Gracefully Insane Page 2

  At odd moments during our walk, huge, spreading, seventyfoot-tall copper beeches heave into view. The staffers accompanying us seem well briefed; they know the fate of each of these towering, golden-brown giants. “This one is slated for preservation. ... This one over here? No, this is where the parking lot will be.” Trees are a very big deal at McLean. The developers working on each of the commercial parcels had to inventory every tree more than two feet tall and have practically apologized personally each time a “signature tree” has been cut down or replanted. Indeed, a forester employed by Northland reminded a McLean gathering I attended that New England is now far more wooded than it was 150 years ago, when most of the land had been cleared for agriculture.

  Virtually every doctor more than sixty years old has a copy of the hand-drawn poster “The Trees of McLean” hanging on his or her office wall. Created by two patients with the help of a specialist from Harvard’s Arnold Arboretum in 1966, it is a precise map of each important tree on the McLean grounds. One of the creators, Stewart Sanders, went on to become a prominent naturalist in the Boston area. In later years, he performed the Audubon Society Christmas bird count on the McLean grounds and even drafted maps of fox habitats and woodcock flight patterns that included some of the hospital territory. “I wanted to control people’s actions in the future,” Sanders told me. “I was showing that this was where the trees were, this was where the foxes were so that they wouldn’t be disturbed.” Now in his sixties, Sanders is a studious yet emotional defender of open space in the Boston area. He was one of the men who won the hundred-foot setback for the threatened brook at the Conservation Commission hearing. “I gave an emotional plea that when the people of Massachusetts enacted the Rivers Protection Act, they meant to include brooks, because they understood that brooks become rivers. It’s very nice that they have fountains at the Burlington Mall, but my heart needs a brook.”

  It is impossible not to be transported by the beauty of McLean. “We are very proud of our hospital. It is very attractive and looks more like a college campus than a mental hospital,” the Babbitty World War II-era director Franklin Wood once boasted. (Wood was an occasional source of unintended humor. Rejecting a suggestion by patients that he erect signs to guide them around the grounds, he said, “If you don’t know where you are, then you’re in the right place.” Writing in the hospital’s annual report, he contributed this gem: “It is not healthy to be depressed.”) Four-fifths of the grounds are just that: grounds, not buildings. This is the patch of rolling, rocky New England woodland that the great landscape designer Frederick Law Olmsted chose for McLean in the late nineteenth century. Olmsted knew what he wanted: a setting that would allow every patient’s window to face south and that would have enough space so that the men’s buildings would not look in on the women’s wards. He foresaw that patients should be segregated according to the acuity of their illnesses. He surveyed two other sites but favored “the wooded land of Belmont, judiciously thinned to groups and glades, opened by walks of long curves, and easy slope.” It would provide, he wrote to the hospital trustees, “more incitements to tranquilizing and recreative voluntary exercise for convalescent and harmless monomaniac patients” than would rival parcels in Arlington and Waltham. Twenty-five years later, Olmsted, debilitated by a series of brain hemorrhages, found himself living in McLean’s Hope Cottage, a single-patient home perched on a ridge above a terraced hillside garden. He had lost many of his faculties but not his sense of orientation. Ever the landscape connoisseur, Olmsted noticed that the buildings were not as tightly grouped as he had suggested in an 1875 sketch for the trustees. Moreover, they now faced the beautiful western sunset and not the southern horizon, as he had recommended. Surveying the setting, he exclaimed: “They didn’t follow my plan, confound them!”

  McLean Hospital is not just a cultural museum. It is also a museum of the many therapies advanced over more than two hundred years to relieve mental illness. In large part, the story of McLean is the story of an idea that originated in Europe at the end of the eighteenth century. The idea was that a relaxed life in a pastoral setting would go a long way toward alleviating the suffering of the mentally ill.

  The theory’s most famous champion was Philippe Pinel, an enlightened French doctor to whom the Revolutionary government had handed the keys of Paris’s most notorious hellhole, the Bicetre Asylum, in 1792. Pinel was a failed rural practitioner who had devoted himself to the study of mental illness after a friend suffered a nervous breakdown, fled into a forest, and was devoured by wolves. “The Bicetre,” wrote historian Albert Deutsch, “owned a questionable distinction: it ranked with the worst asylums in the world. There the patients, or rather the inmates, were loaded down with chains and shackled to floors and walls with irons, at the mercy of cruel attendants armed with whips and the authority to use them freely.” (Terrorizing mental patients, in the hopes of “waking” them from madness, was common all over Europe. One German asylum lowered patients into a dungeon filled with snakes. Even England’s King George III was beaten by an attendant during one of his asylum stays.) Pinel’s first act, immortalized in a famous painting by Robert Fleury that shows a patient kissing his hand in gratitude, was to strike the chains off fifty-three of the filthy, bedraggled “beasts” that had been remanded to his care. Most of them proved to be quite harmless. Their previously violent behavior had mimicked the violence visited upon them by their keepers. Pinel introduced elementary hygiene, humane living conditions, and occupational therapies as substitutes for the leg irons, whippings, and brutal beatings that were the norm in European and American asylums. The same year in England, a Quaker named William Tuke founded the York Retreat for the mentally disturbed, a manor house so named “to convey the idea of what such an institution should be, namely, a place in which the unhappy might obtain a refuge; a quiet haven in which the shattered bark might find the means of reparation and safety.”

  The new movement had a name: moral treatment. A New York doctor named T. Romeyn Beck laid out its tenets in 1811:This consists in moving patients from their residence to some proper asylum; and for this purpose a calm retreat in the country is to be preferred: for it is found that continuance at home aggravates the diseases, as the improper association of ideas cannot be destroyed. A system of human vigilance is adopted. Coercion by blows, stripes and chains, although sanctioned by the authority of Celsus and Cullen, is now justly laid aside....

  Tolerate noisy ejaculations; strictly exclude visitors; let their fears and resentments be soothed without unnecessary opposition; adopt a system of regularity; make them rise, take exercise and food at stated times....

  When convalescing, allow limited liberty; introduce entertaining books and conversation, exhilarating music, employment of body in agricultural pursuits ... and admit friends under proper restrictions. It will also be proper to forbid [the patients] returning home too soon. By thus acting, the patient will “minister to himself.”

  Beck’s outline could have served as a mission statement for McLean; for its predecessor, the Philadelphia Hospital; for the Bloomingdale Asylum outside New York; for the Hartford Retreat; or for the Menninger Clinic through the first half of the twentieth century. More than a hundred years after Beck wrote, McLean’s superintendent George Tuttle had this to say about the hospital “cures” of 1913: “There have been no striking changes during the year in methods of treatment. Emphasis is still laid on the superior advantage of out-of-door exercise, full feeding, and hydrotherapy for its tonic or soothing effect, as against sedative and hypnotic drugs, which practically are never prescribed.”

  The hydrotherapy treatment that Tuttle mentions likewise dates back to the eighteenth century. Another famous French painting, Jacques-Louis David’s The Death of Marat, depicts the emaciated revolutionary slumped over in the bath in his home, after being fatally stabbed by Charlotte Corday. You cannot tell by looking at the Bowditch and Wyman buildings that a half-century ago, the basements of these stately halls were given over to
hydrotherapy baths just like those in the David painting, with their long tubs and sail-like canvas covers intended to prevent patients from drowning. (Some did anyway.) The so-called Scotch douches, showers in which the patients were surrounded by needle-like jets of water and then hosed down with ice-cold water from chromeplated fire hoses—“medieval torture instrument[s],” one doctor called them—were dismantled in the 1950s.

  Over the years, McLean supplemented the rest cure with the various weapons that appear and disappear in the psychiatric armamentarium. Only a historian, or a doctor past retirement age, would recognize such terms as “total push,” “metrazol shock therapy,” or the most alluring of the lot, the “continuous sleep cure.” And yet everything that was old becomes new again. Electroshock therapy, now rebranded “electroconvulsive therapy (ECT),” is still prescribed for recurring, stubborn depression.2 The days when Dr. Walter Freeman barnstormed the country in his Cortez camper-van, proselytizing for while-you-wait ice-pick lobotomies for patients “sedated” by electroshock, are history. But selective psychosurgery still figures in the mental health portfolio. And imagine my surprise when I read in a 1999 McLean brochure that “Milieu Therapy is Alive and Well,” which of course it is. The impetus behind milieu, a 1950s coinage, is almost exactly analogous to Pinel’s eighteenth-century intuition that mental patients, like anyone else, might be able to shed some of the stress and pains of their afflictions in the bucolic environment of a suburban hospital.

  The idea of a rest cure, supplemented with occupational therapies, physical therapies, or talk therapies, seems natural to us. But it has proved to be an idea that we can no longer afford to believe in. First-class asylum care, characterized by lengthy stays and solicitous medical attention, has not been particularly successful. So-called outcome statistics are notoriously unreliable when judging mental hospitals. A hospital that specializes in the “worried well” will discharge many patients claiming to have recovered. But institutions like McLean, which has always been willing to grapple with schizophrenia and other severe disturbances, will not have a stellar success record. Perhaps one-third of severely disturbed patients improve under hospital care and leave in better shape than they came. Another one-third can be stabilized and show only marginal improvement; this group can be weaned from full-time care. And the rest probably belong in the hospital full-time.

  These days, neither individuals nor insurance companies can afford to pay for residential care. A night at McLean now costs almost $900. For the past twenty-five years, we have been embarked on a different path for treating the mentally ill. Ever since the emergence of Thorazine, the immobilizing “prescription straitjacket” introduced into widespread use in the late 1950s, drug therapy has supplanted asylum care as the order of the day. “Now they lock you up in a chemical jail,” is how James Taylor—who has been drug-free for almost twenty years—describes modern psychiatry. Yet for as much as it has been criticized, the “psychopharmaceutical revolution” has proved to be cost-effective in many instances. Now, severely disturbed patients can often live in halfway houses or low-security settings. Many drugs successfully treat, or at least ameliorate, conditions such as depression or compulsive disorders. But the causes and potential cures for schizophrenia—the “broken mind”—are still largely unknown. “Researchers are still in the dark about schizophrenia,” a March 2001 issue of the Harvard Mental Health Newsletter admitted. Mental health is the question for which we have yet to learn the answer. This book is, in part, a history of that question, and the many suggested answers.

  But it is also a book about people. The last person quoted here is a patient, not a doctor, and a patient embarked, hopefully, on the road to a better life. People ask me why I undertook this project, and I have a series of responses, depending on their actual level of interest. Because McLean is an interesting place, full of great stories, I say. That ends most conversations. Because it was a challenge, I say to others; such a book has not been written. That satisfies many questioners. But one afternoon at the Iruna, the delightfully down-at-the-mouth Spanish café across from Harvard’s John F. Kennedy School of Government, Rob Perkins asked me why I had chosen to spend several years of my life researching the hospital. Rob had spent almost two years’ hard time as a patient at McLean and had written movingly about his experiences there. I respected him enormously, and I could not buffalo him the way I could everyone else. “Rob, life is impossible,” I confessed. “Who can’t understand the need for shelter? And who can’t sympathize with the people who seek that shelter? And who could fail to be interested in a place that offered that shelter?”

  So this is a book about the men and women who needed shelter more than most of us, or who, in some cases, were more honest about their need for protection than we are. And about an institution that provided that shelter, imperfectly, in our imperfect world.

  2

  By the Best People, for the Best People

  Crazy people much more pleasant than I expected.

  McLean pharmacist William Folsom, 1825

  By the early nineteenth century, the city of Boston was already two hundred years old. The great Yankee trades to Europe, the Caribbean, and the Far East were pouring money into the counting houses of India Wharf and into the vaults of new banks springing up on State Street. Boston, given to calling itself the “Athens of America,” was locked in a grand rivalry with Philadelphia and New York and hooked on new construction. The society architect Charles Bulfinch was remaking the face of the city, planting his distinctive, boxy, brick, federalist mansions along Boston’s main thoroughfares, culminating in his gold-domed masterwork, the Commonwealth’s State House atop Beacon Hill. The city had just built five bridges spanning the Charles River. The first interurban railroad, the Boston and Albany line, was about to begin service. The city fathers trained in 7,700 tons of marble from Quincy quarries to erect the 220-foot-tall Bunker Hill monument, commemorating the famous battle, and imposed upon the doddering Marquis de Lafayette to lay the cornerstone.

  And yet Boston lacked a hospital.

  New York, Baltimore, Philadelphia, and even Williamsburg, Virginia, had been operating large public hospitals for more than fifty years, all of which accepted mental patients as well as the sick and infirm. But Boston maintained only a quarantine station on nearby Rainsford Island and the public dispensary, which gave outpatient care to the poor. The mad or delirious were either cared for at home, packed off to the (Bulfinch-designed) Almshouse for the destitute, or farmed out to specialized boarding houses. In his book The Mentally Ill in America, Albert Deutsch mentions aDr. Willard, who, about the beginning of the 19th century, maintained a private establishment for the mentally ill in a little town between Massachusetts and Rhode Island. One of the fundamental tenets in his therapy was to break the patient’s will by any means possible. On his premises stood a tank of water, into which a patient, packed into a coffin-like box pierced with holes, was lowered by means of a wellsweep. He was kept under water until the bubbles of air ceased to rise, after which he was taken out, rubbed, and revived—if he had not already passed beyond reviving!

  Two physicians from esteemed Boston First Families, James Jackson and John Collins Warren—it was Warren’s uncle who urged the Colonials not to fire until they saw the whites of their British enemies’ eyes on Bunker Hill—adopted the hospital cause and circulated a petition to the city’s Yankee oligarchs in 1810: Sir—It has appeared very desirable to a number of respectable gentlemen, that a hospital for the reception of lunatics and other sick persons should be established in this town....

  The virtuous and industrious are liable to become objects of public charity, in consequence of the diseases of the mind. When those who are unfortunate in this respect are left without proper care, a calamity, which might have been transient, is prolonged through life.

  Jackson and Warren, “charter members in a society that had only charter members” as Cleveland Amory called them, reminded the Puritan legatees of their responsibilitie
s:It is unnecessary to urge the propriety and even the obligation of succoring the poor in sickness. The wealthy inhabitants of the town of Boston always evinced that they consider themselves as “treasurers of God’s bounty”; and in Christian countries it must always be considered the first of duties to visit and to heal the sick.... It is worthy of the opulent men of this town, and consistent with the general character, to provide an asylum for the insane from every part of the Commonwealth.

  The doctors’ plea did not fall on deaf ears. But it did fall on the ears of merchant princes who were temporarily short on cash. Thomas Jefferson’s foreign trade embargo had ended only the previous year. Moreover, the reason for the embargo—the diplomatic complications of Europe’s Napoleonic Wars—had not disappeared. Indeed, things would get worse before they got better. The British blockaded American ports during the War of 1812 and paralyzed Yankee shipping. Jackson and Warren failed to raise the needed funds.