reviewed by Sue E. Estroff*
By Any Means Necessary? By No Means Necessary
E. Fuller Torrey's most recent book, The Insanity Offense, continues his literary style of provocative, catastrophic language when referring to violent incidents attributable to people with psychiatric disorders. This is not a work in the scholarly convention. It is one activist psychiatrist's impassioned and purposeful argument for a reversion of mental health law, policy, and treatment to the 1950's when involuntary confinement and forced treatment qua medication in hospitals was the standard of practice--often based on the signature of one physician, and the petition of a family member or other person.
Many would agree with Torrey that public mental health care in the U.S. falls far short of what people with serious psychiatric disorders need and deserve. It is under-funded, under staffed with qualified providers, beset with often meaningless paperwork and administrative regulations, and lacking access to safe, affordable housing, employment opportunities, and individualized options for care -- to mention only the most obvious.
I live and work in North Carolina, one of the states that Torrey takes to task, and I am in full agreement that public mental health care here is in a shambles. Where we part company is in both the diagnosis of the causes of the failures and the prescription for "fixing the system." Torrey has devoted considerable effort through speaking, writing and the Treatment Advocacy Center to publicizing the failures of public mental health services, and to promoting changes in mental health law across the country. Formerly a researcher, he has been closely affiliated with the National Alliance on Mental Illness (NAMI), often mobilizing that group to support his positions. Invariably, the center of attention for Torrey is easing commitment statutes and expanding the means for forcing people to take psychiatric medications.
The book begins with seven chapters devoted to a journalistic style retelling of violent crimes, the people who committed them, and the failures of policies, laws, lawyers, and treatment systems that, in his view, set the stage for each. In each case, according to his reasoning, if only the people had been taking medication, if only they could have been forced to take medication, if only they could have been confined in a hospital, if only they knew that they were psychotic and had a disease--these tragic outcomes could have been avoided. The list grows to include lawyers, judges, and elected officials - if only they had not been so concerned with the protection of individual civil liberties and inherent human rights of autonomy and bodily integrity that are the foundations of our democracy. These chapters are followed by five in which the author repeatedly makes an astonishing case for why and how people with serious mental illness must have their civil rights restricted --for the good of the "citizens," and for their own good.
Two appendices summarize, not always accurately, recent research about the prevalence of violence among people with serious psychiatric disorders in community settings in the U.S., and cross national studies of homicides committed by this group. (When citing research that I conducted, the hospital and court record reviews were not included as data sources.)
The new material in this book derives from the impressive amount of personal communication (letters and interviews); archival research primarily of news coverage; and court documents of the cases the author presents. Much of the text includes newspaper descriptions and quotes. Torrey's own writing echoes this overly vivid mode of reporting. The positions and polemics about forced treatment and medication, and the use of fear mongering with wobbly statistical extrapolations disguised as fact, and the righteous certainty of draconian (undoubtedly unconstitutional) solutions, are all familiar.
What is remarkable about this book, however, is the means by which Torrey attempts to make his case-- by any means necessary. Torrey's argument is as follows:
- The only important and effective component of treatment is medication, followed by inpatient confinement.
- People with serious mental illness have a brain disease which prevents them from knowing that they need treatment/medication.
- Civil libertarian lawyers and advocates, state legislators and judges did not understand this and erroneously filed law suits and wrote legislation that resulted in too many civil and legal rights for people with serious mental illness.
- As a result, hospitals were closed and commitment/forced treatment standards set so rigorously and precisely that violent crimes were committed, and increasing homelessness, criminalization, and victimization ensued for people with serious mental illness.
- Adequate community treatment resources and the means to force people to take medications outside the hospital were not put in place.
- There is scientific certainty about: the link between violence and serious psychiatric disorders, about the efficacy of atypical antipsychotic medication, about the benign nature of coerced/leveraged/assisted medication and treatment, about the ability to predict which people with serious mental illness will be violent, and what should be done in the future to prevent horrific crimes of violence by people with serious mental illness.
- By any means necessary, ensure that people with serious mental illness take their medication, particularly making disability income supports contingent on medication adherence.
Danger has become the weapon
The book, its title, and even more pointedly its subtitle, How America Fails the Seriously Mentally Ill and Endangers Its Citizens, and What We Must Do to Stop It are intended to shock and alarm the uninformed reader, to sow the seeds of crisis and fear, and to attach a sense of potential and preventable dangerousness to every person who has a major psychiatric disorder. Note that citizens are apparently distinct from "the seriously mentally ill." In this subtitle--the divide between them and us is drawn, and the citizenship of people with serious mental illness is implicitly denied. A more explicit demand for suspending citizenship rights, based on inadequate and incomplete science and unbridled medical authority, underlies the remainder of the book.
By delving deeply into extreme cases over a ten year period, and citing an additional 103 with a few headline sentences throughout the volume, Torrey evokes the spectacular and melodramatically enlarges the specter of what he admits is a relative small number of people with serious mental illness. There are moments of humane, and almost empathic demeanor in the text--it is clear that Torrey treated his interview subjects with respect when in contact with them. His contempt is reserved for the rest of us--those who hold views that differ from his -- and the core values of American democracy. Laws, policies, lawyers, advocates, administrators, judges, researchers --all have failed to see the truth that Torrey does, and as a result have created what he calls (p. 1) "one of the great social disasters" and "the greatest calamities" "of recent American history."
It is impossible to list all of the flawed arguments and unsubstantiated claims in this book. Evidence that contradicts Torrey's assertions is either discounted or not considered. A fair and reasoned analysis requires that conflicting evidence be at least addressed, if not accounted for. Let us examine some illustrative examples.
Torrey states (p. 91), "The consistency of findings regarding the effectiveness of AOT is impressive." Yet, regarding outpatient commitment (AOT), a 2005 gold-standard Cochrane Library analysis questioned policies designed to "curtail the freedom of 85 people to avoid one admission to hospital or of 238 to avoid one arrest." It is "difficult to conceive of another group in society that would be subject to [these] measures...Evaluation of a wide range of outcomes should be included if this type of legislation is introduced."
The Cochrane Library analysis elaborates:
Based on current evidence, community treatment orders may not be an effective alternative to standard care. It appears that compulsory community treatment results in no significant difference in service use, social functioning or quality of life compared with standard care. There is currently no evidence of cost effectiveness. People receiving compulsory community treatment were, however, less likely to be victims of violent or non-violent crime. . . . We urgently require further, good quality randomised controlled studies to consolidate findings and establish whether it is the intensity of treatment in compulsory community treatment or its compulsory nature that affects outcome.
And another study about coerced treatment found: "perceived coercion neither increases nor decreases psychiatric inpatients' medication adherence or use of treatment services after discharge." Contrary to what Torrey asserts, we lack an adequate scientific assessment of the efficacy or the effects, positive and negative, of involuntary outpatient commitment.
On the topic of medication, we see the same tactic--unsubtantiated certainty and incomplete reporting. Torrey writes (p. 185), "Clearly, clozapine should be the antipsychotic of choice for severely mentally ill individuals who exhibit violent behavior." There is no mention of the findings of debilitating metabolic syndrome side effects of the 'atypical' antipsychotics such as clozapine, olanzapine, quetiapine, and respiradone. Nor is the reader informed of the resulting 64-82% drug discontinuation rate of among participants of the much heralded CATIE and CUtLASS studies of these drugs, done in the U.S. and the U.K. respectively. In the CATIE study "clozapine's advantage was compromised by weight gain and metabolic sequelae." In fact, the newer drugs were found to be no more effective, and sometimes less effective, than the phenothiazines like Haldol and Trilafon that have been in use for some time.
Even the principal investigators of those two studies were sobered by the results, both in terms the substantial weight gain and adverse cardiovascular consequences of these drugs. They ask, "can we handle the truth." The informed reader should expect the same of Torrey.
Finally, Torrey asserts (p.3), "Once a patient was discharged from the hospital, that bed was no longer available for that person to return to or for a new patient to use." This is simply and demonstrably untrue. Hospital beds have been added and eliminated over the years with vastly differing formulas, but there is no evidence that this one-to-one calculus prevailed or even occurred.
Perhaps the most ironic section of the book is about "decreasing stigma." Torrey posits that, "Of all the burdens borne by mentally ill individuals, stigma is one of the heaviest. It affects opportunities for employment, housing, and social relations and becomes the scarlet letter that all mentally ill persons must bear." This followed by: "the public now perceives mentally ill persons to be more violent because they are more violent." More violent than whom? More violent than when? This is not addressed. This book, if read widely, has as its purpose establishing the second declaration, and will, as a consequence, shamelessly increase the first accurate observation that "stigma is one of the heaviest burdens."
Torrey presents us with a false choice between fundamental rights and public safety, between humane, safe, effective care of choice and wild rampages. Between citizenship and protection from danger. These are not actual, viable or defensible opposites. Policies and actions based on this formulation would violate rudimentary principles that we hold dear, and would not achieve the promised results. If reasoned argument and democratic processes such as laws and elections, not to mention science, do not give the desired result, then any means necessary--stigmatizing tens of thousands of people, deeply offending and insulting people who hold views differing from the author's, promulgating uni-dimensional solutions--are apparently justified. We have seen this kind of insinuation before, and should be familiar with the processes of mobilizing the populace based on fear, prejudice, lack of knowledge, seeming facts, and evocations of empathy for undeniable loss and grief caused the group in question. This is by no means necessary.
These inaccuracies, incomplete discussions of the evidence, and incendiary language may make for good story telling, and may advance the author's agenda, but they fall far short of contributing to an informed debate and consideration of the serious issues before us.
*Sue E. Estroff, Ph.D., teaches in the medical school and in the department of anthropology at the University of North Carolina at Chapel Hill where she is a professor. She often consults about issues related to mental illness to state and local mental health systems and organizations, and in the past has done so for the Carter Center Mental Health Stigma Program, the Hogg Foundation Scientific Advisory Board, and the North Carolina Commensense Foundation. She is the author of numerous books and scholarly articles.