Families, Interrupted

And the biggest failure, in my opinion, is that much of the responsibility of caring for people with SMI has fallen on families, not medical professionals.

Lately I’ve been thinking a lot about the 2000 movie Girl, Interrupted based on the 1994 memoir of the same name by Susanna Kaysen, a recounting of her year and a half in a Boston mental hospital in the mid-60s when she was 18 years old. I remember when I first read the book and saw the film over two decades ago, I was disturbed by the issues Kaysen raised about gender bias in the psychiatric community, and the questions of patient rights at the time. I re-watched the movie recently and realized that over thirty years later, our current mental healthcare system hasn’t really improved. It still has disturbing issues. It’s just new disturbing issues.

Not long after Kaysen was released from McLean Hospital and on the heels of several news profiles of troubling practices at other psychiatric hospitals across the country, the United States started deinstitutionalizing state psychiatric hospitals as part of the civil rights movement, incorporating many special needs groups into mainstream society, including individuals with serious mental illness (SMI). At the time, there were three factors motivating the movement of people with mental illness from state-run hospitals into the community: the belief that these hospitals were deplorable and inhumane, that new antipsychotic and other psychiatric medications offered a “cure” for most, if not all, mental illnesses, and to save state governments money.

Changes to federal laws at that time also contributed significantly to reducing the number of available psychiatric beds in state facilities. The passage of the Community Mental Health Construction Act in 1963 made federal grants available to states for establishing local community mental health centers. Then came the introduction of Medicaid, which shifted funding for people with SMI in state hospitals from the states’ responsibility to a shared partnership with the federal government. This created an additional incentive for states to close the facilities they funded and move patients into community hospitals that were then partially paid for by Medicaid and the federal government.

Spoiler alert: this redesigned system hasn’t worked out as predicted.