Thursday, January 1, 2009

Review: Joel Braslow. Mental Ills and Bodily Cures: Psychiatric Treatment in the First Half of the Twentieth Century. Berkeley: University of Californ

In 1977 Charles Rosenberg noted that most historians “have always found therapeutics an awkward piece of business” and “and on the whole, they have responded by ignoring it.” If this statement has been true for medicine in general, it has been even more true for psychiatry. After reading “Mental Ills and Bodily Cures,” it will be harder to ignore this awkward piece of business any longer. This book a concise, clearly written and closely argued series of essays on biological treatments in psychiatry, from hydrotherapy to lobotomy. It does more, however, than present the history of psychiatric treatments. As a psychiatrist I must confess that this book made me distinctly uncomfortable as I found myself reflecting on the effects of the biological treatments that I prescribe. Joel Braslow, a psychiatrist as well as a historian, has written a book that is not merely critical of some past practices but raises questions about contemporary practice as well.

Braslow has not, however, written an anti-psychiatric rant; I wouldn’t have felt so uncomfortable if he had. He understands and explains the medical and scientific literature surrounding the treatments that he describes. More than that, he doesn’t accept generalities about treatments, but writes about specific doctors and patients. Using case records and verbatim typescripts of case conferences from several California state hospitals, he allows us to virtually hear what doctors and patients are saying about treatment. Braslow is frank, but also balanced in his opinions. This is not a book about perpetrators and victims.
Braslow theme is “the power of biological therapies to alter the way in which doctors perceive both their patients and the doctor-patient relationship.” He does not accept the comforting view that psychiatrists treat diseases, syndromes or even disorders that are simply “out there.” Instead he insists that the use of any particular treatment actually structures what psychiatrists count as signs and symptoms of illness. It also structures the quality of the relationship between psychaitrist and patient. He supports this controversial position by developing a typology of how treatments influence the perceptions of psychiatrists as well as their relationships with patients. It matters, he says, whether we use treatments to control behavior, cure disease or ease suffering.
He argues, for example, that hydrotherapy was prescribed to control disorderly behaviors not to cure an illness. While doctors insisted that hydrotherapy was a treatment and not a punishment, patients often received this “treatment” against their wills. As a consequence patients had very different opinions of what it meant to receive hydrotherapy than did their psychiatrists. Braslow uses both hospital records and the proceedings of a governmental investigation to present these differing opinions. By contrast malaria therapy was given for a specific, laboratory confirmed, disease, general paresis. This disease had been a common cause of dementia and death for over a century when malaria therapy finally offered hope of a cure. Patients not only consented to this treatment, at times they requested it, and were even allowed to refuse it. In this case hospital records dramatically demonstrate how physicians’ attitudes towards patients became more respectful after the introduction of this treatment.
In addition to these treatments Braslow also devotes a chapter to sterilization, electroshock therapy and lobotomy, as well as a chapter about the influence of gender on decisions to perform lobotomies. In each chapter his analysis stays close to the psychiatrist and patient. Writing about steralization he argues that a belief in eugenics was not the only ingredient in making decisions, psychiatrists also had to believe the treatment had medical value. Electroshock therapy was used both a therapeutic discipline aimed at behavior and a therapy of despair aimed at releiving psychic pain. Lobotomy, while arguably the most destructive of these treatments, ironically also had the strongest scientific credentials. While psychiatrists performed lobotomies in response to incorigible behavior, they were convinced that they were treating diseased behavior. Astonishingly, but perhaps not surprizingly, Braslow also shows that psychiatrists also found reasons lobotomize women much more frequently than men. Using evidence from case records he argues that what counts as incorigible behavior depends on gender role expectations..
“Mental ills and Bodily Cures” is a book that historians will certainly profit from reading. I believe it will stimulate controversy as well as research on the awkward business of therapy. Hopefully it will also be book that psychiatrists will read and be disturbed by.

Edward M. Brown, Journal of the History of the Behavioral Sciences, 2001

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