For a few days in September—after a psychotic gunman killed 12 people in Washington's Navy Yard—we were forced to ask ourselves, yet again, how we treat the seriously mentally ill in America and whether we need to rethink our policies and assumptions. No one is better equipped to address those questions than E. Fuller Torrey, a distinguished psychiatrist whose earlier books include "Out of the Shadows: Confronting America's Mental Illness Crisis" (1997).
In "American Psychosis," Dr. Torrey documents our nation's shameful legacy of inadequate care for people with serious psychiatric disorders. The book is animated—or, really, haunted—by a vivid case study: the long-forgotten story of Rosemary Kennedy, the third child and eldest daughter of Joseph and Rose Kennedy and the sister of the president. Rosemary was born with mild mental retardation but lived contentedly in rural convents with tutors and caretakers hired by her family. As she grew into a young adult, her sweet nature curdled. She became emotionally unstable and prone to violent rages, much to the mortification of her father. "For a socially and politically ambitious Irish family like the Kennedys," Dr. Torrey writes, "having an insane family member was the definitive disgrace."
Something had to be done, and Joe Kennedy made the fateful decision to subject his 23-year-old daughter to a frontal lobotomy. The procedure went disastrously wrong, and Rosemary lost of most of her ability to speak and to wash and dress herself. Her lobotomy, Dr. Torrey concludes, "was a family sin that demanded expiation."
Atonement came on Oct. 31, 1963, during the presidency of John F. Kennedy. On that day, he signed the Community Mental Health Centers Act, requiring that huge state hospitals for the mentally ill give way to a user-friendly archipelago of federally funded community clinics. "When carried out," said JFK of the act, "reliance on the cold mercy of custodial isolation will be supplanted by the open warmth of community concern and capability.''
It wasn't just guilt that moved Kennedy, of course. The need for reform was already in the air, as Dr. Torrey explains. Books like Albert Deutsch's "The Shame of the States" and popular entertainments like the movie "The Snake Pit," both of which appeared in 1948, exposed shocking conditions of filth and abuse in the care of the mentally ill. State-initiated efforts to improve conditions at state hospitals and to successfully move some patients into the community had already begun, thanks to the availability of Thorazine, an anti-psychotic medication introduced in the mid-1950s. But with Kennedy's community centers under construction, the campaign to empty out state facilities took on new urgency.
Some patients did well upon discharge, but the sickest were caught in a revolving door. Without closely supervised treatment, they failed in the community and went back to whatever institutions were left in place. Others ended up in a kind of limbo, neither institutionalized nor embedded in a community. Indeed, the number of psychotic patients in the federally funded community centers would never rise above 5%. And they were the lucky ones. Many others ended up living in flophouses, on the streets or in jails.
When Medicare and Medicaid came on the scene in the mid-1960s, states had further incentive to depopulate the asylums: They simply shifted the financial burden to the feds, who would pay for housing patients in poorly equipped nursing homes. Finally, legal decisions issued in the 1960s and 1970s made it hard for judges to order needed treatment for debilitated patients who were refusing care. "This malformed marriage of fiscally conservative state officials and politically liberal civil-rights lawyers produced a strong advocacy coalition," Dr. Torrey writes. It guaranteed "that the existing deinstitutionalization policies would be continued."
As Dr. Torrey makes clear, mental-health policy was a bipartisan failure. Neither Richard Nixon nor Ronald Reagan showed particular interest in assuaging the plight of the severely mentally ill. Their care remained financed through an uncoordinated patchwork of local, state and federal agencies with no single accountable overseer. In 1992, a federal law was passed establishing the Substance Abuse and Mental Health Services Administration, which was tasked with overseeing block grants to the states. Curiously, Dr. Torrey says little about the agency in "American Psychosis," though for years he has criticized it for investing too little of its attention, and grant dollars, in the well-being of patients with psychotic illnesses.
All this incompetence does not come cheap. Dr. Torrey estimates that $140 billion is annually spent on "grossly inadequate and disjointed services," a sum that "should be more than sufficient to support excellent services if the money were used wisely."
Many of Dr. Torrey's proposed solutions are based on evidence from enlightened programs that already exist. For example, he promotes "assisted outpatient treatment," a court-ordered treatment (including medication) for individuals with severe mental illness who have a history of doing poorly if untreated. He also urges greater use of teams (social worker, nurse, psychiatrist, occupational therapist) and endorses a "need for treatment" standard for civil commitment. Experiment should be tried too, he says. Perhaps allow select states to use Medicaid funds as they see fit, unfettered from the regulations imposed by Washington.
Dr. Torrey ends as he begins, with JFK, Rosemary's loving older brother who set the stage, inadvertently but nonetheless formatively, for the dysfunctional public mental-health system we have today. The lesson, no less powerful for being familiar, is that good intentions are not enough.