©Copyright 1994-1998 by Robert T. Carroll.
Permission is granted for non-commercial replication of or excerpting from this material, provided that appropriate notice is included of both its authorship and its copyright status. Permission for commercial replication must be obtained from the author.
Madness on the Couch:|
Blaming the Victim in the Heyday of
by Edward Dolnick
I can't help being convinced that my dear fellow men,
with few exceptions, are worthless.
-- Freud, in a letter to Lou Andreas-Salome.
Though Dolnick does not mention Freud in the title, his book is another in a growing list of attacks on the father of psychoanalysis. Freud is attacked not only for his ideas and methods, but for his arrogance and contempt for his patients and colleagues. For example, Dolnick points out that the couch, which has become the symbol of Freudian psychoanalysis, was not used by the master to help the patient relax. Freud explained it this way: "I cannot put up with being stared at by other people for eight hours a day (or more)" (20). It is tempting to apply the same kind of wild speculative interpretation of Freud's methods that he applied to everyone else's behavior. For Freud, nothing is as it seems. Everything is a symbol waiting to be interpreted. Thus, one might say that Freud laid his patients down so he could be above them, could dominate them, Lord it over them. He himself sat erect while his patients lay limp. It was subtle, but he was raping them, taking from them their innocence, using them for his own pleasure. It was his shame, his fear of losing face, that kept him from facing his patients.
Speculation was and is at the heart of psychoanalytic theory and practice. However, unlike scientific speculation, which leads to testable hypotheses and controlled experiments, psychoanalysis was developed mainly by unscientific, if not anti-scientific, minds. One searches in vain among the analysts for any semblance of the typical concerns and attitudes of scientists. There is no concern for testing their claims, which are put forth dogmatically rather than tentatively. Skepticism about their work is rare; bravado and bold assertions are common. Debate and argument with critics is acrimonious and fruitless. Yet, their influence was widespread. Art, literature, philosophy, religion, history; what discipline was not influenced by Freudian notions? Who did not emerge from college in the sixties and seventies "knowing" that repression explained everything and that the unconscious is the gateway to the secrets of the universe?
What can explain the popularity of Freud in America, if his theories and practices were so wrong? Like so many other things in life, it boils down to timing. The world had gone mad in the forties, culminating with the development and use of nuclear bombs. The beauty and genius represented in the development of flying machines was replaced by the horror of rockets and airplanes used to drop bombs on cities. The irrational ruled. Civilization is a thin veneer behind which lurks a raging animal ready to tear it down. How could one possibly make sense out such a world? Freud had an answer and it was better than anything the competition could come up with. Religion and philosophy, the traditional guides for the perplexed, were so vacuous and devoid of answers, they too looked to Freud for help. Furthermore, Freud's ideas had great utility for nearly every discipline. Marxists could gleefully explain capitalism in terms of anal fixations and hoarding feces (i.e., money). Writers could explore dreams, stream of consciousness, sexual symbolism, and feel they were plumbing the depths of hidden profundities. Everybody could explain their weird friends and relatives with these notions. It was creative; it was fun. Best of all, nobody could prove you wrong.
The main bit of good timing, however, did not come from the fact that Freudianism could explain such horrors as the Holocaust (as well as just about everything else), but from the fact that the analysts were primarily European Jews who ended up in America.
Dolnick's book, however, is not an attempt to explain why psychoanalysis became so popular, but how it destroyed many lives in the name of helping people. It is the story of good intentions and promises of hope, of treating patients with respect, treating them as persons who possess free will and who deserve love and patience. In fact, Madness on the Couch should be read by all the New Age medical gurus, such as Andrew Weil and Deepak Chopra, who think that the problem with medicine today is that it lacks a mind/body approach. Treating the mind, rather than the body, was tried by psychoanalysts, psychiatrists, and psychologists during the 1950s and 1960s, and still enjoys a good deal of popularity in some circles. A generation or more of some of our brightest minds seem to have gone mad, however, in their pursuit of understanding madness. What distinguishes them most, however, is not their errors, but their arrogance. They developed theory after theory, treatment after treatment, based almost exclusively on intuition and insight. Nothing resembling a scientific concern for self-deception appears in the methods of the main figures, who are depicted by Dolnick stripped of their power, their unchecked ideas exposed for all to see. Their concern with persons and minds, rather than with bodies and their mechanisms, did not make them either humane or correct.
The story starts, of course, with Freud and psychoanalysis. Though Freud and his followers thought of themselves as scientists, and did a very good job of fooling a good part of the rest of the world on this matter, their main methods of inquiry were untestable. Such methods as free association, interpretation of dreams, and treating thoughts and actions as symbols, gave them a virtual blank check to claim they knew both the cause and cure of madness. They never used control groups because they saw no need for them. Their brilliance alone would show them whether their intuitions and insights were correct. All they needed for evidence was a plausible story affirmed by their colleagues. They had no trouble coming up with either.
That some of the best minds working in this field would ignore fundamental truths about human frailty -- such as the ease with which we can deceive ourselves and the natural tendency toward confirmation bias and self-validation -- is a puzzle in itself. The field seems to attract a particular type of personality: arrogant, authoritarian, and convinced of his or her own brilliance and special ability to see through the way things appear to what they "really" are. They lacked the essential skepticism that marks true scientists. They showed no tendency to propose tentative hypotheses or to test those hypotheses in ways that might exclude or minimize bias or error. Their behavior was more analogous to interpreters of literature than to interpreters of nature. These giants were pseudoscientists in every sense of the term.
Who were these giants and what did they do? First there was Freud, who taught them that the unconscious mind is a storehouse of repressed memories and that behavior, like dreams, must be treated as being symbolic. Furthermore, he taught that everything has meaning and the job of the analyst of the mind is to decipher the patient's thoughts, speech, dreams, and actions. Early on he imagined that mental disorders were due to childhood sexual abuse. Later he imagined that they were due to repressed memories of seeing or hearing adults engaging in various forms of sexual activity. He would not treat the severely mentally ill because he thought they were resistant to psychoanalysis, but he would not hesitate to explain severe mental illness. Schizophrenia, for example, was caused by unresolved feelings of homosexuality. His evidence for his theories and practices came from the insights he gained by seeing his patients, who, for the most part, consisted of middle class Viennese women suffering from "hysteria." His imagination was his only check in reality. Nothing resembling a sense of the need for a scientific methodology issues from his pen. All is speculation and interpretation put forth as dogmatic fact. He was so brilliant that he could examine a single case, even at a distance (as with Daniel Paul Schreber) and declare that to understand one male paranoid is to understand them all. No generalization was too sweeping or too grand for the master. Freud was a guru, not a model scientist.
psychoanalysis in America
Had the Holocaust not occurred, psychoanalysis may never have flourished in America. Three-fourths of all analysts ended up here after the war with Germany. Those who sided with Nature in the Nature/Nurture debate were seen as aligning themselves with Nazi race theorists, as well as with materialism and determinism. Worse, they were saying that the Holocaust was not an aberration and it could not have been avoided. (Freud, by the way, did not think that human nature is neutral and that a person can be made into anything by one's culture. The Holocaust and much more from human history made it indisputable that man is by nature a "savage beast" who desires to die and who has little empathy towards his fellow creatures.)
In America, theories of personality and mental illness based on upbringing, education, training, etc., were favored, not only because they distanced themselves from the Mengele's of the world, but because they seemed to be reconcilable with a belief in free will. Biological explanations, on the other hand, seemed to imply a hopeless determinism. Any discipline or theory which threatens a belief in the soul or in free will faces centuries of cultural resistance. Thus, while there were some scientists after the war who were working on the theory that personality and mental illnesses were biologically determined, it would take decades before their voices could be heard above the din of the Nurture-over-Nature enthusiasts. Even now such voices are still being attacked for being "reductionist" and not "holistic." Psychoanalysis should be proof enough that being holistic does not mean one is any closer to the truth. Likewise, the discoveries of genetic causes of certain diseases should be proof enough that sometimes the material explanation, though reductionist, neither dehumanizes us nor takes us away from the truth. Finally, it should be obvious to even the amateur philosopher, that siding with nurture is as deterministic as siding with nature in the nature/nurture debate. There is a greater illusion of freedom in siding with nurture, since the environment can be changed, while one's genes can't. However, the deterministic power of one's genes might be overestimated, since a genetic defect might cause a problem only when one is exposed to something particular in one's environment, something which might easily be avoided, such as fava beans.
the schizophrenogenic mother
In America, psychoanalysts soon started claiming that they not only understood the cause of such illnesses as schizophrenia, but that they could cure it. The new breed of analysts remained true to the spirit of their master: freewheeling theories and practices unchecked by meaningful empirical tests. But they came up with new explanations for madness. Mothers caused it by their bad mothering. Or, mothers and fathers both caused it by their own mad behavior. Later, it would be claimed that the parents were victims, too, ad infinitum, I suppose all the way back to Adam and Eve.
Of course, if the parents caused the disease, then the cure would have to involve getting rid of the parents. The best way to do this was to devise treatments that isolate the patient, get him to reject his family, and encourage him to accept the therapist as a surrogate parent. It would not be long, however, before attachment to the therapist, encouraged by the very methodologies used, would itself be seen as another problem that belonged to the patient.
The paradigm therapist became someone like Frieda Fromm-Reichmann, who acted as a mother surrogate to her patients at Chestnut Lodge, a private mental hospital near Washington, D.C., for some twenty-two years. She invented the term "schizophrenogenic mother" to describe the kind of mother who caused schizophrenia in her child. She was heroized as "Clara Fried" by Joanne Greenberg in I Never Promised You a Rose Garden, a bestseller in the mid-1960s. According to Greenberg, Fromm-Reichman used empathy to cure her of schizophrenia (84). However, the diagnosis may have been an error. It is as likely that empathy can cure schizophrenia as it is that it can cure diabetes.
Fromm-Reichmann declared that schizophrenia was "a secondary result of very early serious warping of [the schizophrenic's] relationships with the people significant in their environment in infancy and childhood" (90). "Serious warping"--now, there is a truly scientific term! One might say that the serious warping continued with the therapist who now offered hope to the patient by claiming that she could undo the wrong that had been done to the child, the wrong that had caused schizophrenia. She would cure all their wounds and frustrations, like a good doctor and good mommy. How would she do this? By listening to her patients, by showing them that they had a true friend in Frieda, that there was someone who cared and would not run away from them no matter how strangely they behaved or spoke.
Soon there would be analysts claiming that just about every illness, physical as well as mental, was caused by bad parenting. Two analysts in particular were important to this development: Helen Flanders Dunbar and Franz Alexander. In 1947, Dunbar published Mind and Body, in which she declared that people get sick because subconsciously they want to get sick to receive "compensation for the neglect or severity they may have suffered in childhood" (68). In 1950, Alexander published Psychosomatic Medicine in which he claimed that asthma is caused by "a repressed desire for the mother" and other such nonsense.
the holistic Karl Menninger
In the 1950s and 1960s, Karl Menninger, with his father and brother, ran the Menninger clinic in Topeka, Kansas. He proclaimed that love would remove the evil in man's heart, that he was more "Freudian than Freud," that criminals are mentally ill, and that all mental illness was temporary, basically the same, and could be cured by psychoanalysis, i.e., talk therapy. Anxiety was the root of all illness; therapy would relieve anxiety. Since we are all anxious to some degree, the mentally ill do not differ from us in kind but in degree of anxiety. Such a view rendered diagnosis superfluous. One could begin the treatment right away, since the analyst knew before seeing the patient that he or she suffered from excessive anxiety. (This approach is popular today with repressed memory therapists. They know before the patient reaches the door that her problems are caused by repressed memories of childhood sexual abuse.) The fact that Menninger had no scientific evidence to support his notions was deemed of no importance to those who saw him as a messenger of hope who respected the criminal and the insane as fellow human beings with fixable problems. He was holistic and treated the person not the disease. It seems to have mattered little to his supporters that he didn't know what he was talking about.
Searles and Rosen, therapists from Hell
Two other very influential analysts in the 1950s and 1960s were psychiatrists Harold Searles and John Rosen. Both treated their patients as an angry parent who lacks self-control might treat a naughty child. Searles and Rosen not only assumed that their patients were ill because of bad parenting or grandparenting, they believed that the cure would be reparenting with the therapist as the surrogate parent. If the way they treated their patients was their idea of good parenting, however, one would need Dante as a guide through Hell to describe their idea of bad parenting. Like Freud, they treated everything as a symbol and gave themselves absolute power to interpret these "symbols" in any way they saw fit. They abused their patients psychologically and physically. This is a chilling chapter (chapter six) in Dolnick's book as well as in the history of psychoanalysis. These men are described as if they were deranged themselves. Yet, they held positions of respect and authority within the therapeutic community.
Searles contribution to theory was that the mother causes schizophrenia in the child because of unconscious, repressed feelings of love for the child which the mother is unable to express because her mother was a bad parent. Thus, grandmothers are really the cause of schizophrenia. Rosen, on the other hand, was best known for what he called "direct analysis," in which, he claimed, he spoke directly to the patient's unconscious and could cure anybody of anything, including schizophrenia. In 1971, Rosen was named Man of the Year by the American Academy of Psychotherapy. In 1983, he gave up his license to practice medicine when he was faced with sixty-seven violations of the Pennsylvania Medical Practices Act (116). He and his associates beat and tortured a number of patients, at least one of whom died from their reparenting.
help from the wings
As if the doctors themselves could not come up with enough untested and untestable theories and practices, analysts sought allies from any quarter. One of the most notable was Gregory Bateson, one of Margaret Mead's husbands. Bateson had no training in medicine--he was a zoologist by training and an anthropologist by profession-- and had no experience with schizophrenia, yet he claimed to understand the cause of schizophrenia. What's more, he got a large segment of the analytic community to agree with his theory of the "double bind." Schizophrenia is a parenting problem and understanding it involved understanding how to interpret symbols. Parents, by their conflicting speech and behavior, confused the child so badly that the child could not decipher messages. The child would become so confused that as an adult he or she wouldn't even be able to know what anyone meant by "What would you like to do today?" According to Bateson, to the victim of perpetual double binds such a question might mean you were being condemned for what you did yesterday or it might be taken as a sexual invitation. Such a person would "be unable to judge accurately...just what was meant" (120).
Bateson claimed that there were three possible responses for someone caught in perpetual double binds. Not coincidentally, the three responses corresponded to what every text book described as the three main forms of schizophrenia (120).
Schizophrenia, according to Bateson, is caused by a family's communication style, which, in turn, was due to the hostile, anxious, unloving nature of the parents. The schizophrenic's strange speech and behavior, the voices in the head, etc., are all due to linguistic confusion brought about by a childhood of mixed messages. It is indicative of the pseudoscientific nature of psychoanalysis that such a theory could become a centerpiece, though it was proposed by someone who had not done a single observation of a schizophrenic patient.
a psychiatrist for the sixties: R.D. Laing
There are many others in this litany of abuse that Dolnick describes, such as Harry Stack Sullivan and Theodore Lidz. However, one who deserves special mention is R.D. Laing, who was very popular during the sixties. Laing was a psychiatrist who claimed that schizophrenics did not have "breakdowns;" they had "breakthroughs." Like many others during that period, Laing enjoyed his psychotropic drugs and his booze, and found a large audience ready to hear that being mad and getting stoned were akin to experiencing God. To many people, especially those who thought of themselves as being oppressed by society, Laing was a liberator. To hear him declare that the world is mad was to hear the voice of reason in an irrational world governed by racism, sexism, and tribal hatreds. However, when it came to specific patients with their specific problems, Laing was a true Freudian: everything is a symbol to be interpreted by the therapist. Furthermore, the "word salad" commonly identified with schizophrenic speech, was playacting "to throw dangerous people off the scent" (134). Their incomprehensibility is intentional. Schizophrenia is a strategy some people use to deal with an intolerable situation. His proof? He said he "cured" all twelve of his patients in just eighteen months. However, within a year all of them were readmitted to the mental hospital where he had treated them.
ice picks and lightning bolts
Why was psychoanalysis so popular among so many bright people for so long? One reason was its appeal to the creative mind. Freud's ability to create worlds out of dreams, twitches, figures of speech, etc., was unparalleled. There is something in the human psyche that desires to make sense out of things and there is something attractive and exciting about stories that make sense out things in surprising and intelligent ways. For the intellectual, creating myths is fun. So, on one side there is the sheer pleasure derived from coming up with these fantastic explanations of the most irrational or seeming meaningless or mundane thoughts and actions. On the other side, was the fact that the main opposition consisted of doctors who were sticking ice picks into their patient's orbital sockets in order to cause destruction in the prefrontal lobes or who were administering drugs or electricity in an effort to shock the brain into submission.
Chapter eight covers this period in medical history when it was considered a scientific advancement to move from drilling holes through the skull to jabbing an ice pick directly into the brain by entering through the eye socket. Better lobotomies through advancing technologies! Walter Freeman and James Watts' Psychosurgery was a hit in 1942 and Egas Moniz won the Nobel Prize for medicine in 1949 for his pioneering work in prefrontal lobotomies! The operation was so simple that even a non-surgeon like Freeman could do it. Killing a couple of patients by severing their cerebral arteries was considered a minor setback (146).
It was also considered a great step forward when electroconvulsive therapy (ECT), aka electroshock, replaced both intentional overdoses of insulin to induce coma and Metrazol injections intended to induce "epilepticlike convulsions in the schizophrenic" (144). ECT continues to be used for patients with severe and otherwise untreatable depression, although a new therapy using magnets instead of electricity is now being tested: transcranial magnetic stimulation (TMS).
The main defense of these seemingly barbaric procedures was and is that "they work!" In this case, however, that did not mean that the doctors had many satisfied customers. It meant that the doctors themselves were satisfied with the results. It certainly did not mean that anyone with schizophrenia had been cured. It did mean that some patients with severe depression improved significantly, even if only temporarily and even if no one had a clue as to why it worked.
In short, patients had little choice in terms of what treatment was available. Psychoanalysis must have appeared to be the more humane of the available alternatives. But it was like asking the mentally ill whether they would prefer a lethal injection or the electric chair.
biology not quite to the rescue
So, where were the "biopsychiatrists" during this period? Where were the brain researchers, the neuroscientists, and the geneticists? They were there and they were mostly discovering that the brain was much more complex than anyone had ever imagined. Dolnick describes their struggles in chapter nine. The most interesting part of the debate between the Nature and Nurture advocates was that the data could be made to fit either hypothesis. In fact, I suppose, the data could have fit the astrologer's theory as well. The earliest data were gathered, in part, from studies of families and twins. It was known that about one percent of the population in America suffers from schizophrenia. It was discovered that the chances of being schizophrenic double if you have a cousin who is schizophrenic. The chances quadruple if you have an aunt or uncle who is schizophrenic. If a sibling is schizophrenic, the chances increase ninefold. If a parent is schizophrenic, there is a 13 percent chance that his or her child will have the disease. And if one identical twin is schizophrenic, there is a 50 percent chance that the other one is too. Does the data support bad parenting or bad genes as the most significant causal factor here?
Both sides saw the data as supporting their views. These poor schizophrenic creatures not only shared genes, they shared family histories as well. For example, it is no wonder that an identical twin of a schizophrenic is fifty times more likely to have schizophrenia than those in the general population. Their parents treat them alike. They dress them the same, talk to them the same, etc. Those who had blamed parenting already knew that schizophrenia ran in families, and they knew why, too. So, the geneticists' data were unconvincing that this was exclusively, or even primarily, a genetic disorder. In any event, the astrologer knows why twins tend to be alike even in their mental illnesses: they were born at the same time!
enter Leonard Heston, psychiatrist and scientist
A different kind of data was needed, if this issue of bad parenting causing schizophrenia was to be resolved. It would be provided by Leonard Heston, a psychiatrist working in a mental hospital in Oregon in the early 1960s (155). Heston gathered data on children born to schizophrenic mothers and given up for adoption. He compared them to a control group of adoptees born of non-schizophrenic mothers. If schizophrenia was due to bad parenting, there should be no difference in the incidence of schizophrenia in the two groups. Each should have about one percent schizophrenic children. On the other hand, if schizophrenia is caused primarily by a genetic predisposition to the disease, then the adoptees whose mothers were schizophrenic should have a significantly higher incidence of the disease than the control group. Heston gathered the data and another psychiatrist evaluated it without knowledge of whether the adoptee was in the control group or the schizophrenic mother group.
It was difficult, but Heston managed to track down 92 of 97 adoptees of schizophrenic mothers on his list. Five had schizophrenia; whereas none of the control group did. The chance that this was a coincidence was one in forty (157). Some analysts stuck to their guns and said the only surprise was that a bad mother could have such a tremendous impact in the few hours or days she had with her infant before giving it up for adoption (157). A larger study, done on Danish adoptees by David Rosenthal and Seymour Kety, confirmed Heston's work. Kety and Rosenthal studied "more than two decades' worth of adoption records from Copenhagen and its environs, an area that included roughly one-quarter of the population of Denmark" (158). Kety did a later study on the entire country. Elaborate controls were set up to avoid researcher bias. In comparing biological to adoptive relatives of schizophrenic adoptees, they "put in place an elaborate system of safeguards" to isolate "nature" and "nurture" factors (158). The evidence showed that "schizophrenia was concentrated in the biological relatives, although they had never spent time with the child they had given up for adoption" (158).
It was becoming clear that some people have a genetic predisposition to schizophrenia. About the only thing the analysts had been right about was that many of the parents of their patients were weird. They were weird because they suffered from a disorder similar to that of their children. However, their weird behavior did not cause their child's disease.
the cause of schizophrenia: unknown
Even with this data, however, researchers were no closer to understanding what causes schizophrenia. It might not be bad mothering, but something in the environment might serve as a catalyst, triggering the disease in some family members but not in others. To this day, no one knows what causes schizophrenia. All we know is that most children of schizophrenic parents, and most parents of schizophrenic children, are healthy. We don't know why. There is no happy ending here...not yet, anyway. We know that there is an extremely complex biochemical system that affects our cognitive and emotive abilities. The fact that certain drugs which affect neurotransmitters, such as dopamine, significantly affect this system in schizophrenics, but not in healthy people, indicates that the disease is related to a neurochemcial "imbalance." However, the drugs used to treat this and other severe brain disorders have been discovered serendipitously. We really do not understand why or how they work. The psychoanalyst, of course, can say that bad parenting is what causes the neurochemical imbalances. The astrologer can say that neurochemical imbalances are due to astrological imbalances. They can say these things, but their words seem hollow and without force. Where is their proof? What was it about all those adoptive parents that triggered schizophrenia in their adopted children with a genetic predisposition to the disease? Until the psychoanalysts can answer this question, their belief that bad parenting is a significant factor in the development of the disease remains little more than an article of faith. And where is the data showing that schizophrenic adoptees share some significant astrological connection? If it existed, I am sure the astrologers would have informed the world by now. The number of environmental factors that can significantly affect neurochemistry is quite large. Schizophrenia may not be one disorder, but a family of disorders with multiple causes. It is quite possible that very distinct triggering events could result in similar symptomologies. A viral infection might have the same effect on one person that a series of vicious assaults might have on another.
psychoanalysis not the cure for schizophrenia
It remained to be shown that psychoanalysis is ineffective as a cure for schizophrenia. This was done in the mid-1960s by psychiatrist Philip May. He randomly assigned 228 schizophrenia patients at Camarillo State Hospital in California to one of five treatment groups. Some got psychotherapy; some got drugs; some got both; and some got electroshock. The fifth group received "standard patient care" and served as a control group (161). The treatment lasted for six months to a year. May did follow-up studies on his patients three, four, and five years after the initial study. He published a series of papers over the years, detailing his findings. The control group and those who received only psychotherapy did about the same; they did the worst of the five groups. There was some improvement in the electroshock group. The two groups that fared the best were those treated with drugs, and there was almost no difference between those given therapy with their drugs and those who were only given drugs. May didn't know any more than anyone else as to why drugs worked, but it seemed pretty obvious that therapy, at best, was "nonsignificant" (161), i.e., useless. Other studies would conclude that psychoanalysis was not just ineffective; it was often harmful to schizophrenics (162). Karl Menninger responded by calling drugs such as Thorazine (chlorpromazine) "chemical straightjackets" (162). Menninger declared that drugs can't heal persons. Only persons can heal persons. It was a lament one now hears from the likes of "alternative" medicine advocates, such as Dr. Weil, who claim that traditional medicine treats diseases not people.
Of course there is a danger that some psychiatrists will jump to the conclusion that the mentally ill need no therapy at all as long as they get their drugs. Nothing could be further from the truth, especially when many diagnoses are based on the patient's response to different medicines. The worst thing that could happen to psychiatry would be for it to think that everybody with a problem needs a pill, and the challenge is to find the right pill. Just because it has been shown that bad parenting is not the cause of schizophrenia does not mean that bad parenting doesn't cause many psychological problems in children for which there is no magic pill that will make the problems go away. Furthermore, the fact that a good percentage of the "mentally" ill do not respond to drug therapy may indicate that some "mental" illness is not primarily biological.
What makes people like Menninger and Weil dangerous is their kindness. How can one disagree with their idealized speech about proper doctor/patient relationships? A human being is suffering. A human being must understand the other's suffering and give hope to the sufferer. To reduce a human being to the level of cells, organs, neurochemicals, etc., is dehumanizing. We must treat persons as persons, and that requires that we not engage in reductionism or materialism. We must give proper respect to the patient's spirit and treat the whole person. The rhetoric is appealing, but it misguided and misleading. If you have a collapsed artery, you need a doctor who will open it up for you. This does not reduce you to a thing and it does not require medicine that reduces everything to the material level. You no more need a holistic or spiritualistic doctor to perform an angioplasty than you need a geomancer to repair a leaky pipe in your bathroom. Your doctor may pray with you and may treat you with the utmost respect, but if he or she does not repair your artery properly, you will die. The holistic baggage is superfluous metaphysics.
Psychoanalysts and many "alternative," holistic practitioners are fond of pointing out that nobody knows how or why these drugs work. All we know is that in a good number (some 75 percent) of schizophrenics, drugs such as Thorazine and Clozapine can stop the voices inside the head and eliminate the delusions. As a result of these and other drugs, many schizophrenics and others with severe brain disorders (such as manic-depression or obsessive compulsive disorder) are now able to lead productive lives in a broad range of professions, including psychiatry. However, when we say that drug therapy works, we do not mean that it produces many satisfied customers or pleased therapists. We mean that it allows a significant number of patients to live meaningful and productive lives. That is along way from saying that we know what causes schizophrenia and we have a cure for it. Nevertheless, research into biological explanations of thought and behavioral disorders seems to be the most promising now.
Is there no role for psychotherapy, then, in the treatment of schizophrenia? Dolnick does not address this question. He leaves little doubt that there is no role for psychoanalysis here, however, at least not as it was practiced in its heyday. The National Alliance for the Mentally Ill thinks that there is a significant role for therapists in the treatment of mental illness. It would be a mistake for psychiatrists to become little more than dispensers of drugs. But the nature of therapy must be radically different from that offered by traditional psychoanalysis. Some of the key problems that now occur are patients who don't take their medication, monitoring for side-effects of medications, helping with coping skills, dealing with radically diminished capacities and hopes, surviving in a world where one is stigmatized, jobless, etc. These require a different role from trying to come up with a plausible story to explain why your patient fantasizes about being pregnant with her deceased father.
autism1 and the holistic Bettleheim
The history of the treatment of autism parallels that of schizophrenia. The analysts blamed bad parenting for this disorder, as well. The leader of the pack was Bruno Bettleheim (1944-73), whose survival of Dachau and Buchenwald, gave authenticity and sympathy to his opinions. Bettleheim's comparison of the autistic child to the survivor of the concentration camps was at the heart of his analysis. The child withdraws into himself as a defense mechanism against his tormentors, i.e., his parents. But equally attractive to his colleagues was Bettleheim's notion that he was treating the whole person. Those who claimed autism and other mental diseases were actually physical diseases with biological rather than environmental origins, were reductionists. His psychological approach, on the other hand, was holistic and humane.
Bettleheim was director of the Orthogenic School for the rehabilitation of emotionally disturbed children, many of them autistic, at the University of Chicago. He wrote a number of articles and books on child psychology and child rearing, including Love Is Not Enough (1950) and The Empty Fortress (1967). Dr. Bettleheim had a Ph.D. in mythology and was not a trained psychologist or psychiatrist, though, like Bateson, he had tremendous influence on those fields. It was not until a parent of an autistic child entered the fray that the bad parenting therapists were pushed from center stage. Bernard Rimland, a research psychologist for the U.S. Navy, made the case that autism is biological and not caused by bad parenting in his Infantile Autism (1964). He got Leo Kanner, a leader of the bad parenting school who had invented the label "refrigerator mothers," to write the preface. Times were clearly changing. Rimland provided no original research, but he compiled an impressive argument from work already done by others. He may not have known what caused autism, but he knew that it was not bad parenting and that it was biological. His own child, and many others, had it from the moment of birth. The data also showed that parents who fit the pathogenic profile "almost invariably had normal, non-autistic children" (222). Parents who don't fit the pathogenic profile give birth to most autistic children. Siblings of autistic children are almost always normal. He also noted that autism strikes boys much more frequently than girls, an odd fact in a culture that does not prize girls more than boys (to put it mildly). It has since been discovered that the vast majority of autistic children are also retarded, and even the most vehement of parent bashers had not blamed mental retardation on bad parenting.
Bettleheim had allies, however. Harry Harlow's famous experiment with monkeys "raised" by surrogate mothers, one soft and cuddly, the other made of unwrapped wire-mesh, was touted as showing how bad mothering caused infants to go mad. The metal mother might provide milk, but it didn't provide sustenance. The infant monkeys much preferred a wooden mother wrapped in soft cloth to a cold and metallic mother. Harlow was famous for tormenting monkeys to gain insight into mental illness in humans. When he introduced "monsters" to frighten infant monkeys, they ran to the cloth momma, even though the metal momma provided milk. Ergo, a human child's first need is love, not food. Ergo, some families are "characterized by coldness, ambivalence, double binding messages and lack of physical contact" (200). He wrote that in 1971 for the Journal of Autism and Childhood Schizophrenia. In his article, he compared his tormented monkey infants to human infants. Both exhibited "marked social withdrawal" and they retreat to a corner to "avoid social contact." The autistic child, he declared, is a mirror of his isolated monkeys. They try "to shut out all outside stimulation." It seemed to be of little concern that observations of "refrigerator" or "metal" mothers were based on little more than self-fulfilling prophecies. They saw what they were looking for. Their common sense and insight told them what was true. They had no need for studies designed to eliminate confirmation bias as the source of their beliefs.
The one disorder that Freud claimed to know the most about was obsessive-compulsive disorder (OCD). He claimed to have found not only the cause but the cure for OCD. Bad toilet-training caused it: a child forced to control his bowels will grow up afraid of losing control over everything and will be driven to obsessive-compulsive behavior. Psychoanalysis cured it. He had no scientific evidence for either claim, however. Insight and the cleverness of his interpretations of "symbols" were the basis for the diagnosis. Self-delusion or fraud was the basis for his claims of cure; for, there is no evidence he cured anyone of this disorder, despite his repeated claims to have cured many, including two notable failures in patients he dubbed the Rat Man and the Wolf Man.
The obsessive-compulsive (OC) is characterized by being obsessed with certain ideas (such as "germs must be avoided") and being compelled to perform certain behaviors in response to the obsession (such as repeatedly washing one's hands). The OC's behavior bears a superficial resemblance to ritualistic behavior. For this reason, it is generally thought that the OC's compulsions are engaged in for the purpose of exorcising the obsession. After all, the OC admits that he does not want to have these thoughts. However, the OC also admits that he does not want to engage in rituals, which he recognizes are absurd and harmful. Nevertheless, the obsessive thoughts cause anxiety and the compulsive behavior seems to relieve it temporarily.
Freud at one time saw connections between OCs and both Lady Macbeth's attempt to wash away her guilt and religious rituals aimed at the same sort of thing. The OC feels guilty about masturbating, or about resenting her children or her husband. The obsessions and compulsions allowed the patient to replace unacceptable ideas with acceptable ones (248). Freud finally landed on the notion that the OC was repressing his or her excessively rigorous toilet-training. He eventually abandoned some of his wilder "symbolic" interpretations of behavior, but stuck to his guns that repression was the ultimate mechanism behind OCD.
It is worth noting that Freud was rather blind to a basic problem that plagues everyone seeking causal explanations. He did not just see his patients' behaviors as confirming his hypotheses, even when his explanations conflicted with one another. He encouraged his patients to see things his way. For example, one of his patients performed a nightly ritual before going to bed, which consisted of removing all clocks and watches from her bedroom, among other things. Freud noted (252) that
I was obliged to give the girl hints and propose interpretations....Our patient gradually came to learn that it was as symbols of the female genitals that clocks were banished from her equipment for the night....The ticking of a clock may be compared with the knocking or throbbing in the clitoris during sexual excitement....Wild thoughts, you will say, to be running through an unmarried girl's head. I admit that is so. But you must not forget that I did not make these things but only interpreted them.
But he was making these things. The above is only part of the "wild thoughts" in this case. There was more about fluffed comforters representing pregnancy; pillows and the headboard representing intercourse; and, flowers being arranged to represent fear of losing virginity. Not only was he making it all up, he was encouraging his patients to accept his explanations. He was undaunted by their repeated rejection of his notions. Like many repressed memory therapists today, Freud pushed on until his patients agreed with his notions of what was really behind their problems.
Freud declared that, as infants, obsessive-compulsives "refused to empty their bowels when put on the pot because they derive a subsidiary pleasure from defecating; for they tell us that even in somewhat later years they enjoyed holding back their stool, and they remember...doing all sorts of unseemly things with the feces that had been passed" (255). Did he do any controlled studies? No. Does he provide any data to back up these claims? No. Does he give any indication that he realizes he ought to be more scientific? No. This was junk science at its worst, but that did not deter its success.
Freud's notion that OCD is an attempt to exercise control, caused by harsh toilet-training leading to fear of losing control, was seen as a blank check for speculation by followers such as Karl Abraham. "Compulsive orderliness is at the same time an expression of the patient's desire for domination. He exerts power over things. He forces them into a rigid and pedantic system." Such ideas dominated psychiatry for some fifty years (254).
What is essentially different today is that most therapists, such as Judith Rapoport, M.D., of the National Institute of Mental Health, see OCD and other "mental" illnesses as biologically based. The Freudian model of human behavior, for all its deterministic and mechanistic sounding explanations, is ultimately a model with free will at its heart. Patients are either too strong-willed to be argued out of their illness, such as schizophrenics, or they are amenable to change by persuasive arguments. Ultimately, talk therapy is an attempt to persuade the patient to agree with the therapist's interpretations in order to get better. Failure to heal is due to patient obstinacy.
The evidence keeps piling up that disorders such as OCD have biological causes and can be effectively controlled in most cases with medications and cognitive behavioral therapy. (What could be more holistic than providing both medicines for the body and therapy for the person?) Nevertheless, those favoring psychological explanations will probably always have a strong contingent. The main reasons for this seem to be (1) a desire to believe in the mind or soul as a separate reality from the body, (2) a belief that all behavior is ultimately a matter of choice, or (3) the well-founded belief that many troubled people are troubled because of "life-problems," not brain disorders. There will always be those who fear that to advocate biological explanations of behavior is to abandon psychological explanations and free will. The fear is that going down the biology path will lead to determinism, materialism, and the denial of responsibility for our actions. It is to abandon hope. It is to say you are doomed to be ill and you will always be ill. As a result, there will always be therapists who will defend their pseudoscientific and unscientific notions primarily by claiming that they are holistic, that they treat the mind and the body, that they are not reductionists and are therefore more humane and respectful of human dignity, hope, etc. They will point to their own satisfaction or to their satisfied customers as proof that their therapies "work." Their failures will be written off as due to either their patients' unwillingness to trust them and work with them, to interference from concerned family members, to incompetent earlier treatment by other therapists, or to delaying too long before seeking treatment, etc. Finally, there will always be journalists like Ariana Huffington who will recommend discipline, and decry treating children with drugs for thought disorders or behavioral disorders. Anyone who gets out of line should be punished. It's as simple as that for some simpleminded people.
Freud's biggest mistake?
Freud's biggest mistake may have been his focus on the irrelevant, on red herrings. The weird thoughts and actions of the "mentally" ill may not be not clues to anything except the personal history of the patient. If "mental" illnesses are physical illnesses, then the content of delusions will be of no value in understanding the nature of the illness. Focusing on bizarre beliefs or weird behavior is a diversion, however interesting and compelling. All the knowledge in the world about a patient's delusions regarding the C.I.A. or gender metamorphosis will be of absolutely no value in curing the patient. Such knowledge would be as useless as knowledge of the dreams of someone suffering from viral meningitis. Moreover, if the weird thoughts and actions are caused by a brain disorder or neurochemical imbalance, then talk therapy will be ineffective. The therapist and patient might as well talk about the weather. Actually, talking about the weather might be better, for then there would be some check in reality for the therapist's interpretations. Traditional psychoanalysis, however, is like being thrown into the world of Alice in Wonderland. What do the patient's thoughts and actions really mean? They mean whatever the therapist says they mean. In the final analysis, however, the therapist's interpretations may be meaningless to anyone seeking to discover the cause or proper treatment of "mental" illness.
Will history repeat itself?
In conclusion, one can't help but wonder whether the excesses of psychoanalysis will be matched by equally disastrous excesses from those who think that there is a drug for every problem. (Depressed? Here take some Prozac. No need to talk to you. No matter that your brother was recently murdered by your mother's boyfriend. You need a seratonin adjustment.) Will there be Personality Doctors in the future, prescribing designer drug cocktails in an attempt to satsify the customer's desire to change herself? (Cosmetic surgery to your left, Personality Adjustment to the right.) About the only thing that is certain is that whatever happens will mean full-employment for ethicists and critics such as Dolnick, as well as for those in the "helping" professions.
1 Many people got their first look at autism by seeing the movie Rain Man. Experts seem to agree that Dustin Hoffman's portrayal of Raymond, the autistic idiot savant, was essentially correct. Many autistics have strange abilities--at least they appear strange to the rest of us. Some can remember almost any date, or identify the day of the week of a particular date from the past. Some seem like human calculators. In addition, autistics are commonly devoid of affect and of have little sense of what others might be feeling. However, the likelihood that a traumatic experience in childhood is what triggers autism (suggested in the film) is not supported by the scientific literature. For an interesting account of what it is like to be autistic, one might read the work of Temple Grandin or Oliver Sack's account of her in the title essay of An Anthropologist on Mars. Despite her disorder, Grandin earned a Ph.D. and a university professorship at Colorado State. She has become a renowned expert in the handling of livestock bred for slaughter.
2 Many people got their first look at obsessive-compulsive disorder by seeing the movie As Good As It Gets. Jack Nicholson's portrayal of an OC has also been hailed as being essentially accurate, including his non-compliance with taking prescribed drugs and the improvement of his condition when he does take his meds.
Dawes, Robyn M. House of Cards - Psychology and Psychotherapy Built on Myth, (New York: The Free Press, 1994).
Dineen, Tana. Manufacturing Victims: What the Psychology Industry is Doing to People (Montreal: Robert Davies Multimedia Publishing, 1998).
Gold, Mark S. The Good News About Depression : Cures and Treatments in the New Age of Psychiatry (New York: Bantam Books, 1995).
Grandin, Temple. Emergence: Labeled Autistic (Warner Books, 1996).
Grandin, Temple. Thinking in Pictures : And Other Reports from My Life With Autism (Vintage Books, 1996).
Hines, Terence. Pseudoscience and the Paranormal (Buffalo, NY: Prometheus Books, 1990).
Jamison, Kay Redfield. An Unquiet Mind - A Memoir of Moods and Madness (New York: Vintage Books, 1997)
Kramer, Peter D. Listening to Prozac (Penguin, 1997).
Sacks, Oliver W. An anthropologist on Mars : seven paradoxical tales (New York : Knopf, 1995).
Singer, Margaret Thaler and Janja Lalich. Crazy Therapies (San Francisco: Jossey-Bass, Inc., 1996).
Storr, Anthony. Feet of Clay - saints, sinners, and madmen: a study of gurus (New York: The Free Press, 1996).
©copyright Robert Todd Carroll