The Bactra Review: Occasional and eclectic book reviews by Cosma Shalizi   97

Madness on the Couch

Blaming the Victim in the Heyday of Psychoanalysis

by Edward Dolnick

New York: Simon and Schuster, 1998

Mad, Bad, and Dangerous to Be Treated By

This book chronicles the attempts of psychoanalysts, mostly in America from the 1940s through the 1970s, to explain and treat three serious mental illnesses.

Dolnick opens with background on Freud and psychoanalysis in general, and Freud's ideas about psychoses in particular --- generally, he thought he understood them, but couldn't treat them. These are followed by two chapters describing how psychoanalysis, originally a rather grim, deterministic Central European lebensphilosophie became an optimistic technique for pursuing happiness by consulting experts, and (not just in that way) as American as apple pie. Then Dolnick plunges us into the three diseases: schizophrenia, autism, and obsessive-compulsive disorder. These are life-crippling and rather common conditions (the lifetime incidence of schizophrenia is about one percent, for instance). The psychoanalysts tackled their etiology with less care than is typically lavished on blocked drains. Overwhelmingly, they blamed their patients' diseases on their families, most especially and repulsively on their mothers. At best, their attempts at treatment did nothing for their patients, and positive, definite harm to both patients and families was not uncommon. Nor is Dolnick talking about the fringes, about the quacks who always have and probably always will congregate about the edges of medicine, flogging ``great and desparate cures''; these were highly respected and heavily imitated psychiatrists at major hospitals, university department heads, and so on. The generally accepted theory of obsessive-compulsive disorder (though not the other two) was propounded by Freud himself.

I'm a fairly hard-core reductionist, but not even I would rule out, a priori, that major mental illnesses could be due to really bad upbringing: as the poet sings, ``They fuck you up, your Mum and Dad.'' But, in its specifics, this is testable. Are the mothers of schizophrenics significantly more given to ``I wouldn't join any club that would have me as a member'' attitudes? (Thus the fantastic ``double bind'' theory of the equally fantastic Gregory Bateson, which still has adherents --- among novelists.) Are the parents of autistic children especially cold and refrigerator-like? Did obsessive-compulsives have particularly difficult toilet-trainings? These are not especially easy tests to run, but they're not rocket science or particle physics either. The only people who asked them, at least in ways which were not patently asinine (e.g., ignoring control groups, or generalizing from seventeen highly non-random samples) were those skeptical of psychoanalytic explanations, and they were not exactly rewarded for their pains. The answers to those questions, not so incidentally, were all No.

Even if shrinks were wrong about etiology, the could have been right about treatment --- and vice versa, of course. This again brings up a host of questions (does schizophrenia respond better to talking cure than to medication? than to mere hopsitalization? which talking cure?) which are not trivial, but, again, not impossible to ask in a reliable way either. Once again, the answer is No --- talking cures, of every description, are no better than no treatment at curing any of the diseases Dolnick discusses. (About a third of untreated schizophrenics recover spontaneously.) Nothing seems to have any affect on autism; chemical therapies work on schizophrenia, and chemical and behavioral therapies on OCD --- which is not to say that there's no point to counseling patients. (Let me go on record now that, if I go mad, I would really, really like to get drugged as soon and as thoroughly as possible.)

The shrinks, then, were wrong on both the areas where they claimed --- and were accorded --- authority. The best that can be said about them is that, for the most part, they meant well by their patients, though there were some spectacular exceptions (see ch. 6, and chs. 10--11 on Bettleheim). Their attitude towards their patients' families, especially their mothers, was on the other hand simply disgraceful.

It's natural to ask, at this point, ``How did this happen? How did we turn over so much authority over helpless persons to those with no valid claim to that authority?'' Alas, that's most of the story of medicine in a nutshell. The surprise is that things got better. This, unfortunately, is not a story that Dolnick tells in sufficient detail, perhaps because he's doing intellectual rather than social history. About the rise and progress of psychoanalytic ideas, their eventual debunking, and the modern, ``biological'' approaches to etiology and treatment, he is extremely lucid. About the implementation of these ideas, however, especially about the displacement of psychoanalysis by things that worked, he is much less clear. Given that psychoanalysts had a very strong institutional position in American psychiatry, how did new ideas about treatment (e.g. drugs) and causation (e.g. the results of adoption studies on schizophrenia) come to new generations of psychiatrists? What was the role of the parents who were being told that they were responsible for their childrens' mental illnesses? The parents of autistic children organized, but what did this accomplish, and why didn't the parents of schizophrenics do likewise? What role did the insurance companies play in all this? In fairness to Dolnick, answering these questions adequately would probably require another book, or at least one or two hundred pages added to this one.

The etiologies of these diseases remain obscure. Something is clearly wrong biochemically, except perhaps for autism, which looks more neurodevelopmental. These disorders are equally clearly heritable --- identical twins of schizophrenics, raised apart, have a 50 percent chance of being schizophrenic themselves, not the 1 percent chance of the general population --- but equally clearly it's not entirely genetic (otherwise the odds of one twin being schizophrenic when the other is would be 100 percent, just as with other inherited diseases). An intruiging but still very speculative suggestion is that what is inherited is susceptability to some fairly common and otherwise minor viral infection. (One of the arguments is that these diseases greatly lower reproductive fitness. If they were purely genetic, therefore, there'd be strong natural selection against those genes, and we should see them at the very low frequency of conditions like cystinosis, which isn't the case.) However that may turn out, the evidence that these diseases spring from malfunctions in the brain at a fairly low level is now quite compelling.

This is a thoroughly ugly story, told, as it should be, with understanding, clarity, compassion, and an appreciation of the place of farce in tragedies. The obvious and entirely correct moral to draw of the story is that insanity is too important to be left to psychoanalysts, but I want to draw two more. The first is for us intellectuals: no matter how compelling an idea may be, no matter how many riddles it seems to answer, check it out. This should go without saying, but it does not. The second is for those who depend on experts: it is perfectly possible for an entire disciplinary community to be completely off its rocker about key subjects for decades, even though it is large, well-respected and chock-full of clever people. But of course we are not wed to any serious and malign stupidities.

368 pp., 17 black-and-white photos, frontispiece of Dürer's Melencolia I, end-notes, bibliography, analytical index of names, subjects and titles
North America / Psychoanalysis
Currently in print as a hardback, ISBN 0-684-82497-3, US$. LoC RC506 D63
19 October 1999. Thanks to Momand Shalizi