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

• Its a system that doesnt support you when you
  need it, and theres 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 policiesare 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 cont.

• 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.

31
(No Transcript)
32
(No Transcript)
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.

36
(No Transcript)
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
cont.

• Psychiatry is the enemy incarnate. Psychiatry
  has waged a relentless war of extermination
  against us. Were 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 increased training for health care clinicians
  who were educated in the pre-IT era, and data
  that suggest the public sector lags far behind
  the private sector in integrating modern IT into
  leadership and 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