Ill-Treated

Mad in America: Bad Science, Bad Medicine, and the Enduring Mistreatment of the Mentally Ill, by Robert Whitaker, Cambridge, Mass.: Perseus, 334 pages, $27

On January 18, 1959, 17-year-old Jonika Upton was committed by her parents to the Nazareth Sanatorium in Albuquerque. They were sure she was tetched in the head; she had dated someone who seemed homosexual and carried around books by Proust. The final straw was Jonika's fleeing to Santa Cruz with her new boyfriend, a 22-year-old artist.

Her new caretakers ran high-voltage electric currents through Jonika 62 times in three months. Despite her doctor's expectations, this treatment did not heal her mental illness. The doctor lamented, "She has not become nearly as foggy as we might wish." It wasn't all bad news, though: "Of course, there is considerable confusion and general dilapidation of thought."

Even after two more weeks of the most sophisticated psychiatric treatment around -- further electric shocks to a bound, usually terrified patient -- the doctor could only note, regretfully, that "under this type of treatment a patient usually shows a great deal more fogging and general confusion than she has." By the end of April, Jonika's doctors couldn't hide their pride: She was pissing on herself and wandering around naked, and she didn't know if her father was still alive. Their mission completed, the doctors knew it was safe to send Jonika home.

How you react to Jonika's story is a good indicator of how you will react to Mad in America, the new book by award-winning science and medicine journalist Robert Whitaker. If you see the doctors of Nazareth Sanatorium as inhuman tormentors, you will see this book as a hideous history of unspeakable practices. If you think the doctors were honorable medical professionals providing the best available treatment to cure a bona fide mental illness caused by imbalances in the brain, you may think Whitaker has traduced the noble profession of psychiatry.

In his quietly intense history of the discipline's ever-shifting etiologies and cures, Whitaker sets out to show that psychiatric treatments cause more harm than good and that they are imposed, either through force or through subterfuge, on people who we have decided don't deserve or need respect. Psychiatrists would say these practices actually grant the mad the greatest respect we can give them: respect for their higher, sane selves -- the selves they would want to be if only they weren't so desperately, sadly ill. Jonika, according to this view, would want to make sure she was never permitted to flaunt Proust or leave her parents' home in Albuquerque for Santa Cruz and her boyfriend. By the standards of that day, agreed upon by respected medical professionals, a young lady would have to be crazy to choose such a course.

Post-Nurse Ratched, it might seem a cultural commonplace that madhouses are mad and that institutional psychiatry has a lot of dehumanizing psychic (and physical) violence to answer for. As long ago as 1728, the novelist Daniel Defoe noted that life in a typical asylum is enough to drive anyone mad. As recently as 1946, Life magazine was exposing many of America's mental institutions as "snakepits." In his 1948 book The Shame of the States, Albert Deutsch wrote that public asylums reminded him of "Nazi concentration camps at Belsen and Buchenwald...buildings swarming with naked humans herded like cattle and treated with less concern, pervaded by a fetid odor so heavy, so nauseating, that the stench seemed to have almost a physical existence of its own."

Is this book just old news, then, a compendium of out-of-date horror stories from benighted days? Is it, in fact, an insult to the dedicated psychiatrists of today, who are doing their best to deal with the knotty mysteries of the human mind and how it can go awry?

It's easy to dismiss the critiques offered by Deutsch, Ken Kesey, and other such writers as irrelevant to contemporary psychiatry, which presumably has advanced beyond the primitive techniques they attacked (although electroshock has been making a comeback lately). What distinguishes Mad in America is that it draws a clear line from what everyone agrees were insane abuses of the past to the perfectly respectable "best practices" of today. Whitaker concludes that "today we can be certain of only one thing: The day will come when people will look back at our current medicines for schizophrenia and the stories we tell to patients about their abnormal brain chemistry, and they will shake their heads in utter disbelief."

Whitaker understates his case here, as he does -- to fine effect -- throughout the book. The story he tells should elicit not just head shaking but outrage from any reader who cares about human dignity and liberty.

This book is so dense with stories of horrific damage done in the name of psychiatric science that it's a credit to Whitaker's masterfully controlled tone that the reader isn't numbed. Mad in America is a powerfully disturbing reading experience. Whitaker thoroughly exposes psychiatry as a power-hungry, elitist guild practicing social control under the guise of medicine.

Whitaker traces the turns in psychiatric theory and practice through American history, referring when necessary to European trends that were quickly imported here. We meet Benjamin Rush, a signer of the Declaration of Independence and the father of American psychiatry (whose image is still on the seal of the American Psychiatric Association). Rush, who thought mental illnesses were caused by circulatory defects, believed bloodletting (up to four-fifths of a patient's blood) and spinning patients on a board were appropriate treatments. He was also ahead of his time in concern for the rights of American Negroes, convinced that they were white under their disfiguring leprosy. (Whitaker, who assiduously avoids ad hominem attacks, doesn't mention this.)

Whitaker connects the craze for eugenics in early-20th-century America with a shift in cultural attitudes toward the mad. They went from people in deep distress, deserving of human sympathy and aid, to diseased carriers of inferior germ plasm who needed to be strictly and forcibly segregated from normal folk, prevented from reproducing, and perhaps even wiped out for everybody's good.

As this attitude grew, the percentage of Americans in asylums quadrupled from 1880 to 1929. Was mental illness really spreading so virulently, or were asylums merely becoming more popular as places for warehousing society's presumed inferiors? Whitaker reproduces the voice of, and thus gives moral witness to, one fellow trapped in California's sterilization-obsessed mental health system in 1918: "I shall ever bemoan the fact that I shall never have a son to bear my name, to take my place, and to be a prop in my old age."

As the 20th century dawned, dunking bound patients in water was still state-of-the-art treatment. Whitaker introduces a shifting set of cutting-edge psychiatrists on his tragical history tour of American psychiatry: Henry Cotton of Trenton State Hospital in New Jersey, who theorized that germs from tooth rot caused insanity and established a very respectable cure rate by pulling asylum inmates' teeth, then later other body parts he decided were breeding grounds for disease (thereby killing 43 percent of his patients); the Swiss Jacob Klaesi, who discovered that inducing deep sleep with barbiturates for weeks on end was an effective cure; Harvard men John Talbott and Kenneth Tillotson, who found that binding patients in freezing cold blankets until their body temperature fell 10 to 20 degrees below normal was quite therapeutic for the mentally ill; the Viennese Manfred Sakel, the father of induced insulin comas as therapy; and the Hungarian Ladislas von Meduna, who added metrazol to the psychiatric pharmacopoeia. (It possessed the therapeutic property of inducing "a convulsion so severe it could fracture bones, tear muscles, and loosen teeth.")