Mad in America

Schizophrenics in the United States currently fare worse than patients in the world’s poorest countries. Robert Whitaker seeks to find out why.

Whitaker, Robert. Mad in America: Bad Science, Bad Medicine, and the Enduring Mistreatment of the Mentally Ill. New York: Basic Books, 2010.

In Mad in America: Bad Science, Bad Medicine, and the Enduring Mistreatment of the Mentally Ill, Robert Whitaker seeks to determine why treatment outcomes for schizophrenics in America have not improved despite decades of “scientific progress” in psychiatry. Not only have outcomes not improved, but schizophrenics in America fare worse than they do in poorer nations such as Nigeria, India, and Colombia. In order to understand these failures, Whitaker chronicles the history of madness in the West and the development of American psychiatry. The results are horrifying. With the exception of “moral treatment” prescribed during the 1800s, the management of people with schizophrenia has been a series of cruel and inhumane practices that run the gamut from physical torture to chemical persecution through harsh medication.

Whitaker describes “mad medicine” as the precursor to psychiatry. During the 1700s, the mentally ill were institutionalized in unheated, dingy cells, chained, and displayed for the public’s amusement. These “lunatics” and “brutes” were punished and made to fear their keepers. American physician, Benjamin Rush was thought to be a humanitarian, but his scientific perspective on madness caused him to keep using the “therapies” of the day which included bleeding and weakening patients through purges, emetics, and nausea-inducing drugs. Private asylums in England were known to be places where a person could drop off an annoying family member or a vexatious wife. In 1774, the Act of Regulating Madhouses, Licensings, and Inspection passed which prevented anyone from committing a person unless a physician had certified them as insane (this is where the term “certifiably insane” comes from). As a result, physicians became the sole arbitrators that determined who was diagnosed as insane and the practice of “treating” madness flourished. The number of private madhouses soon doubled and insanity became a common condition.

In the early 1800s, a moral treatment movement developed among English Quakers and became the new therapy used to treat the mentally ill. Philippe Pinel believed that a nurturing environment could heal the mentally ill. This was a strikingly different from the punitive approach it replaced. This treatment was premised on the idea that the insane had a capacity for regaining self-control and that their chance for recovery lay within them, not in the external powers of medicine. It was believed that patient’s delusions and depressions resulted from life’s stressors and that a nurturing and compassionate environment could heal those who were ill.  The York Quakers, lead by William Tuke, dramatically remade treatment of the insane. A blueprint for asylums was developed that was based on keeping them limited to a small number of patients, locating them in calm of the countryside, constructing buildings with architecturally pleasing aesthetics and governing them by a superintendent who was humane, empathetic, and reasonable. However, this was not to last. American physicians saw moral treatment’s emphasis on natural healing and egalitarian relationships between patient and healer as a threat to medical science’s hierarchical culture. Physicians took control of American asylums in order to ensure that medicine and biology became the focal point for treating mental illness.

Medical therapies for the mentally ill reflect societal values. In the early 1900s, Sir Francis Galton’s work on the heredity of intelligence spawned a belief that the mentally ill were not like “normal” people in that they were carriers of “poor germ plasm.” This began the eugenics movement and its willingness to embrace anti-immigrant and xenophobic social policies had a devastating effect on the mentally ill. The only solution to stop the spread of mental illness, according to the eugenicists, was sterilization. The country’s lawmakers agreed and as a consequence gave the US the first laws for the compulsory sterilization of the mentally ill. Asylum psychiatry was focused on finding somatic therapies that could be quickly applied to patients. Women were often the victims of “asylum medicine” and in the 1890s, their madness was commonly “cured” by removing their uterus, ovaries, and through amputating their genitalia. Some doctors, such as Henry Cotton, insisted on removing people’s teeth and other organs in order to eliminate “hidden infections” that were thought to cause madness. Submersing patients in water and pummeling them with painful and forceful blasts of water became common forms of hydrotherapy for madness. The ominously-named “Bath of Surprise” and the use of painful spinning swings were considered effective medical treatments of the day. In 1933, insulin coma therapy became a popular way of making patients less psychotic. The coma caused hemorrhages in the brain and destroyed brain tissue. Next was the popular treatment of metrazol convulsive therapy which produced “explosive” seizures in which the “patient would arch into a convulsion so severe that it would break bones, cause spinal fractures and loosen teeth” (p. 93). Electroshock (ECT) was introduced into the US in the 1940s. Electrodes were placed on the patient’s temples and a current of electricity was induced which caused spasms, accompanied by memory loss and reduced cognitive functions. The procedure was repeated many times until the patient was left in a confused and nearly catatonic state. Patients who received the therapy spoke of the extreme pain it caused, in many cases, their bones and teeth would break. Those who tried to resist this treatment were restrained and shocked without their consent. ECT was a common practice for two decades to frighten, control, and punish difficult patients in state-run facilities. Whitaker reserves a special degree of horror for lobotomies. Ever since the turn of the century, psychiatry had been seeking to reform itself into an academic medical discipline and brain surgery carried with it the luster of being scientific and technologically advanced. The lobotomy was a surgery that effected the frontal lobes of the brain, an area associated with higher intelligence. Doctors realized that damage to the frontal lobes brought about a change in emotional behavior in psychotic patients. Lobotomies received a great deal of praise and were used routinely as a way to keep patients quiet and non-disruptive (by reducing them to lethargic and lifeless people).

In the 1950s, state hospitals were gradually dismantled due to the crippling costs to state budgets and there was a push towards community care that aimed to treat the mentally ill on an outpatient basis and allow them to live in “normal” society. In 1954, the first antipsychotic medication, Thorazine, was introduced in the US and thus began the modern era of psychopharmacological treatment of schizophrenia. Thorazine belonged to a class of drugs known as neuroleptics. Initially, Thorazine was hailed as a chemical lobotomy, but as increasing social distaste with lobotomies developed, the drug was recast as a healing agent. Whitaker criticizes neuroleptic drugs for their serious and sometimes debilitating side effects. In his overly harsh assessment, he fails to acknowledge the fact that neuroleptic drugs do help some people, as they themselves have attested. Whitaker also cites studies that question the long-term impact of neuroleptics on schizophrenia. Overall, he sees the treatment for schizophrenia worse than the disease itself. However, Whitaker drastically downplays the discomfort of schizophrenia in his book. He pays little attention to the hallucinations, terrifying delusions, the sense of isolation, and mental confusion that are characteristic of the disease. Because there is a lack of a clear sense of what schizophrenia looks and feels like, it undermines his argument that the costs of treatment outweighs the disease. Whitaker seems way too eager to dismiss schizophrenia as a metaphysical affliction rather than a biological disorder. In fact, he consistently uses quotation marks around schizophrenia, suggesting that the disease does not actually exist. Whitaker also fails to note that today, ECT treatment has changed drastically and is highly successful in treating medication and therapy-resistant depression and schizophrenia. Unlike during the 1950s, patients are now anesthetized during the process and the memory loss associated with the practice is often minimal. This aside, Whitaker does make some excellent points about the less-than-stellar way schizophrenia as been dealt with by mental health professionals. For example, during the 1970s, it became evident that schizophrenia was being “diagnosed” more frequently in African Americans than Caucasians. Black men were labeled paranoid, hostile, and violent at rates four to five times more than other groups. Schizophrenia became associated with violence in the 1960s, just as black men joined protests against racism. There is clearly a troubled history between race and sanity and the definition of schizophrenia has changed dramatically as societal values have changed.

In the end of this book, Whitaker reveals a major claim made by the World Health Organization that living in a developed country is a strong predictor that an individual with schizophrenia will not recover. This shocking finding has been largely ignored by American psychiatry. Unfortunately, Whitaker does not address why schizophrenics in the developing world fare better and does not suggest concretely how the West could improve. American psychiatry today, with its emphasis on the DSM and its adherence to the biomedical disease model of treatment is often criticized for being reductionist and overly focused on symptom management. Perhaps developing countries have been more successful in treating schizophrenia because they see patients as people and not as symptom clusters. Overall, Whitaker tackles a controversial and important topic with fearlessness and depth. Even if you may not agree with all of his arguments, the topic is a vital one that has been in need of being raised for quite some time.