My college publishes a book for each class celebrating a five year reunion. We are invited to submit an essay. This is mine.
A few years ago, someone sitting in my office looked up at the diplomas on my wall and said, “You went to Harvard? I didn’t know you were smart!”
I mention that not only to brag about how stealth I am with keeping any bit of intelligence I might possess under wraps but also to acknowledge — before I launch into what may seem like a rant — that I understand that I have benefited in small and big ways from my Harvard education. Part of the tirade to follow focuses on my impression that we have come to live in a world of branding where a superficial gloss of information overtakes substance. That bothers me deeply even though I am aware of the extent to which I have benefited from my associations with one of the greatest brands there is. Yet, this institution disappoints me. It is hard for me to feel celebratory on the occasion of our 40th reunion. As my career winds down, I feel more disappointment and dismay than the glow of lifelong achievement.
My story is not an uncommon one. My grandparents were all immigrants and I come from one of those hard-working, striving families who benefited enormously from the American promise. Nevertheless, my admission to Harvard was an unexpected surprise. I came to our freshman year with a hopeful sense of awe at my great luck to be among you. I quickly learned that it was not the Harvard way to show one’s awe or aspiration or striving. I was a photographer on The Crimson and I recall a certain disdain my colleagues held for someone who was considering applying to medical school because it reflected an overt ambition. I recall that now with bemusement given that among my fellow Crimeds were some of the most ambitious people I have ever met.
But kudos to them. Many have done remarkable work and I congratulate them. As for me, I did end up in medical school, as seemed somehow preordained for me, and I struggled to use my ambition to do good. I felt a certain sense of burden and responsibility from the legacy of my grandparents’ struggles. They gave up so much and it seemed to be in the service of my success in life. As I write this, I think how naïve and earnest this all sounds. I would have been embarrassed to share these thoughts with you until now.
Given my education, my intellectual skills, and my desire to be worthy of my grandparents’ sacrifices, I probably should have pursued some sort of academic research career. But for reasons that are far more interesting to me than to others, this is where I landed: I have been a psychiatrist for people who have psychotic experiences — hearing voices others do not hear, believing things that no one else tends to believe. I work in public mental health with people who depend on small government stipends to survive. For most of my career, I have derived great satisfaction from this work, I am paid well, and I was able to have the flexibility I wanted when my children were young, so there was no great sacrifice in many respects. However, this is decidedly not a glamour field in medicine or even in psychiatry (which is not a glamour field in medicine!). By choosing to use the great gift of my education to help such a discounted and underserved group of people, it seemed I was honoring my family’s sacrifice on my behalf.
So why the outrage? This is how my career unfolded.
To a casual observer, the narrative of modern psychiatry is that it has undergone a remarkable evolution in the past 30 years. We have shuttered most of our large mental hospitals and the common wisdom is that this was due to the powerful and effective drugs psychiatrists prescribe. These drugs have helped not only those who, in another era, might have been institutionalized but also those who were functioning — in some cases quite well — but suffering with sadness, worry, distraction. To hear this version of the story, I am in a great profession for ambitious strivers who want to do good.
But that is not how I experienced the transformation. When new drugs were introduced in the late 1980s and 1990s, I was optimistic. There was room for improvement. But I quickly observed that, in the clinic, these drugs did not live up to their hype. Of even more concern, their hype did not match what was documented in the studies that had been done to gain their approval from regulatory bodies. And what bothered me the most is that the institutions I would have looked toward to counter the commercial interests — our academic institutions, including our alma mater — seemed to be the ones who were doing most of the promotion.
At this point I may begin to sound like one of my patients — someone who has beliefs that are not shared by others. But my experience and observation is that medical academia has been captured by commercial interests. While most physicians seem to believe that their scientific training protects them from bias — that they are able to look behind the promotion — this is not what I observe. I see arrogance and a lack of humility at our limitations to overcome bias. When challenged, many seem to agree generally with this observation but see it more in others than in themselves. So non-psychiatrists might see the problem in my field but not in their own, or among other doctors but not in themselves.
My concerns go beyond medicine. As an example, industrial agriculture is an environmental disaster. It sometimes seems that we sell drugs to farmers so they can raise livestock in horrific conditions so they produce more food that makes people sick so we can sell more drugs. And while this may not have been a conspiratorial plan hatched in some back room, once in place the obstacles to change appear insurmountable.
We live in an oligarchy. The moneyed interests control our world.
I have no doubt that I am not alone in feeling horrified by our current political leadership. But my outrage precedes this administration. In some ways, our current president seems to be the apotheosis of a culture that values style and hype over substance. The line between analysis and gritty, basic journalism has become terribly blurred. The desire for clickbait seems to supersede the desire to report the news. It doesn’t shock me that Trump exists. It disappoints me that so many people like him. But he seemed to exploit this weakness in our journalistic structure. He was too seductive.
We are the privileged ones. Many of us have reaped the rewards of this era. Do any of you share my outrage? What is to be done?
I will end with an appreciation of a classmate I admire. We met once, and only briefly, so much of what I know of him is from his writing and advocacy work.
David Oaks was hospitalized against his will at McLean Hospital when he was an undergraduate. He recognized, long before I did, the serious flaws in my profession. He could have buried this and gone on to a more comfortable life but he devoted himself to advocacy. He created an organization called Mind Freedom International and he has been an outspoken activist and critic for his entire adult life. He is now working on environmental issues. David had a serious accident several years ago and is now disabled. That has not kept him quiet! Kudos to you, David Oaks! I am proud to be your classmate.
And yes, I have a husband and two daughters. I love them dearly and they are the center of my life. I worry about the future for my daughters but they are strong, courageous people and that recognition provides me some comfort. I still experience awe, and now it is for them.
Dr. Sandra Steingard is Medical Director at HowardCenter, a community mental health center where she has worked for the past 21 years. She is also clinical Associate Professor of Psychiatry at the College of Medicine of the University of Vermont. For more than 25 years, her clinical practice has primarily included patients who have experienced psychotic states. Dr. Steingard serves as Board Chair of the Foundation for Excellence in Mental Health Care.