Affirming Psychiatry - Episode 3

The History of Psychiatry—A History of Failure?

How does a recent critique of the history of psychiatry get it wrong?

AFFIRMING PSYCHIATRY

Psychiatry as a medical discipline is a failure. Even worse, psychiatry constitutes a series of failures over its 2-century history. The 19th-century asylums movement failed. Kraepelin’s descriptive psychiatry failed at the turn of the century. The pluralistic psychiatry of Adolf Meyer failed, leading an anything goes mentality up to and including lobotomies. The Freudian revolution ended in a “slow train wreck,”1 leaving psychiatry in embarrassing disrepute. And last of all, psychiatry’s so-called biological revolution fizzled out in failure, as drug companies abandoned a profession “in crisis.”

Who says so? The writer of the most highly lauded and widely read history of psychiatry today, Professor Anne Harrington, PhD. The name of that history is Mind Fixers.1 And as histories of medical specialties go, Harrington’s work is an undisputed home run. Science called it a “masterpiece,”2 while Nature said it was “enthralling.”3 For the Wall Street Journal, it was “superb,”4 and every major periodical in the country reviewed it favorably. Former National Institutes of Health Director Steven Hyman, MD, offered a back-cover blurb, and Awais Aftab, MD, of Psychiatric Times™ opined that “every psychiatrist should read it.”5

Is the book really as negative as I have described? Yes and no. On one hand, Dr Harrington is a skillful writer who is clearly fluent in social and intellectual history. Reading this work was like diving into an extended New Yorker or Atlantic piece, such that “enthralling” is not an unfair description. And as the back cover tells us, Dr Harrington’s work is even-handed—at least on the surface. It is neither a polemic nor an exposé. Harrington takes a mostly agnostic approach to the controversies surrounding the field, speaking with a sort of sympathetic irony about psychiatry’s misadventures. And to her credit, she regularly empathizes with the perspective of patients and families, whether it is their suffering, their sense of mistreatment, or their sense of gratitude for successful treatment.

So, what is my beef with this universally lauded work? My problem is with its metanarrative, which is neither balanced nor accurate, whose misleading take-home message perpetuates a destructive picture of the state of our field. By giving our intelligentsia the impression that psychiatry is directionless and fundamentally inept, Dr Harrington inadvertently reinforces a cynicism about mental health treatment that is sadly out of date, and a despair about progress that undermines the hopes of individuals with mental illness and their families. In short, she reinforces the notion that psychiatry is particularly prone to corruption, “troubled,” and “in crisis,”1 a notion that continues to do damage to public mental health and public support of mental health treatment.

Does Dr Harrington really describe our history as a series of failures? Consider her own summary1:

“The 19th-century mental hospital has failed as a therapeutic institution? All right, forget about therapy, and focus on learning what you can from the brains of your patients… The anatomical research program has been a disappointment? No problem: Focus instead on… [Adolf Meyer’s pluralistic and pragmatic psychiatry. Does this lead to] more harm than good? That’s okay: The postwar world is in crisis and needs the insights provided by psychoanalysis and social science. Things haven’t worked out with the Freudians’ expansive social agenda? Psychiatry is on the brink of losing all credibility as a profession? Not to worry: Let the biologists take over!”

And the “false dawn” of the biological revolution? It has “now run into the sand as well,” leaving psychiatry shipwrecked and (you guessed it) “in crisis.”1

Given this narrative, does our author truly believe that there has been no progress in psychiatry? In a Psychiatric Times™ interview, Dr Aftab put the question to her, suggesting that there has been a combination of progress and failed revolutions in psychiatry. In response, Dr Harrington doubled down on her narrative, stating that new generations of psychiatrists simply discard the lessons of the past. Even as new approaches uncover new truths, old truths and lessons are forgotten. Psychiatry remains locked in a barren cycle of becoming “more knowledgeable about some things and more ignorant about other things” through revolution after revolution.6

In truth, Dr Harrington’s meta-narrative is demonstrably false. The asylum movement did not fail. It constituted a sustained advance over previous desperate and barbaric responses to severe mental illness, with a genuine effort to provide humane and helpful care. It declined only due to scandalous underfunding and the appearance of effective pharmacological agents. The neuroanatomical psychiatry that followed did not fail. Neuroanatomical research became a permanent and increasingly important aspect of psychiatric science, and it continues to progress along with the rest of neurobiology.

Kraepelinian psychiatry—a longitudinal and symptomatic perspective on nosology—continues to be fundamental for psychiatric diagnosis and will remain so until neurobiological disease categories replace it. Psychodynamic (Freudian) psychiatry continues to thrive, along with numerous other scientifically validated psychological treatments (including cognitive behavioral therapy and dialectical behavior therapy). Indeed, psychotherapeutic approaches to mental illness are now better developed and tested than at any time in the history of psychiatry. Biological psychiatry did not die or even fade during the last decade. It continues to progress, as even a casual glance at any recent issue of a major psychiatric journal will show.

None of the lessons of the major schools of psychiatry have been abandoned. All these approaches have continued to advance and become parts of a larger whole. All psychiatry residents still receive extensive training in inpatient care (asylum psychiatry), neurobiology (anatomical psychiatry), psychopathology and diagnosis (Kraepelinian psychiatry), biopsychosocial treatment (Meyer’s psychobiology), psychotherapy (Freudian psychiatry), and of course biological psychiatry. All of these are alive and well, so much so that Dr Harrington’s inability to acknowledge their survival and growth begins to appear perplexing, if not bizarre.

It does not take a great deal of reflection to recognize profound progress in psychiatry. Seventy-five years ago, there were no specific psychiatric medications, and the average stay in a psychiatric hospital was 11 years.7 Fifty years ago, psychotherapy was scientifically unproven while available medications were extremely difficult to tolerate. Regardless of psychiatry’s shortcomings, today is beyond a doubt the best time in human history for patients and families who face mental illness. If public intellectuals such as Dr Harrington are unwilling to say so, then we as psychiatrists should not be shy about setting the record straight. Failure to acknowledge psychiatry’s progress might be, after all, the most destructive failure of all.

Dr Morehead is a psychiatrist and director of training for the general psychiatry residency at Tufts Medical Center in Boston. He frequently speaks as an advocate for mental health and is author of Science Over Stigma: Education and Advocacy for Mental Health, published by the American Psychiatric Association. He can be reached at dmorehead@tuftsmedicalcenter.org.

The author wishes to thank Ronald W. Pies, MD, and Mark L. Ruffalo, DPsa, LCSW, for their review and comments on an earlier draft of this article.

References

[1]. Harrington A. Mind Fixers: Psychiatry’s Troubled Search for the Biology of Mental Illness. Norton & Company; 2019.

2. Casper ST. The history and future of neurological care. Science. 2019;364(6437):243-244.

3. Harrington A. Psychiatry crisis is a chance to change tack. Nature. 2019;570(7761):307.

4. McNally R. ‘Mind Fixers’ review: there has to be a better way. The Wall Street Journal. May 3, 2019. Accessed April 14, 2022. https://www.wsj.com/articles/mind-fixers-review-there-has-to-be-a-better-way-11556898375

5. Aftab A. It’s time for us to stop being so defensive about criticisms of psychiatry. Psychiatric Times. January 6, 2022. April 14, 2022. https://www.psychiatrictimes.com/view/its-time-for-us-to-stop-being-so-defensive-about-criticisms-of-psychiatry

6. Aftab A. The many histories of biological psychiatry: Anne Harrington, DPhil. Psychiatric Times. 2020;37(7).

7. Kramer M. Long-range studies of mental hospital patients: an important area for research in chronic disease. Milbank Mem Fund Q. 1953;31(3):253-264.