A History of Psychiatry: From the Era of Asylum to the Age of Prozac. - Review - book reviews

Journal of Social History, Winter, 1998 by Constance M. McGovern

By Edward Shorter (New York: John Wiley & Sons, Inc., 1997. xii plus 436pp.).

One can hardly pick up a publication that professes to address intellectual issues these days without being accosted by some discussion of the seemingly deserved demise of Sigmund Freud's ideas. Typical of this ongoing onslaught was last summer's New York Times Book Review essay, "Flogging Freud," that noted, "Freud has proved to be a great whipping boy for our time."(1) And while Edward Shorter's A History of Psychiatry: From the Era of the Asylum to the Age of Prozac offers a broader scope than any of the dozen or more books mentioned in the essay, Shorter nevertheless falls into the same category. Shorter's primary theme is that a biological approach has been the major characteristic of the development of western psychiatry and that psychoanalysis was a mere blip (and a transitory one at that) in the biological continuum.

In the effort to make his case, Shorter traces this history of western psychiatry in his own inimitable, interesting, and informative style. He tells a fascinating story that sweeps across Europe, Great Britain, and the United States, bringing alive the personalities of the many players and their triumphs and foibles which shaped western psychiatry as we know it today. He begins with the age of the asylum and, chapter by chapter, lays out ensuing developments. His characterization of what he calls the "first biological psychiatry" is followed by the requisite chapter on nerves, neurasthenia, and the rest cure, trends that helped lay the foundations for the twentieth-century private office practice of psychiatry. Enter Freud. As Freud and his followers gained influence not only through the impact of their theories and therapies, but also by winning offices in the professional organization of psychiatry and by attaining positions as department heads in universities, psychoanalysis nearly unseated the more traditional approaches to mental illness. But the biologically-oriented never gave up. The psychopharmacology of the turn of the century (alkaloids, bromides, and barbiturates) would yield to later drugs of choice. The now rejected but then innovative work of the 1920s and 1930s of fever therapy, shock therapy, and lobotomy would restore to prominence the biological approach. It was a short step to Prozac with its "promise of problem-free personality and weight loss," its consequent ability to begin the "destigmatization of mental illness," and its relegation of psychiatrists to "serving as gatekeepers to Prozac" rather than as the healers they had claimed to be in the previous century. (p. 323-325)

Shorter leaves little doubt about where he stands as a historian of this era and this profession. The sacred cows of the ongoing academic debate quickly fall as he offers strong statements about the very real nature of mental illness, disposing of the anti-psychiatry movement, the labelers, the social control theorists quickly and convincingly. For instance, he summarily dismisses what he calls the "scorched earth assault on psychiatry" of Andrew Scull and others. (p. 339) He uses graphic evidence to illustrate that even the pre-asylum seventeenth and eighteenth centuries were hardly the carefree environment for the insane that Michel Foucault and others have suggested. Those who exhibited insane behavior were harshly treated; "one has to abandon immediately any romantic notion" of the insane "being permitted to gambol on the village green or ruminate idly in the shade of the oak tree," according to Shorter. (p. 2) In the twentieth century, Shorter not only laments the "ballooned disease labels" created in part by the advent of third party payers, he also concludes without apology that deinstitutionalization is "one of the greatest social debacles of our time." (pp. 291, 277)

The reader will be fascinated by Shorter's narrative about the middle classes and their doctors conspiring in the diagnosis of the "fig leaf of nerves."(p. 113) Spa owners sought a new ailment upon which to build their clientele once the contagion of tuberculosis was confirmed, bringing into question their previous concentration on chest complaints. Their new marketing was successful; thousands suffering from "nerves" traveled across continents to seek the solace of these waters that rescued them from the stigma of mental illness. In another episode, Shorter explains how the decentralized German government operation in the nineteenth century created fierce competition among asylum doctors, putting them on the cutting edge in the profession. France and England were far more organized and, therefore, in Shorter's analysis were merely "French disasters" or "Anglo-Saxon laggards." (pp. 81, 87) Shorter makes short shrift of the argument that the numbers of insane increased in the nineteenth century. He concludes rather that a redistribution took place during which families dispersed their mentally ill to the asylums as these institution became available. Specific types of mental illness did increase, however: neurosyphilis, alcoholic psychosis, and schizophrenia. This etiology, of course, lays the ground for Shorter's basic thesis of the biological roots of these and other mental illnesses and thus the triumphs of the "second biological psychiatry." And, at this point, the reader will not be surprised that Shorter proclaims that Emil Kraeplin, not Freud, is "the central figure in the history of psychiatry." (p. 100) For Shorter, Kraeplin's classification system that rejected symptomology and promoted a medical model had a longer lasting effect on the development of psychiatry than Freud. Freud and his psychotherapeutic theories and therapies were merely passing fancies, although convenient to help move psychiatry out of the asylum and into the private office.