I found the experience of visiting state mental hospitals shocking. To be completely mad in a world of relative sanity is disorienting and unpleasant, but to be walled off in a place where madness is the norm is absolutely ghastly. I dug up all kinds of stories of abuse in the state system. In a brilliant and courageous piece of undercover research, the journalist Kevin Heldman checked himself into the psychiatric unit at Brooklyn’s Woodhull Hospital, claiming that he was suicidal. “The overall environment was custodial rather than therapeutic,” he writes, then quotes Darby Penney, special assistant to the commissioner for the New York State Office of Mental Health, who said, “From my own experience, the last place I’d want to be if I was in an emotionally distraught state is in an inpatient [psychiatric] unit [at a state hospital].” Not one of the state’s meaningful official policies on mental health care was observed at Woodhull. Patients were given no opportunity to converse or interact with psychiatrists; they were given no structure for their days and simply watched TV for ten hours at a stretch; their rooms were filthy; they could not find out what medications they were being given. They were subjected to totally unnecessary involuntary sedation and restraint. The one nurse with whom Heldman had a meaningful interaction told him that having a baby might help his depression. For these services, the state of New York paid $1,400 per day.
My interest as I considered institutions was more in the quality of a good hospital than in the misery of a bad one. My aim was not to seek out abuses so much as to see whether the very model of the state facility was misguided. The question of institutionalization is terribly difficult, and I have not found a solution. Short-term facilities for the mentally ill can be good or bad; I spent some considerable time on the wards of such places, and I would not hesitate to check myself into, for example, Johns Hopkins if I needed such care. But long-term public facilities, where people come to stay for years or forever, are utterly, devastatingly different. I spent several long stretches visiting Norristown Hospital near Philadelphia, an institution run by people who are strongly committed to helping their patients. I was favorably impressed by the doctors I met, by the social workers who interact daily with residents, and by the superintendent of the place. I liked a number of the patients I met. Despite all that, Norristown put my teeth on edge and made my skin crawl, and visiting it was one of the most upsetting and difficult tasks I undertook in my research. I’d much rather engage with every manner of private despair than spend a protracted time at Norristown. Institutionalization may be the best we have at present, and the problems posed by Norristown may not be fully resolvable, but they must be acknowledged if we are to develop the missing link in interventionist law.
Norristown Hospital has a campus that looks at first like a second-tier East Coast college. It is set atop a verdant hill and commands a panoramic view. Big, full trees cast their shade on well-kept lawns; red-brick buildings in a neo-Federal style are covered in vines; the gates to the place are open during the day. Aesthetically speaking, patients are mostly better off in the hospital than out of it. The reality of the place, however, is hellishly like the classic TV series The Prisoner, or like a charmless version of Alice’s Wonderland, where the appearance of an inaccessible logic belies the breakdown of logic altogether. The place has a vocabulary entirely its own, which I learned slowly. “Oh, she’s not doing so good,” one patient would tell me confidingly about another. “She’s gonna end up back in building fifty if she don’t watch it.” To ask someone what happened at “building fifty” was unproductive: in the eyes of patients, building fifty—emergency services—was fearfully anathema. When I eventually went into building fifty, it was really not as bad as the threat of it had been, but building thirty, on the other hand, was really quite awful. Most of the people in it were under physical restraint and constant supervision to prevent them from injuring themselves. Some of them were in nets so that they could be kept from active suicide attempts. I did not see much inappropriate intervention; the people so treated mostly required the treatments, but they were awful to behold nonetheless, and they were worse for being grouped together like the waxworks of criminals in the basement of Madame Tussaud’s. The hierarchy of buildings and numbers, and fear, and embargo of liberty, all whispered around the campus, could not but exacerbate the condition of someone already suffering from depression.
I hated being there. It hit too close to home. If I had been poor and alone and if my illness had been untreated, would I have ended up in such a place? The very possibility made me want to run screaming out the nice gates and back to my safe bed. These people didn’t have any place left outside that would constitute home. Even when there were full complements of doctors and social workers present, the mentally ill were superior in number, and I developed an awful us-and-them feeling. Since affective disorders are the second most common diagnosis in state mental hospitals I could not figure out whether I was more a part of “us” or of “them.” We live our lives by the norms of consensus and hold on to reason because it is affirmed over and over again. If you went to a place where everything was filled with helium, you might cease to believe in gravity because there would be so little evidence for it. At Norristown, I found my grip on reality growing tenuous. In such a location, you have no certainties at all, and sanity becomes as peculiar to the context as insanity is to the outside world. Every time I went to Norristown, I felt my psyche go weightless and begin to disintegrate.
My first visit there, arranged through the administration, was on a lovely spring day. I sat down with a depressed woman who had volunteered to talk to me. We were in a sort of gazebo on a pretty knoll, and we drank undrinkable coffee out of plastic cups that were half-melted from the lukewarm beverage. The woman I was interviewing was articulate and “presentable,” but I was ill at ease, and it was not just the plastic-flavored coffee. As we started talking, people never versed in social convention came and positioned themselves between the two of us or interrupted to ask me who I was and what I was doing, or, in one instance, came over and patted my neck as if I were a Bedlington terrier. A woman I had never seen before stood about ten feet away from us staring for a while, then burst into tears and wept on and on despite my attempts to calm her. “Oh, she’s just a screamer,” someone else explained to me comfortingly. People who weren’t crazy before they arrived in this place would have had to be crazy by the time they left. The population of Norristown is much reduced from what it was in the heyday of the mental-hospital-cum warehouse, and so more than half of the buildings on the campus are deserted. Those empty edifices, many of them built in the sixties in the utilitarian, modernist vocabulary of inner-city schools, exude a ghoulish threat; chained shut, empty for years on end, they suggest a greenish excess of festering life between their beams and in their vacant silence.
Schizophrenic patients stand around Norristown Hospital talking to Martians the rest of us can’t see. An angry young man pounded on the wall with his fists, while patients at the brink of catatonia stared with blind, glazed faces, motionless, depressed or sedated. The you-can’t-hurt-yourself-on-them furnishings were battered and worn, as tired as the people using them. Faded construction-paper decorations made for bygone holidays festooned in a lobby as though they had been there since the patients were in kindergarten. No one had remembered to grant these people adulthood. Each of the dozen or so times I went to Norristown, someone who insisted I was her mother bombarded me with questions to which I could not possibly know the answers, and someone who seemed anxious and highly irritable told me to leave, right away, to just scram before there was trouble. A man with a severe facial deformity had appointed himself my friend and told me that I shouldn’t pay any attention, shouldn’t leave; everyone would get used to me by the end of a month. “You’re not so bad, you’re not so ugly, stay around, you’ll get used to it,” he said abstractedly, in a kind of monotonous monologue to which I was hardly even an accessory. An obscenely fat woman demanded money and kept grabbing at my shoulders for emphasis. At n
o time was I able to escape the basso continuo of nonverbal clamor at Norristown that sounded constantly under the harangue of words: people banging things, people screaming, people snoring loudly, people gibbering, people weeping, people making strange strangled noises or farting shamelessly, the racking coughs of men and women whose only pleasure is smoking. There is no love lost in these places; arguing and arguing and arguing seeps out of the walls and floors. There isn’t enough room at Norristown, despite the closed buildings and the grassy acres. Patients there are pinioned by misery. Forty percent of patients in such facilities are in for depression; they have gone, to recover, to some of the most depressing places on earth.
And yet Norristown was the best public long-term care facility I visited, and the people who ran it impressed me as not only committed but also intelligent and kind. The patients were mostly in the best health they could achieve. The place was hardly Bedlam; everyone was well fed and on appropriate medication, and an expert staff was keeping paternalistic beneficent watch over everyone. People seldom get hurt at Norristown. Everyone is clean and neatly dressed. People can in general name their illnesses and tell you why they are there. The staff, heroically, lavish a surprising degree of love on their wards, and though the place feels lunatic, it also feels safe. Patients are protected there both from the outside world and from their frightening inner selves. The flaws of the place are only those endemic to long-term care.
After a few years in the hospital, Joe Rogers was shifted out of his long-term-care facility to a halfway house in Florida, where he got better treatment and some decent medications. “But I began to understand myself differently—I began to see myself as a mental patient. They told me that I was incurable, and they didn’t see any point to my going to school. I was in my midtwenties. They said I should just get on social security and stay there. I ended up getting very sick and I totally lost my sense of self.” When Rogers left, he took to the streets, where he lived for the better part of a year. “The more I tried to put it together, the more it would fall apart. I tried a geographical cure. It was time to get away from my habits and my relationships. I decided it would be great to be in New York City. I had no idea what I was doing there. I ended up finding a park bench which was not too bad—there weren’t so many homeless then in New York and I was a kind of nice-looking young white kid. I was disheveled, but not grungy, and people took an interest in me.”
Rogers would tell his story to strangers who offered a dime, but he withheld any information that might send him back to the hospital. “I thought that if I went back, I’d never get out. I thought they were going to take me in. I had abandoned all hope, but I was too afraid of pain to kill myself.” It was 1973; “I remember all this noise once, all these people celebrating, and when I asked them why, they told me the war in Vietnam had ended. And I said, ‘Oh, that’s neat.’ But I couldn’t understand what it was or what was happening, though I remembered that I’d once marched to oppose that war.” Then it began to get colder and colder, and Rogers had no coat. He was sleeping on the big piers on the Hudson River. “By that time, I believed that I had become so alienated from the rest of humanity that if I approached someone, he’d be horrified. I hadn’t bathed or changed my clothes in a long time. I probably was pretty disgusting. These people from a church came and I knew they’d seen me toddling around, and they told me they’d get me to the YMCA in East Orange. If they had said they were taking me to a hospital, I would have run a hundred miles to get away and they would never have seen me again. But they didn’t do that; they kept an eye on me and waited until I was ready, and then offered me something I could do. I had nothing to lose.”
It was in this way that Rogers first experienced outreach, which was to become the cornerstone of his social policy. “People who are isolated and lost are usually desperate for a little human connection,” Rogers says. “Outreach can work. You have to be willing to go out and engage them and reengage them until they’re ready to come with you.” Joe Rogers was depressed; but depression is an illness that sits squelchingly on top of personality, and Rogers’s underlying personality was very insistent. “A sense of humor was perhaps the thing that was most crucial,” he says now. “At my craziest and my most depressed, I could still find something to joke about.” Rogers moved to the East Orange YMCA for a few months, and he got a job in a car wash. Later, he moved to the Montclair YMCA, where he met his wife. Marriage was “a huge stabilizing influence.” Rogers decided to go to college. “We sort of took turns. She’d go through periods of acting depressed and I’d take care of her, and then we’d reverse roles.” Rogers began doing voluntary work in the mental health field—“the only area I knew anything about at that point”—when he was twenty-six. Though he disliked state hospitals intensely, “people in serious need of help needed something, and I thought we could just reform hospitals and make them better places. I tried for years, but I found that the system could not be reformed.”
The Mental Health Association of Southeastern Pennsylvania is a nonprofit organization that Rogers founded. It is dedicated to increasing the power of the mentally ill. Rogers has helped to make Pennsylvania one of the most progressive states in the nation for mental health, has personally overseen the closing of state hospitals, and has proposed remarkably good community mental health initiatives, which currently operate on an annual budget of about $1.4 billion. If you’re going to go completely to pieces, Pennsylvania is a pretty good place to do it, and in fact many people from neighboring states make their way into Pennsylvania so they can take advantage of the systems there. Homelessness has traditionally been a big problem in Philadelphia, and when the current mayor was elected, he favored reopening the mental hospitals that had closed down and filling the ones that were still up and running. Rogers persuaded him to close institutions in favor of other care systems.
The guiding principle of Pennsylvania’s current system is that people should not be immersed in hospitals where madness is the given rule, but should rather live in the larger community, exposed constantly to the salutary effects of sanity. Pennsylvania patients with serious illness stay in long-term structured residential services. These are small places, with perhaps fifteen beds each, which offer intensive support, rigorous care, and an ongoing emphasis on integration. They support intensive case management, which allows a psychiatric social worker to establish a one-on-one relationship with a patient. “It’s someone who sort of follows you around and finds out what’s going on and butts in a little bit,” Rogers says. “It needs to be an aggressive program. One person I worked with early in my career threatened to get a restraining order against me. I wouldn’t take no for an answer; I’d push my way in, and if I’d had to, I would have kicked his door down.” These places also offer programs of psychosocial rehabilitation, which aim to help people with the pragmatics of “normal” life. About 80 percent of patients hospitalized for depression in Pennsylvania appear to do better under these circumstances. Full-scale intervention—up to and including forced shelter and treatment—is undertaken when someone is a danger to others or a danger to himself, as when he is outside in extreme cold. The only people who are consistently resistant to treatment of this kind are mentally ill abusers of drugs, especially heroin; such patients must detox before the state mental health system will offer them care.
Rogers also has created a chain of what he calls “drop-in centers,” street-level storefronts, usually staffed by people themselves recovering from mental illnesses. This creates employment for the people who are just beginning to cope with a structured environment, and it gives people who are in bad shape a place to go, hang out, and receive structured advice. Once they are introduced to such places, homeless people terrified of more active intervention will return to them again and again. Drop-in centers provide a transition zone between mental isolation and companionship. Pennsylvania has now established a massive tracking system that smacks of the police state, but it does prevent people from falling off the edge and disapp
earing. A database includes all treatment through state systems, including every emergency-room visit every patient has ever made. “I typed my name in,” says Rogers, “and I was shocked by what came out.” If a patient in the Pennsylvania system goes AWOL, social workers will seek him out and continue to check on him regularly. It’s impossible to escape such attention except by recovering.
The problem with this whole program is its fragility. At the most pragmatic level, it’s fiscally unstable: big mental hospitals are elephantine things with established costs, while noninstitutional programs can easily be pared down during times of budgetary crisis. Then the insertion of mentally ill people into a community requires tolerance, even in open-minded, prosperous areas. “Everybody’s a liberal for deinstitutionalization until they get the first homeless person on their front porch,” says Representative Bob Wise. The greatest problem is that for some mentally ill people, all this independence and immersion in the community is too much. Some cannot function outside a totally insular environment such as a hospital. Such people are regularly expelled into a world whose functioning overwhelms them, and this is not helpful to them or to those who encounter and help to care for them.
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