Psychiatric Hubris

DESPERATE REMEDIES, subtitled “Psychiatry's Turbulent Quest to Cure Mental Illness,” is a depressing book. Its author, Andrew Scull, is a prominent sociologist and historian of psychiatry and, more broadly, of madness. In one of his previous books, Madness in Civilization, he wrote an ambitious cultural history of madness that rivaled in scope Michel Foucault’s Histoire de la folie à l’âge classique. In another, Hysteria, he followed the metamorphoses of this strange “disease” through the ages and the often aberrant “therapies” implemented to control it. In Madhouse, he told the cautionary tale of Dr. Henry Cotton, an influential American psychiatrist of the early 20th century who became convinced that insanity was caused by focal infections that could only be cured through organ removal.

Desperate Remedies extends this exposé of psychiatric hubris to American psychiatry as a whole and even, we are to assume, to psychiatry in general. Scull warns us in his preface: “In this book, I have attempted to provide a skeptical assessment of the psychiatric enterprise — its impact on those it treats and on society at large. […] My focus is on the therapeutics of mental illness and on the professionals who advanced them.” Psychiatry, a medical discipline that emerged at the beginning of the 19th century with the claim to study and treat what it presented as mental illnesses, has in fact never succeeded, Scull claims, in understanding their causes and even less in curing them: “[T]wo centuries after the psychiatric profession first struggled to be born, the roots of most serious forms of mental disorder remain as enigmatic as ever.”

Two hundred years of history and no progress? Still in his preface, Scull tells how “a Hollywood producer who once contemplated making a movie based on one of my books informed me that it provided the basis for a great first and second act. But where, he asked me, was the third act? By this he meant, where was the happy ending?” Hollywood being Hollywood, I suspect that the producer’s question was actually, where is the story — with a proper Aristotelian beginning, middle, and end, happy or not? The story told by Scull in Desperate Remedies does in fact have three acts, or rather three parts, but it has no unity of action, nor a clear narrative arc. Not only do the three parts overlap chronologically, presenting an almost cubist narrative of interpenetrating temporalities, but each one tells the same story: how a new theory or remedy stirred wild hopes, only for its proponents to face disappointment and patients outright harm.

None of this makes for a good story, obviously, but it does make for sobering history. All too often, the history of psychiatry has been written from some happy endpoint in theorization, as if the definitive truth of mental illness had been discovered in 1895 by Sigmund Freud, or in the early 1950s with the advent of the psychopharmacological revolution. No such thing with Scull. Being methodically skeptical of psychiatrists’ theoretical and therapeutic claims, he relates not “what may happen,” but “what has happened” (Aristotle’s difference between poetry and history) without necessarily trying to make sense of the events he narrates. The result is a messy, haphazard, and, yes, utterly depressing tale of ambition, incompetence, and callousness.

Act I. Psychiatry emerged as a profession in the early 19th century from the twin notions that insanity is an illness and also curable. Inspired by William Tuke and Philippe Pinel’s “moral treatment,” social reformers supported the creation of public asylums where the insane would be treated humanely and brought back to reason, instead of being thrown in jail or condemned to homelessness. Very quickly, however, it became clear that psychiatry could not deliver on its rosy promises, and so therapeutic optimism gave way to profound pessimism. By the closing decades of the century, public mental asylums had become vast internment places where a bevy of people languished, including the senile and demented, the alcoholic, the perverted, the feeble-minded, the schizophrenic, the melancholic, the hysteric, or the tertiary syphilitic (the dreaded General Paralysis of the Insane, or GPI). The only quality they had in common was external to them: no one knew what to do with them. Most of those who were not discharged within a year because of spontaneous remission were left in the asylum to die.

This therapeutic impotence was conveniently theorized as a biological fatality inherent in the mentally ill that was nonetheless also social: these poor people, experts claimed, were suffering from compromised heredity. They were paying the price for the intemperance, immorality, or lack of hygiene of their parents and grandparents (this is what the neurologist Jean-Martin Charcot, Sigmund Freud’s teacher, called the “neuropathic family”). According to a variant of this theory of degeneration, the fragile “nerves” from which the neurasthenics and hysterics of good society suffered came, in stark contrast, from the refinement of their ancestors. The well-off, who could afford treatment, were referred to private clinics or sanatoria where they were treated by caring neurologists or “nerve doctors,” but without any expectation of their heredity being cured.

The others, those who could not pay, represented a financial burden and even a danger for society. Some psychiatrists dreamed aloud of euthanizing the “unfits” in order to decongest the asylums, and others advocated for their sterilization in order to stop the transmission of their defective germ plasm. California, followed by other states, passed a law in 1909 authorizing the involuntary sterilization of the handicapped and mentally ill. The practice, soon emulated by most Nordic countries and Nazi Germany, continued in the United States until the 1970s, after some 60,000 forced sterilizations across the country.

Not everyone in the psychiatric community shared this veritable therapeutic nihilism, however. Scull also tells of the therapeutic enthusiasms that followed one another throughout the 20th century, most often based on adventurous and unfounded theories. Take Dr. Henry Cotton and his germ theory of psychosis, whose story Scull retells here. The discovery in 1905 of the bacteria responsible for syphilis (Treponema pallidum), followed by the discovery in 1909 of the efficacy of Salvarsan on the primary stage of the disease, had opened the possibility that psychosis, like GPI, was an infectious disease, as such amenable to an antibacterial strategy. Cotton was so convinced of this view that he tried to inject Salvarsan directly into the brains of his patients. When this did not have the desired effect, he turned to the various infectious sites that he speculated could affect the brain at a distance. It was, he concluded, a question of removing the potential foci of infection — teeth, tonsils, stomach, colon, thyroid, ovaries, cervix, etc. — to eliminate the roots of the disease. Naturally, a lack of results did not mean that the theory was wrong, but that another spot was likely responsible and should be surgically removed. Nothing stopped Cotton in his mutilatory zeal, including patient deaths. An independent report in 1933 established that the mortality rate for his colectomies was 44 percent. According to psychiatrist and psychoanalyst Phyllis Greenacre, the rate of positive outcomes from the thousands of detoxifications Cotton performed was zero.

Other treatments were just as cruel and ineffective. The Austrian psychiatrist Julius Wagner-Jauregg, who had observed that fever caused temporary remissions in some psychotics, decided to artificially induce it in GPI patients by injecting them with blood taken from a war prisoner who suffered from malaria. When it didn’t kill the patient outright, the treatment caused abominable fevers. Wagner-Jauregg, however, claimed marked improvements in GPI symptoms. It is now known that this optimism was greatly exaggerated, but this did not prevent Wagner-Jauregg from being awarded the Nobel Prize in Physiology or Medicine for the development of malaria therapy.

His Swiss colleague Jakob Klaesi claimed for his part to cure schizophrenia by inducing a prolonged sleep with barbiturates. The Polish doctor Manfred Sakel chose instead to provoke a deep coma by injecting his patients with insulin. Ladislas Meduna, convinced that epileptic seizures reduced the symptoms of schizophrenia, caused them artificially by injecting high doses of Metrazol, a circulatory and respiratory stimulant. The Italian Ugo Cerletti obtained the same result by subjecting his patients to electroshocks, which is how electroconvulsive therapy (ECT) was born, the bête noire of 1960s anti-psychiatry. Then came lobotomization, introduced by the Portuguese neurologist António Egas Moniz. Based on the idea that changes in the frontal lobe region could lead to personality changes, Moniz pierced patients’ skulls at the level of the eye sockets in order to rearrange, he said, blocked neuronal connections. Walter Freeman and countless American psychiatrists zealously followed suit, with Freeman using a special instrument inspired by an ice pick found in his kitchen.

Based on purely speculative theoretical considerations and promoted in each case as a miraculous cure, none of these reckless experiments ever obtained convincing results (except perhaps ECT in certain cases of major depression). Instead, they inflicted irreparable damage to the brain functions of those subjected to them. ECT, notably, caused massive memory losses that were exploited by psychiatrist Donald Ewen Cameron in brainwashing experiments secretly financed by the CIA.

Act II. These practices, which continued well into the 1960s, lost their cachet, however, when American psychiatry fell under the spell of psychoanalysis. “Freudo-centric” histories of psychiatry usually date the introduction of psychoanalytic ideas into North America to Freud’s visit to the United States in 1909, but Scull shows that this isn’t accurate: the vast majority of psychiatrists remained impervious and even hostile to psychanalysis during the interwar period. Just as in Europe, psychoanalysis initially recruited its patients and followers from among an elite who could afford long and expensive analyses on private couches. (Freud was, let us not forget, part of the tradition of those neurologists who catered to the well-to-do, as opposed to asylum psychiatrists.)

American psychiatry embraced psychoanalytic theories after the war in part because so many soldiers suffered from “war neuroses.” Not only did these traumatic neuroses prove that psychiatric disorders could be caused by factors other than biology or heredity, but military psychiatrists such as Herbert Spiegel were able to show that applying psychiatric labels to patients was counterproductive. He made the case for “psychodynamic” interventions. Psychiatrist William Menninger then capitalized on Spiegel’s success to sell to American politicians and the public the idea that psychotherapy was a revolutionary method of treating even the most serious mental disorders.

These promises were once again greatly exaggerated, but the GI Bill provided money for establishing training programs in the newly founded Menninger School of Psychiatry. For their part, the 200 or so psychoanalysts who had fled fascist Europe through the Rockefeller Foundation’s “Special Aid to Displaced Scholars” program were more than willing to spread the Freudian gospel and participate in this great effort to transform American psychiatry. In 1948, Menninger was named president of the American Psychiatric Association. Ten years later, most psychiatric department chairs favored psychoanalysis and one-third of American psychiatrists were “psychodynamically” oriented. By 1973, they were the majority. Freud had finally “conquered psychiatry,” as he had promised Eugen Bleuler in 1906.

Scull, strangely enough, does not dwell on the ineffectiveness of psychoanalysis in treating severe forms of mental illness. This is probably because he takes it for granted, and also because he considers it benign compared to the cruelty of somatic methods. In his description, psychoanalysis was essentially an ideology that allowed psychiatrists to shine in professional gatherings and publications while hiding their inability to treat, let alone cure, the patients they were in charge of. Very often, in fact, they continued to perform ECT and lobotomies in an effort to stabilize patients and allow “transference.”

It was mainly outside the hospital that the impact of psychoanalysis was felt. In keeping with the dimensional and psychosomatic approach of psychoanalysis, psychiatry now broadened its scope to address a whole range of conditions and problems that were not previously in its purview: asthma, peptic ulcers, anxiety, personality and behavioral disorders, traumatic experiences, sexual problems, family conflicts, child-rearing, professional difficulties, low self-esteem. Unable to cure their patients, psychiatrists emigrated en masse outside the walls of the asylum, “psychopathologizing” everyday life in order to better treat it in private office practices with the help of transference and talk therapy. The figure of the “shrink” was born, soon followed by — and finally eclipsed by — that of the clinical psychologist using scientifically validated cognitive-behavioral strategies reimbursed by third-party payers. A huge market had been created that would eventually be flooded with the pharmaceutical industry’s pills.

Act III. This act begins at about the same time as the second one, at the turn of the 1950s. In 1949, an Australian physician, John Cade, published an article saying that lithium dramatically calmed manic patients, a discovery that passed almost unnoticed at the time. Three years later, a team of French researchers found that another compound, chlorpromazine, produced by the French pharmaceutical company Rhône-Poulenc, had an even more dramatic and almost immediate calming effect on patients displaying violent agitation. “They look as if they have been turned to stone,” wrote the psychiatrist Pierre Deniker. Here were terrific alternatives to sedatives, ECTs, and lobotomies (the French quickly spoke of camisole chimique, chemical straitjacket). Soon other compounds were shown to have similar effects on major depression (imipramine) and anxiety (benzodiazepines).

At first, these psychotropic drugs were seen as mere “tranquilizers,” not as therapeutic agents. In this sense, it is a retrospective illusion to believe that their discovery immediately sounded the death knell of psychoanalysis in psychiatry. On the contrary, psychiatrists of psychoanalytical persuasion saw them as a convenient adjuvant — as vehicles that prepared the ground for a deep exploration of their patients’ unconscious. It may be that psychoanalysis would never have penetrated American psychiatry as it did without the covert support of psychotropic drugs. It was only gradually (starting in the mid-1960s) that the latter were theorized as “antipsychotic” or “antidepressant” drugs, that is, as disease-specific treatments acting on the illness itself rather than on its expression. This was of course a deeply flawed reasoning: it is not because substance X produces an effect on pathology Y that one may conclude that it acts on the cause of the illness. Obviously, no one would think to call aspirin an “anti-flu” medication because it relieves flu symptoms. Nevertheless, this basic fallacy ended up convincing everyone that mental disorders, including the mildest ones, were of a biological nature rather than the result of psychological conflicts or environmental factors, and that one could reason from the effects produced on them by chemical agents to establish their cause. If, for example, a compound that increased the level of serotonin in the brain was seen as having an effect on depression, then it was assumed that one could safely conclude that depression was due to a lack of serotonin. That is how Prozac, the first SSRI antidepressant, was sold to the world.

The pharmaceutical industry was only too happy to churn out compounds producing some effect, however small, on this or that symptom listed by the DSM, the famous Diagnostic and Statistical Manual of Mental Disorders published by the American Psychiatric Association. The DSM, since its third edition (1980) based on the idea that mental disorders are discrete diseases whose symptoms can be described in neutral and atheoretical terms, provided an ideal blueprint for how pharmaceutical companies could market their wares. It allowed them to segment the market and present each new compound coming down their pipeline as the scientifically validated drug for such and such a disorder, whether bipolar disorder I, II, III, or IV; panic attacks; attention-deficit/hyperactivity disorder; or shyness, renamed “social anxiety disorder.” When no such disorder was readily available, it was created to fit the compound, as when a “premenstrual dysphoric disorder” (PMDD) was included in the DSM-IV to give a new outlet to fluoxetine, formerly known as Prozac. The psychiatrization of daily life over which psychoanalysis had presided in previous decades gave way to its complete psycho-biologization: one pill for every ill, reimbursed by insurance. As for the psychoanalysts, clinging to their dimensional model and haughtily refusing to submit their results to the double-blind randomized placebo-controlled trials used to test drugs, they were simply swept off the psychiatric scene.

But did the psychopharmacological revolution actually improve the condition of the mentally ill? No one denies, and neither does Scull, that the discovery of psychotropic drugs has provided considerable relief to many patients, not to mention to their families and psychiatrists. However, not only have these drugs never cured mental illness, but they have also come with debilitating side effects that often outweigh their benefits. The first antipsychotics, as was soon discovered, caused tardive dyskinesia, a condition involving incapacitating involuntary movements of the mouth, lips, and tongue. Second-generation “atypical” antipsychotics, once reputed to be less toxic than their predecessors, are now known to cause significant weight gain, diabetes, pancreatitis, stroke, and heart disease. Benzodiazepines are highly addictive, as are third-generation antidepressants like Prozac and Zoloft, which also cause anhedonia and loss of sex drive, and in some cases akathisia, whose sufferers experience extreme internal restlessness and suicidal thoughts. Anticonvulsants used to treat mood disorders are liable to cause kidney failure, obesity, diabetes, and polycystic ovary syndrome.

Worse still, the psychopharmacological revolution has been a disaster for patients insofar as it led during the 1960s and 1970s to the gradual closing of most psychiatric hospitals to the benefit of outpatient clinics and community-based alternatives. Why continue to lock up patients, the reasoning went, if they could now be stabilized with medication and returned to a more or less normal life? This was an entirely reasonable argument, but in the United States, as Scull shows, it was used as a justification for the states to offload the tasks and costs associated with state-run hospitals onto a federal welfare system that was utterly unprepared for the task, especially after the brutal budget cuts of the Reagan administration. In practical terms, this means that patients have quite simply been left to fend for themselves, drifting from halfway houses to “welfare” hotels to the streets. In the absence of any real therapeutic follow-up, they usually throw away the medications that were supposed to stabilize them and relapse into a state of delusion or depression. More often than not, they end up in jail for having stolen food in a supermarket or threatened someone in the street. The sad truth is that prisons have to a large extent replaced the old asylums. The psychopharmacological revolution, which was supposed to liberate the mentally ill and return them to a relatively normal life, has in the United States ended up creating a population of homeless people, drifters, and inmates, just as in the days before the creation of psychiatry.

Epilogue. One senses that Scull struggled to write the conclusion to his relentless exposé of the psychiatric enterprise. “Does psychiatry have a future?” he asks. The answer is not forthcoming. What can we hope for after so many failures to understand and treat mental illness? Perhaps the very project itself was misguided from the start. Perhaps madness is not an illness to be cured but a condition to be cared for. Scull muses uncomfortably about overcoming the mind/brain divide that has for so long defined psychiatry, and he ends up with the social: “I am convinced,” he writes, “that madness cannot successfully be divorced from the cultural, social, and psychological matrix in which human beings exist.”

A fairly predictable statement coming from a professional sociologist, but one that at least allows Scull to conclude his book on a political note. If the situation of the mentally ill is so desperate in the United States today, it is not ultimately because of psychiatry, despite all its failings, but because of America and its social arrangements.

The idea that we bear a collective moral responsibility to provide for the unfortunate — indeed, that one of the marks of a civilized society is its determination to provide as a right certain minimum standards of living for all its citizens — has never enjoyed widespread support in the United States. […] If our goal is a revival of a psychiatry that attends to the psychological, physical, and social dimensions of mental disorder, one must recognize just how difficult that transformation is likely to prove.

This is depressing.

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Mikkel Borch-Jacobsen is Professor Emeritus of Comparative Literature and French at the University of Washington.