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David Tarloff, 39, remained at Bellevue Hospital Center, where he was under evaluation after his arrest in the killing of a psychologist, Kathryn Faughey, on the Upper East Side last week... "He didn’t really say anything," [his father] said. "He didn’t talk about the situation. He’s in a fog."
New York Times, February 20, 2008 (1)
Among madmen...there are some whose imaginations are by no means affected, but who feel a blind and ferocious propensity to imbrue their hands in human blood.
Phillipe Pinel (1806) (2)
In the hall in which [Charcot] gave his lectures hung a picture of the "citizen" Pinel causing the poor insane of the Salpêtrière to be relieved of their chains; for after having been the scene of so many horrors during the French revolution, the Salpêtrière had also witnessed this most humane innovation.
Sigmund Freud (1893) (3)
A FEROCIOUS PROPENSITY
After his indictment for murder in February, David Tarloff was kept on a locked ward three floors above my old lab at Bellevue Hospital. He remains accused of murdering a psychologist, Kathryn Faughey, with a meat-cleaver in her office. The case attracted wide attention not only for its ferocity, but also for illustrating how antipsychotic drugs have changed the way we deal with the demented. The New York Post demanded prompt action against "LETTING MADMEN ROAM" (4)
, while the New York Daily News called for preemptive strikes by either then governor or our mayor: "ELIOT, MIKE; YOU MUST ACT" (5)
. The News worried that Tarloff had "passed through New York’s mental health system like water in a sieve." It asked, "Will such madness never end? It must. Governor Spitzer and Mayor Bloomberg must act now" (5)
. A civic newsletter asked "IS MURDER THE THRESHOLD?" for involuntary detention and urged that "judges and district attorneys should be educated as to the potential danger posed by violent mental patients" (6)
.
Tarloff, diagnosed as a paranoid schizophrenic in 1991, has a long psychiatric history. His family repeatedly tried to have him committed; yet he bounced in and out of a dozen institutions in the area. He had also been treated on and off with lithium, Depakote,® Haldol,® Seroquel,® and Zyprexa®—agents as useful in mood disorders as in schizophrenia. One week before the murder, he was arrested for violent behavior at a community hospital. An uncertified practitioner found him lucid, and Tarloff was dismissed with a slap on the wrist by Judge Barry Kron:
Kron: The defendant is 40 years old, has no prior record, is under stressful circumstances, and anybody who has ever been in a hospital dealing with the personnel there can appreciate the frustration one deals with. You need to use restraint and common sense, and if there’s any sort of problem ... you never want to come back here again. Tarloff: I’m sorry (7)
After this (and by then routine) encounter with the legal system, a chastened, unmedicated David Tarloff was released into "the community" to work out his demons by slaughtering Kathryn Faughey.
After his arrest and arraignment, at which he "babbled aimlessly," Tarloff was remanded to Bellevue for medication and evaluation. The next day, two of our staff psychiatrists found him mentally fit to stand trial, and as expected, Tarloff’s own lawyer demanded an independent examination. While the criminal justice and health care systems debated his future, Tarloff was remanded without bail. Those who saw him at Bellevue described him as heavily sedated and essentially docile (1)
. No wonder, he was under restraints as effective as the straightjackets or shackles of yesteryear: antipsychotic drugs.
PEOPLE WHO CAN’T FIT IN
These days, the topsy-turvy care of schizophrenic patients is the resultant of several vectors: our social attitudes towards mental illness in general; our rudimentary understanding of the biology of schizophrenia; and (since thorazine) the prescription of psychotropic drugs taken (or not taken) by the patient. Unfortunately, the social urges that emptied our mental hospitals and asylums have outlived their day. The therapeutic rescue fantasy of the 1960s was that the mentally ill would be freed of their symptoms by medicinal chemistry and returned to the community. Decades of clinical experience have dashed those hopes. Dr. Carol Tamminga, an editor of the American Journal of Psychiatry, admits
People say there are drugs to treat schizophrenia. In fact, the treatment for schizophrenia is at best partial and inadequate. You have a cadre of cognitively impaired people who can’t fit in (8)
It does seem a bit far-fetched to believe that the social structure of our large cities bears any resemblance to the nurturing "community" that might support the fragile psyche of the mentally ill. Cast into an environment limited by the overnight shelter and the park bench, lacking adequate monitoring of their medication, they fall prey to climatic extremes and urban predators. Many deinstitutionalized schizophrenics wind up as conscripts in a vast army of the homeless quartered in temporary shelters such as church basements, armories, and flop houses. In Irvine, California, unused animal shelters were opened to the vagrant (9)
.
Lost in the legions of the homeless, a good number of partially-treated, seriously deranged schizophrenics become involved in violent crime, either as subject or object. Emanuel Tanay, a forensic psychiatrist at Wayne State, sounded a warning that resonates at Bellevue:
The failure to hospitalize potentially violent schizophrenics contributes to the incidence of psychotic homicide [and has] brought about a shift of this population from the mental health system to the criminal justice system (10)
Not just in the USA. Austrian doctors have found that the odds of finding a male schizophrenic among murderers is 5 times that in the general population (11)
. In Finland, where ascertainment is even better, since "police solve 95% of all homicides," the odds are 10 to one (12)
. Worse news yet: released male forensic psychiatric patients, mainly schizophrenics, were 300 times more likely to commit another murder in the year after discharge than the general male population (13)
. Psychotic homicide, of course, is only one side of the equation. These poor, deranged folk are not only ticking time bombs, they are also the walking wounded who themselves are open to violence in the asphalt jungles of our cities (14)
.
One could summarize the experience of two generations in our treatment of schizophrenia. In the 1950s, the sick were warehoused in heated public hospitals with occasional visits by trained psychiatrists who dispensed pills that didn’t work. From the 1960s to the 1990s, the medicines worked better, and patients wandered in the cold without access to psychiatrists to check their pills. We’ve made progress, however. Today, when the streets become too cold, we warehouse the mentally ill in crowded shelters or jail them when they commit a crime. Schizophrenics have access to trained professionals, again, but to cops, not psychiatrists.
THE RECEPTION OF MADMEN
Clearly, we need to recreate a new asylum: a space in which the mad and deranged can be protected from their manias and the brutality of the street. As usual, we could do worse than to consult The Age of Reason for a model on which to build.
In 1792, at the men’s asylum of Bicêtre prison, Dr. Philippe Pinel removed the shackles from the limbs of mental patients and introduced mental hospitals to Enlightenment thought:
In lunatic hospitals, as in despotic governments, it is no doubt possible to maintain, by unlimited confinement and barbarous treatment, the appearance of order and loyalty. The stillness of the grave, and the silence of death, however, are not to be expected in a residence consecrated to the reception of madmen (15)
Philippe Pinel (1745–1826) had been appointed to the Bicêtre by the Revolutionary authorities in 1793 and soon put into action the philanthropic principles of the philosophes. His unshackling of the mad was of a piece with Denis Diderot’s campaign for the humanity of blind folk, and Abbé Gregoire’s plea for equality between White and Negro, Jew and Gentile. Pinel was also cast in the mold of such 18th century taxonomists and encyclopedists of nature as Linnaeus and Buffon: but the atlas of natural history he assembled was of mental disease. In his 1801 "Treatise on Insanity," Pinel documented the number of patients admitted to his care at Bicêtre, their ages, diagnoses, length of stay, the temperature of patients and of ambient air, the outcomes of baths and showers, of bleedings or purgatives, the number who died, who recovered, etc. (1)
. The mad were classified according to his own Nosographie of 1789 which sorted mental disease into five categories: melancholia, mania without delirium, mania with delirium, dementia, and idiocy (16)
. Pinel would have been pleased to consult our texts, or even the DSM-IV to find very kindred spirits in the nosology game (17)
.
Pinel was also an experimentalist whose careful measurements undermined the phrenology of his day. Using an instrument based on the parallelopipedon (a prism whose bases are parallelograms), he made painstaking measurements of dozens of human skulls, of madmen and women, of patients with and without delirium. He contrasted these with the dimensions of the skulls of congenital idiots, and concluded that the fault in delirium lay not in our skulls, but inside:
The anatomical examination...would appear to confirm the opinion which I have already advanced, that intense mental affections are the most ordinary causes of insanity, and that the heads of maniacs are not characterised by any peculiarity of conformation that are not to be met with in other heads taken indiscriminately (18)
It has taken modern neuroimaging, using CT, MRI, PET, SPECT, fMRI, and DTI (19)
. to identify consistent neuroanatomical findings that correlate with those "intense mental affections" found in schizophrenia.
But the mythical Pinel is not the remote taxonomist of madness or the anthropologist of skulls. He is the citizen-hero of the painting in the Salpêtriére that Freud saw many years later (2)
. Tony Robert-Fleury’s painting turned a historical incident in the all-male Bicêtre of 1793 into a saltier version at the women’s asylum of the Salpêtriére, sometime after 1795. As reported by Pinel’s son, his father had been confronted by Georges Couthon, an official of the Commune during its Reign-of-Terror phase. Couthon was seeking "hidden traitors" to bring to trial. Pinel led him to the cells of the most seriously disturbed, where Citizen Couthon’s attempts at interrogation were greeted with "disjointed insults and loud obscenities." It was useless to prolong the interviews. Couthon turned to Pinel and asked:
"Now, Citizen, are not you mad yourself to think of unchaining such animals?" Pinel replied: "Citizen, I am convinced that these lunatics have become so unmanageable solely because they have been deprived of air and liberty...."
"Well, then do as you like with them, I give them up to you. But I fear you may become victim of your own presumption" (20)
The official left, and Pinel removed the chains. He freed twelve of the most violent as an experiment, but, as a safeguard, took care to have made an equal number of "long-sleeved waistcoats fastened at the back" (later to be called straightjackets) should the freed lunatics prove unmanageable. His plan worked, and when Pinel moved his operation from the Bicêtre to the Salpêtrière in 1795, his novel mixture of carrot and stick went with him. He launched the asylum model of firm but supportive care, a model that had the rights of man as its base.
A degree of liberty, sufficient to maintain order, dictated not by weak but enlightened humanity, and calculated to spread a few charms over the unhappy existence of maniacs, contributes, in most instances, to diminish the violence of the symptoms, and in some, to remove the complaint altogether (21)
A PRISONER OF NOTHING BUT HIMSELF
Our loss of the Enlightenment asylum as central to the treatment of the severely disturbed can be traced directly to the advent of first and second generation psychotropic drugs which by now act on every known class or subclass of neuroreceptor—histamine, dopamine, glutamine, serotonin, GABA, etc. (17
, 22)
. But release would not have become widespread were it not for activists convinced that, in the age of the Gulag, involuntary commitment of the mad might lead to Soviet-style incarceration for dissidents.
Another force in the attack on the asylum was led by the late Michel Foucault, a once-trendy French historian of sexuality, prisons, and medicine. Nowadays his polemics seem even less convincing than Timothy Leary’s odes to LSD, but at the time they roused a generation of young social scientists to arms. In his major opus, Madness and Civilization, Foucault traces the history of mental institutions to the "Great Confinement" of Enlightenment years. "The asylum was substituted for the lazar house," he wrote, referring to the leprosariums of the middle ages:
The old rites of excommunication were revived ...and the nineteenth century would consent, would even insist that to the mad and to them alone be transferred these lands on which, a hundred and fifty years before, men had sought to pen the poor, the vagabond, the unemployed (23)
One would have thought that Foucault would have been a great champion of Pinel’s brand of philanthropy. But, no. In keeping with a dated tradition of rhetoric associated with the names of Herbert Marcuse and Ivan Illich, Foucault reserved his hardest blows for Pinel and Enlightenment thought. Foucault accused Pinel of substituting psychological chains, the "moral treatment of the mad," for the iron shackles of the old lazar house. Foucault, displaying that curious affinity of advanced French thought for the punitive tableaux of the Marquis de Sade, went on to grieve for the patients unchained after Pinel’s reform. He posed a very fashionable Gallic paradox:
The dungeons, the chains, the continual spectacle, the sarcasms were, to the sufferer in his delirium, the very element of his liberation .... But the chains that fell, the indifference and silence of all those around him confined him in the limited use of an empty liberty.... Henceforth, more genuinely confined than he could have been in a dungeon and chains, a prisoner of nothing but himself, the sufferer was caught in relation to himself that was of the order of transgression, and in a non-relation to others that was of the same order of shame (24).
THE OTHER DEPARTMENTS OF NATURAL HISTORY
In each critique of the asylum, Foucault used as his point of reference a golden age of madness, a medieval fantasy of monk and mountebank, where fools and crazies added to the richness of everyday life by their unique insights and startling behavior. The "reforms" of the Age of Reason were said to have destroyed this organic fabric and turned it into Pinel’s straitjacket. According to this popular storyline, psychiatrists, psychologists, and social workers were employees of a police state designed to censor the self-expression of the mad. Those accusations of the 1960s were accepted by well-meaning intellectuals of the West and entered the canon of modern social science. They also caught the ear of every municipal, state, and federal official who ever had a budget to balance. In consequence, for two generations now, the asylums have been emptied, mental health budgets cut, and church basements filled.
In American cities, where violent schizophrenics wander the streets, where madmen readily buy attack rifles, where aggressive thugs seek drugs and easy victims, our streets and malls seem trending to the Hobbesian state of nature. But trend is not destiny, as Lewis Mumford taught, and therefore I, too, have a vision of a golden age when diseases of the mind will have yielded to exact knowledge. From neuroimaging, we’ll have learned whether the dopaminergic or glutamatergic hypotheses reflect primary defects; molecular genetics will have cleared up the 50% concordance rate in identical twins; and we’ll have discovered interventions that really work (22)
. Thanks to our new natural science, the schizophrenias will be as well understood and treated as scarlet fever or rabies. Those diseases may have been intractable on the wards of the Salpêtriére in 1795, but yielded their secrets to Pasteur when science was itself unfettered. The rabid are no longer restrained.
Citizen Pinel hoped that:
The time, perhaps, is at length arrived when medicine in France, now liberated from the fetters imposed upon it, by the prejudices of custom, by interested ambition, by its association with religious institutions, ... will be able to assume its proper dignity, to establish its theories on facts alone, to generalise those facts, and to maintain its level with the other departments of natural history (25)
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FOOTNOTES
The opinions expressed in editorials, essays, letters to the editor, and other articles comprising the Up Front section are those of the authors and do not necessarily reflect the opinions of FASEB or its constituent societies. The FASEB Journal welcomes all points of view and many voices. We look forward to hearing these in the form of op-ed pieces and/or letters from its readers addressed to journals{at}faseb.org.
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