making sense of psychiatry: an insecure profession

8/7/2019 MAKING SENSE OF PSYCHIATRY: An Insecure Profession

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AN INSECURE PROFESSION

In my second year of residency at San Antonio I trained in psychiatric

consultation, providing assessment and treatment to patients who wereidentified as having psychiatric difficulties while hospitalized on other

medical services. Problem-solving has always been what I enjoy most about

my job, and the identification and resolution of issues on the consultation

service challenged me to develop a variety of skills that were not necessarily

employed in individual treatment.

At the beginning of the rotation the director of the service, Dr. David

Fuller, taught us that consultations often arose from the complaints of the

medical treatment team rather than from the patient. For example, the

psychiatrist might be consulted to assess a patient for aberrant behavior, but

eventually find that the appropriate intervention was to provide direction and

reassurance to the nursing staff in dealing with a patient who just happened

to have a particularly nasty disposition. Another consultation might require

the psychiatrist to provide counseling to a particularly intrusive family

member who was interfering with treatment. Because the initial consultation

request might be misleading, Dr. Fuller encouraged us to keep an open mind

regarding the motivation behind the consultation, reminding us that we were

being asked to intervene because somebody had a problem and needed our

helpit just might not be the patient. His contention was that There is no

such thing as an inappropriate consulta maxim that is not entirely true, butnonetheless useful in promoting the maintenance of a positive and helpful

attitude for nearly all situations.

My enthusiasm for the work apparently gained me some consideration,

and I developed a collegial relationship with some of the non-psychiatric

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physicians. In the course of friendly conversation one revealed to me that

psychiatrists were commonly referred to as spooksas in, That patients

weird. Lets get a spook to look at him. I was more amused than upset, but

immediately knew that it wasnt at all meant to convey respect for myspecialty. On reflection it may have referenced the detachment from real

medicine that psychiatrists frequently displayed at the time (around 1983,

when the biological model was just taking root); their tendency to appear and

disappear on the medical units with little interdisciplinary communication;

and/or their myriad personal eccentricities (since psychiatrists are generally

quirkier than other doctors). It may have even hinted at some implicit

hostility toward psychiatric patients, whose behavioral foibles and self-

destructive tendencies were not suffered easily by other physicians. At any

rate, it brought home the fact that within the medical community there were

many different types of doctorsand then there were psychiatrists.

Psychiatrys rash embrace of the biological model in the years since then

has generally been attributed to the considerable financial influence of the

pharmaceutical industry. Certainly this was a driving force, as its unlikely

that so many psychiatrists would have changed their clinical thought and

practice if there wasnt a lot of money at stake. But another contributing

consideration was psychiatrys abiding status as the red-headed stepchild of

medical specialties, struggling for a secure sense of its professional identity in

the midst of realdoctors who are dealing with more tangible clinical

problems.Time and again psychiatry has responded to this deficit by hitching its

wagon to half-baked theories, capriciously overreaching its scientific grasp in

a desperate attempt to validate both its treatment philosophydu jour, and its

right to stand shoulder to shoulder with other medical specialties. This

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inconstancy is evident from even a cursory review of its historybut the effort

required to get at that history is itself confirmatory of psychiatrys low self-

esteem. When I was in residency a fair amount of the curriculum was

devoted to the discoveries and theories of past luminaries, particularly thoseof the psychoanalytic movement. Now that the recent swing to the biological

model has made those figures largely irrelevant, the history of psychiatry has

been banished for the most part to arcane corners of academic medicineor

seized upon by its critics in the antipsychiatry movement, who revel in the

follies that have been perpetrated over the years in the guise of treating

mental illness.

The challenge of producing an authoritative and politically neutral

history of psychiatry has even merited its own book, a scholarly collection of

essays entitled Discovering the History of Psychiatry (Oxford University

Press, 1994). In its introductory chapter, editors Roy Porter and Mark Micale

observe that in no branch of history of science or medicine has there been

less interpretive consensus. They go on to state:

From its earliest days, psychiatric medicine has been marked by

the persistence of competing, if not bitterly opposing, schools.

Most noticeably, the field since the eighteenth century has been

convulsed by a deep, dichotomous debate between the somatic

and mentalist philosophies of mind. Moreover, for professional

purposes, each generation of practitioners has written a historythat highlights those past ideas and practices that anticipate its

own formation and consigns to marginal status competing ideas

and their heritages. In this process, individual figures and texts

indeed, entire historical periods and bodies of knowledgehave at

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times been omitted from the historical record. With an intensely

subjective subject matter, complex multidisciplinary origins, and

insecure and shifting epistemological base, porous disciplinary

boundaries, and a sectarian and dialectical dynamic ofdevelopment, it has thus far proved impossible to produce

anything like an enduring, comprehensive, authoritative history of

psychiatry.

The selective suppression of history that is noted here by the authors

smacks of an Orwellian design to reinforce the current truth and consign

dissent (and dissenters) to oblivion. However, I doubt that its real purpose is

to restrain consideration of psychoanalytic theory, since it seems unlikely that

advocates of the biological model would feel at all imperiled nowadays. (After

all, they have Prozac and managed care on their side; the analysts dont.)

Rather I believe that contemporary psychiatrists are embarrassed by the

theories that once held sway in psychiatryand threatened by the larger

questions they raise about the durability of truth in our line of work.

So what exactly is it that psychiatrists are trying to hide? Well,

fortunately there is at least one comprehensive (yet readable) overview

availableA History of Psychiatry: From the Era of the Asylum to the Age of

Prozac (Wiley, 1997), by noted medical historian Edward Shorterand I have

cribbed from it shamelessly. Mr. Shorter does a good job of recounting the

many twists and turns taken by psychiatry over the centuries, and I highlyrecommend the book to anyone who needs more thorough documentation of

just howundisciplined this alleged discipline has been in the past.

But before we begin to ponder psychiatrys many sins against science,

lets first consider the peculiar challenges it faces as a medical specialty. Its

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main anatomical focus is the brainan organ entirely encased in bone.

Underneath the bone are layers of fibrous tissue and fluid that cushion the

brain, all of which are vulnerable to infection if intruded upon. The brain

itself is a fabulously complex array of about a hundred billion nerve cells(neurons), each with numerous junctions connecting it to its neighboring

cells. Cells communicate between each other across these nerve junctions

(synapses) through the secretion of chemical messengers known as

neurotransmitters. There are over 100 different neurotransmitter agents

identified in the human brain, each of which may have either an excitatory or

inhibitory effect on the postsynaptic cell depending on what kind ofreceptor

protein it contacts in the cell membrane. The location of this intercellular

communication is in the synaptic cleft, the microscopic space within the

junction which is crossed by the neurotransmitter, where the balance of

neurotransmitters is constantly adjusted by the two cells through the

processes of release, metabolism, and reuptakewhich in turn are regulated

by an elaborate feedback network incorporating input from other neurons as

well. In short the raw circuitry of the brain is microscopic, profuse, and

unimaginably complex.

The physiological tasks of brain cells are largely determined by their

location within the brainand the higher functions associated with thoughts

and feelings are particularly inscrutable, since they occur within a

microscopic assemblage of neurons acting in a meticulously coordinated

fashion. Hence studies of brain cells in vitro (i.e. outside of the body in alaboratory medium) tell us little about their psychiatric function. This leaves

us with the necessity of studying brain cells in vivo (in the living organism) to

gain an accurate understanding of their function. But doing so would require

passing a needle past the skull and through the surrounding nerve tissue,

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causing irreparable damage to the brain since neurons have little if any

capacity for regeneration. This makes direct observation of living brain tissue

ethically unacceptableand even if it wasnt, how many people would give

informed consent to participate in such a study?The other medical specialties (besides neurology, of course) focus on

organ systems that are infinitely less complicated than the brain, more

physically accessible, and able to withstand a needle biopsy without

irreparable loss of function. Chemical markers associated with these systems

are typically measurable in the peripheral blood (unlike those of the brain);

other intrusive diagnostic procedures such as endoscopy are available as well.

Access to this sort of information allows physicians to be reasonably certain

whats going on inside the patienta feeling with which any prudent

psychiatrist would be dreadfully unfamiliar.

In point of fact, the secrets of the brain constitute a last frontier more

scientifically daunting than astrophysicswhich, after all, is just the study of a

bunch of dumb particles that happen to be very far away. Before one even

contemplates its anatomical and physiological complexities, there is the

conundrum of its dualitythe brain in the corporeal world, the mind in the

ethereal. Like astrophysics, neuroscience is an area of study that raises

existential and spiritual questions, and provokes the sort of controversies that

are attendant to such concerns. In the realm of medical science the brain

stands out as a uniquely remote wonder, a bottomless enigma that weve

barely begun to crack. So lets just acknowledge beforehand the onerousscientific challenge that is confronted by psychiatric researchers.

This predicament is aggravated by the likelihood that once a psychiatric

disorder does become treatable, it will be reclassified as a non-psychiatric

disease. In the 19th Century a large proportion of asylum inmates were

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diagnosed with general paralysis of the insane (GPI)a psychiatric disease

characterized by manic symptoms or other behavioral problems, followed

thereafter by the onset of dementia and progressive paralysis. It was noted

that this presentation was more frequent in men, especially those withdebauched lifestyles. Eventually this problem was identified as

neurosyphilis, an advanced stage of syphilis that takes ten years or more to

manifest itself in infected individuals. Once antibiotic treatments were

developed it became a medical illness, and thus no longer the concern of

psychiatrists. Similar paths were followed by epilepsy, the thiamine

deficiency and hepatic encephalopathy associated with alcoholism,

Parkinsons disease, Huntingtons chorea, and other neurodegenerative

diseases. It would seem that we are in part definedas a specialty by our

ineffectualitysince any disease that can be readily treated becomes someone

elses responsibility. This sequence of events pretty much dooms us to clinical

failure, which is a pretty darned demoralizing state of affairs. (No wonder we

have a complex!)

Another distinguishing characteristic of psychiatric disorders is that

they typically present with behavioralsymptomswhich inevitably drags us

into the murky arena ofwill. Nearly all patients who go to a non-psychiatric

doctor for a medical complaint are doing so on their own volition, for

symptoms that are unequivocally imposed on them by disease. Relief of these

complaints typically entails the administration of medication, but it may also

call for changes in lifestyle or entry into a rehabilitation regimen, all of whichrequire motivation and compliance on the part of the patient in order to

ensure efficacy of the treatment. In most cases the complaint that initially

drove him to seek helppain, fear, or some other sort of discomfortwill

continue to act as an external motivator, prodding the patient to comply

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despite his resistance. Sure, the patient may refuse to follow throughbut

not without persistence of his physical distress, and the knowledge of what he

ought to be doing to relieve it.

The motivation to pursue treatment of a psychiatric disorder is rarelythat simple. At one extreme you have patients who are involuntarily

committed by court order to psychiatric treatmentusually because of

behaviors that are dangerous to the patient or to others (i.e. risk of suicide or

assault), though sometimes due to unmanageable behaviors that are

peculiarly disruptive to society (as I will explore later). Even those who come

into treatment without such a court order may have other extenuating

circumstances coercing them into treatment, such as the demands of a

spouse, job difficulties, or legal concerns (e.g. child custody litigation,

probation, or a recent arrest)which is often a recipe for treatment failure

due to their lack of earnest investment in the process. Patients who are

internally motivated for treatment are often conflicted, struggling with

feelings of guilt, shame, or fear arising from their need to pursue help, or

perceived dependency on medications. Those seeking help for depression

often succumb to the lack of motivation that is associated with that disorder,

skipping medication doses and/or missing appointmentsor have difficulty

making the lifestyle changes (e.g. sobriety, diet, personal hygiene) that would

be beneficial in alleviating their symptoms. Patients struggling with mania

often chafe when confronting the drudgery of reconstructing their lives, and

are tempted to stop their meds so they can fly back into the fantasy world oftheir illness. In short, the issue of patientwill arises over and over again in

the treatment of psychiatric disorders.

Consequently, psychiatrists regularly struggle to attain the degree of

authority and trust within the clinical relationship that is necessary to

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motivate treatment compliancea problem largely unfamiliar to other

medical specialties. In my first year of residency I spent several months in a

neurology rotation under the supervision of a rather cocky senior resident.

Near the end of my rotation I ran into him at a party, where he proceeded tochide me for going into psychiatry since in a few years neurologists will be

treating all your patients. I fired back, Are you kidding? You guys will

neverbe able to stand working with patients that dont do what you tell them

to! Little did I know at the time the enduring truth implied in that drunken

utterancethat the practice of psychiatry is indeed defined by the patient

management challenges inherent to treating disorders of behavior.

With so much to prove to our patients and peers, and a dearth of

reliable scientific information, psychiatry has time and again compensated for

the deficiency of its knowledge base by simplymaking shit up. The

unfathomable nature of our calling conveniently lends itself to grand

fabricationsand when patients bring us uneasy questions about what were

doing and how it works, almost any answer seems more satisfactory than I

dont know. As a consequence psychiatry has been prone to spasms of

radical reinvention over its history, as one line of pseudoscience is replaced by

another in a desperate attempt to cover up the gaps in our comprehension.

As previously noted, two competing schools of thoughtone biological,

the other psychosocialhave struggled for ideological control of psychiatry

since its conception. Always the more covetous of medical legitimacy,

biological proponents have had to vie with the many obstacles that impedestudy of the brain, and make do with the limited technical means available to

them. In the 18th and 19th centuries speculation on the cause of psychiatric

disorders was largely focused on anatomy, since most of their information

came from the study of cadavers. The dearth of hard science invited the

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ruminations of doctors with large egos but limited clinical qualifications

such as Theodor Meynert, a notable neuropathologist at the Vienna asylum

who had the brass to begin lecturing on psychiatry in 1868, even though he

had no apparent interest in patients, saw little hope in treating them, and byall accounts preferred the company of microscopes and brain sections.

The resultant theories now seem coarsely simplistic, and often

childishly wrongheaded. In 1755 Oxford graduate Charles Perry described

hysteric passion as a common and incapacitating nervous disorder among

women that was caused by errors and defects in our accretions and

secretions, and boasted that he was able to treat it with uncommon success

and effect. Soon afterward French and English psychiatrists were diagnosing

female patients with nervous vapours which allegedly arose from the uterus,

and had the power to derange all the functions of the brain according to

Joseph Daquin in 1787. By 1812 Benjamin Rush (proclaimed the father of

American psychiatry by the American Psychiatric Association in 1975)

affirmed that the cause of madness is seated in the blood-vessels of the brain,

and it depends on the same kind of morbid and irregular actions that

constitute other arterial diseases. Complete and utter ignorance of basic

neurophysiology seems to have been no hindrance to the expression of

authoritative opinion on the subject.

French psychiatry was dominated in the 19th Century by the charismatic

presence of Jean-Martin Charcota brilliant neurologist who is credited with

identifying multiple sclerosis, amyotrophic lateral sclerosis (aka ALS or LouGehrigs disease) , and numerous other neurological disorders. In the 1870s

he turned his energies to advancing his personal notion of hysteria, an

assortment of neurotic symptoms that he believed to constitute an inheritable

disease associated with unidentified changes in nerve tissue. He promoted

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this concept by performing public lectures, the highlight of which was his

dramatic demonstration of hysterical symptoms in female subjects that he

hypnotized on stage. These presentations became a national sensation, and

led his theories to gain widespread acceptance among psychiatriststhroughout Europeonly to be debunked after his death in 1893.

An infinitely more regrettable innovation of French psychiatry was the

concept ofdegeneration. At the time nearly all psychiatrists believed

psychiatric disorders to be directly inheritable. In 1857 a French physician,

Benedict-Augustin Morel, proposed that something even more insidious was

happening in the psychiatrically impaired, advancing the pre-Darwinian

notion that acquired characteristics (such as alcoholism and moral turpitude)

could be genetically incorporated and passed on to the next generation. The

anticipated result would be a steady accumulation of inherent psychiatric,

constitutional, and even moral dysfunction in subsequent generations,

leading in turn to an overall deterioration of the human race. The

degenerate offspring of such defective bloodlines were said to recapitulate

in their bodies pathological organic characteristics of a number of previous

generations; and any such individual is not only incapable of becoming part

of the chain of transmission of progress in human society, he is the greatest

obstacle to this progress through his contact with the healthy portion of the

population.

This dystopian vision apparently had broad appeal, spreading rapidly

throughout the European psychiatric community and into other intellectualcircles. It was the first manifestation of social Darwinism, generating a

climate of fear that these natural processes would result in the downfall of

civilization. Another French psychiatrist, Valentin Magnan, fanned the

flames by declaring that society was in a hereditary struggle for life, and

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grimly proposing that society combat it with a rigorous form of social

hygiene. A popular bestseller in the 1890s, Max Nordaus Degeneration,

analyzed the allegedly degenerate characteristics of modern art, music, and

literature. Although degeneration theory fell into disfavor amongpsychiatrists early in the next century, its allure persisted among

antidemocratic circles in Europe, eventually spawning the genocidal policies

of Hitlers Nazi regime.

But the more immediate effect of degeneration theory was that it was

very bad for business. People with psychiatric complaints began to suppress

their symptoms, and avoided psychiatrists for fear of being branded with a

stigmatizing diagnosis. Likewise family members resisted taking family

members in for care, because of the legitimate fear that their whole family

might bear the stain of being degenerate carriers of what was perceived to

be inheritable disease. Having thus succeeded in undermining the economic

viability of their own profession, psychiatry was forced to figure a way out of

the corner into which they had painted themselves.

The answer was the adoption of a nonscientific euphemism, nerves or

nervous disease, for the low-intensity psychiatric disorders that were the

bread and butter of office-based practice. Never mind that this appellation

deceptively implied that the origin of such complaints existed in the

peripheral nervous system, rather than the brain. In order to avoid the stigma

of psychiatric illness and ensure their participation in treatment, it was an

acceptable compromise to tell patients what they wanted to hear rather thanthe perceived truth. Such disorders were typically attributed to overwork,

stress, or humoral imbalances, despite the widely held (but unspoken)

belief among psychiatrists that they were genetic or constitutional in nature.

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The definitive nervous diagnosis emerged in 1869, when a New York

electrotherapist, George Miller Beard, discovered (i.e. contrived)

neurastheniaa disease entity attributed to physical exhaustion of the

nervous system brought on by the stresses of modern living. It embraced avast grab bag of symptoms, including dyspepsia, headaches, insomnia,

weakness, dizziness, fainting, anesthesia, menstrual irregularities, and wet

dreams. Beards proposed mechanism was that the central nervous system

becomes dephosphorylized, or perhaps, loses somewhat of its solid

constituents. This wispy stab at science was apparently enough for the

psychiatric community, as the diagnosis became widely accepted in both

America and Europe.

Clinics and hospitals embraced the new paradigm by changing their

namesinstitutions previously designated for the insane were now for

nervous disease. However, the continued presence of degenerate

psychiatric patients in such institutions continued to inhibit use of these

facilities by those who could afford other options. In 1875 Silas Weir Mitchell

proposed the definitive treatment for neurasthenia, the rest cure. This

regimen called for the patient to be isolated from stress and excessive

stimulation, with special diets (such as the popular milk diet) and a melange

of physical therapies that might include water therapy, electrotherapy, and

massage. This cure could be delivered at private clinics or sanitariums, but

the definitive environment for treatment were the spa clinics that sprung up

on both sides of the Atlantic. Many of the patients were upper class women,providing an enthusiastic (and lucrative) clientele for nerve doctors and the

facilities to which they referred patients. It was a classic win-win scenario

after all, who doesnt like rest? And who doesnt like spas?

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A notable effect of the nervous branding of psychiatric disorders was

that it opened the door for neurologists to treat psychiatric complaints. The

office practice of psychiatry was shepherded into being by neurologists, since

most psychiatrists of the time were affiliated with the asylums. It wasneurologists who observed that the success of these cure models depended

in large part on a rigorously structured regimen that was imposed under the

benign authority of an administering physician, which had a powerful effect

on its largely female clientele. The suspicion grew that the primary

therapeutic benefit arose from the act of submission itself, suggesting that

these disorders were more functional (i.e. psychological) than organic. If so,

this powerful doctor-patient relationship could be moved out of the

sanitariums and spa clinics into the more cost-effective environment of the

doctors office. This led to the emergence of psychotherapy and hypnotherapy

ironically promoted by neurologists rather than psychiatristsand to the

eventual ascendance of one neurologist who would come to dominate

psychiatry for half a century.

The vogue for spa treatment peaked around 1900, waning as the

number of overtly psychiatric patients at these facilities increased, which

considerably diminished the euphemistic cache of nervous disease. The era

stands as a compelling illustration of just how far psychiatry was willing to

compromise its scientific credibility in response to commercial

considerations. Remarkably, neurasthenia still appears on the World Health

Organizations official list of diseases, the ICD-10, since it continues to beused in Asia as a culturally acceptable diagnosis in order to avoid the stigma

of mental illness.

Although the historic focus of neurology had previously been organic

disease, the persistent stigmatization of psychiatrists offered neurologists a

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steady flow of paying customers seeking help for psychoneurosis.

Numerous theories were proposed, and different therapeutic approaches were

explored including hypnosis. In Vienna Sigmund Freud was impressed by

how many sexual issues were emerging in his psychotherapy practice(treating many young female patients), and he began to develop a body of

theory that gave a primacy to sexuality never before contemplated. This

naturally courted controversy and derisionbut also stimulated a lot of

interest and discussion. He successfully cultivated an intellectual following in

and around Vienna that grew to become an international movement, while

laying the foundation for a new treatment model known as psychoanalysis.

As a social revolutionary I revere Sigmund Freud. His frank discussion

of sexuality cut through Victorian repression and propriety like a buzzsaw,

and changed our world forever. Freuds ideas triggered a seismic shift of

Western culture away from repressive decorum toward candor and sexual

freedom, ushering in the acknowledgement and celebration of sexuality in art

and media. He made invaluable contributions as well to the evolution of

psychological theory and treatment, such as delineating the role of the

unconscious in human behavior and developing the technique of free

association. His definitions of the id, ego, and superego, his observation of

psychological defenses, and much of drive theory in general are still useful

concepts that facilitate the exploration and discussion of psychological

problems.

But as a scientist, Freud was an utter disaster. He was hopelessly inlove with his own opinions, lacking the humility to entertain doubt of his

interpretations. He was stubbornly fixated on sexuality as causation, which

made him a better revolutionary but a lousier theoretician. Since his

hypotheses were ill-suited for examination using the scientific method, he had

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free rein to build consensus in the psychiatric community through a

combination of personal charisma and sheer chutzpah. His intellectual

domination of psychiatry was imposed by the coercive abuse of

psychoanalytic terminology to attack his opponents, dismissing criticism ofhis theories as psychological resistance or denial. This technique was

emulated by his legion of followers, who managed to sustain a cultish ideology

for decades that was virtually impervious to rigorous reexamination.

To illustrate the absurdity of some of Freuds ideas, I offer for your

consideration the concept ofpenis envy. According to Freuds psychosexual

development theorywhich, strictly speaking, shouldbe referred to as a

hypothesischildren of both sexes first exhibit a libidinal focus on the genital

area during the phallic stage of development, occurring from age 3 to 6.

Freud proposed that the penis becomes the organ of primary interest for both

sexes, triggering a series of events that result in different outcomes for each

gender due to their differences in anatomy. These events constitute the

Oedipal complex in boys, characterized by castration anxiety; while in girls

they are referred to as the Electra complex, the context within which penis

envy arises and is then resolved.

Freud proposed that at the beginning of the phallic stage the girl

develops her first sexual impulses, which are directed toward her mother. She

then realizes that she does not have the requisite anatomical equipment for

that sexual relationship, and comes to desire a penis and the power that it

representshence experiencing penis envy. The solution is to obtain a penis,leading her to develop a sexual desire for her father, an urge that impels the

elimination and replacement of her mother. The girl concurrently blames the

mother for her apparent castration, which she presumes is retaliation for

daring to compete with her mother for her fathers attentions. Eventually the

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girl begins to identify with and mimic her mother in order to be a better

replacement, but this in turn leads to fear of further retaliation. All this

tension is at last relieved utilizing the psychological defense of displacement,

through which the girl transfers her discomfiting attraction from her father tothe more attainable and acceptable object of men in general.

I dont know about you, but I lost count of the number of intuitive leaps

attempted by Freud within this one hypothesis. The scientific method calls

for observation and testing to confirm a hypothesis, but my bet (and hope) is

that Freud never directly questioned a sample of 3- to 6-year-old girls to

explore what feelings they had about their absent penismuch less all the

other areas of conjecture here. Whats most baffling, however, is that this

bizarrely tortuous conceit was not the idiosyncratic delusion of some crackpot

on the fringe, but a core tenet of the analytic canon, advanced by the man who

was the reigning figure of American psychiatry for most of the 20th Century.

When psychiatrists conferred with each other on individual cases penis envy

would be discussed as a matter of course, and rarely if ever questioned as a

clinical entity. Meanwhile, the coeval cultural phenomenon of penis

narcissismthe preferential allotment of wealth, power, and personal

freedom to those fortunate enough to be born with a peniswent entirely

unnoticed by the (predominantly male) psychoanalytic community. Go

figure.

Untethered by the scientific demand for objective verification, and

inspired by Freuds example, psychoanalysts ran rampant with half-bakedtheories to explain the inner workings of the mind and the pathogenesis of

psychiatric disease. One of the more reckless of these speculations was Frieda

Fromm-Reichmanns proposal in 1948 that the degenerative neuropsychiatric

disease known as schizophrenia was caused by a schizophrenogenic

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mothera hypothesis that in retrospect appears transparently motivated to

justify the use of psychotherapy to treat this disorder. According to Fromm-

Reichmann, such a mother was domineering and overprotective, yet

emotionally rejected the child, triggering the eventual rise of psychosis as thechild became painfully distrustful and resentful of other people. This

supposition was accepted and reiterated by the psychiatric community for

decades, maligning a generation of mothers who probably felt bad enough

having a schizophrenic child without being told they were to blame for their

misfortune. Eventually this hypothesis was debunked by actual scientific

research, apparently because somebody felt that such a charge merited

investigation rather than mere assertion.

Meanwhile, Melanie Klein proclaimed that the origins of psychosis were

in the first six months of life. Klein proposed that in order to develop

properly the infant has to split its world into good and bad objects, because

doing so prevents the perception by the infant that good is being destroyed by

the bad. Integration of good and bad is anticipated in normal development

once the child matures to a point that it is able to safely tolerate ambivalence

and conflict. However if the needs of the baby are not met promptly on a

regular basis because the mother is not there to fulfill them, the absence of the

good object is experienced as the bad object. In fantasy the baby attacks the

bad object, and in turn fears that the bad object will retaliate. As a result the

baby grows up feeling persecuted, and develops chronic paranoia in dread of

the bad objects inevitable revenge.Cleverly, Klein had managed to concoct a hypothesis that noone can

ever prove ordisprove.

Countless volumes of academic literature were filled with such

propositions during the psychoanalytic era. These suppositions carried on

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psychiatrys established tradition of making shit up, now refined to

stratospheric new heights of convoluted audacity. They arise from the same

brand of science that brought us the theory of intelligent designthe

conviction that something must be true because it sounds good, feels right,and supports my existing world view. Except intelligent design is more

elegant and firmly grounded in reality.

So how could this sort of poppycock have risen to prominence in a

century notable for huge leaps in scientific progress? Well, the biggest

contributing factor was Freuds rock star status in American popular culture.

Freud had been on the money in confronting the stultifying sexual repression

of the Victorian era, and clarifying the role of the unconscious in human

behavior. These concepts had a profound cultural impact over and above his

influence as a clinician, spilling over into art and literature. He single-

handedly inspired the surrealist movement, and overtly Freudian references

can be found in Hitchcock movies and other popular media of the era. To this

day Sigmund Freud is probably the only psychiatrist that most lay people can

name.

His ideas were an object of fascination among the chattering classes

who not only elevated his stature, but made up much of the psychoanalysts

natural consumer base. Never before had psychiatry experienced such social

cache. For better or worse, psychiatry was publicly branded by Freuds

preeminenceso when paying patients came into a psychiatrists office

expecting Freudian therapy, they were likely to be obliged. And ifpsychiatrists could get their rambling speculations published and discussed

without having to do the grunt work of actual research, it would be hard for

anyone with a healthy ego to resist.

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Freuds impact was not only cultural and clinical, but commercial as

well. Before Freud the practice of psychiatry was primarily based in the

asylum, where the severely ill could be safely housed and treated. Emerging

from neurology to address low-intensity psychiatric complaints in an office-based practice, Freud revolutionized our profession. As historian Edward

Shorter states, Psychoanalysis was the caisson on which American psychiatry

rode triumphantly into private practicerescuing psychiatrists from the

asylums, and creating the practice model that has endured even into this

medication-oriented era.

However, its worth noting that two centuries of psychiatric research

prior to the advent of psychoanalysis had produced little of lasting clinical

value. As I noted earlier, the obstacles to understanding the brain and its

functions are formidable, and prior to the 20th Century the available

technological means were simply not up to the task. Unfortunately the early

pioneers in the field tended to have more gumption than wisdom, consistently

overestimating their level of understanding and generating a succession of red

herrings disguised as theories, that merely waylaid earnest scientific study

rather than advancing it. Over this entire period there was only one major

psychiatric figure whose discoveries remain clinically relevant todaya

German psychiatrist who was humble enough to know the limits of his means,

to appropriately narrow his focus, and to strictly adhere to the scientific

method.

That man was Emil Kraepelin, head of the university psychiatric clinicin Heidelberg, who over the course of the 1890s carried out methodical

research of patients who were admitted for severe psychiatric illness.

Kraepelin was a notably independent and plainspoken figure for his time. He

came into the profession with a psychological orientation, and was offended

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by the rude indifference his teachers often demonstrated toward patients. He

rejected the biological fixation of most of his peers, since their extensive

anatomical study had already proven fruitless in identifying the causes of

psychiatric illness. He decided early on that the technological meansavailable made it impossible to speculate regarding causation in these cases,

accepting this limitation rather than leaping to uninformed conclusions.

Instead he concentrated his research on the bedside observation of patients

over an extensive period of treatment, with a focus on identifying predictors

of disease course. He did so in hope of identifying discrete diagnostic entities,

so they could be further studiedbut also saw it as a clinical priority, since

loved ones so often wanted to know whether patients would improve and

when. As Kraepelin stated:

The doctors first task at the bedside is being able to form a

judgment about the probable further course of the case. People

always ask him this. The value of a diagnosis for the practical

activity of the psychiatrist consists of letting him give a reliable

look at the future.

With this goal in mind, he gathered extensive data regarding these

patients, analyzing his findings in an attempt to cut nature at the joints and

identify specific disease states. He noted that patients presenting with

psychosis shared many common symptoms, but had wildly differing coursesof their disease. After prolonged study, he observed that patients with a high

degree ofaffective (i.e. emotional) content had episodes that swung in a

cyclical patter, with full recovery of function between these episodes. He

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called this condition manic-depressive illness, a disorder now technically

designated as Type I Bipolar Disorder.

Patients lacking this affective content, on the other hand, trended

toward a degenerative course of illness that was unremitting, exhibiting whathe described as a peculiar destruction of the internal connections of the

psychic personality, with the most marked damage of the emotional life and

volition. He coined the term dementia praecoxfor this conditionwhich

was later renamed schizophrenia, after it became clear that the degree of

cognitive impairment was insufficient to warrant the term dementia.

Although he came to believe that schizophrenia was neurodevelopmental in

origin, he maintained a healthy respect for the non-biological aspects of the

psyche, touting the therapeutic benefits of meaningful activity (especially

farming and gardening) in treatment of the mentally ill.

But Kraepelin was a singular exception in a psychiatric legacy that was

littered with debunked theories, dead ends, and downright quackery. By the

dawn of the 20th Century, the entirety of psychiatric research had culminated

in the exportation of medical diseases (like neurosyphilis and multiple

sclerosis) to other specialties, and the identification of two actual psychiatric

diseases that had no known causation or treatmentthe only durable

psychiatric knowledge to date. In a demoralized state after nearly destroying

itself with the degeneration debacle, its little wonder that psychiatry latched

on to Freuds confident authority and public stature.

As it turned out, psychoanalysis was much more effective for treatingthe worried well than the truely ill. Attempts to apply psychoanalysis to the

asylum population failed miserably, and outpatients who were unresponsive

to analysis were often labelled resistant or even bad patients.

Furthermore it was cost-ineffective, especially in the macroeconomic sense,

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since the type of patients who were most likely to participate and respond to

psychoanalysis were those most likely to be able to maintain employment as

well. In the 1950s psychiatric medications began to improve by leaps and

bounds, emerging eventually as a more cost-effective treatment optionapplicable to a larger proportion of the patient population, including those

who were the sickest.

Even if it flunked science (and economics), psychoanalysis certainly

deserves an A for effort. In analysis, diagnosis was a demanding process that

took place over weeks, months, even years, as ever deeper thoughts and

feelings were revealed in the course of therapy. As convoluted and speculative

as a diagnostic formulation might be, it was an earnest attempt to understand

the patients personality and problems, and to communicate a patients story

without gross oversimplificationand hence inherently respectful of just how

complicated any human being really is. Old school analysts have been some

of the most passionate critics of biological psychiatrys crass reductionism

which is not surprising, given that there always was an element of romance to

psychoanalysis that impelled many of its practitioners.

But theres simply no place for romance in science, since that inevitably

entails attachment to an idea you may have to dispose of later. Most of the

figures cited in this chapter were true believers, passionately attached to their

own ideas or those of their mentors. Any of them who lived long enough saw

their cherished doctrines crushed by whatever passed for progress in that

era. The notable exception was Kraepelin, a scientist rather than a believer,whose discoveries have accordingly endured to this day.

Contemporary psychiatry has good reason to be ashamed of its history.

But if the apparent neglect of its checkered past is by design, I suspect there

are deeper motives beyond mere embarrassment. Over the years we have

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habitually underestimated our scientific task, and overplayed our clinical

hand. Having finally achieved a tenuous foothold on medical legitimacy, its

natural to assume that we might be threatened by a history that challenges

that stature. The new technologies are indeed powerful, and the resultanttreatments are undoubtedly more effective than ever before. But it would be

foolhardy to overlook psychiatrys established proclivity for bending science

to its willand to discount the very real possibility that our current dogma is

just the latest manifestation of that regretful tendency.

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making sense of psychiatry: an insecure profession

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