Psychiatry Research Paper

1. Moral Treatment

Psychiatry’s founding therapeutic strategy was of combined Anglo-French provenance and as such became the subject of a muted, international priority dispute. Cursorily defined, the moral treatment for the cure of insanity meant the use of methods that engaged or operated on the intellect and emotions, as opposed to the traditional methods of bleedings, purges, and emetics applied directly to the lunatic’s body. By all accounts, the British cleric and physician Francis Willis had employed moral methods when in 1788–9 he assumed the weighty responsibility of treating the madness of King George III. His contemporary, the French physician Philippe Pinel, duly credited Willis and others with having inspired his own efforts. But when codifying the moral treatment in his Traite medico-philosophique sur l’alienation mentale (1801), Pinel also accused his British colleagues of willfully failing to spell out the method they so enthusiastically recommended. For their part, British reviewers of Pinel’s Traite dismissed the Frenchman’s supposed innovations as pale imitations of British practice.

Wherever priority lay, the moral treatment proved notoriously resistant to precise definition. Contrary to his avowed intention, Pinel never provided an explicit definition in his Traite. He instead presented a series of case histories of his own use of the treatment, leaving to his readers the task of inferring its central features. These included:

(a) A preference for ‘gentleness’ as a therapeutic technique. This choice was rooted in an optimistic Enlightenment belief that insanity never involved a complete annihilation of reason, reducing the mad person to animality, but that a glimmer of ‘humanity’ always remained and could be appealed to and reinforced.

(b) The use of ‘repression’ only as a last resort and then without anger or cruelty. When acting in a repressive capacity, the healer of the insane was expected to exude authority through his physical presence—Willis, for example, was known for his ability to command the obedience of the mad by his piercing gaze.

(c) The grounding of the treatment in an etiology of insanity based on the sensationalist psychology of John Locke and the abbe de Condillac. Regarded as a set of erroneous ideas that had become implanted firmly in the mind, insanity could be cured by a jolting experience that dislodged those ideas and enabled their replacement by sound ones. Hence the theatrical aspects of Pinel’s moral treatment: vivid scenes were staged deliberately to impress on mad persons the falsity of their pathological beliefs (Goldstein 1987, Porter 1987).

Clearly, such a therapeutic strategy stamped psychiatry as a humanitarian endeavor and a product of the Enlightenment faith in science. In France, these affiliations were strengthened further by the link between psychiatry and the French Revolution. The Revolutionary government put Pinel in control of the Paris institutions for the insane, and according to a myth that took shape over the course of the nineteenth century, and has only recently been debunked by historians, he inaugurated the moral treatment by literally unchaining the inmates of Bicetre, an emancipatory gesture that cured them instantaneously. In the USA, the chief proponent of the moral treatment, Benjamin Rush, was so ardent a supporter of the American Revolution that he even figured among the signatories of the Declaration of Independence (Binger 1966). In Britain, ratification of the moral treatment took place in the context of parliamentary investigations into the civil liberties violations entailed in the maltreatment of incarcerated lunatics (Scull 1975).

But if the moral treatment had strong associations with Enlightenment and political liberty, it also lent psychiatry an unscientific taint that proved difficult to eradicate. For, as its proponents liked to point out, it had originated among healers without official educational credentials. Pinel was a bona fide physician but, in keeping with the hostility of the French Revolution toward all privileged corporations, he proudly announced that neither he nor any other member of a medical faculty had devised the moral treatment, that it was the work of a humble layman who served as hands-on caretaker of the insane at Bicetre. His own contribution was, he said, to have rendered the caretaker’s version of the treatment scientific, translating it into the language of sensationalist psychology and demonstrating its efficacy with the new mathematical tool of statistics. Reliance on the moral treatment left Pinel’s successors vulnerable to competition from traditional Catholic healers of the insane, who argued persuasively that medical men had no special skills in administering a noncorporeal remedy. Indeed in France the dispute between alienists and clerics for control of the treatment of insane continued until the end of the nineteenth century, when the anticlerical policies of the Third Republic decided conclusively in favor of the former (Goldstein 1987).

In Britain, it was a layman, the tea merchant William Tuke, who instituted the moral treatment at the York Retreat, the influential Quaker facility for the insane. Tuke was highly vocal about his distrust of medical practitioners pretending to treat insanity with Physick. After a long period of uneasy debate between the models of medical and moral therapy, the official line of British psychiatry became in the 1840s that a judicious combination of both had greater efficacy than the sole use of either. In adopting this position, British psychiatrists shrewdly obviated the protest that clergymen were better equipped than physicians to handle insanity (Scull 1975).

2. The Asylum

The insane asylum is one of a group of institutions, which, in the 1960s, the American sociologist Erving Goffman (1961) labeled ‘total’ and, in the 1970s, the French philosopher Michel Foucault (1975) described as ‘panoptic.’ For Goffman, such institutions are characterized by locating the ordinarily compartmentalized activities of sleep, play, and work under a single roof and a single authority and by erecting barriers, both legal and architectural, to social intercourse with the outside world. For Foucault, they are characterized by the incessant visibility of the inmates to the authorities, a visibility redounding to the power of the latter. Both theorists stressed the tight schedule of activities enforced in such institutions. Both noted their proliferation in the West during the late eighteenth and early nineteenth centuries, the period that saw the birth of prison and poorhouse as well as insane asylum.

In itself, the incarceration of deviant populations was no novelty. At least since the ‘Great Confinement’ of the mid-seventeenth century, western European governments, especially the absolutist monarchies of the continent, had made a concerted effort to establish good order by removing troublemakers from social circulation. The novelty lay rather in an unprecedented confidence in the rehabilitative power of certain forms of incarceration and in a fresh taxonomic sensibility that led to the division and strict segregation of deviants according to type. By contrast, the French hopital general of the age of Louis XIV and its counterparts, the British workhouse and the German Zuchthaus, had entertained no therapeutic ambitions and had lumped together madness, idleness, and debauchery as fully comparable species of unreason (Foucault 1961).

The classical scientific rationale for the asylum was provided in 1819 by Pinel’s student J. E. D. Esquirol, who also appropriated the old term ‘asylum’ (asile), meaning a place of refuge, to underscore the benevolent ethos of the new institution. The asylum could cure insanity, said Esquirol, because it temporarily removed mad persons from their habitual surroundings. By dint of this ‘isolation,’ as he called it, the institution operated as an instance of the moral treatment: the psychic jolt of sensory stimuli arising from a radically altered physical and interpersonal environment dislodged the patient’s erroneous ideas, which could then be replaced by rational ones through the expert interventions of the psychiatric doctor. The latter’s therapeutic authority was enhanced by the fact that, in the artificial, self-contained world of the asylum, he ruled absolutely (Goldstein 1987).

Like the embrace of the moral treatment, so, too, the wedding of psychiatry to the institutional form of the asylum imposed special professionalization problems on the emergent specialty. In order to survive collectively, psychiatrists needed the support of a governmental or private agency willing to make large capital investments in the construction of asylums and motivated to place the psychiatrist at the top of the asylum’s hierarchy of personnel. These goals were first achieved in France, where Esquirol and his disciples joined with moderate liberal politicians to secure passage of the Law of 1838. The Law mandated the establishment of a nation-wide network of asylums headed by psychiatrists, who thereby became salaried functionaries of the French state. In the less centralized British state, psychiatric victory came more gradually. An Act of 1808 providing for the construction of asylums financed by the county rate made no provision for the inclusion of a medical man on the staff. Only with the passage of the Lunatics Act of 1845, which placed institutions for the insane under a permanent national inspectorate composed of lay, legal, and medical commissioners, did the British introduce even an implicit force for the medicalization of the asylum (Jones 1955, Scull 1975).

A combined impulse toward rational state-building and enlightened humanitarianism led the disunified German lands of the first half of the nineteenth century to a spate of new-style, public asylum foundings as well as the medical restructuring of old-style, multi- functional absolutist institutions of incarceration (Goldberg 1999). In the USA, the asylum-building vogue of the same period occurred in two phases: first, emulation of European models in new, privately funded eastern-seaboard institutions; then, goaded by the Jacksonian-era critique that the frenetic com- petition for wealth and power in democratic America actively bred insanity, the establishment of public asylums by most state legislatures. American asylums were run by medical superintendents—the early name for psychiatrists in the USA—and were so plentiful that an Association for Medical Superintendents was formed in 1844 (Rothman 1971).

3. Late Nineteenth-Century Reconfigurations of Psychiatry

The second half of the nineteenth century saw important changes in the institutional and intellectual models that had launched psychiatry. Most dramatically, the prevailing optimism about the therapeutic effect of the asylum gave way to deep pessimism as asylum populations swelled with chronic patients demonstrably impervious to moral treatment (LanteriLaura 1972, Scull 1979, Rothman 1971). At about the same time, psychiatrists abandoned their earlier conception of insanity as a curable psychological or psychosomatic disorder and theorized it as an irreversible brain condition and often as a product of ‘degeneration.’ This degeneration was defined as a pathological departure from the norm initially caused by a noxious environment, poor nutrition, or alcoholism, and subsequently transmitted in the Lamarckian manner through heredity, becoming more severe with each generation. Every European nation had its fin-de-siecle theorists of degeneration: Benedict-Augustin Morel and Valentin Magnan in France, Cesare Lombroso in Italy, Henry Maudsley in Britain, Richard von Krafft-Ebing and Max Nordau in Austria (Pick 1989).

The shift to an organicist conception of insanity was coupled with a shift in psychiatry’s international center of gravity from France to Germany. By the midnineteenth century, German physicians had thoroughly repudiated an earlier affinity for Romantic, holistic Naturphilosophie. Their new taste for positivism was epitomized in psychiatry by Wilhelm Griesinger’s textbook, Pathologie und Therapie der psychischen Krankheiten (1845) that equated psychiatry with the study of cerebral lesions. Griesinger also epitomized the era’s new psychiatric career pattern: he was not an asylum doctor but a university psychiatrist, having been appointed in 1865 to the recently created Chair of Psychiatry and Neurology at the University of Berlin (Decker 1977). Later adopted in other countries, the university psychiatry model increased the attractiveness of the psychiatric career, offering the practitioner a less reclusive lifestyle than was afforded by residence in an asylum. It also changed the intellectual content of the career: psychiatric knowledge was now assumed to be generated less from clinical contact with the insane than from neuroanatomical research in a university laboratory.

A second late nineteenth-century reconfiguration likewise encompassed both psychiatry’s scientific theory and its career structure. Asylum psychiatry had worked with a simple binary opposition between sanity and insanity. After 1850, however, psychiatrists began to speak of a large intermediate zone occupied by the demi-fous, or half-mad. This conceptual move eventually led to the articulation of two categories fundamental to the enterprise of twentieth-century psychiatry: the ‘psychotic,’ whose contact with reality is severely ruptured, and the ‘neurotic,’ whose minimal maladaptations do not preclude getting on in ordinary society. The former, requiring institutionalization, fit the older model of asylum psychiatry. The latter, who could safely remain in the outside world but would benefit from scheduled visits to the doctor’s office, made possible the practice of outpatient psychiatry.

A rough international division of labor governed research on the neuroses and psychoses. The Parisian Jean-Martin Charcot and his many students dominated the study of the less severe forms of mental illness, especially hysteria. Munich-based Emil Kraepelin and his school continued German psychiatric preeminence through their domination of the study of the psychoses. Kraepelin made a psychiatric staple of the diagnostic category, dementia praecox, a state of emotional detachment and vacuousness that declared itself in adolescence and carried an invariably bleak prognosis. (The Swiss psychiatrist Eugen Bleuler would in 1911 rename the condition schizophrenia and insist that it might have a favorable outcome.) The Kraepelinian approach held sway in many countries, including the USA, through the first quarter of the twentieth century.

4. Twentieth-Century Trends in Psychiatry

In broad outline, three trends distinguished psychiatry in the twentieth century: the emergence of Freudian psychoanalysis; the discovery and use of psychotropic drugs; and the antipsychiatry movement.

Created by the Viennese neurologist Sigmund Freud as an outpatient treatment for neurotic disorders, psychoanalysis was initially distant from institutional psychiatry. Indeed, Freud’s professional overtures to Bleuler and Carl Jung, Bleuler’s assistant at the Burgholzi asylum in Zurich, can be read as efforts to obtain a psychiatric imprimatur for the new discipline of psychoanalysis (Freud 1914). Freud never fulfilled this ambition in Europe, but in the less traditionbound scientific environment of the USA, many professors and medical superintendents welcomed his ideas. Eventually, American psychiatry fully incorporated psychoanalysis. In 1924, when William Alanson White, who had introduced psychoanalytic psychotherapy for schizophrenic patients at St. Elizabeth’s Hospital, became president of the American Psychiatric Association, that organization and the American Psychoanalytic Association began holding their annual meetings together. This arrangement lasted until 1974, by which time the Freudian ardor of American psychiatrists had cooled (Barton 1987).

Waning interest in psychoanalysis on the part of American psychiatrists coincided with rising expectations for psychopharmacology on the part of the international psychiatric community. The first psycho- tropic drug, lithium, was used successfully to manage manic-depression in Australia in 1949. A variety of antipsychotic and antidepressant compounds, most notably the phenothiazines and imipramine, were developed in France and Switzerland in the early 1950s (Baldessarini 1977). The fluoxetine family of antidepressants, whose first member went under the brand name Prozac, was introduced in the USA in the late 1980s and became among the most widely prescribed drugs in the world. Psychopharmacology brought a new wave of self-confidence and therapeutic optimism to psychiatry, promising a relatively safe, speedy, and cost-effective method of alleviating mental illness. It also revived psychiatry’s identity as a ‘hard’ and exact science, the identity cultivated in the second half of the nineteenth century.

Somewhat ironically, then, the reliance on psychotropic drugs was one of the causes of the antipsychiatry movement of the 1960s. Since the beginning of the specialty, psychiatry’s incarcerative practices had given rise to sporadic criticism, and some psychiatric abuses, notably the ‘euthanasia’ program mounted by the Nazi regime during World War II, have only been fully uncovered after the fact (Burleigh 1994). But the antipsychiatry movement of the 1960s, centered on the London-based psychiatrist R. D. Laing, questioned the specialty even more radically and globally. It charged that madness was neither an objective biochemical nor behavioral condition, but a context dependent label; that Western rationalism was predicated on a denial of its value; and that psychopharmacology robbed patients of the potentially enriching and self-healing experience of full-blown psychosis. Laing’s views were supported by the psychiatrist Thomas Szasz in the USA and to some degree by the philosopher Michel Foucault in France. Antipsychiatry gave impetus to the deinstitutionalization of the insane, which occurred in the late 1970s and the 1980s. A less controversial outcome of the movement was the recognition of the patient’s right to refuse antipsychotic drugs and electroshock therapy (Sedgwick 1982).

The antipsychiatry movement has now largely spent its force. But as the twenty-first century begins, psychiatry, while among the oldest of the medical specialties, lacks the stability that age might seem to confer. It remains hostage to the mind–body problem, buffeted between psychological and physical definitions of its object and its methods.

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