My research on this subject spans four decades. Back in the early 1980s, I thought about writing a book on the somatic therapies employed by American psychiatrists. I was spending the year at what was then the Wellcome Institute for the History of Medicine on a Guggenheim fellowship. Like all historians of medicine, I deeply lament the closure of the institute (or “centre,” as it was renamed after its ill-starred move to University College London). The Wellcome Library and its archival collections remain a key resource for all of us working in the field. I am extremely grateful to the then director of the institute, William Bynum, for making my 1981 visit, and many subsequent ones, so enjoyable and productive. I am also grateful to those in charge of its Contemporary Medical Archives, who made it possible to consult the papers of England’s leading lobotomist and enthusiast for physical treatments for mental illness, William Sargant.
During the intervening decades, I have had reason to be grateful to many archives and archivists for the extraordinary assistance they provided. Particularly important were the National Archives and the Library of Congress in Washington, DC; the Rockefeller Archives; the Yale Medical Library’s historical collections; the archives of the New Jersey State Hospital in Trenton; and the Alan Mason Chesney Archives at the Johns Hopkins University. The libraries at the University of California campuses at San Diego and San Francisco have been vital resources over the many years it has taken to complete this book, and I owe them my thanks as well.
Over the course of a long career studying the history of mental illness, and the lives and practices of those who have taken charge of managing it, I have written a good many books on the subject, some more specialized than this one. But throughout my career, two major projects have challenged and provoked me. I’ve thought hard about the issues they raised for me, and I tried to transform vague initial hunches and preliminary reflections into what I hope are disciplined, serious, and sustained examinations of each of them.
The first of these books, Madness in Civilization, which I published seven years ago now, was an exercise in chutzpah, an attempt to provide a cultural history of madness in civilization, ranging from ancient Greece and China to the modern world, and encompassing religion and medicine, the plastic and visual arts, politics and folk beliefs, music and the movies, and much else besides. By comparison, this book, which confines its attention to the period between the early 1800s and the present, and focuses mostly on what American psychiatrists have thought and done about mental illness, would seem to have a simpler tale to tell. But that is not true. Both books depended on a lifetime of research and reflection; both would have been impossible to write without it.
Like its predecessor, Desperate Remedies is driven by both my sympathy for the victims of what constitute some of the most profound forms of human suffering and my concern with the intractable puzzles of how to account for mental illness and how to treat it. Over the many years thinking about the development and practices of American psychiatry, my initial concern with events in the 1910s, 1920s, and 1930s has broadened into an attempt to make sense of psychiatry from its first beginnings until today and to analyze the existential crisis that I believe now confronts the profession—and, by extension, those who seek its help.
Desperate Remedies, as its title suggests, is in many respects a highly critical examination of the psychiatric enterprise. I am therefore particularly grateful to the psychiatrists who have assisted me along the way and who have, in a number of cases, read portions of the manuscript and offered commentary on what I have had to say about their profession. In North America, these include Joel Braslow, George Makari, Will Carpenter, and David Healy; and in Britain, Sir Robin Murray and Sir Simon Wessely. They have not been shy about making clear where they disagree with me, but I have listened and learned much from what they have had to say, and I deeply appreciate their willingness to engage with my critique. I’m grateful, too, to the historian and psychoanalyst Daniel Pick, with whom I’ve had some fruitful conversations and whose work on degeneration I admire. I’m also indebted to the foremost historian of American medicine, Charles Rosenberg. The two of us were colleagues many years ago, and I have admired his wide-ranging scholarship over the years since my time as a junior faculty member at the University of Pennsylvania. The late Gerald Grob and I had a highly contentious relationship in print, which belied our cordial friendship in person. With typical generosity, Gerry provided valuable help with my research on several occasions. Before his untimely death, Jack Pressman and I had spirited conversations about how to interpret lobotomy. We worked in many of the same archives, and while I differ from some of his conclusions, I have great respect for his scholarship.
Franklin Freeman, Walter Freeman’s son, was kind enough to share some family memorabilia with me, including a copy of the unpublished autobiography Walter Freeman wrote for his children. Conversations with Phyllis Greenacre and her son Peter Richter gave me valuable insights into Henry Cotton’s work at Trenton State Hospital, as did a lengthy interview with the institution’s longtime dentist, Ferdearle Fischer, who pulled hundreds of thousands of teeth in a vain attempt to cure mental illness. Among sociologists, Allan Horwitz was kind enough to share his work on psychiatry’s diagnostic manuals before it appeared in print. He also provided a close, careful, and valuable reading of several of the later chapters in this book.
Over the years, the University of California at San Diego, my academic home for over forty years, has provided me with funds to travel to archives. A number of foundations have also given invaluable assistance: the Guggenheim Foundation, the American Council of Learned Societies, the American Philosophical Society, the Rockefeller Foundation, and the Commonwealth Fund. I hope this book in some small way repays their generosity and confidence in my scholarship.
Portions of Chapter 12, “Creating a New Psychiatry,” first appeared in History of Psychiatry and was then reprinted in a collection of my essays, Psychiatry and Its Discontents, published by the University of California Press. I am grateful to Sage and the press for permission to reuse those materials here. A different version of Chapter 18, “Community Care,” was published in Perspectives in Biology and Medicine in 2021, and I thank Johns Hopkins University Press for permission to reprint the passages that appeared in that article here. Chapter 18 also contains a few paragraphs from a paper of mine written in the early stages of the deinstitutionalization movement, “A New Trade in Lunacy: The Recommodification of the Mental Patient,” which first appeared in American Behavioral Scientist. Once again, I am grateful to Sage for permission to reuse those materials. Finally, Chapters 20, 21, and 22 build on ideas first presented in “American Psychiatry in the New Millennium: A Critical Appraisal,” published in Psychological Medicine in 2021, and I would like to thank Cambridge University Press for permitting reuse of those materials.
My agent, Caroline Dawnay, has been an enthusiastic supporter of my work and has worked tirelessly to make sure that this book reaches a broad audience. I worked with her first many years ago and am delighted that she has chosen to represent me again. No author could ask for a better advocate. Thanks to Caroline, I have been privileged to work with two terrific publishers. Casiana Ionita of Allen Lane and Penguin Books provided some most helpful editorial comments on an earlier version of this manuscript. Subsequently, Joy De Menil of Harvard University Press devoted much time and effort to an extraordinarily detailed review of the manuscript. I am immensely grateful to her not only for going through the book line by line, but also for suggesting a change in the way I structured the argument that follows. Quite how Joy found the time to invest so much in a detailed dialogue with me I cannot fathom, but the book has benefited greatly from her engagement with it.
As always, some of my deepest debts are to two friends of many years’ standing, both blessed with superb editorial skills and the kindness to share them with no more recompense than such inadequate thanks as these. Amy Forrest and Stephen Cox read drafts of every chapter of this book, and it is immeasurably the better for their unsparing and insightful comments and criticism. My wife, Nancy, has added her own critical voice and has put up with my obsession with the irrational for fifty years and more. In 2016, we shared the tragic loss of our youngest son, a loss that only our love and the love of our other children and grandchildren have allowed us to endure. It is to our dearest Alex that this book is dedicated.