America Has No Way to Take Care of Mentally Ill People

With evermore unhoused people on the streets of our biggest cities, and publicized subway crimes in New York, mental health treatment is again in the news. Politicians speak about “caring” for the mentally ill in a new way, which turns out to be the old way—putting them away. The mention of involuntary confinement, predictably, sparks anxiety and controversy, giving rise to the question of whom this policy is meant to help: the people taken away or the rest of population, those shopping, jogging, carrying groceries home, who, presumably, will no longer be bothered by the inconvenient reality of a person speaking to God, while blocking the sidewalk.

Nonetheless, whether or not present laws limiting involuntary commitments should be altered, as proposed by New York Mayor Eric Adams and California Governor Gavin Newsom, the real question is where would the mentally ill be taken and how would they be treated? As it is, there is no adequate system in place. There are not enough psychiatric beds available for even the short holds now stipulated by law.

The closest state mental health hospital still open near to where I live is fifty miles away in Norwalk, California. Metropolitan, as the hospital is ironically named, includes, as several of the old asylums still standing do, a museum of itself, put together by people who once worked there, memorializing what the hospital had once been: a vast complex that housed and treated, cared for, and in some cases even cured, up to four thousand patients at a time. Metropolitan opened in 1916, when the area was rural, populated primarily with dairy farms and sugarbeet fields. Norwalk was chosen, over Long Beach and Beverly Hills, because the Anaheim Branch railroad ran there, making it was easy to bring patients by buckboard.

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I spoke many times with three retired staff members, who still volunteer at Metropolitan one day a month. Emily Wong and Shirley Olmstead are both retired nurses, Erma Aalund is a retired psychiatric technician. They were all ward charges for decades. They helped put together the museum, on the grounds in the fire chief’s old house, and they’ve taken on enormous task of organizing the hospital’s archives, in a room which had been the vegetable peeling room in the once-enormous institutional kitchen that’s now repurposed as the hospital library.

One of them came to work at the hospital just out of high school. “I worked admissions. They came in busloads from the County. They were screaming, shouting, nothing made sense. You had to bathe them. Their hair would be all matted and dirty. We did body checks for lice, bruises, tumors, bulges and wounds. It gave me an open mind. You learn to accept people for what they are.”

Later, the hospital paid for her to school, to become an RN. “The state started a program where we worked part time. Metropolitan was the biggest nursing hospital west of the Mississippi.”

Her mother and father had also worked at Metropolitan and she met her husband there. That was very common, she said. “I grew up knowing this place. We used to come and see movies and magic shows over in James Hall.” Some of the staff members lived on the grounds. In exchange for low rent ($19 a month, which would be around $120 today) they were on call if anything happened.

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The executive director lived in a large house on the hospital grounds, too.

Some of the hospital’s labor was done by patients. “They maintained everything,” one of women said (they preferred their quoted comments to be attributed collectively, as they relied on each other to check their memories). “Cows, chickens, pigs, gardens all over. Orchards. Everybody wanted to work on the farm. They had a little house in the field where they ate their lunch.

“In the old days, everyone had a job,” another continued, “No matter how sick the patient was, they had to have a job. A nurse would ask a patient, ‘can you help me fold the laundry?’ And the patient blossomed. They felt needed. If they pushed someone from geri (the geriatric unit) in a wheelchair to the dining room for me, I paid them in tokens, to be used in the little store on the grounds to buy treats. Now they have to get minimum wage. The State took the smoking away too. They no longer provided cigarettes. Smoking had been very calming.”

Many of the older buildings, the three recall, had marble floors in the foyers, and oak staircases, fireplaces, screened in porches and wicker antiques. But they were expensive to keep up, when the patient population dwindled and asbestos was an issue. Some buildings were torn down, others remain abandoned on the grounds, which still feel vast, although they represent only about a third of the hospital’s former holdings.

“Patients were safe and cared for and not sleeping in the streets,” one said. “They used to come back to the hospital and beg me for shock therapy. It was very very effective for the very depressed people After they were out into the community, they would come back for therapy. It didn’t matter who they talked to. They came back to touch the walls.”

Oliver Sacks wrote, in a 2009 piece published by the New York Review of Books, “There were, at Bronx State as at all such hospitals, great variations in the quality of patient care: there were good, sometimes exemplary, wards, with decent, thoughtful physicians and attendants, and bad, even hideous ones, marked by negligence and cruelty. I saw both of these in my twenty-five years at Bronx State. But I also have memories of how some patients, no longer violently psychotic or on locked wards, might wander tranquilly around the grounds, or play baseball, or go to concerts or films. … and at any time, patients could be found reading quietly in the hospital library or looking at newspapers or magazines in the dayrooms.”

Over the past sixty years, since Kennedy signed the Community Mental Health Act, three weeks before his assassinations in 1963, the mental health state hospital system across the U.S., that Sacks remembered, has been largely dismantled. Kennedy’s idea was spurred not only by widespread movements for reform after exposés of overcrowding, abuses and staff shortages and the hopeful introduction of new antipsychotic medications but also by the life of his own sister, who was given a lobotomy and lived in an institution for most of the rest of her life. He intended the large hospitals, like Bronx State and Metropolitan, to empty out and care of the mentally ill to fall to community health centers. But the incentives to create community based care, during the Reagan years, came in the form of federal block grants to the states.

“States could pick,” the nurses said, “highways or mental health. They picked highways.” As it’s always easier to dismantle than to build only half the community centers envisioned were ever opened, while the large hospitals emptied out.

No one organization claims responsibility for the basic needs of the mentally ill in the world outside. Funding falls to Supplemental Security Income, Social Security Disability Insurance and food stamps. Many people don’t qualify for Medicaid and Medicare. Those who were lucky were cared for by the families; those without a home, ended up on the streets or in jails, prisons or forensic institutions. “So many of our patients went to jail and jail has no means of treating this,” the women said. “Many of our patients would go to a restaurant to eat, because they were hungry and then not pay the bill, and then they would be thrown in jail.”

This has been the state of things for decades. We’ve all witnessed the failures. “This could be u,” the artist Mark Hammons stenciled over his installation of tents outside his gallery, just blocks from LA’s real skid row, yet no feasible alternative is on any ballot.

Millions of mentally ill people remain the most excluded people in American society even as it is clear, from books like Ely Saks The Center Cannot Hold: A Tale of Mental Illness from the Inside that even people with severe diagnoses can be helped to live productive, meaningful lives.

I grew up as the child of a person who experienced delusions, both delirious and painful, who heard voices and suffered debilitating depressions. She managed to raise a child and even, in her work as a speech therapist, use a unique talent to teach stroke victims to talk again, all in the larger world, with only the exception of one period in jail, about which she never told me about. Nonetheless, as the child who grew up with her, it was impossible not to wonder, whether there could have been another life possible, an alternative world like the one Dr. Sacks describes and the retired staff members remember, where her struggles could have been eased by good medical care.

By now, it seems clear that the correction, like so many corrections, was an overcorrection. The miracle drugs, introduced in the fifties, proved less miraculous than first hoped. Less than half of the community centers Kennedy envisioned were ever built, though 90% of patient beds in large state mental health hospitals were eliminated. State hospitals should have been improved, better staffed and financed, rather than closed wholesale.

Though they have fond memories of work at the hospital the retired staff members are not sentimental about mental health.

They remember patients assaulting each other, half a supervisor’s ear was bitten off, once a nose. “Before tranquilizers, some patients would have put their eyes out,” one said. Rapes were not infrequent. Another remembered a patient who cut the fetus out of another patient. The building where the lobotomies had once been done had been taken down, they told me. “To erase the stigma, the memory.”

But they object to legislation (the Lanterman-Petris Short Act, in California) sometimes called the Magna Carta for the mentally ill. “We couldn’t force them to take their medicine anymore. If you have TB and you won’t take their medicines, the state has the right to put you in isolation. I had a patient who heard voices to kill her children and she killed all three of them. She later got a ground pass. Her name was Donna. She was the sweetest young thing. Once she was out, she jumped off an overpass onto the freeway.” They had a patient who threatened to burn her house. “She was released and she went right home and set fire to it. Freedom to be sick, helpless and isolated is not freedom,” one said. “It is a return to the Middle Ages, when the mentally ill roamed the streets and little boys threw rocks at them. Now they can die with their rights on. A psychiatrist said that once and it became a refrain.” Just about everyone who worked there thinks the new laws were a mistake, they said. They were too restrictive. Under the LPS act, in order to hold somebody for 72 hours, they must be able to find food, clothing and shelter.

They made a kind of rueful joke. “Garbage, rags ad tents fit the bill.”

Most patients at Metropolitan now no longer have grounds privileges. After a lady stabbed a boy with a ball point pen on the corner near the hospital, the city of Norwalk was outraged, and in response, the hospital locked the ward doors and required passes.

But the three women have happy memories, too, “A psych tech named invited the patients to tea, with china teacups and saucers. They’d talk about daily events on the news. People strived to show her they would behave. They wanted to be invited to the tea.”

A doctor had a rocket club. They’d shoot off rockets, watch them parachute down on the big lawns.

They had a shoe shop, barber, a hair salon. “Our own laundry,” one remembers. Movies shown in James Hall. Fashion shows. Program wide bar-b-ques.

“One unit would invite another unit to come over on a Saturday night for a dance. Staff would do live music.” Despite the dances, dating wasn’t allowed. Patients got around the restrictions, though and they remembers opening doors to find patients having sex in an empty room or outside.

“Geriatrics had wine and cheese parties. I taught a cooking class. There were lots of activities if people wanted to get involved.”

“It was a world,” another said.