Nowhere to Go: The Tragic Odyssey of the Homeless Mentally Ill

by E. Fuller Torrey

Examines the plight of the homeless mentally ill, traces the history and policies of mental health organizations, and offers plans for improving services

Genres: Mental Health

272 pages, Paperback

First published January 1, 1988

Reviews

[Steven H · Rating 5 out of 5]

AN ALTERNATELY SAD, AND "ANGRY" ANALYSIS OF THE PLIGHT OF THESE PERSONS

Edwin Fuller Torrey (born 1937), is an American psychiatrist, who has written many books, such as Out of the Shadows: Confronting America's Mental Illness Crisis, Surviving Schizophrenia: A Manual for Families, Patients, and Providers, Surviving Manic Depression, etc. He wrote in the Preface to this 1988 book, "I thought of what Mike Gorman... had told me: 'No matter how bad it is for those people on the streets, it's better than it was in the hospital.' Are those really the only choices we have for individuals who cannot care for themselves---the brutality of the hospitals or the brutality of the streets? Is this the best we can do in the wealthiest nation in the world?...

"Writing this book has taken me on wild swings between anger and sadness. It has brought back memories ... of five years working at the National Institute of Mental Health when it was claimed that all things were possible. How could things have gone so wrong?... how can we explain our mistakes to the people who have paid such a terrible price for them?" (Pg. xiv)

He states in the first chapter, "'Broken promises' is in fact the motto of America's psychiatric establishment for the past forty years. The professionals promised to improve the lot of the seriously mentally ill, abused and neglected in the nation's asylums. Deinstitutionalization it would be called... So what happened? ... the seriously mentally ill were dumped out of the mental hospitals into communities with few facilities and little aftercare. And as soon as they were gone, the hospitals were closed down so that they could not return... It was as if a policy of resettlement had been agreed upon but only eviction took place." (Pg. 3-4)

He points out, "There appears to be no relationship between community mental health centers and community services for the mentally ill. In fact... community mental health centers have ignored the seriously mentally ill in favor of individuals with relatively minor problems. This is not only true of areas ... that are traditionally thought to provide deficient human services... It is even MORE true in urban areas where psychiatrists and psychologists are abundant and where one would expect services to be better." (Pg. 26)

He argues, "By the end of 1961 three axioms had been established that would profoundly influence services for the mentally ill: (1) psychiatric hospitals are bad and should be closed; (2) psychiatric treatment in the community is better because cases can be detected earlier and hospitalization thereby avoided; and (3) the prevention of mental diseases is the most important activity to which psychiatric professionals can aspire. From that point onward it was all downhill for the mentally ill; the debacle of deinstitutionalization and the tragedies that accompanied it became virtually inevitable." (Pg. 97)

He points out, "While increasing numbers of psychiatrists, psychologists, and psychiatric social workers were being trained with federal funds, state mental hospitals in the 1960s and '70s were finding it increasingly difficult to fill professional staff positions... The solution to this dilemma came from the United States Immigration Service, which ... supported legislation liberalizing American immigration laws. The new laws made it easier for professionals from other countries to come to the United States, and doctors were high on the list of the most desirable immigrants... State mental hospitals in the United States immediately seized upon foreign medical graduates as a means of filling the positions that American medical graduates were refusing to take." (Pg. 170-171)

He concludes with six points: "1. The seriously mentally ill must get first priority for public psychiatric services... 2. Psychiatric professionals must be expected to treat individuals with serious mental illnesses... 3. government responsibility for the seriously mentally ill must be fixed at the state or local level... 4. Housing for the seriously mentally ill must be improved in both quantity and quality... 5. Laws regarding the mentally ill must be amended to insure that those who need treatment can be treated... 6. Research on the causes, treatment, and rehabilitation of serious mental illnesses must increase substantially." (Pg. 206-212)

Although 35 years old, the information and ideas in this book are still of great relevance to anyone concerned with our treatment of mental illness, as well as the plight of the homeless.

[Scott Pearson · Rating 5 out of 5]

In psychiatry, “serious mental illness” is substitute language for bipolar disorder and schizophrenia. These two difficult diseases account for much of the homelessness that American cities see. Thus, these two diseases also account for much of where tax dollars go. The utterly tragic part, however, is that decent biomedical treatments exist for these diseases; in America, the infrastructure to treat them does not. Why? And what can be improved? This book, originally published in 1988 but readapted to 2025 in a second edition, attempts to answer those questions.

The author Dr. E. Fuller Torrey spent a lot of his career at the National Institute for Mental Health (NIMH), a part of the National Institutes of Health (NIH). Thus, he had a high-level view of America’s mental healthcare system. He’s spent most of his professional life advocating that serious mental illness receive a larger share of the mental healthcare financial pie. He does so not by tugging at one’s heart strings but rather by presenting overwhelming data that we’ve misappropriated governmental spending going back to JFK’s time.

We indeed can combat homelessness, he maintains, by building a better mental healthcare system that addresses these difficult, yet treatable, conditions. We might even be able to save money in the long run! Starting with Great Society reforms in the 1960s, attempts to create a mental healthcare system shut down state mental institutions. Most of those “freed” were unable to keep a steady job and simply entered the trap of homelessness. He argues that freedom from mental institutions without “freedom from psychosis” is a mirage.

Homelessness continues to tax urban infrastructures, but few politicians offer any real solutions other than sweeping them under the rug. To his credit, Torrey offers two handfuls of specific ways to improve our policy. He shows how mental health expenditures went to surface-level psychological topics instead of research to address the most difficult of problems.

Policy wonks and mental health workers will benefit the most from this work. Its offerings focus on systemic answers rather than individual ones. It offers a deep history of how we got here and why we got here. It also begs the question of when will we get the collective will to confront these problems. I’m concerned that the stigma of mental illness – still so pervasive – limits constructive conversations. If we’d only be able to fund treating serious mental illness as much as we fund other serious but common diseases, we might be able to build a better society and a more productive country.