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Rock Street, San Francisco
Rock Street, San Francisco

Mary Pfeiffer through her journalistic anecdotal advocacy: Crazy in America: The hidden tragedy of our criminalized mentally ill (2007), have opened the proverbial Pandora’s box, depending on what sector of the society moral judgment is aligned with. The tragedy is no longer hidden but confronts us demanding an intervention that will disrupt its history. Critical analysis places us all in the glaring light that pans negligence, but it is the policymakers that stand in the focus of this beam while the rest of us are in its important penumbra.

Policymakers are challenged to 1) restore and increase proper community mental health structures, 2) deinstitutionalize mental ill-health patients, 3) train police officers, and also personnel serving as wardens where mental health victims are likely to have a presence, to recognize and intervene appropriately is the situation morally requires, 4) provide pre-natal care for mental health patients, 5) and increase government funding for the sustainable care of mental health patients, while 6) providing more public education regarding mental health victims and treatment, and 7) finally to decriminalize drug abuse so that they may the necessary help and attention from the health system that their condition demands. The urgency of these demands is seen in the six cases Ms. Pfeiffer presented. There is only one mutilated survivor of the six, and all of the five deceased have left behind harrowing tales of wretchedness leading up to their deaths. These tales are located in public institutions, facilitated by public policies, to the full knowledge of public officials serving to carry out modern public policy. There is no throwback period of istory when the present condition was tolerable, since the 1827 Act forbade the incarceration of insane persons in prisons or houses of correction. This Act provided that mental illness was i) a curable disease of the brain, ii) that patients must totally isolated from family and the stresses of society, iii) that an orderly regime of light work, exercise and rest will induce self-discipline in patients, and iv) that the causes and solution of insanity rest with the society and not with laboratory. There is a certain amount of compassion and humanity that was carried by this Act that none of Ms. Pfeiffer’s six mental health victims seemed to have experienced. The resulting death of five is an urgency pressed upon a ballooning emergency.

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This emergency follows a downward spiraling trend despite numerous policy reforms between the 1940s and 1959. Fountain House, a Manhattan base support group, constituted from former patients, were the main activists, advocating reform in the 1940s. This led to the Hill-Burton Act of 1946. From that time there exist a prevailing historical trend since the National Mental Health Act of 1946 was passed by President Harry Truman. More accurately the trend started after 1949 when the National Institute of Mental Health (NIMH) was founded, the New York State Mental Health commission was formed, and that state had 27 inpatient facilities that was of the largest population in the nation.

At this time surgery was still the primary option for treating the mentally ill. The surgeries went out of vogue in the 1950s, but so all did New York’s building program due to the war. The “Social Milieu Therapy” offered a change in the method of treatment, due to a fresh reliance on psychiatric pharmaceuticals like Thorazine. In 1960-1970 the Federal Court ruled that mental health patients could not be forced to take these drugs, and many filled the streets. New York mental health population peaked to 93,600 since 1955 and there was a deterioration with a resulting explosion of needs. Pfieffer’s stories could not even belong to the 1840s -1890s era of the asylum, so how much more frightening in the present.

Yet the present can be seen to the outcome of professional take charge that excludes community and their mental health patients as existed since Fountain House. The 1980 Mental Health Systems reserved to the Federal Government the right to shape mental health policy but diminished their responsibility to fund these policies. Community mental health advocacy between 1955 and 1970 encouraged deinstitutionalization, but there was no equivalent investment in community structures. This ultimately saw most mental health patients in jails, in specialized nursing homes, or on the stigma laden streets. This despite the Community Mental Health Act of 1963.

Pfieffer reported that nationally, the total number of public beds available to mental health patients in 1955 was half million, dropped from 98,000 to 59,000 between 1990 and 2000. That these public beds decreased while a program of deinstitutionalization was in place would seem good news, but Pfieffer also reported that two thirds of Americans afflicted with mental health received no treatment. Between 1979 and 1995 their death rate had rose to 15. 5 per 100, 000. The Act funded three initiatives: 1) professional training for those working in community mental health, centers … while overlooking the police as among the stakeholders as members of the community. This oversight is serious since the police was being oriented towards community policing. ) Research was also included concerning the methodology that public health workers use in their job … and this becomes serious when observed from Ms Pfeiffer’s account that this is mostly where the police and prison system failed. 3) Improving the quality of care in existing mental health centers until more care facilities could be developed … it is in this unfulfilled promise that one finds the beginning of all woes that Ms Pfeiffer’s subjects suffered. Ironically the Act for Mental Retardation Facilities and Community Mental Health Structures Construction was passed in 1963, and had been a part of President Kennedy Political platform. Kennedy’s dream of reducing custodial care for mental health patients by 50% is yet to be realized, despite the well meaning amendment of the Community Mental Health Act in 1965.

What is evident between 1965 and 1969 is that $260 million was expended by the Federal government for community mental health centers, however, between 1970 and 1973 the amount dwindled to $50. 3 million under President Nixon. The Mental Health Systems Act of 1980 sought to improve support and development of community mental health centers, but one year after in 1981 the Omnibus Budget Reconciliation Act was passed by President Reagan reducing budgetary allocation to all public agencies. This act did not only reduce funding but rescinded much of the previous legislation that provided support and legal structure for a scientific approach to mental health.

The scientific approach to mental health was developed in 1977 by the Federally funded National Institute of Mental Health (NIMH). It initiated a Community Support Program (CSP) with ten foundational elements vital to a community mental health structure: 1) Responsible team 2) Residential care, 3) Emergency care 4) Medicare, 5) Halfway house, 6) Supervised (supported) apartments, 7) Outpatient therapy 8) Vocational opportunities, 9) Social and recreational opportunities, and 10) Family and Network attention (Turner and Tenhoor, 1978). Now where do we go from here? It is evident that many goals were set in the past, some attempted, some frustrated, and most never reached.

Yet the context of the mental health crisis is that we do have a) some structure we can build on, and there are b) some laws in place that may act as a springboard for better policy formulations. The limitation will not be public education, or a greater forum of sympathizers because c) not only does the internet gives us new advantages, but d) the number of people suffering have caused a greater number of family individuals to be more sensitized by the issues of mental health. It is against the background of this fourfold context that the following proposals can be offered through the medium of this paper: 1) The program of deinstitutionalization should continue through policy and action ) That governance be organized through community structures linked hierarchically to a single, and simple oversight entity with legal powers a) To prepare and submit national budget to Congress b) To allocate funds to community entities c) To regulate and supervise training of stakeholders/service providers, by having commensurate punitive powers d) To facilitate and organize research and public communication in matters regarding mental health. 3) To restore and increase proportionately to the demand, community mental health structures and bedding, with detail plan for family participation and the empowerment of socio-economically marginalized families.

I feel it sufficient to premise mine on and other advocacy of these three obtainable principles, because not only do they speak to the heart of Miss Pfeiffer’s complaints, but the minimal approach should guarantee a greater concentration of resources for success. It would not be hard to lobby Congress about the obtaining of a single comprehensive law that would repeal others, and concentrate their advantages in one place while Congress at this need to find a means of indicating that they understand the people’s problem. It would only be necessary to conclude a mental health convention that brings all activists together for the purpose of orientation so that all act from a common principle towards a common goal.

The concluded comprehensive law would increase the moral weight of requests for increase funding, once the law is in place. The single organization entity would reduce waste and secure greater application of funds from government, while being to tap NGOs and private enterprise for extra research and development funding as that need arises. This structure is needed because mental health advance is not synchronized across all states, and the merit of a New York system does not exist in every place, even with its shortcomings. Miss Pfeiffer took us to different places in the United States as a sample of what happens across the nation. Local gains obtained in any one place are insufficient to meet the crisis in mental health all around.

A uniform policy across the nation is more readily obtainable through a Congressional act. .Correctly reading Miss Pfeiffer we are esoterically challenged initially and primarily, but understanding her purpose must move us beyond the emotional to the objective practice, and logical conclusion. We must assume our responsibility to act as policymakers to 1) restore and increase proper community mental health structures, 2) deinstitutionalize mental ill-health patients, 3) train police officers, and also personnel serving as wardens where mental health victims are likely to have a presence, to recognize and intervene appropriately is the situation morally requires, 4) provide pre- atal care for mental health patients, 5) and increase government funding for the sustainable care of mental health patients, while 6) providing more public education regarding mental health victims and treatment, and 7) finally to decriminalize drug abuse so that they may the necessary help and attention from the health system that their condition demands. The goals have been limitedly obtained in different places and times, and we may conclude to have the skills and know-how already at our disposal, what we may lack is the sense of gratefulness to say thanks to Miss Pfeiffer for showing us again where we are and where should have been. Such a profound gratitude can only be shown in the redress of her complaints, and so by our comment to change the status in mental health policies and programs today. When the emotions are faded may the commitment be brighter yet in the blazing of trail for these reforms to our health mental health system.

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