FEW OF US ESCAPE THE RAVAGES OF MENTAL ILLNESS. We may not suffer from it ourselves, but even then we feel the pain it inflicts on friends or family. And no one escapes its social burdens. Psychiatry seeks to lessen these afflictions, but too often it has increased them. 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. I have focused most of my attention on the United States, because it is here that these interventions stand out in the starkest relief and because, by the closing decades of the twentieth century, American psychiatry had achieved a worldwide hegemony, its categorizations of and approaches to mental illness sweeping all before it. But many of the interventions I examine had their origins in Europe, including the drugs that are now so central to psychiatric identity and operations. So European developments loom large in this story and are woven through the narrative that follows.
For two centuries and more, most informed opinion has embraced the notion that disturbances of reason, cognition, and emotion—the sorts of things we used to gather under the umbrella of “madness”—properly belong in the domain of the medical profession. More precisely, such maladies are seen to be the peculiar province of those whom we now call psychiatrists. Mental illness, we are informed, is an illness like any other—one that is treated by a specialist group of doctors whose primary goals are to relieve suffering and, more ambitiously, to restore the alienated to the ranks of the sane. These are worthy goals, to be sure. How have psychiatrists sought to realize them? How have psychiatrists attacked the problem of mental illness? What weapons have they chosen and why? And have those treatments succeeded in relieving suffering and curing those consigned to psychiatrists’ tender mercies? These are the central questions I propose to explore in the pages that follow.
My focus is on the therapeutics of mental illness and on the professionals who advanced them. But I seek constantly to keep in mind that these interventions are not abstractions but rather organized forms of action carried out upon our fellow human beings. Patients are the constant subtext of my story. They are the people whose bodies and minds are subjected to each of these therapies—sometimes several of them successively—and not always with success.
Psychiatry emerged in the nineteenth century as a specialized branch of medicine claiming expertise in the management and cure of what was then called insanity or lunacy. Psychiatry’s rise was intimately linked to the emergence of the asylum, and for a long time psychiatry and the asylum were locked in a symbiotic embrace. Prior to the Civil War, these institutions housed an almost exclusively white population. When institutional provision for African Americans began to be provided after the war, it took the form of either segregated wards or entirely separate institutions for the “colored insane.”
Psychiatry’s marginalization of the Black population was, of course, of a piece with the exclusion and discrimination they faced in the larger society, and in many ways such marginalization persists into the present. Racism continues to have an impact on life chances, whichever sector of society one attends to: the economy, housing, education, or the criminal justice system, to mention only some of the more obvious arenas. And, of course, with respect to health—both mental and physical—where the cumulative disadvantages of poverty and racial prejudices are vividly demonstrated by, for example, data concerning maternal mortality and life expectancy.1 Unsurprisingly, when the Office of the US Surgeon General examined mental health services in 2001, it found that racial and ethnic minorities had less access to mental health services than whites and that the care that minorities did receive was more likely to be of poor quality.2 That makes the lack of contemporary research on racial disparities in psychiatric treatment even more dismaying. Organized psychiatry has belatedly awoken to the problem; in January 2021 the American Psychiatric Association issued an official “Apology to Black, Indigenous and People of Color for Its Support of Structural Racism in Psychiatry,” following on the formation of a task force on the problem in 2020. There is an obvious need for more research on these issues.3
Mental illness haunts us, frightens us, and fascinates us. Its depredations are a source of immense suffering and often embody threats, both symbolic and practical, to the very fabric of the social order. Ironically, the stigma that surrounds those who exhibit a loss of reason has often extended to those who have claimed expertise in its identification and treatment. Of all the major branches of medicine, psychiatry, throughout its history, has been the least respected, not just by those to whom it ministers but also by physicians and the public at large.
Vast resources have been devoted over time to efforts to intervene in, ameliorate, and perhaps cure the mysterious conditions that constitute mental disorder. Yet, two centuries after the psychiatric profession first struggled to be born, the roots of most serious forms of mental disorder remain as enigmatic as ever. The wager that mental pathologies have their roots in biology was firmly ascendant in the late nineteenth century, but that consensus was increasingly challenged in the decades that followed. Then, a little less than a half century ago, the hegemony of psychodynamic psychiatry rapidly disintegrated, and biological reductionism once again became the ruling orthodoxy. But to date, neither neuroscience nor genetics have done much more than offer promissory notes for their claims, as I shall show in later chapters. The value of this currency owes more to faith and plausibility than to much by way of widely accepted science.
For what it is worth, I should be astonished if several of the major varieties of mental disturbance do not turn out to be at least partially explained by biological factors. But I should be equally astonished if biology turns out to be the whole story. Indeed, in some respects I think the whole debate about nature versus nurture rests on a serious category mistake, because our brains are extraordinarily plastic organs, jointly constituted by the social and the physical—by the biological endowment we are born with and by the psychosocial environment within which our brains grow and develop, a point I shall return to in my conclusion.
But the fundamental point remains: the limitations of the psychiatric enterprise to date rest in part on the depths of our ignorance about the etiology of mental disturbances. Psychiatry’s deficits also reflect the profound limitations of the treatments psychiatrists can offer patients even in our own times. For the most severe forms of mental disturbance—schizophrenia, bipolar disorder, and grave depressions—which are the overwhelming focus of this book, it is important to be clear-eyed: not to deny that there has been some progress, but equally not to ignore the price that is sometimes paid for such relief as psychiatry can now provide. Periodically, as we shall see, enthusiasts have proclaimed that decisive breakthroughs are at hand or that miraculous cures have been discovered. To date, these supposed revolutions have proved evanescent and are often the harbinger of distinctly damaging interventions.
The continuing difficulties in understanding and treating the forms of mental illness have to some extent been masked by the great broadening of the problems claimed by the profession and embraced by the public. If our best efforts to treat schizophrenia, bipolar disorder, and melancholia have advanced slowly and fitfully, much of the energy and efforts of psychiatrists and clinical psychologists are now directed elsewhere. Anxiety disorders, the milder forms of depression, panic disorders, the impact of all forms of trauma, eating disorders, and substance abuse have all become the major preoccupations of psychiatric and psychological professionals. Many patients have welcomed this recognition of their troubles and embraced the combination of psychotherapy and medication that emerged to treat them.
For none of these forms of mental distress does psychiatry possess a magic wand, and the ability to treat this heterogeneous collection of disorders successfully varies considerably. Eating disorders and disorders associated with substance abuse and PTSD are particularly, but not completely, resistant to successful interventions.4 But substantial numbers of people who are anxious or depressed do seem to be helped by psychotherapy or by psychotherapy combined with drug treatments.
Anxiety disorders, the apparent incidence of which has spiked in recent decades, provide a useful example of the value and the limits of existing therapeutics. As a recent comprehensive review notes, “Only 60–85% of patients with anxiety disorders respond (experience at least a 50% improvement) to current biological and psychological treatments. In addition, only about half of the responders achieve recovery.… [P]atients with anxiety disorders … have high rates of recurrence and / or experience persistent anxiety symptoms.”5 For the patients who improve, these results are obviously welcome, but the limitations of our current therapies are sobering.
The picture is similar elsewhere. Psychotherapy has been shown to make a real difference in many cases of depression. At the same time, as a recent review in Current Psychiatry Reports notes,
We have to remember that the effects are still modest as are those of antidepressant medication. The majority of patients improve during treatment, but a considerable number of these would also have improved without treatment. Improvement rates without treatment have been estimated to be about a quarter after 3 months and 50% after 1 year. And on the other side of the spectrum, there is a considerable minority of about 30% of patients who do not respond to any treatment.6
There are, of course, a variety of competing sorts of psychotherapy, focused on very different approaches to the disorders they seek to treat. These approaches include cognitive-behavioral therapy, interpersonal therapy, and psychodynamic therapies—time-limited and less-intensive interventions based on psychoanalytic principles—to mention three of the most prominent. One relatively robust finding from evaluation research is that it is hard to differentiate among these techniques when it comes to assessing the degree of improvement they bring about in patients.7 None is a panacea, but almost all seem to provide a measure of relief to a considerable number of patients with less serious forms of mental distress, even when treatment is provided in primary care settings rather than by mental health specialists.
For a brief period toward the close of the twentieth century, the profession persuaded itself that it had found a reliable way to identify those suffering from mental disorder and to divide their pathologies into separate and distinct subtypes. But that assurance is now vanishing. Lacking any biological markers or tests to identify the disorders they claim to treat, psychiatrists have been forced to rely on symptoms and patient self-reports to construct their categories and decide who belongs where. But the diagnostic manuals psychiatrists have created and relied on have become increasingly unwieldy, and the consensus about the categorization of mental illness has threatened to fall apart. Influential voices have dismissed the whole enterprise as fatally flawed, and the legitimacy of the undertaking, and of the profession that relies on it, has come under fire.8
My discussion in the pages that follow will strike many, quite correctly, as a deeply critical account of the psychiatric enterprise. But I hope it is not a wholly unsympathetic one. The puzzles that psychiatry wrestles with are profoundly difficult to resolve, and the desperation of many of those it seeks to treat is unmistakable. That is not to excuse some of the history that follows, but it does provide a crucial context for understanding how desperate remedies for mental illness have so often surfaced, and why they have been so broadly adopted.
ONE OF THE MOST DISTURBING features of the treatment of the mentally ill over the past century and more has been their extraordinary vulnerability to the therapeutic enthusiasms of the profession that purports to help them. Why is that? Psychosis has been presumed to rob patients of their capacity to make informed choices about their treatment. Legally and morally, patients have often been regarded as nonpersons. For much of the twentieth century, those suffering from major mental illnesses were locked up in institutions that deliberately isolated them from their families and from society, adding to their vulnerability. As wards of the state, they represented an enormous economic burden, while their pain and suffering remained immense. The pressures on psychiatrists to do something about conditions they understood poorly, if at all, were correspondingly great, and restraints on the zeal for therapeutic experimentation were largely absent or readily circumvented.
Hence the emergence of a host of dubious interventions aimed at these recalcitrant disorders. To mention only a handful: there were programs to induce fevers by deliberately infecting patients with malaria, by injecting horse serum into spinal canals to induce meningitis, or by placing patients in diathermy machines that broke down the body’s homeostatic mechanism; there was the surgical removal of teeth and tonsils, followed by the evisceration of stomachs, spleens, cervixes, and colons; the use of the newly discovered insulin to create artificial comas that often brought patients to the brink of death; the induction of artificial epileptic seizures, first with drugs, then with electricity passed through the brain; and, most dramatically of all, the severing of brain tissue, either through surgical operations on the frontal lobes or by thrusting an ice pick through the eye socket into the brain—so-called transorbital lobotomies. Virtually all of these were disproportionately visited on women, though the best data we have indicate that mental illness afflicts men and women almost equally. The pattern of disparate treatment is indisputable, however, and I shall both document it and examine why it surfaces repeatedly.
In the middle decades of the twentieth century, Freudian psychoanalysis appeared to provide an alternative treatment for mental disorders, and some psychiatrists claimed that the reach of the talking cure extended even to the major psychoses. But the claimed efficacy of psychoanalysis in cases of serious mental illness proved chimerical, and in the final years of the last century, the Freudian enterprise lost the dominant position it had once held. These days, classical Freudian psychoanalysis survives in only the most vestigial of forms. Its influence can still be traced in some of the many contemporary versions of psychotherapy that seek to treat the kinds of mental distress that Freud sought to engage with: anxiety disorders, mild and moderate depression, somatoform disorders, and other nonpsychotic disorders. In the United States, though, Freudian techniques face severe competition from new approaches with a quite different intellectual lineage.
A national survey of psychiatrists in private practice undertaken in the early 1970s showed a heavy preference in their ranks for psychotherapy when treating their patients. A majority of patient visits were for fifty or fifty-five minutes—the classic analytic hour, and 86 percent of all outpatient encounters lasted forty minutes or more. The survey found that less than 30 percent of patients receiving nonpsychoanalytic care received “chemical treatment,” a category that liberally included the so-called minor tranquilizers such as Valium and Librium. Among patients seeing psychoanalysts, that figure fell to only 14 percent.
For both groups, “chemical [i.e., drug] therapy was usually an adjunct to psychotherapy.”9 By 1996, only 44.4 percent of visits to a psychiatrist’s office involved psychotherapy and by 2005 there had been a further decline to 28.9 percent. By the latter date, only 10.8 percent of psychiatrists routinely offered psychotherapy of any kind to their patients, overwhelmingly to those who paid for their own therapy.10 Conversely, “a large and increasing proportion of mental health outpatients received psychotropic medication without psychotherapy.”11
The incentives driving this process are clear. With the advent of managed care, a practice based on psychopharmacology was far more lucrative, and insurance companies paid less and less for psychotherapy. In substantial measure, this pattern reflected insurers’ endorsement of new forms of therapy developed and popularized by clinical psychologists. These mental health professionals had emerged in competition with psychoanalysis after the Second World War. Their techniques of cognitive-behavioral therapy, for which there appeared to be statistically based evidence of efficacy, were directly aimed at the relief of patients’ symptoms rather than at the more elaborate and open-ended reconstruction of personality that psychoanalysis proclaimed as its mission.
Cognitive-behavioral therapy and its variants have a definitive end point, making them far more attractive to insurance companies than the years-long process psychoanalysts proclaimed was necessary to achieve results. Even more attractive to the proponents of managed care, these therapies could be supplied by psychologists and psychiatric social workers at far lower reimbursement rates than would satisfy most medically trained psychiatrists. Many psychiatrists decided that they could no longer afford to practice psychotherapy on these financial terms, a development given further impetus by the spread of drug company–inspired claims that mental illness was simply brain disease, by the associated shift of academic psychiatry toward biology, and by the availability of psychotropic medications on which to base the treatment of a broad range of mental distress.12
More and more marginalized in a profession they had once dominated, psychoanalysts were left with a niche market, catering to a minority who could afford to pay for their services out of pocket and who remained convinced of the value of long-term talk therapy. Other analysts have tried to adapt to market pressures by providing a shorter and less intensive kind of psychotherapy that nevertheless draws on the psychoanalytic emphasis on affect and the expression of emotion, the relationship of past experience to the present, and the ways that patients knowingly and unknowingly seek to avoid distressing thoughts and feelings. Their comparative advantage, psychoanalysts claim, is that they not only treat symptoms but also have a broader positive influence on a person’s psychological resources and capacities.
In important respects the demise of psychoanalysis as a dominant force in contemporary psychiatry was brought about, directly and indirectly, by the psychopharmacological revolution that began in the early 1950s. The Freudian enterprise survived and apparently thrived until the late 1970s, though, like the gnawing of termites proceeding unnoticed till a structure is fatally compromised, the new drugs and the transformations that flowed from their discovery undermined the supports of psychoanalysis and eventually led to its startlingly rapid collapse.
The psychopharmacological revolution that began in the years after the Second World War has swept all before it. It has transformed psychiatric practice, the image of the profession, and the patient experience. Biology has been reembraced as the source of mental illness and other possible dimensions of mental disorder largely cast aside. It is to faulty brain biochemistry, and perhaps to genetic factors, that we are supposed to look to explain the origins of mental illness, and with its primary reliance on pills, psychiatric practice now more closely resembles much of mainstream medicine. Progress has arrived, it would seem, but whether we really have a better grasp of the etiology of psychosis and whether the lot of the seriously mentally ill has improved markedly since the mid-1950s are matters to which we shall attend.
Families grappling with the suffering and trauma of mental illness mostly embraced a biologized psychiatry that, instead of blaming refrigerator mothers and ineffectual fathers, assured them mental illness was a real physical illness, the product of genetic flaws and biochemical abnormalities in the brain. Politicians anxious to rid themselves of the immense fiscal burden that updating and operating Victorian museums of madness had become rushed to embrace these magic potions that could return mental patients to the tender mercies of the community. But neither the antipsychotics nor the antidepressants were psychiatric penicillin. Though marketed as such by drug companies and many psychiatrists, these drugs were in fact no more than Band-Aids, sources of symptomatic relief that often carried with them a heavy price in side effects. Many patients found taking them to be intolerable: between two-thirds and four-fifths of those in a recent, carefully designed comparative study of antipsychotics’ efficacy refused to continue taking their pills.13
Certainly, for some patients drugs offered a more tolerable existence than had been their previous lot, and that symptomatic relief is important. Nor is psychiatry unique in treating symptoms rather than causes. We should also remember that all general medicine can offer for such diseases as diabetes, Parkinson’s, autoimmune disorders, and AIDS is palliative treatment, and yet no one would doubt the importance and value of those interventions. For many mental patients, though, modern psychiatry’s drugs have proved to be a Faustian bargain, piling serious side effects on top of the mental turmoil from which they already suffer. For a not-insignificant fraction of the patient population, those complications can prove life-threatening.
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? The story he was mulling had no happy ending, as is true of much of our human experience. Nor does the history I examine here have one. Mental illness remains a baffling collection of disorders, many of them resisting our most determined efforts to probe their origins or to relieve the suffering they bring in their train.
The profession to which I (half) belong, sociology, once embraced the foolish and romantic notion that mental illness was simply a matter of labels and exclusionary societal reactions.14 Renegade psychiatrists like Thomas Szasz proclaimed that mental illness was a myth.15 Both stances are profoundly mistaken. They constitute a failure to come to grips with the severe sufferings of so many people and with the intellectual challenges that face those trying to comprehend and ameliorate, let alone solve, the challenges posed by the protean world of unreason. One must hope that, in the future, serious progress will be made. For the present, 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.