Eva Surawy Stepney reflects on the use of psychosurgery for the treatment of obsessional thoughts
In a collection of first-person narratives edited by two contemporary clinical psychologists and Obsessive-Compulsive Disorder (OCD) specialists, a contributor reflects on his experience of the disorder (retrospectively identified) at an unspecified point in the 1940s. 1 At the age of fifteen he experienced repetitive and unwanted thoughts about killing his mother which subsequently developed into a preoccupation with losing his possessions. Despite struggling to express his distress in an environment imbued with masculine valour, the individual was taken to a ‘pipe smoking paediatrician’ who ‘drew a link between my obsessions and masturbation!’. The author reflects that he ‘didn’t have a clue what [the doctor] was talking about’ but decided silence was the best policy. When the symptoms had failed to subside after six months of ‘talking’ a ‘team of medical professionals suggested the treatment of last resort’ — a prefrontal leucotomy. In the 1940s this procedure ‘was crude and risky. If it went wrong — or even only half right — it could leave me festering for the rest of my life in a mental institution’.2
This narrative offers a glimpse into a unique moment in British psychiatric history: a time in which psychoanalytic therapy and psychosurgery existed as the two available treatments for an individual suffering with obsessional thoughts. Whilst the account refers to leucotomy as a ‘treatment of last resort’ — and the author fortunately did not undergo the procedure — the situation was rapidly changing.3 As the 1940s progressed, and psychoanalytic models waned, leucotomy and its modified forms became the prime treatment for obsessional thoughts and their associated diagnostic categories. As late as 1963 consultant psychiatrist at United Birmingham Hospitals, Dr. Myre Sim wrote of the surgical procedures he had carried out ‘it is obsessionals who produce the most gratifying results’.4
The adoption of leucotomy — the rotation of a spear-headed device in the brain’s frontal lobe — took place within a broader shift towards the use of somatic treatments in some areas of post-war British psychiatry. The ‘value’ of these interventions was framed as an alternative to the ‘time-consuming’ practice of psychoanalysis, which had failed to rapidly cure wounded minds during the conflict, and a renewed desire, in the wake of the National Health Service, to frame psychiatry as ‘just another branch of medicine’.5 It was argued that the latter would be achieved through the rooting of mental pathology in the body. Within this context two concepts framed the use of surgical intervention on those with obsessional thoughts: states of ‘tension’ and the ‘obstinate material’ of the obsessional body.
The use of psychosurgery for the treatment of obsessions was taken up most fervently in Britain by Maudsley-based psychiatrist William Sargant, who in the 1950s and 60s wrote profusely on the topic. Influenced by American lobotomist Walter Freeman’s theory that mental symptoms arose from a ‘fixed circuit’ between the thalamus (the ‘organ of emotion’) and the prefrontal cortex, and Pavlovian ideas of abnormal physiological conditioning, Sargant argued that obsessions emerged when a fear-response became engrained in the nervous system.6 This manifested in a state of bodily ‘tension’ (a metaphor derived from engineering) which could be disrupted or ‘released’ through surgical intervention.
Sargant’s theory of obsessions and their reorientation away from analytic models was presented in the Lancet in 1952. The article began with the statement that those ‘less ready to speculate on the effects of the subconscious mind’ [a dig at Freudian analysis] ‘feel that the symptoms of obsessional thoughts may be provoked by nervous tension’.7 This was elucidated with reference to a woman who had a persistent thought that her son might get locked in an ice-box: ‘every door that slammed sent up her blood pressure’. In 1949 she underwent a sympathectomy (the cutting of a sympathetic nerve in the spinal region) which significantly lessened her fears. Sargant compared this procedure to a leucotomy, which was said to ‘produce the same response by interrupting a vicious cycle at a higher level of the nervous system’. Rather than resulting from repressed psychic conflict, the psychiatrist reconceptualised pathological obsessions as arising from a fear response (produced by external stimuli) which could be mapped onto, and become fixed within, the nervous system. As a result, a state of somatic ‘tension’ was produced. The treatment of both the tension and the thoughts (which sustained each other in a ‘vicious cycle’) consisted of an operation on either the sympathetic nerve or at a ‘higher level’ of the nervous system — the brain.
The majority of scholars of psychosurgery maintain that the explanations established by proponents of the practice were ‘purposefully vague’ and relied heavily on metaphor in making internal processes visible.8 However, Sargant’s ideas became embedded in post-war British psychiatric discourse, with the reduction of ‘tension’ consistently invoked to justify leucotomy in treating obsessional thoughts. In 1953 psychiatrist Walter Neustatter wrote that obsessional ideas (depicted as ‘like a faulty gramophone record, repeated over and over again’) produced a ‘state of tension’ relieved by surgery.9 Akin to Sargant, it was the mounting ‘tension’ — an image of being increasingly wound up is presented — which was problematic, rather than the thoughts themselves. Neustatter remarked that after the operation ‘obsessional thoughts’ persisted ‘but the tension is allayed’ and ‘thus the patient’s life is more comfortable’. In case studies reported at the time, this idea of lessening of ‘tension’ became the standard of post-leucotomy ‘cure’: individuals who were no longer tense when obsessional thoughts entered their mind were categorised as ‘much improved’ — even if this was accompanied by apathy, depression, and a ‘loss of joi-de-vivre’.10
The Obstinate Body
In inter-war Britain, Freud’s depiction of the ‘anal-sadistic’ character greatly influenced conceptualisations of obsessional neurosis. In the post-war era the notion that a person was ‘orderly, parsimonious, and obstinate’ came to imply that they were chronically, and characteristically, diseased and thus only respond to extreme forms of intervention.11 Akin to the idea of ‘fixed’ circuits in the nervous system, the notion of a ‘fixed’ personality dominated psychiatric discourse on obsessional thoughts.
The relationship between the obsessional type and the use of psychosurgery is apparent in a Royal Address given by Sargant and his colleague Elliot Slater in 1950.12 The practitioners remarked that the obsessional neurotic has been ‘psychotherapised, psychoanalysed, shocked, and drugged into sleep’ without much success. The reason being that ‘the obsessional constitution is tough, solid, obstinate material’. Rather than indicating a character trait, the term ‘obstinate’ (central to Freud’s anal-erotic disposition) was used to describe the material bodies of those with obsessional thoughts. The psychiatrists went on to stress that drug treatments fail due to the ‘toughness of the obsessional constitution’ and the obsessional patient can be ‘battered by electroshock and on recovery show his old patterns unaltered’. Improving the physique of individuals with obsessions only increased the ‘strength of their conflicts’; this is compared with one of the psychiatrist’s clients who, when in a state of semi starvation, ‘showed a considerable lowering of tension’.13
A link was thus established between the characteristics of being ‘rigid’ and ‘obstinate’ and the body of the individual suffering with pathological obsessions. The strength of ‘conflicts’ (a Freudian notion) is directly related to the state of their physique, which possessed a greater degree of ‘tension’ when robust. Akin to starvation, the most successful treatment for weakening the obstinate obsessional, and lowering their ‘tension’, was psychosurgery.
The strength of the obsessional constitution was also seen to act as a favourable indicator for the use of leucotomy: if an individual was ‘tough’ to begin with, it was assumed that they were less likely to be damaged by the surgical process. In his third edition of Psychiatry for Students and Nurses (1956) Louis Minski wrote that in patients with ‘obsessional disorders’, leucotomy (to ‘relieve tension’) produced the best results when a patient has shown ‘obsessional drive’ in his personality pre-operation.14 Accordingly, ‘obsessional components such as meticulousness, persistence, conscientiousness’ form ‘excellent safeguards against post-operative disinhibition’.
Whilst a number of historians have argued that surgery went out of favour in the 1950s with the advent of psychopharmaceuticals, this was not the case in cases characterised by obsessional thoughts.15 The ‘obstinate’ nature of those who experience obsessions was framed as making them ripe candidates for surgical intervention. This was because their ‘rigid temperament’ was presented as unalterable with alternative treatments, and their ‘persistent’ traits made them more likely to have greater control of their inhibitions following the procedure.
In contemporary mental health-care the development of cognitive-behavioural interventions (most commonly Exposure Response Prevention) have alleviated suffering for a substantial proportion of individuals experiencing obsessive and unwanted thoughts. However, the use of neurosurgery (in the form of radiation, or ‘gamma knife’) is still used in ‘treatment-resistant’ cases.16 The discourse around such interventions is framed with terms such as ‘intractable’ and ‘disrupting fixed circuits’ , concepts rooted in the post-war efforts to reorientate obsessions away from analytic models. This is significant as it assumes two things: 1. that obsessions can be mapped onto precise (‘fixed’) locations and thus disrupted through direct technological interventions 2. that ‘intractability’ (deeply associated with obsessional characteristics) acts as justification for invasive procedures. Obsessional thoughts are largely understudied within the history of psychiatry and the history of psychosurgery, and this has significant implications for how we understand, and treat, the symptom today.
Eva Surawy Stepney is a PhD candidate in the School of History at the University of Sheffield. Her work explores the history of Obsessive-Compulsive Disorder (OCD) and ideas of evidence-based practice in British clinical psychology. She has lived experience of OCD and has written for Rethink Mental Illness. Twitter @EvaSurawy.
1 Chapter 8 in David Veale and Rob Wilson, Taking Control of OCD: Inspirational Stories of Hope and Recovery (London, 2011), p.146.
2 Ibid., p.147.
4 Myre Sim, Guide to Psychiatry (London, 1963), p.701.
5 On the justification for leucotomy in Britain see: Elliot Slater and William Sargant, An Introduction to Physical Methods of Treatment in Psychiatry (Edinburgh, 1946); Vicky Long, ‘Often There is a Great Deal to be Done, But Socially Rather Than Medically’, The Psychiatric Social Worker as Social Therapist, 1945- 47’, Medical History 55 (2011), p223.
6 For a discussion of Walter Freeman’s theory of lobotomy see: Jennell Johnson, American Lobotomy: A Rhetorical History (Michigan, 2014).
7 William Sargant, ‘Leucotomy in Psychosomatic Disorders’, The Lancet 258.6673 (July, 1951), p.88.
8 Elliot Valenstein, The Psychosurgery Debate: Scientific, Legal and Ethical Perspectives (Michigan, 1980), pp. 61-73.
9 Walter L. Neustatter, Psychiatry in Medical Practice (London, 1958), p.65.
10 R. Strom- Olsen and R. Macdonald-Tow., ‘Last Social Results of Prefrontal Leucotomy’, The Lancet 253. 6542 (Jan, 1949)., p. 89
11 Sigmund Freud, The Disposition of Obsessional Neurosis (1913), in Nagera, H., Obsessional Neuroses, p. 30.
12 Elliot Slater and William Sargant, ‘The Treatment of Obsessional Neuroses’, Royal Society of Medicine Address (1950). Wellcome Archives: PP/WWS/F/II/I.
14 Louis Minski, A Practical Guide to Psychiatry for Students and Nurses. Third Edition. (London, 1956), p. 112.
15 For example: Edward Shorter., A History of Psychiatry: From the Era of the Asylum to the Age of Prozac (Wiley, 1998), p.227
16 Atkins, L., ‘A Radical Treatment in Obsessive-Compulsive Disorder Patients’, The Guardian (December, 2009). https://www.theguardian.com/lifeandstyle/2009/dec/15/obsessive-complusive-disorder-gamma-knife. [Accessed 06/05/19].