Desperate Remedies: Psychiatry’s Turbulent Quest to Cure Mental Illness, by Andrew Scull (Belknap Press, 512 pp., $35)
Andrew Scull describes his new history of American psychiatry, Desperate Remedies, as a “deeply critical account.” The book recounts in detail many shameful episodes from psychiatry’s past: lobotomy, forced sterilization, “snake pit” levels of neglect, greed, and the fatuous promises of “community care,” among others. But unlike Whiggish histories that play up the badness of the bad old days to make the present appear that much gentler and more enlightened, Scull, a social historian and emeritus professor at the University of California–San Diego, sees modern psychiatry as “a profession facing an existential crisis.” Psychiatry still knows too little about where mental illness comes from and how to cure it. What progress researchers have made has mostly served to undermine the field rather than shore it up. Scull accepts the benefits of drugs and therapy, to a degree, but general physicians and clinical psychologists now share in the administration of these treatments. Scull wants his readers to think probingly about who truly needs psychiatrists, and why.
The term itself, rooted in Greek terms for “soul” and “doctor,” was imported from Germany in the late 1800s. “Psychiatrist” replaced “alienist,” “medico-psychologist” and, most straightforward of all, “asylum superintendent.” Asylum-based care, considered cutting edge in the mid-nineteenth century, became deeply embarrassing when the early promise of “moral treatment” failed. Moral treatment emphasized the therapeutic value of a calming environment separated from the pressures of ordinary life, minimal coercion, and healthy, personal relationships between the asylum head and the patients whose care he supervised. Its spirit lives on in some modern-day residential treatment programs. Moral treatment is feasible only at small scale, though. Tasked with supervising a massive, ever-growing institutionalized population, psychiatrists gained a reputation as “glorified boarding house keepers.” To establish themselves as “members of a healing profession,” psychiatrists had to break out from the asylum.
Scull stresses the degree to which external pressures have shaped psychiatry. “Community psychiatry” supplanted “institutional psychiatry” in part because of professional insecurity. Psychiatrists needed a new model for dealing with mental diseases to keep pace with the advances that mainstream health care was making with other diseases. Fiscal conservatives viewed the practice of confining hundreds of thousands of Americans to long-term commitment as overly expensive, and civil libertarians viewed it as unjust.
Deinstitutionalization began slowly at first, in the 1950s, but the pace accelerated around 1970, despite signs that all was not going according to plan. On the ground, psychiatrists noticed earlier than anyone else that the most obvious question—where are these people going to go when they leave the mental institutions?—had no clear answers. Whatever misgivings psychiatrists voiced over the system’s abandonment of the mentally ill to streets, slums, and jails was too little and too late.
That modern psychiatry is mostly practiced outside of mental institutions is not its only difference from premodern psychiatry. Scull devotes extensive coverage to two equally decisive developments: the rise and fall of Freudianism, and psychopharmacology.
The Freudians normalized therapy in America and provided crucial intellectual support for the idea that mental health care is for everyone, not just the deranged. Around the same time as deinstitutionalization, Freud’s reputation, especially in elite circles, was on a level with Newton and Copernicus. Since then, Freudianism has mostly gone the way of phlogiston and leeches. That happened not just because people decided the psychoanalysts’ approach to therapy didn’t work but also because insurance wouldn’t pay for it. Insurance would, however, pay for modes of therapy that were less open-ended than the “reconstruction of personality that psychoanalysis proclaimed as its mission,” more targeted to a specific psychological symptom, and, most crucially of all, performed by non-M.D.s. Therapy was on the rise, but psychiatrists found themselves doing less and less of it.
As psychiatry cast aside Freudian concepts such as the “refrigerator mother,” which rooted mental illness in psychodynamic tensions, it increasingly trained its focus on biology. Drugs contributed to, and gained a boost from, this reorientation. Scull loathes the drug industry and only grudgingly allows that it has made improvements in the lives of mentally ill Americans. He divides up the vast American drug-taking public into three groups: those for whom they work, those for whom they don’t work, and those for whom they may work, but not enough to counter the unpleasant side effects. He argues that the last two groups are insupportably large.
To apply the word “crisis” meaningfully to a problem, there must be some standard or sense of proportion. Scull believes that psychiatry is in crisis because the most recent generation failed to deliver on its three defining promises: the promise to identify the biological (genetic or neurological) roots of mental illness, the promise to establish a definitive typology of mental illnesses (presented in the Diagnostic and Statistical Manual of Mental Disorders), and the promise to develop an array of effective medications for the mind. Psychiatry’s best and brightest participated in these efforts. Biological research, in particular, benefited from billions in federal funding. Americans, too, take more medication than ever. But decades on, psychiatry doesn’t seem to have much more of a handle on mental illness than when these initiatives launched.
That said, in the case of psychopharmacology, failure to deliver on initial hype may not be the most useful standard. We should also consider, for instance, whether someone with serious mental illness is likelier to live a better life on or off their meds. If we want most of the seriously mentally ill somehow to navigate ordinary society on their own, we can’t simply take their word for it when they insist that they’re better off without medication. At times, it seems like Scull is saying that maybe we should.
Desperate Remedies aims to be solutions-oriented. Scull recommends that psychiatry accept the losses on its “bet on the body” and embrace a hybrid approach that appreciates the social and biological dimensions of mental illness. Whether this would be a good idea depends on whether psychiatry can make this shift without becoming hopelessly politicized. Indeed, this has happened in the past; one reason researchers focused so heavily on biology beginning around 1980 was that the Reagan administration demanded a less activistic orientation than had prevailed in the decades prior.
Psychiatry’s state of crisis, if that’s what it is, affects us all. We can’t expect primary-care doctors and therapists to take the lead on subway pushers and other disturbing “service resistant” cases. Psychiatry’s future may look murky, but it’s even harder to see a future without it.