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The Human Nature Review 2002 Volume 2: 95-98 ( 11 March )
URL of this document http://human-nature.com/nibbs/02/mia.html
Mad in America: Bad Science, Bad Medicine, and the Enduring Mistreatment of the Mentally Ill
by Robert Whitaker
Perseus Press, 2002
Reviewed by Claudia Bukszpan Rutherford, Ph.D. Email: firstname.lastname@example.org
Robert Whitaker, whose articles on mental health have won several awards, reports in Mad in America: Bad Science, Bad Medicine, and the Enduring Mistreatment of the Mentally Ill that over the past 25 years, treatment outcomes for schizophrenics in the United States have worsened. They are “no better now than they were in the first decades of the twentieth century, when the therapy of the day was to wrap the insane in wet sheets,” he asserts. Moreover, schizophrenia outcomes in developed countries today are much worse than in the poorer nations of the world.
To understand these apparent failures, Whitaker argues, one must examine the history of the care of schizophrenics in the West, as well as the attitudes behind each era’s approach. Chronicling the treatment of schizophrenics from the 1750s till today, Whitaker creates a review that is by turns interesting, informative, and horrifying. Except for “moral treatment” in the 1800s, management of schizophrenics over the last 250 years appears to have been little more than a dressed-up series of one type of shackling after another. First, patients were literally subdued and fettered via the use of physical restraints; nowadays, says Whitaker, they are shackled chemically instead, with neuroleptic drugs that receive far more praise than they deserve.
Although some of the author’s points about the flaws of neuroleptics are well-taken (e.g., the high incidence of extrapyramidal side effects and tardive dyskinesia), at times the book is more bombastic diatribe against psychopharmacological treatment of schizophrenia than an effort to suggest realistic alternatives. The book’s often outraged tone ironically and unfortunately detracts from some of its quite valid points.
Whitaker begins his book by describing “mad medicine” (the precursor to psychiatry) during the Age of Reason. He cites a 1684 book, The Practice of Physick: Two Discourses Concerning the Soul of Brutes as setting the tone for the 18th-century view of the mentally ill as feral animals devoid of Reason, who must be dominated and broken by the physician. Favored techniques of the period included bleeding them until they fainted, regularly administering “powerful purges,” temporary drowning, and using the ominously-named “Bath of Surprise.”
In the early 1800s, the moral treatment movement arose among the English Quakers and the French. Dr. Philippe Pinel argued that a nurturing environment could heal the mentally ill-a stance strikingly different from the punitive approach it replaced-and he attributed many of his patients’ delusions and depressions to life stressors. Advocates of moral treatment saw the mentally ill not as wild animals who had lost their Reason and thus their humanness, but rather as ordinary people beset by temporary problems who needed human kindness and respect to get better.
The Quakers humbly professed that their treatment did “little more than assist nature.” As Whitaker describes it, they “sought to hold up to their patients a mirror that reflected an image not of a wild beast but of a worthy person capable of self-governance.” The treatment Whitaker describes, as well as its ideological underpinnings, seems like a precursor to mirroring in client-centered therapy, Sullivan’s interpersonal therapy, or Winnicott’s work with troubled adolescents.
Whitaker speculates about why physicians did not make more of an effort to incorporate the tenets of moral treatment into their clinical repertoire. Physicians, he suggests, were leery of moral treatment’s egalitarian, lay approach, which conflicted with medicine’s hierarchical, biological culture and which posed a potential threat to doctors’ “special claim for treating the insane.” Instead, physicians began to take control of American asylums, and spun moral treatment as an approach that was incomplete but soothing, in order to ensure that medicine could continue to occupy a central place in the mental health field.
In the early 1900s, moral treatment was replaced by a belief that the mentally ill were not “like us,” but rather, carriers of “defective germ plasm.” According to Whitaker, this dramatic shift for the worse in cultural perception arose from Sir Francis Galton’s work on the heredity of intelligence, from the eugenics movement, and from an American climate receptive to pseudo-scientific ideas that could bolster anti-immigrant, xenophobic sentiments. While admittedly this was a dark era for mental health care, Whitaker’s tone here is heavy-handed. His strident tone and editorializing (e.g., “Bad science had become bad law.”) detract from the power and persuasiveness of his arguments. Whitaker does, however, do a good job of capturing the prevailing mood of the era, in which mental illness was perceived as contagious and corrupting-a mood still prevalent in our culture today, albeit more implicitly.
The author reserves a special degree of horror for lobotomies. Whitaker not only catalogues the procedures themselves and points out how frequently they were performed without patients’ consent, but also includes chilling discussion of doctors who liked the procedure because it caused patients to behave in ways “much more pleasing to the staff.” By juxtaposing such comments with his review of eugenics, Whitaker raises an important and disturbing question-to the extent that psychiatry still makes the grooming of human behavior a yardstick by which to define treatment progress, are people really being helped or merely made more compliant and conventional?
In 1954, the first antipsychotic medication (chlorpromazine/Thorazine) was introduced in the US; the modern era of psychopharmacological treatment of schizophrenia began. Whitaker reveals that Thorazine was actually first touted as a chemical lobotomy-a pill that hindered brain function. It was only with time, and with increasing cultural distaste for lobotomies, that the drug was recast as a healing agent. Early on, Western physicians realized that chlorpromazine frequently created symptoms seen in Parkinson’s disease, but initially some physicians saw this side effect as a plus, because it created more manageable patients in an underfunded, overcrowded system.
The author criticizes neuroleptics harshly, not only for their side effect profile, but also because of studies he cites that question their long-term impact on the natural course of schizophrenia. Overall, he asserts, the “cure” Western medicine now applies to schizophrenia is actually worse than the disease. Unfortunately, because he downplays the discomfort of schizophrenia itself in the book, giving short shrift to the hallucinations, the terrifying delusions, the sense of isolation, and the mental confusion that many patients have described, Whitaker undermines the credibility of his argument. We do not get a clear description of what schizophrenia looks or feels like, so it seems impossible to make a valid comparison between the drugs’ ill effects and the disorder’s. Whitaker argues that our common image of a schizophrenic is really an image of someone on neuroleptics who has extrapyramidal side effects and tardive dyskinesia, with “awkward gait, the jerking arm movements, the vacant facial expression, the sleepiness, the lack of initiative.” While this may be true, it does not mean there are not other symptoms that can, and do, cause significant distress and danger to patients and those around them. Whitaker frequently puts quotation marks around the word schizophrenia, as if he is skeptical that the disorder even exists. He gives only cursory acknowledgement to the fact that ECT and neuroleptics do help some patients-as they themselves have attested. It is also unclear whether, to the extent that Whitaker’s criticism of neuroleptics and ECT is warranted, the problem lies in the treatments themselves, or rather in their being prescribed to the wrong people and/or in the wrong amounts.
Whitaker attributes the ambivalence and resistance patients sometimes feel about neuroleptics entirely to the medications themselves. He leaves out what one sees in with these patients in therapy-reservations about the drugs that stem from other reasons. For example, patients often say they feel hesitant about taking the drugs because they see doing so as admitting that they have a severe and/or chronic illness, or they lack the insight to realize their illness causes them problems. There are also issues of pride and dependency, with the medications seen as “crutches” that patients wish they could do without. These issues are not particular to neuroleptics per se, but arise whether one works clinically with a patient on antidepressants or one dependent on insulin; these are health psychology issues that reflect some people’s difficulty complying with maintenance medications because of how they feel about having the illness itself-not about the drugs.
By the 1970s, Whitaker reports, several studies suggested that neuroleptics made schizophrenics more likely to relapse, not less [1-4]. And by the 1980s, studies began to suggest that antipsychotic medications increased the risk of suicidal and aggressive behavior [5-7]. This research has not received the attention and concern it merits and Whitaker does a service in bringing it to a wider audience.
The author’s intense skepticism of psychiatry leads him to make some excellent points about the less-than-stellar way schizophrenia has been dealt with in the field-comments that mental health professionals often only whisper amongst themselves off the record. For example, he talks about how by the 1970s, it became clear that “schizophrenia was a term being loosely applied to people with widely disparate emotional problems. It was also a label applied much more quickly to poor people and to African-Americans.” This unfortunate state of affairs persists today to a certain extent, despite well-known studies exposing these diagnostic patterns.
In the end, Whitaker returns to his original claim, saying that World Health Organization “researchers concluded that living in a developed nation was a ‘strong predictor’ that a schizophrenic patient would never fully recover.8” Despite his sometimes strident tone, Whitaker does a good job of fleshing out some of the reasons why schizophrenics in the West are not doing well. Unfortunately, however, he does not go on to address substantively why schizophrenics in the developing world do better and does not suggest concretely how the West could improve. While Whitaker insightfully states that “any hope of reforming our care of those ‘ill with schizophrenia’ will require us to rediscover, in our science, a capacity for humility and candor,” unfortunately he does not take this point any further.
Whitaker does allude briefly to what the developing world may be doing right-if only in the sense of not repeating the errors of the West. In developed countries, he says, neuroleptic drug trials “simply looked at whether the drugs knocked down visible symptoms of psychosis and ignored what was really happening to the patients as people.” Western psychiatry today, with its emphasis on DSM diagnosis and its predominant adherence to a disease model, is often criticized as being reductionist and overly symptom-focused. Perhaps developing countries have been more successful in treating schizophrenics because they see patients as people first, not as symptom clusters.
The author does not discuss the collectiveness that characterizes many non-Western cultures and how that too may be a positive influence on prognosis for schizophrenics in those countries. As is suggested by research on social support, people with mental illness who have a support network and remain engaged with others tend to fare better in the long run. Also, in some non-Western countries, “mad” people are not stigmatized, but rather seen as benign, or even prophetic. While perhaps Whitaker chose to shy away from an in-depth discussion of non-Western approaches to mental health for fear that his book would be less focused, the book still needs a nod to these issues to feel more complete.
All in all, Whitaker takes on a controversial, important topic fearlessly and inquisitively. While at times his lack of editorial restraint actually distracts from his message, and one may not agree with all of his arguments, his topic is a vital one that has needed to be raised for quite some time, and one which will hopefully be a catalyst for further discussion.
1 Gardos, G. (1976). Maintenance antipsychotic therapy: is the cure worse than the disease? American Journal of Psychiatry, 133, 32-36.
2 Carpenter, W. (1977). The treatment of acute schizophrenia without drugs. American Journal of Psychiatry, 134, 14-20.
3 Hogarty, G. (1979). Fluphenazine and social therapy in the aftercare of schizophrenic patients. Archives of General Psychiatry, 36, 1283-1294.
4 Gardos, G. (1978). Withdrawal syndromes associated with antipsychotic drugs. American Journal of Psychiatry, 135, 1321-1324.
5 Drake, R. (1985). Suicide attempts associated with akathisia. American Journal of Psychiatry, 142, 499-501.
6 van Putten, T. (1987). Behavioral toxicity of antipsychotic drugs. Journal of Clinical Psychiatry, 48, 13-19.
7 Schulte, J. (1985). Homicide and suicide associated with akathisia and haloperidol. American Journal of Forensic Psychiatry, 6, 3-7.
8 Jablensky, A. (1992). Schizophrenia: Manifestations, incidence, and course in different cultures, a World Health Organization ten-country study. Psychological Medicine, Suppl. 20, 1-97.
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© Claudia Bukszpan Rutherford.
Dr. Rutherford is a clinical psychologist at New York State Psychiatric Institute in New York City.
Rutherford, C. B. (2002). Review of Mad in America: Bad Science, Bad Medicine, and the Enduring Mistreatment of the Mentally Ill by Robert Whitaker. Human Nature Review. 2: 95-98.