The purpose of the earliest mental institutions was neither treatment nor cure, but rather the enforced segregation of inmates from society. For most of the eighteenth century, mental disorders were not regarded as illnesses and therefore did not fall within the purview of medicine, any more than the criminal behavior that landed a prisoner in a penitentiary. The mentally ill were considered social deviants or moral misfits suffering divine punishment for some inexcusable transgression.
One man was largely responsible for transforming asylums from prisons into therapeutic institutions of medicine and indirectly giving rise to a professional class of psychiatrists—a Frenchman by the name of Philippe Pinel. Pinel was originally a respected medical writer known for his gripping case studies. Then, in 1783, his life changed.
A close friend of Pinel’s, a law student in Paris, came down with a form of madness that now would most likely be diagnosed as bipolar disorder. On one day the friend was filled with the exuberant conviction that he would soon become the most brilliant attorney in all of France; the next day he would plunge into despondency, begging for an end to his pointless life. Soon he believed that priests were interpreting his gestures and reading his mind. One night he ran off into the woods wearing nothing but a shirt and died from exposure.
This tragedy devastated Pinel and prompted him to devote the rest of his life to mental illness. In particular, he began investigating the operation of asylums, which he had consciously avoided when seeking care for his friend because of their notoriously wretched conditions. Before long, in 1792, he was appointed to head the Paris asylum for insane men at Bicêtre. He immediately used his new position to make major changes and took the unprecedented step of eliminating the noxious treatments of purging, bleeding, and blistering that were routinely used. He subsequently went on to free the inmates from their iron chains at the Parisian Hospice de la Salpêtrière.
Pinel eventually came to believe that the institutional setting itself could have beneficial effects on its patients, if properly managed. The German physician Johann Reil described how to go about establishing one of the new Pinel-style asylums:
One might start by choosing an innocuous name, situate it in a pleasant setting, midst brooks and lakes, hills and fields, with small villas clustered about the administration building. The patient’s body and his quarters were to be kept clean, his diet light, neither spirituous nor high seasoned. A well-timed variety of amusements should be neither too long nor too diverting.
This was a far cry from the bleak prisons for undesirables that constituted most other asylums. This started what became known as the asylum movement in Europe and later spreading to the United States. Pinel was also the first to argue that the routine of the asylum should foster the patients’ sense of stability and self-mastery. Today, most psychiatric inpatient units, including the ones here at the New York Presbyterian Hospital–Columbia University Medical Center, still employ Pinel’s concept of a routine schedule of activities that encourages structure, discipline, and personal hygiene.
After Pinel, the conversion of mental institutions into places of rest and therapy led to the formal establishment of psychiatry as a clearly defined profession. To transform an asylum into an institution of therapeutic humanity rather than of cruel incarceration required doctors who specialized in working with the mentally ill, giving rise to the first common appellation for the psychiatrist: alienist.
Alienists were given their nickname because they worked at asylums in rural locales, far removed from the more centrally located hospitals where the alienists’ medical colleagues worked and socialized and tended to physical maladies. This geographical separation of psychiatry from the rest of medicine has persisted into the twenty-first century in a variety of ways; even today, there are still hospitals and mental hospitals, though fortunately the latter are a dying breed.
Throughout the nineteenth century, the vast majority of psychiatrists were alienists. While the various psychodynamic and biological theories of mental illness were usually proposed and debated in the halls of academia, these ideas for the most part had little impact on the day-to-day work of the alienists. To be an alienist was to be a compassionate caretaker rather than a true doctor, for there was little that could be done to mitigate the psychic torments of their charges (though they did minister to their medical needs as well). All the alienist could hope to accomplish was to keep his patients safe, clean, and well cared for—which was certainly far more than had been done in previous eras. Still, the fact remained that there was not a single effective treatment for mental illness.
As the nineteenth century came to a close, every major medical specialty was progressing by leaps and bounds—except for one. Increasingly intricate anatomical studies of human cadavers produced new details of liver, lung, and heart pathologies—yet there were no anatomical drawings of psychosis. The invention of anesthesia and sterile techniques enabled ever more complex surgeries—but there was no operation for depression. The invention of X-rays allowed physicians the near-magical power to peer inside living bodies—but even Roentgen’s spectacular rays failed to illuminate the hidden stigmata of hysteria.
Psychiatry was exhausted by failure and fragmented into a menagerie of competing theories regarding the basic nature of mental illness. Most psychiatrists were alienists, alienated from both their medical colleagues and the rest of society, keeping watch over inmates who had little hope of recovery. The most prevalent forms of treatment were hypnosis, purges, cold packs, and—most common of all—firm restraints.
Karl Jaspers, a renowned German psychiatrist turned existentialist philosopher, recalled the mood at the turn of the century: “The realization that scientific investigation and therapy were in a state of stagnation was widespread in psychiatric clinics. The large institutions for the mentally ill were more magnificent and hygienic than ever, but despite their size, the best that was possible for their unfortunate inmates was to shape their lives as naturally as possible. When it came to treating mental illness, we were basically without hope.”
Nobody had the slightest idea why some patients believed God was talking to them, others believed that God had abandoned them, and still others believed they were God. Psychiatrists yearned for someone to lead them out of the wilderness by providing sensible answers to the questions, “What causes mental illness? And how can we treat it?”
A “Project for a Scientific Psychology”
In W. H. Auden’s poem “In Memory of Sigmund Freud,” he writes of the difficulty of understanding Freud through our modern eyes: “He is no more a person now but a whole climate of opinion.” It’s a pretty safe bet that you’ve heard of Freud and know what he looks like; his Edwardian beard, rounded spectacles, and familiar cigar make him the most famous psychiatrist in history. The mention of his name instantly evokes the phrase, “So tell me about your mother.” It’s also quite likely that you have an opinion on the man’s ideas—and, I’d wager, an opinion shading into skepticism, if not outright hostility. Freud is often maligned as a misogynist, a self-important and domineering phony, or a sex-obsessed shrink endlessly probing people’s dreams and fantasies. But, to me, he was a tragic visionary far ahead of his time.
In the pages of this book we will encounter many psychiatric luminaries (like Nobel laureate Eric Kandel) and psychiatric frauds (like orgonomist Wilhelm Reich). But Sigmund Schlomo Freud stands in a class of his own, simultaneously psychiatry’s greatest hero and its most calamitous rogue. To my mind, this apparent contradiction perfectly captures the paradoxes inherent in any effort at developing a medicine of mental illness.
I doubt I would have become a psychiatrist if it weren’t for Freud. I encountered the Austrian physician for the first time as a teenager when I read his most celebrated work, The Interpretation of Dreams, in a freshman psychology course. There was something about Freud’s theory and the manner in which he communicated it that seemed to unlock the great mysteries of human nature—and resonated with my own efforts
to understand myself. I thrilled to such sentences as: “The conscious mind may be compared to a fountain playing in the sun and falling back into the great subterranean pool of subconscious from which it rises.”
There’s a common phenomenon among medical students known as “intern’s syndrome”: studying the list of symptoms for some new ailment, the student realizes—lo and behold—she herself must be afflicted with diphtheria, or scabies, or multiple sclerosis. I experienced a similar reaction with my initial exposure to Freud. I began to reinterpret my behavior through Freud’s theories with a sudden rush of apparent insight. Did I argue so often with my male professors because of a repressed Oedipal conflict with my father over winning my mother’s attention? Was my room messy because I was stuck in the anal stage of psychosexual development as a consequence of my mother making me wear a diaper to nursery school?
While I may have indulged in overly elaborate interpretation of trivial behaviors, Freud did teach me the invaluable lesson that mental phenomena were not random events; they were determined by processes that could be studied, analyzed, and, ultimately, illuminated. Much about Freud and his influence on psychiatry and our society is paradoxical—revealing insights into the human mind while leading psychiatrists down a garden path of unsubstantiated theory. Most people forget that Freud was originally trained as a hard-nosed neurologist who advocated the most exacting standards of inquiry. His 1895 work Project for a Scientific Psychology was intended to educate physicians about how to approach psychiatric issues from a rigorous scientific perspective. He trained under the greatest neurologist of the age, Jean-Martin Charcot, and—like his mentor—Freud presumed that future scientific discoveries would clarify the underlying biological mechanisms responsible for thought and feeling. Freud even presciently diagrammed what may be one of the earliest examples of a neural network, depicting how systems of individual neurons might communicate with one another to learn and perform computations, foreshadowing the modern fields of machine learning and computational neuroscience.
While Wilhelm Reich frequently made public claims that Albert Einstein endorsed his ideas about orgonomy, in actuality, Einstein considered Reich’s ideas ludicrous and demanded that he stop using his name to market his products. But the great physicist had a very different attitude toward Freud. Einstein respected Freud’s psychological acumen enough to ask him, shortly before World War II, to explain man’s capacity for warfare, requesting that Freud “might bring the light of [his] far-reaching knowledge of man’s instinctive life to bear upon the problem.” After Freud responded with a dissertation upon the subject, Einstein publicly endorsed Freud’s views and wrote back to Freud, “I greatly admire your passion to ascertain the truth.”
Freud’s pioneering ideas on mental illness were initially sparked by his interest in hypnosis, a popular nineteenth-century treatment that originated with Franz Mesmer. Freud was captivated by the uncanny effects of hypnosis, especially the mysterious phenomenon whereby patients accessed memories that they could not recall during their normal state of awareness. This observation eventually led him to his most celebrated hypothesis: that our minds contain a hidden form of awareness that is inaccessible to our waking consciousness. According to Freud, this unconscious part of the mind was the mental equivalent of a hypnotist who could make you stand up or lie down without your ever realizing why you had done so.
These days we take the existence of the unconscious for granted; it strikes us as so obvious a phenomenon that it almost seems ridiculous to credit a single person with “discovering” it. We casually use terms like “unconscious intention,” “unconscious desire,” and “unconscious resistance” and tip our hat to Sigmund by referring to “Freudian slips.” Modern brain and behavioral scientists also take the unconscious as a given; they embrace the unconscious in such concepts as implicit memory, priming, subliminal perception, and blindsight. Freud called his counterintuitive theory of an unconscious mind psychoanalytic theory.
Freud dissected the mind into various components of consciousness. The primal id was the voracious source of instincts and desires; the virtuous superego was the voice of conscience, a psychological Jiminy Cricket proclaiming, “You can’t do that!”; the pragmatic ego was our everyday consciousness, called upon to mediate between the demands of the id, the admonitions of the superego, and the reality of the world outside. According to Freud, humans are only partially privy to the workings of their own minds.
Freud drew upon this novel conception of the mind to propose a new psychodynamic definition of mental illness that would shift the course of European psychiatry, then come to reign over American psychiatry. According to psychoanalytic theory, every form of mental illness could be traced to the same root cause: conflicts between different mental systems.
For example, Freud would say that if you unconsciously wished to have sex with your married boss, but consciously knew that doing so would lead to all kinds of trouble, this would produce a psychic conflict. Your conscious mind would first try to deal with the conflict through straightforward emotional control (“yes, I think my boss is attractive, but I’m mature enough to not give in to those feelings”). If that failed, your conscious mind would try to resolve the conflict using psychological sleights of hand that Freud called defense mechanisms, such as sublimation (“I think I will read some erotic stories about forbidden affairs”) or denial (“I don’t think my boss is attractive, what are you talking about?!”). But if this psychic clash was too intense for your defense mechanisms to manage, it might trigger hysteria, anxiety, obsessions, sexual problems, or—in extreme cases—psychosis.
Freud’s broad term for all mental disturbances caused by unresolved psychic conflicts that affected people’s emotions and behavior but did not cause them to lose touch with the reality of the external world was neurosis. Neurosis would become the foundational concept within psychoanalytic theory for understanding and treating mental illness—and the most influential clinical concept in American psychiatry throughout most of the twentieth century, until 1979, when the seminal revision of psychiatry’s system of diagnosis was completed and neurosis would become the subject of a climactic battle over American psychiatry’s soul.
But in the early 1900s, Freud had no tangible evidence whatsoever of the existence of the unconscious or neurosis or any of his psychoanalytical ideas; he formulated his theory entirely from inferences derived from his patients’ behaviors. This may seem unscientific, though such methods are really no different from those used by astrophysicists positing the existence of dark matter, a hypothetical form of invisible matter scattered throughout the universe. As I write this, nobody has ever observed or even detected dark matter, but cosmologists realize that they can’t make sense of the movements and structure of the observable universe without invoking some mysterious, indiscernible stuff quietly influencing everything we can see.
Freud also provided far more detailed and thoughtful reasoning about mental illness than had been offered as the basis for any prior psychiatric theories. In particular, he considered neurosis a neurobiological consequence of Darwinian processes of natural selection. Human mental systems evolved to support our survival as social animals living in communities where we needed to both cooperate and compete with other members of our species, Freud argued. Therefore, our mind evolved to repress certain selfish urges in order to facilitate essential cooperation. But sometimes our cooperative and competitive urges conflict with one another (if we become sexually attracted to our boss, for example). This conflict is what produces psychic discord, and if the discord is not resolved, Freud postulated, it could unbalance the natural operation of the mind and create mental illness.
Critics of Freud often wonder why sex figures so prominently in his theories, and though I agree that his overemphasis on sexual conflict was one of his most glaring mistakes, he had a rational explanation for it. Since sexual urges are essential for reproduction and contribute so heavily to an individual’s evolutionary success, Freud re
asoned that they were the most potent and selfish Darwinian urges of all. So when we try to repress our sexual desires, we are going against millions of years of natural selection—thereby generating the most intense psychic conflict of all.
Freud’s observation that sexual desires can often lead to inner conflicts certainly resonates with most people’s experiences. Where he went astray, to my mind, was in presuming that because our sexual urges are so strong they must make their way into every single one of our decisions. Neuroscience, as well as casual introspection, tells us otherwise: that our desire for wealth, acceptance, friendship, recognition, competition, and ice cream are all independent and equally real impulses, not merely lust in costume. Although we may be creatures of instinct, our instincts are not solely, or even mostly, sexual.
Freud described several examples of neuroses in his celebrated case studies, including that of Dora, the pseudonym for a teenage girl who lived in Vienna. Dora was prone to “fits of coughing accompanied by a loss of voice,” particularly when talking about her father’s friend Herr K. Freud interpreted Dora’s loss of speech as a kind of neurosis he termed a “conversion reaction.” Herr K. had apparently made a sexual advance to the underage Dora, pressing himself against her. When Dora told her father about his friend’s behavior, he did not believe her. At the same time, Dora’s father was having a furtive affair with Herr K.’s wife, and Dora, who knew of their romantic liaison, thought that her father was actually encouraging her to spend more time with Herr K. as a way of giving himself greater opportunities with Herr K.’s wife.
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