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Barry Blackwell: Pioneers and Controversies in Psychopharmacology

Chapter Two: Enoch Callaway
Preamble

       A full understanding of the impact of modern psychopharmacology on the practice of psychiatry and the benefit to patients requires an understanding of conditions in the asylums portrayed in popular media by the Oscar winning film “The Snake Pit” (1948) which was alleged to have triggered reforms in asylum care co-incident with the arrival of effective medications that ushered in the era of closure and de-institutionalization of inpatients into the community during the 1960’s.

       Brief portraits of these events are touched on in several other chapters but Chapter Two is exemplary. It is a synopsis of Enoch (“Noch”) Callaway’s memoir, “Asylum; A Midcentury Madhouse and its Lessons about Our Mentally Ill today.” First because it records the experiences and opinions of a leading psychiatrist working as a resident during his two most formative years (1948-1950); between his own personal and training analysis, confronting and attempting to help many patients who had failed to benefit from that form of treatment. During this time Cade, in Australia. discovered lithium for acute psychotic mania (Chapter 5) and chlorpromazine was on the near horizon in France, discovered by Delay’s team (Chapter 6).

       Important secondly, because Worcester Insane Asylum fulfilled a key role and “best case” example of the evolution and history of asylum care. It was among the first State asylums built, opening on the outskirts of Worcester, Massachusetts in January 1883. It became a model of compassionate “Moral Therapy” better than the fate of the mentally ill confined in prisons, poor houses and other States exposed by Dorothea Dix in 1843.

      Worcester Insane Asylum had an enlightened history under mostly talented medical and administrative leadership. On the cusp of the 20th Century Adolf Meyer was its Medical Director for six years going on to become America’s leading psychiatrist and President of the American Psychiatric Association. Subsequently excellent administrators acquired extensive academic affiliations, recruited outstanding faculty and attracted the best psychiatric residents and trainees from allied mental health disciplines.

       Never the less the patient population was typically chronic, severely psychotic, often medically impaired and mostly refractory to a slim repertoire of existing treatments which included insulin coma, ECT and lobotomy.

      Noch describes his encounters and adventures in this environment in lively, entertaining, prose in Chapter Two (Parts 1 and 2 of his memoir). How these illuminated his entire distinguished career and some of the predicaments and controversies he encountered is described in Chapter 16 (Parts 3 and 4 of his memoir).

 

 

ASYLUM: A Mid-Century Madhouse and It’s Lessons about Our Mentally Ill Today
by
Enoch Callaway. M.D.
Praeger, Westport, CT, 2007
 
Reviewed by Barry Blackwell, M.A., M.Phil., M.D., and FRCPsych.

 

Enoch (‘Noch’) Callaway’s memoir is a striking accomplishment in format, content and style. Only 187 pages long, it has 54 chapters (average length 3-4 pages) divided into four parts. Its intent is to relate the author’s anecdotal experiences as a resident at Worcester State Hospital (Parts 1 and 2) using them as a metaphor (Parts 3 and 4) for the broader clinical, administrative, educational, research and philosophical considerations that have shaped the author’s long and successful career.

‘Noch’ achieves his literary goal in exemplary prose enlightened with humor, wisdom, humility and razor-sharp insights that fulfill his hope that, “These anecdotes from that forgotten world will add a new perspective to dilemmas of freedom and asylum we face.”

The memoir’s structure makes for an easy read one anecdote at a time but its impact has more to do with the forest than its trees. So, this review accomplishes its task in reverse order. First the life history of the asylum and then selected anecdotes that illuminate today’s controversies and challenges. This should encourage a reader to consume the entire volume.

More than a century and a half long history of the Worcester State Hospital portrays the shifting sands of institutional care for mental illness in America, from overcrowded asylums in the mid nineteenth century to empty beds and community care in the late twentieth century. It paints a picture of how changing political, social and scientific zeitgeists have shaped evolving patterns of care.

In January 1833 the Worcester Insane Asylum opened its doors to 164 patients. Situated on the outskirts of the town of Worcester, Massachusetts, it was one of the first State mental asylums in America. Its enlightened Superintendent, Samuel Woodward created an environment of kind, compassionate and individualized care, free of restraints that became “an international model for moral therapy.” Noch remembers an early photograph of a lawn party from around 1840: “They are elegantly dressed, and the women have parasols. the whole thing looks quite upper middle class.” This is all the more remarkable coming just before Dorothea Dix returned to her native State of Massachusetts to commence pioneer advocacy for humane care of people with mental illness. Her investigation revealed the fate of those in prisons and poor houses: “confined within the Commonwealth in cages, stalls and pens! Chained, naked, beaten with rods and lashed into obedience.” (Her fiery report, “Memorial” was submitted to the State legislature in 1843.)

By 1877 enthusiasm for moral treatment had waned, overwhelmed by the influx of immigrants from different cultures and languages poorly equipped to benefit “from large doses of white, Anglo-Saxon, Protestant values.” Care became more custodial than therapeutic and the population expanded. The State built a new, larger and more impressive asylum which Noch would later describe as “a baroque architectural anachronism.” It stood on a 500-acre working farm, built like a fortress, “defending the mentally ill inmates from society.”

The institution underwent a brief six-year renaissance from 1896 until 1902 when Adolf Meyer was hired as “Director of Clinics and Pathologist.” Trained in Zurich as both a psychiatrist and neuropathologist Meyer migrated to America at the age of 36 to become one of the most influential psychiatrists on the world stage and eventually President of the American Psychiatric Association. He espoused a clinical approach that combined all the biological, psychological and social influences as well as a rigorous attention to detailed history taking and integrative thinking.

Despite his brilliance, Meyer’s influence on the institution failed to raise it above the custodial level where it remained until 1920 when a combination of circumstances lifted it out of the doldrums. The Flexner revolution had moved medicine from a community based apprenticeship to an academic discipline in urban medical schools. Although psychiatry lagged behind the rest of medicine in innovation and discoveries the first partially and selectively effective treatments began to appear; barbiturates, chloral and paraldehyde followed by amphetamines, ECT, insulin coma, the EEG and eventually lobotomy.

Skilled administrators exploited these developments to recruit faculty, build academic collaborations, raise money and create programs initiating a Camelot era that would last until the mid-twentieth century and into which Noch would step. First was Dr. William Bryan (1920-1941), followed by Dr. Bardwell Flower (1941-1969).  Two major affiliations came with money and talent, bringing recognition and attracting students from the allied mental health disciplines. In 1924 a wife whose husband failed to benefit from psychoanalysis endowed the biologically oriented McCormack Schizophrenia Foundation which lasted until 1944. An affiliation developed between Clark University Physiology Department in laboratory space provided by the hospital and blossomed into The Worcester Foundation for Experimental Biology, headed by Hudson Hoagland from 1930 and joined by Dr. Gregory Pincus in 1938.  Together they undertook endocrine research in women hoping to shed light on mental illness, a collaboration that led to the contraceptive pill – an example of serendipity that matches the discovery of Viagra; dual discoveries that perhaps outstrip any in psychopharmacology during those eras!

Noch entered residency training in psychiatry in 1948 and stayed for two years. He chose the specialty while it was still the “Cinderella of Medicine” because (like Jean Delay) he was too clumsy to follow in his father’s footsteps as a surgeon and fell in love with the discipline. He was member of a class of seven men and a token woman fresh from medical school, “intellectually over trained and emotionally under developed.” All were from first rate medical schools. It was a time on the cusp between total hegemony of psychoanalysis over academic medicine and the impending discovery of chlorpromazine in 1952 that ushered in the neuroscience era. To Noch the environment mirrored the image of the 1947 movie, “The Snake Pit” identifying himself with the film’s eager and serious minded, psychoanalytically oriented, young psychiatrist.

By the time Noch arrived the institution housed 3,000 patients, 1,000 employees and 30 physicians including a staff surgeon and an internist with an operating suite and X-Ray facility. It had its own laundry, dairy, farm and industrial therapy unit. Residents, faculty and researchers lived in the hospital as well as wives, some of whom served as nurses or other staff. “The setting was bizarre, the food lousy and the conditions shocking at first; our heterogeneous group lived and worked together in enforced isolation with amazing enthusiasm and good humor. In a sense we were all inmates at Worcester.” Patients were segregated by gender, severity and treatability; a single nurse or attendant might have to care for a hundred patients at nighttime.

What ameliorated this dismal institutional environment was a vibrant intellectual climate dedicated to learning and the best treatment possible. In addition to many of the world’s leading psychoanalytic thinkers “almost every star in the fields of brain and behavior paid us a visit.” All this fed Noch’s self-professed, “ravenous curiosity.”

The mid 1950s saw the beginning of a 40-year decline in prestige and influence as psychopharmacology and neuroscience began to dominate the field followed by de-institutionalization that ushered in community based care. Eventually the institution Noch knew and loved burned down in the spring of 1991.

The research done at the asylum would be archived, but for the inmates and staff, deprived of immortality, Enoch Callaway wrote this “memoir” as a metaphor. But metaphor for what? Surprisingly, not for his distinguished career but to illuminate the shifting sands that engulfed psychiatry over the next 60 years. Those interested more in the man and his career will find it documented in Volume 2 of the Oral History of Neuropsychopharmacology (ACNP 2011) which includes a brief biography of his contributions to clinical research by the volume editor, Max Fink, and an extensive personal interview by the series editor, Tom Ban, which together detail his exemplary career as Emeritus professor at the University of California, San Francisco; Director of Research at Langley Porter Psychiatric Institute; Distinguished Life Fellow of the American Psychiatric Association; and Fellow Emeritus of the American College of Neuropsychopharmacology. Even here, Noch’s inherent modesty identifies his two most enduring life-long interests as being devotion to seeing patients and to mentoring students – themes already apparent in the young resident 50 years earlier as he learned from those he treated and the faculty who mentored him.

Part One: “In the Home of Broken Minds” paints a colorful picture of the patients, the bleak environment and the primitive but partially effective tools of the trade available to an aspiring new psychiatrist.  To appreciate the impact asylum care would have on a neophyte young resident one must remember that in 1948 almost every department chairman of psychiatry was a psychoanalyst, most residents were in analytic therapy with a faculty member and the normal rite of passage to an academic career was a personal followed by a training analysis.  Exposure to the asylum was a two-year interlude where, paradoxically, a newcomer fresh from medical school was confronted with patients who were unsuitable for or had failed analytic interventions.

The “back wards” housed untreatable neurological and psychiatric disorders. Women wore heavy canvas attire, “their straggly unkempt hair made the witches of Macbeth look chic… most of them milled about in aimless agitation, defecating and urinating as the urges arose. Patients no longer recognized their visitors and the visitors ceased to visit.”  Nonetheless, Noch says, “I absolutely loved my work, despite the grim surroundings, the skimpy pay and the lack of reinforcement that our fantasies of healing the mentally ill received.”  The lesson learned and later taught by Noch to his own students was the preservation of compassion in the face of pathology.

Asylum was an environment in which the smallest success was powerful reinforcement and Noch tells how this came about. A tall black man was brought to the asylum in handcuffs and leg irons by State Troopers who found him directing traffic as “God’s chief of police on earth.”  Made worse by the stimulating environment of an acute ward, Sam was placed on the hospital farm, got along famously with the cows and thrived.  Noch relates this improvement to research by Gerald Hogarty 30 years later showing how a “low expressed emotion environment” was an important adjunct to drug therapy in schizophrenia, but bemoans the fact that such farms no longer exist “due in part to the misguided do-gooders who feared that the farms were exploiting mental patients.”

Also in Part One are meticulous descriptions of each of the therapeutic tools in vogue at the time. Insulin coma therapy was in its heyday, safely employed and sometimes effective (perhaps because of the close personal attention it demanded). But it faded fast as quicker, safer and less complex drug treatments took over during the next decade. Electroconvulsive therapy (ECT) is also described in its pre-anesthesia days, widely regarded by inexperienced residents as “a confession of therapeutic incompetence” and a treatment still widely maligned and misunderstood today. Noch tells how he learned otherwise after he was assigned a middle aged, intelligent and obsessive business man with melancholia leading to a workman-like attempt to hang himself. After a month of five-days-a-week hourly therapy sessions went nowhere Noch’s supervisor recommended ECT. After the second treatment the patient began to improve and three weeks later was discharged. Noch continued to receive thank you cards and small gifts from the family for many years until his former patient died of a heart attack.

The Last Resort, (Chapter 10), describes working as an assistant to the visiting neurosurgeon performing lobotomies, an intervention “totally against the grain of the psychoanalytic zeitgeist.” Noch describes two highly successful outcomes though each was marred by an “associated adverse event”; techno-speak for side effects. A schizophrenic became a prominent Boston politician whose attenuation of moral concerns did not hamper his career; “morals and conscience do not seem essential to a career in politics.” After a year of futile psychotherapy for severe compulsive hand washing, Mary Burns underwent a lobotomy with “miraculous results” if it were not for short term memory impairment that prevented her return to an unsupervised outpatient setting.

Paradoxically, the best gift offered a neophyte psychiatrist like Noch was the ability to “observe the course of untreated diseases without any insurance driven compulsion to name everything. Some Comments on the Subject of Schizophrenia (Chapter 12) tells how this encouraged an appreciation for the individual biography of schizophrenia, its often unpredictable course and its distinction from drug induced psychoses and organic delirium. Noch contrasts this with current “clinical self–deception… abetted by statistical pseudo-descriptions.”  He limns the contemporary DSM system of diagnosis as a monochromatic Chinese menu approach; “such cut and dried definitions give the impression that one knows what one is talking about. They not only mask the mystery of the disease but give the impression one knows what one is talking about.”

Pet Paranoid (Chapter 16) offers another feature of asylum life: “It is natural for public institutions to be generally ignored when they function well, but if there is any trouble, they get attacked promptly by members of the public.” Noch gives an amusing anecdote as illustration. A local attorney decided “the hospital was keeping people locked up for evil reasons, that unscrupulous devious physicians were behind the sinister cabal.”  The hospital Superintendent decided to allow the attorney free access to the inmates in the unlikely event he might “get constructive work out of a critical crusader.”  It was not long before the attorney attracted the attention of a manipulative psychopath whose paranoid ideas matched those of his advocate.  When the attorney lodged a formal complaint demanding the patient’s release the Superintendent concurred providing the attorney take the patient “into his own home and vouch for his behavior.”  A few days later the attorney crossed his new lodger, evoking rage and causing the host to flee his home in fear. On return he discovered the patient had absconded with “a bedside clock and modest sum of money.”

In Never Say Die (Chapter 19) Noch learns a new lesson – prognosis is supposedly, but not inevitably, the mark of a good clinician. Exposure to the natural history of disease teaches how to predict its outcome and, in this case, the lesson was amplified by living alongside his patient in the asylum.  Mr. O’Malley was the wealthy head of a large clan eager to inherit his money and anxious for how long they might have to wait. Admitted after a stroke that left him confused and aphasic and based on previous experience with similar cases, Noch felt recovery was unlikely and, in communicating this, learned that the family considered the patient to be “a tight-fisted tyrant and they would be willing to take over financial responsibilities.” The relatives disappeared to await their good fortune but, contrary to expectations, the patient made a rapid and remarkable recovery attended daily by an attractive and devoted young lady who proved to be his mistress.  Upon leaving the hospital and learning what was afoot Mr. O’Malley “promptly disinherited the bunch and married Sally.”

Part 2: Doctor Make the Voices go Away (Chapters 22–39) is devoted to the various forms of treatment available in 1948 and some broader implications.

Noch is at pains to make it clear that the asylum, circa 1948, was “not a run-of-the-mill State Hospital.” It was awash with students and trainees in all the mental health disciplines, taught by competent mentors in a stimulating intellectual atmosphere that bred a great camaraderie.  Although the available treatments sound primitive today they were administered by well-trained staff in a humane manner, often with impressive results. Hydrotherapy (Chapter 25) is an example. Closeted with their patients and immersed in their treatment “residents felt they were learning at warp speed because there was nothing else to do.”

Exposure to the real world of mostly rejects or failures to benefit from psychoanalysis did little to dampen the enthusiasm or residents’ ingrained beliefs although their spouse’s skepticism (Chapter 26) created “the first inkling I had that, for at least some psychoanalytic theory, someone had just ‘made it up out of whole cloth.’”

This tension between the ex-cathedra dogma of psychoanalytic ideology and the nuggets of wisdom embedded within would be an evolving influence on Noch as he became exposed to both the fruits and false starts of scientific methodology.

In A Saint for Schizophrenia (Chapter 27) Noch is exposed to the charisma of Frieda Fromm Reichmann with her insights into the inner workings of a psychotic mind expressed with warmth and acceptance, devoid of narcissism. Equally important (and pedagogically unusual) was her “willingness to acknowledge an error and to explain how she had learned from experience.”

Coarse Brain Damage (Chapter 29) juxtaposes prevailing psychoanalytic dogma that absence of demonstrable neuropathology implied a psychiatric disorder inevitably sprang from psychological roots against the innovative, sensitive psychological tests developed by Dr. Kurt Goldstein. Noch’s patient suffered from “jargon aphasia” and when an EEG indicated a possible left temporal lobe tumor Noch advocated for neurosurgery although the nameless patient was unable to identify anyone to give consent. In a clinical examination Dr. Goldstein’s request that the patient provide his name produced the response “Shit.” Moving closer, talking gently, touching the patient, inviting him to relax and quietly repeating the question eventually produced the wanted answer. Astonished by this “miracle” and shocked by Goldstein’s willingness to ignore the analytic dictum against laying hands on a patient the residents sought an explanation. He replied: “I use visual, verbal and tactile input together to reinforce each other.” Also impressed by the similarity between Goldstein’s demeanor and Fromm Reichmann’s the residents inquired if Goldstein had studied under her? “The great man exploded. She was my pupil.” By the time the patient’s new-found relatives were contacted it was clear the brain lesion was an inoperable glioblastoma and he left the asylum to die at home.

Psychosomatic Medicine (Chapter 30) paints a somewhat similar picture turning traditional wisdom on its head. Tom, a 24-year-old married man, was referred to Noch at his own request with a complaint of severe epigastric distress after a normal physical work-up. Sixty years ago, such patients were almost universally labelled as suffering from an incipient peptic ulcer secondary to “unresolved dependency needs.” Today the cause is almost invariably due to an infection with Helicobacter pylori and treated with antibiotics.  In blissful ignorance of today’s scientific knowledge Noch embarked on a traditional series of psychoanalytic sessions with Tom who was “intelligent and well read” hoping to uncover “deep psychological problems.” In their first session Tom talked about his undercapitalized new business and the associated financial fears which he had not shared with his wife because she idealized him.  At the end of the session Noch could not restrain himself “from committing a psychoanalytic no-no.” He asked Tom, “Do you really think your wife wants to be kept in the dark about what you are thinking?” Tom, “doesn’t know.” Over the next five sessions Noch relentlessly explores Tom’s early life and concludes: “He was in better shape psychologically then than I was.” To Noch’s surprise, at the beginning of the seventh session Tom announces, “That about raps it up” and in response to the question, “What about the stomach pains?” Tom discloses that they stopped after the first session. Following Tom’s “misguided” advice he discussed his feelings with his wife who then joined him in helping to run the shop, resolving their financial worries. Unasked and unanswered is today’s question: if Tom had only been prescribed an antibiotic what would have happened to his marriage?

Probably the most remarkable aspect of life at Worcester State Hospital was not what it did for the patients or for the resident’s love affair with psychoanalysis but how it shaped the resident’s attitudes and behaviors in a scientific direction. Noch provides an answer in Gather Ye Labwear Where Ye May (Chapter 34). At least three quarters of the residents published papers in edited journals.  Noch comments, “Since then I have not encountered such a productive group of residents.” They were surrounded by role models: career psychologists, physiologists and biochemists supported by an excellent library, an enormous patient population and remarkably good clinical records, a data base for almost any enquiry. There were no distractions to discourage them; no grant proposals, no human subjects committee, only a competitive environment and freedom, “so when one had an idea for a study one simply did it.” As yet the Federal government was not involved in funding and scientists who staffed the labs were motivated by a “sense of playful improvisation.”  It is important to note that this kind of milieu at Worcester and a few other select State and Veteran’s Administration Hospitals would form the seed bed for the coming psychopharmacology revolution where the earliest discoveries, measuring instruments and trial methodologies were forged rather than in the halls of academia. The atmosphere and attitudes Noch describes are echoes of the consensus expressed by scientists who worked in those environments during the early days (ACNP 2011).

Some of Noch’s own ventures at playful improvisation are described in Miscellaneous Misadventures (Chapter 35). They include attempts at repairing an EEG machine, building a high-fidelity sound system from spare parts and attempting to boost the alcohol content of apple cider brewed for resident consumption. Noch also learned through experience that science, like psychoanalysis, is often confounded by difficult to measure or predict variables. In The Fortunate Failure (Chapter 36) he learns firsthand about the placebo response, double blind studies, the problems of collecting urine samples from a psychotic patient who likes to pee in his pants – despite the fact that male psychotic patients are more tractable than females, can more easily pee into a bottle and don’t menstruate. Finally, he learned how extraneous variables can invalidate the most carefully planned experiments. Their finding that schizophrenic patients had low urinary corticosteroids was not due to the disease but the fact that so many patients had sub-clinical scurvy because the study was done in the winter and there was almost no vitamin C in their diet.

References:

Callaway E. III interviewed by Thomas A. Ban. In Fink M, editor. Neurophysiology. (In Ban TA, editor. An Oral History of Neuropsychopharmacology The First Fifty Years Peer Interviews. Volume 2).  Brentwood: American College of Neuropsychopharmacology; 1011, p. 7 - 33.

 

December 21, 2017