The Early Psychiatrist: A Piercing Eye and Commanding Presence

Among the many changes in psychiatric practice often attributed to the psychotherapist Carl Rogers was a shift in the therapist’s relationship with the patient. In particular, Rogers is rightly famous for advocating “client-centered” or “person-centered” therapy.

As he put it, “This formulation would state that it is the counselor’s function to assume, in so far as he is able, the internal frame of reference of the client, to perceive the world as the client sees it, to perceive the client himself as he is seen by himself, and to lay aside all perceptions from the external frame of reference while doing so.”^1(p86) In calling for a change in the therapist’s attitude and orientation toward those being treated, client-centered therapy is a response to overbearing psychoanalytic and behavioral therapies, ie, therapies built around rigid models applied by self-assured counselors.

What is often forgotten, however, is that things such as client-centered therapy, “mental hygiene,” and “self-help” were also responses to another phenomenon—the charismatic physician. In the premodern world, before doctors prescribed science and began using an arsenal of instruments, they relied primarily on their experience, skills of observation, and bedside manner to treat patients: the key was to establish and maintain the patient’s trust.²

The role of the physician was partly performative, ie, it was necessary to actively instill confidence in his or her talents and expertise. At the same time, patients were notorious for their reluctance to follow orders. They had a habit of complaining and a penchant for self-diagnosis and self-medication. These patterns continued during the 1800s, when academically trained physicians widely experienced a marked social mobility, entering the ranks of the privileged middle class. The result was that doctors in the 19th and early 20th centuries often assumed an officious air of superiority.²

Things were no different within the specialty of psychiatry. When the first specialists referred to as “mad-doctors” began to emerge in the late 18th century, the force of their personalities was often seen as the key to the success of their treatments. Rev Dr Francis Willis (1718 - 1807)—the man enlisted to treat King George III’s apparent madness from 1788 to 1789—was purported to have an almost magical gaze, described as: “He suddenly became a different figure commanding the respect even of maniacs. His piercing eye seemed to read their hearts and divine their thoughts as they formed and before they were even uttered. In this way he gained control over them which he used as a means of cure.”³

Philippe Pinel (1745 - 1826), credited with removing the use of chains and introducing talk therapy (“the moral treatment”) in asylums, nevertheless insisted on the necessity of applying a mental “force evidently and convincingly superior”⁴ when confronting “maniacs.” This included the staging of what he termed “pious frauds,” such as giving one delusional patient the impression that staff would beat him up if he continued to refuse to eat his meals.⁴

The power psychiatrists wielded over their charges was hardly deemed an ethical challenge or a necessary evil. Far from it. In Germany—where the asylum director was referred to as the “asylum father” (Anstaltsvater)—the role of the alienist or psychiatrist was modeled on the prevailing ideal of the domestic household: the wise director treated his residents as naive and misguided children who required constant supervision and correction.