I come from a family of physicians - there are 10 doctors on my mom’s side. We have cardiac surgeons, orthopedic surgeons, anesthesiologists, an endocrinologist, a rheumatologist, an internal medicine doc, an ophthalmologist. I’m the black sheep of the family: I’m going into psychiatry.
Despite - or maybe because of - my grandfather’s, uncles’, and aunts’ medical backgrounds, they laugh when I tell them I want to be a psychiatrist. They try to convince me otherwise, “Psychiatry isn’t a science,” “Don’t you want to be a real doctor?” “Really, sit on a couch all day?” I laugh, too, and shrug them off, but at the same time, I wonder why this is how they perceive my chosen field.
As I learned more about the history of psychiatry, I began to understand. When my uncles and aunts grew up, and when my grandfather was at the peak of his career as a cardiac physiologist, Freudian (psychoanalytic) psychiatry and the anti-psychiatry movement ruled the psychiatric landscape. To my mom’s family, psychiatry was not a science: it was a field of quackery, couches, and endless Oedipal references.
This held true for the vast majority of the American public. Stigma against psychiatry remains today, and to understand it, we must understand the history of psychiatry. Combating this stigma is key to encouraging patients to seek treatment, so in this post, we’ll take a whirlwind tour through the history of psychiatry.
Mental illness as designed by God
People believed that “lunatics” were born crazy, designed that way by nature or god. They were paying for earlier sins and chose to behave in a “beastly” manner. They typically lived in asylums, where treatments involved things like purging, bleeding, blistering, chains.
Mental illness due to physiologic disruption
Psychiatrists believed that overload of the senses, accumulation of bowel toxins, and disruptions in things like “animal magnetism,” circulation, and orgones (energy) caused mental illness. Treatments included orgone accumulators, conductors of animal magnetism, boxes covering patients’ heads to reduce vision and hearing, rapidly rotating chairs, and laxatives.
Mental illness as a manifestation of a turbulent soul
Psychiatrists believed that madness was a part of human nature. Their belief that “madness is the normal mind’s surrender to the turbulent forces of the soul” paralleled the period’s romanticism in literature, music, and art. Scientific experiments were rejected and lines between mental health and mental illness blurred.
Mental illness as physical brain abnormality
Pathologists tirelessly studied brains, searching for physical signs of psychosis, hysteria, mania, and depression. However, no physical abnormalities could be found.
Psychiatry in crisis and the Freudian Era
By 1900, psychiatry was thought of as “brain mythology” and “speculative anatomy.” It reached a crisis point.
Psychoanalysis, invented by Austrian psychiatrist Sigmund Freud, spread through Europe like wildfire. Freud believed that our minds contain hidden awareness that is inaccessible to our waking consciousness, and that conflicts between the three parts of our brains - the id (instincts/desires), ego (everyday consciousness), and superego (voice of conscience) - caused all mental illness.
An emphasis was placed on sexual mental conflicts because Freud believed that reproduction and sex were the most important aspects of human evolution and survival. Psychoanalysis, the main treatment for mental illness, included dream interpretation, free association, and transference (the projection of past relationships onto a blank therapist).
If other psychiatrists questioned Freud’s theories, they were labeled “mortal enemies of psychoanalysis” or excommunicated from the upper echelons of psychiatry.
Psychoanalysis enters America
The popularity of psychoanalysis decreased in Europe as the primarily Jewish psychoanalytic tradition was forced out during WWII, but it entered America with a vengeance.
“Fever therapy,” frontal lobotomies, electroconvulsive therapy, and coma therapy were used as treatments for the severely mentally ill. Nobel prizes were awarded for fever therapy and frontal lobotomies, as no other treatments existed.
Psychoanalysis will save the world → antipsychiatry
American psychiatrists became enamored with psychoanalysis. They shifted their focus from mental asylums to the worried well, leaving their positions at country asylums in favor of lucrative private practices in the city. Psychoanalysis was used as a “treatment” for schizophrenia, bipolar disorder, autism, and homosexuality, and it was believed that:
- Schizophrenia was caused by mothers’ smothering, rejection, and conflicting demands.
- Autism came from refrigerator mothers.
- Homosexuality was caused by domineering mothers who instilled a fear of castration in their sons.
- Depression was a manifestation of the ego punishing itself to halt punishment by parents.
In psychoanalysis, patients typically lay in comfortable positions. Psychiatrists sat out of view to facilitate the patient’s projection of past relationships onto them (transference).
Many psychiatrists believed that psychoanalysis could solve all political and social ills. The National Institute of Mental Health forbade spending money on biological research as it believed that the future of psychiatry lay in social activism and community engineering.
Consistent definitions of mental illnesses didn’t exist, people were angry at the biased diagnoses and blame psychoanalysts handed out, and there were no medications other than “nerve pills” (tranquilizers, librium, valium) to treat disease. And thus an antipsychiatry movement was born. Psychiatrists were accused of being quacks without real treatments. Insurance companies slashed mental health benefits & asylums were emptied. Psychiatrists were condemned by academics, lawyers, activists, artists, and even fellow psychiatrists.
Objective diagnosis & medication that works
Concerned about the fate of psychiatry, the American Psychiatric Association published its first objective diagnostic guidebook, the DSM-III (Diagnostic and Statistical Manual), in 1979. The DSM contained menus of symptoms that were based on data from published research and had no information about the biological or psychoanalytic roots of mental disorders. Without information about cause of mental illness, psychoanalysis had nothing on which to base itself. Freud’s theory at last fell from grace.
The focus of psychiatry shifted back to severe mental illness. The first antipsychotics, antidepressants, and mood stabilizers became more frequently used, despite having been invented in the 1950s and 1960s. Pyschopharmacologists became the first psychiatrists to focus on using medications rather than therapy to treat disease.
1950s, 60s, 70s until present
The DSM Era
With the DSM came a way to study psychiatric disorders in an objective, consistent way. Neuro- focused psychiatrists began to study the brain using techniques like CT scans, MRIs, and PET scans. Molecular psychiatrists studied proteins, the blood-brain barrier, and the immune system. Genetics researchers found genes associated with mental illnesses and continue to search for more.
A focus on evidence-based medicine emerged; randomized controlled trials are conducted to study new medications and therapies. New forms of therapy including cognitive behavioral therapy, dialectical behavioral therapy, interpersonal therapy, and motivational interviewing are being studied and used today. Most residency programs still offer psychoanalytic training to those who want it, but very few young psychiatrists identify as analysts.
The DSM-5 was released in 2013. It contains 265 diagnoses with menus of symptoms and is based on evidence, data, and discussion. It has no discussion about the underlying causes of disease.
Discovering the biological roots of mental illness
The National Institute of Mental Health is now advocating for the creation of a new diagnostic system based on genetics, neurobiology, neural circuits, and biomarkers. Personalized medicine and further genetic, imaging, and molecular studies are gaining traction. Mainstream psychiatrists believe in a form of psychiatry that is both “mind-based” (therapy, individual development, personality) and “brain-based” (neurons, disorders of cell metabolism and pathways).
The history of psychiatry is one of confusion, trial and error, and a lack of consistency. We saw the prevailing theory of disease shift back and forth: from God-deigned → disruptions in physiologic energy and bowel toxins → strong turbulent forces in the soul → physical brain abnormalities → mental conflicts between the id, ego, and superego → genetic and molecular abnormalities. There were no effective treatments for a very long time, and because diagnostic consistency was lacking, “researchers” were able to make whatever claims they wanted, with whatever “evidence” they had.
American psychiatry was stuck in the psychoanalytic tradition for decades, which slowed the progress of biological psychiatry and led to a belief in the ineffective and quack-ish nature of the field. But the DSM-III was a breakthrough. Since the creation of the manual, we’ve been able to study disease characteristics effectively. This not only has allowed us to make appropriate evidence-based medication and therapeutic recommendations for our patients but has also allowed us to gain a foothold into the biology of the altered brain.
And so to my family I say, “Psychiatry is no longer a field of quackery, couches, and Oedipal references! It’s become one of the most scientific out there, and I can’t wait to become a psychiatrist.”
And yes, family, a psychiatrist is a real doctor.