The Not-So-Loony BinVoluntary Madness doesn't have a new prescription for psychiatric treatment.

(Continued from page 1)

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Vincent returns throughout the book to the vexing question of the nature of mental illness. Is it a biological phenomenon like other medical diseases? Is it the result of an individual's emotional life? Is it, as the critics of the 1960s maintained, a social construct for stigmatizing and controlling deviant patterns of thought and behavior? Is it illness or an existential condition? Vincent tacks back and forth among these, explaining her own behavior and the behavior of those she meets along the way sometimes in one framework, sometimes in another.

At their best, psychiatrists are agnostic on the true nature and causes of mental illness. They are trained to think about their patients heuristically, along three dimensions: the biological, the psychological, and the social. At points during its history, psychiatry has been dominated by biological conceptions of mental illness; in other periods, psychology has reigned; and at still other times, social determinants have taken precedence. After the long postwar hegemony of psychoanalysis, the past 25 years in American psychiatry have witnessed a so-called biological revolution. This revolution, like so many others, took a tyrannical turn with the professional, cultural, and commercial triumph of serotonergic antidepressants. Prozac leached the psychology out of psychiatry, as psychiatric residencies taught psychotherapy less and pharmacology more, to the point where many programs stopped altogether training future psychiatrists in psychotherapy. Although the advent of the new medications was a great benefit to psychiatrist and patient alike, the loss of psychological modes of thinking within the profession has impoverished the skill of practitioners and the treatment of patients by psychiatrists. Although she doesn't tell us much about her decade of treatment prior to undertaking the research for Voluntary Madness, I wonder whether Vincent and perhaps her psychiatrist were not themselves casualties of this biological revolution with its almost exclusive focus on symptoms, diagnosis, and pharmacology. Only in the New Age Sanctum does Vincent encounter therapists who show any interest in addressing deeper emotional matters. Perhaps the failure of contemporary psychiatry to take emotional life seriously accounts for the current proliferation of alternative treatments.

Although in this day of budgetary constraint there are far fewer resources for such therapies, the nonverbal treatments that psychiatric hospitals were once renowned (or despised) for, such as physical recreation, dance, art, and music, do allow people who are so isolated from others and from themselves to become aware of and express what they are feeling and to reconnect in safe ways. In our pharmacological age, such human aspects of care should be neither forgotten nor contemned. For all its shortcomings, psychiatric hospitalization serves an essential role in contemporary treatment. The hospital provides a protective environment for people who are unable to protect themselves from themselves (or protect others from themselves). Hospitalization can also protect manic patients from harming themselves or others by preventing promiscuous sexual binges or ruinous spending sprees. Many a family of a manic patient—and many a patient after recovery from a manic episode—regrets that the law, out of concern for civil liberties, makes it so difficult to be hospitalized against one's will.

In psychiatry as in our culture, the tide may be turning once again, as we become disillusioned with the overuse of medications, more aware of their side effects and disappointed by their results, which could not possibly have met our inflated expectations. Although medications can help with symptoms—at times dramatically, saving lives that could have been lost—they will not treat underlying conflicts. For that, we need some kind of psychological therapy. In my practice, it is a rare patient who feels well enough from medications alone to forgo exploratory talk therapy.

In the end, Vincent concludes that the fault is less with our institutions and professions than with each of us individually: "[T]he vast majority of people don't want to participate in their own recovery. They are unwilling to try, even when they are given every advantage, every freedom, and an abundance of what was lacking in Meriwether [Bedlam], namely, compassion and the human touch." Much ink has been spilled over the question of resistance to change in psychotherapy, and most people are conflicted, whether consciously or unconsciously, about giving up their neuroses. But that is about internal conflict and unconscious motivation, not, as Vincent would have it, "because people—patients—are the way they are, often lazy, stubbornly self-indulgent, passive, and irresponsible." The therapeutic life lesson of her experience at the Sanctum is individual responsibility and self-discipline: "You want to be happy? You want to be well? Then put your boots on." Back to bootstraps. The New Age meets the Protestant ethic and discovers they have a lot in common.

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