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How Prozac Slew Freud
In the past hundred years psychiatry has come full circle: Psychoanalysis lost; medicine won
September 1998 | Volume 49, Issue 5
The broad and thorough failure of early brain science opened the door for theories of the pathological influence of early-childhood events.
This bifurcation of vision was present at the very beginning of the discipline’s history, but at the start the biological version had the upper hand. In 1758 the Englishman William Battie worked out a complicated explanation of mental illness that put at its root muscular “spasms” that led to “laxity” of the blood vessels of the brain, which in turn caused “obstruction” of those vessels, an ensuing “compression” of the nerves, and delusive sensations. In America the great physician Benjamin Rush wrote in a study of psychiatry published in 1812 that “the cause of madness is seated primarily in the blood vessels of the brain, and it depends upon the same kind of morbid and irregular actions that constitute other arterial diseases.”
Throughout the nineteenth century such scientific psychiatry was dominated by German heavyweights—the founders of scientific medicine in general—who tried to explain psychiatric symptoms as a result of lesions in the brain. They did not get very far because they were searching with the wrong tools. At the level of the microscopes available to them, for example, one finds almost no evidence of pathology in the autopsied brains of mentally ill patients whose lesions we can detect today with such high-tech imaging devices as CT and MR scanners. They also did not yet understand about brain chemistry—that is, receptors and neurotransmitters. As a result they came up with little linking mental symptoms to underlying brain disease. Moreover, despite a battery of treatments that ranged from hydrotherapy to dietetic therapy, their efforts to effect real cures were almost invariably disappointing. Their more intractable cases went to asylums and stayed there.
This broad and thorough failure opened the door for theories of emotional causes of mental illness, and so psychoanalysis, which stressed the pathological influence of early-childhood events, began its ascendancy. Of course the titan of the discipline was Sigmund Freud. His theory held that repressed childhood sexual memories and fantasies caused neurosis when reactivated in adult life. Such neurosis could be cured by an elaborate technique emphasizing dream analysis, free association, and the working through of a “transference neurosis,” in which the analyst represents one of the patient’s parents as a love object, the patient then living out and working through attitudes from childhood.
Many histories of psychiatry describe psychoanalysis as the end of the story, the goal toward which all previous events marched. For a brief time in the middle of this century, middle-class society was enraptured by the notion that psychological problems arose from unconscious conflicts over long-past events. Psychoanalysis had a powerful appeal for both doctors and patients, for the latter because with doctor and patient cooperating in the enterprise of soul-searching, the impression arose that the patient was being cared for emotionally. The treatment offered a situation in which patients basked in an aura of concern while seeking powerful emotional and poetic truths.
For doctors, the advantage was even clearer: Freud’s psychoanalysis provided a way out of the asylum. The practice of depth psychology, founded on Freud’s views, permitted psychiatrists for the first time ever to establish themselves as an office-based specialty and to wrest psychotherapy from the neurologists, who worked out of private offices and had started private-practice psychotherapy.
In September 1909 Freud came to the United States to lecture at Clark University. The tour launched the psychoanalytic movement in America. By 1935 Fortune magazine could soberly explain that “the suppression of the sexual instinct in childhood pushed certain experiences and desires deep into the unconscious, where they reappear in the adult as neuroses.” For the first time in history, the depressed businessman or the anxious housewife might seek out the services of a psychiatrist, and if the psychiatrist lived in New York, Boston, or Washington, chances were that he would offer psychoanalysis.
But what ultimately converted a fashionable 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 stripling little American movement the glamour and heft of the wide world. More and more, young Yankee psychiatrists turned away from the German scientific school and toward depth therapy.
Soon psychiatrists were winning a monopoly over the young therapy. In the public mind psychotherapy and psychoanalysis became virtually synonymous. The American Psychoanalytic Association insisted that only psychiatrists, all of whom are M.D.'s, could be trained as analysts. By the early 1960s the triumph of analysis seemed complete.