‘One Flew Over the Cuckoo’s Nest’ - Times have changed - New rules enforcing treatment for the seriously mentally ill are needed.

Published Tuesday 16 of March, 2010

NHMH Board Member Stephen P. Hinshaw reviews new book, The Insanity Offense, by Dr. E. Fuller Torrey.
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Social reforms that occur too quickly or promise radical change often fail. Retrenchment and blaming of the reforms’ beneficiaries typically follow. Indeed, prolific author and psychiatrist E. Fuller Torrey outlines in his new book, The Insanity Offense, two quixotic reforms of the 1960s and 1970s that followed just this pattern: the adoption of cost cutting deinstitutionalization policies that whittled down American public mental hospital patients from more than 550,000 in 1955 to fewer than 40,000 at present (despite the nation’s population having doubled); and the extension of civil rights to those with mental illness that make it nearly impossible to commit someone to a mental facility involuntarily. (A half century ago, all it took to commit a patient was a psychiatric recommendation and a judicial order.)

These reforms, which emanated from a curious combination of conservative, libertarian, and liberal forces, have allowed people, who are sometimes dangerous and who often lack insight into their deteriorated mental states, to languish in decrepit community facilities or even on city streets, without any means of getting the treatment they so urgently need. The results sometimes make headlines: People with paranoia and psychotic thought processes have committed brutal acts. But more often, the reforms have led to tragic, wasted lives of homelessness, despair, and victimization. Far too many people may be “dying with their rights on,” as Wisconsin psychiatrist Darold A. Treffert has put it.

Torrey, who has worked for decades on severe mental illness (schizophrenia, bipolar disorder, and psychotic depression), writes vividly about the sensational, brutal, and sometimes incomprehensible acts perpetrated by a relatively small number of the most severely mentally ill members of society. And he accurately explains what can trigger these people’s outbursts: No longer housed in mental facilities, they are left to fend for themselves or with highly stressed caregivers. Torrey also rightfully points out that given their irrational behavior and extreme poverty, people with mental illness are often jailed and victimized themselves.

I support this call for a pendulum swing back to a more rational policy of enforcing treatment for those in society who may need it most, despite their lack of understanding or insight. I also agree that to do so we must broaden the current criteria for involuntary commitment beyond simply imminent danger to self or others, or utterly impaired self-care skills. Indeed, the narrowness of these criteria makes it almost impossible to secure treatment for floridly psychotic individuals unless they literally have a gun in their hands or are overtly suicidal when police arrive.
Certainly such measures would invoke the wrath of those who insist on upholding the rights against coercive treatment of persons with serious mental illness, but something has to give. Reform will also require the creation of comprehensive community services (therapy, job skills, training in social competence) and programs that ensure that people with mental illness receive psychotropic (mind-affecting) medications. Torrey’s thoughts here are reasonable.

But I have several cautionary notes. First, although Torrey admits that society’s stigmatization of the mentally ill is a major problem, he blames such stigmatization mostly on the violent tendencies of a small subgroup of individuals with extremely severe mental illness, rather than on the media’s constant exaggeration and distortion of that group’s behavior, a host of discriminatory laws, and a plethora of American cultural factors that make discussion or disclosure of mental illness utterly shameful. And as a means of emphasizing just how awful the consequences of untreated serious mental illness can be, Torrey often bullet-points sensational, violent crimes and murders perpetrated by untreated individuals with serious mental illness. Although it is certainly true that psychosis and paranoia – especially when accompanied by substance abuse – are associated with violent behavior, most forms of mental illness are not. By sensationalizing the account in this way, Torrey furthers the stereotyping of all individuals with mental illness.

As to Torrey’s vehemence about the shortcomings of the deinstitutionalization movement – which began with humanitarian goals but quickly became touted as a cost saving device – his argument could be construed as a call for a return to massive public hospitals, which would be an unmitigated disaster. He states only once in the book that the closing of state hospital facilities has led to unprecedented life opportunities for many people with mental illness. “They live with their families, in boarding homes… or on their own. Some are able to hold jobs… and most have a social life,” he concedes. Along this line, recall that large, filthy and inhumane state hospitals flourished in the 1800s after Dorothea Dix and others launched impassioned reform movement decrying the intolerable treatment of those with mental disorders in orphanages or private almshouses. What if new reforms are not backed by adequate fiscal support and are not scrupulously evaluated? It would be a tragic irony if Torrey’s humanitarian pleas led to retrenchment and backsliding – to a return to involuntary commitment for those with unpopular political beliefs or to the snake pits that were omnipresent during much of our nation’s history.

Torrey should also be more critical of current treatment practices for the seriously mentally ill – mainly the belief that psychotropic medications will suddenly erase violence. Although these drugs are far more effective and, in many cases, less harmful than the offerings of 50 years ago, they are far from panaceas, and in many cases have severe side effects..

What we urgently need is multifaceted treatment in the community – accurate psychological diagnoses, education of and support for family members, financial support for housing and employment, and access to individual and group therapy as well as medication. Early identification of the small, potentially violent subgroup of chronically psychotic individuals is a major goal for research; this will require coordination among schools, physicians, families, and support agencies. Parity for insurance coverage of mental health treatments, as well as universal health care, is mandatory if those with mental illness are to receive appropriate intervention. Above all, an extended dialogue about mental illness across all facets of society, facilitated by more accurate media coverage, disclosures by eminent individuals, and legislative action, is essential. All of society would benefit.
Stephen P. Hinshaw is professor and chair of the department of psychology at the University of California, Berkeley. He is a author of The Mark of Shame: Stigma of Mental Illness and an Agenda for Change and The Years of Silence Are Past: My Father’s Life with Bipolar Disorder.

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Only 10% of patients with mental disorders receive evidence-based mental health care treatment from mental health professionals.

(Kathol et al, JGIM 20, 160-167, 2005)