Who Were the Alienists?

With the recent debut of the dramatic TV miniseries The Alienist, based on the 1994 novel of the same name by Caleb Carr, I thought it might be interesting to trace some of the history and significance of this strange term.

Before the advent of psychoanalysis at the start of the twentieth century, psychiatry and psychology were both in their infancy. Starting around the mid-nineteenth century, psychiatrists were referred to as "alienists." It was the alienist's job to study, understand, care for, and assist patients in overcoming their "mental alienation" or illness.

Indeed, the curious title of "alienist" around that time became synonymous with that of "psychiatrist," a term we still employ today, but which first came into use around that same period, signifying a medical doctor specializing in the treatment of mental illness or ailment.

The Alienist is set in 1896, one year following the publication of Sigmund Freud and Josef Breuer's groundbreaking Studies on Hysteria (1895), which marked the birth of psychoanalysis. The fictional psychiatrist and protagonist of The Alienist, Dr. Laszlo Kreizler, could be presumed to have read that book, being exposed by doing so to some of the most basic yet still inchoate psychological concepts Freud would subsequently develop. So we can think of these so-called alienists as being the primitive precursors to psychoanalysts (or analysts, for short, as we say today), psychotherapists (a more generic term popularized by Otto Rank during the 1930s), and particularly, to forensic psychiatrists and psychologists, who specialize in working with the legal system.

Indeed, eventually the term alienist came to be most closely associated with the forerunners of what we today call forensic psychiatrists such as Dr. Kreizler: namely, physicians with specific expertise in criminal psychology who are tasked by the legal system to assess insanity, competency to stand trial, etc. As the field of clinical psychology gradually evolved during that turn-of-the-century period, psychologists specializing in studying and profiling criminal behavior and mentality were also commonly referred to as alienists.

Consider, for example, the use by psychiatrist C.G. Jung, Sigmund Freud's closest collaborator, of this term as applied to himself:

"As I studied Dr. Perry’s manuscript, I could not help recalling the time when I was a young alienist searching vainly for a point of view which would enable me to understand the workings of the diseased mind. Merely clinical observations—and the subsequent post mortem when one used to stare at a brain which ought to have been out of order yet showed no sign of abnormality—were not particularly enlightening. 'Mental diseases are diseases of the brain' was the axiom, and told one just nothing at all.

"Within my first months at the [Burgholzli psychiatric] Clinic, I realized that the thing I lacked was a real psychopathology, a science which showed what was happening in the mind during a psychosis. I could never be satisfied with the idea that all that the patients produced, especially the schizophrenics, was nonsense and chaotic gibberish. On the contrary, I soon convinced myself that their productions meant something which could be understood, if only one were able to find out what it was.

" ... In my attempts to understand the contents of schizophrenic psychoses, I was considerably helped by Freud’s book on dream interpretation, which had just appeared (1900). [Here Jung is referring to Freud's revolutionary The Interpretation of Dreams.] By 1905, I had acquired so much reliable knowledge about the psychology of schizophrenia (then called “dementia praecox”) that I was able to write two papers about it. The Psychology of Dementia Praecox (1906) had practically no influence at all, since nobody was interested in pathological psychology except Freud, with whom I had the honour of collaborating for the next seven years ...

"At the beginning, I felt completely at a loss in understanding the association of ideas which I could observe daily with my patients. I did not know then that all the time I had the key to the mystery in my pocket, inasmuch as I could not help seeing the often striking parallelism between the patients’ delusions and mythological motifs ... Our [the alienists] clinical approach to the human mind was only medical, which was about as helpful as the approach of the mineralogist to Chartres Cathedral. Our training as alienists was much concerned with the anatomy of the brain but not at all with the human psyche." — Carl Jung, 1952, from the Foreword to The Self in Psychotic Process by John Weir Perry)

Clearly, as Jung points out, the earliest alienists, as a group, were extremely biologically oriented as regards their understanding and treatment of mental illness, including neurosis, but especially the most severe syndromes, such as schizophrenia, psychotic depression, and mania. It was first Freud, and then his colleague, Jung, who together focused on the psychology of mental disturbances rather than their neurology or physiology, profoundly influencing the way psychiatrists and psychologists (still called alienists in the early 1900s and beyond) conceptualized these symptoms.

Fascinatingly, the twenty-first century has seen what Freud himself might call a reaction formation and Jung an enantiodromia (one extreme turning into its opposite), regarding their emphasis on psychology over neurobiology in the mental health field in general. In other words, the historic pendulum has swung dramatically over the past hundred years from the crude biologism of the early alienists to the penetrating psychological insights of depth psychology in the twentieth-century, and now, regrettably, back to our predominantly neurobiological and medical conceptualization and treatment of mental disorders.

Currently, the term alienist is considered obsolete and anachronistic here in the United States, though it is still sometimes used in Europe. Indeed, its etymological roots seem to be European, deriving from both the Latin alienus (other) and French aliene (insane). In English, the word is obviously related to alien (foreigner, stranger, or a being from outer space), alienate, meaning to isolate, excommunicate or render hostile, rejecting or unfriendly, and alienation (estrangement or mental derangement).

The concept of "mental alienation" gave rise to the use of the term alienist, referring to those professionals that dealt with and treated the mentally ill. Alienists who were later influenced by Freud and Jung's work, and thus, significantly more psychologically oriented, understood the suffering and symptomatology of the psychiatric patient as stemming from being excessively alienated from society and out of touch with their true selves (self-alienation). Certainly, this psychosocial, systemic and contextual conceptualization of mental disease owes much to Jung's notion of persona and shadow (see my prior post), Alfred Adler's emphasis on "social interest," as well as to Freud's fundamental distinction between consciousness and unconsciousness. All of which has considerable relevance to the way we comprehend and treat mental disorders today.

For instance, the notion of alienation as a source of psychological and spiritual suffering is something contemporary existential psychotherapists still take quite seriously. Indeed, Yalom (1980) speaks of "isolation" as one of the four main "ultimate concerns" and inescapable existential "givens" in life. From the existential perspective, we are born alone and die alone, and live our lives as fundamentally separate beings ultimately isolated and alienated from our fellow creatures.

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Existential aloneness and loneliness (see my prior post) can be ameliorated by interpersonal relationships, but it can never be completely eliminated. We humans are, more so than other creatures, condemned to our psychological aloneness and separateness from others, which is part of what engenders our feelings of alienation. While not necessarily synonymous with alienation, alienation is implied in isolation, which refers to the existential fact of being alone, and the feeling of alienation that this primal existential aloneness engenders.

Moreover, it is understood that individuals can choose, consciously or unconsciously, to further isolate or alienate themselves from the world and others, as well as from their authentic selves, creating, in the latter case, what psychoanalyst D.W. Winnicott termed a "false self" to cover up and protect their "true self." This tendency toward alienating oneself from the world and from existential reality can be seen in extreme (and, therefore, pathological) manifestations of what Jung called introversion, and in serious mental disorders such as schizoid or schizotypal personality, major depression, and schizophrenia.

A subjective sense of alienation from society is especially pervasive in the modern and postmodern era, and can be found in the existentially inclined writings of authors like Kafka and Camus on life's absurdity, as well as in Hermann Hesse's Steppenwolf. Freud's Civilization and its Discontents (1930) discusses the sources of both the individual's alienation from society, with its moralistic prohibitions, and from oneself as the result of repression. This sense of alienation or isolation, of feeling like a "stranger in a strange land," is central to the focus of contemporary existential therapy, in which the patient is encouraged, on the one hand, to accept and come to terms with this feeling and facticity, while at the same time, to work toward the creation of healthy relationships and fully committed, unequivocal engagement in life—which can help, in some measure, to assuage our aloneness and sense of existential alienation—and to learn to acknowledge, live with, embrace and constructively express one's alienated authentic self, particularly one's natural temperament, feelings, values, and creativity.

Presently, "alienists" as such may be extinct. But the psychological phenomenon for which they were named--the mentally disturbed patient's dissociation from him or herself and debilitating sense of isolation and alienation from others-- is still very much alive. Alienation is epidemic in American culture. Feelings of isolation, alienation, aloneness and loneliness are pervasive in the high-tech twenty-first century. (See my prior post.) And this subjective sense of alienation is not only painful but potentially dangerous. Scientific studies suggest some possible linkage between feelings of chronic loneliness and heart disease, dementia, sleep problems, and even premature mortality. Perceiving oneself as isolated, excluded, marginalized, or rejected by society or one's "tribe" may continually trigger our primitive but natural "fight or flight" response and compromise our immune system, since, as with certain animals, separation from the herd represents an existential threat to life. And acute feelings of alienation can, over time, lead to chronic feelings of anger, resentment, rage, embitterment, and, ultimately, destructively violent acts and evil deeds.

Our current raging epidemic of violence (see my prior posts) can be partially understood as a perverse attempt to transcend alienation, as existential psychologist Rollo May (1972) explains: "Violence is the ultimate destructive substitute which surges in to fill the vacuum where there is no related-ness." Violence can sometimes be a desperate, last-ditch effort to break out of one's excruciating yet sometimes self-imposed state of social isolation, as exemplified by the evil deeds of extremely lonely, alienated individuals like John Hinckley Jr. (who shot President Ronald Reagan in 1981 in order to impress actress Jodie Foster), Mark David Chapman (who murdered musician John Lennon in 1980), and so many of the mass shooters at schools, movie theaters and shopping malls since, such as the vicious slaughter perpetrated by Stephen Paddock in Las Vegas last year. (See my prior posts.) Such acts of seemingly random violence can be considered destructive and pathological expressions of a "wicked rage for recognition" in exceedingly alienated, lonely, isolated, frustrated and angry individuals starving for intimacy, love, acceptance, understanding, human contact, a sense of belonging, significance, and social validation.

The second key factor here regarding alienation is related to sense of self: The less solid and stable sense of oneself there is, the less connection to our innermost true self or "soul" we have, the more likely we are to suffer from alienation and painful loneliness. In a way, we are unable to fully appreciate our own company, to amuse ourselves, to be good friends and companions to ourselves, and to accept and tolerate existential aloneness and the existential anxiety that can accompany it. When one feels empty inside, like a nobody or nonentity, totally disconnected and alienated from one's inner life or being, that person must constantly seek affirmation, interaction and attention from others in order to mirror and validate his or her value and very existence. This commonly occurs when, as the alienists suggested, someone is profoundly dissociated or alienated from his or her own nature, emotions, cognitions or values, resulting in low self-esteem, bad boundaries, pathological anxiety, and an inability to tolerate aloneness because of the painful loneliness it engenders. In a sense, we are unconsciously missing and lonely for our lost selves. On the other hand, the stronger the sense of self (not just the ego), the more aloneness one can not only tolerate but actually enjoy and use productively. Solitude is an integral and indispensable part of the human condition, absolutely essential to the creative process as well as self-exploration, growth, and individuation. It could be said that the capacity to accept and tolerate at least some alienation, aloneness, isolation and solitude is a barometer of good mental health.

Nonetheless, it is no coincidence that one of the worst tortures inflicted on human beings by fellow human beings involves imprisonment, solitary confinement, ostracization, exile or excommunication, all forms of involuntarily imposed alienation from society. Moreover, excessive solitude, alienation or introversion is dangerous, even when self-imposed. (See my prior post.) Such morbid self-isolation may come from shunning social contact due to anger toward the world, pathological anxiety, fear of intimacy, shame or self-loathing, which when severe, can take the forms of social phobia, panic disorder, depression, psychosis, schizoid personality disorder, anger disorders and extreme acts of violence. (See my prior post on anger disorders.) The truth is that even introverts need socialization, despite their congenital lack of innate skills or interests in this arena. Which is why, psychologically speaking, one of the fundamental tasks for introverted types is to work on developing and strengthening what Jung called their "inferior function," that of extraversion.

Without some balance between introversion and extraversion, the introvert too will eventually suffer from too much loneliness and feelings of alienation. Yet, unlike the extravert, who, when feeling lonely knows how to ameliorate it by engaging in extraverted activity with others, the introvert with his or her less developed social skills, is at a loss, and can become trapped in a chronic state of isolation and alienation. Conversely, when extraverts constantly quell feelings of loneliness by frantically avoiding being alone, such avoidance of aloneness becomes pathological, compulsive, defensive, further alienating and distancing them from their inner selves. Paradoxically, this renders extraverts even more prone to painful feelings of alienation, loneliness and emptiness when alone, which in turn drives them toward greater extraverted activity in an ultimately futile escalating cycle of avoidance. We cannot perpetually escape from ourselves and our existential aloneness or feelings of loneliness without paying a significant price somatically, spiritually or psychologically.

Back in the day, the psychoanalytically informed alienist recognized and addressed something seemingly foreign, alien, or "other" in the person suffering from mental illness. It was as if there was some dissociated or alienated but essential part of the personality seen by the alienist as residing at the core of the patient's problems. This is precisely what Freud described as "dissociation," a defense mechanism designed to alienate or compartmentalize an unacceptable part of oneself from consciousness.

As Jungian analyst Lilian Frey-Rohn (1967) writes, this "dissociated content. . . in no way loses its efficacy, as the pioneers of depth psychology--Janet, Charcot, and Freud--have demonstrated. Quite the contrary; the deeper the repression, the more active the dissociated content.. . . In such cases, one often has the impression that the psyche is being controlled by a 'stranger' who appears as a 'voice," as a 'spirit,' or even as an 'overrated idea.' This kobold, or 'stranger' in the psyche, is at the root of every neurosis."

Jung's metaphorical term for this disturbing and troublesome inner alien was the shadow. (See my prior post.) But only a century or two prior to the penetrating discoveries of depth psychology, this stranger, this diabolical inner "alien," was widely believed to literally be an invading demon or devil, capable of taking possession of the personality. Before the birth of the alienists, mental illness and criminality was traditionally conceptualized in terms of demonic possession, and treated by exorcists, who would attempt to ritually drive out the diabolical alien entity. (See my prior post.) If truth be told, the depth psychology and phenomenology of so-called demonic possession is similar if not identical to that of mental illness: the afflicted person has been unable or unwilling to accept something elemental about him or herself, others, the world, and existence itself. Hence, this unacceptable, and therefore repressed and dissociated emotion, thought, impulse, memory, insight, tendency, etc. has been disowned, denied, and dissociated, i.e., rendered alien to the conscious persona, ego, and attitude. As a result, such dissociated content is subjectively experienced as something alien, foreign and threatening to us, as some impersonal "it" or autonomous entity, (evidenced dramatically in the delusions and hallucinations of psychosis), and, coupled with our sense of cultural and cosmic isolation and alienation from "god," nature and our instinctual selves, is a primary and archetypal source of psychological and spiritual suffering. This is something we twenty-first-century "post-alienists" must always keep in mind.