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Madness in the Streets: How Psychiatry and the Law Abandoned the Mentally Ill
Examines the cultural and political issues surrounding the problem of America's homeless mentally ill.
436 pages, Hardcover
First published September 30, 1990
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Displaying 1 - 7 of 7 reviews
October 2, 2008
After hearing so much about 'deinstitutionalization', I wanted to know how it actually went down. This was a great review (though maybe a bit heavy on the legal aspects) of the history and turning points that led to the closing down of state mental hospitals in the US. I was really surprised by the variety of groups involved in denouncing mental illness as a myth, and the success they had in fighting for a patient's right to refuse treatment. They happily freed all the patients from mental hospitals (which was not a bad thing given the conditions in many of those hospitals), but they never created an alternative. Many of those ex-patients now experience their freedom on the streets or in jail.
The book goes a step further to show how the laws created around deinstitutionalization continue to affect the mentally ill and their families. The pendulum has swung so far the other way that now people who want treatment can't get it unless they qualify as 'dangerous'. This country definitely needs to reevaluate its mental health care system. Continued acts of random violence by people who need (and sometimes want) mental health treatment may be what it takes to finally pushes the issue. It's just a shame so many non-violent people with mental illness have to suffer while we wait.
The book goes a step further to show how the laws created around deinstitutionalization continue to affect the mentally ill and their families. The pendulum has swung so far the other way that now people who want treatment can't get it unless they qualify as 'dangerous'. This country definitely needs to reevaluate its mental health care system. Continued acts of random violence by people who need (and sometimes want) mental health treatment may be what it takes to finally pushes the issue. It's just a shame so many non-violent people with mental illness have to suffer while we wait.
August 9, 2016
About the Authors: Rael Jean Isaac has a Ph.D. in sociology from the City University of New York. Virginia C. Armat is a former editor at Reader’s Digest.
Overview: This books describes the variety of forces that convinced society to empty state mental hospitals in the United States during the 1960s and 1970s. It began with a movement against seeing mental illness as a medical problem and continued with an effort by misguided civil libertarians to increase patient autonomy in decision making regarding treatment for their mental illness.
Psychiatric Diagnosis: During the 1950s and 1960s the psychiatric establishment was vulnerable to criticism, because the etiology and diagnosis of mental diseases was in a primitive state. Brain scans did not exist. There were no blood tests for mental illness. Still aren’t.
Misunderstanding the Causes of Mental Illness: During the 19th century the belief that mental illness had a biological cause (heredity, brain injury, bacteria) was widespread. But starting with Sigmund Freud, it became more common to look for a psychological cause, to blame early family life. Some even went as far as blaming society itself for driving its members insane.
Accusations of the Anti-Psychiatry Movement
• Psychosurgery (lobotomy) was criticized for reducing the patient to a vegetable
• Electroconvulsive Therapy (ECT) was criticized for causing memory loss
• Neuroleptic drugs were criticized for causing tardive dyskinesia
• Some critics blamed the mental hospitals and psychiatrists for driving people crazy
• Some romantics portrayed schizophrenia as a voyage of discovery
• Some critics denied the existence of mental illness, and declared that people who act differently were not crazy, but just non-conformists
• There were assertions that psychiatrists could not reliably tell who was crazy and who was sane
State Mental Health Hospitals: Many activists portrayed conditions in state mental hospitals as barbaric. Rather than advocate improving conditions in the mental hospitals, they advocated that they be closed, and replaced by community mental health centers.
Peonage Law Suits: Work has substantial therapeutic value for the mentally ill. Traditionally, patients in state mental hospitals did much of the work for the upkeep of the facilities: cooking, housekeeping, laundry, painting, grounds maintenance, and farming. The Mental Health Law Project (now called the Bazelon Center for Mental Health Law) filed lawsuits portraying the unpaid patient work as exploitation (peonage).
Follow the Money: After the peonage law suits, the state governments were faced with the choice of either paying their patients a wage to take care of the mental hospital, or hiring more staff to do the work. This would make state mental hospitals much more expensive. Some activists argued that a more efficient way to spend health care dollars on the mentally ill was on prevention rather than treatment. Unfortunately, they forgot the fact that no one knows how to prevent mental illness. State governments chose to close their mental hospitals, largely to save money.
A Dearth of Heroes: One of the reasons that the anti-psychiatry movement was so successful, was the dearth of heroes in the psychiatric profession who were willing to stand up to the activists. The main opponents of deinstitutionalization were state hospital employees, who would lose their jobs if their facilities were closed.
Where Patients Were Dumped
• nursing homes (the elderly)
• rooming houses
• single-room occupancy hotels
• streets
• jails
• family
Community Mental Health Centers: These facilities are more oriented towards providing social services than medical treatment. But providing mentally ill people with social services is not enough; they also need medical treatment. The mentally ill need life-long, continuing care, not just short-term rehabilitation. Another problem was the small amount of funding that the state legislatures gave to the community mental health centers.
Needs of the Mentally Ill Living in the Community
• Medication
• Work
• Housing
• Help with the Activities of Daily Living (ADL)
Activities of Daily Living
• taking meds
• nutrition
• grooming
• laundry
• public transportation
• shopping
• managing money
Families of the Mentally Ill
• The families of the severely mentally ill cannot cope with providing care, 24 hours a day, 7 days a week. It ruins their lives.
• Those families who are financially well off have the option to pay to put their mentally ill relative in a private facility, but most families cannot afford to do so
• Many family members of paranoid schizophrenics live in fear that their mentally ill child may kill them. Families may even resort to court orders to prevent the mentally ill family member from entering their home
Waiting for Dangerousness: If you have a physical illness that requires hospitalization, you will generally be admitted to a hospital. But if you have a mental illness that requires hospitalization, you will probably not be admitted to a hospital, unless you are dangerous, unless there is an imminent risk that you will behave violently towards yourself or others.
Patient Autonomy: Some civil rights attorneys became progressive activists, and tried to restrict society’s ability to treat the mentally ill as incompetent to make their own decisions regarding their medical treatment. Up till then, involuntary civil commitment had been the primary means to deal with mentally ill people who failed to understand that they needed treatment. The progressive advocates of patient autonomy fail to take into account the impaired judgement of the mentally ill. Some advocates criticized the warehousing and neglect of the mentally ill in state hospitals, and promoted the right to treatment. Other activists promoted its converse, the right to refuse treatment, as a way to increase patient autonomy. Activists pushed the requirement to obtain informed consent from the patient before giving them medication. The previous standard of being in need of treatment was replaced by the standard of being dangerous. No longer were medical doctors the main decision makers regarding patient care. They were replaced by judges. Most of the procedural safeguards of criminal law were imposed on involuntary civil commitment.
The Current Legal Situation of the Mentally Ill
• Protection and Advocacy: Most states have protection and advocacy organizations that serve the physically disabled, mentally retarded, and mentally ill
• Limited Guardianship: The guardian is given a power of attorney to make psychiatric decisions for the ward, but not the power to make decisions in other parts of life
• Protective Placement: A judicial order to put an at-risk mentally ill person into a safe place where they can be cared for (even against their will)
• Outpatient Commitment: A judicial order to administer medication to a patient, even against their will
Clubhouses and Lodges: These are self-help residences for mentally ill people. The residents take care of themselves and their home (cooking, cleaning, maintenance, clerical). The residences are partially self-supporting by work that the members perform outside the residence, which is often janitorial or gardening. Most residents are male. Most residences still require the presence of some staff that are not mentally ill.
Examples of successful clubhouses and lodges:
• Fountain House (started in New York City in the 1940s)
• Horizon House (founded in Philadelphia by Quakers in 1952)
• Council House (founded in Pittsburgh in 1957)
• Thresholds (founded in Chicago in 1959)
• Center Club (founded in Boston in 1959)
• Fairweather Lodge in Palo Alto (founded by George Fairweather in 1963)
• PACT: Program of Assertive Community Treatment (Madison, Wisconsin)
Basaglia Law or Law 180 (Italy): The Italian Mental Health Act of 1978, promoted by psychiatrist Franco Basaglia and his Psichiatria Democratica movement lead to the closure of all psychiatric hospitals in Italy.
Treatments for Mental Illness: Advances in science and medicine have made psychosurgery, electroconvulsive therapy (ECT), and drug treatments for depression and schizophrenia much safe and more effective than in the bad old days.
Treatment Advocacy Center
• Located in Arlington, Virginia
• Founded 1998 by E. Fuller Torrey
• Mary Zdanowicz (attorney, executive director 1998-2007)
• Doris A. Fuller (current executive director)
Overview: This books describes the variety of forces that convinced society to empty state mental hospitals in the United States during the 1960s and 1970s. It began with a movement against seeing mental illness as a medical problem and continued with an effort by misguided civil libertarians to increase patient autonomy in decision making regarding treatment for their mental illness.
Psychiatric Diagnosis: During the 1950s and 1960s the psychiatric establishment was vulnerable to criticism, because the etiology and diagnosis of mental diseases was in a primitive state. Brain scans did not exist. There were no blood tests for mental illness. Still aren’t.
Misunderstanding the Causes of Mental Illness: During the 19th century the belief that mental illness had a biological cause (heredity, brain injury, bacteria) was widespread. But starting with Sigmund Freud, it became more common to look for a psychological cause, to blame early family life. Some even went as far as blaming society itself for driving its members insane.
Accusations of the Anti-Psychiatry Movement
• Psychosurgery (lobotomy) was criticized for reducing the patient to a vegetable
• Electroconvulsive Therapy (ECT) was criticized for causing memory loss
• Neuroleptic drugs were criticized for causing tardive dyskinesia
• Some critics blamed the mental hospitals and psychiatrists for driving people crazy
• Some romantics portrayed schizophrenia as a voyage of discovery
• Some critics denied the existence of mental illness, and declared that people who act differently were not crazy, but just non-conformists
• There were assertions that psychiatrists could not reliably tell who was crazy and who was sane
State Mental Health Hospitals: Many activists portrayed conditions in state mental hospitals as barbaric. Rather than advocate improving conditions in the mental hospitals, they advocated that they be closed, and replaced by community mental health centers.
Peonage Law Suits: Work has substantial therapeutic value for the mentally ill. Traditionally, patients in state mental hospitals did much of the work for the upkeep of the facilities: cooking, housekeeping, laundry, painting, grounds maintenance, and farming. The Mental Health Law Project (now called the Bazelon Center for Mental Health Law) filed lawsuits portraying the unpaid patient work as exploitation (peonage).
Follow the Money: After the peonage law suits, the state governments were faced with the choice of either paying their patients a wage to take care of the mental hospital, or hiring more staff to do the work. This would make state mental hospitals much more expensive. Some activists argued that a more efficient way to spend health care dollars on the mentally ill was on prevention rather than treatment. Unfortunately, they forgot the fact that no one knows how to prevent mental illness. State governments chose to close their mental hospitals, largely to save money.
A Dearth of Heroes: One of the reasons that the anti-psychiatry movement was so successful, was the dearth of heroes in the psychiatric profession who were willing to stand up to the activists. The main opponents of deinstitutionalization were state hospital employees, who would lose their jobs if their facilities were closed.
Where Patients Were Dumped
• nursing homes (the elderly)
• rooming houses
• single-room occupancy hotels
• streets
• jails
• family
Community Mental Health Centers: These facilities are more oriented towards providing social services than medical treatment. But providing mentally ill people with social services is not enough; they also need medical treatment. The mentally ill need life-long, continuing care, not just short-term rehabilitation. Another problem was the small amount of funding that the state legislatures gave to the community mental health centers.
Needs of the Mentally Ill Living in the Community
• Medication
• Work
• Housing
• Help with the Activities of Daily Living (ADL)
Activities of Daily Living
• taking meds
• nutrition
• grooming
• laundry
• public transportation
• shopping
• managing money
Families of the Mentally Ill
• The families of the severely mentally ill cannot cope with providing care, 24 hours a day, 7 days a week. It ruins their lives.
• Those families who are financially well off have the option to pay to put their mentally ill relative in a private facility, but most families cannot afford to do so
• Many family members of paranoid schizophrenics live in fear that their mentally ill child may kill them. Families may even resort to court orders to prevent the mentally ill family member from entering their home
Waiting for Dangerousness: If you have a physical illness that requires hospitalization, you will generally be admitted to a hospital. But if you have a mental illness that requires hospitalization, you will probably not be admitted to a hospital, unless you are dangerous, unless there is an imminent risk that you will behave violently towards yourself or others.
Patient Autonomy: Some civil rights attorneys became progressive activists, and tried to restrict society’s ability to treat the mentally ill as incompetent to make their own decisions regarding their medical treatment. Up till then, involuntary civil commitment had been the primary means to deal with mentally ill people who failed to understand that they needed treatment. The progressive advocates of patient autonomy fail to take into account the impaired judgement of the mentally ill. Some advocates criticized the warehousing and neglect of the mentally ill in state hospitals, and promoted the right to treatment. Other activists promoted its converse, the right to refuse treatment, as a way to increase patient autonomy. Activists pushed the requirement to obtain informed consent from the patient before giving them medication. The previous standard of being in need of treatment was replaced by the standard of being dangerous. No longer were medical doctors the main decision makers regarding patient care. They were replaced by judges. Most of the procedural safeguards of criminal law were imposed on involuntary civil commitment.
The Current Legal Situation of the Mentally Ill
• Protection and Advocacy: Most states have protection and advocacy organizations that serve the physically disabled, mentally retarded, and mentally ill
• Limited Guardianship: The guardian is given a power of attorney to make psychiatric decisions for the ward, but not the power to make decisions in other parts of life
• Protective Placement: A judicial order to put an at-risk mentally ill person into a safe place where they can be cared for (even against their will)
• Outpatient Commitment: A judicial order to administer medication to a patient, even against their will
Clubhouses and Lodges: These are self-help residences for mentally ill people. The residents take care of themselves and their home (cooking, cleaning, maintenance, clerical). The residences are partially self-supporting by work that the members perform outside the residence, which is often janitorial or gardening. Most residents are male. Most residences still require the presence of some staff that are not mentally ill.
Examples of successful clubhouses and lodges:
• Fountain House (started in New York City in the 1940s)
• Horizon House (founded in Philadelphia by Quakers in 1952)
• Council House (founded in Pittsburgh in 1957)
• Thresholds (founded in Chicago in 1959)
• Center Club (founded in Boston in 1959)
• Fairweather Lodge in Palo Alto (founded by George Fairweather in 1963)
• PACT: Program of Assertive Community Treatment (Madison, Wisconsin)
Basaglia Law or Law 180 (Italy): The Italian Mental Health Act of 1978, promoted by psychiatrist Franco Basaglia and his Psichiatria Democratica movement lead to the closure of all psychiatric hospitals in Italy.
Treatments for Mental Illness: Advances in science and medicine have made psychosurgery, electroconvulsive therapy (ECT), and drug treatments for depression and schizophrenia much safe and more effective than in the bad old days.
Treatment Advocacy Center
• Located in Arlington, Virginia
• Founded 1998 by E. Fuller Torrey
• Mary Zdanowicz (attorney, executive director 1998-2007)
• Doris A. Fuller (current executive director)
October 7, 2018
I worked in the Psych unit of a county hospital as a psych nurse's aide from 1970 - 1978 in New York and experienced some of the events, knew some of the hospitals named, and was even (minimally) acquainted with one or two of the principals named. I've also been involved for the past 40 years, since becoming an attorney, with doing court-appointed criminal defense work to assist the poor, including of course the street people, many of whom are chronically seriously mentally ill. I agree with every point made in this book. This was a very enlightening book, invaluable for understanding the lunacy of the anti-psychiatry and deinstitutionalization movements.
February 4, 2018
Some quotes I liked:
"There is no implied right to self-fulfillment madness."
"Pretending that mental Illness is a Civil Rights issue does an enormous disservice not just to the families but the the Mentally Ill themselves."
Great book, a bit dated however it was fascinating to see how various Activist Groups, Comm Tx ideas, Laws and mind sets developed and the results of such.
"There is no implied right to self-fulfillment madness."
"Pretending that mental Illness is a Civil Rights issue does an enormous disservice not just to the families but the the Mentally Ill themselves."
Great book, a bit dated however it was fascinating to see how various Activist Groups, Comm Tx ideas, Laws and mind sets developed and the results of such.
May 1, 2022
In understanding the root causes of the "homeless" situation or some call crisis one cannot go wrong in reading this book. It is a long tome to read but in my opinion well worth the time and effort to do so. And in all these years not much has changed, I witness this almost every day in my city of Seattle.
September 21, 2016
Read this to prepare for an article in our local paper about our county jail. Sadly, nothing has changed since this book was written 25 years ago. Jails have become our de facto detox centers, homeless shelters and mental health facilities.
July 13, 2011
Very dry, like a textbook. I did not finish it.
Displaying 1 - 7 of 7 reviews