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Out of the Shadows: Confronting America's Mental Illness Crisis

By E. Fuller Torrey


Section 7 Copyright © 1997 The New York times

Jan 1997

Outcasts - The author hands up an indictment of the way we treat the severely mentally ill.

By Daniel J. kevles

Out of the Shadows



In New York City, the bag lady roams the streets scavenging in trash cans while she talks with the President of the United States. One day she is found raped and stabbed to death. In a hospital emergency room, a man with symptoms of acute manic depression rejects the advice of the resident and the urgings of his family and walks out. Several hours later, he hangs himself. A woman with a history of schizophrenia walks into a shopping mall and shoots at everyone in sight, killing three. What these tales have in common is that severely mentally ill people declined treatment and that no one could force them to be hospitalized or take medication.

In "Out of the Shadows," E. Fuller Torrey compiles these cases and many more like them into a powerful indictment of how we treat people suffering from acute mental disease. A psychiatrist specializing in schizophrenia, he draws on years of experience working in a public psychiatric hospital in Washington and at a clinic for the homeless who are mentally ill. His new book is written with a passionate combativeness that borders on polemic, but the crisis he delineates should stir any halfway sensitive human being to anger.

Today, in the United States, some five and a half million people over the age of 9 are estimated to suffer from severe mental illness, almost half of them enduring without treatment. The proportion, once large, of such people kept in state psychiatric hospitals has fallen drastically, the result of a 40-year movement known as "deinstitutionalization." Nowadays, many mentally ill Americans are in nursing homes that can provide custodial attention but little else. Roughly 159,000 of the untreated acutely ill are in prison, mostly for minor crimes like shoplifting; another 150,000 of them are homeless, and they make up about one-third of those outcasts of our affluence.

Dr. Torrey attributes the horrific situation to three causes. First, income security and disability programs like Medicaid fostered deinstitutionalization -- far more of it, he argues, than did the advent of antipsychotic drugs like Thorazine -- because they encouraged state authorities to shift patients into programs like nursing home care that the Federal Government pays for. Second, civil liberties lawyers fought successfully against involuntary commitment. For exceptions to be made in cases where people are a danger to themselves or society, Dr. Torrey notes, you either have to try to kill the judge or attempt suicide before the bench. Third, American culture has come to define severe mental illness as just one point on a broad spectrum of "mental health" problems that run from mild neurosis to manic depression, the product of environmental stresses of a Freudian or socioeconomic nature.

Dr. Torrey insists that severe mental illnesses are measurable neurobiological disorders and in most cases are treatable with drugs. He quotes the psychiatrist Darold Treffert in arguing against civil libertarian dogmatism: "The liberty to be naked in a padded cell in a county jail, hallucinating and tormented, without treatment that ought to be given is not liberty; it is another form of imprisonment -- imprisonment for the crime of being ill." Dr. Torrey urges that the criteria for involuntary commitment should include the need for treatment. And he advocates consolidating responsibilities for the mentally ill at the state level, to reduce the practice of shifting costs.

But Dr. Torrey neglects to peer behind his premises. Although we know more every day about the correlation of biology and mental illness, it is not always clear what is cause and what is effect. Then, too, commitment based on need for treatment could invite abuse, especially if hearsay evidence is allowed, a position that Dr. Torrey seems to endorse. And the record of psychiatric hospitals falls somewhat short of ideal. Like all polemics, "Out of the Shadows" should be read with caution, but its analyses deserves attention.

Daniel J. Kevles is the author of "In the Name of Eugenics" and other works on issues in science, medicine, and society.

Confronting America's Mental Illness Crisis. By E. Fuller Torrey. 244 pp. New York: John Wiley & Sons.

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