* For historians of psychiatry who wrote 30 or 40 years ago—the last time anyone attempted an overview of the discipline—the story seemed relatively straightforward. First there were those wicked biological psychiatrists in the nineteenth century, then psychoanalysts and psychotherapists came along to defeat the biological zealots, establishing that mental illness resulted from unhappiness in childhood and stress in adult life. Freud’s insights opened a new frontier in our understanding of mental illness and little more needed to be said. Between the 1950s and the 1990s, a revolution took place in psychiatry. Old verities about unconscious conflicts as the cause of mental illness were pitched out and the spotlight of research turned on the brain itself. Psychoanalysis became, like Marxism, one of the dinosaur ideologies of the nineteenth century. Today, it is clear that when people experience a major mental illness, genetics and brain biology have as much to do with their problems as do stress and their early-childhood experiences. And even in the quotidian anxieties and mild depressions that are the lot of humankind, medications now can lift the symptoms, replacing hours of aimless chat. If there is one central intellectual reality at the end of the twentieth century, it is that the biological approach to psychiatry—treating mental illness as a genetically influenced disorder of brain chemistry—has been a smashing success. Freud’s ideas, which dominated the history of psychiatry for the past half century, are now vanishing like the last snows of winter. The time has therefore come for a new look.
* Part and parcel of European culture, the fateful notion of degeneration was picked up by the eugenists, by social-hygienists intent on combating mental retardation with sterilization, and by antidemocratic political forces with a deep hatred of “degenerate” groups such as homosexuals and Jews. Psychiatry’s responsibility for all this is only a partial one. Academic psychiatrists in the 1920s were not generally associated with right-wing doctrines of racial hygiene, though there were exceptions to this, such as the Swiss psychiatrist Ernst Rüdin who after 1907 worked at the university psychiatric clinic in Munich, and the Freiburg professor Alfred Hoche who in 1920 coauthored a justification for euthanasia. 101 Academic medicine in Germany on the whole stood waist-deep in the Nazi sewer, and bears heavy responsibility for the disaster that followed. After 1933, degeneration became an official part of Nazi ideology. Hitler’s machinery of death singled out Jews, people with mental retardation, and other supposedly biological degenerates for campaigns of destruction.102 The Nazi abuse of genetic concepts rendered any discussion of them inadmissible for many years after 1945. The notions of degeneration and inheritability became identical in the minds of the educated middle classes. Both were synonymous with Nazi evil. After World War II, any reference to the genetic transmission of psychiatric illness, whether as one factor among many or as inexorable degeneration, became taboo. The mere discussion of psychiatric genetics would, in civil middle-class dialogue, be ruled out of court for decades to come.
* The first biological psychiatry as a clinical approach died long before the Nazis. It was not necessarily discredited by research findings. That’s not the way paradigms change within medicine. People simply lost interest in brain anatomy once a new way of looking at psychiatric illness appeared on the horizon. The new approach saw illness vertically rather than cross-sectionally…
* Many histories of psychiatry see psychoanalysis as the end point of the story, the goal to which all previous events had been marching. Yet with the hindsight of half a century since Freud’s death in 1939, we are able to achieve a different perspective, in which psychoanalysis appears not as the final chapter in the history but as an interruption, a hiatus. For a brief period at mid-twentieth century, middle-class society became enraptured of the notion that psychological problems arose as a result of unconscious conflicts over long-past events, especially those of a sexual nature. For several decades, psychiatrists were glad to adopt this theory of illness causation as their own, especially because it permitted them to shift the locus of psychiatry from the asylum to private practice. But Freud’s ideas proved short-lived. In the longer perspective of history, it was only for a few moments that the patient recumbent upon the couch, the analyst seated silently behind him, occupied the center stage of psychiatry. By the 1970s, the progress of science within psychiatry would dim the lights on this scenario, marginalizing psychoanalysis within the discipline of psychiatry as a whole. In retrospect, Freud’s psychoanalysis appears as a pause in the evolution of biological approaches to brain and mind rather than as the culminating event in the history of psychiatry.
Yet it was a pause of enormous consequence for psychiatry. Freud’s psychoanalysis offered psychiatrists a way out of the asylum. The practice of depth psychology, based on Freud’s views, permitted psychiatrists for the first time in history to establish themselves as an office-based specialty and to wrest psychotherapy from the neurologists. Moreover, psychiatrists aspired to a monopoly over this new therapy. In the mind of the public, psychotherapy and psychoanalysis became virtually synonymous. If patients wanted one of the fashionable new depth therapies they would have to go to a psychiatrist for it, for the American Psychoanalytic Association initially insisted that only MDs could be trained as analysts, and later that only psychiatrists could be so. In retrospect, this insistence was bizarre, for psychoanalysis required no more medical training than astrology, and the attempt to impose a medical monopoly over Freud’s technique was a self-interested ploy to exclude psychologists, psychiatric social workers, and other competitors from the newly discovered fountain of riches.
Ultimately, psychoanalytically oriented psychiatrists were unable to preserve their monopoly. After the 1960s, all manner of nonmedical types demanded admission to the training institutes, for there was no intrinsic reason why professors of English could not do analysis as well as psychiatrists. Even worse, what had previously passed for the scientific basis of psychoanalysis began to collapse. It could not be simultaneously true that one’s psychological problems were caused by an abnormal relationship to the maternal breast and by a deficiency of serotonin. As evidence began to accumulate on the biological genesis of psychiatric illness, psychiatry began to regain the scientific footing it had lost at the beginning of the analytic craze: The brain was indeed the substrate of the mind. By the 1990s a majority of psychiatrists considered psychoanalysis scientifically bankrupt. Thus Freud’s model of the unconscious and the elaborate therapeutic techniques he devised for laying bare its supposed contents failed to stand the test of time. Accordingly, analysis largely vanished from psychiatry, discredited as a medical approach to the problems of mind and brain, although nonmedical psychoanalysis continued to flourish. The whole affair turned out to be the artifactual product of a distinctive era. Psychoanalysis failed to survive because it was overtaken by science, and because the needs that it initially met became dulled in our own time.
* In psychoanalysis by its very nature, doctor and patient communicate in the enterprise of soul-searching, creating the suggestion that one is being cared for emotionally. Thus psychoanalysis became popular initially because it filled a sentimental gap in the consultation. It offered a doctor-patient relationship in which patients basked in what they believed to be an aura of concern.
Numerous physicians other than Freud understood these psychological cravings, but Freud was the first to elaborate a therapy that would appeal to middle-class sensibilities, in particular to the desire for leisurely introspection. Yet his theories possessed a powerful additional resonance because, owing to his own ethnic origin and social position, he had privileged access to a group of patients who were especially needy in psychological terms: middle-class Jewish women in families undergoing rapid acculturation to West European values.
…Although by 1860 every city in Western Europe had a contingent of Jews, the Jews of Vienna were distinctive in constituting virtually the city’s entire middle class. Whatever circle one examines—journalists, bankers, businesspeople, academics—all had a significant Jewish component by the end of the nineteenth century. This tremendous preponderance of Jews in the middle classes reflected the great social progress the Jews of Europe had made since the end of the eighteenth century, when they lived largely sequestered in the small towns of Poland, Russia, and the Ukraine. As a result of the Jewish emancipation of the nineteenth century, the small-town Jews of the east flocked to the cities of the west, using the high-school diploma as a launching pad for careers in the liberal professions. In 1890, for example, 33 percent of students at the Vienna University were of Jewish origin.1 Fully one half of the professors of Vienna’s medical faculty were Jewish.2 As many as two-third’s of the city’s physicians were Jews.3 Thus, rather than being marginalized or scorned for his ethnic background as some have claimed, the young Sigmund Freud found in Vienna an intensely Jewish setting where he had every prospect of advancement through dint of hard work.
* The early analysts became well known for searching out sexual material. Viennese psychiatrist Emil Raimann, who knew Freud and his patients well, complained that Freud was able to persuade these complaisant and easily suggestible young women to say anything he wished them to. “The patients who consult Freud know in advance the information he wants to extract from them. These are patients who have let themselves be convinced of the causal significance of their sexual memories. Individuals in whom sexual motives play no role are aware that they would consult Freud in vain.” (Raimann noted that in working-class families in Vienna there was plenty of sexual contact, even incest, but no hysteria. Yet among the closely guarded young women of the city’s better families, where there was no possibility of sexual trauma, hysteria flourished.)
…[the Freudians were ] the only ones to offer a road map of how one got from sexual desire and repression of it to neurosis. On the basis of this map, psychoanalysis, a term Freud first used in 1896, would turn into a movements.17 It launched itself on the world as a group of doctrines comprising three main areas: study of the patient’s resistance to thoughts that attempted to press into the conscious mind from the unconscious; concentration on the causal significance of sexual matters; and an emphasis on the centrality of early childhood experiences.18 The core doctrine, from which Freud never wavered, was that neurotic symptoms represented a trade-off between sexual and aggressive drives and the requirements of reality.
* Freud was so intent on propagating his own views that, by turning psychoanalysis into a movement rather than a method of studying subrational psychology, he denied analysis the possibility of ever acquiring a scientific footing. The master’s insights were to become articles of faith, incapable of disproof. And the efforts of others to criticize Freud’s wisdom would always be considered evidence of “resistance,” of personal pathology, never as scientific hypotheses to be dealt with in the way that science treats all hypotheses. Alfred Adler fell away, as did Wilhelm Stekel, Freud’s physician-patient who had suggested establishing the Wednesday group in the first place. Such far-distant fans of analysis as the Zurich academics Carl Jung and Eugen Bleuler would soon turn heretic, as did later many others. The efforts of all these critical individuals to nudge Freud away from the bedrock of childhood sexuality on which he built his theories would fail. But a core of faithful remained. And it was these loyal captains who, in the belief that they possessed an inner truth, took psychoanalysis to the wide world.
* Did Freud and his followers really know these truths? Or were they simply self-suggesting one another into accepting highly dubious propositions as being somehow “confirmed”? Freud tended to see himself more as an adventurer than a scientist, once telling Fliess flatly, “I am actually not at all a man of science, not an observer, not an experimenter, not a thinker. I am by temperament nothing but a conquistador-an adventurer, if you want it translated—with all the curiosity, daring, and tenacity characteristic of a man of this sort.”20 His inner circle was rife with toadyism, for the other analysts were economically dependent on Freud for referrals. (He kept a pile of their calling cards in his drawer, and would dole them out to patients according to his whim.)21 “Freud never realized how much of a suggestive impact he had on his followers,” writes historian Paul Roazen, “and therefore could be led to think that his findings were being genuinely confirmed by independent observers.”22 The issue of validity would therefore haunt psychoanalysis until its eclipse within psychiatry.
* As psychoanalysis set out to take over psychiatry, therefore, it was with a doctrine that was therapeutically uncertain, intellectually highly speculative to say the least, and best adapted to the psychological needs of a deracinated group in transition: young middle-class Jewish women who aspired to be like their non-Jewish counterparts. It would be hard to imagine a therapy less appropriate for the needs of people with serious psychiatric illnesses.
* Given the intrinsic inappropriateness of psychoanalysis for psychiatry, there must have been some other force driving it forward in Europe than the power of the idea itself. That force was middle-class enthusiasm. Freud’s ideas proved tremendously popular among the educated classes as a codification of the kind of search for self-knowledge that had run through bourgeois culture throughout the entire second half of the century. Psychoanalysis was to therapy as expressionism was to art: Both represented exquisite versions of the search for insight.
* Regular psychiatrists were bemused at the grassfire spread of psychoanalysis within the middle classes. One physician at the Budapest psychiatric clinic tried to account for it along the following lines: “The flood of patients seeking salvation through psychoanalysis is explainable partly from the publicity, partly from the receptiveness of our time to introversion and introspection.” It was a procedure of obvious appeal to “hypersexual neurotics,” he said.31 Thus we have a core of physicians dubious, even contemptuous of “hypersexual neurotics” and their problems, and an educated middle class keening at the doctor’s office for further self-insight.
* What ultimately converted a chic therapeutic boomlet into a mass ideology shaping almost every aspect of American thought and culture was the Holocaust. In the 1930s, fascism drove many analysts who were Jewish from Central Europe to the United States, where they lent the strippling little American movement the glamour and heft of the wide world. On the face of it, this massive transfer of culture from the German-speaking world to the English had positive results for psychoanalysis, reinforcing the homespun American heterodoxy with the prestige of internationally acclaimed figures.81 In the long run, however, the migration of the European analysts proved fatal for psychoanalysis in the New World, for the refugees brought with them a stifling orthodoxy, a reflexive adherence to the views of Freud and his daughter Anna that American analysis was never able to outgrow and that ultimately caused, within medicine at least, its death from disbelief.
* American psychiatry before World War II was biological psychiatry and within a few years after the war it was largely a psychoanalytical psychiatry.
* From the viewpoint of the history of psychiatry, the vicissitudes of the Jews in the Old World and New were a matter of capital importance. The common theme linking the misadventures of psychoanalysis on both sides of the Atlantic was the desire of recently acculturated middle-class Jews for some symbol of collective affirmation. Although Freud sought mightily to downplay any kind of ethnic specificity in psychoanalysis, the subtext of Freud and his followers to the non-Jewish charter culture was: We Jews have given this precious gift to modern civilization.
Why would Jews need such a symbol any more than any other ethnic group? In the history of modern times, Jewish people have had to endure not just one but two great shocks. Every people that undertakes the long journey from small-scale life in the traditional village to middle-class life in the big city undergoes one major shock: the shock of assimilation and integration, the psychological upheaval that goes with newness of arrival. In their move from shtetl life in the small towns of eighteenth-century Poland and the Ukraine to such bustling cities as Berlin, Frankfurt, and Vienna, the Jews underwent this shock just as everybody else did.
But then a second shock lay in store for the Jews, the Holocaust, and the forced transplantation of hundreds of thousands of individuals who themselves had only recently become middle-class, from a comfortable and bourgeois European existence to the nightmare of scrambling for a passage to America. This second shock was experienced by no other cultural group.155 It profoundly shaped the desire of the American Jews for some kind of a special symbol of self-affirmation, a collective badge of pride in the chaos of the living city. That symbol, I argue, was psychoanalysis.
At the turn of the twentieth century, the Jews of Central Europe were experiencing the cultural confusion of a massive deracination. Between the 1860s and 1900, countless numbers of people were torn from the ghettoes and shtetls of Eastern Europe, without becoming as yet newly rooted among the middle classes of the West. Many of the Jews of Berlin and Vienna had left their religion behind and were rapidly trying to assimilate by changing their names and by converting to Protestantism (less so to Catholicism). Yet despite their best intentions, despite their knowledge of the plays of Schiller and of the refinements of the German language, they encountered a baffling wall of anti-Semitism. There was something about psychoanalysis that made it, according to historian John Cuddihy, a “plausible ideology for [a] decolonizing people.”156
Jewish patients with psychoneurosis were therefore drawn to it. Perhaps psychoanalysis was seized upon because it extended the possibility of finding one’s identity from within, as opposed to the external signposts that orthodox Judaism offered. And it may have appealed to Jewish women in particular. Perhaps these cloistered but well read and highly curious women—members of a “middle-class drenched in spirit” in the words of Viennese novelist Robert Musil—were simply more self-reflective, more psychologically minded that the women of the non-Jewish lower-middle classes below them who worked alongside their husbands in shops, or the women of the nobility above, busy with the social whirl of the salon.157 Or perhaps Jewish men and women alike adored psychoanalysis because it was “our thing.” In any event, psychoanalysis in the early days had a very specific social address.
It was above all among the middle-class Jews of Berlin, Budapest, and Vienna that psychoanalysis proved such a hit. Historian Steven Beller finds the Jews of Vienna, as outsiders, using psychoanalysis to “make a political attack on Viennese society by an alliance of scientific rationality with instinct” against the city’s traditional sensual baroque culture.158 In Budapest, there were descriptions of psychoanalysis in the Jewish quarter, the Leopoldstadt, as an almost “incomprehensible and impenetrable secret doctrine or ceremony….”
Historian Paul Harmat concludes, “Psychoanalysis was most popular among enlightened Jewish circles as a result of their minority situation.” 159 Of course, non-Jews had recourse to analysis as well. Yet among patients, there seems to have been a kind of Jewish tropism. The analysts themselves also tended heavily to be Jewish, and many of them assumed that Jewishness helped one to appreciate Freud’s wisdom fully. As Freud said in 1908 to the Berlin analyst Karl Abraham, on the occasion of a malentendu with Carl Jung (then one of the few non-Jews in the movement), “Please be tolerant, and don’t forget that it is actually easier for you than for Jung to follow my ideas … because you stand closer to me as a result of racial affinity, while he, as a Christian and son of a pastor, finds the way to me only in the face of great inner resistance.” On another occasion, Freud reassured Abraham, “May I say that what attracts me to you are our related, Jewish characteristics. We understand each other.”160 Freud’s inner circle was almost entirely Jewish, and Ferenczi said to Freud of the one non-Jewish member, the Londoner Ernest Jones, “It has seldom been so clear to me as now what a psychological advantage it signifies to be born a Jew…. you must keep Jones constantly under your eye and cut off his line of retreat.”161
Within the middle-class Jewish public, psychoanalysis became signposted as belonging to some larger Jewish worldview. Humorist Salomo Friedländer, writing in the 1920s under the pseudonym “Mynona,” made analysis the portal through which Christians who wanted to convert to “true Judaism” must pass. In one tale Friedländer allows the wildly anti-Semitic Count Reschock to fall in love with the beautiful Rebecka Gold-Isak. Losing his bearings completely, the Count decides to convert to Judaism to win his prize. Rebecka insists that he must become truly Jewish before she will accept him. The Count’s first step on the path of a Jewish identity is an analysis with Professor Freud. “This destroyer of fig-leaves,” as Friedländer termed Freud, “robbed the noble Reschok soul of its protective coat with such anatomical certainty that the Count fell with a cry into the arms of his alarmed servant.” (Reschock goes on to have a famous surgeon convert him from a blonde Prussian warrior into a “Jewish Torahstudent.”) 162 Jewish and non-Jewish readers alike found the Friedländer fable delicious, yet accepted implicitly its premise that psychoanalysis was identified with Judaism. If psychoanalysis is written as a history of ideas, these social themes are unimportant. But if we try to understand its rise and decline as a movement, the singular tropism that many Jews felt toward analysis, both as doctors and patients, is of considerable significance.
With the passage of time, in Europe at least, psychoanalysis lost its Jewish stamp. Although it had originated among the Jews of Vienna and Berlin, as it developed, it ceased to be their property. There was certainly no Jewish tropism among the chief physicians of the many private clinics that offered psychoanalysis. And in Switzerland and England, psychoanalysis was known to be a specifically non-Jewish affair. As Swiss psychiatrist Max Muller commented of the 1920s, “It was characteristic of the psychoanalytic movement in Switzerland that, unlike other countries, it did not consist predominantly or almost exclusively of Jewish physicians and lay-analysts.”163 And the two most prominent advocates of analysis in Switzerland before 1914—Eugen Bleuler and Carl Jung—were if anything anti-Semitic. (It is perhaps indicative of the mood of the Bleuler household that, upon discovering that Viennese psychiatrist Erwin Stransky was Jewish, Bleuler’s wife expressed great astonishment and said, “Well then you must at least have an aryan soul in you.”)164 Commenting on the plethora of Jews in psychoanalysis generally, Ernest Jones noted, with relief, that apart from the refugees, “in England … only two analysts have been Jews.”165 Before 1933, a number of Jewish physicians figured prominently among the opponents of analysis.
After 1933, all this changed. As a movement, analysis in Europe was destroyed. Its main representatives who fled to the New World were Jews. For these battered and profoundly disoriented survivors, psychoanalysis became one of the Jewish accomplishments that could be presented to the host population as a ticket of entry. Among the refugee Jews, both physicians and nonphysicians—psychoanalysis became a badge of Jewish solidarity in the face of a population of Anglo-Saxons perceived to be racially hostile, psychologically insensitive, and culturally backward. Said Martin Grotjahn of his fellow emigré analysts, “Psychoanalysis symbolized for them the light of the Old Country to be carried to the New Country.”167 But it was a light that Jews had created, and in whose warmth they would bask for several decades.
The American Jews had not experienced the trauma of emigration. Yet they too had arrived as outsiders, and as psychoanalysis acquired new prestige in medicine after the Second World War many Jewish physicians and patients alike were drawn to it as a symbol of collective self-affirmation: This is what we have created. By it we shall become better and in doing so bring enlightenment to others.
After 1945, American Jews took on psychoanalysis as a kind of mission civilisatrice, a healing gift to all the world, which is not at all an overwrought formulation considering the prose with which Jewish analysts themselves described their mission to humanity. How things have changed for us, Franz Alexander assured his colleagues in 1953, “as soon as all that you professed is accepted and the world is asking you sincerely and avidly to explain the new truth. They turn to you now: ‘Please tell us all about it. How does the new knowledge help us, how can we use it constructively to cure a neurotic or psychotic patient … to alleviate social prejudice and international tension, and to prevent war.’”168 Is it any wonder that Jews themselves would preferentially have recourse to this new knowledge?
Why had psychoanalysis spread so rapidly after World War II? asked psychologist Seymour Sarason. “Most analysts (and a significant portion of the psychiatrists who received training during the war years) were Jewish. For them, Hitler and fascism were not abstractions but threats to existence. And for them, Freud represented a Moses-like figure whose contributions had opened up new vistas about the nature of humans….” 169 For Sarason and Alexander, Jews were a gifted but marginal population, still ill at ease and unintegrated.
Surveys establish the extent to which Jewish physicians predominated in the practice of psychoanalysis. In 1959, two researchers drew up a profile of psychiatrists who believed in psychoanalysis: Eighty percent of them were of Jewish origin and tended to be upwardly mobile, insight-oriented, and deracinated (in contrast to the biologically oriented psychiatrists in the sample, who tended to be mainly Protestant). On a number of characteristics, the psychoanalytically inclined Jewish psychiatrists stood out from the non-Jews: They were agnostic, as opposed to the organically oriented Protestant psychiatrists who retained some shreds of their religious faith. They were more leftist, and they were more aware of the importance of social class, as opposed to the Protestant group who were somewhat embarrassed by the subject.170 When Arnold Rogow quizzed a sample of 35 psychoanalysts and 149 nonanalyst psychiatrists in 1965, he found 26 percent of the analysts willing to declare they were Jewish; a further 17 percent were willing to say they had Jewish mothers; a third were unwilling to say anything about religious affiliation. (By contrast, the figures for the nonanalyst psychiatrists were lower in all three categories.)171 On the basis of these statistics, it is fair to infer that a majority of the practitioners of psychoanalysis were of Jewish origin though of course numerous non-Jews entered the field as well. How about patients? It seems to be the case that Jews overconsume most psychiatric services in proportion to their numbers in the population. This is certainly true of psychoanalysis. In Rogow’s study, one third of the analysts said they had practices consisting heavily or overwhelmingly of Jews.172 A variety of other studies revealed the same finding in other ways.173 Most dramatic perhaps was a random, nationwide survey of the adult American population in 1976, which found that 59 percent of Jewish respondents had at some point in time received psychotherapy (in contrast to the non-Jewish help-seeking rate of 25 percent).174 In other words, more than half of all American Jews had sought out psychotherapy at a time when psychotherapy was overwhelmingly psychoanalytically oriented. It is not stretching the facts to refer to psychoanalysis in the middle decades of the twentieth century as a kind of Jewish “our thing.”
* Yet since Jews are under discussion here, this might be the place to mention the role that the loss of a social base appears to have played in the plunging popularity of analysis. In my opinion the main source of this loss was the increasing social assimilation of the American Jews. They no longer required psychoanalysis as a badge of collective identity because they were no longer affirming themselves. Instead they were becoming like everyone else.
* Yet a handful of intellectuals in particular became identified with the antipsychiatry movement.130 And the force of their ideas brewed up a mass hostility to the advance of biological thinking within psychiatry. The movement’s basic argument was that psychiatric illness is not medical in nature but social, political, and legal: Society defines what schizophrenia or depression is, and not nature. If psychiatric illness is thus socially constructed, it must be deconstructed in the interest of freeing deviants, free spirits, and exceptional creative people from the stigma of being “pathological.”131 In other words, there really was no such thing as psychiatric illness. It was a myth.
Although antipsychiatry movements had flourished throughout the nineteenth century, their late-twentieth-century rebirth began with the virtually simultaneous publication in the early 1960s of a series of exceptionally influential books on psychiatry. Most famous perhaps of these was Michel Foucault’s Madness and Civilization, published in 1961 (see p. 276), which argued that the notion of mental illness was a social and cultural invention of the eighteenth century. Yet there were several other blockbusters, and collectively they became the intellectual springboard from which the theorists of deinstitutionalization of the late 1960s would launch themselves.
Earliest of the founding fathers—they were all men—was Thomas Szasz, a Budapest-born psychoanalyst, who had trained just after World War II in Chicago. When called to active service in the Navy in 1954, Szasz, who was then 34, used the time to put down on paper a notion that had long troubled him, that mental illness was in fact a “myth,” a medical misapprehension foisted on individuals who had problems in living. In his 1960 book The Myth of Mental Illness, he called the whole notion of psychiatric illness “scientifically worthless and socially harmful.”132 The book enjoyed wide currency and the American intellectual class began asking, if there is no such thing as mental illness, how can we justify locking people up in asylums?
* The works of Foucault, Szasz, and Goffman were influential among university elites, cultivating a rage against mental hospitals and the whole psychiatric enterprise. Yet the book that did most to inflame the public imagination against psychiatry was a novel written by Ken Kesey. Kesey had just finished taking a creative writing course at Stanford when he volunteered for government LSD experiments conducted at a veterans administration hospital at Menlo Park. He stayed on to take a job as an orderly at the hospital. Out of this experience came his 1962 novel One Flew Over the Cuckoo’s Nest, a book that formed the image of psychiatry for an entire generation of university students. Kesey’s notion of psychiatric illness was embodied in the novel’s antihero, Randle McMurphy…
By the end of the 1960s, the antipsychiatric interpretation of “so-called psychiatric illness” had gained the catbird seat among intellectuals both in the United States and Europe. In these circles, a consensus had formed that the discipline of psychiatry was an illegitimate form of social control and that psychiatrists’ power to lock people up must be abolished with the abolition of institutionalized psychiatric care, Pinel’s therapeutic asylum.
Even though these interpretations were very popular among college students and intellectuals, actual patients found them less convincing. Joanne Greenberg, author as “Hannah Green” of I Never Promised You a Rose Garden, had a real psychiatric illness. She hated the Kesey book. She later said, “Creativity and mental illness are opposites, not complements. It’s a confusion of mental illness with creativity…. Craziness is the opposite [of imagination]: it is a fort that’s a prison.”
* Long before the rise of the antipsychiatry movement, the destruction of the asylum had begun. Patients were to be returned to “the community.” That the very phrase now turns to ashes in one’s mouth is evidence of one of the greatest social debacles of our time.
* Midst this horrendous publicity for psychiatry, on which the antipsychiatric movement would later feed, several basic realities were obscured. One is that most patients younger than 65 were discharged relatively rapidly from mental hospitals: They did not experience prolonged stays to say nothing of lifelong incarceration. In the years 1946 to 1950 at Warren State Hospital in Warren, Pennsylvania, almost 80 percent of all patients under 65 were released within five years.144 Second, much of the bizarre posturing and disordered movement that Deutsch and later antipsychiatric writers ascribed to “hospitalism,” meaning the iatrogenic results of institutionalization, turned out to be an inherent biological feature of such illnesses as schizophrenia that, in affecting the entire brain, affect the entire nervous system as well.145 Third, even though conditions in mental hospitals were unsettling enough, there were worse alternatives. One was being tossed to the mercy of the streets.
* In the United States, the number of patients in state and county mental hospitals declined from its historic high of 559,000 in 1955 to 338,000 in 1970, further to 107,000 in 1988, representing a decrease over the 30 year period of more than 80 percent.148 The red bricks lost four-fifths of their patients. In 1955, 77 percent of all psychiatric “patient care episodes” occurred in mental hospitals, in 1990 only 26 percent. Amplifying the shift was a fivefold expansion in the total volume of care in mental-health organizations over that period, from 1.7 million episodes in 1955 to 8.6 million in 1990.149 This was a shift in the locus of care virtually without precedent in the history of medicine.
* Reducing the threshold of what constitutes psychiatric illness was partially doctor-driven, partially patient-driven. Psychiatrists have an obvious self-interest in pathologizing human behavior and have been willing to draw the pathology line ever lower in their efforts to tear as much counseling as possible away from competing psychologists and social workers.
* Ignoring the perils of school-teacher psychiatry, educational professionals grasped gratefully for this new pathologizing of boyhood. In 1968, “hyperkinetic reaction of childhood (or adolescence)” entered the official nomenclature, supposedly manifest in restlessness and distractibility.5 In 1980, this became officially known as “attention deficit disorder with hyperactivity.” 6 It is still unclear whether there is some core group of those diagnosed as “ADD” who have a real organic disorder. The point, however, is that medical therapy for it could be done only by MDs, prescribing an amphetamine-like compound called “Ritalin” (methylphenidate). By 1995 doctors were writing 6 million prescriptions for Ritalin a year, and 2.5 million American children were on the drug.7 This is one way of maintaining market share. Since ancient times, both boys and girls have become anxious about scary stories. Yet it would have occurred to no one across the centuries to give psychiatric diagnoses to these anxieties about fantasms, not at least until the advent of “posttraumatic stress disorder” (PTSD), a syndrome initially associated with the trauma of combat (see pp. 304-305). Whether a distinctive veterans’ psychiatric syndrome involving stress actually exists is unclear. But even if it exists, once PTSD became inserted into official psychiatric lingo, the popular culture grabbed it and hopelessly trivialized it as a way of psychologizing life experiences. By 1995, therapists were talking about “PTSD” in children exposed to movies like Batman. According to one authority, 80 percent of children who had watched media coverage of a crime hundreds of miles distant exhibited symptoms of “posttraumatic stress.”8 The anxieties of the children themselves were nothing new under the sun. New was psychiatry’s willingness to persuade parents that the quotidian problems of maturation represent a distinct medical disorder. The boundaries of what constitutes depression have been expanded relentlessly outward.
Depression as a major psychiatric illness involving bleakness of mood, self-loathing, an inability to experience pleasure, and suicidal thoughts has been familiar for many centuries. The illness has a heavy biological component. Depression in the vocabulary of post-1960s American psychiatry has become tantamount to dysphoria, meaning unhappiness, in combination with loss of appetite and difficulty sleeping. Thus it comes as no surprise that the incidence of depression so defined has been rising steadily and occurring at ever younger ages.9 In 1991, the National Institute of Mental Health began organizing a “National Depression Screening Day,” in the context of its “Mental Illness Awareness Week.” Such programs encourage family doctors to diagnose depression more often in their patients and refer them to psychiatrists. Although this is partly legitimate—a missed major depression may result in a patient’s suicide—the ultimate effect is psychiatric empire-building against other kinds of care. Indeed, the American Psychiatric Association jubilates over “record numbers” each year.10 As a consequence of this continual hammering of the depression theme, depression has become the single commonest disorder seen in psychiatric practice, accounting for 28 percent of all patient visits.11 (The availability of drugs such as “Prozac,” said to be specific for an entire “spectrum” of affective disorders [see pp. 323-324], has doubtless contributed as well to increasing the diagnosis of depression: Physicians prefer to diagnose conditions they can treat rather than those they can’t.) Personality disorders have become a whole sandbox for empire building.
Although the concept of a disorder of the personality—in which everybody suffers but the patient—remains scientifically rather murky, in practice imputed personality disorders have taken off. Diagnoses such as antisocial personality disorder arose preferentially in private psychiatric practice and were virtually unknown in other medical settings.12 Multiple personality disorder (MPD) roared in from obscurity to become epidemic in the 1980s.13 Other so-called disorders of personality represented merely the exaggeration of familiar character traits. Yet the entire notion of giving patient-status to people because they are troublesome to others represented a pathologizing of essentially normal if irksome behavior. Thus these diagnoses of personality, as well as the other ballooned disease labels, dipped greatly the threshold at which individuals were said to be ill.
* Leaders in the field started speaking of “minor depression, mixed anxiety-depression, and mild neurocognitive disorder as … conditions that may deserve consideration as separate categories.” The notion of “subthreshold symptoms” gained currency as a means of reaching out to “previously subthreshold patients.”14 This is the language of empire-building and market-conquest. The evidence that these conditions represent diseases, or disorders, in the sense that mumps and major depression are disorders, is extremely slim. In insider discussions, psychiatrists were perfectly frank with one another about shifting the focus from disease to unhappiness.
* In the 1990s, psychiatry was being bent out of shape by a colossal kind of failure-to-fit. Psychiatrists had been trained for one thing and ended up treating another. They had trained as residents to treat the major psychiatric illnesses. But once in office practice, they gravitated to the commoner and more lucrative psychoneuroses. In doing so, they found themselves in direct competition with the social workers and psychologists. Rather than returning to the main psychiatric diseases, the terrain of choice of biological psychiatry, they went in the opposite direction, expanding the definition of illness to include behavior and symptoms previously reckoned as “subthreshold,” and catering to the great American public’s demand for psychotherapy in dealing with problems of living.
* Increasingly, the view became accepted that psychoanalysis was not for illness but for the interior voyage. While insisting that psychoanalysis was still valid therapy for “the major psychoses,” analyst Robert Michels decided to take a more embracing stance: The discipline was ideal for “the optimalization of experience and the enhancement of sensitivity.”96 Indeed, said critic Adolf Grunbaum, picking up on comments that Michels had made elsewhere, analysis was most akin to “an edifying experience of the kind provided by, say, a season ticket to the opera.”97 From Studies in Hysteria in 1895 to a ticket to the opera in 1994: what an odyssey! By the mid-1990s, psychoanalysis had by no means gone out of fashion among intellectuals, and it was a rage in many departments of languages and sociology. In 1994, the University of Dublin began offering an undergraduate arts degree in psychoanalysis. 98 The late-twentieth-century trajectory of psychoanalysis had carried it beyond the discipline of psychiatry and into the ether of arts and letters where, however it fared, it would no longer be identified as a privileged treatment for psychiatric illness.
* American psychoanalysis had always exhibited strenuous resistance to the collection of data on the outcome of therapy.
* “There is virtually no evidence that therapies labeled ‘psychoanalysis’ result in longer-lasting or more profound positive changes than approaches that are given other labels and that are much less time-consuming and costly.”