In the psychiatrist’s lair

In 1907, Henry Cotton was a young psychiatrist on the up. Barely in his thirties, he was made superintendent of the New Jersey State Hospital at Trenton, founded in 1848. A previous incumbent had preferred using mechanical restraints to address the possible causes of his patients’ “insanity” (an ill-defined concept at the time). Fired up by the idea of ​​“focal sepsis” – when an infection in a bodily organ leaks poisons into blood and lymph – Cotton pushed through a radical change of practice. Out with the shackles, in with the more “medical” tool of a scalpel.

Cotton’s enthusiasm for targeting possible infection gained some evidential ballast in 1913, when a syphilitic infection was found to cause the “General Paralysis of the Insane” diagnosed in a quarter of the men admitted to New York asylums. Cotton was particularly tenacious, however. If one organ’s removal didn’t improve symptoms for a patient – usually a woman – he kept going. The “symptoms” he aimed to alleviate had long been conflated with “behaviours”, and the more calm and biddable a patient became, the better the outcome was deemed.

Records tell us that one patient admitted to Trenton for depression and anxiety endured gastric surgery followed by the removal of her thyroid, colon, ovaries, fallopian tubes and cervix. Just to be sure, medical staff then administered a number of “vaccine treatments”. The woman was discharged as “cured” but, as Andrew Scull shows in Desperate Remedies, his scholarly historical analysis of the psychiatric profession, early “research” methods lacked any academic rigour; There was no follow-up assessment of this patient.

While we don’t learn much about Cotton’s mindset as he butchered his patients, presumably because he didn’t write about it, Scull convincingly conveys the idea of ​​an arrogant practitioner letting loose on vulnerable and desperate charges who were ultimately seen as a public nuisance and a drain on society’s resources. The history of the psychiatric profession – both before and after Cotton – seems to be peppered with cavalier men like him, experimenting on live patients without professional supervision or challenge. Symptoms may have been alleviated in some cases, but the suffering continued.

A leading figure in the history of psychiatry, Scull is obviously passionate about the unhelpful directions psychiatry has taken. In his book of essays Psychiatry and its Discontents (2019), he wrote of unethical practices, shoddy research, professional tribalism and the profiteering of Big Pharma. He returns to these themes in Desperate Remedies. Scull’s inquiry begins with the asylums of 1820s America, and he largely remains on that side of the Atlantic. Although Freud and his Viennese acolytes and, later, European pharmaceutical companies have been formative in international approaches to mental health, Scull pivots his thinking around American psychiatry as it became more influential. English psychiatric diagnostic criteria today are guided by the World Health Organization’s ICD-11 (International Classification of Diseases), but the controversial American Psychiatric Association’s DSM-5 (Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition) continues to have a firm grip on the research field and percolates through European thinking.

Scull also notes how, after the Second World War, American cultural winds helped to bring the “problem” of the mentally unwell to a wider audience. Alfred Hitchcock’s film Spellbound (1945) addressed Freud’s talking cure, as did Anatole Litvak’s psychological thriller The Snake Pit (1948). Freud himself hadn’t been keen to puff his theories in a country he referred to as “Dollaria”, however. In 1925 Samuel Goldwyn traveled in an ocean liner, enormous cheque in hand, to enlist Freud’s screenwriting skills, only to be refused an audience when he got to Vienna.

Hollywood helped to challenge interventions too. Miloš Forman’s film (1975) of Ken Kesey’s book One Flew Over the Cuckoo’s Nest (1962) portrayed the damage wreaked by electroconvulsive therapy and lobotomies, and the long story of “psychosurgery” Scull presents makes particularly tough reading. Walter Freeman and James Watts performed their first lobotomy in Washington in 1936 on sixty-three-year-old Alice Hammatt. This involved pushing an ice pick through her eye socket into her frontal lobe, to sever the connections thought to cause mental anguish. Alice’s husband had sought help for her after witnessing years of depression, suicidal ideation and strange behaviours, but her two clinicians characterized her as “a past master at bitching” who “really led her husband a dog’s life”. After the lobotomy the Hammatts both stated that they were satisfied by her calmer nature, despite the epileptic seizures she now suffered. Alice died five years later from pneumonia.

American psychiatry also came under fire from the media in the early 1970s after the publication of an article in Science, “On Being Sane in Insane Places”, by the academic psychologist David Rosenhan, who sent volunteers to mental hospitals. He instructed them to claim to hear voices and, once admitted, to act normally, asserting relief from their symptoms. Rosenhan recorded that they all received psychiatric diagnoses and medications, and this “Rosenhan experiment” gripped the US, showing how easily diagnosed the “sane” were. But Scull goes on to describe a fascinating – and lesser-known – coda to this national media storm: Rosenhan had “perpetrated one of the most egregious and successful academic frauds of the twentieth century”. Thanks to the tenacity of the investigative journalist Susannah Cahalan, it transpired that he’d made most of his experiment up – and Cahalan’s long efforts showed quite how hard it was to discover the truth.

While unprofessional behavior provides a consistent backdrop, Scull also reveals a reductive oscillation between interventions that prize treating the body (including the brain) and those that lean more on the workings of the mind. The former included injecting horse serum into spinal canals to induce meningitis or insulin to induce comas. Surgeries, including lobotomies, were abandoned as Freudian psychoanalysis grew in popularity after the Second World War — but schisms between schools of analysis soon emerged, and none of the approaches actually helped with acute illness. As insurance companies developed their care programs for their US payees, a “talking cure” practice that used cheaper psychopharmacology became more lucrative for a practitioner. Big Pharma then began its ascent, with its theoretical justification pinned, once again, on the problem with the body – or rather, the brain.

Like the physician and author Gabor Maté, who has written extensively about the integral relationship between physical and mental health and the influence of their social context, and patient-advocates such as Johann Hari, who has written about his own depression, Scull rightfully laments the Cartesian dualism that lingers in medicine. “If we are to obtain a better grasp of the boundaries, etiology, and the therapy of anomalous mental states,” he writes, “we must abandon a dogmatism that privileges either psyche or soma.”

When Scull writes early on in the book about Adolf Meyer, a leading figure in psychiatry in the first half of the twentieth century, the reader wonders if he has found a man who took a holistic approach. Meyer pioneered a form of “psychobiology” which aimed to encompass body, mind, surrounding environment and biography. But Scull gives him short shrift: Meyer was fanatical about recording endless “facts” about his patients that trumped any considered treatment or decent outcome. He becomes another arrogant man in the Wild West of early mental healthcare.

Desperate Remedies Nods toward green shoots of progress in neuroscience and genetics, but there’s no doubt, as Scull makes clear, that psychiatry in the US and the UK needs to up its game in response to increasing levels of psychiatric illness. He doesn’t mention other new and promising frontiers, such as research by Skip Rizzo on alleviating post-traumatic stress disorder with Virtual Reality, or Professor Celia Morgan’s research on the use of ketamine to help alcohol relapse, or the work of the Multidisciplinary Association of Psychedelic Studies. Even so, Scull’s history remains a vital rallying cry: “We need to be honest about the dismal state of affairs that confronts us rather than deny reality or retreat into a world of illusions. Those, after all, are classically seen as signs of serious mental disorder”.

Julia Buenois a practice psychotherapist and the author ofThe Brink of Being: Talking about miscarriage2019

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