The Madness of Deinstitutionalization : ...

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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.

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.