by Ron Powers
The future of mental health reform will depend upon whether enough people gather in enough of such venues as these to complete the work of Dorothea Dix by joining to reject and extinguish our modern Bedlams, and replace these Bedlams with a reborn and more sophisticated and more enduring program of moral care. It will depend upon whether enough people will take notice of and be inspired by the rediscovery made by sociologists and psychiatrists: that kindness, companionship, and intimate care are demonstrable counterforces to deepening psychosis. Not cures, but counterforces, particularly when practiced in concert with psychotropic regimens that fit the specific nature of a person’s affliction as well as that person’s specific biosystem.
It will depend upon whether enough people will recognize and volunteer their participation in one of the several ventures around the country similar to that created by the innovative psychiatrist Courtenay M. Harding. In 1985, Harding, a pioneer of the current “recovery” movement, created the Vermont Longitudinal Study of Persons with Severe Mental Illness, an experiment that validated the notion that community care balanced with proper medication can help restore many severe schizophrenic sufferers to happy and productive lives.
The study drew upon the work of George Brooks, a Vermont hospital clinical director who in the early 1950s took a critical look at Thorazine, the first of the “miracle drugs.” Brooks prescribed the drug to “back-ward” schizophrenic patients who had been considered hopeless. Less prone to marketing blandishments than most of his colleagues, he looked beyond the hype and noticed that many of his patients remained unable to leave the hospital despite receiving a high dosage of the new drug. Brooks crafted an experiment that resonated with the assumptions of moral care. He invited his patients to take part in a program of “psychosocial rehabilitation.” As Harding wrote in a 2002 essay for the New York Times, Brooks, with the help of his staff, mentored his patients “in developing social and work skills, [and to] cope with daily living and regain confidence. After a few months in this program, many of the patients who hadn’t responded to medication alone were well enough to go back to their communities. The hospital also built a community system to help patients after they were discharged.”9 It featured “home-like” conditions, complete with regular group therapy, the option of halfway houses and outpatient clinics, and job placement.
Harding, then a professor of psychiatry at the University of Vermont who knew of Brooks’s work, joined with him in the 1980s. She recruited a team of psychiatrists to observe and track the fortunes of former patients in Brooks’s original program. In 1985, the team conducted its last of several follow-up assessments of those patients who agreed to be interviewed. Harding wrote that 51 percent of the 168 subjects still living were rated as “considerably improved” or “recovered.” She added, “The most amazing finding was that 45 percent of all those in Dr. Brooks’s program no longer had signs or symptoms of any mental illness three decades later.”
After that, Courtenay Harding repeated her evaluation protocols through more than eight years of assessing former patients at the Augusta State Hospital in Maine. These people were matched, as closely as possible, to the Vermont volunteers by age, gender, and other criteria. The results were not identical to the previous study: the subjects in Maine did not do as well as those in Vermont in a number of categories: productivity, community adjustment, and persistence of symptoms. Still, they showed a remarkable recovery rate of 48 percent.
(It is important here to stress a point I have made before: Harding does not equate “recovery” with “cure,” though her criteria for the two conditions often seem nearly identical. “I define recovery,” she has said, “as reconstituted social and work behaviors, no need for meds, no symptoms, no need for compensation.”)10
These differences prompted Harding to make a “collateral” discovery that confirmed conventional neuroscience theory: that environment is an important factor in determining the onset and degree of schizophrenia. The Vermont patients were part of a cutting-edge rehabilitation experiment, whereas those in Maine received traditional care.11 As Harding put it, “The Vermont model was self-sufficiency, rehabilitation and community integration. The Maine model was meds, maintenance and stabilization.”12
Since then, Harding has held a series of faculty appointments as a professor of psychiatry, and she has lectured in the United States and around the world on the efficacy of disciplined, professionally supervised community care for chronically ill mental patients. Her philosophy, known among psychiatrists as “psychosocial rehabilitation,” is practiced in an estimated four thousand “dedicated” programs around the country.
In reporting on the rise of community centers for mental health care, I do not categorically endorse them. Given that mental illness itself is subject to endless definitions and cultural biases, not to mention predatory claims by spurious healers of various sorts and by errors among the best-intended professionals, it would be foolish to believe that a decentralized archipelago of self-professed clinics and treatment enterprises is uniformly safe or even legitimate. My personal belief is that oversight and credentialing—by affiliated hospitals or state agencies—must be a mandatory component of any community system. The lessons of deinstitutionalization are too recent, too destructive, and too clear to ignore.
That said, the future of care for the mentally ill will depend upon whether Americans can recognize that their psychically troubled brothers and sisters are not a threat to communities, but potential partners with communities for not only their own but the community’s regeneration. That the mentally ill need not be distractions from pursuing the good life. Instead, they can be instruments of the good life for others, even as they each enjoy a good life themselves. Their needs, their stories, their presence in our lives, and their capacity for responding to the outstretched hand of a neighbor can immeasurably enrich not only the ill person but the neighbor as well. The mentally ill people in our lives, as they strive to build healthy, well-supported, and rewarding lives for themselves, can show us all how to reconnect with the most primal of human urges, the urge to be of use, disentangling from social striving, consumer obsession, cynicism, boredom, and isolation, and honoring it among the true sources of human happiness.
To put it another way: the mentally ill in our society are awaiting their chance to heal us, if we can only manage to escape our own anosognosia and admit that we need their help.
Epilogue
I still dream of Kevin nearly every night. The motif changes through the years. At some point, fairly recently, he began to play his guitar again. We are in a downstairs coffeehouse, late; exposed brick walls, dim light, shadows. The patrons have all gone, but a few musicians linger in front of their beers at wooden tables, figures in a Caravaggio painting. Kevin is among them, yet isolated from them; he is the only one playing, and the source of light. The pick in his fingers feathers over the strings, which are somehow in the foreground, and infinite.
Or he and I are struggling along through an immense crowd in some city, near the bottom of marble steps that descend from a grand hall, where an important event has just ended, a concert maybe. The people around us are exiting the hall. Kevin is small, and people jostle and press in against us, and I hold his hand for fear of losing him.
In the most disturbing and redemptive dream of all, Kevin as a young boy has been struck and killed by a car, and I feel our dream-shock and dream-grief as intensely as I felt it in the actual event of his death; but Honoree gives birth to another baby, and the baby is Kevin.
Dean is thirty-five now, and he is doing fine. He seems in possession of himself, aware of his limitations, and ready to live on his own in the wider world. We have found a small house for him in Rutland. He will move into it soon. Honoree has been preparing him for the skills and duties necessary to live in a house. One of those skills is cooking. Dean has been an eager learner. The other day I walked to the edge of the kitchen and found the two of them huddled at the stove, Dean a head taller than his mo
ther, absorbed in what she was showing him. I can’t be sure, but I believe that she was teaching him how to cook chicken in fancy style.
Acknowledgments
Honoree Fleming, my dear wife and friend of thirty-eight years, all credit for this book begins with you. You set aside your years of quiet grief, and your natural reserve, and your aversion to revisiting the horrors that shattered our family’s tranquility and our children’s promise, and you established yourself as my ally and partner through the long months of researching and writing this. Infallible source on matters of science, tireless editor of my own fallible memory, uncompromising copy-reader, and stubborn adversary when the need arose, you have left the glowing imprint of your loving soul on every page. What a woman you are. What a presence.
Dean, our gallant lion: Thank you for so bravely giving me permission to open up the most harrowing, soul-threatening events in your tumultuous young life. You have made it possible for me to demonstrate that the mentally ill among us, even people in psychosis, remain fully, intensely human, with prospects for significant healing.
Jim Hornfischer, “Agent Jim,” you understood the potential social value of this book instantly, and you represented it with great conviction, as you have all the projects on which we have been partners. You also saw the necessity of including Dean’s and Kevin’s stories, though I had decided against including them in my original proposal. You placed the book with a superlative publisher. And you were a tirelessly committed reader of drafts once the writing began.
Michelle Howry, my editor at Hachette, you came late to this project through no fault of your own, and you shepherded it to consummation with the skill, insights, and conviction of one who had been present at the creation.
David Groff, poet, teacher, and enabling friend of writers, you filled an editorial vacuum for several weeks before Michelle Howry was able to take up her duties. You read and thought brilliantly about every chapter, every paragraph, every sentence, every word, and you resolved many urgent questions of structure and coherence with serene confidence and great prowess. You made me a better writer than I had been before.
Maureen May, genetic counselor at the Allegheny Health Network in Pittsburgh, and my steadfast researcher, you provided reams of reliable data from the most arcane realms of neuroscience and neuropsychiatry.
Raj Narendran, Maureen’s husband, you were among the coterie of clinical and research psychiatrists who helped me sustain the illusion that I know more than I do. Any damage to that illusion is exclusively my fault.
Jeffrey Schaler, psychologist and friend of Thomas Szasz, you opened yourself to my questions about him, though you understood that my interpretations might not be entirely favorable.
I am also in debt to generous assistance from the following people:
Ruth Grant, for lending her extensive neuromedical expertise to my exploration of brain-science issues;
Joe Mark, academic dean emeritus of Castleton College, for awakening me to the career of Thomas Szasz;
Lawrence S. Kegeles, associate professor of psychiatry and radiology at Columbia University, for sharing his research on the effects of cannabis use upon those afflicted with schizophrenia and for his critical readings of my sections covering the nature and duration of the prodrome and the nature of schizophrenia;
Vermont psychiatrist John Edwards for sharing his insights into schizophrenia and into the source of the fears and anxieties that cause people to turn away from the insane.
About the Author
Ron Powers is a Pulitzer Prize–winning critic (Chicago Sun-Times, 1973), an Emmy-winning TV commentator (CBS News Sunday Morning, 1985), and the author or co-author of fourteen previous books. He lives in Castleton, Vermont, with his wife, Honoree Fleming, PhD; their son, Dean; and Dean’s dog, Rooster.
Notes
Epigraph
1. Dorothea Dix, “Memorial to the Legislature of Massachusetts,” January 1843, from “The History of Mental Retardation, Collected Papers,” Disability History Museum, http://www.disabilitymuseum.org/dhm/lib/detail.html?id=737&page=all.
Preface
1. Seep Paliwal and Brendan Fischer, “Walker Staff on the Mentally Ill: ‘No One Cares About Crazy People,’” Center for Media and Democracy’s PR Watch, February 21, 2014, http://www.prwatch.org/news/2014/02/12396/no-one-cares-about-crazy-people-walker-staff.
2. Steve Schultze and Meg Kissinger, “Politics of Mental Health Complex Occupied Walker Staff,” Milwaukee Journal Sentinel archives, February 21, 2014, http://archive.jsonline.com/news/statepolitics/emails-show-scott-walkers-role-in-managing-mental-health-complex-crisis-b99209690z1-246333671.html.
Chapter 1: Membrane
1. The details in this episode are taken from the online files of a number of newspaper and television reporters in eastern North Carolina: most notably F. T. Norton of the Wilmington Star News, Christina Haley and Caroline Curran of the Port City Daily in Wilmington, Alyssa Rosenberg of WWAY TV in Wilmington, Jasmine Turner of WECT Television, and the CNN blogger Andrew Owens.
2. Caroline Curran, “Port City Daily Exclusive: DA, Defense Attorney Offer Different Accounts of Fatal Shooting of Mentally Ill Teen,” Port City Daily, February 4, 2014, http://portcitydaily.com/2014/02/04/port-city-daily-exclusive-da-defense-attorney-offer-different-accounts-of-fatal-police-shooting-of-mentally-ill-teen/.
3. Jason Tyson, “Over a Year Has Passed, Yet No Trial Date for Policeman Who Killed Teen in Own Home,” State Port Pilot, January 7, 2015.
4. Jasmine Turner, “Forensic Psychiatrist Testifies in Day 9 of Vassey Trial,” WECT Television, April 29, 2016, https://www.google.com/webhp?sourceid=chrome-instant&ion=1&espv=2&ie=UTF-8#q=Jasmine+Turner%2C+%E2%80%9CForensic+psychiatrist+testifies+in+Day+9+of+Vassey+trial%2C%E2%80%9D.
5. Hannah Patrick, “Vassey Testifies as Trial for Teen’s Death Nears End,” WWAY Television, May 3, 2016, http://www.wwaytv3.com/2016/05/03/vassey-testifies-as-trial-for-teens-death-continues/.
6. As reported by F. T. Norton of the Star News on April 29, 2016, http://www.starnewsonline.com/article/20160429/NEWS/160429621.
7. F. T. Norton, “Former Detective Bryon Vassey Found Not Guilty in Shooting Death of Teenager,” Star News, May 6, 2016, http://www.starnewsonline.com/article/20160506/NEWS/160509770/0/search?tc=ar.
8. Lindsay Kriz, “The Case of the Missing Screwdriver,” Brunswick Beacon, May 17, 2016, http://www.brunswickbeacon.com/content/case-missing-screwdriver#.Vz23SHJQKLU.facebook.
Chapter 2: What Is Schizophrenia?
1. Julian Jaynes, The Origin of Consciousness in the Breakdown of the Bicameral Mind (Boston: Houghton Mifflin, 1976).
2. Ibid.
3. Veronique Greenwood, “Consciousness Began When the Gods Stopped Speaking,” Nautilus, May 28, 2015, http://nautil.us/issue/24/error/consciousness-began-when-the-gods-stopped-speaking.
4. Jaynes, Origin of Consciousness in the Breakdown of the Bicameral Mind.
5. Maxine Patel and Mark Taylor in their Introduction to “Challenging perceptions of antipsychotic long-acting depot injections,” a “Progress in Neurology and Psychiatry” supplement, sponsored by an educational grant from Janssen-Cilag Ltd., 2007, http://www.academia.edu/171819/Changing_Perceptions_to_Antipsychotic_Long_Acting_Deport Injections.
6. C. Leucht, S. Heres, J. M. Kane, W. Kissling, J. M. Davis, and S. Leucht, “Oral versus depot antipsychotic drugs for schizophrenia—a critical systematic review and meta-analysis of randomized long-term trials,” PubMed, January 22, 2011, https://www.ncbi.nlm.nih.gov/pubmed/21257294.
7. Kelly Gable, PharmD, BCPP, and Daniel Carlat, MD, “Long Acting Injectable Antipsychotics: A Primer,” PsychCentral, http://pro.psychcentral.com/long-acting-injectable-antipsychotics-a-primer/004332.html#.
8. Robert Kaplan, “Being Bleuler: The Second Century of Schizophrenia,” Australasian Psychiatry, October 1, 2008, http://www.academia.edu/1362526/Being-Bleuler.
9. Gary Marcus, “A Map for the Future of Neuroscience,” New Yorker, September 17, 2013.
10. Pak Sham, Peter Woodruff, Michael Hunter, and Julian Leff, “The Aetiology of Schizophrenia,” in Seminars in General Adult Psychiatry, ed. George Stein and Greg Wilkinson (London: RCPsych Publications, 2007).
11. Michael Hopkin, “Schizophrenia Genes ‘Favoured by Evolution,’” Nature, September 5, 2007, http://www.nature.com/news/2007/070903/full/news070903-6.html.
12. Michael C. O’Donovan, “Biological Insights from 108 Schizophrenia-Associated Genetic Loci,” Nature, July 22, 2014, http://www.nature.com/nature/journal/v511/n7510/full/nature13595.html#corres-auth.
Chapter 4: Bedlam, Before and Beyond
1. Berthold Laufer, “Origin of the Word Shaman,” American Anthropologist 19, no. 3 (July–September 1917), http://onlinelibrary.wiley.com/doi/10.1525/aa.1917.19.3.02a00020/pdf.
2. Michel Foucault, “Madness and Society, in Aesthetics, Method, and Epistemology, vol. 2, Essential Works of Foucault, 1954–1984, ed. James Faubion (New York: New Press, 1998).
3. René Dubos, So Human an Animal: How We Are Shaped by Surroundings and Events (New York: Charles Scribner’s Sons, 1968).