I have been catching up on my reading, and Edward Shorter’s History of Psychiatry (John Wiley, hardcover 436 pp. (1997)) seemed like a good
choice, given ongoing professional activities.
Shorter narrates from the point of view of the practicing psychiatrist. The thesis is that psychiatry has struggled to differentiate itself from neurology (and brain science), psychoanalysis (and psychotherapy), finally securing for itself the secure path of a respectable scientific enterprise in the second psychopharmacological revolution, featuring Prozac (floxatine) along with a willingness to make use of some version of “the rapport,” talking with patients as human beings with complex lives and emotions.
Shorter challenges the conventional wisdom since Michel Foucault that there was a “great confinement” in which unconventional eccentrics and the actually medically psychotic being well-cared for by loving families were shifted to asylums in order to accommodate an emerging capitalist economy. Not so. The first asylums were inspired by Enlightenment values that there was still a human being and human soul somewhere to be found in the mentally disordered individual in spite of his or her aberrant behavior. The examples of Samuel Tuke and the Quaker-inspired York Retreat lead to establishing relatively small, manageable asylums in which kindness, work therapy, and spa-like treatments were applied until spontaneous remission occurred. The so-called great confinement took the seriously disturbed out of the squalor in which they were maintained by desperate overwhelmed families and work houses in communities that did not distinguish between the criminal, the indigent, and the authentically insane. Of course, the narrative includes Philippe Pinel’s (1745 – 1826) famous removing of the chains from the incarcerated, an action actually undertaken by his assistant Jean Baptiste Pussin. All the colorful characters, usual suspects and celebrity schizophrenics such as Paul Schreber are noted and narrated. In sum, the initial initiatives for confinement were to engage those suffering psychotic-level disorders with “moral” – that is, “psychologically humane” – treatment, an enlightened undertaking. The explosion in the number of patients subsequently overwhelming the system is attributed to three causes: (i) the worsening of untreated syphilis, the ravages of which can hardly be appreciated from our own perspective with the ready availability of antibiotics; (ii) the spread of alcoholism and alcohol related mental conditions; (iii) and a grain of truth to the discredited “degenerative” trajectory of congenital insanity combined with the stresses of modern living. In short, there really more people suffering from serious, psychotic level disorders. The enlightenment experiment of treating the psychotic humanely was valid in so far as it went, but failed dues to inability to scale to meet the need.
One of many strong points of Shorter’s thesis is to call out psychiatry’s commitment to engaging with the seriously disturbed, psychotic level individuals – what today would be called schizophrenia and bipolar disorders in their psychotic eruptions and uncertain prognosis. Emil Kraeplin (1856 – 1926) is accurately credited with making the distinction between manic-depressive (now bipolar) disorders of the affects and schizophrenic (“dementia praecox”) disorders of thinking. He also famously championed the position that such disorders would turn out to be determined by brain processes gone awry. What Shorter incisively points out is that Kraeplin eventually gave up the search, marking the end of the first biological psychiatry, in order to concentrate on longitudinally tracking the trajectory of the disorder with bipolar endlessly cycling and often spontaneously remitting and thought disorders seeming to follow a downward trajectory with a much more pessimistic prognosis.
No friend of psychoanalysis, Shorter acknowledges that Sigmund Freud (1856 – 1939) was a towering figure whose innovations extended to treating severally disturbed individuals in addition to the worried-well, the latter eventually becoming the bread and butter of conventional psychoanalysis (which itself came to dominate psychiatry until the 1980s). Examinations of Freud’s early case histories show Freud engaging with individual suffering from hallucinations, functional paralysis, paranoia, and thought disorders. Carl Gustav Jung (1875 – 1961) and Eugen Bleuler (1857 – 1939), who were already innovators in their own right when they discovered Freud’s Interpretation of Dreams, get honorable mention as they applied methods of psychoanalytic therapy to individuals who had not been able to be helped in any other way. And in several cases, Freud made a significant difference to the individual’s well being with brief psychoanalysis, without, however, claiming the analytic work got all the way down to “bedrock” and a complete personality transformation. What would that even be? Nevertheless the psychoanalytic establishment has been unable consistently to engage with the more severely disturbed populations that tended to require restraint against hurting oneself or others and ended up in asylums – notwithstanding a few exceptions such as Chestnut Lodge and Harry Stack Sullivan. Up until the second biological revolution, which Shorter dates from the discoveries of the therapeutic effects of chlorpromazine, lithium, and barbiturates, departments of psychiatry were dominated by psychoanalysts. Shorter’s (and psychiatry’s) criticism is that these tended to concentrate on the neurotics, the worried well, and those suffering from thoroughly middle class angst , dysthymia (unhappiness), and emptiness, while leading to the psychoanalytic neglect of the most seriously disturbed individuals, struggling with bipolar and schizophrenia.
Another delicate point. Shorter accurately quotes Freud as saying that he (Freud) was worried his work would be misunderstood and devalued as a “Jewish” science, since he himself was a non-conforming but committed Jewish person as were most of his early followers. By my reading, Shorter seems to buy into and endorses the misunderstanding (pp., 181-189). How can one buy into the misunderstanding without also seeming to accept the devaluation? Anti-Semitism or a clumsy attempt at cultural history? The caution flag is out on this one.
A separate and not entirely integrated thread of the history consists in various forms of therapy designed to shock the deeply psychotic and depressed back to reality. Though not strictly speaking directed against a functional disorder, Julius von Wagner-Jauregg’s early success with curing the advanced syphilis (which was invariably a death sentence) by intentionally infecting the patient with malaria and its fever served as a paradigm. Remember that prior to antibiotics, syphilis infiltrated the spinal meninges, resulting either in paralysis or dementia or both. In any case, death was inevitable and miserable. Insulin shock, electro shock, and related mini-traumas were a cure that was perhaps better than the disorder itself, especially in its most florid aspects, but perhaps not by much. Not one to be guilty of Nachtraeglickeit – the retrospective redescription of the past in terms of contemporary values – Shorter does not bring up the niceties of informed consent. Such was impossible most of those incarcerated in asylums, who were invariably quoted as being pleased with being returned to some measure of normal functioning when they were awoken from their madness. Also missing is acknowledgement that two wrongs do not make a right – the life of a homeless, mentally ill person is miserable in different ways from that of an incarcerated survivor of a lobotomy on the incontinent ward.
Nicely written, Wiley does its usual excellent job of producing an error free text. The one exception that I could find: There is a single, telling typo on p. 191 (of the hardcover): “The doctors were uninformed in white coats, the nurses in regulation caps.” Of course, “uninformed” should “uniformed” – that is, the difference between wearing a uniform such as a white coat or nurses’ outfit and being un-informed. Occurring on a page with a picture of the Georgia State Sanatorium at Milledgeville, at 10,000 beds in 1950, Shorter tells the truth.
Regarding empathy, there is no reference in an otherwise comprehensive index, though Shorter states that he wants to tell the history of psychiatry “empathically” (p. 49), so I believe that he has access to the distinction. On empathy, the psychologist Carl Rogers (1902 – 1987) gets honorable mention – and is devalued, once again, as being unable to engage with the psychotically disturbed with client-centered responsiveness – whereas Heinz Kohut (1913 – 1981), the innovator who put “empathy” on the map in the 1970s and 1980s (and a psychiatrist), is conspicuous by his absence. In sum, by the end of this otherwise engaging and informative text, the rumor of empathy remains one.
Though striving to be empathic towards those whose calling is to take a stand as psychiatrists against the seemingly endless forms of mental suffering, Shorter is no rubber stamp. Ample space is given to R.D. Laing, Thomas Szasz, and the anti-psychiatry movement. While eccentrics and political dissidents may have been made to suffer unnecessarily in imposed conformity, Shorter lines up with those who properly argue that psychotic misery is no romantic dream but a feces smearing nightmare. Also relevant is the input of David Healy, historian of psychopharmacology, whose eventual debunking of Big Pharma qualifies much of the triumphalism of Prozac’s “cosmetic pharmacology” with which Shorter ends his narrative. While such medications have addressed the relatively moderate neuroticism and depressive emptiness of the dysthymic (i.e., unhappy), among those benefiting the most are the psychiatrists themselves who have a renewed revenue model. No longer caught between warehousing the hopeless in back wards and the rigors of talk therapy, psychiatrists are able to engage meaningfully with a market – the middle class and its insurance providers (to whom the power has shifted) – where they can get the satisfaction of making a difference in ending the consultation by picking up a pen and writing a prescription.
(c) Lou Agosta, Ph.D. and the Chicago Empathy Project