Mad, homeless, and unwanted. A history of the care of the chronic mentally ill in America.

The history of the care and treatment of the mentally ill in America for nearly four centuries offers a sobering example of a cyclical pattern that alternated between enthusiastic optimism and fatalistic pessimism. In the nineteenth century an affinity for institutional solutions led to the creation of the mental hospital, an institution designed to promote recovery and to enable the individual to return to the community. No institution ever lives up to the claims of its promoters, and the mental hospital was no exception. Plagued by a variety of problems, its reputation and image were slowly tarnished. When it became clear that hospitals were caring for large numbers of chronic patients, the stage was set for an attack on its legitimacy after World War II. Its detractors insisted that a community-based policy could succeed where an institutional policy had failed, and that it was possible to identify mental illnesses in the early stages, at which time treatment would prevent the advent of chronicity. Between the 1940s and 1960s, there was a sustained attack on institutional care that finally succeeded when Congress enacted and the president signed a piece of legislation that shifted the locus of care and treatment back to the community. The community mental health policy proved no less problematic than its institutional predecessor. Indeed, the emergence of a new group of young chronic mentally ill persons in the 1970s and 1980s created entirely new problems, for the individuals who constituted this group proved difficult to treat and to care for under any circumstances. Each of these stages was marked by unrealistic expectations and rhetorical claims that had little basis in fact. In their quest to build public support and legitimate their cherished policy, psychiatric activists invariably insisted that they possessed the means to prevent and to cure severe mental disorders. When such expectations proved unrealistic, they placed the blame either upon callous governments, an uninformed public, or an obsolete system that failed to incorporate the findings of medical science. If American society is to deal effectively, compassionately, and humanely with the seriously mentally ill, several elements must be taken into account. First, the seriously mentally ill include individuals with quite different disorders, prognoses, and needs. Secondly, outcomes vary considerably over time. Some schizophrenics, for example, have reasonably good outcomes; others lapse into chronicity and become progressively more disabled. Finally, serious mental disorders are often exacerbated by poverty, racism, and substance abuse. Although psychiatric therapies can alleviate symptoms and permit individuals to live in the community, there is no "magic bullet" that will cure all cases of serious mental illnesses in the same way that antibiotic drugs are effective against acute infectious diseases.(ABSTRACT TRUNCATED AT 400 WORDS)