Read a Book, Why Don't You?
Desperate Remedies by Andrew Scull
Desperate Remedies is a serious scholarly book written by Andrew Scull and not to be confused with a less-serious and non-academic Australian movie from the 1990s with the same name. The book Desperate Remedies is a 200-year history of psychiatry in America and carries the subtitle, Psychiatry’s Turbulent Quest to Cure Mental Illness. The author’s surname and the books’ content makes me wish he had a co-author named Bones.
That being said, the book is erudite, polished, meticulously researched, and quite academic, although the author is at time witty and not above an occasional wry observations. To be fair, it’s not a funny topic. The sad conclusion of this important book is that in 200 years of working on mental illness, we not only can’t cure it, we don’t know what causes it, and we aren’t even really clear on how to define it.
Looking back over recent American history, one generation’s mental illness is another generation’s form of self-expression. It does not help that society has often used mental health as a sledge hammer to pound people into or out of certain types of behavior. Too many boisterous boys in the classroom? Bring out the drugs. Young women anxious about living in the modern world? They might need a few prescriptions. Sedentary people watching computer screens all day take benzodiazepines to sleep. Alas, apparently we Americans have always been ready to medicate inconvenience.
You can test a person’s blood to find out if they might be diabetic; you can X-ray an arm or leg to see if it’s fractured; and you can excise a tumor and run histology tests to determine if it is benign or malignant. But with mental illness, the diagnosis is based on signs and symptoms. Signs are things that the doctor or clinical team sees that the patient does not. A sign of mental illness might be incoherent speech or staring off into space for hours. A symptom is what the patient self-reports and self-reports are inherently subjective.
And the really confounding factor is that people with genuine forms of mental illness are precisely the ones who might hide, embellish, exaggerate, or distort symptoms to get attention or medication.
One problem with mental illness is that we do not know what it is. We assume it must originate in the brain, but where? Imaging studies of the brain have been inconclusive in helping us to pinpoint what is actually going on. The brain of a person with Alzheimer’s disease has marked signs of amyloid plaques and shrunken areas, but Alzheimer’s disease is an actual disease and not a mental illness. Imaging studies of people with borderline personality disorder or bipolar disorder do not show specific signs. So what is going on? Genetic studies suggest that schizophrenia might be heritable, but there are cases of identical twins in which one develops schizophrenia and the other does not. And most cases of schizophrenia occur in people with no family history of the condition.
Even the definition of schizophrenia shows you what is wrong with our approach to mental health. The Mayo Clinic says that people with schizophrenia interpret reality abnormally and the condition causes problems with thinking, behavior, and emotions. At the extreme, one can understand debilitating schizophrenia, but all of us have had experiences in which we misinterpreted reality, thought wrong thoughts, behaved inappropriately, and experienced toxic emotions. Since schizophrenia by definition can wax and wane even to the extent that symptoms sometimes go away altogether, it is hard to understand what this condition really is.
In the 200-year history of American mental health efforts that Scull lays out so carefully, it is more than evident that one of the big problems with mental illness is not just the problems it causes the patients; mental illness is inconvenient for everyone else.
Just as asylums were built in the 1800s to warehouse these inconvenient souls, today the mentally ill are adrift in society and are often found in squalid homeless encampments. Homelessness and mental illness go together like narcissism in Hollywood. It is not entirely clear if one causes the other and which comes first. Most longer-term homeless people have a diagnosable mental illness, often compounded by a substance use disorder. This is our modern trifecta of misery: homelessness, substance use disorder, and mental illness. It’s a major public health crisis that boils down to just this: what do we do with these people? The asylum approach decided it was best if these people could just be sequestered where they no longer interfered with the activities of others.
Modern medicine sought to cure them, but our efforts only seem to make things worse.
The asylum approach worked for a while. But mental institutions posed two major and unforgivable problems. First, it was all too easy to whisky an unpleasant person away forever into a sort of quasi-prison with no sentence limits and no way for them to “prove” they deserved their freedom. The second unforgiveable problem was that despite the medical establishment’s occasional zeal in finding a cure for mental illness, no one much cared about the mentally ill as people. Doctors tested bizarre treatments on these confined individuals without informed consent.
When the refined world of European academia met the harsh and unsustainable realities of asylum culture, it gave rise to modern psychiatry, a medical specialty based on an illness that could not be defined. Psychiatrists saw themselves early on as “experts,” and that is a dangerous person to know for a patient with virtually no rights and no voice in their own care decisions. These so-called experts started with physical treatments to their patients. Early on, they might extract the teeth of a mentally ill person in the hopes it would cure him. There was no reason to believe dental extractions would be helpful, but eager psychiatrists were willing to experiment. The patients had no say.
Needless to say, the toothless approach did not work. Psychiatrists then graduated to electro-convulsive therapy or ice baths. The lobotomy was an operation done (sometimes literally with an ice pick through the eye) to scramble the brain tissue in a semi-random way in the hopes that it would help improve the person’s ability to think rationally. There was no scientific evidence that this would help, but lobotomies were presented as “cutting-edge treatment.” The most famous victim of lobotomy was Rosemary Kennedy, John F. Kennedy’s older sister. Rosemary was born “mentally defective” due to lack of oxygen during birth. Intellectually far behind her siblings, Rosemary suffered seizures that further isolated her. Her wealthy parents pulled her out of school and provided tutors and later a private Catholic school education. Rosemary was described as a pretty and affectionate young woman, but she posed a major inconvenience to the Kennedy clan when she started sneaking out late at night and going to bars where she struck up improper relationships with the men.
Never mind that Rosemary’s brothers did far worse things than that. Joe Kennedy was grooming his sons for political office and was worried that a promiscuous sister might be an impediment to their political aspirations. Allegedly without discussing the matter with his wife (Rosemary’s mother), Joe Kennedy authorized his daughter to be lobotomized, after which she had to be institutionalized for the rest of her life. Not only did the lobotomy not cure her mental problems, it disabled her. Rosemary never walked again, lost a lot of mobility in her arms, and could not speak. Rosemary was not mentally ill in the usual sense; she suffered mental retardation. But she was inconvenient to her family and relegated to the experts for her care.
Nobody really said this at the time, but lobotomies were known to be risky. Anyone who understood what the procedure entailed had to be suspicious. These techniques were far from scientific, and they were administered on an almost openly experimental basis.
When it came to electro-shock therapy, the same idea applied. People who had the procedures convulsed, experienced tremendous pain and fear, had brutal violent seizures, and even broke bones with the force of the electricity coursing through their bodies. The risks were well known and the benefits elusive. It was not carried out because there was scientific evidence it worked. There was virtually no proof it worked. Sometimes the people who worked in these mental institutions admitted that they some of these “therapies” were carried out as punishments for unruly patients or to subdue uncooperative individuals.
Some individuals were administered shock treatments multiple times a day, multiple days a week. No one got well.
As Scull points out, the goals of our mental health culture seem to have always been making the mentally ill more manageable so that the rest of us had an easier time. This did not actually change much when psychiatry underwent a cataclysmic jolt: the advent of psychiatric drugs. Now psychiatrists could write prescriptions from big offices, the mentally ill could be mainstreamed as outpatients and live among us, and talk therapy could round out the program. Asylums closed down.
One small problem. We still don’t know what causes mental illness. We don’t even know how to define it. We certainly don’t know how to cure it and we don’t know which among the plethora of psychiatric drugs will work in which patients. And while it is easy enough to prescribe psychiatric drugs, outpatients are notoriously noncompliant with medication regimens. Further, many people who take these drugs dislike them. And a good proportion of these drugs literally do not work as intended.
We don’t have a magic pill to treat, let alone, cure, mental illness. Our approach to mental health is bizarrely unscientific. Unvalidated and unscientific procedures that could never be used to treat, say, heart disease were tested on innocent individuals for mental illness. People were locked up for conditions that could scarcely be defined, so it was impossible to assess improvements except as creating more passive and manageable residents.
The wholly unscientific approach reserved for mental health is evident in the example of homosexuality. In the 1970s, homosexuality was defined in the Diagnostic and Statistical Manual (DSM) as a mental health disorder. This changed in the 1990s. This is probably why the DSM comes out every few years, because they keep shifting and redefining things. Now if there were a scientific reason or breakthrough studies that caused any condition to be reclassified from a disorder to a normal state, that would be one thing. Medical science is constantly learning things and that causes us to re-order our thinking. But in the case of homosexuality, there were no studies. The change was made, as one can suspect, entirely due to the prevailing culture. We changed out ideas about homosexuality. As Mae West once said in another context about goodness, “science had nothing to do with it.”
That brings us to a major issue, perhaps larger than the reclassification of homosexuality. Our medical approach to mental illness appears to define mental illness as whatever society deems to be unacceptable at the time. Observers of psychiatric medicine have often said rather disparagingly that when Big Pharma develops a new drug, once we find out what it does, we create a definition for the “disease” it can treat.
This relegates psychiatry from a hard science to a rogue form of social science. This approach is not scientific at all, it is not medical, in fact, this was not even rudimentary healthcare. Psychiatry became a way to keep inconvenient people away from the rest of us, while busy experts tried to “fix” them. It is clear in reading Scull’s lengthy and exquisitely referenced book that some psychiatrists viewed their patients as not-quite-human.
The asylums are mostly gone now and psychiatric patients have more rights and protections. But is that enough?
Let’s be fair. Some mentally ill people can be dangerous to themselves and others. Some are violent, behave objectionably, and are too unpredictable to live in normal situations. Some need constant supervision. But many are just unhappy people or people with quirks or unrealistic ideas and weird behaviors.
So what is mental illness? We do not know. The best we’ve been able to come up with are descriptions of symptom clusters in the latest DSM. It is not always clear when behavior is normal (or at least “not abnormal”) in its holistic context and when it is frankly aberrant. Nor do we know the point where aberrancy lapses into dangerous or unhealthy behaviors. For example, there was a time when depression was considered normal when it was “incidental,” meaning there was an incident that caused the depression. When Queen Victoria lost her beloved husband Albert, she fell into depression which some say lasted the rest of her life, but it was deemed normal because it was incidental. She was in mourning.
Today, the distinction between incidental and other depression is not well drawn or ignored altogether. In other words, the prevailing mental health attitude is we should all be happy and peppy all of the time. Being sad or tired requires medication. That may not be much of an improvement over the old asylum culture.
In today’s America, one in every 12 children are taking a psychiatric drug. That number includes over 1% of preschoolers. Almost 13% of junior and high school students are taking a psychiatric drug. Some have put the number of American kids taking these hardcore psychiatric medications at over 6 million children. Boys are more likely to be prescribed these medications than girls. Some of these kids are on polypharmacy before they get their high school diploma.
The recklessness of this medication of our youth reminds me of the old ice-pick lobotomies. We have no idea what these heavy-duty medications will do to developing brains. While it might be reasonable to give these drugs to certain children in specific, highly supervised situations for study, they are handed out like candy. Schools practically mandate these drugs for certain unruly students. What happens when an 18-year-old graduates after taking psychiatric drugs for 10 years? We don’t know. Is his brain different than what it might have been had he not been given drugs for so long? Again, no clue.
Do we care? Since the human brain does not fully develop until its owner is in the early 20s, it is not understood at all if taking powerful drugs that can rewire the brain for immediate behavior control might rewire a child’s brain in a permanent way. And not all drugs even work. Some kids are taking psychiatric drugs that aren’t helping them and may harm them.
Oh well.
Scull offers no hopeful conclusions in his book but he may be offering us a sequel at some point. As a historian and reporter, his job is to document what has happened, not to figure out a way out. Still, it was kind of depressing.
Excellent book, but sorry state of affairs.