The Insanity Offense

Make no mistake: Dr Torrey is on the side of the patient. He is enraged by the plight of the seriously mentally ill in the postinstitutional era, and he takes aim at a troika of villains—deinstitutionalization, the civil liberties bar, and the antipsychiatry movement. These 20th-century forces have conspired to relegate citizens with mental illness to a deplorable state of neglect that puts us all at risk. The Insanity Offense threads a needle of making us fear the violent mentally ill without stigmatizing them as a group.

There are many ways to parse the history of psychiatry. I do not want to detract from Torrey’s main thesis by focusing on historiography, but keep in mind that the author has chosen to begin his narrative in the mid-20th century. And he controls the narrative with a viselike grip. The Insanity Offense is journalism—a magnified op-ed piece that, through a relentless litany of horrific examples, supports his subtitle, “How America’s Failure to Treat the Seriously Mentally Ill Endangers Its Citizens.”

Like the crusading journalist Albert Deutsch, who lit a fire under deinstitutionalization (eg, The Shame of the States), Torrey’s prose grabs you and does not let go. The book is not exactly a history lesson, although the accounts of landmarks in civil commitment law (the Lanterman-Petris-Short Act and the Lessard decision) make good reading for psychiatrists who are not in forensic practice. His audience potentially includes mental health professionals, lawyers, consumers, and legislators.

Torrey’s linear narrative informs us that mid-century deinstitutionalization was reckless and ill-conceived; that the idea of citizens with mental illness choosing to live freely was a misdirected play that was per­petrated by clever lawyers; that advocates of anti­psychiatry have distracted us from medical realities; that community-based systems have never replaced the services required by the most ill patients; and, most prominently, that unfettered freedom to be sick has contributed to violence at the hands of psychotic citizens.

A wonderful raconteur, Torrey provides long threads of tragic stories intertwined with news items and vignettes that all lead to the inexorable conclusion that undertreated, seriously mentally ill persons are demonstrably more dangerous than we may think. Torrey “opens the kimono” of the politically correct MacArthur Foundation nonfinding of dangerousness among the mentally ill in the community by making the simple point that its sampling failed to include those most at risk: the homeless, the noncompliant, and the incarcerated. This is Torrey at his most scientific. He proceeds to bludgeon the reader with anecdote after anecdote of violent mentally ill persons in the community against a backdrop of impotent, wrongheaded, or ignorant political machinery. To me, it was overkill, but I must admit I did not need much convincing, having witnessed—and participated in—deinstitutionalization and the failure of community psychiatry to pick up the pieces.

There were some highlights in the middle of the book. First, Torrey recounts his personal encounter with Alberta Lessard, the Milwaukee litigant in the landmark legal decision wedding dangerousness to commitability. Examining her life since 1972, he touchingly reveals her as an impaired but dignified nondangerous 79-year-old woman who was adapting to chronic paranoia. In an unsettling values-clarification sequence, the author notes Lessard’s ongoing contempt for psychiatry and wonders what her life would have been like if her lawyers had been protreatment rather than anticommitment. And therein lies his bias—the doctor knows best—and he will have no truck with a romanticized view of psychosis. The second highlight is the chapter “God Does Not Take Medication,” which looks at the subjectivity behind lack of insight (anosognosia), which is a key dy­namic in treatment nonadherence.

Toward the end of the book, Torrey turns to solutions. There is little he can say about our drug armamentarium, and he does not offer concrete suggestions to fix anosognosia (although he shows interest in its neuroanatomy). He does not dwell on the proposal to register the most dangerous mentally ill persons in the community and instead focuses more on impressive data on assisted outpatient treatment. There is no discussion of partial hospitalization, innovative treatment models (except Program for Assertive Community Treatment), mental health court, or psychiatric advance directives.

The end of the book trails off into another series of lurid murders, this time in North Carolina. If Torrey’s rhetorical tack is to leave the reader angry, bewildered, and exhausted, he has succeeded. This is not a bad thing. He will open your heart and mind, barring you from using your usual defenses against an obvious blight on the social landscape. The Insanity Offense is a must-read for anyone in a position to push the pendulum of mental health care back from an excessively rights-driven model toward a care model in which justice and mercy do not relapse into paternalism.