Mismanaged Mental-Health Care

IS vice or cant the root of folly? ``Out of Bedlam'' blames venality; while ``Madness in the Streets'' blames zealotry for society's failure to provide humane treatment for people with mental problems. Despite their common hook, topic, and premise, these are remarkably diverse books. The hook is public distress at an invasion of our cities by crazed panhandlers and steam-grate dwellers. Mental institutions had long concealed the plight of the mentally ill. They're now in our faces, and that forces concern.

The topic is deinstitutionalization: the emptying of state mental hospitals, which puts the mentally ill on the streets and elsewhere. The authors trace the history of this diaspora, argue its causes, and bemoan its effects.

The premise is that deinstitutionalization went wrong. The authors agree that the back mental wards had to go. The complaint is that the doors opened to nowhere.

``Out of Bedlam'' is a clever title that captures Ann Johnson's pessimism and hope. Bedlam means chaos, but originally, Bedlam was an English hospital, a reformatory turned dungeon for the insane. Reformers inveighed against these lunatic ``bins.'' Johnson traces how small sanatoriums grew gargantuan, becoming bedlams. Closing these hospitals made bedlams of emergency rooms, jails, and flophouses.

Johnson wants the mentally ill out of bedlam altogether. To this end, she would update 18th-century reforms. A social worker, she believes in humaneness. She identifies with Phillipe Pinel, who struck chains from the insane and pioneered moral treatment. In early America, charismatic superintendents respected, supported, and instructed their charges in pastoral surroundings. Private retreats gave clients refuge and work, then coaxed them back to society.

Years of work with the mentally ill have tempered Johnson's expectations. Unlike early reformers, she does not believe in cures for chronic psychotics. She says social work can't do it and neither will psychiatry. Johnson says talk therapy is useless and expects no medical advances. Many patients refuse drugs because they mask problems and have side effects. She aligns with the patient's right to refuse such medication.

Johnson wants respect for the persons and tolerance for their eccentricities. She says society must accept that these are lifelong debilities. The mentally disabled should have lifelong monitoring and dependable help.

Alas, Johnson offers slim hope for her reforms. They require extraordinary compassion, close cooperation, and big budgets. Hers is a Domesday Book of reforms that failed for want of just these things. Johnson lists well-intentioned ideas, but dwells on the indifference, turf wars, and niggardliness these ideas camouflaged.

After World War II, altruists argued for closing state mental hospitals and caring for mental patients in the community. State hospitals were virtual prisons. They provided no effective therapy. New drugs were used to calm patients, allowing them to live on their own. In the 1960s, Congress began funding community mental health centers to give outpatient care and to coordinate community resources for the chronic mentally ill.

Johnson says these centers have not done this. They have focused on neurotics and the politics of poverty. Psychotics went to prisons, flophouses, and the streets. Thanks to Medicaid, the senile went to nursing homes. This was not a failure of good intentions. Johnson argues that the rhetoric of deinstitutionalization was a gloss over baser motives.

This space cannot encompass Johnson's compendium of smallness and selfishness. In sum, these tales have an angle but no perspective. They are informative and engaging but not persuasive.

The same can be said for ``Madness in the Streets,'' by Rael Jean Issac and Virginia C. Armat. The angle, however, is different. These authors dwell on the ideas that were veneer for Johnson. Johnson looks up from bedlam; Isaac and Armat look down from academe.

Isaac and Armat say foolish ideology put madness in the streets. It started as irony. World Wars I and II made people question normality and authority. Perhaps the insane are saner than we if we behave so horrifically? Who are we to cage people who don't accept our sorry normalcy?

In the '60s, numerous books and articles maintained that mental illness is a myth. Most influential were R.D. Laing's ``The Divided Self'' and Thomas Szasz's ``The Myth of Mental Illness.'' These books drew vast followings and many elaborators. The central argument was that mental illness is rarefied thinking, which society squelches to preserve a stilted order. Erving Goffman's ``Asylums'' showed mental patients coping rationally with oppressive ``total'' institutions. Ken Kesey's ``One Flew Over the Cuckoo's Nest'' dramatized this view.

The drug culture of the '60s was a catalyst. In the 1940s, researchers noted the psychotic effects of new psychedelic drugs and felt herein might be a chemical key to mental illness. As more people ``turned on,'' however, a notion grew that psychosis is fine since it is like taking drugs.

Isaac and Armat imply that the counterculture was itself a mass play psychosis. At its height, the mentally unbalanced blended with hippies. When hippies became yuppies, the sick became visible and forsaken.

If mental illness is a myth, much follows according to the authors: Discrimination and therapy are unjustified. Psychotics have full civil rights. Society should not commit psychotics who aren't convicted criminals. Doctors should not treat psychotics without their consent. Psychiatrists are frauds, their therapies are benighted.

The book details how since the '50s, partisans have acted on these assumptions with telling effect. Advocates have used the press, the arts, legislatures, but mostly the courts. The crusade has been a civil-rights franchise. There have been activist attorneys, activist judges, and pious academics. There have been victims' coalitions of ex-mental patients who've railed, rallied, lobbied, and sued.

Partisans won psychotics the right to informed consent. Now, in many jurisdictions, a court must rule that someone diagnosed as psychotic is lethal to himself or others before he can be committed. Even then, it is unlikely he can be formally medicated.

Isaac and Armat are appalled. They hold that psychosis is an organic disease that only medicine can alleviate. Early lobotomies and shock therapies were crude and promiscuously applied, but they've been refined, they say, and they've helped people. Similarly, drugs have cooled the terrors of madness. They say nothing cures severe mental illness, but easement is still a blessing.

Curiously, considering these recommendations, Isaac and Armat portray psychiatrists nearly as negatively as Johnson does. They are irate that psychiatrists easily and sometimes eagerly capitulated to the partisans. Isaac's and Armat's psychiatrists are pusillanimous and myopic. Their quality is uneven. They've built their practices around the ``worried well'' and eschewed the chronically mentally ill. Like Johnson, Isaac and Armat belie their own reform.

These are provocative books. They are meant to persuade the public and, therefore, are informative without being technical. It is obvious that all the authors have a mission. Scholarship, hearsay, and anecdote are marshaled to make a point. If the authors were closeted and compelled to write a single book, it would likely be better than either of these. But fervor would be lost. Also, their single book would still not be definitive.

One wonders about the society these authors describe, which is so conducive to disorientation and so ill-equipped for dealing with its marginal members. The authors agree that the mentally ill do best when the sun rises and sets reliably on their days, the situations are simple, and friends or family are there to help. Our urbanized, mobile modernity has caused many casualties.

None of these authors defines mental health or mental illness. They write as if the contours of their subject were intuitively obvious. They aren't. Without these definitions and other finer definitions of gradations, there can be no judgment of action or actors. The human mind is not a hand or a foot.