On January 3rd 1999
a man named Andrew Goldstein wandered onto the New York City subway platform
and shoved a stranger named Kendra Webdale into the path of an oncoming train.
With the story making national news
reporters dug into Golstein's past and found that he had been diagnosed with schizophrenia
and had a history of violent episodes.
He had been in and out of psychiatric facilities
but his caretakers repeatedly released him back into the streets
against their better judgement because of a shortage of available beds.
The murder of Kendra Webdale brought attention to our inability
to provide adequate treatment to Americans with severe mental health problems.
Which 20 years later is still ongoing.
Prisons and jails are filled with inmates exhibiting symptoms of mental illness
and in need of treatment.
Many of the homeless people crowding the streets of cities
like Los Angeles, San Francisco and New York
are mentally ill and in need of care.
And violent episodes like the murder of Kendra Webdale
have brought renewed calls to bring back one of America's most controversial institutions.
The mental hospital.
And to entrust the state with more authority to force psychiatric care on patients against their will.
Some psychiatrists and bioethicists have proposed 'bring back the psychiatric hospital.'
You know in the old days we had mental institutions
and you could nab somebody like this because, you did, they knew he was, something was off.
The parents of mentally ill patients are among the most vocal advocates.
They shut down all the hospitals
because oh we have all these medicines now and everybody can be in recovery.
Well the unfortunate fact is not everybody recovers.
So where do they go?
What do they do?
So is it time to bring back the asylum?
And why did it disappear in the first place?
My contention is that there is no mental illness and there can be no mental illness.
In the mid 20th century the libertarian psychiatrist Thomas Szasz
first articulated a theory that would rock the profession and define his career.
That the whole concept of mental illness was a fraud.
Thomas Szasz was a psychiatrist who didn't really believe in psychiatry.
Having a book by him on your shelf is enough to start an argument.
Jacob Sullum interviewed Szasz for Reason magazine in 2000
and cites him as a major influence on his own work.
He argued what people call mental illness is not a literal disease
but a metaphorical disease
What he called problems in living, internal conflicts, conflicts with yourself,
conflicts with other people.
You could ask people to define mental illness and no one could.
One could only give examples of it, like homosexuality.
Which American Psychiatric Association wrote that it's no longer a disease,
it's only a disease if you don't like it.
At the time that Szasz was writing,
lots of people were locked up who posed no danger to other people
and possibly not even dangerous to themselves in any way.
And might be subjected to what today look like horrifying treatments
but at the time were considered to be the height of science.
Here the skull is thin enough to transmit light
and it usually can be perforated easily by the sharp instrument
without damage to any important structures.
But the man who discovered lobotomy and got the Nobel prize
did on people who didn't want to be lobotomized,
tens of thousands of Americans were subjected to lobotomy
did they want to be lobotomized?
Lobotomy, if you take a sharp object
and stick it up through someone's eye socket and jiggle it around in the brain,
this person who used to be troublesome and disruptive will calm down often.
Maybe what you end up with somebody who is now less troublesome to other people
but is impaired for the rest of his life.
And you look back and you think how could that have happened?
Like how did they think that was a legitimate medical treatment?
That was the context.
Szasz helped to inspire the deinstitutionalization movement
that started in the 1950s and hit it's stride in the 60s.
The time has come for a great national effort,
nearly half of the 530,000 persons in our state mental hospitals
are in institutions with over 3000 patients, getting little or no individual treatment.
Many of these institutions have less than half of the professional staff required.
45% of them have been hospitalized for ten years or more.
If we launch a broad new health program now, it will be possible within a decade
to reduce the populations now under custodial care by up to 50%.
Mental hospitals started emptying out and closing down.
But critics say deinstitutionalization was a disaster,
dumping thousands of mental patients onto the streets with no plan.
Even Szasz criticized the way deinstitutionalization unfolded.
He thought it sort of doubled the injustice.
That those people were not offered the choice to stay,
this is their home they're being thrown out of now.
So he thought that was wrong.
The number of psychiatric hospital beds available dropped by 95%
between 1955 and 2005 according to the treatment advocacy center.
Starting in 1960 as the mental health population in hospitals declined,
the number of mentally ill people in jails and prisons shot up.
A 2011 Supreme Court case filed against the California Bureau of Prisons
revealed that some mentally ill inmates
were held in telephone booth sized solitary cells.
Some reformers say it's time to cast aside Thomas Szasz
and his attack on the mental health establishment.
I got to say Szasz has been totally disproven
it's kind of like believing the church's teachings on an Earth centric universe.
DJJaffe first became aware of the enormous problems in America's mental health system
after his sister in law was diagnosed with schizophrenia
and it proved enormously challenging to get her the treatment she needed.
My sister in law thought that people across the street were talking about her,
the FBI planted a transmitter in her head.
There are a section of the mental health industry
that believes being psychotic and delusional is a right to be protected
rather than an illness to be treated.
Being psychotic and delusional is not an exercise of free will,
it's the inability to exercise free will.
And medications can free people from the Bastille of their psychosis
and enable them to engage in society.
Jaffe says that the Szasz did offer a valid critique of overreach
and over-diagnosis in the mental health industry.
There are pieces of these anti-psychiatrists which are true.
When you talk about someone with mild depression, mild ADHD
is it so abnormal as to be classified as a disorder?
And we are certainly over-diagnosing and medicalizing that group.
People have gotten the sense that he had good critique at the time but it's sort of outmoded
it really isn't outmoded, I mean
if anything the territory claimed by psychiatry is expanding more and more.
Look at all the other things that are covered by the Diagnostic and Statistical Manual
which is the psychiatric bible, right?
But when it comes to the 4% of the population
that the National Institute of Mental Health characterizes as having a serious mental illness
Jaffe says healthcare professionals need far more power
to involuntarily commit patients to dedicated treatment centers.
The civil commitment law is not good enough,
it basically requires someone to become danger to self or others,
we should prevent people from becoming danger to self or others
not require them to become danger to self or others.
Jaffe also advocates for a policy called, assisted outpatient treatment.
New York passed Kendra's law in November 1999
after Goldstein's murder of Kendra Webdale.
It allows a judge to order outpatient treatment for anyone with a pychiatric diagnosis
who's recently been jailed or hospitalized as a result of going untreated
and who the court determines will likely deteriorate further without intervention.
And I would suggest that it is a libertarian's dream.
It has lowered rates of homelessness, arrest, incarceration, needless hospitalization
in the 70% range for the most seriously mentally ill.
And from a libertarian perspective they maintain more of their freedoms than the alternatives
which are inpatient commitment or incarceration.
This idea that we should just abandon the seriously mentally ill,
who don't recognize their need for treatment,
serves neither the liberty interest of the individual, the financial interest of society,
or the interest of trying to keep the public safe.
When you're trying to get help for someone,
especially for Misty who didn't feel like she needed help,
it's very very difficult.
Linda Mayo who lives in Modesto California
has been advocating for the enactment of Laura's law in her home county.
She's the mother of twin daughters, both with severe mental illnesses
and it's through their experiences that she became an advocate
for strengthening the involuntary commitment and compulsory treatment laws.
It's not a panacea, it's not going to help everyone,
but the people who refuse treatment and consistently refuse treatment
and who are in and out of the hospital, in and out of jail, homeless, suicidal
it can help them.
Mayo believes that the legal obstacles to involuntary commitment
could've cost her daughter her life.
One day five years ago Misty, who was 38 and has schizoaffective disorder vanished.
Mayo discovered that after collecting her $200 paycheck
she had boarded a bus to Los Angeles.
I was frantic, she was in a big city that she was unfamiliar with
and we had no family or friends there, very little money,
I thought '$200 that's going to go fast.'
She had already been sleeping in the parks here before she left
and roaming the streets
so I thought, in LA, it scared me more.
Another week and a half went by, finally the phone rang, it was LAPD.
She was in a neighborhood and sitting on a cliff and the neighbors were concerned about her.
In Mayo's view, Misty posed a threat not only to herself but to others as well.
Mayo later found out that during the time she was missing
Misty had been arrested in a shopping mall.
I can't tell you what was going through her head
but she was trying to take a baby out of a baby carriage.
And the mother said no and Misty didn't heed that.
So she was arrested.
For years Misty had been refusing therapy and medication.
After her arrest the state had legal grounds for forcing her to comply with treatment.
Linda believes this saved Misty's life.
I was very happy that she was being allowed to be in the hospital for a longer period of time
that would require some stabilization.
Laura's law in her view creates a legal path
to getting seriously mentally ill patients like Misty the help they need
before they pose a threat to themselves or others.
This is one step saying 'ok we want to catch you in a court order before it's a crime,
before it's hospitalization, before it's homelessness.'
But some mental health advocates say that Laura's law and similar bills
violate the rights of even seriously mentally ill patients.
There's a big perception in my community that once they get their claws on you,
just like law enforcement, they're not letting you go if they can help it.
Richard Krzyzanowski who himself has suffered from severe depression
is a patients rights advocate who has worked for LA county
representing mentally ill individuals committed against their will.
Some of the most dis-empowering and dangerous words anyone can say is
'we're doing this for your own good.'
you know, 'we're here to help you.'
But if I'm not asking for help.
When you see somebody walking down the street, screaming 'I am the messiah.'
It's not because they think they are the messiah, they know they're the messiah.
They are unaware that they are ill and we should be delivering treatment to them.
But Krzyzanowski says that mental health professionals and reformers
often abuse the concept of 'too sick to know you are sick'
to violate the rights of the mentally ill.
It's a way of saying 'I don't have to listen to you.'
or more to the point 'you're now voiceless.'
The whole involuntary treatment is a hard balance.
No one wants involuntary, all the advocates that I have talked to,
this is the last thing that we want.
But there are cases that require it.
And Krzyzanowski says that even though the state institutions are gone
to this day, many psychiatric patients are locked in facilities
for weeks or even months at a time
under court orders giving legal power over financial and healthcare decisions to a third party
under an arrangement called conservatorship.
The most difficult calls we would get, especially during anybody's holiday season.
Would be people on conservatorship, who are locked away somewhere
they were able to get a phone call
and you just felt like you were talking to one person alone
like they've been locked away in a dungeon
and they hadn't seen, like, the light for months.
Another problem with the idea of bringing back state mental hospitals
is that in the current system commitment often exacerbates symptoms.
A study published in the medical journal Psychiatric Services
found that alarmingly high numbers of patients admitted to one state run mental health system
witnessed traumatic events, were secluded or restrained and even suffered physical assault.
We can change the whole historic dynamic
of the use of coercion in people with serious mental illnesses.
Psychiatrist Scott Zeller is the founder of the Alameda Model,
a movement dedicated to reforming how mental health institutions operate.
It focuses on getting psychiatric patients out of hospital emergency rooms
as quickly as possible
and into dedicated mental facilities that respect their right to personal space and freedom
even if they've been involuntarily committed.
Typically if you're in a psychiatric emergency,
you're very paranoid, or you're very frightened or you're very despondent, or you're very anxious.
And imagine going into the general ER with those kind of symptoms
and basically being put into a small space
and says 'you're going to have to stay here and you can't move.'
You know, people tend to get worse in ERs.
The Providence Medical Center in Saint Peter California
which uses Zeller's approach is a stand alone building just down the road from a hospital.
Unlike in hospitals which are often lacking in on call psychiatrists
staff are able to medicate and stabilize patients around the clock
sometimes through the use of telepsychiatry if a doctor isn't on site
with the goal of discharging them for outpatient treatment within the first 24 hours of admission.
People can move about, nobody's telling them 'get back in that corner' or,
what we find is the vast majority of the time, these folks are going to get better
within ten, fifteen, twenty hours tops.
And the idea that we were holding them for three days to send them to a hospital
makes so little sense when you could have had them home the same day.
The average psychiatric emergency patient in a general medical ER
it may be 25-50% of them being physically restrained,
leather restraints around wrists, ankles.
In an empath unit we're talking about far less than 1%.
People respond very well to a supportive, interacting, nurturing environment
not so much to a coercive cold environment, go figure.
Is social division within the province of medicine?
Zeller says there's one lesson from Szasz
that family members of the seriously mentally ill should internalize:
there's no level of coercion that can force some people to conform with societal norms.
As long as they don't pose a danger to themselves or others
in some cases the best path forward is acceptance.
If someone says 'I want to live in a tent downtown.'
Pretty much you have to let them.
It's really really difficult to determine when you should believe
that they no longer have the right to decide for themselves.
I think that we should be overly safe on the side of protecting individual rights.
I can't have pictures up in my house
of when they were babies in junior high and high school and college
it's the shine, the light in their eyes that I miss.
That sense of joy and fun and happiness is out of the eyes
and that makes me really sad.