Has there ever been a medical specialty as beleaguered as psychiatry? Since the profession’s founding in 1844, the doctors of the soul have had to contend with suspicions that they do not know what mental illness is, what type their patients might have, or what they should do about it—in other words, that they are doctors who do not practice real medicine. Some of the worry comes from the psychiatrists themselves, such as Pliny Earle, who in 1886 complained that “in the present state of our knowledge, no classification of insanity can be erected upon a pathological basis.” In 1917, psychiatrist Thomas Salmon lamented that the classification of diseases was still “chaotic”—a “condition of affairs [that] discredits the science of psychiatry and reflects unfavorably upon our association,” and that left the profession unable to meet “the scientific demands of the present day.” In 1973, the American Psychiatric Association voted to declare that homosexuality was no longer a mental illness, a determination that, however just, couldn’t possibly be construed as scientific. And for the six years leading up to the 2013 release of the fifth edition of its diagnostic manual, the DSM-5, the APA debated loudly and in public such questions as whether Asperger’s disorder were a distinct mental illness and if people still upset two weeks after the death of a loved one could be diagnosed with major depression. (The official conclusions, respectively: no and yes.)
To the diagnostic chaos was added the spectacle of treatments. Psychiatrists superintended horrifyingly squalid asylums; used insulin and electricity to send patients into comas and convulsions; inoculated them with tuberculin and malaria in the hope that fever would cook the mental illness out of them; jammed ice picks into their brains to sever their frontal lobes; placed them in orgone boxes to bathe in the orgasmic energy of the universe; psychoanalyzed them interminably; primal-screamed them and rebirthed them and nursed their inner children; and subjected them to medications of unknown mechanism and unanticipated side effects, most recently the antidepressant drugs that we love to hate and hate to love and that, either way, are a daily staple for 11 percent of adults in America.
It’s not just diagnostic uncertainty or therapeutic disasters that cast suspicion on the profession. It’s also the bred-in-the-bone American conviction that no one should tell us who we are. For that is what psychiatrists (and the rest of us in the mental-health professions) do, no matter whether we want to or not. To say you know what mental health and illness are is to say you know how life should go, and what we should do when it goes otherwise. You’d better know what to do when you’ve made a grievous error in those weighty matters, or at the very least, how to ask for forgiveness. And you’d better hope that, apologies offered, you can give the public a reason to believe that at long last you know what you are doing.
This is the unenviable task that Jeffrey Lieberman, past president of the APA, chairman of psychiatry at Columbia University’s medical school, chief of psychiatry at its hospital, and director of the New York State Psychiatric Institute, has taken on in his book Shrinks: The Untold Story of Psychiatry. “Psychiatry has earned its stigma,” he writes at the outset, and its practitioners must “own up to our long history of mistakes.” Otherwise it will remain “the black sheep of the medical family, scorned by physicians and patients alike.”
In Lieberman’s history, most of the profession’s travails can be traced to the mischief caused by one man: the Viennese neurologist who, on arriving for his first (and only) visit to America, said, “They don’t realize that we are bringing them the plague.” That at any rate is what, according to legend, Sigmund Freud said to Carl Jung as their ship pulled into New York harbor in 1909. Lieberman agrees wholeheartedly that Freud unleashed a plague. The pathogen was not, Lieberman says, the self-doubt and pessimism for which Freud is justly famous, but his autocratic approach to his patients and his insistence that his disciples remain in lockstep. Worst of all, says Lieberman, Freud “blurred the boundary between mental illness and mental health” by maintaining that conflict among the various agencies of the mind, set off by early childhood experience, was unavoidable.
In the early twentieth century, according to Lieberman, the members of the APA weren’t interested in Freud. American psychoanalysts, however, were interested in the APA. The analysts’ campaign for recognition eventually succeeded. Lieberman argues that this was largely because psychoanalysis offered psychiatrists “a way out of the asylum” and into cushy private practices ministering to the well-heeled “worried well.” Having convinced doctors (and patients) that we were all at least a little neurotic, Freud had opened the way to travesties like the pathologizing of homosexuality and endless and ineffective stays on the analytical couch.
To the diagnostic chaos was added the spectacle of treatments. Psychiatrists superintended horrifyingly squalid asylums; used insulin and electricity to send patients into comas and convulsions; inoculated them with tuberculin and malaria in the hope that fever would cook the mental illness out of them; jammed ice picks into their brains to sever their frontal lobes; placed them in orgone boxes to bathe in the orgasmic energy of the universe; psychoanalyzed them interminably; primal-screamed them and rebirthed them and nursed their inner children; and subjected them to medications of unknown mechanism and unanticipated side effects, most recently the antidepressant drugs that we love to hate and hate to love and that, either way, are a daily staple for 11 percent of adults in America.It’s not just diagnostic uncertainty or therapeutic disasters that cast suspicion on the profession. It’s also the bred-in-the-bone American conviction that no one should tell us who we are. For that is what psychiatrists (and the rest of us in the mental-health professions) do, no matter whether we want to or not. To say you know what mental health and illness are is to say you know how life should go, and what we should do when it goes otherwise. You’d better know what to do when you’ve made a grievous error in those weighty matters, or at the very least, how to ask for forgiveness. And you’d better hope that, apologies offered, you can give the public a reason to believe that at long last you know what you are doing.
This is the unenviable task that Jeffrey Lieberman, past president of the APA, chairman of psychiatry at Columbia University’s medical school, chief of psychiatry at its hospital, and director of the New York State Psychiatric Institute, has taken on in his book Shrinks: The Untold Story of Psychiatry. “Psychiatry has earned its stigma,” he writes at the outset, and its practitioners must “own up to our long history of mistakes.” Otherwise it will remain “the black sheep of the medical family, scorned by physicians and patients alike.”
In Lieberman’s history, most of the profession’s travails can be traced to the mischief caused by one man: the Viennese neurologist who, on arriving for his first (and only) visit to America, said, “They don’t realize that we are bringing them the plague.” That at any rate is what, according to legend, Sigmund Freud said to Carl Jung as their ship pulled into New York harbor in 1909. Lieberman agrees wholeheartedly that Freud unleashed a plague. The pathogen was not, Lieberman says, the self-doubt and pessimism for which Freud is justly famous, but his autocratic approach to his patients and his insistence that his disciples remain in lockstep. Worst of all, says Lieberman, Freud “blurred the boundary between mental illness and mental health” by maintaining that conflict among the various agencies of the mind, set off by early childhood experience, was unavoidable.
In the early twentieth century, according to Lieberman, the members of the APA weren’t interested in Freud. American psychoanalysts, however, were interested in the APA. The analysts’ campaign for recognition eventually succeeded. Lieberman argues that this was largely because psychoanalysis offered psychiatrists “a way out of the asylum” and into cushy private practices ministering to the well-heeled “worried well.” Having convinced doctors (and patients) that we were all at least a little neurotic, Freud had opened the way to travesties like the pathologizing of homosexuality and endless and ineffective stays on the analytical couch.
by Gary Greenberg, Bookforum | Read more:
Image: Sigmund Freud's office photo: uncredited
