W.W. Norton & Co., 366 pages, $27.95
In an age of brain scans and plentiful pharmaceuticals, it can be hard to remember that psychiatrists — not exactly known for their aversion to dispensing medication — were once derided for not taking medicine seriously enough.
But as Anne Harrington reminds us, it wasn’t all that long ago when psychiatrists were pilloried as a bunch of woolly Freudians in thrall to specious ideas about absent fathers and smothering mothers. (Or absent mothers: There apparently were infinite ways that mothers could impair the mental health of their children.) In her new book, Mind Fixers: Psychiatry’s Troubled Search for the Biology of Mental Illness, the historian of science at Harvard University says that psychiatry’s biological turn took place sometime around 1980, and it was so revolutionary that before the decade was up, the profession’s “transformation into a biological discipline seemed complete.”
There’s a good deal of drama contained in that little word “seemed.” What “seemed complete” actually wasn’t, Harrington argues. Anticipated discoveries in the biology of mental illness, vigorously hyped before they even arrived, never panned out: All of psychiatry’s diagnostic categories today are still based on observations of clinical symptoms rather than on biological markers of disease. Criticism from outside the profession precipitated “a sense of internal crisis” within it. A number of psychiatry’s practitioners are beginning to concede that the field “overreached, overpromised, overdiagnosed, overmedicated and compromised its principles.”
Neither this harsh realization nor others will necessarily put an end to what Harrington calls “the century-long — if also repeatedly frustrated — effort on the part of especially American psychiatry to define a biological mission for itself.”
To hear the vanguard of psychiatry’s biological revolution tell it, the late 19th century was a period of incredible scientific progress for the profession, interrupted only when Freud and his acolytes took over in a palace coup. But the 19th-century way of “thinking biologically,” Harrington writes, was fixated not on biochemistry, but on brain anatomy. Clinicians were preoccupied with “degeneration” and drawn to eugenics.
In the United States, “feebleminded” became a catchall diagnosis deployed by advocates of forced sterilization. Oliver Wendell Holmes Jr., writing the Supreme Court’s majority opinion for Buck v. Bell in 1927, called the nation’s eugenics program “better for all the world” because, as he put it, “three generations of imbeciles are enough.” Six years later, the Nazis cited the Buck v. Bell decision as an inspiration for their own sterilization program, which laid the foundation for the Third Reich’s systematic murder of those deemed genetically tainted and mentally ill.
Harrington is unsparing in her depiction of what often resembled biological fetishism in this country. Schizophrenic patients were subjected to insulin-induced comas or had their brains scraped by lobotomies. Some psychiatrists, impressed by the germ theory of disease, believed that psychosis could be cured by surgically removing a patient’s “infected” teeth, ovaries, or colon.
Psychoanalysis and talk therapy were supposed to be antidotes to such cruelty and coarse reductionism. Instead, the postwar psychoanalytic dispensation created “a generation of scapegoated parents” who were blamed for their children’s mental illnesses, Harrington writes.
We know what happened after that. Psychiatrists, seeking to distinguish themselves from other mental health professionals, moved away from talk therapy and guarded their prescribing rights. Financial incentives from the pharmaceutical industry meant that practitioners helped drug companies repurpose old medications for new “illnesses,” like “social anxiety disorder.” It was the medical equivalent of mission creep.
Harrington doesn’t romanticize the world of mental illness before drugs, which many patients credit with offering relief and even a chance at survival. What psychiatry needs to do, she says, is narrow its focus to the most severe forms of mental illness and “make a virtue of modesty” rather than hubris. She knows it’s a somewhat fanciful idea, but it’s a measure of her own clear-eyed approach that she appeals to psychiatrists’ self-interest by invoking that most valuable and (these days) elusive currency: trust. “The field would be freed,” she writes, “to find ways to rest its authority and status on more authentic foundations.”