American Psychosis

Sandra Steingard, MD
17
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A colleague from another country e-mailed me with some questions after having read, E. Fuller Torrey’s most recent book, American Psychosis. My initial response was to tell him that Torrey saw things through an ideological filter and to be cautious about taking what Torrey wrote at face value.  But I got to thinking. I have made the mistake in the past of dismissing ideas based on assumptions or group think.  I also think it can encourage less rigorous thinking if one only reads books that are bound to support one’s world view.  I digest a steady diet of such books.  Perhaps I needed to actually read what Torrey wrote before I so glibly dismissed him.  With some dismay (all proceeds go to Torrey’s Treatment Advocacy Center (TAC)), I ordered the book.

So it was with great surprise that I found early sections of the book to be so fascinating.  Torrey tells the story of Robert Felix and his colleagues who essentially pushed through the development of the National Institutes of Mental Health and the Community Mental Health Act of 1963.  This was the last piece of legislation that President Kennedy signed before he was assassinated.  According to Torrey, this legislation was doomed from the outset for several reasons:

  • It was a top down approach that did not effectively integrate this new federal initiative with the state systems that had been in place for many years.
  • It was premised on a public health model. The name was somewhat literal; the hopes of the architects of this bill were that improving the mental health of the community would reduce the rate of mental illness to the extent that state services for severe mental illness would not be necessary.
  • Consequently, there were no programs developed to help the individuals who were getting discharged form the state hospitals.

Torrey is understandably critical of an approach implemented on such a large scale without first testing out the basic hypotheses and assumptions.   He argues that deinstitutionalization had already started before this bill was passed and, in bypassing the states, the bill effectively undermined early efforts at community reintegration. 

It is interesting where this story overlaps with the one told in Mad in America.  Whitaker and Torrey both acknowledge that some innovative and promising work, geared towards promoting recovery in the community, had been undertaken at the local level prior to the passage of the CMHC Act. 

Torrey describes the profound cost shifting that occurred in this era. Once Medicaid was created, it allowed the states to pull down money from the Federal government; this payment structure influenced the creation of programs.  He goes on to tell of the many failures of this system.  Again this is not controversial – I know of no one who suggests we have a great system. 

As the book went on, my disagreements with Torrey were clear.  Torrey, as one would expect, attributes much of the success in discharge from state hospitals to neuroleptics, and the “revolving door” syndrome to the failure of people to remain on the drugs due to the brain condition he calls anosognosia.  I have written about this before.  Torrey and I had a bit of an exchange about this so I will not rehash that argument again.

Torrey gives such short shrift to the recovery movement that he may not have realized the inherent contradictions in his argument. If Schizophrenia is a brain disease that requires treatment to manage it in the same way that diabetics need insulin (yes, he says that), then how can those in the psychiatric survivor movement who “have recovered more or less” be such effective advocates for their cause?

But I doubt this is an area where Torrey and I will ever find common ground.  Another, perhaps less charged, question I would have for him is what makes him think that, absent the CMHC Act or the expansion of Medicaid, states would have been willing to provide money for the services he and I agree are needed?  In many ways, the CMHC Act gave money primarily to build clinics.  There was nothing in there that prevented states from transferring the dollars they put into hospitals to community services.   He discusses the deleterious impact of changes in state policy on the California system.  This was not driven by the CMHC Act.  It was driven by a desire on the part of the state to minimize costs. 

There are huge variations to this day in how generous states are with respect to the needs of the most disenfranchised members of our society.  I agree that it would have made sense to have small pilot projects and to integrate with states.  But since the 80’s we have done that and yet we still struggle.  I work in a state that Torrey correctly identifies as being particularly aggressive about “capturing” Medicaid money and, at least in the early 1990’s, we were rated highly by Torrey.   Our high rating, however, was due to a strong commitment in my state to support community recovery services while minimizing our reliance on state hospitals. It is also a state that has an aggressive and fairly successful advocacy to minimize involuntary interventions. 

I found his discussion of the (implied unrealistic) hope of Robert Felix and others that improved conditions in the community might prevent serious conditions to be of great interest.   While Torrey never truly evaluates the merits of these ideas,  he may be right that in the 1950’s they were based more on ideology than research. However, it could be argued that current research supports Felix’ ideas.  Torrey seems to be rooted to the idea that if the brain is involved then the environment is never implicated.  This outdated conceptualization isolates the workings of the body from its environment.  Just today, I was reading about research that demonstrated the debilitating effects of poverty on cognition.  I think we are still trying to figure out how to address this but the idea has even more salience today than it did 60 years ago.

Torrey and I agree that the politics are complex.  I share his view that it is a problem when programs are driven by ideology, when they are not tested, and when those who are in the trenches are not included in developing new approaches.  I also share his view of the politics.  No one can afford to admit that a program has failed – not the politicians who backed it or the ones who implemented it and are now dependent on it for their livelihoods.  This may be even more true today than it was 60 years ago.  It seems that we live in a world of spin.

But Torrey and I continue to have profound disagreement.  What is so fascinating to me about this is how two people can view the same things but interpret them in such different ways. Where Torrey has clarity, I contend there is much that we still do not understand.  I worry that a perspective that suggests the answers are clear cuts us off from inquiry into alternate approaches.  Maybe I suffer from anosognosia.

17 COMMENTS

  1. There are those who would take issue with Torrey’s analysis of why the Community Mental Health Act of 1963 “failed.” First, it’s hardly true that deinstitutionalization was already underway in 1963. Desinstitutionalization didn’t occur on a large scale until the 1970s, after court rulings in several states stated that forced unpaid patient labor (which is what made large-scale institutions possible) was illegal. Also, the Community Mental Health Act by-passed state bureuacracies for a very good reason: these were the entities responsible for the abuses of large-scale mass incarceration of people with psychiatric labels. The idea of the Community Mental Health Act was to put power & control in local hands. If anything was responsible for undermining the Act, it was that funding didn’t keep pace and states jalously held onto whatever power they could.

  2. Hi Sandy-thanks for the post, which is well thought through like your other posts. As I recall, Torrey had is right on another issue. He was enraged when the NIMH shifted focus from the issue of serious mental illness (schizophrenia) to the problems of the worried well (depression, anxiety disorders). This shift, of course, legitimized the expanding market of the pharmaceutical companies, but seriously neglected those with schizophrenia and brought dangerous drugs to the general public.

  3. Thanks for post Sandy. You again affirm that you are my kind of practitioner and thinker. Acknowledging uncertainty, exploring views counter to our own – keeps us humble and open to the experiences of others. God help those who encounter “experts” (like Torrey) armed with their certainty and righteousness.

  4. “What is so fascinating to me about this is how two people can view the same things but interpret them in such different ways. Where Torrey has clarity, I contend there is much that we still do not understand. I worry that a perspective that suggests the answers are clear cuts us off from inquiry into alternate approaches.”

    While I’d prefer to not comment on personal disagreements between two people whom I don’t know, I think it’s very common for different people to witness the same phenomenon and to perceive it differently. That’s what Rashomon is all about. In fact, everyone in agreement would seem false and inauthentic to me, as we all stand at different vantage points. Isn’t that how we create a diverse collective reality? (Which, btw, is always in flux, given that change is constant).

    Often the interpretations are totally contradicting, which poses an interesting paradox. In the reality in which we’re currently operating, we tend to invalidate our polar opposite, often as being ‘psychotic’ or even just ‘crazy.’ Both clarity and confusion are temporary states of mind, and both can exist simultaneously within the same consciousness/energy field.

    But in a better (in my opinion) and more harmonious reality, we can ascend the paradox to reach truth, without invalidating our ‘opponent.’ All of it—light and shadow—work together as a whole, if we allow them to integrate. I believe that once we get a handle on this, the confusion about mental health and related issues will begin to dissipate naturally.

  5. One thing that I appreciate about you is that I’ve never heard you claim that you have all the answers or that you’re the expert on all of this. You seem to be open and inquisitive and willing to learn. This is what makes you so very different from a lot of your fellow psychiatrists. I’m not trying to build up your ego, just stating facts as I see them. Perhaps this is why you and Torrey seem to have differences of opinion.

  6. “Torrey seems to be rooted to the idea that if the brain is involved then the environment is never implicated. This outdated conceptualization isolates the workings of the body from its environment. Just today, I was reading about research that demonstrated the debilitating effects of poverty on cognition. ”

    This is a very salient point and one that I don’t always see addressed; the influence of poverty on mental illness symptoms. Where I work as a therapist in an inpatient hospital psychiatric setting, I see thousands of people a year who come in with psychotic symptoms. The lion’s share of these folks are deeply impoverished. Because most of these folks are on disability they receive a paltry sum to pay for necessities. Many are homeless, malnourished, living in substandard housing and dealing with the stress of trying to survive.

    In this context of perpetual poverty and trauma, many people suffering from severe mental illness have worsening and increasingly debilitating symptoms. Its hard to imagine separating socio-economics and environmental factors out and simply calling mental illness a “brain disorder”.

    • I am in a similar situation in a state hospital. Anyone with any money goes to the three private hospitals in the city, they don’t end up in the hospital where I work. I’ve met very few people admitted to the hospital who were not on disability. Most of them fit the description that you’ve shared. But no one on staff on any of the units addresses the issue of poverty!

    • “In this context of perpetual poverty and trauma, many people suffering from severe mental illness have worsening and increasingly debilitating symptoms.”

      I think that’s backwards.

      In this context of mental illness, many people suffering from severe poverty and trauma have worsening and increasingly debilitating symptoms.

  7. Anogagnosia is a badge of honour! but strictly speaking by definition if you wonder if you got it you don’t.

    Good on you for having a go. I wouldn’t even try as there are too many better books to read.

    Like you I think if one concludes with absoolute clarity that this is all just brain disease it leaves little room for further exploration. Recovery narratives, Gene studies, neuropathology, biochemical studies all point to a very different conclusion. Makes me wonder how he can be so sure.

  8. Well, if he’s saying an approach should not be driven by ideology, he’s the pot calling the kettle black! I don’t know if I can think of a single person who is more ideologically driven than Torrey, and more unwilling to examine any data that contradicts his dearly-held beliefs.

    I admire your ability to be fair-minded in your critique. I do understand that some of his early writings were quite rational, but as of today, I find the man and his “views” utterly contemptible.

    I never was very patient with hypocrisy…

    —- Steve

  9. This is what I feel about the NY Times review of Torrey’s latest book:

    In 1960, I was hospitalized, slapped with a diagnosis of “schizophrenia,” forced into undergoing 50 insulin and electroshock “treatments” that nearly killed me, and on my way to lifelong institutionalization. So, when Dr. E. Fuller Torrey calls for increasing the number of public psychiatric hospitals and for making it easier to lock up people like me, I am shocked. And while your reviewer calls the book “an object lesson in good intentions gone awry,” I am grateful for those good intentions that saved my life.

    After I spent three horrifying years in psychiatric hospitals, one of those doctors your reviewer calls “well-intentioned, starry-eyed idealists” saved me from being locked up forever or, more likely, an early death. Those brave and compassionate doctors paved the way for the best kind and effective community care we have today. But if Dr. Torrey’s vision becomes reality, it would return us to the days when a “mental illness” diagnosis was a life sentence.