Shrinks (5 page)

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.

The purpose of the earliest mental institutions was neither treatment nor cure, but rather the enforced segregation of inmates from society. For most of the eighteenth century, mental disorders were not regarded as illnesses and therefore did not fall within the purview of medicine, any more than the criminal behavior that landed a prisoner in a penitentiary. The mentally ill were considered social deviants or moral misfits suffering divine punishment for some inexcusable transgression.

One man was largely responsible for transforming asylums from prisons into therapeutic institutions of medicine and indirectly giving rise to a professional class of psychiatrists—a Frenchman by the name of Philippe Pinel. Pinel was originally a respected medical writer known for his gripping case studies. Then, in 1783, his life changed.

A close friend of Pinel’s, a law student in Paris, came down with a form of madness that now would most likely be diagnosed as bipolar disorder. On one day the friend was filled with the exuberant conviction that he would soon become the most brilliant attorney in all of France; the next day he would plunge into despondency, begging for an end to his pointless life. Soon he believed that priests were interpreting his gestures and reading his mind. One night he ran off into the woods wearing nothing but a shirt and died from exposure.

This tragedy devastated Pinel and prompted him to devote the rest of his life to mental illness. In particular, he began investigating the operation of asylums, which he had consciously avoided when seeking care for his friend because of their notoriously wretched conditions. Before long, in 1792, he was appointed to head the Paris asylum for insane men at Bicêtre. He immediately used his new position to make major changes and took the unprecedented step of eliminating the noxious treatments of purging, bleeding, and blistering that were routinely used. He subsequently went on to free the inmates from their iron chains at the Parisian Hospice de la Salpêtrière.

Pinel eventually came to believe that the institutional setting itself could have beneficial effects on its patients, if properly managed. The German physician Johann Reil described how to go about establishing one of the new Pinel-style asylums:

One might start by choosing an innocuous name, situate it in a pleasant setting, midst brooks and lakes, hills and fields, with small villas clustered about the administration building. The patient’s body and his quarters were to be kept clean, his diet light, neither spirituous nor high seasoned. A well-timed variety of amusements should be neither too long nor too diverting.

This was a far cry from the bleak prisons for undesirables that constituted most other asylums. This started what became known as the asylum movement in Europe and later spreading to the United States. Pinel was also the first to argue that the routine of the asylum should foster the patients’ sense of stability and self-mastery. Today, most psychiatric inpatient units, including the ones here at the New York Presbyterian Hospital–Columbia University Medical Center, still employ Pinel’s concept of a routine schedule of activities that encourages structure, discipline, and personal hygiene.

After Pinel, the conversion of mental institutions into places of rest and therapy led to the formal establishment of psychiatry as a clearly defined profession. To transform an asylum into an institution of therapeutic humanity rather than of cruel incarceration required doctors who specialized in working with the mentally ill, giving rise to the first common appellation for the psychiatrist:
alienist
.

Alienists were given their nickname because they worked at asylums in rural locales, far removed from the more centrally located hospitals where the alienists’ medical colleagues worked and socialized and tended to physical maladies. This geographical separation of psychiatry from the rest of medicine has persisted into the twenty-first century in a variety of ways; even today, there are still
hospitals
and
mental hospitals
, though fortunately the latter are a dying breed.

Throughout the nineteenth century, the vast majority of psychiatrists were alienists. While the various psychodynamic and biological theories of mental illness were usually proposed and debated in the halls of academia, these ideas for the most part had little impact on the day-to-day work of the alienists. To be an alienist was to be a compassionate caretaker rather than a true doctor, for there was little that could be done to mitigate the psychic torments of their charges (though they did minister to their medical needs as well). All the alienist could hope to accomplish was to keep his patients safe, clean, and well cared for—which was certainly far more than had been done in previous eras. Still, the fact remained that there was not a single effective treatment for mental illness.

As the nineteenth century came to a close, every major medical specialty was progressing by leaps and bounds—except for one. Increasingly intricate anatomical studies of human cadavers produced new details of liver, lung, and heart pathologies—yet there were no anatomical drawings of psychosis. The invention of anesthesia and sterile techniques enabled ever more complex surgeries—but there was no operation for depression. The invention of X-rays allowed physicians the near-magical power to peer inside living bodies—but even Roentgen’s spectacular rays failed to illuminate the hidden stigmata of hysteria.

Psychiatry was exhausted by failure and fragmented into a menagerie of competing theories regarding the basic nature of mental illness. Most psychiatrists were alienists, alienated from both their medical colleagues and the rest of society, keeping watch over inmates who had little hope of recovery. The most prevalent forms of treatment were hypnosis, purges, cold packs, and—most common of all—firm restraints.

Karl Jaspers, a renowned German psychiatrist turned existentialist philosopher, recalled the mood at the turn of the century: “The realization that scientific investigation and therapy were in a state of stagnation was widespread in psychiatric clinics. The large institutions for the mentally ill were more magnificent and hygienic than ever, but despite their size, the best that was possible for their unfortunate inmates was to shape their lives as naturally as possible. When it came to
treating
mental illness, we were basically without hope.”

Nobody had the slightest idea why some patients believed God was talking to them, others believed that God had abandoned them, and still others believed they
were
God. Psychiatrists yearned for someone to lead them out of the wilderness by providing sensible answers to the questions, “What causes mental illness? And how can we treat it?”

A “Project for a Scientific Psychology”

In W. H. Auden’s poem “In Memory of Sigmund Freud,” he writes of the difficulty of understanding Freud through our modern eyes: “He is no more a person now but a whole climate of opinion.” It’s a pretty safe bet that you’ve heard of Freud and know what he looks like; his Edwardian beard, rounded spectacles, and familiar cigar make him the most famous psychiatrist in history. The mention of his name instantly evokes the phrase, “So tell me about your mother.” It’s also quite likely that you have an opinion on the man’s ideas—and, I’d wager, an opinion shading into skepticism, if not outright hostility. Freud is often maligned as a misogynist, a self-important and domineering phony, or a sex-obsessed shrink endlessly probing people’s dreams and fantasies. But, to me, he was a tragic visionary far ahead of his time.