Our guest today is sociologist and author, Doctor Andrew Scull. Andrew is a professor of Sociology and Science Studies at the University of California, San Diego, and recipient of the Roy Porter Medal for lifetime contributions to the history of medicine and the Eric T. Carlson Award for lifetime contributions to the history of psychiatry.
The author of more than a dozen books, his work has been translated into more than fifteen languages and he has received fellowships from, among others, the Guggenheim Foundation, the American Council of Learned Societies and the Shelby Cullom Davis Center for Historical Studies.
In this interview, we discuss his latest book, Desperate Remedies: Psychiatry’s Turbulent Quest to Cure Mental Illness, published by Harvard Press in May 2022.
Dirk Wittenborn, the screenwriter and novelist, described the book as “A riveting chronicle of faulty science, false promises, arrogance, greed, and shocking disregard for the wellbeing of patients suffering from mental disorders. An eloquent, meticulously documented, clear-eyed call for change.”
The transcript below has been edited for length and clarity. Listen to the audio of the interview here.
James Moore: You are a distinguished professor of sociology and science studies at the University of California and your many books seem to share a similar theme in exploring the history of psychiatry and the cultural history of insanity. How was it that you became interested in researching madness?
Andrew Scull: I first began working in the field in the early 1970s and at that point, I have to say I did not intend to make this my career. I thought I’d write a single book on the emergence of the asylum and the simultaneous construction of psychiatry as a profession in Victorian England and I suspected that I would then move on in rather different directions.
I was led to that area of research by encountering a couple of books that were receiving quite a lot of attention at the time that I first encountered the field. One was David Rothman’s book called The Discovery Of The Asylum which was about the creation of the asylum system in the United States and offered a very ethnocentric view. It was very much as though it was an American discovery which I already was inclined to doubt. The other book was one that is very famous and is echoed by the title of one of my books, Madness in Civilization, but that was the book by Michel Foucault that was translated in an abbreviated form as Madness and Civilization.
When I first encountered that book, Foucault had not become the huge international cult figure that he became within a few years. He was obviously very important in French intellectual circles, but it’s fairly unusual for a French intellectual to make the kind of impact that Foucault did across a whole array of disciplines. Reading those two books convinced me that this was a subject of considerable intellectual importance, and there was nothing comparable written at that point on the English scene.
That was really the launch of my interest and I then emigrated to America for what I thought was a short-term basis to do my doctoral work. It turned out my career started in the United States and, except for some time in England, has continued there.
When I was trying to get a job, one of the rituals in American academic life is that you go around and present a potted history of your research. In this case, I was trying to get a job in a sociology department talking about Victorian Lunacy Reform, which was a rather odd thing to try to do. But as I went around and gave this talk, my sociological colleagues knew virtually nothing about the substance of what I was talking about, and they would say things like, “well, aren’t you glad they’re shutting these places down now?” or “what’s happening in the current environment? Forget about stuff that’s 100 years old, tell us about now.”
I’d been so buried in the asylum archives and in the medical literature about insanity that I really didn’t know and I thought “that’s a really interesting question.” Is it really the case, because there had been a huge amount of social and intellectual capital invested in creating these institutions, justifying them, defending them, and persuading people, that they were the appropriate response to serious mental illness. I thought that I should investigate this, and I did.
I went backwards from the 19th century into the 18th century and did a substantial amount of work on how families and patients came to the attention of mad doctors, the predecessors of modern psychiatry. I moved forward into the early 20th century which was a very unexplored territory at that point. A number of other people had jumped in and looked at Victorian asylums, but hardly anybody had really looked at the 20th century.
As I began those researches I encountered things like lobotomy and I encountered focal sepsis and the idea that you could cure mental illness by eviscerating people. I thought that I really ought to write a book called Desperate Remedies and I already had that title in mind. At that point, my focus was on the first three or four decades of the 20th century when these horrors were visited on captive mental patients. I wrote many other things along the way but kept coming back to that topic and doing research whenever I had the chance.
Since psychiatry had taken a turn towards biological reductionism once again in the 1980s and going forward, I needed to talk about that. Why had that happened? What had been the consequences? Part of that story was the collapse of psychoanalysis which dominated American psychiatry in the period immediately after World War II. Part of it was the drugs revolution, the psychopharmacological discoveries that had underpinned this move towards treating mental illness with things that looked like the sorts of things that mainstream medicine was using to treat other kinds of diseases.
The other side of that was the attempt to provide a theoretical underpinning for this biological revolution. That is the move back once again to looking at the genetics of mental illness and the rise of neuroscience which emerged in the late ’60s and the ’70s and had become, in academic psychiatry, the kind of dominant force as opposed to what the people actually in the trenches dealing with mental illness were up to.
That entailed a lot of reading, a lot of thinking about those issues, and ultimately as I read the literature, largely the failure to be able to comprehend the etiology of any of the things psychiatrists have labeled schizophrenia, bipolar disorder, major depression. There are no biological markers for those things. When you look at the genetics, it’s actually tended to undermine the idea that these are separable conditions. As to the neuroscience, there have been advances in the understanding of the enormously complicated thing that is our brain but these had led clinically nowhere as far as I could see.
Moore: Many promises but not much result.
Scull: Psychiatry has offered promissory notes over and over again in its history and it has dishonored every one of them, more or less. That’s not to say there hasn’t been some movement and some progress. I don’t entirely dismiss drugs though I’m highly critical of the ways in which there’s a Panglossian portrait of how much good they do. It’s a very much more mixed picture and indeed for many mentally ill people these drugs simply don’t work and they often have terrible side effects.
One needs a more balanced look at that it seems to me and I always thought this partly because I knew some people who’d become very seriously disturbed and in one case had committed suicide. I wasn’t one to deny the reality of mental illness and the suffering that it causes. As one of my friends and psychiatric historian colleagues, Michael McDonald put it, he said, “Madness is the most solitary of afflictions for the person suffering from it, and the most social maladies for everyone around them. When people become seriously depressed or hallucinate and embrace delusions about the world, the problems that creates are not just problems for the individual sufferer, but most importantly for their family if they have one and for the larger community, it’s impossible to escape that.”
One of the things about mental illness that I think is almost a historical universal, I hesitate to say that but I think having studied everything from ancient Greece and Palestine and ancient China to now I can say that it is enveloped by stigma and rejection. That compounds whatever problems the mental disturbance brings in its wake and is a real problem that seems impossible to escape. More than that, in an odd kind of way, the stigma that accrues to mental illness itself also sticks to the people charged with treating it or the people who have not accidentally come to be treating it. Of all the branches of medicine, psychiatry is among the most despised, the branch about which we’re highly skeptical.
There’s no anti-cardiology but there is an anti-psychiatry. The problem of course is that psychiatric history throws up all too many pieces of evidence that some of that opprobrium is well earned. Some of the things that psychiatrists have done, not just for their patients but to their patients, neglecting them as having any voice in the whole process, really are very disturbing.
When I was researching Desperate Remedies, there’s this odd kind of thing as a historian, you discover remarkable stories that you can tell based on what you discover in the archives. For example, finding that Walter Freeman, America’s leading lobotomist, talked his patients through the operations and recorded them. I reproduce one of these transcripts in the book. On the one hand, you’re saying, “wow, this is fabulous material.” On the other side of the coin you’re going, “my God, what a monster this man was.”
The way it worked in the early stages of lobotomy before he resorted to the ice pick lobotomies after the war, was that they would do it under local anesthetic. You’d be fully conscious, they drill holes through your skull, like a dentist drilling your tooth only 10 times as bad, and then they slice your brain with a butter knife.
When to stop in this so-called precision lobotomy? Well, when the patient became confused, so you would talk them through it, and when they started to lose track, that was the signal to stop operating. In the case of one patient, Freeman says, apropos of a whole string of questions, “what’s passing through your mind, Mr. Morgan?” There’s a pause and Mr. Morgan answers “a knife.”
I was researching Henry Cotton, who was the Superintendent of New Jersey State Asylum in Trenton, and who conceived the idea that mental illness was the result of your brain being poisoned by lurking infections in various corners of the body. In a pre-antibiotic era, what were you going to do? Well, you had to practice surgical bacteriology. In other words, you had to rip the offending infections out. First, teeth and tonsils and when that didn’t work, you were swallowing the germs, they were going down into the stomach and the spleen and the colon, in the case of women to the uterus for some odd reason. You went in and you discarded these organs one after another sometimes operating two and three times, confessing in print that you were killing 30% of the people you did the serious surgery on to no rebuke. There was no sense that this was improper.
In fact, you were killing 45% of the people you operated on in this way. This went on for nearly two decades. The pulling of teeth and the removal of tonsils at Trenton continued all the way to 1960. I actually interviewed the dentist who had literally pulled hundreds of thousands of teeth in the pursuit of a cure for mental illness and still believed this was correct. Of course, it was utterly bizarre and yet the profession and in particular, its leader Adolf Meyer, at Johns Hopkins didn’t question what was going on, although some people doubted Cotton’s results.
But Meyer knew from the report of one of his assistants, Phyllis Greenacre, that far from curing patients, the more of this treatment people got, the worse the outcome and he suppressed the report. Then when Cotton died unexpectedly from a heart attack, Meyer wrote an obituary saying what a shame it was for psychiatry that such a promising line of inquiry and such a great man had been taken prematurely from our midst.
You encounter these things and they’re great material for a book but they’re also deeply disturbing. When I was doing the Cotton work in the 1980s and early 1990s, I had very little money and I was staying in something that looked a bit like Bates Motel in Psycho. I’d read these patient reports and I turned the page and it would say died, and I’d go back at night and reflect on what I had just seen and it was deeply upsetting. I periodically got contacted by relatives of people who were in Trenton. Somebody got in touch with me and said, “My grandmother was there in 1929. Where can I get the records?” I said, “Well when I was there, they were in the hospital basement.” I lived there with the cockroaches and the vermin while I was researching this with no air conditioning in the New Jersey summer, it was no great fun.
I said, “They’re there, or they may have been transferred to the New Jersey State Archives.” Well, indeed, it turns out some of the hospital records have been. The rest have mysteriously disappeared, no one can now replicate what I did, because it’s pretty clear that the hospital authorities sanitized the whole thing by chucking them out. There were detailed records on every single patient, they no longer exist. What an odd coincidence. If one were inclined to conspiracy, one might think that the profession would determine that it was time to bury those records once and for all.
Moore: I’ve shared the sense of horror in reading Desperate Remedies and reading the history of psychiatry, it’s impossible not to be affected by it. But what comes across for me strongly, the question that entered my mind as I got to the end is, why is it that psychiatry as a discipline seems so vulnerable to fads? New bodily treatments hailed as great advances, yet they never seem to stand the test of time. That was apparent in your writing about the early stages of psychiatry but still seems to be going on today. I wondered what your research had told you about that?
Scull: Well, Desperate Remedies as a title has a kind of ambiguous set of meanings that is pretty obvious when we’re talking about some of the extreme things like injecting horse serum into people’s spines to give them meningitis as a way of curing their mental illness or putting them in prolonged comas with barbiturates and then with insulin. What’s going on here?
I think if we look at the long history when the asylum is born it is an attempt to rescue the mentally ill from the jails and the prisons and the garrets and the pigsties where they’re confined. It launched in a period of extreme optimism when the world is changing dramatically around people. Transportation, canals, railroads, markets opening up, work changing dramatically and people’s day-to-day routines being transformed. Human nature seems to be malleable, the environment seems to matter and seems to be something we can control. The first institutions are labeled retreats after the York Retreat in England, or asylums with a very positive sense of that term.
Moore: A place of refuge, it means.
Scull: Right, it’s a refuge. It later acquires terrible meanings, but at the outset, this is extraordinary optimism and America is bidding up cure rates. Early psychiatry, they don’t yet call themselves psychiatrists, they call themselves medical superintendents, which gives away what their authority derives from. We’re going to cure 60, 70, 80%, or perhaps even more of patients as long as they come quickly.
But the actual cure rates were more like 30 or 40%. When I say cure, these were people who, with some respite and care, were able to be restored to the community with some semblance of ability to cope with daily life, but that left behind a very large fraction of each year’s intake.
Over time, simple mathematics means a couple of things. First of all, the institutions were compelled to grow and grow massively, so that institutions of 30 or 40 patients became 1,000, 5,000, even 10,000 in the early 20th century. Of course, individual care becomes virtually impossible once you’ve got warehouses of unwanted people of that size.
That was one outcome and the other is that the image of the asylum became one as a place where you went and you didn’t come out. That was slightly incorrect; of each year’s intake, a certain fraction did indeed emerge within the first 12 months, but if that didn’t happen you went to what Goffman called a lovely euphemism, “continuous treatment wards,” or no treatment wards. That meant psychiatry had this huge problem: how to explain away what appeared to be a tremendous failure of going backwards, not progressing.
The initial response was to blame the victim. It was the mental patient’s fault because they were biologically defective. In an era where evolutionary ideas are becoming increasingly common in the last third of the 19th century, these were a group of people in whom evolution had run in reverse. They were degenerates, they were moral lepers, they were people who’d lost their humanity. The best thing to do was to lock them away because otherwise, they’d breed uncontrollably and we’d have even more mad people in the next generation.
That explained away why it was a good thing that the profession was failing to cure them. You didn’t want them out in the world reproducing their defective kind, so what else might one do? The answer in early 20th century America is to snuff out their ability to reproduce and then you might be able to release them. Compulsory sterilization laws appeared on the scene, and eventually, a case reached the Supreme Court of America in 1927, Buck v. Bell, the case of a young woman who’d been sterilized against her will. The Supreme Court in an 8-1 ruling written by Chief Justice Oliver Wendell Holmes, one of America’s great jurists said, yes, the state had a compelling interest here. Three generations of idiots were enough, they could, in fact, do this.
California became then the leader in actually conducting these things and continued to do it until 1960. The Nazis adopted California’s law; the superintendent of Stockton State Hospital, a woman I might add, boasted that it was her state’s laws that had guided the Nazis to their sterilization. Whereas in liberal democracies there were some checks and balances and there were opponents of sterilization and there were some limits, in Nazi Germany, there were none.
Then, by the end of the 1930s, Hitler and his cronies decided these were, as he put it, “useless eaters.” They were just consuming resources, they weren’t going to get better, so kill them, kill them all. With the active participation of most leading German psychiatrists, they started shooting them and then the gas chamber technology came in. They killed perhaps a quarter of a million patients and then they packed up the apparatus and moved it to the death camps along with the personnel because now they had worked out how to do it. The mentally ill were the first victims of the final solution.
To be boarding housekeepers, to just lodge the mentally ill or to sterilize them, sat uncomfortably with people who wanted to be thought of as engaged in curing people in a therapeutic exercise. The alternative route forward, having decided that mental illness was rooted in the body, was to say “well, perhaps biology could lead us towards a cure.” What then happens is ambitious men—and it’s mostly men in this era—embark on a series of experiments to try to solve this problem and desperation exists on all sides here. Families are desperate for something to be done. Patients, in some cases, if they retain some agency and voice, are also pretty desperate.
When mental patients were shut up in the asylum, they were shut up in a double sense. They were obviously incarcerated, but their voices were shut up. Whatever they said didn’t matter, because it was a product of their madness, and so could be disregarded. This was a kind of perfect storm, it allowed for any number of interventions to be constructed and visited upon helpless people. Often, even when families were asked to give permission, which was not the norm, they readily gave it. After all, the authority figures were telling them that this was their best chance of restoring their loved one to sanity, even if they went elsewhere. For example, John Fulton at Yale was America’s leading brain physiologist and if he’d been consulted he’d have told his rich consultees, “yes you should get a lobotomy.”
Harvard had a very active lobotomy program. Columbia had an active program, Yale had an active program, University of Pennsylvania, Duke—all of these major medical centers into the 1950s, two decades after the operation’s arrival, were still telling people that this was the solution, and indeed were saying we shouldn’t wait, we should operate. If somebody isn’t better within six months or a year, that’s when we should perform a lobotomy, don’t wait till they’ve deteriorated, because then it’s almost too late.
Moore: It got worse, didn’t it? I was shocked to read in the book that not only did they lobotomize people but then if they didn’t see the results from the lobotomy they expected they then gave multiple rounds of ECT to that person to try and elicit a response from the failed lobotomy.
Scull: Absolutely, or Freeman would often operate twice, even three times. He did so within the space of about five or six days after the operation because, as he explained, these noisy mental patients on general wards were really disruptive and besides, they couldn’t afford to keep paying for inpatient care for too long. So if you didn’t get a result, you went back in and did it again.
Also, one of the things I discovered as I went along was that women were preferentially singled out for many of these desperate remedies. That was true of lobotomy. The statistics are anywhere between 60 and 80% of the cases were female. There was something obviously different about female brains, that was the way things were reasoned about then.
The other thing is that Freeman was willing to operate on children as young as four years of age and indeed said that children’s brains could sustain more damage and the child could become like a pet in the household.
I did a PBS documentary probably about 15 years ago called The Lobotomist about Freeman, which I thought was a bit of a whitewash of Freeman. I really think of him as a monster. One of the other participants in the program was one of Freeman’s last lobotomy cases. He almost was kicked out at George Washington in 1954 and he moved west to the Bay Area and resumed lobotomizing in private hospitals. This was a young man who at the age of 11 had been lobotomized, a man named Howard Dully, and his parents had divorced, his father had remarried, his stepmother found this 11-year-old a pain in the ass. No surprise, they are resentful of the new situation. Her solution was to take him to Freeman and have him lobotomized. The lobotomy, because it involves a direct assault on the brain, is perhaps the most fearsome and striking of these interventions.
The psychological treatment of mental illness, which these days tends to be some variation of cognitive-behavioral therapy (CBT), is largely outside the ranks of medicine. The emergence after the war of clinical psychology plays a major role in that and thus does managed care.
In America, we pay for medical and psychiatric care, and people are used to that. But the insurance companies found CBT to be a much cheaper option. Unlike psychoanalysis it was directed at suppressing symptoms rather than treating the symptoms the psychoanalyst claimed were emblematic of an underlying, much more complex, psychological reality. It’s clinical psychologists, by and large, who now offer psychotherapy as a treatment. That’s a heavily feminized profession and as a sociologist, I know when you look at the jobs, those that are female-dominated tend to be paid less. Certainly, clinical psychologists don’t demand the same fees as psychiatrists and if they did, the insurance companies wouldn’t pay them.
The only exception to that is a small group of psychiatrists still clinging in most cases to psychoanalysis, who take patients not covered by insurance, and that of course means it’s a very niche market only for the very wealthy, because who else can pay that cost?
Moore: In the early stages of the book, the asylum period and the somatic “treatments,” cure is mentioned an awful lot. “We can cure mental illness, we’ve got all these new treatments.” But as you then get into the latter part of the book, the modern history of psychiatry, cure disappears from the picture and it becomes much more about symptom management. I wondered what you thought led to that kind of transition? We’re not talking about curing “mental illness” anymore, we’re talking about managing these conditions.
Scull: I think much of that reflects the limitations of what psychiatrists can do for their patients. A new wave of drugs emerges serendipitously in the early 1950s. We’re talking about anti-psychotics like Thorazine and the first generation of antidepressants or we’re talking about the so-called minor tranquilizers, Miltown, Valium, Librium, those sorts of things. Early on there’s talk about cure, but it becomes increasingly apparent that’s not what’s happening.
These drugs aren’t psychiatric penicillin, very far from it. They are, at best, something that manages some of the symptoms, and I emphasize some, of the symptoms that people are complaining of, are suffering from.
With respect to “schizophrenia,” for example, I put that label in quotations because, as Robin Murray of the Institute of Psychiatry has recently put it, he thinks that within 10 years that diagnosis is going to vanish because the evidence for it as a separate condition is evaporating. But in any event, if we take that, classically, psychiatrists talk about positive and negative symptoms of schizophrenia. This reminds me of when oncologists talk about benign brain tumors. I can’t imagine a brain tumor being benign, but I know what they’re getting at. It’s not cancer.
The positive symptoms of schizophrenia, the delusions and the hallucinations that plague people, do seem for some, by no means all, but some fraction of the patients to be somewhat alleviated, or people stopped caring about them even if they’re experiencing them under the effect of these drugs. But in many ways, far more damaging are the so-called negative effects. We are talking about apathy, blunted social affect, difficulty interacting with people, disorders of thought and language, incapacity to deal with the business of everyday life. None of the drugs really touch those, and so you get a partial relief of symptoms, at best.
Then, of course, the other nasty secret, is that these drugs aren’t a free lunch. When you take them you are courting all kinds of negative effects and iatrogenic illness. Some people develop Parkinson-like symptoms, others become incurably restless and move about constantly, which is very distressing for them and those around them. They suffer from tardive dyskinesia, arguably the real bugbear of the early antipsychotics, uncontrollable movements of the extremities and facial muscles, quacking noises, things that laypeople who are unfamiliar with what’s going on ironically tend to interpret as symptoms of madness. You come across somebody grimacing and shouting coming towards you, you think, oh, there’s somebody who’s mentally ill.
Moore: They don’t realize it’s iatrogenic do they?
Scull: Right, exactly. Then, and this is one of the more striking kinds of things, you look at where modern treatment leaves people. Most of the drug studies have been funded by the drug companies. They operate across national boundaries. The only entity that owns the data and controls the data is the drug company, and they cherry-pick the data. We know that from lawsuits and other studies.
What purports to be evidence-based medicine is really evidence-biased medicine in a very serious way. Virtually all the major drug companies have been fined billions of dollars and that’s one of the reasons they’re pulling back from research in this area. It’s interesting to see one study, known as the CATIE study, that was funded by NIMH. It was designed to test the comparative efficacy of a first-generation antipsychotic produced in the 1950s. A drug no longer under patent, cheaper, easily prescribed, with newer variants that are variously known as second-generation antipsychotics, or atypical antipsychotics, a very broad class of drugs with different modes of action.
Three of those newer drugs were compared to the original one. Do they work better and what are the effects? I think two striking findings emerged from that research. One is the new drugs were no better than the old drugs. They had a different side effect profile but that included gaining 30, 40, or 50 pounds of weight. It included developing diabetes or heart disease and a whole array of life-threatening side effects. But the other thing that I thought was striking about that study, and it was confirmed independently, was that between 67% and 82% of the patients, depending on which drug they were on, dropped out. They dropped out for two reasons: because the damn things weren’t working in their case, or because the side effects they were experiencing were intolerable. That conforms with what we know from other research.
When people talk about the drug revolution, note that between two-thirds and four-fifths of patients on these drugs don’t find them tolerable or helpful. That’s a very damning finding, I think. That’s not to dismiss the cases where the drugs help, but what it does throw up is a very large caution flag if you’re a patient. There isn’t something better on offer, but what’s on offer can be a poisoned chalice all too easily. And on top of that, the drug companies, starting in about 2010, announced they were pulling out of this business altogether. They’ve made their billions upon billions of dollars. They didn’t see any obvious future targets for new drugs, and there were much more profitable alternatives for research that they could put their research folks to work on. So that’s rather disturbing given that we’re stuck with a bunch of, once again, desperate remedies of very doubtful efficacy. Efficacy for some, but only for a minority.
Moore: Again, something that leapt out reading the book was that you expected to see a big transition from the, frankly, barbarous practices of the past to modern developments in neuroscience and genetics and a greater understanding of the brain. But actually, the vestige of the harm of treatments still comes across in the way that modern psychiatry is done, though much less obvious and less apparent.
Scull: Yes, it’s not as dramatic as a lobotomy obviously, especially when done with an icepick through their eye socket, but yes those do persist. People sometimes ask me, could this repeat? I don’t know the answer yet, but I’m deeply suspicious when I see things like deep brain stimulation, another brain operation. When that has been put to a controlled trial test run by the manufacturers of the devices who wanted to find they were effective, those trials were aborted because the results were so terrible. Yet, there continue to be both media stories about this magnificent new treatment and publications in things like the American Journal of Psychiatry touting it as a possible remedy for the depression that afflicts 10%, 15%, even 20% of Americans.
I saw about a year ago in the Washington Post a case of one of the great plagues of 21st Century America besides all the gun violence. It is the opioid epidemic fueled by the Sacklers and their minions. This was a patient with drug addiction who is being treated with this brain surgery, seven hours of it. It was a miracle new cure for addiction. My God.
Then there is ketamine, Special K, a party drug. People take it at parties because it changes their mood in the short run. If they are unlucky, it makes them psychotic. If they’re not, it wears off then they do it again and you become habituated. That’s the sovereign new remedy as claimed in some quarters for depression, even though the scientific evidence for it is thin, if not, nonexistent.
The new vogue for psychedelics, magic mushrooms, LSD and so on. Again, a fad is now on offer. You can get ketamine in infusion clinics all around the country, people who have been used to treating cancer patients now have this whole new group from which they can make a profit and people flock to them. Even though, once again, there’s very little evidence in their favor. There’s some but if you do a 30-day study of depression and you’re mucking with somebody’s mental state, they may well interpret that in the short run as an improvement. Come back in a year or two years and let’s look at what the data show, and we have none of that data. Yet, here we go again, another cycle of “breakthrough.”
I’m afraid medical journalists have a lot to answer for in this regard. I mean, when lobotomy was introduced, the Houston Post said it was as easy as removing an abscessed tooth. Well, it was simple but it wasn’t safe, it did terrible things to the person who got the operation. I think being vigilant about these promises of great breakthroughs is really a responsibility that lies with all of us and to expose the fact that there isn’t much in the way of reliable information to support these often very drastic interventions.
The deep brain stimulation, for example, the number of patients who suffer from serious, serious side effects from the surgery is extraordinary. Yet, the enthusiasts continue to peddle this, and I’m just shocked and appalled I have to say.
Moore: The epilogue to your book is entitled “Does Psychiatry Have a Future?” What did your four decades of research leading up to this book tell you on that question?
Scull: It is a very difficult question to answer completely. We haven’t really talked about it but one of the stories that I mentioned at the very beginning of our interview is the collapse of the asylum and what that was fueled by. It was supported by both left and right ends of the political spectrum but for opposite reasons. It led to the abandonment of any pretense of public psychiatry here and the abandonment of people with serious mental illness.
There were no alternatives created, no sheltered accommodation, no attempt to meet the social needs of people who had a hard time competing in the marketplace. It wasn’t driven primarily by psychiatry. It was driven by the concerns of politicians, by budgetary concerns and development of the vestiges of the welfare state that provided some minimal level of survival for people chucked out into the streets. Psychiatry didn’t create that situation but it didn’t protest for the most part as this happened. It preferred to go after milder kinds of mental disturbance and treat those.
The seriously mentally ill were a standing reproach to the profession because they didn’t have good weapons to deal with the problem and they were deeply unattractive patients. They often weren’t grateful. They often opposed what was happening to them, they regarded it as destructive. But as well, they had no money, so in a society dominated by the market those are people who go to the wall.
Our approach to mental illness has veered from a brainless psychiatry after the war when Freudians were dominant and didn’t pay any attention to anything physical to a mindless psychiatry where we pretend, “Oh, there’s nothing here like trauma or other social setbacks that might have some role in somebody becoming depressed or becoming psychotic.” It seems to me that if psychiatry is going to move forward, it has to stop thinking that that’s the answer.
$20 billion spent under Tom Insel when he headed the NIMH led nowhere, as he has confessed. At best, there ought to be continuing basic research, this is a very complicated problem to solve. But in the meantime, we also need research into how best we can make life more tolerable for these patients and their families and how we might be able to help them avoid cycling from the gutter to the flophouse to the jail and back again.
It’s quite remarkable the way in which in some ways we’ve moved back to the situation that existed before the asylum was created. The largest places of treatment for the mentally ill in inpatient settings are the LA County Jail, the Cook County Jail in Chicago and Rikers Island in New York. That’s an indictment of the system, it seems to me.
If psychiatry is going to have a future, it has to start recognizing the social and the psychological dimensions as well as continuing to look to see what, if anything, biology contributes. In some sense, as I argue in those book pages, this whole separation of the biological and the social or the psychological is severely misplaced. One of the things that define us as a species is that our brains aren’t in a fixed state at the time of our birth. Our brains are remarkably plastic and they are enormously complicated things. We don’t even understand the brain of a fruit fly, let alone the brain of a human being.
We know a little bit more, we understand about neurotransmitters and we understand not everything’s electrical as they thought 75 years ago. But our understanding is enormously primitive. Mostly what we’ve learned is how damn complicated this thing is in our head and so, because it’s plastic, it responds to the environment we’re in. What that means is over time your brain absorbs and is transformed by your experiences. That means this whole separation of mind and body is a false one.
Academic psychiatry has to break with that because that’s the group that trains the next generation. The problem there is that if you’re building a career in academia, particularly in the sciences and the medical sciences, it all depends on attracting grant money. If you have lots of grant money you can get away with almost anything. People at the very top of child psychiatry and psychiatry in general took millions of dollars in drug company money and hid it. When that was revealed, the institutions gave them a slap on the wrist and that was that.
Doing social research is politically very dangerous because you might say, “inequality, racism, trauma, these all are vital, and they have to be addressed if we’re going to move forward.” Politicians don’t want to hear that on both sides of the aisle, I’m afraid. There’s no way to build a career that way. You can’t get grant money and if you do get it, it’s very limited. Whereas your colleagues who are in genetics and neuroscience it’s “here, have millions and millions.” You can publish lots of papers because you can parse that stuff in salami slices so that you get lots of publications and you move up the career ladder. You are the people that dominate.
Do I think things could change a bit for the better? They might, I think there are enormous obstacles to that and that’s a distressing end to the book. I don’t have a happy ending to talk about but I do think there are some possibilities. I think politically and given academic politics and academic careers, I’m rather skeptical. I sometimes do grand rounds with psychiatrists in training and at least they start out, in many cases, with the right values. They know if they encounter problems, they’re aware that there isn’t a pill for every ill and that they’re not going to be able to solve things simply with drugs. I suspect they get worn down when they get out in practice.
Again, if they’re going to make a living, they have to prescribe. That’s the only thing that generates income for them so they are also rather trapped. Even if they think underneath they know better, it’s very hard for them to act on those beliefs.
We face a very difficult future. There have been more than 200 years with some halting progress and lots of blind alleys and lots of dreadful mistakes. I’m not sure we’ve finished with those blind alleys and mistakes.
Moore: It sounds like psychiatry should move away from a purely medical view and towards a sociological view.
Scull: I think there’s room for both. I really would be very surprised for the most extreme kinds of mental illness, the sorts of things that lead people to be institutionalized, I’d be surprised if there weren’t some biological component to some of that. I’d also be even more surprised if that were the whole story. I hate to seem like the proverbial liberal who wants a middle course here but it does seem to me that you don’t want to abandon that kind of research entirely. But after 40 years and no therapeutic payoff, no greater understanding of the origins of each of these conditions, whatever they are, maybe it’s time to adopt a more eclectic broad-based approach to trying to do things.
In the meantime, given that you have no cures to offer, you ought to be working out what is the best thing you can do to ameliorate the suffering of individuals and their families because, with the institutionalization, a huge burden fell back on families.
Organizations like NAMI that were not organizations of patients, they were organizations of patients’ families, they kind of embraced the biological. If you’ve been told you were frozen parents who hated your offspring and had caused them to become mad, then somebody else came along and said, “it’s not your fault at all, it’s the chemical soup in the brain, and here we have a pill that will affect the serotonin levels and then they’ll be fine,” which would you embrace? Of course, you’d embrace the one that said this was nothing to do with you, it’s not your fault, and here’s something modern medical science has done that can alleviate the situation.
It explains why, when budget cuts happen when states have to deal with a fiscal crisis, which they do periodically, resources for the mentally ill are often on the chopping block. They are among the first things to go. Years ago, in 1950, about 30% of New York State’s budget went to mental hospitals. I guarantee you that 30% of New York State’s current budget doesn’t go to mental illness. Then the question is, what substitutes for it? Really, it’s malign neglect. I was going to say benign neglect, but there’s nothing benign about it. It’s malign, it’s malicious, it does terrible things to people’s lives and yet it’s enormously difficult to see how we’re going to move forward successfully from the sort of neoliberal environment we exist in wherein if you’re incapable of competing in the marketplace then you’re so much garbage, so much social rubbish, you almost don’t exist.
Moore: Was there anything else that you felt important to share with the listeners?
Scull: I did talk a little bit about the disproportionate treatment of women, that’s also true along racial lines and that’s something we haven’t mentioned. You can see it across time. In the south, when mental hospitals were built pre-Civil War, black people were kept out. There was no reason to waste money on slaves.
When the hospital system expanded in the late 19th Century, either one of two things happened; black patients were segregated and separated or separate asylums were built for the “colored insane.” Separate but equal, of course, means nothing of the sort. It’s separate, all right, but it’s deeply unequal. If mental hospitals for white patients were often hellhole snake pits, for black patients they were even worse. One can trace this all the way to the present.
We’ve talked about the ejection of patients into a community with no real effort to supply the necessary social support and the cycling of patients into jails. That, again, disproportionately affects blacks and especially black males who are seen as distinctly threatening. In the LA County Jail, for example, in the county, about 11% of the population is African American. In the prisons, it’s about 30%. Of those diagnosed with serious mental health problems, it’s about 45%. You can see that historical trajectory that we’ve talked about being replicated again in the present.
Moore: Thank you, Andrew. I’m sorry we could only just scratch the surface of the book. For people listening, I really urge you to go and read it. It is fascinating. It’s horrifying in parts. It’s forensic. It talks about the characters of the story, so rather than just an overview it talks about the key opinion leaders who set the stage for the changes to come.
Scull: Thank you. This is very much a book I’d like to think is for everyone, not just for people working in the mental health professions. We all experience mental illness, either ourselves, in our family members, or among those dear and close to us. None of us escapes the social consequences of the existence of this kind of suffering. The book is written very much so as to keep the reader drawn into these things and to assist in understanding them as much as I’m capable of doing in as thorough fashion as I can in the space I have. I appreciate all the kind words and I hope indeed people do read the book.