There’s something missing about mental illness — overhyped, maybe
In an age of glowing brain scans and plentiful pharmaceuticals, it can be hard to remember that psychiatrists — not exactly known for their aversion to dispensing medication — were once derided for not taking medicine seriously enough.
But as Anne Harrington reminds us, it wasn’t all that long ago when psychiatrists were pilloried as a bunch of woolly Freudians in thrall to specious ideas about absent fathers and smothering mothers. (Or absent mothers — there were apparently any number of ways for mothers to impair the mental health of their children.) In her new book, “Mind Fixers: Psychiatry’s Troubled Search for the Biology of Mental Illness,” Harrington, a historian of science at Harvard, says that psychiatry’s biological turn took place sometime around 1980, and it was so revolutionary that before the decade was up, the profession’s “transformation into a biological discipline seemed complete.”
There’s a good deal of drama contained in that little word “seemed.” What “seemed complete” actually wasn’t, Harrington argues, as such biological triumphalism began to unravel in the 1990s and the 2000s. Anticipated discoveries in the biology of mental illness, vigorously hyped before they even arrived, never panned out; all of psychiatry’s diagnostic categories are still based on observations of clinical symptoms rather than biological markers of disease. Criticism from outside the profession precipitated “a sense of internal crisis” within it. A number of psychiatry’s practitioners are beginning to concede that “it overreached, overpromised, overdiagnosed, overmedicated and compromised its principles.”
This realization won’t necessarily put an end to what Harrington calls “the century-long — if also repeatedly frustrated — effort on the part of especially American psychiatry to define a biological mission for itself.” The potential rewards are too great. Biology is supposed to offer rigor, precision, measurements — enticing possibilities when it comes to something as nebulous and complex as the mind.
The story Harrington tells is one of push-and-pull, back-and-forth. She starts by presenting the myth she wants to dismantle — the heroic tale of biology’s triumph in the 1980s over a half-century of vulgar Freudianism. The clean lines of that cartoonish tale are easy to delineate. The case Harrington makes to rebut it is more intricate and winding, though her prose remains clear and crisp. Several times she alerts the reader to narrative road bumps by slipping in an “ironically.” I was grateful for these signposts. It turns out that psychiatry’s understanding of mental illness is full of hairpin turns and unintended consequences.
To hear the vanguard of psychiatry’s biological revolution tell it, the late 19th century was a period of incredible scientific progress for the profession, interrupted only when Freud and his acolytes took over in a palace coup. But the nostalgia obscures why psychiatry became vulnerable to a Freudian incursion in the first place. The 19th-century way of “thinking biologically,” Harrington writes, was fixated not on biochemistry but on brain anatomy. When it came to the prospect of individual recovery from mental disorders, clinicians were fatalistic rather than hopeful. They were preoccupied with “degeneration” and drawn to eugenics.
In the United States, “feeblemindedness” became a catchall diagnosis deployed by advocates of forced sterilization. Oliver Wendell Holmes Jr., writing the Supreme Court’s majority opinion for Buck v. Bell in 1927, called the eugenicist program “better for all the world” because, as he put it, “three generations of imbeciles are enough.” Six years later, the Nazis cited the Buck v. Bell decision as an inspiration for their own sterilization program — which in turn laid the foundations for the Third Reich’s systematic murder of those deemed genetically tainted and mentally ill.
Harrington is unsparing in her depiction of what often resembled a biological fetishism. Schizophrenic patients were subjected to insulin-induced comas or had their brains scraped by lobotomies. Some therapeutically-minded psychiatrists, so impressed by the germ theory of disease, believed that psychosis could be cured by the surgical excision of “infected” organs like teeth, ovaries and colons.
Psychoanalysis and talk therapy were supposed to be antidotes to such cruelty and coarse reductionism, and by broadening psychiatry’s concerns from mental illness to the larger category of “mental hygiene,” the profession could serve a social function, too. In the postwar United States, robust mental health was seen as necessary armor for the Cold War. “The greatest prerequisite for peace,” President Truman said in statement to the American Psychiatric Association, “must be sanity.” Neo-Freudian psychiatrists warned about bad moms who coddled their sons and thereby weakened national efforts to fight the Communist menace.
One pattern you begin to notice in “Mind Fixers” is how psychiatric theories — whether biological or psychoanalytical — had a way of grafting themselves onto prevailing prejudices of the day. Another pattern has to do with how each approach prided itself on being more compassionate and less stigmatizing than whatever had come before. Psychoanalysis might have emerged in reaction to biological psychiatry, but once the postwar psychoanalytic dispensation created “a generation of scapegoated parents” who had been blamed for their children’s mental illnesses, Harrington writes, the biological revolution of the 1980s started to look like a “road to redemption.”
We know what happened after that. Psychiatrists, seeking to distinguish themselves from other mental health professionals, moved away from talk therapy and guarded their prescribing rights. Financial incentives provided by the pharmaceutical industry meant that psychiatrists helped drug companies repurpose old medications for new illnesses, like “social anxiety disorder.” Antipsychotics would no longer be limited to schizophrenic patients; as one drug company researcher said, “It’s not like we’re making any more schizophrenic brains.” It was the medical equivalent of mission creep.
Harrington doesn’t romanticize the world of mental illness before drugs — drugs that many patients credit with offering relief and even a chance at survival. What psychiatry needs to do, she says, is narrow its focus to the most severe forms of mental illness and “make a virtue of modesty” rather than hubris. She knows it’s a somewhat fanciful idea, but it’s a measure of her own cleareyed approach that she appeals to psychiatric practitioners’ self-interest by invoking that most valuable and (these days) elusive currency: trust. “The field would be freed,” she writes, “to find ways to rest its authority and status on more authentic foundations.”