What Would Philippe Pinel Do? Old and New Understandings of Mental Illness
I was intrigued when, on February 1, 2018, I heard the journalist and author Johann Hari on Democracy Now! talking about his most recent book, Lost Connections: Uncovering the Real Causes of Depression—and the Unexpected Solutions. In this book, Hari argued that the primary cause of “rising depression and anxiety is not in our heads.” Instead, he wrote, “It is … largely in the world, and the way we are living in it.”1 The solution, for Hari and for the others he highlighted in his book, is not solely chemical antidepressants. From what I gathered, listening to the questions asked by hosts Nermeen Shaikh and Amy Goodman and Hari’s answers, this interpretation has been controversial.
One critical response to Hari’s book is Carmine Pariante’s essay, recently published in the Guardian. In this piece, Pariante argues that Hari’s conclusions are dangerous and while medication for depression is not a “cure-all,” “demonising” antidepressants “plays into stigma meaning that, tragically, more people will be held back from receiving help for a debilitating condition.”
Hari’s response to this criticism during the radio interview, was that “mental health is produced socially. It is a social indicator. It needs social as well as individual solutions.” My ears, attuned to the language of late-18th and early-19th century medicine, pricked up. After all, Hari’s analysis sounded much like the ways doctors wrote about madness or lunacy in the time period I study. Intrigued, I ordered a copy of Lost Connections and spent a few days reading through it.
Hari wrote the book for a popular audience. The prose is clear, the sentences short, and the stories compelling. While I am still processing and questioning much of what I read there, I can say, unequivocally, that the 18th and 19th century doctors and scientists with whom I am most familiar would not have quibbled with many of Hari’s conclusions.
One of the best known “mad doctors” of this earlier era was the French physician, Philippe Pinel. Starting in 1793, Pinel worked closely with lunatic male patients in l’Hôpital Bicêtre in Paris. As he worked with these and other patients, he also published many of his findings. In his Treatise on Insanity published in 1806, Pinel included a case study of a young lawyer who worked so hard at his profession that he cut himself off from the world. “I saw the approaching danger, and I conjured him to change his manner of life,” Pinel wrote.2
Unfortunately, the young lawyer rejected the doctor’s advice, and sank into “[c]omplete lunacy.” In time, he became so ill that he committed suicide. Pinel mourned this loss in his treatise, for he believed this man could have been helped.
Pinel’s conclusions about the causes of the unnamed lawyer’s mental illness are not very different from Hari’s conclusions about some of the reasons for depression and anxiety in the 21st century. Pinel became alarmed that his patient had “secluded himself from society.” For Hari, one of the nine root causes of depression and anxiety is loss of community. Hari believes that, as human beings, we are lonelier than at any time in human history. “Loneliness hangs over our culture today like a thick smog,” Hari wrote. “More people say they feel lonely than ever before.”3
The difference between Pinel’s lawyer patient and the growing number of people in today’s world that suffer from depression and anxiety is not what makes them sick. The difference, instead, is that Pinel’s lawyer was born and raised in a time when people were not isolated from one another, and community connections were everywhere apparent. In today’s world, we have to work hard to find and build community. For Pinel, it was the lawyer’s actions that led to his death. For Hari, it is the world in which we live that leads to our illnesses.
The world in which we live is not only socially isolating but is also extremely unequal. In Hari’s chapter, “Cause Five: Disconnection from Respect,” he detailed the studies done by two social scientists, Kate Pickett and Richard Wilkinson. They had become intrigued by biologist Richard Sapolsky’s studies of hierarchies within baboon populations, and tried to replicate his research in a controlled study with humans.
Hari writes, “If Robert’s insights apply to humans, then Richard and Kate knew that in highly unequal societies like the United States they would find higher levels of mental distress…”4 If it weren’t for Hari’s 21st century casual writing style, I would have thought I was reading an 18th or early 19th century medical text.
Indeed, this chapter gets right to the heart of my current research project about the distress many Americans felt about the rapid changes in political and social structures starting in the mid-18th century. In 1790, Dr. Benjamin Rush had worried that “an increase in the number and magnitude of the objects of ambition and avarice, and the greater joy or distress, which is produced by gratification or disappointments in the pursuit of each of them” created “fruitful sources of madness in our country.”5
He likely would have agreed with Hari that, “In a highly unequal society, everyone has to think about their status a lot. Am I maintaining my position? Who’s threatening me? How far can I fall?”6 For Americans building new governments with changed rules in the late 18th and early 19th centuries, similar questions about status and threat created tremendous anxiety.
In the end, the differences in interpretations between the doctors I study and Johann Hari are the material and technological differences of the eras. Hari worries about our society’s heavy reliance on chemical antidepressants, although in both Lost Connections and the interview I heard, he was very careful to say that he does not believe people shouldn’t take pills for depression and anxiety. He responded to Shaikh’s question about his critics by saying, “I want to expand the menu of options for people with depression and anxious people; I don’t want to take anything off the menu …. Chemical antidepressants do give some relief to some people, which is really valuable.” Instead of doing away with pills, he wants to find additional solutions.
For the doctors and reformers I study, it wasn’t reliance on pills that they questioned, but reliance on other treatments for the mentally ill. In the 18th and 19th centuries, these treatments often included restraint and dominance — the exertion of absolute authority over the patient. Just as Hari doesn’t dismiss the usefulness of chemical antidepressants, doctors in the earlier era did not dismiss the usefulness of often brutal treatments.
In his 1796 dissertation on chronic mania, Alexander Anderson wrote that restraint and dominance “should be avoided as long as possible; for it is of no small consequence to treat [maniacs] as rational beings.” He reminded his readers that the knowledge of “straightjackets, and chains and cells” could lead patients to “a depression of spirits seldom surmounted.”7
Perhaps the lessons from the history of medicine are these: What we know from studying medical practices in the past is that some of the best minds, some of the people truly committed to studying the ill and finding cures for illnesses, both mental and physical, were often wrong. Their ideas and their occasional successes embedded their treatments so deeply into the accepted knowledge of the day, made them seem so rational and challenge-proof, that it took painstaking work and decades of proposing alternatives before practices like straightjackets, waterboarding, and excessive bleeding were largely replaced.
Perhaps, one day, chemical antidepressants will be replaced as well. Even Hari’s detractor, Carmine Pariante, agreed that, “We still do not know exactly how these drugs work. They work differently on different people and there is much scope for the development of better medication.” However, Pariante emphasized that the drugs “certainly have relevant, positive effects on the brain and the body.” For historians of medicine it does not beggar belief to think that in 200 years, future historians will try to explain to their readers that chemical antidepressants were a rational solution to widespread depression and anxiety, even though they might come to understand that doctors of the late 20th and early 21st centuries were wrong.
- Johann Hari, Lost Connections: Uncovering the Real Causes of Depression—And the Unexpected Solutions (New York: Bloomsbury, 2018), 14. Return to text.
- Philippe Pinel, A Treatise on Insanity, In Which are Contained the Principles of a New and More Practical Nosology of Maniacal Disorders Than Has Yet Been Offered to the Public, Exemplified by Numerous and Accurate Historical Relations of Cases from the Author’s Public and Private Practice: with Plates Illustrative of the Craniology of Maniacs and Ideots. Translated from French, by D.D. Davis, M.D. (Sheffield: W. Todd, 1806), 56-57. Return to text.
- Hari, Lost Connections, 73. Return to text.
- Hari, Lost Connections, 121. Return to text.
- Quoted in Jacquelyn C. Miller, “The Body Politic and the Body Somatic: Benjamin Rush’s Fear of Social Disorder and His Treatment for Yellow Fever,” in A Center of Wonder: The Body in Early America, ed. Janet Moore Lindman and Michelle Lise Tarter (Ithaca: Cornell University Press, 2001), 67. Return to text.
- Hari, Lost Connections, 121. Return to text.
- Alexander Anderson, An Inaugural Dissertation on Chronic Mania. Submitted to the Public Examination of the Faculty of Physic, under the Authority of the Trustees of Columbia College in the State of New-York: William Samuel Johnson, LL.D. President: For the Degree of Doctor of Physic. On the Third Day on May, 1796. (New York: T. and J. Swords, 1796), 27. Return to text.