Hundreds of mental patients considered fit to live in community-based facilities are still being housed and treated in St. Elizabeths Hospital despite a federal judge's order six years ago that they be released.
Their continued hospitalization occurs at a time when many neighborhood mental health care providers under contract with the District of Columbia report a surplus of beds and facilities and reflects what hospital officials concede to be serious problems in the transfer of more than 2,400 current patients off the hospital rolls. At the same time, the city has lagged in providing services for those who have been released and has spent more than $900,000 earmarked for the transfer in the last two years on other programs.
The delay in carrying out the court order has been caused in part by bureaucratic confusion and lack of cooperation between St. Elizabeths and the city. The result is that patients have needlessly remained at an institution where the daily routine, according to those who have spent time there, consists mainly of sitting in day rooms and watching television.
"The longer they're there, the more likely it is they will not be able to adjust to life in the community," said Norman Rosenberg, the director of the Mental Health Law Project, the group that won the court order requiring the so-called "deinstitutionalization" of the St. Elizabeths patients. "There's no reason for them to be twiddling their thumbs. It's a waste of people's productive years."
The transfer of patients from St. Elizabeths, the federally run institution for the city's mentally ill, is one chapter in the 25-year-old nationwide effort to move mental patients out of warehouse-like institutions and back into residential neighborhoods. The goal is to provide the kind of mental health care that will enable the former patients to carry on useful lives in the community.
But a month-long inquiry by The Washington Post into the deinstitutionalization effort at St. Elizabeths found that:
* Under an April 1980 agreement signed by U.S. District Judge Aubrey E. Robinson Jr., 573 hospital patients--those identified in 1978 as being able to live independently, in a group home with some supervision or in a nursing home--were to have been released from the hospital by the end of 1980 or by last December.
As of last October, that number had been reduced by only 74 because new patients, who by the hospital's own classification system could live in the community, have been admitted to St. Elizabeths. A total of 70 patients in the 1978 group at the hospital are still there.
Dr. Bernard S. Arons, who heads the hospital office overseeing the transfer of patients to the city, said there are "a variety of reasons" why deinstitutionalization is not going as fast as planned. He said the city has few nursing homes, although under the order it is required to produce more nursing home beds by 1985. Moreover, he said that some patients who have spent years at St. Elizabeths often times show marked resistance to leaving when the idea is suggested to them.
* The hospital has transferred only 45 of its 1,448 outpatients to city rolls, although all of them are supposed to be moved by October. Another 77 are about to be transferred, but hospital officials concede that about 600 should have been moved by now.
* The progress reports that Robinson required the hospital and city submit to him were "fudged a whole lot," according to one source familiar with them. The hospital "tried to focus on something [so] that if the [Mental Health Law Project] came back we wouldn't be totally caught" and omitted mention of parts of the deinstitutionalization effort where nothing was being accomplished.
"We don't highlight, we don't hide," Arons said. "We've tried to focus on what we've done."
* Private mental health care providers--the halfway houses, daytime therapy groups and sheltered workshops hired by the city to provide services to those released by the hospital--generally have only received a fraction of the patients for which they have room.
To Albert C. Massey, the director of the D.C. Mental Health Services Administration, the reason is simple: "We're not receiving the referrals from the hospital we should be."
* Arons and other hospital officials say many members of St. Elizabeths' medical staff fear "the city doesn't have the facilities or arrangements in place" to properly care for the patients.
Massey and other city officials concede that's somewhat true. Joseph Davitt, the city's coordinator for the deinstitutionalization effort, said that only $426,500 of the $1,345,000 specifically earmarked by the city to carry out the transfer of the patients and provide new services was spent on the effort in the last two years.
"You could say [the remaining $918,500] was eaten up by the deficit in some of our other programs," Davitt said. "We weren't geared up. We couldn't hire people and get the contracts" with private providers awarded.
But city officials contend that the failure to release more patients is partly due to the fear among hospital staff members that as the current total of 1,871 patients dwindles, the 3,900-member hospital staff will be cut.
As one city official concluded about the deinstitutionalization effort, "All this energy is spent fending off the enemy. Instead of being in the foxhole together, we're always shooting at each other.
"This would be a very funny Erma Bombeck story if it didn't deal with people's lives," the official said.
James Pittman, who oversees the operation of St. Elizabeths for its parent organization, the National Institute on Mental Health (NIMH), had a slightly more generous assessment of the transfer of patients to the city's care. "It's going well in some respects and dragging in others," he said. "We're doing something that's not easy. For that reason, we are encountering some problems. There are areas of some sluggishness."
For their part, city and hospital officials said they are trying to resolve their differences and predict that eventually more and more St. Elizabeths patients will be treated at community facilities.
"It's clear that sufficient effort and work has been done," Arons said.
More than 15,000 patients, some of them counted more than once and others who stayed only a short time at the hospital, have been discharged from St. Elizabeths in the last five years or transferred to some form of community-based care. Another 15,000 moved from the hospital's inpatient rolls to so-called convalescent leave status in which they still came to the hospital for their medication. During the same period, more than 27,000 patients were admitted, again with some of them counted more than once.
Through most of American history, society has treated the insane or disturbed by placing them in institutions. As recently as 1955, a record total of 558,922 mental patients were housed in 275 institutions in the United States. By 1980, however, that number had been reduced to 137,810 as former patients filtered back into residential neighborhoods, to their own homes, to group living, and sometimes, to the streets.
The reduction reflected a growing conviction, advanced in studies in the early 1960s, that in Rosenberg's words, "institutions were not curative, but were warehouses." The emerging consensus among mental health professionals was that community-based care was preferable and with a strong push from President Kennedy, who had a mentally retarded sister, Congress enacted legislation that established community mental health centers throughout the country.
Reflecting this change of thinking, St. Elizabeths began moving its patients back into the community in the early 1970s. For much of its existence, at least until the 1950s, the hospital had been viewed as a prestigious institution, often leading the way with new forms of treatment of the mentally ill.
But the federal interest in St. Elizabeths waned in the 1960s and early 1970s, to the extent that the hospital eventually lost its accreditation for three years for a variety of shortcomings. The hospital is now accredited again.
In 1974, the move to deinstitutionalize was given an added push when the Mental Health Law Project sued the hospital and the city to increase and speed the number of releases. Rosenberg said St. Elizabeths was chosen for the test case for a variety of reasons, chief among them the fact that the District had "a reasonably good [right-to-treatment] statute" on which to base the claims for deinstitutionalization.
The project filed the class action suit on behalf of all patients at St. Elizabeths it felt did not need to be hospitalized and could just as easily receive their treatment in community-based facilities. Nine patients were listed as plaintiffs in the suit, but today the case is only referred to by the name of the first of those patients, William M. Dixon. He is a 72-year-old former District resident who spent 16 of the last 30 years at St. Elizabeths, but has lived for the last four and a half years in a nursing home in Clinton.
Both the city and federal governments fought the suit, with the city disputing the patients' right to treatment in a nonhospital setting and the federal lawyers arguing that the patients had not proved their contention that alternative treatment facilities would provide a less restrictive setting than at the campus-like grounds at St. Elizabeths.
Judge Robinson's assessment of those claims was blunt: "The court finds these arguments without merit."
Robinson, who still has the case under his jurisdiction, ruled in late 1975 that both the city and federal government "have a joint duty" to give patients "suitable care and treatment under the least restrictive conditions."
Since then, Rosenberg said, the St. Elizabeths ruling has served as a model for numerous deinstitutionalization orders now in effect around the country. But not, Rosenberg wryly observed, for its implementation.
Msgr. John G. Kuhn is one person who knows the difficulties that have been encountered in moving patients out of St. Elizabeths and into community-based programs.
He is a 50-year-old, somewhat balding, stocky Roman Catholic priest and since 1958 he has run the Anchor Mental Health Association, an organization that provides a variety of psychiatric counseling, vocational and housing services to people with mental illnesses. The group has a workshop where "clients"--the preferred term used by mental health professionals for one-time patients--learn how to work in a mailroom or do clerical, custodial or food service work. Anchor also operates a community residential facility for people who need a transition residence between the hospital and independent living.
Since last October, the city's Mental Health Services Administration has paid Anchor $16.67 a day to provide some kind of vocational training for nine people.
There's one problem, however. The city has only sent Anchor one person for most of the time since October and never more than three. The loss to the city now totals more than $14,000.
"Whether we have one person or 18 we have to have staff" to serve the one-time mental patients, Kuhn explained. "It bothers us. We exist to serve these people."
In another Anchor program, the city has filled 16 of 18 slots, but only one of four in a third program.
"Any time you deal with the government bureaucracy," Kuhn said, "you're in deep trouble."
Other community mental health providers tell a similar story: They've contracted with the city to provide various services to the patients being released from St. Elizabeths, but only a portion of the slots have been filled.
At the Barney Neighborhood House, Gail Glick, the program coordinator for psychiatric day care, said that 16 of her 20 slots are filled in a life skills program designed to "get people to take more and more responsibility for themselves." But Barney also operates a center for the elderly leaving St. Elizabeths and only one of 15 slots has been filled there by the city.
"I'm very grateful for the Dixon mandate," Glick said. "I see people who are discovering themselves again, even people who look like they're not going to get anywhere."
Nonetheless, she said, "There are snags all the time when you have a dual system like this," encompassing both St. Elizabeths and the city mental health agency.
At the Green Door, another halfway program where former mental patients learn basic day-to-day living and work skills, there are 30 slots available in the so-called psycho-socialization program. But only 11 of them have been filled.
"There are 19 people in the community who could benefit from these services," said Beverly J. Russau, Green Door's executive director. "It's unfortunate."
St. Elizabeths' Arons said the transfer of patients to the city's care is not as easy as it might seem. He said that when leaving the hospital is suggested to some patients, they might "go around spitting into other people's food or urinating in their beds. That kind of thing wouldn't be tolerated living in a small group home."
Still, Arons conceded that more patients could be transferred to the city's care "if there was a total program of psychiatric care. The city is slowly developing such a plan."
But Arons said, and the city confirmed, that the District now lacks a clinic to dispense the drug lithium, which is prescribed for patients diagnosed as being manic depressive; has no established system for designating a person to receive money for patients who are unable to handle their own financial affairs; lacks the ability to deal with patients' multiple medical problems and does not offer industrial training.
Nonetheless, he said the hospital hasn't "officially given up hope" of meeting the promised October date for transferring another 1,400 outpatients to the community mental health centers. But he conceded that "ultimately we're going to have to rethink that deadline."
Both Arons and Dr. William H. Dobbs, St. Elizabeths' superintendent, said the hospital will continue to work toward transferring hospital patients who are able to live elsewhere, but they disputed the Mental Health Law Project's contention that the number of such people ever will be reduced to zero.
While the hospital struggles to deal with the court order's mandate, the city is trying to cope with more patients at a time when its 400-member mental health staff has been trimmed by about 25 percent in the last two years and its $13.6-million budget has remained virtually the same.
"There is no way we can fully meet all the needs of all the people who are coming out of the hospital," said David Yochim, a D.C. mental health official. In part, that is why the city has hired the private mental health groups to provide a variety of services.
City officials acknowledged there is some fear on the city's part that it might not be ready to handle the droves of patients when, and if, they do materialize. Still, they placed most of the blame for the slow pace of the Dixon implementation on St. Elizabeths.
"There's an attempt by the hospital's mid-level managers to show that the District doesn't have the capability" to assume the responsibility for the additional patients, acting mental health director Massey said.
The hospital's top officials "still have to convince their managers that Dixon is really going to happen," Yochim said, "and that that is an appropriate way to deal with some of those patients."