The Grate Society
Nowhere to Go: The Tragic Odyssey of the Homeless Mentally ill.
by E. Fuller Torrey.
Harper & Row. 256 pp. $18.95.
E Fuller Torrey, a well-known psychiatrist in Washington, D.C., has written a scathing account of the community mental-health centers which were created by the federal government in the 1960’s to take the place of state hospitals in caring for the majority of the seriously mentally ill, vast numbers of whom were still warehoused in often miserable conditions. The centers were described in President John F. Kennedy’s 1963 State of the Union message as “a bold new approach” that would supplant “the cold mercy of custodial isolation” with “the open warmth of community concern and capability.”
There were to be 2,000 community centers, geographically distributed so that everyone would fall into a catchment area. Each center was supposed to provide five services: hospital beds for individuals in crisis; partial hospitalization (generally by day); outpatient services; twenty-four-hour emergency services; and consultation and education.
In the haste to get the centers built, many were funded despite the absence of inpatient or ’round-the- clock emergency services—the kinds essential for serving the seriously ill. Of the 2,000 projected centers, fewer than 800 would be built over a twenty-year period. On only one point did President Kennedy’s predictions prove accurate. He declared that it would be possible “within a decade or two to reduce the number of patients now under custodial care by 50 percent or more.” In fact, within two decades the number of long-term mental-hospital beds was slashed by 75 percent. But instead of inaugurating a new and better era, the program, in Torrey’s mordant pun, helped bring about a “grate society.”
What went wrong? In Torrey’s analysis, the chief blame lies with his own profession, which promised too much and delivered too little. He traces the problem all the way back to psychiatry’s pursuit of the chimera of mental health at the beginning of this century, and in particular to two major ideas. One was the notion of prevention, a dominant theme in American medicine which psychiatrists wrongly believed could be applied wholesale to mental illness. The second was Freudianism, which, by explaining mental illness in terms of early childhood experience, overlooked the biological causes of such major illnesses as schizophrenia and manic-depressive disorder.
Enamored of scientifically unsupported notions that they could dispense “mental health,” and thereby prevent mental illness, psychiatrists by the 1960’s were displaying what seems in retrospect a pathetic hubris. As Torrey points out in a chapter entitled “Psychiatrists Who Would be Kings,” they recognized no limit to what could be dealt with through the promotion of mental health: “poverty, crime and delinquency, racism, sexism, unemployment, divorce, school dropouts, terrorism.” Charitably Torrey omits from his litany of folly Dr. Harold Rome’s 1968 article, “Psychiatry and Foreign Affairs,” published in the American Journal of Psychiatry and arguing that “no less than the entire world is a proper catchment area for present-day psychiatry, and psychiatry need not be appalled by the magnitude of the task.”
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To be sure, it was not with claims for redeeming the earth that psychiatric spokesmen went before Congress to urge passage of the legislation creating community mental-health centers. To Congress they made the rather more mundane promise that the centers would provide an alternative to state hospitals. This is certainly how Congress understood the purpose of the program. Torrey quotes Congressman Kenneth Roberts of Alabama: “We will bring these services back to the grass roots, so to speak, or back to the hometown of the patient who is affected, and gradually large institutions that are concentrated maybe in one or two or more places in each state will be out of the picture. . . .” Yet when the regulations were written by the National Institute of Mental Health (NIMH), no provision was made for a mandatory working relationship between the centers and the state mental hospitals for whose patients they were supposed to assume responsibility. And once the centers were established, their role as caregivers for former or potential state mental-hospital patients was quickly forgotten, to be disinterred chiefly when the time came to approach Congress for additional funds.
What did the centers do instead? A few, at least initially, took seriously the heady mission of transforming society. As Torrey writes, however, their visions of grandeur soon foundered. He cites the experience of Lincoln Hospital Mental Health Services in New York, designated by NIMH as one of eight model centers in the country. Here, in one of America’s worst slums, the professional staff set out to promote mental health through political action. Local black and Puerto Rican activists were hired as aides; the directors of the program preached community control.
The “community” took them at their word. Two hundred strikers, including 70 percent of the program’s employees, occupied the offices of the directors, locked them out, and named a new director from their own ranks. In the words of a report in the New York Times:
Dr. Harris B. Peck, director of the Lincoln Hospital Mental Health Service, used to pound the table at staff meetings and call for a “revolution.” He urged community workers, one of them recalled, to wrest control of their South Bronx mental-health project from him and other professional administrators and put him out of a job. Yesterday they did.
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But if the centers soon gave up the idea of promoting mental health through political organizing, with a few honorable exceptions they still failed to focus their attention on the chronically mentally ill. Rather, Torrey reports, they provided many millions of sessions of psychotherapy and counseling each year to the worried well: the rebellious teenager, the couple considering divorce, the man experiencing a mid-life crisis. It turned out, unsurprisingly, that there was an enormous demand out there for government-subsidized psychotherapy.
In the meantime, psychiatrists themselves were fleeing both the state hospitals and the community centers for private psychiatric hospitals and private practice. The more federal funds went into training mental-health professionals, including psychiatrists, the fewer professionals went into the public sector—although the expectation that they would do so had served as a rationale for the funding. By 1980 foreign medical graduates occupied 54 percent of state psychiatric staff positions; today, the system would collapse without them.
And what happened to the chronically mentally ill patients being discharged in droves from state hospitals? The failure of the community centers to take responsibility for this population certainly did not stop the process of deinstitutionalization. As Torrey emphasizes, there were tremendous financial incentives for state officials to empty the hospitals, for starting in 1963 federal programs would provide income support and pay medical expenses for the mentally ill only if they were not in state hospitals. Their destination became nursing homes and boarding houses, single-room-occupancy hotels, and, increasingly, jails, streets, and shelters.
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E. Fuller Torrey has described passionately and well how psychiatry and the community mental health centers failed the severely mentally ill. The problem with Nowhere to Go lies not in what it describes, but in what it ignores. Torrey pays virtually no attention to the rise of the anti-psychiatry movement of the 1960’s, yet that movement, and the mental-health bar which it spawned, created a situation which fatally influenced the course of deinstitutionalization, quite apart from the fiasco of the community centers.
According to the tenets of anti-psychiatry, which resonated widely in the atmosphere of the counterculture, there was no such thing as mental illness. There were only nonconformists, labeled mentally ill by a society that did not want to tolerate their behavior. This redefinition of mental illness was wrought chiefly by maverick psychiatrists—the most important of them being Thomas Szasz and Ronald Laing—who were joined by “labeling theorists” from the field of sociology. The latter treated mental illness as “residual rule-breaking” on the part of people whose “deviance” was then “stabilized” by official agencies of control.
With amazing casualness, these ideas were incorporated into the newly emergent mental-health bar. The man who must be considered its founder was Bruce Ennis, the first director of the New York Civil Liberties Union’s litigation project to expand the rights of mental patients. Ennis had applied for a job as staff attorney at the NYCLU but was told there were no openings; he was asked instead if he would be interested in starting a special project on the rights of the mentally handicapped. Knowing (as he has testified) nothing about the subject, Ennis went to the library, looked under the headings of law and psychiatry, and found books by Thomas Szasz. On the basis of a reading of Szasz, who of course denies the existence of mental illness, Ennis concluded that there was an enormous civil-liberties problem here and determined to devote much of his life to addressing it.
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During the 1970’s state laws governing commitment and treatment of the mentally ill fell like dominoes under the onslaught of Ennis and his followers. Existing laws, admittedly often too loose, were tightened so that only those dangerous to themselves or others could be committed for treatment. Yet, as the columnist Charles Krauthammer (himself a psychiatrist) has pointed out, the new standard was “not just unfeeling; it [was] uncivilized.” Before commitment became possible, severely ill individuals had to deteriorate radically. Individuals incapable of caring for their most minimal needs were adjudged no danger to themselves so long as their families cared for them. That gave families a choice: serving as institutions, or putting their ill member on the street in the hope that he would then become eligible for treatment. Unfortunately, even hallucinating on heat grates offered no guarantee of treatment.
The full safeguards of the criminal law were grafted onto commitment statutes: effective and timely notice; notice of right to a jury trial, to appointed counsel, in some cases to remain silent; exclusion of hearsay evidence; and a standard of proof beyond a reasonable doubt. Even once committed, individuals could refuse treatment under rulings that began to be handed down by state courts in the late 1970’s, some of which protected psychotic thought as a First Amendment right. (Drug therapy was held to interfere with the freedom to form insane ideas.) The effect was to permit the mentally ill, as psychiatrist Darold Treffert put it in a much-quoted phrase, to “die with their rights on.”
Torrey gives only glancing notice to the transformation of the laws governing treatment of the mentally ill—he remarks that they were “apparently drafted by the law firm of Franz Kafka and Lewis Carroll”—and he never explains how and why those laws came to be written. As for anti-psychiatry, he offers only a brief reference to the writings of Thomas Szasz and another to Erving Goffman, the sociologist who popularized the idea that the behavior of mental patients was primarily a reaction to the “total institutions” in which they resided.
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That Torrey should scant the role of anti-psychiatry is surprising, or upon reflection perhaps not so surprising, in that earlier in his career he himself contributed to the anti-psychiatric movement. Today, Torrey co-directs a major study of schizophrenia in identical twins for the National Institute of Mental Health. As a clinician, he is one of the rare psychiatrists who volunteer time to care for the seriously mentally ill in Washington’s shelters. As a publicist seeking to improve care of the mentally ill, he has written not only this book but has cooperated with Ralph Nader’s Health Research Organization in ranking state systems of care so as to put pressure on those with the weakest programs. (Not the least of Torrey’s services has been to keep Nader’s groups away from the shoals of anti-psychiatry on which they would otherwise almost certainly have run aground.) As a champion of families, he is the chief adviser to the National Alliance for the Mentally Ill and the author of a fine book, Surviving Schizophrenia.
But in the early 70’s, while still a resident at Stanford, Torrey wrote The Death of Psychiatry. In a blurb for that book, Thomas Szasz commended Torrey for his “reasoned review of the mythology of mental illness and the persecutory practice of psychiatry.” Actually, even then Torrey was far from a thoroughgoing denier of reality, for he stipulated that schizophrenia was an organic brain disease. But he also quoted Szasz liberally, denounced involuntary commitment, and declared that “we, who are psychiatrists and should know better, project our irrational impulses onto others whom we cannot understand, label them as mentally ‘ill,’ confine them, and feel better.”
Given Torrey’s energy and the range of his talents, it is fortunate for the mentally ill and their families that he has today moved very far from The Death of Psychiatry. But the movement with which he was once involved still has to be understood—and grappled with—if the mentally ill in the decades ahead are to have, finally, somewhere to go.
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