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Three Centuries of Psychiatry
Just about every aspect of psychiatry is controversial, and the history of the field is no exception. Part of the job of historians of psychiatry is to detail cases of "healers" in the past engaged in irresponsible or self-serving behavior, but the controversy goes deeper than that. There is disagreement even about how to tell the story of psychiatry. Edward Shorter suggests that this is because some historians have fitted the facts to their political agendas. In contrast, as we might expect, Shorter represents himself as speaking the plain truth. He doesn't have any fancy theory that he is trying to push on his readers, or so he claims.
In broad outline, Shorter's version of psychiatry's history is this: for hundreds of years the mad were treated very badly. Then, at the start of the eighteenth century, psychiatry was born, and gradually more care was given to those with mental illness. As the understanding of the brain started to increase, some successful treatments were developed, along with a large number of unsuccessful treatments. Psychiatry took a wrong turn with the development of psychoanalysis in the first half of this century, but eventually it returned to the straight and narrow with the advancements in neuroscience in the second half. Now, with the increasing sophistication of psychopharmacology, we are more able than ever to treat major mental illness. But the tendency of psychiatry to follow fashions and the current trend of turning every quirk of human behavior into a psychiatric disorder are alarming.
Doubtless those who disagree with Shorter's version of psychiatric history will dispute his claim that he is presenting neutral truth. I have some doubts about his claim myself, which I will set out in a moment. But first I should emphasize how good it is to have this book available as a resource. As he points out in his preface, it is 30 or 40 years ago since anyone attempted a book-length overview of the discipline. The old histories are dated in their style and often slanted in their organization, especially if they were written by a psychoanalytically-inclined historian. I am not a professional historian, although after a decade of studying issues in psychology, I have picked up an eclectic knowledge of historical facts. When in the past I have wanted to find out some details of the history of psychiatry, it has been a rather frustrating process, rooting through numerous old general histories or recent specialized books and articles. It has been like putting together a puzzle, finding different small pieces and trying to fit them together. The task of researching the basic history of psychiatry will now be easier. I can start with Shorter's book, and move on from there. Shorter writes well and the 327 pages of text go by quickly. He expresses some strong opinions, some of which are questionable, but his forthright yet casual style helps to draw in the reader. The sprinkling of portraits and photographs throughout the book also helps.
Shorter's book can only be a starting point though, and it would be rash to take it as authoritative. This is partly due to the limitations of space imposed by the ambition of the project, but it is also because Shorter espouses immoderate opinions. In the few areas where I already had some knowledge of the subject, I was surprised by some of his claims. For instance, he pours derision on the nineteenth century French scientist, Jean-Martin Charcot. Shorter says that Charcot "understood almost nothing of major psychiatric illness," (84) and was "quite lacking in common sense and grandiosely sure of his own judgment" (86). He explains that Charcot had a reputation as one of the great figures in psychiatry for his discoveries linking changes in the brain to behavioral changes due to neuropathology. This gave him enormous influence, so that when he proposed his theory of organic hysteria, he was taken very seriously. Charcot had an "obsession" with hysteria (148). Once he died, his whole theory of hysteria collapsed. Shorter's tone leaves us with the impression that Charcot's reputation was not deserved, and that he ultimately had an unhealthy influence on psychiatry. Shorter does not really tell us what was so unreasonable about Charcot's theory. Some of the best scientists have had spectacular failures, but that need not reduce our respect for the scientists or even their failed ideas, so we are left wondering why is Charcot's prestigious reputation so ill-deserved?
Another example of Shorter's derision is his treatment of Adolf Meyer. Meyer is now rarely mentioned in psychiatry, but he was one of the most important figures in early twentieth-century American psychiatry. Meyer was Swiss by birth, and trained in several European countries before coming to the US in 1892. The photo of Meyer in the book is rather bizarre, with him sitting on a bench in a garden, in a three-piece dark suit, legs crossed, with his hands lightly holding a small terrier dog perched on his leg. Meyer seems to be eyeing the dog with some mixture of fear and affection. Under the photo, the caption says that Meyer "indiscriminately advocated all forms of psychiatry thinking from the biological to the psychoanalytic" (110). In the text he Meyer is called "a second-rate thinker and a verbose writer," and he was never able "to disentangle schools that were absolutely incompatible, and ended up embracing whatever new came along" (111).
It is true that Meyer's writing is inelegant and sometimes obscure, but Shorter's evaluation misses Meyer's valuable and lasting contribution to psychiatry. In the early years of this century there were two main ways of thinking about mental illness. Either it was a brain disorder, or else it was a reaction to environmental changes. The former, biological, model was especially prominent in Germany. The latter, psychodynamic, model had its most prominent advocate in Sigmund Freud. All sorts of variant theories were being proposed by other scientists. In short, psychiatry lacked a dominant paradigm, and had not coalesced into a period of normal science, to use Thomas Kuhn's terminology. This presented clinicians with a difficult problem -- how to treat the patients? Different models suggested different, incompatible, treatments. Meyer's solution was to take an all-embracing approach, ready to see the good in each theory. At the same time, Meyer emphasized that no one theory could possibly deliver the whole truth. One of his reasons for thinking this was based on the uniqueness of each person, with his or her own personal life-history. Meyer advocated a skeptical attitude toward psychiatric theory and diagnosis. This seems a healthier approach than strictly adhering to one particular theory and sticking to it no matter what. Meyer had a powerfully beneficial effect on American psychiatry, especially through his influence on psychiatric training.
The current predicament of psychiatry is in many ways similar to how it was one hundred years ago. There is still deep divergence among theorists, and clinicians are still in the position of having to decide how best to treat patients. It seems that the eclectic approach championed by Meyer still makes a lot of sense, and it is certainly used by many therapists today. Thus Shorter's dismissal of Meyer seems glib and unthoughtful. This leads me to wonder, if Shorter's judgment is questionable in these cases where I have some knowledge, how trustworthy is it where I only have his word to go by?
The Future of Psychiatry
If one were going to try to label Shorter as having a preference for one approach in psychiatry, it would be biological psychiatry. This is clear in his treatment of Freud. Although he does not ridicule psychoanalysis as much as some, he does call it an interruption of the progress of psychiatry, and the legion of Friends of Freud will surely take him to task for such disrespect. While we should not underestimate the importance of that controversy, it is rather tired at this stage. So I will pass it by, and move on to the issues in his final chapter.
Shorter's predilection for biological psychiatry is maybe clearest here. For instance, in discussing the creation of the category of attention deficit disorder (ADD), he says, "It is still unclear whether there is some core group of those diagnosed as "ADD" who have a real organic disorder" (290). Implicitly, at least, Shorter seems to be equating the reality of mental illness with its being biologically identifiable. It is not surprising then that he is so suspicious of the rise in the numbers of kinds of disorders, people with those disorders, and people seeking psychotherapy or psychopharmacology even though they don't have any diagnosable disorder. Some have welcomed the growth of clinical psychology because they see it as our finally coming to appreciate and treat the suffering that so many people experience. But Shorter sees it differently, as dangerously trivializing psychiatry, and taking it away from its true position as a branch of medicine.
The causes for this trend for the expansion of the domain of psychiatry, suggests Shorter, are the public demand for it and the readiness of the mental health profession was happy to oblige, since it thought it would help sustain the existence of the profession. It turned out though, that the role of psychotherapist was taken away from psychiatrists as it is increasingly performed by psychiatric social workers and others without medical degrees. Psychiatry has begun to lose its way, complains Shorter, and he says it would have been better off "remaining on the high road of science" (295). The recent history of psychiatry has left it hostage to internal politics, social movements and fashion, despite the remarkable progress of neuroscience and psychopharmacology.
Shorter's wish for psychiatry, then, is that it should rise above the elements that are dragging it down. Presumably he sees the goal that psychiatry enter a phase of normal science as within reach, when it will be dominated by one paradigm rather than suffering from a profusion of different views. After a long adolescence, it should now settle down into adulthood, as the rest of medicine has already done. This vision for psychiatry's future has its attractions, but I have doubts both about the its feasibility and its ultimate desirability. The history of psychiatry shows how contested it is, and its subject matter seems to guarantee that it will remain so. The motives and justification of human behavior will always be disputable, no matter how much information we have about the brain. It is practically inevitable, as long as there continues to be debate about morality and politics, there will be debate about psychiatric judgments, because issues in psychiatry so are strongly enmeshed with moral and political issues. Recent controversies about alcoholism, drug addiction, psychotropic drugs, CFS, Gulf War syndrome, and recovered memories all serve as prime examples.
Furthermore, should psychiatry ever become a monolithic discipline dominated by one pattern of explanation to the exclusion of others, it will be too narrow. Explanations of human behavior occur at many different levels, from neurophysiological and neurochemical, through psychodynamic and psychological, to sociological and anthropological. One level of explanation cannot be reduced to another, but there can be productive interactions between the different levels. An alternative vision for psychiatry, which I favor, sets it apart from traditional views of medicine and science. Psychiatry requires a proliferation of theories from different traditions. We will never achieve a grand unified theory of the mind, and trying to force our understanding of the mind into such a model will just hold us back.