This is the third post in (the first annual?) Mental Illness Week at freddiedeboer.substack.com. Nobody feels good about the state of American mental health care. Happily there’s a lot of agreement about what’s wrong and even what could fix things, though the anti-psychiatry movement - which, once again, please leave me the fuck alone - would certainly disagree. And yet the problems seem intractable, thanks to the general structural problems of health care funding in the United States and the specific issues with psychiatric medicine, including resistance to care and treatments that are only modestly effective, carry debilitating side effects, or both.
Thank you for bringing attention to the deinstitutionalization problem. It sends people to the jails and prisons (LA County Jail claims to be "the nation's largest mental health facility" -- http://shq.lasdnews.net/pages/tgen1.aspx?id=TTC ), but also to the streets. An enormous amount of the "homeless problem" on the West Coast is a mental health problem and/or a self-medication with hard drugs problem.
For anyone interested in the de-institutionalization era of the 60s and 70s, I recommended The Great Pretender by Susan Cahalan. She set out to write about a famous study (published in Science Magazine as On Being Sane in Insane Places) where a psychologist, David Rosenhan, and some other students he recruited, got themselves admitted to mental institutions although they had no existing or documented mental health problems. The results of the study showed that after having to “prove themselves sane” in a Kafkaesque nightmare to be able to leave, they came out with more mental health issues than they went in with and horrific stories of their treatment. The problem? As she researched, she found out the whole thing, a study that greatly influenced the move to deinstitutionalize, was almost certainly faked and that most of the pseudo patients it was based on never even existed.
I wonder if there’s a kind of reinstitutionalization by another name going on in the permanent supportive housing movement. It’s become the solution to chronic homelessness touted by all the big researchers in my (geographic) area, and our state legislature has started earmarking funding specifically to build it. The idea is, somebody who for reasons of disability or mental illness simply cannot hold down housing on their own lives in a place that ostensibly feels like a “home,” not a hospital, has their rent paid, and has medical, psychiatric, and social services support services in-house. This is considered the gold standard in chronic homelessness solutions right now and is lifted up as humane and necessary. I definitely don’t disagree - I think the sooner we just start paying to house those who will never be able to house themselves, the better. But I hadn’t thought about it in the de-institutionalization historical context before.
I worked in a state psychiatric hospital as an aide for about two and a half years from 1987 through 1989 while I was going to college.
At that point, the first wave of deinstitutionalization had passed. The hospital was a huge, sprawling campus with separate buildings for different classes of patients. There were still thousands being cared for there (or locked up, if you prefer), but it was nothing compared to what it was like before the 1970's.
A lot of the old timers liked to tell me stories of what the place was like back in the day. It was its own little town, with a lot of patients working regular jobs to keep the infrastructure of the place running.
Eventually, well after I left to pursue other opportunities, the final wave of deinstitutionalization swept through and the place was completely shuttered. It still remains empty and unused decades later, environmental issues and local NIMBYs keeping from being properly developed.
When I think of the place, I think of some the patients I worked with, many of whom could never function outside of a locked ward.
"prison, which is exactly where they went, as the graph above shows."
It's an elegant graph, but not so.
it falls apart once you consider gender. The inmates filling those asylum beds were disproportionately female (and to a lesser extent, older). The prison population is decidedly not.
It looks like we freed a bunch of folks from the asylums only for them to go to the prisons. But that's not the case. We freed a majority female and skewing-older population, and then shortly after jailed a similar number of young men, disproportionately minorities.
“ I still interact with many people who defend deinstitutionalization”
I’d be interested to hear their justification. One perhaps minor issue I’ve come across is “advocates” taking what the profoundly mentally ill at face value. Whereas if they knew the truth they would have a far more realistic understanding.
I want to emphasize that deinstitutionalization is more than a historical movement -- it's the law in 2022, and one the Department of Justice enforces aggressively throughout the country. Many states have been sued under the Americans with Disabilities Act for not providing services in the "least restrictive" and "most integrated" setting possible.
The federal government has a website where they log their lawsuits and other legal activities to force states to move people out of institutions, including mental institutions. As you can see, they are active in court: https://www.ada.gov/olmstead/olmstead_cases_list2.htm
When they get sued, states typically enter a settlement agreement. Then DOJ lawyers and reviewers are in their business for a decade or more, and they are aggressive in forcing the state to close institutions and move people to independent housing and group homes. States really don't have the option of institutions anymore.
Deinstitutionalisation here is viewed from a moral or ethical ground it seems. I had always had it described, at least here in Ontario where care is publicly funded, as a cost cutting measure.
Over this series of articles I can’t get over how our discussion and interpretation of mental illness is so deeply cultural and bound to our current moment.
You’ve said a couple of times now that there isn’t good evidence for SSRIs. I know there is controversy over their effectiveness in treating depression – but I think it’s important to note that antidepressants are also widely prescribed for anxiety, and there is evidence that these medications are effective for generalized anxiety and panic disorder.
This fits my wife’s clinical experience as a psychiatrist, along with my anecdotal experience (self, family, and friends). Zoloft changed my life. It took a few months and a high dose, but I don’t have panic attacks or anxiety spirals unless something is really wrong – and even then, I’m able to keep functioning.
I don’t know as much about depression, because I’ve never had it. (FWIW, my wife says medication works.) But if you have severe anxiety, an SSRI could help. They don’t work for everyone—some people get more anxious or even manic—but they work for a lot of people.
Here is an example of a meta-analysis found SSRI / SNRI drugs are more effective for anxiety than all sorts of therapy. This fits my experience too—I was in and out of therapy for years, but the therapist who helped me the most is the one who finally referred me to a psychiatrist: https://pubmed.ncbi.nlm.nih.gov/25932596/
I also find it validating to see the lower effect sizes for everything they tell you to do (relaxation, exercise, FUCKING MINDFULNESS…)
I wouldn't be so quick to pile dirt on "outdated and empirically unjustifiable psychoanalytic techniques." I agree that it would be amazing to be able to fully understand the brain and therefore treat peoples' mental illnesses accordingly, but as a mental health professional it's become more and more clear to me that we probably do not have the ability as a species to understand our own brains. They are simply too complex. It's not that much different from expecting a dolphin, chimpanzee, or octopus to fully understand their own nervous systems. I would love for my belief to be proven wrong, for the record.
There are at least a couple very low-hanging fruits for depression and PTSD: psilocybin and MDMA, respectively. Both are currently being studied in various places and are (hopefully) on the path to being approved as treatments like ketamine has been, but such progress is infuriatingly slow. I've used these two substances numerous times to quickly and completely end "treatment-resistant" forms of mental illness in other people. I must do so off the books and at great risk to my career, of course, because they're still considered highly illegal drugs...but the evidence for their efficacy is far, far too strong for me not to suggest them to those who are struggling so badly and who can be cured so easily.
I started therapy and medication last year to relatively good success. I’d been feeling bad and finally spoke to someone who was alarmed at how deep my depression was (I don’t like to brag but I got a very high score on the depression test).
After a year I can say I’m definitely better than I was. I tested out various pills until I found one that seemed to help (an SSRI, incidentally) The talk therapy, though, I’ve found to be a waste of time. My therapist is very nice and our conversations are pleasant, but I can’t see any way they actually help me. He spends time getting me to identify my feelings, their source, and how I respond to them. But, I know all that already. What I don’t know is how to feel better.
I do feel better now so it’s possible the therapy has helped in ways I don’t notice, but I doubt it. I think it’s mostly the lexapro.
Does everyone here hate Lost Connections? I don't, but I didn't read it for the drugs part (the first third) because all the drugs make me sick in one way or another, but for the "village" part, the last two thirds. And the third third was the solutions part, and it also did not fill me with any kind of hope: We have to change our whole culture and mindset. Which is already on the to do list for basically everything wrong, most obviously the environment, so I guess I hope a lot of people read a lot of books.
I'm actually writing this from a psychward here in Britain where I've been for the past two weeks, though I have leave over the weekend. While bed numbers are often very limited and nurses ludicrously overworked, I feel blessed that despite the Tories' efforts we still have a healthcare system where I was able to go to A&E and say that I was at immediately risk of seriously hurting myself and they had me on the ward that evening with new medication assigned the day following, without me having to panic about this putting me in any debt. If I had been in the position of being scared about the cost I simply wouldn't have gone and would, quite likely, have severely hurt myself or worse.
As for the talking cure, I have OCD (diagnosed as a young child) which is sometimes very intense in terms of intrusive images and thoughts. Talking about these horrible images and thoughts offers light relief but also plays into my compulsive tendency towards confessing (look up scrupulosity in OCD if that doesn't make sense to you as part of the condition). I am already well aware of my childhood traumas and upsets and have a tendency to obsessively brood and ruminate as it is.
However much I agree with all of Mark Fisher's critiques of C.B.T. at least it can actually have some lasting impact on OCD, whereas hundreds and hundreds of hours of talking cure therapy really have only helped me construct new narratives to cling to imho.
Thank you for bringing attention to the deinstitutionalization problem. It sends people to the jails and prisons (LA County Jail claims to be "the nation's largest mental health facility" -- http://shq.lasdnews.net/pages/tgen1.aspx?id=TTC ), but also to the streets. An enormous amount of the "homeless problem" on the West Coast is a mental health problem and/or a self-medication with hard drugs problem.
For anyone interested in the de-institutionalization era of the 60s and 70s, I recommended The Great Pretender by Susan Cahalan. She set out to write about a famous study (published in Science Magazine as On Being Sane in Insane Places) where a psychologist, David Rosenhan, and some other students he recruited, got themselves admitted to mental institutions although they had no existing or documented mental health problems. The results of the study showed that after having to “prove themselves sane” in a Kafkaesque nightmare to be able to leave, they came out with more mental health issues than they went in with and horrific stories of their treatment. The problem? As she researched, she found out the whole thing, a study that greatly influenced the move to deinstitutionalize, was almost certainly faked and that most of the pseudo patients it was based on never even existed.
I wonder if there’s a kind of reinstitutionalization by another name going on in the permanent supportive housing movement. It’s become the solution to chronic homelessness touted by all the big researchers in my (geographic) area, and our state legislature has started earmarking funding specifically to build it. The idea is, somebody who for reasons of disability or mental illness simply cannot hold down housing on their own lives in a place that ostensibly feels like a “home,” not a hospital, has their rent paid, and has medical, psychiatric, and social services support services in-house. This is considered the gold standard in chronic homelessness solutions right now and is lifted up as humane and necessary. I definitely don’t disagree - I think the sooner we just start paying to house those who will never be able to house themselves, the better. But I hadn’t thought about it in the de-institutionalization historical context before.
I worked in a state psychiatric hospital as an aide for about two and a half years from 1987 through 1989 while I was going to college.
At that point, the first wave of deinstitutionalization had passed. The hospital was a huge, sprawling campus with separate buildings for different classes of patients. There were still thousands being cared for there (or locked up, if you prefer), but it was nothing compared to what it was like before the 1970's.
A lot of the old timers liked to tell me stories of what the place was like back in the day. It was its own little town, with a lot of patients working regular jobs to keep the infrastructure of the place running.
Eventually, well after I left to pursue other opportunities, the final wave of deinstitutionalization swept through and the place was completely shuttered. It still remains empty and unused decades later, environmental issues and local NIMBYs keeping from being properly developed.
When I think of the place, I think of some the patients I worked with, many of whom could never function outside of a locked ward.
"prison, which is exactly where they went, as the graph above shows."
It's an elegant graph, but not so.
it falls apart once you consider gender. The inmates filling those asylum beds were disproportionately female (and to a lesser extent, older). The prison population is decidedly not.
It looks like we freed a bunch of folks from the asylums only for them to go to the prisons. But that's not the case. We freed a majority female and skewing-older population, and then shortly after jailed a similar number of young men, disproportionately minorities.
“ I still interact with many people who defend deinstitutionalization”
I’d be interested to hear their justification. One perhaps minor issue I’ve come across is “advocates” taking what the profoundly mentally ill at face value. Whereas if they knew the truth they would have a far more realistic understanding.
I'm so chuffed by the Rats of NIMH reference that I can't read any further without communicating my utter delight.
Utter delight!
I want to emphasize that deinstitutionalization is more than a historical movement -- it's the law in 2022, and one the Department of Justice enforces aggressively throughout the country. Many states have been sued under the Americans with Disabilities Act for not providing services in the "least restrictive" and "most integrated" setting possible.
The federal government has a website where they log their lawsuits and other legal activities to force states to move people out of institutions, including mental institutions. As you can see, they are active in court: https://www.ada.gov/olmstead/olmstead_cases_list2.htm
When they get sued, states typically enter a settlement agreement. Then DOJ lawyers and reviewers are in their business for a decade or more, and they are aggressive in forcing the state to close institutions and move people to independent housing and group homes. States really don't have the option of institutions anymore.
Deinstitutionalisation here is viewed from a moral or ethical ground it seems. I had always had it described, at least here in Ontario where care is publicly funded, as a cost cutting measure.
Over this series of articles I can’t get over how our discussion and interpretation of mental illness is so deeply cultural and bound to our current moment.
You’ve said a couple of times now that there isn’t good evidence for SSRIs. I know there is controversy over their effectiveness in treating depression – but I think it’s important to note that antidepressants are also widely prescribed for anxiety, and there is evidence that these medications are effective for generalized anxiety and panic disorder.
This fits my wife’s clinical experience as a psychiatrist, along with my anecdotal experience (self, family, and friends). Zoloft changed my life. It took a few months and a high dose, but I don’t have panic attacks or anxiety spirals unless something is really wrong – and even then, I’m able to keep functioning.
I don’t know as much about depression, because I’ve never had it. (FWIW, my wife says medication works.) But if you have severe anxiety, an SSRI could help. They don’t work for everyone—some people get more anxious or even manic—but they work for a lot of people.
Here is an example of a meta-analysis found SSRI / SNRI drugs are more effective for anxiety than all sorts of therapy. This fits my experience too—I was in and out of therapy for years, but the therapist who helped me the most is the one who finally referred me to a psychiatrist: https://pubmed.ncbi.nlm.nih.gov/25932596/
I also find it validating to see the lower effect sizes for everything they tell you to do (relaxation, exercise, FUCKING MINDFULNESS…)
I wouldn't be so quick to pile dirt on "outdated and empirically unjustifiable psychoanalytic techniques." I agree that it would be amazing to be able to fully understand the brain and therefore treat peoples' mental illnesses accordingly, but as a mental health professional it's become more and more clear to me that we probably do not have the ability as a species to understand our own brains. They are simply too complex. It's not that much different from expecting a dolphin, chimpanzee, or octopus to fully understand their own nervous systems. I would love for my belief to be proven wrong, for the record.
There are at least a couple very low-hanging fruits for depression and PTSD: psilocybin and MDMA, respectively. Both are currently being studied in various places and are (hopefully) on the path to being approved as treatments like ketamine has been, but such progress is infuriatingly slow. I've used these two substances numerous times to quickly and completely end "treatment-resistant" forms of mental illness in other people. I must do so off the books and at great risk to my career, of course, because they're still considered highly illegal drugs...but the evidence for their efficacy is far, far too strong for me not to suggest them to those who are struggling so badly and who can be cured so easily.
I started therapy and medication last year to relatively good success. I’d been feeling bad and finally spoke to someone who was alarmed at how deep my depression was (I don’t like to brag but I got a very high score on the depression test).
After a year I can say I’m definitely better than I was. I tested out various pills until I found one that seemed to help (an SSRI, incidentally) The talk therapy, though, I’ve found to be a waste of time. My therapist is very nice and our conversations are pleasant, but I can’t see any way they actually help me. He spends time getting me to identify my feelings, their source, and how I respond to them. But, I know all that already. What I don’t know is how to feel better.
I do feel better now so it’s possible the therapy has helped in ways I don’t notice, but I doubt it. I think it’s mostly the lexapro.
You write so well that if you wrote a phone book, I would read it.
Does everyone here hate Lost Connections? I don't, but I didn't read it for the drugs part (the first third) because all the drugs make me sick in one way or another, but for the "village" part, the last two thirds. And the third third was the solutions part, and it also did not fill me with any kind of hope: We have to change our whole culture and mindset. Which is already on the to do list for basically everything wrong, most obviously the environment, so I guess I hope a lot of people read a lot of books.
I'm actually writing this from a psychward here in Britain where I've been for the past two weeks, though I have leave over the weekend. While bed numbers are often very limited and nurses ludicrously overworked, I feel blessed that despite the Tories' efforts we still have a healthcare system where I was able to go to A&E and say that I was at immediately risk of seriously hurting myself and they had me on the ward that evening with new medication assigned the day following, without me having to panic about this putting me in any debt. If I had been in the position of being scared about the cost I simply wouldn't have gone and would, quite likely, have severely hurt myself or worse.
As for the talking cure, I have OCD (diagnosed as a young child) which is sometimes very intense in terms of intrusive images and thoughts. Talking about these horrible images and thoughts offers light relief but also plays into my compulsive tendency towards confessing (look up scrupulosity in OCD if that doesn't make sense to you as part of the condition). I am already well aware of my childhood traumas and upsets and have a tendency to obsessively brood and ruminate as it is.
However much I agree with all of Mark Fisher's critiques of C.B.T. at least it can actually have some lasting impact on OCD, whereas hundreds and hundreds of hours of talking cure therapy really have only helped me construct new narratives to cling to imho.