How Far Has Psychiatry Really Come? Historical Practices Versus Modern-Day Psychiatry

By the mid-19^th century, the nascent field now known as psychiatry had begun to attempt to explain symptoms of mental distress with impaired nervous structure. Early experts tried to draw a direct link between physiology and psychology. This was the birth of the “medical model,” which compares mental illness to physical ailments and implies that they, too, can be addressed medically. This theory—which has now become the dominant paradigm for understanding emotional distress—assigns psychiatric disorders to neurological, biological, or hereditary causes.

You may think that modern psychiatry has advanced far beyond the clumsy attempts of early practitioners, with their lobotomies and insulin shock therapies. But the truth is that the basic assumptions behind those early attempts still inform psychiatry’s main treatments today. Biological-based interventions such as psychopharmacology (drug-based therapy), electroconvulsive therapy (ECT), or psychosurgery (brain surgery) are the direct descendants of treatments that are now considered inhumane and were based on guesswork that has still remained unconfirmed.

Similarities between past practices and modern psychiatry

ECT

Electroconvulsive therapy (ECT) is perhaps the most obvious example. ECT has been continuously used with only minor changes since the time of the lobotomy. The purpose of ECT is to trigger seizures, which are theorized to somehow cure a depressive state. This theory has been in circulation since long before any knowledge of neurology—see, for instance, drug-induced shock therapy, which was approved by the FDA until 1982. It’s also little different from insulin shock therapy, although there the goal was coma instead of seizures.

ECT is a procedure in which an electrical current is passed through the brain in order to induce seizures. Advocates of ECT argue that it is the safest and most effective cure for major depression. However, studies have found that ECT is ineffective for reducing suicide—its main indication—and no evidence that it’s effective for depression, either. The studies themselves were of poor quality with inconsistent results.

Moreover, memory loss occurred in up to 79% of participants. Studies have also found that one-third to one-half of people receiving ECT were not given appropriate informed consent or were forced into the procedure.

The only real difference between modern-day ECT and its 1940s counterpart is that it is now administered under anesthesia as opposed to the past, which means that risk of physical harm during the seizure itself is reduced.

ECT’s target demographic today is older depressed women—interestingly, the same demographic as the lobotomy and the diagnosis of hysteria.

Psychosurgeries

At the forefront of current medical “treatments” for psychiatric “disorders” are psychosurgeries, such as deep brain stimulation and anterior cingulotomy. What separates these surgeries from the prefrontal lobotomy? They operate on the same principle—a guess as to where the supposed “disorder” is located in the brain, followed by a tool for destroying that part of the brain. The difference is merely that the lobotomy was more aggressive, destroying more of the brain.

But the lobotomy, too, was once considered the height of scientific practice at the time, and its critics were considered anti-science quacks—just as critics of current practice are now.

Interestingly, the cingulotomy was initially proposed in the 1940s and was viewed as little different from a lobotomy. While lobotomies involved severance of the connections in the prefrontal cortex through the insertion of a long needle through the eye socket, cingulotomy involves severing the circuit in the cingulate gyrus of the brain that processes emotions and regulates behavior. Current cingulotomies are performed using an electrode or gamma knife to cut or burn a half inch of the brain.

This has obvious implications on the emotional capacity of a patient. As with the lobotomy, “side effects” of this targeted brain damage include apathy, memory loss, seizures, nausea, and—perhaps obviously—intense headaches.

Moreover, the inability to understand the consequences of behavior is the most important of all the consequences of a lobotomy and by extension, cingulotomy as well. In fact, it could be argued that this is essential to the procedure. The cingulotomy is currently used in patients with the diagnosis of OCD—who are terribly afraid of the consequences of potential actions. Thus, destroying the part of the brain that connects action to consequence may leave them apathetic, but it also may remove their fears.

While the implications of lobotomy were recognized as evident human rights violations, the same has not been the case regarding the newer procedure.

The similarities between the two procedures are so eerie that they extend to the arguments doctors have used to further their cause. Despite the obvious question of ethics, psychiatrists continued to argue in favor of lobotomies through the mid-20^th century. Although early practitioners openly admitted that the lobotomy wasn’t perfect, they still argued for continuous experimentation in this surgery—and against its regulation.

Consider, for example, these words from 1937:

The hypotheses underlying the procedure might be called into question; the surgical intervention might be considered very audacious; but such arguments occupy a secondary position because it can be affirmed now that these operations are not prejudicial to either physical or psychic life of the patient, and also that recovery or improvement may be obtained frequently in this way.

Another common argument was that, without advancement by research and practical experimentation, the potential benefit of lobotomies will never be understood. However, no law could help deter rare violations without restricting such experimentation. The public interest would be served only by resisting regulatory restraints and relying on the medical profession’s protocol and high discretion for patients’ safety.

A similar argument has been offered for newer procedures like cingulotomy. Doctors continue to argue that scientific progress is only possible through unbridled experimentation. This translates to the belief that it is acceptable to reduce patients to a mere statistic of “surgeries-gone-wrong” as long as it could yield interesting experimentation results.

Institutionalization

When the concept of the “asylum” was introduced in Europe it entailed a relatively moral care system of patients based on the belief that those suffering from mental illness could heal and eventually be cured if they were treated gently and in ways that spoke to the reasonable parts of their minds. This approach was entirely forgotten and radically changed with the introduction of public mental institutions.

Even though institutionalization was introduced in the early 19^th century, the current era is even more rampant with human rights violations in such facilities. According to the World Health Organization (WHO), when human rights commissions toured many mental institutions in Central America and India, they discovered “atrocious and intolerable” conditions.

Many other mental institutions around the world, in developed as well as third-world countries, have similar conditions. Putrid living quarters, dripping roofs, overflowing toilets, crumbling floors, and damaged doors and windows were among them. The majority of the patients who were surveyed were dressed in pajamas or were completely naked. Many patients were seen bound to beds in tiny areas of psychiatric wards where they were left to sit, walk, or lie on the concrete floor all day. They were also constantly referred to as “inmates” rather than “patients.”

This is an obvious indication of the change in perception of people with severe mental distress. The aim of such institutions is not healing; rather, it is segregation of the “insane and untamable” from the society. Patients with mental illnesses were often treated far worse than criminals in such asylums.

The situation in India is much worse than in countries like the USA due to extreme overcrowding in mental institutions and a major lack of proper understanding of mental illness. Further, according to the study, approximately one-third of those in mental institutions did not have a psychiatric diagnosis to warrant their stay. There have been constant insinuations that mental institutions have largely been used to confine political dissidents.

Even in the US and UK, however, where living conditions in psychiatric institutions are much better, the lack or even violation of consent is prevalent. United Nations guidelines state that informed medical consent is a categorical right for everyone. However, in complete contrast with other branches of medicine, there is a complete disregard for consent when it comes to mental health; especially regarding institutionalization.

Due to the lack of delineated laws on the role of consent in mental healthcare, it is generally legal to force a patient to be institutionalized regardless of whether he agrees or not. A common trend in India is a person being institutionalized solely at the request of family members. This has often been used as a ploy to gain an upper hand in property or other familial disputes. There is absolutely no consideration of whether the person consents to be institutionalized or not.

This is an absolute violation of human rights that has been disregarded by public debate and psychiatry at large.

Adverse effects of gross medicalization

The medical model’s linking of physiology and mental health promotes ignorance of the role environmental factors play in this regard. It has time and again been shown that the distressing experiences labeled as depression, anxiety, etc. are inexorably linked to trauma. In fact, perhaps obviously, stopping traumatic experiences has been demonstrated to resolve emotional distress.

The strong nexus between environmental factors and mental distress is widely accepted in psychology and counseling. Trauma-informed psychotherapy, for instance, is a mainstay of the psychology field. But psychiatry sees things differently.

Instead of providing trauma-informed care, psychiatry—and the medical model at its foundation—relies on gross medicalization of patients. Although the evidence for this model’s success is limited (for instance, in 49% of antidepressant trials, the drug was no better than the placebo; long-term outcomes are also worse for people taking the drugs), it is widespread.

This completely separates the psychological state of a patient from social/environmental factors that may affect it. The medicalization of mental illness refuses to acknowledge the varied psychological consequences of different social issues. It aims at a “one size fits all” approach that tries to categorize individuals into distinct compartments of mental disorders solely based on common symptoms and ignoring the root cause.

But without addressing the social cause of distress, it is impossible to assuage it. For instance, in India, only when the oppression faced by the scheduled castes is addressed can the trauma of that oppression be mitigated. Unless we address societal factors, we cannot appreciate the different psychological implications and address them according to their distinct natures. The influence societal factors have on mental health means that mental distress should be revaluated as psychosocial distress rather than “illnesses.” They should not be put in the same category as physical illnesses.

Conclusion

Medicalization of mental health has led to not only to ignoring social factors in mental health, but also egregious human rights violations. Just as it has in the past, psychiatry has found ways to bypass rights in a more subtle manner. Constantly claiming the progression of scientific knowledge and implying that treatments have radically changed cannot hide the fact that the foundations of current treatments are no different from the unethical and horrific interventions of the early 20^th century.

When analyzed closely, ECT, institutionalization, and other mainstays of psychiatry are replete with instances of human rights violations just like their predecessors in the past. This issue can only be addressed when psychiatry is no longer perceived as the primary method of intervention for mental distress. Only then will the veil over it be lifted.

Social intervention—which offers a more individualized approach without pigeonholing an individual’s symptoms into strict categories—needs to become more prevalent. This requires refocusing the approach to mental health to the cause—working to address inequality, injustice, and childhood trauma—as well as providing trauma-informed healing practices.