David Robertson // Over the last twenty years, considerable scholarly contributions have been made to the history of psychiatry. We have had historical analyses of the concept of “nerves” and “neurasthenia,” of “trauma” and the emergence of diagnoses such as Post-Traumatic Stress Disorder.[1] Historians have examined the material settings of neuropsychiatric efforts to localize brain functions and of the material links between hypnotic practices and ‘the emergence of the psychoanalytic setting.’[2] Politically-evoking texts have criticized psychiatry’s repressive overextensions along the lines of race, gender, and sexuality.[3] Some have attempted to replicate the “biography of disease” model that has been a long-standing trope in the history of medicine.[4] More recently, scholars have turned their attention to the history of pharmaceuticals and even the role of hallucinogenic substances or “psychedelics” in psychiatric research.[5] In short, one could be forgiven for knowing the history of psychiatry as the history of multiple strands running parallel but rarely overlapping to form a single tapestry.
Anne Harrington’s Mind Fixers: Psychiatry’s Troubled Search for the Biology of Mental Illness (2019) is a pioneering effort to weave this rich literature together into a single narrative. While her focus is, as the subtitle suggests, on the biological impulses of psychiatry, her story draws from a wide literature on the history of psychoanalysis, deinstitutionalization, psychopharmacology, and research with hallucinogens such as LSD and mescaline.
There is a familiarity to the historical rhythms of Harrington’s account, but this is not, as one reviewer has recently suggested, the history of ‘a series of pendulum swings’ in the discipline.[6] Such an approach tends to portray the history of psychiatry as having its origins in nineteenth-century somatic psychiatry, giving way to a brief psychoanalytic hiatus in the middle decades of the twentieth-century, and then again returning to its purportedly nineteenth-century biological roots with the publication of the third edition of the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders (DSM-III) in 1980.
This is a kind of narrative structure that also drives Mind Fixers, but Harrington references the pendulum metaphor only once, to demonstrate its simplification of the past for purposes of mythic representations. As she clarifies at the beginning of her first chapter, “Betting on Anatomy,” late nineteenth-century biological psychiatrists were ‘most emphatically not us. Their way of thinking biologically was not the same as ours. They were preoccupied with the brain’s solid tissue – with anatomy’ and they ‘had no understanding of the biochemical approaches that so animate our agendas’ (7-8).
Mind Fixers is divided into three parts. In the first – “Doctors’ Stories” – Harrington tracks the failure of this late nineteenth-century gamble that psychiatric disorders were brain diseases. This failure led many, ‘including a number of neurologists’, to turn ‘to non-biological understandings of mental disorders, including psychoanalytic ones.’ Meanwhile, ‘the remaining biological wing of psychiatry was left in a state of disarray and increasingly pursued a hodgepodge of theories and projects, many of which, in hindsight, look both ill-considered and incautious’ (8-9).
This hodgepodge is well-known to historians of psychiatry. It ranges from the Nobel prize-winning malaria fever treatment for syphilis discovered by Austrian physician Julius Wagner-Jauregg (patients suffering from the mental symptoms of syphilis were injected with malaria, thereby triggering a fever which often killed the bacteria causing the disease), to insulin coma therapy, electroconvulsive therapy (still seen as the last line of resort for cases of entrenched depression today) and, finally, lobotomy. While each of these treatments was heralded as a panacea for severe mental disorders, most ultimately fell out of fashion and many are today viewed as barbaric and careless.
The second section – “Disease Stories” – dedicates a chapter to the modern history (from about 1950 onwards) of three disorders: schizophrenia, depression, and manic-depression (now bipolar disorder). These are rich profiles unto themselves. In the era in which American psychiatry was dominated by psychoanalytically-inclined psychiatrists (roughly the 1940s until the 1970s), depression was a rare disorder understood to arise from aggression turned inwards against the self. Unlike today, depression was not a disorder seen as widely prevalent in society, this status instead being accorded to anxiety. ‘To be sure,’ Harrington writes,
patients in these years frequently complained to their clinicians about feeling despondent, low-energy, or chronically sad. However, psychoanalytically oriented clinicians (and even many primary care physicians) assumed that these feelings were not primary symptoms but rather a defense against more taboo and fundamental feelings of anxiety, which was supposed to lie at the heart of all “psychoneurotic disorders” (241-242).
Similarly, telling the history of schizophrenia, Harrington goes over the now familiar story of blaming parents–in particular, “schizophrenogenic” mothers. This is, once again, a history that has largely been told, but Harrington uses these disease biographies to give debates between various biological avenues of research and dominant psychoanalytic ones a new twist. Drawing on recent literature on the history of psychedelic substances in psychiatry, she demonstrates that research on hallucinogens offers an important insight into the downfall of psychoanalytic paradigms and the ascension of biochemical ones.
It is well-known that early antipsychotics such as chlorpromazine and mood treatment drugs such as the tranquillizer meprobamate (branded as “Miltown” and known as “mother’s little helper”) encouraged biological paradigms of mental disorder. However, these drugs did not fundamentally challenge the dominance of psychoanalysts, who could choose to ignore them or even to embrace them as enablers of therapy.[7] What was different about research into hallucinogens, Harrington demonstrates, was that they came to be thought of as replicating specific neurochemical processes in the brain.
Research on LSD – first synthesized in Switzerland in 1938 – began in the 1940s and led to claims that the powerful hallucinogenic drug recreated psychotic experiences in otherwise healthy subjects. Testing the substance on voluntary yet often vulnerable populations (prisoners, patients, veterans, and students) scientists claimed they could ‘make people temporarily crazy [and] create a “model psychosis” that could be studied under controlled conditions.’ ‘By the mid-1950s’, she writes, ‘at least a dozen centers in North America were experimenting with [LSD]’ (193-194).
In 1954 two researchers in New York, Dilworth Woolley and Elliot Shaw, claimed that LSD recreated psychotic states because it ‘interfered with the action of the brain’s serotonin’ (208). The possibility that schizophrenia may arise from an imbalance in neurotransmitters was a turning point in pharmacology’s contributions to psychiatry. Antipsychotics and minor tranquillizers may have been hugely popular and effective at calming psychotic patients and unhappy stay-at-home mothers, but they made no claims about the ability to “target” anything specific about a disorder. The suggestion that schizophrenia could be replicated by drugs such as LSD or mescaline through the mimicking of neurochemical processes, however, challenged psychological explanations about the etiology of mental disorders. If schizophrenia arose from a patient’s abnormal brain chemistry, then psychoanalysts’ claims about its etiology in family relationships appeared unfounded.
Unsurprisingly, the story of neurotransmitters quickly became much more complicated. Researchers experimenting with mescaline (the active ingredient of the hallucinogenic cactus peyote, which produces similar effects to LSD), wondered how serotonin could be at fault when mescaline had no impact on this neurotransmitter. Yet if the findings were unclear, they nonetheless sparked a hunt for the neurotransmitters presumed to underlie mental disorders, an impetus which later led to reductionist fantasies about the singular role of neurotransmitters like dopamine in mental states.
The centrality of hallucinogens in this story reframes present-day criticisms of “big pharma.” In the closing section, “Unfinished Stories,” Harrington draws attention to the current inertia facing the discipline and criticizes its often financially-driven cooperation with the industry.[8] This collaboration has created a threefold problem for psychiatry: there have been no new lines of groundbreaking pharmacological treatments made for decades; the perception that big pharma has hijacked the discipline, widespread among both professionals and the public, contributes to a lack of trust in the discipline; and, the role of placebos continues to challenge both the efficacy and the mechanism of psychiatric medications. In response, Harrington calls for psychiatrists to be more reflexive about the history of their discipline and to limit their interventions to those patients experiencing more severe forms of mental disorder.
Mind Fixers is a study in historical synthesis, bringing order to a long-fragmented body of literature. It is a timely and important contribution to the history of psychiatry. If there is one shortcoming to the story told here, it is its American-centeredness. To be fair, Harrington acknowledges this limit, suggesting that ‘the current confusion, frustrated hopes, and anger of the state of biological psychiatry in [the US] cry out most urgently for historical perspective and illumination’ (xvii).
This is certainly a reasonable ethical justification for her focus. But making boundaries between the production of scientific knowledge coincide with boundaries between nation-states is an impossible task. As a result, the story of the renaissance of biological psychiatry from the 1970s onward remains a US story of the “revolution” of DSM-III, omitting the critical role of events outside the US. In particular, overlooking the revisions of the World Health Organization’s own manual of mental disorders (Section V of the ICD) in the 1960s and 1970s, misses the much wider international contributions to the ascendancy of descriptive psychiatry in the postwar period. This global story, however, is one that remains largely untold and waiting to be woven into the ever-growing tapestry of the history of psychiatry.[9]
- Anne Harrington, Mind Fixers: Psychiatry’s Troubled Search for the Biology of Mental Illness (New York: W. W. Norton & Company, 2019).
Works Cited
[1] Andreas Killen, Berlin Electropolis: Shock, Nerves, and German Modernity (Berkeley University of California Press, 2006); David G. Schuster, Neurasthenic Nation: America’s Search for Health, Happiness, and Comfort, 1869-1920 (New Brunswick, N.J.: Rutgers University Press, 2011); Allan Young, The Harmony of Illusions: Inventing Post-Traumatic Stress Disorder (Princeton: Princeton University Press, 1995).
[2] Katja Guenther, Localization and Its Discontents: A Genealogy of Psychoanalysis and the Neuro Disciplines (Chicago: The University of Chicago Press, 2015); Andreas Mayer, Sites of the Unconscious: Hypnosis and the Emergence of the Psychoanalytic Setting (Chicago: The University of Chicago Press, 2013).
[3] Jonathan M Metzl, The Protest Psychosis: How Schizophrenia Became a Black Disease (Boston: Beacon Press, 2009); Elizabeth Lunbeck, The Psychiatric Persuasion: Knowledge, Gender, and Power in Modern America (Princeton: Princeton University Press, 1994); Jonathan Metzl, Prozac on the Couch: Prescribing Gender in the Era of Wonder Drugs (Durham: Duke University Press, 2003); Ronald Bayer, Homosexuality and American Psychiatry: The Politics of Diagnosis (New York: Basic Books, 1981).
[4] David Healy, Mania: A Short History of Bipolar Disorder (Baltimore: Johns Hopkins University Press, 2008).
[5] Nicolas Rasmussen, On Speed: The Many Lives of Amphetamine (New York: New York University Press, 2008); David Healy, The Creation of Psychopharmacology (Cambridge, Massachusetts: Harvard University Press, 2004); Erika Dyck, Psychedelic Psychiatry: LSD from Clinic to Campus (Baltimore, Maryland: Johns Hopkins University Press, 2008); Matthew Oram, The Trials of Psychedelic Therapy: LSD Psychotherapy in America (Baltimore: Johns Hopkins University Press, 2018).
[6] Jerome Groopman, ‘The Troubled History of Psychiatry,’ The New Yorker, May 20, 2019, <https://www.newyorker.com/magazine/2019/05/27/the-troubled-history-of-psychiatry>
[7] This is a point that historian and psychiatrist Jonathan Metzl made over a decade ago. See: Metzl, Prozac on the Couch, (2003).
[8] Author and psychotherapist, Gary Greenberg, has suggested that Harrington’s ‘dispassion’ risks underestimating ‘the significance of the troubles she is reporting’ in relation to big pharma and mainstream psychiatry. Yet even a brief glimpse of the closing two chapters of Mind Fixers demonstrates that this is an unreasonable assessment. See: Gary Greenberg, ‘Psychiatry’s Incurable Hubris,’ The Atlantic, April, 2019, <https://www.theatlantic.com/magazine/archive/2019/04/mind-fixers-anne-harrington/583228/>
[9] For more on these contributions, see: David Robertson, ‘Mental Disorders, Collective Observation, and the International Classification of Diseases,’ History of Knowledge, May 31, 2018, <https://historyofknowledge.net/2018/05/31/international-classification-of-diseases/>; and, David Robertson, ‘Databases, Diagnoses, and the History of Psychiatry,’ Synapsis: A health humanities journal, November 2, 2018, <https://medicalhealthhumanities.com/2018/11/02/databases-diagnoses-and-the-history-of-psychiatry/>
