OUT OF BEDLAM The Truth About Deinstitutionalization By Ann Braden Johnson Basic Books. 296 pp. $22.95
MADNESS IN THE STREETS How Psychiatry and the Law Abandoned the Mentally Ill By Rael Jean Isaac and Virginia C. Armat Free Press. 436 pp. $24.95
FOR MORE THAN 30 years now, human beings extremely troubled psychologically -- people who in earlier days were kept in mental hospitals for long stretches of time, a lifetime, even -- have lived among us in America: with families and friends, in "half-way houses," on their own. This major shift in how we regard and attempt to care for men and women whom we call mentally ill is now known as "deinstitutionalization," and it is the subject matter addressed by these two books, each of which explores the phenomenon from a different angle of vision, and with a different political agenda in mind.
These books will be of interest to many of us now: "Deinstitutionalization" has unfortunately meant for thousands not an exit from a mental hospital in favor of a return to parents, or an apartment, or even a room in a place inhabited by other former patients, but rather, the life of a homeless person -- shelters and soup kitchens or the streets and alleys as places to eat and sleep. Increasingly, ordinary people, who also use those streets in the course of their everyday lives, have encountered these one-time residents of mental hospials, not always in pleasant or even tolerable ways. The newspapers and television news are full of assertions and arguments with respect to such agitated and confused street people -- and plenty of accusations. Both these books are no exception in that regard. Each has a point of view to uphold, each has criticisms to level, and each does so vigorously and to the reader's occasional edification -- though my hunch is that when each goes the way of most books, becomes out of print, the problem addressed by their authors will still be very much with us in America.
No question, Madness in the Streets is the more provocative and polimical of the two books -- a major challenge, as its subtitle suggests, to prevailing assumptions in both psychiatry and our present-day legal system. As the authors point out, we have in the past three decades, in the name of civil rights, gradually protected even the craziest (and most troublesome, and potentially, the most dangerous) men and women from what used to obtain: the right of families and physicians and the community at large, through its police and judges and social workers, to decide that some people are so disturbed and disturbing, so bizarrely out of control with respect to their thoughts, their speech, their everyday behavior, that they ought be hospitalized for their own good, never mind that of others around them, or at the very least, kept under careful outpatient scrutiny. Now a wildly strung-out person -- who mumbles incoherently or who is transparently deluded and who refuses all medical and psychiatric assistance in favor of sleeping on a street grate, standing in the midst of a busy thoroughfare shouting swear words and displaying petulance, mean-spiritedness in the most vocal manner imaginable, and not only begging but demanding money -- may well be beyond anyone's helping or constraining hand.
The authors, Rael Isaac, a sociologist, and Virginia Armat, a journalist, tell us how we got to where we are -- a consequence of the postwar revulsion at the degrading life so many mental hospital patients lived, and the almost messianic faith in psychiatry (a secular religion for many) that developed in this country during the 1950s. Surely sick people deserved better, our legislators and judges felt, and surely, they believed, our doctors could do better -- and offer more than custodial care. Moreover, many who were profoundly suspicious of psychiatrists were also, with different objectives in mind, enouraging us to empty those old asylums -- to save money, for instance.
Some writers, on the left, went further, turned on psychiatrists as the utterly suspect defenders of the political status quo, their normative language ("healthy," "ill") a convenient way of separating the socially compliant from those who radically distance themselves from prevailing orthodoxies. Mental illness was a "myth," we were told -- an improper way of regarding certain people as "sick," in the medical sense, when it is their idiosyncatic thinking and activities that truly distinguish them. For such critics, the mentally ill became yet another "oppressed minority" -- indeed, sanity was claimed for them, whereas the comfortable bourgeoisie was declared not only wicked but out of its collective mind.
Soon enough, too, drugs such as thorazine arrived on the medical scene -- so that it no longer seemed necessary to keep people locked up: With a pill or two a day men and women would be newly coherent and able to take responsibility for themselves, or so it was hoped. The result -- an emptying of many hospitals, a closing, actually, of some, and a population of hundreds of thousands of hitherto "sick" people making do as best they could.
Supposed, these people were to be "followed up," as the medical term goes -- but in sad fact, as Ann Johnson, a longtime mental health worker, convincingly points out, most of them essentially were on their own -- given no adequate psychiatric outpatient care. The more fortunate ones were able to manage reasonably well, but many others became a terrible burden to family members and friends or neighbors, whose earnest efforts to be of help seemed unavailing against the still mysterious (with respect to origin) but all too evident power of the various psychoses. In a sense, for many patients, to go "out of Bedlam" meant to live in a newly fearsome and dangerous bedlam -- to be prey to an assortment of street hustlers and con artists no less vicious than the occasional and much denounced callous or violent caretakers who worked in the old mental hospitals. BOTH OF these books agree that "deinstitutionalization" has been a social tragedy of sorts, even though welcomed, a decade or two ago (be it noted again) by conservatives as well as liberals, the former in the interests of their ideological preoccupations, balancing budgets and in deference to the rights of the individual, and the latter in response to their particular convictions: that people, for example, deserve the best medical care possible -- in this case, a kind to be had outside the old asylums, a symbol of an earlier, benighted era. But the two books offer quite different visions of what ought to be done -- even of what can be done.
Madness in the Streets emphasizes the violent, unruly, destructive side of craziness -- and what the presence of such craziness on our streets has come to mean for our social order. The authors offer stories that remind us how intractable and exasperating mentally disturbed people can be, to their kind, of course, but these days, to the rest of us, who witness their words and deeds in various public places. What the authors want is a psychiatry ready to demand that such people be confined and treated with medication (even against their will, as so often would be the case) and a law ready to back up such a medical outlook.
Out of Bedlam, however, makes the reader wonder whether even such a radically changed state of affairs would prove all that much better than what now obtains -- because its clinical histories, its various stories, are often enough tales of bureaucratic bungling and arrogance, of crassly officious or self-important doctors, who do anything necessary to keep themselves away from the people they are trained to treat, and who, by the way, speak in a language not much more appealing or comprehensible than that of their confused and confusing patients.
The authors of Madness in the Streets think that our psychopharmacologists, armed with the right to confine more patients than is now possible -- at present a person essentially has to be actively homicidal or suicidal to be confined psychiatrically against his or her will -- will improve the mental condition of their vastly increased population of patients, and (no small part of the book's social agenda) make our our city streets safer and more attractive. They don't, however, go into the matter of all the homeless people who aren't psychotic, and who don't abuse drugs, but who can't find affordable housing. As they readily acknowledge, statistical profiles are quite variable efforts to ascertain who is homeless and why. On that score, even our federal government's census-takers, it seems, haven't found some rock-bottom truth. Whatever the statistics offered by the various studies, it is clear that our homeless are not at all to be equated with the crazy, or with alcoholics and drug addicts.
Nevertheless, the authors of Madness in the Streets insist that "to a great extent then, the 'chronic homeless,' as against those whose situation is temporary, are those too disabled to take advantage of the welfare safety net or the national increase in job openings since 1980." Such language is all too imprecise, if not evasive -- and excludes from consideration thousands of people who are working, or on welfare, and yet can't find a place to live at a rent they can afford. The authors immediately leave behind, unexamined, their assertion -- to tell us that "the mentally ill are the subject" of their book. But even many of those "mentally ill" people may not be so crazy that they need go back to Bedlam; rather, they require a decent place to live, adequate out-patient medical care, and a community to rally round them.
In Out of Bedlam Ann Braden Johnson lets us know that if we are so to respond to such people, we will have to think again about how to do so -- because what we did (and did not do) in our rush to empty our hospitals has brought us to the present sorry state. One wonders, reading her, when our society will decide to find more people like her -- enable and encourage such men and women to do the kind of frontline work she every day tries to do.
Robert Coles is a child psychiatrist who teaches at Harvard. His next book, "The Spiritual Life of Children," will appear this fall.