Psychiatry, from its very inception, has been subject to raised eyebrows if not outright ridicule. Even before Freud came along with his batty theories about infantile sexuality and repressed wishes to kill one’s father, the discipline had struggled to define its methods and objectives. More than two centuries after it emerged as a profession devoted to the care—and hoped-for cure—of the mentally ill, psychiatry is still seen by many as half-baked, neither a science nor an art, pulled hither and yon by an indeterminate purview and changing medical trends.
Two hundred years of research and theorizing have not resolved the most basic differences of opinion among psychiatry’s practitioners as to whether what was once derisively called “madness” is a brain disease amenable to a purely medical treatment, such as insulin therapy or psychosurgery, or something engendered by a more complicated mix of factors. If, for instance, mental illness is based on the input of both nature and nurture, it might benefit from the talking cure—or, more likely, the talking cure in conjunction with medication.
Edging closer to the present with the birth of psychopharmacology in the 1950s (the first antipsychotic drugs appeared on the market in 1954), a biochemical model of mental illness has prevailed; the use of psychotropic medication ramped up in the 1980s and ’90s, proffering relief from schizophrenia, bipolar disorder, and unipolar depression. The only problem with these ostensible advances is that the psychopharmacological revolution hasn’t provided the long-hoped-for wonder drug. The drawbacks start with the intolerable side effects caused by many medications, especially those referred to as “atypical antipsychotics,” such as Abilify and Risperdal. These can include major weight gain, tiredness, and uncontrollable facial tics known as “tardive dyskinesia,” symptoms that, compounded, can sometimes make the supposed cure as destructive as the disease.
Still, for the many of us, like myself, who slog through days and months filled with unbearable sadness or destabilizing mood disorders, the lack of a thoroughgoing solution is in itself despair-inducing. One can unburden oneself to a therapist, swallow a bunch of meds that sort of help, or go to an emergency room and wait to be admitted to a bare, neglected psychiatric unit that couldn’t be more inclined to worsen one’s state of mind if it had been built as a detention center. (There are a few astronomically priced private psychiatric hospitals that go against type.)
If the situation sounds rather dismal, Andrew Scull’s comprehensive, sober, and compulsively readable history of psychiatry, Desperate Remedies, isn’t designed to put the reader’s mind at ease. Scull, a sociologist, provides a lucid and, in his own words, “skeptical” overview of the field, describing a complex and densely detailed series of developments with skill and little mercy. His empathy, which is considerable, is saved for the stigmatized and frequently dehumanized patients who are too often the victims of psychiatric arrogance as well as of the profit-fixated marketplace. Although Scull concedes that mental illness “remains a baffling collection of disorders,” he has no use for psychiatrists such as R. D. Laing or Thomas Szasz, whose attempt to clarify the confusion around mental illness has been to proclaim it simply a story concocted about people who are not really ill so much as unconventional, eccentric, or even visionary.
Meanwhile, the conceptual arguments within psychiatry itself are vague and opaque, hard for professionals to read and almost impossible for the layman to parse. Scull’s book is an effort to provide a sight line through the often turbulent currents of the field, touching on its strengths and (mostly) its shortfalls, from the start of the psychiatric endeavor to the present moment. His hope, I would suggest, is to provide readers with a way of thinking about people with mental illness as part of us rather than as alien or weird presences, best drugged into compliance or shuttled off to an institution. Understanding the long, sordid history of how these diseases of the mind have been treated is a necessary first step toward bringing people with even the most debilitating disorders into the fold and finding the solutions that might aid in their healing or, at the least, alleviate their suffering.
Desperate Remedies begins in the late 19th century, with the reign of what Scull calls the “mausoleums of the mad”—state asylums, which eventually were renamed state hospitals to downplay their stigma. These were basically mammoth holding pens for people who were frequently referred to in the United States as the “dregs of society,” and the number of patients confined in them reached half a million by 1950. Asylum superintendents kept watch over patients who were considered unsound and lumped together—the senile, the syphilitic, and the alcoholic along with those classified as “feeble-minded” and “chronically insane”—behind grated windows and locked doors. In 1894, one eminent Philadelphia neurologist, Silas Weir Mitchell, in a lengthy critique at the American Medico-Psychological Association, pointed out that psychiatrists had been attempting for half a century to convince the public “that an asylum is in itself curative … Upon my word, I think asylum life is deadly to the insane.”
Along with the asylums overflowing with what Scull calls the “poor and the friendless,” private hospitals and sanitariums, including the Hartford Retreat in Connecticut, the McLean Hospital in Boston, and the Battle Creek Sanitarium (run by the Kellogg brothers of Corn Flakes fame), sprang up in the late 19th century together with new diagnoses for “upper class” ailments, such as hysteria and neurasthenia. Self-styled “nerve doctors” treated their wealthy patients’ “nervous prostration” (one thinks of Henry and William James’s gifted sister, Alice, who retired to bed, never to get up again) with nerve tonics, many of which included dangerous substances such as morphine and strychnine. Hydrotherapy and electrotherapy, delivered by elaborate machines that sent painful jolts of electricity through the body, were also put into use. The best-known course of treatment for the well-to-do (primarily women) was the “rest cure,” which consisted of a high-calorie diet and enforced bed rest as well as an absence of physical and mental stimulation. This approach would later be recommended for Virginia Woolf whenever she descended into one of her depressive states, and she never ceased to dread it.
By the mid-1930s, tolerance for the psychologically afflicted was at an all-time low: Some 31 states prohibited mentally ill and “feeble-minded” people from marrying; “the insane,” one superintendent of a state asylum opined, were “notoriously addicted to matrimony and by no means satisfied with one brood of defectives.” Scull tells us that no less a personage than the jurist Oliver Wendell Holmes Jr. “ringingly endorsed” the constitutionality of involuntary sterilization in 1927: “It is better for all the world,” Holmes wrote, “if instead of waiting to execute degenerate offspring for crime, or to let them starve for their imbecility, society can prevent those who are manifestly unfit from continuing their kind … Three generations of imbeciles are enough.”
Over the following decades, the array of psychiatric interventions included insulin coma therapy; injections of camphor or Metrazol, both of which had what Scull calls “savage impacts”; brute physical force; and colectomies and abdominal surgeries, which were thought to cure psychosis but frequently led to the death of the patient (out of 79 patients whose abdomens had been operated on from mid-1919 to mid-1920, Scull reports that 23 died after the operation, generally from peritonitis). In some fashion, the favored approach seems to have been that whatever didn’t kill you would strengthen you. The grim paradox that underlay this conviction wasn’t lost on some observers: “It has long been known,” noted Stanley Cobb, a psychiatry professor at Harvard who was struck in the late 1930s by the “widespread devastation” of patients’ brains during insulin coma and Metrazol treatments, “that any situation that brings a schizophrenic patient near to death may rid him temporarily of his symptoms.”
The advent of ECT ( electroconvulsive, or “shock,” therapy) in the late ’30s came with some caution and controversy—no one understood exactly how it worked when it did, which was mostly in cases of acute or, as it was called, “intractable” depression—but by October 1941, 42 percent of American mental hospitals had resorted to the practice. An individual sometimes received as many as four shock treatments a day and was essentially reduced to an infantile and incontinent condition. One report on a state hospital revealed that women were, on average, given twice as many shocks as men. Many of the treatments involved fractures, sometimes severe, and demonstrable signs of pain. There was a punitive side to the use of ECT as it developed into a means of subduing troublesome patients—an aspect that was captured to indelible effect in Ken Kesey’s 1962 novel, One Flew Over the Cuckoo’s Nest. The amnesiac effect was serious too. Ernest Hemingway condemned his Mayo Clinic doctors who had subjected him to ECT: “What is the sense of ruining my head and erasing my memory, which is my capital, and putting me out of business? It was a brilliant cure, but we lost the patient.”
But undoubtedly, the most gruesome “cure” ever engineered to alleviate mental illness was the lobotomy. (More’s the irony that it won its inventor, a Portuguese neurologist named Egas Moniz, the 1949 Nobel Prize for Medicine.) Reading about it today in Scull’s narrative is enough to make one’s skin crawl and fill one’s head with wonder at man’s benighted capacity for cruelty in the name of kindness.
On November 12, 1935, the Oxford-trained neurosurgeon Almeida Lima performed a frontal lobotomy under Moniz’s direction (Moniz himself was suffering from gout and arthritis). Moniz began by having Lima drill holes into the patient’s skull and then inject alcohol into his brain, but he changed tactics when the “destructive effects of this technique were too unpredictable.” He then had Lima “crush white matter” and cut six cores out of the frontal lobes with a tool he referred to as a “leucotome.” Even more zealous practitioners, such as Walter Freeman, a neurologist with no surgical training, employed far more sweeping surgeries—using a small knife to make bilateral cuts in the frontal lobes, repeating the operation if it failed the first time, and then adding on an unbelievable number of electroshock treatments in the days that followed.
As Scull recounts these developments, his tone remains detached while also suggesting his quiet horror at the violent and essentially unsupervised path the field had taken. Freeman moved on to perform transorbital lobotomies by driving an ice pick through the orbit of a patient’s eye (although he would ultimately hit upon a specially designed tool). In 1941, Freeman, together with a young neurosurgeon named James Watts, performed psychosurgery on a 23-year-old Rosemary Kennedy, whose father, Joseph, feared that the combination of her nascent sexuality and intellectual slowness might bring embarrassment to the Kennedy name. The consequences were dire: “From 1941 till her death in 2005, Rosemary Kennedy was severely mentally handicapped, unable to speak, incontinent, barely able to walk and hidden from public view.” Scull, always sensitive to gender issues, cites a 1949 study that found that, as with shock treatments, women were lobotomized twice as often as men.
Scull’s book is an ambitious undertaking, and in his various explorations of the “crisis of legitimacy” in psychiatry and the profession’s ongoing “quest for validity,” he leaves few subjects untouched—be it the creation, in 1952, of the taxonomic guide now known as the Diagnosis and Statistical Manual of Mental Disorders and the fierce feuds it engendered; the initial embrace of psychoanalysis from the ’40s through the ’60s, succeeded by its gradually falling out of grace and its diminished influence; the emptying-out of psychiatric hospitals during the ’60s and ’70s, contributing to a steep rise in the homeless population and unattended-to psychotic patients; or the so-called psychopharmacological revolution.
As suicide rates among the young remain on the rise and people who suffer from severe emotional disorders continue to need professional help, one wonders whether we have reached a standstill of sorts in the treatment of mental illness—whether our knowledge of how the mind works is too limited to move decisively forward. I would have been interested to hear what Scull makes of ketamine “mills” (having tried six sessions of ketamine infusions myself, I can report that they did little for me other than put me to sleep). There is, as well, the new interest in using psychedelics and MDMA (popularly known as Ecstasy, or Molly) as well as bodywork (the alternative-medicine techniques involving massage and breathing popularized by the best-selling book The Body Keeps the Score, by Bessel van der Kolk) to rejigger the brain-altering effects of trauma.
Then, too, his book gives much less space to the various extant kinds of traditional talk therapy. However limited in its effectiveness it may be, some people still find succor from full-on psychoanalysis on a couch, allowing them to go from “neurotic misery” to “ordinary unhappiness,” as Freud put it. Less intensive psychotherapy and the treatment modalities known as CBT (cognitive behavioral therapy) and DBT (dialectical behavioral therapy) also exist. As someone who has spent decades both in psychotherapy and on a panoply of psychotropic medications, I would say that although they haven’t succeeded in undoing the damage and repercussions of my past, they have been significant in making my life more tolerable.
If Scull’s turbulent history were merely an indictment, it would be a far less powerful document than it is. It’s also a plea for less internecine fighting between the nature and nurture proponents and a greater acceptance of the large gray area that encompasses our inability to fully discern where the influence of biology stops and the influence of environment begins. Scull has joined his wide-ranging reporting and research with a humane perspective on matters that many of us continue to look away from. And understanding these “desperate remedies” helps to elucidate the psychiatric pathologies to which they were responding. The first sentence of his preface explains why we must confront the often elusive and still stigmatized specter of psychological distress instead of consigning it to the sidelines. “Few of us,” Scull writes, “escape the ravages of mental illness.” It’s an observation that strikes me as both tragic and true, much as we might wish to ignore or deny it.