Book Review: 'American
Psychosis' by E. Fuller Torrey
By Sally Satel in the
Wall Street Journal
For a few days in
September—after a psychotic gunman killed 12 people in Washington's Navy
Yard—we were forced to ask ourselves, yet again, how we treat the seriously
mentally ill in America and whether we need to rethink our policies and
assumptions. No one is better equipped to address those questions than E.
Fuller Torrey, a distinguished psychiatrist whose earlier books include
"Out of the Shadows: Confronting America's Mental Illness Crisis"
(1997).
In "American
Psychosis," Dr. Torrey documents our nation's shameful legacy of
inadequate care for people with serious psychiatric disorders. The book is
animated—or, really, haunted—by a vivid case study: the long-forgotten story of
Rosemary Kennedy, the third child and eldest daughter of Joseph and Rose
Kennedy and the sister of the president. Rosemary was born with mild mental
retardation but lived contentedly in rural convents with tutors and caretakers
hired by her family. As she grew into a young adult, her sweet nature curdled.
She became emotionally unstable and prone to violent rages, much to the
mortification of her father. "For a socially and politically ambitious
Irish family like the Kennedys," Dr. Torrey writes, "having an insane
family member was the definitive disgrace."
Something had to be
done, and Joe Kennedy made the fateful decision to subject his 23-year-old
daughter to a frontal lobotomy. The procedure went disastrously wrong, and
Rosemary lost of most of her ability to speak and to wash and dress herself.
Her lobotomy, Dr. Torrey concludes, "was a family sin that demanded expiation."
Atonement came on Oct.
31, 1963, during the presidency of John F. Kennedy. On that day, he signed the
Community Mental Health Centers Act, requiring that huge state hospitals for
the mentally ill give way to a user-friendly archipelago of federally funded
community clinics. "When carried out," said JFK of the act,
"reliance on the cold mercy of custodial isolation will be supplanted by
the open warmth of community concern and capability.''
It wasn't just guilt
that moved Kennedy, of course. The need for reform was already in the air, as
Dr. Torrey explains. Books like Albert Deutsch's "The Shame of the
States" and popular entertainments like the movie "The Snake
Pit," both of which appeared in 1948, exposed shocking conditions of filth
and abuse in the care of the mentally ill. State-initiated efforts to improve
conditions at state hospitals and to successfully move some patients into the
community had already begun, thanks to the availability of Thorazine, an
anti-psychotic medication introduced in the mid-1950s. But with Kennedy's
community centers under construction, the campaign to empty out state
facilities took on new urgency.
Some patients did well
upon discharge, but the sickest were caught in a revolving door. Without
closely supervised treatment, they failed in the community and went back to
whatever institutions were left in place. Others ended up in a kind of limbo,
neither institutionalized nor embedded in a community. Indeed, the number of
psychotic patients in the federally funded community centers would never rise
above 5%. And they were the lucky ones. Many others ended up living in
flophouses, on the streets or in jails.
When Medicare and
Medicaid came on the scene in the mid-1960s, states had further incentive to
depopulate the asylums: They simply shifted the financial burden to the feds,
who would pay for housing patients in poorly equipped nursing homes. Finally,
legal decisions issued in the 1960s and 1970s made it hard for judges to order
needed treatment for debilitated patients who were refusing care. "This
malformed marriage of fiscally conservative state officials and politically
liberal civil-rights lawyers produced a strong advocacy coalition," Dr.
Torrey writes. It guaranteed "that the existing deinstitutionalization policies
would be continued."
As Dr. Torrey makes
clear, mental-health policy was a bipartisan failure. Neither Richard Nixon nor
Ronald Reagan showed particular interest in assuaging the plight of the
severely mentally ill. Their care remained financed through an uncoordinated
patchwork of local, state and federal agencies with no single accountable
overseer. In 1992, a federal law was passed establishing the Substance Abuse
and Mental Health Services Administration, which was tasked with overseeing
block grants to the states. Curiously, Dr. Torrey says little about the agency
in "American Psychosis," though for years he has criticized it for
investing too little of its attention, and grant dollars, in the well-being of
patients with psychotic illnesses.
All this incompetence
does not come cheap. Dr. Torrey estimates that $140 billion is annually spent
on "grossly inadequate and disjointed services," a sum that
"should be more than sufficient to support excellent services if the money
were used wisely."
Many of Dr. Torrey's
proposed solutions are based on evidence from enlightened programs that already
exist. For example, he promotes "assisted outpatient treatment," a
court-ordered treatment (including medication) for individuals with severe
mental illness who have a history of doing poorly if untreated. He also urges
greater use of teams (social worker, nurse, psychiatrist, occupational
therapist) and endorses a "need for treatment" standard for civil
commitment. Experiment should be tried too, he says. Perhaps allow select
states to use Medicaid funds as they see fit, unfettered from the regulations
imposed by Washington.
Dr. Torrey ends as he
begins, with JFK, Rosemary's loving older brother who set the stage,
inadvertently but nonetheless formatively, for the dysfunctional public
mental-health system we have today. The lesson, no less powerful for being
familiar, is that good intentions are not enough.
Dr. Satel, a resident
scholar at the American Enterprise Institute, is a psychiatrist and co-author
of "Brainwashed: The Seductive Appeal of Mindless Neuroscience."
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