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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 lack of any empirical research or pilot projects to test deinstitutionalization before it was implemented on a national scale seems extraordinary in retrospect. It becomes clear from the authors' review of this history that the mental-health professionals who were the architects of deinstitutionalization were afflicted with delusions (mostly grandiose in type) almost as severe as the patients for whom they were planning services.

The heart of "Madness in the Streets" is an account of how anti-psychiatry lawyers (e.g., ACLU, Mental Health Law Project) and a small group of radical ex-patients have colluded to make it increasingly difficult to hospitalize or treat mentally ill individuals in need of care. The history of this movement, which is still very much alive, has not heretofore been written, and it is disturbing indeed. The lawyers, write Isaac and Armat, "are practicing medicine with the wrong graduate degree," creating a situation where "the right to be crazy" has become the law of the land.

The authors well describe the sad and tragic consequences of the current system, where mentally ill individuals simply aren't treated until they have become violent to themselves or others. The anguish of such patients' families is the strongest image left in one's mind. Blame for this state of affairs accrues equally to lawyers (for misunderstanding the nature of mental illness) and to psychiatrists (for abandoning the seriously mentally ill in favor of their more comfortable private counseling practices).

Unlike "Out of Bedlam," "Madness in the Streets" does not hesitate to outline prescriptions for recovering from the disaster of deinstitutionalization. Most individuals with serious mental illnesses need medication, and sometimes this must be given involuntarily because the illness interferes with the person's insight into his own ondition.

Thus, hospitalization (sometimes involuntary) is occasionally necessary, although most people with serious mental illnesses can be treated in the community if proper aftercare, housing and rehabilitation services are provided. Whereas Johnson wrote almost exclusively from her perspective in the New York State mental-health system, Isaac and Armat visited model treatment programs in many states, and their prescriptions reflect this broad experience.

"Madness in the Streets," nevertheless, is weakened by the authors' failure to appreciate the important role that federal funding programs, especially Medicaid, have played in driving deinstitutionalization. To shift the fiscal burden of caring for the mentally ill from the state to the federal government (which pays for most Medicaid and community support funds), many states continue to discharge patients from state hospitals before they have received adequate treatment and before community resources are in place to take care of them.

This shortcoming aside, "Madness in the Streets" is an important book both for understanding what went wrong with deinstitutionalization and how to make it right. Such prescriptions are vital these days, for mental-health-care funds continue to be cut: On July 31, for instance, Gov. George Deukmejian's budget for the 1990-91 fiscal year cut $175 million in financial aid from the state to counties for medical services for the working poor. Mental health program funding alone was reduced by $71 million.

Isaac and Armat not only lead us out of the rabbit hole, they provide us with information essential to avoid repeating such mistakes again.

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