Get Out, Right Now

0:06 Welcome to M4 Medicine, mystery, mayhem, and sometimes murder. I'm Andrea Marziano and RN with 35 years of experience across various fields. From direct patient care in hospitals to home health, geriatrics, and injury medicine, I face life, death, and everything in between. And I'm Crystal Miller and RN with 13 1/2 years of experience. My work spans home health, Hospice, emergency care, geriatrics, and occupational health. From the chaos of trauma based quiet moments with patients, I've seen stories that defy explanations. We've been friends for over 25 years and as nurses we've shared countless stories that have left us and our families speechless. Now we're bringing those stories and many more to you in medicine, mystery, mayhem, and sometimes murder.

0:53 Each week, we'll uncover cases that challenge the boundaries of medicine, sharing the human stories behind the science. From puzzling medical mysteries to shocking real life crimes, we'll bring you stories that'll leave you questioning everything you thought you knew while. We're both experiencing treats, nurses. We want to make it clear we're not here to give medical advice. This podcast is about storytelling, education and exploration, not diagnosing or treating medical conditions. This is medicine, mystery, mayhem and sometimes murder. Let's dive in. Hey Crystal, how are you doing? I'm doing well. How are you? I'm really well, Thank you. What's up? Anything exciting? I had something interesting happen. Do you remember the pop singer Debbie Gibson?

1:35 I do. You really liked her? Yeah, she sang. She wrote the song and performed the song Lost in Your Eyes. You know, I get lost in younger eyes. I'm no Debbie Gibson. But anyway, for those who don't know who she is, she was famous pop singer in the 1980s. She was considered one of the mall singers. And that's because she and another artist, Tiffany and and Belinda Carlisle, they would go and travel and perform in malls. And at the time malls were huge. So this was like a big deal. Anyway, I met her a few years ago. She was helping out with our charity and our charity fundraising event, the Prince, the Princess Festival, got to know her, got to become friends with her and she recently wrote an autobiography and she gave me a shout out in the autobiography.

2:26 So my name is in Debbie Gibson's autobiography, which I think is really cool. Yeah, you're nearly famous. Practically famous. So anyway, it's always. Exciting when something like that happens, even. Yeah, it's just the fact that she thought of you these years later. And maybe you were. And all of that that's. Right, exactly because she was helping out with our charity. She really could have just mentioned the charity and she didn't. She, she named me. She named the charity also, but she named me by name. And that was really flattering and really kind of her, I think. So anyway, everybody go pick up Debbie Gibson's autobiography and see my name in it. Yeah, we'll Sturge and Sturge. And she said it was in here.

3:11 That's funny. Well, cool, that's exciting. Will you still talk to me even though you're super famous now? I suppose. I guess we'll make an exception for this. Well, good, since I Can't Sing, but I have been willing to hang around with you for 25 plus years. We actually we probably need to recount that because I think we're flattering ourselves by saying it was only 25. Now it's. Probably true. Gosh. When I, when I look back at things, I'm like, oh, that was about 20 years ago. Oh my gosh, it was 30. Yeah, no kidding. I never, I never thought I'd be old enough to think of remember something. It was 30 even 50 years ago now. Like, Oh my heavens.

3:51 So I was talking about being 15 recently and realized that was 35 years ago and I'm like, aren't I only 35 years old? Yeah, When, when did this happen? What? What's going on here? I know. It's so ridiculous. And just anyway, we're listeners, we're having a moment. Sorry. OK, So what do you have for us today? Today I have another sad story, which I don't know why I'm saying sad story laughing. That's horrible. Yeah. So today we're going to be talking about the deinstitutionalization of psychiatric care, the waterfall effect that that had. My sources are I have quite a few sources, but primary sources are an article called American Psychosis, How the Federal Government Destroyed the Mental Illness Treatment System from the Oxford University Press, An article called The Mad Among Us, A History of the care of America's Mentally ill from the Free Press. Another article, The Shame of the States by Harcourt, Brace and the rest all put into the show notes 'cause there's quite a few.

4:57 So right. So in 1955 the United States had 558,000 people living inside state psychiatric hospitals, 585,000 people in beds under roofs with staff, However inadequate, however cruel, however broken the system around them, there were staff. By the year 2000, that number had dropped to under 55,000. So it had dropped more than 500,000 in 45 years. Not because mental illness got better, not because we invented a cure, not because the need disappeared, but because we closed the doors.

5:38 Just that's it. Goodbye. Good luck. Yeah, exactly. Right when you find work. Yeah, right. And we told ourselves a story about why that was the right thing to do. And in many ways, in many genuinely important ways, it was. The old system was a horror. I'm going to tell you exactly how much of A horror. But we also told ourselves the second story. We told ourselves that closing the hospitals was a beginning, not an ending. That we would build something better, That the communities we were returning people to would be ready, that the funding would follow, that the care would be there. And it wasn't. And what filled the gap would absorb the 500,000 people who are no longer in psychiatric beds is a different kind of institution entirely, one with bars on the windows and correctional officers instead of psychiatrists and philosophy built not around treatment but around punishment. Today, we're going to follow the long, tangled, heartbreaking thread of psychiatric deinstitutionalization America. We're going to talk about where it started, why it happened, what we were promised, and what actually came to be. We're going to talk about the jails and prisons that became, as one psychiatrist famously put it, the new asylums. We're going to talk about the sidewalks and encampments that absorbed hundreds of thousands of people with serious mental illness when they have nowhere else to go. And we're going to talk about the families, the clinicians, the advocates, and the incarcerated people who have been screaming into the void about this for 50 years. This is one of the most important public health failures in American history, and almost

7:10 nobody calls it calls it that. So let's talk about it. Let's do, although it feels sad already. It's it's, it is. It's. So before we can talk about deinstitutionalization, we have to understand what we were deinstitutionalizing from. And I need to be careful here because the history of the oldest silent system has been weaponized in both directions. On one side, you have people who look back at the old state hospitals as a lost solution. Imperfect, sure, but at least it was something beds, containment, a place to put people. Some critics of deinstitutionalization have romanticized the institutional era in ways that are genuinely dangerous, because what was happening inside those buildings was in many cases barbaric. On the other side, you have people who point to the horrors of the old system as full justification for everything that came after, as if acknowledging the failure of institutionalization means you can't also acknowledge the failure of what replaced it.

8:05 And I want to do neither of those things today. I want to be honest about what the old system was and honest about what the new system became. State psychiatric hospitals in America have their roots in the reform movement of the 19th century. Dorothea Dix is the name most associated with this era. She was a Massachusetts school school teacher and activist who in the 1840s began A crusade to document the conditions in which mentally ill people were being housed. What she found was genuinely appalling. People with serious mental illness are being kept in alms houses alongside the poor, jailed for behaviors they couldn't control, chained in unheated Cellars are simply turned out into the street. In 1843, she presented a report to the Massachusetts Legislature called the Memorial that described what she had personally witnessed people living in cages, closets and stalls, stripped of clothing in winter, beaten and whipped to force compliance.

9:04 Yeah, I've heard about stuff like that. It's. Horrifying. Dorothy has spent the next 40 years travelling across the country and lobbying state legislatures to build hospitals, proper hospitals with trained staff and medical oversight and therapeutic programming to treat them mentally ill with dignity. She was enormously influential. 32 states opened or expanded psychiatric hospitals as a direct result of her advocacy. The original vision was genuinely humane, fresh air, structured routines, moral treatment, which in the 19th century context meant treating patients as human beings capable of improvement rather than as animals to be warehoused. The the early reformers believed that mental illness was treatable, that a well designed environment could heal a disordered mind, and for a while, in small institutions with adequate resources. There is actually some evidence that moral treatment work recovery rates from the early 19th century for mild to moderate cases were surprisingly good by the standards of the era.

10:04 But then something happened that destroyed well-intentioned institutions over and over again across history. The populations grew, and the budgets didn't. By the early 20th century, state psychiatric hospitals had transformed into something almost unrecognizable from Dorothea Dix's vision. Populations had exploded. Facilities built for 200 patients held 2000. Well, I was just thinking, did this increase the number of people in beds in these facilities, these changes, did we go from 500,000 to a bigger number or a smaller number? I mean when but. Went from zero to I don't know how many at this point. Well, I just wondered if some of those who had been previously basically incarcerated, I mean, not in prisons and stuff, but really in lots of other ways, are the same people that came off the streets?

10:56 Or is this a long enough gap that it didn't it didn't cover any of the same people? You know what I mean? Yeah, I'm not really sure, but I think that it was, it was probably a mix of both. It was probably some passed away in these deplorable circumstances in the alms houses and on the street and some were put into these institutions, but it doesn't. I didn't really come across that to be honest. Right. Got you. So just that just that the populations clearly the need was more than people realized because like I said, the facilities built for 200 patients held 2000 patients and the staff ratios were catastrophic. There were no resources for individualized treatment and the entire enterprise shifted from therapeutic institution to custodial warehouse.

11:45 And then there's the treatments being used. And I want to be very clear about this. They were not treatments in any meaningful sense of the word. They were experiments in subduing people. Horrified. Hydrotherapy involved wrapping patients in cold, wet sheets for hours at a time. Insulin coma therapy put patients into repeated hypoglycemic comas, sometimes dozens of them, over weeks, in the belief that inducing and reversing coma could reset the brain. There was no evidence this worked, and people died from it. Lobotomy, the surgical severing of connections to the prefrontal cortex, was introduced to American medicine in the late 1930s and became, for a terrifying window of time, a mainstream psychiatric intervention. Walter Freeman, the most enthusiastic practitioner of what he called the transorbital lobotomy, performed the procedure by inserting an ice pick through the eye socket and moving it around to sever brain tissue. And I want to make it really clear what that means. He literally, literally took an ice pick, stuck it into the corner of the eye socket, hammered it in some depth and then moved it around.

12:53 Like if you've ever had like a, a shake or a Slurpee that you want to kind of break up the ice crystals like that, like swirled it around with, I know with kind of the hope of that it would sever the correct brain tissue. Yeah, and as you describe this, it's just just giving me the chills. That is so awful. Can you imagine? And he did this in his office, and he did it without full anesthesia. He performed it on children and he operated out of a van he called the Lobotomobile, which is also horrifying like. So many reasons it was and. He travelled the country performing surgeries. He lobotomized an an estimated 3500 people.

13:36 That is unbelievable. And the people inside these hospitals had essentially no rights. They could be committed involuntarily by a family member or a physician with minimal legal oversight. Once committed, they were subject to whatever treatment the institution decided to use. They could not easily leave. They had no meaningful access to courts. Their mail was read and censored. Their visitors were controlled. Some people enter these institutions as teenagers and did not come out until they were elderly. The journalist Albert Deutsch published a book in 1948 called The Shame of the States, and I said it was an article and it was a book. My apologies. The documented conditions in state psychiatric hospitals across the country.

14:17 He described patients lying on the floor in their own excrement wards so overcrowded that patients slept in hallways, nude patients in freezing unheated buildings, staff so under trained and overworked that abuse was constant and institutional. It makes me think of 1 Flew Over the Cuckoo's Nest, you know, and that's exactly what that book slash movie is about, is about the the deplorable conditions that these psychiatric institutions maintained. Life magazine wrote a photo, ran a photo essay in 1946 called Bedlam 1946. And I want to pause on that word Bedlam because it comes directly from Bethlehem Royal Hospital in London, which was such a notorious institution for so many centuries that its name became a synonym for chaos and horror. Photos showed emaciated men lying on bare floors, overcrowded wards, patients restrained without 'cause it was shocking at the time, and it's still shocked. So imagine Bedlam being literally named for your hospital, your institution.

15:24 Like, yeah. I mean, that's it's just so, so out of the realm of understanding, I think really. It really is, and this is the system that the institutionalization was a response to, and I cannot stress this enough, The reform impulse was real and it was justified. Something had to change. Two things happened in the mid 20th century that made that made deinstitutionalization feel not just possible but inevitable. 1 was a pill, 1 was a president. In 1952, a French surgeon named Henri Labourri was experimenting with antihistamines in surgical patients when he noticed that a compound called chlorpromazine seemed to produce a profound sense of calm without sedation. The patients were conscious.

16:10 They could respond to questions, but they were utterly indifferent to what was happening around them. Core Promising made it to psychiatric wards within a year. The results were by the standards of what had come before, extraordinary Patients who had been in states of frantic agitation for years became manageable. Patients who had been experiencing Florida hallucinations and delusions showed measurable improvement. Wards that had required physical restraint to maintain order became, for the first time in decades, something approaching quiet core. Promazine, marketed in the US as Thorazine, was hailed as a miracle. Time magazine called it a wonder drug. Psychiatrist who had spent their careers in hopeless custodial institutions suddenly believed they were practicing medicine.

16:56 And here's where the story starts to fracture. Because the drug was real, and its effects were real, but the conclusions drawn from it were catastrophically overconfident, core promising. And the antipsychotics that followed it did not cure schizophrenia. They managed symptoms in they managed them well enough to allow for a significantly improved quality of life, but only with consistent access to medication, consistent monitoring, consistent support services. The medication was a tool, not a solution. It required a scaffold of care around it to work. That distinction got lost almost immediately in the rush of optimism. John F Kennedy had a personal connection to psychiatric institutionalization that almost no one in his in his administration talked about publicly. His sister, Rosemary Kennedy, had been lobotomized in 1941 at the direction of their father, Joseph Kennedy. She was 23.

17:52 The surgeon was intended to address mood swings and the seizures associated with her intellectual disability. It left her permanently incapacitated and institutionalized for the rest of her life. The family kept this secret for decades. And, you know, it's, it's been a secret for it's, it was a secret for a very long time. It's only been recently that we were even, you know, made aware that Rosemary Kennedy existed. And whether Kennedy's personal history shaped his policy thinking is something historians have debated. And I got to tell you, I'm not a historian and I'm not in the debate, but I cannot imagine that it did not shape his. No, it couldn't. I mean, I've read some things about Rosemary Kennedy and from what I understand she was beloved by I like I said, I can't imagine that it didn't have a large impact on on what he was thinking.

18:44 What is in disputed is that in 1963 he delivered a special message to Congress on mental illness and mental retardation, the first presidential message ever devoted to the subject, and signed the Community Mental Health Act into law. It was in many ways a visionary piece of piece of legislation. The plan was elegant in concept. The federal government would fund the construction of a network of community mental health centers, 1500 of them across the nation, one for every catchment area of 50,000 to 200,000 people across the country. These centers would provide outpatient treatment, partial hospitalization, inpatient services, emergency care, and consultation of and education.

19:25 The idea was that people who had formerly required long term institutionalization would instead receive intensive community based support. They could live and be treated in their own neighborhoods, with their own families, in their own lives. That, on the face of it, looks really good. I mean. Well, I want to say that in researching this, like this, this broke my heart. And you'll see why in a second. But this sounds beautiful and perfect, right? And the state hospitals would depopulate and the community centers would absorb the need. It was a beautiful plan. And then Kennedy was assassinated in November of 1963, six weeks after signing the Community Mental Health Act.

20:07 And the community mental health system he envisioned was never fully built. So like it's a super, super bummer because it does, it was a beautiful plan. It was, I feel, I feel like just from my perspective, it would have worked and, and to have the federal funding because that's really where a, a big part of why we did deinstitutionalized was funding, right. Yeah. So from 1955 to 1994, the census of state psychiatric hospitals in the United States fell by approximately 85%. Nearly half a million beds disappeared. And this did not happen all at once. It did not happen because of a single policy decision.

20:47 It happened through a confluence of factors that each individually had responsible justifications that that together produced a a catastrophe. So here's something that almost never gets said loudly enough in histories of deinstitutionalization. The states saved an enormous amount of money by closing psychiatric hospitals, and the federal government created a financial incentive to do it. In 1965, Medicaid was created, and buried in the Medicaid statute was a provision called the Institution for Mental Diseases Exclusion. The IMD exclusion, which prohibited federal Medicaid funding from being used for inpatient psychiatric care in facilities with more than 16 beds for patients between ages 22 and 64. So think, yeah, think about what that means. State hospitals, which were by definition large institutions with hundreds or thousands of beds, could not be funded by Medicaid, but outpatient community care could be. And once a patient was discharged in the into the community and onto Medicaid, the cost of their care shifted from the state budget to a shared state federal funding stream. Governors and straight and state legislatures noticed this immediately.

22:01 Discharging patients was not just ideological aligned with the community mental health vision, it was fiscally profitable for states. The financial incentive to empty the hospitals was enormous, and it operated independently of whether the community infrastructure to receive those patients existed. The IMD exclusion is still in effect today, by the way. It continues to distort the mental health system in ways that advocates have been trying to fix for 60 years. Then, in the 1960s and 70s, we saw a series of landmark court decisions that reshaped the rights of people with mental illness in ways that were both genuinely liberatory and, in practice, deeply complicated. The core issue was involuntary commitment. Before the reform era, a person can be committed to a psychiatric hospital essentially at the discretion of a physician and a family member, with minimal legal review.

22:49 Patients who had been committed had almost no mechanism to challenge their commitment in court. Advocates argued, correctly, that this was a profound violation of civil liberties, that people with mental illness were being deprived of their freedom without due process, that the hospitals themselves were often doing more harm than good, that the right to be free from unwanted institutionalization was a fundamental constitutional right. Courts agreed. A series of decisions through the 1970s established that involuntary psychiatric commitment required meeting a standard similar to criminal law. The person had to be demonstrated to be an imminent danger to themselves or others or gravely disabled, and they were entitled to legal representation and judicial review. The standard for what constituted gravely disabled was interpreted narrowly in many jurisdictions. That result in practice was that it became very difficult to hospitalize someone who is experiencing serious mental illness but was not actively threatening violence or starvation, a person who was psychotic and decompensating but who could articulate a refusal of treatment at legal standing to walk out of an emergency room. This is genuinely one of the hardest tensions in mental health law.

24:03 The civil libertarian case against involuntary hospitalization is real and important. The history of that system being abused, being used to warehouse the poor, the inconvenient, the politically dissenting, the non conforming is real. The argument that forced treatment often doesn't work and that it destroys the therapeutic relationship is real. But there is another reality. There's a population of people with serious mental illness, particularly those with nausea, a neurological condition which the illness itself impairs the ability to recognize that one is ill, for whom the ability to refuse treatment means the ability to remain in a state of untreated psychosis potentially for years or decades. So basically it's a condition where you're mentally ill and you can't see it for yourself, which I feel like I feel like is prevalent in mental illness.

24:50 I feel like it's more rare for somebody to be, to be cognizant of the fact that they have mental illness. And I'm talking in like severe mental illness. I have a friend who is severely mentally ill and he has paranoid schizophrenia, OCD. He's got several diagnosis and I can't remember all of them, but he has done things like he cut off his own finger because the voices in his head just told him to. Yeah. And he's he is 1 of what I consider the rare that is fully aware of his mental illness. And sometimes he bends to the whims of his mental illness and sometimes he's able to resist. But, and I, I, it's anecdotal in the sense of I haven't been in every single psychiatric situation in the world, but I, I do find that it's for the psych nursing that I've done.

25:41 I do find that the majority that I've experienced that have severe mental illness, they're they're fully unaware of and in denial of the fact that they're they have mental illness. And it and that piece that in denial may be actually more accurate than unaware. Yeah, true. That's true. That's that's see, these are not people making an informed autonomous choice. These are people whose illness is preventing them from understanding that they are ill. So you're right, I think denial may be more more accurate than this. Anna's nausea, Anosanosia. I don't know. The legal reforms did not adequately grapple with this population, and that population is a significant part of who ended up on the street. Deinstitutionalization also had genuine intellectual champions, and not all of them were wrong about everything. The sociologist Irving Goffman published a hat a landmark study in 1961 called Asylums, based on ethnographic field work he conducted at Saint Elizabeth's Hospital in Washington, DC. Goffman argued that psychiatric institutions did not treat mental illness, they created it.

26:52 That the dehumanizing conditions of total institutions systematically stripped patients of their identity, agency, and self concept in ways that were themselves profoundly damaging. That what looks like the symptoms of mental illness was often the product of institutionalization itself. Thomas Czaz, a psychiatrist and fierce critic of his own profession, published The Myth of Mental Illness in 1961 and argued that but most of what psychiatry called illness was actually deviance from social norms, that the diagnostic categories were not medical realities but moral judgements dressed in medical language, and that involuntary commitment was a form of social control masquerading his medicine.

27:33 The Italian psychiatrist Franco Basalia LED a movement that resulted resulted in Italy literally abolishing its psychiatric hospital system in 1978 through a law called Lege. 180 believed that the institutions were the problem, that liberation from them was self therapeutic and that society had an obligation to create real community based alternatives. These ideas had enormous influence on the policy environment of the 1960s and 70s and again they contained real truths. The institutions were harmful. Institutionalization did have iatrogenic effects. The civil commitment system had been abused, but the ideological enthusiasm for a deinstitutionalization often outran the evidence and, more importantly, outran the infrastructure.

28:25 The community mental health centers were underfunded from the beginning, and many were never built. The wrap around services that were supposed to support people in the Community, Housing, case management, medication management, crisis response materialized only partially and inconsistently, and in many regions, not at all. By the time Ronald Reagan took office in 1981 and converted the federal community mental health program into a block grant, slashing funding and removing the requirement to build the Promise Centers, the system was already failing. Reagan's cuts accelerated A collapse that was already underway. And I was thinking about this, and I'm not great at my presidential trivia, so I don't know who came between Lyndon Johnson and Ronald Reagan, but it makes me it didn't make me curious what those presidents did in the interim before Ronald Reagan did his really crappy funding slashing jerk face moves.

29:22 But how do you feel? I mean really feel. So there was. There was Nixon, Ford and Carter. Thank you. Heartbreaking in my opinion. Yeah, me too. So in 2016, the Treatment Advocacy Advocacy Center, a nonprofit mental health policy organization, published a report with a title that should have stopped the country cold. Quote The treatment of persons with mental illness in prisons and jails. Estate survey close Quote The report found that in 4450 states the largest single psychiatric inpatient facility was not a hospital, it was a jail or prison. The three largest de facto psychiatric facilities in the United States were the Los Angeles County Jail, Rikers Island in New York City, and the Cook County Jail in Chicago. Let that land.

30:14 The largest psychiatric facility in Los Angeles County is a jail. Wow, we even not having ever really been closely experiencing it, it's like that can't be good. No. That can't be good. Nothing about that. Even if they are getting good mental health care, which I'm dubious about because I've never known any kind of jail or prison that was actually staffed appropriately and doesn't necessarily draw the highest talent is Yeah, that's shocking. So how did this happen? Let's look at the numbers. In 2006, the Department of Justice published a special report on mental health problems of prison and jail inmates. It found that 56% of state prisoners, 45% of federal prisoners, and 64% of local jail inmates had a mental health problem.

31:05 Even with the DO JS relatively broad definition of, quote, mental health problems, those numbers are staggering. Again, I'm going to repeat that 56% of state prisoners, 45% of federal prisoners and 64% of local jail inmates had a mental health problem. So that's more than half in state prisons and local jails and nearly half in federal prisons. And, you know, my thought goes to a lot of federal prisoners are white collar criminals. And I suspect that they're there's there's less mental health issues that are as prominent, I would say, or as severe in those kinds of crime criminals.

31:50 That's just science by Crystal, by Crystal's imagination. But you know, that's kind of where my thought went to that with that just it. Just and the problem is too many people become criminals because they're trying to support their drug habits which they're trying to medicate themselves for psychiatric. They're self medicating, exactly. So more recent estimates for serious mental illness, specifically conditions like schizophrenia, bipolar disorder with psychotic features, and major depressive disorder with psychosis, find that between 15 and 20% of the prison and jail population has a serious mental illness. Applied to the roughly 2 million people incarcerated in the United States at any given time, that means that somewhere between 300 and 400,000 people with serious mental illness are behind bars on any given day.

32:38 So again, that 15, that between 15 and 20% is specifically psychotic features between 300 and 400,000 people in our prisons are psychotic. Yeah. So compare that to the approximately 35,000 to 45,000 people currently in state psychiatric hospitals. The ratio is roughly 12:50. For every person receiving inpatient psychiatric treatment in a hospital, 10 people with comparable illness are in a Correctional Facility. And it's interesting. I, I, I'm in researching this, I'm curious to know what state psychiatric hospitals still exist. And I didn't look it up, but I'm old enough to remember the state hospital in Provo, UT.

33:19 It clearly was not shut down in the 70s because I was born in the 70s. And, you know, it may have been one that was shut down by 1994 because I would have been 18 in 1994. But I do very much remember the hospital on the Hill and I remember it being shut down. And I Remember Remember my mom particularly being really upset about it. I also had a friend whose mom was employed there and she was very upset about it with it because obviously she lost her job, but that's not what she was upset about. She was upset about the deinstitutionalization of these patients who who needed the care, right. And. And may have had nowhere to go at all, right? Exactly. Yeah. Well, and just just for your information, I was just looking up state hospitals and it came to Washington State because of course this is where I am and Washington State has three main state-run psychiatric. Institutions.

34:14 Oh, that's interesting. Yeah, that's that's wild, given that there are only enough to house about 45,000 people. So the psychiatrist E Fuller Tory, who has been one of the most prominent and sometimes controversial voices on the issue for decades, has argued that this represents a complete inversion of what mental health system was supposed to be. We didn't end institutionalization. We re institutionalized in the worst possible settings. So how does this person with serious mental illness end up in jail or prison? The pathways are multiple, interrelated, and often heartbreaking. The most common is what is sometimes called criminalization and mental illness, the process by which behaviors that are symptoms of illness become criminal charges.

35:00 A person experiencing A psychotic episode may be disruptive, aggressive, or threatening in ways that result in police contact. A person with untreated bipolar disorder may engage in reckless behavior, public intoxication, disorderly conduct, petty theft that cycles them through the criminal justice system repeatedly. A person with schizophrenia lying on the sorry living on the street may be arrested for trespassing, loitering, or urinating in public. These are not crimes in the sense that the criminal justice system was designed to address. They are symptoms. But in the absence of a functioning mental health system, the criminal justice system is where they land. The officer on the street who encounters someone in psychiatric crisis has limited options. They can transport them to a hospital emergency room, where they may be held briefly if they meet the narrow standard for involuntary commitment, and then discharged back to the street within hours or days.

35:51 They can try to connect them with the community mental health resource, if one exists and has capacity, which often it doesn't. Or they can arrest them, which at least gets them off the street and into a system that will, however inadequately, feed them and house them. Criticism of individual officers. Many law enforcement officers are deeply uncomfortable with being the default response to psychiatric crisis Crisis Intervention Team training. The model developed in Memphis in the 1980s specifically to address police response to mental health emergencies, has been adopted by many departments as an attempt to handle the situation better. The CIT model is genuinely helpful. It is not a substitute for a functional mental health system.

36:31 This reminds me of the story of a that now this is not mental illness but of a kid that was having that was on the autism spectrum and an outburst and cop shot him to death. Dude, I will say that a lot of police departments are working on partnering with mental health crisis specialist and just to deescalate situations so that they don't result in harm to others or arrest. Unfortunately, it's not enough. It's not enough police departments. I mean, and also it's not enough of an intervention, but it's a, it's a huge step in a better direction because there are mental health professionals that are trained in a much more effective crisis intervention than one would, would get from a police crisis intervention training, right?

37:24 And we do that's like, that's, I think it should be the first step in all police departments that we stop sending, we stop sending only cops to mental health crises situations. And we, and we send in the mental health experts. We, we hear a lot of times of, you know, people with schizophrenia holding people hostage or things like that. And it's just, it's just there's so many things that can be de escalated if you have the tools and not enough people have the tools right now. Yeah, my biological father said help set up a program in California that put teams together, go out with police in in the Oakland area.

38:11 And it was a pilot program and it grew and grew because they were seeing the benefits from it. And there were target times. The way I understand it, there were target times that they sent them out because I guess there were more, more times with psychiatric issues than other times during the day. I mean actually times it was said to have made a huge difference. Yeah, it's that's what they're finding in in these places to have these programs. So good on your, good on Steve, I'll say. Yeah. So what happens to people with serious mental illness once they are inside jails and prisons is in many cases, a story of compounding harm. The jail environment is profoundly hostile to people with psychiatric symptoms. The noise, the unpredictability, the loss of control, the threat of violence, the inability to access medication reliably, all of these things are acutely destabilizing for people with conditions like schizophrenia and bipolar disorder.

39:03 Scales are not designed to treat illness. They are designed to detain people awaiting trial or serving short sentences. The result is that people who arrive in jail in psychiatric crisis often deteriorate rapidly, and the response in many facilities in many jurisdictions is solitary confinement. The logic is perverse but operationally coherent. A person who is behaving erratically and is difficult to manage gets removed from the general population and placed in a small cell with 22 or 23 hours of isolation per day. The research on solitary confinement and mental illness is unambiguous. Isolation causes psychiatric harm in people who are mentally healthy to begin with.

39:46 In people who are already experiencing serious mental illness, it is catastrophic. Studies have documented the emergence of hallucinations, severe anxiety, paranoia, and self harm in people who had no prior psychiatric history after periods of isolation. For people with existing serious mental illness, it reliably causes rapid deterioration. A 2014 study of suicides in New York City jails found that roughly half occurred in solitary. Confinement despite solitary housing only about 77% of the jail population, the risk of suicide in solitary is not modestly elevated. It is orders of magnitude higher. And yet solitary confinement continues to be used as a management tool for people whose primary presenting issue is psychiatric illness.

40:31 Because the system has no other tool. Because the mental health resources inside jails and prisons, while they exist, while there are dedicated correctional mental health workers who genuinely do important and difficult people at work, are nowhere near sufficient to address the need. Perhaps the most pernicious feature of the criminalization cycle is that it doesn't resolve. It recycles. A person with untreated, untreated schizophrenia is arrested. They are held in jail. They may or may not receive medication. They are released. They have no housing, no medication prescription, no connection to outpatient services, often no identification, sometimes no clothing appropriate to the weather. They decompensate. They come to the attention of law enforcement again. They are arrested.

41:14 They cycle through studies of high utilizers in urban jail systems, have documented individuals with serious mental illness who have been arrested dozens or even hundreds of times. One analysis of Los Angeles County Jail found a cohort of 30 individuals who collectively accounted for more than 700 jail stays and cost the county an estimated $19 million over a decade. These 30 people, not 30,030. The cost of incarceration for a person with serious mental illness, accounting for the additional mental health services, the medical care, the administrative overhead of managing someone with complex needs in a custodial setting, is estimated at two to three times the cost of incarceration for a person without mental illness.

42:00 We are spending an enormous amount of money on a system that makes people worse and cycles them back out into the same conditions that brought them in. If not. Worse, if not worse, right? So prisons and jails absorbed one population, the streets absorbed another. The relationship between deinstitutionalization and homelessness is real, important, and significantly more complicated than either the advocates who deny it or the commentators who treat it as the whole story are willing to acknowledge. The contemporary homelessness crisis in America began in the early 1980's, the same period where community mental health funding was being cut and the last wave of large scale hospital closures was occurring. That timing is not coincidental. Current estimates from Hud's annual Point in Time count, HUD being the Housing and Urban Development arm of the federal government, find somewhere between 550 to 600,000 people experiencing homelessness on a single night in the United States.

43:00 Among those, roughly 30% are estimated to have a serious mental illness. That means somewhere between 165 and 180,000 people with serious mental illness sleeping outside or in shelters on any given night. In some cities, particularly in urban areas with large unsheltered populations, the proportion is higher. Surveys of unsheltered individuals, people sleeping on the street rather than in shelters, consistently find serious mental illness rates at 35 to 45%. Does deinstitutionalization explain all of this? No Homelessness is caused by many things. The shortage of affordable housing, poverty, substance use, substance use disorders, domestic violence, economic dislocation. Serious mental illness is a significant risk factor for homelessness, but it is not the only one, and it's not operate in isolation from these structural factors. But is the connection real?

43:59 Absolutely. Studies tracking patients discharged from long term psychiatric hospitalization have found that a significant minority. Estimates range from 15 to 40% depending on the study, the population and the availability of community services, end up unhoused within a year. Research on unhoused populations consistently find that a large proportion of those with serious mental illness report the onset of homelessness coincided with or followed the onset of their illness, not the other way around. OK. The experienced Ness of homelessness is in itself psychiatrically devastating. The chronic stress, the sleep deprivation, the constant threat of violence, the loss of privacy and dignity, the exposure to weather, the inability to maintain hygiene, the social, social isolation.

44:44 These are not neutral conditions. There are conditions that will worsen any psychiatric illness and will cause psychiatric symptoms in people who had none. Maintaining medical adherence, medication adherence, excuse me, while unhoused is extraordinarily difficult. Psychiatric medications often require refrigeration. They require a consistent schedule. They require refills, which require prescriptions, which require appointments, which require a phone number and an address to receive appointment notices, which unhoused people often don't have. The practical barriers to medication access for unhoused individuals with serious mental illness are immense. The result is a population of people who are simultaneously very ill, very visible, very vulnerable to harm, and very difficult for the mental health system to engage. Outreach workers who do St.

45:34 based mental health work, and this is some of the hardest, most important work in the field, will tell you that building trust with a chronically unhoused person with serious mental illness can take months or years. And that trust can be shattered instantly by a single coercive interaction. That the involuntary commitment, however well-intentioned, that results in a person being hospitalized for 72 hours and then released back to the same sidewalk, having lost their belongings in their camp while they were gone, makes that person less likely to engage with services in the future, not more. We have not figured out how to do this well. There are programs and models that work, and I'm going to talk about some of them, but they require resources and patience and political will that have been persistently lacking since the 1990s. A model called Housing First has been gaining ground on as an alternative to their traditional approach to homelessness among people with mental illness.

46:27 The traditional model, sometimes called the Treatment First or staircase model, required people to demonstrate sobriety and medication compliance as prerequisites for accessing permanent housing. The theory was that you need to address the underlying illness before you could stabilize the housing. Housing First flips this It provides permanent supportive housing first immediately without preconditions, and then offers voluntary treatment services in place. The underlying theory is that housing is healthcare that you cannot stabilize, is someone's mental illness while they are sleeping outside, that the trauma and stress of practical barriers of homelessness make treatment nearly impossible, while the safety and stability of housing makes it far more achievable. And I will say that Holly Sue, my sister who is a economist, 100% agrees with the housing first model.

47:14 And I actually, when I was in nursing school, I did AI, did clinicals at a facility in Salt Lake City that was a housing first model. And I'll tell you, it was one of the most interesting places I ever worked. I was, my clinicals were actually in the in the head start classroom. And there were some rough kids in that head start and there were some rough parents coming to pick up those kids. But I'll tell you what that we knew where the kids, you know, they knew where their kids were all day and they knew their kids were being taken care of and they were and they were able, they were not only able to go and look for jobs, they were doing it. And they may still, you don't have a drug addiction, They may still have mental illness that isn't necessarily fully treated, but they were definitely not on the street.

48:00 And even more and more likely than being right, and even more and more likely to be lost in the system. Exactly. Yeah, exactly. The research on Housing First is, relative to most things in mental health policy, unusually positive. Multiple randomized controlled trials have found that Housing First significantly outperforms treatment first models in housing retention, and that it does so without worse outcomes on substance use or psychiatric systems. In many studies, Housing First participants showed better outcomes on both. The model has been implemented nationally in Canada, across Scandinavia, and in various programs in the United States. The sticking point, and it is always the same sticking point point is cost and political will. Providing permanent supportive housing to every person with serious mental illness who is unhoused would require an enormous investment in housing stock that this country has not made housing first programs work for the people who get into them.

48:49 The challenge is scaling them to meet the actual need. And I do want to say that today, in today's climate, political will is a huge part of this. I know that there are hundreds, thousands of empty housing units that could be used to house the unhoused and to do this housing First program, but the funding isn't there and the desire isn't there, unfortunately and so. I think it's, yeah, I think the desire is the part. I mean, because you there's always 2 fold things and they can always blame funding. But really, if it were a priority for people, it would be available. And so, you know, where you do see these programs in the United States, they're typically private.

49:29 They're privately funded. I want to step back from the policy for a moment and talk about what this looks like from the ground, because the story of deinstitutionalization is not just a story about symptoms, It is a story about families. When the state hospitals began closing, the prevailing philosophy in the mental health community was that families were resources, that discharging patients to their families was a therapeutic good, that community and family support was what people needed. And what the old institutions had denied them. And some families were resources. Some families were themselves the source of harm and dysfunction that had contributed to their families memory, illness, their family members illness. But many families, perhaps most families, were simply ordinary people with ordinary resources who were being handed the caregiving responsibilities for someone with a severe and persistent mental illness, without training, without respite care, without crisis support, without adequate mental health resources in their community, and without any honest accounting of what they were being asked to do. The family advocacy movement, particularly the National Alliance on Mental Illness, or NAMI, which was founded in 1979 largely by parents of adult children with schizophrenia, emerged directly out of the this experience. Nami's founders were not abstract policy advocates. They were mothers and fathers and siblings who had spent years trying to navigate a system that didn't exist, trying to get help for family members who were acutely ill and often unable or unwilling to seek treatment, watching their loved ones cycle through emergency rooms and jails and shelters, and finding that nobody in the official mental health system was particularly interested in

51:01 helping them. The experience of having a family member with untreated, serious mental illness is in many cases traumatic. Not in the casual, modern usage of that word. In the clinical sense. Families describe living in a state of chronic crisis, calling police on their own children because there is no other option, watching psychosis take hold and being unable to compel treatment, burying family members who died by suicide or on the street or in altercations with law enforcement. One of the most painful features of the current system is that sometimes is what is sometimes called the compassion trap of confidentiality law. Under HIPAA and most state mental health privacy statutes, clinicians cannot share information about an adult patient's treatment with family members without the patient's consent.

51:48 In principle, this is a reasonable privacy protection. In practice for families trying to coordinate care for a family member who lacks insight into their illness and refuses to consent to information sharing, it creates a situation where the people who know the patient best and are most affected by their illness are systematically excluded from the treatment relationship. I know I can't imagine man families have fought for modifications to confidentiality law for decades with limited success. The privacy rights of patients and the legitimate interests of families are genuinely in tension, and I don't want to minimize that. But the curtain system in many cases serves neither. And I don't want to end this episode in despair. That's not what this podcast is about. We come here to understand things all the way the hard parts and the hopeful parts both. So let me tell you what we actually know works because we know some things.

52:39 In the early 1970s, a psychiatrist named Arnold Marx and a team at Mendota Mental Health Institute in Wisconsin were working with patients with severe schizophrenia who kept cycling in and out of hospitalization. They developed a model called Assertive Community Treatment ACT, built on a simple but radical premises. Instead of waiting for patients to come to the clinic, the clinic comes to the patient ACT teams are multidisciplinary psychiatrist, nurse, social worker, substance abuse counselor, peer support specialist and they carry small caseloads. They meet clients wherever the clients are at home, on the street, in shelters, at the jail exit. They provide medication management, crisis support, help with housing and benefits, and daily living skills and ongoing relationship.

53:24 They're available 24 hours a day, seven days a week. The research base for ACT is one of the strongest in all the psychiatry. Multiple randomized controlled trials have found that ACT significantly reduces hospitalization, reduces incarceration, reduces homelessness, and improves quality of life compared to standard case management. It works. We've known it works for 50 years. A/C TCACT teams now exist in many states, but there are nowhere near enough of them to meet the need. Assisted Outpatient treatment. AOT, sometimes called Kendra's Law in New York where it was first enacted, is a court ordered outpatient treatment program for people with serious mental illness who have a demonstrated history of treatment non adherence resulting in hospitalizations, incarcerations, or violent incidents.

54:10 AOT is controversial. Civil liberties advocates argue that it represents coercive treatment and that it disproportionately effects Black and brown patients. These are legitimate concerns that deserve serious engagement, but the research on AOT outcomes, particularly the New York study, has generally found that participants have significantly reduced hospitalization rates, reduced arrest rates, reduced homelessness, and improved functioning compared to control periods. Crucially, studies of patient experience have found that many people who go through AOT programs report in retrospect that the intervention that the intervention helped them. The debate about AOT is ultimately a debate about the limits of autonomy when illness impairs the capacity for autonomous decision making. That is a genuinely difficult philosophical question, but I think the evidence suggests that well implemented AOT attached to robust service provision produces better outcomes than the current default of cycling through gels and ERS and shelters.

55:11 Yeah. One of the most promising recent developments in mental health policy is the growth of alternative crisis response models. We were just talking about this programs that dispatch mental health clinicians rather than OR alongside police officers to psychiatric emergencies. The CAHOOTS program in Eugene, OR, which began in 1989, sends a medic and a mental health worker to certain 911 calls rather than police. It handles roughly 20% of the city's 911 call volume and has documented significant cost savings and improve outcomes compared to traditional police response. Star program, which launched in 2020, Similar similarly dispatches mental health clinicians and paramedics to low acuity mental health and substance use calls.

55:54 In its first six months, it responded to over 700 calls without police backup being requested in any of them. Yeah, these models are promising and are expanding. They do not solve the fundamental problem, which is the absence of a robust, A robust continuum of mental health care for people to be connected to after the crisis, crisis response to the front door. It needs rooms behind it. Every evidence based intervention in serious mental illness comes with the same footnote. It is dramatically underfunded relative to the need. Mental health and substance use disorders account for roughly 13% of the global burden of disease, but receive approximately 5% of health expenditure in high income countries.

56:34 In the United States, the gap between the need and the resources devoted to meeting it is enormous and has been for decades. The argument that we cannot afford to build a real mental health system is worth interrogating. We are currently spending conservatively 10s of billions of dollars a year incarcerating people with serious mental illness in the most expensive and least therapeutic therapeutic setting imaginable. We are spending billions on emergency room visits and police response and shelter beds. We're paying for the failure of the mental health system through every other system it has offloaded its burden on to. The question is not whether we can afford to build a real community mental health system. The question is whether we are willing to organize the political will to do it. In 1963, John Kennedy stood before Congress and told them that mental illness and mental retardation were among the most critical health problems facing the nation. He said that the old custodial institutions were no longer adequate.

57:29 He said that a quote, bold new approach was required. He signed a law. Six weeks later, he was dead and the bold new approach was quietly defunded. De prioritized, cut block granted, forgotten. The people who left the hospitals had nowhere to go. Some went to families, some went to nursing homes where they were warehoused in slightly different conditions, some went to rooming houses and Sr. OS that have since been demolished and not replaced. Some went to the street, some cycled through emergency rooms and jails for the rest of their lives. The story we told ourselves was about freedom and dignity, dignity and community, and those are real values. The old institutions really were doing real harm. The civil libertarian critique of involuntary commitment really does contain real truths.

58:16 But we use those true things as permissions to do nothing, to cut budgets and call it liberation, to discharge patients and call it progress, to let the jails absorb what the hospitals had held and tell ourselves we've done something humane. The people in those jails are not criminals who happen to be mentally ill. They are people who are ill who are being processed through system designed for criminals. Because we dismantled the system designed for illness and never built what we promised to replace it with, the people on those sidewalks are not choosing to be there. They are the downstream consequence of 50 years of policy decisions made by people who are never going to sleep on the sidewalk. We've known how to do this better for a long time.

58:56 We have the models, we have the research. We have the evidence. What we have not had is the sustained political will to fund and build and scale what works. That choice, it's a choice we make with every budget cycle, is a choice reflected in every jail bed we fund and every AC team slot we don't. It is a choice we can make differently. And I want to close with something that's not a statistic. I want to close with something, a forensic psychiatrist, names named James Gilligan, wrote in his book Violence, Our Deadly Epidemic and Its Causes. He spent years working inside maximum security prisons. He wrote about what he found there, and what he found. What he kept finding, was people who had started their lives in conditions of such profound neglect and chaos and unaddressed suffering that violence and incarceration were not aberrations, they were logical conclusions. He wrote that the most violent people he had ever encountered were, almost without exception, the people who had been treated with the most violence, the most abandoned, the most neglected, the most comprehensively failed.

59:59 The system we built when we. Emptied the hospitals, the jails, the streets, the cycling the crisis and release the crisis again. It itself a form of violence. It is not called that. It is not seen that way by most of the people who administer it or fund it or vote on it. But it is a way of treating a group of vulnerable people with profound neglect and then being surprised when things go badly. We do better. We know we can do better. The question is whether we decide to. I drop. Mic drop. Wow, wow. And that's it's intense and I've seen it in multiple times throughout my career, both as a nurse and early on when I was police dispatcher, because a lot of the things that we got in the calls we got were just people losing it for whatever reason. And they were psychiatric based complaints, many of them exacerbated by alcohol and drug use, as you had alluded to and even mentioned in some of the cases. It's a conundrum because we know, well, I don't even know if conundrum's the right word, but we know what to do, as you say, but it's just not being done.

1:01:05 And I think a lot of the sort of thing is, is significant to a person if they've experienced it within their own family or friends more than it is to people who don't. Because for people who don't understand mental illness or have never experienced it, it's just sort of an out there thing. And some people even considered an excuse for poor behavior. But it's a real thing that needs urgent care and consistent care. When a person is not competent to make the decisions on their release after an emergency hold and things like that, then that gap is definitely huge. And then people are surprised when someone is hearing voices and then kills their family and they're. Surprised, Right, Right.

1:01:46 Yeah. Well, I think another thing to consider is a lot of us grew up, and I know that this is a buzzword and that there's a lot of, there's a lot of charge to this word, but a lot of us grew up with privilege. And the reality is there are households in this country where children are introduced to heroin at 8 years old by their parents or crack or crack cocaine. Yeah. I mean, I was listening to a podcast and there was a guy who dad was giving him heroin and crack cocaine at 8 years old. And like, that was his lifestyle moving forward was just using drugs. And so he ended up killing somebody. And it was like, well, of course he did. And, you know, and I mean, I've read several books because it's an interest of mine where, yeah, there's just the, the, the neglect epidemic and the drug epidemic is just absolutely horrifying. And it, it's what it's not even what we don't believe in our, in our privileged state, but we, we're not even aware of it. It's not something we see.

1:02:48 It's, it's outside of the realm of our experience. That's another thing we aren't addressing. There's a great, great documentary if you're interested. It's on HBO Max. And I will say it's very, it's very raw. It's called Life of Crime 1984 to 2020. And it, it's, it follows 33 individuals who are drug addicts and live a life of crime to support their habits. And it is just, it's very eye opening. So I would recommend it again, it's, it's graphic, it's, it's raw, but it is very eye opening. Anyway, it, it really gives some insight into what is going on in these communities that you and I aren't a part of and that probably the majority of our listeners aren't a part of. And I would, I would close honestly with just reminding our listeners and reminding ourselves, like it really is important to have compassion and to try to see things for the perspectives.

1:03:48 If you're in a place where you can volunteer for organizations that promote mental health support, you know, do it. It's so important. And like I said earlier, right now, the desire is not necessarily there from our government. And so we are currently having to rely on private institutions and private funding and nonprofits and those sorts of things. We continue to prove the model. Eventually there's got to be, we've got to get to a point, I believe, where we can get the political will there, where it's, you know, it's UN, it's unavoidable. I I think we got to start with the grassroots, I think. Yeah, we do. Well, thanks for that. Definitely, certainly informative. Thank you very much.

1:04:30 Yeah. Thank you. And we'll see you next week. All right, if you've made it this far, clearly you like a little mayhem with your medicine. Or you just enjoy hearing us ramble about weird medical mysteries. Either way, we'd love you for it. So hit that follow or subscribe button wherever you're listening. And toss us a rating or review while you're at it. Helps other curious weirdos find the show. And we know there are a lot of you out there. Oh so many. Come join the chaos. Thanks for listening to Medicine, Mystery, mayhem, and sometimes Murder. Do you have an idea for an episode of this podcast? Just want to say hi? You can get in touch with us at our M4 pod. That's OURM thenumberfourpod@gmail.com. We read every e-mail, and sometimes we even respond just like real professionals.

1:05:22 Because we are. Old friends with new twists and lots of body bags.