Madness in the Streets: How Psychiatry and the Law Abandoned the Mentally Ill, by Rael Jean Isaac and Virginia C. Armat, New York: The Free Press, 348 pages, $24.95
Out of Bedlam: The Truth About Deinstitutionalization, by Ann Braden Johnson, New York: Basic Books, 259 pagess, $22.95
If you spend some time walking the streets of New York City or Los Angeles, you're likely to encounter at least one foul-smelling man in ragged clothing whose shuffling gate, incoherent ranting, and wild eyes suggest a confused and disordered mind. Or perhaps a woman in a housecoat and slippers, muttering to herself as she pushes a shopping cart filled with junk.
These are the conspicuous homeless, but are they typical? Are most Americans living on the streets crazy? If so, it seems plausible to suggest that their current state can be blamed on deinstitutionalization—the policy, begun in the 1960s, of removing the mentally ill from state institutions.
Madness in the Streets makes the case that the release of inmates from the large mental hospitals where they had been warehoused for years is the principal source of the apparent surge in homelessness in the United States. The authors view deinstitutionalization as the expression of a radical 1960s ideology. The policy was ill-founded and bound to fail, Rael Jean Isaac and Virginia Armat claim, because it mistook the nature of mental illness, its sources, and its cure. Isaac and Armat maintain that mental illness—particularly schizophrenia—is a sickness of the brain that is best dealt with through drug therapy.
In Out of Bedlam, Ann Braden Johnson casts doubt on Isaac and Armat's conclusions about the causes of homelessness and the nature of mental illness. She argues that deinstitutionalization put relatively few people on the street and that economic factors play a more important role in homelessness than mental illness does. She is also far less sanguine about the medical approach and focuses instead on community-based programs.
Both books seek to explain why deinstitutionalization has not accomplished what it set out to do: reintegrate the mentally ill into the community. For Isaac and Armat, the solution is to send the mentally ill back to the hospitals, where they can undergo surgery and drug therapy. Johnson outlines the appeal of the argument that the homeless are crazy and craziness can be cured: "If the homeless are all crazy, then we have a built-in solution: treat mental illness, and homelessness will go away, too."
But the actual distribution of patients who were "deinstitutionalized" contradicts this notion. In the large majority of cases, Johnson notes, patients were simply shifted to other institutions.In 1981, the National Institute of Mental Health estimated that the number of chronically mentally ill Americans was between 1.7 million and 2.4 million. Almost a million were in hospitals, prisons, and nursing homes, and another 400,000 were living in a new type of institution called "adult homes." Thus a majority, perhaps as many as three-quarters, continued to live in institutions. (The rest of the mentally ill are not necessarily homeless; many live with their families, for instance.)
If most of the mentally ill are still in institutions, then deinstitutionalization does not seem to be a major source of homelessness. Johnson argues that homelessness has instead been caused largely by unemployment, the scarcity of affordable housing, and cutbacks in public assistance programs. Isaac and Armat note that the best estimates place the number of homeless at about 500,000 nationwide, a number dramatically lower than the estimates of advocate organizations. Given the uncertainty of these figures, it's difficult to say by how much—or even whether—the homeless population has increased since the 1950s.
Evidence from surveys of the homeless also runs counter to Isaac and Armat's thesis. Studies have found that from 20 percent to 30 percent of the homeless are mentally ill but that more may be alcoholics or addicts. A Johns Hopkins University Medical School study published in 1989 offered a higher than usual estimate of the percentage of the homeless who are mentally ill: about 45 percent. But the same study found that 68 percent of homeless men were alcoholics and 22 percent were drug addicts. Of course, the mentally ill and addict/alcoholic populations overlap. But these data suggest that drug and alcohol abuse are more important sources of homelessness than schizophrenia is.
The two books differ not only on the issue of how many homeless people are crazy but also on the question of how to help those who are. The authors' backgrounds have shaped their views of the medical approach to mental illness. Ironically, Johnson—whose analysis is largely economic, historical, and political—is a clinical social worker who has treated the chronically mentally ill for more than 15 years. On the other hand, Isaac is a sociologist and Armat is a professional writer.
Not being therapists or physicians and not having worked directly in the mental health field, Isaac and Armat are overly optimistic about medical treatment of mental illness. While noting cases of patient abuse, misdiagnosis, and mismanagement, they tend to dismiss these as exceptions that prejudice the public against genuinely effective medical therapies.
By contrast, Johnson gives a thorough historical review of the reasons mental institutions failed in the first place. These failures are not only the extreme cases, like those depicted by Frederick Wiseman in his 1967 film Titicut Follies, which documents abuse and neglect in a Massachusetts mental hospital. For Johnson, the entire institutional treatment system is shaky, relying as it does on drugs to sedate and control patients while almost never leading to permanent improvements.
For their part, Isaac and Armat laud biomedical treatments for insanity. They even cite the Nobel Prize awarded to Egas Moniz for developing the lobotomy operation—an award more commonly regarded as an embarrassment for the Nobel Committee than as a tribute to the efficacy of biological treatments. (Elliot Valenstein offers a more critical picture of lobotomy and all the other discarded "magic bullet" treatments for mental illness in his 1986 book Great and Desperate Cures. Valenstein shows that each new psychiatric remedy has been greeted enthusiastically, only to be discarded in light of negative long-term results.)
Johnson began her career when psychiatrists generally treated mental illness by sedating patients with mind-numbing Thorazine. Since that time, antidepressants have replaced the major tranquilizers as the "miracle" drug therapy for the mentally ill. As a number of recent legal claims by patients against Prozac (the most popular antidepressant) indicate, this new cure will also founder on the shoals of exaggerated claims, inflated expectations, growing observations of negative side effects for many, and intractable personal and social problems.
Isaac and Armat believe that emotionally disordered people should be forced to accept medical treatments they don't want, since their disease prevents them from making sound judgments on their own behalf. This argument is Isaac and Armat's response to a major difficulty in their approach: If the therapies they espouse are so helpful, why do so many people refuse treatment?
In fact, mentally ill patients may be acting quite sensibly, given the numbing and traumatic effects of electroshock and drug therapies. Yet Isaac and Armai reserve their greatest contempt for those like psychiatrist Peter Breggin, who defends the right of patients to refuse medication and surgery. Included in their frequently ad hominem attacks are former mental patients and homeless advocates who contest coercive psychiatric practices.
Johnson does not subscribe to the Pollyanna school of thought that sees mental illness as simply a different, equally valid view of life. She recognizes the suffering and despair of the mentally ill and understands that some people need to lead supported and circumscribed existences. At the same time, she appreciates the insights of radical psychiatrists such as Thomas Szasz and R.D. Laing. For Isaac and Armat, on the other hand, Szasz and Laing, along with psychiatric critics such as Breggin, are the bêtes noires of the modem treatment quagmire.
Szasz described mental illness as a myth created to categorize and dispose of those who are unwilling or unable to conform to social norms. While it seems indefensible today to take a completely laissez-faire approach to the emotionally disturbed, Szasz's philosophy contained important ideas that can help revitalize therapy for the mentally ill. It's true that we need to be wary of assertions that some people are inherently sick. When you strip away the labels and self-reinforcing expectations about the mentally ill, you're left with people who have difficulty coping with the everyday demands of life. But removing stigmas is not enough. The emotionally disabled need extra support to manage their lives. This is the idea behind the policy of moving patients to supportive community-based institutions.
Psychiatrists increasingly recognize that using drugs to remove symptoms such as hallucinations and delusions does not address the core problems of the mentally ill. Rather, contemporary treatment is more likely to focus on the self-perpetuating apathy and lack of coping skills that make it difficult for the mentally ill to escape their plight. There have been several highly successful demonstrations of this approach, including one reported by the New York Times in 1986: "A 30-year study of hospitalized schizophrenics who had been given up on as hopeless, but were released in a program that closely manages and monitors their lives, has found that two-thirds of them are now living normal lives…half of them without any signs of the disorder."
Results such as these led many to believe that deinstitutionalization was the route to take in the '60s and '70s. But this kind of community program, which was supposed to supplant state hospitals, is still quite rare. As Johnson makes clear, mental institutions discharged patients without offering the support required to develop community alternatives. Owners and managers of adult homes today keep their residents docile with the same medications used in hospitals.
Johnson notes that the failure to implement real alternatives is not saving any money. The cost of care for the mentally ill continues to rise, even as therapy remains largely ineffective. But these costs are not recognized by the state bureaucrat, medical provider, or adult-home manager, who is instead driven by union contracts for hospital workers, lucrative psychiatric referral fees, or residential head counts.
Still, Isaac and Armat's proposed revival of coercive treatment is not the answer. If implemented, their vision would lead to another round of exposés about mental institutions and a new movement against medical therapy for mental illness. Furthermore, their approach is no solution for homelessness, which is linked to basic societal failures: the failure of treatment for drug, alcohol, and emotional problems; the failure to implement useful community-based programs; and the breakdown of community in general.
Cohesive neighborhoods are necessary for the creation of community-based support services. If urban ghettos cannot maintain safe and effective institutions, they won't be places where the mentally ill can be protected and nurtured. Moreover, neighborhoods that are economically and socially unstable are associated with higher levels of dysfunctional behavior, including both drug addiction and mental illness, in the first place. (Mental illness is more common among members of lower socioeconomic groups, a fact first documented by sociologist August Hollingshead in 1958.)
Helping both the homeless and the mentally ill in the United States is a daunting task, especially since their numbers are growing. Each year in this country, for example, another 100,000 people are diagnosed as schizophrenics. Yet Americans seem ambivalent about helping those incapable of living independently. We are less willing than ever to interact even with neighbors who aren't crazy. What chance is there that we will welcome into our communities the woman with the junk-filled shopping cart or the man railing at invisible powers?
Contributing Editor Stanton Peele is a psychologist and health-care researcher.