November 2013

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An Interview with E. Fuller Torrey

In 1963, President John F. Kennedy delivered an historic speech on mental illness and "retardation," announcing that there would be many new programs to replace "the shabby treatment of the many millions of the mentally disabled in custodial institutions" with treatment in community mental health centers. The intended overhaul was to protect those who were the most vulnerable not only to the effects of mental illness, but also to the institutional horrors present in institutionalized care. The birth of the federal mental health program was to make sure that those who suffered would be adequately taken care of through an outpatient system and that mental health would be a predominant objective in the American health system. Yet here we are in 2013, and it seems that the system set in place has failed, not only leaving many unprotected or untreated, but also seeing the most mentally ill go into the hands of unfit, for-profit care homes; in jail; homeless; or worst, killed by police forces who often don't recognize mental illness.

Enter E. Fuller Torrey, author of American Psychosis: How the Federal Government Destroyed the Mental Illness Treatment System. Torrey is a research psychiatrist specializing in schizophrenia and bipolar disorder, as well as the founder of the Treatment Advocacy Center and the executive director of the Stanley Medical Research Institute. The book chronicles Kennedy's mental health and retardation initiative, starting with how it was influenced by Kennedy's own mentally ill sister, Rose Marie ("Rosemary"), and continuing into the current dilemma of how one-third of the homeless are seriously mentally ill, how many other mentally ill people are in grossly overpopulated jails and prisons, and how public facilities are overrun by untreated individuals with few options. It is a collection of incidents and failures, detailing each and every misstep on the way, however well intentioned.

Torrey himself seems to incite strong reactions, often splitting audiences into camps of start black and white opinion, yet no matter which side you're on, those who are being discussed stand as the most vulnerable, the most underprotected, the population that still needs help, and yet, are turned into sound bites or betting chips. American Psychosis is a book that uncovers some of the worst failures of the current mental health system, and Torrey is intent on speaking about those failures.

I interviewed Torrey on the release of American Psychosis to learn why he wrote the book, as well as the importance of how recognizing history is often the first step to making sure it doesn't repeat itself.

American Psychosis is an examination of the mental health care system in the United States, starting with the birth of what we know as modern mental health care, aka "The Kennedy Initiative." Your claim is that since the birth of the program, government agencies and private institutions have been unable to care well for the severely mentally ill, which is what the initiative set out to do. Why did you write this book, and what it is you intend for the reader to take away?

I wrote the book because I am appalled at the current disaster of public mental health services in this country, and I wanted to put it into historical perspective, both for myself and for others. I hope readers will better understand how we got here when they finish the book; it is only by understanding the mistakes of the past that we can hope to not repeat them.

In the book, you say that we are looking at the breakdown of the system in place over the last half-century, where deinstitutionalization is happening, but treatment is not provided in the community for those who need it. You say that while most tend to get better and get help, this is why we have people in jail who are mentally ill, a large population of the mentally ill homeless, and increasing episodes of violence from those who suffer from mental illness. For the most part, deinstitutionalization seems to have failed in your eyes. Can you discuss whether you think this is an accurate statement, and what it means for both those suffering from severe mental illness and the general public?

Deinstitutionalization was a success for approximately half of the patients who left the state hospitals. They were the ones who were less severely ill, who had family resources and support to help, and who were aware of their illness and the need to continue to take the medication needed to control their symptoms. It is the other half of the patients I am writing about in American Psychosis.

You talk about what seems to be two camps: those who successfully live with their illness, and those who do not. You advocate for a return to involuntary hospitalization and forced treatment for this latter group. However, many feel that this infringes on those people's civil liberties and might react in a way that makes this seem like you may want to return to the days where being a socially out-of-control woman was enough to get you institutionalized or even lobotomized. I'd like to think there is much more complexity to it than that. Can you elaborate on what you mean by the return to this method?

I believe involuntary treatment, such as assisted outpatient treatment (AOT), is needed for only a very small number of people. In the book, I suggest it is needed for approximately one percent of individuals with serious mental illnesses and provide a breakdown of how many people that would be in each state. These are the people who have proven dangerousness and no awareness of their illness. I am not advocating a return to the days of massive state hospitals, since most treatment can be done as outpatients.

Can you clarify why the civil liberties question is sticky and why, in your opinion, it makes it difficult to keep the mentally ill safe? Can you also account for the need for mental illness as a civil liberties issue?

Civil liberties is a key issue, but as things currently stand, we are misusing them to protect the rights of people to remain ill. It is important to remember that almost half of people with schizophrenia and bipolar disorder are not aware that they are sick because of the effect of the illness on their brain. If I develop schizophrenia next month, am homeless, being victimized, unaware of my illness and thus refusing treatment, I certainly hope someone will ignore my civil liberties and make sure I get treatment.

Do you think there is a for-profit model in regards to mental healthcare in this country? If so, do you see that ever changing?

The for-profit model of care is a disaster for the most severely mentally ill individuals. The for-profit companies focus on the easiest-to-treat patients and ignore the sickest ones because that is how they make their money. North Carolina is an example. Ten years ago, they essentially privatized their state mental health system. Since then, no state in the U.S. has gone downhill as fast as North Carolina has. Government has a moral responsibility to provide care for its sickest and most disabled members.

You seem to have worked mostly with the debilitating condition of schizophrenia. Do you feel that this exposure is skewed to the most ill (and potentially violent) of patients? Do you think you would have a different viewpoint of the system at large if you had focused on people with OCD or depression? Do you think that the system's failures would still resonate? Or is the care we give to one type of mental illness different than another?

My perspective would certainly be different if I were focusing on individuals with OCD or depression. Such individuals are aware of their illness and wish to get treated for their symptoms. But these are not the mentally ill people who end up homeless or in jail.

You have claimed that "this federal program failed because not enough centers were funded and not enough money was spent." What can we do to make our mental health system better?

There is actually tons of money in the system -- it is just being used very poorly and not focused on the sickest patients. And ninety percent of the centers that were funded were failures, so funding twice as many wouldn't have helped.

How does the phrase "the road to hell is often paved with good intentions" feel to you?

One of the things that intrigued me about the failure of the Kennedy Community Mental Health Centers program was that people with the best intentions created it. So yes, the saying is absolutely true in this case.

What do you wish most of the general public knew about mental illness, and the mental healthcare system that we have?

I hope readers will come away knowing that (a) severe mental illnesses like schizophrenia are brain diseases, (b) they are treatable diseases, and (c) there are solutions to the disaster of current public mental health services if only we can summon the political will to implement then.