How Prozac Slew Freud

The real world of psychiatric illness is just as tricky and just as filled with ultimate tragedies as is the real world of cardiology.

When another of Crichton-Browne’s patients in the asylum died, R.W., who saw the body being removed, glanced a little later in the mirror and exclaimed in horror, “Good heavens! I’ve got his head on!” He told Crichton-Browne, “This is not my head, Doctor. Just look at it! This is not my nose, it is [the other patient’s]!” He began “bewailing it daily and even threatening suicide to end his trouble.”

After three weeks of this, Crichton-Browne decided to try an experiment. Passing R.W. in the hall one day, he looked surprised and asked, “When did the change take place? When did you get it back again?”

R.W. quickly explored his face with his fingers. “You don’t mean to say that—but yes, it is. Oh, Doctor, I’m so rejoiced.” He looked at himself in the mirror. “I wasn’t the least aware of it till you spoke.”

Concluded Crichton-Browne: “There is such a thing as psychotherapy.”

Indeed there is, though it almost never works that abruptly. The power of suggestion can be very potent, the more so when the suggestion comes from a figure of authority like a physician. Medical students learn that they must not frown and grunt suspiciously when listening to a patient’s heart. Doing so can suggest the patient into having chest pain.

The therapeutic power inherent in the doctor-patient relationship represents in itself a form of psychotherapy, a form no less effective than any of the psychotherapeutic systems in circulation, such as Jungian therapy, family therapy, and so on. Psychiatrists are singularly well placed to administer this kind of psychotherapy in addition to medication, for according to the National Ambulatory Care Survey, the average psychiatric consultation lasts more than forty minutes, in contrast with the average consultation in internal medicine or obstetrics, which lasts only around ten minutes. In those forty minutes the psychiatrist has ample opportunity to work on the patient’s mind, listening and counseling. There is a synergy between psychopharmacology and psychotherapy; each makes the other more effective.

Today only 2 percent of psychiatric patients receive psychoanalytic therapy. Although many psychiatrists retain Freudian couches in their offices, they increasingly use them to pile their offprints on. Of 163 residency training programs for psychiatrists in the United States, more than 100 have abandoned instruction in intensive psychotherapy. The hallowed psychoanalytic concepts, such as inferiority complex and anal retentiveness—once so familiar in cocktail-party chitchat—have ceased to be important in the understanding of psychiatric illness. The critic Frederick Crews of the University of California at Berkeley says in his book The Memory Wars: Freud’s Legacy in Dispute , “Entities like the psychic troika of id, ego, and superego deserve to be regarded not as discoveries like radium or DNA, nor even as mistakes like ether or animal magnetism, but as pure inventions like Esperanto, Dungeons & Dragons, or closer yet, Rube Goldberg algorithms for making something happen with maximum complication.”

But we aren’t just talking about psychopharm beating psychochat. Rather it’s a growing confidence within the profession that psychiatric illness can be handled much the way heart disease or kidney disease is, that psychiatry is a specialty of medicine, and that the function of the psychiatrist is to treat illness, not to act as a glorified social worker or literary pundit. Today more than a quarter of all psychiatric training programs offer a combined residency in internal medicine or family medicine. The psychiatry of the year 2000 is linked firmly to the rest of medicine.

What does the future hold in store? The new psychiatry offers the same therapeutic promise as did internal medicine in the early 1950s, in those days eager to attack illnesses with brand-new antibiotics such as penicillin and anti-inflammatories such as cortisone. The promise inherent in the “wonder drugs” of that era beckons again with the new “atypical” antipsychotics, such as Lilly’s Zyprexa (olanzapine)—atypical because they cause fewer of the involuntary movements that bedeviled patients with the earlier antipsychotics. The promise beckons, too, with the new SSRIs, which turn out to be effective for many psychiatric illnesses, such as panic disorder, bulimia, and obsessive-compulsive behavior, in addition to depression.

Yet there are problems. Although the new psychopharmacology sounds great in the drug ads directed at doctors, many people with schizophrenic relatives will tell what a martyr’s path they had to tread until the right antipsychotic was found. Despite the SSRIs, bleakness still visits the lives of many affected by depression. The real world of psychiatric illness is just as tricky and as filled with ultimate tragedies as is the real world of cardiology.