History: Psychiatry Versus Medicine

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http://www.cchr.org/doctors/eng/page07.htm

 

 

" We would do well to remember the art of medicine and heed the word of

he who wrote the [Hippocratic] Oath.... "

 

http://www.cchr.org/doctors/eng/page07.htm

 

— John Dorman, M.D. Physician, Stanford University

Journal of American College Health, 1995

 

 

HISTORY: PSYCHIATRY VERSUS MEDICINE

 

 

The best way to grasp the psychiatry of today is to understand the

psychiatry of yesterday.

 

While numerous texts recount psychiatry's history in detail, the

following brief account offers clues to understanding the drastic,

recent changes in the practice of medicine.

 

Unlike medicine itself, with a history dating at least from Ancient

Greece, psychiatry is an infant practice. According to Professor

Edward Shorter, author of A History of Psychiatry, " Before the end of

the 18th century, there was no such thing as psychiatry. " 30 Doctors

Franz G. Alexander and Sheldon T. Selesnick report that in the 1700s

and 1800s, the mentally unsound were considered beyond the physical

methods of medicine.31

 

It was 1676 when Louis XIII decreed the establishment of hospitaux

generaux (general hospitals) throughout France, to contain " the

debauched, spendthrift fathers, prodigal sons, blasphemers, men who

`seek to undo themselves,' [and] libertines. " That decree marked the

beginning of the " great confinement of the insane. " 32

 

In reality, France's hospitaux generaux were merely custodial

institutions. They attempted no therapy and were renowned for horrific

conditions. Inmates were flogged, bound in chains, and subjected to

unhygienic conditions.

 

From asylums grew the expertise of the institutional custodian, the

direct predecessor to the institutional psychiatrist. The phrase snake

pit—slang for " mental hospital " —stems from these early custodial days,

when the insane were thrown into a serpent-filled hole to shock them

back to their senses.

 

Relegated to the position of asylum work, such early " psychiatrists "

still asserted " a legitimate claim to [medical] guild status on the

grounds that running an asylum in a therapeutic manner was an art and

science as intricate as chemistry or anatomy. " 33 It is a claim to

which psychiatry steadfastly clung for 100 years in the face of

damning evidence to the contrary.

 

Although psychiatry was accepted as " needed " , medicine saw it as

suspect, and ensured it was " kept in a marginal position " , Doctors

Alexander and Selesnick state.34 The psychiatrist, therefore, remained

segregated from his fellow physicians.35

 

In 1858, Rudolf Virchow released his Cellular Pathology as Based upon

Physiological and Pathological Histology, signaling the birth of

modern medicine as a profession based on empirical science. The study

of pathology as the phenomenology of disease, combined with the study

of bacteriology as the etiology [cause] of infectious disease, placed

medicine as the study of bodily disease on the rock-solid foundation

of modern science.36

 

As medicine traveled quietly apace on its surefooted, scientifically

based path to major discoveries, psychiatrists developed their own

ideas independent of the scientific model. " A new generation of asylum

physicians grew up filled with confidence in their ability to heal, "

wrote Edward Shorter.37

 

In 1803, Johann Reil, who later coined the word psychiatry, meaning

study of the soul, wrote of the early custodians as " stepping forward

at once to improve the lot of the insane. " He referred to them as a

" bold race of men " who dared to take on this " gigantic idea " of

" wiping from the face of the earth one of the most devastating of

pestilences. " 38 In other words, psychiatry's pioneers believed they

could eradicate insanity.39

 

Reil was the first to label the " psychic method of treatment " as part

of medical and surgical methods. His " psychic treatments " meant

massage, whipping, flogging and opium.40 John G. Howells, M.D., in

World History of Psychiatry, says that Reil's recommendation of these

" methods of cure for mental disease " made a " significant contribution

towards the establishing of psychiatry as a medical specialty. " 41 In

the 1840s, Dr. Thomas S. Kirkbrade, superintendent of the Pennsylvania

Hospital for the Insane, announced that " recent cases of insanity are

commonly very curable... " 42

 

Such " cures " included the " so-called Darwin chair " in which " the

insane were rotated until blood oozed from their mouths, ears and

noses; and for years most successful cures were reported as a result

of its use. Castration and starvation cures were also employed. " 43

 

Moral Treatment was described by Theodric Romeyn Beck, author of

Inaugural Dissertation on Insanity in 1911, in this way: " Convince the

lunatics that the proper power of the physician and keeper is

absolute,... " and " if unruly, forbid them the company of others, use

the strait waistcoats, confine them in a dark and quiet room.... " 44

 

In 1918, psychiatric pioneer Emil Kraepelin defined a psychiatrist as

" An absolute ruler who, guided by our knowledge of today, would be

able to intervene ruthlessly in the living conditions of people and

would certainly within a few decades achieve a corresponding decrease

of insanity. " 45

 

World War I was raging when Kraepelin established a psychiatric

research center in Germany " for the purpose of determining the nature

of mental diseases and of discovering techniques for effecting their

prevention, alleviation, and cure. " Ground had been taken already, he

said, " that will enable us to win a victory over the direst

afflictions that can beset man. " 46

 

The book, Freud and the Americans, tells of psychiatric hopes in the

early 1900s. " Magazines eagerly printed almost any hopeful medical

news: the speculation that insanity might be caused by a toxin and

cured by an antitoxin, that insanity was not a `disease' but an

inability to adapt to environment. Some physicians urged that the old

words `chronic and incurable' be abandoned. Psychiatry, they insisted,

despite lack of improvement in recovery rates, was on the threshold of

a golden age. " 47

 

However, in 1916, Shepherd Ivory Franz, an American scientist wrote,

" We have no facts which at present enable us to locate the mental

processes in the brain any better than they were located 50 years ago. " 48

 

Thus, after 100 years, in spite of psychiatry's confident boasts, the

bottom line was that psychiatry was no closer to understanding or

curing insanity or mental problems.

 

Early in the 1900s, psychoanalysis became the new trend in Central

European psychiatry and spread rapidly throughout the United States as

well. The 1930s and 1940s saw a swing towards physical " treatments. "

As Elliot S. Valenstein, Ph.D. observed, " Physical treatments also

helped psychiatrists gain respectability within the field of medicine

and enabled them to compete more successfully with neurologists, who

often treated patients with so-called `nervous disorders.' " 49 Thus, in

the decade between 1928 and 1938, psychiatry introduced such horrors

as Metrozol shock, insulin shock, electroshock and psychosurgery.

 

Meanwhile, most other physicians, who generally regarded psychiatry's

theories as strangely metaphysical and unrelated to " scientific

medicine " , continued to hold psychiatrists in particularly low esteem.50

 

The 1950s and 1960s saw the introduction of psychotropic drugs

designed to alleviate some of the symptoms of mental illness, and thus

made patients less of a problem for those responsible for their care.

Simultaneously, psychiatry introduced a system for mental disorder

diagnosis. Shorter called this era the " second biological psychiatry. "

It held that " genetics and brain development " were causes of mental

illness and that psychoactive drugs and informal psychotherapy were

its remedies.

 

In the next thirty years, psychoactive drugs rapidly became the

mainstay of psychiatric therapy, and the psychiatric industry—fully

armed with its own drugs and its own system of diagnosis—was ready to

expand. In 1989, an American Psychiatric Association (APA) " Campaign

Kit " told APA members, " An increase of psychiatry's profile among

non-psychiatric physicians can do nothing but good. And, for those who

are bottom line oriented, the efforts you spend on building this

profile have the potential to yield dividends through increased

referrals. " 51

 

In 1998, a concerted effort was made by psychiatrists—primarily

through the Collegium Internationale Neuro-psychopharmacologicum

(CINP), the National Institutes of Mental Health (NIMH), and the World

Psychiatric Association (WPA)—to garner support from physicians.52 The

World Health Organization (WHO) even produced a " Mental Disorders in

Primary Care " kit that was internationally distributed, to make it

easier for primary care physicians to diagnose mental illness.53

 

Based on the DSM-IV and ICD-10, the kit was primarily designed to

garner more business for the mental health system. Clearly, what

psychiatry traditionally lacked in science was being compensated for

by a burgeoning use of marketing.

 

That marketing includes an unholy alliance with the pharmaceutical

industry. Pat Bracken and Phil Thomas, consultant psychiatrists and

senior research fellows with the University of Bradford in the United

Kingdom, state, " Psychiatry is a major growth area for the

pharmaceutical industry. By influencing the way in which psychiatrists

frame mental health problems, the industry has developed new (and

lucrative) markets for its products. " 54 Says Carl Elliott, a

bioethicist at the University of Minnesota, " The way to sell drugs is

to sell psychiatric illness. " 55

 

With the selling of mental illness to primary care physicians well in

hand, the selling of psychiatric drugs followed. Harvard psychiatrist

Joseph Glenmullen writes, " As they gain momentum, use of the drugs

spread beyond the confines of psychiatry and they are prescribed by

general practitioners for everyday maladies. " 56

 

Today, for the first time since its inception, psychiatric thinking

and practice is no longer fighting to emulate and gain acceptance from

medicine. Through heavy marketing of its " system " of diagnosis and

psychoactive drugs, it is becoming an integral part of general medical

practice.