Psychiatry’s Troublesome History: How Far Have We Come?

I was browsing the gift shop of the Glore Psychiatric Museum in St. Joseph, MO. Freudian Sips read the print on a bright yellow coffee mug. I smiled, attempting to restore a sense of levity after processing the exhibits I’d just explored. Maybe I should buy one of the Glore Museum branded squishy foam brains, I thought. A few squeezes might help ease the images in my mind’s eye away from a permanent residence in my own medial temporal lobe. I kneeled and inspected another souvenir. Would the women in my yoga class find me odd if I wiped my brow with a State Lunatic Asylum towel?

Glore Psychiatric Museum documents the history and legacy of State Lunatic Asylum No. 2. The asylum was the second state-funded facility for people labeled mentally ill to be established in the state of Missouri. It opened for business on November 9, 1874 when it accepted 25 inhabitants from among residents of the Buchanan County Poor Farm and Fulton Missouri’s State Lunatic Asylum No. 1.

State Lunatic Asylum No. 2’s construction followed a style known as the Kirkbride Plan. Dr. Thomas Story Kirkbride was a physician and a founding member of the Association of Medical Superintendents of American Institutions for the Insane. In his treatise, The Construction of Hospitals for the Insane, he makes a case for the institutionalization of those considered insane:

“There is abundant reason why every State should make full provision, not only for the proper custody, but also for the most enlightened treatment of all the insane within its borders. Most other diseases may be managed at home. Even with the most indigent, when laboring under ordinary sickness, the aid of the benevolent may supply all their wants, and furnish everything requisite for their comfort and recovery at their own humble abodes. It is not so, however, with insanity; for while all cases need not leave home, the universal experience is, that a large majority of them can be treated most successfully among strangers, and very generally, only in institutions specially provided for this class of disease. It is among the most painful features of insanity, that for its best treatment, so many are compelled to leave their families; that every comfort and luxury which wealth or the tenderest affection can give, are so frequently of little avail at home; and that as regards a restoration or the means to be employed to effect it, those surrounded with every earthly blessing, are placed so nearly on a level with the humblest of their fellow beings.”

The “enlightened” treatment Kirkbride referred to involved housing mentally ill people in hospitals with staggered wings that allowed fresh air and sunlight to permeate the building. But as Kirkbride discloses later in the same publications, this benevolent view of institutionalization was not solely because of his belief in the potential for healing within asylums. He also thought “insane” individuals had great potential for violence:

“The dangers incident to insane persons being at large, are much greater than is commonly supposed. Not a week, scarcely a day, indeed, passes without the public press containing the details of some occurence [sic] resulting in loss of life, or serious injuries to individuals, or destruction of property, from a neglect of proper care and supervision on the part of their friends or the public authorities, of those who had become insane and irresponsible for their actions. Very many of the cases of suicide that are reported very clearly belong to this class, and of those a large proportion, there is good reason to believe, were curable if their cases had been understood and properly treated. It is worthy of note, too, that many of these acts, even those of peculiar atrocity, are often committed by individuals who, with all their obvious mental infirmity, had previously been regarded as perfectly harmless.”

When State Lunatic Asylum No. 2 was established, patients would be seen walking the grounds of the hospital, playing card games, relaxing on benches, and lounging in swings. This treatment of patients changed as time passed. By the 1930s, the asylum, now renamed State Hospital No. 2, had become more crowded. Three other facilities, State Lunatic Asylum No. 3 in the city of Nevada, State Hospital No. 4 in Farmington, and St. Louis County Lunatic Asylum had been built, but the perceived need to house a growing population of insane Missourians drove the occupancy of State Hospital No. 2 to almost 3000 patients.

A fire destroyed the original building on January 25, 1879. A new facility replaced the burnt structure by 1880. The new building was designed to hold about 1/3 more people than the original design, which had been planned to house 275 residents. Kirkbride’s well intended but distorted view of those considered insane wouldn’t forecast the treatments humans housed within the walls of the hospital would endure once personnel and resources became scarce during World War I and World War II. Well-intended early 20th century treatments for mental illness became increasingly inhumane and invasive.

The first such treatment was Insulin Coma Therapy. During such a treatment, a patient was given several high doses of insulin to induce severe hyperglycemia. The treatment was invented by Austrian-American psychiatrist Manfred Sakel. Sakel believed insulin comas relieved psychosis by combating the adrenal system. He worked to popularize his theory in the early 1930s. Insulin therapy was finally abandoned by psychiatry in the 1950s.

Metrazol Convulsive Therapy was a strategy used to treat people diagnosed with schizophrenia. It was invented by Hungarian neurologist Dr. Ladislas Meduna in 1934. Dr. Meduna believed that epilepsy was incompatible with schizophrenia, so concluded that inducing seizures in schizophrenics might be therapeutic. The therapy was discontinued in 1941 after side effects such as broken bones led practitioners to decide the alleged benefits were not worth the risks involved in the treatment.

Among the other treatments showcased at the museum was Fever Therapy, a procedure during which a patient was placed in a cabinet designed to raise the body temperature above 105 degrees. The fevers were induced in attempts to cure patients of syphilis until physicians learned in the 1940s that the disease responded to penicillin.

Lobotomies became popular in the same era. In 1936, neurologist Dr. Walter Freeman and neurosurgeon Dr. James Watts performed the first prefrontal lobotomy in the US in Topeka, KS. By 1942, the two had performed over 200 prefrontal lobotomies.

In 1946, Dr. Freeman completed the first transorbital lobotomy. The transorbital or “ice-pick” lobotomy didn’t require a neurosurgeon or an operating room. According to the exhibit at the Glore Museum, over 40,000 people were eventually lobotomized in the United States.

Some practitioners loved lobotomies because they made patients docile and manageable, but critics of the era pointed out the ethical implications of using such a strategy for patient management.

In 1948, mathematician and philosopher Norbert Wiener remarked, “Prefrontal lobotomy has recently been having a certain vogue, probably not unconnected with the fact that it makes the custodial care of many patients easier. Let me remark in passing that killing them makes their custodial care still easier.”

Electoconvulsive therapy, or ECT, arose as a treatment in 1938. It began to replace Metrazol and Insulin Shock treatments in the late 1930s.

My mind returned to the present era while viewing the ECT exhibit. The treatment is still used today, despite critics’ assertions that it causes brain damage.

The exhibits I discuss here are only a small slice of the history on offer at Glore Psychiatric Museum, but they prompted me to consider several questions. How far have we come in the US in terms of what we view as acceptable treatment for the many conditions collectively referred to as mental illness? How far has medicine come in uncovering the multitude of potential causes for the widely varied mental states experienced by so many of us?

Many self-proclaimed mental health advocates promote ending a perceived stigma surrounding treatment of mental illness. The same people usually promote the use of psychiatric medications to treat said illnesses.

The questions some of us pose to the advocates, such as whether antipsychotics are overused to reduce aggression in certain patients, are reminiscent of the questions surrounding earlier, more grossly invasive psychiatric treatments. More questions remain, such as whether other side effects, such as severe weight gain, are acceptable trade-offs for the relief psychiatric drugs may or may not offer.

I wonder if a Mental Health Awareness Month campaign in 1940 would have led to greater humanization of mentally ill people, or if it would have just paved the way for more lobotomies?

Some people who speak or write about mental illness deride any research efforts that seek to reveal physiological reasons for mental distress. They assert that most or all states described as manifestations of mental illness are due to trauma and stress, and can be alleviated by resolving issues associated with adverse life events.

Psychiatry’s troublesome history, as well as its current practice, have led other people to reject the validity of all psychiatric diagnoses and treatments. Former patients or psychiatry survivors sometimes choose to embrace the label of ‘mad’ as a way of affirming their distinct ways of thinking, feeling, and interacting with the world.

Few people look to psychiatry to cure the symptoms they present with. Most hope to establish relationships with providers who will find the right cocktail of drugs to help them simply get by for the foreseeable future. Pills that will lessen the frequency or severity of their suffering, but never alleviate it. That dynamic leads some to believe psychiatry isn’t the place to search for a cure for mental distress. Those who celebrate complete recovery from former psychological afflictions often laud lifestyle modifications offered by dietitians and exercise physiologists, or treatment protocols offered by endocrinologists and immunologists.

I think all these voices and perspectives are important. It is my hope that if we listen to each other, and learn about one another’s lived experiences, all while promoting and consuming heavy doses of research and science, humanity will be on the right course for finding ways to celebrate, co-exist with, or survive divergent or troublesome mental states. This is what humane and enlightened mean to me.

I was tempted to buy a Glore Psychiatric Museum branded hip flask, but thought it might be overkill for my herbal tea. I paid for a packet of Freudian Slip sticky notes and headed for the exit. Outside, the sun glinted off the razor wire that helps confine the men incarcerated by the Missouri Department of Corrections, which transformed the hospital building into a state prison in the 1990s.

More questions flowed through my mind.

Will there ever be places in the Western world where we can live peacefully among one another — mutually respectful, mutually respected, and unconfined? What kind of behaviors would such a utopia require from each of us, and would the realm of medicine need to play a role in achieving those behaviors?

Perhaps considering such a fantasy is simply insane.