Nurse Ratched with Footnotes
A review of Mad in America: Bad Science, Bad Medicine, and the Enduring Mistreatment of the Mentally Ill, by Robert Whitaker (New York: Perseus Publishing, 2002, $27.00)
Reviewed by E. Fuller Torrey, president, Treatment Advocacy Center
"Histrionic" is perhaps the kindest adjective that can be used to describe Robert Whitaker's new book on American psychiatry. "Deeply disappointing" would also be appropriate, since Whitaker has heretofore been known as a serious medical writer for the Boston Globe. Mad in America, however, rarely ascends to the level of that newspaper; rather, it mostly descends to the level of the tabloid Globe, available at supermarket check-out counters.
The first half of the book recounts the history of psychiatric treatment in America until 1950. This was the era of Benjamin Rush's spinning chair, eugenics, forced sterilization, the removal of teeth, and lobotomies. It is a sad history that has been described in less overwrought tones in books such as Daniel Kevles's In the Name of Eugenics, Sander Gilman's Seeing the Insane, and Gerald Grob's Mental Illness and American Society 1875-1940. Whitaker, by contrast, approaches his subject as did Ken Kesey in One Flew Over the Cuckoo's Nest, and the result is Nurse Ratched with footnotes. Nowhere does Whitaker acknowledge that these approaches to treatment were measures of desperation in desperate times. The nation's overcrowded psychiatric wards were filled with continuously increasing numbers of very psychiatrically ill patients for whom no effective treatments were available.
The second half of the book describes the use of antipsychotic drugs to treat schizophrenia. Whitaker, however, appears unsure whether schizophrenia even exists, describing it as a term "loosely applied to people with widely disparate emotional problems." At some points in the book, he appears to have even bought Thomas Szasz's myth-of-mental-illness nonsense: "American medicine, in essence, had developed a process for minting 'schizophrenics' from a troubled cast of people…" Nowhere does Whitaker include references to the many studies showing structural brain abnormalities, neurological abnormalities, and neuropsychological deficits in individuals with schizophrenia who had never been treated with any medication.
Whitaker has nothing good to say about antipsychotic medications. He calls them "not just therapeutically neutral, but clearly harmful over the long term" and claims that the drugs themselves cause many of the symptoms of schizophrenia. Like Scientologists and other antipsychiatry groups, Whitaker exaggerates the adverse effects of antipsychotic drugs, saying, for example, that tardive dyskinesia occurs "in a high percentage of patients." He also includes statements that are patently erroneous. For example, he claims that "even moderately high doses of haloperidol were linked to violent behavior," when, in fact, studies have shown that haloperidol and other antipsychotics decrease violent behavior in individuals with schizophrenia. Many of Whitaker's errors originate in his liberal footnoting of Dr. Peter Breggin, who has acknowledged having received support from Scientology, as a source.
In place of antipsychotic drugs, Whitaker extols the virtues of "love and food and understanding, not drugs." Like many antipsychiatry advocates, Whitaker romanticizes the early eighteenth-century era of "moral treatment" in which psychiatric patients were humanely treated. At that time, claims were made for impressive cure rates, culminating in 1843, when Dr. William Awl, director of an Ohio asylum, announced that he had achieved 100 percent recoveries; thereafter he was known as "Dr. Cure-Awl." The failure of "moral treatment" alone as a cure for insanity was clearly established in 1876 by Dr. Pliny Earle, who showed that the prior claims had been highly exaggerated. Whitaker highly praises the more recent version of "moral treatment," Soteria House, started by Dr. Loren Mosher. Mosher was a protégé of Dr. Ronald Laing's, and Mosher's experiments, like Laing's along these lines, have all passed into history because they failed.
In a similar vein, Whitaker discusses at length the WHO multi-center schizophrenia study that reported that individuals from developing countries (Nigeria, Colombia, India), "where such medications are less frequently used," had a better outcome than did individuals in developed countries. In fact, the study reported that the percentage of chronically disabled patients was similar in all the countries. What did differ was the percentage of complete cures-40 percent in developing versus 25 percent in developed countries. As has been widely discussed, the fact that more patients in the developing countries had a very acute onset of their illness suggests that many of them probably had a reversible viral encephalitis or other organic cause of their schizophrenia-like symptoms and thus had better outcomes.
Despite its major shortcomings, Mad in America is not without merit. Chapter 11, on the problems in the clinical trials industry, reflects the author's considerable prior expertise in this area. Indeed, he could have profitably written the entire book about this. And given Whitaker's writing skills, it is unfortunate that he did not turn his attention to one of the many real problems in American psychiatry, such as for-profit managed care, Medicaid rip-off, the excess influence and profits of the pharmaceutical industry, or the tragedy of untreated seriously mentally ill individuals on the streets and in jails. Instead, Whitaker chose to return to the sixties, revisiting Ken Kesey's mythical psychiatric ward. The ghost of Nurse Ratched lives on.