Rethinking mental health care

De-institutionalization of mental patients was better than locking them away, but outpatient treatment has often been inadequate and underfunded. Now a new effort is being made to coax those experiencing mental problems into programs that gently support them and foster their reintegration into society. 

Mental illness is a riddle within an enigma: A person dealing with it can be unaware something is wrong, unable to describe the problem, incapable of following a course of treatment, and ashamed of the stigma that accompanies it. Often, people in this state retreat into their own world. The writer Sylvia Plath recalled that telling someone about the depression she was experiencing was “so involved and wearisome that I didn’t say anything. I only burrowed down further in the bed.”

Those who live with, care for, or come into contact with a person in the grip of mental illness can be confused as well, not knowing how to help or when or if to intervene. In an earlier age, people considered mental illness to be demonic possession. The modern medical approach has oscillated between environment and heredity in trying to explain it and has employed everything from therapeutic conversation to isolation wards, powerful psychotropic drugs to disturbing operations in an attempt to cure it.

As late as the 1990s, doctors were obtaining permission from mental patients (by definition, this was not “informed consent”) to conduct experiments in which their medication was drastically altered so that researchers could observe acute episodes of the disease. Doctors said this was the only way to understand psychosis, since a patient couldn’t describe what was going on. Patients were, in effect, being treated like human guinea pigs.

Until the late 20th century, society “solved” the problem of mental illness by forcing those dealing with it into asylums and clinics. Those who had been committed – some with severe problems but others who were merely eccentric or occasionally troublesome – were out of sight and out of mind. And while people joked about the “funny farm” and “loony bin,” the dire conditions inside asylums, when finally exposed by journalists and reformers, shocked polite society.

All of which made deinstitutionalization seem progressive when it began in the 1960s. But outpatient treatment of the mentally ill has been largely inadequate and underfunded over the years, leaving families, friends, and individuals with mental issues to shift for themselves. Some eke out productive lives. Some live in the shadows. From time to time, a very few have fateful encounters with the outside world. Mass murders in Aurora, Colo.; Newtown, Conn.; and other places have raised new questions about whether enough is being done to help the mentally ill and to spot those who are potentially violent.

The paradox of mental illness – the inability of the individual and those nearby to understand it and of doctors to treat it – makes it a problem with no simple solution. In a Monitor Weekly cover story (click here for the story and here to subscribe to the Weekly), Amanda Paulson spotlights promising new programs aimed at coaxing those experiencing mental problems into programs that gently support them and foster their reintegration into society. That seems to help in some cases. More aggressive intervention may be still needed in other cases. 

If society has long struggled to figure out how to help the mentally ill, at least it has moved on from believing that anyone acting odd should be locked away. We seem to be moving beyond the laissez faire approach as well. New attention to mental illness is bringing it into the open – and that is giving rise to new ideas for dignified treatment. This isn’t the kind of problem that has ever gone out easily, but thoughtfulness, patience, and hope help.