Part 3 of a 3 part series
Psychiatry Emerges from its Creative Illness
Psychiatry had found itself the Cinderella amongst medical specialties.
Its melancholia was lifted in 1917, however, as ‘malaria therapy’ for general paralysis of the insane (GPI) kickstarted the emergence of a series of radical new therapies, renewing confidence in psychiatry as a ‘real’ medical speciality, with effective tools to combat insanity.
Intriguingly, this development coincides with the last years of WW1. Soldiers were developing ‘shell shock’ or ‘combat neurosis’ (now post traumatic stress disorder, PTSD), with the officer class predominantly affected. Rhodri Hayward suggests that this brought home to the Establishment the realisation that mental illness was not a result of moral deficits and poor breeding.
In the Essex Asylum, this period of profound change started with clinical rooms appearing on the wards for the first time in 1920, before ‘experiments with physical interventions’ commenced. ‘Hydrotherapy’ was the first of these at Essex, starting in 1926. Water of different temperatures was applied to the patient in various ways. This included baths (in which the patient may have been confined for days) and high pressure jets. Warm water was used to treat insomnia, whilst cold was used to control the manic.
It was 1926 before malaria therapy for GPI was introduced at Essex. This involved malarial blood being administered to induce a fever, which killed the syphilis causing organism. The malaria infection was then treated with quinine. Julius Wagner-Jauregg won the Nobel Prize in 1927 for this therapy, which was widely used until the discovery of penicillin offered a more straightforward treatment for syphilis.
From Asylum to Brentwood
The Essex Asylum changed its name to the Brentwood Mental Hospital in 1920, before the 1930 Mental Health Act banned the use of the word ‘asylum’. This Act also introduced another significant change, allowing for the first time voluntary inpatient admissions and outpatient treatment within the hospital.
The Brentwood Mental Hospital Outpatient Department first opened in 1931. In 1932, the hospital gained its first social worker, supplied by the ‘Mental Aftercare Association’.
These changes to the legal landscape were accompanied by further therapeutic ‘advances’. Prolonged narcosis was first used at Brentwood in 1937. A brainchild of the Swiss, Jakob Klaesi, this used barbiturates to sedate patients for long periods – the so called ‘deep sleep therapy’. In the same year, chemical convulsant therapy was also introduced at Brentwood. A Hungarian pathologist, Ladislas von Meduna, pioneered the idea, after observing that epilepsy sufferers were calm after seizures. After testing a variety of drugs to induce seizures, he settling on metrazol (also known as cardiasol).
Chemical convulsants were later replaced by Electroconvulsive Therapy (ECT), after Italian, Ugo Cerletti, successfully adapted the technique of electric stunning of slaughter house animals to humans. His first subject was apparently a vagrant found at Rome railway station. First used in Brentwood in 1941, ECT continues to be used around the world today.
1946 saw psychiatry’s most infamous procedure, the lobotomy (or pre frontal leucotomy), reach Brentwood. The hospital employed its own neurosurgeon, who carried out 200 procedures up to 1953. A lobotomy involved destroying part of the front of the brain, in the (false) belief that this would relieve insanity without affecting other functioning. Egas Moniz, a Portuguese neurologist, and his colleague, Almedia Lima, performed the first such procedure, and another low point in the Nobel committee’s history was marked by Moniz receiving the 1949 prize.
In the 1940s and 1950s, more than 50,000 people around the world suffered a lobotomy. In the USA, Dr Walter Freeman travelled the country performing the technique, sometimes, incredibly, using a mallet to push an ice pick above the eye into the brain. His most famous victim was the 23 year old Rosemary Kennedy, the sister of President John F. Kennedy, who underwent a lobotomy in 1941. The indication was, reportedly, her poor fit within the prominent political dynasty. She was left permanently disabled.
It was not over. In 1946, what was to later to prove a key step in psychiatric thought, insulin coma therapy, arrived at Essex.
Crossing the Rubicon
The use of insulin to produce a coma and convulsions, in order to treat insanity, was the creation of Manfred Sakel in Vienna. The technique caught on, and until a Medical Research Council study proved otherwise, it was claimed to be highly effective. More than that, as Dr Joanna Moncrieff points out in ‘The Myth of the Chemical Cure’, it came to be thought of as a specific treatment for madness. Moncrieff highlights this statement from a 1966 German textbook:
“the introduction of insulin coma treatment by Sakel was from a historical point of view the decisive step from a purely symptomatic to a curative therapy of the endogenous [of internal cause] psychoses.”
Before this point, psychiatrists had used drugs, in copious quantities, but only as a means to relieve or reduce symptoms. The causes and nature of the disorders that they were treating were a mystery. Whilst their colleagues in medicine were pioneering revolutionary new treatments and cures such as antibiotics and insulin, well-meaning psychiatrists felt helpless against a tide of people in distress. Historian Roy Porter argues that it was this context, combined with the social alienation and powerlessness of the patients, that had led to the increasingly invasive and damaging experimental treatments.
Insulin coma therapy was later made obsolete by the introduction of synthetic drugs, which proved more effective, and were, it appeared at least, to be much safer. We now know these drugs as ‘antipsychotics’, and they continue to be the basis of our treatment for psychosis.
The first such drug, produced in 1950, was chlorpromazine (marketed in the US as Thorazine). At first, it was referred to as a ‘tranquilliser’ or ‘neuroleptic’ – a drug that ‘seized the nerves’. It was marketed as Largactil in Europe, due to its large range of action. Later on, however, it came to be seen as a specific treatment for schizophrenia: an antipsychotic.
Moncrieff charts this paradigm shift in the perception of medication – from crude restraints to cures – and notes how this empowered psychiatry to claim a scientific basis. Soon afterwards, psychiatrists gained power over admissions to hospitals at the expense of magistrates, in the 1959 Mental Health Act. The first brick in the modern structure of psychiatric services was placed by the 1962 Hospital Plan for England and Wales, which recommended the closure of the asylums and their replacement with community services.
In this, the same year that its fate was sealed, our hospital (which had changed its name to Warley Hospital in 1953) received a Roman Catholic chapel, dedicated to St. Dympna, the Patron Saint of the mentally ill.
Warley Hospital actually continued to expand, with new wards opening in the 1960s. By the end of that decade, admissions had increased to over 1600 people per year. There was a parallel increase in community services, and the number of outpatients increased from under 10,000 in 1964 to 14,500 in 1968. Attempts were made to reduce readmissions through follow up of discharged inpatients, but this was unsuccessful. A portion of the blame was attributed to the ‘modern phenomenon’ of large numbers of adolescent drug addicts, who posed a ‘considerable therapeutic problem and considerable nuisance value in any given ward’.
Medical education became established, with one consultant being made an honorary clinical tutor under London University, and regular teaching sessions for medics started.
At the same time, there was a greater emphasis on ‘purely psychological therapy’. In 1963, a psychology department was opened, followed soon after by a centre dedicated to inpatient and outpatient group psychotherapy. Psychological perspectives on mental illness had, earlier in the 20th century, dominated the profession. Most famously, Freud’s psychoanalysis and its offshoots had had a strong influence, especially in the USA. However, it was ultimately Emil Kraepelin’s biomedical legacy that prevailed, as evident from today’s DSM and ICD psychiatric classification systems. This was, and still is, the time of biological psychiatry.
The 1960s counter culture spawned the ‘Anti-psychiatry’ movement, a stream of thought running against the mainstream biomedical viewpoint, a rebuke to the Enlightenment. Relativist philosophers, such as Kuhn and Feyeraband, argued that there no unique truth, and that even empirical data is shaped by prior conceptions. In a similar vein, Michel Foucault, in his ‘Psychiatric Power’ lectures, spoke of the ‘medical authority’ of the psychiatric profession functioning as a power before it functioned as knowledge.
‘Anti-psychiatry’ (a term that many of those labelled as such rejected) has lost much of its influence, but there remains a healthy body of critical thinkers within the profession.
Pat Bracken and Phil Thomas, both members of the UK Critical Psychiatry Network, have expressed concerns about the over-reliance of scientific, rational thought in psychiatry:
‘…while science has played a great role in illuminating the world of madness and distress, it has also served to silence other perspectives, traditions, ideas and insights. Post-modern thought/post-psychiatry is the idea of trying to turn down the bright light of scientific approaches within psychiatry, and to start to see that there are other ways of encountering states of madness; there are other forms of knowledge; there are other traditions that may be helpful to us in this work.’
This ‘bright light’ appears to illuminate the room in which Foucault’s ‘silence’ reverberates:
“…modern man no longer communicates with the madman. There is no common language: or rather, it no longer exists; the constitution of madness as mental illness, at the end of the eighteenth century, bears witness to a rupture in a dialogue, gives the separation as already enacted, and expels from the memory all those imperfect words, of no fixed syntax, spoken falteringly, in which the exchange between madness and reason was carried out. The language of psychiatry, which is a monologue by reason about madness, could only have come into existence in such a silence.”
The records for Warley Hospital end with an account of the ‘modernisation’ of its buildings. The author laments the demolition of the old gates and the walls around the gardens, but finds solace in the fact that a ‘pepper pot earth closet’ is left ‘in splendid isolation, as a relic of the past’.
They follow this with comments that now serve as a fitting warning to the psychiatric profession not to forget the wisdom that existed for thousands of years before the the rise of Science and Rationality:
“One cannot help hoping that future generations may perhaps be sufficiently sentimental to regard it as an ancient monument and resist the temptation to sweep it away in the sacred name of ‘progress'”.