Have you ever walked down the street and seen someone with mental illness, agitated, and yelling, or lying on the sidewalk, and wondered why? Have you ever wondered why, despite myriad reforms from bold thinkers and progressive governments over centuries, does this still occur? Why, despite miraculous technology, comfort, and opportunity for the majority of the Western population, do people living with serious mental illness continue to miss out on a good life? Or even a humane one?
Take the case of a recently arrested man later admitted to a state hospital. In a condition of homelessness and untreated symptoms, he was standing in a fast-food restaurant in an agitated state, yelling at what he perceived to be a manifestation of the devil. The police were called, and when they arrived, they noted that this individual was missing an eye, which he reported to them he would remove himself as he provided an unintelligible explanation related to a conflict with the devil. The police, understandably, felt the individual was in need of mental health care, and put hands on him to take him into custody, at which point the terrified man took out an imaginary phone to call the “police,” and reported into this delusional device that he was being attacked by an agent of the devil. He proceeded to fight for his life, and in the process lashed out physically leading the officers to charge him with two felonies and book him into custody. He was found incompetent to stand trial (did not have the cognitive capacity to participate in the court process), sent to a hospital for restoration to competency and in the process received mental health services. The devil disappeared after a month on antipsychotic medication, the patient was sent back to court, sentenced to a short term in prison, and then discharged back into homelessness. Treatment soon ceased. He returned to the very conditions that led to his arrest. Only now he had one additional burden; as a convicted felon he was denied the already scant social and mental health services in the community.
The historian Grob stated about the failed state of institutional care, “to attribute bad results to evil people or to condemn an entire society may prove psychologically and intellectually satisfying.”Reference Grob 1 It would be easy to blame the failure of institutionalization on immoral superintendents, for instance. Or the failure of deinstitutionalization on disorganized governance. It is not so simple. Why then does “good” policy repeatedly fail those with serious mental illness? Why, despite well intentioned reforms, policies and treatments, does care for the seriously mentally unwell have a recurrent tendency toward maltreatment?
Societal Treatment of Psychotic Disorders is a Sisyphean Task
In this paper, we suggest that society’s treatment of people with serious mental illness is a Sisyphean task—constantly regressing to a baseline of maltreatment. We define maltreatment as neglect, abuse, or other forms of harm. We suggest that, even when treatment is appropriate for some with psychotic disorders, society struggles to maintain this. Many will deal with absent or improper treatment. For some, conditions today are no better than they were centuries or millennia ago.
Sisyphus. Credit: Gerard Van der Leun. [Sisyphus was a deceitful King. He was eternally punished by Zeus, requiring him to push a boulder to the top of a hill, only for the boulder to roll down every time he neared the top.]
The criminalization of individuals living with serious mental illness in the United States is a current example of this type regression to inhumane treatment, but the pattern is global. Institutional care in the 19th century is but one example where good intention in mental health policy went awry. Deinstitutionalization in the 20th century is another. While it is possible to identify isolated examples of positive reform and therefore dispute the degree to which maltreatment exists, we demonstrate the pattern of regression to maltreatment and its ongoing existence.
We do not wish to imply that psychiatric treatment is inherently harmful. We believe modern treatment is beneficial when judiciously applied. Rather, we wish to demonstrate that societal treatment of those with serious mental illness, including medical, legal, and governmental measures, is highly susceptible to regression to harm over time.
When the people of the 22nd century gaze back to now, will they consider psychiatry and its allied professions as benevolent institutions capable of advocating for the vulnerable insane? Or perhaps as misguided tools of social control, unable to correct the neglect and mistreatment that has recurrently haunted the mental health professions? We suggest that deeper consideration of history will help guide us toward the former.
A sampler of psychiatric (mis)treatments
To detail the history of treatment, mistreatment and reforms in the domain of mental illness is beyond the ability of most books, no less a single scientific paper. Herein lies a tour of notable occurrences across time and geography, mostly in chronological order, demonstrating a tendency to maltreatment.
Early treatment was idiosyncratic, but usually harmful
In ancient civilization, there was little recognition that mental illness was a disease, and therefore it was not treated as one.Reference Porter 2 , Reference Scull 3 Conceptualization of madness centered on demonic or other types of supernatural influence. Families, communities, religious healers, and leaders dealt with insanity in idiosyncratic ways to protect themselves and society and to promote their institutions. If not able to be contained within a home environment, either humanely or inhumanely, families would seek the help of others, often resulting in ceremony, admonishment, containment, exorcism, or whatever the community and religious sentiment of the time dictated. Treatment was regularly harsh. The insane may have ended up beaten, chained, banished, or dead.Reference Porter 2–Reference Shorter and Healy 4
This is not to say that examples of humane treatment did not exist. In some ancient indigenous and Eastern cultures in particular, there is evidence of humane treatment and integration into society.Reference Scull 3 But in almost every case, there are certain to be examples of the exact opposite. The tendency to harm was rife.
A small and temporary reform from spiritual to corporeal treatment
Although ancient Chinese society pre-dated a western shift to physical understandings of disease,Reference Tseng 5 ancient Greek society was the first Western society to treat mental afflictions as a medical illness.Reference Scull 3 , Reference Porter 6 The separation of church from state allowed free thinking individuals, such as Hippocrates, to explore wholly naturalistic causes of disease. It was in the asclepeion, or “healing sanctuary,” where those with mental illness were first cared for outside the home, albeit in a temple.Reference Porter 2 , Reference Porter 6 These sanctuaries were not hospitals, but they provided retreat for the afflicted, a revolutionary idea for the times. A mixture of somatic and mystical treatments including bathing, purging and dieting, followed by prayer, were common.Reference Porter 6 , Reference Risse 7 Porter notes that “around the temples religious and secular healing rubbed shoulders.”Reference Porter 6
The religious understanding of mental illness was too intoxicating for most societies, however, and with the decline of Greek civilization, the physical understanding of “madness” again lay dormant in most Western societies.Reference Scull 3
Here, the Sisyphean pattern is evident. Recognition of corporeal understanding of disease led to more progressive treatment, only for the understanding to be cast aside in many places. For centuries after, beatings and various eclectic exorcisms far outnumbered any semblance of care.
The beginnings of institutional “care”
The first societies to have hospitals in which those with mental illness could be cared for were the ancient Islamic cultures approximately half a millennium later (starting in the 8th century AC).Reference Miller 8 The “bimaristans” (in Persian, “bimar” meaning “ill person” and “stan” denoting “place”), or hospitals, in Baghdad, Damascus, and Cairo were indeed revolutionary, and founded on the ideal in Islamic culture that no individual needing care should be turned away.Reference Miller 8 , Reference Youssef, Youssef and Dening 9 This being the perfect policy for those who had lost their senses, most of the bimaristans had special areas of their hospitals reserved for those with serious mental disorders.Reference Scull 3 , Reference Youssef, Youssef and Dening 9 Although they would be judged as harsh by today’s standards, often using chains to contain behavior, they were provided in good will and were a valiant early attempt to help a neglected population.
Roy Porter, the late patient-focused medical historian, clarified that the bimaristans should not be over-glorified in their ideals, which were just that.Reference Porter 6 These ideals were symbolic in nature, and although bringing the medical profession together, cared for a “drop in the ocean” of those with mental afflictions. The progress, also, was arguably symbolic. Most with serious mental illness remained neglected. Further, Islamic policy has not always served the mentally ill. Many countries based on Shariah law have previously relied on cautery, exorcism and physical violence to manage the “mad.”Reference Dubovsky 10 , Reference Pridmore and Pasha 11
The “progress” of asylums
Bethlehem Hospital is thought to be the seat of institutional care in the Western World. It opened its doors in 1247 and began to care for the insane sometime between 1377 and 1403.Reference Andrews, Briggs, Porter, Tucker and Waddington 12 As is well documented, conditions were appalling. This was not so much a regression as a progression of maltreatment—the maltreatment now legitimized through institutionalization. Dark and dank rooms (exacerbating the prevailing English climate), minimal or adverse treatment, beatings, and shackling were all prevalent. Despite its prominence, Bedlam (as it became known) held only a handful of patients, with the familial home remaining the dominant place of care until the 17th and 18th centuries.Reference Shorter and Healy 4 , Reference Andrews, Briggs, Porter, Tucker and Waddington 12
Private alms houses and asylums began to proliferate in 17th and 18th century Britain. In this so-called “trade in lunacy,” entrepreneurs charged a fee for containing the unwanted within their makeshift and converted “mad-houses.”Reference Porter 2 , Reference Scull 3 , Reference Parry-Jones 13 The demand for such facilities is likely to have justified their existence. The early asylums and alms houses proffered humane alternatives for desperate families, although their marketing pitch was rarely matched by the product.Reference Scull 3 From the beginning, a conflict of interest predestined poor treatment. In other words, the better the care, the lower the profit.
William Parry-Jones, a professor of psychiatry and historian of the Trade in Lunacy, warned against the generalization of horror-stories in the private asylums with the exception of the “pauper” lunatics—who, in fact, were the majority of inpatients until the mid-19th century, when public asylums proliferated.Reference Parry-Jones 14 He writes, of “crowded, ill-ventilated cells in converted stables and outbuildings where pallid, half-naked lunatics were housed on filthy straw.”Reference Parry-Jones 14 Thus, the façade of progression hid the reality of maltreatment for many.
The spread and reform of asylumdom
Regardless of institutional abuses, there was widespread adoption of the asylum as a place of containment throughout the Western World and colonies. Several distinct but connected reforms and reformers in the 18th and 19th centuries are mentioned. Although they signified progress, they were unable to stop a regression to the maltreatment so well reported in many asylums, particularly in the United States.Reference Maisel 15–Reference Deutsch 17
The first reform was public oversight of asylums, best documented in England and Wales. The mental illness of King George III and a number of high-profile false imprisonments, especially of women, drove reform.Reference Scull 18 A series of laws led first to licensing requirements for private asylums. From 1845, asylums were mandated in each county, the same year official oversight was required in all asylums by the “Lunacy Commissioners.”Reference Scull 18 Other countries enacted protective laws such as the requirement for two doctors to certify insanity (eg, Australia’s first “lunacy law” in 1843),Reference Kirkby 19 or the use of the courts to help determine lunacy (eg, statutes in mid-19th century United States).Reference Appelbaum and Kemp 20
The second reform was “moral treatment,” simultaneously enacted by Phillipe Pinel and Jean-Baptiste Pussin at the Bicetre in Paris, William Tuke in England, and Vincenzo Chiarugi in Italy. At its heart, moral treatment reconceptualized the madman as a human, with similar needs of self-esteem, purpose and interaction, rather than the animalistic “treatments” and containments of the past (such as shackling, seclusion, beatings, verbal degradation, and ostracism).Reference Scull 21 Patients were encouraged to re-exercise their powers of self-control through positive reinforcement of good behavior in a welcoming environment. Increased access to grounds and nicer accommodation might be the rewards for self-control. The small early institutions could give close attention to the individual patient, with a high degree of success to match.Reference Scull 21
Third, perhaps aided by the former movements, several humanitarian campaigners promoted appropriate asylum-based care. Here we mention but two. Dorothea Dix, an American hero, was a tireless advocate for the expansion of asylums in mid-19th century America. As a woman, she was unable to attend the Massachusetts legislature at the time, although her written submissions resonated. In her first Memorial to the legislature, she wrote, “I proceed, Gentlemen, briefly to call your attention to the present state of insane persons confined within this Commonwealth, in cages, closets, stalls, pens! Chained, naked, beaten with rods, and lashed into obedience!” To not have asylums, she said, was “aggravated culpability.”Reference Scull 3 Dix is credited with establishing 32 new asylums and championed moral treatment within them.Reference Dix 22
Another campaigner, Sir John Charles Bucknill, an English psychiatrist and reformist, was a determined campaigner for the removal of physical restraints and move toward humane asylum care.Reference Scull, MacKenzie and Hervey 23 Although Robert Gardner Hill, a provincial surgeon, was the first to implement a system of care without restraint in the 1830s,Reference Topp 24 Bucknill’s ongoing efforts contributed to the relative absence of restraints in Britain asylums. He was the founder of the Asylum Journal, within 3 years called the Journal of Mental Science, ultimately becoming the British Journal of Psychiatry. Reference Langley 25 In 1875, he engaged in a tour of the eastern United States and Canada and then published criticism of American psychiatry’s widespread use of restraints—the use of which is still ongoing today.Reference Bucknill 26
Taken together, these improvements were significant advances for the treatment of those with serious mental illness. Asylum care, when enacted under certain moral terms, provided a humane and specialized service for vulnerable people.
Although it is tempting to idealize the asylum model in retrospect in comparison to the failures of today’s deinstitutionalized care, a significant proportion of institutions did not adequately protect those within them. From custodial style, untherapeutic care, to downright dangerous and unregulated treatments, overcrowding, disenfranchisement, overmedication, sexual violence, and shackling, the reality for many in asylums was truly treacherous. This is explored in the following sections.
The reality of asylum care for most was custodial and untherapeutic
In England, the shining light of moral treatment was the Quaker William Tuke’s Retreat at York. Just up the road from The Retreat, the York Lunatic Asylum claimed to espouse moral principles before and after The Retreat’s opening in 1796, although failed miserably in their enactment.Reference Digby 27
In a summary of well documented cases, the historian Anne Digby notes,
“the York Asylum had many of the characteristics of a “total institution” where patients faced loss of determination and identity. Whippings, rape, and contamination from a filthy environment, threatened physical integrity. Accommodation was over-crowded, damp, gloomy, and ill-ventilated. Violent or incontinent patients were housed indiscriminately with the clean, quiet, or convalescent. Clothing was often conspicuous by its absence, and food was wretched even by the standards of contemporary workhouses. Lack of attention to patients meant that they were often dirty and could suffer from untreated illnesses.”Reference Digby 27
Mortality was so high that the number of deaths were concealed by the Apothecary and the official record fraudulently altered.Reference Digby 27 An extraordinary level of abuse despite the outward declaration of a moral institution.
Although care for those at the York Asylum (eventually Bootham Park Hospital) undoubtedly improved from this nadir, what of the effects of institutionalization, overcrowding, and then deinstitutionalization, including the recent failed attempt to improve the safety of the 240-year-old building, followed by a sudden requirement to move its vulnerable inpatients and outpatients to distant institutions within 5 days?Reference Kirby 28 The prioritization of patient welfare was lost multiple times.
England, of course, was not the only country where institutional care was less than ideal, despite a number of reforms. Custodial and overcrowded institutions proliferated in many countries.
In early 19th-century Australia, unsurprisingly, the priority was the containment of criminals, and as such those recognized as insane and dangerous were typically kept in jails.Reference Kirkby 19 , Reference Coleborne and MacKinnon 29 , Reference Dax 30 The Female Factory in Sydney housed “a motley collection of fallen women and prostitutes, indigents, the elderly and the insane, initially in a loft above a gaol.”Reference Kirkby 19 Political imperative helped find a new space for the mentally ill, with the “less than comfortable converted barracks building” in Castle Hill, Sydney used until 1825. As many as a third of convicts in jail had mental illness, and as asylums were oversubscribed, “many lunatics were being held in both metropolitan and provincial gaols and susceptible to ‘the moral injury now too often inflicted on them, by compulsory association with all classes of criminals’.”Reference Kirkby 19 Unsurprisingly, “commissions of inquiry into shortcomings of the various asylums were commonplace from their inception.”Reference Kirkby 19
In Africa, asylum care proliferated in the early 20th century. Parts of jails were transformed into asylums, such as the asylum in Zanzibar “situated physically inside the walls of the prison, overseen by prison guards, run administratively by the Prison Department and operated essentially as an additional cell block in close proximity to the gallows.”Reference Mahone 31 Or, in the case of Hoima Gaol in Uganda, simply re-established as Hoima Lunatic Asylum in 1923 as it had become, “without any official designation,” a “dumping ground for a variety of inmates whose presence was deemed undesirable or disruptive among the general prison population.”Reference Mahone 31
Hospitals in West Africa were “all-purpose institutions,” with most superintendents not of a medical background.Reference Oyebode 32 “Dark, congested cells, poor bathing facilities, lack of basic supplies and the use of chains” were prevalent.Reference Oyebode 32 , Reference Sadowsky 33 A 1936 survey noted most asylums “were run down and poorly serviced and were no more than prisons.”Reference Oyebode 32
Femi Oyebode, a psychiatrist and author, writes “that the asylums were developed, at least partly, in response to a perceived need to assist the mentally ill.”Reference Oyebode 32 Good intention, perhaps. Although, he goes on, “as in other parts of the world, the actual facilities were poorly resourced and maintained.” Asylum care was promoted in Africa, but the custodial nature of the institutions undoubtedly caused additional harm to many.
In 19th century India, asylums “were greatly influenced by British psychiatry and catered mostly to European soldiers posted in India at that time. Their function was more custodial and less curative.”Reference Nizamie and Goyal 34 The law dictating care for the mentally ill in the early 20th century was “purely custodial, did not understand the medical view, and the need for proper care and cure, but instead viewed these with suspicion.”Reference Jain and Murthy 35 “Financial rather than therapeutic reasoning” guided care, a common theme in the custodial care of those with serious mental illness over time.Reference Jain and Murthy 35 Here, too, the care needs of the insane were likely forgotten, and harm ensued.
In the United States, despite several, mostly private, asylums based on moral treatment, state asylums became so overcrowded humane care was not possible. One asylum in Georgia contained 14,000 individuals. Repetitive inhumanity and scandal were a notable feature of its history.Reference Judd 36
Here, the pattern of regression to maltreatment was evident across multiple countries and multiple centuries, a Sisyphean task indeed. Morally based institutional care had prima facie merit. Dorothea Dix and others had previously argued this case.Reference Scull 3 Scholars continue to make the case today.Reference Sisti, Segal and Emanuel 37 If this model of care were to dominate psychiatry again, what would be different this time around? What would stop us regressing to the maltreatment that harmed thousands, if not millions, of vulnerable people? Alas, institutionalization was not the first method of care to harm those with serious mental illness (among others), nor would it be the last.
Twentieth century abusive treatments
With increasing medicalization of mental illness, the tendency towards harm continued in the 20th century.
Notwithstanding individual treatments, the guise of “treating” or helping society, such as the eugenics movement, caused extensive harm the world over. In total, hundreds of thousands of people considered, at the time, to be “mental defectives” were sterilized in the United States, Scandinavia, Western and Eastern Europe, and Latin America to advance the human race.Reference Kevles 38–Reference Broberg and Roll-Hansen 41 Sobering, was the general acceptance by the academic world and that involuntary sterilization was practiced well into the 1970s in places such as Sweden and the United States.Reference Bashford and Levine 39 , Reference Broberg and Roll-Hansen 41
Direct “treatments” of mental illness, however, also irreparably harmed (and sometimes killed) many with mental illness. The extent of harm is documented by authors such as Scull.Reference Scull 3 , Reference Scull 42 , Reference Scull 43 Outlined below are some prominent examples.
One of two psychiatrists to be awarded the Nobel Prize in Medicine, Julius Wagner-Jauregg noticed that patients with General Paralysis of the Insane (GPI; later discovered to be syphilis) sometimes improved when they had a fever. He settled on malaria as the best agent to induce “pyrotherapy” in 1917, injecting the blood of GPI patients with infected blood.Reference Wagner-Jauregg 44 Even although this procedure killed 3% to 20% of patients (records were poorly kept), the desperation and inevitable death of end-stage syphilis justified the treatment at the time.Reference Ouwens, Lens and Fiolet 45 Notwithstanding, the lack of controlled trials of the procedure and uncertain prognosis of GPI clouds the certainty of success.Reference Scull 42 It was not necessarily the harm caused by pyrotherapy in GPI itself that is the lesson. Rather, it was the fervour with which some somatic treatments, including pyrotherapy, were thereafter trialled on the mentally ill in the quest for further success. From unorthodox uses of pyrotherapy (such as injecting blood directly into the brain of those with GPI),Reference Lieberman 46 to “surgical bacteriology” (the removal of teeth and other organs to rid the body of occult infections leading to insanity),Reference Scull 3 to deep-sleep therapy (prolonged sedation as therapy),Reference Walton 47 and Metrazol therapy (inducing intense convulsions),Reference Scull 3 the benefits were few and the harm immense.
Another somatic therapy, “insulin-coma therapy,” was developed by the Viennese doctor Manfred Sakel, while working in Berlin in 1927. Schizophrenia cure rates of up to 80% were reported. It was widely adopted by the scientific community and was the standard of care from approximately the 1930s to the 1950s, prior to the advent of chlorpromazine.Reference Jones 48 “The Insulin Myth” was published in 1953 in The Lancet, reporting a lack of evidence for the treatment.Reference Bourne 49 A subsequent controlled trial found no statistical difference to placebo.Reference Ackner, Harris and Oldham 50 But the damage was done. Approximately 1 in 100 patients died during the procedure. Many others suffered brain damage from the resulting hypoglycaemic coma or were rendered obese from the effects of insulin. A widely accepted treatment by professionals and academics, later found to have no evidence of beneficial effect while damaging many.
In the mid-20th century, Egas Moniz, the Portuguese neurologist and to-be Nobel prize-winner, pioneered the frontal lobotomy (earlier called leukotomy). The Americans Walter Freeman and James Watts developed a transorbital method, completed in just 20 minutes with the use of an ice-pick and a mallet.Reference Scull 3 , Reference Shorter and Healy 4 Beyond the 0.85% to 2.5% mortality rate (although reported as high as 18% in some centers),Reference Swayze 51 the effects on personality and cognition were obvious. Its recipients traded one form of madness for an iatrogenic mental deficiency, often left “soulless,” bland, and without emotional capacity.Reference Shorter and Healy 4 The sister of President John F. Kennedy, Rosemary Kennedy, was a notable case of someone left incapacitated from the surgery.Reference Larson 52 , Reference Torrey 53
The above treatments occurred largely in a time before randomized-controlled trials, so they must be viewed in that light. But were these times also absent of regulatory measures? What forces were at play? What checks and balances were lost? For there were certainly detractors in all cases. But this did not stop the inexorable rise of damaging treatments. Is it possible that current treatments will be viewed in retrospect as failed experiments on vulnerable people?
Deinstitutionalization in the United States
In the 1950s United States, institutional abuse was particularly rife. Overcrowded “snake pits” and lack of evidence-based treatment and care led to abhorrent conditions within America’s asylums.Reference Scull 3 , Reference Gorman 16 , Reference Deutsch 17 At its peak, 560 000 people were institutionalized in 1950s United States. Undoubtedly, there were examples of good care. But with this degree of overcrowding it was simply not possible to provide this to most. Preceding the civil rights movement, a number of damning exposes demonstrated the plight of the institutionalized mentally ill, altering the social climate.Reference Maisel 15 , Reference Gorman 16
The reasons for deinstitutionalization are discussed in depth elsewhere. Notable, is the certainty of those that promoted deinstitutionalization, similar to the certainty of those that promoted institutionalization centuries before. Nevertheless, the reform’s noble intention was to create a community mental health plan that focused on prevention and would negate the need for state hospitals.Reference Torrey 53 This plan simultaneously failed in its preventative intent while disregarding patients that flooded out of state hospitals.Reference Torrey 53 Whereas the relative contribution of deinstitutionalization to the increase in homelessness and incarceration of those with serious mental illness is debated,Reference Lamb 54 , Reference Lamb 55 it is well-recognized that the clumsy handling of deinstitutionalization contributed to both.Reference Torrey 53 , Reference Lamb 54 Thus, the regression to maltreatment continued for many.
The regression of Indonesia’s promising system
In the wake of the country’s independence from Holland and deinstitutionalization in the Western World, Indonesia’s mental health system was reformed under the leadership of Professor R. Kusumanto Setyonegoro in the 1960s and 1970s. The commencement of a new mental health law, separate from the general health laws, occurred in 1966. The law emphasized the principles of prevention, treatment, and rehabilitation, which had been enthusiastically agreed upon at a meeting of psychiatrists organized by the Ministry of Health earlier in the same year.Reference Pols 56 , Reference Pols and Wibisono 57
Kusumanto, appointed in 1971 as the Director of the Directorate of Mental Health within the Department of Mental Health, opened 22 new mental health hospitals, resulting in a psychiatric hospital in 26 of Indonesia’s 31 provinces. The hospitals were integrated with the community mental health program, providing in and outpatient care, public health education, and consultation to general hospitals. The period from 1970 to 1985 was designated the “golden age” in Indonesian psychiatry by some authors.Reference Pols 56 , Reference Pols and Wibisono 57
This peak in Indonesian mental health care was gradually eroded by reductions in funding and a decentralization of mental health provision (almost certainly a move to reduce the burden on the government). The once central place of the community mental health system was threatened. As the mental hospitals were under resourced, they were no longer able to integrate with the general health programs. As the integration reduced, so did the quality of care.
Indonesia is the fourth most populous country in the world. The current state of care for those with mental illness is, in many places, tragic. While exceptional care can be found in some wealthy private institutions, other private facilities—borne out of declining public facilities—have “deplorable conditions, [where patients] receive inadequate nutrition, suffer from a variety of ailments, and are often restrained.”Reference Pols and Wibisono 57 Pasung, or chaining, was outlawed in the 1970s, but exists to this day in many places, as demonstrated by the photojournalist Andrea Star Reese in 2012.Reference Star Reese 58 Some of the treatment facilities are cages with no sanitation facilities.
Criminalization, homelessness, and neglect: the current (troubling) picture in the United States
Of the approximately 10 million people with serious mental illness in the United States, at least 300 000 people are incarcerated,Reference Lamb and Weinberger 59 at least 60 000 people are homeless,Reference Fazel, Khosla, Doll and Geddes 60 and at least 5 million do not receive stable treatment at last reliable measurement.Reference Kessler, Berglund and Bruce 61 Further, it is estimated that more than 2 million arrests each year involve people with serious mental illnesses, many of whom are homeless at the time of arrest.Reference Iglehart 62 , Reference McNiel, Binder and Robinson 63 Perhaps unsurprisingly, this results in at least three times more seriously mentally ill people in jails and prisons than in mental health hospitals.Reference Torrey, Kennard, Eslinger, Lamb and Pavle 64 Jails and prisons, therefore, are the principal care facility for those with serious mental illness. Interestingly, in an odd reversal of the 19th century pattern of jails converted to asylums (eg, Africa and Australia—as described above), some state hospitals converted to jails. 65– 67 Additionally, there are approximately 4000 prisoners with mental illness kept in solitary confinement in U.S. prisons.Reference Resnik, VanCleave and Bell 68
Indonesia (Credit: Andrea Star Reese); San Francisco (Credit: Associated Press, Ben Margo).
What does history tell us?
The task of Sisyphus was to push a boulder up a hill. He was able to do this, but invariably it rolled down again and he would start over. We hope to demonstrate the repetition of maltreatment of those with serious mental illness—despite the efforts of many to reform and progress—and while doing so, to inspire deeper reflection. We demonstrated the pattern in democratic and/or “modern” societies. The abuses of psychiatry in Nazi Germany and Soviet Russia, while atrocious, remove attention from the fact that harm occurs in progressive societies, and therefore were not discussed in this paper.
We do not suggest that outcomes for those with serious mental illness are universally poor. The authors have seen many inspiring stories of recovery and good policy. In fact, one can choose to see a series of reforms leading to overall improved care. No longer are there witch hunts and exorcisms for souls gone mad. Hospitals of today are, for the most part, better than asylums of yesteryear, with an increasingly professional workforce. Advances in psychopharmacology and evidenced based psychological therapies have improved the lives of those with serious mental illness, but people are often not accessing the treatment.
Because of a lack of access or utilization of care, many people with serious mental illness are locked up in prisons. Others are homeless and untreated. Of those accessing care, which treatments and laws we consider necessary treatments today, will be understood as mistreatment of those with serious mental illness tomorrow? We wonder what “progress” will be considered regression in years to come.
In all, those with serious mental illness die, on average, 10 to 17 years earlier than those without.Reference Walker, McGee and Druss69–Reference Chang, Hayes and Perera 71 People with cancer and heart disease are rarely locked up within jails or found lying in the streets for reasons to do with their illness. Why then those with serious mental illness? Intelligent and passionate policy makers, clinicians, and advocates debate and attempt to implement the best forms of care and treatment. Yet, something is amiss.
We conclude that scientific advancements and policy reform does not seem to be enough to ensure humane treatment for the approximately 5% of the population with serious mental illness.Reference Kessler, Berglund and Bruce 61 While caring individuals have improved the life of many with serious mental illness, the societal treatment of those with serious mental illness often regresses to harm. We hope this provides a basis for deeper reflection on the context of reform failure and maltreatment through which more resilient policy can be created.
Acknowledgments
We acknowledge Paris Beauregard, Charles Daugherty, Andrew Scull, William Taft, and Sunny Wade for their help in the preparation of this manuscript.
Disclosures
Brendan Daugherty, FRANZCP and Katherine Warburton have nothing to disclose. Stephen M. Stahl, MD, PhD, Dsc (Hon.) is an Adjunct Professor of Psychiatry at the University of California San Diego, Honorary Visiting Senior Fellow at the University of Cambridge, UK and Director of Psychopharmacology for California Department of State Hospitals. Over the past 36 months (January 2016 to December 2018) Dr. Stahl has served as a consultant to Acadia, Adamas, Alkermes, Allergan, Arbor Pharmaceutcials, AstraZeneca, Avanir, Axovant, Axsome, Biogen, Biomarin, Biopharma, Celgene, Concert, ClearView, DepoMed, Dey, EnVivo, EMD Serono, Ferring, Forest, Forum, Genomind, Innovative Science Solutions, Intra-Cellular Therapies, Janssen, Jazz, Lilly, Lundbeck, Merck, Neos, Novartis, Noveida, Orexigen, Otsuka, PamLabs, Perrigo, Pfizer, Pierre Fabre, Reviva, Servier, Shire, Sprout, Sunovion, Taisho, Takeda, Taliaz, Teva, Tonix, Trius, Vanda, Vertex, and Viforpharma. He has been a board member of RCT Logic and Genomind; he has served on speakers bureaus for Acadia, Astra Zeneca, Dey Pharma, EnVivo, Eli Lilly, Forum, Genentech, Janssen, Lundbeck, Merck, Otsuka, PamLabs, Pfizer Israel, Servier, Sunovion and Takeda and he has received research and/or grant support from Acadia, Alkermes, AssureX, Astra Zeneca, Arbor Pharmaceuticals, Avanir, Axovant, Biogen, Braeburn Pharmaceuticals, BristolMyer Squibb, Celgene, CeNeRx, Cephalon, Dey, Eli Lilly, EnVivo, Forest, Forum, GenOmind, Glaxo Smith Kline, Intra-Cellular Therapies, ISSWSH, Janssen, JayMac, Jazz, Lundbeck, Merck, Mylan, Neurocrine, Neuronetics, Novartis, Otsuka, PamLabs, Pfizer, Reviva, Roche, Sepracor, Servier, Shire, Sprout, Sunovion, TMS NeuroHealth Centers, Takeda, Teva, Tonix, Vanda, Valeant, and Wyeth.
