HA 87 : Madness and
Medicine
Final Study Guide (2/24 –
end)
Lecture Notes 2/24: Schizophrenia, between Freud and biology
What did Freud say about Schizophrenia?
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He wasn’t working in asylums but with private practice women (later men)
o Early 20th century: begins to distinguish between “neurosis” and
“psychosis”
o Neurosis: still in touch with reality but having trouble coping with it (as a
therapy, psychoanalysis only works on this)
 a range of disorders resulting from efforts by a patient to “defend”
himself against becoming aware of threatening (and therefore
repressed) feelings, fantasies, and memories
 (examples for him include hysteria, anxiety, narcissism, and
obsessive- compulsive disorder)
o Psychosis: out of touch with reality (as a research subject, really
interesting for psychoanalysis b/c like a pure window to unconscious
mind, can be interpreted like dreams)
 a range of conditions in which neurotic defenses break down, and
the person is “overwhelmed” by the fantasies and needs of his or
her unconscious.
 (examples for him include paranoia, mania, and (after 1911)
Schizophrenia)
Daniel Paul Schreber
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Highly educated patient in Germany, lawyer, judge, then has psychotic
breakdown, convinced he is turning into a woman, rays of the sun, etc.
publishes book: Memoirs of My Nervous Illness
One of the more famous/admired patients of psychiatry, wise madman, something
infectious/poetic about the way he describes mental illness
Paul Flechsig, the director of the asylum was working with God to “soul murder”
him
Freud has never met Schreber but reads his memoir. He analyzes the book rather
than the man.
o Its sex, repressed homosexual tendencies towards father.
o How he got from repressed homosexual tendencies to ‘he’s persecution
me’: I love himI do not love him, I hate himHe hates me.
Significance of this: through the 1970s psychoanalysts pursue the idea that
paranoia involving a persecutor is due to a homosexual desire for the persecutor
Emil Kraepelin searches for valid diagnostic categories
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Believes in lab, brain (what happened with syphilis can be done with others)
accurate descriptive diagnostics need to come before investigations into etiology
or cause
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don’t diagnose on the basis of symptoms seen at any one time; focus on natural
history and prognosis (outcome) to differentiate disorders from one another
Only 2 types of psychosis:
1.
Manic depression; (draws Mania, Melancholy, and Circular insanity
together b/c follow the same time course) affects emotions
2.
Dementia praecox; (draws Paranoia, Hebephrenia, and Catatonia
together) affects primarily intellect/reasoning ability, incurable
Eugen Bleuler
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Didn’t agree with Kraeplin, imbeciles don’t inevitably decline, can get better, still
people, , matters were more complicated then charts/cards could convey
Engaged a lot with patients, (theme: doctor-patient relationship)
People didn’t think it was a problem that the director of his sisters asylum
couldn’t understand the patients language because it was all about study of brains,
no need to engage. As a result, Bleuler creates a new disease: schizophrenia.
Not many minds, but splitting/fraying of links between ideas.
Follows and introduces Carl Gustav Jung (inventor of word association test and
Freud’s famous follower) to Freud, 1st time someone has given Freud such an
endorsement.
The assumption that dementia praecox was an inevitably deteriorating intellectual
condition (a “dementia”) was not true
The assumption that it always began in youth (“praecox”) was also not true
The value of paying attention to the psychology of the disorder (using methods
inspired by Freud), and not just course and outcome, had been amply
demonstrated
Hence, a new name was needed: schizophrenia (or the schizophrenias), that
challenged the pessimism of Kraepelin about outcome and put a spotlight on the
psychological (not biological) mechanisms associated with the disease
The “Four A’s” in Bleuler’s concept of schizophrenia
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Association: associations among thoughts are disturbed; they are rambling,
incoherent, lacking associative connectivity, rapidly changing.
Affect: emotional responses are flattened, extreme, or otherwise inappropriate.
Ambivalence: people hold conflicting feelings simultaneously, such as loving and
hating someone at the same time.
Autism: cross-checking between inner experience and outer reality is no longer
effective; there is a withdrawal into a fantasy world.
Invention of schizophrenia as disease category: Freud is complicated part of story
o Recognizes two ways of being mentally ill: neurotic and psychotic people
o Neurosis: still in touch with reality, but has trouble coping
o Psychotic: out of touch with reality- hallucinations, delusions, etc.;
interesting for research in psychoanalysis (window into unconscious mind)
o
Daniel Paul Schreber- patient who had psychotic breakdown and wrote
Memoirs of My Nervous Illness
o Offered first-person description of inner world of psychosis
o One particular delusion: director of asylum was in cahoots with God to
torture and commit soul murder: Freud’s entry point
o Freud analyses book not the man
o Finds sex as the root; repressed homosexual fantasies towards the
father that Shreber had projected on psychiatrist
o Structure of paranoid delusions: I love him  I hate him  he
hates me
o Idea that paranoia involving persecution complex is caused by
repressed homosexual desires for the persecutor
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Others starting to develop ideas in their own ways
o Emil Kraeplin: disinterest in Freud
o Convinced that research suffered from flaw- people were trying to
find basis of illness without classifying different illnesses
o Psychiatry needs to focus on natural history and course of illness
over time  created universe in which psychosis was divided into
two types based on prognosis: manic depression (can get better)
and dementia praecox (incurable)
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Eugen Bleuler, director of Burgholzi, challenges Kraeplin with Freud as
basis for challenge
o Commitment to patient interaction, engage them as people
o Argues that dementia praecox isn’t incurable
o Assumption that dementia praecox always began in youth was not
true
o Value of paying attention to psychology of disorder (using
methods of Freud) and not just course and outcome
o New name was needed! Schizophrenia  challenged pessimism
of Kraepelin about outcome and put spotlight on psychological
and biological mechanisms associated with disease
Why called schizophrenia?
o Bleuler wanted to say that it involves a splitting in multiple ways- four
A’s of schizophrenia: association, affect, ambivalence, autism
o Suggests that four A’s are caused by a brain defect, something organically
wrong with the patient, caused by people using Freudian mechanisms to
cope with a world in a brain that doesn’t work
o Bleuler says there must be a middle ground between biology and
psychoanalysis  Bleuler breaks with Freud because he doesn’t think he
is scientific enough
Lecture Notes 3/3: Mental Hygiene
New mission: prevention.
Context: Mental hygiene was
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In United States
In Progressive era (characterized by belief that through legislation, can do a lot to
improve peoples’ lives)
A movement driven by a larger belief in the power of experts to intervene in
people’s lives for the better
Freud visits US
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ppl not completely on board, what they take away is the idea that mental illness
comes from bad habits/experiences early in life.
Adolf Meyer
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Behind mental hygiene mvmt and probably Am.’s most influential psychiatrist
Coins term “Maladjustment” in medical context
o Almost Darwinian, what world demands of you and your ability to deal
with it
Find constructive ways to build mind, connect with others/society
Clifford Beers, poster child for mental hygiene
Focus on children, “the golden age of mental hygiene”
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Time when children are building healthy habits/personalities
This philosophy becomes new ethos in US public schools
New “helping” professions of psychiatry
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Child guidance counselors
Clinical psychologists
Psychiatric social workers (new partial “feminization” of the psychiatric
profession)
The invention of the “juvenile delinquent”
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No one is born a criminal, crime is caused by bad environments/experiences
Focus not on punishment but turning them around: reform/vocational schools
invented
But: “Feeble-mindedness” and “moron”
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New category for the incurably maladjusted popularized by Henry Goddard
Congenitally dysfunctional shouldn’t be allowed to reproduce
o Forced sterilization—unconstitutional? Supreme Court rules that he can
forcibly sterilize imbeciles.
The legacy of “Buck vs. Bell”
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Following the Supreme Court’s ruling on the constitutionality of the Virginia law,
30 states adopted sterilization laws. Over the next several decades, more than
60,000 people nationwide would be sterilized (the largest number were in
California)
Buck vs. Bell was cited in the early 1930s by the National Socialist government in
Germany as part of its argument for a coordinated massive sterilization program
of mental defectives
Though enthusiasm for involuntary sterilization waned in the United States after
the 1930s, the Supreme Court never explicitly overturned its decision.
Sterilization laws lingered on the books of a number of states into the l970s
What was mental hygiene?
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An American movement, Progressive movement
o Progressive era 1890s – 1920s: legislation and intervention to
improve lives; US emerging as a powerhouse
o Freud visits U.S. in 1909 and makes a splash
o Way of reading his message that fit into progressive era- Freud
had challenged biological basis and argued that the source of
mental illness in bad habits or experiences
o Progressive attitude – change environments or bad habits 
mentally healthier
o Adolf Meyer- psychiatrist and visionary behind mental hygiene
o Worked with Kraeplin and studied life course of patient, but came
to different conclusion  impressed by extent to which different
things in environment trigger the illness; recasts Freudian
message of looking beyond the brain to life events and
experiences
o Deems mental illness as “maladjustment”- emotional responses
to life challenges that were inappropriate, erratic, exaggerated, etc.
o How was his message spread? National Committee of Mental
Hygiene created in 1909, Clifford Beers as spokesperson of
mental hygiene, self-help literature, mental hygiene in school
o Clifford Beers, patient who suffered breakdown and was
institutionalized, writes book about experience; wants to
overcome stigma of mental illness and agitate for reform
o Meyer persuades Beers to develop public education
programs to keep people out of asylums
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o Mental hygiene prominent in school years- childhood seen
as golden era; school years should be time for children to
build adjustment habits
o New “helping” professions of psychiatry: guidance counselors,
clinical psychologists, social workers
o Women play important role in populating new professions;
“feminization” of psychiatric profession
o Invention of the “juvenile delinquent”; faults are not due to
hereditary traits or bad brains, but to bad environment
From mental hygiene to a “therapeutic society”: taking stock of the legacy
o Turn psychiatry in extending therapeutic sensibility wherever
people may be at risk: courts, prisons, schools, etc.
o Twist to the story: there still remained a belief that some people
can never adjust no matter what: feeble mindedness
o Popularized by Henry Goddard ran school for these
children, believed they shouldn’t be allowed to reproduce,
worked to pass laws to allow the forcible sterilization of
“feeble minded”
o Carrie Buck and the supreme court case Buck vs. Bell
o Can people be forcibly sterilized against their
will?
o Oliver Wendall Holmes says yes!
Lecture Notes 3/8: The First Somatic Therapies: Fever and Shock
-Backdrop: new therapeutic innovations in general medicine (surgery, insulin, polio
vaccine, antibiotics)
-But asylum was perceived as a place for psychiatry’s “failures”
-Asylum joins Era of Golden Innovation with 4 new somatic treatments:
1.
Malaria-fever therapy
o For GPI
o Pace-setter for others to come; resulted in Nobel Prize in medicine, 1927;
used through the 1940s
o Julius Wagner-Jauregg, “burn out” disease
o Reshaped patient-doctor therapy (before seen as scum of asylum)
2. Insulin shock therapy
o For Schizophrenia
o Insulin used for diabetes
o Manfred Sakel accidentally overdoses drug addict, causes hypoglycemia,
changes behavior
o Send patients into a coma then give them glucose
o Deemed the first successful treatment ever for schizophrenia, brought a
new “medical” feel to the work of the asylum, widely used through the
1950s (then began using drugs).
o Critics: survival instinct to stop pain, the insulin myth-picked patients
likely to recover, more helpful for the doctors than the patients (feel like
real doctors instead of attendents)
3. Convulsive shock therapy (Metrazol and ECT)
o Metrazol shock treatment for schizophrenia & Electroconvulsive
treatment (ECT) for depression
o Ladislav Meduna-theory that schizopgrenia and epilepsy were
antagonistic, create artificial epilepsy to cure, but convulsions produced by
Metrozol were intensely violent
o Ugo Cerletti-creates convulsions by electrical means instead
o Began in the 1930s as treatment for schizophrenia; then became first
somatic treatment for depression. After a period in the 1970s of
widespread vilification, it has been rehabilitated today and is still used for
severe depression (though critics remain)
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Legacy: Treatments gave doctors a sense of agency and helped the asylum
reinvent itself as a professional institution.
Mental hygiene encouraged mental health to move out of the asylum and in to court,
schools, prisons, etc… Where did this leave the asylum?
o Era in mainstream medicine: golden age b/c of innovation, concerned with cure
o Asylum psychiatry as “failed field”; reject the incurability of people in asylums;
join arena of therapeutic innovation
o William White: mental hygienist with “can do” interventionist approach;
wants to reject idea of incurability of people in asylums
o People in asylums begin to talk about hope; they too are part of the new
era in mainstream medicine
o 1917-1933  4 new treatments for disorders in asylum that had
previously been thought of as incurable
Is the best way to think about these somatic therapies as being part of the new golden age
in medicine?
o Often described with words like “barbaric” “torture” “reckless” and “brain
damage” …WHY?
o Has to do with the way in which shock treatments become framed as
torture in the 1970s as a central part of the anti-psychiatry critique
o One Flew Over the Cuckoo’s Nest  portrays ECT as method of
discipline and torture rather than cure
Make sense of somatic therapies as they were understood
o Malaria Fever Therapy 1917
o Juilius Wagner Jauregg had seen psychotic patient who underwent skin
infection and recovered more lucid than before  starts research on GPI
using tuberculosis to induce fever; abandons work b/c patients are dying
 First world war comes; shell-shocked soldier with malaria leads to
Jauregg using malaria instead of tuberculosis because it can be
controlled
 25% success rate, but reshaped the doctor-patient relationshippatients before therapy were perceived as distasteful and repulsive
o Insulin Coma therapy 1927-1950
o Comes from the discovery of insulin; Manfred Sakel thinks it could be
used apart from diabetes  uses for drug addicts, accidentally gave too
much to one patient who went into coma, but who recovers friendlier and
nicer than before
 Applies to schizophrenics, inducing coma to patients; 88%
improve?
o Convulsive Shock Therapy 1934
o Ladislas Meduna- 1930s, shows that schizophrenia and epilepsy are
antagonists and can’t coexist in a person; finds metrazol to produce
convulsions  problem of violent convulsions
o Ugo Certletti in Italy uses Meduna’s idea but tries to control the
convulsions; uses electricity rather than metrazol
o Years later, ECT actually proves to only be effective for depression
 What about the earlier effectiveness for schizophrenia? Were those
real?... We don’ know
 We do know that at the time it did have a profound effect on the
doctors; asylum reinvents itself as real and therapeutic
medicine
Lecture Notes 3/10: The History of Psychosurgery (Lobotomy)
 Psychosurgery evolved out of mainstream medicine and was never marginalized – it was
only eventually rejected because alternatives (pharmaceuticals) became available.
 Late 1800s – damage to frontal lobe is thought to be the cause of mental illness. What
changed?
 1930s –
o post WWI, machine guns create focused bullet wounds in the brain. War doctors
specializing in frontal lobe damage find that patients with focused frontal lobe damage
could still function well: they are rational, have a good memory, but lose initiative.
o Percival Bailey: neurosurgeon considering frontal lobe tumor surgery – weighs
costs and benefits, depending on the persons social status, would not operate on an
important business man, would operate on a washerwoman.
 Animal lab + studies of learning: Hampton rat maze in 1900 – focus on learning speeds of
rats in the maze – conclusion: “men are not rats”.
 Becky the Chimpanzee: John Fulton at the Yale primate research center. Becky is “The
face that lopped 10,000 lobes”.
o Delayed response testing: chimps with damaged frontal lobes cannot remember
where the food is.
o Emotional changes in Becky: before the surgery she was ill behaved and anxious.
After the surgery, totally changed. Could frontal lobe surgery relieve anxiety in
humans?? “she seemed to have joined a happiness cult and turned all of her troubles over
to the Lord”.
 Egas Moniz (Portuguese neurosurgeon) considers using a focused surgery to cure mental
illness: leucotome. He thought he was cutting chords responsible for anxiety. Won nobel prize
in 1949
 Walter Freeman: read Moniz’s results reports from operations, developed the “Standard
Freeman Watts” lobotomy procedure. Partially severed connection between frontal lobe and
Thalmus. Calmed anxious patients.
o “Turning tax eaters into tax payers”
o took lobotomy on the road. Visited asylums. Performed 225 lobotomies in 12 days
 The popular press played a major role in promoting a positive image of lobotomy. Life
Magazine, Saturday Evening Post, etc.
 The Ice Pick Operation and schizophrenics. Made schizophrenics more manageable.
 Adolf Meyer: Mental health = social adjustment. Lobotomy can help with social adjustment
 Transorbital Lobotomy:
o Takes 15 minutes
o Sally Ellen Lonesco: first transorbital lobotomy.
 Howard Dully: received lobotomy at age 12. Wrote book: “My Lobotomy”
 Lobotomy is rejected when other solutions arise: Chlorpromazine.
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Frontal lobotomy
o 1970’s pop culture – gore, deviation from normal ethical standards, best
forgotten
o History is important because lobotomy grew out of mainstream practices,
never marginal, even though it was controversial
New understandings of frontal lobes
Meynert’s textbook argues for seeing frontal lobes as highest part of brain,
seat of reason
o Machines guns of WWI created injuries that provided subjects for
neurologists…frontal lobe damage
o People with focal frontal lobe damage were able to perform well on basic
memory tests, give rational responses
 Still intelligent and rational, but weren’t quite right…lacked ability to
draw abstract conclusions
 Personality changes, loss of initiative
By 1920’s, some neurosurgeons were prepared to operate on frontal lobe…patients
had tumors growing on brain.
o Cost versus benefit…result from surgery on frontal lobes…loss of frontal lobe
may be disastrous
o No reason to operate on frontal lobes in absence of tumor…why did things
change?
Animal laboratory and experimental studies of learning
o Hampton Court rat Maze, 1900…test speed at which rats can learn complex
patterns, era of behaviorism
 Took out parts of brain and examined ability to learn different tasks,
expanded from rats to humans
o Robert Yerkes Primate Research Center, in collaboration with John Fulton’s
physiology laboratory, Yale
 Worked on chimps and examined learning tasks
 Becky
 Delayed response test…two cups, treat under one, screen,
remove, chimp remember
 Without frontal lobes, chimps unable to perform…short-term
memory
 Becky joined “happiness cult” after operation
 Moniz wants to reduce frustration and anxiety in humans too
 Moniz’s leucotome, “core” operation
o Walter Freeman…performed surgery, thought procedure worked for anxious
patients, subdued overly active frontal lobe activity, instead of cutting cores
Freeman inserted knife in frontal area to sever connections between frontal
part and thalamus…separate thinking and feeling part – lobotomy
Mainstream culture…explanations of psychosurgery to public using language of
psychoanalysis
Turn to schizophrenia, rise of Operation Ice Pick
o Belief that operation may restore mentally ill to citizenship
o Came out of idea of mainstream norms…goal of treatment is citizenship came
from Adolf Meyer, mental health=social adjustment
o Turning tax-eaters into taxpayers…allure of using lobotomy on schizophrenics
o Freeman turn from major surgical procedure to 15-minutes transorbital
lobotomy…enter brain through eye, used ice pick
o Freeman took lobotomy to asylums
o Criticism begins…new framings of lobotomy killing people’s souls
Chlorpromazine…pharmaceutical pill for schizophrenia…chemical lobotomy
Howard Dully operated on age 12, said he lost a part of himself with the lobotomy
o
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Lecture Notes 3/24
Neo Freudianism (Americanized, adapted, revised Freud)
 1930’s just before WWII: a lot of students of Freud come to the United States from
Europe, escaping anti-Semitism. Pursue a reevaluation of Frued.
o Eric Ericson, Harry Stacks Sullivan, Karen Horney
 What does Neo-Freudian mean? How is it different from what Freud taught?
1.
Focus on Personality instead of sub conscious. What makes a healthy, resilient
personality?
2. Real relationships, instead of fantasy.
3. Anxiety as the core source for all mental illness.
4. Psychotherapy: important therapeutic relationships between patients and psychiatrists.
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After WWII Neo-Freudians took control of the world of psychiatry. Why? WWII.
o In the 1940s everyone believed that biology did NOT win the war, the NeoFreudians did. How? Preventative measures and treatment of soldiers during
WWII
 Screening of soldiers for proneness to mental breakdowns using
Rorschach tests
 Developed educational literature for soldiers: preventative psychiatry
– provided soldiers with coping mechanisms for facing the horrors of war.
 Frontline clinics for quick therapy, and hospitals to put damaged
soldiers back together again.
 Psychotherapy was at the center of treatment and prevention, NOT
drugs or surgery. The war gave psychotherapy legitimacy.
 WWII changed perceptions of psychotherapy: exposed tons of people to its benefits.
Not just for rich anymore. No more couch lying – direct, personal relationships with
therapist.
o The message gets out to the civilian population.
o Cornerstone: patient – therapist relationships this is NEW.
o The benefits of psychotherapy are advertised all over: magazines,
newspapers, movies at the theater. Lots of options available for everyone
 Meninger School of Psychiatry: new training center for neo-Freudian
psychiatrists. People trained here are leaders in the field. Get the National Mental Health
act passed.
 National Mental Health Act 1946
o Mental health is a matter of national urgency. 1949 National Institute of
Mental Health: 1st agency dedicated to mental health.
 The war had revealed a disturbing prevalence of mental health problems in the U.S.
– 12% of recruits were deemed unfit because of mental health issues. 1 million diagnosed
cases of mental illness by the end of the war in addition to 2 million men rejected for
mental health reasons. 3 million men total. WHY?
 Edward Strecker thought he had the answer. He is the surgeon general of the
Army and Navy during the war. He blames MOTHERS… or women unworthy of being
mothers (Mom).
o Mom: term coined by Philip Wylie. Women are undermining mental
strength of America. Strecker thinks that mothers failed to help their sons become
mentally strong and mature men by keeping them too close. Mother blaming.
 Neo-Freudian framework: stable childhood w relationship w mother is important
o Anna Freud looks at breakdown of children separated from mothers during
the war.
o Marasmus: term used by Rene Spitz to describe children who fail because of
a lack of a strong relationship with a maternal figure.
o Rejecting and hostile mothers are also a problem
 Leo Kanner: blames Austism on refrigerator Mothers
o Smothering Mothers cause homosexuality.
 Epidemic of Homosexuality – 1948 the Kinsey Report on male sexual behavior
reported that 10% of American males were homosexual and 30% had had a homosexual
experience.
 Schizophrenogenic Mother: responsible for mental illness of children
(schizophrenia and Autism) because they break gender roles. They are mothers with
dictator-like qualities.
o A product of the Cold War Age of Anxiety. At this time there was a huge
emphasis on conformity in American culture – particularly with families.
o Gender roles are being broken because of the war. Women had to go to work
while to men were fighting, and after the war they didn’t want to return to the
home.
o Breaking down of gender roles seen as dangerous to democracy (people
scared of communism and facism).
o Strecker again: says women are preventing men from effectively fighting the
cold war. Menace of moms
o Gays are also responsible for breaking down the family and threatening
democracy
 Women are also responsible for the Nazism. Respected Social science research said
that after WWI a generation of German men was killed off, the women were left in
charge. Matriarchal families produce children with authoritarian personalities.
 Frieda Fromm Reichmann: German theorist who said women in German families
had become too powerful. They were creating fascist environments and raising
schizophrenic children.
o The Schizophrenogenic mother is the only non-biological explanation for
schizophrenia. Now neo-Freudians own schizophrenia instead of the asylums.
 Taught that psychotherapy, not shock or drugs, could cure
schizophrenia. Psychiatrists just had to be patient and tolerant enough to
build a trusting relationship with schizo patients.
 Demonic mothers in media: Murderous mother in “Psycho” and manipulating
mother in “The Manchurian Candidate”
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“Let There Be Light” – new kind of Freudian (not having to do with sex)
o Neo-Freudianism. Childhood experiences.
 New focus, not on unconscious, but on factors that make for
personalities that “break” sooner rather than later
New emphasis on anxiety (not sex) as core problem driving
neurosis, all mental illness
 New conception of psychotherapy, not just as road to insight,
but as way of providing connective emotional experience
General consensus that Neo-Freudians had helped win WWII
o Educational materials routinely shown to soldiers, many preventative
measures
o Psychotherapy on battlefield (psychotherapy helps win war), also in
hospitals
o More people practiced psychotherapy after war…introduced
experience, idea of psychotherapy
 Introduced different methods of psychotherapy, not only laying
on couch, many options
 “Let there be light” – face to face interaction between
doctor and patient
New centers, much bigger core of neo-Freudianism…based on lack of
psychiatrists
o Menninger School of Psychiatry established in 1946, Topeka, Kansas
(most important training center)
 Drs. Carl, Karl, and William Menninger
o 1946 – Congress passed National Mental Health Act which called for
establishment of a National Institute of Mental Health
o NIMH formally established with Robert Felix as first doctor
War had revealed that American population as whole suffered from much
greater amounts of mental illness than previously thought possible. MOTHER
BLAMING
o 12% recruits screened for psychiatric reasons – 38% rejected for
psychiatric reasons
o Edward Strecker was a neo-Freudian, asked why were so many people
ill?
 Blamed MOTHERS. “Mom” was derogatory term. Mothers had
failed to help children from developing into mature men.
Smothered them, kept them immature. Failed to wean children
emotionally and physically
o Who better than the person responsible for development? NeoFreudianism focused on childhood.
o Without mothers, some soldiers could not do stuff. Potty-trained
people reverted.
o Rene Spitz
 kids who are raised in institution without mothers waste away
literally if mother-daughter bond is not there even if their
physical needs are met
 Inadequate mothering, if after birth does not hold baby, baby
goes into coma shortly after
o Leo Kanner – certain kinds of behavior produce certain illnesses
 Studied mute children, did not socially interact with others,
called “autistic”
 Because mother was cold. Refrigerator mother
 Smothering mother held on so tightly to mother that child did
not have bond with father, became pansies, homosexuals
Schizophrenogenic mother related to time
o An “age of anxiety” – Cold War
o Enormous emphasis on conformity. American nuclear family
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“crisis of American masculinity” – A. Schlesinger
Rosie the Riveter - men had all gone overseas, wartime industries, get
women out of home and into workplace
 Supposed to be temporary, but many wanted to stay
Needed to create nation of warriors to defend against Red. Moms were called
threat to society
o Homosexuals thought to be as dangerous, persecuted almost as
intense as persecution of communists. Mothers to blame for son’s
sexuality
o “matriarchal families” create young people susceptible to allure of
authoritarian figures. 1930s Nazis
Schizophrenia
o Frieda Fromm Reichman made link between facism and
schizophrenogenic mother
The facist F scale given to test. Mothers accused of creating authoritarian
state in house
Schozophrenia disorder caused by pathological communication
o
o
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Lecture Notes 3/29: Drugs in a Freudian World: The Wonder Drug Years
1. What about Barbituates?
 sleeping aid, preferred managerial drug. highly sedative like opiates. none
supposedly considered to make mentally ill cured and fine again.
 drug wanted that did more than just sedate. hence, the chlorpromazine story
2. Chlorpromazine: goes back to Europe WWII
 why did people go into surgical shock? histamine reaction, narrowing of blood
vessels. over release became dangerous and harmful
 rhone-poulene’s work on anti-histamine synthesis. new antihistamine developed
by rhone-poulene was chlorpromazine. first brand name for chlorpromazine:
largactil
 given to patients as part of pre-surgical prep. this is all done by Henri Laborit.
drugs seem to help with post-surgical shock, BUT also reduce anxiety level.
makes people “indifferent” to the surgery process (they stop worrying)
3. The first psychiatric test of chlorpromazine: a “chemical lobotomy”
 accomplished the pharmacologic revolution of psychiatry. mental hospitals in
paris (where testing was first done) were transformed, no more straitjackets,
noise, etc.
 for many types of mental patients, chlorpromazine was a highly effective relaxer
 smith kline & French bought market rights to chlorpromazine in 1952, renamed
the drug “thorazine” and made plans to sell it as an anti-vomiting medicine that
would be good for children
CHANGES IN 1954: The U.S Food and Drug Administration approved chlorpromazine
for use in the treatment of psychosis!
 advertisement began to hit the public. many brochures showing how a person
could avoid a life in a mental institution and actually live a normal life with their
loved ones
 “by combining drug treatment with psychotherapy, it is possible to establish and
to guarantee the minimal psychic stability required for the effective conduct of
psychotherapy”
NEW DRUG: MEPROBAMATE
 a 1955 film created the first “buzz” about meprobamate. it showed rhesus
monkeys unmedicated and vicious, on barbiturates and unconscious, and finally
calm, tractable, and awake on meprobamate.
 Wyeth Laboratories became marketer of meprobamate (or Equanil, it’s brand
name)
 Miltown: the “original brand of meprobamate”
4. The Miltown sensation: drugs for the “healthy unwell”
 considered the perfect remedy for an “age of anxiety”


became a part of popular culture, celebrities would recommend it, 1957
valentine’s day car had the theme “be my little miltown”, the “miltini” cocktail
Miltown and the Cold War “crisis of masculinity”
a) risk of “ tranquil extinction”, too many men becoming significantly
indifferent to politics, or to other important responsibilities
6. Valium
 Medication mom (schizophrenogenic mother became the patient)
 Targeted women, ideas of never marrying, being weak, unhappy, etc
 “mother’s little helper”
Lecture Notes 3/31: Deinstitutionalization:
Shuttering the Doors of the Mammoth State Asylums: The End of an Era
1. Many state asylums are now abandoned
 being used for entertainment purposes
 also being used for real estate purposes
 most often, however, buildings have just been abandoned
How did we get to this point? Why did deinstitutionalization occur and why does it
matter to psychiatry?
2. WWII
 WWII and experiences of treating combat soldiers
a) military psychiatrists found on-site treatment very important and more
helpful for those soldiers that were experiencing difficulties
b) “treatment in the battle zone”

WWII experience meets mental hygiene
a) early intervention in the community, getting children to express their
problems instead of keeping things in having adults help by teaching
children how to be healthy and how to confront their problems.
b) people were encouraged to be strong-minded.
c) juvenile courts, guiding centers, etc. not only were kids given new
treatment options, but everyone else as well. new kinds of treatment
centers for everyone were established (1940s).
NEW GOAL: to liberate the seriously mentally ill from a life of “banishment” in mental
hospitals. Mental hospital was a place for the failures of the psychiatrists and doctors.
3. The promise of new drugs
 even if they did not cure, they did stabilize. gave patients a shot at a normal life.
pharmaceutical companies began to do ad campaigns, trying to promote drugs
(1950s)
 1955: Eisenhower administration asks for a review of mental health policy. After
6 years, a conclusion is reached and the administration in charge of review
recommends that a new national policy be reached.
 1961: “The objective of modern treatment of persons with major mental illness is
to enable the patient to maintain himself in the community in a normal manner.
To do so, it is necessary:
a) to save the patient from the debilitating effects of institutionalization as
much as possible,
b) if the patient requires hospitalization to return him to home and
community life as soon as possible, and
c) thereafter to maintain him in the community as long as possible.”
 1963: Congress passed Mental Retardation Facilities and Community Mental
Health Act
 NIMH assumed responsibility for monitoring the nation’s community mental
health centers (CMHC)
4. Deinstitutionalization begins
 1965: Medicaid/Medicare drastically decreases numbers of patients in asylums
per year. covered the elderly and treatment in nursing homes. Anti-psychiatry,
civil rights and changes to mental hospitals… WHAT ABOUT COMMUNITY
MENTAL HEALTH CENTERS??
a) poor at maintaining mental health. especially for psychotic schizophrenia
patients. thorazine and related drugs. inconvenient side effects for patients,
some were so distressing that patients would stop taking medication alltogether.
b) mental illness in the streets, prisons?
Lecture Notes 4/7
The focus of this lecture was putting Jamison’s memoir (1995) into its historical context.
The Jamison memoir is a story about mental illness from a patient’s point of view.
Manic-depression: getting oriented

Kraepelin in the late 19th century called for a “diagnostic housecleaning” and said
there should be only 2 big categories: dementia praecox and maniacdepression. Maniac depression was an expansive category that included
periodic/circular insanity, simple mania, melancholia and confusional insanity.
Freud’s 1923 account of manic-depression


Rejected Kraepelin’s view that this was a medical disease
Freudians: believed that these people cycled between grandiosity and despair. At
certain times, they were on the top on the world and at other times, they wanted to
commit suicide. There was a deep inner conflict in the unconscious. Freud
believed that this was due to a war within the unconscious, between the forces of
life and death (libido vs. superego). Psychoanalysis was offered as a form of
treatment for manic-depression. No data, however, suggested that these
treatments were successful.
Overall, manic depression was a neglected disorder. However, soon, things started to
change, with the discovery of LITHIUM
Story of “Lithium:” the “Cinderella” drug of psychiatry






In a time of wonder-drugs, “Lithium” was a drug that no company really wanted
to own.
Nobody loved lithium! WHY?
1) It’s not a manufactured substance. It can be found naturally in the world
2) Lithium had a history as a “health tonic” = a general, all purpose “pick me up”
tonic
3) LiCl was used as a substitute salt (found to be a scandal)
4) Li was used as treatment for manic-depression
o JOHN CADE (unaware of the salt scandal in the US) published an article
that Li was a successful treatment for manic-depression.
o From experiences in WWII, believed that maniac symptoms was caused
by a type of toxin in the brain. As he couldn’t open up the brain, he
theorized that if there is a toxin the brain, there would some metabolite in
the patient’s urine
o Cade analyzed urine samples from different types of patients (3 groups:
Mania, Schizophrenia, Control). He injected urine samples into the abs of
guinea pigs. The guinea pig went into convulsion and died. Interestingly,
o
o
o
more guinea pig went into convulsion if they were injected with urine
from a manic patient.
To test whether the toxin might be uric acid,
 He tried to mix uric acid and urea, but these two chemicals were
not soluble together. So he went to physiologists to help him make
this formula soluble. The physiologists mixed in Lithium
carbonate. When this solution was injected into the guinea pigs,
they survived!
Moreover, Lithium carbonate made the guinea pigs very calm! Cade
believed that he discovered a therapy!
In 1949, Cade takes some lithium himself = says it is safe
 Gives it to 10 manic-patients; 10 schizophrenic; 3 depressed.
Witnessed a profound effect on the symptoms of manicdepression!
 Publishes: Medical Journal of Australia = most prominent medical
journal in the country. However, NO ONE PAID ANY
ATTENTION TO THIS PAPER OR DISCOVERY!
Mogens Schou - 1952



1952: psychiatrist in Denmark– discovers Cade’s article and thinks Li should be
re-examined
1952: Schou conducts a PLACEBO-controlled clinical trial (cutting edge
approach)
o Conclusion: Cade was right; it did treat manic-depressive symptoms
Within a few years, he becomes less interested in manic depression. Now
interested in a far more radical use of Li = now as a preventative treatment that
patients would take on a continual basis in order to AVOID becoming a manicdepressed patient (Different use of medicine – as a MOOD STABILIZERS)
1970: FDA approves Li carbonate for manic symptoms



Pfizer: Markets it under “Lithane” (this had very lackluster advertisements)
After a few months, Pfizer stopped pushing the drug altogether
Since this drug is not manufactured (and thus can’t be patented), the companies
wouldn’t expect to make much money from this drug.
A public education campaign was conducted to promote this “Cinderella” drug


Raise awareness/de-stigmatize manic-depression and offer info on its treatment
(even though it wasn’t approved by FDA yet)
Joshua Logan: on TV, he tells American people that he suffers manicdepression. For 30 years, he had highs and lows. Since going on Li, he doesn’t
have the symptoms and lives life to the fullest. As a famous
producer/screenwriter, he soon became the poster child of manic-depression.


Ronald Fieve = writes book that describes businessmen, artists, etc. with manicdepression. After Li, they are able to go on with their lives
On some levels, the public education worked
o 1974: the FDA approves the use of Li carbonate for its prophylactic
(preventative) use
A new cultural note: MANIC-depression as the “creative” and “artistic” person’s
psychosis


Psychiatry’s interest: Is there something about manic-depression that can explain
creativity?
KAY REDFIELD JAMISON
o Published evidence of creativity and manic-depressive disorder. She
looked at famous artists/writers/disorders who were “undiagnosed” manicdepressive patients = Van Gogh, etc.
o She may have done this to de-stigmatize the disorder. However, this
complicates the belief that manic-depression is a biochemical imbalance
(if it has links to creative genes, do we treat it?)
 Jamison said society should NOT try to get rid of the disorder –
there would be no creativity!
Lecture Notes 4/12
The focus of this lecture was on how we got to the diagnostic category of “depression”
and the story of three types of anti-depressants. Moreover, we studied the “chemical
imbalance” theory of depression.
The making of a new diagnostic category, DEPRESSION







Some say that the history of depression starts in the 2nd half of the 20th century,
some say it is as old as humanity (to Hippocrates)
Before there was this modern category, “depression,” there was a much older
category that felt much like depression = MELANCHOLY
Melancholy
o Ex: entryway to Bedlam (16th century) – life-size sculpture represents two
primary ways that people in this era were to go mad: MANIC &
MELANCHOLY
o Melancholy – understood in context of humeral theory
o Considered the disorder you got when you studied too much = a scholar’s
disorder
Emil Kraepelin’s clean-up job
o 2 main categories: Dementia praecox and manic depression (Melancholy
gets packaged in with manic depression)
Some decades after Kraepelin, people who are admitted into hospitals, tend to be
given the diagnosis of “manic depression” - even if they never had a manic
episode! (The assumption is that it is latent, it might still come)
1953: Karl Leonhard
o Proposed that some patients only suffer from “one pole” of the “bipolar
“condition of manic-depression (Said we should call depression = “unipolar” disorder = the depressive pole)
unipolar disorder was sometimes called “major depression” = endogenous
depression = vital depression (A serious disorder; a rare disorder; a biological
disorder)
But that’s not the end of the story; something else happened during this same period – in
the Freudian world = Psychotherapy offices


A class of patients who suffered from despondency, irritability, lack of energy,
problem going to sleep, etc. are now seen as suffering from neurosis [Sometimes
called “neurotic depression” = reactive depression = minor depression]
Assumption: no biological cause; has a psychogenetic cause; some unconscious
mourning for a love-object
1950s: Two kinds of depression: [Major depression (unipolar disorder) vs. Reactive
Depression (common)]
The arrival of anti-depressants (1950s)





1950s: supposed to be only used for the much smaller group of “major
depression” = target of anti-depression
Discovery (1953) of Iproniazid (Drug for TB had a side-effect – give them
energy!)
Nathan Kline
o Psychic Energizer (Opposite of tranquilizer)
Marsilid (Iproniazid) = the first “psychic energizer” = Found a respected place
in hospitals
Within a few years, people became aware that this was dangerous
o By late 1950s: people were hoping for something better
Roland Kuhn


Switzerland, a psychiatrist. Hospital did not have enough $ to buy
chlorpromazine; so he got in touch with another pharmaceutical company, Geigy,
and asked if they had any unpatented anti-histamines that he can try out for
schizophrenia. They sent over IMIPRAMINE
o Wasn’t helpful for schizophrenics, but really helpful for the depressed!
o This drug = turned out to have considerably better side-effect than the
older psychic energizers; But still had some side-effects: nausea, etc. but
not life-threatening
o Newer drugs = now called TRICYCLICS!
Geigy called it Nardil = Tofranil (Imipramine)
Discovery of Neurotransmitters: in 1920-1958 (all discovered transmitters were
catecholamine transmitters)



Animal studies showed that anti-depressions works by keeping neurotransmitters
in the synapse HIGH!
Early 1960s: depression = a biochemical disorder and anti-depressants = the
preferred treatment
Joseph Schildkraut, MD = Wrote an article that basically created the “chemical
imbalance theory of depression”
Hamilton Scale (1960) 
Rating scale that was not designed to distinguish b/t neurotic/minor/reactive
depression from major depression (more rare group of people). The scales simply
assess the severity of the symptoms at the time of testing. (But it’s all just one
kind = depression is depression)
Pharmaceutical industries now have an opportunity


Development of a new “anti-depressant” (1st new one in 30 years)
Called FLUOXETINE = perfect for more expanded definition of depression
o Selective serotonin re-uptake sites = cleaner = more targeted drug
o Can give to a less severe depressed patients
o Put on market by Pfizer under the name “Prozac”
1980s benzodiazepine “dependency” scandal (minor tranquilizer for anxiety)


Showed that this was really addictive – the market totally collapsed
Pfizer tried to push Prozac not just for depression, but also for anxiety
Mid 1990s: we become a Prozac nation!
Lecture Notes 4/14
This lecture was given by a guest speaker, Nate Greenslit. The focus of this lecture was:
(i) deconstructing the marketing strategy used for depression, (ii) understanding the
collaboration between advertising and pharmaceutical companies, and (iii) analyzing the
social history of fluoxetine.
The Social Life of Fluoxetine = chemically the same as Prozac (Lily markets it
differently)


Prozac = yellow/green color; Associated with depression
Purple = Sarafem = “Seraphim” (angels) = target women with PMDD
Directed Consumer Advertising: Approved by FDA in 1997




Marketing differentiates Prozac & Sarafem - Relatively recent that
pharmaceutical companies have been differentiating drugs in this way
Sarafem came into the market when Prozac lost its patent
Difference b/t generic drugs & brand-name drugs
o Generic drugs look different b/c trademark laws in the US do not allow a
generic drug to look exactly like other drugs already on the market
DCA Speaks to patients and physicians in different ways (Sarafem had separate
patient & physician information on the website)
“Sarafeminism?” – How women’s health issues gain public awareness in the US






Linked to their social roles as wives, mothers, workers, etc.
Early congressional acts allotted funds ONLY to maternal and child health
In more recent years, women health = scientific research done on women’s bodies
Women entering work force after WWII, pre-menstrual emotions were seen as a
loss of productivity (Anti-depressants keep women “in place”)
Peter Kramer “Listening to Prozac”
o “there is a sense in which antidepressants are feminist drugs, liberating &
empowering”
o Exactly what Lily wants to tell – and what the women’s movement is
against
Sarafem TV commercial/marketing portrays PMDD as a severe premenstrual
condition (it’s women’s responsibility to get help for this)
National Women’s Health Network


Published “Our bodies, Ourselves” - criticized this type of advertising
Started their own policy of monitoring ads: “DTC ads are incomplete &
inaccurate”
Pharmaceutical companies argue that DTC is educational about illness and treatment –
making healthcare more democratic
How women have been represented in psycho pharmaceutical advertising?

Women at a grocery store, trying to extract a cart out of a row of carts = “Think
it’s PMS? It could be PMDD”
PMDD in the Making






Mid 1980s: whether pre-menstrual disorder should be in the DSM-III-R
o Psychiatric disorder specifically for pre-menstrual symptoms
2 sides:
o 1) creation of PMDD would pathologize all pre-menstrual symptoms =
and thus, women
o 2) long-overdue recognition of the suffering of women
DSM-III was supposed to represent distinct diagnosis (not psychoanalytic)
PMDD vs. PMS?
o PMDD –established treatment for it; psychiatric
o PMS – somatic, cramping
Health insurance logic: Patients can get reimbursement for the drugs if they are
diagnosed with PMDD
Really socially controversial
o Even in mainstream media – NY Times, etc.
o American Psychiatric Association – made an appendix for “disorders
needing extra research” (Gave PMDD some acknowledgment, but not in
the body of the DSM)
Lecture Notes 4/19
This lecture began a series of three lectures that attempted to describe and explain the
counter-psychiatry movement that has developed since around the 1950s/60s. In this
lecture, the significance of R.D. Laing, the sixties culture/politics, and LSD were
discussed. R. D. Laing, along with Thomas Szasz, were the two biggest, most visual and
important counter-psychiatry proponents of this era, although their respective arguments
had little in common, and they did not work together to lead the change.
What made the larger culture of skepticism possible? Where did it come from?
“Radical Psychiatry Manifesto”
DSM created in part as reaction against the detractors
Want to radically re-imagine psychiatry
o
o
o
o
o
Re-classify these things as not being real diseases
People do suffer, however. Just not because of brain chemistry
 Due to oppressive culture
Symptoms are part of a poor social structure
Politics should be used to fight these problems
 “psycho”-politics
Leading the pack: Ronald David Laing (R.D.Laing)
 Most important model for the movement
R. D. Laing
o
o
If you lived in the 70s, you would have heard of him
Had a large cultural footprint
 Timothy Leary also popular “Turn on, tune in, drop out”
 Maharishi Yogi, too
“The Sixties”
o
o
o
Engaged in an urgent political battle
Widespread skepticism toward “the establishment”
Vietnam War at the center of all this skepticism
 University campuses become radicalized
 Psychiatry also comes under suspicion
 Accused of working in league with US Government to
create killing machines disguised as “therapy”
 Psychiatrists seen as “part of the War machine”
LSD – Developed by Albert Hoffman at Novartis
o
o
o
Seen at the time as a tool that might someday soon change the entire
experience of living
Piques the interests of psychiatrists because it seemed to make users
“crazy”
 A chemically induced schizophrenia
Legal to test on college students
 Ken Kesey takes place as a student
 Has the idea that crazy people aren’t sick, they’re just nonconformist
 Authors “One Flew Over the Cuckoo’s Nest”
 Buys bus, drive across America offering people samples of
LSD
 Saw himself as stopping the coming end of the world
R. D. Laing (who was actually a psychiatrist) also saw himself as preventing impending
doom
o
o
o
o
o
o
o
o
o
Proposes a transformation of psychiatry from within
Wrote “The Divided Self”
Added an existential component
 Up to each person to create his/her own meaning
 This proves too terrifying for most people
 So they flee into religion, etc.
 Laing sees this as bad/self deception
Still need to give psycho-therapy, but in the Freud model
 Doctor needs to take off mask, meet the patient as “person to
person”
“Sanity, Madness, and the Family” pushed the argument more radically
political
Why do usual accommodations of society fail schizophrenics?
 Answer: it’s the families, mothers
 Twist: can’t just implicate the family, must also implicate
psychiatry itself
 Political act, not just medical
“The Politics of Experience” – Laing had been using LSD
 Future people will see that schizophrenics were people that had
discarded “mask of normalcy” to discover true reality
 Wants to explore the inner space and time of consciousness
Family considered the source of brainwashing people into being willing to
fight senseless wars, allow corporatism, etc.
Thinks psychiatry should be about empowering people to take ownership
of their own reality
 Kingsley Hall home of radical experiment
 Mary Barnes (in sourcebook) former nun, nurse
 Resulted in smearing of feces on the wall, not awesome
LSD alternate realities
Mary Barnes and Joseph Burke (her therapist) co-author a book about her experiences
o
o
Concludes that feminist revolution should have been taken into account by
Laing
Mothers are also victims, not just the kids
By 1970s, de-institutionalization causes less trust in Laing’s theories
o
o
Judi Chamberlin “On our own”
Howie the Harp
 Creates a patient-run center for mentally ill
Radical Psychiatry
1) Huge influence in the 1960s
a) political project to develop alternatives to the social structures of the time
that they thought were putting the planet at risk
i) occurs in the context of a time characterized by wide-spread
skepticism and concern about institutions such as the military /
government
ii) at the center was the Vietnam War – outrage at civil rights abuse
leading to wide spread protests and international
radicalism/agitation
b) want to reinvent the way the world looks
i) psych itself seemed to create a tool for a whole new way of seeing
the world
(1) LSD (came from same culture of opportunistic culture
making chlorpromazine etc)
(a) research interest because seemed to make people
‘mad’ and created ‘model psychosis’ – chemically
induced schizophrenia
(b) Ken Kesey (student recruited to be a subject for
tests)
(i) didn’t think ppl in hospitals were crazy, just
non-conformists that society couldn’t deal
with and thus locked away
(ii) wrote One Flew Over the Cuckoos Nest and
tried to save the world by opening minds with
green acid Koolaid test
2) Radical Psych movement headed by Ronald Laing - want to save world by
changing psych from within
a) took mainstream practices and theories and radically reinvent them to fit
the political and cultural agendas of the time
b) 3 Key publications
i) 1960 - existential challenge and the Divided Self –
(1) say schizophrenics starts like rest of us, presenting false
mask to world, but their uncertainty about roles make the
masks fall apart. what we hear from them is tangle of these
masks
(2) Laing wanted psychotherapy, but not Freudian. Rather, the
therapist needed to be as 'real' as they demanded of the
patient and not behind labels like doctor vs. patient and
make things rather a person to person
ii) 1964 – family challenge and Sanity, Madness, and the Family –
(1) radicalization of neo-Freudian mother blaming explaining
origins of schizophrenia. Say that it’s the mother’s fault, but
also psychiatry’s fault because by labeling child with a
problem, parents begin to ignore the problem
iii) Radicalization of schizo as experience and The Politics of
Experience
(1) based in subculture of LSD where patients not lost, but on
journey to find what life w/o masks are like. They’re
exploring the inner space of consciousness
c) Kingsley Hall – counter culture hospital housing his radical LSD
experimentation
i) most famous patient was Mary Barnes – showed LSD not lead to
unconscious journeys, but instead devolve into child-like, deviant
behavior
ii) theme – disconnect between realities of practicing psych vs. ideas
of professionals
3) Rise of patient-led radical alternatives
a) disillusion around Laing because rise of deinstitutionalization
b) patients say don’t need psych help, but will make it on their own
i) eg Howie the Harps and ways to deal with homelessness resulting
from deinstitutionalization
People: Ronald Laing, Ken Kesey, Mary Barnes
Themes: Deinstitutionalization, skepticism about institutions, influence of
war/sentiments around war, drug subculture,
Connections: another example of the re-invention of previous concepts like
deinstitutionalization, psychotherapy, family influence. this shows an
increase in the role patients playing within own treatment
Lecture Notes 4/21
The previous lecture focused on Laing, this one focuses on Szasz. Szasz stresses the
importance of individual liberty, he believes the only time that someone can be justifiably
locked up is if they have committed a crime, or are immediately trying to commit a
crime. A legal movement came out of his ideas, and a few landmark cases are discussed
in the notes as well, more significantly Lessard v Schmidt (1972). Scientology is also
addressed, as is the theory of consumer choice in opening up different ideas about
treatment.
Szasz and the “myth of mental illness”
From political rebellion to consumer choice
By now, it’s no longer a political movement, it becomes consumerized
Patients consume mental health services, whether they consume inside or
outside what’s actually shown to work
o Hearing Voices group that claims that hearing voices doesn’t need
pathologizing, that it can be ok
o Even Psychedelic treatments are on the upswing
o
o
New Strand of Criticism of psychiatry: Thomas Szasz
o
Gets lumped with R.D. Laing as the two leaders of anti-psychiatry, but in
fact they had nothing in common
Thomas Szasz
o
o
o
o
o
o
Sees himself as libertarian – classical liberalism
 Should only face government intervention when you actively
harm someone else
Medical Physicalism
Doesn’t think this behavior counts as a disease, as there is no evidence
 Doesn’t think people should be locked in mental hospital without
“proof” of diseases
“The Myth of Mental Illness”
 opening salvo against psychiatry
 claims that Charcot cheated, thinking symptoms were proof of
underlying physical symptoms
 Problems in life suck, but that doesn’t mean they have a medical
basis says Szasz
The only mental illness he says is real is General Paralysis, as there is a
physical, identifiable thing in the brain that causes it
Doesn’t matter if the illness is real or not, you don’t lock people up
against their will (lawyers band together for this)
Harvey Milk murder by Dan White and the Twinkie Defense (1978)
o
o
Sudden increase of sugar had further aggravated untreated depression
Jury is persuaded, convicts only on manslaughter, not murder
Szasz as a theorist for “psychiatric civil rights”
o
Largely patient led movements
 Saw themselves as fighting against stigma, coercion
o Young lawyers also galvanized, such as Bruce Ennis
 “Prisoners of Psychiatry” by Ennis
 Mental Health Law Project founded 1972
Rennie v Klein (1978)
o
Stops psychiatric hospitals from forcing treatment on their patients
Wyatt v Stickney (1972) (slightly paradoxical to Rennie v Klein)
o
Forces hospitals to care for all patients, can’t just allow them to languish
in back wards
Lessard v Schmidt (1972) Andrea Lessard
o
o
Changed involuntary commitment laws across the country
Simply suffering from mental illness no longer enough to be
involuntarily committed
o Now, it’s only legal to lock up only if person is showing immediate
threat of harming him/herself or others
 Now had to be proven in court, burden of proof on the doctors
o Critics: Mentally ill homeless dying in the streets “with their rights on”
Szasz and the Church of Scientology
o
o
L. Ron Hubbard, founder of Scientology
Core spiritual claim: humans have forgotten their true nature as immortal
spiritual beings
o Auditing: alternative path to mental health
o Sees medical psychiatry as standing in the way of people’s mental health
o Church is committed to all out war against psychiatry
 Hubbard’s “Project Psychiatry”
 Szasz and Hubbard jointly found Citizen Commission for Human
Rights
In more recent years, Szasz and his followers work to distance themselves from
Scientology
"Myth of Mental Illness"
Psychiatry's discontents PART 2
1) Thomas Szasz
a) trained in psychoanalytic psych and published many critiques of psych b) disliked that he was lumped with Laing b/c had two different philosophies
i) Laing – Marxist, leftist, liberal etc
ii) Szasz – linertarianist (‘free minds and free markets’ where do what
want w/o govt)
c) part of medical physicalism and scientific materialism
i) says that if have a disease, must have some physical evidence of
it. simply 'suffering' is not enough. must be a change in tissue or
physical functioning
2) 1961 – bumper crop year for discontent with psychiatry
a) Szasz turns against psych because he says that it claims things such as
mental illness while it has no physical evidence etc. Moreover, it takes
away people's personal liberties
b) book – “Myth of Mental Illness” – explains how Charcot w/ hysteria was
also a medical materialist and he was never able to find any psychical
evidence of hysteria as disease
i) Szasz found nothing medical wrong with hysterics. They’re using
language of illness to complain about what is unsatisfactory and
these claims make it easier to be ‘sick’ when one isn’t
ii) saying that immoral to confine people even when claim it's better
for them. saying that all should have right to refuse treatment even for those ill with cancer etc. Also immoral to forcibly treat
patients (as happened with schizo patients etc).
3) Szasz and the insanity defense
a) said that the claim of mental illness allowed people to cop out of personal
responsibility for actions with the claim that are mentally ill
i) eg case of Harvey Milk and his murderer – Dan White acquitted
because used claim that suffered from untreated depression and
indulge in sweets, thus system aggravated chemical imbalance
4) (S) became theorist for psychiatric civil rigts
a) modeled on past civil rights movements and saw self as next chapter for
providing civil rights to all different sectors of the population - comprised
of ex-patient or psychiatric survivor organizations
b) Ennis was a 'civil libertarian' and focused on psychiatry saying that even
though he believed mental illness existed, still didn't have the right to lock
people up against their will
i) also works to found the Mental Health Law Project - wanted to
challenge the legality of a range of laws that might violate the civil
rights of the mentally ill
ii) most important ruling to come out of it was Lessard v. Schmidt
(1972) - changed the commitment laws across the country. Were
no longer allowed to commit a person who didn't want to go the
state hospital
(1) argument that they made was that simply suffering from
mental illness is not grounds of involuntary commitment.
the only reasonable grounds are if they represent an
immediate danger to self or others.
5) Church of Scientology
a) Hubbard was founder and claim that one thing blocking ppls minds is
pych, considered n some ways the ‘evil other’
b) Hubbard as "Project Psychiatry" that was supped to wage all out war
against psych 0 with (S) founded Citizens Commission for HUman Rights
(CCHR).
People: Thomas Szasz, Hubbard
Themes : medical physicalism/scientific materialism, discontent with current
psychiatry, patients rights
Connection: movement towards increasing patients rights, also want to increase
deinstitutionalization
Lecture Notes 4/26
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Neo-Kraepelinian 1970 “manifesto”
o Responds to critics and neo-Freudians: psychiatry should treat people who are sick!
Mental illness is real
Diagnostics before the 1970’s
o 7 diagnostic categories used in census 1880-1918 to count people in institutions
 Mania, melancholia, monomania, paresis, dementia, dipsomania, epilepsy
o Statistical manual for the use of institutions for the insane 1918
 22 categories of mental illness (including mental retardation), but by no
means a bible. Guides American diagnostics for next 30 yrs
WWII + DSM
o Must be classified/diagnosed for gov’t purposes
o Current manual basically useless since it only classifies institutionalized/chronic
mentally ill
 1. DSM-I, 1952
 3 classes of mental disorder
o Major psychotic disorder
o Disorders of mental deficiency/retardation
o Functional (neurotic), personality, and reaction disorders:
all assumed to have environmental origins (ex: trauma,
psychosocial development)
 106 types of mental illness
 2. DSM-II, 1968
 Bring into alignment w/ international standards of WHO, headed by
Robert Spitzer. Not very newsmaking.
1970’s
o 1973 article in Science “On Being Sane in Insane Places”
 Mental illness may not exist, just a stigmatizing label
 Studies where people pretended to be crazy to be admitted, then started
acting normal once hospitalized. Took between 9 and 52 days to be
released!
 All diagnosed with schizophrenia or bipolar in remission. Drs had no clue,
but pts knew
o Gay activism, 1973 vote to remove homosexuality from DSM after a century
 Stonewall riots at popular gay bar 1969
 Start showing up at APA meetings, want the right not to be pathologized
 Dr. H Anonymous (John Fryer) speaks at 1972 APA mtg about being a gay
psychiatrist and the community (Gay-PA). Secrecy, shame
 Spitzer says that mental illness must involve subjective distress. 1973
removed from DSM. Some debate in 80’s, officially renounced in 1994
o
o
Recession years. People start holding NIMH/researchers accountable. Need for
placebo-controlled trials. Insurance co’s argue about covering mental illness
costs/legitimacy of mental illness diagnoses
DSM-III
 Spitzer and neo-Kraepelinians come in to bring new accountability to field
 Out with Freud- excision of psychosocial/psychoanalytic language
 Reliability as new gold standard
 Checklists of symptoms with min # required for diagnosis
 But still the question of validity (is this a real condition?)
 DSM promises to bring psychiatry into ranks of evidence-based medicine
 Becomes a publishing phenomenon! Can’t keep it on the shelves.
 **Psychiatry becomes a DSM world**
 Growth in # of diagnostic categories with each DSM- 106 182  265 
307
 Is this all the result of scientific discovery or is it affected by politics,
culture, medicalization of ordinary experience?
Lecture Notes 4/28
: Post-DSM psychiatry
 2 stories from time of DSM-III and neo-Kraepelinian revolution: PTSD &
cosmetic psychopharmacology (aka neuroenhancement)
 1. Vietnam war + making of PTSD
o Sarah Haley: social worker. Vietnam vet tells her how he has recurring
visions of war (took part in My Lai massacre), can’t sleep
 Staff says he’s paranoid schizophrenic but Haley disagrees
 DSM-I (1952) has a 4 page section on “gross stress reactions”
including rxn to combat
 DSM-II (1968) Takes gross stress rxn out- changes to
“Adjustment Reaction of Adult Life” = short-term response to
stressful adjustment, but if the subject fails to adjust quickly
enough, then they have another more serious condition
 Taken out to smooth tensions & opposition to Vietnam
(some psychiatrists were working w/ the Army, etc)
o 2 doctors: Chaim Shatan + Robert Jay Lifton
 Assert that this was a different war- men live in chronic fear, bad
reception upon returning home. Double pain of experience +
reentry
 Lifton calls symptoms post-Vietnam syndrome. Hypervigilance,
guilt, anger, numbing thru self-medication, abuse/threats towards
family
 Accuses psychiatrists of teaming w/ military to deny this illness bc
acknowledging it would mean the war had gone wrong
 Sara Haley article: “When the patient reports atrocities”
o After a dam breaks in WV causing many deaths and 90% remain
traumatized, Shatan and Haley are able to convince Spitzer that this
response needs to be included in DSM, resulting in the creation of Posttraumatic stress disorder in DSM-III
 Diagnosis can include trauma from war, disaster, etc.
 Sort of contradicts neo-Kraepelinian position that mental illness is
not environmental
 Sparks an outpouring of books, uncovers hidden victims of child
sexual abuse, domestic abuse, concentration camps, etc.
 2. Cosmetic psychopharmacology/neuroenhancement
o Prozac enters scene in post DSM-III world
 Explicitly marketed to treat all 9 symptoms of depression (very
DSM)
o “Listening to Prozac”- Kramer argues we’re on the brink of a new chapter
in psychopharm bc of the intrinsic goals of new drugs
 Don’t just treat depression- they can resculpt personalities and
make you better than well.
o Media unease over Prozac in 90’s
 “Pharmacological Calvinism” idea that happiness must be earned
and we shouldn’t be too quick to take a drug to improve our mood.
You don’t want to be too happy.
o 2000’s
 Prozac loses rockstar status due to suicide warnings for young
people
 Doubts of efficacy (placebo does just as well in some cases)
 Today, we hear less about drugs resculpting personalities+ more
about “smart drugs” that improve discrete fxns like memory and
learning- neuroenhancers
 Off-label Ritalin, Adderall use in college. Modafinil keeps
you from sleeping
Notes - "Let There Be Light" (3/22)
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1946 documentary filmed in state hospital
Shell-shocked soldiers from war…banned after release despite being
commissioned by US Army due to “potentially demoralizing effects the film
may have on soldiers”
o Maybe army wanted to maintain “warrior myth,” that soldiers fought in
war and returned stronger, proud for serving country, spirit
unwounded
Soldiers described as having feelings of fear and utter hopelessness…narrator
says fear of death common
Fake? Treatment scenes seem too good to be true
o Hypnosis scene seemed to work too perfectly to be real
 Treatment of conversion hysteria…patient had paralysis of leg,
narrator said it was purely psychological…hypnosis shown to
work perfectly, patient walked immediately
o Amnesia treated through hypnotic suggestion…patient “falls asleep,”
rigid arm to demonstrate…is this real? Remembers experience as thing
of past…”Now he can remember”
o Man with speech problem…hypnotized…while hypnotized was able to
recall when he lost speech ability (“s” was sound of explosive
shells…patient feared sound)
Series of scenes in psychiatric hospital showing treatment over 8-10 weeks in
hospital
o Psychiatrists sit and talk to soldier…asks questions…what happened,
how did you feel?
o Soldiers said to have anxiety, restless sleep, fear of loneliness
o Choice of occupation during stay…mechanics, sewing…thought was
that they were building instead of destroying
o Sports said to bring soldiers out of isolation
o Group psychotherapy
Psychiatry of the time
o Related physical problems to mental symptoms
o Interpretations of pictures to reveal thoughts
Progress over stay
o Shock from war starting to wear off
o Soldiers shown to start smiling, living less in past and more in present,
thinking about future
o Start thinking of selves in relation to society…occupations
WWII revealed large numbers of mentally ill soldiers…20% of battle casualties
were of neuropsychiatric nature
Plotting: what is the structure of the story told?
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The structure alternates between narration of life at the ward and scenes of
patient-doctor meetings, group patients meetings
A group of soldiers is depicted from the beginning to end of a several week
program at a psychiatric ward. They are shown working with psychiatrists to be
healed.
Verisimilitude: Which scenes seem most authentic? Which, if any, might seem “staged”?
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The authentic scenes are the sessions with soldiers talking through their
memories, fear, problems with therapists. Many of them cry or show other
emotions
Staged scenes are those depicting life in the ward: making phone calls home upon
arrival, making a home for themselves at the ward, etc.
Striking moments: Which scenes left the strongest impression? Why?
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Emotional scenes with soldiers remembering the war, talking through their fears.
Hypnosis scenes: doctors healing patients using sodium amytol and hypnosis.
One soldier is able to walk again, another able to remember, another able to speak
after hypnosis. Is this for real?
Theory: what makes men psychologically disturbed? What makes men well?
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Emotional and physical trauma from the war. Also links to upbringing and
methods for handling troubles.
Therapy and time makes men well. NOT pills.
Therapeutics: how is the healing process produced?

The ill soldiers all move to a ward for a few weeks. They have one on one
sessions with doctors, group meetings, occupational therapy, exercise.
Doctor-patient relations: how do they work in the film?

Doctors help patients work through their problems and create a safe and peaceful
environment. Doctors are the source of healing.
Parents, girlfriends, and other significant relationships: how do they figure in the film?

These relationships are a source of stress and anxiety for the soldiers – mostly
because these are the people that they love most and worry about most. Men miss

their girlfriends, worry about their brothers also fighting in the war, and worry
about sick mothers they aren’t around to care for.
Doctors ask a lot about soldier’s relationships with their mothers, and how their
mothers dealt with troubles.
Civilians and civilian life: how do these figure in the film?
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The goal of the therapy appears to be reintegrating the ill soldiers successfully
into civilian life – finding jobs, and dealing with the stress of civilian life.
The film is also to help civilians understand the trauma that soldiers have been
through. Hopefully employers will understand and give soldiers a chance at work
even if they have struggled with mental health before.
Presence of African-Americans and white-black race relations, and effect on the
messages of the film (in a time when the American military followed a policy of racial
segregation)
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There is 1 African American patient. He appears to be treated just the same as the
other patients, and is equally involved in all therapy activities.
Messages about war and its effects: Is war hell? Is war a noble pursuit? Something else
again?
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There is not any mention of the war being a noble pursuit, the focus of the film is
on the patients trauma and healing.
We hear a lot about the horrors the soldiers have endured – the war is hellish for
most of them.
Destabilizations: what in the film might account for the judgment that the military saw
the fim as a “failed” piece of military propaganda?

The war has seriously messed these soldiers up. Why would anyone want to fight
if this is what might happen to their mental health?
Notes - "Madness and the Brain" (4/5)
FILM: “Madness and the Brain”
1980s: Absolving families, blaming brains: the new understanding of schizophrenia
BASIC SUMMARY:
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Schizophrenia and the impact it has on patient
a) patient often shows anger, confusion, constant shifting of emotion
b) often fearful of others, scared of people, constantly believing that they will
harm them
c) patient in movie does not understand why he needs treatment, would like
to go home but family does not agree, causes conflict and arguments
d) feelings of sympathy or love are not portrayed, very conflictive instead
Schizophrenia and the impact has on family
a) family often in conflict of keeping a close relative at an institution
b) brings about a lot of sadness and even feelings of guilt
c) often halts family life, very difficult to take care of loved one and yourself
as well
When it comes to schizophrenia, both sides (patients and family) is heavily
affected.
Treatment is often hated by the patients, who would like to live in a regular home
and be free.
However, the disorder affects people in such a way that they truly become
incapable of functioning in society. In a sense, they can cause more harm to
themselves and others by not seeking professional help and living in a mental
hospital.
Notes - "One Flew Over the Cuckoo's Nest"
Themes:
1) patients are rebels and truth tellers of repressed society
a. seen as seeing the view from different perspective, not constrained by
societal constructs
i. McMurphy not actually dangerous, just enjoying life more and is
free spirited, not living to the social constraints set up for him.
However, film portrays his actions – like wanting to watch the ball
game and the trip they take out of the asylum as positive for the
patients
ii. idea that viewers root for him and some may go so far as to
identify with him, but also see that he fits in really well with the
institution and the patients. Thus, idea that not much difference
between the ‘mad’ and the ‘normal’
b. mental hospital as ‘total institution’ – control their every move, keep them
confined and all action analyzed
i. need to go through psychotherapy almost with the group talks and
how life is regimented by times that must sleep and times that must
take medicines
ii. not allowed to do anything beyond what Nurse Rached says
c. mental illness as labeling – see internalization of label by patient and elect
to confine themselves. scene where most patients reveal that there
voluntarily
d. use of drugs shows the idea of silencing those deemed as mentally ill –
keep people’s true feelings under wraps.
i. see at the end with shock-therapy, that essentially kill McMurphy’s
brain cells to keep him under control (take away what makes
Characters and Interactions
1) women as characters
a. not positive – beyond the Nurse, no powerful female figure
i. With Billy – see the example of the psychosis causing mother who
so overbearing as to cause child to be ‘soft’. After sleeping with
the woman, he is fine until the nurse mentions the way mother may
react
b. two women are unintelligent symbols of sexuality, there for the pleasure
and whim of men
c. Nurse is overbearing and also controlling – would be a refrigerator mother
if she had kids. not allow the patients to do anything she doesn’t want
2) Relations between psych professionals and ‘mentally ill’
a. uneven relationship with psych professionals seeing themselves as the
only rational ones whose job is pass judgment on the patients
b. not seen as helping, but rather often causing the problem. strongest
example is the change that overcomes billy when nurse mentions his
mother. in many regards, she is the one that drives him to suicide – abuse
of her power and willing to drive the patients to worsen their problems,
rather than help them
3) Men as patients
a. run of the gamut in terms of problems and different neurosis. interesting to
note that a lot of their problems come from problems with women. not just
billy, but the other man who is having marital issues
Bleuler, Eugen, “The Fundamental Symptoms of Dementia Praecox or the Group of
Schizophrenias” (1911), in C. Thompson, ed. The Origins of Modern Psychiatry
(John Wiley & Sons, 1987, pp. 165-207.
Major Points
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Bleuler heavily influenced by Kraepelin’s definition of schizophrenia (SZ)
Nice compromise btwn neuropsychiatry + psychoanalysis/Freud- makes symptoms
“understandable” by looking at psychological root
Bleuler cares about the patient. Does in depth interviews w/ patients, book contains
extremely detailed clinical observations/case studies
Cares about creating diagnostic category/standardized criteria of SZ. Breaks SZ down into “4
A’s” Disruption in Association & Affectivity + Ambivalence and Autism
Article Outline
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Looking at standardized symptoms of schizophrenia (SZ) across population, focusing on
“large symptom-complexes” not the little particularities
Fundamental symptoms are characteristic of SZ (caused by toxins) while accessory
symptoms may be in other illnesses (caused by psychological mechanisms)
Stresses that each presentation is different and different symptoms may or may not exist at
certain stages of disorder
This article displays an extensive, careful analysis of many patients to come up with this
standardized set of criteria
Fundamental symptoms
o Disturbances of association + affectivity
o Predilection for fantasy agst reality
o Inclination to divorce oneself from reality (autism)
o
o
Disturbances of association
 Train of thought doesn’t make sense, ideas get confused, no unifying
concept, bizarre ideas
 Can vary in extremity of disorganization depending on patient/stage of SZ
 Gives a lot of examples, quotes from pts. Goes into extreme detail about
different types of disturbed associations
 Ex: blocking. Pt will discuss one idea, stop abruptly, and then start a
new conversation with no relation to past train of thoughts. Pts find
this very unpleasant.
Disturbances of affectivity
 Emotional deterioration- affect begins to disappear
 Expressionless face, indifferent, don’t react to injury, not happy or sad. No
self-preservation instinct. Difficulties interacting w/ others.
 The ability to produce affect has not disappeared though- moods can
reemerge (ex: anger, irritability, parental love)
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o
o
“The character of the schizophrenic is as manifold as that of the normal”
Affective ambivalence: pt both loves and hates his wife. Ambivalence of will
: wants to eat & doesn’t want to eat. Intellectual ambivalence: I am a
person, I’m not a person
The intact simple fxns
 Sensation, memory, consciousness and motility are not directly disturbed
The compound fxns
 SZ characterized by peculiar alteration of relation between patient’s inner
life and external world.
 Inner life assumes pathological predominance + detachment from external
world = autism
 May stare at blank walls, cover their eyes
 “The reality of the autistic world may seem more valid than that of reality
itself; pts then hold their fantasy world for real”
Shorter, A History of Psychiatry, pp. 99-112.
The End of the First Biological Psychiatry
It wasn’t that there was a problem with neurologists’ findings, but most did not seem useful.
Kraeplin, not Freud, was key to ending 1st biological psychiatry: His observations, cards, emphasis on
patient history led to paradigm shift -cause is biological, but we don’t know it, so instead of wasting time
looking at things under the microscope, categorize mental illnesses and focus on prognosis.
Kraeplin published textbooks instead of articles.
Kraeplin consolidated what had become a “sprawl of clinical disease labels” based on circumstances or
collection of symptoms; instead based on course outcome. First example of focus disease course is
“hebephrenia,” (by Kahlbaum and Hecker) which would later be called schizophrenia.
In 1893 edition of his textbook, after years worth of patient cards, coined dementia praecox –early onset
neurological degeneration, the concept of which was common by 1893.
Big shift in 1896 edition of textbook: abandon categories, focus on prognosis, not cause, because cause is
unknowable.
1899 edition – 13 big groups. Importantly, all those without obvious organic cause are put into just two
categories: affective (emotional/mood-related) and non-affective disorders.
Affective becomes “manic-depressive psychosis.” –good prognosis for recovery
Non-affective becomes dementia praecox. –bad prognosis. Doctors marked as “d.p.” in notes.
Counter to Kraeplin: Eugen Bleuler, 1908, sees that d.p. patients not necessarily young or demented ->
coins schizophrenia.
Additionally, Kraeplin wasn’t universally well received. Subcategories persisted. Some thought his
textbook arrogant.
Big picture: “the interpretation of mental symptoms had been dethroned” –Details, such as what the patient
was saying, were largely unimportant. Kraeplin’s is a “medical model,” as opposed to the “biopsychosocial
model” that would arrive later.
An American Postscript
Adolf Meyer, “a sort of American Kraeplin.” He liked Kraeplin’s break from old biological psychiatry, and
played a large role in bringing Kraeplinian ideas, such as meticulous records of patient histories, to
America. Later turned from Kraeplin to psychoanalysis.
Pre-psychoanalytical Meyer: built large clinic for studying patients, integrated psychiatry with general
hospital- thus more “medical” than in Germany/Austria. –Patients arrived in ambulance.
Shorter concludes that Meyer seemed confused in his beliefs – early on favored degeneration, somewhat
rejected biological psychiatry while favoring somatic treatments, and by 1940s finally rejected Kraeplin
and embraced psychoanalysis and his formulation of “reaction types.”
Kraeplin was clearly far from Freudian, but the transition to psychiatry based on an “understanding of
mental illness based on life history of patient” could be considered transitional to the Neo-Freudian
conceptions that life events are causal in the illness. It is good to recall Kraeplin’s philosophy of
categorization and etiological agnosticism when considering DSM-based psychiatry.
Shorter gives a brief overview of the medical movement towards biological psychiatry
and away from Kirkbride's "moral therapy". However, this biological psychiatry should
not be confused with degeneration. Instead of using physical traits to distinguish and
outcast those with the potential chance of developing mental illness, psychiatrists at this
time shift to researching a relationship between the mind and brain at universities and
institutes…not asylums.
Shorter explains that this need for a greater relationship between psychiatry and science
is due to a greater demand in psychiatric education for medical doctors and scientific
curiosity of the age. For contemporaries, it was important that medical doctors to be able
to understand the brain and the central nervous system in order to treat mental illness. He
then moves on to briefly describe the contributions made by several significant German
psychiatrists.
Early efforts to teach psychiatry to medical students were inefficient because medical
schools lacked a nearby department of psychiatry (asylums were the only sources) that
would admit patients whose illnesses the professors wanted to demonstrate in lecture and
that could make psychiatry a convincing part of medicine by belonging to a general
hospital. So when Wilhelm Griesinger (portrait of him on page 122 - potential ID!)
became a professor of psychiatry at Charité hospital, the medical view of psychiatry
changed. Not only was Griesinger to become the single most influential represenhtative
of the first biological psychiatry, he established the modern model of the department of
psychiatry as dedicated to teaching and research rather than to custodialism.
Griesinger divided the Charité clinic into halves, one for the "usual nervous diseases,"
the other for "nervous disease with a primarily psychiatric presentation". Alternating
between them by semester, he could hold clinical lectures on them. He encouraged his
students to focus on diagnosing these diseases. He emphasized that mental illness
stemmed from illnesses of the brain and brain, and therefore psychiatry needed to become
medicalized.
The reading also mentions Theodor Meynert (also mentioned in lecture). As a student of
therapeutic nihilism, he found that the method of curing the insane as utterly useless,
instead he devoted his time in psychiatry strictly for research. His research included
pioneer work in the microscopic structure o the brain and the spinal cord, as well as
searching for pathological lesions in those with neurosyphilis (rather revolutionary,
because it connected science to psychiatry - keep that in mind!). However, perhaps
because of his therapeutic nihilism, Meynert had no interest in patients and had terrible
personal relationships with them. In any case, Meynert began what Shorter calls the "last
phase in the development of the first biological psychiatry" which is a concentration on
anatomy, instead of symptoms of a disease.
Shorter goes on to mention several other significant names in biological psychiatry,
including Paul Flechsig (portrait on page 128, also potential ID), who laid down the basic
map of what regions of the cerebral cortex are responsible for what functions ("cerebral
localization"), as well as Eduard Hitzig who established that the brain responds to
electrical stimulation (also mentioned in lecture). Both these men were also terrible to
their patients, which leads Shorter to the conclusion that as research into brain anatomy
and brain physiology accelerated, the first biological psychiatry became nihilistic about
the possibilities of clinical care.
Quotes from lecture 6 that characterizes the movement toward a scientific understanding
of mental illness and away from clinical treatment or cures:
“The more that psychiatry seeks, and finds, its scientific basis in a adeep and finely
grained understanding of the anatomical structure [of the brain], the more it elevates itself
to the status of a science thatdeals with causes.” Meynert, 1890
“Why think when you can experiment?” – Claude Bernard, French medical physiologists
in 1876.
“A doctor who visited the hospital [ in Vienna] told me he saw a party of students
sounding a woman who was dying of pleurisy or pneumonia, in order that they might
hear the crepitation in her lungs as her last moments approached. She expired before they
left the ward. He said something about treatment in another case to the professor who was
lecturing these young men. The reply was, ‘Treatment, treatment, that is nothing; it is the
diagnosis that we want.’”
Cohen, Sol, “The Mental Hygiene Movement, the Development of Personality and the
School: The Medicalization of American History”
Cohen addresses the integration of mental hygiene ideas into “common sense,” which
was the result of a massive, direct assault on teachers and schools (largely Thomas
Salmon’s doing), in contrast to theories “trickling down” to public. Drew on Progressive
era optimism, successes of public health movement. Bypassed scientific proof of their
theories, in stark contrast to neurologists/biologists of late 19th century.
Beginning, Progressive: National Committee for Mental Hygiene (NCMH) 1909
 Made of academics, social workers, docs, psychs. Including Clifford W.
Beers.
 Adolf Meyer, head of Johns Hopkins’ Phipps Psychiatric Clinic -> medical
leadership of mental hygiene
 Inspired by public health advances against TB.
Funding difficult, due to therapeutic pessimism left over from late 19th century.
Mental illness not disease of the brain, but a personality disorder.
 Personality is malleable. Childhood is everything. Psychs must enter schools.
WWI -> shell shock exposed those susceptible due to childhood
 Dealing w/ soldiers moves psychs into treating “normal people”
Hygiene in competition w/ eugenics. But both came from same sense that there was too
much mental illness abounding. But hygiene said personality malleable. Eugenics said
feeble-mindedness innate.
1922 – Salmon starts “Program for the Prevention of Delinquency”
 Child guidance, social work, and child psych are team to “adjust” the
“predelinquent”
o Found this was too late to help. Needed to address parents.
Parent education. 1920s. Done by Bureau of Child Guidance and NCMH.
 Not enough participation to satisfy hygienists. Must target school.
School. Academic “failure” is bad -> inferiority -> harm to personality
 Solution: de-emphasis on academics, the old “rigid curriculum”
o Too much teaching, not enough guiding
 Discipline: Authoritarian teaches make children hide emotions.
 Psychs, social workers, guidance councelors, etc. were secondary
Making it happen – much of this done through Salmons “Program” from above
 NCMH 1917 makes journal Mental Hygiene, aimed at community leaders –
by 1924, it and Mental Hygiene Bulletin had 15,000 subscribers.
 Visiting teachers sent to train educators and parents. Lectures, courses etc.
 Massive distribution of books and pamphlets.
 Cohen emphasizes language: hygienist vocab, terms, for education “socially
canalize thought”
 1930 “White House Conference on Child Health and Protection” is landmark
of acceptance. Cohen argues this wasn’t to create new ideas, was to legitimize
them.
 Made legitimate, widely-used textbooks for teachers in training.
By 1950 the NCMH disappeared. But its ideas were already integrated.
Why did it work?
 Urgency: “modern plague” of mental illness.
 Public health successes- if people could be made not to spit, class could
change.
 Desire for social control without coercive laws.
 Confidence. “therapeutic furor” that sacrificed research for action
Cohen studies the emergence of "mental hygiene" as a as a popular concept from the
1920s through the '60s. The term "personality development" in particularly
representative of this field, as its use encapsulated the belief that personality was
individual, could be molded, and should be molded in young people through the
education system. Much like one would be taught math or English, students should
be taught proper psychological maintenance of their selves. The National Committee
on Mental Hygiene, established in 1909, was the first manifestation of the increasing
importance of psychiatric knowledge in popular culture. At first, general pessimism
regarding psychiatric therapeutics prevented the NCMH from doing much more than
disseminating information on the prevalence of personality disorders and attempting
to improve institutional conditions. However, with the emergence of Freudianism,
soon the concept of personality and emotions being at the heart of most disorders
gained momentum, as well as the concept that certain emotional maintenance could
prevent these disorders. Furthermore, the onset of the first World War and the
increasingly important role of psychiatrists in treating shell-shock gave these doctors
a new professional identity, that of a treater of personality disorders. WWI allowed
doctors to move out of the asylums and treat broader, more common forms of mental
illness.
The best place, mental hygienists argued, to effect change was in the classroom. This
was because each child had to attend school, and would be under the influence of a
teacher during a particularly malleable part of their lifetimes. Students were therefore
analyzed for potential personality defects, and teachers were urged to treat
"maladjusted" children, especially quiet, withdrawn ones, in order to prevent mental
illness. Academic rigor was criticized, and instead the "attitude" of students was
supposed to be the focus on teachers. The NCMH worked to instill these beliefs on
the importance of mental hygiene in schools throughout the psychiatric profession, in
hopes that they would trickle down to teachers and guidance counselors. Soon the
movement would pass through the elementary schools into high schools, and various
teacher education books were published on the topic of running a classroom in which
mental hygiene was part of the curriculum.
Cohen argues that in a time of instability the mental hygiene movement was an outlet
for the desire to control human behavior. After the failure of the Treaty of Versailles,
people were anxious to put faith in a new manner of reform, mainly that of
personality maintenance and adjustment to form healthy, productive members of
society.
Williams, Frankwood, “Community Responsibility in Mental Hygiene,” Mental
Hygiene 7 (1923): 496-508
I. Williams begins the article discussing babies and the future. Some will die, some will
never function properly, some will contract an infectious disease, and some will get a
nervous disorder. In the past, we have mistakenly thought these courses were inevitable,
but we now know that negligence  typhoid, for example. Some kind people delight to
take care of invalids.
II. 50,000 new patients arrive each year in insane asylums (for the protection of the
community), not including nervous disorders. Somehow, they don’t seem real, but
they’re increasing. The key observation is that we can see the beginning of oddities and
idiosyncrasies (evidence of “difficulty in adjustment”) early.
III. Once upon a time, we attributed that we could not see to god or devil; we make these
attributions today in the world of emotions. However, “INDIVIDUALS ARE NOT
BORN ODD, OR QUEER, OR PECULIOR . . . THEY ARE MADE . . . BY QUITE
HUMAN AGENCIES. THESE THINGS COME ONLY IN RESPONSE TO VERY
DEFINITENEEDS ON THE PART OF THE CHLID AND ARE AN EXPRESSION OF
THE CHILD’S EFFORT TO DEFEND HIMSELF IN A SITUATION THAT IS FULL
OF CONFUSION . . . NO ONE HELPS HIM.” We sit, watch, hope, punish, threaten,
berate, misunderstand, give moral platitudes w/o confidence.
IV. There are options for children who are failing to adjust.
 Some will find an adjustment and become “captains,” but they will crush many of
the rest.
 Some will find their own adjustments that are less bizarre, but they will be
handicapped and viewed to have character flaws. “Life is not made richer by these
emotional conflicts.”
 Most will “curl up within themselves . . . quietly rebellious, dispirited, unhappy
[man-made] mediocrity.” They will become “ ‘hard boiled.’ ”
 Some will be bad. Children are born well, and delinquency comes. These are the
quieter types.
 Many will be told to control their tempers and be cheerful, but there is something
inherently weak in them. We find the same unfortunate traits in their parents. “Mothers
[with] ‘nervous’ headaches when difficulties arise,” so the weakness is inherent.
Consequently, hysteria, neurasthenia, anxieties, nervous aches, etc. have their cause in
grandparents or someone farther back, not teachers or physicians. “Mental disease
develops over a long period of time . . . [then] blossoms forth.” Some will seem fine all
their lives, but then will become insane. For years, psychiatry has been searching for
answers; others have ignored the problem. It’s a huge problem due to the rising numbers
in asylums.
Williams writes an emotional testament to the large number of American youths who will
eventually succumb to mental illness. He does not so much propose a remedy as lament
their fate. It is more an attempt to raise awareness of the effect mental illness has on
American society than a call to action, although he does insist that something should be
done to prevent their falling in in order to maintain a healthy community. As noted in the
Cohen reading, the operative themes of the mental hygiene movement are emotions and
personality defects, all of which may be changed through "hygiene", and not biological
explanations.
Buck versus Bell, 1927
Setting the Stage


By 1920s, term “feebleminded” became popular to describe someone not severely
mentally disabled, but not normal either
o Feeblemindedness thought to be hereditary
Institutions were set up in the US to keep epileptics and feebleminded
o These institutions sometimes used involuntary sterilization
Case





Brought to US Supreme Court in 1927 to decide the Constitutionality of involuntary
sterilization
Plaintiff Carrie Buck – minor sent to Virginia State Colony of Epileptics and Feeble
Minded
o Was going to be sterilized under Virginia's new statute of 1924 that allowed it
Defendant John Bell – superintendent of the State Colony, had already won the case in
two lower courts
Mr. I. P. Whitehead lawyer for Mrs. Buck, claimed that sterilization violates her
constitutional right of bodily integrity under 14th Amendment
o Virginia statute of 1924 prevents the reproduction of mentally defective people,
but who gets to decide what constitutes “mentally defective”?
Aubrey E. Strode lawyer for Mr. Bell, claimed sterilizing Mrs. Bell does not impose cruel
and unusual punishment
o State v. Felin set the precedent that an asexualization operation, vasectomy in
that case, was not a cruel punishment
o 1924 Virginia Act affords due process of law (it’s legal)
o In Virginia, marriage of a feebleminded person is illegal, so Mrs. Buck should
not be having children anyway
Outcome


Opinion given by Justice Oliver Wendell Holmes – upheld the Constitutionality of the
Virginia Act and of Mrs. Buck being sterilized
o Carrie Buck is the daughter of a feebleminded woman and the mother of an
illegitimate feebleminded child
o Involuntary sterilization is necessary to prevent our being swamped with
incompetence
o “Three generations of imbeciles are enough.”
Outcome – placed the health of the nation over the rights of the individual
o legitimated sterilization procedures in Virginia from 1927 until 1974.
Feebleminded: 1920 terminology for the “incurably maladjusted”; condition considered
hereditary:
Supreme Court Case of US heard in 1927 to decide Constitutionality of involuntary
•
sterilization:
Carrie Buck was a minor sent to Virginia State Colony of Epileptics and
•
Feeble minded and was to be sterilized “for protection and health of
the state”
•
•
Legitimized sterilization until 1974 in Virginia, 30 other states adopted
Bell was Superintendent of the institution; claimed i) due process has been given ii)
•
should exercise state’s power to look over social wellbeing and iii) Buck can’t
make choice herself
Judge: “We have seen more than once that the public welfare may call upon the
best citizens for their lives… It is better for all the world, if instead of waiting to
execute degenerate offspring for crime, or to let them starve for their imbecility,
society can prevent those who are manifestly unfit from continuing their kind.
The principle that sustains compulsory vaccination is broad enough to cover
cutting the Fallopian tubes. 3 generations of imbeciles are enough.”
In 1927, Carrie Buck brought her case against John Bell to the Supreme Court. Buck
was a minor who had been sent to the Virginia State Colony of Epileptics and Feeble
Minded, and was going to be involuntarily sterilized for the "health of the state". Buck
argued that the severing of the fallopian tubes to induce sterility - termed a salpingectomy
- violated her rights as termed under the Fourteenth Amendment which guaranteed her
right to the life and enjoyment of her own body. Bell, the superintendent of the Colony,
argued that as a minor, and furthermore with a "congenital mental defect", the plaintiff
was not in a position to determine what was in her own best interests. In addition, it was
argued that as a occupant of the Colony she would be unable to procreate, but if the
surgery were performed she could be released and be of benefit to society. The court
agreed with Buck, stating that there was nothing inherently unconstitutional in either the
surgery itself or the process by which it was decided who deserved to be sterilized.
"Three generations of imbeciles are enough," concluded Judge Holmes, who wrote the
decision. The verdict of the Supreme Court safeguarded the involuntary sterilization of
the residents of mental institutions until 1974.
Brown, Edward, “Why Wagner-Jauregg won the Nobel Prize,” History of Psychiatry
11 (2000): 371-382.
o 1927 the Viennese psychiatrist Julius Wagner-Jauregg was awarded one of only two
Nobel prizes ever given to a psychiatrist for his discovery of the malaria treatment of
general paresis.
o
So why has he been forgotten, while his contemporary Freud is remembered?
o
One reason is that general paresis has been so nearly eradicated that we forget
it once played a major role in psychiatry
o Some like Andrew Scull suggests we have forgotten Brown in “embarrassed silence”
because his cure for GP seems ludicrous now
o Yet “general paresis had frustrated all attempts to find a cure for over one hundred years
before Wagner-Jauregg introduced his treatment.
o General paresis of the insane was first identified as a distinct disease by Antoine Laurent
Jesse Bayle in the 1820s.
o 1857 progress toward the general acceptance of the idea that syphilis caused general
paresis was begun by the eminent nineteenth-century ’syphilographer’ Alfred Fournier
(1832-1914).
o
Found that women who live “irregular lives” (prostitutes/sluts) had paresis
more frequently than other groups, used data from 50,000 cases of paresis
o
BUT GP did not respond to anti-syphilitic treatment, so psychiatrists were
still skeptical
o To explain this phenomenon, Fournier coined the term parasyphilis
o
a non-syphilitic sequel of syphilis, a degenerative process
o
new term did little to persuade skeptics
o 1897 Krafft-Ebing inoculated 9 paretics with no history of syphilis with luetic material
o
none of them developed symptoms of syphilis -> must have already been
infected
o Work by Nissl and Alzheimer, published in 1904, definitely showed the pathology of
paresis stemming from syphilis
o Wasserman serologic test could be conclusively used to diagnose
o Psychiatrists hoped that the new anti-syphilitic treatment Salvarsan would be effective
against GP too, but it wasn’t
o Wagner-Jauregg became interested in the idea of treating syphilis with fever just after
taking his first position as a psychiatrist in 1883
o
Approached the issue cautiously, for fear of disapproval of the technique
o
In 1888 and 1890 he began two experiments to induce fever in paretics, but cut
both short due to fears of disapproval from peers
o Beginning in 1917, Wagner-Jauregg began using artificial tertian malaria to treat paretics
o
By 1926 27.5% treated with fever therapy were found greatly improved, and
25.6% moderately improved
o
Gained wide popularity and respect for its results
o Malaria treatment continued to be used up to the 1950s
o
No question that malaria treatment was a desperate treatment
o
Still, it offered hope for this disease after 100 years of hopelessness
o
Also claimed to have given more respect to paretics
“The Insulin Treatment of Schizophrenia,” in: An Introduction to Physical Methods
of Treatment in Psychiatry (First Edition) by William Sargant and Eliot Slater
o Manfred Sakel used insulin hypoglycaemia to counter the symptoms of withdrawal in the
treatment of morphine addiction
o Sakel then tried insulin hypoglycaemia in treatment of schizophrenia, and the Vienna
Clinic, which had seen the first introduction of the malarial treatment of general paralysis,
provided him with the patients to experiment on.
o 400 patients treated in Swiss hospitals before 1937, when the technique was still new,
59 per cent. of persons treated within the first six months after onset reached either a
complete or social remission.
o The results are much more favourable when treatment is given early.
o Provided early cases are treated, it is then probably true to say that insulin treatment brings
about a remission quicker and in a higher proportion of patients than occurs spontaneously
or with convulsive therapy.
o Abilities of the therapist administering the insulin treatment was very important
o
Some had great results, others not as good
o The patient who has only recently come to show definite and unmistakable symptoms but
has been known to have been gradually becoming queerer for several years is not a
favorable case for treatment.
o Most favorable case would be the patient who had been well up to a few days or weeks of
being seen, and he should be selected even if there is some lingering doubt of the true
nature of the illness and probabilities only speak in favor of schizophrenia
o Next in importance ranks the quality of the personality before the illness began. A frank,
open and socially well-adjusted personality reacts better than one which has always been
shy, shut off, awkward and autistic.
o Rapidity of onset is generally held to be a favorable factor
o The bodily physique has been found to be of importance, and the physical or athletic habits
are more favorable than the asthenic and the dysplastic.
o The tragedies of neglected insulin treatment in England are today a commonplace
to the psychiatrist of experience; we have as yet seen no tragedies from premature
treatment skillfully applied.
o Figures gathered in the United States give a mortality of 90 deaths in 12,000 patients
treated
o give full treatment on five days a week. On the sixth half-doses of insulin are given, and
the seventh is a rest day.
o Once coma has been induced, the insulin dose should be adjusted until the minimum
satisfactory coma dose has been found. Neglect of this principle will lead to the
occurrence of irreversible comas.
o When the patient has begun to go into coma the length of the coma period allowed is
increased gradually from five minutes on the first day to what proves to be the maximum
safe duration for the individual.
o Epileptic fits occur early or late in the hypoglycaemic period.
o In patients who are going to react well to the treatment it will generally be found that after
the first few comas, wakening from coma leads to an hour or two of a considerably
improved mental state.
o
great improvement in rapport and the affective attitude.
o Although convulsive therapy is no method of treatment of the schizophrenic psychosis
itself, it can often play an adjuvant part, and be particularly useful for dealing with
individual symptoms.
o Catatonic stupor usually yields to convulsive therapy, but sometimes passes into a catatonic
excitement.
o When recovery has occurred it is advisable to discharge the patient from hospital as rapidly
as possible.
Following trends of mainstream medicine (“Golden Age”), psychiatry in early 20th C was infused
with an imperative to seek cures. Modern laboratory science made new somatic treatments
possible:
Example 1: Malaria-fever therapy for GPI, as described in the Brown reading:
• Malaria-treatment of general paresis of the insane (GPI)
• Discovered by Julius Wagner-Jauregg in 1917, Austrian
• Somatic treatment now an “embarrassed silence” but won him the Nobel Prize in 1927
GPI fatal disease in early 20th Century, associated with huge stigma
•
Already understood causation of GPI from syphilis (in turn caused by treponema
•
pallidum)
But
GPI
proved unresponsive to anti-syphilitic treatment (e,g, mercury and potassium
•
iodide of 19th C or Salvarsn of 20th C- “magic bullet” for syphilis)
Noticed instead improvements following an undercurrent illness with high fever
•
Wagner-Jauregg used artificial tertian malaria to produce fevers
•
Solider with malaria in his ward – his blood taken and injected into GPI
•
patient; put in fever cabinet;
“Malaria
fire” has “cleansing” quality; 6/9 improved but with relapses
•
Not
without
ethical
critique even at the time, but was pace-setter for others to come
•
Example 2: Insulin coma therapy (ICT), as described in Sargant and Slater’s reading:
• Insulin coma therapy for Schizophrenia
• Therapy discovered by Manfred Sakel, Austrian
• Saw small does improved appetite in anorexia and improved general physical mental state;
hypoglycemia also used to counter withdrawal from morphine
• Dangerous but readily controlled by administration of sugar (patients closely watched)
• Surprisingly positive results; spread quickly; used worldwide throughout 1950s
• Article is a manual for clinical users (plus some stats.) -- mostly irrelevant for our purposes
Possible take-home point:
skeptical about treatment: efficacy seems
•
contingent upon whether it is given at early stage/ to already “favorable”
cases, whether personnel is well trained, whether “special insulin
treatment unit” is available
• Deemed first successful treatment ever for schizophrenia
• Mixed reviews (critiques: placebo/ painful treatments/ “insulin myth”) but unarguably brought
renewed sense of purpose to asylum work in midst of mental hygiene movement
Cerletti, Ugo, "Old and New Information about Electroshock " in American Journal
of Psychiatry, vol. 107 (1950), pp. 87-94

Thinks it was inevitable to use ECT instead of drugs to induce convulsions for
therapeutic purposes
 Practice that goes back in history
 Story of ECT can be broken down into three periods: prepatory, actual invetion,
applications
Preparatory period
 Begins with Cerletti first trying to prove experimental epileptic fits in dogs
 Had been known convulsions could be induced by toxic substances and electric
currents across the head
 Uses mouth rectum circuit instead of applying current to head so that irreparable
damage is not done
 Some dog deaths in the process—realizes its not dosage of current but duration
 During this process he’s appointed chair of neuropsychiatry at Rome University
Invention of the Electroshock
 Introduces new method of inducing convulsions by use of Cardiazol and
continues with electricity
 Public is not yet receptive to ECT b/c too reminiscent of the electric chair, seen as
too dangerous for man
 Turns to learning what conditions make an animal die (ie. no longer efforts to
keep convulsed animals alive)-no serious consequences so he begins testing
ECT on humans
 Also discussed in lecture: first person is a schizophrenic who had arrived in
Milan by train. Assistants and outside doctors are fearful and disapproving of the
experiment. After a small dosage, these assistants and doctors suggest taking a
break but suddenly the patient says in comprehendible words, not a second! More
shocks. Finally, patient sits up and smiles and when asked how he got to Milan he
says he must have fallen asleep on the train.
Period of Application
 After 11 complete and 3 incomplete ECTs, patient discharged, declared to be in
complete remission.
 ECT begins to be applied to a variety of different patients. He is initially
concerned b/c of potential of blindness, death, epileptizing patients
 ECT greatest for treating schizophrenia and manic-depressive psychosis
 Don’t patent ECT machine, it gets simpler and simpler
Recent Advances
 Repetitive ECT many times a day leads to amnesiagood for obsessive states,
expressions, paranoid cases
The Origin of the Idea of electroshock
Therapeutic applications/conceptions of ECT in ancient times, i.e. the
idea is quite old
Preparatory Period
Talks about his research into electroshock with dogs
The Invention of the Electroshock
Research shocking pigs gave him good reason to believe that the
treatment should not be very harmful to humans given optimal
conditions (such as height of voltage and duration of shock)
Describes first patient and his amazing recovery
Period of Application
Just talks about how it became legitimate after initial experiments
proved that it isn’t that harmful to humans
ESSENTIALLY: The significance of this article, for us at least, is simply
to showcase the enthusiasm and optimism with which psychiatric
researchers viewed ECT for therapeutic applications.
Pressman, Jack, "Sufficient Promise: John F. Fulton and the Origins of
Psychosurgery," Bulletin of the History of Medicine (1988), pp. 1-22
At the beginning of the article, Pressman discusses how psychosurgery has been
proven to be a failure as a concept/experiment. However, in the 1940’s,
psychosurgery was a very popular procedure and widely accepted among the medical
community. Pressman’s main purpose in the article is discussing the factors that lead
to the popularity of psychosurgery.
The main figure is John Fulton, who was an extremely renowned physiologist, and he
was the protégé of famous neurosurgeons Harvey Cushing and Sir Charles
Sherrington. Eventually, he was chairman of the Department of Physiology at Yale
University. There, he met Carlyle Jacobsen who did research in mammalian brains,
control on the central nervous system. While he was researching on most animals,
there was no research done on chimpanzees. The two(Fulton and Jacobsen) opened
up a chimpanzee lab to do studies on the brain functions of monkeys. However, they
noticed that the monkeys got frustrated on problem solving tasks, and during this time
Pavlov(the one who experimented on dogs, classical conditioning) noticed that dogs
occasionally freaked out and had essentially mental breakdowns. This observation
was also seen in the chimpanzees, so research shifted from observing central nervous
system to seeing what happens when you mess with the chimpanzee’s frontal lobe
area. As a result, the chimpanzees no longer had freak outs when frontal lobe
removed and Egas Moniz a Portuguese neurologist was inspired by this experiment
and did the same procedure on humans and it worked out fine. Eventually, James
Watts took this further and did this experiment on humans in the United States with
the support of Fulton.
The main factors that pushed the scientific community to accept this procedure was
mainly because of Fulton. He was funded by the Rockefeller Foundation and a lot of
other important projects were funded by the same company so this added to his
credibility. Furthermore, Fulton was a physiologist so he had the medical
professional background to back up Watts’s procedure. Also, Fulton had many
underlings who were also semi-important medical physicians and they believed him
and supported the procedure. Basically, he was well connected, a lot of people
respected him, and he supported Watts’s work with psychotherapy to the death.
Pressman concludes that while psychosurgery was a fraud, it is important to
understand why it was accepted and how it evolved. The aforementioned reasons are
why it was pushed and was successful.
Psychosurgery -- brain operations such as lobotomy or leucotomy
1970s -- denounced as ultimate form of mind control
1940s -- "not an aberrant event but very much in the mainstream of psychiatry
Why would reasonable physicians and scientist at first value a procedure so
highly, only to abandon it later?
1949 -- Portuguese neurologist Egas Monlz won Nobel Price for psychosurgery,
but many argue that john Fulton was the true father of psychosurgery
Fulton's discovery: brain operations could alter the intellect the behavior of
two chimpanzees -- Becky and Lucy. (Becky became happier after
neurosurgery)
psychosurgery became as the only significant treatment available for severe
chronic mental illness
2000 operations were performed in U.S.
Stanley Cobb, president of American Neurological Association, described it as a
dramatic translation from laboratory observation to therapeutic procedure
One of the first patients who got lobotomy became perfectly calm, rational and
entirely conscious after two years o impossible schizophrenia, Fulton wrote that
he felt it was one of the milestones of modern medicine.
Fulton wrote a letter to persuade other psychiatrists such as Glen Spurling to use
lobotomy.
Fulton also publicized the procedure to both professional and more general
audiences. Fulton played a crucial behind the scenes role in helping to insure
psychosurgery would gain a fair hearing and survive its controversial first few
years. The fathers of psychosurgery was Freeman and Watts. But Fulton had a
powerful influence.
Why was Fulton so closely involved?
The scientific justification for the procedure appeared to rest upon experimental
findings that originated in his own lab.
The procedure had been introduced into America by an alumnus of his lab.
Lobotomy is a research enterprise that had a significant meaning to him.
Fulton launched young investigators on fruitful research projects and then using
his professional standing to advance their careers to extend his influence through
a new generation of rising neurosurgeons.
The deciding factor for Fulton was Jacobsen's observations that bilateral removal
of the frontal association areas in chimpanzees permanently eliminated
experimental neuroses and agitated behavior.
The goal of Fulton's program was to widen the scientific basis for future clinical
advances.
The significance of lobotomy
it allowed people to think that the psychoses may have something to do with the
brain, rather than entirely with the heart as Aristotle thought.
Due to Fulton's labors, the cause of psychosurgery gained both early recognition
and a solid professional footing.
In linking Motiz's initial lobotomy attempts to ideas implicit within the
chimpanzee experiments, Fulton drew attention to , but didn't create, a scientific
justification for lobotomy
psychosurgery was an unintended consequence, but it was by no means an
undesired one.
the experimental neurosis provided a compelling intellectual context that united
the disciplines of physiological psychology, psychiatry and neurophysiology.
standard medical practice and belief does not stay fixed, but evolves.
Freeman, Walter, & Watts, James, "Prefrontal Lobotomy in the Treatment of Mental
Disorders" in Southern Medical Journal, 30 (1937) pp. 23-31





Operation of prefrontal lobotomy in treatment of certain psychoses first
introduced by Egas Moniz of Lisbon 1936
Freeman & Watts say that they can say no one has died or been worse off by
having the procedureas we know from lecture there eventually were deaths,
people who actually were worse off like Howard Dully
Say patients have been relieved of troublesome symptoms, not sure yet if relieved
permanently of symptoms
In patients, common denominator of worry, apprehension, anxiety, insomnia,
nervous tension and in all symptoms were relieved to a greater or lesser extent
Psychical conditions of patients improved
Technic
 Here, they just discuss the technical aspects of surgery. Relevant points at this
points holes were madethis is pre-ice picks
 Patients discharged 1 – 2 weeksunlike ice pick lobotomy that was on the spot
and sent home
Cases
 Case 1. Mrs. A.H, elderly was emotionally, agitated when asked
questionsafterwards she does not have any of her old fears, cant’ remember
what she was afraid of, no longer upset
 Case 2. A widowed mother who has finished raising her two children loses it after
a heart attack. Becomes depressed and confused. Has surgery. Returns to job, no
longer anxious, or has bitter taste in her mouth, or suspects of being poisoned as
before.
 Case 3. Mr. LR 33 yrs. Depression, hot and cold extremes. Has surgery. Fixed.
 Case 4. Widow 59 yrs. Fear of contamination. Husband died of TB. She worked
hard for family and educated children. Lots of handwashing. Throwing out food,
etc. After surgery she has speech and manner back, has lost worried look. Some
return of distress b/c of a dog in the house.
 Case 5. Mrs V.G. 47 yrs. Depression. Easily depressed even before marriage.
After having a child had depression for 5 yrs and couldn’t do any household
duties. Suicidal and thinks she’s a burden on husband. After surgery says she is no
longer worried, depressed, no longer involuntary movements. But still
disoriented, poor judgment, etc. In mental institution.
Comments
 They say indiscriminate use of procedure can result in vast harm. Only when
other treatments haven’t yielded results.
 Need to have psychological tests to see if learning ability has been affected
These prefrontal lobotomies are the precursor of Freeman’s 10 minute lobotomies. While
they say to exercise caution, this article in the Southern Medical Journal makes it seem
like there are very few downsides to the procedure and rids people of anxiety, depression,
delusions, etc
Technic
Basically goes through lots of surgical details surrounding lobotomies
(irrelevant for us)
Report of Cases
Basically a narrative showcasing how wonderful lobotomies can be
ESSENTIALLY (as for the Cerletti article): The significance of this
article, for us at least, is simply to showcase the enthusiasm and
optimism with which psychiatric researchers viewed lobotomies for
therapeutic applications.
Kaempffert, Walter," Turning the Mind Inside Out" in Saturday Evening Post (May
24, 1941) pp. 18-19, 69, 71-74
Written in 1941 in The Saturday Evening Post, this article discusses a new procedure
introduced to the US in 1936 and developed by Dr. Walter Free and Dr. James Wattspsychosurgery. This article deals primarily with prefrontal lobe surgery that separates
the thalamus from the parts of the cerebrum (also called roof brain) that lie right behind
the forehead (called association areas or prefrontal lobes). The thalamus was thought to
be “the seat of emotion” that sits right in the middle of the brain. It is in charge of desire,
passion, hate, fear, combativeness, love, appetite, and although it cannot think it “colors
thinking,” because our thoughts must travel through it before leaving the brain. The roof
brain lies behind the forehead and is in charge of intelligence, morals, plan making, and
creativity.
Freeman and Watts developed a new technique (different from Egas Moniz’s apple corer)
that probes that brain with a long, hollow shafted needle and a special that is inserted
through a hole in the temples. Comparing the brain to a watch, this article explains that
Freeman and Watts “know the ‘works’ within the skull: they know what arteries, cavities
and spots to avoid.” The entire process of a prefrontal surgery with Dr. Watts is
explained. Using a local anesthetic “because the brain itself is insensitive” Dr. Watts
drills a hole into the temple and slowly inserts a long needle. After finding a safe path he
inserts the knife and makes four careful cuts. This procedure rids patients of worries,
persecution complexes, obsessions, indecisiveness, and nervous tensions. “From
problems to their families and nuisances to themselves, from ineffectives and
unemployables, any of the two hundred have been transformed into useful members of
society. A world that once seemed the abode of misery, cruelty and hate is now radiant
with sunshine and kindness to them.”
This article explains how Dr. Freeman and Watts used a new type of psychosurgery to
sever the emotional (thalamus) from the intellectual (prefrontal lobes). Written with a
very favoring light this article seems almost like propaganda for this surgery.
“My Lobotomy: Howard Dully’s Journey,” All Things Considered, National Public
Radio, November 16, 2005
This is the story of Howard Dully and his journey to learn more about his transorbital
lobotomy. Dr. Walter Freeman performed the first transorbital lobotomy in 1946
when he grew tired of drilling holes in the skull to get to the brain. This new
procedure only took ten minutes to complete and was described as easier than curing
a toothache; Freeman believed that it would revolutionize medicine. First, Freeman
would knock out the patient using electroshock and then insert a sharp ice pick-like
instrument above the patient’s eyeball to get to the frontal lobe of the brain, and then
he would move the ice pick in a side-to-side motion in order to cut away that was
related to overactive emotions. Freeman was a bit of a showman; he began duelwielding, hammering ice picks into both eyes at once. After a while he decided that
this lobotomy could be used on others besides the incurably mentally ill.
Howard Dully was tricked into getting this operation when he 12 years old. His
stepmother claimed to be afraid of him, but Dully says she hated him and “she’d do
anything to get rid of [him].” After finally speaking to his father about why he
allowed this to happen Dully felt that he was at last at peace.
Other cases of people receiving this surgery include a woman who was violently
suicidal; she was cured. A woman who suffered from severe headaches; she stopped
worrying but lost social graces and acted like a child. A woman with postpartum
depression; her daughter believes the lobotomy destroyed her mother’s life.
Freeman’s last lobotomy was on a woman named Helen Mortenson in 1967, she died
of a brain hemorrhage and ended Freeman’s career.
Turnour, Quentin, “In the Waiting Room: John Huston's Let There Be Light,” Senses
of Cinema (2000).
This article is a review if the film Let There Be Light (1946) by John Huston. This
documentary used as propaganda by the U.S. military. Huston spent 3 months in
New York’s Mason Hospital and documented “psychoneurotic” illness – anxieties
emerging from soldiers in combat or through alienation from home. While some
scenes were real, some parts of the film were staged: Group Therapy sequences were
rehearsed and some behavior was undoubtedly provoked by the presence of camera;
this group improved much faster than the norm. The film also denies the lack of
social integration in the U.S. army. In the end Turner writes that this film is a
classical work that shows what can actually happen to men at war.
Strecker, E., Their Mothers' Sons (J.B. Lippincott Co., 1946), pp. 13-29, 160-168
• “Mom”: verbal hook for mother who has failed to properly wean offspring
• saw two types of soldier in WWII: 1) those injured who promptly returned to battle;
and 2) incurable psychiatric patients
• reverence for injured soldiers and victims of combat fatigue, a psychological disorder
that often encompasses guilt and self-blame for atrocities witnessed in battle
• combat fatigue victims were strong until broken by great hardships, deprivation,
emotional experiences --> they were honorable; sons of “mothers”!
• “mothers”: mothers of mature men that they bred to be independent and strong
• meanwhile, draft dodgers, men rejected or discharged from service for psych reasons
were “sick”: this sickness involved inner conflict of self-preservation vs. soldierly
ideals
• some men have stronger motivation to resist their self-preservation urges
• immaturity: causes some soldiers to succumb more easily to self-preservation;
these soldiers are not fully developed emotionally
“Moms”
are responsible for immature men
•
• “Moms” put our nation in jeopardy by breeding immature, ineffectual men
• “give-and-take” rearing by mother must occur for child to mature, survive in “giveand-take” world
• mother must learn to wean, reject, and emancipate a child while loving him
(balance)
• child who has only been protected by his mother will be weak and dependent
• critical age in childhood for learning to be independent, mature
• Matriarchal society supports role of “moms”: statesmen applaud moms for their hard
work”
• moms get politicians votes
Progressivism
in education, elsewhere, ignores the societal importance of competition
•
• Both Mom and progressive education responsible for overprotection of young men
• progressive education intends to breed maturity of self-expression, independence at
young age; however, this removed much of the incentive to achieve in the
classroom setting, negatively affected American workers when they grew up
Edward Dolnick, Madness on the Couch (New York: Simon and Schuster, 1998), pp.
83-100, and 117-123
• schizophrenia is “mother-made”, not organic
• must show the schizophrenic patient that he is no different from the rest of us; don’t
waste time trying to understand the schizophrenic intellectually, just extend
sympathy/compassion to him like would to any other patient
• schizophrenia considered by many to be the “cancer of psychiatry”
• impossible for unaffected to understand what it’s like to think chaotically at all times
• dream-analogy: environmental stimuli bombard schizophrenic in dream-like fashion;
voices, clues to uncover
• delusions and hallucinations, imaginary nightmare images
• sudden onset of schizophrenia: dearth of accounts of disorder until nineteenth
century, when schizophrenia suddenly became a scourge
• Freida Fromm-Reichman: single-handedly took on schizophrenia; believed, unlike
Freud, that schizo was indeed treatable
• withdrawn nature of schizo PTs was secondary characteristic, caused by fam.
environment
• treatment through undoing “warping” caused in childhood; however, rarely
successful
• 1/3 schizo patients recover, 1/3 improve, 1/3 do not improve
• engage patient as friend and ally, attempt to bring them back to real world (talk
therapy)
• schizophrenogenic mother: introduced by Fromm-Reichman in Psychiatry journal
• Trude Tietze: study showed that mothers of schizo PTs were considered nervous,
high-strung, over-demanding, superficially eager to please, lacking in warmth
• mothers acted like model patients, but Tietze suspected they were trying subtly
to dominate doctor-patient relationship like they would dominate mother-child
• Tietze convinced these mothers lacked empathy; manipulativeness injured
children
• Schizo patients felt rejection by their mothers
• Study failed to ask if mothers were jumpy BECAUSE of children’s
schizophrenia
• study also lacked control group
• study began attack of psychiatry on schizophrenogenic mother
• From Bad Mothers to Bad Families
• Gregory Bateson: intellectual vagabond that had confused students and scholars
alike with his scatter-brained academic pursuits
• schizophrenics spent family lives stuck in double binds that led to
schizophrenia
• double binds were mixed messages from family members that drove
children to become schizophrenic
• kids in double binds have diff responses to their binds: 1) suspicion: assume
every communication had secret meaning; 2) dismissal: give up trying to
discriminate between messages; 3) withdrawal: ignore messages altogether
• family’s style of communication was responsible for creating double binds,
and thus driving kids crazy from mixed messages (“family-borne disease”)
• this theory based on no observations of schizophrenic patients, purely
academic
• Bateson conceded that came up with theory first, tried to prove, no statistical
evidence
Ostow, Mortimer, “The New Drugs,” The Atlantic Monthly (1961): 92-96
Shephard, Michael, “Neurolepsis and the Psychopharmacological Revolution: Myth
and Reality,” History of Psychiatry 5 (1994): 89-96
Metzl, Jonathan, “Mother’s Little Helper: The Crisis of Psychoanalysis and the
Miltown Revolution,” Gender and History 15 (2003): 228-55
Mechanic, David and David A. Rochefort, “Deinstitutionalization: An Appraisal of
Reform,” Annual Review of Sociology (1960), 16: 301-327
Mechanic and Rochefort provide a balanced, statistically dense assessment of the
phenomenon of deinstutionalization: the drastic reduction of inpatients in mental
hospitals after the expansion of welfare programs in the 1960s.
ROOTS
WWII – rejection of large numbers from military service for psychiatric reasons,
psychiatric problems during and after combat
Growing population + fiscal strain on state mental hospitals
Growing interest in preventive ideology – mental hygiene movement
New drugs
1946: National Mental Health Act -> NIMH, funding for community care programs
1950: Chlorpromazine synthesized
1963: Community Mental Health Centers Act (CMHC). Kennedy’s goal: drastic
deinstitutionalization.
1965: Social Security Act -> Medicare + Medicaid
VIEWS
Deinstutionalization represents:
-a reflection of shifting social understandings of mental illness and its treatment
-Neoconservatives: Deinstitutionalization was a failure: new form of community-based
social control aided by the state, with poor follow-up care and mass transfer to nursing
homes
-According to Mechanic + Roquefort: Deinstitutionalization was a a poorly managed,
disjointed process in which outcome was loosely connected with policy. Ultimately, the
result is disappointing compared to the movement’s great expectations.
Isaac, Rael Jean and Virginia C. Armatt, “Community Mental Health Centers: the
Dream,” in Madness in the Streets: How Psychiatry and the Law Abandoned the
Mentally Ill, New York: The Free Press, 1990, pp. 67-85.
Isaac and Armatt argue that psychiatrists abandoned asylums because they were
deluded into believing preventive community psychiatry could eliminate mental
illness.
CAUSES:
-Exposes of state mental asylums after WWII comparing asylums to Nazi
concentration camps (e.g. LIFE magazine), corroborated by psychiatrists
-Faith in psychiatry grew after the war. Psychiatric war casualties suggested that
many more people were psychiatrically
-Revival of “primary prevention”: idea of preventing mental illness by nurturing
healthy personalities, creation of community psychiatry
-1960 riots in black ghettos pressures preventive community psychiatry movement
-Utopian climate of thought within social sciences as a whole
-State mental hospitals were draining state budgets
COMMUNITY MENTAL HEALTH CENTERS: ROOTS AND PROBLEMS
-Joint commission report: advocates community mental health clinics, rejects primary
prevention as an unfounded article of scientific faith
-Kennedy ignores joint commission when creating CMHC legislation. NIMH neglects
needs of chronic patients in application.
-Emphasis on prevention causes neglect of chronic + psychotic patients. Prevention
would eliminate problem, so why worry about relics from the past?
-Drugs encourage optimism that CMHCs could maintain former patients in the
community on prescription drugs
-NIMH doesn’t mandate coordination with state hospitals in order to free CMHCs
from the state-controlled system of care
-NIMH and antipsychiatry: Erving Goffman’s Asylums (1961) was funded by the
NIMH. NIMH bought the anti-psychiatric argument that institutions caused the
disabilities that were falsely attributed to mental illness.
Bernheim, Kayla, “Myths, misconceptions shroud mental illness,” The Register,
Oelwein, Iowa (October 7, 1986)
Bernheim attempts to demystify and destigmatize mental illness by explaining it as a
biologically based brain disease.
Myths:
-Mental illness doesn’t really exist
-Mental illness results from faulty parenting
-Mentally ill people are dangerous and should be locked up
-Mental illness is contagious
-Mental illness is totally and permanently disabling
-Mental illness only affects a few people who represent the bottom rung of society
-Large amounts of money are spent researching mental illness
Walsh, Maryellen “A family meets schizophrenia,” The Register, Oelwein, Iowa
(October 7, 1986)
Johnson, Dale L., “Schizophrenia as a Brain Disease: Implications for Psychologists
and Families,” in American Psychologist (March, 1989) 44: 553-555
National Alliance on Mental Illness
Jamison, Kay R., An Unquiet Mind (New York: Random House, 1997), pp. 3-8, 4148, 65-136, 177-216 44
 Descriptions of manic-depression illness:
o Mild manias – in Jamison’s eyes, these were good; heightened perception,
lots of energy/passion, got stuff done
o Depressions
o Manic episode – to her, felt even worse than the worst depressions
 Struggle against medicine:
o At first, didn’t realize she was sick
o Then, didn’t want to let go of the mild manias
o Then thought she could handle it alone
o Finally decided to see a psychiatrist because job, marriage, and life were at
stake
o Still, went back and forth abt taking medicine
 How to change the stigma surrounding mental health?
o Not necessarily best to focus just on changing the lang surrounding it;
rather, combo of successful treatment, advocacy and legislation can help
change attitudes toward mental illness
 Issues of genetics:
 finding genes  better treatments, better diagnosis, benefits to
patients, families, society
 ethical issues:
 It can be passed on to children – her doctors sees it as an
ethical issue (will she be an adequate mother? is it bad to
bring more manic-depressives into the world?)
 What are implications of prenatal testing for M-D?
 “Do we risk making the world a blander, more
homogenized place if we get rid of the genes for M-D
illness…?” (194) – Jamison says NO
 Is she capable as a doctor? To counter this, Jamison always
made sure she had safeguards in place – collegues,
chairmen of the hospital etc knew about the MD so if they
ever had reason to doubt her capability, they’d inform her
psychiatrist and remove her from responsibility
immediately. So then not jeapordizing patients, staff or
anyone else.
o Stigma/fear keeps many physicians from admitting
they are ill  compromise patient safety
 How to talk about M-D?
o Personal (family privacy) and professional (whether she’d be allowed to
get her MD, whether ppl would still think of her as an academic when she
lectured, etc) concerns
 “There is always a part of my mind that is preparing for the worst, and another
part of my mind that believes if I prepare enough for it, the worst won’t happen”
(213).
Themes of the book: academic vs personal experience of mental illness; how
psychotherapy and medication work together; ethical issues in mental illness;
stigma; struggle against medication
Book by Kay Jamison, psychiatrist who has manic-depressive disorder
Significant because discusses the effects of these new drugs that came out &
addresses the issue of identity and mental illness (being mentally ill in a
pharmaceutical era, although helps with effective treatment, is existentially
complicated and more destabilizing than was expected)
p 3-8
-feels beholden to moods, constantly caught up in the cycles of manic-depressive
illness
-her illness was seductively complicated, a fascinating but deadly enemy and
companion
-believed that illness was an extension of herself
-did not like medications because they cut into her intoxicating mania states, but
medication saved her life
p 41-48
-college was crazy for her as she went through depression (didn’t want to do
anything) and manic (very productive) episodes, and would make compulsive
purchases
-didn’t think she was ill, thought she should see a psychiatrist but too afraid
-lucky to have met a professor who told her that she gave very
“imaginative” responses to the Rorschach test and offered her a lab research position
that she found exhilarating
pg 65-136 (A Not So Fine Madness)
Flights of the mind
-when high, the feeling is amazing and tremendous but once it gets too fast/chaotic,
there is confusion and anger—“madness carves its own reality”
-“which of the me’s is me?” – the crazy one, or the shy one?
-had a gradual acceleration from quick thought to chaos
-“summer, a lack of sleep, a deluge of work, and exquisitely vulnerable genes
eventually took me to the back of beyond, past my familiar levels of exuberance and
into florid madness” (70)
-mania was financially destructive, made her even more depressed once the
depression stage hit
-first time that she was manic was the most dreadful she had been her entire life,
wanted to kill herself and took drugs that finally slowed down her mind
-needed to see a psychiatrist in order to save her job, marriage, life, etc.; felt weird
being the patient rather than the doctor; but her psychiatrist was amazing for her &
helped save her life
-pills + psychotherapy were necessary for her
Missing Saturn
-resisted taking medication b/c of her denial that she had a real disease, was difficult
for her to give up the high flights of mind + mood
-she compares herself to her former self, not with “normal” others, when she thought
she was at her best
-lithium had bad side effects for her à vomiting, disorientation, impaired
concentration and reading
-her upbringing made her believe that she shouldn’t need to rely on medication; sister
disapproved of her taking lithium- said that she was but a shell of her former self
-believed in psychiatric medications as much as treating physical diseases, but still
believed she didn’t need lithium
-part of the reason why she didn’t want to take it was b/c of her fear that it might not
work (that she would risk her last resort)
-example of a patient she worked with who suffered from manic-depression and
refused to take lithium even though Jamison tried to do everything she could do
convince him, case that tormented her
The Charnel House
-when she refused to take lithium she had mania + depression and suffered greatly
-psychiatrist wanted her to stay in a psychiatric hospital but was afraid that her illness
would become public knowledge and hurt her job
-attempted to commit suicide by lithium overdose; felt like she would be helping
others
-importance of friends, her psychiatrist, and mother during this time
-gender roles: manic violence (restless, aggressive, fiery) is more associated with
men, and depression (passive, helpless) more with women, although manicdepression affects males and females equally
-manic-depression is a giver and taker, like how fire both creates and destroys
Tenure
-difficult race being a woman and suffering from mental disease
-did many things to try to change the public conception of manic-depression: opened
a outpatient clinic in UCLA specifically for it (emphasized medication +
psychotherapy), organized concerts featuring works of composers who suffered from
the disease
-high stress academic world, and she still had mood fluctuations
-difficulties for women at that time, but she ultimately received tenure
p 177-216 (an unquiet mind)
Speaking of madness
-controversy about the proper terms for mental illness
-important to make sure ppl who are mentally ill are not discriminated against and not
offended, but how much changing/rejecting words will affect public attitudes is
uncertain
-Jamison finds bipolar disease instead of manic-depressive disorder more offensive
b/c it implies that mania and depression are separate and distinct
-attitudes about mental illness are changing although slowly b/c of successful
treatment, advocacy, and legislation
-the work of those people who try to increase research about mental illness, pass
legislation for mentally ill, etc. make it possible for ppl to have the luxury of debating
the language of mental health
The troubled helix
-work to scientifically understand mental illness and determine genetic causes
-that it is a genetic disease is complicating: should they have kids? Work to delete the
gene? But would that make the world a blander, more homogenized place?
-many scientific and neurological advances being made with MRI images, etc. on
manic-depressive disorder
-the importance of science in giving hope to the future of mental illness
Clinical privileges
-Jamison believes that is important for clinicians with mental illness should be
supervised reasonably so that they do not ever jeopardize the patient
-also need to treat these doctors too with accessible, competent treatment that allows
them to heal
A life in moods
-although sometimes she longs for those highs that she had, she knows that she owes
her life to lithium
-still remains a bit fatalistic about her disease
-still suffers from inevitable mood/energy swings (b/c takes lower dosage of lithium),
but accepts that life has storms and that it’s constantly changing
Hirshbein, Laura D., “Science, Gender, and the Emergence of Depression in
American Psychiatry, 1952–1980,” Journal of the History of Medicine and Allied
Sciences 61(2) (2006):187-216
The conclusion of the article had a nice summary, so I’ve used that as the study guide
summary:
“In 1974, Jonathan Cole summarized the tremendous variety of treatments and
possibilities for depressed patients in his editorial connected to a special issue of the
American Journal of Psychiatry on treatments of depression. Cole enthused that "From
the psychiatrist's viewpoint only, depression is an exceedingly satisfactory disease. It is
comforting, in this day of existential doubt and psychosocial malaise, to have an illness
that is quite treatable and that is recognized by almost everyone as a real illness
demanding real treatment."97 In the decades following Cole's comments on the positive
aspects of diagnosing and treating depression, the illness would a larger and larger role in
the medical literature. By the 1980s, depression was frequently described as the
"common cold" of mental illness, and family practitioners were encouraged to diagnose
and treat it in their patients.98 In a very short period of time, depression had been
transformed from a murky set of signs and symptoms to a clear, specific, and treatable
diagnostic entity. But in the process, a number of assumptions (particularly about
women) were buried within the "scientific" basis of the disease.
First, psychiatrists assumed from the 1950s onward that women were depressed
more than men. Researchers studied hospitalized depressed women, counted their
symptoms, and then used them to define a category of depression. The question of
whether women were depressed more than men was never raised. Second, the vast
majority of studies on psychiatric medication between the 1950s and the 1980s included
substantially more women than men.99 This is particularly problematic since so much of
the current theory around the etiology of depression was inferred backwards from the
presumed mechanism of action of the antidepressant medication. Thus the connection
between women and depression has been a closed circle: researchers have assumed that
women are depressed more than men, which means that women have been preferentially
diagnosed, treated, and theorized about, leading to further conclusions that women are
depressed more than men. At the present time, the assumed connection between women
and depression is fueling a great deal of research on the presumed biological mechanism
of depression that is frequently assumed to somehow be connected to women's unique
biology.
As I have shown with the example of depression, what gets called scientific truth
is very much contingent on social, cultural, and professional factors. Certainly there have
been in the past, and continue to be, real people suffering from real mental illnesses. But
having said that, it is not at all clear—even with the trappings of modern science that
psychiatry has acquired in the past few decades—how to sort out the roles of biology and
culture in constructing a particular patient's or society's definition or experience of
illness.100 In this article, I have focused on the ways in which psychiatric theories and
practices have embedded within them assumptions about gender and illness. The complex
relationships among psychiatric theory and ethnicity, race, class, and age still require
further investigation.101 The details of the construction of the modern diagnosis of
depression have implications for further study of the history of psychiatry, as well as the
current practice and research in psychiatry and the approach of patients toward
psychiatric theory and therapies. How a diagnosis is made matters—both to psychiatrists,
as they engage in research and treatment, and to patients, as they explain their
experiences and negotiate with treatment providers. Depression has become a widely
discussed—and treated—illness and warrants further historical attention.”
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Article is mainly concerned with the progression of depression from an illness that
was barely mentioned in the medical literature two decades earlier to a widely
discussed problem.
depression was not in 1952 DSM-I
o described as a symptom of neurasthenia, other ailments prior to 1950s, 60s,
but never as its own illness
DSM-III in 1980 first presented depression as a diagnostic category
main argument is that depression as a disease is a 20th C phenomenon—incorporates
assumptions about gender, profession, and science.
uses healy’s argument that antidepressants created depression as a disease to start,
and carries a focus on gender throughout-primary evidence includes clinical trials of psychiatric medications, and theories of
depression in psych journals in 1950s
1960s and 70s was marked by call for use of scientific methods to perform clinical
trials.
finally, looked at translation of these changes in perspective on depression into
diagnostic criteria.
Depressive symptoms were part of many diagnostic categories
for psych, depressive symptoms were part of manic-depressive psychosis, for
neurologists, part of neurosis
depressive symptoms were not part of focus of psych attn until first half of 20th C.
Involutional melancholia was recognized as a separate illness by the 1930s—
Kraepelin had first suggested it but it did not become commonly agreed as a distinct
disorder until 30s.
use of shock therapy (ECT) for it became popular, and by 1950s, patients w/
involutional melancholia included in trials for manic depressives.
Medication trials in the 1950s
first trials of antipsych meds were given to wide population of hospitalized patients,
no regard for diagnoses because not emphasized at that time.
specific measures of efficacy were lacking—relied on comments from investigators
that patients had improved—very subjective evidence gathering.
o actually often valued clinical experience/ case reports over trials/
investigation.
psychiatrists recognized an effect on depression: imipramine had effect on depressive
conditions, but none on paranoia, disturbed behavior, etc.
o ran into problems of what depression really was
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those in trials were predominantly women—in striking contrast to other fields of
medicine where they were only including men. was reflection of higher numbers of
women being in hospitals (men with schizo had benefited from ECT, now the patients
in the hospital were women with neuroses). but later the explanation for this would
be that women had depression more often.
research methods began to change in 1960s, 70s
move toward comparing groups that received diff medications, or placebo
critiqued use of case studies/ clinical experience to demonstrate efficacy of treatment.
late 50s, early60s: researchers wanted to avoid simply giving medication to patients
because of effect of suggestion.
o transitional: psychiatrists gradually became more systematic, but at first still
based things on clinical experience.
**explicit assumption that better research design would lead to better patient
selection and better responses (ie. when depressed patients responded better to a
schizophrenia drug, problem was diagnosis, not drug)
researchers had changed by 70s—came from large academic medical centers, used
biochemical explanations and statistics. but problems remained unquestioned
pharmaceuticals posted their own studies, with their own statistics
**enforced circular def of depression: depressed patients were those who
responded to antidepressants.
o changed the way clinicians would design their studies, bc sought to exclude
anyone who might not respond to the drugs
no comment on why women were in trials more frequently, but started to use this as
evidence that women had depression more often—1970s.
o while some criticized psych for this, others used this as evidence of the greater
social stress placed on women, and encouraged treatment for women.
o studies done on women were reported as studies of depression—sometimes
did not even indicate it in title.
theories of depression
early 50s: mostly debate over whether or not depression was a standalone illness
1950s,60s: how to understand and classify depression became conflated with what
patients would respond to medication.
wanted to use medication effects to explain the mechanism of depression.
o at first tried stimulants because that is the opposite of depression
 50s: one of first drugs was iproniazid, caused euphoria in TB.
 60s: found that some of the drugs that worked in animal models had
effects on serotonin and norepinephrine, recently discovered
neurotransmitters. inferred that depression = deficiency in
neurotransmitters.
 Joseph Schildkraut proposed “catecholamine hypothesis”—
drugs that decrease norepinephrine cause sedation, depression
in animals, while drugs that increase levels cause behavioral
stimulation, excitement. thus began to use this to explain
mechanism of disease as well.
 used this biological model of depression to explain prevalence
of disease in women: tried to prove that women had less
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norepinephrine, and connect to premenstrual tension
syndrome. even tried to use testosterone to treat men with
depression (failed- became paranoid)
in face of lots of inconsistent data, established scales to try to track progression of
symptoms over time
60s: developed a number of rating scales—patient population often defined what was
included in scale, so scale based off of male patients (Hamilton Rating Scale)
emphasized more bodily symptoms, didn’t work as well for women.
o aaron beck method, based on patients that were predominantly women, had
over ten items devoted to feeling states.
choice of what scale to use was circular, because each scale was tailored to the
therapy prescribed for that population, and depended on prevailing ideas about what
caused depression, what depression looked like—aaron beck and Cognitive
Behavioral Therapy won out in US.
little done to look back at how different populations might respond differently to the
scale
appeared unscientific because diagnostic criteria were all over the place
Robert spitzer pushed for DSM to standardize symptoms—to determine symptoms,
looked at patients in hospitals. ignored fine distinctions in depression, and counted
and analyzed patients to see what were most important symptoms.
70s: st louis and NY group come upon common criteria—formalize depression
category in DSM III. by 1980, was clearly defined, and DSM criteria used to screen
for prevalence of disease.
o assumed ok to use patients recorded from hospitalized patients to draw
conclusions about general population—not surprisingly found more
prevalence in women (all scales had been tailored to women, etc.)
BASIC IDEA: Depression evolved from a symptom to a distinct psychiatric disease
in the span of 2 decades. This was largely driven by the discovery of antidepressants,
which served to define the new disease category—anyone who responded to
antidepressants was depressed. The attempt to standardize research and clinical
techniques led to seemingly more objective rating scales and diagnostic criteria that
were really based off of skewed patient populations and prevailing ideas about
depression. Throughout this process, women were consistently targeted as being more
frequently depressed, first because greater numbers of women were in the hospitals,
and then because more women appeared in the studies, and studies and therapeutics
continued to isolate women and tailor their rating scales and treatment regimens
toward them.
Greenslit, Nathan, “Depression and consumption: psychopharmaceuticals, branding,
and new identity practices,”.Culture, Medicine, Psychiatry. 29 (2005): 477-502.
Summary: as pharmaceuticals are moving from private conversations with doctors into
the pop culture arena it is changing how people understand health and sickness
-complications regarding packaging prescription drugs
-uses Sarafem and premenstrual dysphoric disorder as a case study
-Sarafem and Prozac are chemically identical, but Eli Lilly (the manufacturing company)
justifies the separate branding of Sarafem for PMDD as an ethical response to consumer
demand
-personalization of pills (to separate from generic medicine) through use of non-essential
features, such as color, but you need to make sure there are no symbolic mistakes (ie,
pink viagra)
-difference between physician and patient descriptions of Sarafem: for physicians, same
drug with different packaging, for patients: different drugs, with same ingredient
-there was debate over including PMDD in the DSM because some argued that creation
of PMDD would pathologize all premenstrual symptoms (and therefore pathologize all
women) while others embraced the diagnosis as a long-overdue recognition of the
uniqueness of female suffering
-the media often picked up the question of whether PMDD was created for the marketing
of Sarafem since PMDD and the release of Sarafem was at the same time as patent
expiration of Prozac
-in advertising generally, mental illness is medical, not mental, and the promotional
material for psychopharmaceuticals typically refers consumers to “doctors” or
“physicians”--never psychiatry or psychiatrists
-PMDD is socially manifold because it lives in APA's DSM-IV but gynecologists feel in
an important sense it is theirs
-patient identity can become branded identity and we need to account for how this might
be changing the ways in which people experience and identify with illness.
-since the advent of DTC, prescription drugs are being produced not only as
chemicals consumed by bodies, but as texts that have to be consumed socially,
culturally, and personally
SUMMARY:
Sarafem vs. Prozac: Prozac and Sarafem both contain fluoxetine as their active
ingredient. However, they are prescribed for different conditions—depression and
premenstrual dysphoric disorder (PMDD) respectively. Thus, the differentiation of
Prozac and Sarafem presupposes a distinction between depression and PMDD.
Why does this matter?: Because the fact that Sarafem can treat PMDD has two
implications for women. First, it could offer women more control over their bodies—they
can take a pill to discipline their hormones. Second, however, it also pathologizes female
physical processes and limits women’s treatment options.3
Direct-to-consumer advertising: Prozac and Sarafem are the same drug. However, they
have different names in part because they appeal to different groups. Sarafem, which is
pink and purple, is directed towards women. This introduces some ethical issues. For
instance, is it misleading to market Sarafem differently than Prozac, when it is the same
thing?
HISTORICAL SIGNIFICANCE:
Direct-to-consumer advertising:
-As mentioned earlier, the Sarafem/Prozac issue intersects with the discussion of directto-consumer advertising. One complaint, for instance, is that women who take Sarafem
don’t always know that it is Prozac. In this case, Eli Lilly may be taking advantage of
their lack of knowledge. Another example of this is the outcry over Sarafem commercials
asserting a distinction between PMDD and PMS. The criticism made is that the ads did
not provide enough information about the difference.
Cultural, societal, and political influences on mental disorders
-Sarafem was seen as both a feminist and antifeminist drug. On one hand, it gave women
power over their premenstrual processes. On the other, however, it pathologized their
bodies.
-There were concerns that PMDD, like ADHD, was not a real mental disorder. Instead
being a attempt by pharmaceutical companies to capitalize on the discomfort of
premenstrual processes.
Showalter, Elaine, “Women, Madness and the Family: R.D. Laing and the Culture of
Anti-Psychiatry,” in The Female Malady (Pantheon Books, 1985), pp. 2
Feminine Malady
symptoms of schizophrenia could be caused by the patient's unlivable home situation as
parents contradicted and fought their daughter's efforts to achieve independence and
autonomy. Laing concluded that schizophrenia was not an organic disease but a social
process.
-new view of madness as a social construct and the asylum as a “total institution”
-labeling theory of deviance proposed by Thomas Scheff—the symptoms of mental
illness were primarily people were being labeled and then launching their career as a
metnal patient
-labeling theory provided a way of looking at female insanity as the violation of sex-role
expectations
-Laingian theory interpreted female schizophrenia as the product of women's repression
and oppression within the family
-in his education Laing never felt comfortable with traditional medicine and felt medical
training was fragmented and hobbled by its efforts to achieve distance and scientific
objectivity
-he worked with incurable female patients in the schizophrenic ward, and all of them
were cured
-this experience made him aware of the role played by the family network in the
establishment of schizophrenia
-realized the importance of the human bond.
-began to understand how effective a force for social control benevolent
institutionalization could be
-for laing, psychosis was the intensification of the divisions within the self that mirrored
the compartmentalization and fragmentation of modern society
-the behavior of the schizophrenic becomes a text to be decoded with the psychiatrists
full resources of knowledge, understanding, and empathy
-came to believe that schizophrenia was merely a sociological label applied to those who
had not adapted to a mad society by those who had, psychiatry was not merely detached
but pathological
-view of schizophrenia as a religious vision and spiritual quest, with a properly
supportive environment, the schizophrenic would eventually pass safely through the
acute phases of his journey, shock treatments and surgery would only disrupt a natural
healing process
-proper role of a therapist “in a truly sane society” is to act as the patient's guide in a
metatonic, or transforming, journey that is archetypically epic, heroic, and masculine, a
psychic pilgrimage.
-Mary Barnes joined the community. Wrote a narrative of her sickness and treatment
which is combined with an account by her therapist Joseph Berke. Depicts her voyage,
went from nurse to be reformed. The image of the schizophrenic voyage that Laing had
created drew upon his own heroic fantasies, it was a male adventure of exploration and
conquest—scarcely the reality of Mary Barnes experience
-the successes of antipsychiatry did not outlast the 1960s.
-”my view of laing is that at an appropriate time in Britain, he challenged extreme
rigidities in psychiatry with alternative viewpoints,and made other attitudes than the
official ones possible. That is what he did no more and no less”-doris lessing. Some also
attributed his loss of popularity to part of the general erosion of the beliefs of the 1960s
-even laing became anti-langian and dropped anti-psychiatry
-the importance of his analysis of madness as a female strategy within the family. For a
whole generation of women, laing's work was a significant validation of perceptions that
found little social support elsewhere.
-as laing himself had discovered, the elimination of shock treatments, psychosurgery, and
drugs does not in itself guarantee a restructuring of the forces of social control.
SUMMARY:
Thesis: R.D. Laing and co. ignored the role of gender roles in schizophrenia because they
were locked in the notion of schizophrenia as a literally voyage of self-discovery.
R.D. Laing: Tell us the story of how Laing, from modest beginnings became a specialist
in schizophrenia treatment, and then a famous public intellectual, the spokesperson of
artists and radicals.
Laing’s theory of schizophrenia, at first, was that it resulted from a separation of the body
and the mind. Later on, he came to believe that psychiatry was what was pathological, not
schizophrenia.
Laing and Gender: Mary Barnes was one of the patients of Laingian psychiatry. She
was a schizophrenic, who eventually recovered. However, her account of her illness and
her Laingian therapist differ on their emphasis on gender. Namely, Barnes framed her
story as one about a woman restricted by her gender, who strived to do more than her role
allowed. Laing and Barnes’s psychiatry, Berke, saw her story as just another example of
the schizophrenic voyage on the inner seas. A host of novels, written from a Laingian
perspective, also exhibited this same blind spot towards gender roles and their
contribution to schizophrenia.
Laing’s fall from grace: After the 1960s, Laing became much more conservative,
leading many to conclude that they were right in thinking him a charlatan. His movement,
ultimately, was a male one that emphasized a conquest into the psyche. It thus ignored
women.
HISTORICAL SIGNIFICANCE:
Antipsychiatry:
-discusses the blind spots in antipsychiatry. Enamored with the idea that schizophrenia
was some type of journey into the unconscious, Laing ignored the fact that schizophrenia
may have had something to do with gender roles and their restrictiveness.
-discusses the post-1960s conservative turn of antipsychiatry. Even Laing, the most
prominent and charismatic of the liberal 1960s antipsychiatrists, became far tamer. LSD
was no longer the key to inner peace, it was, instead, yoga.
Gender Roles:
-Simone DeBeauvoir said in 1979, “At bottom anti-psychiatry is still psychiatry. And it
doesn’t really address itself to women’s problems.” Laing’s neglect of gender roles is part
of a greater narrative of psychiatry’s relationship to women. With psychoanalysis too,
women seemed to be an afterthought. Freud came up with the Oedipal complex first, then
tacked on the corresponding Electra complex later.
Laing, Ronald D., The Politics of Experience (Ballantine Books, 1967), pp. 118-130
-the clinical point of view is giving way before a point of view that is both existential and
social
--it is of fundamental importance not to confuse the person who may be “out of
formation” by telling him he is “off course” if he is not
--if the formation is itself off course, then the man who is really to get “on course” must
leave the formation
-”schizophrenia” is a diagnosis, a label applied by some people to others. This does not
prove that the labeled person is subject to an essentially pathological process, of unknown
nature and origin, going on in his or her body. But it does establish as a social fact that
the person labeled is one of Them.
--there is no such “condition'; as “schizophrenia” but the label is a social fact and the
social fact a political event
-sometimes (not always and not necessarily) these unusual experiences expressed by
unusual behavior appear to be part of a potentially orderly, natural sequence of
experiences. This sequence is very seldom allowed to occur because we are so busy
“treating”; the patient.
-what we see in some people whom we label and “treat” as schizophrenics are the
behavioral expressions of an experiential drama.
-we need not be unaware of the “inner” world. We do not realize its existence most of
the time, but many people enter it—unfortunately without guides, confusing outer with
inner realities, and inner with outer—and generally lose their capacity to function
competently in ordinary relations
-the person labeled as schizophrenic is going on a journey.
--no age in history of humanity has perhaps so lost touch with this natural healing process
that implicates some of the people whom we label schizophrenic
-instead of the degradation ceremonial of psychiatric examination, diagnosis, and
prognostication we need, for those who are ready for it (in psychiatric terminology, often
those who are about to go into a schizophrenic breakdown), an initiation ceremonial
through which the person will be guided with full social encouragement into inner space
and time, by people who have been there and back again.
Relation to course: this is a key figure in the antipsychiatry movement who advocated
that those who were considered “schizophrenic” were really just going through a
process of inner discovery. Psychiatry does not let them finish this journey.
SUMMARY:
Thesis: In brief, R.D Laing argues for the value of the schizophrenic experience, which
he believes his contemporaries have short shrifted.
Labeling: First, he takes to task the idea that those who drift from societal norms are in
some way ill. Schizophrenia, Laing writes, is not necessarily the brain gone haywire.
Rather, it is a label attached to those who do not conform to a society that is itself mad.
“The perfectly adjusted pilot may be a greater threat to species survival than the
hospitalized schizophrenic deluded that the Bomb is inside him.”1
This is problematic because the label schizophrenia carries with it a lot of baggage.
The psychotic is forced into a role where he is thought to be too irresponsible to exercise
his own choice. He is relegated to asylum until he is so broken that he must conform.
Alternative Interpretation of SZ:
Laing starts with the premise that one can make sense of the schizophrenic experience.
And from this, it can be observed that schizophrenia has use indeed. “We do not regard it
as pathologically deviant to explore a jungle or to climb Mount Everest,” Laing writes. In
other words, schizophrenia is just another type of brave exploration, and we ought to treat
it as such. The sane man remains so only for his ignorance. Psychotics, on the other hand,
are individuals plunged into the inner worlds that most people protect themselves from. It
is terrifying at first, but they can2 find their way out. And when they do, they know things
about the inner world that well-adjusted people don’t. Jung is one such example—he
developed much of his psychoanalytic theory while enduring transient psychotic
episodes.
HISTORICAL SIGNIFICANCE:
Antipsychiatry:
-Related to psychedelic drug proponents like Ken Kesey and Timothy Leary.
-Provided a liberal counterpoint to the libertarian Szasz. Both, however, rue the fact that
the insane are forced against their will to abide by someone else’s. Both, also, discuss
diagnosis as…
-labeling, the idea that the mentally ill aren’t really pathological; rather, they simply
march to the beat of their own drummer.
Biological psychiatry:
-Laing sees schizophrenia as something gone wrong in the patient’s psyche. This
downplays, but does not deny outright the possibility of biological causes. This kind of
thinking was soon to be obsolete as the 2nd biological psychiatry came around with the
advent of drugs. If chemicals could treat mental illness, then mental illness is chemical.
Therapeutic Nihilism:
-Not only does Laing believe that schizophrenics can recover, they can recover fully and
by themselves. This is in sharp contrast to Emil Kraepelin, who believed that those
suffering from dementia praecox were doomed to chronic insanity. It is also in sharp
contrast to the more optimistic Eugen Bleuler, who, like Laing, believed that one could
make sense of the schizophrenic experience. Bleuler believed that, with intense and
personalized care, schizophrenics could achieve partial recovery.
Chamberlin, Judi (1998) “Confessions of a non-compliant patient,” Journal of
Psychiatric Nursing (1998), 36, 49-52.
The gist is that Judi Chamberlain was involuntarily committed, and she felt that
she lost her hopes and dreams when she complied in the institution, making her a “good
patient,” rather than a bad patient. But she says that it is BETTER to be a bad patient
(when not in relation to the institution, because if you’re bad, you get consequences)
because a bad patient takes control over one’s own healing process and moves his or her
own progress. She argues that one should be able to decide what types of drugs one
should get, thereby getting to pick your own side effects and having your own
experiences. Basically she advocates for the patient’s own control over his or her
treatment, and it’s all about the patient’s view and feelings on their illness and their
healing process!
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In a difficult time, being stigmatize and labeled only made it worse
Idea of “good” (appreciative, obedient) vs. “bad” patient is harmful to patients.
Chamberlain learned to “play the game” because she wanted to get out. (This
hearkens back to early units on the asylum where people said they were only
teaching patients to internalize mental illness)
Drugs: Patients will and should use cost/benefit analysis to determine whether or
not to use drugs. For some, these drugs do wonders. For others, they are awful.
People should understand that patients have different experiences. In mental
illness, patients don’t get to decide unlike in physical illness
Everyone can recover, but they need to believe in themselves. These hospitals
only make patients feel worse. Patients need to have goals. They “are
indoctrinated with the message that they are defective human begins who should
not aim too high”
People are perceived as having problems in they don’t fit
Good patient does what she’s told, has accepted self as patient, doesn’t get better
Workers misunderstand motivation, they criticize patients for not being motivated
about doing dishes or being forced into meetings
“Let us celebrate the spirit” of the noncompliant patient
McLean, Athena Helen, “From ex-patient alternatives to consumer options:
consequences of consumerism for psychiatric consumers and the ex-patient
movement” International Journal of Health Services, Volume 30, Number 4 (2000),
pp. 821–847
- The psychiatric consumer movement in the United States evolved out of the political
activism of a small group of antipsychiatry “ex-patients” (former patients) early in the
1970s. The shift in the movement from radical opposition to the medical model to
viewing the latter as a possible choice in treatment occurred gradually under a series of
social and political changes (e.g., deinstitutionalization), responses to those changes (e.g.,
the Community Support Program of the National Institute of Mental Health), and the
involvement of new actors on the scene (e.g., the National Alliance for the Mentally Ill, a
family consumer movement).
- Since the early 1970s in the United States, diverse groups of recipients and former
recipients of mental health services have mobilized for change in the nation’s mental
health system. The movement was started by a small group of antipsychiatry political
activists who called themselves “ex-inmates” or “ex-patients.”
- The ex-patients who mobilized for change in the early 1970s were loosely organized
into the Psychiatric Inmates Liberation Movement. The movement was overwhelmingly
antipsychiatry, anti–medical model, and opposed to forced treatment and involuntary
commitment. They argued that the debilitating consequences of these experiences—
damaged self-esteem, motivation, and confidence and a profound sense of
hopelessness—destroyed their trust in institutions and in authoritative control by experts.
They came to see psychiatry as an oppressive, harmful institution and were cautious
about organizing their movement nationally for fear of creating similar oppressive
conditions.
- During the 1960s and early 1970s, a diverse array of mental health professionals, who
called themselves “radical therapists,” voiced dissatisfaction with traditional therapy as
well for similar reasons.
- A wide variety of public and private organizations and institutions were established by
ex-patients (such as Howie the Harp’s patient-run clinic) to help consumers receive the
treatment they needed and to instate the change that they felt was needed.
- The role of consumers (in this case those who receive the mental health treatment) has
provided the central link among social, ideological, and political systems to sustain the
ex-patient movement. Propelled by consumerism, the once marginalized ex-patient selfhelp alternatives, developed as political opposition to the mental health system, became
institutionalized as options for the consumer within that system.
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ex-patients “mobilized for change” in the 1970s. the patients had lower self
esteem, lost motivation from experiences as patients, found mental hospitals
harmful and sought empowerment
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“Radical Therapists” 60s + 70s professionals who dissented. Ex-patients moved
away from them, thought their criticisms were mainly “intellectual exercises”
NARPA- National Association for Rights Protection and Advocacy- ex-patients
rejected medical model
Community Support Program (CSP): wanted a “comprehensive” program that
was “sensitive to client needs”
CSP looked to families of mentally ill for support; wanted families, clients to have
impact in policy
Not enough funding to meet goals
1970s, families, who had to pay bills wanted input, accountability
National Alliance for Mentally Ill (NAMI) wanted to “improve service”,”increase
research” and “advance training”
Two tiered system- different level of choice in private vs. public
Mental Health Association- promoting consumerism, consequences
Ex-patients involved in government, had voice in CSP
Wanted patients, families to be seen as separate groups. Patients should be
allowed to refuse treatment
CSP became one of the biggest supporters of the movement.
A larger movement
Title 5: 1986
Problem- relying on government funding, funding change as politics change
Internal problems- abuse of power, people break away, consumer-staff controlled
instead of consumer controllered
“Empowerment” as meaning within system, not independent of it
American movements were different than European movements because of
internal disagreements, power of families, and emphasis on self-help
Self-Help is becoming incorporated whereas it might seem like anti-psychiatry
1963 Community Mental Health Restructuring Act looked for input from
consumers
Conclusion-language of consumerism masked differences between public, private
sectors
Szasz, Thomas, The Myth of Mental Illness (1961) (New York: Granada), pp. 9-27.
- Szaz’s Main Argument is…MENTAL ILLNESS IS A MYTH! You need physical proof
that someone is actually ill, something he refers to as “medical materialism.” Real disease
shows an alteration in bodily function. Mental illness makes good HISTORIC sense, but
not good rational sense. Real
- So what’s wrong with psychiatry? Szaz says the lack of “medical materialism,” and the
other problem Szaz has with psychiatry is the lack of liberty and affront to their rights.
- Szaz has such problems with the indistinctness of psychiatry that he helped out patient
led groups to give them vocabulary to protest their own treatment, as well as
framework/arguments for lawyers and the court system in cases of patients that patients
did not want to be committed voluntarily.
- The ethics behind psychiatry are flawed, Szaz says, there is a lack of personal
communication and people are taken advantage of by the system, their rights are violated
by a field that lies within ambiguous boundaries, and people are given
drugs/institutionalized, against their will, this violates their liberty.
- Plus Szaz argues that MENTAL ILLNESS DOESN’T EVEN EXIST, so involuntary
drugs and institutionalizion is REALLY bad. This is why one could conclude why Szaz
would by a supporter of the Scientologists’ views on psychiatry and mental illness.
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when people claim to be ill (physically), they suffer and want help
Can someone act ill if he’s not? Can someone act as a therapist? How should we
regard these people
Mental Illness- “metaphorical disease”
Substantives and Entities vs. Processes + Activities (Processes and Activities is
better, psychiatry uses substantive)
Psychiatrists never say what they are doing. There is a “need for clarity”
Psychiatry, communication analysis makes sense, it’s similar to language,
communication behavior- but people frame in terms of medicine
Fashioned from physicians
Historicism- historical prediction the same as physical prediction (how does this
play in?)
Psychosocial lawes are different from physical laws. Psychosocial studies used to
be tied to philosophy, ethics
It’s not medical yet psychiatrists consider themselves the same as biologists
Hysteria: caught the attention of people like Charcot and Freud. Highlights the
need to understand real vs. fake; non verbal communication rule following, going
for domination
Change in bodily structure- how you determine illness
There’s functional illness, voluntary falsification fake illness
A social issue- who has the right to judge who is mentally ill?
Szasz, Thomas, “J'Accuse: Psychiatry and the Diminished American Capacity for
Justice,” Political Psychology. Vol. 2, No. 2 (Summer, 1980), pp. 106-113
- Szaz is basically outraged that the trial of Dan White (the murder of the mayor of SF
and Harvey Milk; definitely Wikipedia it if you need the facts) resulted in a ‘travesty of
justice.’ Why was Dan White acquitted for murder? BECAUSE OF PSYCHIATRY, Szaz
argues. When one hands power in the courts to psychiatrists, they have the power to
redefine crimes and behaviors.
- So psychiatry is a political weapon? It can change who “gets away with murder!”
- What was used in the Dan White case? The TWINKIE DEFENSE, which said that due
to the high amount of junk food in his system, he had “diminished capacity” and did not
know what he was doing in his right mind. Is that true? WHO KNOWS, but it got White
cleared of murder charges.
- However, one aspect of this assassination that is not looked at is its political weight, as a
political assassination of an openly gay politician; the persistent appeal to the jury’s
antihomosexual prejudices was one of the two pillars on which White’s defense rested
(the other was the Twinkie defense).
- Szaz says the White Case showed psychiatry’s real view of homosexuality, as a mental
illness – Psychiatrists tried to portray Dan White as a man who was homophobic who
committed his crimes in reason because of the victim’s homosexuality. Szaz says this was
not the case, does not match the facts, and it was psychiatry’s “ugly head” being reared to
mislead judges and jurors, as well as showing “psychiatry’s true feeling about
homosexuals.” Szaz says that the fact Harvey Milk was gay had NO BEARING ON
DAN WHITE’S ACTIONS.
- So American Psychiatry is White’s accomplice in crime! “While White pulled the
trigger of the gun…psychiatry pulled the wool over the eyes of law makers and
journalists and the public with having their ‘fantasies’” about the Twinkie Defense
(as well as anti-gay sentiments) being used as “expert medical testimony,” and
therefore clearing Dan White of all charges.
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The Dan White Trial was a “travesty of justice”. It was possible because of
psychiatry
Psychiatry allows you to get rid of useless people in war and put away dissenters
in times of peace
Diminished mental capacity- we know organs have diminished capacity. But
criminal responsibility can’t be measured that way.
American psychiatry has gotten rid of the concept of political crimes. People who
commit these crimes are sick.
“American psychiatry…is a political weapon”
Evidence- hopes hurt, he was a “good man” and he ate junk food
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They supposedly didn’t want homosexuals on the jury because they might think
the crime was about Milk being homosexual. Szasz finds this an outrage.
In psychiatry you don’t have to face facts but in a court of law you should
He was white and straight (his “background”), and that got him away with murder
“In each and every case a psychiatrist who testifies in court is a hired gun”
American psychiatry uses homosexuals as a scapegoat and target. This explains
the outcome of the Dan White trial.
Isaac, Rael Jean and Virginia C. Armatt, “Thomas Szasz: Oracle of Autonomy,” in
Madness in the Streets: How Psychiatry and the Law Abandoned the Mentally Ill,
New York: The Free Press, 1990, pp. 33-40..
This article is very critical of Thomas Szasz’s ideas concerning mental illness and
psychiatry (namely that mental illness does not exist except for GPI and
neurosyphilis because of their biological bases). The authors attack Szasz for
not being more sympathetic to those with mental illness, as he sees mental
illness as “a test case in human liberty.” (33). His argument that all people are
responsible for their own actions as autonomous beings has worked its way into
the legal system, as lawyers can use that reasoning to work around expert
psychiatrist witnesses. Szasz argues that psychiatry created the mentally ill, and
that if psychiatry was to disappear so would the schizophrenics. Szasz’s
reasoning is that because there are no physical lesions in the brain, mental
illness does not exist. The authors of the article point out, however, that the
majority of diseases do not have any kind of discoverable lesions, which
according to Szasz means they do not exist, yet these “non-diseases” still cause
a great deal of suffering and premature death. The authors particularly dislike
Szasz’s way of using words and redefining things to claim that mental illness
does not exist. They claim “his aim is to contaminate the concept of mental
illness through repugnant, if inappropriate, parallels.” (37). Szasz often
compares mental illness to slavery, the Inquisition, and Jewish persecution in the
Holocaust, making it impossible for the reader to accept the idea of mental illness
as legitimate. Szasz also appeals to the left by defining the mentally ill as an
oppressed group that is the victim of a capitalist conspiracy to make more people
consumers of services. The article’s authors are also critical of Szasz’s ideas on
what the family should do about their mentally ill members, namely to withdraw
from the ill family member. The authors note that the hospital where Szasz was
employed still treated mental illness as if it was a disease, using all the typical
treatments such as shock therapy and drugs. Not as many were influenced by
Szasz as were by Laing, although those who were tended to be strong followers.
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Thomas Szasz: Oracle of Autonomy
o Szasz vs Laing (the two ‘fathers’ of anti-psychiatry)
 Szasz (libertarian)
 The Myth of Mental Illness – one year after Liang’s work
(initially rejected)
 His work reflected contempt for the New Left and rejected
the term ‘anti-psychiatry’ in his attempt to prove that mental
illness did not exist at all (complete denial of the reality of
mental illness)
 He continued to argue the same fundamental position for
many decades
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Laing
 The Divided Self (initially rejected)
 In his work, he attempted to undermine the idea of insanity
by trying to understand the perspective of the schizophrenic
and make sense of it
 Laing recognized that “mentally ill” people were in pain
The ‘Word Magic’ of Thomas Szasz
o According to the author, Szasz tried to use verbal tactics to logically
undermine the validity of mental illness; like a child he tried to use “word
magic” – the idea that words alone can create or destroy something like
mental illness
o Szasz believed mental illness could not exist because the mind was not an
organ, but he waivered in his stance on the involvement of the physical
brain in mental illness
Reasoning by Analogy
o Szasz relies heavily on analogies in his argument
o He repeatedly compares mental illness to morally offensive behaviors,
witchcraft, etc (inappropriate/invalid parallels) in order to contaminate
the concept of mental illness
o During a speech, he said that he may not be able to help “mentally ill”
patients and if he can’t then that’s life because the world is about survival
of the fittest, and they are unfit
Szasz Versus the Family
o Szasz relates mental illness to capitalist conspiracy (as capitalism
expanded, there had to be “an ever greater number of the superfluous
people in industrial nations to be treated as mentally disabled so that they
would become consumers of services.”)
o He values the “autonomy of the individual” over the “integrity of the
family” but he recognizes the burden of “mentally ill” people on the
family unit
Szasz’s Following
o He did not attract the same kind of following as Laing
o He did, however, gain popularity among a small circle at Syracuse (e.g.
Ronald Leifer)
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“Mental illness is a myth, whose function is to disguise and
thus render more palatable the bitter pill of moral conflicts
in human relations.”
He believes that mental illness is purely a test case in human
liberty
He also strongly believes in autonomy and that “mentally
ill” patients simply lack the ability to exercise autonomy (his
goal in treatment is thus to restore this ability)
In reality, Szasz knew very little about schizophrenia at all
and never actually treated it
o E. Fuller Torrey (wrote The Death of Psychiatry) was deeply influenced by
Szasz
“Psychiatry: An Industry of Death” [On-line museum exhibition developed by the
Citizens Commission on Human Rights [Church of Scientology]
The website is a series of videos, very fancy looking. Also quite sensationalist,
gongs ringing, deep voiced narrator asking questions like “Think psychiatry has
nothing to do with your life? Think again.” Sweeping claims, “No such thing as
mental illness...nothing is being done that is legitimate.” Thomas Szasz makes
an appearance in the videos, as well as a number of people who appear to be
experts in psychiatry. Patients talking about their experiences, children and
teenagers who were diagnosed with several different diseases. Tragic stories of
people dying as a result of treatment that they received, repeated again and
again that this is all about the money. History of psychiatry video ignores Pinel’s
contributions, Andrew Scull interviewed about growth of asylum. Lots of
description about the various barbaric treatments patients received, everything
going back to money (“bad biology” ideas came about as a way for psychiatrists
to make more money with treatments).
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Video segment with dramatic music, dramatic statistics, and tons of
interviews (including Dr. Szasz and Dr. Andrew Scull)
Some of the messages include:
o Psychiatry is invading everyone’s life
o If you’re too anything, you’ve got a disease
o Psychiatrists are creating this diseases
o It’s all FRAUD
o There’s no scientific basis
o They treat people against their will
o It ruins people’s lives
o There are 0 cures
Gumbel, Andrew, “Scientology vs Science: Psychiatry, says L. Ron Hubbard's
church, is responsible for Nazism, school shootings, and even 9/11,” Los Angeles
City Beat (January 12, 2006)
This article is a narrative of the author’s experience visiting the anti-psychiatry
Scientology museum in Los Angles. Author judgmental/poking fun at how
serious the people in the museum take themselves. Everyone he meets in the
museum feels the need to tell him of the evils of psychiatry. Talks about the
paranoia Scientologists feel regarding their beliefs, although the author admits
that psychiatry makes itself an easy target for criticisms from its seemingly
barbaric historical treatments to the controversies that surround things such as
teenagers on anti-depressants and the prevalence of ADHD now. Author
believes that Scientology is trying to blame all of the world’s problems on
psychiatry (education standards declining, health insurance premiums rising),
which is unrealistic. The author notes at the end of the article however, how
dangerous this type of thinking can be, and lumps it in with those who don’t
believe in evolution or global warming as well as the Bush administration's
“general disregard for established scientific fact.”
Lehmann-Haupt, Christopher, “Ken Kesey, Author of ‘Cuckoo's Nest,’ Who Defined
the Psychedelic Era, Dies at 68,” New York Times ( Nov 11, 2001), p. A47
This article is an obituary, chronicling some of the more major events of Ken
Kesey’s life. The author writes about the road trips and acid trips Kesey and his
friends took all over the country. LSD was used frequently, and given out in
Kool-Aid in “Acid Tests.” Kesey worked at a mental asylum where he thought,
after watching patients, that was hurting rather than helping their mental states.
This was the inspiration for his novel, One Flew Over the Cuckoo’s Nest, which
was supposed to expose this world to the general public. The hospital was also
supposed to be a symbol of repressive America as a whole. Kesey was not
pleased with the movie that came out his book, and refused to see it. Kesey’s
childhood is described as being all-American, and then towards the end of his life
he began scaling back significantly on the LSD and drugs.
Zeidner, Lisa (review of “Cuckoo’s Nest”), “Rebels Who Were More Angry Than
Mad: The originality of Milos Forman lies in his rejection of too much easy drama,”
New York Times (Nov 26, 2000), pp. AR11-12
Wilson, Mitchell, “DSM III and the Transformation of American Psychiatry: A
History,” American Journal of Psychiatry 150 (3) (March 1993): 399-410
Diagnostic and Statistical Manual of Mental Disorders: DSM IV (Washington, D.C.,
American Psychiatric Association, 1994): “front matter” and “schizophrenia and
other psychotic disorders.”
Wood, Mary E. “‘I’ve found him!!’: Diagnostic Narrative in the DSM-IV Casebook,”
Narrative 4 (2) (May, 2004): 195-219.
Edward Shorter, A History of Psychiatry, pp. vii-x.
*Kramer, Peter, Listening to Prozac (Penguin Books, 1993), “Introduction,” “Chapter
one,” “Chapter 9”
Lyke, M.L., “The unseen cost of war: American minds: Soldiers can sustain
psychological wounds for a lifetime,” Seattle Post-Intelligencer Reporter