Monday, April 23, 2007

Lethal coalition

Of what I have read on the Virginia Tech tragedy, I like Jonathan Kellerman's op-ed (excerpt below, from today's WSJ ) best. A "confederation of progressives, libertarians and fiscal conservatives" formed in California in the 1970s and shut down asylums.

Baptists and bootleggers often find common cause to make bad public policy. Prohibition in the U.S. lasted 13 years and exacted huge costs.

Deinstitutionalization trumped selective and targeted reforms. The results include mass murders as well as the loss of most big-city public spaces. Many in my field are in love with the idea of more "open space" but say nothing about how so many common areas have become uninviting -- to say the least. And further retreat into private enclaves elicits all sorts of self-righteous hectoring (e.g. Robert Reich's "secession of the successful", Robert Putnam's Bowling Alone) which neatly avoids the real issue.

Bedlam Revisited


I was in graduate school, studying clinical psychology
when they began shutting down the asylums. The place was California, the time
was the early 1970s, and "they" were an unprecedented confederation of
progressives, libertarians and fiscal conservatives.

From the left marched battalions of self-styled mental health
"liberation activists" steeped in the writings of Scottish psychiatrist R.D.
Laing. Though he denied being opposed to his own profession, Laing's notion that
madness could be a reasonable reaction to an unjust society, or even a vehicle
for spiritual transformation, helped fuel the anti-psychiatry movement of the
post Love-In era. The most radical of Laingians carried revisionism one step
further: Not only wasn't psychosis a bad thing, it was evidence of a superior
level of consciousness.

The libertarians were fueled by Thomas Szasz, an iconoclastic
psychiatrist who was, and remains, an outspoken foe of virtually every aspect of
his chosen specialty. Hungarian-born in 1920, and witness to vicious state
exploitation of medical practice by the Nazis and the communists, Dr. Szasz
pushed an absolutist dogma of individual choice, finding ready converts among
members of the Do-Your-Own-Thing generation. Though his early essays offered
much-needed critiques of the Orwellian nightmares that can result when autocracy
corrupts health care, Dr. Szasz devolved into something of a psychiatric
Flat-Earther, insisting in the face of mounting contrary evidence that mental
illness simply does not exist. Currently, he serves on a commission, cofounded
with the Church of Scientology, that purports to investigate human rights
violations perpetrated by mental health professionals.

Accepting the arguments of the liberationists and the
libertarians at face value led to the assertion that no matter how bizarre,
disabling or life-threatening a person's hallucinations and delusions,
involuntary treatment was never called for. And to the assertion that violation
of that premise created yet another class of political

While moderate members of the anti-asylum movement were
willing to concede that psychosis might pose difficulties for a few individuals,
they insisted that society had no more right to force psychoactive drugs upon
mental patients than it did to hold down diabetics for insulin injections. If
treatment was to be offered, it needed to be consensually contracted between
caregivers and care-recipients on an outpatient basis. That fit perfectly with
the sensibilities of conservative scrooges searching for ways to cut the state
budget, and all too happy to dismantle a massive state hospital system
denigrated as inefficient at best and inhumane at worst. The replacement chosen
was an untested, less costly treatment model: the community mental

How nice that everyone agreed.

Everyone, that was, except for many families of hospitalized,
hopelessly-decompensated, often self-destructive and occasionally violent
psychotics. They'd lived with the reality of severe mental illness and wondered
what "freedom" would bring. But there weren't enough of these families to

Were the state hospitals wretched nightmare-palaces straight
out of "One Flew Over the Cuckoo's Nest"?

A few were. But many were well-run institutions for patients
in wretched circumstances, providing optimal care within the limitations of what
constituted psychiatric treatment at that time: a handful of poorly understood
psychotropic drugs and supportive talk-therapy. Perhaps more important, they
offered clean beds and three squares a day, which led to them being belittled as
warehouses. But the protective environment of the best state hospitals has yet
to be improved upon, or even matched.

No matter, this was baby-and-bathwater time.