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Other Side of the Couch
This chapter covers background material about psychiatry that will help the reader in later sections. Largely historical, these pages give a short explication of the backdrop that psychiatrists take for granted, particularly in three areas: the differences between psychiatry and psychoanalysis; the interconnection of medicine, psychiatry, and psychoanalysis; and the enduring conflict within psychiatry between biological and psychological explanations of mental disorder. By putting this material in one place at the beginning, I hope to quickly orient the reader.
When Freud graduated from medical school in 1881, the European world believed mental disorders to be the creation of a diseased or injured brain or--most often-degenerate heredity. These beliefs had become part of the general climate of thought that was created by advances in the sciences and by the scientific hypothesis that all the complexity of life--and mind--would ultimately be reduced to a few fundamental principles of chemistry and physics.
Freud himself was profoundly influenced by this grand scheme, and was extraordinarily well-trained to pursue it, having worked for years in the laboratories of Europe's greatest physiologist (Ernst Brücke) and finest brain anatomist (Theodore Meynert), and having studied with the brilliant French neurologist Jean-Martin Charcot.1 Freud never abandoned the hope that mental function would ultimately be described in terms of physical processes in the brain, and he gave up his own attempts to reduce the mind to physical biology only as he became convinced that there simplyweren't enough physiological data for what he called "The Project."2 Even so, his later psychoanalytic formulations were in large part metaphors for the biology he couldn't get at, involving energy flow, balance of forces, and other basic nineteenth-century concepts of physics. And he continued to believe in the central role of heredity.3
When Freud began his work with "nervous" patients in the 1880s, psychiatry was a branch of neurology, and most psychiatric patients were seen as people with obscure but nasty neuropathology that demonstrated hereditary taint. His position was revolutionary not because he denied hereditary influence but because he argued that in many patients mental illness could be treated anyway, by psychological means. If Freud had been armed with modern medications, he would have used them to attack the constitutional vulnerabilities we now describe in the language of brain biochemistry.4 But the medicines didn't exist, and Freud turned to talk because he had nothing medical to offer. "Anyone who wants to make a living from the treatment of nervous patients must clearly be able to do something to help them," he was to tardy observe years later in "An Autobiographical Study" (1925).5
In 1891 he published a remarkably accurate work on aphasia, and by 1893 two exhaustive studies of childhood paralyses, one of which is still considered a classic.6 During these same years he turned his genius to mental disorders. Opening a world that had only been glimpsed before, he was to create--in psychoanalysis--a new vision of the human mind and a revolutionary treatment, the first attempt to cure mental illnesses by purely psychological techniques.7 In this context, Freud's emphasis on the importance of childhood events and the critical role of sexuality are merely details, a gloss on the overriding shift in viewpoint that came with psychologizing what had been seen until then as purely physical, and, most often, a matter of immutable hereditary weakness. And as Freudian thought was adopted in America, it became ever more psychological, with heredity, constitutional vulnerability, and questions of abnormal brain function the Freudian equivalent of dirty words.
The first psychiatrists in the United States were superintendents of institutions for the insane.8 Practicing "psychological medicine,"9 they generally accepted the contemporary view that their patients had some sort of brain malfunction. As Americans, however, they were shaped by dreams ofequality and by the fluid class structure of a nation shaped by immigration and an expanding frontier. The tone was set by Benjamin Rush, the titular father of American psychiatry (and signer of the Declaration of Independence). In the only textbook of psychiatry printed here until the end of the nineteenth century, he wrote, "Man is a single and indivisible being for so intimately united are his mind and body that one cannot be moved without the other."10
Retreating from European images of hereditary taint, American psychiatrists in the nineteenth century looked for the causes of brain disorder in the environment--in disease, diet, or injury--and stressed the importance of environmental influence on the course of mental disorders. The "moral therapy" movement that flourished during the nineteenth century emphasized humane care and simple manual labor to counteract mental disorders.11 The most influential psychiatrist of the twentieth century, Adolph Meyer, stressed the interrelationships of multiple biological, social, and psychological factors in normal development as well as disease states.12
In fact, head wounds among soldiers during the American Civil War had provided important evidence that environmental factors--in the form of injury-induced certain psychiatric conditions. Then, in 1886, the Russian psychiatrist Sergei Korsakoff described a remarkable kind of amnesia brought on by chronic alcoholism, in which alcoholic patients confabulated--and believed--involved stories about themselves to cover loss of memory, frequently changing their stories from day to day as they'd forget what they'd already said. Korsakoff syndrome became a model of the potential effects of brain injury.13
Two decades later, when Freud was publishing his early papers on psychoanalysis, a test for syphilis (the Wassermann) and a cure (Salversan, "the magic bullet") were both discovered. The spread of syphilis to the brain accounted for up to one-third of all mental hospital admissions--apart from those cases that never reached the hospital, for untreated syphilis (that hadn't yet attacked the nervous system) was a common plague. Like AIDS, it spread to sexual partners and unborn children; once a cure had been found, neurosyphilis became the most exciting disease of the era for medicine.14
Meanwhile, vitamin deficiencies were found to be the cause of pellagra, another dementia-causing disorder that filled mental hospitals (causingthe characteristic bronzing of the skin seen in many derelicts today). Almost always reversible with vitamin treatment, pellagra essentially disappeared in the United States once niacin and other B vitamins were added to flour.15 Vitamin-B deficiencies also turned out to be responsible for Korsakoff syndrome.16 Between 1910 and the late 1920s, then, psychiatrists uncovered the physical causes of three of the most common major mental illnesses-and found medical treatments.
Unfortunately, the origins of illness in the majority of patients remained stubbornly elusive as the following decades wore on. And psychiatry remained isolated from the rest of medicine. Psychiatrists had created the earliest American medical society in 1844 (the Association of Medical Superintendents of American Institutions for the Insane), and worked to have psychiatry taught in medical schools and psychiatric patients moved from the freestanding asylums to psychiatry wards in general hospitals. But as late as the 1930s most patients were still in mental hospitals that had no medical school affiliation for their staffs, only half of all medical schools had any study of psychiatric patients in the curriculum, and only a few general hospitals had added psychiatric wards.17 Meanwhile, Freudian theory and practice offered an entirely different track, at first infiltrating and, after World War II, dominating, American psychiatry.18
Even in 1909, Freud was greeted by a surprisingly large and enthusiastic audience when he gave a series of lectures at Clark University, for his work resonated with American interest in psychological forces. In the following decades, his theories were widely disseminated by a variety of psychiatrists, 19 particularly William Alanson White and Adolph Meyer, the two most influential American psychiatrists of the twentieth century. Meyer, in particular, shaped every aspect of modern American psychiatry, from the psychiatric interview to hospital organization and residency training; and Meyer and White together gave psychiatry its present form as a hospitalbased medical specialty rooted in psychoanalytic insights.20
From 1945 until the late 1970s, psychoanalysts controlled psychiatry, holding most of the academic positions, teaching classes, supervising residents-in-training as they worked with patients, and making a psychodynamic orientation central to almost every residency program.21
Psychiatrists who wanted the ultimate education capped their residency with additional training at a psychoanalytic institute, focusing solely onpsychoanalytic theory and technique; graduates got diplomas certifying them as full-fledged psychoanalysts. It usually took candidates about seven years to finish classes and to carry through the analysis of two or three outpatients plus their own personal psychoanalysis with a "training" analyst appointed by the institute. (Some psychoanalytic institutes also accept psychologists, social workers, and, occasionally, professionals not in the mental health field. Nowadays there are, if anything, more psychologists graduating from psychoanalytic institutes than psychiatrists, in part because there are many more psychologists, and in part because fewer psychiatrists want psychoanalytic training.)
But few hospitalized patients were ever cured by psychoanalytic techniques alone, and Freud himself never tried to treat all psychiatric diseases psychoanalytically, initially developing psychoanalysis to treat hysteria, and then gradually extended his theories to other forms of neurosis. Along the way, he concluded that analysis was an inappropriate form of treatment for still other mental disorders, and he limited psychoanalytic treatment to people well enough to see him in private practice.22
On the one hand, he thought the most serious psychiatric abnormalities might well be signs of true brain disease. Apart from acknowledging the impossibility of affecting a truly damaged brain by talk, he also stated that analysis was out of the question for sicker patients because they hadn't the ability to tolerate the frustrations of the analyst's neutrality and often had too weak a grasp of reality to follow the rules of the psychoanalytic game.23
But a few pioneers began to build on Freud's work as early as the 1920s to extend the psychoanalytic domain to the kinds of patients Freud rejected. Modifying Freud's procedures over many years, these brilliant psychotherapists24 worked with even the most psychotic patients in hospitals, reporting improvement and, sometimes, cures. They also began to hypothesize a continuum from normalcy through the most severe mental illnesses, and to contend that psychological issues were causal in even the most bizarre psychoses.25
Standing on Freud's shoulders, they vastly increased the range of psychoanalysis, extending both theory and practice to patients far sicker than Freud ever intended to treat. And as psychodynamic theory permeated psychiatry at large, so did the new belief that all kinds of mental diseasecould be traced to essentially psychological causes and treated by variations of the psychoanalytic method. As psychiatrists trained by Freud and his disciples began to teach and supervise the next generation of psychiatric residents, the American interpretation of Freud's work and this psychological view of mental illness came to dominate psychiatry 26
But before medications existed, only a handful of the most dedicated and talented therapists were actually able to treat sicker patients with variants of traditional psychoanalysis. Most patients were relegated to the crowded wards of state hospitals, where a few organic treatments (such as electroconvulsive shock) were available, and patients faced the prospect of a lifetime locked away if these efforts failed. Most psychiatrists limited their work to relatively healthy patients, and psychiatry after World War II split into two fields: the more or less psychoanalytic treatment of neurotics seen in private practice, and the locked ward for those with generally immutable illnesses. During this time, psychiatry's interest turned away from the medical and began to meld with a version of psychoanalysis in an approach most of us still associate with psychiatry, largely purged of Freud's emphasis on the interpenetration of biology and psychology 27
Then came the observation in 1952 that chlorpromazine (better known here by its brand name Thorazine), a sedative used by surgeons in France, also acted on patients suffering from schizophrenia. A few years later, in 1958, Thomas Kuhn found the first antidepressant, imipramine (Tofranil), Nathan Kline reported on the efficacy of another class of antidepressants called monoamine oxidase inhibitors,28 and in the course of the sixties and early seventies, the Food and Drug Administration approved lithium to treat mania and to prevent recurrences of both mania and depression. Suddenly the psychiatrist had effective treatments for the three mental illnesses that were most likely to bring people into the hospital.29 In the first wave of excitement, the state hospitals released one-quarter of their patients.30
During the next few years, a flood of other medicines, including the anti-anxiety agent Valium (and more recently, the antidepressant Prozac), extended psychopharmacology to more and more of us. Psychiatry was transformed as dozens of drugs for all kinds of mental problems followed Thorazine, drugs that worked not only against derangements that required hospitalization but also against less severe, but still disabling, disorders of mood and thought. In all, this revolution takes in mentalillnesses affecting a minimum of 10 percent of Americans, almost thirty million people, in any given year.31 Now we have medicines for depressions, phobias, compulsions, panic attacks, and a range of symptoms that only a blink ago were considered character defects requiring years of psychotherapy. And new classes of medication keep appearing monthly.
As a result, the definitions of both psychiatrist and patient have been forced to change, and the relationship between them has been profoundly altered. For the relative roles of biology and psychology must be reconsidered in all types of mental disorder, and the interplay of the two considered in all psychotherapy. Powerful medicines exist now that did not exist even a year or two ago, much less five, ten, or twenty years back, and they can do a great deal of good--if the right diagnosis is made.
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