Wednesday, February 28, 2018

Institutions, Care, and Better Conversations

Do we need more mental healthcare institutions?

A 1900s photo of St. Elizabeths Hospital in DC
This question has entered the national discussion after the horrific shooting in Parkland, Florida. I've written in far-too-great length (at least for a blog) about the problem with associating mass violence with mental illness -- here's Part I and Part II of "Mental Illness Isn't Violence (But Our Systems Sure Are Sick)." But the discussion around institutionalization is close to my heart -- my book, which will be released next month, largely revolves around my own experiences with psychiatric hospitalization -- and I thought it would be worth sharing a few quick points about it:

-- Deinstitutionalization began in the 60s and 70s as a response to civil rights and mental health advocates who spoke out against institutional abuse and neglect. The idea was to close big institutions, which were horrendous and often served not so much as health care centers as prisons for folks who didn't "fit," and replace them with community mental health centers. These centers would be smaller, more localized, and more integrated into communities, allowing for people with mental illnesses to remain connected to other sources of support such as families, faith communities, friends, and other community services.

-- During the 80s, community mental health centers fell victim to tax cuts and lack of funding. Rather than transitioning from big, awful institutions to smaller, community-based centers, we went from institutions to not much of anything at all. Many advocates trace the modern realities of homelessness in this country to this period.

-- Currently, there is a massive shortage of psychiatric beds in this country. According to a report by the Treatment Advocacy Center, in 2010 there were only about 14 beds available for every 100,000 people in this country.

An image from the Treatment Advocacy Center's "A Bed Instead" campaign

-- This shortage, among other factors, means that hospital emergency rooms, prisons, and homelessness have effectively taken the place of psychiatric hospitalization for many people experiencing serious mental illness.

-- Like everything else in this country, this reality is further impacted by racial and socioeconomic factors. Who gets a bed, and who ends up in prison, is affected by intersecting and oppressive systems.

-- We need more psychiatric beds, but not because mental illness is predictive of violence. As I've written about previously, those with mental illnesses are much more likely to be victims of violence in this country, and if we want to have conversations around the mental health implications of mass violence, we need to take a systems approach that considers factors such as toxic masculinity, white supremacy, cultures of violence, and access to guns.

-- We need more and better mental health care facilities, but this administration's rhetoric on the matter is stigmatizing, reactionary, and harmful. It ought to go without saying, but of course it doesn't these days, that saying we need more institutions to deal with "sickos" demonizes and scapegoats people with mental illnesses.

-- We need more and better care options for folks with mental illness because folks with mental illness are people who deserve care, compassion, and health. 

There is more to say on the matter from a policy perspective, but these are at least a few framing points for the conversation, centering it where it should be centered -- actual, effective, compassionate care -- rather than as a reactionary conversation that equates mental illness with violent crimes.

Let me wrap this up with a few words about my own experience with psychiatric hospitalization/institutionalization.

If you want more than a few words, I know where you can find them.
First of all, my experience was a privileged one. I had access to quality care, and to people who knew how to connect me to quality care, which are not realities that can be taken for granted by most people in the U.S. I also had a level of awareness of my own need for help, both because of conversations within my family about mental illness and also because of the nature of my illness. My racial identity, socioeconomic background, and other factors allowed me a level of access that is often denied to people in this country who are impacted by multiple oppressions. And still, in spite of all of this, psychiatric hospitalization felt scary, and isolating, and out of my control. I am very grateful for the hospitals that kept me safe and gave me space to stabilize and start on the path toward healing; and also, conversations around psychiatric hospitalization -- and even more so long-term institutionalization -- should be approached with a great deal of care, compassion, and nuance.

On a second, and related, note: we can't talk about "bringing institutions back" without acknowledging the fact that the prison system is standing in for an actual mental care system in this country. When I was discharged from a longer-term stay at a hospital in Connecticut, I returned to the DC area and began working with a therapy group using an approach called Dialectical Behavior Therapy. When I first met with the psychologist who ran the group, she shared with me that it was relatively rare for her to have men in her groups.

"Why is that?," I asked.

"Because men with your diagnoses usually end up in prison first," she said.

So if we're going to talk about the past abuses of institutions, we also need to be talking about the current abuses of our nation's de facto biggest mental health care institution -- the prison system -- not to mention the complete lack of institutional support faced by those experiencing homelessness. (I wrote more about this latter reality recently).

Finally, my experience of hospitalization looked nothing like the popular perception of such a thing, which in my own pre-hospitalization experience was a mishmash of One Flew Over the Cuckoo's Nest-esque images of straitjackets and dictatorial nursing staff. You can read a whole heck of a lot more about my experience in my book (did I mention it's coming out next month?). Suffice to say I think it's really important that we de-stigmatize psychiatric hospitalization. It saved my life. At the same time, we need to acknowledge the history of institutional abuse and neglect and be very careful that our approach to mental healthcare institutions is focused on compassionate and effective care. Reactionary, stigmatizing rhetoric will not produce this.

Psychiatric hospitalization saved my life. It deserves to be talked about. We do need more, better mental health care institutions. And the importance of these institutions deserves a conversation focused on compassion, care, and effective treatment, not on blaming and scapegoating people with mental illnesses.

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