Flying Over the Cuckoo’s Nest

Parker Mee
Jul 10, 2017 · 13 min read

The National Institute of Mental Health approximated that 100,000 citizens will face their first onset of psychosis this year. All this with a total of only 108,000 psychiatric bed in the United States to assist them and their approximately 44,129,689 other adults with serious mental illnesses. While asylums of the past have been havens for negligence and abuse, the prior failure of programs should not determine their future. By examining how the structure of institutions failed in the past, more ethical institutions can be formed in the present. While some would say this program would be too expensive, the disproportionate prevalence of people with serious mental illnesses in prison shows that society is already supporting many people with mental illness. The problem with the current way the United States is dealing with these mental illnesses is that these people are being held, not thoroughly treated. The United States is facing an intense shortage of quality mental health care and the only way to work towards a more equitable solution is by turning to the past, noting what caused the shortage to exist in the first place.


Michel Foucault wrote a seminal work in the study of history and the philosophy around the creation of mental institutions called Madness and Civilization (1977). This work argued that mental illness was a separate entity from madness. It posited that madness was such a nebulous idea that it was nearly impossible to become “cured.” He argued there were two purposes of the early asylum, to cure the “mad” and to store the “mad” away from society to protect the society as a whole. As time went on, he saw the modern asylum losing these central tenants and beginning the process of being the only place a person could receive mental health treatment. He argues, “There is no common language: or rather, it no longer exists; the constitution of madness as mental illness… bears witness to a rupture in a dialogue… The language of psychiatry, which is a monologue by reason about madness, could only have come into existence in such a silence” (1977, p. xxvii-xxxix). This silence instigated changes behind the scenes in psychiatry, eventually leading to its own fall in credibility.

Hamilton Psychiatric Hospital- A Kirkbride Style Asylum

Danvers State Hospital is a representative microcosm of the journey of the mental health system in America. Founded in 1874, the Danvers State Hospital was built according to what was known as the Kirkbride Plan, an architectural philosophy surrounding around the idea that more air and sunlight made treatment even more effective (Kirkbride, 1880). The hospital started with 500 patients and a few dozen staff. However, as with many good things, this too came to pass as Massachusetts increased the number of patients assigned there while cutting the budget. The hospital was built to sustain 500 patients at a time. However, by December of 1918, the average population of the hospital was 1500 and over 230 people died per year. The superintendent of the hospital noted that “there is… a tendency to turn over… the helpless infirm, the troublesome dotard, the friendless bedridden. The medical certificates in many of these cases are an interesting study, the indications of insanity recorder often being trivial, far-fetched and insignificant” (Annual report of the trustees, 1918, p. 34). Just seven years later, the hospital was still increasing the number of patients treated while its capacity was getting no bigger. The average annual population for the Danvers Lunatic Hospital was 1705, just over 1200 more than its intended capacity (Annual report of the trustees, 1918, p. 32).

The inability of the staff to deal with the patients is noted by the superintendent of the hospital in his letter to the trustees. He pleaded with the legislature to build new living quarters saying, “Those who are acquainted with the conditions of our wards are deeply imbued with a sense of the embarrassment of service due to over-crowding… The normal working capacity of this hospital is estimated at 1550. Our average population for the six months has been 1730. These facts are sufficient arguments in favor of additional ‘breathing space’” (Annual Report of the Trustees,1925, p. 20). Unfortunately, the legislature denied a budget increase to support for construction of necessary expansions at Danvers.

In 1935, a solution arrived on scene; the problems presented by overactive patients were those of days past. A solution that was awarded the Nobel Prize for Medicine (Jansson, 1998). A “humane” solution to suffering in the mentally ill: the Prefrontal Lobotomy. Created by António Egas Moniz of Portugal, the prefrontal lobotomy scrapes portions of the frontal lobes and prefrontal cortex leaving the patient sedate and intellectually disabled. These surgeries were carried out by neurosurgeons and in the controlled environment of operating rooms; however, this was about to change again. Walter Freeman, a neurologist trained at the University of Pennsylvania Medical Center, wanted to help overcrowded state mental facilities which did not have surgeons or operating rooms. What he developed was the transorbital lobotomy, more commonly known as the “icepick” lobotomy. This was a procedure despised enough to break his partnership with surgeon James Watts, who had serious moral objections to the transformation of the procedure from surgery to one not requiring a surgical degree (El-Hai 153–187). The first transorbital lobotomy was performed by Freeman in 1946. Over the next 25 years Freeman performed around 2500 “icepick” lobotomies before killing his patient Helen Mortensen. This was in no way his first kill. He killed as many as one hundred patients over his career going around the country in the “lobotomobile” (“A Lobotomy Timeline”).

The advent of this new procedure and its ease led to over 40,000 taking place in a span of around ten years (“A Lobotomy Timeline”). At its height, there were true travesties being committed, such as the lobotomization of children including Walter Dully. His memoir My Lobotomy (Dully & Fleming, 2007) covered not just his own lobotomy at the age of 12 but also the general atmosphere surrounding the media’s support of the procedure in the early days of the procedure. While this was supposed to help institutions by lightening their patient load, instead the nurses were now expected to assist patients with little to no mental capacity. Dully and Fleming talk about this in My Lobotomy saying, “Many of Freeman’s patients were so damaged by the surgery that they needed to be taught how to eat and use the bathroom again. Some never recovered” (2007, p. 67).


Photo: Bill Allen, AP

Dr. Leon Eisenberg, a psychiatrist who practiced from 1940 up though 2010, extensively covered the changes in the social and medical treatments of mental illness in his article “Were we all asleep at the switch?” He says that the deinstitutionalization movement was motivated by “a socio-political movement in favor of open hospitals and community mental health services; the advent of psychotropic drugs able to abort psychotic episodes; and a financial imperative to shift costs from state to federal budgets” (Eisenberg & Guttmacher, 2010, pg. 97). Deinstitutionalization officially began with the Community Mental Health Act under President John F. Kennedy. This act outlined the building of 1500 decentralized mental health care facilites, “meaning that the population of state mental hospitals…could be cut in half” (Smith, 2013). However, this dream was never realized. Michelle Smith continues, “only half of the proposed centers were ever built, and those were never funded” (2013). As deinstitutionalization became the policy within the United States, policy makers forgot to examine what caused the issues in the asylums in the first place. This led to issues of the same variety as before, underfunded and overcrowded psychiatric wards. While the psychiatrists fall under greater oversight, the people who need treatment are generally unwatched and unregulated.

The promise of freedom and relief from suffering for the patients in mental hospitals was an unactualized one. The money given to states to build these new centers were given in the form of block grants with a suggestion of building mental health community centers. However, with the tightening of budgets in the late 1970s and early 1980s, one of the easier things for state and federal budgets to cut was mental health care (Eisenberg & Guttmacher, 2010, pg. 97). This has had wide-reaching implications even into the current situation with mental health care, or, more precisely, the lack of it.


It is time to fulfill the promise of freedom from oppression in mental hospitals while also providing for freedom from the ails of mental illness. Currently due to the lack of mental health care availability, a disproportionate amount of the mentally ill are homeless or in prison. In the Time Magazine article titled “Dangerous Cases,” it notes that while only 4% of the general population suffer from serious mental illness, the mentally ill make up 15% of state prisoners and 24% of jail inmates. While this might suggest that mentally ill people are dangerous, most of these incarcerations are from non-violent offenses (Edwards, 2014, p. 54–59).

Some might argue that in this time of high federal and state budgets there is no room for an investment in mental health community centers or that there are bigger issues at hand. However, the American citizens have already been paying to support the mentally ill. Not just through the cost of prisons, homelessness or early mortality, but in health care expenditures, loss of earnings and disability benefits. The cost of serious mental illness to the US in 2002, according to Dr. Thomas Insel, is $317.6 billion, not including incarceration, homelessness, or early mortality (2008, p. 664). However, the cost of mental illness is not just limited to benefits and lost earnings, the storage of the mentally ill in prisons substantially increases the cost to the United States. The Stanford Law and Policy Review published an article titled “A Reflection on the Madness in Prisons” in 2015. Alongside the discussion of how prisons can breed mental illnesses through constant fear and solitude, it also discusses how “Los Angeles County Jail and Rikers Island have become the largest de facto mental institutions in this country. Nevertheless, those with mental illness are usually subject to harsher treatment, longer sentences, and leave jails or prisons sicker than when they entered” (2015, p. 256). They continue by saying, “the proportion of people in this country who are currently housed in either a mental hospital or a correctional facility is almost exactly the same as it was fifty years ago…Then, approximately 75% were in mental hospitals and only 25% in prisons, jails, and juvenile detention centers; today, 95% are in correctional institutions and only 5% in mental hospitals” (p. 258–259). With the average stay for a mentally ill individual being over five time the average stay at Rikers Island, the cost to the public is large. During this time the conditions that breed further mental illness can exacerbate the possibility of recidivism (Lee & Prabhu, 2015, p. 261–262). America is currently spending its money on the containment of mentally ill individuals, rather than the treatment of their illnesses.

Thomas Insel director of the NIH from 2002 to 2015, wrote an editorial in June of 2008 titled “Assessing the Economic Costs of Serious Mental Illness,” arriving at a cost of $317.6 billion (pg. 664). However, this excludes “incarceration, homelessness, comorbid conditions, and early mortality” (pg. 664). The cost of comorbid conditions and early mortality are difficult to predict and, therefore, are nearly impossible to calculate. However, the cost of incarceration is more easily calculatable and has a relatively predicable cost. According to the Treatment Advocacy Center, there are “approximately 356,000 inmates with serious mental illness in jails and state prisons” (2014). By using the data referenced by Director of NAMI, Mary Giliberti, “housing an inmate with mental illness in jail costs $31,000 annually” (2015). By using this amount and multiplying it by the number of prisoners, a safe estimate of $11,036,000,000 can be reached. By adding this amount to the original approximation, the total cost of mental illness to the United States per year sits at $328,636,000,000.

Another cost which can be approximated into our total is the cost of the chronically homeless who suffer from serious mental illnesses. Approximately one third of the chronically homeless population is suffering from untreated mental illness (Mondics, 2014). The approximate chronically homeless population is 77,486, per the US Department of Housing and Urban Development (“The 2016 Annual Homeless Assessment Report (AHAR) to Congress”, 2016, pg. 62). A study in 2002 from the University of Pennsylvania states that for shelter use and hospitalizations used by the seriously mentally ill homeless cost “about $40,449… (1999 dollars)” (Culhane, Metraux, and Hadley, pg.107). By using the change in the Consumer Price Index to calculate the “real cost,” the cost is equivalent to $59,144.64 per year for that same individual (“CPI Inflation Calculator”, 2017). Taking $59,144 and multiplying by the chronically homeless population who suffer from serious mental illness, the total cost is around $4,582,881,575. The final total for the costs of serious mental illness including incarceration and chronic homelessness is $333,218,881,575, or just under a third of a trillion dollars. This is a staggering amount, showing how much the United States is already spending to contain mentally ill individuals without providing them longtime support.

In the 2002 study of supportive housing costs for seriously mentally ill, chronically homeless individuals in New York State. By using the cost of living index for New York state, a normalization of cost can be calculated. Dividing the net cost increase by 2.3 results in an average net cost increase of $432.61, which in 2017 has the same buying power as $632.56 (“CPI Inflation Calculator”, 2017). According to Newsweek, 18.2% of the total adult population has a serious mental illness meaning that 44,129,689 adult people suffer from serious mental illness (Bekiempis, 2014). By multiplying this amount by the average increase in spending on housing the seriously mentally ill, a total increase of $227,914,676,073.80.

While this seems like a significant increase in spending, the benefits from the system would be outweighed by the cost. In housing the seriously mentally ill throughout their recovery, a decrease in the overcrowding of prisons and hospital emergency rooms would increase the effectiveness of both the criminal justice and heath care systems. Past this, the cost above is from New York who was simply housing and aiding the mentally ill, not charging anything to the residents.

Along with New York City, Salt Lake City instituted a plan to end chronic homelessness and the serious mental illness commonly found alongside it. The residents of their community mental health housing are expected to pay 50 dollars a month or 30% of their salary, whichever is higher (McEvers, 2015). Residents are put in contact with employment opportunities and through this they are able to pay this fee. Even at the minimum of $50 dollars a month, the cost increase would be reduced to just $32 dollars a year per person. Other benefits would be the increase in demand for food and clothing, increasing the aggregate demand in the United States. These individuals will be transitioned out of the government housing and into private housing once they can support themselves, financially and mentally. By getting the chronically homeless in cities into housing, whole areas can be revitalized into bustling developments without the issues tourists and cities encounters with homelessness.

Instead of focusing on punishing those with mental illness, the United States can invest in a more robust system that treats its mentally ill citizens instead of just storing them. By using the history of mental hospitals, a cause for the institutional abuse arises: a lack of oversight and budgetary limitations. While the United States would need to spend money to support these communities, it is already spending hundreds of trillions of dollars to handle the seriously mentally ill. The United States should ensure the ability for all of its citizens to receive the treatment necessary for their physical and mental health.

Resources

A lobotomy timeline. (2005, November 16). Retrieved from http://www.npr.org/templates/story/story.php?storyId=5014576

Annual Report of the Trustees of the Danvers State Hospital at Danvers, Mass. (Vol. 48, pp. 1–12, Rep. №20). (1925). Boston, MA: Rand, Avery & Co.

ANNUAL REPORT OF THE TRUSTEES OF THE DANVERS STATE HOSPITAL AT DANVERS, MASS. (Vol. 41, pp. 7–37, Rep. №20). (1919). Boston, MA: Rand, Avery & Co.

Bekiempis, V. (2014, March 04). Nearly 1 in 5 Americans suffers from mental illness each year. Newsweek. Retrieved from http://www.newsweek.com/nearly-1-5-americans-suffer-mental-illness-each-year-230608

Culhane, D. P., Metraux, S., & Hadley, T. R. (2002). The Impact of Supportive Housing for Homeless People with Severe Mental Illness on the Utilization of the Public Health, Corrections, and Emergency Shelter Systems: The New York-New York Initiative. Housing Policy Debate, 13(1), 107–163. Retrieved from http://www.tandfonline.com/loi/rhpd20

Dully, H., & Fleming, C. (2008). My Lobotomy: A Memoir. New York City, New York: Crown.

Edwards, H. S. (2014). Dangerous Cases. Time, 184(21/22), 54–59

El-Hai, J. (2007). The lobotomist: A maverick medical genius and his tragic quest to rid the world of mental illness. Hoboken, NJ: Wiley. doi:0470098309

Gilberti, M., (2015, May 5). Treatment, not jail: It’s time to step up. Retrieved from http://www.nami.org/

Insel, Thomas R. Assessing the economic costs of serious mental illness. American Journal of Psychiatry 165.6 (2008): 663–665. Web. Retrieved from http://ajp.psychiatryonline.org/

Jansson, B., (1998, October 29). Controversial psychosurgery resulted in a Nobel Prize. Retrieved from https://www.nobelprize.org/nobel_prizes/medicine/laureates/1949/moniz-article.html

Kuno, E., Rothbard, A. B., Averyt, J., & Culthane, D. (2000). Homelessness among persons with serious mental illness in an enhanced community-based mental health system. Psychiatric Services, 51(8), 1012–1016. Retrieved from http://ps.psychiatryonline.org/loi/ps

Kirkbride, T. S. (1880). On the construction, organization, and general arrangements of hospitals for the insane: with some remarks on insanity and its treatment . Phildelphia, PA: Lippincott.

Lee, B. X., & Prabhu, M. (2015). A reflection on the madness in prisons. Stanford Law & Policy Review, 26(1), 253–268. Retrieved from https://journals.law.stanford.edu/stanford-law-policy-review

McEvers, K. (2015, December 10). Utah reduced chronic homelessness by 91 percent; Here’s how. National Public Radio. Retrieved from http://www.npr.org/2015/12/10/459100751/utah-reduced-chronic-homelessness-by-91-percent-heres-how

Mondics, J. (2014, July 25). How many people with serious mental illness are homeless? Retrieved from http://www.treatmentadvocacycenter.org/fixing-the-system/features-and-news/2596-how-many-people-with-serious-mental-illness-are-homeless

United States of America, Department of Housing and Urban Development, Office of Community Planning and Development. (2016, November). The 2016 Annual Homeless Assessment Report (AHAR) to Congress. Retrieved from www.hudexchange.info

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