatment. This requires finding a delicate balance best serving the sometimes conflicting values of patient welfare, protecting civil liberties, and public safety.
More than any other medical specialty, we sometimes feel compelled, and empowered, to treat patients against their will. With this comes two great responsibilities—to protect free choice and civil rights whenever and to the fullest degree possible, but to restrict them on the very rare occasions when this is clearly necessary to protect the patient and/or society.
The state-operated inpatient “asylums” in the United States, originally intended as a respite for psychiatric patients, soon degenerated into overcrowded and degrading warehouses. Patients were deprived of liberty without due process, subjected to harmful neglect, and often locked up for years, sometimes for life, without any real treatment or normalizing interpersonal interaction. Rather than foster recovery, the social exclusion of hospitals often made patients much sicker.1,2
As recently as the 1960s, there were more than 600,000 Americans involuntarily committed to psychiatric facilities that really functioned more like prisons than hospitals. False commitment was common. Hazardous and unproven treatments like lobotomy and insulin shock were sometimes imposed on unwilling patients for unclear indications.2-4 One of us (AF) worked in several of these facilities and can bear personal witness to how dreadful they were.
Five nodal points contributed to the massive deinstitutionalization of psychiatric patients that occurred in the 1960s and 1970s. The Snake Pit—Mary Jane Ward’s bestselling novel (1946)1 that later became an Academy Award winning film (1948)—exposed the dire plight of the mentally ill to an outraged public. In 1961, psychiatrist Thomas Szasz2 published his classic book The Myth of Mental Illness, describing the destructive threats to civil liberties and a decent life posed by state “hospitals.” And also in 1961, sociologist Erving Goffman3 described how the neglect and humiliation of asylums-turned-dungeons made patients much more symptomatic and dysfunctional than they would be in more real-life situations. The availability of antipsychotic drugs in the 1950s and 1960s made feasible the closing of many state hospital beds and treatment in the more normal and socially inclusive community outpatient clinics. And finally, Jack Kennedy, the newly elected president, had a strong personal commitment to help the mentally ill based on his sisters’ disastrous experience with lobotomy.
The idea was to close the massive state hospitals and instead care for patients in community settings that would end their isolation from the world and recognize their rights as citizens. When funded and practiced well, community psychiatry was an enormous success. But, sadly, the money saved from closing the custodial state hospitals was often misallocated to tax cuts and prison construction—depriving the mentally ill of adequate community treatment and housing. The result has been a terribly broken American mental health “non-system” that overtreats the worried well and vastly undertreats the seriously mentally ill. Instead of 600,000 in state hospitals, we now have 350,000 mentally ill in prison and 250,000 homeless—because the vast majority of the are unable to obtain decent housing and access to treatment.
Funding for mental health continues to be cut by millions each year, long-term hospitalizations are virtually nonexistent, and many patients who desperately need short-term help are turned away because there really are no beds and no outpatient alternatives. This leaves them, and their families and loved ones, stranded without any recourse in a sea of neglect.
An all-too-common scenario in modern psychiatry is the person who can clearly benefit from psychiatry receiving no help because of the combination of unavailable treatment and/or too stringent commitment laws. If he then commits a (usually petty) crime, the police learn that time in the emergency department is wasted because there is usually no psychiatric treatment available in anything approaching a timely fashion. Because the only alternative is jail, cops are too often forced to turn would-be patients into inappropriate prisoners. And, occasionally, the seriously disturbed person will commit a major crime—one that could have been avoided had he received proper psychiatric care, counseling, and housing. The cruel paradox is that it is often too easy for the mildly ill person to receive medication, but far too difficult (and often impossible) for the seriously mentally ill to receive anything approaching appropriate care.
1. Ward MJ. The Snake Pit. New York; Random House:1946.
2. Szasz TS. Law, Liberty, and Psychiatry: An Inquiry Into the Social Uses of Mental Health Practices. New York; Macmillan: 1963.
3. Goffman E. Asylums: Essays on the Social Situation of Mental Patients and Other Inmates. New York; Anchor:1961.
4. Shorter E. A History of Psychiatry: From the Era of the Asylum to the Age of Prozac. Hoboken, NJ; Wiley: 1998.