Gracefully Insane

by Alex Beam

  Stanton assigned his trusted deputy Kahne to probe the causes of the suicides. Kahne ended up publishing four papers on the subject, which echoed some of the key lessons in The Mental Hospital. “The central theme that I got out of it was when the strength of the relational system was diminished, chances of suicide were very high,” Kahne told me years later. “For example, people were killing themselves in the middle of summer, when the academic residents were leaving and there was tremendous personnel turnover.”

  Kahne concluded that the rapid pace of change at McLean was destabilizing patients’ lives. Even with the average length of stay plummeting to less than four months, 40 percent of the patients were having their cases shuffled among different social workers during their stay. Many of the older doctors were cutting back their hours at the hospital, increasing the workload on the young residents drafted into the hospital. Stanton had eliminated the traditional admissions unit, for instance, placing new patients directly into wards. Stanton wanted to spare patients the disruption of a move during their stay, but often the new arrivals, experiencing a mental hospital for the first time, roiled ward life.

  In another change, new, inexperienced nurses were assigned to the disturbed wards instead of being allowed a breaking-in period in a more tranquil setting. And the new McLean was growing very big. In just a few years, Stanton had increased McLean’s professional staff—doctors, psychologists, and social workers—tenfold, from ten to one hundred. “People would be killing themselves when the aides and the personnel didn’t even know their names, because they hadn’t had time to learn them,” Kahne said. “I suggested that they slow down the turnover or try out different hiring procedures.”

  Kahne also interviewed the McLean psychiatrists who had lost patients to suicide—doctors whose patients had “fired” them, in the dark vernacular of the hospital wardroom. They criticized the administration’s panicked reaction to each suicide: “All decisions seemed to have been reduced to one overriding concern—to insure the passage of about 72 hours without another death.” Change itself, it seemed, was killing them:As the “epidemic” of suicides wore on, the most prominent ethos about the cause of the epidemic, which increasingly pervaded the opinions of most therapists (including those who had had a patient commit suicide) ... was that there was an excessive moral demand for the patients to change their way of living and that this had become so much an implicit part of the social expectations that patients unable to meet the demand experienced intense guilt. The guilt was believed to be so intense for some as to cost their lives.

  As it happens, Stanton had allowed a professional sociologist, Rose Coser, free access to McLean during the early 1960s so that she could write a book on the residency training of young psychiatrists. “While she was doing her interviews, there was also this incredible suicide epidemic going on,” recalls Harold Williams, who started working at McLean in 1962. “So she had a front seat on that arena and could tap into everybody’s ongoing feelings.”

  In the middle of the suicide wave, Coser chronicled a sense of cynicism and despair among the residents. From her interviews, she learned that Stanton continually postponed his scheduled weekly meetings with the first-year residents—unless there had been a suicide. One resident told her, “You’ll be interested to know that Dr. X [Stanton] has canceled again. This is the fourth time. What we need is another suicide. (Smiles uncomfortably.)” Coser then asked Stanton if she could examine his appointment calendar. Initially taken aback, he opened up his appointment books for the six years of her study. She correlated his frequent absences, and the sense of abandonment among the residents, with suicides at the hospital.

  “Whenever Stanton went away, he got really nervous, because he was leaving his post and we wild guys were going to be running the hospital,” Williams recalled. “That’s when he would say, ‘You guys are playing Russian roulette with five chambers loaded,’ stuff like that, which made you feel really good. The more he said that, the more he drove down confidence and self-esteem, and the more our knuckles got white on the joystick.” Tense and overreactive when in his office and a poor delegator outside the office, Alfred Stanton was running a dysfunctional hospital.

  McLean was almost twice as large as Chestnut Lodge, where Stanton and Schwartz had conducted their groundbreaking research. The suicides, some of them children of prominent families, were prompting difficult inquiries from the hospital’s trustees. Furthermore, McLean was running a deficit, which had to be funded by other Harvard teaching hospitals. Under pressure, Stanton appointed a director of hospital affairs and then created and filled the new position of clinical director to insulate himself from the running of the hospital. As any reader of The Mental Hospital might have predicted, the agitation did not help matters any. The abrupt resignation of the freshly minted clinical director, who correctly perceived that he had been brought on as a flak-catcher, triggered what may have been a mental institution first: a fulldress, placard-waving (“Bring Back Sam Silverman!”) patient demonstration in front of the administration building. In the following academic year, 1965/1966, seven more suicides occurred at McLean.

  Pressured from many sides, Stanton gave up running the hospital and concentrated instead on psychiatric research. In an act of almost gratuitous cruelty, Harvard denied him a coveted endowed professorship that Stanton thought he had been promised. “He had the energy of Niagara Falls, but later his enthusiasm faded,” says Peter Choras. “Alfred never lived up to his promise, although his brilliance was always there.” Dr. Edward Daniels points to McLean’s impossible parking situation as evidence of Stanton’s signal achievement: getting McLean going again. “When he came, there used to be six cars parked in front of the administration building. Now all the lots are full.” But like most of his colleagues, Daniels gives Stanton mixed reviews: “Stanton had a way of being preoccupied with tiny details.... he could immerse himself for a week in a nonsensical hunk of nothing.” In the middle of the first suicide wave, Stanton issued this memo, to which he twice affixed his psychiatrist-in-chief stamp:OFFICIAL NOTICE; File Under: H

  TO: All Physicians and Nursing Personnel

  SUBJECT: Hot Water Bottles

  Effective at once, the use of hot water bottles as medical procedure is to be discontinued at McLean Hospital.

  December 13, 1961

  In questions of administration, Stanton could simply get lost. Longtime facilities manager Henry Langevin remembers presenting Stanton with three competing bids for resurfacing McLean’s central tennis court, where Stanton himself often played. But the director was paralyzed by indecision because the switch from the clay to a hard surface would eliminate a cherished job—rolling and sweeping the ochre-colored clay—for one of the hospital’s elderly, chronic schizophrenics. “What’s poor Elmer going to do?” was Stanton’s plaint, as the trivial court resurfacing decision hung fire for months. Yet “when he gave a conference on a major problem patient, it could have been recorded and published, it was so good,” according to Daniels. “His failure was not in his clinical work; his failure was in the very thing he specialized in, in interpersonal relationships.”

  It was a terrible paradox: The man who wrote the book on mental hospitals proved to be not terribly adroit at running one.

  Alfred Stanton’s career was to have one more interesting twist. He surrendered the title of psychiatrist-in-chief in 1967 and devoted the next fifteen years to research. During that time, he raised money, recruited doctors, and oversaw one of the most ambitious psychiatric research projects ever undertaken, a project that would scuttle one of his own most cherished beliefs: that intensive psychotherapy could help deeply disturbed, schizophrenic patients.

  When Effects of Psychotherapy in Schizophrenia, I and II was finally published in 1984, the book-length work claimed nine authors, and the research had engaged eighty-one therapists and 164 patients from five major teaching hospitals, including McLean. Stanton played the role of honcho-godfather-coordinator for the study, which took ove
r a decade to design and implement. He left the heavy lifting to Dr. John Gunderson, an ambitious and intelligent young psychoanalyst just beginning a research career in the field of borderline personality disorders. The timing of the schizophrenia study was crucial. The psychopharmaceutical revolution had just begun. For the first time, doctors realized that comparatively cheap drug regimens might hold out more promise for treating, or at least stabilizing, disturbed patients than psychoanalysis. “This was at the beginning of the rift within psychiatry between the psychodynamic and the biological people,” Gunderson explained to me in his office at Bowditch Hall. “Before we started there had already been three studies that failed to show much benefit from psychotherapy, but they were flawed. What was needed was a really definitive study—enter us.”

  Although the logistics of quantifying the purported progress of an unstable sample of 164 schizophrenic patients were daunting—sixty-nine subjects dropped out within six months—the research design was relatively simple. Two groups of schizophrenic patients would be assigned different kinds of therapy: One was the Sullivan /Fromm-Reichmann type of intensive psychotherapy, called EIO, or exploratory, insight-oriented therapy, administered three times a week. The other patients received a more modern treatment called RAS, or reality-adaptive supportive psychotherapy, offered once a week or less. The aim of the insight therapy, the study explained, was “to explore the patient’s inner life,” often using the traditional Freudian tools such as discussions of family history, childhood traumas, and so on. RAS was something else. It was deemed to be more “present-oriented” and more practical, “intended to identify problems that could be solved or that could be expected to recur in the future.... Another major feature of the RAS therapy was its focus on the patient’s behavior itself rather than the potential covert meanings behind the behavior.” Perhaps most importantly, it “provided patients with a coherent theory about their illness which emphasized its biological origins and the need for long-term, largely pharmacologic treatment.”

  The authors buried their conclusions beneath the usual mound of academic qualifiers, for example: “There is no easy way to reduce the results into a single statement that one form of therapy is preferential to another.” But the message came through loud and clear. “Obviously the results failed to confirm either the strength or breadth of favorable effects that we hypothesized would be associated with the EIO as opposed to the RAS treatment,” they wrote. Translation: Occasional, supportive sessions with carefully medicated schizophrenics yielded the same results as expensive, staff-intensive psychotherapy. “Equally important was the finding that by some external standard, most notably time spent outside of a hospital and in full-time employment, the RAS therapy emerged as the preferable form of treatment.” This, the authors conceded, was “clearly the single most convincing finding of the study.” Translation: Modern psychiatric management could get schizophrenics not only out of the hospital but even into jobs! No, the patients probably wouldn’t return to their labs at MIT or to the Harvard lecture hall, but they might be able to work in an academic library or hold down a job as a research assistant in a white-collar office.

  The study had a huge impact on psychiatry. “I don’t think our study showed that psychotherapy can’t be effective, or is never effective,” Gunderson says. “A safer interpretation is that it can’t be counted on to be effective. But in the larger psychiatric community, the message was that insight-oriented psychotherapy won’t help schizophrenic patients. So that approach wilted on the vine overnight—within a few years it was not practiced or taught in medical school.” Its impact on Stanton was less clear. He died one year before the study was published, although of course he was familiar with the results. At weekly meetings with Gunderson, he would analyze, reanalyze, and overanalyze their research findings, prevaricating madly in the same way that he managed to stave off the decision about resurfacing the tennis court. “He would always wrap up these meetings by saying, ‘We’ve decided that a decision is not possible,’” Gunderson recalls. “It drove me absolutely crazy. He was a mild, sweet man who liked intellectual discourse, but he lacked productivity. He liked research, but he didn’t really want answers.”

  Alfred Stanton is almost completely unknown to the world of modern psychiatry. The Mental Hospital is no longer required reading in medical schools. Patients today rarely stay on wards long enough to develop the kind of covert conflicts that Stanton and Schwartz took such pains to document in 1954. At McLean, Stanton’s career went into rapid eclipse in the mid-1960s when the hospital began running up deficits, attributed mainly to his lack of administrative ability. Ever since Gilbert Stuart painted John McLean, the hospital has commissioned portraits of its directors and top benefactors and awarded them pride of place in the administration building. Stanton’s portrait was relegated to the Alfred Stanton Room in Higginson House, where many of McLean’s “attending,” or part-time, doctors had their offices. After a few years, the elegant sitting room was carved up into secretarial cubicles, and Stanton’s portrait was removed to the hospital library. The land under Higginson House has been sold, and it will soon be torn down to make way for an office park.

  Ironically—because Gunderson confesses to having mixed feelings about Stanton—he is the executor of a small endowment that organizes an annual dinner and lecture in Stanton’s memory. In the present era of all psychopharmaceutical all the time, Gunderson remains firmly committed to psychosocial therapy, or talk therapy, as a primary mode of healing. A full professor in the Harvard system, he is also McLean’s director of psychosocial research services.

  Gunderson invited me to attend the Stanton Lecture, which was preceded by a dinner at the Harvard Faculty Club. Of the twenty-five attendees, only a handful had actually known Stanton. The rest were therapists in their late forties and early fifties who may have stood in the back of the room during a Stanton patient “consult” or who perhaps remembered his name from medical school. The lecturer, Daniel Stern, an American expert on motherchild development with an appointment in Geneva, admitted that he had never heard of Alfred Stanton until his invitation arrived in the mail. When Stern spoke at McLean the following day, Gunderson joked to the overflow audience in Pierce Hall that “the Alfred Stanton Lectures have become better known than Alfred Stanton himself.”

  The dinner resembled a meeting of the Last of the Mohicans. As always, the Harvard Faculty Club atmosphere was subdued and elegant in the downbeat, academic manner; the wine was drinkable and the sautéed chicken breast in basil sauce a full cut above rubbery institutional fare. The bar was open, but in public company, psychiatrists drink carefully. As the evening wore on, the men and women toasted the threatened ideal of “talk therapy.” The talk even turned to Freud’s famous (to this audience) analysis of the paranoid Judge Schreiber, a genuine museum piece of psychiatric history. One therapist noted sardonically that he practices in “the last bastion of long-term care”: a prison hospital for the criminally insane. The old-timers glumly swapped medical updates. Irene Stiver, whom Stanton chose as McLean’s first clinical psychologist, had passed away. Harold Williams had suffered a stroke. No one was precisely sure if Harriet Stanton, Alfred’s widow, was living in Virginia or had moved to a rest home in Florida. I had spoken to Stanton’s two surviving children during the past year and shared my information.

  A little wine brought forth the customary reminiscences. Golda Edinburg, McLean’s retired chief of social work, remembered that the straitlaced Stanton had taken her and several colleagues to a striptease show in San Francisco during a business trip, all in the service of broadening horizons. A psychiatrist recalled a crowded patient consultation from the mid-1970s, when a perplexing case was presented to a group of McLean doctors, with Stanton in attendance. The presenting physician was describing his patient’s sexual fantasies and seeking therapeutic guidance. In some detail, the doctor told how this man wanted to get down on all fours and crawl around the streets of Boston, sniffing the rear ends of all the a
ttractive women he met. The presentation was greeted with silence; even a full decade into the so-called sexual revolution, a certain squeamishness prevailed when bow-tied Harvard doctors assembled in a room. After a few moments, it was Stanton’s voice that broke the silence: “And did the patient think this behavior was normal?” he asked. The tension dissolved; Stanton laughed; the doctors laughed. Psychiatry continued on its appointed rounds.

  8

  The Mad Poets’ Society

  ... I feel like a periwinkle

  Left too high on the beach

  By the tide ...

  What flood was it

  That brought me here?

  Eleanor Morris, “Easter Sunday”

  The poet Anne Sexton thought that writing poetry kept her sane. Shortly after her first suicide attempt at age twenty-eight, Sexton was institutionalized at Westwood Lodge, a comfortable sanitarium not far from her home in Wellesley, Massachusetts. While recuperating, Sexton met a talented young musician who was also a patient of her psychiatrist, Dr. Martin Orne. “I was thrilled to get into the Nut House,” Sexton later told a friend. “I found this girl (very crazy of course) (like me I guess) who talked language.” By “language,” Sexton meant the bold, figurative language of poetry. According to Sexton’s biographer Diane Middlebrook, the poet created her own Genesis myth, as a writer “born again” from the trough of despair. “I found I belonged to the poets,” Sexton said, and with the encouragement of her psychiatrist, she started writing poetry. Dr. Orne responded generously to her first baby steps into her incipient profession. “He said they were wonderful,” Sexton recalled. “I kept writing and writing and giving them all to him. ... I kept writing because he was approving.” Middlebrook concludes: “Poetry had saved her life.”