By Anne Harrington WW Norton, 2019 Review by Christian Perring on Sep 10th 2019
Anne Harrington is a historian of science at Harvard who specializes in the sciences of the mind and brain. Her slightly out of date home page reports that the title of the book she is working on is The Biological Revolution in Psychiatry: What Really Happened? The title she ended up with, Mind Fixers: Psychiatry's Troubled Search for the Biology of Mental Illness, is not just more catchy but also more indicative of Harrington's scepticism about the so-called biological revolution that is meant to have transformed our understanding of mental disorders. There have been many books providing a history of psychiatry, and they tend to be either giving some version of the great triumph of this branch of medicine, or else exposing the weakness of the science, the fanaticism of the researchers preferring their theories over the welfare of the patients, and the influence of the profit motives both for individual doctors and companies selling products. Some are polemical while others are more scholarly and balanced, even if they deliver a verdict one way or the other. Edward Shorter's A History of Psychiatry (1997) is a staunch defender of a biological approach. Andrew Scull has written a lot on the topic, and he generally takes a somewhat skeptical approach: his new book Psychiatry and Its Discontents seems to fit in this pattern. Ultimately the question of whether psychiatry is successful is a scientific one, depending on testing of treatments and data on whether people with mental illnesses are being helped or cured by psychiatry and the social structures that are intended to support them. The history of the topic always plays a secondary role, and is dependent on scientific assessment, in providing a verdict. But the institution of medical psychiatry and associated health professions, plus the social policies directed at people with mental illnesses are far from unitary, and the complexity of the whole leaves room for different interpretations.
What is clear is that for centuries, people have been claiming to have the answers to madness and neurosis, and yet the fate of people with mental illnesses waxes and wanes, with some improvements in some aspects of their lives. Generally, supporters of psychiatry emphasize the positive and have faith that the great discoveries that will transform the field are just around the corner. The skeptics on the other hand focus on the negative, and there is a great deal of neglect, exploitation, sexism, racism, and cruelty to be recorded. Given the number of times that the great predictions for cures have failed to come true, it is very easy to be doubtful about the current optimism voiced by some ardent supporters of psychiatry. In previous work, Harrington has remained fairly neutral, although her previous book, The Cure Within: A History of Mind-Body Medicine (2008) did show an interest in a holistic approach that does not fit will with the reductionism of biological psychiatry. In her new book, her tones are measured, but also consistently showing how psychiatric science has failed to live up to its own claims, and has proceeded in a haphazard motion, very much subject to the influence of a range of problematic influences.
It is deceptively difficult to write history, especially when aiming at a more general readership. It is neither possible nor even a good goal to just give a bunch of facts. There have to be themes with which to group the facts. Stories are helpful, and details of colorful characters will draw the reader in. If the author is making a claim, then the claim has to be defended. The task is made more tricky when the author is covering well-trodden ground, because there has to be something that keeps the experience fresh for the reader. Harrington uses anecdotes and photographs, and her main innovation is to divide her history up into three main sections.
The first is Doctors' Stories, covering a little over a hundred years from the late nineteenth century up to the 1980s, in just over 130 pages. So it goes at a pretty brisk pace, covering the main approaches to understanding mental illness and treating it. It contrasts the psychodynamic approaches of Freud with the more biological approaches stemming from Kraepelin and reductionist thinkers in psychology. The focus moves mostly to the USA and gives a good amount of attention to the important figure of Adolf Meyer, who held a lot of influence and managed to hold a more inclusive view of mental illnesses as biopsychosocial reaction types during the middle of the twentieth century. The division between psychodynamic and biological approaches increased after that, leading to the supposed dominance of biological psychiatry at the end of the century. This section also sets out some of the innovations of treatment including electroshock, lobotomy, large scale institutionalization and community mental health centers, and the various scandals about misuse and mistreatment that followed them. There's also discussion of how homosexuality was removed from the DSM and how DSM III became so influential for thinking about mental illness.
The main value of Mind Fixers comes in its second section, Disease Stories. It has three chapters, one each on schizophrenia, depression, and manic depression, in a little over 100 pages. Each goes from the mid twentieth century up to the current stage of research, with special focus on brain research and medication. Her take on the history looks like it comes from a close reading of journals and other sources from the time, and some reflection on other subsequent historical accounts. There is no indication that Harrington talked to the researchers, did any interviewing, or found other forms of evidence. The chapters are well footnoted, and her account is thorough. For each disease, there are all sorts of theories about them, and in particular, different ideas about what kinds of abnormalities in the brain causes them. Time and again we see an initially promising idea surge and then fail. Readers are left with the impression that while we have some validated results about what brain activities are associated with these mental illnesses, we are still a long way from having a strong understanding. Nearly always treatments created by pharmaceutical research are discovered by accident when being used to treat other problems, and medications created as the result of theories of brain disorders rarely have much therapeutic effect.
The final section of the book is titled False Dawn, and consists of just one chapter on the current state of psychiatry. It is the most explicitly pessimistic chapter in Mind Fixers. Two section headings are "Psychopharmacology in Crisis" and "Psychiatry Loses Faith in the DSM." While it acknowledges that there are still researchers who believe that we will have major breakthroughs in our lifetime, Harrington suggests that that they could be decades away.
Mind Fixers is a well written and useful introduction to the history of psychiatry. Its chapters in section 2 on the three major mental illnesses will be especially good sources for people seeking out the history of psychopharmacology. Those looking for more detail might look to the work of David Healy. There is also a nicely set out guide for further reading at the end of Harrington's book, which lists many great resources.