I’ve been talking and writing about our broken mental health care system and the need for change since shortly after our son was diagnosed with mental illness in 1999 and we began battling to find good treatment in that “system.” It’s been well over a decade now, yet nothing has changed. That we dare to call mental health care a “system” is laughable. After all “system” implies organization of services, coordination of care, and oversight. In too many cases, there are no services at all. And instead of care, there is only chaos. I’ve never understood how this could have happened—how we could be failing the mentally ill among us so completely.
E Fuller Torrey, in his recently released book, American Psychosis, has made it painfully clear. With uncompromising and fierce analysis and insight, he has explained how things went so wrong after JFK signed the community mental health act in 1963. The motivation for legislation was laudable, the outcome, however, was a disaster. Fifty years since, the mental health care system is in shambles.
Mental health hospitals had already begun closing in the 50’s and continued to do for many reasons—exposure of the horrible conditions and lack of treatment in some, new medications that brought the worst symptoms under control, changes in Medicare and Medicaid that disallowed coverage for psychiatric hospital care, lawsuits and changes in commitment criteria, and the feeling that there were better ways to treat those who live with mental illness. With the closings and the new law came a hopeful paradigm– community mental health centers would provide care in outpatient settings where those with mental illness could reengage as members of their families and communities.
Why was the plan such a failure? The legislation, says Torrey was fatally flawed. “It 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. It included no plan for the future funding of mental health centers. It focused resources on prevention when nobody understood enough about mental illnesses to know how to prevent them. And by bypassing the states, it guaranteed that future services would not be coordinated.”
The failure of the community mental health care program was due to more than just poor planning and lack of funding. For me, the most troubling was the changing philosophy of those who were charged with leading the program. As plans were being formulated, their focus shifted from the care for those with severe mental illness to one of prevention, which in turn became a movement to address our social and cultural ills in order to promote mental health. Admirable perhaps, but such grandiose notions were far beyond the scope of community mental health centers that were supposed to serve those with mental illness. The change in thinking, Torrey says, altered the essential function of community treatment.
Many of those who were released from hospitals were severely ill, didn’t have family support, had chronic long-term needs, and had no place to go. Says Torrey, “Our failure to protect such mentally ill people by insuring they receive treatment is a major miscarriage of our mental health care system and a blot on our claims to be civilized.” So many ended up homeless and in jail and the travesty continues to this day. The result? The largest mental health providers in the nation are our prisons and jails: Cook County in Illinois, Los Angeles County, and Rikers Island in New York among them. The complete failure of mental health care in this country is a sad commentary on how personal biases and ambitions, wrong headedness, and political aspirations can shape policy and impact people in such devastating ways.
In the last chapter Torrey acknowledges that change does not come easily. Progress is impeded by the lack of understanding of serious mental illness, failure to understand the magnitude of the problem, economic and political interests, and the lack of leadership. However, “the fact that we know what to do to correct the existing mental illness diaster is the good news,” he says. He explains how we can incorporate what we’ve learned into successful programs. When we know how and why the system fails and when we look at what successful treatment looks like, as Torrey does, then we can begin to work to achieve it.
Torrey concludes his book with a 1947 quote from Out of Sight, Out of Mind by Frank Wright:
“Throughout history the problem of the mentally ill has been dodged. We have continually avoided mentally ill patients—we have segregated them, ostracized them, turned our back on them, tried to forget about them. We have allowed intolerable conditions to exist for the mentally ill through our ignorance and indifference. We can no longer afford to ignore their needs, to turn a deaf ear to their calls for help. We must come face to face with the facts.”
“Isn’t it time to finally do so?” Torrey asks.
I urge anyone who is concerned about the current state of mental health care to read this book. And I thank Dr. Torrey for writing it.
E. Fuller Torrey, M.D., is the Executive Director of the Stanley Medical Research Institute in Chevy Chase, MD, founder of the Treatment Advocacy Center, and Professor of Psychiatry at the Uniformed Services University of the Health Sciences.