Don’t Shrink from Mental Illness

That reminds me of the time I spent 18 months in a psychiatric hospital… … pause … … as the director of Finance.

I have used the above line and it is interesting watching people’s reaction as they anticipate the end of the sentence  For that millisecond they are evaluating me and potentially re-assessing me in their own mental model.  Of course it is also a reflection on me in that I belatedly made clear that I was not a patient.

In other words, mental illness is something that society is still trying to figure out.  While we applaud Celebrities who come out of the closet, we also cross the street to avoid the disheveled and pungent homeless man screaming at his own personal demons.

The Shrink

Jeffrey A. Lieberman, has written a good book about the history of mental illness (Shrinks: The Untold Story Of Psychiatry).  While not without its own flaws (more on this later), it does give a good overview of the evolution of the professions aligned to treat mental disorders.

As a past-President of the American Psychiatric Association and a physician practicing since the mid-1970’s, he is well placed to provide observations on the evolution of the practice.  Two common themes struck me in this book.  Firstly the quiet desperation for both those afflicted and those trying to help the mentally ill and secondly the earnest-quackery involved in those attempting to alleviate this desperation. A few examples of theories/quackery are worth pointing out:

  • Animal Magnetism: invisible energy coursing through thousands of magnetic channels in the body.
  • Orgone Theory: a hidden form of energy uniting all of nature’s elements.  Treatment include sitting in orgone accumulators.
  • Psychoanalytic theory: A therapeutic method, originated by Sigmund Freud, for treating mental disorders by investigating the interaction of conscious and unconscious elements in the patient’s mind and bringing repressed fears and conflicts into the conscious mind, using techniques such as dream interpretation and free association.

The Greatest Quack

The last also had the greatest credibility for longest time.  Psychoanalysis is part of our understanding of the human mind (e.g. the concepts of unconsciousness or the ego).  It was also the first theory that provided some hope to alleviate the quiet desperation.  As a result, Lieberman spends a good portion of the book discussing the rise and eventual fall of psychiatric theory as the preeminent treatment modality in American psychiatry.  This includes the fight for and significant changes to the Diagnostic and Statistical Manual of Mental Disorders; DSM-5 being the most current version.

Much of the criticism for psychoanalysis was its disinterest in empirical evidence.  Because adherent saw Freud as a modern prophet and psychoanalysis as perfect gospel, testing or even questioning the precepts of the theory were vigorously fought against, at least in the United States.  In time, some brave souls (and an anti-psychiatry movement) dethroned psychoanalysis.  As an aside, like other treatments, psychoanalysis and talk therapy does have its place – for example in the treatment of post-traumatic stress disorder.

The American Experience is Too Narrow

Unfortunately this is also where Lieberman could have made a ‘good book’ a great book had he spent less time on the American based politics of mental illness and more time on a global perspective.  While the DSMs were being created, other great psychiatric stories were being played out.  For example, the use of psychiatry in the former Soviet Union to muzzle dissidents, the role of mental illness in non-Anglo/euro cultures or even a larger history of mental illness and whether it is a relatively new phenomenon or not.

A more complete discussion on the alternatives to psychiatry would have been interesting as viewed from an insider’s point of view.  Although Lieberman spends sometime discussing the concerns of anti-psychiatry, in the end he primarily dismisses them in the context of current treatments.

The Hope for the Desperate

Despite these short comings, this is still a good book which sheds hope to the mentally ill because of treatments developed primarily (but not exclusively) over the past 40 years, including:

  • Pyrotherapy for advance syphilis.  Discovered by Julius Wagner-Jauregg.
  • Lobotomies which did not actually cure the mentally ill but did make them easier patients to house and manage.  Not currently used as a treatment.
  • Electroconvulsive therapy which applied a general electrical shock to the brain.  Still in use and effective for some conditions.
  • Psychopharmacology is the most common treatment currently with a myriad of drugs some developed for uses widely different from treating mental illness.
  • Talk Therapy.  Evolved out of Freudian psychotherapies, it has evolved from the therapist being an unemotional observer to the therapist being an empathetic partner in exploring issues.

The Mind versus the Brain and the Read

Psychiatry has centred around a dichotomy of the mind versus the brain as the source of mental illness.  Lieberman does a good job of merging these two extremes into current thinking that mental illness is both.  As well, Lieberman demonstrates great compassion about the plight of those afflicted and the social stigma it carries.

Overall Lieberman has done a good job of providing an American focused history of mental illness and its current state of affairs.  A book for those with interests in general and medical history as well as a general read about mental illness.