Before there was mental health care as we know it, before there were clinics, hospitals, psychotherapists, psychoanalysts, psychiatrists, medications, and insurance to pay for it, there was a forgotten profession of people who took care of the most seriously mentally ill, called the alienists. If you heard the word before, you must have read Caleb Carr’s novel by the same name, or its television adaptation. It features a brilliant physician in 1890s New York who solves a murder mystery by trying to understand the killer. Although alienists didn’t turn into murder detectives, that’s not a bad introduction to the type. The alienist was the doctor of the alienated, those who are different from everyone else to such a degree that society doesn’t feel safe with them or tolerate them. But what does it mean to be the doctor of the alienated? Do you stand beside them, or against them? Do you become the means of their repatriation or the instrument of their alienation? Do you close the gap, or patrol its border? Most modern day caretakers of the mentally ill, I’m convinced, are inclined to stand with the alienated. We often are a bit alienated ourselves, and become more so through our association with them. But social factors are always pushing the alienated further away. Society wants safety, the institution wants efficiency, the insurance company wants brevity, the administrator wants documentation; and all of these pressures, taken together, produce something that looks like care but forgets the person who needs it. The UnchainingOne spring day in 1793, the alienist, Philippe Pinel walked into an asylum in Paris and ordered the chains removed from the lunatics. He didn’t come up with this idea alone; he was working within a reform movement, borrowing ideas from the Quaker, William Tuke in England, building on a tradition of humane practice that existed in pockets before him. Pinel saw an opportunity in the middle of the French Revolution which was declaring that human rights were for everyone. Pinel drew on the Revolution’s own rhetoric and applied it to people no one had a particular interest in liberating and said his patients were human, too. He was going against the prevailing attitude that the mad were different from us: bestial, demon possessed, and beyond reason. You could chain them, exhibit them for a fee, purge and bleed and blister them, because they were not quite people. Pinel said, look at how you’re treating them. Treat them like animals and they’ll act like animals. Their madness is, in part, the institution’s madness. The results were not miraculous. Some patients did better when the chains came off; some did not. Pinel never claimed this would cure them all. He did it because he felt kindness was an ethical obligation. Moral TreatmentPinel called his method moral treatment. It has two meanings. One is to treat patients like people because it was right to do so, the other is to treat their morale, which has to do with generating trust and agency. In his view, mental illness was neither demonic possession, nor hopeless organic decay, not a punishment from God or a defect in the blood; it was a disorder of the mind, of the passions and the reason, and in many cases it could be improved, or even resolved, through the right conditions and the right relationships. The therapeutic environment was the primary instrument of healing, not drugs, not physical intervention, not punishment. A well-run asylum could be curative in itself: light, air, meaningful work, regular rhythms, freedom from the grinding pressures of the world that might have broken the patient in the first place. The relationship between caretaker and patient mattered as well; respect for staff’s authority and the patient’s autonomy, but also the professional’s engagement, attention, curiosity, and fundamental regard for the patient as a human being. You had to actually want to know the person if you were going to be their doctor. You had to believe there was something there worth knowing. When you read Pinel’s case notes, what strikes you is they are not symptom checklists; they’re portraits. This man worked in such a trade, had this kind of family, suffered this loss, had these preoccupations, and told these stories. His patients were individuals, complicated and particular. He was interested in them. He wanted to understand what the illness meant from the inside. The Asylum as MedicineThe alienists were committed to the idea that improving where a person lives is part of their treatment. The well-designed asylum was not just a place to keep dangerous people locked up; it was a therapeutic instrument. The alienists cared intensely about design, architecture, the quality of light, and the arrangement of space. There were often working farms; patients gardened, cooked, tended animals, worshipped together, and took meals at communal tables. They had something useful to do, the rhythms of the day were regular; the relationships were intentional. Society at large, with its noise and competition, poverty and chaos, severed communities and degraded relationships, was understood as pathogenic. The asylum was a refuge from poor conditions, a place where the mind might find the stability to recover. The most important thing asylums offered was community. Being around people you can trust is far more important than anything else that can be done towards healing serious and persistent mental illness. A community is just what people with serious mental illnesses most lack. They’re generally judged, feared, and discriminated against. They can’t get a job and are shunned at most of the places people gather. Many are not welcomed by even their families on Thanksgiving. Community is essential for everyone, especially for people without serious and persistent mental illness. By the twentieth century, these asylums deteriorated into snake pits. Industrialization brought family disruption and more people to the asylum door than could be absorbed. The therapeutic community became a custodial warehouse, once again. The patient who was once a person with a history became a bed number, a diagnostic category, a management problem. The very institution that had been designed to heal began to produce a particular kind of damage, the damage of being told, by the structure of your daily life, that you are not a person but a problem. By the middle of the twentieth century, the reformers who had built the asylum movement would be horrified by what it had become. The chains Pinel removed had been replaced by lobotomies, indiscriminate electroshock, overmedication, the tedium of the locked ward, and the slow erosion of self that comes from living in a place that treats you as dangerous rather than as suffering. Another book and movie, One Flew Over the Cuckoo’s Nest, captured it well. Deinstitutionalization in the 1960s and 70s tried to correct that. With the advent of anti-psychotic medication, civil liberties advocacy, the exposé of asylum conditions, and the desire of state governments to save money, asylums were emptied out. Patients were returned to their communities and outpatient mental health centers provided continued care. I worked in one such center where we created a therapeutic community where seriously mentally ill could spend the day. We had wonderful resources at first, but funding cuts whittled them away. Bean counting administrators, state regulators, and insurance companies who didn’t appreciate the therapeutic properties of community put an end to them, believing they were an ineffective use of resources. Where did my clients go? Many went in the street, many went to jail, which turned out to be the asylum we’re willing to pay for. Some recovered before we were shut down, and some survived. I see the survivors at Dunkin Donuts and hope they don’t see me. I moved on to private practice. They have a corner booth, a small coffee, and nowhere particular to be. What Science SaysResearch confirms what the alienists said two hundred years ago. Scientists have been asking what predicts positive outcomes in psychotherapy. They expected the answer to be medication or technique; the right chemical and the right protocol, applied to the right diagnosis, would produce the right result. It didn’t work out that way. The research found that the single factor that most contributes to success is not a particular medication or technique, but the quality of the relationship between therapist and client, the client’s sense that the therapist understands them, is genuinely engaged with them, and is on their side. The relationship is not the delivery vehicle for the medicine. The relationship is the medicine. These findings have been widely cited, consistently replicated, and largely ignored. The training of therapists continues to emphasize medication and technique; the payment systems of managed care continue to reward protocol; everything continues to push toward drugs and standardization; while the research keeps saying none of it makes people better. Back To My QuestionLet’s go back to my question. What does it mean to be the doctor of the alienated? Do you stand beside them, or against them? When I take care of the estranged, I’m always in two positions at once. I wield the authority of the medical establishment, the legal system, and the social consensus about what counts as sanity. I have the power to commit, to diagnose, and to release. If I was a physician, I’d have the power to medicate. This all amounts to the power to define the alien as alien, to make official the estrangement that the person is already experiencing. The alienist who wields that power without reflecting on it is doing something closer to alienation than to care. On the other hand, I can use my position in society as the ally of the estranged to insist on their full humanity. I can bring curiosity where the institution brings classification. Put that way, the choice is clear; I can be a decent human being or a despot. I wish it was as simple as that. The forces that threaten the alienated do not all come from society. Some come from within: the addiction that promises relief and delivers deeper isolation, the obsession that hijacks the personality and drives everyone away, the grandiosity that crowds out everything human and replaces it with a burden too large for one person. The alienist must stand between the patient and all of these at once: between the social forces that would reduce and manage them, and the interior forces that would consume them. This requires a kind of double loyalty, to the patient’s humanity and to the patient’s survival, harder to maintain than simple advocacy and impossible to teach. It’s no wonder so many in the mental health field burn out and give up. How does anyone do it? Well, let’s look and see what they’ve done. Bearers of the Alienist TorchPinel did unchain the lunatics; but he also, at times, put the chains back on when they were a clear and present danger to self or others. Today we still still have that principle, along with that of favoring the least restriction possible. When I worked in an emergency room, I would order a patient to go under restraints if he became a hazard, but, as soon as he calmed down, we released them one limb at a time. Carl Jung spent years working in an asylum finding the hidden logic inside his patients’ delusions. To explore those same dark depths of the unconscious without being consumed by them, he kept one hand anchored to reality: a stable, grounded sense of self that could withstand the descent. He said that, before any inner journey can begin, you must first build an ego solid enough to withstand the pressure of both the inner and outer worlds. British psychoanalyst, Wilford Bion, working with traumatized veterans of the First World War, discovered he didn’t have to do it all, a group could help him. Something therapeutic happened when people with shared suffering were brought into a relationship with each other and with a clinician willing to sit in the middle of the chaos without getting authoritarian. The group takes in what the patient cannot bear, metabolizes it, and gives it back in a survivable form. At the same time, the group is a refuge from the society that can’t tolerate the members. Having led many groups for the seriously mentally ill, I can testify to the way they both contain and gently modify the most disturbing craziness. Carl Rogers staked his whole person-centered psychology on the proposition that the client knows something the therapist cannot know, the direction of their own growth, the nature of their own experience. He said the therapist’s job is to trust and get out of the way. However, he found the limits to this when he worked with schizophrenic patients and decided his method didn’t work with them as well as it works with others. I’ve found when I modify his method it works fine as long as I can distinguish the person from the problem. Often, it’s the problem that’s in the driver’s seat and I have to intervene authoritatively to give the person the wheel. François Tosquelles ran a hospital in France. He argued that the institution itself could be as sick as the patients and needed treatment before it could treat anyone. That insight applies to the doctor as well. Today’s alienist has to examine his own motivations; whether his impulse to stand here or there has more to do with his need than his patient’s. Tosquelles’s student, Frantz Fanon went on to work in an asylum in Algeria and applied the alienist tradition to a revolutionary struggle. He indicted colonialism as a crazy-making system, and his books may have made him the most revolutionary psychiatrist in history, as well as one of the most innovative. He died of leukemia at thirty-six, still writing. We’ll never know if he could have kept that up without burning out. Another of the alienist tradition, Harry Stack Sullivan is known for saying, “Everyone is much more simply human than otherwise.” But, he didn’t give exact percentages. The ratio of person to madness varies from person to person and from day to day. Being an alienist is more an art than a science, it’s a matter of acquiring a knack for seeing the proportions and a willingness to take a risk on what you don’t know. The alienist tradition bets against every tendency to see a patient as a problem to be managed, a disorder to be corrected, or a deviation to be normalized; it insists on betting on the patient’s resilience, their capacity to find their own way if we walk with them and not chain them up. That betting window is not closed and, if the evidence is to be believed, the odds are good, but they are still just odds. The smart alienist studies them carefully and doesn’t bet everything on every horse for every race. I wrote this essay too late to include it in my latest book, Sorry, But Your Ex Is Probably Not a Narcissist: Essays on Depth, Complexity, and Human Transformation. However, it is of the same spirit. For Further ReadingOn the alienist tradition and the history of psychiatry: Andrew Scull, Museums of Madness and Madness in Civilization — the best historical overviews of how Western society has treated the mentally ill, written for general readers without sacrificing rigor. Robert Whitaker, Mad in America — a critical history of psychiatric treatment in the United States, particularly useful on the asylum era and deinstitutionalization. On the figures discussed: Sonu Shamdasani, Jung: A Biography — and Jung’s own Memories, Dreams, Reflections for his account of the Burghölzli years. Adam Shatz, The Rebel’s Clinic: The Revolutionary Lives of Frantz Fanon — the best recent biography, which takes the clinical work as seriously as the political. Fanon’s own The Wretched of the Earth and Black Skin, White Masks remain essential. Helen Swick Perry, Psychiatrist of America: The Life of Harry Stack Sullivan — the standard biography. On therapeutic alliance research: Bruce Wampold, The Great Psychotherapy Debate — the most thorough examination of the outcome literature. More technical than the others but accessible to determined general readers. On the therapeutic community: Maxwell Jones, The Therapeutic Community — the foundational text, now historical but still readable. Invite your friends and earn rewards
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