No One Cares About Crazy People

Powers, Ron. No One Cares About Crazy People: The Chaos and Heartbreak of Mental Health in America. New York: Hachette, 2017.

This is an extraordinary and courageous book that took Ron Powers a decade to work up the courage to write. His son Kevin, the younger of his two children, hanged himself in 2005, just before turning 21. Kevin’s brother Dean, two years and eight months older, experienced a psychotic break on Christmas Day 2012; the following summer, he tried to drown himself. Schizophrenia drove both boys to the brink. For years, Powers was determined to not write this book. Thankfully for us, he reconsidered: “I realized that my ten years of silence on the subject, silence that I had justified as insulation against an exercise in self-indulgence, was itself an exercise in self-indulgence” (p. xviii). Powers comes to this passionate and personal project in search of answers. “Something terrible happened to my sons,” he writes, “And I want to know what and why” (p. 126).

This text is part memoir, part social history. The history of mental illness, no one will be surprised to learn, is doleful. Powers provides deep dive accounts of how the mentally ill have been treated over centuries including chapters dedicated to Bedlam, the rise (and fall) of moral treatment, eugenics, the relationship between creativity and madness, the creation of the first psychotropic drugs, deinstitutionalization, the antipsychiatry movement, and the horrors modern warfare takes on the psyche. He interweaves his family’s steadily-worsening crisis with schizophrenia with a broader historical inquiry into how societies have dealt with the mentally ill (not well), and specifically how American society deals with the epidemic today (still not well). The result is a collection of histories tethered together with achingly tender accounts of his beloved boys as they experience carefree and rambunctious childhoods and the beginning of seemingly ordinary teenage years all the while lurking under the surface of all the family happiness is what Powers calls the “scourge” of schizophrenia (p. xv). Below are some of the areas Powers touches on.

What is Schizophrenia?

“This illness,” Powers writes, “shares with cancer, its partner in catastrophic affliction, an almost otherworldly imperviousness to definitive understanding and cure” (p. 2). Even today, it remains the most devastating and feared of all mental disorders. Schizophrenia is best understood not as a single disease, but as a chronic and incurable group of related psychiatric disorders that are thought to be the result of a combination of genetic mutation and “psychosocial” or environmental factors. The illness produces three sets of symptoms: positive, negative, and cognitive. Positive symptoms are often the most dramatic and include auditory and visual hallucinations and delusions. In extreme cases, patients will act on their delusions, sometimes with violent and (self)destructive results. The negative symptoms can be characterized as a range of emotional responses characterized by withdrawal or a lack of something. These take the form of decreased motivation, inability to experience pleasure, cauterized emotions, self-isolating behavior. These negative symptoms are similar, but distinct from clinical depression. Cognitive symptoms can include a loss of memory or diminished ability to process information. A particularly unfortunate feature of this illness, one that often proves to be the greatest barrier to receiving timely (if any) treatment is called anosognosia, or “the false conviction within a person that nothing is wrong with his mind” (p. 27). In psychiatric parlance, this is referred to as a lack of insight.  What this means is that despite their irrational and out-of-control behavior, the patient remains convinced that nothing is wrong with their mind. Anosognosia is a by-product of psychosis and occurs in approximately half of all cases of schizophrenia. Schizophrenia afflicts slightly more than one in one hundred people.

Schizophrenia’s prognosis today is essentially the same as it was during the time of Emil Kraepelin, the early twentieth century German psychiatrist who first used empirical brain science in his quest to understand psychological maladies. Kraepelin is credited with much of the medical community’s initial understanding of schizophrenia. “Dementia praecox,” as Kraepelin knew it was a progressive and neurodegenerative disease that he observed in a significant number of patients in their teens and early twenties. Kraepelin was the first to observe a distinction between manic depression (also known as bipolar disorder), a condition that can also include psychotic symptoms, and what is today called schizophrenia. Swiss psychiatrist Eugen Bleuler was responsible for coining the actual term schizophrenia (or “the schizophrenias”) to replace dementia praecox. In Greek, the word literally means “a splitting of the mind.” Bleuler also introduced the medical community to the “spectrum” concept when he argued that schizophrenia was actually one disorder along a spectrum. Schizoaffective disorder, which includes a mood disorder alongside the basic symptoms of schizophrenia, is listed “Schizophrenia Spectrum and Other Psychotic Disorders” in the the latest edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM). Though it is closely related to schizophrenia, it is considered to be a different disorder.

Bedlam and Moral Treatment

Powers begins his historical accounting of mental illness with Bedlam and the rise (and fall) of moral treatment. The most influential environmental factor affecting schizophrenia is stress. Because of an Industrial Age intensity toward urban living, “early London was a petri dish for human stress. And madness” (p. 59). The sentiment at the time, one not much different from today, was that the mentally ill contributed nothing to society, held no political sway, and therefore we not fully people: “The mad don’t vote; the mad don’t do anything to generate wealth. Many don’t even know who they are. Why toss good money at them, beyond the costs of keeping them alive?” (p. 63).

As a result, the sane sought accommodations for this growing population at the lowest economic price possible. Their solution was Bedlam, “the vernacular name assigned to the first and most famous madhouse of them all” (p. 59). That infamous institution was London’s Bethlem Royal Hospital and by the mid-eighteenth century, it’s horrifying approach to “caring” for the mentally ill was on full display. This period of time can be marked, according to Powers, as “the true dawn of the epoch in which no one cared about crazy people.” It wouldn’t be the last. In Bedlam, “patients” were routinely shackled, starved, taunted, beaten, experimented upon, hygienically neglected, and forced to live in the most decrepit of conditions. Powers notes how:

patients were “treated,” occasionally and haphazardly—and always, of course, by physicians with no grasp of how the brain worked. More often they were punished…doused with icy water or strapped inside chairs that spun rapidly, or both. These procedures were popular partly because they delivered a double benefit: they also answered as therapy. Some inmates (to use a more accurate term than “patients”) were chained to walls—sometimes for months, occasionally for years, their ankles and wrists festering with gangrene (p. 62).

In response to Bedlam and asylums alike, the first widespread reform movement came about in the late eighteenth century, principled on what came to be known as “moral treatment.” Asylum pioneers such as Philippe Pinel, William Tuke III, and Benjamin Rush advocated a more humane and empathetic approach to dealing with society’s insane. They came to see madness as an affliction that could be cured through respectful relationships and a healthy environment. While reform did occur, it was ultimately short lived. As the general population increased so did the number of insane people needing accommodations and soon new asylums in Western Europe and America were overwhelmed: “There were simply too many more patients, too many more criminals, and too many other kinds of hard cases among patients” (p. 73). Eventually, overcrowding eroded the moral treatment agenda and society once again maintained unkept institutions and asylums notorious in their neglect for patients. It was during this time that Dorothea Dix rose up as an advocate for the mentally ill. Tirelessly, she:

embarked upon an eighteenth-month itinerary that took her to jails and asylums throughout Massachusetts, barging past guards to interview patient-inmates and their keepers. At the end of her journey, she was convinced that the moral treatment asylums were in fact benefiting patients, but that their jailing of excess “mad” people was rampant and their plight a front to humanity (p. 71).

As the number of public and private asylums swelled, the agenda for moral treatment became less and less of a priority until it went away entirely. And while conditions never returned entirely to that seen in Bedlam, “the horrid systematic cruelty” towards the mentally ill can still be seen today—“a fact documented by almost weekly news accounts from the human disposal systems that our large urban prisons and hospitals have become” (p. 75).

Eugenics and “the Mentally Unfit”

“It is nearly impossible to make sense of the furious arguments that to this day energize and often impede the interests of the mentally ill without understanding eugenics” (p. 82).

Eugenics, or the practice of manipulating biological systems to refine reproduction, was a movement based on the drastic misunderstanding and misapplied teachings of Charles Darwin’s theory of evolution. Darwin’s theory would become the basis for techniques used by the Nazis to control population through the elimination of the unwanted. However, the eugenics movement was not isolated to Europe and Nazis. The Nazis also borrowed from the U.S. eugenics sterilization program:

In America, sterilization and more invasive measures flourished before and after the war. Indiana enacted the country’s first compulsory sterilization law for the mentally ill in 1909, Washington and California quickly followed…The Golden State became the national leader in the practice, neutering twenty thousand mental patients between the onset and 1979. It was not until September 2014 that the practice was prohibited by a bill signed by Gov. Jerry Brown, following revelations that the state cleaned the ovaries of 148 women between 2006 and 2010 (pp. 98-99).

In 1927, the U.S. Supreme Court decided, by a vote of 8 to 1, to uphold a state’s right to forcibly sterilize a person considered unfit to procreate. The case, known as Buck v. Bell, centered on a young woman named Carrie Buck, whom the state of Virginia had deemed to be “feebleminded.” The law authorized the forced sterilization of anyone deemed to be “unfit.” Buck v. Bell remains law today “and the science of eugenics remains in the annals” (p. 102).

Creativity and Madness

“Do neural links exist between creativity and mental illness? Or, to put it in a couple of other ways: Did Kevin’s and Dean’s artistic gifts put them on a path to schizophrenia? Or, perhaps, vice versa?” (pp. 117-118).

It’s not surprising that Powers dedicates a chapter to the debate over whether artistic talent and mental illness are causally linked. Both of his sons were gifted musicians and writers. He uses this chapter as an opportunity to cite research by psychiatrist Nancy Andreasen, who for more than a decade interviewed and tracked 30 faculty members from the renowned writing workshop at the University of Iowa. She also interviewed and tracked 30 control subjects of similar age and IQ who worked as administrators, lawyers, social workers, and so on. She questioned and diagnosed subjects using a methodology she devised. Instead of identifying a passel of schizophrenic novelists, Andreasen stumbled on extremely high rates of mood disorders like depression and mania among the writers. The gap between the writers and the control subjects was huge with 80 percent of writers reporting some mental illness compared with 30 percent of nonwriters. Andreasen’s findings jive with research done by Kay Redfield Jamison, who in her book, Touched With Fire: Manic-Depressive Illness and the Artistic Temperament, examined 47 prominent poets, playwrights, novelists, biographers, and artists and found that a significant portion of them had mood disorders. Though research has shown that there is a link, it still remains an unqualified and inconclusive one. Powers notes that one major problem for this has to do with coming up with an agreed upon conceptualization of creativity. What exactly is it?

Antipsychiatry

Powers devotes a chapter of his book to “one man tsunami” (p. 156) Thomas Szasz. Szasz was a psychiatrist best known for undermining his own profession, accusing it of being fraudulent, misguided, abusive, and based on a concept that he believed did not exist: mental illness. Szasz’s iconoclastic views, expounded upon in his countless publications, brought him an ardent (if small) devoted following who have had considerable influence. Szasz compared psychiatrists to slave owners and Nazis. During the 1950s and 1960s, Szasz’s ideas gave rise to the antipsychiatry movement, “a loose but enduring affiliation of citizen groups in every state dedicated to the abolition of involuntary mental health care” (p. 160). While this group was small in size, it was disproportionately influential in when it came to legislature and lobbying politicians, medical providers, and the public to partake in their movement.

Modern Warfare and Mental Illness

“The indifference to the suffering of mentally ill servicepeople and service veterans remains a national disgrace” (p. 322).

The demise of eugenics did not result in a moratorium on suffering in the name of “perverted science” (p. 273). Postwar America produced an “unprecedented numbers of disabled servicepeople and veterans—both men and women” and neuropathologist (note: not neurosurgeon) Walter Freeman saw an opportunity to push forth a radical pseudoscientific new cure: the lobotomy. The modern lobotomy, which Powers describes as “the back-alley abortion of brain surgery” was conceived of as an antidote to schizophrenia in 1935. Freeman crudely “simplified” the procedure by using an ice pick to enter the brain under a patient’s eye socket. It was estimated that one-third of his patients’ outcomes were considered “failures” (p. 275). A few medical professionals criticized Freeman and attempted to stop him but because no laws existed to prohibit the procedure, nothing could be done. Freeman was in demand and his impunity derived from a need facilitated by the second world war. Eventually, Freeman was banned from the medical community after losing his operating privileges, but the lobotomy did not die with him. It was still used, albeit rarely once the antipsychotic revolution began.

The war and postwar effects on the mental health of combatants and civilians are incalculable, but due to a “military code of manly silence,” many individuals suffer in silence. Drawing on his own experience of combat, Harry Truman is credited as the first U.S. president willing to recognize the intensity and chaos of war and its effect on the psyche. He was revolutionary in pushing for guaranteed financially protected treatment for not only “warfare’s psychic casualties,” but the rest of the nation’s mental health. In 1946, Truman signed the National Mental Health Act which provided federal money for the first time ever for research into the human mind. Unfortunately, many administrations have cut back or eliminated this funding.

Drugs, Deinstutitonalization, and Disaster

The very notion—Sanity in a bottle! Peace of mind in a popped pill!—so perfectly fit postwar American marketing-conditioned faith in E-Z solutions via consumer products that the wonder-drug blitzkerg was complete as soon as it started (p. 221).

In 1954, a new antipsychotic called Thorazine came on the market.  Among many things, it was touted as a cure for schizophrenia. It wasn’t. At best, it suppressed symptoms. With these drugs and the “atypical” or “second generation” antipsychotics that were pushed to the market in the 1970s came a range of unpleasant and serious side effects including weight gain, heightened anxiety, increased blood pressure, and a condition known as tardive dyskinesia, which resulted in uncontrollable facial tics and tongue-thrusting. It is because of these side effects that a large number of people with schizophrenia stop taking their medication against medical advice.

The development of pharmaceuticals to treat schizophrenia became the impetus for a well-intentioned social program that had disastrously unintended consequences for the mentally ill. On the eve of Thorazine came the Community Mental Health Act (CMHA), signed by President Kennedy in 1963. The CMHA was “designed to solve, once and for all, the malingering scourge of decrepit mental asylums and barbarous care” by allocating promising $150 million in funds over four and a half years to be spent on grants to states for establishing community health centers for the mentally ill. It sounds good, but it quickly “became one of the century’s most enduringly disastrous policy experiments for the mentally ill” (p. 187). Powers writes:

This historic blunder has a name that grotesquely fits the elegance of its design and effects. The name is deinstitutionalization. Deinstitutionalization uprooted what meager stability insane people clung to—the dismal care of state mental asylums—and drove tens of thousands into the streets where they pioneered an entirely new urban subpopulation, the accursed demographic of the mad that we call the homeless (p. 3)

The mentally ill homeless soon shuffled between the streets, hospital ERs, and jails and prisons. The worst of that unmerciful world, unsurprisingly, is the world of US jails and prisons – a world that comes into the ambit of the book because of the legal problems his son Dean encounters. “The American prison system is an archipelago of barbarity,” he writes with damning directness“ (p. 146). According to a Department of Justice study, more than half of the country’s roughly two million prisoners suffer from some kind of mental health problem. Particularly unforgivable and gruesome are the liberal uses of solitary confinement which is known to trigger schizophrenic-like symptoms such as hallucinations and delusions in people who are mentally fit. For people who are already ill, “it is a quick route to deep and lasting psychosis” (p. 148). Powers describes solitary as “a petri dish for the suicidal impulse” (p. 148). Powers’s spends a good amount of pages detailing the fact that jails and prisons have become the de facto mental institutions. The criminalization of mental illness fuels some of the book’s most scathing prose.

Involuntary Commitment

Good intentions and unintended consequences borne by the mentally ill are a theme in this book and in legal history of mental health issues. A desire to preserve autonomy and civil liberties of individuals with mental illnesses has resulted in legislature that presupposes that a person who displays a mental disorder is fully capable of choosing her own treatment, including medications, and therefore may not be forced into doing so. The Lanterman-Petris-Short (LPS) Act, passed by then California governor Ronald Reagan, set the precedent for involuntary commitment procedures today.

According to Powers, these laws fail people with schizophrenia and their families, functioning:

to barricade state hospital doors against the admittance of stubbornly resisting patients—at least until a hearing was held. Not a medical hearing, with psychiatrists, but a judicial hearing, with a judge and lawyers. Because stubbornly resisting patients almost always were patients in psychotic states who almost always were in the collateral grip of anosognosia, the legislation meant that the most desperately vulnerable of all sufferers were the ones least likely to get help (p. 195).

Anosognosia is another theme that runs the course of Powers’s book. While it foremost describes the companion affliction of schizophrenia and schizoaffective disorder that blocks a person’s self-awareness and insight into their disease, it also serves a symbol of society’s collective denial and obliviousness towards the needs and humanity of the mentally ill.

Ultimately, Powers intends for this book to comfort families dealing with severe mental illness, to shock general readers with examples of atrocities befalling the mentally ill, to show that “crazy people” are rarely dangerous to anybody but themselves, and to push for significant reform. “I hope you do not ‘enjoy’ this book,” he writes in the Preface. “I hope you are wounded by it; wounded as I have been writing it. Wounded to act, to intervene” (p. xiii). Readers will certainly feel that wound, and they will finish the book more convinced than ever of Powers’s central anthem: “Too many of the mentally ill in our country live under conditions of atrocity” (p. xix).  If any book can begin to change those conditions, this is the one.