Gracefully Insane (20 page)

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 over 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 mod
ern 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 attractive 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.

... I feel like a periwinkle
Left too high on the beach
By the tide ...
What flood was it
That brought me here?

 

 

 

T
he 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.”

Sexton had another idée fixe: She wanted to be admitted to McLean. “I want a scholarship to McLean,” Sexton confided to her longtime friend and amanuensis Lois Ames, as if she was talking about a fellowship to the American Academy of Arts and Science. Sexton certainly had the qualifications: Two suicide attempts by the age of thirty; extended stays at the Glenside and Westwood Lodge sanitariums. She wrote about her mania in her first poetry collection,
To Bedlam and Part Way Back.
She reveled, theatrically, in her madness and was not above exploiting her shocking mood swings to manipulate her friends and family. But Dr. Orne, wary of McLean’s high prices and extended stays, refused to commit her there. Sexton had won the Pulitzer Prize and been profiled in national magazines. But she had never punched her ticket at McLean.