Mad in America

1. The Enduring Cycle of Mistreatment in Psychiatry

"We are still mad about the mad. We still don’t understand them and that lack of understanding makes us mean and arrogant, and makes us mislead ourselves, and so we hurt them.”

Historical pattern. The history of treating the mentally ill is marked by a recurring cycle of misunderstanding, harshness, and self-deception. From the 18th century's "Bedlam" to modern practices, a consistent thread of mistreatment emerges, often justified by the prevailing scientific or societal beliefs of the time. This pattern suggests a fundamental failure to genuinely comprehend or empathize with those experiencing mental distress.

Early practices. In the 18th century, the insane were often confined in deplorable conditions, treated as "brutes" and subjected to physically debilitating and terrifying "medical" interventions. These included:

• Copious bleeding to the point of fainting
• Powerful purges and emetics causing violent sickness
• Nausea-inducing agents like mercury
• Painful blistering and scalp irritation
• "Surprise baths" and swinging chairs designed to induce terror and physical exhaustion.
  Such methods were believed to "tame" the mad, reflecting a view of them as animal-like and needing to be dominated.

Justification and consequences. Physicians, eager to establish medicine's authority, often rationalized these cruel treatments as curative, even when they inflicted immense suffering. This medical paradigm, driven by a desire for control and a lack of true understanding, set a precedent for future interventions that would prioritize managing symptoms over genuine healing. The cycle of "hurting them" continued, often under the guise of scientific advancement.

2. Moral Treatment: A Brief Era of Humane Care

"If there is any secret in the management of the insane, it is this: respect them and they will respect themselves; treat them as reasonable beings, and they will take every possible pain to show you that they are such; give them your confidence, and they will rightly appreciate it, and rarely abuse it."

A radical shift. In the early 19th century, a profound shift occurred with the rise of "moral treatment," pioneered by figures like Philippe Pinel in France and Quakers in England. This approach rejected the brutal methods of the past, advocating for kindness, respect, and a belief in the inherent capacity of the mentally ill to recover. It was a humanitarian reform rooted in democratic ideals and religious values, viewing the "mad" as distressed individuals rather than subhuman creatures.

Core principles. Moral treatment emphasized creating a nurturing, homelike environment where patients were treated with dignity. Key elements included:

• Small, aesthetically pleasing facilities in rural settings
• Engaging activities like gardening, reading, and games
• Minimal use of physical restraints
• Superintendents acting as compassionate father figures
• Encouragement of self-control and social interaction.
  This approach aimed to restore patients' reason and self-governance, fostering a sense of purpose and belonging.

Remarkable outcomes. Initially, moral treatment yielded surprisingly positive results, with many asylums reporting high recovery rates (35-80% of admissions). Patients often returned to their families and functioned well in society. However, as state asylums grew overcrowded and underfunded due to increased admissions (partly spurred by Dorothea Dix's advocacy), the principles of moral treatment eroded. This decline, coupled with attacks from neurologists seeking to medicalize mental illness, led to its eventual dismissal as a "naive notion," paving the way for a return to more physically invasive and less humane interventions.

3. Eugenics: Dehumanization and Forced Interventions

"Why do we preserve these useless and harmful beings? The abnormal prevent the development of the normal. This fact must be squarely faced. Why should society not dispose of the criminal and insane in a more economical manner?"

A dangerous ideology. The early 20th century saw a chilling shift in America's attitude towards the mentally ill, fueled by the eugenics movement. This "science," championed by figures like Charles Davenport and funded by industrial titans, posited that severe mental illness was a hereditary defect, a "bad germ plasm" that threatened the nation's genetic health. This ideology dehumanized the mentally ill, labeling them as "social wastage" and a burden on "normal" society.

Societal assault. Eugenics led to a widespread societal assault on the severely mentally ill, justified by claims of scientific necessity and economic burden. This included:

• Prohibiting marriage for the "insane" in many states
• Forcible commitment to underfunded state hospitals, acting as detention camps
• Compulsory sterilization, with California leading the nation in these procedures.
  The U.S. Supreme Court, in Buck v. Bell (1927), even upheld forced sterilization, with Justice Oliver Wendell Holmes famously stating, "Three generations of imbeciles are enough."

The Nazi connection. American eugenicists, including prominent figures like Davenport, actively encouraged Nazi Germany's sterilization programs, which sterilized 375,000 citizens. This American influence on Nazi policies tragically foreshadowed the Holocaust, where the mentally ill were among the first victims of the gas chambers. The dehumanizing rhetoric of "useless eaters" and "malignant biological growths" paved the way for state-sanctioned killing, demonstrating the horrific endpoint of such a "scientific" worldview.

4. Brain-Damaging Therapies: The Darkest Era of Asylum Medicine

"I think it may be true that these people have for the time being at any rate more intelligence than they can handle and that the reduction of intelligence is an important factor in the curative process. I say this without cynicism. The fact is that some of the very best cures that one gets are in those individuals whom one reduces almost to amentia [simple-mindedness]."

A desperate search. Following the decline of moral treatment and the rise of eugenics, 20th-century psychiatry, desperate for a therapeutic triumph, embraced a quartet of "brain-damaging therapeutics." These interventions, including insulin coma, metrazol convulsive therapy, electroshock, and prefrontal lobotomy, were adopted with vigor despite their inherent brutality and questionable scientific basis. The underlying, often unspoken, rationale was that reducing a patient's cognitive function or "intelligence" could alleviate their suffering or make them more manageable.

Trauma as therapy. Each therapy inflicted severe physical and neurological trauma:

• Insulin coma: Repeatedly induced hypoglycemic comas, starving brain cells of sugar, causing "widespread degeneration and necrosis of nerve cells." Patients often emerged infantile and disoriented.
• Metrazol convulsive therapy: Injected to trigger violent seizures, leading to bone fractures, muscle tears, and brain hemorrhages. Patients experienced extreme terror and physical pain.
• Electroshock: Electric currents passed through the brain, causing convulsions, immediate unconsciousness, and significant memory loss. Repeated shocks were used to induce "therapeutic confusion" and "extinguish" personality.
• Prefrontal lobotomy: Surgically severing connections in the frontal lobes, the seat of higher intelligence and personality. This resulted in apathy, lack of initiative, and emotional blunting, effectively creating a "surgically induced childhood."

Dehumanizing outcomes. These treatments, often administered without patient consent, were justified by the prevailing eugenic view that the mentally ill were "hopeless" and had little to lose. The "cures" often involved reducing patients to a more docile, less self-aware state, making them easier to manage in overcrowded asylums. This era solidified a profound rift between doctors and patients, with the latter perceiving themselves as tortured, and the former rationalizing brain damage as a legitimate medical intervention.

5. Neuroleptics: From Chemical Restraint to "Antipsychotic" Miracle

"The drug produced an effect similar to frontal lobotomy."

A new era of control. The introduction of chlorpromazine (Thorazine) in 1954 marked the beginning of the modern psychopharmacological era. Initially, this "neuroleptic" (meaning "to take hold of the nervous system") was openly described by pioneers like Henri Laborit and Jean Delay as inducing a "veritable medicinal lobotomy" or a "vegetative syndrome." Patients became lethargic, apathetic, and emotionally detached, often exhibiting Parkinson's-like symptoms. This effect was seen as desirable for calming disruptive patients in overcrowded state hospitals.

Image transformation. Driven by the pharmaceutical industry's burgeoning marketing machine and the government's desire to reduce the financial burden of state hospitals, chlorpromazine underwent a remarkable image makeover. It was recast from a chemical restraint into a "safe" and "antischizophrenic" wonder drug, akin to "insulin for diabetes." This narrative, heavily promoted in medical journals and the popular press, promised:

• "Cures" for mental illness
• Record rates of patient discharge
• The ability for family doctors to treat mental illness in their offices.
  This transformation was crucial for justifying the shift from institutional to community care, despite the drugs' known brain-hindering effects.

The dopamine delusion. The "dopamine hypothesis" emerged, suggesting schizophrenia was caused by overactive dopamine systems, which neuroleptics supposedly "balanced." However, scientific investigations consistently failed to find evidence of naturally high dopamine levels in schizophrenics. Instead, research revealed that neuroleptics:

• Caused a pathological increase in dopamine receptors
• Made the brain "supersensitive" to dopamine
• Increased the biological vulnerability to psychosis.
  In essence, the drugs induced the very abnormality they were claimed to treat, turning a normal brain into one more prone to psychosis, a truth largely concealed from the public.

6. The Patient's Reality: Suffering and Resistance to Drug Treatment

"The drugs I had taken for so many months affected every part of my body. My eyes kept going out of focus, especially when I tried to read. My mouth was dry, my tongue swollen, my words slurred. Sometimes I forgot what I was trying to say. My body was puffy. I hadn’t menstruated in months and was able to move my bowels only with enormous amounts of laxatives. I had no energy at all. If walking around in a constant haze is supposed to be tranquility, I was successfully tranquilized."

A profound disconnect. While society and psychiatry celebrated neuroleptics as breakthroughs, patients often experienced a starkly different reality. They described the drugs as "poisons" that turned them into "zombies," causing profound physical and emotional suffering. This subjective experience, often dismissed by doctors as unreliable due to their "madness," highlighted a deep disconnect between the perceived benefits and the actual lived experience of medication.

Drug-induced pathology. Patients reported a litany of debilitating side effects, which collectively formed a "drug-induced deficiency in dopamine transmission." These included:

• Physical pain and uncontrollable twitching (akathisia)
• Slurred speech, blurred vision, and cognitive impairment
• Extreme lethargy and emotional blunting ("zombie-like" state)
• Severe constipation, weight gain, and hormonal disruptions
• A sense of alienation from self and the world.
  These effects were not merely "side effects" but fundamental alterations of brain function, robbing individuals of their full sense of being and autonomy.

Resistance and dehumanization. Patient resistance to neuroleptics was widespread, leading to practices like secretly mixing drugs into food or using long-acting injectables to ensure "compliance." Legal battles for the "right to refuse medication" emerged, with patients arguing forced drugging was a violation of civil rights. However, courts often sided with the medical establishment, maintaining that "mind control" with neuroleptics was "medically sound treatment." This reinforced the dehumanizing notion that what was considered torture for others was acceptable "therapy" for the "mad."

7. Scientific Deception and Financial Influence in Drug Promotion

"A pharmaceutical company goes to great pains to construct studies that are likely to turn out in its favor."

Corruption of science. The promotion of neuroleptics, and later atypicals, was deeply intertwined with scientific deception and the pervasive influence of pharmaceutical money. By the 1990s, the clinical trials industry had become a for-profit enterprise, where drug companies exerted significant control over study design, data analysis, and publication. This environment fostered biased research, with academic physicians often serving as consultants or listed authors for ghostwritten articles, blurring the lines between independent science and corporate marketing.

Suppression of harm. The medical establishment, including the FDA and the American Psychiatric Association (APA), often turned a blind eye to mounting evidence of neuroleptic harm. For instance, tardive dyskinesia (TD), an irreversible brain-damaging motor disorder, was known since 1959, yet the FDA only required warnings on drug labels in 1972. The APA delayed educating its members about TD for decades, only acting after highly publicized lawsuits. This deliberate neglect, driven by financial interests and the need to maintain psychiatry's image as a medical discipline, led to hundreds of thousands of Americans suffering preventable brain damage.

Fabricated narratives. The narrative of drug efficacy was often built on flawed or manipulated studies. Researchers like Richard Borison, who fabricated data to favor drug companies, exemplified the ethical compromises. Patient deaths in trials, particularly suicides linked to abrupt drug withdrawal, were frequently omitted from published results. This systematic distortion of scientific findings, from exaggerated benefits to downplayed risks, created a "medical fraud" that misled the public and ensured the continued profitability of these problematic medications.

8. Cross-Cultural Outcomes Challenge Western Drug-Centric Model

"The findings of a better outcome of patients in developing countries was confirmed."

A global paradox. World Health Organization (WHO) studies, initiated in 1969, revealed a profound and unsettling paradox: schizophrenia patients in developing countries (India, Nigeria, Colombia) consistently achieved dramatically better long-term outcomes than those in developed nations (U.S., Europe, Japan). At 15-20 year follow-ups, over 50% of patients in poor countries were "never psychotic" anymore and 73% were employed, compared to significantly worse outcomes in rich countries. This suggested that living in a developed nation was a "strong predictor" of chronic illness for schizophrenics.

The medication variable. While the WHO studies explored various cultural factors, they overlooked the most striking difference: medication use. In poor countries, only 16% of patients were regularly maintained on neuroleptics, whereas in rich countries, 61% were. This strong inverse correlation between continuous drug use and positive long-term outcomes directly challenged the Western belief that lifelong antipsychotic medication was essential for recovery. The Soviet Union, with the highest drug maintenance rate (88%), also had among the worst outcomes.

A missed opportunity. These findings, along with independent studies by American researchers like Courtenay Harding and Martin Harrow, consistently indicated that recovery from schizophrenia was more likely off medication than on it. This presented a critical opportunity for American psychiatry to rethink its drug-centric model and embrace alternative, psychosocial approaches. However, this evidence was largely ignored or dismissed, as it threatened the established narrative of antipsychotic efficacy and the financial interests tied to it.

9. Atypical Antipsychotics: A "Breakthrough" Built on Bias

"The spurious invention of the atypicals can now be regarded as invention only, cleverly manipulated by the drug industry for marketing purposes and only now being exposed."

The next "wonder drugs." In the 1990s, new "atypical" antipsychotics like risperidone (Risperdal) and olanzapine (Zyprexa) were introduced with immense fanfare, marketed as "breakthrough" treatments superior in safety and efficacy to older neuroleptics. This narrative was meticulously crafted by pharmaceutical companies, who invested heavily in marketing and clinical trials to position these drugs as revolutionary, capable of improving cognition and negative symptoms without the debilitating motor side effects.

Biased trials and inflated claims. FDA reviews of the atypical trials, however, revealed a pattern of biased design and inflated claims. Companies often:

• Compared multiple doses of their new drug to a single, high, problematic dose of an older drug (e.g., 20mg haloperidol).
• Used "abrupt withdrawal" protocols for placebo groups, artificially worsening their outcomes.
• Included patients who had previously failed on older drugs, biasing comparisons.
  Despite these flaws, academic psychiatrists, often financially tied to drug companies, published glowing reports in medical journals, claiming superiority that the FDA explicitly warned against in advertising.

Disappointing reality. Independent, government-funded studies later debunked the "breakthrough" claims. Trials like CATIE (NIMH) and others found atypicals to be no more effective than older, cheaper antipsychotics, with similar discontinuation rates due to side effects or lack of efficacy. Furthermore, atypicals brought their own set of severe problems:

• Significant weight gain and metabolic issues (diabetes, cardiovascular risk)
• Increased risk of obsessive-compulsive disorder
• Continued neurological side effects, albeit sometimes different in presentation.
  The "spurious advance" of atypicals, driven by marketing and profit, ultimately left patients with new risks and society with soaring healthcare costs, without delivering on the promise of superior treatment.

10. Unethical Research: Experimenting on the Vulnerable

"Everything they did to me was for the purposes of their research. As my medical record shows, when I went into the hospital I was calm and cooperative. I was just worried and vulnerable. I came out thinking I was crazy, and my parents thinking I was crazy, and my friends thinking I was crazy. My family and I believed that every psychotic feeling and behavior was natural to me, rather than caused by their experiment."

Echoes of Nuremberg. Despite the Nuremberg Code's mandate for informed consent in human experimentation, American psychiatrists conducted symptom-exacerbation experiments on vulnerable mentally ill patients for decades. These studies, often funded by the NIMH and conducted at leading medical schools, involved administering drugs like LSD, mescaline, amphetamines, and ketamine to actively psychotic or "borderline" patients, with the explicit goal of worsening their symptoms to "model psychosis" or study brain chemistry. This practice mirrored the very abuses the Nuremberg Code sought to prevent.

Deception and harm. Researchers frequently misled patients about the true nature and risks of these experiments. Consent forms often omitted warnings that symptoms would be exacerbated, instead promising "diagnosis" or "safety." Patients, like Shalmah Prince, who sought help for distress, were unknowingly subjected to procedures that intensified their psychosis, leading to:

• Increased delusions and hallucinations
• Extreme agitation and violence
• Forced restraints and prolonged suffering
• Lasting psychological trauma and a deepened sense of "madness."
  The justification—that patients were "altruistic" or capable of "informed consent" even while psychotic—was contradicted by the evidence of deception and the patients' profound distress.

A legacy of abuse. This line of research, which continued for fifty years, yielded no discernible clinical advances in understanding or treating schizophrenia. It did not lead to better diagnostic tests or new drugs. Instead, it perpetuated a pattern of exploiting the vulnerable for scientific curiosity, reinforcing the dehumanization of the mentally ill. The cessation of these NIMH-funded experiments in the late 1990s, largely due to public outcry, highlighted a shameful chapter where the pursuit of scientific knowledge overshadowed ethical responsibility and patient well-being.

11. The Persistent Call for Humility and Candor

"Little is known about what causes schizophrenia. Antipsychotic drugs do not fix any known brain abnormality, nor do they put brain chemistry back into balance."

A troubled legacy. The history of "mad medicine" in America reveals a consistent pattern: a lack of understanding of mental illness, leading to the adoption of harsh, often damaging, treatments. From the "Bedlam" era to the "brain-damaging therapeutics" and the "antipsychotic" era, interventions have frequently prioritized control and symptom management over genuine healing, often with devastating long-term consequences for patients. This troubled history underscores a profound failure of humility and candor within the psychiatric establishment.

The need for honesty. A fundamental reform requires acknowledging the limitations of current knowledge and treatments. The prevailing narrative that schizophrenia is a discrete biological disorder caused by a "chemical imbalance" and "fixed" by drugs is a "medical fraud." Instead, candor would admit:

• The causes of schizophrenia remain largely unknown.
• Antipsychotics alter brain function, often inducing new pathologies.
• Long-term outcomes are often worse with continuous medication.
• The "breakthrough" claims for new drugs have been largely debunked.
  This honesty, though humbling, is a necessary first step toward ethical and effective care.

A path forward. True reform would involve rediscovering the principles of moral treatment and learning from successful, less drug-centric models of care, such as Finland's "open dialogue" therapy, which has achieved high recovery rates and reduced the incidence of schizophrenia. This approach emphasizes social support, empathy, and selective, cautious use of medication, if at all. Without a shift from hubris to humility, and a willingness to prioritize patient well-being over pharmaceutical profits and professional prestige, the cycle of mistreatment and self-deception in American psychiatry is destined to continue.

Last updated: January 6, 2026