NOTE: This is a slight variation of the proposal submitted to the
Independent Television Service (ITVS), a CPB-funded project to develop programming
for PBS. It was selected as a finalist (out of 1200 proposals submitted)
but did not make the final cut; only 8 projects actually received ITVS funding.
The Hill Crest Foundation has provided funding to continue research and
development, so we would appreciate any comments or suggestions you might
care to make. You can send them to me at wadeblack@mindspring.com
. Thanks!
(And if you want to write a support letter . . . !)
--- Wade
Mentally Ill:
The Patients or the System?
Summary: Many recent documentaries have dealt with the homeless.
Fewer have dealt in detail with why the mentally ill are so over-represented
among them. None (to my knowledge) have dealt with the complicated court
history of well-meaning mental health reform gone terribly awry. This program
examines legal and legislative history in Alabama, to consider how mental
health reforms designed to meet the financial needs of one of our poorest
states became - for better and for worse - the model for mental health reform
nationally.
Mentally Ill: The Patients or the System?
Mentally Ill will focus on the Alabama origins of the legal
and legislative history of mental health reform since 1970. The two key
cases -- Wyatt v. Stickney, reforming institutional care, and Lynch v. Baxley,
reforming civil commitment procedures -- originated in Alabama. As a result,
related cases continue to be brought before federal courts in Alabama even
today. As a related result, reforms designed for one of America's poorest
states are shaping the direction of mental health reform nationally.
Mentally Ill is approximately one-third complete. More than 15 hours of
interviews, live action footage, and rephotography has already been collected
in BetacamSP, and a twenty-minute short version focusing on the Wyatt case
has been completed. The proposed project will permit completion of a one-hour
broadcast version, expanded to examine the troubling legacy of a twenty
year legal and legislative history of mental health reform since Wyatt.
Funding will permit an expansion of the production to address four issues:
1) how Wyatt and other related cases led to genuine reforms within
public mental hospitals;
2) how Wyatt and other related cases affected mental health care outside
the institutional setting, especially how well-meaning reform (deinstitutionalization
and related reforms in civil commitment) simply shifted the crisis in mental
health care from the institutions to the community;
3) how the legal and legislative response to Wyatt by one of our poorest
states modeled the response that was taken by other states nationally;
4) how this model, which originated in financial rather than medical necessity,
may yet lead to genuine reforms in mental health care. By stripping away
the institutional invisibility of the mentally ill and returning them to
the broader community, the mentally ill and their advocates have become
a far more powerful constituency that must be addressed both judicially
and legislatively.
Background
In 1970, when a budget shortfall threatened staff cutbacks at Alabama's
mental institutions, patients and staff at Bryce State Mental Hospital in
Tuscaloosa, Alabama, went to court. When they did, they opened the doors
on one of Alabama's terrible secrets: a mental health system so underfunded
and understaffed that conditions were like an 18th Century nightmare --
patients housed in old stables, supervised by other patients, while the
limited staff worked desperately to provide care with almost no resources.
The Wyatt v. Stickney case set detailed national standards for institutionalized
mental health care and patients' rights and led to major national reforms
in mental health care. The related Lynch v. Baxley case led to similar reforms
in civil commitment procedures. But with terrible irony, this reform movement
began in a state, Alabama, that was woefully ill-equipped to deal with it.
By all measurable standards, Alabama is a seriously poor state with chronically
high unemployment, high rates of illiteracy, low tax revenues, and low potential
to increase tax revenues. Unable to fund the institutional reforms required
by the courts, Alabama sought alternatives to civil commitment and institutional
care. Reducing the patient loads of the state mental hospitals was not simply
a treatment decision supported by mental health professionals -- it was
also a financial necessity.
The only alternative that was financially available to Alabama was "deinstitutionalization"
-- moving patients out of the state mental hospitals and into the less-expensive
community mental health system. At just one hospital (Bryce), the patient
load was reduced from more than 5,000 patients in 1970 to less than 1,500
patients today. In all, more than 6,000 Alabama patients were moved from
institutional settings to alternative community treatment.
Deinstitutionalization, which was forced on Alabama by financial rather
than medical necessity, gradually became the national model for mental health
reform, as the effects of the Wyatt v. Stickney case began to be felt in
other states. Other states, facing the high cost of improving their institutional
care as a result of this decision, copied the Alabama model. The financial
advantages of deinstitutionalization, and its appeal to the patients rights
movement that began in the 60s, quickly made it a national preference for
the delivery of mental health services.
Twenty years later, in the 1990s, the legacy of Wyatt and Lynch is a complicated
one. There have clearly been major improvements in institutional patient
care and in commitment procedures. In-hospital care is much more likely
to be therapeutic rather than custodial. Patient loads have been greatly
reduced, and civil commitment procedures are much less likely to be abused.
National standards for patient care have been adopted and widely implemented.
At the same time, nationwide, the Wyatt and Lynch standards have led to
massive deinstitutionalization, patient dumping, mental patients living
on the streets, and reduced access to mental health facilities. Community
mental health systems have been overwhelmed by their increased client load,
yet they must deal with more seriously ill patients. Intermediate-care facilities
such as half-way houses and day programs and sheltered workshops, a critical
necessity for successful deinstitutionalization, have been excruciatingly
slow to develop, are fiercely resisted by many communities (the NIMBY effect),
and community mental health care remains a low priority for both federal
and local funding. Few states have developed adequate or humane means for
monitoring (or enforcing) treatment compliance among out-patient clients,
or for crisis-intervention, or for less restrictive alternatives to civil
commitment. In many communities, emergency mental health intervention has
shifted from the mental health system to law enforcement, where it is addressed
by police officers and a criminal justice system ill-equipped and ill-trained
for this type of intervention.
What began as a crisis in the mental institutions has become instead a crisis
in the community.
In many ways, Alabama illustrates successful reform: greatly improved institutional
care, limited inappropriate "dumping," increased attention to
community mental health services, major improvements in civil commitment
procedures. At the same time, Alabama illustrates many symptoms of the financial
crisis that today haunts mental health care nationally -- an overwhelmed
community mental health system, poor provisions for crisis intervention,
limited intermediate care facilities, inadequate alternatives to the civil
commitment procedure.
Also, Alabama illustrates the development of an important third party in
mental health reform - the client advocacy movement. In 1970, at the time
of the Wyatt v. Stickney case, grass roots mental health advocacy in Alabama
was minimal, because its constituency was hidden away in institutions and
shunned by the general public. Today, strong advocacy groups such as the
Mental health Consumers of Alabama (MHCA), the Alabama Alliance for the
Mentally Ill (AAMI), and the Mental Health Association (MHA) closely monitor
state mental health care and keep mental health issues visible to the broader
community.
Mentally Ill is not intended to be simply another look at the present state
of mental health care or a report on the status of the homeless. Instead,
it will look at how the financial situation in one of our poorest states
generated -- for better and for worse -- the national model for state and
federal roles in mental health care.
Approach to the Subject
This videotape is NOT intended to present a single point of view. It is
also NOT intended to be "objective." It is probably NOT even meant
to be complete. It presents multiple points of view and can perhaps best
be understood as group autobiography: multiple individuals with common interests
but often conflicting concerns speak individually about events in which
they are or have been active participants. Though firmly rooted in the documentary
tradition, its stylistic ancestry has perhaps less to do with documentary
than with the multiple points of view in Istvan Szabo's 25 Fireman Street.
In the making of this videotape, central participants in the issues and
events described have been brought directly into the documentary process.
Mentally Ill makes use of no outside narrator, no scholarly commentators,
no authorial voice of the producer. It is told instead entirely by participants
directly involved -- patients, legal and mental health professionals who
were involved in Wyatt and related cases, members of the client advocacy
movement, and other such participants.
These participants have also been made a part of the production and editing
process, critiquing rough cuts, providing suggestions for material to be
added or removed, monitoring factual accuracy. Every effort is being made
to insure that those involved feel that their participation is accurately
represented.
This approach is not just a stylistic decision -- it is also a production
necessity. As documentary producers like Fred Wiseman and others have learned,
sometimes painfully, producers deal with public mental health issues at
their peril. Privacy considerations both are a major patient concern and,
when used politically, are a means for silencing discussion. By opening
up the discussion, by giving the involved parties a full voice, these considerations
can be addressed. The project has enjoyed exceptional cooperation from all
parties involved, including full access to candid interviews and permission
to tape within the mental institutions.
This lack of outside "objective" narration does not mean that
the project lacks scholarly and journalistic rigor. Wyatt, Lynch, and the
related cases were ground-breaking legal precedents, and the guidelines
they established govern public mental health care policy nationally. The
judge in the case, Frank M. Johnson, is best known publicly for his rulings
against George Wallace, but he is nationally respected by jurists for his
precedent-setting rulings on mental health reform, on prison reform, on
reapportionment and equal protection law, and on First Amendment law. The
defendant in the Wyatt case, Dr. S.B. Stickney, is a nationally respected
authority on community mental health. The legal and patient care issues
involved have been closely monitored and widely studied, and are readily
represented among the participants in this project.
Who speaks for the Mentally Ill?
Giving voice to the mentally ill is a difficult process. Doing it on videotape
for broadcast is enormously more difficult. Doing it within the context
of legal and legislative history is a slow, often tedious, and occasionally
frustrating process. The agendas of the parties involved are complicated,
torturously intertwined, and in considerable conflict. Nevertheless, it
is critically important that we hear from, not just about, the mentally
ill and their advocates. This project has gone to extraordinary lengths
to provide an effective voice to a population that occupies one-fourth of
all hospital beds nationally, that is grossly over-represented among the
homeless, and that is far more frequently spoken about than spoken with.
The mentally ill are too often an invisible constituency. Many of them cannot
vote, their interaction with their community is sometimes problematic, and
as late as the 1970's society sought to hide them away in asylums. Even
today, this population is rarely heard from.
Similarly, it is rare that the national media, in treating issues of national
concern, reach outside the traditional centers of production for more than
token comments. In this case, the omission is a critical one, because it
obscures the origins of a national mental health policy that was formed
as the direct response of a state with seriously limited financial resources.
Deinstitutionalization is not just an Alabama issue, but it cannot be understood
without understanding its Alabama legal and legislative roots. Because of
the inherent difficulties of videotaping with the mentally ill and with
public institutions, it is not probable that a project such as this one
could be undertaken successfully except by a producer with a long-term commitment
to Alabama production and with community support for his or her work here.
But the answer to the question, "Who speaks for the mentally ill?",
is simple. They do.
This is a work in progress. More to come. #8->
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Please send comments, corrections, and suggestions to wadeblack@mindspring.com
Copyright © 1996 L. Wade Black. All rights reserved.