19th-century psychiatry and mental health experienced an important change towards a physician-oriented doctor-patient relationship. Until the time of Philippe Pinel (1745-1826), who advocated for the unchaining of the insane at the Parisian Bicêtre at the end of the 18th century, diagnostic and therapeutic options for patients with mental illness were limited to contingent forms of care by the family, local community, and guardians acting from charity perspectives—for example, the catholic church. The introduction of moral therapy in the wake of Pinel introduced a new era of treating madness as a disease, one that required humane intervention. This changing view of madness corresponded with a gradual rise of asylums, alongside prisons and workhouses in the care for the mentally diseased—a social problem that eugenicists later in the United States, Britain, and Central Europe drew particular attention to.
With the arrival of larger hospitals during the middle of the 19th century and specialized research approaches towards the demands of people with mental illness (originating in France and the German-speaking countries), therapeutic options began to increase—for example, non-restraint measures of custodianship were developed. The introduction of physical therapies led not only to rising social concerns about the practices of psychiatry, but also to redefinitions of therapies in medicine and psychology. Following WWII, more “modern” approaches began to develop such as psychiatric shock therapy. These developments crucially changed the clinical options for patients with mental illness. They opened up a new era of drastic treatments. This moved psychiatry into the realm of racial theories and eugenics, boarding the search for physical “treatments” to psychiatric illnesses. In more recent times, these somatic treatments and notorious shock therapies have become examples of the limits of medicine and psychiatry.
Developments leading to “objectification” and “medicalization” in psychiatry
Continued Enlightenment thinking throughout the 18th century gave rise to re-conceptualizations of “human rationality,” “personhood,” and the “mind-brain relationship”. These topics were no longer issues of strict philosophical interest; rather they began to include changing attitudes towards the lower classes, women and children, as well as people with mental illness. The inclusion of such “social” components into psychiatric thinking resulted in treatments centered on more “moral therapeutic” views. These conceived of the deranged or disordered mind as an effect of the oppressive and harmful social conditions. During the post-revolutionary period in France, treatment of people with mental illness transitioned from traditional remedies towards medical therapies, ones promoted by reformers as “moral treatments.” Hospitals/asylums/retreats became the predominant place for the healing of people with mental illness, rather than custodial institutions in which the patients had been traditionally housed for years. However, the clinical encounter moved away from being a rather mutual venture between the doctor and the patient. Particularly through the introduction of new forms of technological instruments, such as the stethoscope, the thermometer, and later the reflex hammer, communication between patient and physician came to be minimal, as the patients were rendered into objects for study (“patient material”) rather than seen as equal partners.
Until the latter half of the 19th century, the dominant care model for the mentally ill were still the community asylums, charity institutions, and church-based facilities. Psychiatric reformers often saw contemporary asylums as lacking means of patient observation in the early stages of mental and nervous disorders, while research needed to become more systematic. Academic professors of psychiatry in particular criticized the dominance that asylums had assumed in psychiatry. This was because asylums were regarded as unacceptably overcrowded, with their staff clinging to inappropriate forms of mechanical restraint. Together with German internist Carl Wunderlich (1815-1877) and the surgeon Wilhelm Roser (1817-1888), the Berlin doyen of psychiatry Wilhelm Griesinger (1817-1868) put forward many programmatic concepts based on the natural sciences. In his medical practice at the mental asylum of Winnenthal he came to side with the earlier French “non-restraint movement.” As Griesinger later saw it, psychiatry had stagnated during the 1860s and revolved around abstract theories, while because of these limitations young scientists––such as Sigmund Freud (1856-1939)––chose to study hypnosis under Jean-Martin Charcot (1825-1893). Renewed interest in clinical research led to a reemphasis in the use of measuring approaches, hospital graphs, and new instruments, which Griesinger integrated into psychiatry. At the same time, he integrated his widely received care division of implementing hospital care for acute patients in urban centres, while establishing “agrarian colonies” for chronic patients in the suburban outskirts.
By the early 20th century, Munich professor Emil Kraepelin (1856-1926) was the international leader in psychiatry; Kraepelin was markedly influenced by Griesinger. For Kraepelin, the pathogenic element of “irritable weakness” was the basic explanation for nervous diseases. Kraepelin received here Bénédict Morel’s (1809-1873) concept of nervous “degeneracy”, which Morel had published in his “Treatise on Physical, Intellectual and Moral Degeneration of the Human Race” (1857/58) and used it in his own eugenics writing, such as “On the Question of Degeneration” (1908). Prominent psychiatrists’ views on hereditary “neuropathic dispositions” and medicalization of disability also reflected recent sociocultural trends, such as urbanization, industrialization, and the labour question. During the late 1880s, Kraepelin introduced the important concept of the surveillance wards to quantify the nervous diseases and draw conclusions about their inheritability. Kraepelin’s patient files and diagnostic cards were introduced as tools of his classification system. This emphasis on epidemiological analyses made its way into the multiple editions of Kraepelin’s classic “Handbook of Psychiatry” (1915) and through this also into the “Diagnostic and Statistical Manual of Mental Disorders” (DSM). Today the DSM-V is used to classify all mental and psychiatric disorders and forms the basis of most epidemiological and “evidence-based medical” research approaches in most industrialized countries.
Clinical psychiatry as a form of “applied eugenics”
In the presentation of their research programs, in publications, and academic lectures, neurologists and psychiatrists’ views––such as those of Carl Wernicke (1848-1905) at the University of Breslau, Kraepelin as director of the German Research Institute for Psychiatry, or Oswald Bumke (1871-1950) as chief of the University of Munich’s department of psychiatry––all reflected the cultural context of early 20th-century Europe. Many were struggling with the social and political effects of “modernity.” Public discourse witnessed passionate debates on the health consequences of urbanization, industrialization, and medical implications of the labour question. Particularly “degenerative views” in psychiatry underpinned widespread cultural beliefs about “The Age of Nervousness” which had taken most European countries into its grip. About one fourth of the patients in psychiatric hospitals were patients with physical forms of illnesses, when Bumke succeeded Kraepelin as psychiatry chair in Munich in 1924 and engaged in larger scale epidemiological research on “nervous degeneration” (such as alcoholism, feeblemindedness, epilepsy, neurasthenia, etc.). Published in Bumke’s 11-volume “Handbook of Mental Diseases,” psychiatrists’ answers to these social conditions were often couched in eugenics language: patient segregation, marriage counselling, and early ideas about forced sterilization.
Similarly, with his pathogenic notion of “irritable weakness”, Griesinger had alluded back to Benedict A. Morel’s (1809–1873) concepts of degeneracy that the latter had published in his “Treatise on Physical, Intellectual and Moral Degeneration of the Human Race” (1857/58). Griesinger however used the concept of nervous degeneration in a narrower sense, relating it to the causes of hereditary disease of the mind and the brain. In his article “On Degeneration” (1908), Kraepelin argued that the origin of neurasthenia and related disorders (including social deviance, prostitution, and criminality) depended on the general conditions of modern life. These views about nervous degeneration became powerful in social medicine and psychoanalysis, but also later during the interwar period with eugenics councillors and administrators who interpreted these conditions as intentional behaviours of “the unfit. Many prominent psychiatrists, such as Kraepelin, began to focus on “nervous degeneration” as a rhetorical means to promote their own eugenics agendas, particularly within the debates about the consequences of urbanization. They acted as scientific underlabourers of an increasingly politicized health care field.
The development of “heroic” somatic therapies
The impact of the physical and somatic therapies on psychiatry since the 19th century can barely be overstated, while also the effects of the international research relationships as well as the exodus of Jewish and oppositional neuroscientists from Central Europe need to be emphasized. With respect to biological psychiatry, the “emigration” of insulin-shock therapy, electro-shock therapy, and psychiatric genetics were highly influential on American psychiatry. According to Jack Pressman’s “Last Resort” (1998), the reevaluation of mental health practices towards the development of aggressive interventional psychiatric therapies was underway during the 1930s, when the new somatic or physical treatments became introduced as answers to the rising problem of mental illness. Among these, were malaria and insulin coma therapy, Metrazol and electroconvulsive shock therapy. Although some treatment protocols were “successful” in several cases, additional somatic treatments continued to be adopted by the medical community in hopes of more effective solutions. The new therapy forms had been particularly associated with Egaz Moniz’ (1874-1955) psychosurgery in Lisbon, and Ugo Cerletti (1877-1963) and Lucio Bini (1908-1964) at La Sapienza University in 1938, where electroshock convulsion therapy (ECT) developed. ECT quickly became more popular than Insulin or Metrazol shock, since patients did not experience as many negative side effects. Like other somatic treatments, there were nevertheless cardiac concerns, fractures, and symptoms that appeared like the original mental diseases. Similar to Metrazol shock therapy, ECT was found more effective in treating depressed patients than schizophrenics for whom it was originally intended. When the Vienna-trained neurophysiologist Manfred Sakel (1900-1957) noticed the effect of hypoglycemic states in drug addicts, where insulin had positive effects on detoxification, he thought that he had had discovered a new psychiatric therapy to induce coma states in schizophrenic patients. Sakel was himself forced into North American exile when Austria became annexed to Nazi Germany in 1938. Once he reached the US, Sakel worked as a staff-attending physician in New York, where he pioneered the adaptation of shock therapies in the American medical community.
The problem of large hospitalization numbers had also been recognized as a major strain on public health. In this situation, psychiatrists perceived the new shock therapies as a major technological relief. Where forms of eugenics and psychiatric genetics paved the conceptual and social way for a widespread application of the new shock therapies, the belief in technological progress and social blessings therefrom provided an enabling ideology, leading to a groundbreaking transformation of modern neuroscience in North America. The common link between above-mentioned somatic treatments and the major ethical and social concerns with them, was that they had limited effectiveness as desired by patients, families, and physicians, while these treatments were at the same time perceived as very dangerous.
Another form of invasive treatments in clinical psychiatry that should be mentioned here is psychosurgery. Before it took shape there were many surgeons and physicians who had begun to flirt with the idea that neurosurgical means might be able to ameliorate mental disease. Most prominent in the literature is the Swiss psychiatrist Gottlieb Burckhardt (1836-1907), who completed the first modern psychosurgical attempt in 1888. However, his procedure proved to be fairly unpopular among medical practitioners because of the high bleeding and infection risks associated with it. Psychosurgery––as a single surgical procedure or in combination with neurophysiological stimulation measures––developed as a form of neuropsychiatric treatment which has continued to be criticized from medical practitioners and patient advocates, particularly after its widespread use of thousands of operations by António Egas Moniz (1874-1955) and Walter Freeman (1895-1972). The term “psychosurgery” itself came to be applied to all surgical procedures that have sought to manipulate the brain in order to change higher psychological functions between the 1920s and the 1960s, while the use of these drastic forms of operations has today become limited––after the introduction of psychopharmacology in the 1950s and deinstitutionalization during the 1960s.
Since the early days of hospitalizing the mentally ill in the late 18th and early 19th centuries, the gap between physicians’ healing intentions and the harm produced in mental patients has been an important dimension in the modern history of psychiatry. This general development was augmented largely through research advances in biological psychiatry in the 1920s and 1930s, along with the development of somatic therapies in the clinical neurosciences since the 1940s and 1950s. The technological properties of the shock therapies and the neurostimulatory approaches make it clear that the invasive operations on patients’ central nervous system need to be regarded as two sides of the same coin. In mapping out some of the major biomedical and technological advances in psychiatry and mental health over the past two centuries, some significant co-developments have become visible (such as the objectification of patients, pejorative views of Social-Darwinism, and explicit emphases of the economic dimension of mental illness, along with the use of the mentally ill in human experimentation). The blessings of modernized treatment approaches of the mentally and nervously ill became themselves a major subject of ethical debates in psychiatry and neuroethics – often criticizing visible “newgenics” undertones
-Frank W. Stahnisch
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