(This review of the book Mad in America by Robert Whitaker was originally published under the title "Some Dynamics of Psychological Reactions to Encountering Madness in Others" in Contemporary Psychology: APA REVIEW OF BOOKS, in 2004)
Reading the first few pages of this book was like approaching the scene of an obviously serious automobile accident. I could see that I was about to catch a glimpse of something quite gruesome, but could hardly will myself to look away. Indeed, in the course of having earned two degrees in psychology I was never exposed to anything like the grim details of the history of the treatment of madness presented in Mad in America.
In the 18th and 19th centuries, in England and later in the United States, there emerged a series of amazingly cruel and sadistic “treatments” for insanity. The theories about human behavior offered in support of the use of these treatments were as bizarre as the treatments themselves, as were the diagnostic criteria by which individuals were deemed to be in need of them. Periods of humanitarian reform, such as the “moral treatment” of the Quakers and Philippe Pinel’s reforms in French asylums, came between waves of barbaric assaults on the bodies and minds of those unfortunate enough to be considered lunatics. Eugenics mixed with blatant racism became part of the not-at-all-pretty picture, reaching a peak in Nazi Germany.
Clearly there has been a tension between two basic points of view that has been playing out over time. One point of view saw lunacy as a the result of a presumed hereditary defect and resulted in drastic and degrading physical interventions to subdue the behavior resulting from this presumed defect, as well as forced sterilization to stop its spread. The other point of view saw the experiences of madmen (and women) as something which might actually have some kind of significance, and in any case would respond better to kind and gentle treatment than to torture.
The bizarre forms of torture administered in the name of healing during the 19th century evolved in the first half of the 20th century into chemical and electrical shock treatments, as well as lobotomy and other types of psychosurgery. The kinder and gentler moral treatments found new expression in certain types of psychotherapy, the community mental health movement, and therapeutic communities.
In the second half of the 20th century the picture gets more complex. The advent of thorazine and other neuroleptics seemed to integrate the efforts to subdue and control psychotic process with the effort to be kind and gentle with those experiencing such processes. Asylums could be mercifully emptied, as their former residents were told that they had an illness analogous to diabetes, which could be controlled if they simply made a commitment to keep taking neuroleptic medication for the rest of their lives. Over the next few decades this view of a medical breakthrough became the dominant belief of organized psychiatry as well as the general public. It certainly looked as if the two points of view had been successfully integrated.
What was overlooked during these decades, and sometimes actively concealed, was the mounting evidence that the primary long term effects of neuroleptics on those who took them were to (1) profoundly and permanently reduce the qualify to life, (2) induce drastic and irreversible neurological damage, and (3) enhance one’s vulnerability to future psychotic episodes if one were to discontinue taking neuroleptics because of (1) and (2).
The motives driving those who overlooked and/or concealed the effects of thorazine and its later mutations were a mixture of factors. Plain old fashioned greed on the part of pharmaceutical companies who were making a fortune off the neuroleptics was most certainly one of them. Psychiatry’s desire to be like other medical specialities, which were able to offer a definitive medical treatment for an identifiable illness, induced a sort of arrogant dismissal of the evidence that contradicted the belief that a “cure” had been found . Mad in America does a fine job of documenting the manor in which the factors of greed and arrogance have supported the ongoing horrors of trying to suppress psychosis.
However, it seems to me that there is third factor, and it is one that plays out today in subtle ways. It has to do, once again, with the frame of reference in which one views psychosis.
In addition to greed and arrogance, the question of how one basically conceptualizes psychosis has a great deal to do with the anxiety that can be stirred when one is a close observer of a person who is psychotic. One can hardly be such an observer for very long without noticing, perhaps ever-so-slightly, one’s own capacity for madness. The anxiety stirred by such awareness, especially when it is not fully conscious, seems to me to be a factor in all the brutality, both historical and modern, directed at those who are experiencing psychosis. I suspect that this same anxiety has much to do with the current forces within our culture that would ignore or discount the profound interpersonal intimacy that underlies genuine psychotherapeutic healing. To be able to view psychosis as the result of a genetic defect which occurs in others, and not in one’s normal and presumed sane self, gives one a sense of distance from such frightening experiences. However, it also concurrently stirs enormous anxiety in response to the even remote possibility that one might be the victim of such a defect, given the prognosis attached to this point of view.
Further, it appears to me that the anxiety stirred by being in close proximity to madness, whether one’s own or another’s, is in turn a result of something more fundamental that the fear of being insane and out of control. It has to do with the dawning realization that there are profound subjective forms of reality in each of us which are much more compelling than objective consensual reality. The direct experiencing of these subjective realities is the basis for mystical rapture and its possible sequel--enlightenment. In a perhaps less dramatic way (or perhaps more), such experiences are the basis of the healing which occurs in depth psychotherapy. While these may be goals to which most would pay lip service, we all know that to allow them into our own lives will at least initially make things quite chaotic.
The good news is that such chaos, if gently contained and meaningfully attended to, will follow a natural arc back to a more harmonious way of experiencing life. Many depth psychotherapists have reported such a pattern. Loren Mosher, a highly respected psychiatric researcher, had the audacity to demonstrate this pattern objectively with a rigorously scientific study comparing people randomly assigned to one of two groups: those whose psychotic episodes were suppressed with neuroleptics and those whose psychotic episodes were allowed to unfold in a safe and gentle therapeutic environment. Not only did those spared neuroleptic treatment return quite naturally from their madness, but they were also less likely to become psychotic in the future when compared to those whose psychosis had been treated with medication. His reward for this profoundly significant piece of scientific research was to be ostracized by the scientific peers who had previously lauded his work and put him in charge of schizophrenia research at NIMH. His findings called into question the prevailing conceptualization of psychosis--that of chaos in need of suppression. It was an unpopular finding and made him an unpopular scientist.
While Mad in America gave an excellent account of Dr. Mosher’s research, I found it to be somewhat deficient in its treatment of LSD and its more organic cousins, mescaline and peyote. The proper name for the category to which these compounds belong has been a subject of some debate over the last 50 years. In the decade between 1950 and 1960 they were often called “psychotimimetic,” implying that they had the capacity to mimic psychosis. Mad in America reports some of the highly unethical research that was done within this frame of reference, but does not go beyond that. Starting around 1960 there began a period of about 3 decades when these compounds were referred to as “psychedelic,” meaning mind-manifesting. The implication of this model was that the experiences elicited by the compounds were a reflection of the human mind in a broader sense, rather than simply madness. During this time an obscure paper by a little-known author (Rhead, 1978) concluded that research with LSD gave strong theoretical support for the findings of Mosher and others that the long-term prognosis for a person having a first psychotic episode was significantly better if he or she were not treated with neuroleptics. In the past decade there has been another name change, from “psychedelic” to “entheogen,” reflecting the association noted above between the profound subjective realities these substances seem to catalyze and mystical or religious experiences. Mad in America would have given a more complete account of this particular aspect of its subject matter had it covered the psychedelic and entheogen periods that followed the psychotimimetic.
What Mad in America covered in great detail and with very convincing evidence is the fact that the corruption by pharmaceutical money of science, and even mental health support organizations, is virtually complete at this point. The older neuroleptics are becoming less profitable as their monopoly-granting patents expire. In their place pharmaceutical companies are beginning to turn their powerful PR apparatus toward manipulating psuedo-science and public opinion to promote the new “atypical” antipsychotic agents. Unlike the older neuroleptics, which primary disrupted just one neurotransmitter (dopamine), this new generation of drugs of will disrupt as many as five, which may lead to even more bizarre and disastrous long-term side effects. These side effects will in turn probably be successfully concealed and/or rationalized away, as new pharmaceutical patents for the drugs that cause them produce profits in the billions.
Mad in America also does a good job of documenting the repeated finding that the long-term functioning of schizophrenics has been shown to be vastly superior in underdeveloped countries, where they are rarely exposed to antipsychotic medication and where their unusual thoughts are better tolerated so that they do not tend to be isolated from others. Some industrial nations, most notably in Scandinavia, have taken note of these findings and have been adjusting their treatment of psychotic persons accordingly--with excellent results. This is probably the most, if not only, hopeful note I took away from reading Mad in America. Seeing a grisly automobile accident may cause at least a few drivers to be more vigilant and prudent.(1)
Rhead, John C. “The Implications of Psychedelic Drug Research for Integration and Sealing Over as Recovery Styles from Acute Psychosis,” Journal of Psychedelic Drugs, Vol. 10, No. 1, 1978, pages 57-64.
(1)In trying to decide about publishing this review, I shared it with three colleagues. Two, psychologists, offered very positive feedback about the quality of the review and the significance of the book, and strongly encouraged me to publish. One of these two suggested Contemporary Psychology . The third colleague, a psychiatrist who has published extensively in the biological treatment of schizophrenia, suggested I spare myself the public embarrassment of publication. From reading my review he concluded that the book was so filled with inaccuracies as to make it useless. My hope is that this review will encourage more psychologists and psychiatrists to read Mad in America, so that it can stimulate debate and inform future research.