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Out of the ShadowsReview - Out of the Shadows
Confronting America's Mental Illness Crisis
by E. Fuller Torrey
John Wiley & Sons, 1996
Review by Tony O’Brien
Jan 16th 2003 (Volume 7, Issue 3)

E. Fuller Torrey is one of the more internationally well known spokespersons on mental health issues and has produced a large number of books and papers detailing his views that mental illnesses are biological brain diseases the same as Alzheimer’s and Parkinson’s disease. Linked to this view, and apparently implied by it, are the notions that the widespread provision of hospital facilities is the appropriate social response to mental illness, and that a greater degree of coercion is necessary to ensure that those who suffer from mental illness accept their need for care, and comply with treatment regimes prescribed by psychiatrists. The crisis referred to in the title is the result of the mistaken policy of deinstitutionalisation and the excessive freedoms afforded the mentally ill.

The thesis of the book is contained in the first chapter, where the treatment of mental illness is compared to treatment for heart disease. From this comparison, a case for the treatability of mental illness is developed, together with an outline of the scale of reduction in hospital beds between 1954 and 1994. Deinstitutionalisation is described as a ‘psychiatric Titanic,’ a disaster that has lead to thousands of mentally ill Americans being denied the care and treatment which modern psychiatry is able to provide. As a result, the mentally ill now make up substantial proportions of the homeless, the indigent and populations of correctional facilities. They represent a substantial risk of violence to other members of the community and of harm and neglect to themselves.

The book explores issues of homelessness, incarceration, violence and accommodation as they affect people with mental illness. There is a long chapter on funding and organisation of mental health and related social services, and a critique of the current standard of dangerousness used to invoke involuntary committal. Torrey attacks the ideology of ‘mental health’, which in his view distracts the proper focus of psychiatry from those most in need of treatment, the severely mentally ill. He concludes by arguing that psychiatry should be assimilated into neurology, as the case for a biological basis for mental illness is well proved. Torrey’s assembly of state by state numbers of inpatient beds and their reduction makes striking reading. Matched to figures for homelessness and correctional incarceration the argument that deinstitutionalisation is the root cause of these ills appears compelling. If mental illness were indeed as treatable as heart disease the case for reopening hospital beds would be impressive. However the case for a purely biological model of mental illness, and for more coercive intervention requires closer examination.

Within the book there is an assumption that the level of hospitalisation seen in 1954 can be used as a default against which to measure the adequacy of current service provision. However, Torrey himself acknowledges that the institutions of the 20th century became overcrowded centres of custodial containment that offered little therapeutic benefit to the majority of their patients. There is a not uncommon public perception, shared by many health professionals, that the current problems of community care can be viewed against a backdrop of a more humane era in which societies understood and met their responsibilities to the mentally ill. However, this is a rather naïve reading of the history of mental health care, and hardly an adequate basis on which to develop contemporary mental health services.

Several times Torrey makes the point that the effect of sensationalist media reporting of incidents of violence linked to mental illness is that the public loses trust in psychiatric professionals. However although he recognises that the link between mental illness and violence is often overstated, he emphasises that ‘there is an association between acts of violence and mental illness’ (original emphasis, p. 57), apparently accepting that the degree of known risk justifies both acknowledgement of that risk, and its overstatement in various forms of media. This is a frequently used and rather simplistic treatment of media portrayal of risk, and it is disappointing that this aspect of mental health care is not subjected to more critical treatment. However there is an important message in this book that health professionals have an obligation to understand and respond effectively to risk, a message that is sometimes lost in health professionals’ attempts to reduce the stigma associated with mental illness.

An issue never resolved in the book is that of the contribution of substance abuse to acute psychosis and violence and to the reduced effectiveness of community care. Torrey defines the focus of the book as ‘severe mental illness’. He excludes substance abuse from that definition although acknowledges that drugs such as alcohol, marijuana, cocaine and PCP make a major contribution to mental illness. However substance abuse, especially its endemic forms in major cities, is an uncomfortable fit within any biological theory of mental illness.

While there might be room for argument about the conceptualisation of mental illness and the appropriate degree of paternalism in mental health care, there can be little argument that the byzantine structures of funding for mental health services in the United States have a large role to play in the fragmentation of services and the uneven provision of services within and between states. Torrey reviews the cost shifting made possible by moving patients from hospitals provided and funded by states, to services, such as general hospital beds provided by the states but funded from federal grants. It seems that in many states more energy has gone into channeling patients into the service that makes the least demand on state resources, regardless of whether this serves the interests of the patient. Similarly, the splitting of responsibility for provision of income support from provision of treatment creates a perverse incentive to continue payments without incurring the costs of providing treatment. This means that income support payments are made but without any attempt to encourage the recipient into treatment. There are other mechanisms which militate against involvement in treatment by rewarding organisations which prevent people from receiving services The solution of single responsibility seems eminently sensible, and Torrey suggests that it would lead to the development of practicable alternatives to hospitalisation. However single responsibility funding seems unlikely to be achieved given its political implications.

In his dismissal of social models of mental health and illness Torrey is at odds not only with advocates of greater autonomy for people with mental illness, but with medical colleagues and researchers who recognise the social basis of many illnesses with a more legitimate claim to biological causes than mental illnesses. Diabetes, heart disease, HIV/AIDS and some forms of cancer come to mind as ‘biological’ illnesses which are responsive to social interventions. Psychiatry has long sought to establish its legitimacy by demonstrating that it too is a branch of medicine that investigates real diseases that respond to medical treatments, and Out of the Shadows can be seen as part of that tradition. Ironically, this denies psychiatry’s enormous contribution to health care made by embracing the social model of community mental health care.

The book is liberally illustrated with examples designed to support the major arguments of each chapter. The ready availability of such a stream of case studies illustrates the ubiquity of the issues raised, if not the correctness of Torrey’s explanation for them. At every turn there is another homeless person, jail inmate, abuse victim or violent offender whose plight can be sheeted home to deinstitutionalisation or an insufficiently assertive approach to care and treatment.

Out of the Shadows is motivated by concern for the plight of the mentally ill. Reading it, I sense the impatience of someone who feels constrained to stand by while those who might benefit from his clinical skills and ethical commitment unwisely choose to decline that help. Adding to Torrey’s frustration is that, in his view, professionals who should know better adopt a liberal view of the human rights of the mentally ill which supports those mistaken choices. But the cause of the mentally ill will not be advanced by the blind assertion of an ideological position of either a biological or social basis for mental illness. Much of the history of mental health care is a history of disappointed idealism and resigned coercion. While the beneficent intent of a more assertive mental health regime can be acknowledged, even lauded, the danger is that it may pander to public and professional prejudice. The result could be that an admirable intent may disguise a state-sponsored encroachment of liberties that would not be tolerated in any other group of citizens.


© 2003 Tony O’Brien


Tony O’Brien, Senior Lecturer, School of Nursing, University Auckland, New Zealand.


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