E. Fuller Torrey has been a tireless advocate for the proper treatment of mental illness; so much so that he has become something of a hate figure for those who object to the concept of involuntary treatment. In his latest book Torrey singles out the ideological intrusion of the US federal government into the business of providing mental health care as being primarily responsible for the desperate state that many people with serious mental illness find themselves in today.

Rosemary Kennedy’s psychosis and the terrible outcome of the lobotomy inflicted on her by Walter Freeman in 1941 is regarded by Torrey as a crucial ingredient in the garnering of the necessary political support that allowed a swathe of federally funded community mental health centres to be established at the same time as state run psychiatric hospitals were starting to close. The National Institute for Mental Health was established in 1946 and its first director, Robert Felix, drove forward an ambitious programme based on the idea that mental illness could be prevented by early attention to psychosocial factors. Torrey argues that the closure of psychiatric hospitals had, in fact, little to do with the new federally funded community mental health services as these had little interest in caring for people with serious mental illnesses:

For Torrey, ‘deinstitutionalisation per se was not the mistake. The mistake, rather, was our failure to provide continuing treatment and rehabilitation for these individuals once they left the hospitals’. He provides numerous anecdotes, expert opinions and research evidence, detailing the desperate boarding houses and nursing homes that many were discharged to, as well as the growth in homelessness, victimisation and imprisonment in this population. The picture Torrey paints seems to me to be too negative, giving too much weight to worst case scenarios. The parade of examples of homicides by mentally ill people is attention grabbing but it is stretching the truth to suggest that all of these could have been prevented if appropriate treatment had been made available to them.

Torrey proposes a number of solutions, including quadrupling bed numbers from the current low level in the US of 14 per 100 000; more compulsory treatment in the community; greater continuity of care; better rehabilitation services; robust independent inspection of services for the mentally ill; abandoning the support of for-profit services; sharing of information between agencies; and strong leadership. Torrey would like to see ‘mental health centres’ being rebranded as ‘mental illness centres’ as part of a process of shifting resources back towards the most severely mentally ill. More radically, he suggests that the justice department could formally take over as the provider of mental health services and that disability payments should be tied to treatment compliance.

This is a fascinating behind the scenes look at the historical evolution of community mental health care in the United States. Some of it, such as the conflicts of interest between the states and the federal government is particular to the United States, but much of it is more generally relevant. From an Irish perspective, it is interesting to reflect on our own shift towards the provision of mental health services to a widening community, and whether this has been to the detriment of those who were served by the old hospital system. It seems to me that we have done better in providing services for those who were or would have been institutionalised but Torrey certainly provides plenty of food for thought as we continue along this path. This is an impassioned, intelligent but at times, overzealous book that argues for the reprioritisation of mental health services towards the needs of those with the most severe mental illnesses.