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Willem van der Does sheds new light on the at times pitch-black history of psychiatry

Piercing through the skull with an ice pick, administering electric shocks without an anaesthetic, or applying leeches to the uterus: these may seem like medieval methods of torture, but they are in fact therapies used in medicine. Willem van der Does writes about all of them in his new book. ‘Physicians performed these treatments with the best intentions.’

Willem van der Does is Professor of Clinical Psychology. He has also written ‘Geluk is ook niet alles’, ‘Zo ben ik nu eenmaal’ (available in English as ‘Just the way I am’) and ‘Met de wetenschap van nu’.

‘A reckless procedure, even with the knowledge available in 1935.’ This is how clinical psychologist Willem van der Does describes a lobotomy, a surgical treatment where the connection between the frontal lobe and the posterior areas of the brain was severed, or the brain tissue was destroyed by injecting pure alcohol.

This procedure was devised by Portuguese physician Egas Moniz, who first saw it performed on a chimpanzee during a medical conference. Convinced of the therapeutic benefits of a lobotomy for sufferers of mental illness, Moniz quickly set to and had the skulls of his most vulnerable patients pierced. And  he even did this without waiting for the results of one patient before applying the treatment to the next one. He concluded from his highly unsophisticated reports that the intervention was a great success.

Glowing articles appeared in scientific journals and the lobotomy became firmly embedded in mainstream psychiatry. In 1949 Moniz was awarded the Nobel Prize for Medicine for his discovery. ‘In total, this operation was performed on some 40,000 people. Many of them suffered permanent brain damage, and in some cases with fatal consequences,’  Van der Does recounts.

No, the Moniz history is by no means a good advertisement for psychiatry. Nor are the thirteen other histories from Van der Does’s book ‘De magie van genezing’ (‘The Magic of Healing’). ‘Even given this history, I wanted to write about these therapies in such a way that people could still have confidence in the field of psychiatry. It shows just how much progress has been made. These are stories about "occupational casualties", but I didn't want to write an anti-psychiatry book.’

Why did you write this book?

‘In my many years of experience in psychology and psychiatry I have seen a whole series of new trends appearing one after the other. Another new therapy, test or drug would come along that everyone was over the moon about, and then later - and it might be one year or ten years later – it would vanish into obscurity. At the end of the eighties, for example, a new antidepressant came onto the market that was hailed as a breakthrough: much more effective and with fewer side-effects than the existing drugs. The same happened with an antipsychotic drug.’

'These are stories about “occupational casualties”, but I didn’t want to write an anti-psychiatry book.’

‘These drugs are still being used but they have proved to be about as effective as the ones we were using previously. I wanted to write this book because it’s important that people, including those involved in medical teaching, know the history so that we don’t get carried away by the next new trend. If you keep on following the hypes, you’ll never really make good progress.’

How did some of these radical treatments become so popular, even though there was so little evidence that they worked?

‘For a long time there was a climate in psychiatry where people were willing to try anything that seemed as if it might work. The hospitals were full, and people were desperate. Doctors had good intentions: they wanted to relieve the suffering of their patients. At the same time, the methodologies were far less well developed. The principle of controlled research, where you give some patients the active drug and others a placebo, had been discovered, but it was difficult to apply to these kinds of treatments. Ambition also played a role. Doctors were always looking for proof that their treatment worked, and they were blind to counter evidence.  

‘One example was Italian neurologist Ugo Cerletti, who invented electro-convulsive therapy in the 1930s. He was convinced that epilepsy produced a substance in the brain that protected against psychosis and schizophrenia. He believed he could extract this substance from the brains of pigs, by  administering electric shocks to them in the lab. He then ground up their brains and injected them into psychiatric patients, hoping the substance would cure their condition. He devoted his entire life to the search for a substance that does not exist

Doctors were always looking for proof that their treatment worked, and were blind to counter evidence.’

‘At the same time, shock therapy seemed to be effective in patients suffering from depression, and it is still in use today. So that misconception did ultimately lead to something positive.’  

Have you ever let yourself be swayed by what seemed to be a promising therapy?

‘It’s a tradition in Leiden to be skeptical about all these kinds of innovations, so I can’t say I have ever experienced an excess of enthusiasm. Twenty years ago there was a new trend in the treatment of anxiety disorders. It was a training in focusing attention, where people learned to distract their attention from information they found threatening and to focus on positive information by doing a computer activity.

‘We did a trial at the time in people suffering from post-traumatic stress and found it had no effect. In retrospect, we realized that we should have done more preliminary research. We did get the research published, but it was difficult because it went against the trends. You could just see the publication bias (Ed: where positive results are always easier to get published than negative or ambigous ones) playing our before your eyes. Four journals turned it down and the fifth accepted. Afterwards, I did regret having tried to be too quick to score with a hype.’ 

Is there a present-day hype that you think we’ll look back on with disillusionment in fifty years?

‘Treatments using psychedelic drugs are popular right now. I do think it’s an interesting new development, something that is very different from anything else we have in our arsenal. I can also imagine that it works for some people, but at the moment it’s sometimes being applied too broadly.

‘Take ketamine, for example, an old medicine that has been used in anaesthesia for a long time. Higher doses have a “dissociative” effect, a kind of trance. Research on ketamine as a treatment for depression has been going on for twenty years or so, and some people do indeed improve within just a day. That’s a spectacular effect. It’s very short-lasting, but it can help someone who is in a seriously depressed state to get through a few weeks.

'There were already 500 ketamine clinics in the US last year. Unbelievable.’

But what’s now happening in the US is that there are so many ketamine clinics springing up; there were already over 500 clinics there last year. That’s incredible. A treatment like that obviously attracts clients, including people on whom ketamine hasn’t been tested. We have to make sure we don’t try to run before we can walk, and we need to make sure this kind of treatment isn’t oversold.’  

In the book you call for a “not too radical form of psychiatry”. How do you envision that?

‘I see the history of psychiatry as a river. It sometimes meanders a bit to the left, and then to the right, sometimes in the direction of the brain and genetics, and then a bit later psychosocial factors come more into play. And there are times when we go too far too fast. We need to study those things that keep afloat in the stream. EMDR therapy, for example. In principle that’s a small, technical variant on what we were already doing in behavioural therapy. Rather than saying: “We’re going to do only EMDR”, we  need to make a careful study of those aspects of the variant that make the treatment successful.  Think more in small steps rather than making huge leaps forward. In that sense, this book isn’t just a warning, but also a story of progress

Images of psychiatry

The painting above this article is A Clinical lesson at the Salpêtrière  by André Brouillet dating from 1887. It depicts thirty doctors watching how the French neurologist Jean-Martin Charcot hypnotizes an 18-year-old patient diagnosed with hysteria.

Jean-Martin Charcot, a famous neurologist at that time, is regarded as one of the founders of neurology. Sigmund Freud was a great fan of Charcot and had a replica of this painting hanging in his consulting room. 

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