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The Insanity Offense is an informative and important book about a social problem of pressing concern in the United States: the enormous number of preventable tragedies involving severely mentally ill individuals. These tragedies take the forms of homelessness, incarceration, victimization, violence and homicide. Torrey illustrates the nature and the scope of the problem by focusing on statistics augmented by narratives from three states with relatively good mental health care systems: California, Wisconsin and North Carolina. Torrey's lucid and moving descriptions of the problem are rich with reliable statistics and gripping stories whose pathos is on par with the work of Euripides and Sophocles.
Torrey selects a single case study from each of the three selected states. The chapter entitled "Death by the Roadside" reports the story of Malcoum Tate, a severely mentally ill man from North Carolina, who was shot to death by his sister. Tate's mother and sister conspired in his death because they had strong reasons to believe that Malcoum was going to kill his sister's daughter (or one of them). The local police and mental health authorities were not authorized to intervene, since Malcoum's threats were not perceived to be an "imminent threat" to anyone. The chapter "Thirteen Murders to Prevent an Earthquake" describes the case of Herb Mullin; a severely mentally ill individual from California who murdered thirteen people, sacrifices that he believed had to be made in order to prevent California from slipping into the ocean. The chapter "The Killing of Three Devils" details the case of Bryan Stanley, who was a severely mentally ill man from Wisconsin who killed three people after Mass at a Catholic church. He thought that three devils were in the church and they had to be destroyed. Torrey's reports of these cases are detailed, reliable and serve to advance his case. In each situation there was strong evidence that the severely mentally ill individuals involved were a threat to themselves or others. But it could not be established that these men were an "imminent threat" to themselves or others, in the sense required for them to be involuntarily committed. Torrey's central claim is that mentally ill individuals like those described in the cases above should receive psychiatric treatment, involuntarily if need be, before the danger that their illnesses pose is realized.
According to Torrey, there should be strict regimes of treatment for severely mentally ill individuals in order to prevent tragic outcomes like the ones suffered by Malcoum Tate and the victims of Herb Mullin and Bryan Stanley. Torrey's description of their cases is interwoven with a discussion of the historical origins of the legal and social policies that provide the background setting for these tragedies. He identifies two main trends that have led to the current widespread presence of untreated and dangerous mentally ill individuals in the community. The first trend is the deinstitutionalization movement that began shortly after World War II and ended during the 1980s. This movement resulted in the release of the vast numbers of psychiatric patients from mental health hospitals, placing them in the community without any form of follow up treatment. The second trend is the legal reform initiated by civil libertarians during the civil rights era of the 1960s. These legal reforms changed mental health laws by creating a very strict standard of "imminent threat" (defined in terms of imminent physical harm) that must be satisfied to commit mentally ill individuals to psychiatric treatment. Malcoum Tate, Herb Mullin and Bryan Stanley could not be involuntarily treated for their mental illnesses because they did not meet the civil commitment criterion used in their states: they were not considered to be "imminent threats" to themselves or others. Torrey provides a plausible and detailed account of how deinstitutionalization and the legal reforms initiated by civil libertarians led to the current state of civil commitment laws and the presence of approximately 40,000 unmedicated, dangerous and severely mentally ill people in the community.
Torrey articulates four suggested reforms to the current mental health system that are intended to provide greater protection to mentally ill individuals and to their communities. The first proposal involves modifying the current civil commitment laws to allow for more outpatient treatment. Torrey is a member of the board for the Treatment Advocacy Center in Arlington, Virginia, and their webpage contains specific proposals for legal reform along these lines. The second proposal is the construction of a nationwide database that contains a list of severely mentally ill individuals that are particularly susceptible to becoming violent. To be placed on this list, a mentally ill individual would have to manifest all of the following characteristics: a past history of violence, substance abuse, anosognosia (i.e., unawareness of one's own illness) with medication noncompliance, and antisocial personality disorder. The third proposal is to ensure that severely mentally ill persons who are likely to become violent are treated with the use antipsychotic medication. Torrey recommends that the most dangerous mentally ill persons are treated with clozapine, a powerful antipsychotic drug with massive side effects. Also, to prevent those individuals from abusing drugs, Torrey recommends that Disulfiram (Antabuse) be the mandated treatment for those individuals who are also alcoholics and that methadone be the mandated treatment for those individuals that are also heroin addicts. The fourth proposal is the recommendation that the federal government does more to fund research about the issues surrounding violence and mental illness, and then they should use the findings of that research to play a more active role in evaluating the effectiveness of state and regional public mental health facilities.
The book has two main shortcomings. Torrey's proposals for revising the mental health system are given in one chapter of twenty pages and his case for them would greatly benefit from more details and argumentative support. Moreover, Torrey's arguments against the perspective of civil libertarians are underdeveloped and often loaded with ad hominem arguments appealing to various civil libertarians' specific ideological leanings and personal vendettas against psychiatric treatment. Torrey reports that civil libertarians maintain that (1) individuals have a right to refuse treatment and (2) individuals also must give their informed consent to receive psychiatric treatment. He responds to the first claim by asserting that individuals have a right to adequate treatment and the type of liberty advocated by civil libertarians leaves severely mentally ill persons "rotting with their rights on." Torrey responds to the second claim by maintaining that it is an egregious error to assume that severely mentally ill individuals can make informed decisions about their own psychiatric care; especially since their condition also commonly involves a lack of awareness of their own condition. Torrey's claim that a right to receive adequate treatment is more fundamental than an individual's right to refuse treatment does not undermine the civil libertarian position, because even if individuals have a right to receive adequate treatment, it does not follow that those individuals do not have a right to refuse that treatment. Torrey's argument against the claim that mentally ill individuals must give their informed consent to receive psychiatric treatment is suggestive but a convincing case would need to say much more about the nature of informed consent and who is going to decide which mentally ill individuals are in a position to give it. Moreover, important issues surrounding the potential for abuse of the involuntary commitment power are largely ignored. Presumably some kind of government official or mental health professional will be given the authority to make treatment decisions for those who are incompetent, but without spelling out the exact details of this proposal it raises genuine worries about giving too much paternalistic power to the state or the mental health care system. Torrey's own proposals, such as the nationwide database and giving the government greater use of parens patriae powers (i.e., the right of the government to make decisions for persons declared mentally incompetent), seem to reflect an enormous amount of trust in government officials and mental health care professionals. There is a long history of the abuse of parens patriae powers (in the U.S. and elsewhere) and Torrey's discussion does little to register the magnitude and scope of those abuses.
In sum, The Insanity Offense is essential reading for anyone interested in issues related to civil commitment laws and the plight of the severely mentally ill people in the U.S. that are not receiving psychiatric treatment.
© 2009 Daniel D. Moseley
Daniel Moseley received a Ph.D. in Philosophy from the University of Virginia. He is currently a Visiting Assistant Professor of Philosophy and a Clinical Assistant Professor of Psychiatry at the University of North Carolina at Chapel Hill.