News of scandal is a few decades too late

Mad In America

October 3, 2003

As a polemic against abusive societal reactions to madness, this book succeeds admirably. As a scholarly offering, it leaves a lot to be desired.

The author, a journalist, writes clearly and spices up the text with entertaining drama. We are told that he "stumbled onto an unusual line of psychiatric research" in 1998. After that he made some inquiries into the state of psychiatry and its treatment of "the mentally ill". His list of acknowledgements highlights several established psychiatric historians including Andrew Scull, Edward Shorter, Gerald Grob and Nancy Tomes.

Robert Whitaker has attempted to go beyond the investigative reportage he produced on mental illness for the Boston Globe in 1998.

However, to then make a leap to a book with a serious academic ambition requires a period of study that the hit-and-run world of journalism rarely permits. As a consequence, the sources he rapidly digests are selective and incomplete. The book would fail as a literature review for a PhD. Books (whether written by scholars or not) are not obliged to be as scrupulous as doctorates. However, they do invite exactly the same degree of critical appraisal if they make claims of new knowledge. This point leaves this book open to attack. For example, there is no exploration of the rise (and fall) of anti-psychiatry, nor is there any analysis of the international social movement of patients opposed to psychiatric orthodoxy. A particularly important omission is that of Richard Warner's Recovery from Schizophrenia , which is highly relevant to Whitaker's core thesis.

According to the fly-leaf, Whitaker "reveals an astounding truth: schizophrenics in the United States currently fare worse than patients in the world's poorest countries, and quite possibly worse than asylum patients did in the early 19th century". Warner and others have already explored this point with less hyperbolic drama.

If a reader knew nothing of the prolonged and polarised divisions in mental-health debates, then Whitaker's work would indeed have been a revelation. However, nearly everything he documents summarises what has been claimed in the academy for decades: the dark entanglement of psychiatry with eugenics; the brutalising impact of mass institutional containment; the scandalous iatrogenic toll of psychotropic medication; and the mystifying use of medicine for the regulation of our moral order.

Whitaker makes no mention of the post-structuralist take on the shortcomings of mental-health work. He writes as if the latter is about only the management of madness -a picture true 100 years ago but not today. Other professional pretensions are now apparent, such as the amelioration of neurotic distress, the management of personality problems and the promotion of positive mental health. Whitaker's singular focus on madness obscures this complexity and the critiques it has provoked.

The strongest points in the book relate to a topic relatively underexplored in professional literature -the new confidence in "atypical antipsychotics". Attention is drawn to the premature willingness of the medical establishment to embrace these drugs as a cost-effective alternative to low-dose older ones or even to supporting people through a non-medicated mad episode. The latter prospect is blocked by the collusion of medical paternalism and the need of others for social control. The term "anti-psychotic" is itself a misnomer. Drugs control some of the manifestations of madness, some of the time, in some people. They are about "symptom reduction", not cure. Whitaker argues well about the blinkers imposed by pharmaceutical hegemony.

Do the book's academic shortcomings matter? If it is read as a popularising summary of why the role of psychiatry in society and dubious medical claims of beneficence about madness should be held up to scrutiny, it will serve a useful function for readers new to the contested world of mental-health policy. However, many accessible books have already been written about the history and current role of the mental-health industry. This book adds little value to this legacy; apart from drawing attention to the need to properly evaluate new psychiatric drugs.

Had the author been more comprehensive in his academic sourcing and more modest in his claims of originality, his product would have been more persuasive. Alternatively, it would have stood up well as a polemical tract, stripped of its scholarly pretensions. The semi-academic froth he generates distracts the reader from a legitimate outrage, which is not his alone. It was shared by many others well before 1998.

David Pilgrim is professor of mental health, University of Liverpool.

Mad In America: Bad Science, Bad Medicine and the Enduring Mistreatment of the Mentally Ill

Author - Robert Whitaker
Pages - 334
Publisher - Perseus
Price - £20.99
Editor - 0 7382 0385 8

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