Care, Treatment, and Liberty

Morse is certainly correct, however, to worry about the potentially repressive consequences of allowing people to be confined "for their own good." As Conolly's remarks on the Nottidge case demonstrate,^[87] the range of behaviors that might render one subject to such intervention (in the eyes of at least some psychiatrists) has in the past been extraor-

[81] For a defense of medicihe's claims, see, generally, John Wing, Reasoning About Madness (London: Oxford University Press, 1978); for alternative views, see David Ingleby, "Mental Health and Social Order," in Social Control and the State: Historical and Comparative Essays, ed. Stanley Cohen and Andrew Scull (Oxford: Basil Blackwell; New York: St. Martin's Press, 1981), 141–88; David Morgan, "Explaining Mental Illness," European Journal of Sociology 15 (1975): 262–80; and Peter Sedgwick, "Mental Illness Is Illness," Salmagundi 20 (1972): 196–222.

[82] S. Pfohl, Predicting Dangerousness (Lexington, Mass.: Heath, 1978), 230.

[83] This, incidentally, is also the conclusion Pfohl reaches (ibid., 228–30), and Morse himself agrees that involuntary commitment decisions could be taken on grounds independent of "the vagaries, unreliability, and internecine disputes of mental health science" (Morse, "Preference for Liberty," 84 n. 12).

[84] Morse, "Preference for Liberty," 81 (emphasis added).

[85] Warren, Court of Last Resort, 5.

[86] Ibid., 202.

[87] See pages 284–85.

dinarily wide: adolescent rebelliousness, harmless eccentricity, violation of conventional standards of morality or of sexual propriety, extreme carelessness with one's money or property.^[88] It is this extravagance, I suspect, that has prompted the claim that "psychiatric opinions are essentially political judgments."^[89] Yet the fact that "benevolent" concern for the welfare of others has served to legitimize egregious violations of some people's freedom does not invalidate the claim that there are occasions when we may indeed be justified in intervening in others' lives "for their own good."

It may be objected, however, that mental hospitals "rarely cure, nor do they decrease the stigma."^[90] Worse, "even in 'advanced' states that supposedly maintain the best services" all too often one encounters "revelations of . . . inadequate and sometimes inhumane care and treatment."^[91] Again, there is a good deal of truth to both claims, though once more I shall suggest that this does not compel us to embrace Morse's chosen alternative of abolishing involuntary confinement.

The critique of the mental hospital's structural deficiencies has a very long history.^[92] In the late nineteenth century, for example, neurologists—then in the process of constituting themselves as a medical specialty—provoked a bitter internecine conflict with institutional psychiatry by urging the asylum's total unsuitability for the treatment of mental disorders.^[93] A long series of exposés by muckraking journalists provided further ammunition for the mental hospital's critics.^[94] And, most notably of all, a mass of social scientific research in the 1950s and 1960s was devoted to the elaborate documentation of the irredeemable deficiencies of what Erving Goffman dubbed "total institutions."^[95]

[88] For recent examples, see Ronald Leifer, In the Name of Mental Health: Social Functions of Psychiatry (New York: Aronson, 1969); Bruce Ennis and Eugene Litwack, "Psychiatry and the Presumption of Expertise," California Law Review 69 (1974): 693–753.

[89] Pfohl, Predicting Dangerousness, 229.

[90] Morse, "Preference for Liberty," 89.

[91] Ibid., 92.

[92] See Andrew Scull, Decarceration: Community Treatment and the Deviant—A Radical View, 2d ed. (Oxford: Polity Press; New Brunswick, N.J.: Rutgers University Press, 1984), 105–33.

[93] See Bonnie Blustein, "A 'Hollow Square of Psychological Science': American Neurologists and Psychiatrists in Conflict," in Madhouses, Mad-Doctors and Madmen, ed. Scull, 241–70; Andrew Scull, "The Social History of Psychiatry in the Victorian Era," in ibid., 17–20.

[94] The most famous of this genre is Albert Deutsch's The Shame of the States (1948; New York: Arno, 1973); for a more up-to-date example, see Wendell Rawls, Cold Storage (New York: Simon and Schuster, 1980).

[95] Goffman, Asylums, 4. See also R. Barton, Institutional Neurosis, 2d ed. (Bristol: Wright, 1965); Ivan Belknap, Human Problems of a State Mental Hospital (New York: McGraw-Hill, 1956); A. H. Stanton and M. S. Schwartz, The Mental Hospital: A Study of lnstitutional Participation in Psychiatric Illness and Treatment (New York: Basic Books, 1954); Robert Perrucci, Circle of Madness: On Being Insane and lnstitutionalized in America (Englewood Cliffs, N.J.: Prentice-Hall, 1974).

Such apparently objective findings have been widely disseminated, serving as one of the major ideological supports for the movement to deinstitutionalize the mental hospital population.^[96] In the process, mental hospitals have been stigmatized as inevitably providing a disabling, counterproductive environment, one that exacerbates any preexisting pathology through an "organizational tyranny [calculated to produce] the thwarting of human possibilities."^[97] Unquestionably, the historical record demonstrates that most mental hospitals have more closely resembled warehouses for the storage of the unwanted than institutions providing treatment and cures.^[98] But this is a far cry from the more extravagant claims made by Goffman and his epigones. It is these more extreme "findings" that Morse and others rely on when they urge us to abolish involuntary hospitalization altogether; and yet the research purporting to document these effects is so methodologically flawed and empirically inadequate^[99] that one must seriously question the wisdom of depending on it.

Of at least equal significance in the present context, those social scientists who have criticized the mental hospital have almost entirely neglected to consider what the alternatives to it are, preferring to make the bland (and untested) assumption that "the worst home is better than the best mental hospital."^[100] In practice, this has proved to be a tragically mistaken belief. A growing volume of research^[101] has demonstrated that community "care" for the chronically crazy is in fact community neglect

[96] See Andrew Scull, "The Decarceration of the Mentally Ill: A Critical View," Politics and Society 6 (1976): 173–212; see also Stephen Rose, "Deciphering Deinstitutionalization: Complexities in Policy and Program Analysis," Milbank Memorial Fund Quarterly 57 (1979): 429–60.

[97] Nicholas Perry, "The Two Cultures and the Total Institution," British Journal of Sociology 25 (1974): 353.

[98] Gerald Grob, Mental Illness and American Society, 1875–1940 (Princeton: Princeton University Press, 1983); David Rothman, The Discovery of the Asylum: Social Order and Disorder in the New Republic (Boston: Little, Brown, 1971); idem, Conscience and Convenience: The Asylum and Its Alternatives in Progressive America (Boston: Little, Brown, 1980); Gerald Grob, Mental Institutions in America: Social Policy to 1875 (New York: Free Press, 1973); John Walton, "The Treatment of Pauper Lunatics in Victorian England: The Case of Lancaster Asylum, 1816–1870," in Madhouses, Mad-Doctors and Madmen, ed. Scull, 166–97; Nancy Tomes, "A Generous Confidence: Thomas Story Kirkbride's Philosophy of Asylum Construction and Management," in ibid., 121–43.

[99] See Craig McEwen, "Continuities in the Study of Total and Non-Total Institutions," Annual Review of Sociology 6 (1980): 147–48; and Chapter 13 below.

[100] Elaine Cumming and John Cumming, Closed Ranks: An Experiment in Mental Health Education (Cambridge: Harvard University Press, 1957).

[101] A. Davis, S. Dinitz, and B. Pasamanick, Schizophrenics in the New Custodial Community (Columbus: Ohio State University Press, 1974); General Accounting Office, The Mentally Ill in the Community: Government Needs to Do More (Washington, D.C.: Government Printing Office, 1977); Senate Special Committee on Aging, Subcommittee on Long-Term Care, 94th Cong., 2d sess., 1976, Nursing Home Care in the United States: Failure in Public Policy, Support Paper no. 7, The Role of Nursing Homes in Caring for Discharged Mental Patients, 1976, Committee Print; Robert Emerson, E. B. Rochford, and Linda Shaw, "Economics and Enterprise in Board and Care Homes for the Mentally Ill," American Behavioral Scientist 24 (1981):771–85; S. Kirk and M. Thierren, "Community Mental Health Myths and the Fate of Former Hospitalized Patients," Psychiatry 38 (1975): 209–17; Rose, "Deciphering Deinstitutionalization"; Scull, Decarceration; idem, "A New Trade in Lunacy: The Recommodification of the Mental Patient," American Behavioral Scientist 24 (1981): 741–54; idem, "Deinstitutionalization and the Rights of the Deviant," Journal of Social Issues 37 (1981): 6–20; Julian Wolpert and Eileen Wolpert, "The Relocation of Released Mental Patients into Residential Communities," Policy Sciences 7 (1976): 31–51.

and that "the effective meaning of liberty for the involuntarily committed is social marginality, deprivation, and despair."^[102] So far from being the grand reform of mental health care its ideologues have proclaimed, the practical implementation of community treatment has created "a system which, daily and quietly, harms and kills the sick."^[103]

At least Morse recognizes that the problem exists: "The condition of many 'deinstitutionalized' ex-patients in the community is a national disgrace."^[104] But he immediately seeks to evade its implications:

One should not compare the all-too-questionable benefits of hospitalization to complete or near-complete neglect in the community. The only fair comparison is to community living and treatment where society meets its moral obligations rather than cynically avoiding them.^[105]

I find this an astonishing claim. Such a comparison is "fair" only in the sense that it supports the argument Morse is advancing—but at the unacceptable price of leaving behind the social realities we must confront. Discharged mental patients do not live in a society that "meets its moral obligations." The alternatives they (and we) must face are inadequate and underfunded mental hospitals or a grossly underdeveloped and often nonexistent system of community care. Here the choices are tougher and the answers less clear-cut than those Morse provides us with; but they have the distinct merit of being the real ones. And when we confront them, I think we must conclude, as Warren does, that for a substantial proportion of the chronically crazy,

[102] Warren, Court of Last Resort, 203.

[103] Sedgwick, Psychopolitics, 229–30.

[104] Morse, "Preference for Liberty," 95.

[105] Ibid., l00. In parallel fashion, Morse insists on comparing the reality of a psychiatric commitment process (focusing especially on the most egregious misuses of "expertise") with a wholly idealized portrait of the law as a routinely adversarial system offering clear-cut and uncompromising protections of individual rights. That our legal system bears only the most superficial resemblance to his picture of it seems to discomfort him not one whit. But those who come before the courts populate the real world, and not this theoretical heaven. One must compare reality with reality, not with some pretty fantasy that better suits the case one wants to make.

care in a profit-making institution at a cost of $14.50 a day seems more treacherous and less human than care in a state institution at $31 a day. And the confines of the state hospital, for the dispossessed, seem to threaten effective liberty less vitally than the sidewalks, streets, and cheap hotels of the completely homeless.^[106]

To suggest that the mental hospital is sometimes a defensible—indeed preferable—solution to the problems posed by mental disorder, and to argue that compulsory commitment is also an option we should retain, is not to deny the need to place a sharp check on psychiatric enthusiasms, since these are no less capable of leading us astray. Indeed, when we debate the merits and demerits of compulsory commitment, we ought constantly to bear in mind that "the real scandal of contemporary public psychiatry is not the particular section of the mental-health statutes under which patients get into hospitals, but the alternatives offered to these supremely weak members of society by our present social arrangements both inside and outside the mental institution."^[107]

[106] Warren, Court of Last Resort, 207. See also J. Rubin, Economics, Mental Health, and the Law (Lexington, Mass.: Heath, 1978); J. F. Borus, "Deinstitutionalization of the Chronically Mentally Ill," New England Journal of Medicine 305 (1981): 339–42.

[107] Sedgwick, Psychopolitics, 180.