The Insanity Offense. How America’s Failure to Treat the Seriously Mentally Ill Endangers its CitizensRichard Balon, MD
Wayne State University, Detroit, MI, USA
By E. Fuller Torrey. New York, NY: WW Norton & Company; 2012; ISBN: 978-0-393-34137-9; pp 284; $16.95 (paperback).
The care for the seriously mentally ill—ie, schizophrenia patients and manic-depressive patients—has been the Cinderella and Achilles’ heel of contemporary psychiatry. What do we, as a society, provide for them and how much do we really care for them? I am fully aware of those few dedicated community psychiatrists, but how many graduating residents would like to work in community mental health centers or the few remaining state and forensic hospitals? Those jobs are considered to be at the low end of the totem pole, mostly filled by international medical graduates. The seriously mentally ill do not have many advocates beside the National Alliance on Mental Illness. Yet, there is at least 1 big advocate among us—E. Fuller Torrey, MD. No one has been pleading the issues of the seriously mentally ill more forcefully and eloquently than him. One can understand this by looking at the titles of some of his books published over the last several decades—Surviving Schizophrenia: A Family Manual; Care of the Seriously Mentally Ill; Nowhere to Go: The Tragic Odyssey of the Homeless Mentally Ill; Criminalizing the Seriously Mentally Ill; and Out of the Shadows: Confronting America’s Mental Illness Crisis. I have read some of his books and frequently cite his Witchdoctors and Psychiatrists, originally published in 1972 and still worth reading. Dr. Torrey’s books are written with passion for the seriously mentally ill, filled with interesting information, and easy to read. One can disagree with some of his opinions, but nobody can deny that he passionately cares for the seriously mentally ill.
His newest book, The Insanity Offense. How America’s Failure to Treat the Seriously Mentally Ill Endangers its Citizens—originally published in 2008 and re-published with a new epilogue in 2012—postulates what the subtitle suggests: by its failure to take care of the seriously mentally ill, our society endangers all of its citizens.
The core of the book are the tales of violent crimes; murders perpetrated by the seriously mentally ill. Crimes that could have been avoided if not for our neglect of the seriously mentally ill and for the legal limitations put on what could be done with/for the seriously mentally ill. These tragic stories start in chapter 2, “Death by the roadside,” with the tale reminding us of a Greek tragedy. It is a story of Malcoum Tate, a schizophrenia patient who throughout his illness had become more aggressive, agitated, and threatening. As there was no place for him and for his permanent care, he ended up with his family who had become increasingly afraid of him. Being scared, running out of options, and feeling helpless, his sister, with the help of Tate’s mother, killed him. The reader finds out in a later chapter that the sister was sentenced to life in prison and died there of untreated diabetes; the mother served a short prison term. The sister wrote in her appeal to her sentence, “I feel and felt then my brother should have been in the hospital where he could have been watched and taken care of properly. The police and hospital said they couldn’t do anything until he hurt someone. I just couldn’t let that happen to my daughter or family” (p 203). What an attestation to the failure of our society to protect its citizens.
In the introductory chapter, Dr. Torrey calls our care of the seriously mentally ill “one of the great social disasters of recent American history” that should be included “among the greatest calamities” (p 1). He postulates that the 2 major origins of this disaster are deinstitutionalization and the legal profession (p 1). Why deinstitutionalization? Well, as Dr. Torrey points out, there is a temporal relationship, frequently denied, “between the closing of state mental hospitals and the increase in homelessness, incarceration, victimization, and acts of violence associated with some of the released patients” (p 2). Also, once patients are released from hospitals, essential aftercare in most places varied from inadequate to invisible (p 2). And why the legal profession? Well, they pushed the legal actions targeted at closing state hospitals in some states (p 4) and, most importantly, “also brought lawsuits that sought to make it as difficult as possible to get patients back to the hospitals” (p 4). While having no experience with the mentally ill, many of them pushed for the abolition of involuntary hospitalization (p 4).
The third chapter, after describing a mentally ill California man who killed 13 people, brings to our attention that in California, it was the “marriage of Southern California conservative John Birchers to northern California’s liberal civil libertarians” (p 31) that made the passage of the legislature limiting the treatment options for the severely mentally ill. In the conclusion of the next chapter Dr. Torrey summarizes the legacy of that legislature. In California, some of the numbers are staggering: “approximately 32,000 severely mentally ill individuals are in state prisons, constituting 20% of all state prisoners. Between 1970 and 2004, severely mentally ill individuals, most of whom were not receiving treatment, were responsible for at least 4,700 California homicides. Each year, they are responsible for an additional 120 homicides” (p 68). The following 2 chapters provide a similar illustration and the legacy of the commitment laws in Wisconsin. One chapter mentions a great Program of Assertive Community Treatment in Dane County, WI. This program worked well, yet the homelessness and other problems of the mentally ill kept increasing. The problem was the program was available to only approximately 10% of people in need (p 97).
Chapter 7, “God does not take medication,” discusses anosognosia as the main problem leading to refusal of medication and later to violence. Chapters 8 and 9 summarize the consequences of “unconstrained civil liberties: homelessness, incarceration, victimization of mentally ill (protectors became perpetrators in many cases), and violence and homicides perpetrated by the mentally ill.” The author brings to our attention that, “Conservatively, it seems reasonable to predict that 5% to 10% of individuals with severe psychiatric disorder will commit acts of serious violence each year” (p 143). Dr. Torrey also mentions the attacks on public figures and mental health professionals. We are not fully aware that although the annual rate of job-related victimization by violent crime was 12.6 incidents per 1,000 workers, it was 16.2 for physicians and 68.2—more than 5 times higher—for psychiatrists (p 155).
The following chapter, “An imperative for change,” calls for protecting those afflicted with mental illness (“what kind of civilization allows seriously mentally ill persons to be victimized” [p 162]), decreasing stigma, protecting the public, making better expenditures, and other measures. Chapter 11, “Fixing the system,” continues in proposals on how to fix the system—through modification of the laws, identification of the target population, provision and enforcement of treatment, and assessment and research. The part on provision and enforcement of treatment emphasizes that, “medication is only part of the treatment plan. An effective system also must include a sufficient number of psychiatric beds for the admission of acutely ill patients and sufficient funding to allow patients to remain hospitalized long enough to achieve control of their symptoms, normally a period of 2 to 4 weeks. Such a system must also include a small number of beds for severely and chronically ill individuals for whom medications are not effective” (p 185). Chapter 12 contains the mentioned follow-up of chapter 2, the Malcoum Tate case. The last chapter, the newly added Epilogue: “Tragedy in Tucson,” discusses the shooting of Congresswoman Gabrielle Giffords and other people by Jared Loughner in Tucson, AZ. A similar story all over again. Dr. Torrey calculated that there are 100 potential Jared Loughners in each congressional district. Should the Representatives be at least a bit nervous?
This is a very interesting and passionate book, the kind of book one would expect from its author. Reading it one cannot help but wonder…what did we achieve by closing those state mental hospitals instead of modernizing them and making them more livable? One also wonders whether a combination of identifying the target population and creating new, specialized hospitals for this population could be the answer. Last but not least, I agree with another reviewer of the book’s previous edition, Dr. Philip Veenhuis, that “this book should be required reading for all legislators and civil rights attorneys,” and for anybody interested in the plea of the severely mentally ill.
Annals of Clinical Psychiatry ©2012 Quadrant HealthCom Inc.