This book is a true story about a precociously talented young man who develops severe psychosis but perseveres despite debilitating symptoms and graduates from Yale Law School. Essentially, it is a love letter from his best friend from childhood, the author Johnathan Rosen.
On another level, it is a clinical dissection of the chaos of mental health policymaking in the USA from the 1960s onwards. There was a heady brew of forces ranging from Marxism, postmodernism, libertarianism and anti-statism to the family experiences of powerful people such as John F. Kennedy (JFK), which led to the wholesale rewriting of mental health policy and provision. Our protagonist, Michael Laudor, was very much caught in this crossfire with disastrous personal consequences for him and others. For me, the book also has a personal resonance as all the story takes place during my lifetime, including my training and practice as a psychiatrist.
There are clues early in the book that Michael is not neurotypical. He is nicknamed ‘toes’ as he always seems to be on tiptoes. He also discloses in his early teens that his paternal grandma had schizophrenia. In his late teens, he develops erratic circadian rhythms spending ‘whole days in his room with the lights out’. During his undergraduate years at Yale, a clear and severe psychosis gradually develops, leading to hospital admission and treatment with antipsychotics. He responds somewhat to medication but remains psychotic for the duration of the book. The ‘community care’ he clearly requires is missing. He is supported by friends and family (a number of whom are psychiatrists), but his suffering and risk are both minimised by the prevailing winds of Szasz's The Myth of Mental Illness,Reference Szasz1 which ‘elevated untreated victims of a terrible disease to the status of free spirits’. Michael stops taking his medication and has a severe relapse with fatal consequences.
JFK signed the Community Care Act in 1963 as one of his final bills prior to his assassination. He aspired to replace the ‘cold mercy of mental hospitals’ with the ‘open warmth of community, concern and capability’.Reference Kennedy2 This led to the widespread closure of asylums but a failure to re-provide the care and support in the community. This failure of community care along with the triumph of ‘autonomy’ over all other principles (such as duty of care) is something that I am sure rings bells with many modern-day psychiatrists and which played its part in the disastrous outcome of the story.
This book should be essential reading for all psychiatrists who should continue to remind the populace that mental illness is real and severe.
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