Madness on the Couch: Blaming the Victim in the Heyday of Psychoanalysis

If other medical specialties taught untested and unproven methods as the basis of their therapies, their training programs probably would be disaccredited. Yet many academic psychiatry departments and psychoanalytic institutes continue to espouse psychoanalysis and psychodynamic therapy with little scientific proof, or even evidence, of their efficacy. From its beginnings in the networking efforts of the nation’s early asylum superintendents (1), American psychiatry began a gradual evolution to eclecticism and away from hospital-based practice. The biggest changes began after World War II, when American and European-trained Freudians ascended to psychiatry’s leadership. Their zeal and belief in the master and his methods brought an energy and optimism to the specialty and helped found the National Institute of Mental Health, fund federal and state training subsidies, and propel the community mental health movement. Their psychoanalysis-only agenda for psychiatry, however, was obdurately exclusionary: hostile to eclecticism, emerging scientific discoveries, and the introduction of psychotropic medications. Because psychoanalytic-based training provided poor tools for treating the mentally ill, graduates largely shunned public psychiatry and concentrated their attention on those who could respond to (and pay for) their treatment. The legacy is psychiatry’s continuing internal struggle with contending ideologues: “biological psychiatrists” dismissive of psychotherapy versus psychoanalysts who promote their revelations as the vital bases of our discipline. These divisions are confusing to young psychiatrists and redound to the continuing advantage of the managed care industry (2).

Dolnick’s prologue, “In Search of El Dorado,” sees Sigmund Freud placing “his discoveries on a par with Copernicus and Darwin” and cautioning that psychoanalysis offered nothing for the psychoses: “By the 1950’s and 60’s the master’s warnings had been drowned in a tumult of excited voices. Psychoanalysis…could cure even schizophrenia…simply by talking to…patients.” The author disavows an antitherapy stance but sensibly believes questions about “talk therapy” (“Which talk therapy? For which conditions? What about the combination of drugs and talk?”) should be settled only by testing. He proceeds through 18 chapters in six sections to explore Freud’s charisma, his rationalizations, and intellectual entanglements that characterized his excesses and mistakes. Poor Emma Eckstein, whose months of repeated hemorrhages during Freud’s and Wilhelm Fliess’s surgical experimentation on her were explained by Freud’s ridiculous theory that her bleeding was hysterical and a product of her own unconscious wishes. This baseless supposition adumbrated subsequent, equally unsupported psychoanalytic theories and interpretations. Finding that many of Freud’s discoveries were not original or sound, Dolnick invokes an evaluation by Samuel Johnson: “Your manuscript is both good and original, but the part that is good is not original, and the part that is original is not good.”

The sad story of how all this came about is the central theme of this devastating deconstruction of Freud, his theories, his followers, and his followers’ followers. The author, a contributing editor to Health magazine and former chief science writer for The Boston Globe, presents extensive primary source material—archives, professional publications, and personal interviews—in an engaging, accessible style to depict Freud and his followers as seldom revealed in training curricula and medical school lectures.

All of this uncomplimentary information is taken from published material that may not be familiar or generally offered to trainees and students. Many of Freud’s failings are now acknowledged by most psychoanalysts, but their implications are dismissed as irrelevant to what they continue to believe is sound method and brilliant theory. Such “casual disdain for the founding father of psychoanalysis is new…in the 1950’s and 60’s it would almost have counted as sacrilege.” Dolnick characterizes the 1950s and 1960s as a period in which psychoanalysis dominated psychiatric academia and practice, attracted respectable percentages of medical school classes into psychiatry, and produced an extensive group of vocal, highly visible leaders and therapists who promulgated theories and practices that to this day have not been subjected to as much scientific testing as an over-the-counter cold tablet.

Quotations from leading psychiatric figures, nay icons, of that era on the subject of families and mothers as the cause of schizophrenia and autism will make the uninitiated reader cringe. The chapter (“Dr. Yin and Dr. Yang”) on psychoanalysts Harold Searles and John Rosen, the era’s leading exponents of “direct analysis” for schizophrenia, which used bullying, threats, intimidation, and physical grappling (pinning the patient to the floor while threatening to “castrate,” “kill,” or “eat” the patient), is a chilling indictment. Their therapy was based on an absolute certainty—published and repeatedly proclaimed—that “mothers caused schizophrenia, and insanity was, literally, a kind of perpetual nightmare.” Psychoanalyst Theodore Lidz refused, to the end of his long life in the mid-1990s, to recant his assertions on the family/mother etiology for schizophrenia. In the chapter “Ice Picks and Electroshocks,” Dolnick balances his censure by comparing the attractiveness of Freud’s psychotherapy with these alternative psychiatric therapies of the time. He digresses briefly, nominating Emil Kraepelin, not Sigmund Freud, as the father of modern psychiatry and comparing the two in several respects. Dolnick’s “Conclusions” chapter assures us that this entire tale is a “tragedy not a scandal” and that, with some exceptions, “it was a tale almost without villains.”

The extensive research that sustains the author’s formidable authority for this work is authenticated by 36 pages of chapter notes and a 16-page bibliography. The inescapable subtheme of this work about a charismatic leader and his specious discoveries, the religiosity of his followers, their irrational misapplication of psychoanalytic tenets, and the ultimate achievement of mainstream recognition is the unmasking of the psychoanalytic movement as a cult.

As disturbing as this work is for psychiatrists, it is our history and cannot be dismissed. Our medical specialty needs a clearer definition of itself. Most of us who have spent our careers in public psychiatry would likely insist that training be directed toward care of the most severely ill. If psychoanalysis is unsuitable for the treatment of mental illness (3), and its theories remain burdened by their untested assumptions, it should no longer be included in training curricula. Earlier debunking of Freudian iconolatry (4) may have had little effect, but Dolnick’s arresting depiction of Freud and his movement may facilitate a rethinking of our future directions. If all this should happen, we and the desperately ill patients who need us will be in his debt, and Goethe’s precept will have been honored.