On June 21, 2023

‘The system is broken’ is a cruel joke, there is no system


By Richard Rawson

Editor’s note: , Ph.D, is a research professor at the UVM Center for Behavior and Health. He lives in Brandon. He also is a professor emeritus in Psychiatry at the David Geffen School of Medicine at UCLA.

In a June 8 commentary, Jim Tomczak poignantly described the impossible situation he faces in caring for his son who suffers schizophrenia. 

He and his family members have spent many years experiencing the grim consequences created by the periodically severe symptoms of his son’s brain disease. He describes without anger or accusation his “no good choice” options that he has in caring for his very sick son. Let the son live at home and subject the family to living as hostages to their son’s brain disease, or, evict the son to fend for himself on the street. A choice no parent should be forced to make.

Tomczak is far from alone in this Catch-22 world. Many parents and spouses and children of seriously mentally ill or severely addicted individuals live in this world without humane choices. Options for involuntary treatment are very limited. The abuses of involuntary commitment portrayed in “One Flew Over the Cuckoo’s Nest” in the 1970s led to laws that make it nearly impossible to intervene on an individual against their will. 

In his brilliant new book, “The Best Minds: A Story of Friendship, Madness and the Tragedy of Good Intentions” (2023), Jonathan Rosen tells the story of his brilliant childhood friend, Michael Laudor, who overcame his struggle with schizophrenia to graduate from Yale Law School, only to crash into tragedy when psychosis gained control of his brain and behavior. 

As he tells the story of his friend, Rosen weaves into the narrative a history of the American mental health system from the idealistic days of the Kennedy administration, when the 1963 Community Mental Health Act outlined a plan to “deinstitutionalize” people with mental illness. The plan involved closing the state mental institutions and a transition to a system of community mental health centers, combining medication treatment and psychological and social supports. 

Over the next decade, many mental institutions in the U.S. were closed. But the community mental health system never happened. “Deinstitutionalization” became synonymous with “dumping” seriously mentally ill individuals into communities with no adequate system of treatment and support.

The current situation described by Tomczak is repeated for millions of families in the U.S. Individuals like Mr. Tomczak’s son are the “lucky” ones, as they have families who provide love and support. However, for those without families to provide support, or for individuals whose illness is so severe that they are unable to accept support, they are abandoned to life on the street, with their lives governed by brains tortured by psychosis and/or addiction. 

The often-heard “the system is broken” is a cruel joke. Although there are many deeply committed individuals and organizations working to provide help to individuals suffering from serious mental illness and severe addiction, there is no coordinated “system” that is even close to being adequate to meet their needs. 

And while no one is advocating for a return to an authoritarian civil commitment approach in pre-“Cuckoo’s Nest” times, for individuals like Tomczak’s son and Michael Laudor, a new paradigm is needed so that individuals whose brain is controlled by psychosis and addiction can be helped despite the wishes of their dysfunctional brains. 

In every American city and in rural America, there are legions of unhoused individuals, some percentage of whom have serious mental illness and/or severe addiction. In many communities, the people who are called upon to manage crisis situations with these most seriously ill patients are the police. With what other illnesses do we call on police to be the health care system’s therapeutic agents? 

When the coronavirus derailed normal life in the U.S. and was killing tens of thousands every week, the U.S. scientific community, together with pharma and the public health system, almost miraculously came together to develop and deliver multiple effective vaccines in less than a year. This Covid vaccine story demonstrated that, when a problem is deemed serious enough, America can focus and coordinate its technical expertise and funding to produce solutions. 

The situations described by Tomczak and Jonathan Rosen and experienced by millions of seriously mentally ill and addicted individuals requires a similarly intensive and coordinated effort. Half-measures won’t fix this situation. 

Fifty years ago we shut down mental hospitals, but failed to build a replacement system. It’s time to bring together the best minds in psychiatry, addiction treatment, housing, and social services to create a coordinated response to the needs of these individuals with severe brain disease and provide hope and alternatives to them and their families.

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