• How to be humane
    May 07,2013
     

    Vermont is still paying for the transformation of its mental health programs undertaken over the past half century to treat troubled people in community settings rather than in a central institution.

    It’s a transformation that has been accomplished with varying degrees of success around the country. In Vermont one consequence has been the enormous cost shouldered by the Agency of Human Services to treat offenders emerging from the state’s prisons who are “severely functionally impaired.” One person with severe needs can cost the state as much as $500,000 to maintain in the community after he or she has completed a prison term.

    In a previous era the nation was much more inclined to lock people up in mental institutions and to keep them there. Involuntary commitment of troubled people was a fact of life. In Vermont the Vermont State Hospital in Waterbury held hundreds of people at a time. The mentally retarded had their own institution, the Brandon Training School.

    But by the 1960s and 1970s the laws began to reflect the recognition that people with a mental illness or disability also had rights, and policy was changed so people were served in the least restrictive setting that was appropriate. The term of the day was “deinstitutionalization.” The Brandon Training School closed as people moved to community settings, including group homes where people with disabilities could receive services and live in the community as productive citizens.

    The Vermont State Hospital shrank to a core of about 50 patients, who were eventually scattered by Tropical Storm Irene. The state is building a replacement hospital in Berlin to serve about half that number.

    Around the country the emptying of mental hospitals was often not accompanied by the establishment of suitable community homes for treating people with mental illnesses. The population of homeless mentally ill has swollen over the years, and the nation still has not developed an adequate response to the problem. Rather than holding people against their will in mental hospitals, we have dumped them on the streets.

    One result is that a good number have ended up in prison. Vermont is now trying to come to grips with the cost of caring for them after they emerge from prison. Human Services Secretary Douglas Racine has announced that he intends to halt the outlay of money for those dozen or so enormously expensive offenders. Instead, he plans to provide them treatment in prison before they are released.

    There is debate among officials about whether the services they receive in prison before release are adequate or whether the program of transitional services outside of prison is more effective — partly because the threat of returning to prison is hanging over the heads of the former inmates.

    A recent survey found that more than half of the severely functionally impaired prisoners actually belonged in a secure psychiatric hospital — about 14 people — rather than in prison or outside prison in a transitional program. In other words, we may be saving money because we no longer maintain large institutions for a large population of people with needs, but we still have a nucleus of people with serious needs who could end up doing harm to themselves or others unless they receive care. Dealing with those needs continues to have a price tag.

    Racine is betting that a way can be found short of the half-a-million-dollars-per-person price tag that he has sometimes had to pay, and he is probably right. But there will be a price tag nevertheless. We have made a decision as a society that we will not warehouse people. Nor can we simply ignore people and let them create havoc. And because we have a Constitution we cannot keep people in prison beyond their prison terms. To find a workable, affordable solution, the Legislature is considering the appointment of a study committee to examine the complexity of the problem.

    Legislators will have to face the central dilemma, which is that we have chosen to be humane but we have not yet figured how to pay for it.

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