Category Archives: History of psychiatry

Madness and Meaning

By Dr David Laing Dawson

As a young physician entering the world of the asylum, the mental hospital, the world of insanity, like many others before and since, I was fascinated by the prospect of finding meaning within madness, understanding behaviours that appeared, at first blush, inexplicable, understanding the de-contextualized speech patterns of many patients, understanding their delusions and voices.

This was the era of Timothy Leary, of a wish on the part of some to find a chemical path to enlightenment, the era of R.D. Laing seeking parental and family causes of insanity, of Thomas Szasz telling us that mental illness is a myth, the time of Foucault telling us that our society causes madness, and Alan Watts telling us that, really, madness was just an alternate flight path.

And, I must admit, madness, delusions, hallucinations, voices, fractured speech patterns, catatonia, mania, and even stuporous depression, contain rich and fertile ground for an artistic and literary imagination, and always fodder for philosophical questions about reality, meaning, semiotics, the nature of a human being, the manner in which we define deviance.

In our therapeutic communities of the day we talked and talked, in small groups and large groups. We listened to delusional ranting, to the reporting of voices emanating from the back of the head or from the dead, from an alien spacecraft, from God, and from the devil. I have spoken with several Queens, a few Christs, a man who tried to kill a president, a man harbouring evil beings inside his body, a man with the gift of teleportation, with many who believed the radio and television and popular songs were sending them personal messages, to many who believed they were being controlled by radar, radio waves, microchips, to men who wanted to cut off their genitals, to others who wanted to gouge out their eyes, to a few who wanted to kill someone who was controlling them from afar.

Of course we can find meaning in all of this, in each and every delusion, in each and every ephemeral message. And the meanings can be deep, intellectual, fanciful, alluding to Greek Mythology, Shakespeare, intrusive government programs, Kafka. They can be Freudian, Jungian, Adlerian, Foucaultian. They can even be new age and theosophic.

Or the meaning can be found more simply in those basic parameters of our social world and our sense of self: power, control, influence, intimacy, sexuality, responsibility, worth, love, hate, guilt, fear.

But does this help?

If it helps us empathize, yes. If it helps us form a relationship, develop trust, rapport, acceptance, yes. If it helps us accept these sufferers as fellow human beings, yes.

But might it not be more important to treat that young man who wants to gouge out his eye, before he actually does it, rather than worry about Oedipus Rex?

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Shrinks – The Untold Story of Psychiatry – A Review

Marvin RossBy Marvin Ross

Last week my colleague, Dr David Laing Dawson, provided his own personal history of prescribing psychiatric medications since he became a physician in the late 1960s. David’s experiences fit in with the development of that profession as described by Dr Jeffrey Lieberman in his new book Shrinks, The Untold Story of Psychiatry. Lieberman is a psychiatrist himself, chair of the Department of Psychiatry at Columbia University and the past president of the American Psychiatric Association.

It is highly readable book and what I particularly enjoyed were his anecdotes based on his many connections within the profession. He points out that RD Laing, one of the father’s of the anti-psychiatry movement, had his “convictions ….. put to the test when his daughter developed schizophrenia. After that, he became disillusioned with his own ideas. People who knew Laing told me that he became a guy asking for money by giving lectures on ideas that he no longer believed in.”

Lieberman attributes this information to Dr. E Fuller Torrey. Lieberman also mentions that the other leader of anti-psychiatry, Thomas Szasz, made it clear that schizophrenia did qualify as a true brain disease but that he was never going to say that in public.

Of less intellectual interest is the origin of the term shrink. Headshrinker entered broad use after a 1950 Time Magazine article about Hopalong Cassidy saying that anyone who predicted that he would become a hero of kids would have been led off to a headshrinker – Hollywood jargon for a psychiatrist. Hopy was my hero and I still remember lining up for hours in Toronto wearing my Hopy chaps and vest waiting for a chance to shake his hand.

North American psychiatry was heavily influenced by the psychoanalysts who, Lieberman points out, followed a rigid set of theories that were not grounded in science or scientific proof. In fact, two psychoanalysts from different schools of thought would likely come up with different interpretations for the same patient. As a reaction to this lack of rigour, science and the criticism from anti-psychiatrist, some in the profession began to establish menus of symptoms for each disorder based on data from published research. This was an effort influenced by the Kraeplin approach of the previous century.

And while the psychoanalysts had always emphasized cause based on unconscious conflicts, the development of this new Diagnostic and Statistical Manual (DSM) was to be based on two key concepts. First was that the symptoms must be distressing to the individual or must impair his ability to function. Second was that these symptoms must be enduring. It is interesting that the development of the DSM partly arose from the criticisms of the lack of evidence by anti-psychiatrists. Today, the anti-psychiatrists argue that the DSM is pathologizing everyday life. Lieberman states that the DSM-5 has actually reduced the number of diagnoses to 265 from the 297 in the DSM-4.

In addition to his description of the serendipitous discoveries of effective anti-psychotics, lithium for mania and anti-depressants, Dr Lieberman’s comments about families will please all who have kids with schizophrenia. It is worth quoting in its entirety:

It was not enough that parents had to endure the tragedy of a child’s mental illness; after this onslaught of inane diagnostic formulations, they also had to suffer the indignity of being blamed for the illness because of their own misbehavior. Schizophrenia and bipolar disorder……were now believed to be curable through the right kind of talk therapy. Like a pet cat in a tree, a deranged individual merely had to be coaxed into climbing down to reality.

All in all, a very informative and entertaining read.

To Learn From History We Must First Know It.

David Laing DawsonBy Dr David Laing Dawson

PART II

And then there are those who want to make schizophrenia go away, along with psychiatrists and their medications. Some are claiming that it is a misdiagnosis. Most of these folks, they say, are suffering from disorders of entirely psychological cause and explanation, such as DID (Dissociative Identity Disorder, which is the child of Multiple Personality Disorder) or a form of PTSD from childhood trauma, or, on the other hand, simply experiencing just one of the unusual states of mind and perception within the vast normal array of human potential.

Well, I must admit, we psychiatrists continue to struggle with, argue about, investigate, study, re-conceptualize, re-define schizophrenia, while searching for causation and better treatment. In the manner a fever and a rash are not the illness itself, but rather the body’s reaction to a pathogen, many of the symptoms of schizophrenia are the person’s, the brain’s reaction to underlying dysfunction(s). And we are only beginning to understand, at a cellular/pathway/messenger/neuron by neuron level this most complex of organs, the human brain.

There may be as many as six different pathways to this most devastating and misunderstood of illnesses, each with a different genetic vulnerability and epigenetic influence. But we know it happens quite consistently in all cultures and historical times. How we have thought about these people who become so cognitively dysfunctional, so specifically irrational, has varied from culture to culture and age to age. But they have been there and they are there now:  In African villages where they might be tied to trees outside the village for families to feed until the mania passes or the patient dies. Suffering in the streets and jails in Dorothea Dix’s time. Burned as witches. Punished in stockades. Banished from villages in Europe and left to wander the country side. Poets (who undoubtedly never had to live with an insane person) speculating that insanity may be simply a form of creativity, and being someone more in tune with the rhythms of the invisible world than the rest of us. Yes, we’ve been there before.

And then in our part of the world between 1880 and 1980 mostly residing in Asylums and Mental Hospitals. And now, of course, as described in previous essays by Marvin Ross  and myself, we find that vast numbers of people so afflicted are being housed in, have been returned to our jails and prisons, and kept away from public view .

(In considering historical and cross-cultural data it is always well to remember that life expectancy for the general population was about 40 years in 1850’s North America, 60 today in India, less than 50 today in Africa, and in all times and places, considerably less for the mentally ill, the poor, and the indigent.)

As Marvin Ross pointed out recently, the doctors who observed and described schizophrenia as a progressive disease with inevitable poor outcome, were doing so at a time when we had no effective treatment. They were not wrong in their observations. Untreated schizophrenia invariably leads to a progressive deterioration of function, early death, and sometimes violence.  Although there are always, as with everything in this world, a few exceptions. A few.

Only 65 years have passed since we discovered the effectiveness of anti-psychotic medication, starting with the famous Chlorpromazine (Largactil, Thorazine) in France. And only 60 years have passed (1954) since this drug was first introduced to North America. And because we were so tentative with these drugs at first, often weaning our patients off them after three months of recovery without relapse (1965), and when that didn’t work, waiting six months, then a year (1970) , then making that two years, then five, then ten, (1975) and with our patients sometimes lost to follow-up, and stopping the medications themselves, some because of side-effects, and relapsing and being readmitted, and then starting over – it really has been only about 20 to 30 years now that we have concluded that most (if not all) people who suffer from schizophrenia will need to take these medications for life in order to remain stable and well. And this has finally allowed us to have, as I have had, the opportunity to see some people take these medications regularly for 30 years, and observe that with very consistent treatment (anti-psychotic medication), a good support system (usually family and some counseling), schizophrenia need not be a progressive illness with a bad outcome.

One Step Forward, Two Steps Back – Mental Illness Treatment Over the Past 150+ Years – Part IV

David Laing DawsonBy Dr David Laing Dawson

It is difficult, if not impossible, to fully understand the forces altering, changing, insidiously impacting our attitudes, laws, institutions, and behaviour in our own time. It takes distance and serious historians to dissect these things, and even then we are probably viewing them from a clouded contemporary prism. But something happened between 1990 and 2015 I would not have expected in 1970. Many of our mentally ill fellow citizens today are worse off than they would have been had they been born 50 years earlier. There are parts of the United States where one could make the case that they are worse off than they would have been had they been born in 1850. How could this have happened during a period of increasing knowledge, advanced medical tools, relative peace and prosperity?

This is one part of the puzzle:

The mental health laws were tightened, restricted during those years (1970 to 1990), and safeguards put in place, all toward the righteous goal of preventing anyone, ever, from being unnecessarily stripped of freedom and independence without “due process”. On paper it looks fine. Now one could not be held for a psychiatric assessment unless he or she was judged to present an imminent threat of harm to self or others. Within 72 hours if a psychiatrist came to the same conclusion about imminent threat to self or others, that person could be kept for another two weeks. Further safeguards were put in place – appeal processes, Review Board Hearings, lawyers made available, patient advocates. The wording, the processes are all a little different in each North American jurisdiction, but with similar intent and outcome.

And then the act of treating was separated from the act of detaining. A second process is required for involuntary treatment: a determination of not being competent to consent to treatment, and then the treatment authority would be conferred on a nearest relative, or, failing that, a public official. And this determination could also be appealed, taken to a Review Board, and ultimately to court.

This distinction between the right to detain and the right to treat has led to some paradoxical situations in which everybody loses. A person can be deemed too imminently dangerous to self or others to set free, to be allowed to leave, yet competent to refuse treatment. The patient suffers physically, mentally, left in a state of psychosis for a long period of time; families watch this suffering; unhappy doctors and nurses watch someone deteriorate to a state of chronic psychosis, to a state of true madness and unpredictability not seen in our mental hospitals since the introduction of effective medication.

Apart from this paradox all the new rules sounded commendable, and guaranteed to reduce or eliminate type I errors. Type I errors being the unnecessary detention of someone eccentric, a nuisance, but not dangerous, and the forced treatment of someone who should (within our current view of individual rights) be allowed to decide for himself. They prevent the abuse of a Nurse Rached, or a Dr. Donald Cameron. And these new rules were informed, to some extent I am sure, by our increasing awareness of the use of Psychiatry in the Soviet Union to deal with people deemed to be enemies of the state.

We need strong safe guards in all our systems and institutions, for humans in positions of power are always capable of abusing or misusing that power, of convincing themselves on some philosophical basis or other, that they are doing the right thing.

But when we completely eradicate the possibility of type I errors we open the door for type II errors. In this case not detaining someone who, in hindsight, should have been detained, not protecting and treating people who need treatment and protection. The most dramatic form of Type II error brings about the headline that we have read with horror and disbelief about twice per year the past twenty years. A patient is released from hospital, gets on a Greyhound bus, and decapitates a fellow passenger. A young man stops taking his pills and butchers his mother;  another shoots a journalist with a crossbow; yet another shoots an Arizona politician in the head.

But a less dramatic and more insidious type II error has been the increasing numbers of mentally ill (not deemed imminently dangerous to self or others) left to fend for themselves on the street, in shelters, and in jails and prisons. For a significant number of mentally ill people (and their families) we have, over the past 30 years, reversed the reforms provoked by Dorothea Dix in 1843.

 

One Step Forward, Two Steps Back – Mental Illness Treatment Over the Past 150+ Years – Part III of IV

David Laing DawsonBy Dr David Laing Dawson

Part II ended with the phrase: “gradually reduce reliance on mental hospitals.” “Gradually” is the operant word here, even though, as I recall, during the kinds of planning workshops, conferences, meetings we had in those days, at least during the “visioning” part of the exercise – the “vision thing” as George H. W. Bush once called it – some of us imagined a day when mental hospitals would no longer be necessary.

From 1971 until 1995 I worked in a variety of settings, sometimes as a participant, sometimes as a leader, developing comprehensive outpatient programs for serious mental illness – programs for schizophrenia, supported housing, programs for mood disorders, programs for early detection and comprehensive treatment, programs for brain injury, for crisis intervention, programs for isolated regions, programs for consultation to medical wards and family doctors. We revamped the mental hospital, transferring more and more funding to outpatient services, redefining “chronic ward” to rehabilitation program, reducing the use of restraints. We worked at connecting with school and social services, housing and job training.

Still, for some people, the mental hospital remained an asylum, the one place in the world where they were safe, could eat meals and sleep in a bed, could receive medical and nursing and dental care, could sit in the sun on a bench, have a shower, cadge money from the medical director for a coffee, and wander about in eccentric fashion making outrageous observations.

And someone mentally ill in the jail on minor charges might be transferred to the hospital without a great deal of fuss. Some fuss, but not a great deal. Police would apprehend someone creating a disturbance, observed to be mentally unbalanced in some way, and bring that person to the emergency department, to the emergency psychiatric team rather than the jail. They would have to sit around for a bit to await outcome, but they could usually count on the hospital keeping that person and they could get back on patrol.

Government policy shifted focus and money from the worried well to those suffering from severe and persistent mental illness.

Better treatments were being developed, more money spent on research; our country was not at war, the economy was growing, more people were being educated, the digital age arrived, information became readily available. This era of progress could only continue, one would think.

Of course the new drugs proved only marginally better than the original mood stabilizer, the original anti-depressant, and the original anti-psychotic. Talk therapies were being refined, codified, made more practical, but they too did not add much more than having an empathic, nonjudgmental, reasonably wise counselor in your corner. Yet the world was becoming a better place for the mentally ill and their families, at least my part of the world, and much of Europe, and parts of the United States. Surely this progress would continue and Dorothea Dix, Drs. Pinel, Kraeplin, Tuke, and Rush would be pleased.

During the latter part of those years, I attended a psychiatric conference in San Francisco. I was probably there to talk about comprehensive treatment for schizophrenia. But what I remember most clearly is the number of homeless and psychotic people living on the streets near the hotel and convention headquarters. An ironic tableau: a thousand psychiatrists within, a hundred mentally ill living on the streets outside, and a few people picketing with anti-psychiatry placards. Another psychiatrist from another state (I think it was Georgia) came to give a talk in Ontario during that period. He came with a warning. Do not let happen in Canada what was happening in his country. His hospital, the mental hospital in which he had worked, in which he had pursued all the same goals mentioned in that second paragraph of mine – it had been closed and transformed into a medium secure prison facility for the mentally ill and criminally insane.