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Since the 1960s in the United States, hundreds of thousands of patients with severe psychiatric disorders were discharged from public mental hospitals. At the same time, activists forced changes in commitment laws that made it impossible to treat many of those patients, relegating them to a precarious existence on the margins of society. Over forty years later, the problem persists. One of its most dramatic manifestations is violence: untreated individuals commit crimes, including murder and assault, and many are themselves victims of violent crime.
Determining the proper scope of involuntary care of the severely mentally ill is not exclusively a state matter. The federal government plays a surprisingly influential role in shaping treatment laws—and in undermining their reform. In his book The Insanity Offense (W. W. Norton, 2008), psychiatrist E. Fuller Torrey outlines what needs to be done to reverse this troubling state of affairs. A panel of specialists in community psychiatry and politics will comment.
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E. Fuller Torrey, M.D., Stanley Medical Research Institute
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Jeffrey Geller, M.D., University of Massachusetts Medical School
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Howard Goldman, M.D., University of Maryland Medical School
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William Galston, Brookings Institution
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Sally Satel, M.D., AEI
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Involuntary Treatment Helps the Mentally Ill, Protects Society, Scholars Say
WASHINGTON, JUNE 10, 2008 -- How far should we go to protect the seriously mentally ill and the citizens in whose midst they live? Is involuntary treatment too extreme a measure? Renowned psychiatrist E. Fuller Torrey said at AEI on June 9 that it is not--in fact, our failure to insist on involuntary care for the most severely mentally ill endangers both them and the rest of society. Dr. Torrey presented his book, The Insanity Offense: How America's Failure to Treat the Seriously Mentally Ill Endangers Its Citizens (W.W. Norton, 2008) at a forum moderated by AEI's Sally Satel, and other mental health professionals commented.
Since the 1960s, hundreds of thousands of patients with severe psychiatric disorders have been discharged from state mental hospitals. According to Dr. Torrey, the "consequences of deinstitutionalization" of the severely mentally ill include
- Suicide and self-mutilation. At least 17 percent of those who commit suicide in the United States each year are psychotic at the time.
- Homelessness. At least one-third of single homeless people have severe psychiatric disorders.
- Victimization. One-third of women in Washington, D.C., reported "at least one sexual assault while homeless."
- Incarceration. In every state, state prisons hold more severely mentally ill people than do state mental hospitals.
- Violence and homicide. About 10 percent of homicides in the United States are committed by the untreated severely mentally ill, and they account for half of all rampage murders.
Dr. Torrey said that he supports involuntary community treatment as a primary strategy for helping severely mentally ill individuals. He specifically advocated for assisted outpatient treatment (AOT), in which mentally ill patients are released into the community on the condition that they continue to take their medication--that is, they are "coerced" into adhering to treatment. Dr. Torrey referred to the findings of several studies that AOT decreases hospitalization, homelessness, victimization, arrests, and violent behavior. He advocated amending state laws to permit and encourage outpatient commitment throughout the nation. "The answers are going to come from the states," he said.
Psychiatrist Howard Goldman of the University of Maryland School of Medicine, a self-described "civil libertarian," countered Dr. Torrey's view with the argument that although conditional release and the tools of coercion are useful, "respecting the wishes of people who need treatment is the key to their recovery, as well as the basic production of human decency." In other words, he said, "coercion should not be a substitute for effective care that is sought voluntarily." Dr. Goldman recommended conservatorships or guardianships as more appropriate tools for dealing with the severely mentally ill.
Jeffrey Geller of the University of Massachusetts Medical School agreed with Dr. Torrey. Although he said that coercion is in some cases a poor substitute for adequately funded services, he insisted that the converse of that statement--that coercion is unnecessary if services are sufficiently funded--"doesn't hold water." Dr. Geller offered western Massachusetts as an example: although its mental health system has the highest per-capita expenditures on community programs in the nation, he said "there is no doubt that we still needed coercion."
William Galston, a political theorist at the Brookings Institution, was invited by Dr. Satel to offer a different perspective from the other panelists. Quoting Plato, he said that "political regimes tend to be weakened by an intensification of their defining features." In the case of the severely mentally ill, he added, a devotion to "liberty" has become strong libertarianism, a mistrust of authority has turned into paranoid populism, and limited government has meant that people are left on their own. "Do people have a right to be crazy?" Galston mused. "The right to swing my arm ends at your nose."
For video, audio, and more information about this event, visit www.aei.org/event1724/.
A practicing psychiatrist, Dr. Satel is the author of several books, including Drug Treatment: The Case for Coercion (AEI Press, 1999).
For more information about AEI's work on mental health policy, contact Tal Manor at firstname.lastname@example.org or 202.828.6037.
For media inquiries, contact Véronique Rodman at email@example.com or 202.862.4870.