Back to Peter Lehmann PublishingAbout Loren R. Mosher in: San Diego Weekly Reader, Vol. 32 (2003), No. 2, pp. 26 and seq. With a letter to the editor by Carla Jabobs in the San Diego Weekly Reader from May 24, 2003 and the response of Loren Mosher from June 23, 2003
Jeannette De Wyze
"Still Crazy After All Those Years: Local Shrink Assails the Schizophrenia Racket"
Sometime in the next few months, the Journal of Nervous and Mental Diseases will publish an article that describes an unusual experiment with newly diagnosed schizophrenics. This experiment randomly assigned young people with that diagnosis to one of two different forms of treatment. Some entered a psychiatric hospital where they received drugs to quell their psychotic ravings. The others went to a place known as Soteria House. They lived there for several months with a small group of other schizophrenics and a team of empathetic men and women (not medical doctors) who gave the disturbed individuals round-the-clock emotional support. The study tracked the research subjects for two years. According to the new report, the schizophrenics who lived in the therapeutic home and received no drugs fared better than the ones who received medication in the hospital. Furthermore, "The ones who did the best are those who would have been predicted to have the worst outcomes," Loren Mosher says. Mosher, a San Diego psychiatrist, was the principal architect of the Soteria experiment. What unfolded during the years it operated (1971 through 1983) shaped his ideas about schizophrenia, a condition estimated to afflict 1 to 2 out of every 100 Americans. Unlike the majority of his professional colleagues, Mosher was never persuaded that psychotic behavior is caused by brain abnormalities. He moreover came to believe that if schizophrenia is not an organic disease, then it's wrong to force schizophrenics to take drugs that change their brains. He acknowledges that the powerful antipsychotic medications prescribed for schizophrenia nowadays often do suppress the symptoms of lunacy and make disturbed individuals easier to control. But Mosher argues that there are better ways to help most schizophrenics recover their sanity - cheaper, more humane and libertarian, less devastating to the human body and soul.
Because he holds these beliefs, the 69-year-old doctor claims, "I am completely marginalized in American psychiatry. I am never invited to give grand rounds. I am never invited to give presentations. I am never invited to meetings as a keynote speaker in the United States." Yet from 1968 to 1980, the period when many of his unorthodox beliefs came into focus, Mosher occupied a prominent position in the American psychiatric research community. He was the first chief of the Center for Studies of Schizophrenia at the National Institute of Mental Health in Washington, D.C. He founded the Schizophrenia Bulletin, and he served as its editor in chief for ten years. The story of how and why he became an outcast in his profession reveals much about the profound ways in which the concept of madness has changed in America over the past 40 years.
In Mosher, maverick tendencies can be traced to his childhood. A sickly boy plagued with allergies and asthma, he lost his mother to breast cancer when he was 9. Shunted between various relatives, he says he more or less raised himself from the ages of 8 to 14. By 1949, he had settled with his father in Marin County, but he continued to enjoy extraordinary freedom as a teenager. He had both a car and a driver's license when he was 14. Summers he explored the Sierra Nevada wilderness on an old Arabian stallion loaned to him by an uncle. In the two and a half months after his high school graduation, he toiled as a roughneck in the oil fields of Montana and Wyoming, having used a fake ID to prove he was 21. "My story was that I was working after college to get money to go to medical school." The lie transformed him, he recounts. "Presto chango. I was 'Doc.' My practice was luckily limited to simple first aid, common ailments like colds, and sexual complaints like the crabs and gonorrhea." But Mosher was astonished and delighted by the importance he suddenly gained in the eyes of his fellow roughnecks "because I seemed smart and was 'going to be a doctor.' "
College had to come first. He'd won a scholarship to Stanford, then known as a party school for WASPs. He says he liked the idea of partying but also had to work for all his living expenses. Mosher knew that a medical degree was his ultimate goal. He'd admired the lady physician who had treated his many childhood illnesses and says her competence and empathy made him want to be a doctor too. Turned down by Harvard's medical school, he attended Stanford's for two years, then took off a year to work and save money. At that point, Harvard accepted him as a transfer student. "So my degree - with honors - is from Harvard Medical School. Which is important," he says, looking mischievous. "It explains a lot of things I've been able to do that other folks have trouble getting away with." Mosher likens the Harvard credential to having a "very, very good union card.… Your ability to do things is enhanced." After graduation, he did an internship at the University of California in San Francisco. "And then I took my psychiatric residency at Harvard again."
Why psychiatry? Mosher points to several experiences in medical school that piqued his interest in the field. He once came down with "a case of medical student hypochondriasis" severe enough to make him get psychological help. "In psychotherapy for more than a year, I experienced firsthand the healing possibilities of a caring, human relationship." A summer psychiatric fellowship introduced him to visionary Bay Area psychiatrists such as Gregory Bateson and provided a glimpse into "humanistic possibilities" in psychiatry that to Mosher contrasted with the technological, mechanized aspects of many other medical specialties. All his friends seemed to be going into psychiatry; he followed suit.
He says the year he spent as a medical intern helped form some of his key attitudes. Confronted daily with "sickness, unkindness, and death, situations over which I had little influence or control," Mosher felt determined not to think of his patients as objects, as so many of his fellow physicians seemed to do. He found inspiration in the writings of existential and phenomenological thinkers of the day, such as Rollo May, Søren Kierkegaard, Jean-Paul Sartre, Maurice Merleau-Ponty, and others. "Their thing was, basically, enjoy yourself because you may not wake up tomorrow morning," Mosher explains. "And they had a very straightforward attitude of accepting people for what they are and not judging and categorizing and putting them in pigeonholes. Just try and be there and be the best you can be in whatever you're doing. When people are dying all around you every day and there's nothing you can do, that's good solace, if you will."
In 1962, he arrived for his psychiatric residency at the Massachusetts Mental Health Center (an institution "long known as the 'Psycho' because of its previous name, the Boston Psychopathic Hospital"). There a white-haired, rotund, Santa Claus look-alike "quickly divested me of any remaining pretensions about 'curing' patients," Mosher says. This man, who became Mosher's mentor, exhorted his psychiatric residents to forget about doing things to patients. Instead he urged them to be with the suffering individuals - understanding, accepting, and forming relationships with them. "His encouragement to relate to schizophrenics as people with very serious life difficulties, to treat them with dignity and respect, and to attempt to see things as they saw them was a critical piece of my subsequent development," Mosher asserts.
But Mosher also confronted evidence that the culture of the psychiatric hospital militated against such attitudes. "[D]ecisions that made the staff, not the patients, more comfortable were rationalized, and physical treatments such as electroshocks were applied to relational problems." By the time his residency ended, he had developed two conflicting sets of attitudes. The first was that "human relationships could be therapeutic for even those whose distancing maneuvers were most masterful" - that is, schizophrenics. On the other hand, he thought the realities of life in the mental hospital thwarted the formation of such relationships.
Mosher had no intention of spending his career in psychiatric hospitals. He envisioned a path that would lead him to prominence as a psychiatric researcher, and as the first step to that end, he won a position as a "clinical associate" at the National Institute of Mental Health (NIMH). Beginning in 1964, he worked in the institute's Family Studies branch, scrutinizing families with schizophrenic offspring.
"Research on twins and schizophrenia had been done since the early 1900s," he says. "The Germans were the first to do it." By 1960, according to Mosher, some authorities were asserting that in almost two-thirds of the cases in which one identical twin was schizophrenic, the other identical twin shared that condition. If true, this would have represented strong evidence of a genetic cause, since identical twins share the same genetic makeup. By the time Mosher arrived at the institute, however, he says critics had begun to cast doubt on the trustworthiness of the twin studies. Newer and methodologically sounder studies were showing a much lower "concordance rate."
The group that Mosher joined wasn't studying such statistical correlations but was rather trying to understand what happens in cases of discordant identical twins - that is, those in which one twin is crazy but the other isn't. "We would bring both twins and their families into the clinical center for two weeks or so and study them as a group." What they found, Mosher says, is that in these families, the twin who grew up to be schizophrenic "was basically treated differently from his or her twin in a variety of ways."
Today Mosher looks back on this research and sees "lots of problems" in it. The study he worked on included only 16 pairs of twins. The way they were selected to be studied was questionable, and other biases might have influenced the work. But the work "did generate some interesting hypotheses," Mosher says. And the two years he was involved with it gave him credentials as a promising young psychiatric researcher.
For his next step up the professional ziggurat, Mosher persuaded the National Institute of Mental Health to send him to London, then one of the yeastiest centers of creative ferment in the psychiatric realm. During his year there, he soaked up a broad range of intellectual influences. As a therapist, he saw couples at the British National Health Services' Tavistock Clinic. "Then I would run out to Anna Freud's clinic and spend an afternoon in her so-called borderline group, where they would discuss cases according to Freudian theory," he recalls. He spent time at the Maudsley Hospital with a famous psychiatric geneticist named Eliot Slater, "very, very biological in his orientation." Nothing, however, left a deeper impression than the time Mosher spent with R.D. Laing and the controversial experiment in which Laing was then immersed.
A charismatic Scot who'd become a British Army psychiatrist by the age of 20, Laing had burst into international prominence with the 1960 publication of a book called The Divided Self. "It attempted to make the process of going mad intelligible to ordinary people," writes one of Laing's biographers. Schizophrenia, in Laing's view, was an attempt to cope with an unbearable situation. Mosher had read The Divided Self when it first appeared, and he had thought it matched his own experiences with patients so closely "that I wondered why it was causing a stir."
In June of 1966, Laing brought the young American up to date on developments at Kingsley Hall. This East London building, owned by the Quakers, had housed Mahatma Gandhi during his negotiations with the British in the early 1930s, and it had reclaimed the spotlight when the Quakers made it available to a group called the Philadelphia Association, whose membership included Laing. The previous fall (in 1965), "They had assembled people who had been labeled as having serious problems," Mosher explains. "The original notion was that the professionals would live there with the people who were (as they would say) 'less together.'… The environment itself would be the therapeutic instrument…an egalitarian community where the boundaries between the sane and the insane were not defined by status."
By the time Mosher arrived in London, some of the original ideals had fallen by the wayside. "Most of the professionals didn't live there very long," he recalls. "They didn't like the constant intrusion of the crazies. They had no privacy." A constant stream of visitors also trooped through, and Mosher says, "It became like a zoo - where the visiting American firemen would come to look at the animals in the cages." He says Kingsley Hall's residents eventually rebelled, declaring that no one could enter the facility unless invited by a resident. For several months, Mosher was excluded, but he was later invited back, and he often spent an evening a week there.
As he did so, he made a mental list of things that bothered him. He felt critical of the "run-down dirty state of the house, the chaotic disorganization of its money matters, and the at best haphazard gathering and preparation of food." He thought the residents' isolationist and even hostile attitude toward the surrounding neighborhood was apt to lead to a backlash. Inside the hall, he raised an eyebrow at the reliance on altruism and friendship to generate interpersonal involvement. "While the aim sounds noble, the result was that unattractive residents spent large amounts of their time alone on their 'trips.' " Mosher thought "some salaried staff, whose job it was to be nonaggressively involved with spaced-out residents, would achieve better results than leaving the mad to their loneliness and misery."
Despite its shortcomings, the experimental treatment model fired Mosher's imagination. "I decided, for example, that madness need not be - and is probably better not - treated in a hospital." Mosher felt that Kingsley Hall at least had proven that schizophrenics could recover in an open institution where the residents' roles were not defined rigidly and status and power hierarchies were minimized. Medical and psychiatric trappings were "at best irrelevant and at worst harmful for the mad," he concluded.
Sooner than he anticipated, he had an opportunity to test this conviction. When Mosher left London, he headed for Yale University's medical school, where a job as assistant professor awaited him. Mosher had been recruited to Yale's faculty in the expectation that he would share the new family-study methods he had learned at the National Institute of Mental Health. After experiencing the vibrant countercultural energies surging through late-'60s London, however, Mosher says his new domain gave him a serious case of culture shock. Yale's psychiatry department was "conservative, psychoanalytic, and dominated by powerful full professors." Furthermore, when another assistant professor got sent to Vietnam, Mosher was asked to assume this man's duties of overseeing a 20-bed psychiatric ward in the brand-new Connecticut Mental Health Center. To Mosher it seemed like the perfect opportunity to put his unconventional ideas into practice.
The result was "totally open, voluntary, with everyone doing what he wanted. People were allowed to decorate their rooms. It was a lot like a college dormitory." Mosher phased out staff-only meetings; he unlocked the doors and made it clear that patients could organize their own activities. They should be treated like consumers, rather than patients, the psychiatrist urged his staff. And he says, "The patients loved it! And the psychiatric residents I trained were delighted. This was the late '60s.… We did all kinds of weird things, like, someone would come in on a commitment paper, and I would sit down and talk to them. I'd say, 'Well, what can we do to help you?' And if they couldn't find something, I would say, 'If this isn't the place for you, you can go.' "
By Yale standards, it was "a deviant place," Mosher acknowledges in hindsight. "There were wards above and below it that were very, very different - much more traditional." He says by spring, the hospital administrators' consternation had become intense. They saw it leading to an increased number of suicide attempts, violent incidents, and patients being sent to the state hospital. After a year, Mosher agreed to move on.
Once he left, however, he studied the data pertaining to his free-form ward and to the traditional wards that had operated above and below it. He says he found no evidence that patients on his floor had fared any worse than those in the other wards. "It turns out if you allow people to be free, they actually behave pretty well," Mosher asserts. "Probably better than under force." He says his study taught him something else. Until he analyzed the data, he'd accepted what his powerful and respected medical supervisors had said about his experiment. "It's the role of power and perception. If those who are more powerful and in charge say that black is white, you're apt to say maybe black is white." Victims can come to embrace the way their persecutors see the world - "a paradigm utterly applicable to the development of madness."
Mosher at this point turned his sights on a place where the analysis of hard scientific data promised to have top priority, namely the National Institute of Mental Health. His previous work there had won him friends, and his job inquiries came at a fortuitous time. Amidst the free-spending euphoria of Lyndon Johnson's Great Society, Congress was lavishing money on all sorts of Washington institutions. Mosher says the legislators "had put a box in their organization chart labeled Center for Studies of Schizophrenia and said, 'Fill this box.' " At 34, he became the center's first chief. "I got there in 1968, and I lasted until 1980. Not without considerable turmoil."
Although the Center for Studies of Schizophrenia was new, the National Institute of Mental Health had already funded hundreds of studies of the baffling psychosis. Mosher says the first thing he did upon his arrival was to review the institute-sponsored schizophrenia research then in progress. He also began scrutinizing all new requests for research funds, as well as sitting in on committee meetings of scientists who reviewed the grant applications.
He says in 1968 he wasn't convinced schizophrenia was an organic illness. "In my mind, it was sort of an open question. There were so many differences among people who had the same label that it made me pause." Schizophrenia was then, as it is now, considered to encompass a long list of potential symptoms (see page 27). "And you can get that label without sharing a single characteristic with some other person with the same label," Mosher points out. No blood test or brain scan or other external validating criterion for schizophrenia has ever been established. Instead, a diagnosis "boils down to the subjective impression of the interviewer." The question of whether a person receives the label is "just my call, as the diagnostician."
Mosher leaned toward the view that schizophrenic behavior resulted from psychosocial experiences. But today he insists that as chief of the center, "I had no objection to people approaching it from a disease standpoint.… I just thought that both [disease and social models] ought to get equal time and an equal amount of money." Mosher says his attitude toward biologically oriented research proposals was " 'Fine. If you obey the canons of science and produce an answer, that's great. And the same with the social side.' But of course, it was always the biological types and the drug types, the interventionists, who announced the causes and the cures."
During his tenure, Mosher says, "There must have been three or four causes and four or five different cures announced." He says his all-time favorite cure was kidney dialysis. "It was very easy to figure out why it worked," he says with a chuckle. "The guy who was doing it was this preacher type of doctor." He and his staff set up schizophrenics in pleasant, comfortable housing; they showered them with attention. "He was really a great guy, and they did all sorts of proper stuff." He also made his patients undergo twice-weekly dialysis, even though their kidneys were normal. And when the patients improved, he proclaimed that the dialysis was responsible. "Meanwhile, they were having a nice life," Mosher says. "But we were forced at the NIMH to spend a couple million dollars studying dialysis not done by him. And guess what? It didn't work. I had told them that it wouldn't. But the NIMH is a political animal. So we had to go out and help people design studies" that attempted to confirm that kidney dialysis could rescue people from madness.
Although he looks back on the alleged dialysis cure with something approaching fondness, Mosher has darker memories of the drug research he saw unfolding under the aegis of the National Institute of Mental Health. In 1968, the notion that schizophrenic symptoms could be controlled by pills (or injections) was hardly new. Smith, Kline & French had started selling a drug called chlorpromazine to American doctors in May 1954 (when Mosher was just completing his junior year at Stanford). Patented as Thorazine, this was the first substance marketed as an antischizophrenic medication - one that in later years would be likened to penicillin in general medicine.
As soon as the Food and Drug Administration approved chlorpromazine, Smith Kline produced a television show called The March of Medicine that suggested Thorazine was nothing short of miraculous. This program "was the kickoff in an innovative, even brilliant plan for selling the drug," writes Robert Whitaker, the Boston-based author of Mad in America: Bad Science, Bad Medicine, and the Enduring Mistreatment of the Mentally Ill, a trenchant critique of contemporary schizophrenia treatment released by Perseus Publishing last year. According to Whitaker, Smith Kline's marketing campaign included setting up a national speakers' training bureau "to coach hospital administrators and psychiatrists on what to say to the press and to state officials.…" The message they spread told of "lost lives being wonderfully restored." Whitaker writes, "The company also compiled statistics on how use of the drug would save states money in the long run - staff turnover at asylums would be reduced because handling the patients would be easier, facility maintenance costs would be decreased, and ultimately, at least in theory, many medicated patients could be discharged. This was a win-win story to be created - the patients' lives would be greatly improved and taxpayers would save money."
In his book, Whitaker asserts that the evidence supporting this rosy vision was sketchy at best. The U.S. Department of Agriculture had used some phenothiazines (the family of compounds that includes chlorpromazine) in the 1930s to kill insects and swine parasites. In the following decade, the chemicals "were found to sharply limit locomotor activity in mammals, but without putting them to sleep. Rats that had learned to climb ropes in order to avoid painful electric shocks could no longer perform this escape task when administered phenothiazines." Intrigued by these findings, researchers in France had used chlorpromazine as an anaesthetic adjunct for surgery patients and then on manic patients, who became like zombies under the influence of the drug. The first North American psychiatrist to test it noted with approval that chlorpromazine might "prove to be a pharmacological substitute for lobotomy."
Doctors in Europe and America also pointed out that patients taking the drug often developed the shuffling gait, masklike visage, and drooling associated with Parkinson's disease. Others observed that it mimicked the symptoms of encephalitis lethargica (a so-called sleeping sickness). Whitaker comments that in the early 1950s, "such effects were seen as desirable." Most psychiatrists then perceived insulin coma, electroshock, and frontal lobotomy to be beneficial; they made patients quieter and easier to handle. "Approximately 10,000 mental patients in the United States were lobotomized in 1950 and 1951," Whitaker writes, and in 1954, "hospital administrators were still struggling with horribly inadequate budgets and hopelessly overcrowded facilities. A drug that could reliably tranquilize disruptive patients was bound to be welcomed."
Sniffing the potential for big profits, Smith Kline wanted to rush the drug to market, and so the company tested it primarily as an anti-emetic agent, records Whitaker, who adds, "All told, the company spent just $350,000 developing the drug, administering it to fewer than 150 psychiatric patients for support of its new drug application to the FDA." Once approved, however, Thorazine (and the other so-called neuroleptic drugs that followed it) became the subject of press reports that gushed over the way the medications worked on lunatics, not vomitters. In an early article entitled "Wonder Drug of 1954?" Time magazine described how patients given Thorazine "sit up and talk sense [when a doctor enters the room], perhaps for the first time in months." U.S. News and World Report suggested that the "wonder drugs" might be a "new cure for mental ills." The New York Times ran at least 14 positive articles about neuroleptics in 1955 and early 1956.
Amidst the rising tide of hyperbole, federal spending on mental health research ballooned from $10.9 million in 1953 to $100.9 million in 1961. Whitaker writes that by 1963, President Kennedy was announcing that the new drugs "made it possible for most of the mentally ill to be successfully and quickly treated in their own communities and returned to a useful place in society." A series of reports that documented a modest decline in mental hospital censuses between 1955 and 1960 - years when the neuroleptics were being introduced - accounted for this belief. Whitaker, however, notes that when the California mental hygiene department looked at first-episode male schizophrenics admitted to California hospitals in 1956 and 1957 and compared the hospitalization lengths of drug-treated patients versus nontreated ones, the drug recipients were found to have stayed in the facilities longer. "In short, the California investigators determined that neuroleptics, rather than speeding people's return to the community, apparently hindered recovery. But it was the [other] research that got all of the public attention."
Mosher was making his way through medical school and beginning his early psychiatric training just as the neuroleptic bandwagon began rolling. He prescribed drugs during his residency training; none of his mentors had denigrated them. Even the experience at Kingsley Hall had been ambivalent. Although the overall gestalt of the experimental London facility looked down on drug therapy, Mosher says a number of the residents took neuroleptics prescribed by doctors unaffiliated with the Philadelphia Association.
Only at Yale did alarms begin to sound, he recalls, as residents and medical students confided to him their belief that drugs were the only useful treatment in psychiatry. That seemed extreme, Mosher thought, and he says his first few years as the chief of the Center for Studies of Schizophrenia did nothing to allay his concern about the growing influence of the pharmacological industry within American psychiatry. He thought the National Institute of Mental Health was doling out an "inordinate" amount of its funding for studies that the drug companies themselves could well afford. (Smith Kline's annual revenues, for example, soared from $53 million in 1953 to $347 million in 1979.) The drug research that the institute was funding, though sophisticated, seemed to him repetitive "especially in view of the fact that the neuroleptics developed early on were as good as those being endlessly and expensively tested with federal money." It made more sense to Mosher to spend taxpayer dollars on evaluating psychosocial therapies, since they lacked commercial patrons with deep pockets.
So he perked up at the grant proposal that came across his desk one day in 1969. A couple of psychiatric researchers in Northern California were asking the National Institute of Mental Health for money to compare two wards in a state mental hospital: a traditional one that employed neuroleptics, and a drug-free ward that offered a special psychosocial milieu. To Mosher, this sounded like a perfect opportunity to assess scientifically how a place like Kingsley Hall stacked up against one that used drugs as the mainstay of treatment. Unfortunately, the hospital administrator balked at the proposal, and the two psychiatric researchers lost interest in pursuing it.
The idea continued to intrigue Mosher, however, so he refined it, coming up with a plan that proposed randomly assigning newly diagnosed schizophrenic patients to one of three treatment venues: a general hospital ward that relied on drug therapy, a community treatment center that used drugs, and a community center where drugs were avoided if possible.
Although he was a high-ranking insider, Mosher couldn't just wave his hand and conjure up the money for his own study. Instead, the project had to go before the institute's Clinical Project Research Review Committee. And in 1970, when Mosher first appeared before the top academic psychiatrists who were its members, he got a lukewarm reception. According to Whitaker, who reviewed the minutes of the committee's review sessions while researching Mad in America, the resistance was understandable. Mosher's proposal "didn't just question the merits of neuroleptics," Whitaker writes. "It raised the question of whether ordinary people could do more to help crazy people than highly educated psychiatrists. The very hypothesis was offensive."
On the other hand, turning down the chief of the Center for Studies of Schizophrenia would have flouted bureaucratic niceties. So the committee compromised by giving Mosher less than he had requested. It slashed one community treatment center from the study design and offered only enough money to run the second (drug-free) center for 18 months (instead of five years). This was supposed to be a kiss of death, Mosher claims. But he immediately started working to get the funding extended. As he toiled on that, the project that came to be known as Soteria (a Greek word meaning "deliverance") got underway.
In April of 1971, it was ready for business. The facility was to operate out of a rambling two-story, 1912-vintage wooden house that sat between a nursing home and a two-family dwelling on a busy street in a poverty-stricken section of San Jose. The building's 12 rooms were designed to accommodate a maximum of six schizophrenics. Two full-time staff members, plus various volunteers and part-time assistants, would live with them; a house director and psychiatrist would contribute advice.
Staff and residents shared the cooking and other household chores, and the staff "aimed to provide a simple, home-like, safe, warm, supportive, unhurried, tolerant, and nonintrusive environment," Mosher has written in a detailed description of the project. Most "worked 36- to 48-hour shifts to provide an extended opportunity to relate to 'spaced-out' (their terms) residents continuously over a relatively long period of time.… [They] were explorers in an uncharted frontier; they were in a place where few people without preconceived notions had ventured before, and they were there without the usual trappings of power to control madness." They didn't carry "the highly symbolic keys to freedom: There were no locks on the doors. There were no syringes and few medications; and there were no wet packs, restraints, or seclusion rooms."
As for the residents (never "patients"), the study's design dictated that all be young, unmarried, and newly diagnosed as schizophrenic - the subgroup known to have the worst long-term outcomes. One by one, the randomly assigned participants began arriving at the house. Some stumbled around muttering to themselves or hearing terrifying voices. Some stood mute and paralyzed; others rocked for hours on end. One 17-year-old girl regressed to speaking baby talk. She pranced around the house naked, urinated on the kitchen floor, and demanded to be breast-fed. A young man insisted that residents of Venus were coming to Earth to visit him.
Mosher says that to a large extent the staff tolerated eccentric behavior. Someone accompanied the young man expecting the extraterrestrial visitors to the spot where he said the celestial bodies would be in the proper alignment, then waited with him until he conceded that the Venusians weren't coming that day after all. Residents were supposed to be figuring out what they wanted to be (as opposed to what others expected of them). But a few rules stood firm. Violence was forbidden, and illegal drugs were banned. Although family members and friends could visit, curious outsiders weren't allowed into the house without special arrangements. After a skeletal young woman began jumping, naked, into the laps of male staff members and exclaiming, "Let's fuck!" the staff also instituted an "incest taboo" on sex between the staff and the residents.
Rules about the use of antipsychotic drugs were a bit more flexible. Mosher says the staff made every effort to refrain from administering neuroleptics or major tranquilizers during the first six weeks of each individual's stay. It sometimes took that long for the residents to form relationships and otherwise respond to Soteria's psychotherapeutic environment. Only uncontrollable violence or threats of suicide or "unrelenting psychic pain" led the staff to break the no-drugs rule in the first six weeks, Mosher says, and then only when the resident agreed.
At the six-week mark, each client's progress was evaluated, and if no improvement had occurred, a trial drug treatment usually ensued, providing that the person consented. In such cases, Mosher says the drugs were used sparingly. The fundamental credo at the house was that psychotherapeutic support - rather than drugs - was what could help the residents recover from their psychoses.
Mosher points out that the kind of therapy dispensed at Soteria House differed profoundly from the work that went on at the famous Chestnut Lodge psychiatric hospital in the '50s and '60s. There psychiatrists had tried to cure patients with traditional Freudian-style psychotherapy. "I'm fond of saying psychosis does not fit the 50-minute hour - because it goes on 24 hours," Mosher says. "So you ought to conform your treatment to fit the problem." Rather than scheduling specific sessions with their charges, the Soteria staff members made a commitment to be available every moment of the schizophrenic residents' waking hours. Mosher says the overall feeling had much in common with the "moral treatment" asylums that appeared in America in the first half of the 1800s. Small, humane, and pleasant environments, these institutions promoted the concept that many lunatics could recover their sanity if treated with decency, gentility, and respect. As peculiar as that notion might appear today, Whitaker in Mad in America writes that "Moral treatment appeared to produce remarkably good results." He cites records from five moral-treatment asylums showing that between 50 to 91 percent of their patients were able to return to normal lives in their communities. Such outcomes led one asylum superintendent to declare in 1843 that insanity "is more curable than any other disease of equal severity.…"
Like this man, the staff at Soteria embraced the notion that "recovery from psychosis was not only possible but probable and to be expected," Mosher asserts, adding, "You start there, and you're way ahead of the game right away." And Mosher went further. By the time the Soteria project got rolling, he had come to believe that rather than being an unfathomable mystery, psychosis was an understandable coping mechanism.
He claims that in this way it resembles shell shock. "Men would be in combat and their entire platoons would be killed, and they would survive and be covered with blood and guts. And they would go out of their minds." What such individuals look like as they're ranting and raving "is really no different than what acute psychosis is like," Mosher says. "Except that the [shell-shock victim's] trauma - the overwhelming experience - is very readily identifiable. It's right there, easy to see."
In contrast, he says the trauma that drives schizophrenics over the edge "is not often so readily identifiable, and it is more often cumulative, rather than a single event." Mosher claims that a number of well-done scientific studies over the years have implicated various psychosocial factors. "Something on the order of 60 percent of adult admissions to psychiatric hospital wards have histories of sexual and/or physical abuse," he says. "This has only been studied in the last 20 years." Furthermore, "There are two aspects of family life that have been consistently highly associated with what's called schizophrenia. One has been dubbed 'communication deviance.' It's simple. Just means that when you sit with these parents, you can't figure out what the hell it is they're talking about. They can't focus on things. You can't visualize what they say. They go off on tangents. They are loose in the way that they think." He says the other thing that's pretty clear from studies is that "when families are very hostile to and critical of their offspring, that's not good for them."
Mosher acknowledges that no single one of these factors can be said to be the sole cause of schizophrenia. "Not every person who's been sexually or physically abused becomes psychotic. Some do. But often there's a lot of things going on, and usually there's also a trigger event" - a romantic rejection, the death of a parent, an excessive involvement with recreational drugs. "So if you add sexual or physical trauma to having a hostile, critical, fuzzy family - and then somebody breaks your heart - your chances of going to pieces are pretty good."
Going to pieces is a way of coping, Mosher contends, because "Basically what they're saying is, 'Hey, folks, I'm out of here. I'm constructing this world as it pleases me, and I don't need to pay attention to that world out there. I'm going to live in this one because that one out there hurts.' " He says a person's chances for returning to normal life in the outside world depend on how far from it they've retreated. "Some people have been so hurt by relationships that they give up all hope. But that's a very small minority. And the majority will try again."
Mosher insists that almost no one is so crazy that it's impossible to talk with them. "If you believe that the person is in there and you can really speak to them, there are very few instances when you can't. It's really a matter of attitude." His eyes sparkle when he thinks about experiences he's had while doing grand rounds at hospitals. "They would always bring me the person who was the very craziest. I would sit down with this very, very crazy person, and he or she and I would have a conversation that - after the first five minutes or so - could be understood by all the members of the audience. And the people in the audience would say afterward, 'Well, [the patient] must have been having a good day today.' " That was never it, Mosher retorts. "It's just a matter of how you approach people. If you treat them with dignity and respect and want to understand what's going on, want to really get yourself inside their shoes, you can do it."
These days, he says, "If you say 'psychosis,' people step back and say, 'Well, I'll talk to them after you give them drugs.' But that's hardly any fun at all! Truly. The most fun that I have had in my life was just sitting, talking for hours to people who were out of their minds. And it doesn't take very special training. What it takes is just attitude and interest and intensity and willingness to sort of suspend your own reality and not worry about it."
The staff members at Soteria House cultivated all those things, and Mosher says they saw a pattern. First one person would work to establish a bond with the newcomer, something that might take anywhere from two hours to three weeks. In the weeks that followed, the newcomer would gradually develop relationships with others in the house, creating a role for him- or herself in the extended family of the community. These relationships stimulated the schizophrenic residents to change, Mosher believes. "As you have a relationship with another person, you can come to recognize that they're thinking and behaving in quite a different way than you are. And if you come to have a sort of affection for that person, then it can become safe to think and act more like they do" - i.e., less crazy and more sane. He says in a third and final stage, the Soteria residents would become increasingly competent at directing their own activities as they prepared to create lives for themselves outside the house.
As such transformations were unfolding, Mosher says he made frequent trips from his home in Washington, D.C., to the West Coast. "I spent a lot of time out there…basically every summer for about four years." He'd managed to get the initial grant to run Soteria House extended, and in 1973, he'd proposed to open a second Bay Area house to demonstrate that the experience in Soteria could be replicated. This time he submitted his request for funds to a different arm of the National Institute of Mental Health, "and they said it was the most elegant study that you could ever imagine. They loved it." This second committee gave Mosher enough money to run a second house for seven years. He called it Emanon, "no name" backwards.
"So by 1974, we had two houses going. For a while, we were in fat city." That same year he began presenting the first papers reporting Soteria's outcome data. "We would cut the data, and it would be sent to the NIMH, where my staff would analyze it as fast as it arrived," Mosher recalls. "So we were producing papers by the carload. And that was a major mistake. We wrote too much too soon, and the results were very positive." Rather than heralding the findings as a breakthrough, the Soteria review committee sniped that the "credibility of the pilot study [was] very low." Mosher says the grant "had the most checkered history in the entire NIMH history. It was reviewed more times by more committees than any grant in history. It questioned so many of the psychiatric beliefs that people hold near and dear to the heart. Like that you need hospitals. That you need a trained staff. That you need neuroleptics. And that you need the medical model to explain things."
He says the denouement came in 1975, when the committee said it would continue to fund the project only if Mosher's role was diminished and the data analysis conducted on the West Coast. Whitaker, who reviewed the committee records while researching Mad in America, writes, "The irony was that Mosher was not even doing the outcomes assessment.… Mosher well knew that experimenter bias regularly plagued drug studies." He'd turned to independent evaluators to rid the Soteria experiment of that problem. Yet Mosher had no choice but to search for his own successor as principal investigator of the study he had brought to life.
This all took place in 1976. "So you could see then that my reputation at the NIMH was one of becoming a very controversial character." Mosher says three or four well-known professors of psychiatry charged that the Center for Studies of Schizophrenia wasn't paying enough attention to neurobiology, so a committee was set up to investigate the center's operation. "If you want to stop someone from doing real work, you set up a committee to investigate him," Mosher says with some bitterness. "It stops anything from going forward."
"I was incredibly demoralized," he reflects about these years. As Soteria and Emanon limped along, Mosher would fly to California on weekends and "just hang out with the crazies and the staff." During this interval, he met a young Italian psychiatrist who spent a year and a half studying and working at Soteria. This man told Mosher about a new Italian law that had just passed, governing the country's mental health system. "It was an absolutely revolutionary law that would be the law of my dreams," Mosher says. "It essentially closed the front doors of all the big hospitals - just like that." Fascinated, Mosher got the National Institute of Mental Health to send him to Italy for eight months so he could learn more about what was happening. When he arrived home again in 1980, he discovered, "They had given my job away to my deputy. I had a desk and a secretary and no official title. That makes it very clear your presence is no longer needed in that particular place."
Mosher wasn't out of work. He was an employee of the Public Health Service, which is "like the military," he explains. "Unless you do something really heinous, they can't fire you, but you can be transferred." In his case, he wound up going to Bethesda, Maryland, where he became a full professor and the vice chairman of the psychiatry department of a medical school that trains doctors for the uniformed military services.
While there, he says he worked with a group in Washington, D.C., to create a replication of Soteria. It differed from the California facility in a couple of key ways. "It was part of the public system, and it had a restrictive length of stay - about a month" (versus the five months, on average, that residents had stayed at the original Soteria). Mosher says it also "took in any kind of patient - that is, anybody deemed in need of hospitalization in Washington, D.C." For the most part, that meant "black, lower-class, homeless, fucked-up, multidrugged individuals." Because the clientele tended to be so heavily drug-dependent, this facility "didn't make any big deal about the issue of drugs," Mosher says. "But the model of the organization - the place, the staffing - was a reproduction of the Soteria thing." And he says, like Soteria, "It was very successful. Ninety-five percent of the people admitted there were discharged straight back to the community without having to be hospitalized."
In 1988, Mosher changed jobs again, becoming the medical director of the Montgomery County, Maryland, public mental health system. There he established yet another small, Soteria-like facility and got a National Institute of Mental Health grant to compare the outcome of patients randomly assigned to it and to a local general-hospital ward. Once again, as in Washington, D.C., "No one was excluded because they were too crazy or too suicidal or too homicidal." The only people rejected were those who refused to enter voluntarily. As in Washington, "We did not make an issue of no drugs," Mosher says, adding that the Maryland schizophrenics had an average duration of illness "for something like 14 years and average number of hospitalizations of 17. So these were really career mental health people."
Mosher says this study showed that the people in the Soteria replica fared as well as those who entered the hospital, and "the cost savings of getting them through the crisis were about 45 percent. In the hospital, they stayed only 12 days, on average, and they got them out mostly by being given so many drugs they couldn't see straight. We didn't do that. We actually tried to lower drugs and change drugs and be more sensitive. And they got as much better and it cost a lot less because the staff we used were paraprofessionals." Over six months, it cost about $19,900 per person on average to treat the outpatients, versus $25,700 per person for those dealt with in the hospital.
Although Mosher described these findings and published them, no new data about the original Soteria and Emanon research reached print for years after his departure from the National Institute of Mental Health. Emanon had closed its doors in 1980, and Soteria, after struggling to find revenue sources other than the institute, finally came to an end in 1983. The institute had awarded a grant to analyze the data collected between 1976 and 1982, but that money didn't become available until 1989. Mosher and a psychologist then began studying the information, and "We finally published a paper about the second part of the study in 1995. That's a long time."
Today Mosher says more than 40 publications have described the study. Mosher thinks the "cleanest, most important" finding was the outcomes for the hospital and Soteria patients after six weeks (the point at which neuroleptic drugs are known to be most effective at reducing psychotic symptoms). Comparing the outcomes at that point showed that the Soteria subjects experienced as great a reduction of their psychotic symptoms as did the hospital patients, Mosher says. Whereas all of the hospital patients received neuroleptic drugs, only 24 percent of the Soteria patients did during that interval, "and really only 16 percent had enough to be said to have had a possibly therapeutic course - two weeks or more." Mosher adds that the 76 percent of Soteria patients who got no drugs at all did better than those who took some form of medication. To Mosher, that means "If you can construct the right kind of social environment for newly diagnosed people who have schizophrenia, 76 percent will respond in that environment as well as or better than they do to drugs."
Mosher's move to San Diego had no direct connection to his Soteria project. It came about as a result of the work he did in Maryland, where he created a community-based system of mental health care, one that "worked extremely well for as long as they let us do what we wanted." Mosher says the Montgomery County supervisors then decided to hand over various county programs to private contractors, a move Mosher opposed. At about the same time, he says, "San Diego recruited me to come out here and change the San Diego system as I had the Montgomery County one." In 1996, he started work as the clinical director of mental health for the County of San Diego. "Unfortunately, I landed here at the same time that the San Diego County Board of Supervisors was also bitten by the privatization bug." The supervisors mandated that some kind of managed care be implemented in San Diego County. Mosher says that about 18 months after his arrival, he submitted a plan that he believed would have decentralized and improved the mental health care system here. But it would have required hiring about two dozen new staff members, a move that the supervisors opposed. A year later, Mosher and the county parted ways.
Sometime in the year after his resignation, Mosher received a routine notice from the American Psychiatric Association asking him to pay his annual dues. He says he'd begun having doubts about the cozy relationship between the professional organization and big pharmaceutical companies as far back as the mid-1980s. "But you know, when you work at an official job, it is really impolitic not to be a member of the APA." When Mosher at last found himself "deinstitutionalized," however, he felt free to give full vent to his concerns. In December 1998, he fired off a letter of resignation to Rodrigo Muñoz, a San Diego psychiatrist who at the time was serving as president of the national psychiatrists' organization.
The letter made no attempt to be diplomatic. "At this point in history, in my view, psychiatry has been almost completely bought out by the drug companies," Mosher stated. "The APA could not continue without the pharmaceutical company support of meetings, symposia, workshops, journal advertising, grand rounds luncheons, unrestricted educational grants, etc. etc.… Psychiatric training reflects [the pharmaceutical industry's] influence as well: the most important part of a resident's curriculum is the art and quasi-science of dealing drugs, i.e., prescription writing."
"No longer do we seek to understand whole persons in their social contexts," he continued. "Rather we are there to realign our patients' neurotransmitters." Mosher further charged that the American Psychiatric Association had "entered into an unholy alliance" with the National Alliance for the Mentally Ill, the powerful group founded and controlled by the parents of schizophrenics. "The two organizations have adopted similar public belief systems about the nature of madness. While professing itself the 'champion of their clients,' the APA is supporting nonclients, the parents, in their wishes to be in control, via legally enforced dependency, of their mad/bad offspring.… 'Biologically based brain diseases' are certainly convenient for families and practitioners alike. It is no-fault insurance against personal responsibility. We are all just helplessly caught up in a swirl of brain pathology for which no one, except DNA, is responsible." Declaring that he wanted "no part of a psychiatry of oppression and social control," Mosher concluded by asking, "Is psychiatry a hoax - as practiced today?" and answering, "Unfortunately, the answer is mostly yes."
"I was delighted that he wrote that letter," Muñoz declared in a recent interview at his Hillcrest office. "This is Loren. It's a letter addressed to psychiatry. It's a perfect example of how he thinks." Muñoz characterizes that thinking by saying, "Loren is a stargazer."
Muñoz, in contrast, is a man who's very much grounded in the political realities of medicine. A native of Colombia, he came to the United States hoping to do research on schizophrenia and soon thereafter wound up working in a laboratory at Yale. For the past 25 years, he's had a clinical practice in San Diego, and although he's no longer head of the American Psychiatric Association, he's the current president of the San Diego County Medical Society. "There is plenty of evidence that there are structural changes in the brains of schizophrenics," Muñoz says. "There is no doubt. It's clear that those changes may not be the same for all the patients, and a specific change may not exist in a given patient. But when you take all these patients together, you see that those brains are not typical. It's fairly clear that we are gradually advancing to the point when we will be able to pinpoint functional and structural changes in the brain that are related to schizophrenia."
Muñoz didn't deign to answer Mosher's letter of resignation. However, it came to the attention of Psychology Today's editor, who asked Mosher if he would summarize his position for the magazine. In the September/October 1999 issue, Mosher's contribution ran under the splashy headline, "Are Psychiatrists Betraying Their Patients?" Alongside it, the magazine ran four "responses." A spokesman for the National Alliance for the Mentally Ill pointed out that "some individuals with brain disorders such as schizophrenia and bipolar disorder may at times, due to their illness, lack insight or good judgment about their need for medical treatment." But "involuntary treatment of any kind should be used only as a last resort."
The director of the National Institute of Mental Health harrumphed, "It would be tragic if Dr. Mosher's personal history prevented anyone with mental illness from obtaining effective treatment." He declared that a treatment revolution had occurred "in the years since Mosher has been active in research.… In place of medications with questionable efficacy and major negative side effects, or unproven and expensive psychotherapies, we now have a variety of safe and effective medications and psychotherapies for mental illnesses."
A spokesman for the American Psychiatric Association conceded that Mosher's fears about the commercial influence on medication education were "an issue of great concern for all of medicine." However, the American Psychiatric Association had "instituted a careful review and monitoring process, ensuring that sessions supported by the pharmaceutical industry at our meetings present solid scientific information in an unbiased manner."
By far the longest rebuttal to Mosher's essay was the one written by Frederick K. Goodwin, a Washington, D.C., psychiatrist with weighty credentials. A former director of the National Institute of Mental Health, Goodwin today is a professor of psychiatry at the George Washington University Medical Center, as well as director of its Center on Neuroscience, Medical Progress, and Society. He also hosts a radio program called The Infinite Mind that airs on 200 Public Radio stations throughout the country. Contacted by phone, Goodwin agreed to discuss his prickly response in Psychology Today. "I knew Loren many years ago when he was at NIMH, and he was always way outside the mainstream." According to Goodwin, Mosher believed that psychiatry was simply used for political and social control. "That was actually a legitimate position in the '60s," Goodwin asserted, explaining that biological psychiatry was just getting started at that time. "There wasn't a lot of evidence, so it was still an open debate." A psychiatrist named Thomas Szasz had written a book called The Myth of Mental Illness that was "very influential," according to Goodwin. "Szasz had come from Hungary under the Soviet Union, and there his position probably had some reality to it. Later on, we found out that the Soviet Union did use psychiatry for social control."
Goodwin contended that Mosher continued to be fixated on ideological issues. "What really gets a man like Loren Mosher upset is coerced treatment," he stated. "He's very aligned with a group called the Psychiatric Survivors, who are largely people who when you talk to them still have their paranoid processes going on. And they feel that somebody shouldn't have medications forced on them." The problem, Goodwin suggested, is "that one of the critical symptoms of these serious illnesses - both bipolar illness and schizophrenia - is loss of insight. Every psychiatrist has horror stories of patients who were let go from an involuntary hospitalization to go on to either kill themselves or wreck their lives." The assumption "on Mosher's side," Goodwin continued, "is that when a person refuses treatment, they're doing it with the same capacity to make judgments as you and I would. They refuse to see that the very organ of judgment, the organ of insight, is itself diseased. So what do you do when a person's psychosis tells him that he's going to be poisoned by this medication?"
"Virtually the entire field was upset by that Psychology Today piece, including the editor of Psychology Today," Goodwin asserted. Parents of schizophrenics who saw it also had reason to be outraged, Goodwin suggested. "These are people who live with these patients and love them and are desperately frightened that there's not going to be enough help for them when they die. They don't have any ideological battle to defend. All they know is how sick their kids are when they don't take their medication. They must think these arguments about whether this is a real illness or not are quite silly."
In his published response to Mosher's essay, Goodwin also attacked Mosher's Soteria research, stating, "Incidentally, Mosher's 1970s 'study' purporting to compare 'meaningful relationships' with medication was no such thing. A true scientific inquiry would have required a single pool of patients randomly assigned to either psychotherapy or drug groups." When pressed for further details about this charge, Goodwin said that his statement "was really a kind of throwaway line." He stressed that he wrote the response at the request of the Psychology Today editor on just three days' notice, "and I first said no because I wouldn't have time to really research it carefully." He said what he meant was that "in this kind of study people had to agree to go into one group or the other. And [Mosher and his colleagues] didn't really report how many people didn't want to be assigned to the no-drug group or the no-hospital group. So it's hard to know whether the less-sick patients opted to go into the Soteria House and the sicker ones and their families and their doctors wanted to be in the hospital. So that's not truly random." (Mosher retorts that patients in the study did not choose where they were treated. "The two groups were absolutely comparable.")
"I'm not saying that that kind of environment can't help people," Goodwin hastened to add. "There are some people who can get really psychotic with a little bit of vulnerability under tremendous stress. And then with a lot of support, they can pull out of it on their own. As a clinician, I would never question that. The question is, Is this generalizable? And did his experience with Soteria House give him the right to say that everyone else is ignorant, or they're just trapped by the drug companies' money, or they're Nazis who really want to control people?"
"Fundamentally," Goodwin said, "the argument is, Are these real illnesses? Do they involve biology? Are these brain diseases or not? And this is a battle that should have been over years ago. When [Mosher] says in his letter that there's no evidence that these are brain diseases, that's just pure ignorance."
Goodwin's area of expertise is bipolar disease (also known as manic depression). But he suggested that any number of prominent schizophrenia specialists could discuss the mountain of evidence demonstrating that schizophrenia is an organic illness. One whom he recommended was Dr. Daniel Weinberger, chief of the clinical brain disorders branch of the Intramural Research Program at the National Institute of Mental Health. Contacted by e-mail, Weinberger responded, "There are many, many pieces of evidence that Schizophrenia is a disease.… There is no ONE preeminent thing. There is an accumulation of compelling SCIENTIFIC evidence, objectively ascertained and subjected to the scientific method of disproof. The statements of [Mosher] are personal biases, likely motivated by a desire to be heard, not to help people with these terrible illnesses."
Another schizophrenia expert praised by Goodwin was Dr. Nancy Andreasen. Head of the psychiatry department at the University of Iowa College of Medicine, Andreasen also is editor of the American Journal of Psychiatry, and she herself conducts neuropsychiatric research. Asked (again, in an e-mail) about Mosher's contention that schizophrenia is not a medical disease, Andreasen suggested that Mosher lacks "any kind of scientific track record, as indicated by peer-reviewed publications."
For an overview of the supporting evidence that schizophrenia is a brain-based disease, Andreasen offered a chapter in her book, Brave New Brain, published by Oxford University Press last year. In the section that addresses the question of what causes schizophrenia, Andreasen begins by making one unequivocal assertion. It "is not a disease that parents cause," she declares. "In most cases several causes have conspired to injure the developing brain and mind, but bad parenting is not one of them."
The earliest evidence of the biological basis of schizophrenia came from genetic studies, Andreasen writes, and it began with the "simple observation that mental illnesses sometimes run in families." She acknowledges that this might mean certain families do things that drive their children crazy, but she says the transmission pattern instead suggests a genetic role. "If one parent has schizophrenia, there is about a 10% chance that one of their children will develop schizophrenia. If both parents have schizophrenia, then this risk increases substantially to about 40 or 50%. Likewise, chances for developing schizophrenia if one brother or sister has the illness are about 10%, and these increase to about 20% if one parent and one brother or sister is ill with schizophrenia."
Studies of twins provide additional evidence. Andreasen says more than ten studies involving hundreds of twin pairs have consistently shown that identical twins (who share almost exactly the same genes) both have schizophrenia far more often than nonidentical twins (who share only about half of their genes) - about 40 percent of the time compared to only 10 percent.
Although she sees this as "clear evidence that genes must play a role," she points out that genetic factors cannot be the only cause. If they were, the concordance rate for identical twins would approach 100 percent, not four out of ten. Moreover, no single gene for schizophrenia has been found. "Most experts now think that schizophrenia is clearly multifactorial, involving multiple genes, and possibly even different genes in different individuals, as well as many nongenetic or environmental influences," Andreasen writes.
A number of environmental influences occurring early in life have fallen under suspicion, according to Andreasen. She says researchers have found a higher rate of schizophrenia among people who had traumatic births, as well as among those whose mothers were malnourished during their pregnancies or gave birth during influenza epidemics or in the wintertime ("a season during which mother and child are more often exposed to a variety of viral influences"). Brain MRI scans, however, provide "perhaps the strongest evidence" that schizophrenia occurs because something interrupts the orderly development of the brain from conception through adolescence, Andreasen contends. She says about 5 percent of schizophrenic males have been shown to have something called ectopic gray matter, "tiny islands of neuronal cells that did not make it to their proper destination…during the second trimester of pregnancy." This rate is higher than that seen in normal healthy individuals. Another 20 percent of schizophrenic males also seem to have a small gap between the two hemispheres of their brains (whereas fewer nonschizophrenic adults have such a gap).
Even more convincing, in Andreasen's eye, are the five or six MRI studies of newly diagnosed schizophrenics conducted at centers in Australia, Asia, Europe, and North America. These have shown "substantial structural brain abnormalities," including overall smaller brain size, enlarged ventricles, and other anomalies.
She says one cannot conclude, based on these studies, that schizophrenia damages any specific brain cells or regions. "A diligent search by many talented neuroscientists has not identified any such specific regional abnormalities or nerve cell lesions," she writes. Instead, she theorizes that schizophrenia is a "misconnection syndrome," meaning that it's a disorder that "damages the way regions are connected to one another, so that a breakdown in signal transfer occurs.… Like a malfunctioning computer, the various nodes in brain networks send information back and forth in a way that causes file corruption, garbled information, or crashes."
Andreasen says PET scans (which measure changes in blood-flow associated with brain function) have shown people with schizophrenia to have abnormal blood-flow patterns while performing a variety of tasks. "We now suspect that the cerebellum may be malfunctioning as a 'metronome' or timekeeper, causing signaling to lose its synchrony and coordination," she writes. "The thalamus, which functions as a filter or gatekeeper that helps determine how much information should be let in or out of the brain, may be failing to screen information out, so that the system becomes overwhelmed with so much data that the person's thinking becomes confused or sluggish."
Brain chemistry is yet one more area where Andreasen and other psychiatrists see evidence of an organic disorder in schizophrenics. Andreasen says researchers early on noted that stimulants such as amphetamines, which cause the brain to release lots of the neurotransmitter dopamine, can produce schizophrenia-type symptoms. Conversely, nearly all antipsychotic drugs prevent dopamine molecules from delivering chemical messages to the nerve cell membranes that normally receive them. "These observations led to the formulation of the 'dopamine hypothesis of schizophrenia' " in the 1960s, writes Andreasen. "Simply stated, it suggested that the symptoms of schizophrenia were due primarily to hyperactivity in the dopamine system."
Although this hypothesis "was universally accepted…for nearly thirty years," Andreasen says that in the past decade, "the plot has thickened" as antischizophrenic drugs that block the function of two other neurotransmitters, serotonin and glutamate, have hit the market. The newer drugs, known as "atypical neuroleptics," are believed to work as well as and have fewer serious side effects than the older generation of antipsychotics. Andreasen writes, "Clinician scientists now think that schizophrenia occurs as a consequence of a much more complex chemical imbalance that includes multiple neurotransmitter systems that interact with and modulate one another."
Mosher finds none of this convincing. "There are very good critiques of the adoption studies and the twin studies," he asserts. The problem with explaining the higher concordance of schizophrenia among identical twins by pointing to their shared genes is that identical twins also share the same environment to a greater extent than even nonidentical twins. Mosher says a number of studies have demonstrated that they're "clearly raised more similarly than nonidentical twins or siblings. People tend to dress [identical twins] more alike. They look the same. They generate a similar response. And they do have this sense of being one person." So that shared environment may explain why a higher percentage of both of them go crazy than do nonidentical siblings.
One traditional way of subtracting environment from the picture in identical-twin studies has been to look at pairs who've been raised separately. But, Mosher says, so few identical twins are separated at birth and later diagnosed with schizophrenia that there aren't enough of them to be statistically significant.
On the other hand, you can find plenty of schizophrenic parents whose offspring were raised by adoptive parents, and a number of researchers have examined what happens in such cases. Andreasen cites two studies of adopted children who grew up in families considered normal or healthy. Both studies showed that the rate of schizophrenia among children with a schizophrenic parent was the same (about 10 percent) regardless of whether the children were raised by the adoptive family or the schizophrenic mother.
Mosher, however, says both of these studies had major methodological flaws. In contrast, he says a twin study begun about 20 years ago by a Finn named Tienari and an American named Wynne is "one of the best pieces of research done this century." It compared the outcome of children who had a schizophrenic parent with that of children of normal parents when both groups were placed in normal adoptive families, and it found that the children of schizophrenics developed schizophrenia only slightly more often than the control group. "So you can say, well, there's a little genetic bit there, but it takes the family to make that bit be expressed," Mosher says. One's genetic makeup "at most may be a sort of background variable. But it's so weak and so indefinable as to be useless in terms of defining the condition."
As for the abnormalities that researchers have found with brain scans, Mosher thinks the antischizophrenic medication accounts for much of this. He says, "The Germans, who invented neuropathology, looked at the brains of thousands of schizophrenics before there were any neuroleptics. And they were never able to find anything. They never reported increased ventricular volume, which at postmortem you can measure quite easily. And they also never reported any specific cellular pathology, and they studied many, many, many brains." He adds that "there are a whole lot of people who don't have schizophrenia and also have enlarged ventricles. And there are people who have other psychiatric conditions who have enlarged ventricles, and there are a number of known causes of enlarged ventricles that are not schizophrenia. So, yes, there is a statistical difference, but it is not specific."
"On the other hand," Mosher continues, "there are studies that have shown that people treated with neuroleptics have changes in brain structure that are at least associated with drug treatment, dosage, and duration - and have been shown to increase over time as drugs are given." He cites one "horrific study" of children between the ages of 10 and 15 in which the researchers measured the volumes of the kids' cortexes. "The cortex is what you think with, the part on the outside," Mosher explains. Over time, "They watched the cortical volume of these young people decline, while the cortical volume of the nonschizophrenic controls was expanding because they were adolescents and still growing." The researcher concluded that their schizophrenia had caused the decrease in the subjects. "And yet every single one was taking neuroleptic drugs," Mosher says.
He concedes that the German neuropathologists working earlier in the last century didn't have access to PET scans, a tool that Mosher categorizes as being a significant advance. "They show you activity, not just structure. They show which parts of the brain are working at a given task. And okay - there they do find differences between people who've been labeled schizophrenic and normal people." But how, Mosher asks, can anyone tell if those differences cause the psychotic behavior or result from it? He says he's not at all surprised that the frontal lobe metabolism of drug-naïve schizophrenics looks different on PET scans than that of normal people. "Because if you meet such people, you know that they are in an unusual state of consciousness. They may be going 100 miles a minute. They may be totally distractible. You could measure a lot of other things, and they'd all be different at that point in time. But you don't know if that's a cause or an effect of the way they are."
Mosher insists he could still be convinced that schizophrenia is a disease. "If you show me something - either a lesion, meaning a structural abnormality, or a particular neurophysiologic process that is identifiable, can be replicated, and is found only in those people who've been labeled as having schizophrenia, and it's there before the onset of the disorder - I would change my mind tomorrow. I've held that position for 30 years." But lacking that sort of evidence, he argues that to label anyone as being schizophrenic is to sentence them to a life of discrimination. "It is a sticky label which, once given, is extraordinarily difficult to get rid of," Mosher says. If you have pneumonia and you get over it, you're not forever more considered to be a person with pneumonia. "You're fixed," he says. "But if you are once labeled schizophrenic, the tendency is you are always a person who will be called schizophrenic. This is totally crazy. It violates all the rules of medicine."
It also flies in the face of a number of studies that have looked at how people fare many years after being given a diagnosis of schizophrenia. Perhaps the best-known American example of this research was conducted by a psychologist named Courtenay Harding. She decided to focus on a group of men and women who had once inhabited the back wards of Vermont State Hospital. "Middle-aged, poorly educated, [and] lower-class," these people had been hospitalized for an average of six years and given long courses of phenothiazines when they were chosen to be discharged and placed in a community rehabilitation program in the mid- to late 1950s. In the early 1980s, Harding and her colleagues at Yale University managed to track down what had happened to 97 percent of the 269 original subjects. Using their medical records, the researchers had independent experts rediagnose the subjects according to updated criteria. In the light of the more stringent modern standards, 118 subjects received a schizophrenia diagnosis, and 82 of them were still alive and willing to be interviewed.
Contrary to the researchers' expectations, the former mental patients for the most part had encouraging stories to tell. They had evolved "into various degrees of productivity, social involvement, wellness, and competent functioning," the resulting 1987 article in the American Journal of Psychiatry reported. Some 68 percent displayed no signs or symptoms of their previous crazy behavior. Furthermore, Harding's group wasn't the only one to study long-term outcomes; at least four similar efforts have been made. "Together these studies found that one-half to two-thirds of more than 1300 subjects studied for longer than 20 years achieved recovery or significant improvement," Harding noted in another publication.
Nonetheless, many doctors continue to believe that schizophrenia "is a disease that's always there," Mosher complains. People like John Nash - the Nobel Prize-winning mathematician whose recovery from schizophrenia was dramatized in A Beautiful Mind - are "a thorn under [their] saddle," he says. Mosher was appalled by the way the movie seemed to credit the pharmacological industry for Nash's return to sanity. This occurs when a representative of the Nobel committee comes to visit actor Russell Crowe at Princeton in the early 1990s, and Crowe/Nash declares, "I take the newer medications." Mosher points out that in fact Nash has stated on numerous occasions that he has not taken any antischizophrenic medication since 1970.
Harding's study of the former mental patients in Vermont offers confirmation that a drug-free recovery like Nash's was no fluke. Half the subjects interviewed in the 1980s never took any psychotropic medication, and an additional 25 percent said they took it only sporadically. All of those who had fully recovered had long since stopped taking medication, the American Psychiatric Association's Monitor quoted Harding as stating in February 2000.
There's some debate over whether a massive study of schizophrenic outcomes conducted by the World Health Organization (WHO) shows a similar correlation between lower reliance on neuroleptic medication and recovery. Begun in 1968, this research identified schizophrenics in nine countries (China, Colombia, Czechoslovakia, Denmark, India, Nigeria, USSR, United Kingdom, and the U.S.) and tracked what happened to them over the next five to ten years. The most striking - some might say astounding - finding was that the patients from the three poorest countries - India, Nigeria, and Colombia - fared far better than their cohorts in the developed countries. Whereas more than three-quarters of the Indians, Nigerians, and Colombians were either recovered or doing fairly well five years after their diagnosis, only 25 percent of the patients in the rich countries enjoyed a similar level of success.
Critics of this study charged that it must have suffered from design flaws. The patients from the poor countries must not have been as sick. So the World Health Organization launched another investigation, making every effort to use the same criteria in every country. It didn't matter. The new study "replicated in a clear and, possibly, conclusive way…the existence of consistent and marked differences in the prognosis of schizophrenia between the centres in developed countries and the centres in developing countries," the authors wrote. "It can now be said with a fair amount of confidence that they are not the result of differing sample composition in the two groups of centres."
Muñoz, the San Diego psychiatrist and former president of the American Psychiatric Association, says he's familiar with the study. He's a good friend of the principal researcher. And Muñoz complains, "No matter what the criteria were, you are not comparing apples to apples.… To say that American schizophrenics have a poorer prognosis is just reading into the study things that the study was not studying.… If we are going to try to examine which country gets the best outcome, first you have to know the country." Americans live with a higher level of stress and more barriers to success, Muñoz contends. "For example, if someone is an anthropologist in Colombia, he's probably employed and very successful. If he's an anthropologist here, he's either dusting windows at the museum or doing research that makes him famous. Once you have a degree in this country, either you belong to the minority that is very successful or you will be unhappy for the rest of your life."
Whitaker, the Boston medical journalist who wrote Mad in America, sees "an obvious flaw" in the notion that cultural differences account for the difference in outcomes spotlighted by the World Health Organization study. "The poor countries in the WHO studies - India, Nigeria, and Colombia - are not at all culturally similar," Whitaker argues in his book. "They are countries with different religions, different folk beliefs, different ethnic groups, different customs, different family structures." The developed countries studied also share no common culture or ethnic makeup - but they do provide similar medical care. While in the poor countries, "Only 16 percent of the patients were maintained on neuroleptics. In rich countries, 61 percent of the patients were kept on such drugs," Whitaker points out. "Certainly if the correlation had gone the other way, with routine drug use associated with much better outcomes, Western psychiatry would have taken a bow and given credit to its scientific potions.… Yet, in the WHO studies, that was the model of care that produced the worst outcomes."
Today the percentage of American schizophrenics taking neuroleptic drugs is much higher. Mosher says, "The standard practice is to treat all such persons with one or another neuroleptic drug and to advise them that they will need to take this drug for the rest of their lives." Concurs Michael McDaniel, a San Diego doctor who has practiced psychiatry for almost 20 years, "You've got to be on the medication. It's a mainstay of treatment." McDaniel asserts that schizophrenics who go off their medication have a relapse rate of 10 percent per month. "So yeah, you've got to be on the medication."
McDaniel says he thinks that in most cases, the medication alone is not sufficient. Most patients also need to participate in a rehabilitation program. "The studies all show that rehabilitation helps patients coordinate the details of life." The local psychiatrist adds that when the county surveyed schizophrenia patients a few years ago, "The number-one thing the patients wanted was individual psychotherapy." However, few patients receive this, according to McDaniel, who cites several reasons. "One is the nature of the illness. People tend to be erratic. They don't come to appointments regularly. It's also partly historical. Time was when schizophrenia was seen as a psychological condition, and medicines were thought to be bad.… You had people describing the medications as chemical restraints." Today the pendulum has swung too far in the other direction, McDaniel says. "Now nobody really wants to talk or listen to these folks." Economics adds one final complication. "There's not a lot of money for therapists.… It can easily cost $300 to $400 a month for a single antipsychotic medication. And people often take several. The fact is that MediCal pays for medicines. But it pays very poorly for psychotherapy. I don't know if there's a cause and effect there. Probably there is."
McDaniel estimates that as many as 95 percent of all schizophrenic patients today are taking the newer atypical neuroleptics, instead of the old-fashioned varieties such as Thorazine. "The advances in the medications are huge," he enthuses. Patients still dislike taking them, and "They don't necessarily work that much better. But they are a lot safer," he asserts. "And one of them - clozapine - probably is the best antipsychotic ever. It's in a different category. It works in different parts of the brain. The brain is enormously complex! It's three pounds of electronic oatmeal." Every cell connects to every other cell by as many as three connectors. "So a certain amount of what goes on in the brain has to do with timing. And there are wave phenomena because the body releases different chemicals at different times of the day and night. Clozapine seems to work with the brain in that sort of timed fashion. I think that makes a difference."
McDaniel acknowledges that even clozapine has some drawbacks. In rare cases, "It can destroy someone's bone marrow. So that means you have to check the patient's blood count every two weeks. A lot of people don't like that. Patients still get a lot of other side effects. You have to take it more than once a day. You feel sick. You drool all night. You get sleepy," McDaniel says. "But when it works, it works great! And for your really sick people with schizophrenia, it's great."
David Oaks offers a different perspective on what it's like to take the antipsychotic drugs. An Oregon resident, Oaks 15 years ago founded an organization called Support Coalition International, dedicated to "defending the human rights of people in the psychiatric system." He says unlike recreational drugs that increase the brain's dopamine levels, neuroleptics are "anti-feel-good drugs." Subjectively, the person taking them feels antsy - "like your feet can't stop moving. But you're wiped out. It's harder to think. The more you try to think, the harder it is. You feel lobotomized."
Oaks speaks from personal experience. He says he had a breakdown in the mid-1970s, while attending Harvard on a Teamsters Union scholarship. The offspring of a working-class Lithuanian-American family, he had grown up on the South Side of Chicago and attended a Jesuit, all-male college prep school. It "wasn't the best for learning social skills, but…I appreciated [the] academic commitment," he has written in an oral history posted on Support Coalition International's MindFreedom website. At Harvard, he felt that he didn't fit in, and at times he "ingested too much cannabis, to which I'm highly sensitive. I stopped sleeping." When his speech and behavior became erratic, Harvard authorities took notice, and over the course of his sophomore, junior, and senior years, Oaks was admitted to psychiatric hospitals five times.
He says he did need support during those years. "For whatever reason, I had been entering altered states that were sometimes delightful, sometimes painful, but that all had some validity to my life - just as dreams often do," he writes. "There were times when I thought the CIA was making my teeth grow, or that a UFO was appearing in my living room, or that God was talking to me via the radio, or that the performers on TV were directly talking to me. I learned a lot from those states of mind."
He says "a whole bunch of psychiatrists" diagnosed him as being schizophrenic. "I was told I would have to stay on psychiatric drugs the rest of my life, like a diabetic on insulin. I was told that I was genetically flawed and had a permanently broken brain." Angry and defiant, Oaks recalls receiving his first neuroleptics by injection, against his will, then being locked in a solitary-confinement cell. "I experienced forced neuroleptics as torture.… I could understand some overwhelmed person choosing to take them, but for me it was like taking a wrecking ball to the cathedral of thoughts, feelings, and experiences that defined me at that moment. It was incredibly intrusive. I could feel how the chemical affected my vision, my movement, my thoughts. I had terrible paroxysms of my muscles.…"
With his family's blessing, Oaks finally put the psychiatric hospitals behind him. He wrote a senior paper in college about his experience with an early psychiatric protesters' group, the Mental Patients' Liberation Front. In 1977, he graduated with honors from Harvard and continued to work on causes such as banning electroshock. He founded Support Coalition International in 1987.
Today he doesn't share the sanguine view of many mainstream psychiatrists that the latest generation of neuroleptics (the "atypicals") pose only minor risks. Oaks remembers the psychiatric establishment's reaction to the suggestion that the older neuroleptics were causing a form of often irreversible brain damage called tardive dyskinesia. Characterized by repetitive, involuntary, purposeless movements such as grimacing, tongue protrusion, lip smacking and pursing, rapid eye blinking, and other bizarre tics and limb movements, this disorder was first named in 1960. Numerous studies linked it to neuroleptic usage throughout the 1960s, '70s, and early '80s. Yet not until 1985 did the American Psychiatric Association finally send out a letter warning its members that patients taking the drugs were in danger of getting the disorder. Oaks points out that the risk of developing tardive dyskinesia while taking conventional neuroleptics is now estimated to be a cumulative 5 percent per year. "So John Nash and I would have a 95 percent change of getting it, had we stayed on the drugs," Oaks says. "That's assuming we were still alive, but there's a lot of ways that neuroleptics can kill you."
Although he acknowledges that tardive dyskinesia appears to be a less common consequence of taking atypical neuroleptics, Oaks points out that they've been on the market for only a dozen or so years, so all their long-term consequences are not known. Since the newer drugs shut down a broader array of neurotransmitters, "They're more of a smart bomb for the mental and emotional receptors," he believes, and "the mental and emotional changes may be worse." Oaks says all neuroleptics are now recognized to cause physical changes in the brain. "The debate is now over. For years, we were saying that and running into complete denial. But now we have admission." Although defenders of the atypicals respond that the changes in the brain's structure wrought by the drugs are not dangerous, Oaks categorizes those changes as "damage."
Oaks says many of the members of Support Coalition International nonetheless continue to take neuroleptics, and he can understand why. "Some people take them because they weren't offered many alternatives," he explains. "Usually the only one is electroshock, which is being done more and more." Once someone starts taking a neuroleptic, he usually feels terrible whenever he tries to stop, according to Oaks, who adds, "You can go crazier than you ever have been in your life when you quit." Finally, families and other social institutions put intense pressure on schizophrenics to stick with their pharmaceutical regime.
"Right now the public thinks the drugs are a panacea," he observes. "They think they 'lift the fog of delusions and clear the mind.' It's like thinking there's some magic dust for peace. Or a magic wand that can make the violence in our society vanish." Defenders of the drugs also "have a pretty strong sound bite," Oaks concedes, whenever someone hurts another person and avoids punishment by convincing a judge that he or she was crazy. He says Support Coalition International opposes the insanity defense. "Our movement needs to take more responsibility. If someone breaks a law, society has the right to take away their liberty."
On the other hand, spiritual experiences aren't supposed to be against the law, Oaks says, pointing out that the First Amendment guarantees the right to a free mind. He argues that this includes the right to think in ways others might judge to be delusional or abnormal. "Remember: they define a delusion as an unshared belief that's implausible on its face." By that criterion, many revolutionary ideas have appeared delusional at first, Oaks argues. "You could have said that about the first person who questioned slavery. You can't have social change unless you have people thinking differently."
Oaks also thinks American society has little tolerance for altered states of consciousness. "You could create religions 2000 years ago. But that's not okay anymore." He's appalled by the fact that the National Alliance for the Mentally Ill's "assertive community treatment" program in some cases sends overseers into patients' homes to make them take medication against their will. "It's fascism!" Oaks exclaims. "I would prefer a lobotomy to long-term neuroleptics - and I hate both of them!"
Like Oaks, Mosher has long been critical of all enforced drugging. Mosher also sits on the board of Support Coalition International and a few kindred organizations, but he says that's about the extent of his political activism. He fills his time with other activities. Most weekdays, he joins an eclectic group of older men for lunch at the Pannikin in La Jolla. He also writes and spends a lot of time on the Internet, where he maintains a website that presents some of his heretical views and explains his experience with Soteria.
In part because of that exposure, Mosher estimates he gets an average of three requests a day from people seeking help. Most have been diagnosed with schizophrenia or have children with that diagnosis, and they're looking for nonpharmaceutical forms of treatment. Some think Soteria is still operating, but most just want to find someone using similar methods, "And I always have not much good information to give them," Mosher laments. "There just isn't much out there." Although he thinks many psychiatrists "really don't believe the mainstream," Mosher says the price of defying it is very, very costly. "These days if you don't treat somebody who's truly psychotic with neuroleptic drugs, you can be sued for malpractice. It's that bad."
Once in a while, Mosher says, he personally takes on a few boutique clients - "young people who are crazy and don't want to take psychiatric drugs and have families who are supportive enough to take them through it with me." Since he has no place where he can refer such patients when they need to be with someone sympathetic around the clock, he says he has to be very selective. "I used to take patients in my own house and let them sleep there and hang out with me and my kids. That was an experience. My kids still talk about it. They found it quite interesting. But it takes a lot of energy to keep up with someone who's crazy. And I'm not a youngster anymore."
When he does accept patients, Mosher says he often tells them and their families that being psychotic compares with having the common cold. "You feel real bad for three or four days, then you feel not so good for two weeks," he says. "Then if you just sort of manage the supports right and try to understand what's going on and don't mess with it too much, things will happen and the person will get better." But Mosher says this private practice "is a very small-time endeavor, because I travel a lot too."
He receives invitations to give presentations in Europe quite often. The first true replication of Soteria opened in Bern, Switzerland, in 1984, according to Mosher, and it's still operating today. He describes at least ten Swedish facilities as being "Soteria-like," as are a couple of others in Germany. "The whole concept is extremely popular there," Mosher says. "They think it's wonderful." He speculates this may be because "there's less homogeneity" in Europe. There's also "less drug-company pressure," he asserts. "They all have national health care. And they have more of a culture of not always going with fashion. I don't know."
In the United States, however, Mosher confesses to feeling hopeless about the future of anyone misfortunate enough to receive the label he so hates. When asked what words he prefers instead of "schizophrenic" or "mentally ill," Mosher responds, "Why not call it a severe personal emotional crisis? Or a severe psychological crisis? Why not call it disturbed and disturbing behavior - a pretty good description, since that's how it looks from the outside. There are lots of ways of recognizing that these folks are acting in ways which are unconventional - and that still recognize they're in severe psychological pain."
"Blame" is also the wrong word to apply to these people's families, Mosher insists. "With rare exceptions, I think parents do their best. They try. But there are a lot of ways in which they can go astray. One way is if the parents themselves were raised in homes where they didn't learn to think straight. They grew up, and they can think straight enough to get along, go to school, whatever." But when a person with this kind of communication style marries someone from a similar one, "You can get two parents who are just loose as a goose," Mosher says. Add some additional trauma, and the result may be a psychological breakdown, he believes.
"But it's not that the parents are consciously trying to hurt these children," he stresses. He thinks that with the proper therapy, such people could be taught to "think a bit more clearly and communicate better. There are things that could be done. But we're so busy with drugs that you can't find a nickel being spent on that kind of research." He adds that "These days, for the very first time, schizophrenia has become a source of enormous corporate profits. Schizophrenics were somewhat profitable ever since the mid-'50s, though nothing like today. The sales of the antipsychotic drugs were running about $600 million a year for years until the '90s, when the new atypical drugs arrived. Since then, the bill for antipsychotics has grown to more than $4 billion a year. That's a lot of money."
Today Mosher calls himself "a lapsed psychiatrist" because he thinks the biological explanations of psychotic behavior embraced by so many of his colleagues resemble a religion more than they do a body of science. From his perspective as a heretic, he reflects, "We are all afraid of going crazy. And as long as we have someone out there who can sort of do that job for us, it's not our burden." He thinks it's comforting to believe schizophrenics act the way they do because their brains are diseased. Biological differences "make them different from us fundamentally," he says. "They're sort of a slightly different race than we are." Mosher thinks it's all "a way of carefully saying, 'These people are really different. And therefore we have the right to do whatever we goddamn please with them.' "