Social and Political Factors and Their Influence on Change in the Care of the Mentally Ill

1. Social and Political Factors and Their Influence on Change in the Care of the Mentally Ill William E. Downey, Jr., MSW Director, Division of Psychiatric Social Work, Duke University Medical Center Dept. of Psychiatry and Behavioral Sciences

2. Consumer Perspective - 2007 “It’s a system that doesn’t support you when you need it, and there’s no hope in the system.” -- Patient with Bi-polar Disorder

3. The burden of mental illness on health and productivity • The burden of mental illness is often profoundly underestimated. • Mental illness, including suicide, ranks second in the burden of disease in established market economies, such as the United States. 
 • Major depression is equivalent in burden to blindness or paraplegia. • Active psychosis seen in schizophrenia is equal in disability burden to quadriplegia. Data developed by the massive Global Burden of Disease study, conducted by the World Health Organization, the World Bank, and Harvard University

4. Disease burden by selected illness categories in established market economies, 1990 • *Disability-adjusted life year (DALY) is a measure that expresses years of life lost to premature death and years lived with a disability of specified severity and duration (Murray & Lopez, 1996).

5. Assumption “Public policies…are more often than not evolutionary in nature; only rarely do they emerge in some novel form following a cataclysmic event.” Gerald N. Grob Rutgers, The State University of New Jersey

6. A Sociopolitical Perspective “The extent to which [any] new approach to mental health care delivery will benefit patients and society depends not so much on psychiatry as a discipline as on the perceptions and actions of politicians.” Assen Jablensky

7. Historical Snapshots • Slavery • In-patient Facilities • Eugenics • Change within APA • Relation to Present

8. The Slave and Mental Illness

9. 1840 Census Results

10. Justification of Slave Holders “The slave in the state of mental ease, separated from the trauma of modern life, rarely came into contact with the life stresses that the white man faced.”

11. Regarding Census ‘Results’ “Here is proof of the necessity of slavery. The African is incapable of self-care and sinks into lunacy under the burden of freedom. It is a mercy to him to give him the guardianship and protection from mental death.” John C. Calhoun

12. Propositions on Insanity in the ‘Colored’ Race: • Insanity is very often the result of moral or physical evil brought on by vicious habits and uncontrolled passions. • The vast disparity between insane blacks, free and slave, is because of moral causes. • Free blacks in the North are vicious to an enormous extent. • Vices of the freed blacks have increased in proportion to the time that has elapsed since their emancipation. • General emancipation would be attended with most injurious consequences, and eventually would prove fatal to the emancipated race. . Reflections on the Census of 1840, Southern Literary Messenger 9 (Richmond 1843): 350-351

13. In-Patient Facilities Friends Hospital in Philadelphia is the oldest psychiatric facility in the U.S. (Source: www.friendshospitalonline.org)

14. Plato Plato regarded social deviance as a disorder of the mind and recommended the placing of delinquents with appropriate guardians. Sigerist, H. (1951 ) History of Medicine, Vol. I. London: Oxford University Press

15. Obligations The alienist worked through the lunatic asylum as the primary mode of treatment, analysis, and investigation. As such, the alienist was confronted with his obligation as a medical practitioner and his obligations to the state as an appointed officer.

16. Functions of a Mental Hospital • Physical segregation of the ‘residually deviant,’ perceived as an irritant or a burden on the economy or society. • Ideological legitimization of this segregation, by transforming the ethno cultural image of madness into a concept of mental illness, constructed on the model of the natural sciences and subdivided into classes, species, forms, etc. Jablensky, A. (1992). Politics and Mental Health. The International Journal of Social Psychiatry, Vol. 38 No.1 24-29

17. North Carolina MH Hospitals • 1825-1856 • 1876-1882 • 1948 • 1965 • 2002-Present The Royster Building, Dorothea Dix Hospital Source: NC Dept. Health & Human Svc. (www.ncoes.net)

18. Fiscal Conflict Divided Responsibilities • State paid for construction of physical plants and renovations • Local areas pay hospitals for actual cost of care and treatment

19. 1890 • Change in method of payment • Results in change in populations if hospitals; ‘Senile’ is now defined as ‘mentally ill’ • Alms houses population dropped precipitously

20. Seven Official Categories of Disease – 1880 Census • Mania • Monomania • Paresis • Dementia • Dipsomania • Epilepsy Early Census Tabulation Machine Source: U.S. Census Bureau (www.census.gov)

21. Diagnoses of Institutionalized Women • Overexertion • Suppressed Menstruation • Radical Religious Beliefs • Domestic Troubles • Nymphomania • Insane by Unknown Reasons

22. Examples of Diagnosis

23. Eugenics and Mental Healthin North Carolina: A Timeline 1933-1974 Logo from the 2nd International Eugenics Conference, 1921

24. 1933 • The N.C. General Assembly approves an overhauled sterilization law modeled after a similar law in Virginia that had passed muster with the U.S. Supreme Court. • The new law authorizes sterilizations of the feeble-minded, mentally diseased and epileptics

25. 1935 • Wickliffe Draper, an eccentric philanthropist who bankrolled racial research, attends a conference on eugenics in Nazi Germany Nazi poster from 1931 reads, “We do not stand alone,” and depicts the flags of other countries with sterilization legislation.

26. 1938 • Dr. Clarence Gamble works with Planned Parenthood founder Margaret Sanger on the "Negro Project," an effort that leads to North Carolina providing the first government-sponsored birth control program in the nation.

27. 1943-1944 • A sterilization program in Forsyth County, separate from the state program, operates with the approval of county commissioners

28. 1945 • Dr. Clarence Gamble, heir to the Procter & Gamble fortune, contributes $6,000 to the Eugenics Board to study the need for sterilizations in North Carolina. He later pays for IQ studies of schoolchildren and sterilizations in Orange County.

29. 1945 con’t. • World War II ends. Revelations about Nazi atrocities, including eugenic research, forced sterilizations and concentration camps, begin circulating around the world.

30. 1946-1948 • For the first time, the number of sterilizations in North Carolina performed on members of the general public exceeds the number performed on inmates and patients in state institutions. • With the exception of the 1950-1952 biennial reporting period, the number of institutional sterilizations never again exceeds the number performed on members of the general public.

33. 1953 • Wickliffe Draper donates $100,000 to the Bowman-Gray Genetics Program. • Draper was one of the co-founders and primary benefactor of The Pioneer Fund, which distributed grants furthering genetic and eugenic research. Wickliffe Draper

34. 1958-1960 • For the first time, the number of blacks sterilized under North Carolina's program exceeds the number of whites sterilized. Source: The Winston-Salem Journal

35. 1974 • The Eugenics Board of North Carolina is officially disbanded. • The Board authorized approximately 7,600 sterilizations over the course of 40 years. • Shortly before the Board is disbanded, N.C. Rep. Joy Johnson, a black preacher from Robeson County, tells the House committee, “Sterilization is a vicious atrocity -- gruesome, cruel, dehumanizing, degrading, barbaric, unethical, un-Christian, and unconstitutional.”

37. The APA, DSM, and Homosexuality: 1970-1974

38. 1970 American Psychiatric Association Convention • Interrupter Presentation – “Outside agitator” R. Bayer, Homosexuality and American Psychiatry: The Politics of Diagnosis. Princeton: Princeton University Press (1987), p. 104

39. 1971 American Psychiatric Association Convention • Program chairperson allegedly threatens that if panel on homosexuality is not approved, the whole meeting will be disrupted • APA agrees to sponsor special panel not on homosexuality, but by homosexuals • Protestors disrupt the lifetime service award meeting

40. 1971 American Psychiatric Association Convention con’t. • “Psychiatry is the enemy incarnate. Psychiatry has waged a relentless war of extermination against us. We’re rejecting you as our owners. You may take this as our declaration of war.” As reported by Jeffrey B. Satinover, M.S., M.D.

41. 1972-1974 • American Psychiatric Association Membership votes to remove homosexuality as a disorder • In 1974, the American Psychological Association and the National Association of Social Workers follow suit

42. 1974 American Psychiatric Association votes “to eliminate Homosexuality per se as a mental disorder and to substitute therefore a new category titled Sexual Orientation Disturbance.” 7th Printing of Diagnostic & Statistical Manual, 1974

43. 2003 The American Psychiatric Association holds a symposium debating the removal of the paraphilias, including pedophilia, from the DSM

44. Surgeon General 2002 • “The duel policies of community care and deinstitutionalization were implemented without evidence of effectiveness of treatments and without a social welfare system attuned to the needs of hundreds of thousands of individuals with disabling mental illnesses.”

45. Goals of The President's New Freedom Commission on Mental Health • Americans understand mental health is essential to overall health • Mental health care is consumer and family driven • Disparities in mental health services are eliminated • Early mental health screening, assessment, and referral to services are common practice • Excellent mental health care is delivered and research is accelerated • Technology is used to access mental health care and information

46. “Barriers to greater HIT adoption are the need for increasedtraining for health care clinicians who were ‘educated in thepre-IT era,’ and data that suggest the public sector lags farbehind the private sector in integrating modern IT into leadershipand operations.”

47. “I am an invisible man. No, I am not a spook like those who haunted Edgar Allan Poe; nor am I one of your Hollywood-movie ectoplasms. I am a man of substance, of flesh and bone, fiber and liquids – and I might even be said to possess a mind. I am invisible, understand, simply because people refuse to see me. Like the bodiless heads you see sometimes in circus sideshows, it is as though I have been surrounded by mirrors of hard, distorting glass. When they approach me they see only my surroundings, themselves, or figments of their imagination – indeed, everything except me.” Ralph Ellison, Invisible Man