American Madness

Thousands of people with severe mental illness have been failed by a dysfunctional system. One of them, Jonathan Rosen wrote in the May 2023 issue, was his friend Michael.

LLike Michael Laudor, I was diagnosed with a serious mental illness, and like Michael Laudor, I graduated from an “elite” law school, just this spring. Certainly this makes us part of a small club—but it’s not as small as Rosen or the New York Times profile he references would suggest. Perhaps the most notable example is Elyn Saks, a professor whom I had the privilege of communicating with when I had a psychotic episode as a firstyear law student. Why doesn’t Rosen compare Laudor’s story to Elyn’s? Two Jews who developed schizophrenia and went to Yale Law School; one murdered his partner and the other won a Macarthur genius grant. This reflects a larger failure in Rosen’s article, I think: By not acknowledging that Laudor’s story is an aberration—that mental illness isn’t statistically correlated with violence—he further stigmatizes mentally ill people.

To live with a serious mental illness is to be in a constant fight for your agency, your autonomy. What a shame that Rosen has joined New York City Mayor Eric Adams’s side of that fight.

Name Withheld by Request

Washington, D.C.

Jonathan Rosen’s poignant “American Madness” hit home for me: I was diagnosed with borderline personality disorder and chronic depression. I, too, have experienced the malfunctions of American psychiatry. I spent 38 years un or underemployed and suffered 47 years of inept psychiatric care in community mentalhealth centers and university clinics, which turned me into a desperate, dependent outpatient. I finally received the treatment I needed—70 months of excellent psychotherapy—because when I turned 65, I at last had insurance, Medicare, to pay for private treatment.

I am now recovered and living a productive life. And despite my mental illness, I managed to earn a degree in economics and experienced some success as a writer and poet. Today, though, I still must work fulltime, because my 38 years of poor employment devastated my Social Security benefits. Rosen’s contention is true: How we treat mental illness in the U.S. is sheer madness.

George Fish

Indianapolis, Ind.

As a mother whose child was hospitalized for serious mental illness, I’ve seen the worst and the best of the mentalhealth system. I agree with Jonathan Rosen that the system is broken, but not for the reasons he discusses. Rosen argues that Michael Laudor and his partner would have been saved if only Michael had been forced into treatment, reflecting the widespread view that people with serious mental illness refuse treatment for no other reason than their being delusional.

I used to share this view, before I saw how forced treatment made my daughter’s psychosis much worse. My daughter entered the hospital with relatively mild delusions. It was in the hospital that she became paranoid and lost all touch with reality. Unfortunately, her negative experience of psychiatric hospitalization appears quite

typical. Studies show that prior negative encounters with the mental-health system are among the main reasons those on the verge of a psychotic breakdown refuse to seek help. Fears of being locked up compel many people to hide their problems, sometimes with tragic outcomes. Such tragedies are extremely rare, but when they occur, the calls for force and coercion increase, driving more people into hiding and away from mental-health services.

Thankfully, there is a way to break this vicious cycle: evidence-based, noncoercive treatment methods, such as Open Dialogue and Soteria. Providers trained in these methods know how to build trust and establish connections with even the most severely psychotic and paranoid individuals. My daughter recovered completely under the care of a clinician using Open Dialogue. Now, more than three years later, she is healthy and thriving. These and other treatment methods bypass the false dichotomy between patients’ rights and public safety, using medications sparingly and only with the patient’s consent.

What Michael needed was indeed asylum, but asylum premised on these methods, not the kind where people are kept isolated. Mayor Adams would have done better had he invested in treatments like Open Dialogue instead of business-as-usual on steroids. A real opportunity for visionary leadership—and robust healing—has been lost.

Yulia Mikhailova

Socorro, N.M.

In 1973, the same year Jonathan Rosen met Michael Laudor, I took a position in New York City’s mental-healthservices office, where I worked throughout the ’70s and early ’80s. Deinstitutionalization was our highest goal, and federally funded community mentalhealth centers (CMHCS) were to be the means of realizing it. My colleagues and I sincerely believed that we were working toward a revolution in mentalhealth care. But as Rosen points out, the CMHC initiative fell short of what we’d envisioned. In New York City, only about a quarter of the more than 50 planned centers ever opened. Lack of funding and community resistance were part of the reason. The psychiatric profession itself was divided on whether CMHCS could replace institutional care for the most severely ill. Many of those who “returned to the community” slipped through the cracks in the system that was supposed to support them. Later in my career, though, as an associate director of a community mental-health center in the Bronx, I witnessed how much good CMHCS could do for people in need of care, even if they didn’t meet their ultimate goal.

I still support progressive solutions to many social issues. But I’ve come to realize that great intentions live in a world of political, fscal, and social realities that we ignore at our peril.

Joseph A. Buonocore

Dumont, N.J.

Jonathan Rosen replies:

The varied responses to the extract of my book reinforce a lesson I learned over and over in the years I spent researching and writing The Best Minds: A single story can never capture the essence of severe mental illness, any more than a single medication can resolve its symptoms, or a single policy can repair the damage of past systemic failures. The Best Minds grew out of a childhood friendship, and spans five decades of cultural and political transformation; nevertheless, I’m amazed to find so many echoes of past battles in current debates about what we owe people with severe mental illness, especially those too sick to care for themselves and who reject treatment, convinced that they are not ill.

I’m grateful for the mention of Elyn Saks, a heroic figure who wrote in her memoir that news of Michael killing his fiancée, Carrie, initially convinced her to keep her illness hidden. In my book, Saks wonders aloud why she never became violent like Michael, given the paranoid impulses that prompted her to conceal a knife in her pocketbook when she visited her therapist, before she had come to terms with her schizophrenia and the medication she needed to control its symptoms. When I asked the dean of Yale Law School if he could hold both Michael and Saks in his mind at the same time, he told me he wasn’t sure.

Making room for Saks, for Michael, for Carrie, and for many other lives was part of the challenge of writing a book about a tragedy many years in the making, which explores a mystery of infinite complexity that benefits from many voices, including the passionate responses of Atlantic readers.

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