[content note: psychiatric abuse]
A History of Psychiatry: From the Era of the Asylum to the Age of Prozac is essentially what it says in the title. It’s a psychiatrist-focused history of psychiatry, which is good for me, because as a mentally ill person I tend to be focused on the patient side of things.
Still, there are some odd oversights. A History of Psychiatry repeatedly describes patients fleeing doctors trying to inject a particular medication, but doesn’t seem to consider the possibility that the doctors shouldn’t have injected them with it. The author criticizes deinstitutionalization because psychotic people could stop taking their medications if they hate the side effects, without considering that discontinuing medication might be the right choice. Most people are allowed to stop taking their meds if they don’t like the side effects! If they’re on antipsychotics, presumably they are in touch enough with consensus reality to make an informed choice!
The discussion of deinstitutionalization was brief and shallow. It read as if the author had not read the previous chapters where he discussed how institutions routinely committed human rights abuses. For a more nuanced discussion of deinstitutionalization from a psychiatrist, I recommend Claim 10 in Scott Alexander’s review of San Fransicko.
The author also had a lot of axes to grind: Foucauldians, anti-psychiatry advocates, Freudians. As someone who is against both Freud and Szasz, A History of Psychiatry had a pleasant tendency to confirm all of my biases. Still, I haven’t fact-checked A History of Psychiatry, and I’d take a lot of the information in it with a grain of salt; people with axes to grind tend to misrepresent the evidence.
I found it really fascinating to get a psychiatrist’s-eye view of asylums, since (as I said above) I usually have a patients’ view of them. The modern asylum began out of the best Enlightenment-era idealism. Given that they couldn’t actually treat psychosis, the treatments suggested by the people who invented asylums were… fine? The asylum should be a calming, pretty place where the patients were kept busy, and the doctor should be kind and empathetic to them and listen to them about their problems. Seems fine. Probably helpful in a lot of cases!
Actual asylums were not like that.
The primary reason was that there were always too many patients. A small staff can do activities and empathy for thirty people; they really can’t do it for three hundred, much less three thousand. At some point your goal is to keep them warehoused and fed. The asylums were overcrowded for three basic reasons:
First, people learned that asylums existed and then pu their mentally ill relatives in them. In some cases, the mentally ill person was worse off; in some cases, they were probably better off, because at least they weren’t being chained in their own feces. Relatedly, reformists wanted to put people in asylums where they can get treatment, instead of workhouses or prisons that just warehoused them, which was a nice thought at least.
Second, there was alcohol-induced psychosis caused by the nineteenth-century rise in alcoholism.
Third, neurosyphilis was incredibly common in the nineteenth century. Five to twenty percent of the population had syphilis, which meant that between 0.25% and 1% of the population had neurosyphilis. A huge percentage of mentally ill people had syphilis. Incidentally, this explains a lot of the “jerking off sends you to the asylum” stuff we make fun of. Psychiatrists didn’t know that neurosyphilis was caused by an STI, but they observed that sexually libertine people who had extramarital sex were much more likely to become psychotic. From this, they conclude that extramarital sex and masturbation cause psychosis. It’s actually a not unreasonable extrapolation from the evidence they had! I love it when history makes sense.
Compounding the problem, “warehouse mentally ill people you can’t help” is an extremely depressing job. Most people, looking at that job, are going to decide to go into cardiology or something, where they can actually make people better sometimes. Therefore, at a certain point, essentially all doctors who worked in asylums were:
Too bad at medicine to qualify for a different job
Lazy and in search of a job where none of the patients can complain if you fail to do anything
Both
Which made the problem way worse.
Incidentally, this is why psychoanalysis exploded in popularity in the early twentieth century! Like I said above, any reasonable psychiatrist would not want to work in an asylum. Psychoanalysis meant that you could charge very high fees to listen to depressed middle-class people talk about their sex lives. You made more money and worked with much less obnoxious patients and maybe could actually help: what wasn’t to like about it? Many psychoanalysts even said that psychotic people couldn’t be helped with psychoanalysis, because psychotic people didn’t have the necessary insight to solve their problems; therefore, it was totally fine that psychoanalysts were ignoring psychotic people in order to concentrate on people with smaller problems.
One thing that’s very striking about the early history of psychiatry is how desperate many psychiatrists were to fix anyone. “We can… give them malaria? We can… put them in comas with barbiturates? We can… deliberately induce seizures?” (Weirdly, all of those worked—high fevers treat neurosyphilis, and both comas and seizures improve mental illness by turning the brain off and turning it back on again. Eventually, ‘deliberately induce a seizure’ became electroconvulsive therapy.) If you were one of the handful of people who had both a brain and a conscience and went into working in an asylum, you were really incredibly desperate to do anything that might help.
Antipsychotics are dangerous medications. Anyone who’s been around severely mentally ill people has their own horror stories of antipsychotics ruining people’s lives, sometimes for years. But I think it’s incomplete not to mention that antipsychotics gave a lot of people their lives back. The invention of thorazine was the first time psychiatrists could actually help people without putting them in a barbiturate coma or giving them dangerous diseases. It is difficult for me to imagine the sense of hope and relief any empathetic psychiatrist would experience after the invention of thorazine.
Incidentally, lithium’s effect on mania was discovered in 1949. The FDA approved it for the treatment of mania in 1970. I think this should be everyone’s new favorite story about the evils of the FDA.
A History of Psychiatry: From the Era of the Asylum to the Age of Prozac, by Edward Shorter. Published 1998. 448 pages. $27.00.
Ezra Klein's interview with Thomas Insel covers some of the same area and talks a bit more about deinstitutionalisation. Transcript: https://www.nytimes.com/2022/07/22/opinion/ezra-klein-podcast-thomas-insel.html?showTranscript=1