Paul McHugh: How the emptying of state-run mental hospitals produced a social disaster
[Dr. McHugh is a University Distinguished Service Professor of Psychiatry at Johns Hopkins University. His book "Try to Remember: Psychiatry's Clash Over Memory, Meaning, and Mind" will be published in October.]
There are times and situations that call for prophets. Not fortunetellers or soothsayers, but biblical prophets like Amos or Jeremiah who furiously proclaim the old truths, puncture our pretensions and predict from current tribulations worse to come if what lies deeper than sin -- idolatrous worship of false gods -- continues. E. Fuller Torrey, a psychiatrist who cares for patients with schizophrenia and manic-depression, is to my mind the doctor nearest in character to an ancient Hebrew prophet.
In "The Insanity Offense," he describes the grim consequences -- in death, violence and suffering -- of laws that, beginning in the late 1960s, released the seriously mentally ill from the oversight of state mental-health services and permitted them to wander away from the treatment and protection they desperately needed. Dr. Torrey identifies an unholy alliance of rash conservatives seeking to save public money by abandoning a traditional state obligation and self-righteous liberals defining the neglect of these patients as "defending their civil rights." We need prophets to confront such alliances -- anything less will fail -- and in this splendid book we hear one.
"The Insanity Offense" is "about one of the great social disasters of recent American history," Dr. Torrey writes. "It began within the lifetime of many of us, is continuing, and today affects approximately 400,000 individuals and their families. In the annals of twentieth-century American history, it should be included among the greatest calamities."
Some of the background should be familiar. From the mid-19th century right up until the 1960s, state governments accepted responsibility for the care and treatment of the seriously mentally ill. This arrangement came about because in the 1840s such civic crusaders as Dorothea Dix (in what may be the first piece of social research ever conducted in America) revealed the special ordeal of delusional and distressed mental patients: They tended to lose their way in life and, because of their unpredictable and occasionally violent propensities, filled the country's jails, workhouses and shelters, where they often suffered ugly mistreatment. Dix reported to the Massachusetts legislature in 1843 on "the present state of Insane Persons confined within this Commonwealth, in cages, cellars, stalls, pens! Chained, naked, beaten with rods, and lashed into obedience!"
The state mental-hospital system was founded to care for these patients. Though psychiatrists before the mid-20th century could offer them little more than shelter and protection, even that modest level of care was far from inconsequential: It kept the patients and the community from harm. State mental hospitals stood as beacons of a public obligation.
By the 1950s, though, these hospitals had become overcrowded and were themselves prompting calls for reform. It was a missed opportunity: Much could have been accomplished if psychiatric leaders at the time had moved quickly to repair a failing system and to educate the public about serious mental illness. The discovery of "anti-psychotic" phenothiazines and "anti-depressants" meant that the symptoms of these patients could be greatly relieved and their dangerous behavior much reduced if such medications were used properly. Steps could have been taken to address the concerns of the growing civil-rights movement and ensure that long-confined patients were not victims of neglect. And the increasing zeal for fiscal restraint and tax reform in state government should have been met head-on with a frank discussion about the costs and benefits of shouldering responsibility for some of our most vulnerable citizens.
Instead, psychiatric leaders at the time offered little or no defense. Worst of all, they failed to explain why state responsibility should continue, no matter what changed in the settings for patient services, so that the mentally ill would be monitored and not slip from sight. Patients with schizophrenia and manic-depression, it should have been explained, often lack any sense of their own mental disorders and so need regular supervision to sustain their treatment....
Read entire article at WSJ
There are times and situations that call for prophets. Not fortunetellers or soothsayers, but biblical prophets like Amos or Jeremiah who furiously proclaim the old truths, puncture our pretensions and predict from current tribulations worse to come if what lies deeper than sin -- idolatrous worship of false gods -- continues. E. Fuller Torrey, a psychiatrist who cares for patients with schizophrenia and manic-depression, is to my mind the doctor nearest in character to an ancient Hebrew prophet.
In "The Insanity Offense," he describes the grim consequences -- in death, violence and suffering -- of laws that, beginning in the late 1960s, released the seriously mentally ill from the oversight of state mental-health services and permitted them to wander away from the treatment and protection they desperately needed. Dr. Torrey identifies an unholy alliance of rash conservatives seeking to save public money by abandoning a traditional state obligation and self-righteous liberals defining the neglect of these patients as "defending their civil rights." We need prophets to confront such alliances -- anything less will fail -- and in this splendid book we hear one.
"The Insanity Offense" is "about one of the great social disasters of recent American history," Dr. Torrey writes. "It began within the lifetime of many of us, is continuing, and today affects approximately 400,000 individuals and their families. In the annals of twentieth-century American history, it should be included among the greatest calamities."
Some of the background should be familiar. From the mid-19th century right up until the 1960s, state governments accepted responsibility for the care and treatment of the seriously mentally ill. This arrangement came about because in the 1840s such civic crusaders as Dorothea Dix (in what may be the first piece of social research ever conducted in America) revealed the special ordeal of delusional and distressed mental patients: They tended to lose their way in life and, because of their unpredictable and occasionally violent propensities, filled the country's jails, workhouses and shelters, where they often suffered ugly mistreatment. Dix reported to the Massachusetts legislature in 1843 on "the present state of Insane Persons confined within this Commonwealth, in cages, cellars, stalls, pens! Chained, naked, beaten with rods, and lashed into obedience!"
The state mental-hospital system was founded to care for these patients. Though psychiatrists before the mid-20th century could offer them little more than shelter and protection, even that modest level of care was far from inconsequential: It kept the patients and the community from harm. State mental hospitals stood as beacons of a public obligation.
By the 1950s, though, these hospitals had become overcrowded and were themselves prompting calls for reform. It was a missed opportunity: Much could have been accomplished if psychiatric leaders at the time had moved quickly to repair a failing system and to educate the public about serious mental illness. The discovery of "anti-psychotic" phenothiazines and "anti-depressants" meant that the symptoms of these patients could be greatly relieved and their dangerous behavior much reduced if such medications were used properly. Steps could have been taken to address the concerns of the growing civil-rights movement and ensure that long-confined patients were not victims of neglect. And the increasing zeal for fiscal restraint and tax reform in state government should have been met head-on with a frank discussion about the costs and benefits of shouldering responsibility for some of our most vulnerable citizens.
Instead, psychiatric leaders at the time offered little or no defense. Worst of all, they failed to explain why state responsibility should continue, no matter what changed in the settings for patient services, so that the mentally ill would be monitored and not slip from sight. Patients with schizophrenia and manic-depression, it should have been explained, often lack any sense of their own mental disorders and so need regular supervision to sustain their treatment....