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The Insanity Offense: How America’s Failure to Treat the Seriously Mentally Ill Endangers Its Citizens
Reviewed by PAUL S. APPELBAUM
Am J Psychiatry 2008;165:1493-1494. doi:10.1176/appi.ajp.2008.08060938
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by E. Fuller Torrey. New York, W.W. Norton, 2008, 288 pp., $24.95.

Since 1980, psychiatrist E. Fuller Torrey has been collecting newspaper clippings of stories about violent acts committed by persons with mental illnesses. The collection now occupies several file drawers, and many of the choicest items are reproduced in this, his latest book decrying the sad fate of persons with severe mental illnesses in America today. They are recruited here to support an argument that he considers self-evident: “The public now perceives mentally ill persons to be more violent because they are more violent” (p. 165). Torrey considers this violence the most obvious symptom of the “disaster” that constitutes the current treatment system.

Torrey and the advocacy organization that he leads, the Treatment Advocacy Center, have adopted a strategy of trying to propel change in our admittedly inadequate mental health system by emphasizing the potential for violence from people with mental illnesses. This strategy, along with the center’s favored remedy of broadening the scope of inpatient commitment and adopting outpatient commitment statutes, has made him a polarizing figure in the mental health realm. Unfortunately, this book will do little to calm the concerns of his critics.

Along with the blizzard of anecdotes that Torrey cites to make his case that people with severe mental illnesses are disproportionately violent, he presents an idiosyncratic summary of the literature on violence and mental illness. Based on studies of homicides occurring 23 and 31 years ago in two counties and a 1994 survey of 33 counties, Torrey concludes that “a conservative estimate…suggests that seriously mentally ill individuals are responsible for at least 5 percent of homicides in the United States” (p. 146). A few pages later, this “estimate” morphs into the conclusion that “it is clear that severely mentally ill individuals are responsible, by conservative estimates, for at least 5 percent of all homicides in the U.S.” (p. 166). Not only has a guess based on inadequate data become a “clear” finding, but Torrey’s own speculation has been transformed into multiple concurring estimates (note the use of the plural form).

Another example of the dubious use of data in this book comes in the claim that the most important finding of the MacArthur Violence Risk Assessment Study was that “treatment had reduced violent behavior [in the study sample] by half” (p. 174). Indeed, Torrey has been making this claim for a decade now. However (I speak as one of the authors of the study), no such conclusion can be drawn, given that subjects were not randomly assigned to treatment or no treatment; thus, it is equally plausible that those patients who did not follow up with treatment were a group more inclined toward violence to begin with. However one reads the data, the study is decidedly not “one of the clearest demonstrations to date that treating severely mentally ill individuals leads to a dramatic decrease in violence” (p. 174).

Notwithstanding Torrey’s odd uses of data—for other examples could be cited—there is no question that he correctly identifies many of the flaws in how psychiatric illnesses are dealt with today. It is, in fact, too difficult to hospitalize many patients in need of treatment, and the competition for the limited number of beds all but ensures that they will be discharged prematurely. The outpatient services to which they will be referred are underresourced, and all too often patients lack access to assertive community treatment, rehabilitation and vocational programs, housing, and other critical components of support. As a sad consequence, the correctional system has become the major locus of public mental health services in the United States.

What, then, is the problem with Torrey’s strategy of using tales of violence as a lever for change? First, of course, is the stigmatization of persons with mental illnesses, which Torrey at times decries but which this book will promote. Creating a needless sense of panic about the man or woman with schizophrenia down the street will hardly aid his or her integration into the community, nor is it likely to motivate many taxpayers to spend money on anything other than mechanisms to keep the mentally ill away from them. Indeed, most states that have embraced the Treatment Advocacy Center’s favored approach of outpatient commitment have failed to provide any additional funding to cover the costs of care—with the predictable result that such statutes are largely ignored in most jurisdictions. Moreover, Torrey may be promising the one outcome that even a superbly funded mental health system cannot provide: the prevention of random acts of violence by persons with mental illnesses (or anyone else).

There is one piece of information about violence and mental illnesses that readers will not find anywhere in the book but would do well to keep in mind: the best estimate we have (albeit from the 1980s) of the proportion of violence in the United States accounted for by mental illnesses is 3%–5% (estimates from abroad are even smaller). Hence, even if a majority of such acts could be prevented, which is uncertain, the incremental gain in societal safety would be small. There are many reasons to fix our pathetic shell of a mental health system. Unfortunately, the author of The Insanity Offense is preoccupied with the wrong one.

+Book review accepted for publication July 2008 (doi: 10.1176/appi.ajp.2008.08060938).

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