A broken system
I was relieved to see your article “I have a dream … for psychiatry” (From the Editor, Current Psychiatry, November 2021) about your wish for changes in psychiatry. I have been feeling this way for a very long time, and it’s truly disturbing to feel like society as a whole has turned a blind eye to this humanitarian crisis.
Psychiatry does need better treatments. On the other hand, we do have many effective treatments that simply are not available to many.
This brings me to ask, how is it that overall psychiatric care is actually worse now than in, say, the late 20th century? There might have been fewer psychopharmacologic treatments available back then, but there was overall better access to care, and a largely intact system. For lower-functioning patients, such as those who are homeless or in jail, I do believe this is the case, as I will explain. But even higher-functioning private practice patients are affected by the shortage of psychiatrists.
In 2022, the system is broken. Funding is abysmal, and numerous psychiatric hospital closures across the United States have led to simply no reasonable local access for many.
Prisons and jails are the new treatment centers! As you have rightly pointed out, by being housed in prisons with violent criminals, severely mentally ill patients are subjected to physical and sexual abuse daily.
Laws meant to protect mentally ill individuals, such as psychiatric holds, are often not implemented. Severely mentally ill patients can meet the criteria to be categorized as a danger to self, danger to others, or gravely disabled, but can’t get crisis intervention. Abandoning these patients to the streets is, in part, fueling homelessness and drug addiction.
In my opinion, the broken system is the fundamental problem that needs to be solved. Although I long for novel treatments, if there were such breakthrough treatments available—as exciting as that may be—how could they be delivered effectively in our current broken system? In other words, how can these patients be treated with neuroscientific breakthrough treatments without the necessary psychiatric infrastructure? We are at such an extreme, I worry for our specialty.
In Karl Menninger’s The Crime of Punishment, one passage stuck with me: “I suspect that all the crimes committed by all the jailed criminals do not equal in total social damage that of the crimes committed against them.”1 I have often wondered how that relates to the criminalized mentally ill, who are punished daily by being in horrific, abusive, unsafe settings. What truly is their crime? Being mentally ill?
Given how the system is now engineered to throw these patients in prison and allow them to be abused instead of admitting them to a psychiatric hospital, one must wonder: How did this come to be? Could it go beyond stigma to actual hatred and contempt for these people? After all, as psychiatrists, the abuse is in plain sight.
Finally, I have often wondered why there has not been a robust psychiatric organizational response to the breakdown in access to patient care. I can only hope that one day there can be.