Outrages of Disturbed People Find Society Set on Inaction

Last Friday, two days after being released from a psychiatric ward, a 33-year-old Los Angeles man with a history of mental problems took his troubles to the street. Witnesses said that David Hasson was driving at speeds as high as 70 m.p.h. when his car collided with another, killing a young man and three children and critically injuring their mother. Hasson had been confined in a county facility for 10 days after his father told police that he had been “driving up and down the street trying to hit people.”

Reports like this one are becoming more common across the country. In Philadelphia a woman who had been hospitalized 12 times in 10 years for violent attacks was let out (again) after a four-month confinement for stabbing someone; her parents and psychiatrists had been unable to commit her against her will. She then killed two people in a shopping mall with a semi-automatic rifle. In New York a man named Adam Berwid was released from a psychiatric hospital in spite of his repeated statements that he planned to murder his wife. The hospital notified her, by mail, of its intention to release him. The notification arrived two days after he killed her.

Every time one of these horrible stories hits the news, an outraged public demands accountability from the psychiatrists in charge or the hospital management. Some people are blaming the mental-health center for releasing Hasson “early,” but in fact he could have been legally held only four more days. Would four days have made any difference?

The problem lies not in the individual decisions of psychiatrists (though some may be blameworthy). The Hasson cases occur because our society has made a collective legal and moral decision not to confine indefinitely or punish people who might do something, whether they are legally sane or insane. For every man who threatens to kill his wife and does so, there are thousands who threaten and do not. For every person who harms others, there are thousands of disturbed “screamers” whose only crime is to rant curses and make everyone around them uncomfortable. And for every person with a history of mental disorders who commits a violent crime, there are thousands of so-called normals who do. Lord knows how many hotheads are walking (or driving) around with guns, waiting for a chance to play Rambo; our society has decided not to lock them up until they do play Rambo.

In our anger over the exceptional cases we tend to forget a different kind of horror story that used to crop up regularly in the news. A woman named Gladys Burr was involuntarily confined in 1936, incorrectly diagnosed as mentally retarded and psychotic. No one paid attention to her requests for freedom for 42 years. (She was released in 1978, and, seven years later, was awarded $235,000 in compensation.)

Today hospitals commit far fewer Gladys Burrs. But the three factors that brought about this beneficial development have led to the release of more David Hassons.

First, the discovery of anti-psychotic medication succeeded in calming most of the extreme symptoms of psychotic patients, allowing people to return to their families and communities. This was a big improvement over straitjackets and padded cells, and made possible a life outside the hospital. Unfortunately, the medication works only as long as it is taken (and there are some hazards to taking it for too many years). Unfortunately, too, patients are released without support services; frequently their families are unable to care for them. So the patient stops taking the drug, the psychotic symptoms return, the patient is rehospitalized, becomes well enough to be released, and the cycle continues.

The civil-rights and patients’-rights movements succeeded in eliminating many abuses of institutionalization. Many people were being committed without sufficient cause and warehoused without treatment. Many were spending far longer in mental hospitals for committing minor crimes than they would have spent in prison. Others, like Gladys Burr, were confined by mistake, by oversight or because they could not speak English. There also were no review procedures to enable them to get out of hospitals. In many states today the law mandates hearings to determine whether patients should be released. Typically, a judge listens to the arguments of a hospital’s psychiatrists and of the patient’s advocate, and makes a decision.

These changes produced unanticipated new problems. Hospital administrators, anxious to avoid legal challenges of violating patients’ rights, began to discharge patients as soon as possible without regard for where they might go. In some states it is very difficult to hospitalize anyone involuntarily for longer than a few weeks--even someone who is a danger to himself or others, even a patient who wants to stay.

The third factor was the result of a government push toward deinstitutionalization and a simultaneous cutback in funding. In 1963 Congress passed the Community Mental Health Centers Act to establish a nationwide network of centers that would provide inpatient and outpatient treatment, emergency services for normal people in temporary crisis as well as for schizophrenics having psychotic episodes, and day treatment for people whose families cannot care for them around the clock. It was a terrific idea; all that it lacked was the money to carry it out. The states were well into emptying their mental hospitals when cutbacks began in federal and state funding for public-health and housing programs. The result was the dumping of thousands of patients onto the streets.

The public, meanwhile, sends mixed messages to politicians and mental-health professionals. We are uncomfortable knowing that many thousands of disturbed people are without homes as well as help, but we don’t support more government spending to provide for them. We are outraged by stories of abuse and neglect in the old system, but we refuse to have halfway houses or community shelters on our block.

With a problem of such complexity, it is not enough to ask who was at fault when we hear about a mentally disturbed person committing a sensational act of violence. The harder questions to be asking are: What is government’s responsibility? What federal, state and local services should be provided for disturbed people? Should we invest in a better program of community care, or should we reopen state institutions? How can communities protect the rights of the mentally ill, the vast majority of whom are not violent, while protecting the safety of the public? Do we want to set off on the road of “preventive detention,” and how long should we detain someone who might do something? Four more days? Four years? A lifetime? And whom, exactly, will we detain? An Adam Berwid? Or a Bernie Goetz?