A New York Times reviewer called The Caretakers a clarion call for investigation and reform. Sure enough, in 1962, a Colorado grand jury delivered a scathing thirty-page attack on the hospital in Pueblo, revealing many of the same problems that had been depicted in The Caretakers: neglect and abuse of patients; unlicensed doctors (at least one of them drunk on the job); patients escaping and running wild on the grounds. The occupational therapy school had become “the center of immoral activity”; one shady section of the hospital grounds where patients would meet to have sex had become known as “Bushville.” In one case, an illness reported on a Monday was not acted on until Saturday; that patient subsequently died.
Reform, it turned out, was just around the corner. President John F. Kennedy’s Community Mental Health Act of 1963—inspired, in large part, by the Kennedy family’s tragic experience lobotomizing and institutionalizing the president’s eldest sister, Rosemary—ordered the downsizing of large institutions like Pueblo. This was supposed to be good news both for the people who had been unnecessarily warehoused and the harder cases who could use more individualized attention. It didn’t exactly work out that way. At the same time that the federal government was emptying out large institutions for the mentally ill, the doctors at Pueblo had gone all-in on the new, miraculous neuroleptic drugs that could treat the mentally ill without expensive person-to-person contact.
These drugs, the most consequential advancement in the treatment of psychotics in the twentieth century, had arrived a decade earlier, well outside the field of psychiatry. In 1950, a French surgeon named Henri Laborit was working on a new type of battlefield anesthesia that mingled narcotics with sedatives and hypnotic drugs. The drug, which he called chlorpromazine, had its first human trial in 1952. As Laborit described it, patients on his new drug developed a “euphoric quietude,” becoming “calm and somnolent, with a relaxed and detached expression.” Laborit himself even likened the effects of the drug to a “chemical lobotomy.” Chlorpromazine debuted in the United States in 1954 under the brand name Thorazine.
In the years that the Galvin boys were coming of age, Thorazine was becoming widely accepted as a sort of miracle drug, able to calm patients out of psychosis when nothing else but surgery or shock therapy would have done the trick. By the time Donald was committed and sent to Pueblo, in 1970, more than twenty drugs had entered the market, all variations of Thorazine. For large state-run hospitals like Pueblo, medication promised to deliver what therapy had seemed unable to—fulfill the Kennedy-era vision of mental health treatment, stop the warehousing of these patients, and help some or even many of them leave the hospital. But Thorazine was no cure—it reduced some symptoms, but at best forced an unsteady truce with the illness itself. And from the start, there were questions, starting with side effects: tremors, restlessness, loss of muscle tone, postural disorders. What Laborit saw as calm and somnolent seemed to others more like muzzled and muffled—a knockout punch. Some patients never seemed to come out of their pharmaceutical stupors, and if they went off the drug at any point, the next round of psychosis tended to be more acute than the last. And perhaps the biggest question of all: How did it work?
Even today, no one knows for sure why Thorazine and other neuroleptic drugs do what they do. For decades, doctors have been treating schizophrenia pharmacologically without a clear understanding of the biology of the illness. At first, the best that researchers could do was examine what Thorazine does to a patient’s brain and extrapolate theories of the illness based on what they noticed. The first credible theory came in 1957, when a Swedish neuropharmacologist named Arvid Carlsson suggested that Thorazine treated the symptoms of schizophrenia by blocking the brain’s dopamine receptors, stopping many of those hallucinogenic, deranged messages from spiraling out of control. Carlsson’s work formed the basis of what, among schizophrenia researchers, became known as the “dopamine hypothesis”—the notion that overactive receptors somehow caused the disease.* The problem with the dopamine hypothesis was that another neuroleptic drug, clozapine, emerged that alleviated some of schizophrenia’s symptoms even better than Thorazine, only it worked on those same dopamine receptors in seemingly the exact opposite way—increasing dopamine levels where Thorazine had inhibited them. If two effective antipsychotic drugs were sending dopamine levels in different directions, something besides the dopamine hypothesis had to be explaining why they worked.
Practically every drug prescribed for psychosis, from Donald’s time until now, has been a variation on Thorazine or clozapine. Thorazine and its successors became known as “typical” neuroleptic drugs, while clozapine and its heirs were “atypical,” the Pepsi to Thorazine’s Coke. Like Thorazine, clozapine could be dangerous: Concerns over drastically low blood pressure and seizures were serious enough to take it off the market for more than a decade. Even so, drugs became the common treatment of schizophrenia, and the psychiatric profession’s great schism only widened. On one side of the street, doctors at the large state hospitals said schizophrenia required drugs, while the therapists in more rarefied settings still recommended psychotherapy.
Like most families, the Galvins were at the mercy of what was a mental health care system in name only, forced to choose from options they weren’t equipped to assess. In the end, their decision came down to money. While insurance paid for the dependents of Air Force personnel, Donald was twenty-four now, and no longer covered. And so the decision was made for them. Pueblo was his only option.
* * *
—
DONALD CAME TO Pueblo after six days in jail waiting for the commitment to come through. That gave him six days to become increasingly terrified by the prospect of being committed to a mental hospital. In his intake interview, he tried to say that he had a perfectly reasonable explanation for what he’d just tried to do to Jean and himself with the cyanide: He’d taken peyote for the first time a few weeks earlier, he said, and later heard that the peyote could have been LSD. He said that he was fine now, and that he would let his wife leave him without any objections; he’d been “uptight” like this once before, he said, when his first fiancée had left him, and he’d gotten over it then, too.
The doctors at Pueblo were wary. “Psychotic episode should be considered,” the notes read. “Diagnosis: depressive neurosis—or psychotic depressive.”
The next day, during another visit with doctors, Donald gripped the table as he insisted he was well, and ready to stand on his own two feet. He did not want to be institutionalized—that much was clear. While the doctors did not necessarily believe him, they also weren’t sure, the cyanide incident notwithstanding, exactly how sick he was. Donald received a new diagnosis: “anxiety neurosis, moderate to severe, with obsessive features.”
By Donald’s arrival, Pueblo had retrenched from its peak of six thousand patients to something more like two thousand. And yet with still only a handful of real doctors tending to the patients, the standard of care hardly improved. The staff members caring for the patients mainly were called “psych techs,” people with basic nursing training but often no nursing degree. Their main responsibility was dispensing Thorazine, Haldol, and other meds—the substitute for a doctor’s care. The pills were brought to the wards in bulk, and the psych techs would pass them out to patients, often at their discretion. “It was like passing out snacks,” remembers Albert Singleton, who spent decades as the hospital’s medical director.