Book Review

The Turning Point: How Men of Conscience Brought About Major Change in the Care of America's Mentally Ill

N Engl J Med 1994; 330:1546-1547May 26, 1994

Article

The Turning Point: How Men of Conscience Brought About Major Change in the Care of America's Mentally Ill
By Alex Sareyan. 309 pp., illustrated. Washington, D.C., American Psychiatric Press, 1993. $43.50. ISBN: 0-88048-560-4

This is a history of conscientious objectors during World War II, the vicissitudes of their experiences from 1940 to 1946, and their lasting effect on the American mental health system. The author was one of these conscientious objectors.

In September 1940 the Selective Training and Service Act was adopted, reopening the military draft. Options for alternative forms of service were extended to all men who, because of religious training and belief, could not in good conscience serve in the military. An extremist group of about 3000 refused to cooperate with the government in any manner. They received prison terms of up to five years. Noncombatant service with the troops was acceptable to other conscientious objectors. Several thousand more, who were willing to be conscripted only to perform “work of national importance” under civilian rule, were assigned to the Civilian Public Service. Approximately 12,000 conscientious objectors served in the Civilian Public Service programs during the war.

The 3 principal pacifist religious groups (the Mennonites, the Bretheren, and the Quakers), plus 200 other churches and pacifist groups, established the National Service Board for Religious Objectors to serve as a liaison with the federal government and offered to pay for the costs of administering the alternative service provided by their young men. Eventually, all agreed on an arrangement under which camps were to be financed and operated by the church organizations, with the programs subject to government direction. The first projects were mainly rural and routine.

Soon there was a demand for “more meaningful service.” At the same time, “severe disruptions in services to the nearly 600,000 persons confined in public mental hospitals and state schools for the retarded” were pointed out. In response, the first Mental Hospital Unit was established in June 1942, and by the time the last conscientious objectors had been demobilized (November 1946, 18 months after the end of the war), 65 mental hospitals and training schools had been served by over 3000 conscientious objectors and many of their wives, who volunteered specifically for the assignment.

When the conscientious objectors arrived, the situation was bad. The call to war had emptied the public mental hospitals and schools for the retarded of most of their trained personnel. Instead of providing treatment and care, these institutions were being converted into warehouses for humans. The prevalent attitude was nihilistic, pessimistic, and untherapeutic. Patients were made to behave by any means available. Snake pits abounded.

The conscientious objectors and their wives observed, took notes, protested, and went public. The press entered the struggle. Walter Lerch, from Cleveland, sounded the first trumpet. Eleanor Roosevelt and others followed suit. All this activity had made a tremendous impact on the American conscience. Many of the concepts of mental illness that we take for granted today began with the crusade spearheaded by the conscientious objectors and their wives. They have the right to be proud of their legacy as agents for social change.

Nevertheless, Sareyan's book contains some exaggerated claims and parochial views. The Mennonites are quoted as stating, “`Through their engagement in the CPS program the 200,000 Mennonite membership in the United States probably encountered the biggest experimental impact of any Christian church group in all history regarding mental illness and treatment.”' This statement does not take into account the Order of the Hospital of St. John of Jerusalem, in continuous existence for more than four centuries, giving uninterrupted treatment to mental patients on all the continents (including North America). Although Dorothea Dix and Clifford Beers are mentioned, the national and international influence of their work is not properly considered. Psychoanalysis, the various schools of psychotherapy, the Menninger Clinic and other specialized centers, the efforts of the American Psychiatric Association and the Group for the Advancement of Psychiatry, the early work of the Veterans Administration hospitals in the years following the war, and the medical schools and psychiatric training centers -- all exerted an influence worthy of much more credit. Perhaps more than any other factor, the “third psychiatric revolution” of 1952-1954, when psychotropic medications were introduced, contributed to the emptying of the psychiatric hospitals and the creation of community mental health centers.

The law of unintended consequences was also a crucial factor. Dix's crusade was too effective and ended, in the long run, by flooding the mental hospitals. During the 1960s, an odd coalition of unsophisticated amateurs, well-intentioned therapists, politicians, administrators, and accountants started to convince society that mental institutions deserved not improvement but destruction. The ultimate consequences of deinstitutionalization are now visible on the streets, among the homeless, inside the jails, and in fragmented and bankrupted families. The Turning Point ends by calling for a new crusade to denounce and reverse, as before, this contemporary “shame of the States.” Perhaps “we, the people,” will rise to the occasion. This time, we can all become conscientious objectors to this state of affairs.

Ruben D. Rumbaut, M.D.
Baylor College of Medicine, Sugar Land, TX 77487-0231