Classics of Community Psychiatry: Fifty Years of Public Mental Health Outside the Hospital

This is a fascinating and illuminating collection of writings that will be a nostalgic reminder of developments in the field for those who have devoted their careers to community psychiatry and a mine of valuable information for those who are just entering it. If the book has a flaw, it is merely that the title calls for the word “American” to be inserted. Of the 50 or so essays and articles, only three deal in depth with topics beyond the shores of the United States. One is Leighton's 1963 description of psychiatric disorder in West Africa; another is Wing's call to recognize the importance of asylum in psychiatry, using British examples; and the third is the account of Scheper-Hughes and Lovell of Franco Basaglia's role in the Italian Democratic Psychiatry reform movement, which began in the 1960s.

The topics in this volume of (primarily American) classic articles are wonderfully varied in their focus. Community psychiatrists struggle every day to deal with the effects of social policy on their work, learn how services can be delivered through different treatment and rehabilitation models, and discover, at some point, that underpinning their work is a set of values that often goes unrecognized and is seldom discussed. This book throws light on all of these areas.

The topic of American social policy in psychiatry is nicely covered in the opening essay by Miller et al. on the origins of the community mental health movement and by the recommendations in the 1961 report by the Joint Commission on Mental Illness and Health titled “Action for Mental Health.” A later essay by Davidson and Ridgeway details the effect of the community support movement in the 1970s and its demise, specifically the services implemented under the Carter Administration Community Support Program and the effects of the cuts under the Reagan Administration in Supplemental Security Income, housing benefits, and community services. The authors remark that capitation systems of government health funding and other forms of managed care for people with mental illness, in more recent years, have failed to improve service provision. The Davidson and Ridgeway essay and the 1976 article by Scull titled “Decarcerating the Mentally Ill” highlight the under-recognized fact that deinstitutionalization in the United States was not the direct consequence of the advent of new and effective antipsychotic medications but rather of a transfer of patients from state hospitals to nursing homes as state governments took advantage of new federal social welfare and health benefits to reduce the cost to the state of psychiatric hospital care.

The articles in this book present the origins of a number of treatment models that have been developed in the past five decades, for example, Fairweather et al.'s 1969 description of the Fairweather Lodge model, the 1975 article by Stein and Test on the effectiveness of their assertive community treatment model, and Mosher's development of a domestic-style environment for treating people in the early stages of a psychotic illness with minimal or no medication. Strangely absent, however, are classic articles dealing with the Clubhouse model of psychosocial rehabilitation, family psychoeducational approaches, and supported employment. While it may be true that seminal articles emerging from the Clubhouse movement have not been published, this would not be the case for the latter two great innovations in the community treatment of people with mental illness.

The values underpinning community psychiatry, which are seldom taught in residency training programs, are covered in this collection of articles. Bockoven's 1956 article takes us back, appropriately, to the principles of nonrestraint and normalization embodied in moral treatment and contrasts these with the horrid truth of the dehumanizing conditions of American psychiatric hospitals in the 1950s. Even today, it is valuable to draw upon the innovative principles of Tuke's York Retreat in designing inpatient care and alternative community approaches. The inclusion of first-person accounts is in itself a value statement encouraging us to listen closely to our patients' reflections on our attitudes and services. Outstanding among these accounts is an article by Leete, published in 1989, of her personal strategies for dealing with the symptoms of her illness—a classic essay predating the introduction of cognitive-behavioral therapy for psychosis that one can still present to patients and family members as a useful guide. And who could resist the dark humor of an article written by someone who underwent ECT in the early 1960s titled “Scrambled Eggs for Brains”? Moreover, who could stop reading the article by the medical anthropologist Estroff on homelessness and mental illness after the opening sentence, “In our very suspicious society, losing one's home, like losing one's mind, raises questions about cause, usually among those who have lost neither” (p. 306)?

In recent years, the recovery movement has refocused the attention of mental health professionals on important value questions. How much power should our patients have in determining their treatment? Should we encourage optimism about outcome from psychosis or adhere to our traditional preference for “realism”? Is mainstreaming always the right approach to the social inclusion of people with mental illness, or should we take a closer look at the mutual support to be found in subcommunities of people with psychiatric disabilities? In this volume, there are thoughts about these issues to be found in the contributions by Hopper, Mosher, Estroff, Scheper-Hughes, and many others. There is something to interest everyone in this fascinating collection.