The Madness of Deinstitutionalization

The Wall Street Journal, February 20, 1996

By Sally Satel

Ralph D. has molested scores of children and set at least seven fires, one of which destroyed an apartment building. Forty-three years old and mildly retarded, he is now under the care of the Massachusetts Department of Mental Health, which has set him up in a two-bedroom state-funded house. Round-the-clock psychiatric aides maintain a constant vigil at the house lest Ralph D. start a fire. As part of his treatment, they keep the shades drawn so he won’t become aroused by the sight of neighborhood children.

Ralph D.’s treatment consumes $150,000 of the $2 million annual residential treatment budget in the county where he now resides. That’s enough money to fund five residential treatment beds for homeless, mentally ill people for three years, or to provide three years of supervision by social workers and psychiatrists for 15 outpatients living in their own apartments.

The Massachusetts Department of Mental Health squanders its limited resources on Ralph D. because it has adopted a rigid imperative: Keep patients out of mental institutions and “in the community.” According to the department’s contract with Ralph D.’s monitoring agency, the goal of his treatment is to establish “meaningful degrees of autonomy” through “services that enable the individual to fully participate in the activities generally afforded to any other citizen.” Never mind that Ralph D.’s “autonomy” is, itself, a travesty.

Beginning in the 1950s, advocates of deinstitutionalization sold it as both a recognition of patients’ rights and a cost-cutting strategy. But as the case of Ralph D. shows, an obsession with patients’ freedom can be a big drain on the taxpayer, not to mention risk to the community.

The infamous Larry Hogue, a mentally ill man who terrorized Manhattan’s Upper West Side for years while high on crack, ended up costing New Yorkers a small fortune in property damage, law enforcement, jail sentences, legal fees, outreach teams and emergency room visits before a court finally ordered him to Creedmoor Psychiatric Center.

The cost of a year in Creedmoor ($120,000) is just a small part of Mr. Hogue’s cost to society. Take just a few of Mr. Hogue’s acts of vandalism — repeatedly breaking a stained glass window of the First Church of Christ Scientist ($22,000), and smashing windshields and defacing cars on or near 96th Street (about $8,000). Add to that a year in jail for pushing a girl into traffic on Amsterdam Avenue (about $50,000), monthly veterans benefits ($36,000 annually) that went for crack and alcohol, and thousands of dollars in acute hospitalizations and detoxifications.

At a VA hospital in Connecticut, a severely alcoholic man was admitted to a drug treatment unit three separate times over a five-week period. Each time he had drunk rubbing alcohol, landing him in the intensive care unit for about 72 hours ($1,200 a day). Then sent to the treatment unit ($250 a day), he demanded to leave before the week was up.

Although this patient was literally drinking himself to death, the state of Connecticut would not permit the hospital to institutionalize him, because state policy prohibits involuntary commitment of severe alcoholics even for their own protection. Had the hospital been able to place him at a private, not-for-profit residential facility upstate, the annual tab would have been $7,000, about the cost of six days in ICU.

The passion for civil liberties at any cost is the legacy of the deinstitutionalization movement. Back in the ’50s, lawyers were instrumental in liberating patients from decrepit back wards. At the same time, the emergence of powerful antipsychotic medications and lithium made it possible for many to live independently. States, eager partners in closing state hospitals as a way to save money, cut the number of institutional beds in the country by more than 85% over 40 years.

Yet, although it is cheaper and more humane to treat most people outside a hospital, even the best outpatient programs aren’t enough for individuals who are so psychotic or persistently intoxicated that they don’t even know they need help. For some mentally ill people, compulsory care is absolutely necessary.

The human cost of deinstitutionalization’s excesses have long been clear. With budget cuts in store at every level of government, the financial costs will soon be unbearable as well.