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.")
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.
Researchers found that "psychotic symptoms had abated in the Soteria patients to the same degree as in medicated patients. Even more striking, the Soteria patients were staying well longer. Relapse rates were lower for the Soteria group at both one-year and two-year follow-ups. The Soteria patients were also functioning better socially -- better able to hold jobs and attend schools."
Picked at ruthlessly by influential psychiatrists, project leader Loren Mosher, a former director of the Center for Schizophrenic Studies at the National Institute of Mental Health, lost his NIMH money. Soteria faded from memory. The most recent study of the Soteria data, done by researchers with no hand in the experiment itself, found that "only 31 percent of Soteria patients who continued to avoid neuroleptics...relapsed during a two-year follow-up period, compared to 68 percent of those treated conventionally with neuroleptics."
Whitaker does not frame his attack on psychiatric practices with a fully formed, radical critique of the entire psychiatric project. Although many of the chilling anecdotes he tells raise the question, he does not stress the idea that standard psychiatry might simply be wrong about what it's dealing with. Thomas Szasz, a corrosive skeptic of the view that so-called mental illnesses are always the result of biological ailments such that the sufferers should be relieved of both responsibility and liberty, declares openly that mental illness is a myth. By showing us the crimes that psychiatrists have defined as cures, Whitaker raises disturbing questions about psychiatry's founding definitions. But because he rarely raises the question of exactly what behaviors got people condemned to mental institutions, he may give psychiatry's notions of illness more credence than they deserve.
More cautious, or more circumspect, than Szasz, Whitaker merely writes that "the American belief that schizophrenics necessarily suffered from a biological brain disorder, and thus needed to be on drugs for life, wasn't true." Whitaker, lacking the professional need to assert known causes and cures that drives psychiatry, is willing to say that the jury is still out on the real nature of the problems that psychiatry deals with. But he's sure that the methods it has used to deal with them have been, and continue to be, mistaken, frequently with tragic consequences.
Psychiatry throughout its history has blithely relied on the gambler's wisdom that you can't beat something with nothing. It thus comes up with a continual series of absurdities and abuses disguised as therapy, only openly admitting the failures of the previous "therapy" once a new one materializes. But contrary to popular belief, psychiatrists still don't know what causes schizophrenia, don't know how to cure it, and in fact don't even seem to know what it is. (Whitaker recounts experiments showing that psychiatrists are easily confused about how to properly diagnose this centerpiece mental illness.)
This book's message, delivered artfully and intelligently, is that there have been hundreds of thousands of Jonika Uptons -- victims of psychiatric pretensions and controls -- and that there still are today, despite the industry's consistent insistence that it finally has the right cure.
Psychiatry may very well be the arena where an elite guild with cultural power has done the greatest amount of damage by lording it over powerless individuals. Whitaker's book does a singular service in reminding us that authority of all sorts -- medical, state, or the unholy combination of both that has frequently defined psychiatry -- is always in danger of shifting into tyranny.