Reviews

Treatment of mental illness is a contentious topic.  Some decry the use of antipsychotic medications, others rely on them heavily.  Which is better: commitment to a inpatient psychiatric clinic or ongoing weekly sessions with a psychiatrist?  There are widely varying evaluations of the efficacy and worth of the various treatments as new studies come out or state budgets are cut.  And in the middle of those quandaries is the question of our responsibility as a society and as individuals to those with mental illness.  The three selections for today each bring a different perspective to these issues, raise important points, and come to insightful conclusions.

“You want to be well? Then put your boots on.”

 Voluntary Madness: My Year Lost and Found in the Loony Bin

By Norah Vincent

Ms. Vincent has suffered from depression off and on for a large part of her adult life.  A believer in “immersion journalism,” Ms. Vincent decided to personally investigate the treatment offered to the mentally ill in three different settings: an urban, public hospital; a private rural clinic; and an alternative-therapy private clinic.  She is utterly, completely, baldly honest, revealing thoughts and reactions that do not always paint herself in a positive light.  But her candor compels the reader to examine his/her own thoughts and admit she’s got a point.  For example, she describes being in the large, urban hospital and the population she met there.  They were, for the most part, either homeless or very low income, generally with poor hygiene, childish manners, and very quick to take advantage of those who may have something to offer.  In one of these moments of ugly, unflattering truth, Ms Vincent reports, “They were my subjects, and if I cared about them at all it was out of authorial self-interest and pity and moral vanity.  Moral vanity being that great middle-class indulgence that makes us write checks to charities and do the right thing for the less fortunate, because doing so reinforces our fiercely guarded belief that we are good people.  But when the less fortunate come banging on your door and your heart in real time, up close, blowing their not so fresh breath in your face, wanting to be a person instead of a project or a write-off, then your cherished little antibacterial ideals turn all squeamish and stuttery…and finally show themselves outright to be as vaporous and self-serving as they always were.”   Painful, but too often true.

Ms. Vincent’s acerbic wit crops up frequently as she faces the contradictions and dilemmas in the system head-on with a refreshing admission that she doesn’t have the answers.  Her perspective is what she has to offer.  But she doesn’t allow herself to take the easy route.  She mentions the “paradox of asylums” and says, “Put a person in a cage and you cannot help him.  But leave him to his devices and he cannot help himself, or will not.  Freedom is a prerequisite for healing a broken mind.  It cannot be fixed against its will.  Yet a broken mind is a broken will, a freedom that does harm, even potentially serious physical harm to itself and possibly others, a freedom that can attack or maim.   So, how else to heal but by force?”

She also reiterates the conundrum of the “classic public policy debate.”  Summing it up succinctly,  she says, “The liberal will raise taxes to pay for places like Meriwether [the urban hospital], assuage his conscience, and see the sorry results of inefficient bureaucracy and impersonal care.  The conservative will ask the community, often the religious community…to take up the burden on its own, rather than fobbing off the unwanted on big government.  But that is a burden that many do not want to take on.”  Again, she sees both sides.  “Staying at Meriwether only inflamed this debate in my mind.  I couldn’t come down on either side.  In a way, I had come down on both.”

The importance of the individual’s will – or agency – is a common theme.  For example, Ms. Vincent defines quitting as “a very active resistance, a work stoppage, a throwing down of the spade in the face of adversity.  Despair, in this sense, is not a giving up, but rather a taking up, a forceful ‘No’ that says ‘I will not participate.’”  After experiencing three vastly different treatment settings and interacting with dozens of patients committed in each, she maintains that “nothing and no one can do for a person what he will not do for himself, even if he is crazy…No one can heal you except you.”  Of course, she clarifies, facilities matter.  Resources including family, friends, good food, exercise, quality therapy, medication, and education are “necessary but not sufficient” to ensure recovery to mental health.

Ms. Vincent, as someone who has fought her mental illness for years, comes across as forthright readable, and above all, credible.  Her insights are pointed, searching, and persuasive.  While not completely objective – after all, it’s her own mental health, how could she be? – she recognizes the merits and drawbacks of each treatment setting and gives each its fair due.  And the conclusion she reaches is that at some point the individual involved must make a choice to fight for wellness if the fight is to have any chance at success.

Warning: While all three of the books reviewed today include some vulgar language – many mental illness are characterized by socially inappropriate behavior – Ms. Vincent uses rather more colorful language than the other two.  And quite a bit of it.  However, if you are able to get past that element, I found her observations to be of great worth.

“If it could happen to my family, it could happen to yours”

 Crazy: A Father’s Search through America’s Mental Health Madness

By Pete Earley

 “Our jails and prisons have become our nation’s new asylums because there is nowhere else for the mentally ill to go.”  Mr. Earley’s book documents the deinstitutionalization of the 1960s, when many mental hospitals were closed and their patients turned out.  The promised community mental health centers – which were supposed to provide follow-up care in less restrictive, more accessible circumstances – were never built.  Adequate services simply didn’t exist to provide the support needed for those who had been hospitalized to live on their own. 

Not much has changed today. 

Many who are severely mentally ill end up homeless, living on the streets where they are vulnerable and often victimized.  Inevitably, they are arrested for trespassing, being a public nuisance, or some other misdemeanor, and sent to jail, an “atmosphere…counter to treatment or helping improve anyone’s mental health.”  A game of ping-pong ensues.  The person with a mental illness is sent to a psychiatric hospital with the single, short-sighted goal of becoming “mentally competent” enough to stand trial.  When that threshold is crossed, s/he is sent back to the local jail to await the court date, often without any follow-up treatment.  An inevitable deterioration follows and the person becomes unable to assist with his/her own defense.  The judge is then forced to send the unfortunate soul back to the hospital to get made “competent” again and the cycle starts all over.

While the civil rights of those who are mentally ill must be protected, Mr. Earley argues that the current system is heavily biased against treatment and intervention and makes it nearly impossible to get an adult loved one the care they need since many who are mentally ill don’t believe they are sick.

  Laws today – many passed in reaction to the “lax commitment standards and ghastly conditions in state-run hospitals” in the 1950s and 60s that led to deinstitutionalization – make it extremely difficult to commit someone involuntarily, and explicitly permit the mentally ill to refuse treatment unless they are an imminent danger to themselves or others.  Ironic then, that so many mentally ill end up – involuntarily – in jail.

Mr. Earley weaves his own son’s story into his description of this revolving door system.  Towards the end of his college career, Mike had a psychotic breakdown.  Completely out of touch with reality, he broke into a home in a nearby neighborhood, turned on the stereo full blast, ransacked the kitchen, urinated on the carpet, and took a bubble bath before being arrested by the police.  Mike is actually one of the lucky ones.  He has a supportive family with sufficient money to hire an excellent, experienced lawyer who was able to negotiate reduced charges in regards to the home break-in.  He has a father who was a reporter for the Washington Post and with the threat of bad press was able bully the insurance company into allowing Mike to remain hospitalized when they insisted – according to their charts – that he’d had enough time to stabilize after three or four days.  He has the medical insurance and other resources to allow him to receive ongoing care with a psychiatrist, and to afford medications. 

Not everyone who is stricken by a mental illness is so fortunate.  Society – and that means each one of us – needs to see these people “as human beings who are suffering from serious brain disorders and who need medical attention,” instead of accepting laws which “defend their right to be crazy, as if having a chemical imbalance in your neurons is a choice.”  With both personal experience and thorough investigative reporting, Mr. Earley puts together a strong and convincing case.

 “Hubris is everywhere”

Mad in America: Bad Science, Bad Medicine, and the Enduring Mistreatment of the Mentally Ill

By Robert Whitaker

This was a difficult book to read.  Like Anne Frank, I tend to believe that people are really good at heart.  I assume they have the best intentions.  After all, they were doing the best they could with what they knew, right?  This book challenged that conviction.  I kept envisioning people I love who struggle with various mental illnesses being subjected to the inhumane actions that too often passed for “treatment” in the past: near-starvation diets, electroshock therapy, drugged into a drooling vegetative state.  For Mr. Whitaker, what started as a few simple questions (“Why have outcomes for people in the United States with schizophrenia worsened over the past twenty-five years?  And why are outcomes in the United States and other developed countries worse than in the poor countries of the world?”) became years of study into the history of treatments for mental illness.

He starts in the 1700s when “treatment” meant blistering with caustic mustard powders, whipping, temporary drowning, and immobilization in “restraint chairs” (complete with a bucket under the seat to catch excrement) for weeks or even months.  By the late 1800s and early 1900s, when eugenics was popular, forcible institutionalization at the behest of a single relative, sterilization against the patient’s will, and a prohibition on anyone with a mental illness marrying were the order of the day.  Insulin-induced comas, toxic injections that triggered violent, bone-breaking seizures, electroshock therapy – sometimes applied dozens of times within a week – and lobotomies were among the next wave of treatments thought to be effective.  After World War II, pharmacological treatments gained popularity.  The first “wonder drug,” Thorazine, produced a “vegetative syndrome” in patients which made them less disruptive and easier to manage, though their efficacy in reducing psychosis was questionable at best.  Severe side effects, including a feeling of “emptiness,” weakness, apathy, and Parkinson’s-like symptoms, were ignored repeatedly in clinical practice and in studies.  Successive new drugs often offered equally severe side effects and were often prescribed at massive, brain-damaging dosages.

Mr. Whitaker charges that the billions of dollars to be made discouraged the industry and many medical professional organizations from examining the underlying premises of the ubiquitous drug therapy or the unethical practices of some individuals.  He provides dozens of examples where “evidence of the harm caused by the drugs was simply allowed to pile up and up, then pushed away in the corner where it wouldn’t be seen.”  He states that, “the trials again and again simply looked at whether the drugs knocked down visible symptoms of psychosis and ignored what was really happening to the patients as people.”  To say the least, this track record does not inspire confidence.

There was, however, one bright spot in the history as Mr. Whitaker recounts it.  In 1796, Quakers in York, England opened a small home for the mentally ill.   The home had gardens, good food, tea parties, a variety of available tasks and games, and warm baths – a complete departure from earlier asylums.  The York Quakers’ guiding philosophy was that those with mental illness should be treated with “gentleness and respect, as the ‘brethren’ they were.”  Following this “moral treatment” approach, Dr. Thomas Kirkbride, a Quaker physician, opened the Pennsylvania Hospital for the Insane in 1841.  The hospital boasted a bowling alley, a greenhouse, a museum, meticulous landscaping, physical exercise programs, classes in reading and sewing, high quality evening entertainment and semi-private rooms.  An early version of “talk therapy” was also used to encourage patients to form friendships, develop greater social conscience, and take personal responsibility for their mental health.  Unfortunately this approach, despite excellent outcomes (up to 80 percent at some hospitals were discharged as either cured or improved), eventually fell victim to demand that outstripped supply.  The hospitals became too crowded, costs rose astronomically and corners were cut to bring state budgets back under control.  The “extras” that were vital to moral treatment were dropped one by one and positive outcomes steadily declined.

While Mad in America often comes across as a wholesale indictment of both psychiatry and the pharmaceutical industry, I’m not ready to slap a “quack” label on all psychiatrists or antipsychotic medicines.  I’ve known too many individuals, including several in my own family, who have been helped by caring, responsible professionals in the field.  But I’m also close to people who have chosen to forego their prescribed medications because the side effects they experienced negatively impacted their quality of life.  These powerful medications, however much good they may do, also carry serious risks that need to be studied impartially and carefully managed and balanced in conjunction with additional therapy and a supportive environment.   Mr. Whitaker’s research shows that by themselves, they do not provide a lasting solution to mental illness.

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On My Bedside Table…

Just finished: The Sea of Monsters by Rick Riordan

Now reading: Perfect Recipes for Having People Over by Pam Anderson

On deck: Me Talk Pretty One Day by David Sedaris

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We’ll tie up this topic in two weeks with a column exploring more about how medicine and other therapy can work together to support treatment of three specific mental illnesses: PTSD, schizophrenia, and antisocial personality disorder.