By Michael Oldani
By an odd coincidence I was able recently to watch the end of One Flew Over the Cuckoo’s Nest on television, while I was reading the end of the script for Next to Normal – the winner of the 2010 Pulitzer Prize for drama. This proved to be an interesting and disturbing juxtaposition that allowed me to ruminate on the state of modern psychiatry and mental health treatment. In Cuckoo’s Nest we have a fictional representation of the ‘beginning of the end’: the end of the mental health institution as we knew it (coming out of its 1950s high/low points), and the beginning of the deinstitutionalization movement in the United States. The lasting final image embodies this moment, that of “Chief” breaking out of the institution and wandering back into the unknown, on his own, and reclaiming his life outside the institution.
Next to Normal, which I recommend reading (or seeing), captures the current moment forty years after Cuckoo’s Nest was published. The musical centers on Diana, a bi-polar mother, who struggles with medication, family relationships, and the meaning of her life. If Diana had been cast in Cuckoo’s Nest she easily would have been a permanent resident in the women’s ward of that institution, perhaps even suffering the lobotomized fate of Randle McMurphy (Jack Nicholas’s character in the movie). Instead, Diana lives with her family on and off medication for over a decade, trapped between pharmaceutical cocktails, eager-to-prescribe psychiatrists, and unspeakable grief (the loss of an infant child). So much for psychiatric progress.
Similar to Chief at the end of Next to Normal, Diana breaks free and goes off on her own, walking away from her family (at least for the time being). For me interesting parallels emerged between Chief and Diana and the representation of mental health (care) in America. In particular, neither individual perceives their “self” as mentally ill. Chief is a victim of institutional racism and clearly is sane. For Diana the question is less clear-cut, her symptoms and moods allow for functional and less functional days. Nonetheless, these characters and the fictional worlds they inhabit direct our attention towards pathologies that have changed little over the last forty years. They point us away from the inner pathology of the mentally ill person and towards outer pathologies; the sickness of society, institutions, experts, caregivers, and even psychotropic medication itself – the pharmakon of efficacy/toxicity.
What has happened to psychiatry over the last forty years? Why have deinstitutionalization, the DSM-revolution, the modern pharmacopoeia of psychiatric medication, and the emergence of bio-psychiatry as the dominant form of expertise not converged to significantly improve the lives of the mentally ill, or reduce “psychiatric disease” – as mental illness is increasingly referred to by bio-psychiatrists and neurologists? Here is where I think Robert Whitaker’s Anatomy of an Epidemic: Magic Bullets, Psychiatric Drugs, and the Astonishing Rise of Mental Illness in America becomes a very useful explanatory text. Whitaker uses his considerable skill as an investigative journalist (e.g., in-depth interviews; archival work; media/press analysis; and exegesis of the psychiatric literature) to help tell an important story about psychiatry, roughly covering the last sixty years.
One thing to keep in mind is that most mainstream psychiatrists would find this book too radical. They might lump it together with Thomas Szasz and Scientology, thus dismissing this critique as conspiratorial or as operating on the fringe. Whitaker astutely anticipates these types of dismissals of his research by showing how most critics of psychiatry in the 1960s and 1970s were indeed marginalized as part of Szasz’s anti-psychiatry movement and/or “the cult” of scientology – many clinician’s careers were irrevocably altered.
So what is so radical about Whittaker’s claim? His work is part of a growing body of literature that questions the pharmaceutical-first model of psychiatric disease management (see Marcia Angell for a two-part published review of these newer works, including Whitaker’s http://www.nybooks.com/articles/archives/2011/jun/23/epidemic-mental-illness-why/). Whitaker’s real success is to show readers how a psychiatric narrative of care has been constructed over time. There are powerful stories being told about mental illness or psychiatric disease that have deep political and ideological roots. To put it another way, psychiatric science remains important if it fits with the dominant psychiatric story of our times. And this powerful narrative is quite simple: psychiatric disease is caused by neuro-chemical imbalances in the brain with biological/genetic roots, which can be treated by psychiatric medication. He astutely shows through case studies how, for example, depression became a “chronic disease” (chapter 8), bipolar (II) became an “epidemic” (chapter 9 and 10), and in particular how children have become the new markets for psychiatric medication (chapter 11).
In my opinion Part Four of this text, “Explication of a Delusion,” is the most powerful and most damning. Here Whitaker provides us with a cultural history of psychiatry’s conversion to the biological model (at any cost – including marginalizing the careers of psychiatrists that encouraged social psychiatry models or non-drug-first models). Of particular interest to readers may be the role granting agencies, such as the NIMH, played in funding biologically/pharmaceutically oriented studies.
Whitaker does for mental healthcare history what Greene (2007) accomplished for the diabetes-lipid-hypertension triad in Prescribing by Numbers. We cannot just blame Big Pharma’s marketing machine. Instead, it takes real detailed historical investigations to unearth how public (mental) health research dovetailed with ideological transformations within psychiatry to provide fertile ground for a sea change in how we view and treat the mentally ill individual.
Yes, researchers in the early half of the 20th century “discovered” drugs that altered “mental states” in all kinds of patients. These became psychiatry’s “magic bullets” (see Part Two: The Science of Psychiatric Drugs). However, after reading Whitaker, it becomes clear that the real magic happened afterwards when psychiatry, and a range of institutions, staked everything on the pharmaceutical model.
The challenge after reading Whitaker’s important contribution will be how to use it to make real changes in psychiatric care. A recent exchange between Thomas Szasz and Edward Shorter in the journal “The Psychiatrist” exemplifies the ongoing divide and the challenges ahead. Both, in my opinion, have made important contributions to the history and critique of psychiatry. Yet, Szasz remains too radical for Shorter, who dismisses most of Szasz’s essay. In fact, Shorter, whose Before Prozac is a recent contribution to psychiatric critique, advocates for using the term “psychiatric disease” to stress biological causation of mental distress. Szasz, like Whitaker, continues to push us to see the ideological, the political, and the cultural components to the current psychiatric narrative. And this narrative has real human effects – Whitaker takes pains in his opening chapter to point out the consequences of 1,100 people a day (a quarter of them children) being diagnosed as mentally disabled in the United States. How can this be described as psychiatric progress?
Michael J. Oldani, Phd, MS is Associate Professor of Medical Anthropology at the University of Wisconsin-Whitewater. He also holds an adjunct faculty appointment in the Medical Humanities and Bioethics Program at Northwestern University School of Medicine. He previously worked in the pharmaceutical industry during the 1990s. His work focuses on the intersection of pharmaceuticals sales and marketing, medical care, and culture. He is currently working on an ethnographic manuscript (Duke Press) entitled Tales from the Script: An Ethnography of Pharmaceutical Prescribing – 1989 to 2010.