Desperate Remedies: Psychiatry’s Turbulent Quest to Cure Mental Illness
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 interven-tions stand out in the starkest relief and because, by the closing de cades of the twentieth century, American psychiatry had achieved a worldwide he-gemony, its categorizations of and approaches to mental illness sweeping all before it. But many of the interventions I examine had their origins in Eu rope, including the drugs that are now so central to psychiatric identity and operations. So Eu ro pean 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 be-long in the domain of the medical profession. More precisely, such mala-dies are seen to be the peculiar province of those whom we now call psy-chiatrists. 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 prob lem 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 in-terventions are not abstractions but rather or ga nized forms of action car-ried 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 institu-tions 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 so-ciety, and in many ways such marginalization persists into the pre sent. 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 re spect to health— both mental and physical— where the cu-mulative disadvantages of poverty and racial prejudices are vividly dem-onstrated by, for example, data concerning maternal mortality and life expectancy.1 Unsurprisingly, when the Office of the US Surgeon General examined mental health ser vices in 2001, it found that racial and ethnic minorities had less access to mental health ser vices than whites and that the care that minorities did receive was more likely to be of poor quality.2 That makes the lack of con temporary research on racial disparities in psy-chiatric treatment even more dismaying. Or ga nized psychiatry has belatedly awoken to the probl em; in January 2021 the American Psychiatric Asso-ciation issued an official “Apology to Black, Indigenous and People of Color for Its Support of Structural Racism in Psychiatry,” following on the for-mation of a task force on the prob lem 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 im mense suffering and often embody threats, both sym-bolic 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 strug gled 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 de cades that fol-lowed. Then, a little less than a half century ago, the hegemony of psycho-dynamic psychiatry rapidly disintegrated, and biological reductionism once again became the ruling orthodoxy. But to date, neither neurosci-ence nor ge ne tics have done much more than offer promissory notes for their claims, as I shall show in l ater 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 va ri-e ties 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 re spects I think the whole de-bate 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 pro-found 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 impor tant to be clear- eyed: not to deny that there has been some pro gress, but equally not to ignore the price that is sometimes paid for such relief as psychiatry can now provide. Peri-odically, as we shall see, enthusiasts have proclaimed that decisive break-throughs 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 prob lems claimed by the profession and embraced by the public. If our best efforts to treat schizo phre nia, bipolar disorder, and melancholia have advanced slowly and fitfully, much of the energy and efforts of psy-chiatrists 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 trou bles and em-braced the combination of psychotherapy and medi cation 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 dis-orders successfully varies considerably. Eating disorders and disorders as-sociated with substance abuse and PTSD are particularly, but not com-pletely, 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 re-cent de cades, provide a useful example of the value and the limits of ex-isting therapeutics. As a recent comprehensive review notes, “Only 60–85% of patients with anxiety disorders respond (experience at least a 50% im-provement) to current biological and psychological treatments. In addi-tion, only about half of the responders achieve recovery. . . . [P]atients with anxiety disorders . . . have high rates of recurrence and / or experi-ence per sis tent anxiety symptoms.”5 For the patients who improve, these results are obviously welcome, but the limitations of our current thera-pies are sobering.
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