We have a crisis of violent crime in America. We have a crisis of mental health in America. We have an explosion of homelessness in America. These crises are all related.
David Oshinsky, writing in The Saturday Essay for The Wall Street Journal, says, “The ongoing saga of the severely mentally ill in America is stirring attention again in a sadly familiar way. In Los Angeles in early 2022, a 70-year-old nurse was murdered while waiting for a bus, and two days later a young graduate student was stabbed to death in an upscale furniture store where she worked. That same week in New York City, a 40-year-old financial analyst was pushed onto the subway tracks as a train was arriving, killing her instantly. All three assaults, random and unprovoked, were committed by unsheltered homeless men with violent pasts and long histories of mental illness. In New York, the perpetrator had warned a psychiatrist during one of his many hospitalizations of his intention to commit that very crime.”
Fast forward to this May, 2023, when Jordan Neely, a homeless and schizophrenic man, threatened violence on a Manhattan-bound subway car. Neely has spent most of his adult life in and out of emergency rooms, psychiatric wards and prison. He had 42 prior arrests, mostly for nuisance crimes, but also for assault. He’d recently pleaded guilty to punching an elderly woman in the face, fracturing her eye socket. Neely died subsequently when subdued by a former Marine, who is now on trial charged with second-degree manslaughter. Many of the witnesses on that subway car are referring to him as a hero. Oshinsky says, “Most of all, Neely’s death highlights the failures of a mental health system that allows profoundly disturbed people to slip through the cracks.”
How did we get to this failure of our mental health system?
In 1977, I was a third-year medical student when I spent three months on a psychiatry rotation at the Eastern Pennsylvania Psychiatric Institute in Philadelphia. The hospital was a state-run psychiatric facility for voluntary and involuntary treatment of the mentally ill. Most of my patients were diagnosed with schizophrenia. A recently developed drug, called Thorazine, showed great promise in treating these people – as long as they took their medications. Unfortunately, there were many uncomfortable side-effects that caused many of the patients to stop their medications unless they were in a hospital setting.
However, the promise of Thorazine was that these patients could be managed as out-patients, reducing the need for state-run psychiatric institutions – asylums as they were often referred to. Although the term “asylum” actually implies “refuge” for those in distress, the term has sometimes had a negative connotation due to reports of patient abuse and Hollywood versions such as “One Flew Over the Cuckoo’s Nest” with the famous “Nurse Ratched.”
Therefore, pressure mounted to close these institutions. This began actually in October, 1963, when President John F. Kennedy signed his last bill called the Community Mental Health Act, which aimed to demolish the walled-off world of the asylum in favor of 1,500 local clinics where patients could receive the drugs and therapies they needed. It seemed like a good idea at the time – and then reality set in.
Surveys of those released from state asylums found that close to 30% were either homeless or had “no known address” within six months of their discharge. One critic called it “a psychiatric Titanic.” The problem is these mentally ill patients need to take their medicine to avoid psychotic episodes, but without a stable family home with someone to make sure they took their medicine, most were off their medications in weeks. Homelessness became their new way of life.
On an average night, according to the U.S. Department of Housing and Urban Development, close to 600,000 people in the country will be homeless—a figure seen by many as an undercount. More than 40% will be “unsheltered,” or “living in places not suitable for human habitation,” and about 20% will be dealing with severe mental illness. Experts sharply disagree about the contribution of homelessness to rising crime rates. Some emphasize that most of these crimes are low-level victimless offenses, such as loitering or public urination. But others note the disproportionately high level of all crimes, including assaults and homicides, committed by those battling homelessness and mental issues simultaneously.
Oshinsky says, “Had Jordan Neely and the others been born a generation or two earlier, they probably would not have wound up on the streets. There was an alternative back then: state psychiatric hospitals, popularly known as asylums. Massive, architecturally imposing, and set on bucolic acreage, they housed close to 600,000 patients by the 1950s, totaling half the nation’s hospital population. Today, that number is 45,000 and falling.”
This explosion of homelessness and violent crime was predictable. In 1973, a Wisconsin psychiatrist named Darold Treffert wrote an essay about the dangerous direction in which his profession was headed. His colleagues had become so fixated on guarding the patient’s civil liberties, he noted, that they had lost sight of the patient’s illness. What worried him was the full-throated endorsement of recent laws and court decisions that severely restricted involuntary commitments. What purpose was served by giving people who couldn’t take care of themselves the freedom to live as they wished? He titled his piece, “Dying with Their Rights On.”
The impact of deinstitutionalization of the mentally ill on them, as well as society as a whole, is hard to measure, but the statistics are frightening. The role once occupied by the asylum has been transferred to the institutions perhaps least able to deal with mental health issues – prisons and jails. The number of inmates in the U.S. in 1955 was 185,000; today that figure is 1,900,000. Unsurprisingly, the nation’s three largest mental health facilities are the Los Angeles County Jail, the Cook County Jail in Chicago, and Rikers Island in New York City. Approximately one quarter of their inmates have been diagnosed with a serious mental disorder.
This is no way to treat the mentally ill, nor to treat society as a whole. It’s time to bring back state-run mental health institutions to treat the thousands that need in-patient treatment. The cost of not doing this far exceeds the cost for taxpayers to run these institutions.
