Psychiatry P: From the Era of the Asylum to the Age of Prozac [Paperback]

Maybe I was wrong. When I reviewed Gemma Blok's history of anti-psychiatry in the Netherlands, I criticized her for interjecting her opinions, instead of sticking to reporting the facts. Perhaps that's not how historians see their role. Edward Shorter never even bothers to make a pretense of objectivity. I do admit that his unashamedly judgmental writing style makes for a stirring read. Let me be equally unashamedly judgmental about him.

For one thing, Shorter loves psychiatry. That's clear. For another, there's no mistaking what his favored model of psychiatry is. He lavishes praise on early German psychiatry which was well-funded by the state, enabling plenty of experimentation, as "the triumphs of science" add to the national prestige. He even goes so far as describing the structure within which Kraepelin worked as "majesty." On France of the same period he pours scorn for being "a second-rate psychiatric power," whereas in pitiful England, where teaching hospitals were dependent on charity, there was little science at all, according to Shorter.

Shorter credits Kraepelin, a neurologist according to him, with being the inventor of psychotherapy, although it wasn't called that at the time of course. Wealthy people loathed asylums, so they avoided them by pretending their personal problems were neurological diseases. That's why they became known as neuroses. Neurologists soon recognized the role of placebo treatments (which worked) for these non-diseases, although neurology is actually, according to Shorter, the science of unusual and incurable diseases of the central nervous system. The nerve doctors, poor things, didn't have much choice but to go along with doing psychotherapy and running resorts, as that is where the money was at the time, and they couldn't cure any of their real patients anyway.

The irony is that Kraepelin, whatever his real job title was, worked in asylums where people were taken involuntarily. He is today considered the discoverer of "schizophrenia," a supposedly brain-based disease.

Freud, too, was a neurologist, Shorter points out (this time correctly), though he has no sympathy for psychoanalysis. He juicily describes a lecture given by a German émigré to the U.S., which was so well received that "it brought the house down." "Respected by all and understood by none," the émigré had spoken in broken English about "penis envoy." Psychiatrists in the U.S. welcomed psychoanalysis as a means to escape the asylums. Why they would want to leave all that majesty, Shorter doesn't say.

The early treatments for people brought into the asylums were geared at making them physically sick. Patients would be administered emetics (drugs to make them vomit) or injected with blood from people who were ill with malaria and tuberculosis. These treatments worked, according to Shorter, as did prolonged narcosis (keeping people asleep with drugs), a successful therapy that might still exist today had not some of the patients messed it up by dying. Alcohol was another treatment tried. Pharmaceutical treatments were promising, but unfortunately, Swiss psychiatrist Jakob Klaesi who was doing drug research at Hoffmann-La Roche, was subject to manic-depressive personality swings, says Shorter, and became a nazi sympathizer.

One would think that Shorter, writing in a period that the works of Healy (who is mentioned by him) and Breggin (who is not) are well-known in the psychiatric community, might have connected the term narcosis to the modern term narcotics, which is what all psychiatric drugs are. But no, to him they are medicines, and bear no relation to the early efforts to cure whatever ailed people by making them sick or drowsy. Nor does he express any skepticism of the bombastic claims for the success of any biological treatments, whether the ones mentioned above or ECT, opposition to which he labels "hostility." Only about the curative capacity of lobotomy is Shorter less confident.

For a book boldly named "A History of Psychiatry," reference to the psychiatric obscenities in Germany leading up to and during WWII is surprisingly brief. Not delving deeply into the facts, as though this were a minor sidestep in the history of psychiatry, Shorter condemns these events in no uncertain terms, manic-depressive personality swings or not. "Academic medicine in Germany on the whole stood waist-deep in the Nazi sewer" he asserts, suddenly forgetting about the glories of state funding and experimentation, which were the hallmarks of nazi medicine even more than of the earlier regime so praised by Shorter. Strangely, he ascribes the events under the nazis only to the theory of degeneration, not to the theory of heredity, even though degeneration rested on heredity.

Degeneration, Shorter laments, was seized upon by the eugenicists (so there was nothing wrong with the theory itself?). Later in the book Francis Galton is credited with proposing twin studies, about which Shorter is enthusiastic, without any mention of Galton being the founder of the eugenics movement, and twin children being the infamous Mengele's favorite victims. Mengele isn't mentioned in the book either. Instead, Shorter says defensively, "There was nothing intrinsically racist about the technique of twin studies in psychiatric genetics. ... Indeed, the next major contributions to the field came form Jewish scholars." Shorter misunderstands the meaning of the word racism in the nazi context, and implies that whatever any Jew does cannot be racist. He but regrets the influence of nazism on psychiatry because it imposed taboos on the discussion of biology and heredity in psychiatric disease for decades to come.

Advances in drug therapy were fortunately not held up too much by the nazi sewer, and by May 1952, Delay and Deniker's patients were all doing great on chlorpromazine, according to Shorter. It even cured "patient number one, Giovanni A., a 57-year-old laborer" of his propensity for "making improvised political speeches in cafés ... and ... preaching his love of liberty."

To his credit, although I'm not sure his heart is in it, Shorter isn't totally oblivious to the aggressive expansion of psychiatric territory. He notes regarding "Tom-Sawyer-esque enthusiasm ... the natural spirits of ladhood, [that] in the 1960s and after a whole series of psychological diagnoses arrived to define such behavior as pathological" and "[Such programs as] Mental Illness Awareness Week encourage doctors to diagnose depression. ... the ultimate effect is psychiatric empire-building against other kinds of care." He also mentions some of the various influence groups which affected the content of the DSM (apparently only in the past).

As I started this review with a reference to Gemma Blok, let me not leave out Shorter's section on antipsychiatry movements. They flourished, he claims, throughout the nineteenth century, then apparently mysteriously disappeared for a while. In the 1960s they were reborn, with books published by Michel Foucault, Thomas Szasz, and Erving Goffman. But what really caused the movement to flair up was a novel by Ken Kesey, One Flew Over the Cuckoo's Nest. The movie made from it swept the academy awards of that year, winning all five main Oscars, Shorter relates. That none of these authors considered themselves antipsychiatrists is apparently beside the point. Like Blok, he pronounces this movement a failure.

Shorter ends the book with a justification for the existence of psychiatry. "Whereas the average consultation in internal medicine or obstetrics lasts only around 10 minutes, the average in psychiatry lasts over 40. Within this 40 minutes, psychiatrists do essentially two things that their competitors on either side - the psychologists on the one side, the neurologists on the other - do not do. Psychiatrists offer psychotherapy, which the neurologists generally speaking do not... And psychiatrists prescribe medication, which the nonmedical competition is not permitted to do. This combination of psychotherapy plus medication represents the most effective of all approaches in dealing with disorders of the brain and mind."

Conspicuous by their absence from this justification for the existence of a field of medicine so hated by many of its supposed benefactors, are words like cure, improvement, and customer satisfaction.

There's a snapshot of Shorter on the dust cover. He's quite good looking. If you happen to see him somewhere - turn around and run!

Copyright © MeTZelf

This book is packed with valuable information that will be of interest to a mental health professional and an interested layman alike. Based on a well-researched material, this book brings what could have been a boring subject to life, and makes for a very entertaining reading. It helped me to understand the development of the field before I committed myself to psychiatric training, and in some ways influenced my career choice. While Shorter certainly cannot be mistaken for a fan of psychoanalysis, he does present a well-balanced overview of the history of psychiatry (where psychoanalysis has an important, but not THE MOST important role). In fact, he accepts that organic psychiatry and psychoanalysis each have their place in the discipline, and some of the best minds in the history of psychiatry practised both as appropriate (e.g., Kuhn - the pioneer of imipramine and EEG in Switzerland - was also a trained analyst).

Now that history of psychiatry is examined in Paper 1 of MRCPsych, I think this book ought to be added to the official MRCPsych reading list. Highly recommend.

For those who, like myself, want to explore the subject in more detail, I recommend Dr Shorter's "From Paralysis to Fatigue" and "Shock Therapy" (the former describes the historical development of psychosomatic illness, the latter - the history of ECT).

Reading a book describing the history of your own discipline may not only be interesting and informative, but helpful too. Helpful meaning putting contemporary psychiatric practice in perspective and all the relevant context, which in turn enables one to understand one's place in the society better.
The author begins his story at the end of 18th century and continues with it more or less chronologically, changing specific subjects of interest from chapter to chapter. Generally narration is fluent and makes the book easily readable.
Nevertheless, as I was reading through the book, my misgivings were steadily growing. The author quickly turns out to be biologically-minded, and he doesn't hide it. That wouldn't be fault in itself (I'm also a biological psychiatrist), weren't he acting as a historian rather than ideologist. It results in the unfolding events or people responsible for them being either praised or mocked, depending on whether they are rooted in biological thinking or not, respectively. The author is clearly anti-psychoanalytical and it surfaces now and then. He generally blames psychoanalysis for seriously hampering the development of psychiatry. It's of course clear, now, that psychoanalysis has proved dead end, but such a unilateral account isn't what I expect from historical account of psychiatry.
The book can boast many a positive features, too. Above all it reads well, is enganging and quite thorough.
The last, but most important thing for me - the book has 'history of psychiatry' in it's title, but it doesn't mention 'ICD' even once and you can't find it in the index. That's why I won't give it more than three stars.
Not mentioning 'ICD' the author seriously undermines his authority and makes me not to count this book as authoritative. It's interesting but only partialy helpful.