Shrinks

by Jeffrey A. Lieberman

  Elena had responded to her initial treatment well, and I believe that had she continued with the prescribed aftercare plan, she too would have had a good recovery and resumed her education and previous lifestyle.

  But if I can be so confident about Abbey and Elena’s diagnoses now, then why did psychiatrists stumble so egregiously in the past? To answer this, we must travel back more than two centuries, to psychiatry’s origins as a distinct discipline of medicine. Because from the very moment of its birth, psychiatry has been a strange and wayward offspring: the stepchild of medicine.

  A Medicine of the Soul

  Since ancient times, physicians have known that the brain was the seat of thought and feeling. Any toga-clad medico could have told you that if the grayish-pink stuffing packed inside your skull was roughly thumped, as it often was in battle, you might go blind, talk funny, or drift into the comatose land of Morpheus. But in the nineteenth century, medical science in European universities began to combine the careful observation of a patient’s abnormal behavior with refined autopsy dissections of their bodies after they died. Physicians peering through microscopes at brain sections and tissue of expired patients discovered, to their surprise, that mental disorders appeared to fall into two distinct categories.

  The first category consisted of conditions where there was visible damage to the brain. While studying the brains of individuals who had suffered from dementia, doctors noticed that some looked smaller and were dotted with dark clumps of protein. Other physicians observed that patients who had abruptly lost movement in their limbs often had bulging blockages or ruddy stains in their brains (from strokes); on other occasions, glistening pink tumors were unearthed. The French anatomist Paul Broca analyzed the brains of two men with a combined spoken vocabulary of less than seven words (one man was named “Tan” because he relied on that single word for all of his communication). Broca discovered that each man had suffered a stroke in precisely the same location on the left frontal lobe. Gradually, many disorders became associated with readily identifiable “pathological signatures,” including Parkinson’s, Alzheimer’s, Pick’s, and Huntington’s diseases.

  Yet, when analyzing the brains of patients who had suffered from other kinds of mental disturbances, physicians failed to detect any physical abnormalities. No lesions, no neural anomalies—the brains of these patients had no features that distinguished them from the brains of individuals who never evinced behavioral dysfunction. These mysterious conditions formed the second category of mental disorders: psychoses, manias, phobias, melancholia, obsessions, and hysteria.

  The discovery that some mental disorders had a recognizable biological basis—while others did not—led to the establishment of two distinct disciplines. Physicians who specialized exclusively in disorders with an observable neural stamp became known as neurologists. Those who dealt with the invisible disorders of the mind became known as psychiatrists. Thus, psychiatry originated as a medical specialty that took as its province a set of maladies that, by their very definition, had no identifiable physical cause. Appropriately, the term “psychiatry”—coined by the German physician Johann Christian Reil in 1808—literally means “medical treatment of the soul.”

  With a metaphysical entity as its subject and raison d’être, psychiatry swiftly became a fertile ground for grifters and pseudoscientists. Imagine, for instance, if cardiology split into two distinct specialties: the “cardiologists” who dealt with the physical problems of the heart and the “spiritologists” who dealt with the nonphysical problems of the heart. Which specialty would be more vulnerable to fanciful theories and fraud?

  Like the Bering Strait, the schism between the neurological brain and the psychiatric soul separated two continents of medical practice. Again and again over the next two centuries, psychiatrists would declare fraternity and equality with their neurological counterparts across the border, then just as abruptly proclaim liberty from them, insisting that the ineffable mind was the field of greater truth.

  One of the earliest physicians who sought to explain and treat mental disorders was a German named Franz Anton Mesmer. In the 1770s he rejected the prevailing religious and moral accounts of mental illness in favor of a physiological explanation, making him arguably the world’s first psychiatrist. Unfortunately, the physiological explanation he put forth was that mental illness could be traced to “animal magnetism”—invisible energy coursing through thousands of magnetic channels in our bodies—as could many medical illnesses.

  Now, our modern minds might instinctively visualize these magnetic channels as networks of neurons with bioelectric impulses charging from synapse to synapse, but the discovery of neurons, let alone synapses, was still far off in the future. In Mesmer’s time the notion of animal magnetism seemed as unfathomable and futuristic as if CNN announced today that we could now instantly travel from New York to Beijing using a teleportation machine.

  Mesmer believed that mental illness was caused by obstructions to the flow of this animal magnetism, a theory eerily similar to the one Wilhelm Reich would espouse a century and a half later. Health was restored, claimed Mesmer, by removing these obstructions. When Nature failed to do this spontaneously, a patient could benefit from coming into contact with a potent conductor of animal magnetism—such as Mesmer himself.

  By touching patients in the right places and in the right way—a pinch here, a caress there, some whispering in the ear—Mesmer claimed he could restore the proper flow of magnetic energy in their bodies. This therapeutic process was meant to produce what Mesmer referred to as a “crisis.” The term seems appropriate. Curing an insane person, for example, required inducing a fit of unhinged madness. Curing a depressed person, one had to first render him suicidal. While this might seem counterintuitive to the minds of the uninitiated, Mesmer declared that his mastery of magnetic therapy allowed these induced crises to unfold under his control and without danger to the patient.

  Here’s a 1779 account of Mesmer treating an army surgeon for kidney stones:

  After several turns around the room, Mr. Mesmer unbuttoned the patient’s shirt and, moving back somewhat, placed his finger against the part affected. My friend felt a tickling pain. Mr. Mesmer then moved his finger perpendicularly across his abdomen and chest, and the pain followed the finger exactly. He then asked the patient to extend his index finger and pointed his own finger toward it at a distance of three or four steps, whereupon my friend felt an electric tingling at the tip of his finger, which penetrated the whole finger toward the palm. Mesmer then seated him near the piano; he had hardly begun to play when my friend was affected emotionally, trembled, lost his breath, changed color, and felt pulled toward the floor. In this state of anxiety, Mr. Mesmer placed him on a couch so that he was in less danger of falling, and he brought in a maid who he said was antimagnetic. When her hand approached my friend’s chest, everything stopped with lightning speed, and my colleague touched and examined his stomach with astonishment. The sharp pain had suddenly ceased. Mr. Mesmer told us that a dog or a cat would have stopped the pain as well as the maid did.

  Word of Mesmer’s talent spread across Europe after he performed several remarkable “cures” using his powers of magnetism, such as restoring the sight of Miss Franziska Oesterlin, a friend of the Mozart family. Mesmer was even invited to give his opinion before the Bavarian Academy of Sciences and Humanities on the exorcisms carried out by a Catholic priest named Johann Joseph Gassner—a remarkable moment of irony, as one self-deluded faith healer was called upon to make sense of the methods of another. Mesmer rose to the occasion by proclaiming that while Gassner was sincere in his religious convictions and his exorcisms were indeed effective, they only worked because the priest possessed a high degree of animal magnetism.

  Eventually, Mesmer made his way to Paris, where the egalitarian physician treated both wealthy aristocrats and commoners with his self-proclaimed powers of animal magnetism. As Mesmer’s fame continued to grow, King Louis XVI appointed a scientific
committee that included the visiting American scientist and diplomat Benjamin Franklin to investigate animal magnetism. The committee ultimately published a report debunking the methods of Mesmer and other practitioners of animal magnetism as nothing more than the power of imagination, though Franklin astutely observed, “Some think it will put an End to Mesmerism. But there is a wonderful deal of Credulity in the World, and Deceptions as absurd, have supported themselves for Ages.”

  There is strong evidence that Mesmer really did believe in the existence of preternatural magnetic channels. When he became ill and lay on his deathbed, he waved off physicians and repeatedly attempted to cure himself using animal magnetism—to no avail. He perished in 1815.

  Though Mesmer’s fantastical theory did not survive into the twentieth century, he was a psychiatric trailblazer in one important respect. Before Mesmer, mental illness was widely believed by physicians to have moral origins—according to this view, the deranged had chosen to behave in a disreputable, beastly manner, or at the very least, they were now paying the piper for some earlier sin. Another common medical view was that lunatics were born crazy, designed that way by the hand of Nature or God, and that therefore there was no hope of treating them.

  In contrast, Mesmer’s peculiar theory of invisible processes was actually quite liberating. He rejected both the deterministic idea that certain individuals were born with mental illness wired into their brains, and the sanctimonious notion that mental illness signaled some kind of moral degeneracy, suggesting instead that it was the consequence of disrupted physiological mechanisms that could be treated medically. The psychiatrist and medical historian Henri Ellenberger considers Mesmer the very first psychodynamic psychiatrist, a physician who conceptualizes mental illness as resulting from inner psychic processes.

  For a psychodynamic psychiatrist, the mind is more important than the brain, and psychology more relevant than biology. Psychodynamic approaches to mental illness would heavily influence European psychiatry and eventually come to form the central doctrine of American psychiatry. In fact, psychiatry would swing back and forth for the next two centuries between psychodynamic conceptions of mental illness and their intellectual opposite: biological conceptions of mental illness, holding that disorders arise from disruptions to the physiological operations of the brain.

  After Mesmer, the first generation of physicians to embrace the term “psychiatrist” sought out other occult processes of the mind. Sometimes known as Naturalphilosophes, these early psychiatrists borrowed ideas from the Romantic movement in European arts and literature and pursued the irrational and covert forces in human nature, often believing in the power of a transcendent spirit and the inherent value of emotions. They rejected scientific experiments and direct clinical experience in favor of intuition and did not always draw a sharp line between mental illness and mental health. They often viewed madness as the result of a normal mind surrendering to the passionate and turbulent forces of the immortal soul.

  The height of Romantic thought in early psychiatry found expression in the 1845 German textbook Principles of Medical Psychology, penned by a physician-poet-philosopher named Ernst von Feuchtersleben, who believed that “all branches of human research and knowledge are naturally blended with each other.” Feuchtersleben’s book was in such high demand that the publisher recalled the advance reading copies given free to universities and physicians so that they could be transferred to booksellers.

  As you can imagine, a psychiatry of intuition and poetry did little to relieve the suffering of individuals assaulted by inner voices or immobilized by depression. Gradually, physicians came to recognize that focusing on unobservable processes shrouded within a nebulous “Mind” did not produce lasting change, or any change at all in patients with severe disorders. After decades of sailing through the foggy seas of psychic philosophizing, a new cohort of psychiatrists began to realize that this approach was steadily leading to their intellectual estrangement from the rest of medicine. These reactionary physicians condemned, often in harsh tones, the psychodynamic psychiatry of the Romanticists, accusing the Naturalphilosophes of “losing touch completely with practical life” as they plunged “into the mystico-transcendental realms of speculation.”

  By the mid-nineteenth century, a new generation of psychiatrists valiantly attempted to bridge the growing chasm between psychiatry and its increasingly respectable Siamese twin, neurology. This was the first wave of biological psychiatry, grounded in the conviction that mental illness was attributable to identifiable physical abnormalities in the brain. This movement was led by a German psychiatrist named Wilhelm Griesinger, who confidently declared that “all poetical and ideal conceptions of insanity are of the smallest value.” Griesinger had been trained as a physician-scientist under the respected German pathologist Johann Schönlein, who was famous for establishing the scientific credibility of internal medicine by insisting that diagnoses should rely on two concrete pieces of data: (1) the physical exam and (2) laboratory analyses of bodily fluids and tissues.

  Griesinger tried to establish the same empirical basis for psychiatric diagnosis. He systematically catalogued the symptoms of the inmates at mental asylums and then conducted pathological analyses of the inmates’ brains after they died. He used this research to establish laboratory tests that could be performed on living patients, and crafted a structured interview and physical exam that could be used in conjunction with the laboratory tests to diagnose mental illness—or at least, that’s what he hoped to achieve.

  In 1867, in the first issue of his new journal, Archives of Psychiatry and Nervous Disease, Griesinger proclaimed, “Psychiatry has undergone a transformation in its relationship to the rest of medicine. This transformation rests principally on the realization that patients with so-called ‘mental illnesses’ are really individuals with illnesses of the nerves and brain. Psychiatry must therefore emerge from its closed off status as a guild to be an integral part of general medicine accessible to all medical circles.”

  This declaration of the principles of biological psychiatry inspired a new contingent of psychiatric pioneers who believed that the key to mental illness did not lie within an ethereal soul or imperceptible magnetic channels but inside the soft, wet folds of tissue in the brain. Their work gave rise to an enormous number of studies that relied heavily on the microscopic examination of postmortem brains. Psychiatrists trained in anatomy linked brain pathology to clinical disorders. (Alois Alzheimer, who identified the signature “senile plaques and neurofibrillary tangles” of the eponymous dementia, was a psychiatrist.) New brain-based theories were formulated, such as the proposal that mental disorders like hysteria, mania, and psychosis were caused by overexcited neurons.

  Given these developments, you might have thought that the biological psychiatrists had finally positioned their profession on solid scientific ground. After all, there must be some discernible basis for mental illness in the brain itself, right? Alas, the research of the first generation of biological psychiatrists fizzled out like a Roman candle that soars into the sky without detonating. Despite making important contributions to neurology, none of the nineteenth-century biological theories of and research on mental illness ever found physical evidence to support them (other than the signature pathology of Alzheimer’s disease), none led to eventual psychiatric breakthroughs, and none ultimately proved correct. No matter how carefully the biological psychiatrists pored over the fissures, gyri, and lobes of the brain, no matter how assiduously they scrutinized the slides of neural tissue, they could not find any specific and consistent aberrations indicative of mental illness.

  Despite Griesinger’s noble intentions, a reader of his Archives of Psychiatry and Nervous Disease would have no better understanding of mental illness than a reader of Mesmer’s “Dissertation on the Discovery of Animal Magnetism.” Whether you posited magnetic channels, a Universal Soul, or overexcited neurons as the source of mental illness, in the 1880s you would find precisely the same amount of
empirical evidence to support your contention: none. Though brain research vaulted many nineteenth-century physicians into professorships, it produced no profound discoveries or effective therapies to alleviate the ravages of mental illness.

  As the year 1900 fast approached, the conceptual pendulum began to swing again. Psychiatrists grew frustrated with the fruitless efforts of their biologically minded colleagues. One prominent physician dismissed biological psychiatry as “brain mythology,” while the great German psychiatrist Emil Kraepelin (to whom we will return later) labeled it “speculative anatomy.” Unable to find a biological basis for the illnesses within its province, psychiatry became ever more scientifically estranged from the rest of medicine. As if that wasn’t bad enough, psychiatry had also become geographically estranged from the rest of medicine.

  Caretakers for the Insane

  Until the nineteenth century, the severely mentally ill could be found in one of two places, depending on their family’s means. If the patient’s parents or spouse had the good fortune to be a member of the privileged class, care could be administered at the family estate. Perhaps the patient could even be tucked away in the attic, like Mr. Rochester’s mad wife in Jane Eyre, so that the affliction could be hidden from the community. But if the unfortunate soul came from a working-class family—or possessed heartless relatives—he would usually end up a homeless vagrant or in a residence of a very different sort: the asylum.

  Every document of the era recording conditions inside pre-Enlightenment asylums makes them out to be wretched, filthy, teeming dungeons. (Horrific depictions of asylums would continue for the better part of the next two centuries, forming one of the most prominent themes of psychiatry and serving as endless fodder for journalistic exposés and causes for civil rights activism.) Inmates could expect to be chained, whipped, beaten with sticks, submerged in freezing water, or simply locked up in a cold, tiny cell for weeks at a time. On Sundays, they would often be displayed as freakish marvels before a gasping and taunting public.