This book by a prominent psychoanalyst is so interesting and written in such a fierce and gripping style that it was impossible to put it down. Actually, Gedo’s book consists of two books, skillfully integrated with each other. Especially in chapters 15, 18, and 21, one finds a lucid (except for the long, overly condensed paragraph on pages 265–266) exposition of Gedo’s psychoanalytic theories; the rest of the book presents in a remarkable form his experiences in the psychoanalytic wars during the "analytic age of gold" (p. 25) that has recently come to an end. Even the footnotes should be read carefully, reminding me of a similar necessity in studying Robert Pinsky’s new translation of Dante’s Inferno(1). Like Dante, Gedo certainly roasts his opponents.

Gedo’s enemies will say this book demonstrates that he is grandiose and paranoid or at least "arrogant and elitist" (pp. 274–275). His supporters will insist that he is a brilliant individual who is quite accurate in his observations about colleagues in the psychoanalytic bureaucracy who betrayed him or tried to use him as a "selfobject," in his descriptions of the psychoanalytic civil wars, and, above all, in his clinical knowledge. Certainly, Gedo’s suggested emendations of psychoanalytic theory are carefully thought out and well presented in the series of books and papers listed at the end of this book, which I have followed as they appeared over the years. I have been influenced by them, especially by his notion of "apraxias," in my own practice (2, pp. 35–36). For Gedo (pp. 187, 222, 263), apraxias are the absence of normal skills or values, which must be taught to the patient in treatment. Such interventions are "beyond interpretation," but Gedo considers them to be crucial to successful psychoanalytic treatment of many types of disorders. Correcting apraxias enables a widening scope of psychoanalysis beyond the treatment of classical oedipal disorders: "At first, it may be necessary to enter into the analysand’s life as an auxiliary who supplies the psychological skills unavailable to the latter" (p. 222).

Like Gedo, I also have pointed out that the prevailing theories in psychoanalysis, such as Freud’s instinct theory, object relations theory, and self psychology, are based on fundamentally conflicting epistemological and basic assumptions (3). Gedo offers an admittedly "exceedingly complex theoretical schema" (p. 275) focused on what he calls "self-organization," which he considers "preferable to the alternatives currently available…because it can account for the entirety of the observational data of psychoanalysis, where­as the other theories do not do so and therefore have to be used in conjunction, despite their irreconcilable differences" (p. 194).

I cannot attempt in a brief book review to summarize Gedo’s theory here; fundamentally, he follows a kind of psychophysical parallelism, viewing psychoanalysis as "a branch of biological science" (p. 31), in which the clinical theories must rely on propositions "that reflect our convictions about the biology of the human organism—that is, the latest conclusions of cognitive psychology and brain science" (p. 193). There exists in each of us, he says, a hierarchy of modes of mental functioning (described in his early book with Goldberg [4]) that developmentally evolve pari passu with neurobiological maturation. Patients may function in any of these modes, some of which are archaic and preverbal. Because of this, Gedo is not impressed with the hermeneutic school of psychoanalytic theory, which focuses on the meaning of the patient’s articulated "text," ignoring all the communications that come from preverbal patterns. He also regards constructivist or intersubjective theories as too simplistic. Dealing with the various early modes of mental functioning, he says, requires a considerable expansion of the analyst’s interventions, sometimes using rhetoric, telling jokes, and even whistling or singing to the patient. I was pleased to read that Gedo agrees with what I have been writing for years (2) when he says that his theory implies that "borderline states cannot be seen as disease entities" (p. 189).

What will undoubtedly produce the major reactions to this book, and I think some of them will be apoplectic, are Gedo’s descriptions of his interactions with his colleagues. He seems to imply in chapter 11 that his main purpose in writing this book was to correct statements made by some of his colleagues regarding his disaffection and eventual profound dissatisfaction with Heinz Kohut, who was once one of his earliest supporters. Gedo repeatedly attacks Kohut in this book, suggesting that Kohut was at times paranoid (p. 146), was chronically overtly needy (p. 149), possibly was alcoholic (p. 149), possibly was homosexual (p. 154), engaged in boundary violations (p. 163), and had some kind of pathological yearning or attachment to Gedo. Gedo reports (p. 56) that his wife was always unimpressed and felt depreciated by Kohut and that, at least to some extent, Dr. Arnold Goldberg, one of Kohut’s principal disciples, also had a privately disparaging view of Kohut. Gedo accuses Kohut of "steal­ing some of my ideas and then acting vengeful toward me" (p. 134).

Gedo is deeply concerned about what he regards as the "current decay of American psychoanalysis" (p. 103), the excessive development of bureaucracy in the various institutes and in the American Psychoanalytic Association. He says that the vitality of American psychoanalysis has been "sapped" by "the enormous expenditure of time and resources on unnecessary administrative activities, the politicization of essentially scientific decisions through the selection of the relevant committees on a geographic basis, the suppression of novel viewpoints because of their inevitable failure to gain majority support in democratic elections, and so on" (p. 118).

As a result of these experiences, Gedo gradually moved into a position of intellectual solitude, reminding me of Montaigne (5), who is mentioned in Gedo’s book on pages 4, 84, 109, 210, 313, and 317, although curiously the index does not list all of these. Gedo, who (with E. Wolf) at one time wrote a "psychobiographical" (p. 85) paper on Montaigne (6), concluded that he was "better suited for working alone. (I have been slow to accept this verdict, probably because to do so condemns one to work in perpetual solitude)" (p. 69). And so, at a considerably later age than Montaigne, Gedo retired from practice and found himself "free to enjoy solitude in my study. I look northeast across Lake Michigan; there is only blue water between my chair and Canada" (p. 43). (The geography of this eludes me). At the end of his book Gedo concludes, "I have begun to look upon my study as a present-day monastic scriptorium—Lake Michigan can easily stand in for the Irish Sea" (p. 275).

Gedo describes his conversion, during his 3-year psychoanalysis with Maxwell Gitelson, from a timid individual to a very outspoken one who was not afraid to confront the politically powerful and who became known as a formidable opponent in debate. In fact, this book is a continuation of a debate in which he expresses his disagreement with object relations theory and especially with self psychology, its notions of empathy, and its concept of the self. For example, Gedo makes personal attacks on his previous collaborator, the self psychologist Dr. Ernest Wolf, and on a number of other colleagues, some of whom are still living and will undoubtedly be profoundly offended. As Gedo says, his book is "principally focused on my subjective reactions to various people and events" (p. xi–xii), and so it is.

Gedo advocates a high elevation of standards for graduation and qualifying to be a psychoanalyst. He implies that many of today’s psychoanalysts are incompetent, and he seems to have even less respect for those who practice what they call psychoanalytic psychotherapy; he regards such therapeutic attempts as doomed to end in failure (p. 53) because, he says, they involve an attempt to mimic a psychoanalysis confined to interpretation in settings that fail to meet the criteria of an analytic situation. He advocates the use of five sessions weekly "in an absolutely invariable schedule" (p. 110) as optimal for psychoanalytic treatment, and scattered through the book are brief reports of successful psychoanalyses with difficult patients that he has carried out. He claims that "untalented practitioners have brought the discipline into disrepute by performing inadequately" (p. 11), and he decries the ease with which many unqualified individuals are allowed to graduate from psychoanalytic institutes that he calls "shamefully poor" (p. 123). He advocates the acceptance of nonmedical mental health professionals into psychoanalytic training but not without raising the standards for acceptance and graduation. He reports, "Reading the applications of more than a hundred would-be analysts provided a fascinating vista of the multitude of therapists of every stripe active in our major cities. A very small number of these even seemed to know what they were doing" (p. 131).

Gedo claims that his bitterness and pessimism stem from his continual collisions with the bureaucrats who established what he calls a tyranny that was or is prevalent in many psychoanalytic institutes, including the one in Chicago; the book contains many descriptions of these collisions. Although he correctly believes that psychoanalysts should be "generous" (p. 4) and "gentlemen" or "gentlewomen" (p. 21) in order to be therapeutically effective, his book refreshingly offers some examples where he confesses to having fallen short of his own standards of conduct. He complains, "Because I have been intolerant of my failures and seldom feel really satisfied with my results, I have found others’ view of me as a man filled with certitude difficult to understand" (p. 24).

Gedo says that the psychoanalyst should "not put anything about patients on paper" (p. 33) and, in contrast to his deceased colleague Fleming, whom he calls the "wicked witch" (p. 79) and accuses of having tried to maintain at the Chicago Institute a collegial atmosphere that he says she defined as "automatic deference to one’s inadequate elders who claim to be betters" (p. 35), he believes that psychoanalysis should be in a continuing state of "permanent revolution in order to remain viable" (p. 23). He writes, "It is a measure of the decay of the profession that most members no longer wish to hear views different from their own" (p. 144).

Gedo documents the upheaval in departments of psychiatry; at the beginning of the golden age of psychoanalysis, almost all were headed by psychoanalysts, but now almost all are headed by psychopharmacologists or psychobiologists. Gedo depicts the uneasy relationship between academic departments of psychiatry and psychoanalytic institutes, and he reports, "Blinded by success, the leadership did not foresee that psychiatric residencies were about to abandon their psychoanalytic orientation…I tried to shout this cautionary tale from the rooftops, but nobody would listen. What is left in the wake of these vicissitudes? A bloated bureaucracy, deprived of its reason for being" (p. 128).

Gedo describes hostility and envy stirred up by his "scientific activities" (p. 120), and he claims, "On the whole, the analytic community is narcissistically gratified by opportunities to rub elbows with socially prominent, wealthy people" (p. 274). Although he states that "theories tend to capture the allegiance of most practitioners without validation or even proof of their pragmatic utility" (p. 227), I would have appreciated more discussion of two of the salient issues in this book, namely, to what extent does one’s personality determine whether or not one’s theories are given attention and to what extent does the simplicity or complexity of a theory affect its acceptance or rejection?

Gedo seems to emphasize spleen more than nostalgia, and probably the spleen will be the most controversial part of his book. Neither the spleen nor the nostalgia contained in this book should put off the reader, however, because each is extremely well integrated with Gedo’s description of his own theoretical conceptions, which are indeed important and deserve careful consideration, as well as his disagreements with self psychology and object relations theory. This book is a proposed historical document that will require a response from the psychoanalytic establishment, and I view it as mandatory reading for any psychiatrist who is interested in psychoanalysis and concerned with its future.