Madness in the Streets.

THESE TWO BOOKS, along with E. Fuller Torrey's Nowhere to Go, offer a history of the deinstitutionalization" of mental patients during the 1970s and 1980s. Of the three, Rael Jean Isaac and Virginia Armat's Madness in the Streets is incomparably the best.

Torrey's book, published last year, outlined how, under President John Kennedy, "community mental-health centers" were conjured up as a replacement for the old state mental hospitals, which had been branded as "snake pits"-and which were resented by the state governments because of their high costs.

Encouraged by the development of therapeutic drugs in the 1960s, the Federal Government began a policy of emptying the back wards. The most effective tool was the decision that the new Medicaid program would only reimburse treatment in "community centers," not in state hospitals.

But the community centers never materialized in large numbers. When they did, their staffs expressed much more interest in treating the "worried well" than in housing the chronically insane. As a result, tens of thousands of former patients fell through the cracks and onto the streets. That is the story as told both by Torrey and by Ann Braden Johnson.

Rael Jean Isaac and Virginia Armt, however, lift the explanation to a whole new dimension. The real story of the last two decades, they argue, is not just that we have emptied the mental hospitals. The tens of thousands of former patients who have become "homeless" are only the tip of the iceberg. The real story is that we are no longer treating mental illness in this country. In fact one might even say it is now illegal to treat mental illness. Over the last two decades, the practice of psychiatry has been virtually eviscerated by another profession-civil-libertarian law. As the saying goes, the lawyers are "trying to treat the insane with the wrong graduate degree."

As Madness in the Streets carefully documents, there have really been two "deinstitutionalizations." The first-described accurately in Nowhere to Go and Out of Bedlam-involved long-term patients, mostly the senile elderly. These people were relocated in nursing and boarding homes (which quickly led to the nursing-home scandals of the early 1970s).

But that was only the beginning. With the 1970s came a completely different movement-"anti-psychiatry," born out of the writings of Thomas Szasz (The Myth of Mental Illness) and R. D. Laing (The Divided Self).

With the aid of civil-liberties attorneys, anti-psychiatry attacked the entire premise that mental illness is a disease that should be treated by trained professionals. Instead, the mental patient has become another victim of oppression." Rather than suffering from pathological conditions that have been observed in every culture at all times throughout history, the mentally ill have suddenly become unwilling individuals who have only been "labeled" mentally ill by others. Their symptoms, rather than being clearly definable brain malfunctions, have become the effect of this "labeling"-plus the ordeal of having been kept in hospitals or treated by psychiatrists.

Mental patients were "prisoners of psychiatry." Their bizarre and incomprehensible thought patterns were only another constitutionally protected form of "free speech." As Madness in the Streets bluntly puts it, there is now a "right to be crazy." With astonishing ease, mental illness moved from being a clinical condition to being just another form of "victimization" in leftwing ideology.

By the early 1970s, angry ex-patients were picketing meetings of psychiatric associations, hallooing, "We're not crazy." As usual, the courts listened, and soon the entire mental health system was dominated by legal proceedings. In most states, it now takes a full court hearing before a psychiatrist can prescribe basic therapeutic medicine. Mental-health clinics regularly take in troubled, obsessive, even violent people, board them for a few days, then turn them out, "cured" of all their "dangerous tendencies." Parents, siblings, and spouses-who are often being threatened and terrorized by these people-are left to cope with the problem. Not surprisingly, there have been many murders-both deranged people killing parents and spouses, and parents and spouses killing them.

Meanwhile, the old state hospitals have retreated behind a wall of bureaucratic indifference. Perfectly fulfilling Parkinson's Law, they have managed to increase their staff and budgets even while losing 80 per cent of their patients. Hemmed in by procedural rules and liability lawsuits, they want the funds without the bothersome burden of treating patients. As the saying in the profession goes, "It is easier to get admitted to an exclusive Ivy League university than it is to get into a state mental hospital."

Upon closer examination, of course, the concern of the civil libertarians for their new wards turns out to be the usual Machiavellian piety. One despairing mother of a "liberated" patient, in making an incognito visit to a civil-libertarian support group, heard the lawyers talk about a case that had been "successfully resolved" when a depressed young woman committed suicide. The "success" was that she avoided commitment to a state hospital.

In addition to learning the law, the patient liberationists have picked up all the civil-libertarian tricks for extracting subsidies from Washington. Even while advancing the myth of mental illness, mental-patient liberationists regularly collect millions of dollars in federal funds for "protection and advocacy" groups-plus another $6.5 billion in fiercely defended "mental-disability" benefits paid annually by Social Security Insurance.

What Rael Jean Isaac and Virginia Armat do not explore is the way in which the ACLU, even while pushing the psychiatrists to the fringes of their own profession, has welcomed them into criminal procedures as allies in expanding the insanity defense. Even while upholding the argument that "mental illness is just a myth," the ACLU simultaneously supports hundreds of death-penalty appeals on the grounds that every little character defect and past trauma actually constitutes a full-fledged psychiatric condition ("post-traumatic stress syndrome") that excuses any and all forms of violence.

At least Thomas Szasz, the founder of anti-psychiatry, is consistent. He argues that the insanity defense should be abolished. The ACLU-as usual-has it both ways.

Ann Braden Johnson's book, Out of Bedlam, is interesting only insofar as Mrs. Johnson herself is part of the problem. A psychiatric social worker in New York, she is a former supporter of deinstitutionalization who has changed her mind-without necessarily admitting that anyone was wrong.

After reviewing the anti-psychiatry theories of Szasz and Laing, she concludes:

Unfortunately, the new ideas were only ideas about hospitals, custody, environments, care, and problems in living. Some of the ideas gave us brilliant insights into a phenomenon that had been too long neglected, and many of them were profoundly right and can never be ignored totally again. But ideas, however brilliant, profound, and morally correct, could not by themselves reshape the treatment facilities whose purpose and goal they had reframed and whose hidden agendas they had exposed. In our collective zeal to right the conceptual wrongs of hundreds of years, we forgot that theory and practice often diverge, and we forgot what chronic mental patients were like. [Emphasis in original.]

In psychiatry as in any other field, "Ideas have consequences." Where Mrs. Johnson is most interesting is in recounting anecdotes from the front. One story is priceless.

After one colleague left our hospital to become team leader at an in-patient unit at another state facility, he told me that he quickly learned that when all else failed, staff were expected to discharge patients to an address that turned out to be a vacant lot in a remote part of the city. One of the greatest advantages of this procedure was that the vacant lot was part of another state facility's catchment area," or area of accountability, so that discharged patients could be expected to wind up on someone else's back ward when, inevitably, they needed to be rehospitalized.

In Madness in the Streets, meanwhile, we have an explanation of why America itself has become such a crazy place in which to live. Next time you hear about some tormented soul who has machine-gunned seven people in McDonald's, or a person terrorized by a deranged family member, don't be puzzled by the thought that "the system isn't working." That's the way the system is designed to work.

On the other hand, if you want to chart a course for bringing some sanity back into American life, start by reading Madness in the Streets.