Psychoanalysis was introduced to the United States in 1909 when Sigmund Freud (accompanied by Carl Jung) delivered a famous lecture at Clark University, in Worcester, Massachusetts,but its influence grew fairly slowly for the next three decades. Bizarrely, it was World War II that brought psychiatry, and more specifically, psychoanalysis, into the mainstream of American culture.

During the war, for the first time in any national conflict, all recruits and draftees were screened by psychiatrists and physicians for their mental fitness. An astounding number of men—at least 1.1 million and perhaps as many as 1.8 million of the 15 million men evaluated—were rejected because of psychiatric and neurological problems. The war then produced an unprecedented stream of new patients for psychiatry: an endless supply of, to use the euphemism of the day, “battle fatigued” soldiers suffering from guilt, anxiety, and terrifying flashbacks. There were 1.1 million admissions for psychiatric disorders in military hospitals over the course of the war.

There was no coherent system of care to treat this unprecedented amount of anguish other than psychoanalysis. Psychoanalytic practices and concepts were directly infused into military policy beginning in 1943, when William C. Menninger, an outspoken and articulate member of the Topeka Psychoanalytic Society, was appointed chief military psychiatrist. His ability to act as psychiatry’s salesman, both during and after the war, was helped immeasurably by his hyper-normal, squeaky-clean, Chamber of Commerce image. Within two years, Menninger assertively brought psychiatry into the mainstream of military life.

In 1944, he issued a bulletin for Army physicians, “Neuropsychiatry for the General Medical Officer,” in which the role of the subconscious in symptoms was explained, as well as the influence of infancy and childhood on adult character. Menninger’s recommended treatment methods for war neurosis included hypnosis and psychoanalytic therapy. In 1945, Menninger introduced an entirely new diagnostic nomenclature for the field. He created new categories specifically geared to incorporate the war experience, such as “transient personality reactions to acute and special stress,” which included “combat exhaustion” and “acute situational maladjustment” as diagnoses. The section on neurosis was lifted directly from Freud, with sections on repression, conversion (the expression of psychological distress as physical complaints), and displacement (the shifting of emotions from the original object to a more acceptable substitute). Menninger’s taxonomy had influence far beyond the war, becoming the basis for the American Psychiatric Association’s first diagnostic manual in 1952, the direct predecessor of today’s Diagnostic and Statistical Manuals.

The war also saw the advent of new treatment techniques. Group therapy was invented by beleaguered and overwhelmed medical staff, and it showed great promise for soldiers suffering from what we would now call post-traumatic stress disorder. It has been suggested that one of the reasons that group therapy worked so well is that it broke down the hierarchies of military life and the prewar social structure. Medical staff rarely wore white coats, and patients and staff referred to one another by their first names.

The experience and trauma of war bolstered belief in the environmental causes of mental illness. Genetic and hereditary explanations lost substantial ground in the face of the demonstrable evidence of the damage that experience could do.

In the optimistic glow immediately following the war, Americans really did believe that psychoanalysis could help make the world a better place. In 1945, Menninger could write that “psychiatry, for better or worse, is receiving a tremendously increased interest. This is manifest on all sides by articles in magazines, in the newspapers, frequent references to psychiatry and psychiatric problems on the radio and in the movies.” Shortly thereafter, the central dilemma of the psychoanalyst was identified in the journal Daedalus: There weren’t enough of them to be everywhere at once. It was seriously argued that if only statesmen were to go through psychoanalysis there would be no more wars, and articles in psychiatric journals pondered the psychoanalytic implications of President John F. Kennedy’s death for the nation.

How soon, and how easily, it would all crumble away.

If this portrait sounds a little underwhelming, don’t blame microcredit. The real issue is that we so often underestimate the severity and inertia of global poverty. Natalie Portman may not be right when she says that an end to poverty is “just a mouse click away,” but she’s right to be supportive of a tool that helps soften some of poverty’s worst blows for many millions of desperate ­people.

It is fashionable nowin academic psychiatry to condemn the fancies of the last century. “All sciences have to pass through an ordeal by quackery,” wrote the psychologist Hans Eysenck. “Chemistry had to slough off the fetters of alchemy. The brain sciences had to disengage themselves from the tenets of phrenology. . . . Psychology and psychiatry too will have to abandon the pseudo-science of psychoanalysis. . . and undertake the arduous task of transforming their disciplines into a genuine science.

“Psychology itself is dead,” writes Michael Gazzaniga, a prominent neuroscientist at the University of California, Santa Barbara, in 

 (1998). “Today the mind sciences are the province of evolutionary biologists, cognitive scientists, neuroscientists, psychophysicists, linguists, computer scientists—you name it. . . . The odd thing is that everyone but its practitioners knows about the death of psychology.”

Ironically, Freud essentially predicted what would happen—that is, he predicted his own death. In 

 (1924), he wrote about psychoanalysis: “The deficiencies in our description would probably vanish if we were already in a position to replace the psychological terms with physiological or chemical ones. We may expect [biology] to give the most surprising information and we cannot guess what answers it will return in a few dozen years of questions we have put to it. They may be of a kind that will blow away the whole of our artificial structure of hypothesis.”

Freud, it turns out, still has at least one lesson for today’s biopsychiatry enthusiasts: humility.

 worked with the homeless mentally ill in New York City for 10 years. He is a lecturer in psychiatry at Yale University and the author of 

Songs From the Black Chair: A Memoir of Mental Interiors. 

This essay is adapted from his new book, 

Comfortably Numb: How Psychiatry Is Medicating a Nation.

4724841560_3bf41e8e58_b.jpg

Bizarrely, it was World War II that brought psychiatry, and more specifically, psychoanalysis, into the mainstream of American culture.

How Freud Conquered America, Then Lost It

A team of American researchers attracted national attention last year when they announced results of a study that, they said, reveal key factors that will influence how swing voters cast their ballots in the upcoming presidential election. The researchers didn’t gain these miraculous insights by polling their subjects. They scanned their brains. Theirs was just the latest in a lengthening skein of studies that use new brain-scan technology to plumb the mysteries of the American political mind. But politics is just the beginning. It’s hard to pick up a newspaper without reading some newly minted neuroscientific explanation for complex human phenomena, from schizophrenia to substance abuse to ­homosexuality.

The new neuroscience has emerged from the last two decades of formidable progress in brain science, psychopharmacology, and brain imaging, bringing together research related to the human nervous system in fields as diverse as genetics and computer science. It has flowered into one of the hottest fields in academia, where almost anything “neuro” now generates excitement, along with neologisms—neuroeconomics, neurophilosophy, neuromarketing. The torrent of money flowing into the field can only be described in superlatives—hundreds of millions of dollars for efforts such as Princeton’s Center for the Study of Brain, Mind, and Behavior and MIT’s McGovern Institute for Brain Research.

Psychiatrists have been in the forefront of the transformation, eagerly shrugging off the vestiges of “talk therapy” for the bold new paradigms of neuroscience. By the late 1980s, academic psychiatrists were beginning literally to reinvent parts of the discipline, hanging out new signs saying Department of Neuropsychiatry in some medical schools. A similar transformation has occurred in academic psychology.

A layperson leafing through a mainstream psychiatric journal today might easily conclude that biologists had taken over the profession. “Acute Stress and Nicotine Cues Interact to Unveil Locomotor Arousal and ­Activity-­Dependent Gene Expression in the Prefrontal Cortex” is the title of a typical offering. The field has so thoroughly cast its lot with biology, and with the biology induced by psychoactive drugs, that psychiatrists can hardly hope to publish in one of the mainstream journals if their article tells the story of an individual patient, or includes any personal thoughts or feelings about the people or the work that patient was engaged with, or fails to include a large dose of statistical data. Psychiatry used to be all theories, urges, and ids. Now it’s all genes, receptors, and ­neurotransmitters.

As a result of these changes, the field, once seen as the province of woolly-headed eccentrics, has gained a new public image. Psychiatry is now seen as a solid branch of medicine, a bona fide science built on ­white-­coated certitude. It has joined Big Science. The completion of the Human Genome Project in 2003 contributed to the growing popular belief that psychiatric disorders proceed in neat Mendelian inheritable patterns, and that psychiatrists are starting to methodically unlock these patterns’ mysteries. But if anything has been gleaned from the last two decades of work in the genetics of psychiatric disorders, it is that the origins of these maladies are terribly complex. No individual gene for a psychiatric disorder has been found, and none likely will ever be. Psychiatric disorders are almost certainly the product of an infinitely complex dialogue between genes and the ­environment.

Nevertheless, earlier paradigms in academic psychology and psychiatry—­“soft” disciplines such as old-fashioned psychoanalysis and behaviorism and ­psycho­therapy—­have been chucked aside like so many rotting vegetables. Ironically, this shift—which is terribly premature—is occurring even as psychotherapy is rapidly improving. Psychiatry used to be brainless, it’s said by some in the field, and now it’s mindless.

Sea changes such as the advent of biopsychiatry are not unusual in the history of American psychiatry. In fact, they have been common. One paradigm replaces another, and each one is embraced with certainty and passion. Only in hindsight are the revolutions questioned and ­discredited.

Fifty years ago, psychoanalysis enjoyed the same prestige and influence that biopsychiatry does today. In 1959, during the heyday of psychoanalysis, the sociologist Philip Rieff observed that “in America today, Freud’s intellectual influence is greater than that of any other modern thinker. He presides over the mass media, the college classroom, the chatter at parties, the playgrounds of the middle classes.” The literary critic Lionel Trilling, in 1947, called Freud’s thought “the only systematic account of the human mind, which, in point of subtlety and complexity, of interest and tragic power, deserves to stand beside the chaotic mass of psychological insights which literature has accumulated through the centuries.” Today, of course, psychoanalysis is largely a cultural afterthought for all but a few wealthy ­acolytes.

The history of American psychiatry can be divided into three overlapping eras: Asylum Psychiatry, Community Psychiatry, and today’s Corporate Psychiatry. In its improbable odyssey, psychiatry has gone from the back wards of hospitals to the boardrooms of corporations, from invisible to virtually omnipresent. As the psychiatrist and author Jonathan Metzl has pointed out, for its first century at least, psychiatry dealt with what were considered obscure mental processes and was conducted in the shadows. Now it is ­everywhere—­in the movies, in advertisements, on television shows, and, most significantly, in our ­bloodstreams.

Asylum Psychiatry was born around the beginning of the 19th century with the founding of a number of institutions for the mentally ill, such as Maryland’s Spring Grove State Hospital. By 1904 there were 150,000 patients in U.S. psychiatric hospitals, and by ­mid­century the asylum population peaked at more than a million. Asylum Psychiatry followed two ­tracks—­one perfectly ­well ­intentioned and generally benign, the other horrific. The initial impetus was to provide retreats, often in sylvan settings, where, in the absence of any actual ­evidence-­based treatments, patients could at least be left alone in a tranquil setting. But there was an equally long tradition in the asylums of providing (or imposing) the most wretched treatments imaginable. What Daniel Defoe wrote in 1728 has been echoed many times since: “If they are not mad when they go to these cursed Houses, they are soon made so by barbarous Usage they there suffer. . . . Is it not enough to make anyone mad to be suddenly clap’d up, stripp’d, whipp’d, ill fed and worse. . . ?”

, journalist Albert Deutsch compared state mental hospitals with Nazi concentration camps, their “buildings swarming with naked humans herded like cattle and treated with less concern, pervaded by a fetid odor so heavy, so nauseating, that the stench seemed to have almost a physical existence of its own.” Not uncommonly, patients were sterilized so as to permanently halt the moral contagion of their illness. Editorials in 

 endorsed the practice. By 1945 some 45,000 Americans had been sterilized, almost half of them psychiatric patients in state ­facilities.

In 1916, Dr. Henry Cotton of Trenton State Hospital, believing that germs from tooth decay led to insanity, removed patient’s teeth and other body parts, such as the bowels, which he thought might be the causes of their madness. He killed almost half the patients who received his “thorough” treatment, more than 100 people. Cotton’s practices were covered up by the hospital board and the leading figure in American psychiatry of the day, Adolf Meyer, and Cotton was allowed to continue practicing at the hospital for nearly 20 more years. In a eulogy for Cotton in 1933, Meyer lauded his “extraordinary record of achievement.”

Two years later, the Portuguese neurologist Egas Moniz performed the first lobotomy, or what he called a “leucotomy” (white cut). Moniz had failed to win a Nobel Prize for his earlier brain research and was eager to make a splash. After hearing a lecture in which the speaker conjectured that the prefrontal cortex was the site of psychopathology, he decided to try out a method of destroying that part of the brain in his patients. One of the brutalized subjects of these experiments repaid Moniz in 1939 by shooting him, leaving him partially paralyzed. None-theless, Moniz’s efforts were re­warded with the Nobel Prize in Physiology or Medicine in ­1949.

The American champion of the lobotomy, Walter Freeman, roamed the country as a veritable Johnny Appleseed of the technique, to which he added his own refinements, which amounted to jamming an ice pick through the patient’s eye sockets and destroying the frontal lobes. A successful operation, in Freeman’s view, was one in which the patient became adjusted at “the level of a domestic invalid or household pet.” Between 1935 and 1950 some 20,000 American psychiatric patients were subjected to lobotomies, or, as the procedure was more gently called, “psychosurgery.”

What finally ended the lobotomy era was not any newfound compassion or enlightenment, but the emergence of antipsychotic drugs that made psychosurgery “redundant.” The groundwork of the new Community Psychiatry had been laid when the psychiatric profession took its first, tentative steps from universities and hospitals into office practice between the world wars, led by émigré European psychoanalysts who established themselves in prestigious private practices, mainly in the big cities of the East. Especially after World War II, ­American-­born psychiatrists rapidly abandoned their bases in universities and hospitals for private practice in order to serve the ­cash-­carrying middle and upper classes. (Psychiatrists are medical doctors with a specialization in psychiatry; psychoanalysts may have either an M.D. or, thanks to relatively recent rule changes, a Ph.D., in addition to psychoanalytic training.) By 1955, more than 80 percent of American psychiatrists were working in private practice. At the time, neither group was very ­large—­there were only 1,400 psychoanalysts in the world in 1957, and a somewhat larger number of psychiatrists in the United States alone. (Today, there are some 45,000 psychiatrists and more than 3,500 psycho­analysts in the United States.) But the influence of the two groups was profound, greatly amplified by legions of social workers, assorted therapists, and popular culture (see sidebar on page 38).

As with Asylum Psychiatry, there have been two prongs of Community Psychiatry. One has proved a great success, the other a national disgrace. For the “worried well,” the 1960s through the ’90s saw an explosion in the number of non–psychiatrist therapists (social workers, clinical psychologists, addiction counselors), who have treated an ­ever-­expanding proportion of the population. By the early 1980s, one in 10 Americans was being treated for mental ­problems.

Therapists treated an ever-expanding proportion of the population: By the early 1980s, one in 10 Americans was being treated for mental problems.

Community Psychiatry for the seriously mentally ill began with the introduction of Thorazine in the 1950s, which led relatively quickly to the mass depopulation of the asylums. At first, “deinstitutionalization” was thought to be a wonderful thing. By giving their patients a medication that appeared to work and then sending them on their way, ­biologically ­minded psychiatrists thought they were setting patients free. Those with an activist bent saw the release of patients into the community as an act of liberation from the oppressive institutions and hierarchies of medical care. State governments were only too happy to divest themselves of the bad karma and expense of massive networks of ­long-­term care ­facilities.

For all the high expectations and lofty rhetoric, the reality was that the effectiveness of the drugs was overestimated and the necessity of appropriate community support for patients was underestimated or ignored. The goal of John F. Kennedy’s 1963 Community Mental Health Act to create a national network of outpatient clinics proved too ambitious. The clinics that were opened were quickly co-opted for therapy sessions for the ­middle-­class worried well, and funding withered during the prosecution of the Vietnam War. Kennedy’s death, too, certainly played a part. He was an early advocate of community treatment, influenced no doubt by the experience of his sister Rosemary, who was developmentally disabled and mentally ill, and who herself had been subjected to a ­lobotomy.

Eventually there was simply no place for patients to go but the parks, the bus stations, the public libraries, the emergency rooms, and the homeless shelters. Deinstitutionalization coincided with the arrival of AIDS and the emergence of crack cocaine in the early 1980s, and the numbers of the homeless mentally ill rose dramatically across the ­country.

Today, state hospitals house only about five percent as many patients as they did at their peak. Community Psychiatry is being eroded by managed care and the national obsession with psychiatric medications instead of therapy. The new, biologically driven Corporate Psychiatry, with its blockbuster products and its hi-tech glow, is where the juice is now.

And today’s psychiatry really is corporate. A large proportion, arguably the largest portion, of the major pharmaceutical companies’ extraordinary profits in recent decades has come from psychiatric drugs. The medical historian Carl Elliott has written that antidepressants were one of the most profitable products in the most profitable industry in the world over the course of the 1990s. The first tremors of Corporate Psychiatry were felt in the late 1960s and the ’70s, when Valium became the ­top-­selling drug in America, and the earthquake began in 1988 with the introduction of Prozac, which eventually became one of the ­best-­selling drugs in history. Antidepressants are now the sixth-­best-­selling category of drugs in the world, and antipsychotics the seventh. By 2002, more than 11 percent of American women and five percent of American men were taking antidepressants, or about 25 million people. And the use of antidepressants, despite bad press and black-box warnings indicating the resultant risk of suicidal thoughts in young people, has only increased in recent years. Counting the multiple and serial prescriptions often issued to patients, along with renewals, some 227 million antidepressant prescriptions were dispensed in the United States in 2006.

Two developments were at the heart of the revolution that has brought us the biologically based Corporate ­Psychiatry—­the discovery of drugs that actually work, at least for some people, and the rise of brain ­imaging.

Thorazine was the first drug to work. Its invention has been called one of the seminal events in human history, and it was the beginning of the revolution in psychiatry, comparable in its importance to the introduction of penicillin in general medicine. Like many other significant drugs, it was discovered by accident, and when it worked, no one had any idea why. In 1952, Henri Laborit, a French surgeon, was looking for a way to reduce surgical shock in patients. Much of the shock came from anesthesia; Laborit reasoned that if he could use less anesthetic, patients could recover more quickly. Casting about for a solution, he tried Thorazine, a shelved medication that had been developed to fight allergies. Laborit noticed an immediate change in his patients’ mental state. They became relaxed and seemingly indifferent to the surgery awaiting them. Laborit thought Thorazine might be helpful to psychiatric patients, but at that time “no one in their right mind in psychiatry was working with drugs. You used shock or various psychotherapies,” says psychiatrist Heinz Lehmann, Thorazine’s first champion in North America.

The psychiatrist Pierre Deniker heard about Thorazine from his brother-­in-­law, a colleague of Laborit’s, and Deniker tried it on his most agitated, uncontrollable patients in the recesses of a Parisian psychiatric hospital. This was a startlingly novel idea. “Those cases were in the back wards and that was it. The notion you could ever do anything about [them] had never occurred to anyone,” said John Young, an executive at the drug company that later bought the rights to Thorazine (and first put it on the market as an ­anti­vomiting treatment). Another French doctor, Jean Perrin, gave Thorazine to a barber from Lyon who had been hospitalized for years and was unresponsive to any intervention. The barber promptly awoke and declared that he knew who and where he was, and that he wanted to go home and get back to work. Perrin hid his shock and asked the patient to give him a shave, which he did, perfectly. Another patient, suffering from catatonic schizophrenia, had been frozen in various postures for years. He responded to the drug in one day. Within 24 hours, he was greeting the staff by name and asking for billiard balls to ­juggle.

After Deniker and others got over their initial shock and enthusiasm, it became clearer what antipsychotic drugs can ­do—­and what they can’t. In no fashion do they cure the illness, but for many, if not most, people with psychotic disorders such as schizophrenia, they do help to make the condition eminently more tolerable. In many cases the medications, quite literally, lower the volume. Many patients have told me that the drugs dampen the volume of the voices that plague them, reducing the screams and rants to faint echoes, and occasionally drowning them out entirely. Psychiatrists compare the way in which such drugs help, when they are effective, to how insulin works for people with diabetes: Although far from being a cure, they do help the majority of patients manage, and allow them, for the most part, to function, or function better. Or, as Scientific American more clinically put it, “Antipsychotics stop all symptoms in only about 20 percent of patients. . . . Two-thirds gain some relief from antipsychotics yet remain symptomatic . . . and the remainder show no significant response.”

What also became evident over time were the incredibly harsh side effects of the first antipsychotics: involuntary muscle movements, endless pacing (or the “Thorazine shuffle,” as it became known), and, for some, a horrible restlessness, the feeling of needing to crawl out of one’s skin. Later antipsychotics, though they generally have a better side-effect profile, still can lead to major problems, such as massive weight gain and high cholesterol. Patients vote with their feet on the tradeoff between the positive and negative effects of these drugs. In a massive “real world” study published in 2006, three-quarters of those given antipsychotic drugs stopped taking them by the end of the study’s 18 ­months.

Almost as soon as Thorazine became available, psychiatric hospitals in the United States gave it to nearly all their patients, and it was widely prescribed for various uses outside hospital walls. From 1954, when Thorazine was approved by the U.S. Food and Drug Administration, through 1964, 50 million people took the ­drug.

If Thorazine started the revolution in psychiatry, brain imaging finished it. While brain imaging has its origins with computerized tomography (CT) in the 1960s, its most spectacular contributions have occurred in the past 15 years. Even when CT scans did reveal startling images in the 1970s, the results were received with doubt. A landmark 1976 study that showed that the brains of people with schizophrenia had much larger ventricles than “normals” did was met with skepticism, as schizophrenia was assumed to be a psychological disease.

As George H. W. Bush’s 1990 presidential proclamation announcing “The Decade of the Brain” explained, three things happened simultaneously in the 1980s that set up the miraculous pictures to come: Technologies such as positron-­emission tomography (PET) and magnetic resonance imaging (MRI) allowed researchers, for the first time, to observe the living brain; computer technology reached a level of power and sophistication sufficient to handle neuroscience data in a manner that reflected actual brain function; and discoveries at the molecular and cellular levels of the brain shed greater light on how neurophysiological events translate into behavior, thought, and ­emotion.

Almost as soon as Thorazine became available, psychiatric hospitals in the United States gave it to nearly all their patients.

The first ­brain-­imaging technologies, CT scans and MRI, could image brain 

: what the brain would look like if you could take it out of the skull and place it on a table. MRI had the advantage of producing better-quality images without requiring the use of ionizing radiation in the brain, as CT scans do. The resolution of MRI is ­superb—­it yields “slices” of brain that look like they were obtained in a postmortem pathology lab. PET and SPECT (single photon emission computed tomography) scans, which came later, provide an image of brain ­activity—­or 

, by measuring blood flow in the brain as a reflection of brain activity. PET actually shows how neuroreceptors live in the ­brain—­allowing one to see the distribution and number of receptors in particular areas of the brain, the concentration of neurotransmitters at the synapse, and the affinity of a receptor for a particular drug. PET specifically measures glucose metabolism, an indicator of which parts of the brain are using the most energy, which allows neuroscientists to undertake the process of mapping the neural basis of thought and emotion in the living ­brain.

The most spectacular technology of all, ­fMRI—­or functional magnetic resonance imaging—­burst on the scene in the early 1990s. Unique in that it is able to provide images of both structure and function, fMRI produces not just slices of the brain but what are, in effect, extremely ­high-­resolution movies of what the brain looks like when it is working. By measuring blood flow, which is an indicator of brain activity, fMRI reveals which parts of the brain are being used most actively during a given task. That permits observation of the brain while it is actually functioning as a ­mind—­thinking, remembering, seeing, hearing, imagining, experiencing pleasure or ­pain.

Unlike earlier technologies, fMRI requires a very short total scan time (one to two minutes), and it is entirely noninvasive and extraordinarily comprehensive: It can measure brain responses at 100,000 locations. Of the wonders of brain imaging, and in particular fMRI, the leading neuropsychologist Steven Pinker has written exuberantly, “Every facet of mind, from mental images to the moral sense, from mundane memories to acts of genius, has been tied to tracts of neural real estate. Using fMRI . . . scientists can tell whether the owner of the brain is imagining a face or a place. They can knock out a gene and prevent a mouse from learning, or insert extra copies and make it learn better.”

While the sudden visibility of the brain is indeed remarkable, the greater significance is perhaps more symbolic. Brain images are still far cruder than one would think after reading the sensational revelations attributed to them in the science pages of newspapers and magazines. And it must be remembered that these are 

 images of blood flow and glucose in the brain, and not of brain tissue itself. We seem to forget that it is not as if a camera were entering the brain and taking pictures of what is going on. At this point, the most that can be said is that brain imaging indirectly and very broadly measures the activity of groups of thousands of neurons when the brain is engaged in a physical or mental task. While there are some correlations between brain activity in certain regions and external, observable behavior, it is very hard to gauge what the pictures really mean. How does the flow of blood in parts of the brain correspond to feelings, moods, opinions, emotions, imagination? It remains a daunting task to create theories to “operationalize” what is going on underneath all the pretty pictures.

The state of the art right now is that we can read brains—to some very crude extent—but we can’t even begin to read minds. 

 science writer Sharon Begley has coined the term “cognitive paparazzi” to describe those who claim they can. “What does neuroscience know about how the brain makes decisions? Basically nothing,” says Michael Gazzaniga, director of the SAGE Center for the Study of the Mind at the University of California, Santa Barbara.

Another limitation of contemporary neuroscience, Gazzaniga says, is that many brain imaging studies are based on averages of the scans of many patients. “The problem is if you go back to the individual scans, you will see wide variation in the part of the brain that’s activated.” And if you were to do the same scans of the same activity a year later, you might get quite different ­results.

“The community of scientists was excessively optimistic about how quickly imaging would have an impact on psychiatry,” says Steven Hyman, a professor of neurobiology and provost at Harvard as well as former director of the National Institute of Mental Health. “In their enthusiasm, people forgot that the human brain is the most complex object in the history of human inquiry, and it’s not at all easy to see what’s going wrong.”

There are currently no standard ways of treating or assessing mental illness based on brain images. The only unequivocal clinical use of imaging is in detecting raw abnormalities. “The only thing imaging can tell you is whether you have a brain tumor or some other gross neurological damage,” says Paul Root Wolpe of the University of Pennsylvania’s Center for Bioethics. The unfortunate fact remains that the most accurate way of gauging the thoughts and feelings of others is simply by asking them what they are thinking and ­feeling.

Steven Pinker, again: “We are still clueless about how the brain represents the content of our thoughts and feelings. Yes, we may know where jealousy ­happens—­or visual images or spoken ­words—­but ‘where’ is not the same as ‘how.’”

The three-to-four-pound human brain is the most complicated object in the universe.

Nevertheless, the smashing victory of biological psychiatry was almost universally endorsed by the end of the 1990s. David Satcher, U.S. surgeon general, declared in 1999, “The bases of mental illness are chemical changes in the brain. . . . There’s no longer any justification for the distinction . . . between ‘mind and body’ or ‘mental and physical illnesses.’ Mental illnesses are physical illnesses.” Nobel laureate Francis Crick put it more directly: “‘You,’ your joys and your sorrows, your memories and your ambitions, your sense of personal identity and free will, are in fact no more than the behavior of a vast assembly of nerve cells and their associated molecules. As Lewis Carroll’s Alice might have phrased it: ‘You’re nothing but a pack of neurons.’”

The ultimate indicator of our newfound faith in scientific psychiatry may be the mysterious growth of the placebo effect in tests of the drugs the new psychiatry dispenses. When Columbia University psychiatrist B. Timothy Walsh analyzed 75 trials of antidepressants conducted between 1981 and 2000, he discovered that the rate of response to placebos, which are, of course, nothing more than sugar pills, increased by about seven percent per decade. Simply because people thought they were taking the all-powerful medicines, they thought they were getting ­better.

All of the evidence points to the conclusion that today’s full embrace of biological psychiatry is terribly premature, especially since we have available an increasing number of nondrug therapies of proven effectiveness. We are only in the very early stages of understanding how the brain works and what alters its functioning. Somewhere along the way we seem to have misplaced the notion that, at this stage of our scientific evolution at least, the brain’s capacity to understand itself is minimal. The task is endlessly daunting. There are, for example, more than 100 billion neurons in the human brain. Each neuron is connected to hundreds of thousands of other neurons, and each can fire electrical and neurochemical messages hundreds of times a second to other neurons across synapses. Altogether, there are 100 trillion synapses through which these signals flow. All of this activity happens within the confines of a three-to-­four-­pound object. And the brain is not even mainly composed of neurons. Ninety percent of the cells in the brain are not neurons but glial cells, which provide nutrition and protection to the ­neurons.

The brain is the most complicated object in the universe. Nobel ­Prize–­winning psychiatrist Eric Kandel has written, “In fact, we are only beginning to understand the simplest mental functions in biological terms; we are far from having a realistic neurobiology of clinical syndromes.” Neuroscientist Torsten Wiesel, another Nobelist, scoffed at the hubris of calling the 1990s “The Decade of the Brain.” “We need at least a century, maybe even a millennium,” he said, to comprehend the ­brain.

 works,” Wiesel said, referring to a small worm often used by scientists to study molecular and cell biology. In my own travels in the world of neuroresearch, I have consistently found that the elite scientists are surprisingly modest about how much we know about the brain, despite the spectacular progress in recent decades. It is the ­mid­level scientists who are prone to making large ­claims.

To this day, no one knows exactly how psychoactive drugs work. The etiology of depression remains an enduring scientific mystery, with entirely new ways of understanding the disease—or 

, since what we think of as “depression” now is probably dozens of discrete disease entities—constantly emerging. Indeed, the basic tenet of biological psychiatry, that depression is a result of a deficit in serotonin, has proven to be one that was too eagerly embraced. When this “monoamine” theory of depression emerged in the 1960s, it gave the biologically minded practitioners of psychiatry what they had long been craving—a clean, decisive scientific theory to help bring the field in line with the rest of medicine. For patients, too, the serotonin hypothesis was enormously appealing. It not only provided the soothing clarity of a physical explanation for their maladies, it absolved them of responsibility for their illness, and to some degree, their behavior. Because, after all, who’s responsible for a chemical imbalance?

Unfortunately, from the very start there was a massive contradiction at the heart of the monoamine theory. Whatever it is that Prozac and the other members of the widely used class of drugs called selective serotonin reuptake inhibitors (SSRIs) do to change brain chemistry, it happens almost immediately after they are ingested. The neurochemical changes are quick. However, SSRIs typically take weeks, even months, to have any therapeutic influence. Why the delay? No one had any explanation until the late 1990s, when Ronald Duman, a researcher at Yale, showed that antidepressants actually grow brain cells in the hippocampus, a part of the brain associated with memory and mood regulation. Such a finding would have been viewed as preposterous even a decade earlier; one of the central dogmas of brain science for more than a century has been that the adult brain is incapable of producing new neurons. Duman showed that the dogma is false. He believes that the therapeutic effects of SSRIs are delayed because it takes weeks or months to build up a critical mass of the new brain cells sufficient to initiate a healing process in the brain.

While Duman’s explanation for the mechanism of action of the SSRIs remains controversial, a consensus is building that SSRIs most likely initiate a series of complex changes, involving many neurotransmitters, that alter the functioning of the brain at the cellular and molecular levels. It appears that SSRIs may only be the necessary first step of a “cascade” of brain changes that occur long after and well “downstream” of serotonin alterations. The frustrating truth is that depression, like all mental illnesses, is an incredibly complicated and poorly understood disease, involving many neurotransmitters, many genes, and an intricate, infinite, dialectical dance between experience and biology. One of the leading serotonin researchers, Jeffrey Meyer of the University of Toronto, summed up the misplaced logic of the monoamine hypothesis: “There is a common misunderstanding that serotonin is low during clinical depression. It mostly comes from the fact that many antidepressants raise serotonin. This is a bit like saying pneumonia is an illness of low antibiotics because we treat pneumonia with antibiotics.”

The flimsiness of the entire enterprise was brought home to me in devastating fashion in a conversation with Elliot Valenstein, a leading neuroscientist at the University of Michigan, and the author of three highly regarded and influential books on psychopharmacology and the history of psychiatry. I was talking to Valenstein about why today’s psychiatric drugs address only a very small proportion of the neurotransmitters that are thought to exist. Virtually all these drugs deal with only four neurotransmitters: dopamine and serotonin, most commonly, and also norepinephrine and GABA (technically known as gamma-aminobutyric acid). While no one knows exactly how many neurotransmitters there are in the human ­brain—­indeed, even how a neurotransmitter is defined exactly can be a matter of ­debate—­there are at least ­100.

So I asked Valenstein, “Why do all the drugs deal with the same brain chemicals? Is it because those four neurotransmitters are the ones understood to be most implicated with mood and thought ­regulation—­that is, the stuff of psychiatric disorders?”

“It’s entirely a historical accident,” he said. “The first psychiatric drugs were stumbled upon in the dark, completely serendipitously. No one, least of all the people who discovered them, had any idea how they worked. It was only later that the science caught up and provided evidence that those drugs influence those particular neurotransmitters. After that, all subsequent drugs were ‘copycats’ of the ­originals—­and all of them regulated only those same four neurotransmitters. There have not been any new radically different paradigms of drug action that have been developed.” Indeed, while 100 drugs have been designed to treat schizophrenia, all of them resemble the original, Thorazine, in their mechanism of action. “So,” I asked Valenstein, “if the first drugs that were discovered had dealt with a different group of neurotransmitters, then all the drugs in use today would involve an entirely different set of neurotransmitters?”

“In other words, there are more than a hundred neurotransmitters, some of which could have vital impact on psychiatric syndromes, yet to be explored?” I ­asked.

“Absolutely,” Valenstein said. “It’s all completely arbitrary.”

The irony is that the shift to drug-oriented treatments has occurred even as the techniques of psychotherapy have improved dramatically. The old ­one-­size-­fits-­all approach of long-term, fairly unstructured, verbally oriented psychoanalysis or dynamic psychotherapy has been replaced by a number of new approaches specifically geared toward particular kinds of ­patients.

Traditional therapies can work well for highly verbal “worried well” patients with a fair degree of insight into their problems and motivation to do something about them. But such therapies clearly don’t work for many other people. Among the new, more tailored approaches developed during the past 20 years is cognitive­behavioral therapy (CBT), which gives patients the tools to examine the thoughts, feelings, and beliefs that lie behind their behavior, and develops the skills they need to enact change at a practical level. CBT has often been shown to be as effective as drugs in treating mild to moderate depression, with a significantly lower recurrence rate. It has also been used effectively to treat a broad variety of conditions, including bulimia, hypochondriasis, ­obsessive-­compulsive disorder, substance abuse, and ­post-­traumatic stress disorder, and it has even emerged as a means of reducing criminal ­behavior.

Two other innovative treatment ­approaches—­the Stages of Change model and Motivational ­Interviewing—­have helped caregivers understand how to motivate (and help) people to change. These methods’ tenets, in a nutshell, are that change should be viewed as a cyclical rather than linear process; that the job of bringing about change is the responsibility of the patient, not the caregiver (a reversal of the ­centuries-­old hierarchical construct of the ­doctor-­patient relationship); and that the caregiver’s approach must vary according to the client’s “stage of change”—that is, the patient’s level of insight and motivation to move forward. The positive outcomes of these kinds of “psychosocial” approaches in addressing some of the most difficult human ­problems—­including ad­dic­tion and the resistance of people with mental and other illnesses to being drawn into ­treatment—­have been shown ­repeatedly.

These and other verbally oriented treatments are increasingly used by mental health professionals, but they have less appeal in the citadels of modern psychiatric thought. There, the biological model has triumphed, and not only because of the glittering promise it holds. Biopsychiatry is driven by a complex network of forces, not the least of which are the allure of treating patients expeditiously with drugs rather than time-consuming and sometimes-messy therapies, and the huge profits to be reaped from antidepressants, antipsychotics, and other psychoactive drugs. For patients, however, the benefits of the new paradigm are not nearly so unambiguous. By focusing so heavily on ­drugs—though they can be highly effective, particularly for severe ­con­ditions—­we are neglecting to expose patients to the full array of treatments and approaches that can help them get ­better.

If there’s any lesson to be gleaned from the recent history of psychiatry, it is, in the anthropologist Tanya Luhrmann’s words, “how complex mental illness is, how difficult to treat, and how, in the face of this complexity, people cling to coherent explanations like poor swimmers to a raft.”

We don’t know much, but we should know just enough to recognize how primitive and crude our understanding of psychiatric drugs is, and how limited our understanding of the biology of mental disorder. The unfortunate fact remains that the ills of this world have a tantalizing way of eluding simple explanation. Our only hope is to be resolute and careful, not faddish, in assessing new developments as they arise, and to adopt them judiciously within a tradition of a gradually but steadily growing arsenal in the fight against genuine human ­suffering.

 worked with the homeless mentally ill in New York City for 10 years. He is a lecturer in psychiatry at Yale University and the author of

 Songs From the Black Chair: A Memoir of Mental Interiors. 

This essay is adapted from his new book, 

Comfortably Numb: How Psychiatry Is Medicating a Nation

2798522576_9518e78d2c_o.jpg

Despite stunning advances in neuroscience and bold claims of revelations from new brain-scan technologies, our knowledge about the brain’s role in human behavior is still primitive.

The Brain: A Mindless Obsession

In September 2001, I was working in Manhattan as an assistant director of a homeless shelter in which lived 200 men. Each had a psychotic illness. For two days after the 9/11 attacks I was unable to get into Manhattan, but I made it to work on Thursday, September 13, taking the bus over the George Washington Bridge. The city felt like a war zone. The acrid smell of smoke suffused the air; sirens and alarms sounded constantly; armed soldiers or police officers stood on every corner. I steeled myself, expecting the shelter to be, well, more insane than usual.

I was astonished to find everything at the shelter as it always was—if anything, a little calmer. When I asked the residents if they had any concerns, someone pointed out that the hot water was not working very well. No one mentioned the fact that a large portion of lower Manhattan was no longer there. At last I felt compelled to bring up the attacks. The men said they felt bad for those who had suffered, but all of that had happened a couple of days ago. At first I was indignant at their seeming apathy, but over time I realized that 9/11 was for many of them the day the level of crisis in the world met their own. Functioning in a crisis mode was something they knew how to do very well.

This phenomenon is more or less what Nassir Ghaemi adroitly explores in 

. The book, though psychologically nuanced, has a simple thesis: Leaders who have mental illness or have experienced periods of mental abnormality are often better able to handle crises than their mentally healthy peers. When it comes to wars and depressions, it’s better to have someone at the helm who has suffered than someone who has not. In Ghaemi’s formulation, George W. Bush, a fairly untroubled soul once he got past his substance abuse, was ill equipped to handle 9/11. In his response to the tragedy, he was rigid, insufficiently empathic, and overly optimistic. Abraham Lincoln, depressed and tortured, would have done a lot better.

Ghaemi, a psychiatrist at Tufts University School of Medicine and author of a number of distinguished books on psychiatry, sees four potential derivatives of mental suffering: creativity, realism, empathy, and resilience. Mania, for example, is strongly associated with torrents of new ideas. People who have suffered from depression often see the world in more realistic and pragmatic terms than “normal” people, who have been shown in studies to be overly sanguine about the world and their place in it. Those who have suffered any illness tend to be more empathic, understanding that life is fragile and difficult. And those who can survive mental illness (and there’s the rub) learn skills of resilience that are applicable to any of life’s hardships.

Through a series of deft and highly perceptive case histories, Ghaemi explores how figures including Lincoln, Civil War general William Tecumseh Sherman, media mogul Ted Turner, British prime minister Winston Churchill, father of Indian independence Mahatma Gandhi, civil rights leader Martin Luther King Jr., and Presidents Franklin Delano Roosevelt and John F. Kennedy, all of whom either suffered from mental illness or sustained periods of mental abnormality, brought special attributes to the crises of their times and ultimately became great leaders and innovators. (The pool of female political leaders from which to draw is admittedly small, but the fact that Ghaemi’s sample does not include a woman is a shortcoming.)

Ghaemi’s thesis is a provocative one, and like a lot of ideas that push our cultural narrative forward, it simultaneously holds water and does not. 

 is at its most convincing in its analyses of individuals whose depression (Lincoln, Churchill) or bipolar disorder (Sherman, Turner) was either self-admitted or, based on the historical record and personal diaries, indisputable. While Lincoln and Churchill lived in a largely preclinical age, one cannot read their writings about the depths of their periodic suicidal states and not be absolutely convinced that they suffered from major depression for most of their lives. These were men who stared into the abyss early and often, and thus were able to take wars and secessions in stride. For these great figures, as for my men in the shelter, crisis was normal, and they were able to retain the ability to function.

The novelist Walker Percy, a major depressive himself, wrote of the phenomenon of the ex-suicide: the person who almost kills himself but chooses not to. Take a man waiting for the bus on a March day in the rain, Percy said. Life is dull, annoying, and vaguely painful. Take that same man waiting for the bus, having just escaped his own suicide: Life is an unexpected gift, profound and joyous. Everything is gravy—he had not expected to be alive. Lincoln and Churchill were ex-suicides many times over. “I don’t like standing near the edge of a platform when an express train is passing through,” Churchill told his doctor. “A second’s action would end everything.” Having survived chronic inner anguish, Lincoln and Churchill found the battles at Gettysburg and on the Normandy beaches relatively manageable.

The chapters on Kennedy and Roosevelt are less persuasive. Ghaemi argues that FDR and JFK were mentally abnormal—that at the very least, they suffered from hypomania (a mood state characterized by loquacity, an excess of energy, an inordinate need for sex, and general recklessness). Though Kennedy’s sexual voracity was indeed abnormal, it seems to me that both his and Roosevelt’s abnormalities were more physical (Roosevelt’s polio, Kennedy’s severe Addison’s disease) than mental. Roosevelt’s struggle with the physical impairments of polio led him to become more empathic and less of a rich, arrogant dandy. Kennedy’s enormous resilience seems more a reflection of his personality and his unbridled ambition than a product of his mental state.

 has important implications for public policy and how we view the stigma of mental illness. Perhaps we should be more tolerant of our leaders’ foibles, indiscretions, weaknesses, diagnoses, and, yes, psychiatric histories. In Bush and Barack Obama, we’ve had stable, “mentally healthy” presidents who arguably have not been particularly adept at managing crises. I have no doubt that someone who had faced the abyss would have done a better job of leading the country as it faced a decade of abysses.

Ghaemi makes clear from the outset that his troubled but great leaders are best for times of crisis, not tranquility. When peace and prosperity reign, he writes, “mental health is useful. One meets the expectations of one’s community, and one is rewarded for doing so.” Yet in reading 

 I kept thinking of Dwight Eisenhower, a figure absent from its pages. As a military commander Eisenhower functioned on the brink in World War II and on D-Day, and as president he led the country during the relatively placid 1950s. He had his flaws, and he may not have been flashily creative or intellectual. But as a victorious general he was humane, he was profoundly realistic (warning us of the dangers of the evolving military-industrial complex), and he was enormously resilient. Yet Eisenhower, I submit, was about as sane as any man who ever lived, or at least as sane as anybody who ever wished to be president. Perhaps the true value of Ghaemi’s book is that it shows how diverse the wellsprings of leadership are, from the fervor of madness to staid and prosaic sanity.

, a lecturer in psychiatry at Yale Medical School, is the author of 

Comfortably Numb: How Psychiatry Is Medicating a Nation (2008). 

He is currently writing a novel about a depressed detective.

A First-Rate Madness: Uncovering the Links Between Leadership and Mental Illness

 by Nassir Ghaemi, Penguin, 2012, 340 pp.

15346881021_52dec8694d_k.jpg

Leaders who have mental illness or have experienced periods of mental abnormality are often better able to handle crises than their mentally healthy peers.

The Lunacy to Lead

Psychotherapy has been a series of generally ­well-­intentioned attempts to throw mud against a wall to see what sticks. Over the past century, that method has told us this: Psychotherapy works. ­Two-­thirds of patients improve within six months of starting treatment (longer treatment yields few further results). The therapist’s training and the school or philosophy of therapy in use make little difference. What does matter is the empathy level the patient perceives in the therapist, the patient’s willingness to engage in therapy, the severity of the patient’s illness to begin with, and the appropriateness of match, or treat­ment alliance, between patient and ­practitioner.

The pursuit of ­therapy—­if not ­happiness—­is a largely American phenomenon, Jonathan Engel tells us in 

. By the 1960s, the United States had more clinical psychologists, psychiatrists, and psychiatric social workers than the rest of the world combined. “The history of psychotherapy in the United States . . . is a classic American tale of discovery, entrepreneurship, and ­self-­promotion,” writes Engel, a professor of health care policy and management at Baruch College.

For it was in America, in the early 1900s, that Freudianism and psychoanalysis took hold as nowhere else (despite Sigmund Freud’s personal antipathy toward the United States). A therapeutic parade has followed: behaviorism (which views human beings as stimulus-­response machines in which only observable, measurable behavior matters); humanistic approaches (which focus on social relationships as the key to wellness); cognitive therapy (which posits that thinking and beliefs drive our behavior and emotions); populist ­self-­help programs such as Alcoholics Anony­mous and Narcotics Anonymous; the largely ­1960s-­vintage therapies such as electroshock, transcen­dental meditation, and primal scream (the latter favored, briefly, by John Lennon and Yoko Ono); and so ­on.

There appears to be some truth to the notion that sick souls have a particular insight into what can make us well.

Engel writes, but does not write enough, about the characters who invented these various approaches. These doctors and visionaries were typically ­brilliant—­and many were famously troubled. The humanist Harry Stack Sullivan (whom novelist Walker Percy called perhaps America’s greatest psychiatrist), for example, championed the importance of social relations, but was alcoholic, depressed, and misanthropic. There does appear to be some truth to the notion that sick souls, such as the great early psychologist William James, have a particular insight into what can make us well. (Among the exceptions is midwesterner William Menninger, hugely influential in raising psychiatry’s profile and credibility during and after World War II, who appears to have been a particularly sanguine character.)

Psychotherapy’s progress did not come without much confusion and excess, and even ­cruelty—­lobotomies, excessive use of electro­shock therapy, and charlatanry. A 1970s study by the California State Psychological Association found that more than five percent of male psychologists had had sex with female patients, some claiming that intercourse was a bona fide therapeutic tech­nique. Today, such excesses have diminished. In recent decades, the profession for the first time has exposed itself to the light of day by objectively examining its actual clinical outcomes, pro­ducing what could be called a rational approach to psychotherapy. Good therapists these days are schooled in a variety of techniques and can de­ploy, with a fair degree of certainty, the appropriate approach for the individual ­patient.

 is a thoroughly researched and elegantly organized survey of therapy on America’s historical landscape. It is a commendable effort and would make a fine ancillary text for introductory psychology courses. But therein lies the problem. Engel’s assertion that the rise of psycho­therapy is a uniquely American ­story—­one that suits our nation’s varying sensibilities of optimism, pragmatism, and ­reinvention—­is absolutely true. Each school of therapy has reflected the particular preoccupations of the era in which it was invented: Behaviorism and cognitive approaches came of age in the rational 1950s, ­self-­help and self-exploratory journeys in the trippy ’60s, ­self-­esteem inter­ventions in the battered ’70s. Since the ’80s, we have seen the rise of approaches (and psychiatric medications, that new adjunct ­of—­or replacement ­for—­psychotherapy) designed to help us function in increasingly competitive economic times. Engel’s narrative does not do justice to the fascinating dialectic (or the ­stimulus-­response, if you will) between our exterior and interior ­landscapes.

But Engel does show that throughout this long, strange trip, psychotherapy has truly mattered in America. Has it served as an antidote to American individualism? Have we used it to refute F. Scott Fitzgerald’s assertion that there are no second acts in American lives? Who knows. What we can conclude from 

 is a truth more universal than it is American: There has always been something unutterably and mysteriously healing about the unburdening of one’s soul to another ­person.

, a lecturer in psychiatry at the Yale University School of Medicine, is the author of

 Comfortably Numb: How Psychiatry Is Medicating a Nation, 

 Songs From the Black Chair: A Memoir of Mental Interiors.

American Therapy: The Rise of Psychotherapy in the United States

 by Jonathan Engel, Gotham, 352 pp, 2009.

3129761684_25b6cf7701_o.jpg

Charles Barber finds American Therapy "thoroughly researched and elegantly organized," but says it does not quite capture the "fascinating dialectic" between "our exterior and interior landscapes."

America on the Couch

All surgeons must devise a “way in” to their operation—choosing the entry point and the methodology for each complex procedure. In 

, Ira Rutkow, a surgeon himself, hits upon an elegant approach to the contentious story of American medicine. Throughout his remarkably entertaining account, Rutkow selects telling medical episodes—the tormenting of colonial surgeon Zabdiel Boylston by a violent mob, who believed that his smallpox inoculations spread disease; President James Garfield’s death in 1881 at the hands of his own surgeons, who neglected basic antiseptic techniques in treating his gunshot wound; or doctors’ extraordinary measures in 1926 to save Harry Houdini from appendicitis, which were unsuccessful but underscored clinical advances—to capture the essence of medical knowledge of the day, and place it in a social context.

Several powerful themes emerge in Rutkow’s account. One is the persecution and general calamities endured by many of the great innovators of American medicine. Boylston was so terrified of the mob that he visited his smallpox patients under cover of darkness and disguised in a wig. The three men who, in the 1840s, made the findings that led each to claim he had discovered anesthesia, all went under-recognized and largely uncompensated. All three also had unhappy deaths: One took his own life, aided by chloroform; another, beset by despondency and paranoia, suffered a fatal stroke; the third spent his last days in a Massachusetts insane asylum. William Halsted, whom Rutkow describes as perhaps America’s greatest surgeon, tested cocaine on himself in the 1880s before using it as an anesthetic for his patients. He became addicted and spent months in psychiatric hospitals, before resurrecting his career—by using morphine to wean himself off cocaine. Reading 

 is not unlike watching the television series 

: The great medical visionaries are simultaneously portrayed as brilliant, eccentric, and suspect, and the narrative is told through specific, pithy anecdotes that illuminate larger controversies.

Another theme is the inexorable growth of the medical-industrial complex. Between 1940 and 1965, as expensive technologies came to dominate American medicine and the power of the American Medical Association (AMA) grew, national health care expenditures multiplied tenfold. Today, health care spending accounts for nearly a fifth of America’s gross domestic product. Rutkow describes the current system of “for-profit corporate-guided medicine,” which rewards physicians and hospitals for how much care they provide rather than how clinically valuable that care is, as “an economic tyranny of medical services and scientific technology.” Yet this “tyranny” was perhaps not inevitable. Harry Truman raised the notion of national health insurance in the 1948 presidential campaign and eventually brought a bill before Congress. The AMA spent nearly $3 million—more money than any interest group had ever mustered for a single lobbying effort before that time—to defeat the bill. In 1962, it opened its war chest again to defeat President John F. Kennedy’s more limited proposal to provide national health insurance for senior citizens. It is one of the many contributions of

 to place recent events in the health care debate in a historical context.

Rutkow’s otherwise graceful narrative suffers from the occasional infelicitous phrasing, as when he writes that no disease encapsulated medical progress as well as appendicitis, “which burst onto the medical scene in the years surrounding World War I.” And the narrative concentrates overly much on the history of surgery—which is perhaps natural given that Rutkow himself is a surgeon. He acknowledges this bias in the book’s introduction, where he quotes Henry Bigelow, a 19th-century Harvard surgeon: “Why is the amphitheater crowded to the roof on the occasion of some great operation, while the silent working of some drug excites little comment? Mark the hushed breath, the fearful intensity of silence, when the blade pierces the tissues, and the blood wells up to the surface. Animal sense is always fascinated by the presence of animal suffering.”

Comfortably Numb: How Psychiatry Is Medicating a Nation (2008).

Seeking the Cure: A History of Medicine in America

5103017579_5680581e61_o.jpg

All surgeons must devise a “way in” to their operation—choosing the entry point and the methodology for each complex procedure. 

Doctoring History

When the psychiatrist George Vaillant was a teenager, he received in the mail his father’s 25th Harvard class reunion book, which detailed in short paragraphs the activities of classmates who were by then in their late forties. Young George found the twisting narratives fascinating, and pored over them obsessively. The very arrival of this book must have been extremely difficult for him, as a few years earlier, George’s father, a privileged and successful man with no overt signs of depression or distress, had fatally shot himself in his backyard after a nap. George, then 10 years old, was the last to see his father alive.

Drawing upon the resilience that characterizes the themes of 

, Vaillant has presided for the last five decades over the ultimate class reunion book, the Grant Study. Named after its patron, the variety-store magnate W. T. Grant, the study began tracking 268 Harvard students, most members of the classes of 1942, ’43, and ’44, in 1938. Vaillant inherited the project in the 1960s, directed it for over 30 years beginning in 1972, and remains a co-director. Exact criteria for selection to the study remain obscure — the original investigators declined Norman Mailer and Leonard Bernstein, but included John F. Kennedy. Sixty-eight members of the original cohort, now in their nineties, are still living.

Over the last 70 years, Harvard scientists have checked in on the members of the group at regular intervals, and poked and prodded them using virtually every psychological and physiological instrument. The sheer amount of data is astonishing, most of it collected by Vaillant himself. “Some men came to Cambridge … but in most cases I went to them — to Hawaii, Canada, London, New Zealand,” writes Vaillant, who himself is now 78.

 elegantly summarizes the findings of this vast longitudinal study, unique in the annals of research. (Sustaining the funding for it has also been a herculean feat.) Vaillant has written two previous books about the Grant Study — 

 (2002) — which provide snapshots of the men’s lives at earlier stages. This latest book analyzes how the men fared over their late adulthood, and indeed their entire lives. In it, Vaillant masterfully chronicles how their life successes, or lack thereof, correlate with the nature of their childhoods, marriages, mental health, physical health, substance abuse, and attitudes.

Extensive quantitative findings are interspersed with the detailed stories of individual study participants, under pseudonym, and with identifying details expunged or changed. Here Vaillant proves that his skills are literary as well as scientific. The case histories are engaging novelistic capsules that artfully bring the quantitative material to life. Vaillant, who of course has aged along with his subjects, includes scenes from his own development, honest stories that involve both struggle and maturation.

The study, a product of the period in which it was conceived, has its limitations. Its only subjects are white, privileged men. Still, many of its findings seem universal. If they could be boiled down to a single revelation, it would be that the secret to a happy life is relationships, relationships, relationships. The best predictors of adult success and well-being are a childhood in which one feels accepted and nurtured; an empathic coping style at ages 20 through 35; and warm adult relationships.

Regarding finances, just one of Vaillant’s 10 measures of adult well-being, men who had good sibling relationships when young made an average of $51,000 per year more than those with poor sibling relationships or no siblings at all, and men who had warm mothers earned $87,000 more annually than those who did not (in 2009 dollars). Overall, reflecting their privilege, the Grant Men made a lot of money. The findings go on and on like that, and the message relentlessly emerges: The secret to life is good and enduring intimate relationships and friendships. Mental health, as Sigmund Freud and Erik Erikson indicated, is embodied by the capacity to love and to work.

The other overarching message of this book is that resilience counts. Men with the most mature defense mechanisms — defined as altruism, humor, sublimation (finding gratifying alternatives to frustration and anger), anticipation (being realistic about future challenges), and suppression (yes, “keeping a stiff upper lip”) — were three times more likely to flourish in later life. Furthermore, men with good defense mechanisms were able to alter their paths by developing the capacity for emotional warmth and connection to others despite difficult upbringings or individual setbacks.

Vaillant provides compelling evidence that many individuals — by no means all — can write (or rewrite) their own scripts, disproving F. Scott Fitzgerald’s maxim that there are no second acts in American lives. Other studies of quite different populations have arrived at similar conclusions. In 

, a 2001 study of hardcore criminal offenders, the criminologist Shadd Maruna documents that those who learned to desist from crime scored vastly higher on measures of self-agency (taking control of your life) and generativity (being able to respond positively to negative events) than those who continued their criminal careers.

Resilience plays out at a physiological level too, of course. Vaillant found that maintaining a healthy weight, not smoking, not drinking much, and controlling blood pressure before age 50 made all the difference in the health of the men at 80 and 90. But here, too, relationships seem to lay the groundwork. In 1978, Vaillant reviewed a subset of the men who had been healthy at age 40; they were now about 55 years old. Of those who had had the bleakest childhoods, 35 percent were dead or chronically ill, as compared to only 11 percent of those with the warmest childhoods.

There is a small but vital call in medicine and psychiatry to pay much greater heed to the stories of patients, as a means of building empathy and guiding care. Psychiatry, like so much of medicine, has been overrun by technologies and pharmacologies. In the excitement over this supposed progress, the old-fashioned “healing arts” have often been neglected.

In response, Rita Charon, a professor of clinical medicine, has created a highly influential program in narrative medicine at Columbia University’s medical school, predicated on the value of listening to the stories of patients. This past fall I taught a course on the narratives of illness and recovery at Wesleyan University. The students, up to their ears in neuroscience and psychological science, couldn’t get enough of the real-life first-person narratives of people suffering from mental illness and trauma. The point of all this is not to revel in the illnesses, but to learn what constitutes health.

Vaillant is that rare thing: a psychiatrist more interested in mental flourishing than in mental illness. With 

, he has turned the Harvard men’s disparate stories into a single narrative and created a field guide, both practical and profound, to how to lead a good life.

 is a lecturer in psychiatry at the Yale School of Medicine and director of the Connection Institute for Innovative Practice, dedicated to the study of the narratives of people recovering from mental illness. He is the author of 

Triumphs of Experience: The Men of the Harvard Grant Study

 by George E. Vaillant. Harvard University Press. 457 pp.

1280px-Harvard_yard_winter_2009j.JPG

"The best predictors of adult success and well-being are a childhood in which one feels accepted and nurtured; an empathic coping style at ages 20 through 35; and warm adult relationships."

What a decades-long Harvard study tells us about mental health

Thirteen years ago, David Deutsch was arrested in Salinas,

 California, while making his regular drug trafficking run from Los Angeles to San Francisco. When his car was pulled over, he was under the influence of marijuana; police found large amounts of cocaine and marijuana in the vehicle, as well as $715,000 in cash. Although he had been using and dealing drugs most of his adult life, Deutsch had never previously been caught, so he received a rather lenient sentence (by California standards) of six years in San Quentin State Prison.

The day of his arrest was the last time Deutsch used drugs. Early in his prison term, he says, he decided to dedicate the rest of his life to helping others with drug problems. At San Quentin he volunteered to run a peer tutoring program, joined Narcotics Anonymous, and became a chapel clerk. He published an article on prison education in 

— unlike most inmates, he held a college degree. After his release, he became a certified addiction counselor and earned a master’s degree in social work, with a 4.0 grade point average. Despite all that, he needed no less than 58 letters of recommendation to get his license as an associate social worker. Once equipped with those testimonials, Deutsch received a formal Certificate of Rehabilitation — declaring him to be officially reformed — from the state of California in 2011. His drive to inspire others to turn their lives around has an almost physical intensity. He currently works as a clinical director for one of the country’s largest mental health agencies, where he runs a program for former prisoners who are mentally ill.

Deutsch’s story is both extraordinary and highly ordinary. Extraordinary because more than half of all released prisoners are returned to prison for new crimes or parole violations within three years of their release. Ordinary because most ex-offenders do, eventually, manage to overcome the substantial hurdles they face and “go straight.” After all, crime is a young person’s game. Research on the life paths of prisoners over long stretches of time suggests that around 85 percent of them grow out of criminal behavior by the time they turn 28.

F. Scott Fitzgerald famously wrote, in his personal essay of doom, 

 (1936), that there are “no second acts in American lives.” Yet most Americans firmly believe that there are. President George W. Bush, who had his own second chance after years of alcohol abuse, made this case in introducing new prisoner rehabilitation legislation in his 2004 State of the Union speech. “America is the land of second chance, and when the gates of prison open, the path should lead to a better life,” he declared. Dan McAdams, a professor of psychology at Northwestern University and author of 

The Redemptive Self: Stories Americans Live By

 (2006), has spent a lifetime studying the stories that Americans, to borrow a phrase from Joan Didion, tell themselves in order to live. McAdams argues that there is in the American psyche a deeply ingrained belief in a special destiny and self-reinvention that dates from the Massachusetts Bay Puritans and has continued through Benjamin Franklin and Horatio Alger on to the present-day reign of Oprah and 12-step therapy. Alexis de Tocqueville, visiting from France in the 1830s, wrote that Americans “have an immensely high opinion of themselves and are not far from believing that they form a species apart from the rest of the human race.”

Redemption is a centerpiece of nearly every religion and culture, but in none does it loom larger than the Judeo-Christian tradition, particularly the American variant. The redemption narrative sustains Hollywood’s happy endings and Madison Avenue’s mantra of endless self-improvement. As book critic 

, “There is no public narrative more potent today—or throughout American history—than the one about redemption.” The saga of redemption and reinvention—the creation of our own individually unique second acts—is arguably the American story.

Yet there are signs that our faith in this narrative is slipping. Champion cyclist 

 is the latest in a string of fallen celebrities and politicians — from actor 

, both emphatically denied spots in the Hall of Fame in the last balloting — who have found that the old rituals of repentance and redemption are not as effective as they used to be.

A more serious early symptom of our declining faith came several decades ago with the loss of belief within the criminal justice system in the possibilities of criminal rehabilitation. Beginning in the 1970s, states gave up this ideal, and began warehousing prisoners in ever greater numbers. The United States now incarcerates a larger percentage of its citizens than any other country, with about one in 100 adults currently behind bars. About a quarter of the world’s prisoners are confined in U.S. prisons and jails. President Bush’s Second Chance Act, which funded community and mentoring programs for prisoners after their release, was inadequate when he announced it nine years ago, and the programs have seen their combined budgets shrink from $100 million in 2010 to $63 million last year. With nearly 700,000 former prisoners hitting the streets annually across the United States, such sums are little more than token gestures. Far more is spent simply to put people behind bars and keep them there. California alone has a corrections budget of $9 billion.

Americans still love a good redemption story, at least in movies and other imagined worlds. (The middling 

 is consistently ranked online as one of the country’s greatest films, and 

 has been one of the longest-running shows on Broadway.) But they are often less convinced about such accounts in reality. Many would regard a story such as David Deutsch’s with either skepticism (interpreting his change as a con game) or hostility (asking why he should be allowed to be so successful after what he has done). Indeed Deutsch says that he met resistance early in his journey. His parole officer took a wait-and-see attitude, while the criminal justice system as a whole operated on a simpler assumption: once a criminal, always a criminal.

The skepticism about second acts is no longer confined to corrections systems.

 Once universally known as the land of irrepressible optimism, America seems to have entered a sustained period of doubt, a kind of antiswagger. A series of national and international cataclysms have shaken Americans’ traditional confidence. A recession that never seems to end has left many resigned to just hanging on. Upward mobility, the traditional elixir of American society, seems increasingly out of reach. Almost half of American boys reared in households in the bottom quintile of income stay there as adults, according to a recent study, and only eight percent rise to the highest quintile. In Britain, young men who start out in the bottom quintile have a 50 percent better chance of rising to the top than their counterparts in the United States. Higher education, the most reliable avenue of upward mobility, is significantly less attainable than it used to be. Family income has been largely stagnant, while the cost of attending a public university has risen 60 percent in the last 20 years.

A less obvious factor in the waning of the redemption script is the rise of social media such as Facebook and Twitter, which, with their obsessive focus on the chronicling of personal micro-events, have drawn many users away from the larger narratives and collective themes that provide hope and inspiration. Only other people can provide redemption, yet social media are a boon to narcissism, calling for us to publish and advertise our every move, no matter how incidental. As Daniel Boorstin wrote, with remarkable prescience, a half-century ago in 

The Image: A Guide to Pseudo-Events in America

, “We have fallen in love with our own image, with images of our making, which turn out to be images of ourselves.”

Each generation tends to have its characteristic or favored mood or diagnosis. During the Cold War we had the Age of Anxiety; in the late 1970s it was “malaise.” In the Prozac-fueled 1990s the diagnosis was depression, followed soon after by attention deficit disorder, often treated with Adderall. The signature diagnosis of the last decade may be PTSD: posttraumatic stress disorder. Legions of soldiers returning from Iraq and Afghanistan have received that diagnosis, and enormous resources have gone into its treatment. But trauma of all sorts — from 9/11 to Hurricane Katrina to Newtown — now feels like a constant on the American scene. Memoirs of suffering such as James Frey’s best-selling 

 that Frey had embellished his hardships as a recovering drug and alcohol addict — have burgeoned into a new genre of “misery lit,” a far cry from the long line of self-improvement tales descended from the Horatio Alger stories. The victim — or perhaps “survivor” — has become one of our reigning cultural figures.

Highly publicized tragedies such as the December massacre in Newtown, Connecticut, that left 26 children and adults dead pose the greatest threat to our belief in the redeemability of the most marginalized among us. (And when such events occur, as Newtown did, in the kind of tranquil, upper-middle-class community to which many Americans aspire, they subtract all the more from our hopes.) Take, for example, the story of Sister Karen Klimczak, a Catholic nun who was murdered in Buffalo, New York, on Good Friday in 2006.Two decades earlier she had opened HOPE House (the acronym stands for Home of Positive Experience), a Buffalo-based residential treatment center for ex-offenders, where she also lived. She was known as a whirlwind of grace and positive energy, described locally as “Mother Teresa in fast-forward.” Klimczak was murdered in her room by new resident Craig Lynch nine days after his release from prison, where he had served time for car theft. She walked in as he was stealing her cell phone, and he strangled her in an attempt to keep her from screaming. Hours before she was murdered, Klimczak had said about the man who would kill her, “I think Craig’s doing well. I think he’s going to be all right.” Her funeral is believed to have been the largest in Buffalo history. After killing Klimczak, Lynch traded in the cell phone for a rock of crack. When he tried to smoke it, it wouldn’t light. The rock was fake.

There was a horrible forerunner to Klimczak’s murder. Several years earlier, she had moved her halfway house to a former rectory and renamed it Bissonette House in honor of a Catholic priest who had once lived there. The Reverend Joseph Bissonette was killed in the building in 1987, at the height of the crack era, by two teens who had sought him out for help. In the spirit of forgiveness, Sister Karen had made it a point to lead prayers every morning in the ground-floor room where Bissonette was killed.

If, as a result of tragedies such as those in Buffalo and Newtown, Americans have become more cynical about hope and second chances, who can blame them? Perhaps F. Scott Fitzgerald was right about second acts. Certainly for Fitzgerald, who wrote so much about the promise of youth yet died an alcoholic at 44 without ever equaling the dazzling success of his 1925 novel 

, there was no second act. Maybe America is finally facing an uncomfortable reality.

Dan McAdams argues that the American redemption script has two key components.

 The first is the belief that we, as individuals and as a people, are fortunate, blessed, or “chosen for a special, manifest destiny” to do great things in the world. The second is the conviction that by responding successfully to hardships and tribulations, we will only grow stronger and better. We will take bad things and create good things out of them. Both beliefs are under threat. Americans have probably never been as special and blessed as they believed themselves to be, but they are particularly less special today. In many areas, from educational achievement to average life span to rates of violent death and infant mortality, measurable evidence shows that we are special only by virtue of our poor standing compared with other countries. And as for our capacity to overcome adversity, it may be limited in the future by increased global competition and environmental challenges.