American Psychosis: How the Federal Government Destroyed the Mental Illness Treatment System, by E. Fuller Torrey (Oxford, 224 pp., $27.95)
Reviewing American Psychosis, I should declare an interest: Dr. Torrey was the first author who ever sent me a signed and dedicated copy of a book, and I have remained silently grateful to him ever since. It was his 1980 book Schizophrenia and Civilization, in which he argued that, there having been no convincing descriptions of schizophrenia before the 19th century, something new must have arisen at the time of the Industrial Revolution to cause it. (Viral theories were popular at the time he wrote, and the urban overcrowding caused by industrialization would have favored a virus’s spread.)
In the present book, Torrey describes the causes and consequences of the hasty closure of state mental hospitals. It is part historical and part epidemiological; as always, he writes very clearly and is forthright in his views, which are commonsensical. I do not mean this in any derogatory way: Descartes started his Discourse on Method by saying that good sense was the most evenly shared thing in the world, but in those days he had not the advantage of knowing the American Psychiatric Association or the Medicare system.
The book begins with a moving and terrible account of the Kennedy family’s response to Rosemary Kennedy’s mental retardation. As a socially and politically ambitious family, they thought their image would be hurt by having such a relative. They never publicly admitted her existence; instead, they inflicted a disastrous pre-frontal lobotomy on her and hid her away in an institution for decades. From a sense of family guilt, and no doubt a genuine feeling that something ought to be done for the mentally afflicted, President Kennedy fell prey to the schemes of Dr. Robert Felix, the head of the National Institute of Mental Health, who was a reforming zealot with great bureaucratic ability.
The times were propitious for change. The conditions in state mental hospitals, where hundreds of thousands of people had been parked and were often subject to not-so-benign neglect, had become a matter of public scandal. Anything, it was widely thought—and asserted—would be better than the state hospitals.
The irony was that the state hospitals were emptying anyway, in large part because of the use of the first drug that genuinely ameliorated the symptoms of psychosis: chlorpromazine, discovered in France in the early 1950s. The states were beginning to develop constructive ways of rehabilitating patients who had been released from hospitals, often after half a lifetime spent there, but the matter was taken out of their hands by a scheme to introduce federally funded community mental-health centers. Financial responsibility for the care of the mentally ill was transferred to Medicare and Medicaid, to the great satisfaction of the states, which were able to save money simply by emptying the state hospitals and closing them down. Reforming zeal had met budgetary parsimony and bureaucratic indifference to results. Felix and his fellow reformers, incidentally, not only had no evidence that their scheme would work, but had no awareness that such evidence was actually required. Everything for them stood to reason.
The results of deinstitutionalization were appalling. Many patients were left homeless; many more were placed into private nursing homes that were often more interested in squeezing the last cent of profit than in looking after them. Whole areas of cities seemed to be overrun by weird or threatening people; in some of them, people became afraid to use public facilities such as parks and libraries, where former inmates of mental hospitals (or newly psychotic people) gathered.
The reformers were often utopians seized by moral grandiosity. Because they thought (again, without any evidence but the schemata in their heads) that mental illness must be brought about by social conditions, they wanted to heal society rather than to help individual patients. They formed a strange alliance with extreme libertarians of both the Right and the Left, whose libertarianism would ultimately lead to the imprisonment of many of the mentally ill. This bore out Dostoevsky’s dictum that perfect liberty would end up in perfect servitude.
One of the influential libertarians mentioned by Torrey is Thomas Szasz, a professor of psychiatry who thought that any compulsory treatment was wrong in the absence of demonstrable pathology. In the absence of such pathology, all forcible treatment was but disguised and sinister social control, with the doctor serving as the witting or unwitting agent of the state, imposing its values and enforcing its conventions.
For Szasz as a polemicist I had a high regard, and I found him personally charming. I was impressed by the force of his character and convictions; but once, at a dinner party in London at the home of a mutual friend, I had a discussion with him that I thought showed that, like many idealists, he was more interested in the general than in the particular, and preferred to preserve his ideas pristine rather than sully them with the grubby or ambiguous nature of reality.
It so happened that I had been on duty the night before the dinner party as the doctor on call for a prison; and I had been called in the early hours of the morning to see a prisoner who had stripped naked, was talking loud gibberish, had smashed the light in his cell, and appeared to be trying to plug himself directly into the electricity.
I did not think that this was the moment for a Socratic dialogue about the nature of mental illness. I ordered that he should be held down while I gave him an injection. A few hours later he was as right as rain; he had probably been intoxicated with some drug or other. I asked Szasz what he would have done in the circumstances. He replied that he would never have put himself in those circumstances; in other words, that I should not have made myself available to perform this kind of work. In the absence of demonstrable pathology—how could one have demonstrated it, even if present, in those circumstances?—the man should have been allowed to electrocute himself: no doubt pour encourager les autres, as Voltaire put it.
This seemed to me callous in the extreme, favoring intellectual consistency over the most elementary humanity, as well as being as a complete abrogation of moral responsibility. But Szasz, as Torrey demonstrates, was not alone. The book has many examples of how a concern for civil liberties, taken to its illogical conclusion, impinges on or destroys the civil liberties of others. My favorite example among those Torrey gives, because amusing, is that of a chronically ill man in Maine who dug himself a cave in a slope below a parking lot. He would accept no help or treatment; there was no legal provision by which he could be made to accept treatment; and it was only when the lot began to collapse that he was arrested—to save the lot, not the man.
What has happened in America has happened, perhaps to a lesser extent, in countries in Europe. If anyone wants to see care in the community under a regime of exaggerated personal rights, I suggest the Paris Métro station of Réaumur-Sébastopol, where for years resident schizophrenics have imparted a smell to the passageway between lines that makes the passersby—by now, millions of them—hurry on, trying not to breathe until they reach cleaner air. In other stations, muttering and gesticulating psychotics are avoided by passengers who do not want to run the risk of being pushed in front of oncoming trains.
The reduction in hospital places for psychiatric patients has been pursued as an end in itself by a strange alliance of ideologues and penny-pinchers, irrespective of the consequences for patients or society, and as a sign of progress in itself. It is typical of bureaucracies, of course, to pursue procedural rather than real goals; and the consequence of the shortage of places is that such as still exist have come to resemble the Bedlam of the 18th century, as they concentrate only the worst and most refractory cases. In one British city known to me, the closure of the psychiatric hospitals was followed a few years later by the opening of large, semi-prisonlike facilities for what used to be known as criminal lunatics, the number of places for them now outnumbering by a factor of four the number of places for psychiatric patients who have committed no crime. Naturally, the expense has risen astronomically. In a word, this is mad.
Dr. Torrey is the first to admit that terrible cruelties have been inflicted on patients in the past, no doubt sometimes from sheer desperation. But while we should learn from history, we should not be paralyzed by it; we have a responsibility always to do our best in the circumstances, which are seldom ideal, just as our knowledge is always imperfect. Torrey’s outrage at what has been done, originally with the best of intentions but no longer so, is evident; his book is a timely warning—because such warnings are always timely—against the dangers of well-meaning zealotry.
– Mr. Dalrymple is a contributing editor of City Journal and the author, most recently, of Farewell Fear.