Review: Mad in America by Robert Whitaker

Mad in America: Bad Science, Bad Medicine and the Enduring Mistreatment of the Mentally Ill [2002] – ★★★★1/2

Robert Whitaker opens his book with this quote by David Cohen: “We are still mad about the mad. We still don’t understand them and that lack of understanding makes us mean and arrogant, and makes us mislead ourselves, and so we hurt them”. His book is an engaging overview of the methods to treat mentally ill patients through centuries (starting in the pre-1750s period and continuing to the present day), and how changes in societal attitudes and perceptions, as well as in psychiatry politics and business considerations impacted the treatment. “Scientific” and “therapeutic” approaches to treating mentally ill had competed with each other for centuries, and Whitaker shows how politics of this or that time period ultimately dictated what mentally ill patients were supposed “to need”, with mentally ill people often caught in a trap of doctors and businesses’ ambitions to make a mark in science or earn money respectively.

The book is divided into four sections: (a) The Original Bedlam (1750 – 1900); (b) The Darkest Era (1900 – 1950); (c) Back to Bedlam (1950 – 1990s) and (d) Mad Medicine Today (1990s – present).

• The Original Bedlam (1750 – 1900)

The story starts circa 1796, in a period when psychiatry was finally “wakening up” from the “chain-the-mentally-ill” and “patients-as-a-spectacle” mentality and finally realising that patients in psychiatric institutions need a more humane medical treatment. Before that, mentally ill patients were held in terrible conditions, and Bethlehem (Bedlam) Hospital in London testifies to that. “Like all wild animals, lunatics needed to be dominated and broken” [2002: 7], was the opinion of that time. Unflinchingly, Whitaker goes through the horrific and shocking arsenal of “treatments” for the mentally ill at that time, talking about the Bath of Surprise, Spinning Therapy, and the Tranquiliser Chair. For example, the reasoning behind the Drowning Therapy was the following: “if a patient was nearly drowned and then brought to life, he would take a fresh start, leaving his disease behind” [2002: 17].

So, Benjamin Rush [1745 – 1813], “the father of American psychiatry”, was the proponent of a kinder treatment for the mentally ill at that time in Philadelphia, but even he thought that it was the circulatory disorder in the body that was the cause of all madness [2002: 17], and, accordingly, was in favour of bleeding his patients severely to “fix” that. A glimpse of hope at that time was the exemplary role of the Quakers in caring (gently and without medical intrusions) for the mentally ill in Philadelphia, as well as the influence of Philippe Pinel [1745 – 1826] and his promotion of “moral treatment” in Europe.

• The Darkest Era (1900 – 1950)

Robert Whitaker states that “at the beginning of the twentieth century, the generous attitude towards the mentally ill disappeared in American society” [2002: 41]. The first half of the twentieth century was all about the rise of eugenics, segregation mentality and sterilisation efforts in psychiatry. The 1940s also saw the rise of shock treatments for mentally ill which were considered “quick, easy, reliable, and cheap” [Whitaker, 2002: 98]. However, it was also clear early on that these also produced “a more profound, lasting trauma” and “changes akin to suffering a concussive head injury” [2002: 102]. Whitaker writes: “[shock treatments were] a form of a brain damage, but that was not how [they] were presented to the public” [2002: 103]. The public were made to believe that the shock treatment was safe, effective and painless, and any memory loss was only temporary. However, they were anything but benevolent, and before the introduction of paralysing drugs, up to forty percent of all patients used to break bones in this treatment, and they were said to be used to “quieten the ward and insure good citizenship” [2002: 106].

If a shock treatment sounds awful, the rise of a procedure which became known as prefrontal lobotomy may sound even more so. Dr Walter Freeman [1895 – 1972] and Dr James Watts [1904 – 1994] were neurosurgeons who were the pioneers of a method by which an instrument was drilled/inserted into a patient’s brain to cure them of disorders. Even though the procedure gained a “medical approval”, it was also deemed to be akin to a “partial euthanasia” and “the removal of a patient’s soul” because it induced the unprecedented state of passivity and regression to childhood.

• Back to Bedlam (1950 – 1990s)

Of course, the latter half of the twentieth century was all about drugs as a cure for mentally ill patients, and a drug chlorpromazine (Thorazine or Largactil) had all the attention. That was a time when the shift occurred from the asylum to the community care, and schizophrenia was an illness of interest. Whitaker writes how pharmaceutical companies had the most to gain from promoting all sorts of antipsychotics as safe for consumption, and drugs were even prescribed for the elderly, for children with learning difficulties and simply for people who had mild stress in their daily jobs: “19 million prescriptions were written annually” [2002: 205]. And that was all happening at the time when the same patients were reporting dangerous side-effects from those drugs and immense addiction. A glimpse of hope in that period was probably a study conducted by American psychiatrist Dr Loren Mosher [1933 – 2004] who opened a house Soteria for mentally ill and had results that showed that a controlling atmosphere and over-use of drugs hindered recovery for patients and more attention should be paid to therapeutic and benign treatments, as well as to the atmosphere of kindness. However, Mosher’s results were generally ignored, and testing various drugs on patients without their consent continued to be practically a norm.

• Mad Medicine Today (1990s – present)

“The transformation of chlorpromazine from a drug that induced a chemical lobotomy into a safe, anti-schizophrenic drug took a decade”, but “by the mid-1980s, it was no longer possible to ignore the many drawbacks of neuroleptics” [2002: 258], reports the author. So, what did pharmaceutical companies do? They invented new, “safer” drugs, and their prime goal was to outperform their business competitors. Whitaker talks in this section about the proliferation of drugs, such as risperidone, which causes mania where none was before, and about hasty and negligently conducted preliminary trials on those drugs [2002: 286].

 “With the new drugs presented to the public as wonderfully safe, American psychiatrists [were] inviting an ever greater number of patients into the madness tent” and “evidence of the harm caused by the drugs was simply allowed to pile up, then pushed away in the corner where it wouldn’t be seen” [2002: 289], writes Whitaker. He convincingly shows how politics and business became the biggest winners in a game where patients’ care and needs were hardly prime considerations, and where corruption in the sector was ever-present (for example, see this documentary on corrupt mental hospitals of the 1990s).

Robert Whitaker’s book may be too general for some and it does engage in some innocent “cherry-picking” of information, but it is still an engaging read and will be a very eye-opening read particularly for those who know little about the topic. The author provides testimonies from patients themselves, and demonstrates how “madness” is essentially a social construction and how the manipulation of public perception of the disease through the centuries gave medical professionals the licence to treat mentally ill patients in the most demeaning and horrifying way possible. It seems that those who benefited the most from all the alleged “treatments” and “cures” were medical professionals concerned with scientific progress and credentials as well as big businesses, with little attention being paid to the experience and needs of the actual patients.