The Rise and Fall of the Asylum
The president’s budget proposal includes the repeal of Medicaid’s IMD (Institutes for Medical Diseases) exclusion, a Johnson-era policy that withholds federal Medicaid monies from residential adult psychiatric facilities with 16 or more beds. In 1965, Congress incorporated the exclusion in the seminal Medicaid statute for two distinct purposes: first, to honor the spirit of the late John Kennedy’s 1963 Community Mental Health Act, which called for the large-scale depopulation of American asylums, and second, to ensure that states retained a role in funding those state mental hospitals, whose maintenance had been a state responsibility for more than a century. The results of this and other deinstitutionalization policies are no doubt familiar to readers here: the explosion of homelessness, the surging incidence of mental illness in jails and prisons, sporadic cases of mass violence. But other outcomes, such as the “psychiatric boarding” crisis of psychiatric patients languishing in emergency rooms, or the takeover of state hospitals by the criminally insane, are less obvious to a disinterested observer.
Support for the proposed repeal of the IMD exclusion runs the gamut from contributors to the Wall Street Journal through the New York Daily News editorial board, but critics have crawled out of the woodwork to defend the exclusion as the only thing standing between the mentally ill and the “snake pit” asylums of old. With the homelessness crisis at a fever pitch and mental-health policy very much in the news, I asked Dr. E. Fuller Torrey, the founder of the Treatment Advocacy Center and the author of four books about psychiatry and mental-health policy in the United States, to discuss the state of our national mental-health system in light of the president’s proposal. Remarks are edited for clarity.
John Hirschauer: I’m sure you’re familiar with the Penrose hypothesis — the British psychiatrist Lionel Penrose’s theory that there is an inverse relationship between the rate of incarceration, and the size of “asylums” and psychiatric hospitals. In 2013, Steven Raphael and Michael Stoll released a study in the Journal of Legal Studies, which is often cited by civil libertarians and other deinstitutionalization proponents. The study estimates that the large decline in state-hospital populations over the past 70 years has accounted for only 4–7 percent of the concomitant increase in incarceration. Do you dispute that estimate?
Dr. E. Fuller Torrey: I’m not familiar with that particular paper. But the increase of the number of mentally ill people in jails and prisons, by all measures that I’ve seen, has been much, much higher and has pretty much paralleled the deinstitutionalization movement. I started following this in the early 1980s, when I first wrote on the subject. During the 1980s, about 5 percent of people in jails and prisons — especially jails, at that time — were mentally ill. A decade later it was 10 percent, a decade later it was 15 percent, and today it’s not unusual for 20 to 25 percent of prisoners in a correctional facility to have a mental illness. So there’s been a very close parallel between the numbers of patients who have been emptied out of the hospitals and the increase in the number of mentally ill estimated to be in jails and prisons. In two or three of my books, I mentioned the first person who was looking at this phenomenon in early 1980s. He looked at the number of mentally ill in the — I think it was in San Jose, Santa Clara, or San Mateo jail. I forgot which one. In any case, he had been a resident with me at Stanford, just a year ahead of me. He was the first one I could find who actually said, “Hey, look what’s going on. You just emptied these folks out of the state hospital, and now they’re all appearing in jail.”
Locally, I have volunteered at the shelters for many years and have followed the situation in D.C. A couple of my nursing staff who had been working on the ward at St. Elizabeth’s [Hospital] with me, I later saw them, and they told me that they had gone to work for the jail system. They said, “You know, it’s not very hard, because we’re seeing the same patients.”
JH: Yeah. I wanted to ask you about that, too. You said you volunteered and spent some time with the homeless, and particularly people who have mental illness — serious mental illness — and are homeless. I think most people are aware, at least instinctively, of the relationship between homelessness and serious mental illness. From your experience, can you expound upon the relationship between the two?
FT: I was involved in one of the very first studies that tried to estimate the incidence of mental illness among the homeless. Back in the 1980s, I did a study jointly with a colleague — I think we were probably the second or third published study on this subject. I was working at St. Elizabeth’s at the time, and I also started volunteering in the women’s shelters in Washington back in the early 1980s. During my final years on the wards at St. Elizabeth’s, I was also volunteering twice a month at the women’s shelters. I can tell you that I was seeing the same people who had been at St. Elizabeth’s — some of them on my ward — who were then discharged and then stopped taking their medication. Then they would turn up homeless. When I would go to the shelters, I would think, “I already know this woman, I took care of her when she was in the hospital.” So it was no great mystery. They were in the hospital, they were discharged, they stopped taking their medication, they ended up homeless and in the shelters.
JH: Can you speak a little bit more about your time at St. Elizabeth’s? How long did you spend at the hospital? What did you learn, and what experiences struck you most in your time there?
FT: I started at St. Elizabeth’s in January 1977. I had worked at NIMH [National Institute of Mental Health] in 1970, and then spent a year at the Indian Health Service in Alaska. When I came back from the Indian Health Service in 1976, I decided that I was not going to stay at NIMH indefinitely. I was already involved in research on schizophrenia at the time and had developed ideas about infectious agents as being possible causes of the disease. So I decided I would go work at St. Elizabeth’s, which at that time was still under the control of NIMH and the federal government. It was later transferred to the district government. Ultimately, I called the head of St. Elizabeth’s and said, “I’d like to come over and work in the wards, just as a ward doc.” He was very happy to oblige.
I told him that I would like to do research on my patients, and he said that would be fine. So I went to work in January 1977 and worked there continuously until 1986, at which time I had completed my 20 years of public-health service and retired. I was there on the wards for about eight years, and in that time, I started one division, and they made me the director of another division — I eventually had 12 wards, about 260 employees, and about the same number of patients under me for several of those years.
It was a very rich experience. I learned a lot about mental illness in a way that you can only learn if you take care of the patients. I also did a lot of research — I got very much involved in research at that time. It was a very defining experience for me because it really got me deeply involved, both clinically and research-wise, in schizophrenia and bipolar disorder, which were the two diseases that most of my patients had.
JH: What do you say to people who claim that the current failures of deinstitutionalization are not a product of having emptied the hospitals — except for the “forensic patients” committed after criminal behavior? The real problem, they claim, is that we don’t invest enough in so-called community services. Were the problems that followed mass deinstitutionalization inherent to the policy, or did it fail because we didn’t set up suitable community options?
FT: There’s no question that most people who were in the hospitals, before we started deinstitutionalization, could live successfully in the community if you provided the ongoing services for them in the community. There is no question about that. On the other hand, there is a core group of mentally ill people who could not live in the community, who are just too chronically, psychiatrically disabled. It’s important to recognize that deinstitutionalization was not for everyone. It was for the majority of patients, but not for everyone. You need a core number of chronic beds for people who actually can’t make it in the community, and you need the beds — as we still do today — for the people who need to be re-hospitalized and stabilized. And so, the Bazelon Center approach — basically saying “Close down all the beds” — is absolutely absurd. If you’ve ever taken care of these patients, you know that it’s absurd.
JH: You mentioned the Bazelon Center, which opposes most forms of involuntary treatment — do you think that there is any room for compromise between people at the Treatment Advocacy Center, an organization that you founded, and a place like Bazelon? Or do you think that your visions of psychiatry and mental-health policy are just irreconcilable?
FT: I think it is probably irreconcilable. I have suggested several times that if the Bazelon people would all volunteer to work at a public shelter, and work on the wards, and actually see what is wrong with these people, then I think we could come to a compromise. But it’s really — the Bazelon Center is an outgrowth of the movement that Bruce Ennis, who is now deceased, started in his book. He said that our goal — as he saw it — is to close down all hospitals and not have anyone ever involuntarily admitted. It’s a very strong ideological belief among some people that the mentally ill should not be treated involuntarily, and that whatever treatment they do receive should be voluntary. I don’t have any great hope that in my lifetime I’ll see any kind of compromise.
JH: How do you respond to critics who claim that schizophrenia and other serious mental illnesses, while they may have a biological component, cannot be identified with foolproof medical tests and therefore that psychiatrists should not have the power to involuntarily treat people whose conditions they can’t diagnose with certainty?
FT: I’d say it’s a position that I understand in theory, but if I am the person who is mentally ill, I wouldn’t want someone to leave me on the street. I would want someone to take care of me. If I have anosognosia [the inability to recognize a disorder that is clinically evident], then I don’t even understand that I am mentally ill — and there is good biological basis to show that brains of people with schizophrenia, who have anosognosia, are different from those who don’t. So, no, we don’t have a definitive test. We don’t have a blood test yet that we can give to say, “Yes, this person has schizophrenia.” But clinically speaking, 95 percent of people with schizophrenia, there’s just no question of what they have. It’s not a mystery. It’s very clear from their symptoms, and the fact that they don’t understand that they’re sick. You can show that the brains of people who have anosognosia are different from those who have an understanding of their illness. So I’m not very sympathetic to people who say, “Until we have a blood test, you shouldn’t do anything.” I think that absurd.
JH: Branching out a bit here to forensic psychiatry — how do you feel about psychiatry and its role in judging an offender’s culpability? How do you feel about forensic psychiatry, and its ability to aid in those decisions?
FT: I spent my last year and a half at St. Elizabeth’s in the forensic division, so I’ve had some experience with these issues. My answer would be that I feel pretty good about forensic psychiatry. It’s not perfect, but it’s pretty good. Especially some of the competent forensic psychiatrists that I work with and have known over the years. You get situations where people who are mentally ill commit crimes that are not related to their mental illness. I had a patient like this once — I had taken care of her on the civil side of St. Elizabeth’s for several years and had taken care of her brother, also. I knew the family very well. She shot and killed her husband one night; she was just sick and tired of being abused by him. I was not involved in the case at that point, but I thought, “This woman may well have shot and killed her husband even if she didn’t have schizophrenia.” That’s an example of a crime that was committed by someone with schizophrenia, but not because of their schizophrenia. But that case is very much an exception. I think the ability of a forensic psychiatrist to take a reasonable guess as to the relationship between the serious mental illness and the crime is pretty good.
JH: How do you respond to people who say that the fact that two forensic psychiatrists — one for the defense, one for the prosecution — can sometimes come to different assessments of the defendant’s culpability at the moment of the alleged crime? Does that undermine the forensic psychiatrist’s claim that he has a relevant role to play in the legal process?
FT: Oh, sure. Forensic psychiatrists run a wide range, just as wide a range as non-forensic psychiatrists do. Some are much better trained than others, some are better psychiatrists than others. I certainly have experience with forensic psychiatrists who I suspected didn’t know what they were doing, just as I’ve had contact with a number of civil psychiatrists who I don’t think know what they’re doing. So yeah, no question, it discredits the field when you get these high-profile shouting matches, disagreements between two forensic psychiatrists in court.
JH: This leads me to another question. You worked at St. Elizabeth’s for eight years or so?
FT: I worked on the ward for nine years, actually.
JH: Nine years, okay. I volunteer at a large state institution, and I’ve been struck at how it has changed over the years. It was built in the early 20th century on a large, rural, patch of land — 1,600 acres, more than 100 buildings, and a fully functioning farm. It was a self-sustained little world. Then the deinstitutionalization movement came, and the higher-functioning patients moved out, creating a static population. Now you had this 1,600-acre campus with 100 buildings being used for, you know, 200 patients, and half of the buildings are mothballed. I wonder if you could speak about your time at St. Elizabeth’s and how things changed over time — particularly as you’re on this big, Victorian campus serving a much different purpose from the one for which it was designed.
FT: I was at St. Elizabeth’s during a transition period. When deinstitutionalization was going on, we were strongly encouraged to empty out the wards. I became aware that we were placing patients — some of the ones who had been there for 30 years or more — we were putting them in nursing homes downtown. I remember a guy who followed up with some of the patients and visited them in these nursing homes. One patient had been placed in a part of Washington that was very crime-ridden, and he couldn’t leave the nursing-home building — he would get mugged if he went outside. I realized that we were placing a lot of patients who had been able to walk the grounds of St. Elizabeth’s, who had a certain social life there — we were putting them in a situation where they actually had less freedom, although they were in the “community.” Perhaps, by the letter of the law, the patient had been “deinstitutionalized,” but they were actually worse off.
I had patients who did whatever they had to do to get back into St. Elizabeth’s. One started a fire in the group home, for example. And while most deinstitutionalized patients were better off, a minority were worse off. And I realized that we were not doing them any favor at all. Deinstitutionalizing them was not in their best interest.
The hospital now — I haven’t been out there in several years, but half of it has been turned over to the federal government. The other half is still active, but with a lot of empty buildings. It has a very sad quality to it. I grew quite convinced of the fact that there was a small group of patients who are very severely disabled, that living in an “asylum” really was in their best interest.
JH: You mentioned nursing homes earlier. I read in your book American Psychosis about the sort of “dumping” that went on, where deinstitutionalized patients were sent to nursing homes, with diagnoses that were not psychiatric in nature, in part because of the IMD exclusion. The IMD exclusion, as you know, prohibits federal Medicaid funding from flowing to residential facilities with 16 or more psychiatric-specific beds. So, I wanted to ask — in the president’s budget, he calls for the repeal of Medicaid’s IMD exclusion. What do you think that would mean for patients with serious mental illness who need inpatient hospital care?
FT: I think it would improve things. I’ve written a lot about the IMD exclusion, especially in a book I published in 1997 — Out of the Shadows, where I traced the whole “federalization” of mental-health policy. You have to remember, back in the 1960s, there was almost no federal money in the state-hospital system. This was a state issue — my calculations showed that about 2 percent of the money that was in the state-hospital system, at that time, was from the federal government. The other 98 percent was state money. Then that changed. I documented how that changed, in Medicaid especially, so that, without really meaning to, we have federalized what had been a state responsibility for 150 years.
The IMD exclusion was passed because people in Washington didn’t want to fund the state hospitals. They wanted to fund the outpatients, but they didn’t want to fund what had been a state responsibility, so they put the IMD exclusion into the Medicaid bill. Of course, states gamed the system almost immediately and figured out that by closing down the state-hospital beds, they could force the federal government to pay for patients, either on the psych ward of a general hospital, or in the community in other facilities. So the IMD exclusion was an attempt by the federal government to prevent things from becoming completely federalized, but it has created, really, a half-assed system, where states are incentivized to empty those hospitals and shift patients onto federal funding one way or another. At this point, to answer your question, abolishing the IMD exclusion would enable states to make a decision about whether to put the person in the equivalent of a state hospital, or not. And I think that is much more rational.
JH: Is there an equal-and-opposite risk, if you repeal the IMD exclusion (and thereby take state-hospital funding out of states’ hands), that things will change when another president and other lawmakers come into power someday? People who are perhaps more — I don’t want to say “progressive,” because these issues cross ideological lines, but there tends to be an alliance between civil libertarians and progressives on these issues. If someday the IMD exclusion were to be reinstated, would states lack the appetite to begin funding those hospitals once again?
FT: That’s definitely right. Bernie Sanders’s mental health position has been very “progressive,” in the sense that you’re using the word, and much of it is taken right from the Bazelon Center. So the scenario you suggest is not farfetched at all. I think that would be a possibility. The decision in the ’60s to federalize what had been a state program was a mistake in this respect. If I could go back to the 1960s and change things, I would have left this in state hands. There’s evidence that states could do a better job overall than federal government on these issues, and I’ve never been impressed by the ability of my colleagues here in Washington to figure out how things should be funded. It’s too big of a country for that.
But that’s all kind of by the board, now — it has already happened. It is federalized now. States are spending as little money as they can. The main job of a state commissioner of mental health — ask any of them, and they’ll tell you — their main job is to figure out how they can shift more of the cost to the federal government and away from the states.
JH: The grand narrative about America’s mental-illness policies that we always hear holds that John Kennedy had this great idea, inspired by his sister, Rosemary, who was lobotomized. He wanted to reform or eliminate state hospitals that were, in many cases, snake pits — underfunded, overcrowded, and so forth. In the 1963 Community Mental Health Act, Kennedy comes up with this idea for “Community Mental Health Centers” (CMHCs). The narrative goes that these centers were never properly funded, and, as I mentioned above, that the only reason we have this patchwork system now is that we never fully invested in the Kennedy model. Can you elaborate more on your view of this narrative?
FT: That’s a very popular myth among my colleagues. They love to use it because it ignores the fact that the centers that were funded were failing. I described that in great detail in my book, Nowhere to Go, which was the first book that I wrote about these things. In that book, published in the 1980s, I described in great detail how these “mental health centers,” which we funded — and we funded over 700 of them! — were not taking care of the people coming out of the hospitals. They were taking care of the “worried well,” and that was part of the plan from the very beginning. The people who planned the CMHC movement felt that you could prevent schizophrenia if you provided psychotherapy for people while they were young, and that therefore, we wouldn’t even need the state hospitals because these people wouldn’t get sick in the first place. So the whole basis for the community mental-health centers was flawed from the very beginning. Many well-meaning people were involved in the program; I have a good friend who worked in a CMHC. He will tell you that most of its failures were a money problem, but the data — which I collected at the time and have published — are very clear. Community mental-health centers were not taking care of the people who were coming out of the hospital, who most needed the care. There was very little interest in these patients’ well-being. It was a flawed system from Day One, but my liberal friends would prefer to believe it was just a question of money, and that Reagan destroyed our mental-health system [by block-granting mental-health funding to the states.] It’s just not true.
JH: I know that you’ve written about your sister’s experience with serious mental illness and schizophrenia. Is there one anecdote that sticks out to you as something that motivates you as a psychiatrist and as a public-policy professional?
FT: I’m not sure if there is one anecdote. Certainly, I was influenced by my sister — it just seemed wrong what we were doing, as a society. When I see something wrong, I have a habit of talking about it. I think that my time at St. Elizabeth’s — I was already involved in these things, but my time at St. Elizabeth’s was very influential because I saw just how sick some people are, what poor care some of them receive, and the consequences of not treating them. I think I captured a lot of this in my first book, Nowhere to Go. By the time I wrote that book, I was volunteering in the shelters in the community, and seeing what happens when you don’t provide treatment for people after they are released from the hospital.
JH: In closing, with your years of work in mental-health policy, why do you think people should concern themselves with the plight of the seriously mentally ill, even if they don’t know someone who has a serious mental illness?
FT: I think you could you put it either in humanitarian terms or religious terms, but you have to acknowledge some obligation to take care of the people who cannot take care of themselves. The people who I most respect in mental-health work usually come at it from that point of view. If they don’t have a family member with serious mental illness, they are involved because they see people who clearly are in need, and they are eager to help. They say a civilization should be judged by how it treats those people who are most in need, and I think that’s true.
JH: Dr. Torrey, thank you. I’m a great admirer of yours, and thank you for your years of service to — as you say — people who can’t take care of themselves.
FT: You’re welcome, John.
