How Politicians Strafed the Cuckoo’s Nest
After criticizing some scholarly articles and books, I have three books to recommend. First, here’s a tribute to 86-year-old psychiatrist E. Fuller Torrey, author of American Psychosis: How the Federal Government Destroyed the Mental Illness Treatment System (Oxford University Press, 2013). I first met Torrey in 1989 and heard about what was going wrong. Thirty-five years later, it’s even clearer that the federal panaceas have not panned out.
Torrey shows how local and state charities and governments cared for mentally ill individuals, sometimes poorly but often adequately, until 1940, by which time state mental hospitals housed 423,445 individuals. During World War II half of the hospitals’ professional staff members were in the armed forces. Torrey: “The hospitals were grossly overcrowded and understaffed,” sitting ducks for investigations published in newspapers such as The Daily Oklahoman and magazines such as Life.
Torrey also shows how ambitious federal officials used the opportunity to create the National Institute of Mental Health (NIMH) and other offices that had to decide whether to work to mend the state hospitals — or end them. The president of the American Psychiatric Association in 1958 recommended that state mental hospitals, which peaked in 1955 at 558,922 patients, should be “liquidated as rapidly as can be done in an orderly and progressive fashion.”
Bertram Brown, who became NIMH’s head in 1970, wanted to set up federally-funded community mental health centers throughout the land, one for every 50,000 people. Brown later explained that in the 1950s “the power structure of mental health was the state hospital superintendents and the state commissioners. . . . That was the system we had to break in order to have a community mental health system.”
Liquidate! Break! The ideological basis for destruction came from Thomas Szasz’s The Myth of Mental Illness (1961), Erving Goffman’s Asylums (1961), and Ken Kesey’s One Flew Over the Cuckoo’s Nest (1962, Oscar-sweeping film in 1965). Torrey writes that the books “portrayed mental patients as fundamentally sane and implied that if they were simply allowed to leave the hospital, they would live happily ever after.” Patients armed with prescriptions would have little need for supervision.
The reality was different. Torrey explains that “large numbers of the patients in those hospitals had no families to go to if they were released, that large numbers of the patients had a brain impairment that precluded their understanding of their illness and need for medication, and that a small number of the patients had a history of dangerousness and required confinement and treatment.”
NIMH disregarded studies showing that more than half of schizophrenic patients deteriorated within one year of discharge, often because they didn’t take their medications. After heavy lobbying, Congress in 1963 passed legislation that, in Torrey’s words, “encouraged the closing of state mental hospitals without any realistic plan regarding what would happen to the discharged patients, especially those who refused to take medication they needed to remain well.”
Two dueling forecasts of the future emerged. In one, community mental health centers emphasizing outpatient services would change America. Psychiatrist Alan Miller: “It was an exhilarating time for many of us who were caught up in this project. One of the most powerful intoxicants is the feeling that you are making history.” Federal outlays went to 789 local centers created from 1967 to 1980.
The other forecast, from Rep. Horace Kornegay (D-NC), recognized “the tendency on the part of the state and local officials that if someone in Washington will pay the bill, it is the easy way out for them.” Meanwhile, “civil rights lawyers were instituting lawsuits to further encourage states to empty the hospitals.” Torrey shows how a “malformed marriage of fiscally conservative state officials and politically liberal civil rights lawyers produced a strong advocacy coalition guaranteeing that the existing deinstitutionalized policies would be continued into the future.”
State hospitals closed. Tens of thousands among the insane hit the streets. Liberal journalists began focusing on homelessness in the 1980s in part because they could blame the Reagan administration for it, but also because about 650,000 individuals who would have been hospitalized thirty years earlier were on the streets. Many suffered from anosognosia, the disease of having a serious mental illness and being unaware of it. Torrey quotes newspaper accounts: “discharged patients . . . living in skid row . . . wandering aimlessly in the streets.”
Jails began creating special mental health units. A generation after exposing problems in state mental hospitals, Life ran a story titled “Emptying the Madhouse: The Mentally Ill Have Become Our Cities’ Lost Souls.” Studies in Massachusetts and Ohio showed 27-36% of discharged patients becoming homeless. Current studies show at least two-thirds of homeless individuals acknowledging mental illness. Iconoclast Torrey deserves credit for showing that those who think the current regime works . . . are crazy.