Bulletin of the History of Medicine 72.1 (1998) 153-155
Edward Shorter. A History of Psychiatry: From the Era of the Asylum to the Age of Prozac. New York: John Wiley & Sons, 1997. xii + 436 pp. Ill. $U.S. 30.00; $Can. 42.50.
Edward Shorter is a historian who delights in enlightening, shocking, and annoying his readers. His past work is characterized by deep scholarship and shrewd insights, and also at times by untenable interpretations. The latter follow from his [End Page 153] ideological stance, which generally commences with a firm and unyielding faith in the efficacy of modern scientific medicine. The goal of his new book is simple: to "rescue the history of psychiatry from the sectarians who have made the subject a sandbox for their ideologies" (p. viii). His animus is directed toward psychoanalytic and psychodynamic psychiatry, as well as toward those who took part in the antipsychiatry movement of the 1960s and 1970s, denied the very existence of mental illnesses, and emphasized either the social control functions of psychiatry or its role as an apologist for capitalism.
Shorter's narrative properly emphasizes the two extremes of psychiatric thought. At one end stand the neurosciences with their emphasis on brain chemistry and anatomy (biological psychiatry) and their insistence that the origin of mental illnesses is to be found "in the biology of the cerebral cortex" (p. 26). The other pole emphasizes the psychosocial aspects of mentally disordered persons and the role of social and personal stresses. Within this framework Shorter traces the history of psychiatry during the past two centuries. The strength of his book is that it transcends national boundaries: he is at home in European, British, and American sources, and his delineation of national differences adds a novel but welcome dimension. The breadth of his sources is equally striking. He is familiar with virtually all of the major figures in the history of modern psychiatry, as well as the growth of asylums and the evolution of public policy. His descriptions and analyses of psychiatric theories are for the most part penetrating despite his proclivity to evaluate them in terms of his personal faith in biological psychiatry. Similarly, his discussion of the history of therapy is also valuable, although his preference for taking at face value the efficacy of many biological interventions is questionable.
Nevertheless, this is a puzzling work because of its internal contradictions and claims that are sometimes based on inadequate (if not erroneous) data. Those who are familiar with the history of psychiatry will be able to sort out the reasonable from the implausible. Those who are less knowledgeable about psychiatry's past, on the other hand, could be misled by claims presented as established fact. For example, Shorter begins his book with the often-repeated assertion that "home care in the world we have lost was a horror story" (p. 2). Recent scholarship, however, has all but decimated this claim: seventeenth- and eighteenth-century communities dealt with "lunatics" and "distracted" persons in varied ways, many of which were by no means inhumane. Similarly, Shorter's hostility toward psychodynamic and psychoanalytic psychiatry detracts from his narrative. Even if mental disorders have a biological and/or genetic base, there is little doubt that environment from birth is also crucial. In a sense, Shorter creates a straw person to strengthen his own claims, which simply vitiates his real contributions. Finally, his description of deinstitutionalization (which, oddly enough, deals only with the United States) leaves much to be desired because of his unfamiliarity with an extensive literature that demonstrates successes in community care and treatment. To be sure, deinstitutionalization has worked poorly with some individuals, especially those with a dual diagnosis of a severe mental disorder and substance abuse. For a larger group, however, it has been [End Page 154] somewhat more successful (partly because of the availability of federal entitlement programs). It is also not trivial to note that virtually 100 percent of severely mentally ill persons themselves prefer living in the community instead of an institution.
The contradictions and ambivalence of Shorter's book are perhaps best illustrated in his opening and closing words. In his preface he insists that "the biological approach to psychiatry--treating mental illness as a genetically influenced disorder of brain chemistry--has been a smashing success," while Freud's ideas "are now vanishing like the last snows of winter" (p. vii). At the end, by contrast, he argues that "psychotherapy plus medication represents the most effective of all approaches in dealing with disorders of the brain and mind" (p. 327). Aside from omitting any mention of the need for care and management--which are a sine qua non for chronic and severe mental illnesses--Shorter's opening and closing statements have little in common. I do not, however, want to close this review on a negative note, for this is a significant (if flawed) work. Used with care and discrimination, it has much of importance to tell us about the history of psychiatry.
Gerald N. Grob