The first step in helping the mentally ill is not to hurt them.
Unfortunately, the US approach of exclusion and neglect often makes people get much sicker, rather than helping them get well.
The specific forms of mistreatment have changed dramatically during the past 50 years, but their cumulative dehumanizing impact has been a constant.
The severely ill used to be warehoused in state hospitals that were dirty, crowded, smelly, and dispiriting—giving the originally benign concept "asylum" its current terrible connotation.
I was there and saw, smelled, and felt the degradation of these disgraceful "snake pits." Living hopelessly and helplessly, with no freedom or rights or future, was enough to drive anyone crazy. No surprise that it caused the emergence of the worst symptoms in people who were already troubled by mental illness. Much of what seemed to be primary symptoms of sickness was rather a secondary response to the sickening context in which we placed our inmate "patients."
So I was hopeful and excited when the mental health reform movement gained strength. It sought to close the dreadful hospitals and substitute dignified community care and housing. This cleansing wave would combine the advantages of new techniques in community psychiatry with the seeming magic of the new wonder drugs that were just then being introduced into everyday practice.
The theory behind deinstitutionalization was great, but its implementation in the US turned out to be an utter disaster. State governments, previously responsible for covering the costs of mental health care, exploited deinstitutionalization to offload responsibility and cost. The money saved from closing hospitals was supposed to be spent on opening community-based treatment services and for providing decent community housing. Instead it was diverted to tax relief or to support other programs.
Deinstitionalization turned into transinstitutionalization—at first to nursing homes for the older patients, then to prisons for the younger ones. Hundreds of thousands fell through the cracks and became chronically homeless.
The medications that first seemed so wondrous turned out to be less effective than hoped and routinely caused harmful sign effects. They were usually necessary, but never sufficient—and certainly were no miracle.
Unprepared patients were quickly and ruthlessly dumped from dismal hospitals to often worse conditions in prison or on the street. The end result? The US is now probably the worst place in the developed world to have a severe mental illness.
I just attended an inspiring conference organized by the World Health Organization to help promulgate what is the contrasting best of psychiatric care—how to do things right. It was appropriately held in Trieste, the place I would most want to be if I had a severe mental illness.
The conference's 400 participants came from more than a dozen different countries representing a wide variety of cultures, needs, and resources. They reported how they have been able to apply the wonderful model created first in Trieste to their very different contexts.