Gracefully Insane (19 page)

Addie, one of the two female leads, is the “Belle of Belmont Hill.” She confesses to “primitive instincts”:

Close to Home
ends happily. The shiftless Homer works up the courage to leave the Bettering House and takes Addie with him. Andy and his girlfriend Cassie sing a beautiful duet, “In Love, Sort Of,” and decide to ask the psychiatrists if they can leave Belmont to start a new life together. In the face of so much true love, even the shrinks briefly shed their forbidding masks, singing that “everyone is human after all.” They graciously release Cassie and Andy, who reprise their love duet with these lines:

Close to Home
was a great success, playing to packed houses on three separate evenings in the Pierce Hall auditorium. The show even went on the road, to the Austen Riggs sanitarium in Stockbridge, Massachusetts. There was talk of going to New York, if not to Broadway then perhaps to Bellevue or to the Bloomingdale Asylum. In real life, alas, not all endings are happy. The
Close to Home
story ends on a mixed note, combining the grievous and felicitous events that make up real life in a mental hospital. The female librettist committed suicide. Composer Sam Heilner, who played the piano during the show, later returned to his job at the
Boston Globe.
¹⁶

Alfred Stanton had his critics; he had them all his life. But there is
no doubt that he succeeded in introducing McLean to the twentieth century. Not only did he modernize patient care at the hospital, but he also laid the groundwork for future innovations. He helped launch the day care, or outpatient, program, an important change for a hospital that had always viewed itself as a high-class
hotel for the mentally afflicted. In the 1960s and 1970s, medical insurers would come to favor such partial-payment, nonresidential plans over the costlier inpatient schemes. Gradually, Stanton changed the demographics of the inpatient population, refusing to let his asylum become a storage facility for batty Brahmins and reaching out to different, more-challenging cases. As the 1960s progressed, he correctly deduced that troubled young people might benefit from sojourns at McLean and that affluent parents would be willing to finance them. It was on Stanton’s watch that McLean opened the Arlington School, an accredited high school for boys and girls living inside and outside the hospital. Just as important, he traveled the country, jawboning government and private funding agencies for grants and promoting McLean as a first-class teaching hospital of national renown.

But his tenure at the helm of McLean ended on a plaintive note, following two successive, apparently uncontrollable waves of suicides. Although the deaths were never mentioned in the hospital’s annual reports, they were described as an “epidemic” in published research papers.

Psychiatrists who worked at McLean in the early 1960s have trouble remembering the precise dates of the suicides because they spiked in two different years. Six patients killed themselves during the 1961/1962 academic year, and then seven committed suicide in 1965/1966. In between the two spikes, there were seven additional suicides. These were very high numbers for a 250-patient hospital. Dr. George Lawson, a McLean psychiatrist, distributed an informal paper in 1966 that put McLean’s numbers in context—a context that amounted to a scathing indictment of the Stanton regime. From 1936 until 1956, the year Stanton arrived, McLean experienced seven suicides, an average rate of 0.35 a year. In the first decade of Stanton’s regime, Lawson wrote, “thirty-six people have died by suicide who were either patients of the hospital or intimately connected with its treatment programs.” So suicides had increased tenfold under Stanton, and the rate compared unfavorably with that of other mental hospitals. “The present rate
of 3.6 [suicides a year] is three times higher than the overall mental hospital average, or a rate of 150 times higher than the general population,” according to Lawson. “Stanton had advertised to the psychiatric world that if you can’t take care of the desperately ill, we can at McLean,” recalls one doctor. “So many patients arrived there having failed at Shepherd Pratt or at Chestnut Lodge. They arrived with the expectation that they had come to the best mental hospital in the world, and when they began to fail, they were hopeless.”

Stanton himself, a cool customer in staff conferences and in one-on-one analyses, was distraught by the suicides and the impact they were having on his hospital’s reputation. In response, he committed what many consider to have been a cardinal error: He tightened his supervision over the ward administrators. By so doing, he broadcast his concern about the deaths. But at the same time, he instructed his subordinates never to discuss the suicides with the patients, who were of course fully informed through the hospital grapevine. “Stanton behaved in the most uncharacteristic way of not wanting to discuss it,” says Irene Stiver, the woman whom Stanton hired as the hospital’s first clinical psychologist. “He was afraid that the situation would escalate if you allowed people to talk about it. I think it was very poor clinical judgment, but he was the psychiatrist-in-chief and he was the one responsible. He got into this crazy thing about how we couldn’t even bring the subject up at conferences.”

Some psychiatrists lied to their patients about the suicides, and some did not. The patients picked up on this conflict immediately; indeed, it is precisely the kind of destabilizing disagreement described in Stanton’s book
The Mental Hospital.
“The preoccupation with the avoidance of suicide is so great that it is immediately and accurately telegraphed to the patients, which places a dreadful weapon in the service of their anger,” Lawson wrote in his critique. And the more disturbed patients were perfectly willing to wield the weapon. Even patients who were monitored twelve times an hour on five-minute “checks” managed to kill themselves.
Suicide pacts arose; two women swallowed cyanide in the kitchen of an apartment where their therapists allowed them to live. A group of young women on South Belknap, the ward that Susanna Kaysen would later make famous in her book
Girl, Interrupted,
branded themselves the “OSS girls”: “Over-Sexed, Over Sixteen, and Over-Suicidal.” A young man hanged himself inside Eliot Chapel. “They said he should have hung himself on the sign outside McLean,” one administrator remembers, “because that’s what the hospital specialized in.”

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 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: