By NATALIE ANGIER
One of the most miserable experiences of my young adulthood, in the mid-1980s, was the year I spent in formal Freudian psychoanalysis. How well I remember lying on that uncomfortable couch with its built-in simulacrum of a pillow, as I struggled desperately to just “let my mind go,” to free associate, to disinter childhood memories or impulses that might prove remotely useful to me or at least satisfy my psychiatrist, who often seemed to be picking distractedly at lint on her skirt. She was a brilliant woman, no doubt about it, yet I always left her office feeling like a failure, and the science writer in me couldn’t help wondering, Where is the clinical evidence that this excruciating and expensive ordeal really works?
As Jeffrey A. Lieberman, chairman of psychiatry at the Columbia University College of Physicians and Surgeons, makes clear in his chatty, expert, sometimes scathing but ultimately upbeat account of the history of psychiatry, the evidence, quite simply, doesn’t exist. Whether for the treatment of relatively mild afflictions like my dysthymia, or for serious conditions like bipolar disorder, schizophrenia or depression, psychoanalysis never had much, if any proof of efficacy. Yet the Freudian conceit that repressed desires and conflicts were the source of mental illness, and that talking those urges out of hiding could lead to a cure, dominated American psychiatry for over half a century, Lieberman says, stranding the field in “an intellectual desert” from which it has only recently emerged. “Sigmund Shlomo Freud,” Lieberman writes, was “simultaneously psychiatry’s greatest hero and its most calamitous rogue.”
Lieberman recognizes that many people remain skeptical about his specialty and uncomfortable with the notion of mental illness generally. It’s one thing for somebody to suffer from a malfunctioning of the body’s infrastructure, like thyroid disease or appendicitis. But mental illness targets the mind, the seat of the self, and its symptoms are often disguised as personal defects — laziness, weakness, a bad attitude. Lieberman tells the story of an unidentified celebrity and his wife, who brought their Yale-student daughter to him for advice. The daughter had been behaving erratically, skipping classes, accusing her sorority sisters of theft, insisting to a professor that James Joyce was speaking to her in code. After a lengthy interview and a series of medical tests and scans to rule out alternatives, Lieberman concluded that the daughter suffered from schizophrenia and recommended she be hospitalized for her initial treatment. The famous father was indignant, insisting, “She doesn’t need to be locked up in a hospital, for God’s sake. She just needs to buckle down and get her act together!” Despite parental balking, the daughter spent three weeks in the hospital, where she was prescribed the antipsychotic drug risperidone along with cognitive and group therapy sessions, and her condition improved dramatically. Yet after her release, Lieberman said, her parents’ skepticism again took hold, the daughter received no further outpatient treatment and she very likely relapsed into psychosis.
One in four people will suffer from mental illness at some point in life. “You are more likely to need services from psychiatry than from any other medical specialty,” Lieberman notes. And those services are ready and able. “For the first time in its long and notorious history,” he adds, “psychiatry can offer scientific, humane and effective treatments” to combat most mental disorders. If public wariness persists, Lieberman says, perhaps psychiatry itself is to blame — for not coming clean about the sins of its past, and for failing to elucidate how the profession has changed.
In “Shrinks,” he takes on both tasks. He describes psychiatry’s inglorious beginnings as “the stepchild of medicine.” By the 19th century, researchers could distinguish between neurological disorders with obvious physical causes that were visible on autopsy, like the blockages behind strokes, or the clumping proteins in the brains of the demented; and mental illnesses, which left no obvious mark on the brain. Neurologists claimed as their turf the palpable brain pathologies and were accorded the same respect given to cardiologists, gastroenterologists or any other medical specialist. Psychiatrists traded in the invisible realm of mental illness, with no concrete tools or assays to validate a diagnosis, and no treatments to offer besides. For much of psychiatry’s history, nothing could be done for severely disturbed patients but warehouse them in remote asylums, which were located at such a remove from other hospitals that the presiding psychiatrists were nicknamed alienists. Psychiatrists were often considered the Western version of shamans or witch doctors, from which another professional epithet likely arose: shrinks, a shortening of the headshrinkers often lumped together with other tribalist figurines.
The ineffable nature of mental illness also proved fertile aeroponics for quacks, hucksters and would-be do-gooders who did terrible things. Among them was Wilhelm Reich, the Austrian psychiatrist active in the early- to mid-20th century, who attributed mental illness to the constriction of hidden energy currents that he called orgones and prescribed as treatment that patients strip down to their underwear, dangle a rubber hose around their neck and squeeze into one of Reich’s closet-size “orgone accumulators.” Then there was Walter Freeman, everybody’s favorite medical monster, who “performed ice-pick lobotomies on no fewer than 2,500 patients in 23 states by the time of his death in 1972.” Lieberman describes meeting a lobotomized patient during his medical training and being struck by the man’s robotic voice and “lifeless and blank” eyes.
Lieberman recounts the noble if often futile efforts of some of his predecessors to find reliable biomarkers for mental illness. In 1968, for example, researchers using the new technique of chromatography excitedly announced that the urine of schizophrenic patients left a distinctive “mauve spot” on blotting paper not seen in the urine tests of healthy people. The triumph was short-lived; other researchers soon traced the rosy spotting to the drugs the patients were taking rather than to any metabolic signature of the illness itself. Nevertheless, the struggle to put psychiatry on a firmer and more scientific footing was essential, Lieberman says, and here is where Freud led us astray.
Freud knew he lacked evidence for many of his “daring ideas about mental illness,” Lieberman says. Yet rather than conducting research to fill in the gaps, he instead began attacking anybody who questioned him. “He demanded complete loyalty to his theory, and insisted that his disciples follow his clinical techniques without deviation,” Lieberman argues, thereby “fossilizing a promising and dynamic scientific theory into a petrified religion.”
Lieberman hails the advent of the Diagnostic and Statistical Manual of Mental Disorders, the “bible of psychiatry” that describes in symptomatic detail all mental illnesses currently recognized by its publisher, the American Psychiatric Association, and therefore billable for insurance purposes. He recounts, at rather too much length, the infighting that erupted over different editions of the manual, including the latest version, published during his tenure as president of the A.P.A., but he makes a convincing case that its format has given the field a precision and reliability it lacked in the past. Psychiatrists have also taken advantage of new imaging technology to scan the brains of living patients, tracking subtle differences between the well and the ill that may not be obvious post-mortem.
Ultimately, though, the real secret to psychiatry’s success is drugs. One by one, the most devastating and formerly intractable mental diseases were tamed, if not completely routed, by pharmaceuticals: chlorpromazine for schizophrenia, lithium for bipolar disease, imipramine for depression. Lieberman describes the serendipity behind each spectacular discovery. He glides over the very real problem of side effects, and the fact that psychiatric drugs don’t always work or stop working over time. Still, for all the hand-wringing in some quarters that we are an overmedicated society, psychiatric drugs give patients what no rubber hose or hectoring daddy can: peace of mind, a piece of sky, a life.