Thursday, November 6, 2014

The Shadow State Hospital System

Up until fairly recently, every psychiatrist at some point in their career was aware of a state hospital system.  The state hospitals were at one point the only available resource for long term care for most residents in a state.  They were also the facilities designated to care for people who were mentally ill and in some cases designated as dangerous to society.  That includes a population  with severe neuropsychiatric illness who have disorders that do not respond well to treatment and always represent some risk in terms of chronic aggressive behavior.  There is a population of people who are adjudicated as mentally ill but criminally culpable - that is they have failed a Not Guilty By Reason of Insanity (NGRI) defense.  This same group can be in a state facility being treated to the point where they are competent to proceed to trial or the minority group of NGRI defendants who have been adjudicated as not guilty but still need treatment before they can be released.  There is an assumption at some nonmedical level that psychopaths and people with antisocial personality disorders associated with aggression can be separated from the mentally ill persons and sent to the correctional system while some of those same definitions result in indefinite stays in specialized state mental hospitals.  The legal systems of some states designate certain forms of psychopathy or other criminal behavior a mental illness in order to allow for indefinite detention of people who are considered to have committed more heinous crimes like violent sexual offenses or sexual offenses against minors.

 At one point there were very large numbers of persons in state mental hospitals.  Two historic movements resulted in large numbers of these patients being released.  The first was the deinstitutionalization movement.  Historian Edward Shorter attributes the start of deinstitutionalization to psychopharmacology - specifically the invention of chlorpromazine that was FDA approved in 1954.  According to Shorter, the total number of patients in state and county mental hospitals declined from a high of 559,000 in 1955 to a low of 107,000 in 1980 or an 80% decrease.  In reality, many of the discharged patients did not take the medication reliably or developed side effects.  Shorter credits the "antipsychiatry movement" with providing continued impetus for state hospital discharges by suggesting that the institutions could be replaced by ""therapeutic communities" - a romanticized version of welcoming friends and neighbors clasping the mentally ill to their bosoms."  He also credits the National Institute of Mental Health with promoting this view.  The movement led to large numbers of mentally ill persons being homeless, not cared for medically or physically,  and  with dwindling resources for outpatient medical care when Community Mental Health Centers started to focus on providing psychotherapy for people without severe mental illnesses.  The Treatment Advocacy Center looks at available bed per 100,000 population as a rate.  They put the minimum acceptable figure at 50 beds/100,000.  In 1955, there were 344 beds per 100,000.  In 2005, that number had dwindled down to an average of 17/100,000 with a range of 7.1 to 50.  According to that same report 42 of 50 states had less than the minimum recommended number.

My copy of Shorter's text was published in 1997 and it says nothing about the managed care era and the effect of managed care on state hospital systems and the community systems of care that were supposed to be there to treat the deinstitutionalized.  There were few of these systems at the outset.  In the 1970s and 1980s there was the beginning of a larger community psychiatry movement and some experts began to develop systems of care to support patients who had been in state hospitals in the community.  Those systems of care were by far the exceptions rather than the rule.  When managed care took over there was no longer an asylum or a containment function in community hospitals.  People with severe mental illnesses could no longer go to short term hospitals because they were no longer able to function or they had numerous problems that were too difficult to be managed in an outpatient setting.  The only reason for hospitalization was the managed care concept of "dangerousness".  Suddenly it no longer mattered if you were manic and squandering your resources, ruining your marriage and losing your job.  Unless "suicidality" was detected or there were threats to kill somebody, a person would be discharged from the emergency department.  Not only that but, anything said in the emergency department was now taken at face value.  A patient could have been tearing up their home, obviously paranoid and threatening a neighbor.   As long as that person said he or she had no intent to harm themselves or anyone else,  they would be discharged even if the family bringing them to the hospital was horrified with that decision.  That is the state of managed care and its impact on psychiatry even to this day.  The reason is quite clear.  Several studies have shown that adequate community treatment of some persons with mental illness may be no less expensive than state hospital treatment.  It is only by providing rationed or no treatment at all that a state or health care company saves money.  That is also referred to as "cost-effective" care by the people who are rationing care.

The other interesting twist is the spin put on deinstitutionalization.  I know one of the leading proponents of this process in the 1970s and had him as an individual supervisor.  I can still recall his presentation about why he became interested in community psychiatry and was one of the leaders.  It was a single black and white photo of a large gymnasium sized room in a state hospital.  There were about a hundred men in the photo and there was room enough to have all of their cots arranged edge-to-edge across the floor.  So never let it be said that state hospitals were luxurious places to begin with.  That fact alone was one of the main reasons that psychiatrists were interested in getting patients out.  

So what is the shadow state hospital system?  At the first level it is an administrative one.  The administrative systems for any state hospital systems have always been fairly intensive.  At some point, there is a predictable scandal and a political reaction to the fact that the many of  these hospitals were mismanaged by the political system in the first place.  It is another case of politicians reinventing themselves by reforming something that they mismanaged  in the first place.  Some clear examples include each of the following:

1.  People with psychiatric illnesses used to pack state hospitals and now they pack jails and emergency departments.  One of the primary goals of the shadow state hospital is to give the public the impression that this is more humane and more effective treatment than real state hospitals run by psychiatrists.  It also effectively removes a large block of people with chronic mental illness from active treatment relationships with psychiatrists.  Any family advocates for these patients and psychiatrists themselves can unite to advocate for these patients but they are neutralized when the system is managed to allow a few 20 minute appointments with the psychiatrist per year.

2.  Rationing to the point of of the absurd is a theme that crops up on a regular basis over time.  That is true, whether you were an asylum psychiatrist seeing 500 patients or a hospital where serious injuries to staff and patients occurs.  Another goal of the shadow state hospital is to give the impression that no matter what, administrators somehow have special knowledge on how to run psychiatric services.  Nothing could be further from the truth.  The psychiatrists themselves end up jumping through a large number of administrative hoops since they are caught in this endless stream of bureaucracy and have less and less time for direct patient contact.  Bureaucrats with no appreciation of clinical medicine lack an appreciation for two critical factors in psychiatry.  Those factors are the quality of all assessments of a patient's problem depends on the time spent in direct contact with that patient.  The quality of any intervention including the prescription of medication also depends on time spent with the patient.  Together that time and relationship with the patient is the best predictor of outcome.  All administrative measures in the shadow state hospital seem to be designed to negatively impact that parameter, including the replacement of psychiatrists by "prescribers."

3.  The shadow state hospital doesn't really need psychiatrists.  Despite the fact that psychiatrists have (by far) the most training of any group of physicians or mental health professionals in hospital care and care of patients with the most serious mental illness, all of the administrative focus is the general elimination of psychiatrists.  I think it makes perfect sense from the administrative side.  If you are an administrator who is accountable to politicians or government bureaucrats - eliminating psychiatrists accomplishes two goals.  The first is taking out any professional opposition to any measures that you decide to implement from the perspective of a person with little to no training in the treatment of mental illness.  The second, is having a group of professional employees to scapegoat.  What better arrangement could there be than hiring people who are overworked to the point that they have little time left to muster any opposition to your plans and that same overworking in a dangerous environment puts them at risk for adverse events that they can ultimately be blamed for?  All of these events are the predictable outcome of people working in a split environment.

4.  Collecting data on citizens for reasons other than their psychiatric care.  To address the ongoing problem of gun violence by some of the mentally ill, many states have adopted legislation that allows a bureaucrat to collect data on people who have been committed for the purpose of putting them on a master list to prevent them from acquiring firearms.  The number of people denied in this manner is very small compared with domestic violence perpetrators or felons, but that doesn't prevent this false solution to the problem of gun violence at the cost of collecting this data.  In many states the only way to get into any existing mental health facilities is by civil commitment.  There is also a process for collecting financial data on the same population for the purpose of collecting money for the cost of hospitalization.  Is it ethically correct to forcibly collect fees from people with few resources who have been court ordered to get treatment?  I don't think so but apparently state and county governments do.

5.  Creating more administrative burdens to adequate treatment.  Some people who were previously treated in state hospitals are in foster care settings.  In Minnesota there was a recent ruling about developmentally disabled patients in a state hospital being secluded and restrained excessively.   That resulted in a long court ruling that applied to that incident and resulted in a financial reward to members of the class action suit, the closing of that hospital, and several administrative procedures that started to affect the providers of adult foster care.  In one case the administration of any "as needed" medication including sedatives for sleep, anti-anxiety medications, and antipsychotic medications - required a foster care provider to go online and complete a 7 page report.  Even a few extra doctor ordered doses of medication per week results in a tremendous paper work burden.  This burden was created for people who have been in stable foster care situations for years and who had been receiving excellent medical and psychiatric care.

6.  The prevention of violence and the care of the violent or aggressive patient in the community is a more bothersome situation.  Several years ago, a friend of mine told me that his son was involved in staffing a small group home that specialized in the treatment and support of violent mentally ill patients in their own adult foster care setting.  If the patient because aggressive, the staff would use pads to hold the patient to the floor until the aggression passed.  I was shocked to hear about this arrangement because there was no onsite supervision or training by anyone specializing in the treatment and containment of a physically aggressive person with mental illness.  Treating this behavior in a hospital setting with a well trained staff and clear support by the administration is difficult enough.  Now it seems that we have mini-facilities trying to provide some level of containment for aggression in residential buildings with a few staff on site.

7.  The use of limited state hospital resources for political purposes continues.  The best example is commitment for psychopathy or sexual offenses, both disorders that have no treatment and are not considered psychiatric disorders in most cases by the legal authorities.  How is it that people committing sexual offenses are hospitalized indefinitely and people with severe mental illnesses are refused admission to hospitals and eventually incarcerated for minor crimes?  Only through a shadow system.

8.  The large population of mentally ill persons who are continuously cycling between the emergency department (ED), very brief and ineffective stays on short term psychiatric units, and jail.  This constant churning is typically covered in the press as a reason for overcrowding of the ED, but the real travesty is that these patients never get their psychiatric and social problems resolved and that keeps them cycling in and out.  Discharging a person with a severe mental illness from a short term psychiatric unit or the ED does not solve anything for that person.  It is nothing more than an expensive time out.

9.  The family as hospital staff has always been with us but it has not been as prevalent since the 1950s or 1960s.  I can recall violent and aggressive patients cared for at home to the point that the entire home was trashed and family members and the patient in question had frequent severe injuries.  Short of that scenario, it is much more common today that a family becomes the default hospital staff in cases where a person with severe mental illness does not meet the managed care "dangerousness criteria" for admission.  That means the patient does not tell an emergency room physician or social worker that they are going to kill themselves or become aggressive.  Family members recognize the person needs supervision and monitoring 24 hours a day/7days a week.  I have really never met a family who could do that for more than a couple of days.  Of course they should never be put in that position, especially with the fees and taxes that every family pays for health care in this country.  Anybody who requires 24/7 supervision should be in the care of professional staff who can offer appropriate therapy and maintain a neutral relationship with the affected person.

10.  It is all about the money.  The war cry of managed care systems, government systems, and government systems managed like they are managed care systems is "cost effectiveness".  It has been known since the Hay Report that psychiatric and mental health systems took a disproportionate hit relative to all other areas medicine.  There has never really been an informed discussion of what  a reasonable budget for the provision of mental health services should be.   The cost of services is often impossible to find.  That is a bureaucratic recipe for transferring money somewhere else.  Even standard bureaucratic solutions like "a 5% budgetary cut across the board" will obviously hit the most marginally funded systems first and the hardest.  Those services are psychiatric services.  The Shadow State Hospital System can function as a funding source for other projects at the cost of providing treatment for persons with severe mental illness.

11.  Let's all pretend that there is a real State Hospital System.  The front end of this illusion usually starts out when a person actually meets managed care "dangerousness criteria" and the hospital case managers cannot discharge them.  In this case, the court usually assists the hospital in getting the patient out.  For example,  there used to be a system to commit patients with substance use problems to treatment.  Those patients are frequently released by courts on the basis that they "no longer do chemical dependency commitments".  In the case of severely disabled patients with mental illness, the court may ignore that standard in a state commitment statutes and release the person for not being imminently dangerous.  In both cases the patient is hospitalized for a few days longer than the 3-5 day managed care length of stay instead of being committed to a system of care.   It appears as though something has occurred but it really has not.  

The Shadow State Hospital System allows the state and its partners in private business to establish covert control over any mental health system of care - to the detriment of the professionals and patients in that system.  The exact number of administrative measures and facilities like the ones I outlined above are unknown.  Shadow systems thrive on a lack of transparency, at least until the next scandal happens.  At that point there seems to be some level of transparency, but it is always incomplete and the real story of what happened and why never seems to surface.

The real state hospitals systems were far from perfect, but it is time for medical accountability to replace government bureaucrats and the very weak standard of accountability of these bureaucrats.  Until the Shadow State Hospital System is recognized as the prime example of mismanaged care we will not be able to address the miscalculations of deinstutionalization or what Shorter called:

" of the greatest social debacles of our time."

George Dawson, MD, DFAPA


1:  Shorter E, A History of Psychiatry. John Wiley & Sons. New York, 1997.

Supplementary 1:  The image used for this post is of Dexter Asylum attributed to Lawrence E. Tilley [Public domain], via Wikimedia Commons.  The original image was Photoshopped with a graphic pen filter.


  1. Another very thoughtful post.

    The whole thing is one big charade. Reminds me of homelessness; what you don't see, doesn't exist. And, the idiocy of things like in your number 7 struck me particularly.

    There are many on the anti-psychiatry boards that believe that no care is better than bad care. However, reading your article reminded me that even if I accepted their premise, it is still the lack of compassion driving both.

    No care or bad care is equally abhorrent to me because one of the consequence of adopting the attitude of no care is that it contributes to bad care. It allows people to turn a blind eye to those in need for a self-righteous reason vs a political or economic one. And I really don't know why that makes it a better path to follow.

    1. Your point about no care versus bad care is far reaching.

      It is not only compassionless but it also lacks technical expertise. After all, the same boards you are referring to also make the associated arguments that all psychiatric care is bad care and therefore equivalent to no care. In fact, many of the complainers don't know what good psychiatric care is.

      The reasons for that are many fold but among them are rhetorical posturing and of course direct exposure to the shadow system. Since the shadow system is not run by psychiatrists - it makes sense that it is a low quality system.

      The following thought experiment might be useful - a shadow system of care for any group of medical problems run by administrators, politicians, and the courts and run strictly on subjective decision making.

  2. BTW, love the graphic pen filter on the image. That turned out really well.

    1. Agree Adobe makes good stuff. Not a shareholder but this is my plug to get them to reconsider their cloud based licensed approach. Make me a new Photoshop that I can purchase flat out for my Mac. I imagine there are a lot of folks like me using older versions of Photoshop who (like me) will never upgrade to a licensed cloud based version.