The Insanity Offense: How America's Failure to Treat the Seriously Mentally Ill Endangers Its Citizens

Psychiatrist E. Fuller Torrey, President of the Treatment Advocacy Center, has authored more than 200 articles and 20 books. His latest book, The Insanity Offense: How America's Failure to Treat the Seriously Mentally Ill Endangers Its Citizens, explores how upholding the civil liberties of people with mental illness often comes at great cost to individuals and society. Torrey expands on psychiatrist Darold Treffert's idea of “dying with one's rights on” and outlines “the consequences of unconstrained civil liberties,” including victimization of the mentally ill, homelessness, incarceration, and violence. He also offers a four-step plan for “fixing the system.”

According to Torrey, deinstitutionalization and restrictive mental health laws have resulted in negative consequences. He asserts that about one-third of the homeless population and at least 10 percent of incarcerated individuals are mentally ill. He argues that untreated and under-treated individuals with psychiatric disorders are at an increased risk of victimization. In addition, he states that “unconstrained civil liberties” can lead to violence against society by the mentally ill. This premise is the main thrust of his book.

The first few chapters of The Insanity Offense provide abundant examples of mentally ill individuals who committed violent acts after being provided with inadequate treatment or after refusing treatment. For instance, in Chapter 3, Torrey recounts the story of 25-year-old Herb Mullin, who was diagnosed with schizophrenia at the age of 22. He was hospitalized several times, lacked insight into his illness, and was inconsistent in complying with his medication. His family encountered legal barriers when they tried to access treatment for him. In 1972, Mullin received “telepathic” communications that compelled him to believe that he could prevent an earthquake by sacrificing humans. Consequently, he killed 13 people. Torrey uses this vivid example, and others, to support his assertions and to engage the reader.

In Chapter 9, Torrey introduces methods and research involving measuring violent behavior in persons with mental illness. He summarizes salient research in Appendices A and B and concludes that it is reasonable to predict that, each year, 5 to 10 percent of individuals with severe psychiatric disorders will commit acts of serious violence.

Torrey details important changes in mental health laws and practices in Chapter 10. For example, California's Community Mental Health Services Act (1969), also known as the Lanterman-Petris-Short Act (LPS), made imminent dangerousness the sole criterion by which persons with psychiatric illness could be hospitalized for greater than 17 days. Also, the deinstitutionalization movement limited psychiatric hospital bed availability for people like Mr. Mullin. In addition, Wisconsin's Lessard v. Schmidt decision, 349 F.Supp. 1078 (E.D. Wis. 1972), established a strict dangerousness standard for involuntary commitment and lessened the government's responsibility to care for and protect those who cannot care for themselves. LPS, Lessard, and deinstitutionalization, explains Torrey, had a major impact on mental health laws in the rest of the nation and made it difficult to provide involuntary treatment for mentally ill individuals.

Also, in Chapter 10, Torrey attempts to persuade readers that “An Imperative for Change” exists. Some of his points, such as protecting those afflicted with mental illness and protecting the public, flow very naturally from the plethora of examples provided throughout the text. I found the section on “Resistance to Dealing with the Problem” to be the most thought-provoking portion of this chapter. Torrey states that among mental health professionals, “it is politically incorrect to acknowledge publicly that mentally ill persons may be dangerous.” This section suggests that mental health workers and advocates may minimize the risk of violence in well-intentioned efforts to decrease stigma. He advocates that education of professionals about violence among the mentally ill is necessary before changes in clinical practice and laws can take place.

Torrey provides a four-part plan for “Fixing the System” in Chapter 11: modification of the laws, identification of the target population, provision and enforcement of treatment, and assessment and research. He clearly elaborates each part of the plan and provides specific examples of success. He ends the chapter by asserting his belief that we have the means to make these changes. The real question is whether we have the will to do so.

I have only a few criticisms of The Insanity Offense. First, there is a repetitive quality to the content. For example, although Chapters 8 and 9 are specifically dedicated to the consequences of unconstrained civil liberties, descriptive outcomes are present throughout the text. The redundancy detracts from the overall organization of the book. Second, the text is teeming with examples of extreme violence that have the unintended effect of minimizing the other costs of nontreatment of persons with mentally illness (e.g., homelessness, victimization). Finally, and most important, Torrey's argument would ultimately be more potent if he had addressed the counter-argument more thoroughly. He weakened his position by virtually ignoring the harm done when individuals with mental illness are denied civil rights.

This book will interest readers who share Torrey's dismay about the present state of mental health care. It will resonate with mental health professionals who work with the subset of severely mentally ill individuals who are violent. I hope, however, that this book will reach an audience beyond those in the mental health field so that the general public and lawmakers can gain an appreciation of the dangers of unconstrained civil liberties.

• American Academy of Psychiatry and the Law