Atlas›Domain XVI · Historical, discredited & harmful›Guide 050
Guide XVI-050

Prefrontal and transorbital lobotomy

Egas Moniz, Walter Freeman, James Watts1935Lisbon
A 29 · L 56 · M 1519 interventions in the Trinity explorer
Client cardCompare
[source: …] where a claim comes from[uncertain] not confirmed in a primary source[synthesis] the writer's reconstruction

Lobotomy is listed here for history and safety. It caused deaths, seizures and lasting changes of personality and is not a treatment. The guide describes what patients and families went through, never how the operation was performed, and covers the psychotherapist's own work: historical literacy, recognition, assessment, work with families and the few surviving patients, records and redress, safeguarding and the profession's history.

1. Introduction

Version followed: the history of prefrontal leucotomy (Egas Moniz, Lisbon, from 1935) and of prefrontal and transorbital lobotomy in the United States (Walter Freeman and James Watts from 1936; Freeman's transorbital operation from 1946), as stated by the Nobel Prize organisation's historical article (Jansson 1998), PBS American Experience, the Minnesota Governor's Council on Developmental Disabilities, the e-WV encyclopedia, Norwegian official and encyclopedia sources, and a 2021 international legal review; modern neurosurgery for mental disorder is covered only as regulated today and is a different matter (see Domain IX 029, stereotactic psychosurgery).

Lobotomy (called leucotomy in Moniz's and much British usage) was destructive brain surgery performed on psychiatric patients from the mid-1930s. Moniz performed his first operations in November 1935 and published in 1936; he received the 1949 Nobel Prize in Physiology or Medicine [source: Jansson 1998, nobelprize.org]. Freeman and Watts performed the first prefrontal lobotomy in the United States in 1936; Freeman began the transorbital operation in January 1946 in his Washington office, which led Watts to end the partnership because he held that brain surgery belonged in a surgical setting [source: PBS American Experience; Minnesota DD Council].

Its proponents' idea of change: Freeman believed mental illness was tied to emotions that were too intense, so reducing those feelings would relieve the illness [source: Minnesota DD Council]. In practice success was often defined as the patient no longer being agitated, even when the person could no longer function socially [source: PBS American Experience]. The historian Elliot Valenstein argued that lobotomy was "not a medical aberration, spawned in ignorance" but part of mainstream medicine of its time [source: Valenstein 1986, Great and Desperate Cures, as quoted by the Minnesota DD Council].

For the psychotherapist lobotomy matters because its legacy reaches clients in several ways: as family history (a parent, grandparent or great-aunt who was operated on, often in a state or county hospital), as a source of fear of psychiatry and of brain-based treatments, in gender and disability history, through compensation schemes, and through popular media. The therapist's change model here is ordinary trauma-informed and grief-informed psychotherapy applied to this history [synthesis].

2. Framework

Historical phases (outline only)

  • Origins, 1935-1936. Moniz's first operations in Lisbon (November 1935); his early series were reported as surviving without serious complications, though he noted that deteriorated patients benefited little [source: Jansson 1998].
  • Spread, 1936-1949. Freeman and Watts became the most prominent followers and performed about 600 operations by their method, which became the US standard; the operation spread to Brazil, Italy, the US and elsewhere; about 10,000 operations had been done in the US by August 1949 [source: Jansson 1998]. US annual numbers rose from about 150 in 1945 to over 5,000 in 1949 [source: PBS American Experience].
  • Mass use in public hospitals, 1946-mid-1950s. Freeman's transorbital operation was designed to be quick and cheap in state hospitals; he claimed it could be learned in an afternoon and travelled widely, often for the press [source: PBS American Experience]. He performed more than 2,900 lobotomies in 23 states, including 19 on children under 18 [source: PBS American Experience]; another source gives about 2,500 transorbital patients in 23 states [source: Minnesota DD Council]. Figures differ by source and by whether they count all operations or only transorbital ones [uncertain]. In England and Wales a survey for 1942-1954 recorded 10,365 operations plus 762 patients operated on more than once [source: Jansson 1998]. Norway performed about 2,500-3,000, and had the second-highest rate relative to population after Denmark [source: Store norske leksikon; Torkildsen 2022].
  • The West Virginia Lobotomy Project, 1952-1955. Launched by Freeman with the consent of the State Board of Control; 787 West Virginians were operated on between 1952 and 1955 (about 900 in all including earlier cases), the highest per-capita rate of any US state, at hospitals in Huntington, Spencer, Lakin and Weston; many patients never consented [source: e-WV, Spencer]. PBS gives 238 operations in West Virginia over 30 days in 1952 [source: PBS American Experience]; a figure of 228 in 12 days is attributed to the Science Museum [uncertain: not verified].
  • Ban and decline, 1950-1960s. The Soviet Union banned lobotomy in 1950, after debates among psychiatrists that became politicised in 1947-1949 and a Party intervention in 1949-1950 linked to the campaign against Western influence [source: Zajicek 2017, abstract as listed by historypsychiatry.com; Store norske leksikon]. Chlorpromazine (1952) made lobotomy largely obsolete for schizophrenia and its use fell sharply after about 1960 [source: Jansson 1998]. By the mid-1950s long-term studies showed poor results; in February 1967 a patient died of a brain haemorrhage after Freeman's last operation, at Herrick Memorial Hospital in Berkeley, and Freeman lost his hospital privileges [source: PBS American Experience]. No formal ban on his practice is documented [uncertain].
  • Regulation and redress, 1970s onward. The US National Commission for the Protection of Human Subjects reported on psychosurgery in 1977 with safeguards for institutionalised people and those unable to consent [source: Chandler et al. 2021]. In England and Wales, section 57 of the Mental Health Act 1983 requires both consent and an independent second opinion for any surgical operation for destroying brain tissue or its functioning [source: legislation.gov.uk]. Norway's last known lobotomy was in 1974; a 1991 government review criticised the practice, and in 1996 the Storting granted surviving lobotomised people a one-off ex gratia payment [source: Store norske leksikon; Innst. S. nr. 276 (1995-1996)].

Phases of the psychotherapist's work

Session number and length follow the client's needs and the setting [synthesis].

  1. Orientation and historical literacy. Goal: the therapist knows the outline above, its uncertainties and the language to use. Move on when the therapist can explain the history accurately without sensational detail [synthesis].
  2. Recognition and assessment. Goal: identify how the history reaches this client (family member operated on, fear of treatment, interest, records, compensation). Format: ordinary individual or family sessions. Move on when the client's question and the impact on them are clear [synthesis].
  3. Safety and safeguarding. Goal: assess risk (despair, suicidal thinking, family conflict, vulnerable surviving relatives in care) and route medical questions to medical professionals. Move on when risk is assessed and any referrals are made [synthesis].
  4. Processing and repair. Goal: grief for ambiguous loss, shame and stigma, anger at institutions, meaning-making, and distinguishing past from present treatment. Move on when the client can hold the history without being organised by it [synthesis].
  5. Advocacy, records and follow-up. Goal: support access to records, redress routes, commemoration or testimony as the client chooses; end with a plan for what may resurface (anniversaries, media, archive releases) [synthesis].

3. Guiding principles

  • Never a treatment option. The therapist never provides, recommends, supervises or refers to destructive brain surgery outside the regulated neurosurgical frameworks of today. Practical meaning: questions about modern neurosurgery or deep brain stimulation go to the client's psychiatrist and neurosurgical team, not to the therapist's opinion [source: legislation.gov.uk s57; Chandler et al. 2021] [synthesis].
  • Past and present are distinct. Modern neurosurgery for psychiatric disorders and deep brain stimulation are separately regulated; deep brain stimulation is adjustable and can be stopped, unlike ablative procedures [source: Chandler et al. 2021]. Practical meaning: do not equate a client's current treatment with lobotomy, and do not reassure beyond what the treating team says [synthesis].
  • No medication advice. Practical meaning: a client frightened of antipsychotics or other treatment because of family history is helped to talk to the prescriber; the therapist never advises starting, stopping or changing a medicine [synthesis].
  • Accuracy over sensation. Practical meaning: use attributed, dated facts; mark disputed figures as disputed; avoid graphic description and nicknames that glamorise [synthesis].
  • Patients are not named. Practical meaning: refer to people operated on by role ("a young woman left severely disabled by the operation") even where they are famous or spoke publicly [source: PBS American Experience for the fact] [synthesis].
  • Consent was often absent. Families often had no real choice and consent practices were minimal; in West Virginia many patients never consented [source: PBS American Experience; e-WV]. Practical meaning: name this when a family carries guilt for "signing" [synthesis].
  • Harm fell unevenly. Women, children, institutionalised and disabled people were among those operated on, and outcome was often judged by compliance and placidity [source: PBS American Experience; Minnesota DD Council; AusWHN, Western Australia]. Practical meaning: listen for gendered and disability-related shame [synthesis].
  • Mainstream, not lone villainy. Lobotomy was part of mainstream medicine of its time and won a Nobel Prize [source: Valenstein via Minnesota DD Council; Jansson 1998]. Practical meaning: help clients see institutional and professional responsibility rather than only blaming one doctor or one relative [synthesis].
  • The client's family story leads. Practical meaning: the therapist follows what the client wants to know; archives and history are offered, not imposed [synthesis].
  • Clear roles. Practical meaning: if the therapist is also a researcher, writer or advocate on this history, keep that role separate from therapy with a client whose family is involved; see APA Ethics Code Standard 3.05 on multiple relationships [source: APA Ethics Code].
  • Trauma- and grief-informed stance. Practical meaning: pace, choice and collaboration; expect ambiguous loss and anger [synthesis].
  • The profession's own history. Practical meaning: the therapist can acknowledge that the mental health professions caused this harm, without defensiveness [synthesis].
  • Safe messaging. Practical meaning: where despair or suicidal thinking appears, assess risk and give crisis resources; no method details [synthesis].

4. Intervention inventory

The interventions below are the psychotherapist's own work; steps not drawn from a cited source are marked [synthesis]. None of them is a step of the operation.

4.1 Preparing one's own historical literacy

  • Purpose / when: before working with any client affected by this history, or when it comes up unexpectedly [synthesis].
  • Steps: (1) Learn the outline in section 2, with dates and sources. (2) Note where figures conflict (Freeman's totals; the West Virginia tour) and keep them marked as uncertain. (3) Learn the vocabulary: leucotomy, lobotomy, psychosurgery, neurosurgery for mental disorder, deep brain stimulation. (4) Know the legal frame in your jurisdiction (e.g. section 57 of the Mental Health Act 1983 in England and Wales). (5) Decide in advance not to repeat graphic or sensational detail [synthesis] [source: Jansson 1998; PBS American Experience; legislation.gov.uk].
  • Example language (illustrative): "What I know is the outline: it was brain surgery used on psychiatric patients from the 1930s to roughly the 1960s, and it often left people permanently changed."
  • Watch for: your own fascination or horror leaking into the session; over-certainty about contested numbers. Working: you can answer factual questions briefly and return to the client's experience [synthesis].

4.2 Taking a treatment-history genogram

  • Purpose / when: when a client mentions a relative who was "in the state hospital", "had an operation on the brain" or "was never the same" [synthesis].
  • Steps: (1) Ask permission to map the family across generations. (2) For each relative with psychiatric admission, record approximate dates, place (state, county or private hospital), what the family was told, and what changed afterwards. (3) Note who made decisions and who was excluded. (4) Mark what is known, what is family story and what could be checked in records. (5) Ask what the client wants from this [synthesis].
  • Example language (illustrative): "Can we sketch your family's experience of hospitals and treatment? We can mark what you know for sure and what is just what people said."
  • Watch for: the client being flooded by unexpected material; family secrecy rules being broken in the room. Working: the client finds the map clarifying rather than accusing [synthesis].

4.3 Recognising a lobotomy legacy in the client's account

  • Purpose / when: throughout assessment; the client may not use the word [synthesis].
  • Steps: (1) Listen for descriptions such as a relative who became "childlike", apathetic, lost initiative, could not read, write or remember, or developed seizures after a hospital operation between the late 1930s and the 1960s; these match documented effects [source: PBS American Experience; Jansson 1998]. (2) Listen for timing and place (e.g. West Virginia state hospitals in 1948-1955; Norway 1941-1974) [source: e-WV; Store norske leksikon]. (3) Do not diagnose a historical operation; frame it as a possibility the client may wish to explore [synthesis].
  • Example language (illustrative): "Some families describe someone coming back from hospital in that era quite changed. Did anyone ever say what treatment she had?"
  • Watch for: suggesting a history the client then adopts without evidence. Working: the client holds it as a question and can tolerate not knowing [synthesis].

4.4 Accurate, non-graphic psychoeducation

  • Purpose / when: when the client asks what lobotomy was, or is distressed by media accounts [synthesis].
  • Steps: (1) Ask what they have already heard. (2) Give the outline: destructive brain surgery, widely used and once celebrated (Moniz's 1949 Nobel Prize), applied to tens of thousands, abandoned as drug treatments arrived and long-term results proved poor [source: Jansson 1998; PBS American Experience]. (3) State the harms plainly: deaths, epilepsy, apathy and personality change [source: Jansson 1998]. (4) Give no detail of how it was done. (5) Check what the information means to them [synthesis].
  • Example language (illustrative): "It was mainstream medicine then, which is part of what makes it so painful now. It harmed many people, and it is not done today."
  • Watch for: the client seeking ever more graphic detail as a way of staying close to the relative or of self-punishment; gently redirect to meaning [synthesis].

4.5 Ambiguous-loss grief work

  • Purpose / when: for children, siblings and descendants of a person who survived but was profoundly changed [synthesis].
  • Steps: (1) Name the loss: present in body, changed in self. A mother quoted by Jansson described her daughter as with her "in body" but her soul "in some way lost" [source: Jansson 1998]. (2) Invite the client to describe the person before and after, where known. (3) Allow both grief and continuing love. (4) Explore unfinished conversations and rituals of remembrance. (5) Normalise anger and relief [synthesis].
  • Example language (illustrative): "It sounds as if you lost her twice: once to the operation and again when she died."
  • Watch for: frozen grief, guilt for having distanced from the relative, complicated grief. Working: the client can speak of the person as a whole person, not only as a casualty [synthesis].

4.6 Working with guilt about family consent

  • Purpose / when: when a client (or their parent) believes a family member "signed for it" [synthesis].
  • Steps: (1) Hear the story without correcting it. (2) Offer context: families often had no real choice, consent practices were minimal, the operation was promoted by leading physicians and state boards [source: PBS American Experience; e-WV]. (3) Separate responsibility (institutions, professionals) from blame (the relative who signed under pressure). (4) Explore what the relative was told and feared [synthesis].
  • Example language (illustrative): "Your grandmother was being told by doctors, the hospital and the newspapers that this was the best hope. That doesn't make it right, but it does matter."
  • Watch for: the context being heard as excusing harm; let the client hold both. Working: guilt becomes grief or proportionate anger [synthesis].

4.7 Addressing fear of modern psychiatric treatment

  • Purpose / when: a client with this family history avoids psychiatric help, fears medicines, ECT or neuromodulation, or fears being "made docile" [synthesis].
  • Steps: (1) Validate the fear as historically grounded. (2) Distinguish then and now: today's neurosurgery for mental disorder and deep brain stimulation are separately regulated, and in England and Wales a destructive brain operation needs the patient's own consent and an independent second opinion [source: legislation.gov.uk s57; Chandler et al. 2021]. (3) Help the client prepare questions for the prescriber or treating team. (4) Never advise starting, stopping or changing a medicine. (5) Offer to support the client in attending that appointment [synthesis].
  • Example language (illustrative): "Your caution makes sense given your family's history. Shall we write down the questions you'd want your psychiatrist to answer?"
  • Watch for: the therapist arguing the client into or out of treatment; the client disengaging from needed care. Working: the client engages with the treating team on informed terms [synthesis].

4.8 Supporting a client considering regulated neurosurgery or deep brain stimulation

  • Purpose / when: rarely, a client with severe, long-standing illness is offered or researching modern neurosurgery for a psychiatric condition [synthesis].
  • Steps: (1) Clarify that the therapist does not recommend for or against surgery. (2) Help the client understand the decision-making process and their rights, e.g. independent approval procedures, eligibility restrictions and reporting requirements that many jurisdictions apply [source: Chandler et al. 2021]. (3) Support capacity and voice: values, fears, family pressures. (4) Raise concern about "medical tourism" to less regulated settings with the treating team [source: Chandler et al. 2021]. (5) Keep in contact with the team with consent [synthesis].
  • Example language (illustrative): "My part is to help you think through what matters to you; the medical questions belong with the surgical team."
  • Watch for: coercion by family or services; unregulated clinics. Working: the decision is the client's own and made inside a regulated pathway [synthesis].

4.9 A gender lens on the history

  • Purpose / when: when the relative was a woman, or the client is exploring women's psychiatric histories [synthesis].
  • Steps: (1) Offer the documented pattern: in Western Australia leucotomy shifted in the 1950s from men with psychosis to women, mostly married and middle-aged, with depressive or obsessional diagnoses; success for women was judged by pleasantness, calmness and placidity [source: AusWHN, Western Australia 1947-1970] [uncertain: secondary, unverified]. (2) Invite the client to consider the relative's life and role pressures. (3) Explore what the client inherited about women's distress being "managed" [synthesis].
  • Example language (illustrative): "Records from that era sometimes judged a woman's recovery by how calm and agreeable she became. Does that fit anything in your family's story?"
  • Watch for: over-generalising one region's findings. Working: the client gains context without losing the specific person [synthesis].

4.10 A disability and institutional lens

  • Purpose / when: when the person was a child, a long-stay patient or a person with intellectual disability [synthesis].
  • Steps: (1) Note that Freeman operated on children under 18 and that the operation was carried out in state hospitals, sometimes to produce compliance [source: PBS American Experience; Minnesota DD Council]. (2) Acknowledge the double loss of institutionalisation and surgery. (3) Explore the family's relationship with the institution. (4) Link, where wanted, to disability-history resources [synthesis].
  • Example language (illustrative): "He was a child in an institution with very little protection. What would you want people to know about him?"
  • Watch for: the client's own disability-related shame or fear of inherited illness. Working: the person is restored to the family narrative [synthesis].

4.11 Supporting access to records and archives

  • Purpose / when: when the client wants to know whether, when and why a relative was operated on [synthesis].
  • Steps: (1) Clarify what the client hopes the records will answer and what they will do if records are missing. (2) Help identify likely holders: the hospital or its successor body, state or national archives, university special collections. Regional archives and historians have studied, for example, the West Virginia project and a Western Australian payments file [source: e-WV; AusWHN]. (3) Encourage the client to check the holder's own access rules for next of kin. (4) Plan support for reading the file, ideally not alone. (5) Debrief in session [synthesis].
  • Example language (illustrative): "Before you request the file, let's think about what you might find and who could be with you when you read it."
  • Watch for: clinical language in old records that wounds (diagnoses, judgements of the person); records that contradict family stories. Working: the client can integrate what is found or tolerate gaps [synthesis].

4.12 Signposting compensation and legal routes

  • Purpose / when: when a surviving patient or family asks about redress [synthesis].
  • Steps: (1) Do not give legal advice; refer to a lawyer, patient-advocacy service or the relevant public body. (2) Know examples: Norway's Storting in 1996 granted surviving lobotomised people a one-off ex gratia payment of NOK 100,000, estimated about 500 then living, with relatives excluded and no state legal liability accepted because the operations were considered defensible at the time [source: Innst. S. nr. 276 (1995-1996)]; several hundred received compensation [source: Store norske leksikon]. Whether any such scheme is open today is [uncertain: not verified]. (3) Help the client manage hope, delay and possible refusal. (4) Address feelings about relatives being excluded [synthesis].
  • Example language (illustrative): "A lawyer or advocacy service can tell you what is possible now. Whatever the answer, what happened to your father still matters here."
  • Watch for: money becoming the only measure of acknowledgement. Working: the client pursues or declines redress from a settled place [synthesis].

4.13 Narrative, testimony and commemoration

  • Purpose / when: when the client wants to honour the relative or make the history known [synthesis].
  • Steps: (1) Explore forms: private letter, family album, oral history, contributing to a museum or archive, public writing. (2) Discuss consent and privacy for the relative and other family members. (3) Consider the impact of publicity, including on the client's own privacy. (4) Keep therapy as the place for the personal meaning [synthesis].
  • Example language (illustrative): "What would feel like the right way to remember her, and who in the family would need to be consulted?"
  • Watch for: pressure from media or campaigns; family rifts over disclosure. Working: commemoration supports grief rather than replacing it [synthesis].

4.14 Working with a client drawn to the topic through media

  • Purpose / when: a client is preoccupied with lobotomy through documentaries, true-crime or horror content, or online images [synthesis].
  • Steps: (1) Explore the function of the interest (fear about one's own mind, trauma re-enactment, curiosity, identification). (2) Point to accurate, non-sensational histories such as museum and public-broadcaster accounts [source: PBS American Experience; Minnesota DD Council]. (3) If consumption is distressing or compulsive, work on limits. (4) Assess any fears of being forcibly operated on, and check whether they are part of a current mental state needing psychiatric review [synthesis].
  • Example language (illustrative): "What draws you back to these films? What do you notice in yourself afterwards?"
  • Watch for: intrusive images, paranoid fears about treatment, self-harm ideation; respond with risk assessment. Working: the interest becomes manageable and informed [synthesis].

4.15 Working with an older surviving patient or their carers

  • Purpose / when: occasionally an elderly person who was operated on is still living, often in care [synthesis].
  • Steps: (1) Work with the person's own communication and capacity; involve carers only with consent or under the relevant legal framework. (2) Recognise possible long-term effects such as seizures or cognitive loss and ensure medical care is in place [source: Jansson 1998; PBS American Experience]. (3) Offer acknowledgement of what happened. (4) Check the person is safeguarded in their current setting [synthesis].
  • Example language (illustrative): "I've heard you had an operation in hospital a long time ago. Would you like to talk about that time, or not today?"
  • Watch for: distress on recall; neglect in care settings; carers speaking over the person. Working: the person is treated as a person with a history, not a case [synthesis].

4.16 Suicide- and risk-assessment where despair arises

  • Purpose / when: when the history triggers hopelessness, fear of inherited illness, or suicidal thinking [synthesis].
  • Steps: (1) Ask directly about suicidal thoughts, intent and plans, using current standard risk-assessment practice. (2) Build a safety plan collaboratively, including means safety (storage and removal) without method detail. (3) Give crisis resources: 988 Suicide and Crisis Lifeline (US); Samaritans 116 123 (UK and Ireland). (4) Arrange urgent medical or crisis-team review where risk is high. (5) Follow up [synthesis].
  • Example language (illustrative): "When you talk about being afraid you'll end up like her, are you having any thoughts of ending your life?"
  • Watch for: hopelessness about one's own treatment prospects; anniversaries of the relative's death. Working: the client has a plan and a connection to help [synthesis].

4.17 Duties if a colleague or institution performs unregulated destructive brain procedures

  • Purpose / when: highly unlikely but serious: a client reports, or the therapist learns of, brain surgery or brain-destroying procedures for psychiatric reasons outside the legal framework, or offered abroad to vulnerable people [synthesis].
  • Steps: (1) Ensure the client's immediate medical safety. (2) Consult supervision and your professional body. (3) Report to the relevant regulator, health authority or safeguarding service as your professional body publishes it; where a minor or a person lacking capacity is involved, follow child-protection or adult-safeguarding routes. (4) Document carefully. (5) Never take part in or refer to such a procedure [synthesis] [source: legislation.gov.uk s57 for the English legal frame; Chandler et al. 2021 on medical tourism].
  • Example language (illustrative): "I'm worried about what you've been offered. I'd like to check with the right authority so that you're protected."
  • Watch for: confidentiality limits, which should be explained early. Working: the concern is with the body able to act [synthesis].

4.18 Teaching and reflective practice on the profession's history

  • Purpose / when: in supervision, training or team settings [synthesis].
  • Steps: (1) Present the history as mainstream medicine of its time, honoured with a Nobel Prize and abandoned when results and alternatives became clear [source: Jansson 1998; Valenstein via Minnesota DD Council]. (2) Draw lessons a Norwegian review named: the practice was described in 1959 as "random, indiscriminate" and lacking neurophysiological insight [source: Torkildsen 2022]. (3) Discuss consent, outcome definitions based on compliance, and treatments justified as making patients easier to manage, a justification also used in the Soviet debate [source: e-WV; PBS American Experience; Zajicek 2017 abstract]. (4) Link to present safeguards [synthesis].
  • Example language (illustrative): "What in our own practice is judged by how manageable the patient becomes rather than how their life goes?"
  • Watch for: presentism or, conversely, excusing harm as "of its time". Working: the team names current practices to examine [synthesis].

4.19 Ending and follow-up

  • Purpose / when: at the close of a piece of work [synthesis].
  • Steps: (1) Review what the client now knows and how they hold it. (2) Anticipate triggers (anniversaries, new archive releases, media). (3) Agree how to return. (4) Confirm any referrals are in place [synthesis].
  • Example language (illustrative): "If a documentary or a new record brings this back, you're welcome to come back and talk it through."
  • Watch for: premature closure after a single record is found. Working: the client feels able to return without shame [synthesis].

5. Handling problems

The problems below are the psychotherapist's own synthesis [synthesis], except where a source is given.

  • Stuck in fact-finding. The client pursues records or figures endlessly and avoids feeling. Response: acknowledge the value of facts, then ask what finding the answer would change for them emotionally; set a shared limit on archive work between sessions [synthesis].
  • No records exist. Response: grieve the gap itself; help the client build a "good-enough" account labelled as uncertain; note that some states' records were partial even for official projects [synthesis].
  • Rage at psychiatry, including at the therapist. Response: do not defend the profession; acknowledge its history, including the Nobel Prize and mass use in public hospitals [source: Jansson 1998; e-WV]; separate the therapist's role; repair any rupture explicitly [synthesis].
  • Overwhelm and intrusive images. Response: slow down, ground, stop psychoeducation, and avoid any graphic material; consider trauma-focused work only once stable and with consent [synthesis].
  • Family conflict over disclosure. Response: map who wants to know and who wants silence; offer a family meeting only with agreement; protect the client's right to their own history [synthesis].
  • Fear blocks needed treatment (non-adherence). Response: work on the fear, involve the prescriber, never advise on medicines; if risk rises, arrange urgent review (see 4.7, 4.16) [synthesis].
  • Conflation of past and present. The client equates ECT, deep brain stimulation or modern neurosurgery with lobotomy. Response: note that modern procedures are separately regulated and that deep brain stimulation is adjustable and can be stopped [source: Chandler et al. 2021]; route technical questions to the treating team; do not offer reassurance beyond the evidence [synthesis].
  • Sensational or glamorising interest. Response: explore its function; redirect to accurate history; set limits on sharing graphic content in session [synthesis].
  • Identifying with the relative ("it will happen to me"). Response: explore fears of heredity and of being controlled; assess mental state and risk; offer current, supported care pathways [synthesis].
  • Therapist's own reactions. Response: use supervision for horror, shame about the profession or fascination [synthesis].
  • Contested figures. Response: say plainly that numbers differ by source (e.g. Freeman's totals: more than 2,900 per PBS; about 2,500 transorbital per the Minnesota DD Council) [source: PBS American Experience; Minnesota DD Council]; do not resolve disputes that remain open [synthesis].
  • Naming famous patients. A client may name a well-known person who was operated on. Response: discuss the history without repeating identifying details in notes or teaching; refer to people by role [synthesis].

Harm account

What was actually done

From November 1935 Egas Moniz in Lisbon operated on the brains of psychiatric patients to destroy tissue, publishing in 1936; he received the 1949 Nobel Prize [source: Jansson 1998]. In the US, Walter Freeman (a neurologist and psychiatrist) and the neurosurgeon James Watts began prefrontal lobotomy in 1936 and did about 600 operations by their method, which became the US standard [source: PBS American Experience; Jansson 1998]. From January 1946 Freeman performed a transorbital operation in his office and later in state hospitals across 23 states, without an operating room; Watts ended their partnership over this [source: PBS American Experience; Minnesota DD Council]. Freeman's own total is given as more than 2,900, including 19 children under 18 [source: PBS American Experience]. About 10,000 lobotomies had been done in the US by August 1949 [source: Jansson 1998]. The West Virginia Lobotomy Project (1952-1955), consented to by the State Board of Control, saw 787 people operated on, many without their consent [source: e-WV]. In England and Wales 10,365 operations were recorded for 1942-1954 [source: Jansson 1998]; Norway performed about 2,500-3,000, mostly at Gaustad Hospital, the last known in 1974 [source: Store norske leksikon]. In Western Australia from the 1950s leucotomy was used mainly on middle-aged married women with depressive or obsessional diagnoses [source: AusWHN] [uncertain: secondary, unverified]. The USSR banned it in 1950 [source: Zajicek 2017 abstract; Store norske leksikon].

What it looked like to patients, families and staff. The operations cut into or destroyed tissue in the frontal lobes [source: Jansson 1998]. Freeman and Watts's early prefrontal operations were done in a hospital operating room [source: PBS American Experience]. The transorbital operation that Freeman introduced needed no operating room, anaesthetist or neurosurgeon: he performed it in his office, in back rooms and in state hospitals, and patients were first made unconscious with electroconvulsive shocks instead of anaesthesia [source: PBS American Experience]. Each operation took minutes, and Freeman often did several in a row, sometimes many in a single day, in front of hospital staff, reporters and photographers, on tours of state hospitals from the mid-1940s that he called "head hunting" expeditions; staff who watched sometimes fainted or vomited [source: PBS American Experience]. Those operated on were mostly long-stay state-hospital residents, often poor and with no family to speak for them, with depression, anxiety, agitation or psychosis; others were housewives, and some were children with behaviour problems, the youngest four years old [source: PBS American Experience]. Families often agreed out of desperation, and patients usually had no say; one boy, brought to Freeman at 12 by a parent who complained that he was disrespectful, learned only weeks afterwards that he had been operated on [source: PBS American Experience]. Afterwards many patients were calm, inert and childlike, and some had to relearn walking or using the toilet [source: PBS American Experience]. Freeman courted the press, and newspapers presented the operation as removing madness rather than damaging the brain [source: PBS American Experience]. Warning signs in a family history: a relative who "came back different" from a state hospital in the 1940s to 1960s, a sudden change to placid, childlike behaviour, and records or family memories of an "operation" given to calm a relative [synthesis].

How it caused harm

  • Death. Mortality of 0.8%-2.5% is cited, and 4% of 9,284 followed-up patients in England and Wales died [source: Jansson 1998]; in some periods Norwegian mortality reached as high as 30% [source: Store norske leksikon]. Three patients died on the operating table at Cherokee State Hospital, Iowa, and a patient died of a brain haemorrhage after Freeman's last operation in 1967 [source: PBS American Experience].
  • Epilepsy. About 10% of patients had epilepsy problems [source: Jansson 1998].
  • Personality and cognitive loss. Patients were often dull, apathetic and lacking initiative [source: Jansson 1998]; many were left in a vegetative state or at a childlike level of functioning, some unable to read, write or retain long-term memory; others developed disinhibition or overeating [source: PBS American Experience]. The e-WV entry describes reduced volition, abstraction and personality [source: e-WV].
  • Relapse and repeat surgery. Many relapsed and had further operations [source: PBS American Experience]; 762 patients in England and Wales were operated on more than once [source: Jansson 1998].
  • Absent consent and social control. Families often had no real choice; many West Virginia patients never consented; success was defined by reduced agitation or by compliance and placidity, especially for women [source: PBS American Experience; e-WV; Minnesota DD Council; AusWHN].
  • Harm to families. Relatives lost the person they knew while the person lived on; Norway's 1996 scheme excluded relatives [source: Jansson 1998; Innst. S. nr. 276 (1995-1996)].

Recognising it today

  • Lobotomy is no longer performed. Modern neurosurgery for psychiatric disorders and deep brain stimulation exist in a small number of regulated settings and are distinct (see Domain IX 029); many jurisdictions require independent approval, restrict eligibility and require reporting [source: Chandler et al. 2021]. In England and Wales destroying brain tissue for mental disorder requires the patient's consent and an independent second opinion [source: legislation.gov.uk s57].
  • Warning signs of concern today: brain operations for psychiatric reasons offered without independent approval, offered to people who cannot consent or to children, or marketed abroad to avoid regulation ("medical tourism") [source: Chandler et al. 2021] [synthesis].
  • In clients' lives the legacy appears as a relative changed after a mid-century hospital operation, family secrecy, fear of psychiatry, records, compensation questions and media interest [synthesis].

What to do instead and how to help those harmed

  • Supported care today. For psychosis and schizophrenia, NICE's public information describes CBT (at least 16 individual sessions), family intervention (3 months to a year, at least 10 meetings) and arts therapies alongside medical care [source: NICE CG178 information for the public]. Medical treatment decisions belong to the client and prescriber.
  • Survivors. Medical review for seizures, cognition and care needs; acknowledgement; safeguarding in care settings (see 4.15) [synthesis].
  • Families. Ambiguous-loss and guilt work, records support, commemoration (see 4.5, 4.6, 4.11, 4.13) [synthesis].
  • Redress and legal routes. Legal or advocacy advice; Norway's 1996 ex gratia payment is one documented scheme [source: Innst. S. nr. 276 (1995-1996)]; current schemes elsewhere [uncertain: not verified].
  • Reporting. Concerns about unregulated destructive brain procedures go to the regulator, health authority or safeguarding services (see 4.17) [synthesis].
  • Survivor organisations. No survivor organisation specific to people lobotomised or their families is known [uncertain]; families may find support through general mental-health service-user and carer organisations [synthesis].
  • Crisis resources. 988 (US); Samaritans 116 123 (UK and Ireland).

Sources

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