Does psychiatry have a future? Only if it realises its limitations
DESPERATE REMEDIES by Andrew Scull
494pp, Allen Lane, £25, ebook £12.99
★★★★★
AFollowing the Second World War, just about everything was blamed on the parents
re mental illnesses real? Well, says Andrew Scull, in his erudite, precise, blisteringly critical history of 200 years of psychiatry, they hurt; they blight lives; now and again they kill people. So there’s that.
But are they illnesses in any recognisable sense? They can’t be cured. Some people, after years of suffering, experience complete remission for no reason. The search for reliable genetic markers for schizophrenia and major depression has proved a snark-hunt. And so on: Scull’s new book, Desperate Remedies, is the story of what happens when the world stubbornly refuses to reward our efforts at rational understanding.
There are two traditions in psychiatry. The first, greatly shaped by our experience with syphilis, assumes that mental illness is an organic failing, perhaps the result of an infection. Henry Cotton is the unlovely posterchild of this tendency, a man whose fin de siècle war on “focal infection” involved the surgical removal of teeth and tonsils first of all, then colons and cervixes, and then just about anything his knife could reach – and killed very nearly half his clientele.
The other tradition, mindful especially of those traumatised by war, assumes that mental illness is grounded in individual experience. At its psychoanalytic height, in the 20 years following the Second World War, it could blame just about everything on the parents. The psychoanalyst Franz Alexander believed that “the asthmatic wheeze was the ‘suppressed cry’ of a patient suffocated by an over-attentive mother”. The current crop of trauma therapies – springing from the roots of 1960s-era PTSD, like mushrooms after a spring rain – is the latest lurid flowering of this tradition.
Meanwhile psychiatrists, the poor bloody footsoldiers in this intellectual conflict, have been treating ordinary people in oversubscribed, underfunded institutions – or in the absence of those institutions, where “care in the community” holds sway. It’s their “desperate remedies”, from shock therapies to lobotomies, that form the core of this book.
Scull spends many pages explaining what happens when overambitious clinicians meet clients deprived of their rights. (Not everyone in the profession is a Nurse Ratched, but it’s worth remembering that One Flew Over the Cuckoo’s Nest was drawn from Ken Kesey’s personal experience.) In spite of everything, Scull still holds out the narrow possibility that psychiatry has a future, if only it would calm down and own up to its limitations. In the psychopharmological present, for instance, much that we’re told “works” doesn’t – or not for very long. Or it’s accompanied by so many side effects that many people feel they would be better off if it didn’t work. And what works doesn’t work nearly as well as the press says it works. And – the cherry on the cake – we don’t know why it works. (Any piece of folk wisdom you may have picked up about “dopamine imbalances” or “serotonin levels” is almost certainly wrong.)
The opioid crisis in America is a public-health scandal that’s been waiting to happen since the early 1940s, when Arthur Sackler, among others, worked out how to couch drug advertisements as clinical information. In its wake, the efficacy of countless drugs is being reassessed. Old trials are being picked over, old claims re-examined. The result? “GlaxoSmithKline has all but closed its psychiatric laboratories,” Scull explains, surveying the ruins left by this latest “paradigm shift” in psychiatry; “AstraZeneca has essentially dropped internal research on psychopharmacology, and Pfizer has dramatically reduced its spending in the psychiatric arena.”
Were all their efforts quackery? Of course not. It is easy (and cheap) to cherry-pick horror stories from Scull’s impassioned history. But his far more worrying point is that plenty of the effort expended over the last 200 years was intelligent, sincere and honestly conducted – and that, too, has brought only marginal and temporary relief to the suffering mind.