A History of Psychiatry: From the Era of Asylum to the Age of Prozac.
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.
Shorter is equally intriguing in his treatment of the role of institutions such as the National Institute of Mental Health and drug manufacturers. He sees the NIMH as a vehicle of paramount influence, noting that in its earliest years sympathetic directors funneled research dollars into psychoanalytic projects, while a quick turnover of control to more biologically-oriented directors led NIMH on a different track. His history of the role drug companies illustrates even more revealingly how scientific developments are shaped outside the laboratory and often controlled neither by academicians nor clinicians. "A given disorder," Shorter notes, "might have been scarcely noticed until a drug company claimed to have a remedy for it." The intertwined history of the Upjohn Company's work on Xanax, the DSM III's definition of panic disorder, and drug manufacturers' sponsored studies illustrates his conclusion that a previously obscure diagnosis like panic disorder then "became epidemic" as Upjohn marketed its new drug. (pp. 319-320)
There are caveats for the reader of this well-written book, however. Shorter sometimes uses false dichotomies (the issue never was so clearly "psychoanalysis versus custodialism," for instance); he often fails to distinguish between neuroses and psychoses or among psychiatrists, neurologist, psychoanalysts, and other practitioners; and he does not especially entertain voices that see the historical development of western psychiatry differently. And the reader needs to be aware that in his flair for telling a good story dramatically, Shorter has people like Adolf Meyer "gasping" (p. 108) and occasionally exaggerates the meaning of his sources. There are two cases in point. For instance, when Shorter attempts to explain the predominance of Jews in the practice of psychoanalysis, he states that Ernest Jones "notes, with relief, that apart from refugees, 'in England ... only two analysts have been Jews.'" (p. 185) Jones, however, relates quite a different version of his attitudes in the very source Shorter cites - Jones's memoir, Free Associations. 2 Jones, far from expressing any trepidation about the predominance of Jews actually relates an anecdote that suggests he virtually identified as one of his Jewish colleagues. In a second instance, Shorter takes out of context remarks that Robert Wallerstein made about the decline in the proportion of psychoanalytic training that was required of psychiatric residents in the late 1980s and early 1990s. Shorter uses ellipses to indicate that Wallerstein acknowledged that psychoanalytic training and, thus, psychoanalysis, were on the wane. But Wallerstein actually writes: "Let me say that psychoanalysis, as theory and as practice the intellectual well spring of dynamic psychiatry and psychotherapy, survives, and taking a broader view ... flourishes."(3) It is not that Shorter's broader thesis is not well taken and, indeed, presented with considerable evidence and astute analysis, but in his enthusiasm for his subject, he sometimes tests the credulity of the reader who is familiar with his sources.
Shorter has a strong thesis. In particular, he wants psychoanalysis to take a walk toward science. In his critique of its failure to do so, he acknowledges neither the cultural or social limits of science nor does he discuss the changing definitions of what has constituted science or the scientific method over the last several centuries. Shorter presents the development of biomedical psychiatry brilliantly but the reader must also explore the work of historians like Nathan Hale if she or he is to have a full picture of the history of western psychiatry. Hale's latest work acknowledges the current declining place of psychoanalysis within the psychiatric profession, but recognizes the ideological and cultural impact of Freudian theories. Hale and others point to the "intrinsic qualities of Freud's system," to its "sweep and dramatic interest," its "boldness," and its ability to bring "science into areas where custom and religion had prevailed." Psychoanalysis, as Hale notes, is still "one of the many modalities of psychotherapy" and "remains the most developed and systematic psychology;" its theories are still "part of standard texts" and "its personnel the most meticulously trained."(4) But psychoanalysis is, and has been, more than psychiatry or psychology; it has been an intellectual system that has permanently altered western thought. Shorter, for all his brilliance, misses this point. Shorter's History of Psychiatry, though, is a fine history; it is an important, albeit, controversial work.
Constance M. McGovern Frostburg State University
1. Sarah Boxer, "Flogging Freud," New York Times Book Review, August 10, 1997, 12, 14.
2. Ernest Jones, Free Associations: Memories of a Psycho-Analyst (New York, 1959), pp. 208-210.
3. Robert S. Wallerstein, "The future of psychotherapy," Bulletin of the Meninger Clinic 55 (1991): 421-443, for the quotation, see 437.
4. Nathan G. Hale, Jr., The Rise and Crisis of Psychoanalysis in the United States: Freud and the Americans, 1917-1985 (New York, 1995), pp. 380, 391.