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 Sometime
in the next few months, the Journal of Nervous and
Mental Diseases will publish an article that
describes an unusual experiment with newly
diagnosed schizophrenics. This experiment randomly
assigned young people with that diagnosis to one of
two different forms of treatment. Some entered a
psychiatric hospital where they received drugs to
quell their psychotic ravings. The others went to a
place known as Soteria House. They lived there for
several months with a small group of other
schizophrenics and a team of empathetic men and
women (not medical doctors) who gave the disturbed
individuals round-the-clock emotional support. The
study tracked the research subjects for two years.
According to the new report, the schizophrenics who
lived in the therapeutic home and received no drugs
fared better than the ones who received medication
in the hospital. Furthermore, "The ones who did the
best are those who would have been predicted to
have the worst outcomes," Loren Mosher says.
Mosher, a San Diego psychiatrist, was the principal
architect of the Soteria experiment. What unfolded
during the years it operated (1971 through 1983)
shaped his ideas about schizophrenia, a condition
estimated to afflict 1 to 2 out of every 100
Americans. Unlike the majority of his professional
colleagues, Mosher was never persuaded that
psychotic behavior is caused by brain
abnormalities. He moreover came to believe that if
schizophrenia is not an organic disease, then it's
wrong to force schizophrenics to take drugs that
change their brains. He acknowledges that the
powerful antipsychotic medications prescribed for
schizophrenia nowadays often do suppress the
symptoms of lunacy and make disturbed individuals
easier to control. But Mosher argues that there are
better ways to help most schizophrenics recover
their sanity - cheaper, more humane and
libertarian, less devastating to the human body and
soul.
 Because
he holds these beliefs, the 69-year-old doctor
claims, "I am completely marginalized in American
psychiatry. I am never invited to give grand
rounds. I am never invited to give presentations. I
am never invited to meetings as a keynote speaker
in the United States." Yet from 1968 to 1980, the
period when many of his unorthodox beliefs came
into focus, Mosher occupied a prominent position in
the American psychiatric research community. He was
the first chief of the Center for Studies of
Schizophrenia at the National Institute of Mental
Health in Washington, D.C. He founded the
Schizophrenia Bulletin, and he served as its editor
in chief for ten years. The story of how and why he
became an outcast in his profession reveals much
about the profound ways in which the concept of
madness has changed in America over the past 40
years.
In
Mosher, maverick tendencies can be traced to his
childhood. A sickly boy plagued with allergies and
asthma, he lost his mother to breast cancer when he
was 9. Shunted between various relatives, he says
he more or less raised himself from the ages of 8
to 14. By 1949, he had settled with his father in
Marin County, but he continued to enjoy
extraordinary freedom as a teenager. He had both a
car and a driver's license when he was 14. Summers
he explored the Sierra Nevada wilderness on an old
Arabian stallion loaned to him by an uncle. In the
two and a half months after his high school
graduation, he toiled as a roughneck in the oil
fields of Montana and Wyoming, having used a fake
ID to prove he was 21. "My story was that I was
working after college to get money to go to medical
school." The lie transformed him, he recounts.
"Presto chango. I was 'Doc.' My practice was
luckily limited to simple first aid, common
ailments like colds, and sexual complaints like the
crabs and gonorrhea." But Mosher was astonished and
delighted by the importance he suddenly gained in
the eyes of his fellow roughnecks "because I seemed
smart and was 'going to be a doctor.' "
College
had to come first. He'd won a scholarship to
Stanford, then known as a party school for WASPs.
He says he liked the idea of partying but also had
to work for all his living expenses. Mosher knew
that a medical degree was his ultimate goal. He'd
admired the lady physician who had treated his many
childhood illnesses and says her competence and
empathy made him want to be a doctor too. Turned
down by Harvard's medical school, he attended
Stanford's for two years, then took off a year to
work and save money. At that point, Harvard
accepted him as a transfer student. "So my degree
-- with honors -- is from Harvard Medical School.
Which is important," he says, looking mischievous.
"It explains a lot of things I've been able to do
that other folks have trouble getting away with."
Mosher likens the Harvard credential to having a
"very, very good union card.… Your ability to
do things is enhanced." After graduation, he did an
internship at the University of California in San
Francisco. "And then I took my psychiatric
residency at Harvard again."
Why
psychiatry? Mosher points to several experiences in
medical school that piqued his interest in the
field. He once came down with "a case of medical
student hypochondriasis" severe enough to make him
get psychological help. "In psychotherapy for more
than a year, I experienced firsthand the healing
possibilities of a caring, human relationship." A
summer
psychiatric fellowship introduced him to visionary
Bay Area psychiatrists such as Gregory Bateson and
provided a glimpse into "humanistic possibilities"
in psychiatry that to Mosher contrasted with the
technological, mechanized aspects of many other
medical specialties. All his friends seemed to be
going into psychiatry; he followed
suit.
He
says the year he spent as a medical intern helped
form some of his key attitudes. Confronted daily
with "sickness, unkindness, and death, situations
over which I had little influence or control,"
Mosher felt determined not to think of his patients
as objects, as so many of his fellow physicians
seemed to do. He found inspiration in the writings
of existential and phenomenological thinkers of the
day, such as Rollo May, Søren Kierkegaard,
Jean-Paul Sartre, Maurice Merleau-Ponty, and
others. "Their thing was, basically, enjoy yourself
because you may not wake up tomorrow morning,"
Mosher explains. "And they had a very
straightforward attitude of accepting people for
what they are and not judging and categorizing and
putting them in pigeonholes. Just try and be there
and be the best you can be in whatever you're
doing. When people are dying all around you every
day and there's nothing you can do, that's good
solace, if you will."
In
1962, he arrived for his psychiatric residency at
the Massachusetts Mental Health Center (an
institution "long known as the 'Psycho' because of
its previous name, the Boston Psychopathic
Hospital"). There a white-haired, rotund, Santa
Claus look-alike "quickly divested me of any
remaining pretensions about 'curing' patients,"
Mosher says. This man, who became Mosher's mentor,
exhorted his psychiatric residents to forget about
doing things to patients. Instead he urged
them to be with the suffering individuals
-- understanding, accepting, and forming
relationships with them. "His encouragement to
relate to schizophrenics as people with very
serious life difficulties, to treat them with
dignity and respect, and to attempt to see things
as they saw them was a critical piece of my
subsequent development," Mosher
asserts.
But
Mosher also confronted evidence that the culture of
the psychiatric hospital militated against such
attitudes. "Decisions that made the staff, not the
patients, more comfortable were rationalized, and
physical treatments such as electroshocks were
applied to relational problems." By the time his
residency ended, he had developed two conflicting
sets of attitudes. The first was that "human
relationships could be therapeutic for even those
whose distancing maneuvers were most masterful" --
that is, schizophrenics. On the other hand, he
thought the realities of life in the mental
hospital thwarted the formation of such
relationships.
Mosher
had no intention of spending his career in
psychiatric hospitals. He envisioned a path that
would lead him to prominence as a psychiatric
researcher, and as the first step to that end, he
won a position as a "clinical associate" at the
National Institute of Mental Health (NIMH).
Beginning in 1964, he worked in the institute's
Family Studies branch, scrutinizing families with
schizophrenic offspring.
"Research
on twins and schizophrenia had been done since the
early 1900s," he says. "The Germans were the first
to do it." By 1960, according to Mosher, some
authorities were asserting that in almost
two-thirds of the cases in which one identical twin
was schizophrenic, the other identical twin shared
that condition. If true, this would have
represented strong evidence of a genetic cause,
since identical twins share the same genetic
makeup. By the time Mosher arrived at the
institute, however, he says critics had begun to
cast doubt on the trustworthiness of the twin
studies. Newer and methodologically sounder studies
were showing a much lower "concordance
rate."
The
group that Mosher joined wasn't studying such
statistical correlations but was rather trying to
understand what happens in cases of
discordant identical twins -- that is, those in
which one twin is crazy but the other isn't. "We
would bring both twins and their families into the
clinical center for two weeks or so and study them
as a group." What they found, Mosher says, is that
in these families, the twin who grew up to be
schizophrenic "was basically treated differently
from his or her twin in a variety of
ways."
Today
Mosher looks back on this research and sees "lots
of problems" in it. The study he worked on included
only 16 pairs of twins. The way they were selected
to be studied was questionable, and other biases
might have influenced the work. But the work "did
generate some interesting hypotheses," Mosher says.
And the two years he was involved with it gave him
credentials as a promising young psychiatric
researcher.
For
his next step up the professional ziggurat, Mosher
persuaded the National Institute of Mental Health
to send him to London, then one of the yeastiest
centers of creative ferment in the psychiatric
realm. During his year there, he soaked up a broad
range of intellectual influences. As a therapist,
he saw couples at the British National Health
Services' Tavistock Clinic. "Then I would run out
to Anna Freud's clinic and spend an afternoon in
her so-called borderline group, where they would
discuss cases according to Freudian theory," he
recalls.  He
spent time at the Maudsley Hospital with a famous
psychiatric geneticist named Eliot Slater, "very,
very biological in his orientation." Nothing,
however, left a deeper impression than the time
Mosher spent with R.D. Laing and the controversial
experiment in which Laing was then
immersed.
A
charismatic Scot who'd become a British Army
psychiatrist by the age of 20, Laing had burst into
international prominence with the 1960 publication
of a book called The Divided Self. "It
attempted to make the process of going mad
intelligible to ordinary people," writes one of
Laing's biographers. Schizophrenia, in Laing's
view, was an attempt to cope with an unbearable
situation. Mosher had read The Divided Self
when it first appeared, and he had thought it
matched his own experiences with patients so
closely "that I wondered why it was causing a
stir."
In
June of 1966, Laing brought the young American up
to date on developments at Kingsley Hall. This East
London building, owned by the Quakers, had housed
Mahatma Gandhi during his negotiations with the
British in the early 1930s, and it had reclaimed
the spotlight when the Quakers made it available to
a group called the Philadelphia Association, whose
membership included Laing. The previous fall (in
1965), "They had assembled people who had been
labeled as having serious problems," Mosher
explains. "The original notion was that the
professionals would live there with the people who
were (as they would say) 'less together.'… The
environment itself would be the therapeutic
instrument…an egalitarian community where the
boundaries between the sane and the insane were not
defined by status."
By
the time Mosher arrived in London, some of the
original ideals had fallen by the wayside. "Most of
the professionals didn't live there very long," he
recalls. "They didn't like the constant intrusion
of the crazies. They had no privacy." A constant
stream of visitors also trooped through, and Mosher
says, "It became like a zoo -- where the visiting
American firemen would come to look at the animals
in the cages." He says Kingsley Hall's residents
eventually rebelled, declaring that no one could
enter the facility unless invited by a resident.
For several months, Mosher was excluded, but he was
later invited back, and he often spent an evening a
week there.
As
he did so, he made a mental list of things that
bothered him. He felt critical of the "run-down
dirty state of the house, the chaotic
disorganization of its money matters, and the at
best haphazard gathering and preparation of food."
He thought the residents' isolationist and even
hostile attitude toward the surrounding
neighborhood was apt to lead to a backlash. Inside
the hall, he raised an eyebrow at the reliance on
altruism and friendship to generate interpersonal
involvement. "While the aim sounds noble, the
result was that unattractive residents spent large
amounts of their time alone on their 'trips.' "
Mosher thought "some salaried staff, whose job it
was to be nonaggressively involved with spaced-out
residents, would achieve better results than
leaving the mad to their loneliness and
misery."
Despite
its shortcomings, the experimental treatment model
fired Mosher's imagination. "I decided, for
example, that madness need not be -- and is
probably better not -- treated in a hospital."
Mosher felt that Kingsley Hall at least had proven
that schizophrenics could recover in an open
institution where the residents' roles were not
defined rigidly and status and power hierarchies
were minimized. Medical and psychiatric trappings
were "at best irrelevant and at worst harmful for
the mad," he concluded.
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