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KPBS Midday Edition

American psychiatry's complicated legacy focus of new book

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Courtesy of Harvard University Press

Author and UC San Diego Professor of Sociology emeritus Andrew Scull has a new book on the history of psychiatry in America. It's called "Desperate Remedies: Psychiatry's Turbulent Quest to Cure Mental Illness."

Scull joined Midday Edition on Thursday's show to talk about psychiatry's complicated, and at times disturbing, history of how the mentally ill have been treated in the U.S.

The interview below has been lightly edited for clarity.

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Courtesy of Harvard University Press
In this undated image, the cover of UC San Diego Professor of Sociology Andrew Scull's book "Desperate Remedies: Psychiatry's Turbulent Quest to Cure Mental Illness" is shown.

Q: Your book is about the history of psychiatry in America. What was the main question you wanted to answer with this book?

A: Well, it's a book I've been thinking about writing for very many years. And what I wanted to do was look at the whole arc of psychiatry in America: Where it came from and where it ended up, where we are now. So I was very concerned with how it was that psychiatry came to understand mental illness through time because that has varied a great deal. And what it tried to do to treat mental patients, because those two things are somewhat separate, although they tend to go hand in hand.

Q: In your book, you talk about three eras of psychiatry in America's history that in many cases did far more harm than good. Tell us about those.

A: Well, psychiatry started with extreme optimism. Early American psychiatrists thought they would cure 70% or 80% of those they treated. They, unfortunately, could not do that. And by the end of the (19th) century, things were looking pretty bleak. And they tended to blame the victim to say the patients were biologically defective and that was why they couldn't be cured. Ambitious psychiatrists weren't happy with that. And so they started searching for cures with a population that was shut up in mental hospitals in every sense of the term. They were locked away and their voices were silenced and they had no voice in their treatment. So it was easy to experiment on them. And we saw things like explanations of mental illness that traced it back to chronic infections in the body. And in a period before you had antibiotics, the only way to eliminate those infections was actually to cut the offending pieces out. And they started with teeth and tonsils. And when that didn't work, instead of saying, oh, the theory is wrong, they started taking out stomachs and spleens and colons and uteruses, and that persisted for more than a couple of decades.

There were other attempts. The most famous or infamous of them all emerged in the last half of the 1930s, and that was lobotomy, which involved physically damaging the frontal lobes of the brain. So there were a number of other drastic interventions, which in retrospect, looked horrible, but at the time were greeted as possibly saving the mentally ill from a lifetime of illness.

Q: You write about how psychiatry has really relied on the biological aspects of mental illness while ignoring the social aspects of it. Why is the social aspect so important?

A: Well, it's not the case that for its entire history American psychiatry ignored the social and the psychological. That happened really in a major way starting in about 1980. And the problem with that is much of mental illness, even serious mental illness clearly has roots in trauma and in social factors and psychological factors. I think monism, that is, choosing either the psychological or the biological is a serious mistake in approaching these things.

And American psychiatry in the last four decades has really gone overboard on just one side of that equation. And unfortunately, it's led to some improvements. But they are very limited. And research in genetics and in neuroscience has given us a good deal more information about the brain and about genetics. But in terms of its clinical usefulness, what it does for patients, it's done nothing. And one of the ways we can see that is if you look at how long the rest of us live and how long people with serious mental illness live, you'll see that the differential is 15 to 25 years. So the mentally ill die that much sooner, and that gap is growing, not diminishing. So that's not a good sign.

Beyond that, of course, a lot of mental illness is of a somewhat milder but still distressing sort. And we're seeing an epidemic of that at the moment post-COVID, especially among the young. And that's a very worrisome development, and it's obviously not something we can explain simply in terms of biology.

Q: You also write how ignoring the social aspects of psychiatry feed into racial disparities and mental illness treatment that persists even today. Can you talk a bit about that?

A: In the first half of the 19th century, Black Americans were largely kept out of the asylum. When they did start to enter the asylum after the Civil War, they usually were put into separate but not equal institutions or where they were put into racially mixed institutions. They were segregated in separate wards. And of course, as we see in other aspects of American history, the treatments were very much worse if you were a racial minority.

The same thing happened with women. I spoke of lobotomy earlier. We know from studies of individual hospitals that even though men slightly outnumbered women in mental hospitals, about 65% of all lobotomies were performed on women.

Racial discrimination obviously persisted and persist. So we're in an era now where we shut our mental hospitals and we've rejected the mentally ill. We talk about community treatment, except there's no community and effectively there's no treatment. The single largest places of treatment for the mentally ill now are the Los Angeles County Jail, Cook County Jail in Chicago, Rikers Island in New York, and disproportionately those prisoners who are mentally ill are racial minorities.

Q: In the mid-1900, psychiatry started to use medicines to treat mental illness, giving rise to the pharmaceutical industry. You question the effectiveness of that approach, though?

A: Well, it's a mixed picture And I don't want to suggest that there's been no progress. The first antipsychotics came to market in 1954. The first antidepressants shortly after that, the first so-called minor tranquilizers Like Miltown and later Valium again in the same general period. And those medications, for some patients, clearly marked an improvement. Psychiatrists weren't lying when they saw changes, and changes they interpreted as positive. But the problem with those medications is there is no psychiatric penicillin. What they do is help with symptoms and that's a good thing, but they only help some patients — by no means all — and they carry with them a pretty heavy price in side effects. So when you choose whether to use drug treatment or not, it's the best set of remedies we have now, but they're at best a very partial. They're a band-aid, not a real solution.

Q: How would you sum up American psychiatry's failure in treating mental illness?

A: It's a mixed picture, but what I would say is the profession has put all its eggs in one basket in the last 40 years. That's the biological basket. It's looked to neuroscience and to genetics, and largely those have failed to deliver clinical improvements. I think, as always when you're operating in a position of extreme uncertainty, the smart thing is to spread your risk, to try multiple approaches. And indeed, American psychiatry needs to focus, it seems to me, much more on how they can help patients. Not to dismiss the need for primary research, but there also needs to be an inquiry into how we can help our patients in the here and now in better ways, how we can solve the problem of, for example, all the homeless, mentally ill we see in our streets, the numbers of mental patients consigned to jails. This is really a scandal. It's not a psychiatry scandal alone. This is policy choices by politicians and indeed, by the rest of us that I think have been seriously misguided.