Anne Harrington. Mind Fixers: Psychiatry’s Troubled Search for the Biology of Mental Illness; New York, NY: W. W. Norton & Company, 2019; 384 pages; hardcover $27.95: 978-0-393-07122-1
By Violeta Ruiz Cuenca
In 2013, the American Psychiatric Association published the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5). The DSM was first created in 1952 with the purpose of defining and classifying mental conditions in order to aid diagnosis and treatment. Since this first edition, the manual has undergone multiple changes and revisions, the most notable of which is the decrease of the influence of psychoanalysis in favour of biological theories of the cause of mental disorders. This so-called ‘biological turn’ in psychiatric thinking, which took place over the 1980s, supposedly as a result of discoveries in neuroscience, genetics, and psychopharmacology, is the focus of Anne Harrington’s new book, Mind Fixers. In it, she argues that the current dominant narrative among psychiatrists that presents the ‘biological revolution’ as a triumph over the erroneous Freudian ideas of the 1940s and 50s is incorrect. Instead, she shows how the popularisation of psychoanalytical ideas in the early twentieth century, followed by the biological turn later in the century, is more a result of professional crises within the groups than of the discovery of any decisive piece of science.
Harrington’s study begins by focusing on the debates that took place between (and within) the biological and psychoanalytical theories as each tried to identify the causes of mental illnesses during the late-nineteenth and twentieth centuries. The first part of the book centres on the development of nineteenth-century brain psychiatrists, the popularisation of psychoanalytical theories after the First and Second World Wars, and the progressive overhaul of these ideas by biological psychiatry in the second half of the twentieth century. She convincingly argues that the root cause of the debates, especially during the twentieth century, was one of professional rivalry. Debates over expertise and authority were rampant and often arbitrary, since psychiatric theories were commonly a result of new therapies that seemed to give insight into how the mind and brain worked, rather than the other way around (that is, preceding the development of new forms of treatments). In this section, Harrington demonstrates how psychiatry has a guilty past in which it effected abuse on patients, covering notorious examples such as Edgar Moniz’s popularisation of lobotomies in the 1930s and the classification of homosexuality as a mental disorder until the DSM-III-R (1987), as well as lesser known ones, like the medical director Henry Cotton’s abuse of the therapeutic effort to treat schizophrenic patients through the extraction of supposedly infected organs in the body at the New Jersey State Lunatic Asylum in the 1910s and 20s.
The second part of the book focuses on three different diseases – schizophrenia, depression, and bipolar disorder – in order to show that there was never one single, dominating theory that explained each condition. Instead, biological and psychoanalytic theories co-existed and even influenced each other in the development of new ideas. Furthermore, Harrington shows that these changes in the theories were not only caused by psychiatrists and their research, but were also highly influenced by other factors, such as changes in the psychopharmaceutical legislation, social movements like the feminist and anti-psychiatry movements of the 1960s and 70s, popular responses to unethical scientific studies and the questionable application of psychiatric ideas to court cases. This allows the author to convincingly argue that psychiatry’s search for a biological explanation of mental conditions was pluralistic (and messy), and cannot be told in a simple, linear way.
Finally, in part three, Harrington reflects on the ways in which the promises made by biological psychiatrists to offer the key to managing mental illness have unravelled since the 1990s, arguing that psychiatry has paid the price for its arrogance in former years, having made promises that it could not deliver. This section includes her own first-hand experiences, like the pessimistic atmosphere that permeated the launch of the DSM-5. Rather than presenting a set of conclusions, Harrington opts for an Afterthought where she presents a new way of doing psychiatry, one in which patient well-being is at the centre of treatment, and in which dialogue between patients, families, and doctors serves to generate powerful leverage against big pharma.
Throughout the book, it becomes evident that the true protagonists of the story are not the professionals, but rather the patients and their families, who suffered the practical consequences of the changing medical discourses, competing theories, and arguments over professional expertise and authority. Her interviews with these groups, and perhaps in particular with the mothers who lived with mental illness in their families through the 1970s, makes Harrington especially sympathetic to their plight. The popularisation of different theories since the 1940s, like the “dissociative-organic types of parents” or “refrigerator mom”, that blamed the development of autism in children or schizophrenia in adults on the parents, had severe consequences on the families, while patients were affected by either the over-medicalisation of their disease with drugs that often turned out to have dangerous side-effects, or with the lack of access to drugs in a system that overvalued the success of psychoanalysis.
Mind Fixers certainly serves to stir debate among psychiatrists and is clearly a useful tool for patient/family activist groups at present. It is likely that the main purpose of the book is precisely that; the engaging writing style and the affordable price make it readily accessible to a general audience. However, as a work of scholarship in the History of Medicine, it has some serious methodological shortcomings that limit its usefulness to an expert audience. One of the main drawbacks is the attention paid to individual actors and their motivations, often giving character evaluations and presenting new ideas as ‘discoveries’ that seem to emerge out of their genius (or malice, or absurdity), failing to contextualise the political, social and cultural context in which they emerged. For instance, in chapter one, she describes Emil Kraepelin as an impassioned workaholic who developed his approach to the classification and diagnosis of mental conditions because he decided to ‘shift gears’, and the degree to which it was accepted by his colleagues depended on his individual ability to persuade them. One doesn’t have to be an expert in Kraepelin to know that this characterisation of his persona is problematic. Despite criticising heroic origin stories for generating caricatures of historical actors, she generates the same kind of narrative, which has long been inadmissible in the field of History of Science.
Harrington’s focus is admittedly on the twentieth century and the USA, but a significant issue with grand narratives is that they run the risk of over-simplification. Harrington’s leaps from different national contexts, characteristic of these types of narrative, are problematic in this sense, since they not only assume a static interpretation of concepts, but also obviate the fact that these ideas had to be transported to different contexts, very often undergoing a process of appropriation, therefore making these processes far more complex than they might initially seem. Following on from the example above, a deeper reflection on how Kraepelin’s ideas were appropriated in the USA, and the reasons why they were accepted, contested, or modified, would have provided a richer history than that which is on offer.
Additionally, while Harrington argues that a plurality of interpretations existed, her narrative still leans towards the linear: one dominant interpretation is replaced by another without an exploration of how multiple theories of mental illness co-existed at the same time. For example, in chapter three, ‘A Fragile Freudian Triumph’, she claims that the consolidation of psychoanalytic theories after the Second World War had more success than physical therapies because the human fellowship they appealed to seemed to have more long-lasting effects than any physical treatment; ‘[a]nd then drugs arrived’, in Harrington’s words, and changed the state of affairs. The book’s analysis of the reasons for this plurality – economic, social, political, and cultural – remain superficial, while mentions of race and gender issues are brief and serve to argue the case that psychiatry failed in its mission, rather than to explore the ways in which power was instituted to oppress or benefit different groups. These issues result in an overly simplistic analysis, which can be useful for political purposes, but is disappointing to the historian.
Harrington’s analysis of the actors involved suffers from the same problem, and is especially salient in the case of the patient and family groups, whom she presents as a homogenous bloc who were victims of, and stood together against, the professional rivalry that plagued psychiatry. This generates a single narrative about patients and their families, and how they were affected by the discipline and its institutions, obfuscating the plurality of attitudes towards psychiatry within these groups. For instance, Harrington makes no mention of grass-roots movements and radical patient groups who self-identified (and identify) as survivors of the psychiatric system, and who were often forced into psychiatric detention by their families. Furthermore, Harrington places too much emphasis on a single factor – often the development of a new pharmaceutical drug – as the cause for change, rather than showing the messy and disjointed way in which change happens.
Although the point of the book is to show that the idea of ‘progress’ in psychiatry is erroneous (an idea that is well-accepted within the History of Science), Harrington occasionally makes statements that suggest an inclination towards this idea, even if it is not explicitly articulated. The book’s description of neurasthenia, a late-nineteenth-century disease considered to be a result of the modern condition of the struggle for survival that characterised the period, as a ‘fictive’ disease in the afterthought is surprising. It reduces the condition to nothing more than a label without contextualisation within the moment from which it emerged – something the book does not do when it comes to discussing schizophrenia, depression, or bipolar disorder.
Mind Fixers reads better as an introductory text for undergraduate medical and psychology students who are training to be practitioners, or for family and patient groups who are interested in the history of the profession, than for historians of psychiatry or of any other sub-discipline within the field. It reflects the disillusionment that currently plagues the field of psychiatry, especially since the publication of the fifth Diagnostic and Statistical Manual (DSM-5) in 2013, and the frustrated struggle of patients and families to find a solution to the way in which their lives are affected by mental health, poor institutional support, and lack of adequate treatment for their condition. Still, it holds hope that a new approach within psychiatry is in the making, one which builds on the interdisciplinary relationship between the humanities and the sciences. In that sense, Harrington’s book is certainly a success.
Violeta Ruiz is a PhD candidate in the Centre for the History of Science at the Universitat Autònoma de Barcelona. Her thesis explores the links between neurasthenia and modernity in Spain between 1880 and 1930, focusing on the points of intersection between medical, national and gender discourses and the constructions of identity at the time. During her PhD, she has carried out research residencies at the Department of History, Classics and Archaeology at Birkbeck, University of London (winter/spring 2016) and at the Centre for the History of Emotions at the Max Planck Institute for Human Development in Berlin (autumn/winter 2018-2019). She recently delivered a paper titled “Ambition, Responsibility, and ‘The Struggle for Survival’: The Medical Discourse of Neurasthenia in Spain in the Fin de Siècle” at the ‘Diseases and Death in Premodern and Modern Era’ Workshop that took place from the 10-11th of December 2019 at the University of Pardubice, Czech Republic.