Mental Illness and Homelessness
The Ghost of Nurse Ratched Still Haunts Us
The novel “One Flew Over the Cuckoo’s Nest” by Ken Kesey was published in 1962. It was widely read and acclaimed. The book was adapted into a Broadway play in 1963 and re-appeared as a film starring Jack Nicholson in 1975. I was entertained first by the book and then by the film. Little did I realize at the time that “One Flew Over the Cuckoo’s Nest” was a primary driver of the public attitude around society’s treatment of the disabled and mentally ill. (Fiction and popular non-fiction shape public attitudes on many topics to a degree we often fail to recognize— except in hindsight. Think “Uncle Tom’s Cabin,” the “Left Behind” series, and “To Kill a Mockingbird” to name only a few—but that’s another topic.)
As it is put in wikipedia, “the narrative [“One Flew Over the Cuckoo’s Nest”] serves as a study of institutional processes and the human mind; including a critique of psychiatry, and a tribute to individualistic principles.” Totally opaque to me at the time I read it (and probably to most readers and movie goers) was the fact that “Cuckoo’s Nest” fueled a profound distrust of the motives and methods by which society tries to take care of its disabled and mentally ill, including even the methods by which society decides who is disabled and mentally ill.
Concurrent with the era in which “Cuckoo’s Nest” was shaping public attitudes, federal legislation was setting in motion a movement dubbed “deinstitutionalization”. Shortly before he was murdered in 1963, President John F. Kennedy signed into law the Community Mental Health Act (CMHA) providing federal funding for building local mental health centers. The CMHA, along with the availability of new anti-psychotic drugs, fueled the emptying out of state hospitals, but the CMHA’s best intentions around community-based psychiatric care were not realized:
Only half of the proposed centers were ever built; none were fully funded, and the act didn't provide money to operate them long-term. Some states saw an opportunity to close expensive state hospitals without spending some of the money on community-based care. Deinstitutionalization accelerated after the adoption of Medicaid in 1965. During the Reagan administration, the remaining funding for the act was converted into a mental-health block grant for states. Since the CMHA was enacted, 90 percent of beds have been cut at state hospitals.
Most Spokanites (including me, until recently) are only dimly aware of the existence of Eastern State Hospital in Medical Lake, Washington, just 15 miles west of Spokane. The history of Eastern State Hospital, as detailed in its wikipedia article, chronicles the local manifestation of the deinstitutionalization movement. In 1954 the patient population peaked at 2,274, housed in 23 buildings. In 2016, the hospital had a bed capacity of 274, with “91 in the Adult Psychiatric Unit, 101 in the Geropsychiatric Unit, and 95 in the Forensic Services Unit.” Meanwhile, the population of Spokane county has more than doubled, from 196,000 to 456,000, while the patient population at Eastern has dropped by a factor of 10. Many of the buildings at Eastern State Hospital stand empty.
Neither God nor evolution makes all of us humans mentally stable, non-drug using, model citizens. Ever. Coping with those of our fellow humans who are either temporarily or permanently mentally ill, drug addicted, destructive, and/or psychopathic—or just plain lawless—is an issue human society will never escape. Sometimes we are more successful and sometimes less, but the problem never goes away, especially not with something as simplistic as just building—and filling—a larger jail.
All of us, even the homeless folk pushing their worldly belongings in a shopping cart, all of us want—and deserve—to be safe from physical harm and our “stuff” safe from vandalism, thievery, and befoulment. It is worth a bet that in the 1950s many of those 2,274 folk held at Eastern State Hospital were examples of the same unfortunates who today wander our city’s streets talking to themselves, threatening others, defecating on sidewalks and in alleyways, and breaking windows. Some of them are known patients who are “off their meds”. The 1960s were full of hope that with burgeoning improvements in psychiatric medications that outpatient mental health services and the new medicines could allow people to live in the community. For some people among those formerly housed at Eastern State, rejoining local communities with outpatient support worked well, but others, over time, were condemned to a life on the streets. We ought to ask ourselves how that happened.
For some, deinstitutionalization was seen as an opportunity to reduce costs. After all, if, with a little counseling and some pills, people can manage in the community mostly on their own it will be cheaper than the state or county providing room and board along with some form of behavioral management in a centralized institution. Officials in state and local governments, faced with managing budgets strained by endless anti-tax rhetoric from the Republican Party, saw other needs on which to spend constrained funds. The federally enacted and well-meaning Community Mental Health Act did not guarantee funding for the community-based alternatives—and Reagan’s subsequent “states’ rights” move of block grants shifted decision-making to state and local officials buffeted by competing budgetary demands.
Over the same seventy years since “Cuckoo’s Nest”, laws began to change that gave people the “freedom” to refuse to cooperate with treatment as long as they were not deemed a “clear threat” to themselves or to others. These laws and court cases were in line with public perception that was, in part, driven by “Cuckoo’s Nest”. Nurse Mildred Ratched became the emotional stand-in for the institutional system of psychiatric care, while the gentle giant, "Chief" Bromden, came to represent the put-upon institutionalized psychiatric patient with whom the public could identify. The movie, and the general attitude of the 1960s, fostered not only suspicion of psychiatric diagnosis (and government authority in general) but validated the “freedom” of individual expression. The consequences of all this still reverberate.
Mental illness is endemic to humanity. There is no magic pill and no universal identifier. Many of us have experienced the pain and heartache of dealing with and trying to help—and get help for— a mentally ill family member. The struggles are heart-rending, emotionally draining, and often tragic, like that of Ethan Murray, gunned down by a Sheriff’s Deputy in Spokane Valley. The current mental health system that might have saved Ethan is both underfunded and hamstrung by law and precedent.
Unrestrained, unmanaged mental illness is the most visible and, arguably, the most damaging contributor to the issue of homelessness. The damage includes damage to property, damage to other people, including other homeless people, and damage to the image of the overall homeless population.
We cannot successfully address homelessness or mental illness in Spokane by building a bigger jail and filling it with the product of a wildly overzealous County Prosecuting Attorney. Nor can we (nor should we) return to the 1950s, re-fill the empty buildings at Eastern State Hospital, and re-visit the abuses of the time (even if making some use of those buildings might make sense as part of a broader plan). At the same time we cannot allow behavior that will destroy our downtown by people who at one time would have been inmates at Eastern State Hospital .
We got to where we are now with both homelessness and mental illness very gradually, like the proverbial frog in the warming water. Getting out of this mess cannot happen overnight—and no simple solution like a bigger jail or moving the downtown police station to new digs is going to solve it either. First, it will take understanding and acknowledgement of how we got here and then a long term, concerted effort to get ourselves out.
Law enforcement cannot help us sort out the downtown dilemma until we find a workable place for people living on the margins of society to be safe and stay out of the weather. Downtown has had enough—and NIMBY (not in my backyard) responses counter nearly every attempt secure a location anywhere in the city. We need to look at outlying, safe, manageable locations and then provide ample transportation and a social service hub. That will cost money—but it already costs both private and public money to manage the problem downtown. It will be far easier to address the vandalism, filth, and behavior that threatens the viability of our downtown when secure shelter is available to those willing to accept it.
In the longer term we need to work to improve society’s ability to care for the Ethan Murrays among us. That will take empathy, money, and some legal and judicial change that gives families, mental health professionals, and law enforcement the tools with which to help. Let us not be hamstrung by the public image of mental health care embodied by the memory of Nurse Ratched in “Cuckoo’s Nest””.
Keep to the high ground,
P.S. In writing this I was struck by understanding that nearly all of us (including, I suspect, the majority of people now homeless) want the same things: food, shelter of some kind, warmth, and safety for ourselves and our stuff. We, as a society, have always had to reckon with social outliers who are mentally ill or psychopathic. We struggle to properly define those terms as applied to any one individual. Each person has their unique story. Laws and appropriations can steer the ship’s course, but ultimately homelessness and mental illness must be addressed one person at a time.