|
 Sooner
than he anticipated, he had an opportunity to test
this conviction. When Mosher left London, he headed
for Yale University's medical school, where a job
as assistant professor awaited him. Mosher had been
recruited to Yale's faculty in the expectation that
he would share the new family-study methods he had
learned at the National Institute of Mental Health.
After experiencing the vibrant countercultural
energies surging through late-'60s London, however,
Mosher says his new domain gave him a serious case
of culture shock. Yale's psychiatry department was
"conservative, psychoanalytic, and dominated by
powerful full professors." Furthermore, when
another assistant professor got sent to Vietnam,
Mosher was asked to assume this man's duties of
overseeing a 20-bed psychiatric ward in the
brand-new Connecticut Mental Health Center. To
Mosher it seemed like the perfect opportunity to
put his unconventional ideas into
practice.
The
result was "totally open, voluntary, with everyone
doing what he wanted. People were allowed to
decorate their rooms. It was a lot like a college
dormitory." Mosher phased out staff-only meetings;
he unlocked the doors and made it clear that
patients could organize their own activities. They
should be treated like consumers, rather than
patients, the psychiatrist urged his staff. And he
says, "The patients loved it! And the psychiatric
residents I trained were delighted. This was the
late '60s.… We did all kinds of weird things,
like, someone would come in on a commitment paper,
and I would sit down and talk to them. I'd say,
'Well, what can we do to help you?' And if they
couldn't find something, I would say, 'If this
isn't the place for you, you can go.'
"
By
Yale standards, it was "a deviant place," Mosher
acknowledges in hindsight. "There were wards above
and below it that were very, very different -- much
more traditional." He says by spring, the hospital
administrators' consternation had become intense.
They saw it leading to an increased number of
suicide attempts, violent incidents, and patients
being sent to the state hospital. After a year,
Mosher agreed to move on.
Once
he left, however, he studied the data pertaining to
his free-form ward and to the traditional wards
that had operated above and below it. He says he
found no evidence that patients on his floor had
fared any worse than those in the other wards. "It
turns out if you allow people to be free, they
actually behave pretty well," Mosher asserts.
"Probably better than under force." He says his
study taught him something else. Until he analyzed
the data, he'd accepted what his powerful and
respected medical supervisors had said about his
experiment. "It's the role of power and perception.
If those who are more powerful and in charge say
that black is white, you're apt to say maybe black
is white." Victims can come to embrace the way
their persecutors see the world -- "a paradigm
utterly applicable to the development of
madness."
Mosher
at this point turned his sights on a place where
the analysis of hard scientific data promised to
have top priority, namely the National Institute of
Mental Health. His previous work there had won him
friends, and his job inquiries came at a fortuitous
time. Amidst the free-spending euphoria of Lyndon
Johnson's Great Society, Congress was lavishing
money on all sorts of Washington institutions.
Mosher says the legislators "had put a box in their
organization chart labeled Center for Studies of
Schizophrenia and said, 'Fill this box.' " At 34,
he became the center's first chief. "I got there in
1968, and I lasted until 1980. Not without
considerable turmoil."
Although
the Center for Studies of Schizophrenia was new,
the National Institute of Mental Health had already
funded hundreds of studies of the baffling
psychosis. Mosher says the first thing he did upon
his arrival was to review the institute-sponsored
schizophrenia research then in progress. He also
began scrutinizing all new requests for research
funds, as well as sitting in on committee meetings
of scientists who reviewed the grant
applications.
He
says in 1968 he wasn't convinced schizophrenia was
an organic illness. "In my mind, it was sort of an
open question. There were so many differences among
people who had the same label that it made me
pause." Schizophrenia was then, as it is now,
considered to encompass a long list of potential
symptoms (see box above). "And you can get that
label without sharing a single characteristic with
some other person with the same label," Mosher
points out. No blood test or brain scan or other
external validating criterion for schizophrenia has
ever been established. Instead, a diagnosis "boils
down to the subjective impression of the
interviewer." The question of whether a person
receives the label is "just my call, as the
diagnostician."
Mosher
leaned toward the view that schizophrenic behavior
resulted from psychosocial experiences. But today
he insists that as chief of the center, "I had no
objection to people approaching it from a disease
standpoint.… I just thought that both
[disease and social models] ought to get
equal time and an equal amount of money." Mosher
says his attitude toward biologically oriented
research proposals was " 'Fine. If you obey the
canons of science and produce an answer, that's
great. And the same with the social side.' But of
course, it was always the biological types and the
drug types, the interventionists, who announced the
causes and the cures."
During
his tenure, Mosher says, "There must have been
three or four causes and four or five different
cures announced." He says his all-time favorite
cure was kidney dialysis. "It was very easy to
figure out why it worked," he says with a chuckle.
"The guy who was doing it was this preacher type of
doctor." He and his staff set up schizophrenics in
pleasant, comfortable housing; they showered them
with attention. "He was really a great guy, and
they did all sorts of proper stuff." He also made
his patients undergo twice-weekly dialysis, even
though their kidneys were normal. And when the
patients improved, he proclaimed that the dialysis
was responsible. "Meanwhile, they were having a
nice life," Mosher says. "But we were forced at the
NIMH to spend a couple million dollars studying
dialysis not done by him. And guess what?
It didn't work. I had told them that it wouldn't.
But the NIMH is a political animal. So we had to go
out and help people design studies" that attempted
to confirm that kidney dialysis could rescue people
from madness.
Although
he looks back on the alleged dialysis cure with
something approaching fondness, Mosher has darker
memories of the drug research he saw unfolding
under the aegis of the National Institute of Mental
Health. In 1968, the notion that schizophrenic
symptoms could be controlled by pills (or
injections) was hardly new. Smith, Kline &
French had started selling a drug called
chlorpromazine to American doctors in May 1954
(when Mosher was just completing his junior year at
Stanford). Patented as Thorazine, this was the
first substance marketed as an antischizophrenic
medication -- one that in later years would be
likened to penicillin in general
medicine.
As
soon as the Food and Drug Administration approved
chlorpromazine, Smith Kline produced a television
show called The March of Medicine that
suggested Thorazine was nothing short of
miraculous. This program "was the kickoff in an
innovative, even brilliant plan for selling the
drug," writes Robert Whitaker, the Boston-based
author of Mad in America: Bad Science, Bad
Medicine, and the Enduring Mistreatment of the
Mentally Ill, a trenchant critique of
contemporary schizophrenia treatment released by
Perseus Publishing last year. According to
Whitaker, Smith Kline's marketing campaign included
setting up a national speakers' training bureau "to
coach hospital administrators and psychiatrists on
what to say to the press and to state
officials.…" The message they spread told of
"lost lives being wonderfully restored." Whitaker
writes, "The company also compiled statistics on
how use of the drug would save states money in the
long run -- staff turnover at asylums would be
reduced because handling the patients would be
easier, facility maintenance costs would be
decreased, and ultimately, at least in theory, many
medicated patients could be discharged. This was a
win-win story to be created -- the patients' lives
would be greatly improved and taxpayers would save
money."
In
his book, Whitaker asserts that the evidence
supporting this rosy vision was sketchy at best.
The U.S. Department of Agriculture had used some
phenothiazines (the family of compounds that
includes chlorpromazine) in the 1930s to kill
insects and swine parasites. In the following
decade, the chemicals "were found to sharply limit
locomotor activity in mammals, but without putting
them to sleep. Rats that had learned to climb ropes
in order to avoid painful electric shocks could no
longer perform this escape task when administered
phenothiazines." Intrigued by these findings,
researchers in France had used chlorpromazine as an
anaesthetic adjunct for surgery patients and then
on manic patients, who became like zombies under
the influence of the drug. The first North American
psychiatrist to test it noted with approval that
chlorpromazine might "prove to be a pharmacological
substitute for lobotomy."
Doctors
in Europe and America also pointed out that
patients taking the drug often developed the
shuffling gait, mask-like visage, and drooling
associated with Parkinson's disease. Others
observed that it mimicked the symptoms of
encephalitis lethargica (a so-called sleeping
sickness). Whitaker comments that in the early
1950s, "such effects were seen as
desirable." Most psychiatrists then
perceived insulin coma, electroshock, and frontal
lobotomy to be beneficial; they made patients
quieter and easier to handle. "Approximately 10,000
mental patients in the United States were
lobotomized in 1950 and 1951," Whitaker writes, and
in 1954, "hospital administrators were still
struggling with horribly inadequate budgets and
hopelessly overcrowded facilities. A drug that
could reliably tranquilize disruptive patients was
bound to be welcomed."
Sniffing
the potential for big profits, Smith Kline wanted
to rush the drug to market, and so the company
tested it primarily as an anti-emetic agent,
records Whitaker, who adds, "All told, the company
spent just $350,000 developing the drug,
administering it to fewer than 150 psychiatric
patients for support of its new drug application to
the FDA." Once approved, however, Thorazine (and
the other so-called neuroleptic drugs that followed
it) became the subject of press reports that gushed
over the way the medications worked on lunatics,
not vomiters. In an early article entitled "Wonder
Drug of 1954?" Time magazine described how
patients given Thorazine "sit up and talk sense
[when a doctor enters the room], perhaps
for the first time in months." U.S. News and
World Report suggested that the "wonder drugs"
might be a "new cure for mental ills." The New
York Times ran at least 14 positive articles
about neuroleptics in 1955 and early
1956.
Amidst
the rising tide of hyperbole, federal spending on
mental health research ballooned from $10.9 million
in 1953 to $100.9 million in 1961. Whitaker writes
that by 1963, President Kennedy was announcing that
the new drugs "made it possible for most of the
mentally ill to be successfully and quickly treated
in their own communities and returned to a useful
place in society." A series of reports that
documented a modest decline in mental hospital
censuses between 1955 and 1960 -- years when the
neuroleptics were being introduced -- accounted for
this belief. Whitaker, however, notes that when the
California mental hygiene department looked at
first-episode male schizophrenics admitted to
California hospitals in 1956 and 1957 and compared
the hospitalization lengths of drug-treated
patients versus non-treated ones, the drug
recipients were found to have stayed in the
facilities longer. "In short, the California
investigators determined that neuroleptics, rather
than speeding people's return to the community,
apparently hindered recovery. But it was the
[other] research that got all of the public
attention."
Mosher
was making his way through medical school and
beginning his early psychiatric training just as
the neuroleptic bandwagon began rolling. He
prescribed drugs during his residency training;
none of his mentors had denigrated them. Even the
experience at Kingsley Hall had been ambivalent.
Although the overall gestalt of the experimental
London facility looked down on drug therapy, Mosher
says a number of the residents took neuroleptics
prescribed by doctors unaffiliated with the
Philadelphia Association.
Only
at Yale did alarms begin to sound, he recalls, as
residents and medical students confided to him
their belief that drugs were the only useful
treatment in psychiatry. That seemed extreme,
Mosher thought, and he says his first few years as
the chief of the Center for Studies of
Schizophrenia did nothing to allay his concern
about the growing influence of the pharmacological
industry within American psychiatry. He thought the
National Institute of Mental Health was doling out
an "inordinate" amount of its funding for studies
that the drug companies themselves could well
afford. (Smith Kline's annual revenues, for
example, soared from $53 million in 1953 to $347
million in 1979.) The drug research that the
institute was funding, though sophisticated, seemed
to him repetitive "especially in view of the fact
that the neuroleptics developed early on were as
good as those being endlessly and expensively
tested with federal money." It made more sense to
Mosher to spend taxpayer dollars on evaluating
psychosocial therapies, since they lacked
commercial patrons with deep pockets.
So
he perked up at the grant proposal that came across
his desk one day in 1969. A couple of psychiatric
researchers in Northern California were asking the
National Institute of Mental Health for money to
compare two wards in a state mental hospital: a
traditional one that employed neuroleptics, and a
drug-free ward that offered a special psychosocial
milieu. To Mosher, this sounded like a perfect
opportunity to assess scientifically how a place
like Kingsley Hall stacked up against one that used
drugs as the mainstay of treatment. Unfortunately,
the hospital administrator balked at the proposal,
and the two psychiatric researchers lost interest
in pursuing it.
The
idea continued to intrigue Mosher, however, so he
refined it, coming up with a plan that proposed
randomly assigning newly diagnosed schizophrenic
patients to one of three treatment venues: a
general hospital ward that relied on drug therapy,
a community treatment center that used drugs, and a
community center where drugs were avoided if
possible.
Although
he was a high-ranking insider, Mosher couldn't just
wave his hand and conjure up the money for his own
study. Instead, the project had to go before the
institute's Clinical Project Research Review
Committee. And in 1970, when Mosher first appeared
before the top academic psychiatrists who were its
members, he got a lukewarm reception. According to
Whitaker, who reviewed the minutes of the
committee's review sessions while researching
Mad in America, the resistance was
understandable. Mosher's proposal "didn't just
question the merits of neuroleptics," Whitaker
writes. "It raised the question of whether ordinary
people could do more to help crazy people than
highly educated psychiatrists. The very hypothesis
was offensive."
On
the other hand, turning down the chief of the
Center for Studies of Schizophrenia would have
flouted bureaucratic niceties. So the committee
compromised by giving Mosher less than he had
requested. It slashed one community treatment
center from the study design and offered only
enough money to run the second (drug-free) center
for 18 months (instead of five years). This was
supposed to be a kiss of death, Mosher claims. But
he immediately started working to get the funding
extended. As he toiled on that, the project that
came to be known as Soteria (a Greek word meaning
"deliverance") got underway.
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