Reading about the state of institutional care for mentally ill people in Mexico brought to mind an experience of my own from a pre-internship training practicum in the early 1980s at a hospital in the United States.
Recently, the New York Times featured an article on the state of institutional care for the seriously mentally ill in Mexico. The kinds of attitudes and practices which the New York Times reported are particularly shocking not only because they seem so antiquated but also because they have gone unabated for years.
As far back as 2000, the New York Times reported on the findings of a team led by Dr. Robert Okin which found, among other things, that some facilities the team examined in the late 90s were still housing patients with conditions like epilepsy and mental deficiency who would have been much better served in alternative settings. The team also noted that conditions in some of the institutions inspected were unsanitary, with feces and urine stains dotting the walls. In 2010, the newspaper reported that even ten years after the first scathing report put out by Mental Disability Rights International, the same group found “atrocious and abusive conditions” within the Mexican mental health care system that included “lobotomies performed without consent, children missing from orphanages, widespread filth and squalor, and a lack of medical care” to needy patients. The latest article suggests that despite promises and efforts made by the government and assurances given by the country’s president, Mexico still merits a failing grade in its care for the institutionalized mentally ill.
While the Mexican government has reportedly taken some steps to address the system’s problems, the dedication and determination of a group of formerly institutionalized patients may ultimately prove to be the real force in turning things around. The group of former institutional patients turned activists, called Colectivo Chuhcan, tackles the issue of reform in the Mexican mental health care system head-on. The group began as part of an international disability rights group but now operates independently.
This ongoing coverage is unsettling to say the least, evoking memories of conditions that were prevalent in many U.S. mental institutions during the early part of the twentieth century. Those conditions improved considerably under the influence of two factors. One was the advent of powerful psychotropic drugs that made it possible for many seriously and chronically mentally ill patients to function outside of confinement. The other was legislation that not only promoted de-institutionalization for many mentally ill patients but also provided funding for a community mental health care network that could provide necessary and ongoing supportive care for most of these patients on an outpatient basis. However, stigma, indifference, and injustice have been chronic problems affecting mental health care, especially institutional care. And because there are still occasions when someone with a serious mental illness requires inpatient care — sometimes even for extended periods — it’s unnerving when reports still surface about abusive and neglectful practices in mental institutions. (See “Patient Dumping: Mental Healthcare Thrown under the Bus”.)
Reading these articles brought to mind an experience indelibly stamped in my mind that occurred during a pre-internship training practicum I completed in the early 80s at a state hospital in a relatively isolated part of Texas. The hospital’s location and meager budget made it hard for administrators to attract top notch staff, which is one reason why interns and pre-interns were in demand. Although the facility’s physical appearance and location were definitely not attractive, I readily developed an affinity for the patients in its care.
Unfortunately, I also developed a degree of unease about many of the conditions and practices I witnessed there. One day particularly stands out.
I had to attend a clinical staffing — a psychiatrist-supervised treatment team discussion on the status of a patient’s diagnosis, treatment regimen, and progress — on one of the cases with which I was involved. Before my patient was brought up for review, I listened while one of the hospital psychiatrists presented another case. Two things I witnessed sent shock waves through my system. Although I had only seen one other manifestation of it before during my clinical training, I observed that the psychiatrist was clearly in a manic state, speaking so rapidly (and chain-smoking cigarette after cigarette in rapid-fire succession) that I could barely keep up with what he was saying, and demonstrating very poor judgement about the kind of language he was using as well as the kinds of unrestrained emotion he displayed.
Now physicians are human beings and are certainly not immune to developing a mental illness. But the fact that a physician was not only working but making clinical decisions in a clearly impaired mental state certainly got my attention. What took me aback even more was that when one of the treatment team members reported that this doctor’s patient had failed to comply with one of her treatment plan’s stated objectives while she was on a weekend therapeutic leave of absence, the doctor impulsively ordered a new round of electro-convulsive therapy (ECT) for the patient in response to this — loudly shouting into his Dictaphone that her non-compliance was “probably” due to her “hearing voices” that she was “probably” afraid to report. Despite the shock on almost everyone’s face at the strangeness of such a decision, especially in the absence of clear clinical indications of its appropriateness or necessity, no one at the staffing table said a word, and the ECT was scheduled.
Later, after checking all the facts and confirming things with staff, I knew I had to report this incident to my clinical supervisor. I did so with some trepidation, fearing not only that my status as an inexperienced student would cast doubt on my judgment and credibility but also that my internship might be in jeopardy. But to my relief, the supervisor appeared both to understand the situation and appreciate the heads-up, and took the right action in response, assuring me that the psychiatrist in question was not only the best they could get but also a fairly astute and reliable clinician when he stayed compliant with his own medication regimen. Still, it bothered me a great deal to think about what might have happened had I not spoken up, because it sure appeared that others were willing to sweep the whole incident under the rug. I witnessed other things during that training, and I can say unequivocally that once you experience first hand how the disadvantaged in a confined situation can be mistreated, especially in a setting purportedly dedicated to their well-being, you simply can’t forget it.
Back to the situation in Mexico: according to the disability advocates, it would be both insufficient and unwise for Mexico merely to spend more money on physical improvements to their mental health facilities. When a system is failing in its core mission, it’s often the culture that’s developed within the system that needs to change the most. And the group of ex-patients who’ve banded together to help ensure the rights of the institutionalized mentally ill have made addressing what they see as a culture of indifference, neglect, and abuse a top priority. And they’re doing so by reaching out to patients, listening to them, sharing experiences, and educating workers about what they learn. They’re also pressing the government to make good on its promises of reform. But pressure and scrutiny needs to come from a variety of sources, and we can only hope the New York Times and other news organizations continue to follow this story. Hopefully, with the eyes of the world watching, the next reports from Disability Rights International and Colectivo Chuhcan will give Mexico’s institutional mental health care its first passing grade.
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