Madness: A Brief History (18 page)

Freud’s ideas proved crucial for favoured twentieth-century views of the self, amongst them belief in the dynamic unconscious and the insights into it afforded by free association; the meaning of dreams; repression and defence mechanisms; infantile sexuality; the sexual foundations of neurosis and the therapeutic potential of transference. Though he liked to see himself as a natural scientist, his beliefs were fated to enjoy their greatest acclaim and influence in fiction, art, and films. With his disturbing view of a self which was divided and not master in its own house, Freud became the principal myth-maestro of the twentieth century.

The psychoanalytical movement

In creative tension with Vienna, a vigorous tradition of depth psychiatry emerged in Switzerland. At Burghölzli, the Zürich psychiatric hospital, Eugen Bleuler (18571939) deployed psychoanalytic theories in his delineations of ‘schizophrenia’, his term for the condition he honed from Kraepelin’s
dementia praecox,
one marked by delusions, hallucinations, and disordered thought. Such schizophrenics were ‘strange, puzzling, inconceivable, uncanny, incapable of empathy, sinister, frightening’. But it was Carl Jung’s (1875-1961) influence which prevailed, especially after his break with Freud in 1912, when he developed his alternative ‘analytical psychology’—a less sexual and more idealistic rendering of the unconscious.

A pastor’s son, Jung trained in medicine in his native Basel before specializing in psychiatry. After meeting Freud in 1907, he became the master’s favourite son, gaining a reputation as the ‘crown prince’ of psychoanalysis—or its non-Jewish frontman. Oedipal conflicts flared, however, exacerbated in 1912 when his
The Psychology of the Unconscious
challenged many of Freud’s key theories, notably the sexual origin of the neuroses; within two years the rift was total and final—the first of the epic feuds which balkanized psychoanalysis and undermined its scientific pretensions.

The analytic psychology developed by Jung claimed to offer a more rounded view than Freud’s of the psyche and its various personality types, including the ‘extravert’ and ‘introvert’ announced in his
Psychological Types
(1921). A healthy balance of opposites was to be prized (animus and anima, the male and female sides of the personality), as was the integration of thought, feeling, and intuition. Jung proposed the existence of a ‘collective unconscious’, stocked with latent memories from mankind’s ancestral past, passed down from generation to generation by some Lamarckian inheritance of acquired characteristics mechanism. Studies of dreams, of art and anthropology fed a fascination with archetypes and myths (e.g. the earth mother), which were said to fill that collective unconscious, shaping experience and, as stressed in his final book,
Man and His Symbols
(1964), constituting the springs of creativity. With its vision of the self realized in the integrated personality, Jung’s analytic psychiatry retains its inspirational appeal as a personal philosophy of life.

France developed psychodynamic traditions of its own which left it relatively impervious to Freud—at least prior to the pyrotechnic prominence enjoyed in the 1970s by the maverick Jacques Lacan, who read Freud through a structuralist semiotics. In the wake of Charcot, Pierre Janet (1859-1947) elaborated theories of personality development and mental disorders which long dominated French dynamic psychiatry. Exploring the unconscious, he left sensitive clinical descriptions of hysteria, anorexia, amnesia, and obsessional neuroses— and of their treatment with hypnosis, suggestion, and other psycho-dynamic techniques. Correlating hysteria with what he called ‘subconscious fixed ideas’, he proposed treating it with ‘psychological analysis’.

Though Freud took a dim view of American society, psychoanalysis found a particularly receptive environment in the New World. Many key analysts migrated there, even before the Nazi persecution of Jews. Amongst the earliest was Alfred Adler (1870-1937), best remembered for his notion of the inferiority complex: the neurotic individual overcompensating by manifesting aggression. After participating in Freud’s psychoanalytic circle in its early years, Adler broke with the master and elaborated his own theory in
The Nervous Character
(1912). Moving to the USA, he turned his attention to the relations between individual and environment, stressing the need for social harmony as the means to avoid neurosis. His views became central to the commitment of interwar American psychiatry to a vision of social integration and stability based on individual ‘adjustment’ and adaptation to healthy social forms.

With so many Jewish practitioners forced to flee Europe, the United States became the world headquarters of psychoanalysis, and by the mid-twentieth century American psychiatry at large, in university departments and teaching hospitals, was heavily psychoanalytically oriented. Writing in the 1960s, two psychoanalytically oriented American practitioners, Franz G. Alexander and Sheldon T. Selesnick, could pronounce, with assurance, that ‘psychiatry has come of age’.

Psychoanalysis spread far more slowly and partially to the United Kingdom, by contrast, due perhaps to Anglo-Saxon phlegm and distrust of navel-gazing. An early supporter, David Eder, recalled addressing a paper in 1911 to the Neurological Section of the British Medical Association on a case of hysteria treated by Freudian methods: at the end of his talk, the entire audience, including the Chairman, walked out in stony silence. Small wonder, with psychiatrists around like the venerable Charles Mercier, who gloated in 1916

that psychoanalysis is past its perihelion, and is rapidly retreating into the dark and silent depths from which it emerged. It is well that it should be systematically described before it goes to join pounded toads and sour milk in the limbo of discarded remedies.

Despite such ‘resistance’, inroads were nevertheless made, sped perhaps by the crisis in standard explanations produced by shell shock in the Great War. The thought of mass cowardice was too dreadful to contemplate but no regular psychiatry could explain why brave men of good background all of a sudden could no longer fight.

Early British psychoanalysis crystallized around Ernest Jones (1879-1958). A founder of the London Society of Psychoanalysis (1913), this Welshman, whose zest, vanity, and phenomenal energies made him a born proselytizer, became a close friend of Freud and eventually his biographer, and in 1912 he brought out the first book published in England in this field:
Papers on Psycho-Analysis.
Later, the London scene was animated by the theoretical battles waged by Melanie Klein (1882-1960) and Anna Freud (1895-1982), who had fled to England with her father in 1938 after the Nazi occupation of Austria: Freudians and Kleinians unforgettably crossed swords over the interpretation of infant/mother relations. In London the Tavistock Clinic, founded in 1920, promoted psychotherapy, especially for children and families, and fostered the British ‘object relations’ school. From the 1940s, great faith was vested by Donald Winnicott and John Bowlby in the nuclear family, and particularly the
mother, as the sheet anchor of psychosocial adjustment.

In time, the infiltration of broadly psychodynamic turns of thinking helped the idea to gain ground—it had become conventional by the 1950s—that mental disorder was not confined to the certifiable. Ordinary people might have ‘complexes’, and neuroses, it was now said, ran like a watermark through the population at large: housewife blues, family conflicts, alcoholism, adolescent adjustment problems, generational tensions, and so much more—the precursors of the depression, eating, and sexual disorders ubiquitous by the close of the century.

By the 1950s, pop culture had created new and even glamorous psychological types like the juvenile delinquent—the slumming modern version of the melancholy poet or Romantic genius. The ‘psychiatrization of everything’ predictably occurred first in the United States—a trend deliciously mocked in Leonard Bernstein’s musical,
West Side Story
(1956), in which the crazy-mixed-up young New Yorkers taunt a police officer on the warpath:

Officer Krupke, you’re really a square;

This boy don’t need a judge, he needs an analyst’s care!

It’s just his neurosis that oughta be curbed,

He’s psychologic’ly disturbed.

The shock of the new

While Freud was being lionized by the avant-garde as the conquistador of the unconscious, the medical treatment of the institutionalized saw striking therapeutic innovations, some effective, many dubious, a few dangerous. In the wake of the new microbiology, the effects of bacterial infections on brain pathology were identified, beginning with syphilis; and in Vienna Julius von Wagner-Jauregg (1857-1940) found that counterinfection with artificially induced malaria was effective against general paresis of the insane. This discovery— an effective treatment against a familiar and terrible condition—won him the Nobel Prize in 1927: he remains the only psychiatrist so honoured.

Wagner-Jauregg himself was one of many advocates of Faradization (electric-shock) treatment for that new disorder, shell shock. Prolonged-sleep therapies, induced by barbiturates, then enjoyed a hazardous vogue in the 1920s. Pioneered by Manfred Sakel, insulin-induced coma—insulin had been introduced against diabetes in 1922—was employed from the 1930s against schizophrenia and, though dangerous, it apparently brought some benefit. Shock treatments of many kinds thus came into vogue.

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The microbe world. Ashing papa;
pen drawing by C. Harrison, 1913. A common cold germ is asking the father of a neurasthenia bacillus if he can marry her; he is refused on account of the social gap between them: ‘You cannot have my daughter the social gulf is too wide remember you are a mere germ of a common cold—she is a bacillus of neurasthenia.’ Like melancholy, neurasthenia was adjudged the malady of very superior people.

Working with epileptics, the Budapest psychiatrist 
Ladislaus Joseph von Meduna developed a different shock treatment in which a camphor-like drug (marketed as Cardiazol, Metrazol in the USA) was the convulsive agent, producing seizures so violent that patients sometimes suffered broken bones. The theory underpinning Meduna’s innovation was that epileptiform seizures naturally produced improvements in schizophrenics so why not induce them artificially? And then in 1938, at his neuropsychiatric clinic in Genoa, Ugo Cerletti (1877-1963) began to use electric shocks (ECT) to alleviate severe depression—a treatment with a highly controversial history—it became a key target for psychiatry’s critics—though some measure of success.

Psychosurgery too enjoyed a vogue from the 1930s. At Lisbon University, the neurologist Egas Moniz (1874-1955) claimed that obsessive and depressive cases could be improved by leucotomy, surgical severance of the connections between the frontal lobes and the rest of the brain. Lobotomy and leucotomy were enthusiastically taken up in the United States, spearheaded by Dr Walter Freeman, a neurologist at George Washington University Hospital (Washington, DC). Often using an ordinary cocktail-cabinet ice-pick, inserted, via the eye-socket, with a few taps from a carpenter’s hammer, Freeman at one point was getting through a hundred transorbital lobotomies a week—he performed some 3,600 in all. By 1951 over 18,000 patients in the USA had undergone lobotomy, before it was overtaken by growing doubts, and by the psychopharmacological revolution.

Psychosurgery was a plausible try—was it not likely that behaviour modification could be achieved through direct surgical intervention into the brain? The neuro-physiological advances discussed in Chapter 6 had shown that specific cortical centres controlled particular aspects of cognition and affect, and though the front brain remained somewhat of a mystery, animal experiments suggested that it might be implicated in mental balance. Furthermore, surgery had established itself as the cutting-edge of medicine. From the humble tonsillectomy upwards, operations had become routine, increasingly safe, and even fashionable. Surgeons, stated the
New York Times
in 1936, ‘now think no more of operations on the brain than they do of removing an appendix’. Like other shock treatments, lobotomy held out promise not just for the mentally ill but for psychiatry itself. That speciality had been bumping along the bottom in the early decades of the century, bemired by the unsavoury associations of huge, squalid public warehouses for the mad poor. Psychosurgery promised to change all that—to turn no-hope asylums into true hospitals, rescue psychiatry through the knife, and thus provide a lifeline for the discipline back into mainstream general medicine. In any case, what else was to be done with the half-a-million lost souls in America’s asylums living in the concentration-camp conditions soon to be exposed by Albert Deutsch’s chilling
The Shame of the States
(1948)? Any attempt at cure seemed better than none—did not the old medical adage state that desperate conditions required desperate remedies?