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c h a p t e r 1 Introduction The mental health system today bears scant resemblance to that of the first half of the twentieth century. Albert Deutsch, after a decade of investigation, indicted mental health care in 1948 in The Shame of the States. Deutsch described how people with severe mental illness languished on the filthy back wards of public mental hospitals, lacking any care or being subjected to generally ineffective and often painful therapies . In one provocative passage he wrote of mental hospitals as “buildings swarming with naked humans herded like cattle . . . pervaded by a fetid odor so heavy, so nauseating, that the stench seemed to have almost a physical existence of its own.” For people with mental illness, life outside public mental hospitals was only marginally better. Many of the severely ill eked out an existence, living in squalid hotels or slum apartments with no reliable source of income and little prospect of treatment. Those with less severe illnesses—depression, or anxiety, or phobias— might turn to a sympathetic member of the clergy or a friend, but they had little other recourse. Their physicians’ therapeutic arsenal contained only addictive or ineffective medications. Prosperous patients, the privileged few, were likely to receive humane, caring treatment in private psychiatric hospitals or from psychiatrists in private practice. But the treatment itself was not much more effective than that received by their more disadvantaged peers. Over the second half century, from 1950 to 2000, there occurred a dramatic transformation in the way the United States addressed the needs of people with mental illnesses. Today the vast majority— even those with a severe illness— never see the inside of a public mental hospital. Almost all severely ill patients receive some treatment. That treatment, although not always entirely effective, is unlikely to be dangerous or inhumane. The living conditions of people with severe illnesses have generally improved at least as much as have conditions for the rest of society over the past five decades. Most severely ill people today receive regular income through federal insurance programs, and their medical care, in the community and in hospitals, is 2 Better But Not Well paid for by public or private insurance. A small army of specialty-trained psychiatrists , psychologists, nurses, and social workers, who collectively number more than two hundred thousand, has replaced the seven thousand psychiatrists practicing in 1950. Family doctors who had long ignored mental health problems now assume an active role in the management of many psychiatric illnesses. Average spending on care for each person treated has expanded many times over, even after accounting for inflation. People with mental illnesses, their families, and the population at large have better financial protection against the costs of mental illness. And people with mental illness share more civil liberties. The courts have restored their dignity by extending new rights protecting them from being hospitalized against their will. Many now lead productive lives as active members of their communities. The result is that the lives of most people with mental illnesses are better today than they were fifty years ago. Undoubtedly, the circumstances of people with mental illness remain far from acceptable. President Bush’s New Freedom Commission of 2003 reported that the mental health system is “in shambles.” The report described excessive disability, homelessness, dependence on social programs, school failure, and incarceration in jails and prisons. Though evidence of improvement is abundant, the picture we sketch should not obscure how extraordinarily disruptive mental illnesses remain. People with severe mental disorders still have among the lowest rates of employment of any group with disabilities. Their earnings are lower and they are less likely to return to work than are other people with disabilities. The World Health Organization calculated that mental illnesses lead to a greater collective disability burden in established market economies than does any other group of illnesses, including cancer and heart disease (WHO, 2001). Mentally ill people disproportionately populate the nation’s largest social insurance programs. They account for up to 35 percent of those on public disability and 28 percent on welfare rolls (Loprest and Zedlewski, 1999; US SSA, 2001). As we will show, the growth of these mainstream social insurance programs has been vitally important in improving the circumstances of people with mental illness. Nonetheless, public disability insurance does not pay enough to lift an adult above the federal poverty line. For the vast majority of people with a severe mental illness, a life in poverty is to be expected...


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