"OHIO ONCE HAD one of the top mental health systems in the country," lamented the National Alliance on Mental Illness in a 2011 report. "Today, after several years of significant budget cuts, thousands of youth and adults living with serious mental illness are unable to access care in the community and are ending up either on the streets or in far more expensive settings, such as hospitals and jails."
The glory days of Ohio's mental-health department had already come to an end by the time the budget crises of the late 2000s rolled around. But the recession and the subsequent tea party austerity movement made things even worse. On the list of the 10 states that cut the most from mental-health budgets between 2009 and 2011, Ohio was No. 6. Then Gov. John Kasich's 2012-13 budget slashed local government funds by a billion dollars and continued a trend of downsizing community mental-health programs. "The most fragile people in our society, we looked out for them," the governor said. "And if there's a hole or a mistake, we'll come back later to figure it out." (He's since proposed restoring some services.)
"Ohio," as Roth explains, "is a microcosm of the United States." Collectively, states have cut $4.35 billion in public mental-health spending since 2009.
As in the rest of the country, Ohio allocates funds differently to different counties based on formulas and politics. My Aunt Terri was lucky to live in Lake County, Eleanor says. Not that it's perfect there: All the Neighboring programs Terri once participated in have been eliminated, and the county doesn't have the budget for enough group homes for its lowest-functioning mentally ill, which, if my family had been unwilling—or unable—to procure Terri her own place, would have been her last option. In this county of 236,000, there are a total of 18 "acute beds" in such facilities, so while Terri waited for someone occupying one of them to die, she'd have been checked into a psych ward at a hospital, and if Lake County didn't have any psych ward beds open, she'd have been moved to a hospital in Summit County, an hour away, if it had a bed. Eleanor says the need for group homes contributes to homelessness in largely suburban Lake County, where the single operating shelter, 30 percent of whose residents are mentally ill, turns away 800 calls a year. But at least Lake County still had the funds to give Aunt Terri a caseworker.
In some other places, Eleanor says, people "just fall through the cracks." Take next-door Cuyahoga County—home of the Cleveland Indians, and the largest mentally ill population in the state. William Denihan, CEO of the ADAMHS board there, explains that Cuyahoga has been the biggest loser, since the Ohio Department of Mental Health cut funding for community services there by 60 percent in 10 years. "The average county in Ohio got $4.20 per person" in state mental-health funding in fiscal 2012, he tells me in his office overlooking Lake Erie. But in Cuyahoga? They got 20 cents per person. Meanwhile, demand for beds in homeless shelters, along with emergency room and jail admissions, is exploding. "The prison population is the largest cost in Ohio," Denihan shakes his head. "The largest mental-health hospital is our jail system."
This is true across Ohio, where, 25 years into the Reagan-era policy changes but even before the recent austerity cuts, there were enough high-profile cases of mentally ill inmates being beaten, undertreated, killed by guards, or committing suicide to make it the subject of the 2005 Frontline documentary The New Asylums. But it is also true across the nation, where the three largest de facto psychiatric facilities are jails. In 2011, the sheriff of Cook County threatened to sue Illinois for making the jail the largest mental-health provider in the state. "We're not set up to do that, obviously," he said. As of 2006, 1.3 million of America's mentally ill were housed right back where they were in Dorothea Dix's day: in prisons and jails. Between 1998 and 2006, the number of mentally ill behind bars more than quadrupled; the share of mentally ill people among the incarcerated was five times higher than in the general population. More-recent national prison stats aren't out yet, but in some county jails, mental-illness rates have increased by nearly 50 percent in the last seven years. It's not uncommon for individual jails to report that 25 or 30 percent of their inmates are mentally ill, or that their mentally ill population rises year after year.
In Summit County, Ohio, just south of Cuyahoga, the sheriff announced last year that he would not "be a dumping ground anymore for these people," and shut the jail to admissions of the mentally ill. He was the first sheriff in the country to do such a thing—somewhat ironic given that the county is exceptionally proactive in keeping the mentally ill out of jails. To make up for the lack of state funds, Summit County passed a dedicated mental-health levy on local property taxes in 2007. It is also one of five training sites in the nation for mental-health courts, which get offenders into treatment rather than locking them away.
"No one ends up in jail rotting," Summit ADAMHS chief clinical officer Doug Smith promises me, dismissing the very notion of that happening here with a shake of his head. "We don't have those problems here, like they have in California."
Ah, California. No. 1 in the amount of mental-health funding cut from 2009 to 2011, No. 7 in cuts as a percentage. Home to one of the largest jail/psych facilities in the nation, the LA County Jail. Where visitors can't believe how many bat-shit-crazy homeless we've got. Where deinstitutionalization was pioneered under Gov. Ronald Reagan with the 1967 Lanterman-Petris-Short Act, which made it vastly more difficult to commit people, and where the rate of mentally ill in the criminal-justice system doubled just one year after it took effect. Where, often, the severely mentally ill live in jail for three to six months because they're waiting for a bed to open up in a psychiatric facility. California: where, says Torrey, the psychiatrist who warns about "predictable" violence like my cousin's, "they led the way in [deinstitutionalization], and they've led the way downhill. They're certainly leading the way in consequences."
THE TENDERLOIN, a neighborhood on the western edge of San Francisco's downtown, has never been quite as infamous as New York City's skid row once was, but it is no less deserving of its own depressing show tune. Emerging from the Civic Center subway station—with a guy stalking behind you barking, "Bitch. Bitch. Bitch"—you can generate a tour of movie-drama levels of abandoned humanity by simply doing a 360-degree spin. See a guy in a camo jacket selling four boxes of Kraft Macaroni and Cheese, cursing at unsellable mac and cheese. A guy rubbing his hands and smelling them, rubbing his hands, smelling them. A guy with a skateboard and chatty invisible friend to his lower right; another guy earnestly preparing a crack pipe; a filth-covered gal sitting and staring intently at nowhere; a lady with one shoe, no bra, a high ponytail, and a confused face, weeping and glancing around, lost in the broad light of day.
"This is not a ghetto," says Cindy Gyori, executive director of Hyde Street Community Services, one of the city's underfunded community mental-health centers. "Nobody is born here. They're looking for the end of the rainbow," and they end up here because San Francisco has "a reputation for being open." Of the 1,000 individuals the clinic sees per year, 44 percent walk in the door homeless. Fifty percent admit to substance abuse. From wherever they came, "they bring their problems with them."
Gyori, a petite white-haired lady with an exuberance you wouldn't expect to last 20 minutes, much less 40 years, in this neighborhood—its 35 square blocks host 6,000 homeless people and 72 crimes on any given day—joined the civil and patients' rights movement that had helped a cost-cutting Gov. Reagan pass Lanterman-Petris-Short. As a social worker, she experienced deinstitutionalization shake out; she's had to call the police, invoking LPS's Section 5150, on "lots of people" who "didn't know how to take care of themselves" and were a threat to their own or others' safety. But she still disagrees with those who think it should be easier to get people committed, medicated, or treated against their will. Whether they're in their "right mind" or not, she says, mentally ill people should be able to do whatever they choose until they're a danger—just like non-mentally-ill people. That violence has often already occurred by the time someone gets 5150'd is, Gyori says, a necessary "complication of our rights in America."
What of the studies that show that involuntary-treatment laws decrease rates of violence and hospitalization and incarceration among severely mentally ill patients? Such laws are "stupid," Gyori says. If your concern is public safety and crime prevention, she adds, "it's the funding that matters." Funding for school screening programs that could catch signs of severe mental illness. Funding for early treatment to keep the moderately mentally ill from becoming a lot sicker, and funding for rehab programs for those who didn't get treatment and started self-medicating. Funding for intensive case management, subsidized housing for people who are functionally disabled. All things that combat the isolation and desperation and hopelessness that can help cause and exacerbate mental illness—schizophrenia included. The majority of Gyori's clients are suffering afflictions like PTSD, anxiety, depression, and the associated addiction issues. That is: With treatment, they're theoretically capable of recovery and (nonsubsidized) functioning. But Gyori's staff is short, underpaid. New clients can't be seen for initial risk assessment for a month. The city's public-housing shortage is so severe that it closed the list to new applicants. "This society is set up to create Tenderloins," she says.
"We're dealing with the most stigmatized and misunderstood population. You can scream outside my window," she says, turning her face in the direction of the guy screaming outside her window—something about "dinner"—"and I'm not gonna make assumptions that it's your fault. As long as a person is disabled, and income is limited, you have to help them. Destigmatization is a big part of it."
Sure. When I leave the clinic, it is admittedly difficult not to judge the strung-out-looking fellow lunging through the crosswalk hollering a song about monkeys, the refrain of which is a monkey call, or the parties responsible for the two piles of human shit I sidestep in as many blocks. Though an estimated 1 in 5 families contains someone with a mental illness, even families of the mentally ill aren't always sympathetic. "We have families who aren't willing to work with us or do anything," says my Aunt Terri's caseworker, Eleanor. "Your family was so willing; everybody was there to do whatever." But she's certainly not talking about my great-grandmother, who pronounced Terri lazy, and not even so much my grandfather, who thought his daughter was a spoiled brat who just wanted attention. And she wasn't talking about me, whose total uselessness in Terri's transportation and other needs earned me the resentment of at least one cousin.
Sonoma County NAMI's David France told me about classes his organization holds for families to combat this lack of compassion. I saw a similar school talk in Ohio once as a teenager. I remember the heavyset woman well, her matching blouse and pant of some artificial peach fabric. I don't remember whether her illness was depression or bipolar or what, but I do remember that she told us her method of self-harm was to pull out all of her eyelashes because it was a self-harm no one noticed. She told us, with the inevitably pleading look of a person who knows they're telling you something important but also knows you can't possibly understand, that suicide was a permanent solution to a temporary problem. That no matter how sick you are, there's room for improving and becoming a functioning member of society, like her.
Forcing the criminal-justice system to substitute for services is not cheap: "Two to three thousand dollars in treatment saves $50,000 in jail."
I remember finding her totally weak and disgusting.
"People with mental illness are not valued in this society," says Roth. Not valued members of the family Christmas party. Not valued recipients of dwindling state budget dollars. "It's not a place where people want to give money. We're in a country right now that is so mean-spirited, people really aren't in any mood to spend any money on anybody."
But as Randall Hagar, director of government relations for the California Psychiatric Association, points out, the country will pay for it one way or another. "Taxpayers pay for nuisance issues related to the homeless," he says, especially since the total elimination of California's $55 million mentally ill homeless outreach program, which deployed teams to help with everything from housing crises to paperwork. Since the defunding of the state's mentally ill offender crime reduction program, which delivered services like training, counseling, and outpatient assistance to discharged transgressors, the incidence of violence has increased among that population, says Hagar. In Virginia between 2010 and 2011, mental-health treatment facilities turned away 200 people determined to be dangerous because there were no available beds. In Arizona, a Phoenix hospital saw a 40 percent jump in psychiatric emergency room episodes after the abolition of mental-health services to 12,000 non-Medicaid-eligible mentally ill. The moral issues of not taking care of society's sick and vulnerable aside, Hagar says, our post-deinstitutionalization transinstitutionalization is not cheap: "Two to three thousand dollars in treatment saves $50,000 in jail."