Reprinted from Barron’s, March 4, 2002
Shedding Light—And Darkness
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.