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Empire of Asylumdom

Today’s mental health system pushes medications on growing numbers of Americans while largely abandoning the chronically mentally ill.

Desperate Remedies: Psychiatry’s Turbulent Quest to Cure Mental Illness, by Andrew Scull, (Harvard University Press: 2022), 512 pages.

If you’re one of the millions of depressed or anxious Americans who assume that the interests of psychiatry and your mental health are the same, then chances are you’ll change your mind after reading sociologist Andrew Scull’s Desperate Remedies.

This is not Scull’s first publication on the history of psychiatry. When he began publishing in the 1980s, he possessed “an infatuation with neo-Marxist ideas,” in his own words. As the years have gone by, his work has tended to focus on the impact of professionalization—the process of licensing and credentialism—on the history of psychiatry and how those factors affected the growth of the field. Scull has consistently challenged what he calls “the rhetoric of reform” in mental health care, meaning he has asked searching questions about the periodic waves of change that have swept through psychiatry and psychology in the last two centuries. 

Scull’s story begins after the Civil War with what he calls “the empire of asylumdom,” when the many state mental hospitals built earlier in the nineteenth century began their steady decline. Constructed at a time when optimism about institutionalization reigned, by the end of the century these asylums had become places where patients with mostly chronic, incurable diseases resided. The redefinition of asylums as places for custodial care rather than cure set the stage for the “desperate remedies” of Scull’s title, employed to treat patients with senility, dementia, syphilis, severe depression, or full-blown psychoses such as schizophrenia. Ovariotomies, tubal ligation, vasectomy, malarial fever therapy, focal infection surgery, prefrontal lobotomy, and insulin, camphor or metrazol shock therapy—one after another, psychiatry’s stabs at effective treatments fell far short of success. Scull spends a full three chapters on lobotomy when one might suffice, but his point stands: all of these therapies, with the possible exception of electroconvulsive therapy, were dead ends that severely damaged countless Americans’ lives. 

Psychiatry’s resort to dubious treatments was not restricted to physicalist methods. In retrospect, the dominance of Freudian psychoanalysis from roughly the end of World War II to the early 1970s is as shocking as any cutting of the nerve connections in the frontal lobe of the brain. Psychoanalysts did not just run up bills on wealthy Manhattanites over years of treatment. They dominated academic psychiatry to the point where professors asserted with a straight face that schizophrenia was a neurosis due to unfeeling mothers. Freud’s ideas dovetailed with the fashionable liberal notion that nervous and mental disorders were due to poverty, injustice, faulty schooling, bad parenting, unsafe neighborhoods, or combat experience. Freudianism showed up in Dr. Benjamin Spock’s popular theories about child psychology as well as Hollywood movies such as Alfred Hitchcock’s Psycho (1960). The neo-Freudian emphasis on bad environments also appeared in The Snake Pit, the highest-grossing Hollywood film of 1948, signaling the beginning of the end of state hospitals with their overcrowding and oftentimes horrendous conditions. 

In the 1960s, states discharged tens of thousands of hospital inmates under the fashionable view that the mentally ill would recover their wits once they were “normalized” by care in the “community.” It was amazing, a Canadian psychiatrist said at the time, “how hospitals screw people up.” The discovery that certain drugs muted the symptoms of chronic psychosis without sedating patients reinforced the idea that hospital residents could live outside the institution. But, as Scull writes, “both the community and the care were chimeras.” In the annals of social policy, deinstitutionalization ranks as one of the most catastrophic failures of law-making in American history.   

The early returns on deinstitutionalization in the 1970s hastened the end of Freudianism in medicine. A new movement, called “brainspot psychiatry” by Scull, arose aiming to revise the field’s diagnostic system and purge it of psychoanalytic language and concepts. It was based on the notion that mental diseases are as natural as any other physical disease, that they are due to biochemical changes in the brain, and that for each diagnosis there ought to be a specific drug for treatment. In retrospect, much of biological psychiatry’s approach actually made sense, but under pressure from insurers and the pharmaceutical industry psychiatry began multiplying the list of conditions in psychiatry’s “bible,” the Diagnostic and Statistical Manual. When the fifth edition of the DSM appeared in 2013, 947 pages long, it listed 157 separate disorders that qualified for insurance. In Scull’s words, “Rather than diseases calling forth remedies, remedies called forth new ‘diseases.’”   

Which brings us to the present day, when, according to Scull, psychiatry is mired in a “crisis.” Today’s mental health system pushes medications on growing numbers of Americans while largely abandoning the chronically mentally ill to “the euphemistically named ‘board-and-care’ homes, to the gutter, and to the jail.” According to Scull, psychiatry’s “claims to diagnostic competence seem increasingly threadbare.” Scull concludes by observing that “it would help enormously if psychiatry were to be more honest about the limits and imperfections of its knowledge… Psychiatrists have no way of knowing which response any given patient will have when a particular pill is described. Taking antipsychotics or antidepressants is thus a game of craps.” 

Scull’s revelations in particular about what he calls psychiatry’s “incestuous relationship with the pharmaceutical industry,” as well as the intimate connections among America’s psychiatrists, medical schools, insurance companies, and the federal Food and Drug Administration, recall the sordid story of the Sackler family’s role in the deaths of hundreds of thousands of Americans addicted to opioids. Indeed, Arthur Sackler, himself a psychiatrist, played a big role in the history of psycho-pharmacology with his pioneering methods of medical advertising. His advertising campaigns for the tranquilizers Valium and Librium (Arthur called them “emotional aspirin”) “were perhaps his greatest marketing triumph and brought him a fortune,” Scull writes. According to Arthur’s brothers, only his death in 1987 kept him from getting into the business of advertising for Prozac and other antidepressants. 

Though he does not say so directly, one of Scull’s important accomplishments in Desperate Remedies is to demolish the notion that “political correctness” is destroying medicine in general and psychiatry in particular. It is surely true, as psychiatrist Miriam Grossman has argued, that intersectional ideology and woke activism have taken over campus counseling and mental health services and harmed the health of countless young people. Similarly, the American Psychiatric Association itself shows all the signs of going “woke.” In 2020, the APA publicly lamented its “ingrained” racism both in the low numbers of black psychiatrists and its failure to “promote equity in mental health for all.” 

Yet Scull rightly argues that psychiatry’s current crisis is due to a “neoliberal” consensus shared by both Democrats and Republicans. Historically, neither political party has questioned the reigning consensus about mental illness, articulated back in 1999 by former Second Lady Tipper Gore, who argued that she got depressed because her “brain need[ed] a certain amount of serotonin, and when you run out of that, it’s like running out of gas.” Heated debates over whether or not terms such as “crazy,” “psycho,” or “looney” stigmatize people with mental disabilities, or the strategy of boosting the numbers of African-American psychiatrists, may be distractions from the otherwise powerful and systemic problems that plague the discipline. Saying political correctness is destroying psychiatry is like saying Covid killed a 93-year-old patient with cancer and heart disease.  

None of this means that there are no compassionate American psychiatrists with integrity today, nor does it mean that there haven’t been advances made by previous generations of clinicians and researchers who, often under appalling working conditions, made some remarkable discoveries about the nature of the mind. It is simply to say that psychiatry’s past has culminated in a current profession riddled with massive conflicts of interest and operating under a set of circumstances that block most reasonable hopes for success in fighting mental illness.

Ian Dowbiggin teaches history at the University of Prince Edward Island. He is the author of The Quest for Mental Health: A Tale of Science, Medicine, Scandal, Sorrow and Mass Society (2011).