#502 – Psychiatry, Insane Asylums, Mental Illness, ECT, Lobotomies, Freud & Jung

I wanted to start at the end: are we in a modern psychiatric crisis? Andrew Scull has traced our changing confidence about madness—from asylums and eugenics to lobotomy, psychoanalysis, and drugs—and how often certainty outruns knowledge.

Psychiatry confronts minds, emotions, and our relation to reality. We have treatments for symptoms, not penicillin-like cures. Drugs and psychotherapy can help, sometimes substantially, but can also fail or harm, and we usually cannot predict who will benefit.

DSM-III, built in 1980, used symptom checklists because clinicians could not reliably agree on diagnoses. Shared labels bring consistency, not proof of underlying diseases. Categories multiplied, while DSM-5’s hoped-for biological rewrite never arrived.

The brain route has an understandable appeal: neuroscience, genetics, data, rigor. But mental suffering also sits amid culture, policy, families, insurance, pharmaceutical firms, and the social world around distress.

Brain and mind are not separate camps. Social and psychological experience becomes embodied, and epidemiology gives ample reason to think conditions matter. Psychiatry moved, as Leon Eisenberg put it, from neglecting the brain to neglecting the mind.

NIMH invested heavily in genetics and neuroscience on the premise that illness was brain disease. Thomas Insel later conceded that roughly 20 billion dollars of interesting science had not improved life for people with serious illness. Genetics also crosses DSM boundaries.

Care for the severely ill has failed badly. Many cycle through brief admissions, homelessness, and jail; Los Angeles County Jail, Cook County Jail, and Rikers have become vast sites of psychiatric confinement.

That sounds, in a grim sense, like a return to the asylum.

Early asylums began optimistically: remove people from prisons and chains, offer routine and humane care. Claims of 60, 70, or 80 percent cures were fantasy. Chronic patients accumulated, wards crowded, and therapeutic hopes became warehouses. Deinstitutionalization then promised community care without building enough of it.

When asylum medicine disappointed, patients were cast as biologically inferior “degenerates,” dangerous to reproduce. That rationalized confinement and sterilization. American eugenic ideas fed developments abroad; Nazi Germany carried their logic into mass murder, often with psychiatric participation. Dehumanizing language leads somewhere dark.

The urge to do more than contain suffering spawned uncontrolled experiments. Lobotomy became the public symbol: Walter Freeman’s transorbital method made severing brain connections quick enough for batches. It gained prestige before clinicians recognized profound damage and rejected it.

Other supposed miracles followed. Henry Cotton extracted teeth, tonsils, even organs for “focal infection,” claiming spectacular success despite deaths. Insulin coma and seizure therapies also arrived with extravagant promises. Intense interventions can persuade doctor and patient that improvement exists when it does not.

ECT needs a more careful place than lobotomy. It was brutally used for control and carries memory costs, but modern modified ECT can benefit some people with severe, suicidal depression. It is no cure, we do not know why it helps, and risks remain serious.

That’s the uncomfortable tension. A friend who had exhausted other options found ECT life-changing, while my own image mostly came from One Flew Over the Cuckoo’s Nest.

The film captured boredom, humiliating staff relations, and punitive shock, though hospitals varied. Women bore a disproportionate share of invasive interventions, including Cotton’s operations, lobotomies, and shock treatment.

Freud worked with people outside the asylum, treating hysteria, trauma, repression, and hidden memories as clues to conflicts outside awareness. Psychoanalysis—free association over long sessions—became culturally irresistible, but expensive, difficult to test, and impossible to scale.

After the war, psychotherapy expanded. CBT focused on defined symptoms, habits or thought patterns, practiced alternatives, and measured results. It is shorter, reproducible, and often useful for milder depression, but no universal answer; evidence is far weaker in severe psychosis.

Chlorpromazine emerged accidentally from an antihistamine. It calmed agitation and reduced hallucinations and delusions for some people, but did little for negative symptoms: withdrawal, apathy, and loss of initiative.

Antipsychotics brought restlessness, Parkinsonian effects, and sometimes permanent tardive dyskinesia. Newer drugs reduced some dangers but added weight gain, diabetes, and heart risks; they did not outperform the old drug overall in a major independent comparison. Prescribing remains trial and error.

Antidepressants grew from tuberculosis drugs that lifted mood. Prozac’s serotonin-deficiency story was more confident than the evidence. SSRIs beat placebo statistically, but practical benefit is often modest; some are helped, others face flattening, sexual dysfunction, or punishing withdrawal. We cannot know beforehand.

So for someone suffering now—psychosis, depression, whatever form it takes—what are they supposed to do?

In acute suffering, drugs may be worth trying, with careful monitoring and honesty about tradeoffs. Research must look beyond molecules, brains, and genes: support families, reduce homelessness, and help isolated people regain agency and human contact.

Biology is not irrelevant, but pills cannot be the whole answer. We need humility, skepticism toward miracle headlines, independent research, and room for negative findings. Ketamine, psychedelics, AI, and other possibilities deserve rigorous study, not hype.

What gives me hope is that many psychiatrists meet this suffering face to face and want better lives for people. We must be less technocratic and more caring: acknowledge limits, avoid enthusiasm’s dangers, and offer help people genuinely experience as help. The problem is profound, but no reason for cynicism.

If you’re hearing this while suffering, please know you’re not alone. Stay strong. There is legitimate hope, one person speaking to another. I’m grateful for Andrew’s willingness to walk through the darkness and keep looking for wisdom that might help us do better.

Thank you for having me. You pushed me in useful directions, and I hope people take something constructive from this alongside the darkness we had to confront.