TThere may not have been good times to be mentally ill in the last 200 years, but there have been some spectacularly bad ones. Having all your teeth pulled to put an end to your “insanity” may seem as extreme as it gets, but if you were unlucky enough to be under the care of Dr. Henry Cotton in the early decades of the 20th century, there was a real risk of that his intestines could follow. If you were a woman, your cervix was also a potential victim. As expected, survival was not guaranteed, no one got better, and the quality of life for those who survived was severely reduced.
Fast-forward a few years, past insulin-induced coma treatment and frequent administration of electric shock therapy (several times a day), and you may also want to avoid Dr. Walter Freeman, who wielded a modified ice pick to lobotomize up to 20 patients in one session. Not surprisingly, perhaps, those who could afford it turned to psychoanalysis, often painful in itself, but in a very different way.
Andrew Scull’s book, which tells the story of mental illness in the US over the past two centuries, is dominated by extremes and hopes. It’s meticulously researched and beautifully written, and even funny at times, despite the harrowing content. This is a story of serious mental illness (schizophrenia, bipolar disorder, severe depression) and there is no happy ending. But there is considerable and diverse effort among psychiatrists to understand causes, discover remedies, and, frankly, make patient management easier.
While each wave of medical professionals seems to think they have achieved these elusive goals, they are largely doomed to disappointment and often disgrace. Sometimes their egos fly much higher than their ideas, but maybe that’s human nature, and maybe it’s necessary. Without ambition and mistakes, we would never achieve much. For some there is an almost frantic hope of success, but it is not always clear whether it is for the benefit of patients or for personal aggrandizement.
The attempt to elucidate the biological underpinnings of mental illness has fueled much of this experimentation. If these could be revealed, then psychiatrists would be real doctors and real cures could be found. But in this context, patients lost to “cutting-edge” treatments, or simply appalling care, hardly seem like people, something Scull is painfully and compassionately aware of. Most of the time they are women and seem to have been considered expendable.
Scull, as a sociologist, is not entirely sympathetic to psychiatry and psychiatrists. He’s fine that he doesn’t forgive them, and as the book draws to a close, he writes passionately about the need for a broader approach, one that encompasses more than the currently dominant biological paradigm. His analysis of prevailing diagnoses and his links to drug treatments is skeptical, but he also acknowledges the vital symptom relief that some medications and modified ECT can provide. He asks for prudence, honesty, humility and, above all, understanding.
This book is an unfinished story, and I would very much like to know what happens in the sequel. What we’ve seen so far is a roller coaster of emotions, with many casualties scattered along the way. It is easy to recoil in horror when reading about the treatment and asylum conditions of the early 20th century, but we judge by our own standards and will be judged by those of the future. Mental illness is something we all fear, in ourselves and others, and those who experience it are often powerless in their interactions with specialists. One hopes that we are showing more kindness now than in the past, but Scull is right that we have a long way to go.