The Death of Freud and the Rebirth of Psychiatry
Jul 17, 2000, Vol. 5, No. 41 • By PAUL R. MCHUGH
The condition of psychiatry today can be compared to that of Russia after the fall of communism. Like Russia after Marxism, psychiatry after Freudianism has lost its once dominant doctrine. Like that vast nation attempting to operate under a rudimentary capitalism, psychiatry now labors under the sway of a classificatory system, The Diagnostic and Statistic Manual of Mental Disorders (DSM-IV), so crude as to foster inept educational programs and clumsy clinical practices. Just as Russia searches for a structure to replace communism, so psychiatry, with Freudianism in ruins, struggles to find a coherent concept of the mental disorders and the best way to treat them.
Surveying this confusing scene, the anthropologist T. M. Luhrmann has produced Of Two Minds: The Growing Disorder in American Psychiatry, a bleak assessment of contemporary psychiatric education. Casting her eye on the "enculturation" of young psychiatrists into their profession, she argues that the recent discoveries in biomedicine, which the public may think are great advances, have in fact plucked the "soul" from psychiatry, leaving it a cold business that dispenses magical pills rather than addressing patients in all their tragic particularity.
Much of Luhrmann's criticism is dead-on target, and it is useful to have it said in this public way. Unfortunately, she concludes that the answer is a return to Freudian psychoanalysis. It is as though, after visiting Russia, an anthropologist decided the country had made an enormous mistake in abandoning Marxism. Luhrmann misleads for two reasons: She slights the history of psychiatry, aspects of which explain both its problems and its promise; and, more important, she neglects fundamental issues of method, particularly those of assessing, differentiating, and understanding patients, from which therapeutics emerge. Thus, Luhrmann fails to see that the present, with all its shortcomings, is actually auspicious, a stage in the development of psychiatry where, even amid the rubble, it is possible to discern the foundations of progress.
I began my own career in psychiatry in the 1950s, in the middle of what historian Edward Shorter called "the hiatus," the generation-long period, roughly from 1935 to 1975, when Freudianism was the unchallenged doctrine of American psychiatry. During the hiatus, psychiatry ceased to grow as a science-based, evidence-driven discipline.
As medical students, my classmates and I were taught that psychoanalysis had revealed that mental disorders differed only in degree rather than in kind. Mental disorders were invariably the consequences of mishandled early-life conflicts of a sexual nature -- universal experiences varying in severity. We were taught that particular symptoms identified the character of those conflicts; no other evidence was needed because the "symptoms tell the tale." Compulsiveness and perfectionism denoted over-forceful toilet training in infancy, anxiety was the product of the childhood discovery of anatomical differences between boys and girls, and paranoid suspicions gave evidence of repressed homosexual conflict.
We were also taught that these early conflicts and pathogenic events were masked by repression but alive in the "dynamic" unconscious, shaping our mental life. Because sexual conflicts in infancy were universal, no real distinction existed between us students and the patients. We were taught that if our society altered its methods of child rearing and attitudes toward sex, mental disorder would diminish and all would be well. A brave new world seemed to be dawning.
At the same time, we students noted that the psychiatric wards differed radically from other medical wards, like neurology, cardiology, and surgery. The most obvious difference was that on the psychiatric wards not only the patients but most of the staff were in therapy. Again, this practice was prompted by the theory that psychiatrists and patients differed only in degree of disorder. Young psychiatrists were told to think of themselves as "little messes" caring for "bigger messes." Their supervisors encouraged this idea.
With most doctors, nurses, social workers, and even office personnel in therapy, the libidinal mini-dramas of everyone's encounters with his or her therapist became a topic of gossip within psychiatric centers. Certain psychoanalysts (particularly those who claimed close descent from Freud and retained the accents of old Vienna) dominated these centers and frequently used the political power that came from knowing many secrets to advance their favorites and banish their foes.