Abstract
American Psychosis, a book that recounts the unintended consequences of American mental health care policy, is likely to garner mixed reviews from earnest readers who are able to complete it. Initially, I did not think that I would be among them. The first two chapters of the book are scathing reviews of people, not policy. They read as sensationalized exposes of individuals Dr. Torrey believed to be key players in developing and implementing the current mental health care model. The Joseph Kennedy family, who had a daughter lobotomized, and Robert Felix, who was misguided, just so happened to be in the wrong and right places at their respective times. The Kennedy family’s actions constitute a tragedy, and perhaps not one that should engender sympathy; however, it is difficult to digest the author’s rampant speculation about ulterior motives.
In Chapters 3–5, Torrey begins to expound on the causes and effects of deinstitutionalization. Many clinical social workers agree that this has had resounding consequences. The book lays out three sparks that fueled the current fire of rapid hospital discharge, in order of level of fault: federal involvement, court decisions, and the advent of typical antipsychotic medications.
In 1963, the Mental Retardation Facilities and Community Mental Health Centers Construction Act, or Community Mental Health Act (CMHA), was passed. This was in reaction to post–World War II illustrations of despicable and filthy state mental hospitals and despite more recent state innovations in community mental health care. The CMHA’s concern with mental “health” rather than illness, and its focus on “prevention” are critically flawed elements, from Torrey’s perspective. He provides a sufficient argument for the detriments of phraseology. Though an emphasis on wellness is desirable from a resiliency perspective, legislation should be specific in scope in order to be effective. Corrupt agencies saw a way to profit, treating the worried well at the expense of individuals who had more severe and persistent illnesses, all while remaining perfectly within the scope of social and mental “health” promotion. Unfortunately, this is an unintended consequence without a straightforward solution, including the one Torrey recommends in his conclusions. Additionally, the promise of mental health prevention has yet to be realized, and Torrey is right in pointing out that it may remain so.
During the implementation of the CMHA, several court rulings increased consumer rights. The 1966, Lake v. Cameron introduced the “least restrictive alternative” mandate, which allowed individuals to make decisions regarding their mental health care. This was followed in 1966 by the “right to treatment” decision on Rouse v. Cameron, which demanded that hospitals provide adequate treatment in the event that their use was unavoidable. Finally, the verdict that changed compulsory admission from “need for treatment” to “danger to self or others” set an absolute criterion that is much more stringent and rigorous and, therefore, difficult to manipulate. Torrey argues that these cases present an unreasonable, and often insurmountable, burden placed on mental health professionals. From a social work perspective, however, the values expressed by these opinions should absolutely be upheld as fundamental to an individual’s civil rights.
In 1965, the Social Security Act was amended to include Medicare and Medicaid, two forms of public health insurance. The straw that broke the state hospitals’ backs was Medicaid’s Institution for Mental Disease restriction. According to Torrey, this provided the last incentive states needed to shift the expense of providing treatment to mentally ill individuals beyond their own hospitals. The states’ reaction to the Medicaid exclusion was to rehouse individuals from psychiatric hospitals at nursing and boarding homes or to shift their care to general hospitals where Medicaid provided coverage (i.e., federal funds). This led the way to the for-profit nursing and boarding homes, many of which, as direct practice social workers are aware, may be even more abysmal than state hospitals ever were. Case examples are given of state public officials, whose campaigns were financed by for-profit nursing homes, being elected in areas where regulatory oversight of such facilities mysteriously ceased. Torrey (2013, p. 164) concludes that “Medicaid reimbursement, not patient needs, has been the driving force behind the organization of public psychiatric services for four decades.”
The most disconcerting aspect of this book is the amount of ink Torrey devotes to describing instances of violence and murder incited by individuals with mental illness. He concedes such behavior is representative of a minority of the population, but in many fewer pages. For this reason, Torrey and his Treatment Advocacy Center have been condemned as fear mongering, especially angering mental health consumers (Dundas, 2013). The use of scare tactics to promote compulsory treatment further stigmatizes a vulnerable population and promulgates stereotypes. These methods are entirely inconsistent with social work values and represent a point of contention that the profession must continuously dispute.
Torrey also spends a considerable amount of the book discussing the negative impact deinstitutionalization has had in terms of homelessness and incarceration of mentally ill individuals. In Chapter 6, The Perfect Storm, Torrey discusses the phenomenon of transinstitutionalization, which he blames on state agencies using Medicaid maximization strategies. He also presents case studies of cities with particularly large homeless camps, especially San Francisco and New York, the abodes of many individuals with schizophrenia and other untreated mental illnesses. In Chapter 7, Dimensions of the Current Disaster, there are a number of studies cited that support Torrey’s claims that police officers have become the new mental health providers, and jails and prisons the new asylums.
In his final chapter, Solutions, Torrey lists recommendations for policy changes. Social workers may find it encouraging that Torrey supports the use of Assertive Community Treatment (ACT) teams. He reports a strong belief in the continuity of care provided by ACT teams and also promotes the clubhouse and peer support models. He advocates for tight oversight of nursing and boarding care facilities, including unannounced inspections by impartial agencies. Conflicting beliefs may lead individuals to agree or disagree with his support of assisted outpatient treatment that tie consumer benefits, cash and in kind, to “involuntary” outpatient treatment, including medication compliance. He recommends that services be prioritized to serve individuals with the most severe of mental illnesses, in order to prevent future dumping of difficult clients by agencies interested solely in profits. This is a contentious recommendation because it has the potential to engender an opposite set of unintended consequences.
American Psychosis is an overview of mental health policy that highlights its failures and unintended consequences. What it lacks in original content, it makes up for with scandal; it is not a dry or boring historical read but might strike some as flagrant and unappealing. Torrey missed the opportunity, in his latest text, to discuss the potential impacts of new legislation on health care. He only mentions briefly, and without apparent optimism, that he hopes that the Affordable Care Act provides an avenue for some change in the current model.