The question, “Does psychiatry work?” is like the question, “Does medicine work?” The answer is rather Talmudic: it depends. It depends on the problem (or “diagnosis”), on various external circumstances, on the patient and on the doctor. And it depends on how you define success. Unfortunately, while Desperate Remedies is an entertaining compendium of scandals and scoundrels in the history of psychiatry, it is too burdened with authorial outrage to offer a serious discussion of historical efforts to help people with what we now call psychiatric disorders.
Andrew Scull, whose professional career has apparently been devoted to summarizing various atrocities among practitioners of mental healing over the centuries, has not set himself a difficult task. Physical interventions to cure or reverse mental or spiritual maladies over the ages have been numerous and brutal enough to attract the Madame Tussaud's clientele in droves. Of course surgery without anesthesia or antisepsis, copious blood-letting, and ingestion of various noxious and/or disgusting substances characterized management of all kinds of ills of the flesh.
The nineteenth century saw significant progress in many areas of medicine, as a corollary to the general advances in science and technology that accelerated during that period. Scull's view, however, is that “alienists” and their ilk either took no notice of this or perverted it into justification for more barbarity. Philippe Pinel's reforms, celebrated in the classic mural of him removing the chains of the inmates of the Salpetriere, and his efforts to introduce a system of humane asylums where the severely disturbed could be protected and, hopefully, cured do not fit Desperate Remedies consistently outraged tone and are omitted, in favor of a pointlessly condescending discussion of the futility of phrenology, and later, of recording behavioral symptoms in “obsessive detail.” This is the viewpoint of the non-scientist who disdains the work of all of the people – most actual investigators -- who pursue plausible lines of inquiry that turn out not to be useful.
In Scull's highly personalized telling, psychiatry's leading lights (as he sees them) are invariably arrogant, personally obnoxious, sadistic or at least hypocritical, venal liars. He can quote from their writings to prove it. Money, power and glory are the only motivators. Kraepelin and Freud and Big Pharma may all disagree and offer different approaches, but they are all cut from the same cloth which has nothing to do with helping people.
As for the present and future, analytic therapy is finished, drugs are being sold relentlessly, there is lots of well-funded research (though Scull, interestingly, fails to mention neural networks), but there is little cause for hope.
What is this all about? Are things really as bad as that?
We can quite reliably treat severe depressions—what used to be called endogenous or psychotic depressions—often without hospitalization. using various antidepressant medication or even ECT (which as currently practiced is not brutal if perhaps unesthetic) and supportive psychotherapy.
Many of the ills that used to be called neurotic (anxiety, phobias, less severe depressions) often respond to psychotherapy, although this is the area where medication use and overuse is an issue.
We can rapidly abort most acute psychotic episodes with medication and supportive care without resort to hospitalization (if people have an accepting living situation). About a third of these often young patients recover fully within six months, and about half of the rest can be well stabilized and lead essentially normal lives. There remains an unfortunate group who are chronically severely incapacitated, though we do have the knowledge and skills to make them quite comfortable. While Scull dismisses the early asylum managers as “innkeepers”--betraying his ignorance of the challenges of managing any residential program, even an inn—some of the physician leaders of these institutions have made heroic and successful efforts to improve the lives of very impaired patients who cannot be cured. Unfortunately, except for the very wealthy, the resources for this effort, never generous, have been severely curtailed for political reasons. Scull says the psychiatric profession has accepted the dumping of state hospital patients without protest because they are not financially rewarding, ignoring even prominent doctors like John Talbott who have tried eloquently to raise the issue.
So it's obvious that the author of Desperate Remedies is driven by more than academic interest as a historian. Taking a leaf from his book, one might suspect simply that he believes a popular expose will sell better than a scholarly review, and he simply wants the money. But that may be doing him an injustice. I could not help noting that he drops his usual sardonic tone and become frankly enraged describing Bruno Bettleheim (whom he neglects to note was actually not a psychiatrist but a psychologist) as a “charlatan” who abused his patients. The context is his discussion of psychoanalytic speculation about the role of parents in development of schizophrenic or autistic children. Bettleheim was a leader in this school of thought. And Desperate Remedies is dedicated to Andrew Scull's late son. I apologize for thinking like an “analytically oriented” psychiatrist, but it does not seem unduly far-fetched to speculate that Scull may have strong personal reasons for disparaging psychiatry and psychiatrists.
The question, “Does psychiatry work?” is like the question, “Does medicine work?” The answer is rather Talmudic: it depends. It depends on the problem (or “diagnosis”), on various external circumstances, on the patient and on the doctor. And it depends on how you define success. Unfortunately, while Desperate Remedies is an entertaining compendium of scandals and scoundrels in the history of psychiatry, it is too burdened with authorial outrage to offer a serious discussion of historical efforts to help people with what we now call psychiatric disorders.
Andrew Scull, whose professional career has apparently been devoted to summarizing various atrocities among practitioners of mental healing over the centuries, has not set himself a difficult task. Physical interventions to cure or reverse mental or spiritual maladies over the ages have been numerous and brutal enough to attract the Madame Tussaud's clientele in droves. Of course surgery without anesthesia or antisepsis, copious blood-letting, and ingestion of various noxious and/or disgusting substances characterized management of all kinds of ills of the flesh.
The nineteenth century saw significant progress in many areas of medicine, as a corollary to the general advances in science and technology that accelerated during that period. Scull's view, however, is that “alienists” and their ilk either took no notice of this or perverted it into justification for more barbarity. Philippe Pinel's reforms, celebrated in the classic mural of him removing the chains of the inmates of the Salpetriere, and his efforts to introduce a system of humane asylums where the severely disturbed could be protected and, hopefully, cured do not fit Desperate Remedies consistently outraged tone and are omitted, in favor of a pointlessly condescending discussion of the futility of phrenology, and later, of recording behavioral symptoms in “obsessive detail.” This is the viewpoint of the non-scientist who disdains the work of all of the people – most actual investigators -- who pursue plausible lines of inquiry that turn out not to be useful.
In Scull's highly personalized telling, psychiatry's leading lights (as he sees them) are invariably arrogant, personally obnoxious, sadistic or at least hypocritical, venal liars. He can quote from their writings to prove it. Money, power and glory are the only motivators. Kraepelin and Freud and Big Pharma may all disagree and offer different approaches, but they are all cut from the same cloth which has nothing to do with helping people.
As for the present and future, analytic therapy is finished, drugs are being sold relentlessly, there is lots of well-funded research (though Scull, interestingly, fails to mention neural networks), but there is little cause for hope.
What is this all about? Are things really as bad as that?
We can quite reliably treat severe depressions—what used to be called endogenous or psychotic depressions—often without hospitalization. using various antidepressant medication or even ECT (which as currently practiced is not brutal if perhaps unesthetic) and supportive psychotherapy.
Many of the ills that used to be called neurotic (anxiety, phobias, less severe depressions) often respond to psychotherapy, although this is the area where medication use and overuse is an issue.
We can rapidly abort most acute psychotic episodes with medication and supportive care without resort to hospitalization (if people have an accepting living situation). About a third of these often young patients recover fully within six months, and about half of the rest can be well stabilized and lead essentially normal lives. There remains an unfortunate group who are chronically severely incapacitated, though we do have the knowledge and skills to make them quite comfortable. While Scull dismisses the early asylum managers as “innkeepers”--betraying his ignorance of the challenges of managing any residential program, even an inn—some of the physician leaders of these institutions have made heroic and successful efforts to improve the lives of very impaired patients who cannot be cured. Unfortunately, except for the very wealthy, the resources for this effort, never generous, have been severely curtailed for political reasons. Scull says the psychiatric profession has accepted the dumping of state hospital patients without protest because they are not financially rewarding, ignoring even prominent doctors like John Talbott who have tried eloquently to raise the issue.
So it's obvious that the author of Desperate Remedies is driven by more than academic interest as a historian. Taking a leaf from his book, one might suspect simply that he believes a popular expose will sell better than a scholarly review, and he simply wants the money. But that may be doing him an injustice. I could not help noting that he drops his usual sardonic tone and become frankly enraged describing Bruno Bettleheim (whom he neglects to note was actually not a psychiatrist but a psychologist) as a “charlatan” who abused his patients. The context is his discussion of psychoanalytic speculation about the role of parents in development of schizophrenic or autistic children. Bettleheim was a leader in this school of thought. And Desperate Remedies is dedicated to Andrew Scull's late son. I apologize for thinking like an “analytically oriented” psychiatrist, but it does not seem unduly far-fetched to speculate that Scull may have strong personal reasons for disparaging psychiatry and psychiatrists.
Great review. Thanks.