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Then we reach the zenith of mid-20th-century psychiatric medicine: electroshock and lobotomy. Electroshock was based on the (now discredited) theory that seizures and mental illnesses were somehow opposite, so inducing one eliminated the other. Lobotomy derived from the notion that damaging the frontal lobes -- the center of most higher human personality and mental functions -- was the key to a happy cure for madness. Portuguese neurologist Egas Moniz, developer of the lobotomy, thought that mental illness resulted from fixed thought patterns and that "to cure these patients we must destroy the more or less fixed arrangements of cellular connections that exist in the brain." Moniz won the Nobel Prize for his innovation. He was also once shot by a disgruntled patient. (Brain damage as therapy, with chemicals instead of ice picks, dominates psychiatry to this day.) To the extent that they could reduce you to a characterless stupor, psychiatrists thought they were on the right track.
The story of Walter Freeman, once head of the American Medical Association's certification board for neurology and psychiatry, is especially enlightening and inspirational. After years of failing to find any anatomical differences in dead human brains that could pinpoint the physical causes of madness he knew must exist, Freeman became the Johnny Appleseed of lobotomies in the 1940s. He became a roving instant brain surgeon, lining up patients in a row to jam ice picks simultaneously up both eye sockets to destroy both frontal lobes, taking less than 10 minutes per patient. The operation was a success if, in Freeman's own words (written with his partner James Watts), the patient was "adjusting at the level of a domestic invalid or household pet."
Whitaker shows how little evidence of therapeutic quality there could have been for any of these theories, practices, and beliefs -- except in one respect. They served the interests not of the patient but of the doctor or caretaker. A lobotomized patient may not feel any happier, but affectless, quiescent people are surely easier to deal with in an institution.
The abuses of psychiatry are rooted in the fact that the doctor-patient relationship is frequently not one of service provider to customer but all too often a hegemonic one, with the doctor forcing treatments on the patient. Although no one keeps set figures on this, by cobbling together available sources it is safe to say that even today well more than half a million Americans a year are under the care (and control) of a psychiatrist by law rather than by personal choice. As Whitaker is not the first to note (see the writings of Michel Foucault or of Reason Contributing Editor Thomas Szasz), the history of psychiatry fits more comfortably in the history of penology than of medicine.
Defenders of psychiatry argue that things have changed. Such historical unpleasantness says no more about psychiatry today than bloodletting and pre-anesthetic surgery say about standard medicine. Constant changes in theories of etiology and cure no more condemn psychiatric science than outdated theories of phlogiston or ether discredit chemistry or physics.
But Whitaker has just gotten started when he hits the modern, chemical era of psychiatric medicine. When the first modern psychiatric wonder drug, chlorpromazine (Thorazine), was introduced in France in 1950, it was as an anesthetic. It produced a "vegetative syndrome" such that you could do whatever you wanted with patients and they wouldn't complain. Within a few years, the wonders of the psychiatric complex's P.R. -- and its hunger for new treatments that justified psychiatry as a bona fide medical discipline, with medicines that cured ailments -- had completely recast Thorazine in the eyes of physicians and the public.
The Thorazine fad spread, aided, as Whitaker documents, by credulous popular media reports and paid-for research from drug companies. It was soon joined by fluphenazine (Prolixin) and haloperidol (Haldol). Whitaker tells not just medical history but social and cultural history, tracing how these drugs are hyped and sold. All the emphasis in medical journals on how Thorazine caused motor dysfunction and induced Parkinson's disease-like syndromes gave way to praise for the latest psychiatric miracle.
A new theory of the cause of madness again followed the treatment: Madness was now the result of excessive dopamine levels, since the new wave of "neuroleptic" drugs begun with Thorazine blocked dopamine reception. (The section of the book detailing the damage these drugs do to your nigrostriatal, mesolimbic, and mesocortical systems are not for the squeamish.) Now the dopamine theory, too, is passing into the psychiatric dustbin (though still widely believed by laypeople). Whitaker cites studies finding that schizophrenics who haven't been drugged do not show higher dopamine levels than non-mentally-ill controls, and that any apparent increase in dopamine receptors in schizophrenics follows, not precedes, the use of neuroleptic drugs.
Just as with electroshock, lobotomy, insulin coma shock, and dunking, psychiatrists reported many successes with dopamine blockers. But again, that success was mostly in producing tractable zombies who didn't pose problems for their caretakers or families. As to whether the drugs solved problems for the patient, that isn't so certain. While some patients may love what these neuroleptic drugs do for them, Whitaker presents the testimony of many who hate them -- voices usually ignored by the psychiatric establishment.
He quotes Anil Fahini, speaking before a Senate subcommittee in 1975, saying that standard psychiatric drugs led to "the most fatalistic and despairing moments I've had on this planet. The only way I can describe the despair is that my consciousness was being beaten back....They prevent you from carrying on thought processes. They hold you in a tight circle of thoughts that never find fulfillment, that never find freedom of expression." Whitaker provides many testimonies of this sort.
Whitaker notes that by the mid-1980s, after decades of using these drugs allegedly to cure schizophrenia, "a fairly clear profile of the long-term course of 'medicated schizophrenia' had emerged in the medical literature. The drugs made people chronically ill, more prone to violence and criminal behavior, and more socially withdrawn. Permanent brain damage and early death were two other consequences of neuroleptic use."
As ever in the history of psychiatry, some new now-we've-really-got-it cure came along in time to replace one whose flaws were getting too hard to hide. Clozapine, olanzapine, and risperidone became the new wonder drugs for mental illness. Whitaker stresses that official drug testers are more or less in cahoots with the drug companies trying to find the next market-dominating medicine, leading to exaggerated or misleading praise for new drugs. (In market terms, the real "consumer" of these drugs tends to be the doctor who chooses what to prescribe, not the person actually consuming them, so the success of these drugs doesn't prove they meet the needs of users.) Whitaker presents plenty of evidence indicating that these new antipsychotics, known as the "atypicals," are probably no more safe or effective in the long term than the older neuroleptics they are replacing. The cogency of the evidence supporting most psychiatric cures is called powerfully into question throughout the book.
Mad in America is not just a hopeless story of unabated psychiatric abuse. Whitaker also touches on a subterranean alternate history of dealing with madness, bred from the early innovations of concerned Quakers in England and America. Men such as Thomas Kirkbride ran institutions, such as the Pennsylvania Hospital for the Insane, dedicated to "moral treatment." This involved treating patients as human beings who needed care, solicitude, and a normal amount of discipline -- discipline that demanded they clean up after themselves and dress and behave like civilized people, as opposed to the kind that whipped them or strapped them to chairs.
Unfortunately, the very demand for more public asylums ginned up by do-gooders like Dorothea Dix in the mid-19th century led to the medicalization and professionalization of mental institutions. But moral treatment, heresy to the medicalized psychiatry of the late 20th century (since it doesn't require an elite guild of M.D.s to administer it), still resurfaced occasionally.
Whitaker describes a fascinating experiment in the early 1970s called the Soteria Project, in which people diagnosed as acutely ill schizophrenics were kept off drugs and treated humanely by nonmedical caretakers. The patients were held to basic standards of decent behavior and made to do chores in an environment more like a disciplined summer camp (or a well-run college group home) than a madhouse or hospital.