Review of Scull

 OUTLOOK

Psychiatry’s brutal history and unanswered questions 

Review by Siri Hustvedt 

June 3, 2022 at 8:00 a.m. EDT

A guard at the state prison hospital in Vacaville, Calif., prepares an inmate for a lobotomy in 1961. Under superintendent William Keating, a psychiatrist who was convinced that “criminality” was lodged in certain areas of the brain, lobotomies became routine at the facility. (Ted Streshinsky/Corbis/Getty Images)

Andrew Scull’s “Desperate Remedies” tells the story of psychiatry in the United States from the 19th-century asylum to 21st-century psychopharmacology. His lucid prose and urgent narrative style take the reader through psychiatry’s dubious characters, its shifting conceptions of mental illness and fluctuating diagnostic categories, the often gruesome treatments visited upon patients and their families, and the ultimate demise of public mental hospitals for “community care,” which, as he explains, meant no community and no care. Instead, severely ill patients were abandoned to fend for themselves, ending up on the streets or in prison, where many of them remain today.

Scull describes how doctors, driven by hubris, greed and flimsy theoretical assumptions, embraced invasive, brutal techniques as solutions to insanity and then summarily pronounced them effective, often protected by the profession as a whole. These purported “successes” depended not only on a gullible public but on a press eager to tout the most recent medical miracle.

Belknap Press 

Some of Scull’s horror stories are well known. From the late 19th and well into the 20th century, a host of conditions, which included lunacy but also feeblemindedness, epilepsy and pauperism, were believed to be caused by an inborn hereditary taint impervious to any and all treatment. Eugenic-genetic science fueled arguments for the isolation of “defectives” in institutions, for the highly restrictive 1924 immigration law and for the legalization in America of involuntary sterilization directed at “the unfit.” Induced coma, electroshock (in its earlier and often bone-breaking version) and lobotomies (the removal of portions of the brain’s frontal lobes with a modified version of an ice pick) as cures for mental illness all deserve their current status as grotesque violations of human rights. I knew nothing of Henry Cotton, however, whose career was founded on the conviction that low-grade bacterial infections lurked inside the bodies of mental patients and the affected parts required excision. Whole sets of teeth, tonsils, cervixes and colons were lost or mutilated in this pursuit. Almost half of Cotton’s patients died.

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The victims of these ferocious remedies were far more often women than men. Scull cites research finding that female patients were also far more likely to be restrained, straitjacketed, and strapped to beds and chairs. Scull freely acknowledges the sexism at work in both treatment and ward discipline but leaves it to the reader to deduce the sadistic sexual misogyny that was played out on the bodies of unwilling patients.

“Desperate Remedies” documents the rise of psychoanalysis and its hold on psychiatrists for decades in the 20th century. Intellectuals, artists and Hollywood reinforced the fashion for the unconscious and sexual repression. Scull cites the dogmatic schisms inside psychoanalysis, the professional arrogance and the fact that psychoanalytic institutes were not associated with research universities (which would come to benefit from massive government science funding) as reasons for the demise of psychotherapeutic psychiatry, but most important, the talking cure lost its status as a science. It could provide no hard evidence for its efficacy.

Scull is well aware that psychiatry has vacillated between treating “the mind” with therapeutic dialogue and treating “the body” with surgery and psychotropic drugs. At the peak of its power, psychodynamic psychiatry, Scull writes, claimed “that psychological factors loomed large in the genesis of illnesses that had traditionally been seen as rooted in the body.” He mentions ulcers, asthma, autism and schizophrenia. Smothering mothering is not responsible for asthma, but strong emotions do trigger asthma attacks. Ulcers, as Scull points out, are now known to have a bacterial origin but were once ascribed to “Type A” personalities and stress.

What Scull misses is that recent research makes it clear that the immune system is highly sensitive to psychological stress and that a lowered immune response creates vulnerability to a host of illnesses, including those caused by bacteria. “Mental” stress also affects gene expression, as many recent epigenetic studies have shown. Despite the fact that it is an inert substance, a placebo has potent physical effects, and the more time a physician spends with a patient while delivering the innocuous sugar pill, the more robust the results. As the neuroscientist Fabrizio Benedetti has argued, placebo effects crucially involve the physiology of the doctor-patient relation. At the very least, these findings complicate Scull’s critique of psychodynamic thought.

By skirting the philosophical mind-body problem, Scull avoids psychiatry’s crucial dilemma. The medical discipline has never known and still does not know what it is treating. Can the mental be reduced to the physical? Are mind and brain identical, or is the reduction of feelings and thoughts to genes, brain regions and neurochemicals a mechanistic fantasy that has haunted science since the 17th century? If human development and its dynamic biological processes (including brain development) are at once genetically constrained and experience-dependent, then a new understanding of “the mental” in psychiatry and in popular culture is vital to negotiating the future.

As a sociologist, Scull is attuned to the broad upheavals that transform societies. He is also sensitive to cultural repetitions. He quotes William Laurence, a science reporter for the New York Times, who, in 1937, celebrated lobotomy as a procedure that “cuts away the sick parts of the human personality.” For readers who believe that such crude thinking belongs to a bygone era before neurobiology and genetics came along with answers, I recommend “Desperate Remedies” as a tonic for your optimism. Headlines declaring depression “a chemical imbalance,” announcing Prozac as its magical solution and touting the discovery of genes for schizophrenia are no more or less absurd than Laurence’s boosterism for lobotomy. Scull directs the reader’s attention to the fact that after decades of research and billions of dollars spent, not a single biomarker for psychiatric sickness has been discovered.

“The phenomenological and social dimensions of mental illness have all but disappeared as questions worthy of serious and sustained attention,” he writes. On the whole, this dismal assessment is accurate. I will add only that inside psychiatry, there are many people, and the numbers are growing, who like Scull believe that a complex biopsychosocial model is the only way forward. The suffering of millions of people depends upon it.

Siri Hustvedt is the author of 13 books, most recently “Mothers, Fathers, and Others.” She is a lecturer in psychiatry at Weill Cornell medical college.