OLIVER SACKS: WHEN ‘CHANGE’ GOES BAD

Oliver Sacks has a rueful piece in ‘The New York Review of Books’* entitled "The Lost Virutes of the Asylum", about the loss of the mental asylums where he once served as a doctor.

Since the end of the American asylum is still within the memory of a number of Us, it’s well worth the read to get a sense of how something that was insistently touted as very enlightened and very liberating and very progressive and a moral emergency of the first order and an outrage that demanded Our immediate action (the pols act and We pay) … something that was all those things when it was ‘sold’ to Us, now turns out to be something a lot less than We were guaranteed. But then, in modern America, about the only folks who can’t function the way used car salesmen used to operate are used car salesmen – everywhere else, especially in the great ‘complexes’ of education, defense, finance, policy, and the ever-receptive Beltway it’s apparently the only game they’ve got.

All the more reason for every kid to learn how to kick serious tire, and for every grown-up who knows how already,to make sure that s/he is passing this vital citizenship skill on.

The 19th century Victorians built asylums as actual ‘sanctuaries’; in an America that had no psychiatry and no drugs and no ‘therapy’, the country didn’t know what to do with the mentally ‘challenged’ and the overtly unhinged. And those burdened sufferers did not know what to do with themselves.

Compared to much Old World practice, especially in the pre-Victorian era, the asylum was a true gift from heaven: solidly built, on spacious grounds, away from the often addling hubbub of the 19th-century city (not that it’s gotten all that much better), the asylum provided the sufferers not simply a roof, but grand, airy surroundings, a regular order, regular meals, and a sense of orderliness in the world around them, and even some competent and caring attention. And nobody unfamiliar with effluvia and miasma enshrouding the 19th century American manufacturing city, chock full of plop-dropping horses and un-showered humans (who used outhouses) can fully grasp how hugely valuable a commodity that was – fresh air.

The Victorians had the money and the good heart, and they put both to good use to do their ‘Christian duty’. Which, doubtless, relieved as well a tremendous burden on communities that were unprepared – perhaps, even then, unwilling – to allow the disorder of the disordered to seep into the community around them.

Further, “in the absence of specific medications [or diagnoses] for mental illness at this time, ‘moral treatment’ – a treatment directed toward whole individuals [holistic, it might be called now] and their potential for physical and mental health, not just a malfunctioning part of their brain – was considered the only humane alternative”.

Kinda neat, those Victorians. Who knew?

A hundred years later or less, these huge facilities seemed to be themselves insanely monstrous prisons whose bureaucratic inertia and self-defeating complexity were even more unhinged than the inmates’ assorted debilities.

The restrictions went along with the well-shaped, safe and secure environment. The restrictions kept the patients from over-stimulating themselves or getting into situations they couldn’t handle, while assuring the order and predictability which their own brains could impose on experience for them.

They go together – shape and boundaries. In a sense, good fences don’t just make good neighbors, they make good adults. The interior fencing, well maintained, and the essential framing that holds everything up, go a long way toward giving ‘structure’ – something that is nowadays deemed essential for ‘patients’ and prisoners, but absolutely toxic to ‘normal’ folks. Go figure.

As Sacks noted, after some years in such a place, an individual might well become ‘institutionalized’, i.e. unwilling or even unable to conduct his/her life beyond the walls of the institution. Of course, many of the patients were – in light of the psychiatry of the era – indeed intended for ‘permanent’ residence there, and given the alternatives available, they were most certainly fortunate for such a permanent membership card.

By 1959, there were seven thousand inmates at Creedmoor Hospital in Queens (by then not far at all from the encroaching precincts of the expanding City), and it outgrew the capacities of its staff, its budget, and its capacities generally. “And yet the original gardens and livestock were maintained, providing a crucial resource for some patients who could care for animals and plants even though they might be too disturbed, too ambivalent, to maintain relationships with other human beings”.

Additionally, the place had a gym, a pool, a theatre and stage, a TV studio, all of which were for the use of the patients’ creative expression and physical well-being. Oh, and a patient orchestra. Most toney prep schools can’t boast all that, and the farm and gardens.

Today the place is closed down and decaying.

The advent of early anti-psychotic drugs in the 1950s brought the possibility of the suppression of some of the more serious symptoms, though there was no ‘cure’. The thought occurred to some psychiatric thinkers – and later to cost-conscious legislators – that these huge institutions might no longer be necessary.

The ‘new’ idea was that a psychotic ‘break’ would occasion a short hospital stay were the new medications would return the patient to ‘normal’, and then s/he could be released and put on a clinic schedule to get the drugs that would maintain normalcy.

But, too, as Sacks ruefully recalls, “in the 1960s, work opportunities for patients virtually disappeared under the guise of protecting their rights”. Ah that takes me back. The idea, eerily communist, was that if somebody is ‘working’, then somebody else must be forcing him/her to do it and probably living off the proceeds as well. Who is doing what to whom for what? – as Lenin would ask. So it was ordered by pols and bureaucrats that the patients would be ‘liberated’ – they wouldn’t work; just what a person is to do with his/her day in an institution if s/he can’t work … well, nobody thought to think.

Work as therapy was – again in the Leninist mode – Incorrect; nobody could or would want to work ‘for free’; the idea of work as therapy did not enter into Lenin’s assessments, and didn’t enter into the assessments of the revolutionary reformers now seeking to slug it out with ‘Amerika’ in the 1960s. Ah, those were the days. Don’t tell me about unintended consequences and good intentions; all of this was clearly a possibility, perhaps a probability, from the get-go.

By the late 1970s – as the country’s postwar economic world-primacy became impossible to maintain (on any honest basis, anyway) – States were cash-strapped and eager to ‘empower’ and ‘liberate’ whomever promised to shrink the State’s outlays (though the budgets would keep growing).

Out went the patients, assured that their serious mental illnesses would be resolved by a supporting web of neighborhood psychiatric clinics dispensing those marvelous wonder-drugs.
Alas.

With no homes, they became “sidewalk psychotics”. When the clinics were not built, they didn’t get the wonder drugs. Although it’s a question whether the States, realizing that they were about to spend more money building and funding the clinics than they had saved by closing the asylums, and perhaps already realizing that no thought had been given to what might happen if a former patient could not or did not want to keep the drug-dispensal appointment regimen or perhaps even “give up their psychoses” – the only life and even self that they had ever known, just figured they’d quietly walk away.

In that same Hundred-Flowers era, alcohol and drug addiction were re-perceived as ‘medical’ problems, shifting the focus from the characterological and self-discipline issues which were to remain, as they always were, a distinctive characteristic of these addictions, on top of any personality problems that predated the addictions or were a consequence of them.

The numbers of ‘homeless’ grew rapidly.

In the Reagan era, it was imagined that in addition to ‘welfare queens’, there were – from the leftish point of view – large numbers of inner-city mothers with children now homeless because of Reagan’s economic approach (a celebratory idealization of wealth plus a smoke-and-mirrors expansion of the economy not through new production, but by hugely increased national borrowing on the international markets).

The numbers of inner-city mothers (which is to say, unmarried) with children grew frightfully, as the effects of certain of feminism’s politically successful tenets made such a status desirable and – theoretically – a doable do since ‘gender’ would now require the same preferences as race in the government’s growing list of those groups eligible for affirmative action.

The under-parented children, despite many of the mothers’ best efforts, suffered in their capacity to sustain a discipline of education, even as the education bureaucracies themselves were in the grip of their own ‘hundred flowers’ revolutionary excitements. And for decades now, such now-grown children have been far more liable to becoming homeless.

The homeless had become a motley crew indeed, and there was little political possibility of re-institutionalizing any of those that needed it.

It is Sacks’s opinion that “by 1990 it was very clear that the system had overreacted, that the wholesale closings of state hospitals far too rapidly, without any adequate alternatives in place”. He asserts that the asylums need fixing, not “wholesale closure”.

Some thoughts arise.

First, those were ‘wholesale’ times, the heady Hundred-Flowers and Many-Revolutions days of the late Sixties and the Seventies. The ardor for ‘escaping’ that “dead hand of the past” would brook no deliberation, no circumspection, in fact no frakking mature Seriousness at all. It was all ‘this has to be done yesterday!’ and ‘this will be a true liberation’, and Congress (perhaps aware that the general trend of postwar world events were going to be taking the whole country to a place it didn’t want to go, and always happy to be ‘perceived’ as ‘liberators’) threw their boards into the surf and lent the massive power and authority of the centralizing postwar Federal government to the whole thing. Nor did the Executive and Judicial Branches remain immune from the infection.

I am reminded not only of the revolutionary assumptions and presumptions and methodology of Lenin and Stalin and Mao and their pappy, Marx; I am also reminded of Turgot’s exclamation when Louis XVI ascended the throne in the mid-1770s (ill-fated and inadequate monarch for his times): “Give me five years of despotism and France shall be free!”. Well, We’ve been walking along that path for forty-plus years now, and not only has it not worked out so really well, but it’s branched off into some other “dark” paths as well.

In fact, I wonder if Cheney with his purposeful stroll on the “dark side” was not so much aberrant as ahead of his time. Perhaps he saw (or at least supported with his authority those who thought they saw) that the nation was no longer going to be able to maintain its primacy – or perhaps even its viability – as a now “quaint” Constitutional Republic, and that the ‘wise’ leader should start spackling things up in order to make a ‘long march’ through the ‘darkness’ of a more concentrated and directive national authority.

Funny, but that means that on top of the still-bubbling ‘revolutionary’ excitements of the Left, there is now an equally dangerous back-to-the-old-days trend toward a monarchical system without the Monarch (although Bush 2 was frequently referred to among Beltway insiders as “the Leader”, which was a most ominous and unhappy sign.

And I can’t get out of my mind the small but significant change in military uniforms. Not only the Foreign-Legion pizza-flop beret that replaced the postwar fore-and-aft cap – not just that. But in the postwar era military regulations required that servicemembers did not wear ‘field’ uniforms (those camouflage or ‘cammie’ outfits designed for use in field operations) out into the ‘civilian’ world when you went “off base”. You had to wear the more civilian-friendly ‘uniform of the day’ or a dress uniform. It struck me when it started that this betokened an effort to get folks used to combat-ready troops out on the streets, which even in its present still-modest shape is a gambit not to be welcomed.

Second, the America of 1990 – its position in the world and its economic capability (the smoke hadn’t yet been dissipated and the mirrors still hadn’t been broken) – is no more, and will probably never return to that level. In the past 20 years – and surely in the past 10 – We have passed some awful points beyond which there could be no full return to what had been. There is thus almost a wistful and rueful pall rather than a vital and corrective clarion tone, to such comments as Sacks acutely makes.

Third, it is clear that the baaad habits of American government – especially since the Age of Many Revolutions At the Same Time (to borrow a trope from Gerald Ford) – are deeply seated in almost the entire sitting political class (at this point only Death’s vote seems to count for ‘dis-electing’ the elected officialdom of that indistinguishable nomenklatura into which the Parties – for the sake of survival – have quietly fused).

The roll can be called of ‘reforms’, ‘revolutions’, ‘liberations’, ‘solutions’, and ‘emergencies’ for which hasty and ill-considered action was taken at great expense in fiscal and human wrack and ruin. Both in domestic and in foreign policy, the American polity – somehow aware, I think, of its profoundly difficult situation – has allowed itself to be distracted by consumerist frenzies (based on cheap, almost fantasy, credit) while its essentially feckless politicians have kept pandering to the old demands of this or that organized pressure group, while sending the forces abroad to find some way to repeat 16th-century Spain’s discovery of fresh resources and wealth in a New World or in the reborn power-plays of the Old World and its Great Powers.

A programme which is not bearing much edible fruit, for all its staggering costs.

The addled may never get their asylums back now. But they may get a lot of company on the streets, and in their tortured personal worlds.

NOTES

*Issue of September 24, 2009, pp. 52.