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The Madness of Deinstitutionalization : OUT OF BEDLAM; The Truth About Deinstitutionalization By Ann Braden Johnson (Basic Books: $22.95; 296 pp.; 0-465-05427) : MADNESS IN THE STREETS; How Psychiatry and the Law Abandoned the Mentally Ill By Rael Jean Isaac and Virginia C. Armat e Free Press: $24.95; 414 pp.; 0-02-915380-8)

September 09, 1990|E. Fuller Torrey | The most recent book by Torrey, a research psychiatrist in Bethesda, Md., is "Nowhere to Go: The Tragic Odyssey of the Homeless Mentally Ill" (Harper & Row). and

The deinstitutionalization of the mentally ill that accelerated during the early years of the Reagan Administration--one of the more dramatic social experiments of 20th-Century America--is widely viewed as an abysmal failure. Many of the former denizens of state mental hospitals, liberated in theory but evicted in fact, have found their new homes either in jail or on the streets.

For example, Boston's public shelter, the Pine Street Inn, has become Massachusetts' largest "institution" for the mentally ill. Almost half of its 1,000 nightly residents suffer from schizophrenia or manic-depressive illness. The largest "institution" for the mentally ill in California is the Los Angeles County Jail, where an estimated 15% of its 24,000 inmates are diagnosed with these same diseases. Not since the 1820s have so many mentally ill individuals been forced to reside in public shelters (then called "almshouses") or jails in the United States. Well intentioned though it may have been, deinstitutionalization has been a bad trip down a rabbit hole.

"Out of Bedlam" and "Madness in the Streets" describe this bad trip and explain how we happened to embark on it. "Out of Bedlam" is the work of Ann Braden Johnson, a New York social worker who has spent many years working in the public sector with seriously mentally ill individuals. Johnson's tone is impressively warm and empathic: "Chronic mental patients are both more realistic about their condition and more graceful in failure than the rest of us, for their forced detachment from the normal world the rest of us inhabit has given them the wisdom that comes with tolerance of the inevitable."

Johnson also excels at showing how New York's disjointed, illogical health-care bureaucracy manages to ensnare many patients each day. Getting someone approved for Medicaid, she writes, is like "having a root canal, a mortgage closing or a tax audit." Her derision of administrators who never see patients is both palpable and accurate: "Administration can be a refuge, a chance to dictate and control without having to expose the limits of one's own skills and abilities." Her descriptions of the nursing-home industry, finally, are poignant reminders that some businesses have profited handsomely from deinstitutionalization, at the patient's expense.

The book's major shortcoming is Johnson's failure to consider what is wrong with the patients she cares for. Are they simply social misfits, as Thomas Szasz and R. D. Laing have contended, or do they suffer from brain maladies such as multiple sclerosis and Alzheimer's disease, as current neuropsychiatric research strongly suggests?

Studies of brain structure and function, using the latest methods in neurological research, have shown measurable differences in the brains of those suffering from schizophrenia and manic depressive illness. Physical defects in early brain development, viruses, genetic abnormalities and immune system dysfunction are now all suspected of playing a role in mental illness. Many mental health professionals such as Johnson, however, are still unfamiliar with this research.

Johnson strongly opposes involuntary hospitalization ("I don't see much difference between forcing someone into a cell and forcing him or her into a hospital bed"), suggesting that she leans toward the Szasz-Laing viewpoint, but she never seriously grapples with the issue.

This is, no doubt, why Johnson also fails to write any prescriptions for improving the system, a rather startling omission in a book that has spent 11 chapters detailing what is wrong. It is precisely professionals like Johnson, the ones who are spending time in hands-on clinical care, who should be making suggestions for improving the system, yet she merely says that "Although I certainly have thoughts on the subject," she cannot share them with us. It's as if she has given us a tour of the land down the rabbit hole but then quietly disappeared before telling us how to get back to the surface.

"Madness in the Streets" picks up, in many ways, where "Out of Bedlam" leaves off. Authors Rael Jean Isaac, a sociologist, and Virginia Armat, a writer, manage to pinpoint many of the problems with the way we have been treating those who suffer from serious mental illnesses, and don't hesitate to suggest promising solutions.

Bolstered by extensive interviewing and library research, their book, the most complete history of deinstitutionalization to date, documents how "dumping patients in the community on the theory that alternatives will be created is a well-tested recipe for chaos," and offers a devastating critique of the failure of the federally funded community mental-health centers.

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