D. J. Jaffe died last weekend. He was an acquaintance of mine and a friend to many. Unfortunately, when you spend your life fighting for men and women with serious mental illness who languish on street corners and in prison cells, forgotten by the masses and abandoned by the advocacy groups sworn to protect them, you will also make your fair share of enemies, and he did.
Whenever Jaffe spoke at a conference or public hearing — and given the opprobrium he engendered in certain corners of the mental-health community, his appearances were never without controversy — he said basically the same thing: Everyone in the United States can stand to have their mental health improved; around 18 percent of the adult population has a mental illness that you can find in the Diagnostic and Statistical Manual. But his concern was for the 4 percent of the adult population with a serious mental illness, such as schizophrenia or bipolar disorder. He spent his life astounded by the fact that the mental-health industry at large seemed to have little interest in this group’s plight. “I am not a mental-health advocate,” he would often say, with some indignation. “I am an advocate for the seriously mentally ill.”
It should not have been an incendiary message, but many of the government agencies, nonprofits, and advocacy groups ostensibly dedicated to mental health found Jaffe to be abrasive. The cause of their unease was obvious: His message struck straight at the heart of the foundational myth on which countless “wellness” and “self-improvement” campaigns were built, and the never-ending rhetorical war on “stigma” that defines the bulk of modern mental-health advocacy.
“Mental health,” as distinguished from mental illness, was a mid-20th-century invention of psychiatrists eager to step beyond the asylum walls and become something like philosopher–kings. After President Kennedy signed the 1963 Community Mental Health Act, the National Institute of Mental Health began its years-long fixation on “prevention” — the idea that mental illness could be effectively prevented if politicians would endeavor to create a “mentally healthy” society.
NIMH director Stanley Yolles, who assumed the position in 1964, celebrated the fact that psychiatry in the post-asylum era was “no longer concerned only with patients and only with illness,” but instead was “increasingly becoming involved in social planning and the contemporary issues of the day.” Because the conditions of poverty “constitute a breeding ground for mental disease,” Yolles reasoned, the psychiatrist should use his special knowledge to “help the statesman, the politician, and the poor man himself to intervene in this condition of poverty before it creeps into the fiber and style of a man’s thoughts and behavior.” If the government provided housing subsidies to the poor and implemented expert-approved wellness programs in schools, the thinking went, mental illness could be effectively eliminated.
Many of the original architects of the prevention fad later realized their errors, when the failures of deinstitutionalization became too obvious to deny. One of Yolles’s assistants, Dr. Alan Miller, said that the prevention era “was an exhilarating time for many” psychiatrists and advocates; it gave them “the feeling that [they were] making history.” Their ambition led the old asylums to be downsized or mothballed. Involuntary commitment was made nearly impossible. In turn, the prisons and sidewalks became the site of a modern Bedlam. The human costs of this revolution fell disproportionately on the seriously mentally ill, and the people such as D. J. Jaffe who advocated for them.
It was always personal for Jaffe. He became the guardian of his sister-in-law when she fell into psychosis. Outraged by the lack of treatment available to her after she left the hospital, he left his job and became a full-time advocate for the seriously mentally ill. He started as a volunteer at the National Alliance on Mental Illness, where he recalled the pain of parents and friends of paranoid schizophrenics whose loved one had fallen into psychosis. He recalled with some pain the agony of telling those families that there was nothing to be done for their psychotic loved ones unless and until those loved ones deteriorated to the point of violence. He left NAMI, joined the board of the Treatment Advocacy Center, and eventually founded his own group, Mental Illness Policy Org., where he sought to remedy the systemic failures he identified in the mental-illness treatment system. He was a key player in the passage of Kendra’s Law in New York, and the 21st Century Cures Act on the federal level.
Today, the theory of prevention, despite being well beyond its sell-by date, continues to inspire much mental-health advocacy. To take one example, ThriveNYC — the billion-dollar New York City mental-health campaign that Jaffe claimed “mostly consists of smoke and mirrors” — dedicates millions of dollars to school “consultants,” ostensibly hired to advise educators on how to improve “wellness” in city schools. Jaffe’s fight against such quackery was brave, and his legacy will live on: His book, Insane Consequences, remains a canonical text for those looking for an alternative to the modern mental-health regime. He was rarely thanked for that bravery, because the men and women he fought for exist on the peripheries of our society, penned in a prison cell or strewn out on a street corner. But they, and we, owe him a debt. He will be missed.