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To better treat brain disorders, we must look beyond biology

Everything in Its Place: First Loves and Last Tales

Oliver Sacks
Knopf
2019
282 pp.
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Mind Fixers: Psychiatry's Troubled Search for the Biology of Mental Illness

Anne Harrington
2019
Norton
384 pp.
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I was a teenager when I first read Oliver Sacks. I was enchanted, and I read him whenever possible in college and afterward. Sacks could take a simple compound, a patient, a hospital, an island, a situation, or a human condition and could draw out of each wider inferences that felt true. What’s more, his inexhaustible curiosity, his sharpness of wit, and his special ability to create, maintain, and write about meaningful friendships, often with his patients, lent his writing humane, uncommon compassion. I returned to his writing again and again. I suspect that like many of his readers, I mourned him in 2015 in a way that I had never done for a stranger and may never do for another.

All of these most endearing qualities are on full display in Everything in Its Place: First Loves and Last Tales, a posthumous collection of Sacks’s essays—some new, some previously published, and some previously published but here in expanded form. Sacks is again larger than life—as memoirist, clinician, naturalist, antiquarian, and philosopher.

We walk with him briefly into the natural history museums of his youth. We see him blissfully swimming, his first love. We learn that he carried a pocket spectroscope everywhere. We get the backstory on his famous friendship with photojournalist Lowell Handler and their visit to La Crete, a small, mainly Mennonite village in northern Canada where Tourette syndrome is endemic.

Sacks thinks in exceptional cases, describing, for example, a patient with no thyroid function who existed for years in a state of hypothermic stasis only to be cured and then found to be dying from a proliferating but previously dormant oat-cell carcinoma. Sacks writes with irony: “His family let him sink into coldness, which saved his life; we warmed him up, and, in consequence, he died.”

Sacks allowed us to imagine what an idealized, more humane medicine might be. He gave meaning to death and suffering; he found in pathos, life, and from that created a metaphysics; he saw uplift and hope in incurability. In the powerful force of his prose, he crafted an explicit archetype for what we all might desire from our doctors.

Understanding why Sacks’s ability to tell stories possessed such resonance requires another tale all together. Historian Anne Harrington offers a version of that story in her latest masterpiece, Mind Fixers: Psychiatry’s Troubled Search for the Biology of Mental Illness.

Harrington is the preeminent historian of neuroscience in the world. Her book, not about Sacks but focused on his historical context, complements his collection of essays by providing a readable, revisionist synthesis that shows that mind and brain medicine has not come as far as we imagine or wish.

Harrington writes energetically about the contributions of seminal figures in psychiatry, neurology, and biology. She tells how hospitals, standards, and therapies evolved across the past century. She reflects on the rise of Freudianism and shows the way that psychodynamic approaches to mind and mental illness fired public imagination, patient hope, and academic theories.

Freudianism arose, she writes, as an explicit critique to 19th-century biological theories of mind, to early-20th century eugenics, to ethically problematic therapies in neurology, and finally in the certainty that the social environment mattered enormously in the construction of mental disease burden. It unwound simultaneously in deinstitutionalization, powerful theoretical and countercultural critiques of psychiatric power, the decriminalization of homosexuality, and a professional takeover in the American Psychiatric Association by clinicians reasserting the biological basis of mental illnesses.

It is tempting to say that psychiatry’s postwar return to biology was a failure. Of course, just the opposite is truer. As Harrington turns her focus away from doctors and toward psychiatric illness, it is startling to witness the whole-scale transformation epistemologically and economically of schizophrenia, depression, and manic depression from psychodynamically constructed entities into biologically and pharmacologically coconstructed illnesses.

Her history aligns with but substantially unpacks what scholars Nikolas Rose and Joelle Abi-Rached have pithily termed the emergence of the neuromolecular conception of self (1), an identity, Harrington explains, that made personal concerns about managing serotonin and dopamine levels a common habit of the informed and a target of mass marketing campaigns. Drugs—ranging from LSD to amphetamines, tranquilizers to antidepressants—held out promises for therapy, care, possibly transcendence, and, most importantly, hope that the explanation for what mental disorders are and whence they arose was around the corner. It didn’t happen.

Quoting Tom Insel, former director of the National Institute of Mental Health (NIMH), Harrington caps her analysis with Insel’s own powerful self-critique: “I spent 13 years at NIMH really pushing on the neuroscience and genetics of mental disorders, and when I look back on that I realize that while I succeeded at getting lots of really cool papers published by cool scientists at fairly large costs—I think $20 billion—I don’t think we moved the needle in reducing suicide, reducing hospitalizations, improving recovery for the tens of millions of people who have mental illness. I hold myself accountable for that.”

What went wrong? Wondering whether our future studies of brain activity may show us “components for which at present we have no names,” Harrington offers that a humanistic dialog among stakeholders that seeks to understand “the actual diversity of the suffering they seek to alleviate” might help. The result, she argues, would de-center psychiatry from biology, situate prescription drugs as one path among options, mitigate stigma, and open avenues to alternative medical frameworks of mental illness. In short, Harrington calls for a holistic psychiatry that seeks remedy in narrative, pluralism, and humility rather than biology and drugs.

While Sacks wrote about humans as neurological beings, he also helped us see ourselves as metaphysical ones. He showed us that much was possible even within our peculiar neurologies. Moreover, he seemed able to practice that attitude with consistent admirability. Sacks’s example as the doctor, naturalist, and storyteller thus seemingly embodies that holism and humanity Harrington searches for as she contemplates psychiatry’s future renewal.

Both storytellers find ways to critique biomedicine’s embrace of the technical and instrumental at the expense of much that makes life worthwhile. Assessing deinstitutionalization, Sacks reflects critically that by 1990, it was clearly a failure. “For the chemical approach” Sacks writes, “while necessary, was not enough.”

For all their coldly bureaucratic features, asylums had provided some therapeutic sources of compassionate communalism: “We forgot the benign aspects of asylums, or perhaps we felt we could no longer afford to pay for them: the spaciousness and sense of community, the place for work and play, and the gradual learning of social and vocational skills….” Harrington, equally reflective albeit a bit more critical, shows us why the expediency of pharmacology left us unsatisfied with our identity as neurochemical beings.

Both Sacks and Harrington are masterful narrators. Harrington’s grasp of this story and the clarity with which, with limited moralism, she delivers a tale about the “big picture” of psychiatry and neurology is emblematic of the historian’s craft. Sacks, meanwhile, combines familiar storytelling elements of such 19th-century naturalists as Charles Darwin with medicine’s longstanding tradition of describing disease through archetypal cases. This technique might not have originated with him, but Sacks made it popular in a way no other author did.

In a perfect illustration of his inspirations, Sacks discusses the aging brain, drawing on many cases that reveal the varieties of dementia experience. As he comes to the conclusion that human beings cannot be taught wisdom, he recommends that we may nonetheless find inspiration in the example of 19th-century naturalist Alexander von Humboldt, who remained “incessantly active” to the end of his life.

Sacks appears to have followed his own prescription. Among all of the delicacies he serves up in his book, the best is his last essay on gefilte fish. Writing in the final weeks of his life, Sacks recalls how his mother mixed fresh ground fish with raw eggs, matzo meal, pepper, and sugar, turning them into jellied fish balls that he devoured with alacrity. Sacks, dying, marvels that they don’t aggravate his nausea. He tries to remember how it was that even as an infant he had acquired a taste for them. In so doing, he brings his reader full circle with him: “Gefilte fish will usher me out of this life, as it ushered me into it, eighty-two years ago.”

There he is boiled down to his purest form: the naturalist, the anthropologist, the doctor, the man who could mistake gefilte fish for a satisfying, profound lesson about the meaning of life and be right. If Harrington’s Mind Fixers tells us how everything became disordered in our approach to psychiatric illness, then Sacks’s Everything in Its Place offers us up a recipe for psychiatry’s future.

References

  1. 1. J. M. Abi-Rached, N. Rose, Hist. Hum. Sci. 23, 11 (2010).

About the author

The reviewer is associate director of the Clarkson Honors Program, Clarkson University, Potsdam, NY 13699, USA.