Reprinted from Barron’s, March 4, 2002
Shedding Light—And Darkness
Gracefully Insane
By Alex Beam
PublicAffairs, 288 pp., $26
Mad In America
By Robert Whitaker
Perseus, 304 pp., $27
Reviewed by David L. Nathan, MD
When ordinary people undergo successful psychiatric treatment, no
one takes note. But when a troubled but talented young musician,
like James Taylor, makes good, or a twisted psychiatrist uses an
ice pick to cause brain damage in his patients, now, that’s a story.
So I would conclude from Gracefully Insane and Mad in America.
Both books discuss the history of psychiatry. The first focuses
on Harvard’s McLean Hospital in Belmont, Massachusetts, where many
of the rich and famous have gone to recover from or learn to live
with their psychiatric problems. The second deals with horror stories
that are part of the lore of American psychiatry.
Gracefully Insane, whose subtitle is
“The Rise and Fall of America’s Premier Mental Hospital,”
sometimes reads like a gossip column, but is also an engaging history
of the psychiatric treatment of the American socioeconomic elite
since the early 19th century. And Beam outlines the ups and downs
of McLean in the context of the changing field of mental-health
care: The “moral treatment” of the 1800s, the coming of
psychoanalysis in the early 1900s, and the development of medications
in the latter half of the 20th century all shaped the character
of McLean, which in turn influenced the practice of American psychiatry.
Many household names have been, at one time, patients there, including
James Taylor, Robert Lowell, Sylvia Plath and Anne Sexton. John
Nash of A Beautiful Mind fame was treated
at McLean, as was Susanna Kaysen, who wrote Girl,
Interrupted. The stories are fascinating, even if the people
and problems described are not representative of psychiatric sufferers
in general.
Despite the use of the phrase “rise and fall“ in the subtitle,
McLean never fell. I was a medical resident there when the administration
made drastic cuts in its staff and facilities — and I was left
scratching my head when the book closed on an optimistic note. I
had assumed that the “fall” related to the decimation
of mental-health care by managed care and poor government funding,
but in truth McLean now cares for more patients than ever and has
expanded to serve all segments of society. Even so, low reimbursement
rates have led to across-the-board reductions in the amount (and
inevitably the quality) of services that America provides for the
neediest.
In contrast, Mad in America, filled
with venom disguised as fact, is a general attack on the treatment
of severe mental illness. This book is propaganda, not scholarship.
Whitaker’s message resembles that of the small but vocal anti-psychiatry
movement, which has long opposed medication and involuntary treatment
for the mentally ill.
The book sets out to prove that psychiatry is a morally bankrupt
profession, based upon the actions of some misguided and even malicious
caretakers of patients.
Certainly, the days of forced sterilizations and lobotomies as “treatments”
for schizophrenia have left a black stain on psychiatry that may
never be removed. The antipsychotic-drug revolution of the mid-20th
century was overrated. Outcomes didn’t improve as the institutions
emptied patients into cities and towns that didn’t provide adequate
support for them. Even today, antipsychotic drugs are less effective
and more problematic than anyone would like — although they’re
still an indispensable part of the lives of millions around the
world.
Unlike Beam, Whitaker doesn’t clearly address how the quality of
psychiatric care is proportional to the resources allocated to it,
and how our society — not just psychiatry — has often chosen not
to care for the mentally ill properly. The anti-psychiatry movement
has unsuccessfully lobbied to outlaw involuntary treatment in any
circumstance — even when schizophrenia impairs sufferers’ judgment
to the point where they reject all help and their illness makes
them a threat to themselves or (rarely) others.
Whitaker makes inflammatory, though subtle, allusions to slavemasters
and Nazis. And he judges psychiatry solely by those who have perverted
its practice, while ignoring any evidence of progress that is incompatible
with his premise. Psychiatry and other medical fields have had their
share of quackery, but we must work to improve, not eliminate, mental-health
care. Who would seriously suggest that we ban chemotherapeutics
and vilify oncologists simply because our treatments for cancer
remain dangerous and often ineffective?
Both books reviewed here include epithets for the psychiatrically
ill that carry over into the text and should offend any sensible
reader. While “insanity” and “madness” were
widely used terms at one time, they now seem as dated and degrading
as older terms used to denote race.
Beam uses words like “batty” and “gaga,” while
Whitaker uses “lunatics” and “the mad” to describe
people with psychotic disorders. As psychiatric illness is still
treated as a joke by too many in American society, and discrimination
remains the norm, I’m saddened that two men who spent so much time
speaking with the mentally ill would sacrifice sensitivity for the
sake of colorful language.
Dr. Bruce Cohen, my former residency director and the current president
of McLean Hospital, has called the treatment of psychiatric illness
“the civil rights issue of this century.”
Let’s hope that we will improve the lot of the mentally ill by studying
the deeds and misdeeds of psychiatrists, their critics, and the
society in which we live.
