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Still Crazy After All These Years 1

Cover PhotoSometime 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 summerLoren Mosher 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. "Decisions 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. RDLHe 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. 

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San Diego Weekly Reader, Vol. 32, No. 2, Jan. 9, 2003
Jeanette De Wyze

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