From Asylum to Community: Mental Health Policy in Modern America.

The late twentieth-century crusade that created community mental health centers throughout the United States was a "radical policy innovation". Not only did the locus of mental health practice shift from the state mental hospital to the community and public authority move from the state to the federal government, but the crusade disrupted a unity of care and treatment that had been sacrosanct for more than a century and a half. Gerald N. Grob explains how Americans came to such a turnabout in the few short decades following the Second World War.

From Asylum to Community is Grob's last volume of a trilogy about public policy and the mentally ill. As he did in Mental Institutions in America: Social Policy to 1875 and Mental Illness in American Society, 1875-1940, Grob narrates the saga of the psychiatric profession, the interplay of personality, politics, and policy, and the evolution of the public mental hospital. Few others are as well-informed or as astute about the operations of American asylums, the thought of professional leaders, or the relationships between the pacesetters and the government.

As we have come to expect, Grob meticulously leads the reader through the developments that catapulted the country from institutionalization to deinstitutionalization in a surprisingly short time. Beginning with the experiences of the Second World War which shifted American attitudes about psychiatric practitioners, broadened the arena of psychiatric thought and practice, and widened the gap between the somaticists and the promoters of psychodynamic and psychoanalytic therapies, Grob moves on to describe the "bitter and acrimonious battle" that erupted in the American Psychiatric Association between somaticists and those oriented toward psychodynamic and psychoanalytic theories. State hospitals increasingly came under attack as outmoded, horrific warehouses for the hopelessly ill, further undermining the traditional approach to the care and treatment of the mentally ill. Meanwhile, other mental health practitioners such as clinical psychologists, psychiatric social workers, and psychiatric nurses encroached upon the hegemony of institutional psychiatry and on the broader profession itself.

Even as the individual, social, and environmental approach prevailed, advances in biomedical techniques emerged. Electroshock, insulin, and metrazol therapies, as well as the use of chlorpromazine and its derivatives, created a therapeutic environment that was no longer necessarily based in the hospital. Finally, a number of disparate groups, each with its own agenda, coalesced to shift the locus of policy-making for the mentally iII from the state to the federal government.

The most influential of these driving forces between the 1940s and the 1960s, according to Grob, were the catharsis provided by the war years and the shift in the seat of governmental authority in matters affecting the mentally ill. The climate of the war years was especially crucial because the need to mobilize quickly and effectively brought an uncommon reliance on the skills of psychiatrists to screen military draftees and to treat battle fatigue. The ability of the profession to respond in a timely fashion, work in the community, and promote early intervention as a preventative measure led to a rising prominence for psychiatry. Those psychiatrists who had come to favor psychodynamic and psychoanalytic theories, who had identified the social and environmental sources of neuroses, and who had illustrated their usefulness during the national crisis carried the day.

Equally important to American society's commitment to psychiatry was the impact of New Deal concepts writ large after the war. Riding on the optimism of their wartime successes, far-seeing leaders like Robert Felix (the first and long-tenured Director of the National Institute for Mental Health) recognized the power of the welfare state ideology. He consistently promoted community psychiatry and understood the role the federal government could play in solidifying the prominence of his profession. From the signing of the National Mental Health Act of 1946 (which established the NIMH) to the final product of the Joint Commission on Mental Illness and Health (appointed in 1955)--the Community Mental Health Centers Act of 1963--Felix prevailed. He and others cajoled, orchestrated, and parried multiple interest groups to shift control of the treatment of the mentally ill from the state hospital administrators to the new power brokers in the profession. It was a predictable outcome in a climate that believed psychiatrists had an obligation to address the major social and environmental issues of American society.

The Community Mental Health Centers Act of 1963 became the symbol for deinstitutionalization. No longer would the mentally ill suffer mere incarceration; they would have a right to treatment, and treatment in the least restrictive environment. As Grob so poignantly reports, however, "reality rarely corresponds with ideals sought"; too many of the severely mentally ill found the streets as home. Grob does not fall prey to the easy explanation. He examines the inability of the profession to handle the sheer numbers of mentally ill in the community, the federal funds that were less forthcoming than had been hoped, the lack of recognition of the real changes that had occurred within the state hospitals, and the impact of Medicare and Medicaid policies, among other factors.

The real tragedy for the mentally ill and the essence of the failure of the move from asylum to community has been the separation of care and treatment. As Grob laments, once again Americans had "dismissed out of hand the experiences of the past" and had "yet to define a mental health policy that integrated decent and humane care with access to medical services for severely and chronically mentally ill persons".

From Asylum to Community is less explicitly counter-revisionist than Mental Illness in American Society, but Grob remains consistent in his approach and in his analysis. He presents solid scholarship, he explodes the more flamboyant interpretations of the anti-psychiatry and social control theorists with large bodies of evidence, and he points the way to new scholarship. From Asylum to Community is an important study in its own right, but it also will set the parameters of scholarship for historians of modern American policy-making for the mentally ill for at least the next decade.

University of Vermont Constance M. McGovern