Stop the madness

By E. Fuller Torrey, M.D.

The Wall Street Journal, July 18th, 1996, Reprinted with permission. Copyright 1996 Dow Jones & Company, Inc.. All rights reserved.

Each year, about 1,000 people in the U.S. are murdered by severely mentally ill people who are not receiving treatment. These killings–about 5% of all homicides nationwide–are a testament to the perversity of deinstitutionalization. The emptying of our public psychiatric hospitals, a massive social experiment involving the release of some 830,000 patients, was undertaken on a multitude of flawed assumptions. It’s time to reverse course.

Only a small minority of the mentally ill is violent, but many more are worse off than if they had remained in the hospital. They can be found carrying on animated conversations with themselves in public, living in cardboard boxes or, like one man who lived beneath New York’s FDR Drive, training themselves for space missions. They often end up victimized, in jail for misdemeanors, or prematurely dead from accidents, suicide or untreated illnesses.

Seymour Kaplan, a psychiatrist who was one of the pioneers of deinstitutionalization in New York State, later called it the gravest error he ever made. The Empire State, which has released some 90% of its mental patients, typifies the policy’s failures. Perhaps the ultimate symbol is the Keener Men’s Shelter. For 75 years it was part of Manhattan State Hospital. As the state emptied the hospital through deinstitutionalization, Keener became a homeless shelter. When I visited a few years ago, it housed 800 men, 40% of whom were severely mentally ill. Several had been hospital patients in the same building–only then, they got the intensive psychiatric care they needed.

Deinstitutionalization has wreaked havoc on the quality of life, especially in New York City. Recent reductions in crime notwithstanding, New Yorkers still live with the fear that, as one local columnist put it, “from out of the chaos some maniac will emerge to . . . cast you into oblivion.” The presence of even nonviolent mentally ill homeless in the streets and parks creates an inescapable sense of squalor and degradation.

Ideology, Not Science

How have things gone so wrong? It is important to realize that the original underpinning for deinstitutionalization was ideology, not science. The idea had appeal across the political spectrum: Liberals found civil libertarian demands for mental patients’ “freedom” persuasive; conservatives were happy to cut mental health budgets by shutting down state hospitals.

When deinstitutionalization shifted into high gear in the early 1960s, only one study had been done on the effects of moving severely mentally ill individuals from psychiatric hospitals to community living. The 20 schizophrenics in that study, published in England in 1960, did relatively well when moved from a hospital to a supervised community facilities. Virtually every American advocate for deinstitutionalization in the 1960s and ’70s cited this paper–and did not mention that the 20 patients had been selected for the experiment because they were functioning at a high level and were able to work, unlike the vast majority of U.S. patients who would be sent packing.

Advocates of deinstitutionalization based their argument mostly on such texts as Erving Goffman’s “Asylums” (1961), which asserted that psychiatric patients’ abnormal behavior was mostly a consequence not of mental illness but of hospitalization. Research in the past decade has proved this assumption false: Studies using such techniques as positron emission tomography scans have shown that schizophrenia and manic-depressive illness are physical disorders of the brain, just as Parkinson’s disease and multiple sclerosis are. Patients with such illnesses need medications to control their symptoms, which usually get worse without treatment.

Advocates assumed that mentally ill individuals would voluntarily seek psychiatric treatment if they needed it. As it turned out, about half of the patients discharged from psychiatric hospitals did not seek treatment once out of the hospital. Many of those who suffer from schizophrenia and manic-depressive disorder do not believe themselves to be ill. These untreated individuals constitute most of the mentally ill population who are homeless or in jail, and who commit violent acts. States, meanwhile, shirked their responsibility, in part because the mentally ill were newly eligible for a variety of federal programs.

During the mass exodus of patients from psychiatric hospitals, nobody bothered to ask what was happening to them. Incredibly, despite the vast scale of deinstitutionalization, the federal and state governments never commissioned evaluations of this social experiment, which after all had been launched with virtually no empirical base. As late as 1981, when deinstitutionalization had been under way for over 15 years, an academic review of research on the subject found only five studies concerned with outcomes, three of which were methodologically flawed. During these same years, the National Institute of Mental Health discovered that patients being released from state psychiatric hospitals were not, with only occasional exceptions, receiving aftercare.

What can be done to correct this debacle? First, responsibility for mental illness services should be fixed at the state and local levels. This is not something the federal government does well. Federal funds now being used for mental illness services should be given to the states in block grants. With responsibility should come accountability. State mental illness services should undergo an annual evaluation carried out by a private contractor that would partially determine the size of the next federal block grant. How would mental illness services change? States would doubtless discover that eliminating all state hospital beds is ultimately not cost-effective. A small percentage of seriously mentally ill persons need long-term hospitalization, and many more need monitoring to ensure their compliance with a treatment regime.

A second, more controversial reform is no less essential: The mental health system must provide for the occasional involuntary treatment of seriously mentally ill individuals. The crux of any commitment law is the conditions it sets for involuntary commitment to be legal. In many states, patients may be committed only if they can be shown to pose a danger to themselves or others. Courts often interpret this provision very strictly. The standard should not be dangerousness but helplessness. Society has an obligation to save people from degradation, not just death.

Temptation to Accept

A major danger in thinking about the disaster of deinstitutionalization is the temptation to accept it. An entire generation of young adults has grown up seeing homeless mentally ill individuals living on the streets and in the parks. From their perspective, why shouldn’t these people always live there? They are just one more inescapable blight on the urban landscape, along with broken-down cars at the curbs and garbage under the bridges. It is important for those of us who are older to speak out. We remember when homelessness was rare. We must not accept as inevitable the debacle of deinstitutionalization and its consequences. We made this problem, and we can correct it.

Dr. Torrey, a Washington, D.C., psychiatrist, is author of “Out of the Shadows: Confronting America’s Mental Illness Crisis” (John Wiley, 1996). This article is adapted from the summer issue of the Manhattan Institute’s City Journal.