The story of modern psychiatry, for many, is triumphant one. The quick-and-dirty history goes like this: Human ingenuity and scientific advances led us from the dark ages of hydrotherapy and solitary confinement to cognitive-behavioral therapy and expertly prescribed medications. While we used to believe the mentally ill were unwell as a result of wayward behavior or demonic possession, we now know that psychic anguish is the result of brain chemistry and nurture, and we’re working harder to analyze the former. We moved, in other words, from mental illness as a moral failure to mental illness as a medical condition.
But if you zoom in on the late 1940s through the early ’60s, a different battle is being waged—a battle between those who believed mental illness was biologically located in the brain, and those who thought mental illness was a matter of emotional disturbance. Back then, those intent upon transforming psychiatry into a reputable science (as opposed to a touchy-feely art) worked tirelessly to develop new methods of medical intervention for the mentally ill. The best-known method was “psychosurgery” (aka lobotomy), which was introduced by neurologist Egas Moniz in 1936. In 1949, Moniz won the Nobel Prize for his work on psychosurgery, and by 1951, the operation had been performed close to 20,000 times.1
Contrast this obsession with the physical brain—slicing it, shocking it, or tranquilizing it—with the ethos held by Chestnut Lodge, the elite private institution where Joanne Greenberg began treatment in 1948. The clinicians at Chestnut Lodge fervently believed that no patient, however psychotic, was impervious to psychotherapy. The champion of this viewpoint was the Lodge’s most famous employee, the gifted psychoanalyst Frieda Fromm-Reichmann. Fromm-Reichmann was Greenberg’s primary analyst and, in both the novel and in real life, led her from insanity to wellness. In the book, Fromm-Reichmann is “Dr. Fried,” and Greenberg so positively depicted the humble German that for years she received letters from struggling fans desperate to track down Dr. Fried and undergo analysis with her.
Fromm-Reichmann immediately recognized something special in her teenaged patient: Greenberg was quick-witted, well-read, and seemed to retain an appetite for life that many of the doctor’s older, chronically ill patients had lost long ago. Greenberg’s symptoms were often referred to as “florid”—interpretable, extravagant, and suffused with meaning, like a story. When Joanne was struggling, Fromm-Reichmann openly empathized. When she began to retreat, the doctor begged to follow. “Take me along with you,” Dr. Fried tells Deborah during a session. She insisted to her young patient that they must pose a united front. “I believe that you and I,” Greenberg has her say in Rose Garden, “can beat this thing.” And, together, that’s just what they did.
This narrative is a little too pat for our contemporary sensibilities. Perhaps that’s why the book is not as well known as, say, Sylvia Plath’s The Bell Jar. (The Bell Jar still sells briskly; the fiftieth-anniversary paperback edition is ranked 1,730 on Amazon, compared to Rose Garden’s 21,792.2) But Rose Garden does not appeal for another reason: It’s easier to think of the psychiatry of yore as entirely backward and as the poetic casualties of it—Plath, Arbus, Sexton—as victims of that ignorance. Their tragic stories, paradoxically, make us feel more secure in the march of psychiatric progress.
The demise of these women—and the subsequent autopsy of past mental healthcare failures that their paper trails encourages—permits us to rest serenely in the knowledge that the world is moving steadily toward a more scientific, humane psychiatry. But, one has to wonder if this is entirely the case. Frieda Fromm-Reichmann spent four years with Joanne Greenberg; she hiked up to the Disturbed Ward to see patients when they were lying limp in restraints. Now, psychiatrists evaluate patients for 45 minutes before diagnosing them and sending them off to fill prescriptions, and many patients go months between appointments. Efficiency is the goal here; medication the cure, meaningful human connection a distant second priority. It is increasingly rare to find a psychiatrist who also performs talk therapy, despite its many proven benefits.
This might be an even greater tragedy with regard to treatment of schizophrenia, where holistic treatment—that is, one that recognizes both the medical and the emotional components and allows for feedback between the two—might hold particular promise. According to Dr. Allen J. Frances of Duke Medical School and the author of Saving Normal: An Insider’s Revolt Against Out-of-Control Psychiatric Diagnosis, DSM-5, Big Pharma, and the Medicalization of Ordinary Life, “Cognitive therapy and social skills therapy are very valuable in treating schizophrenia, but they are rarely available.” And the idea of “complete recovery” is downplayed.
If you are a regular reader of this blog, you know that my wife Wendy has struggled with depression for most of her life. As she has written about before, like many others, she was sexually abused for an extended period growing up and it took a toll on her as she has grown older. It has never gone away and returns with a vengeance each and every summer and causes chaos and pain around here until fall.
This is the process we have to go through to get help.
She needs to go to her family doctor who prescribes depression medication and then writes a referral to the psychiatrist. Since that is a year to two year wait, she goes back to her family doctor who ups her medication, ups it again, ups it again and then realizes it doesn’t work. So then she is weaned off her medication and then the doctor does it again. If that doesn’t work. Repeat.
Finally she gets to see the psychiatrist (18 months later), she walks in, explains her situation, he tells her she has PTSD and then gives her a prescription for a stronger medication. Out in 10 minutes.
That medication may or may not work. If not, she can go back and is back out in five minutes with a new prescription. If it does work, it works for about 8 months and then when she tries to go back, she is told that her file is closed. She needs another referral (and a year wait).
That is what is covered by Saskatchewan Health. What she really needs is talk therapy as well which is not covered by Saskatchewan Health and runs over $100 a session. Since it isn’t part of her health care or any kind of continuum of care, the therapist and psychiatrist don’t talk which means that once summer went spent thousands on therapy that did nothing because Wendy’s medication was off.
What we are told is that Wendy’s condition will be with her for the rest of her life and she just needs to keep taking her medication. In some ways that may be correct but the reality is that it doesn’t have to be as bad as it is or as costly if we spent the resources to treat mental illness like we do other illnesses. I think that is what makes people so uncomfortable, we know we can do better but do not because of a shortage of psychiatrists and clinical psychologists in our system. Heck we don’t even benchmark mental illness treatment in Saskatchewan. How do we hope to get better when we don’t define success?
It’s been a frustrating process to see Wendy struggle like this. Her public presence like many is far different then her private one and I have been more than willing to move to get her treatment. We have explored selling the house and our stuff and moving south to the United States but the equity in our house won’t touch long term treatment costs. So like a lot of families and people who struggle with depression, we stay and try our best to work in the cycle of madness and fight the assumption that mental illness can’t he cured.