Madness in the Streets

Madness in the Streets: How Psychiatry and the Law Abandoned the Mentally Ill by Rael Jean Isaac and Virginia C. Armat, Treatment Advocacy Center, 2000. 

Critics of Psychiatry

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. 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. 

Deinstitutionalization

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. 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. 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.

Civil Rights Activists

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.

Community Mental Health Centers

Community mental health centers 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.

The Impact on Families

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. 

Hospitalization

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.

Work as Therapy

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).

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.