Psychosis, Psychoanalysis and Psychiatry in Postwar USA

On the borderland of madness

Orna Ophir

• Publisher: Routledge
• Year: 2015
• ISBN:
  9781317584889
• Edition: 1
• Topic: Psychology
• Subtopic: Clinical Psychology
• Index: Psychology

Covering the last four decades of the 20th century, this book explores the unwritten history of the struggles between psychoanalysis and psychiatry in postwar USA, inaugurated by the neosomatic revolution, which had profound consequences for the treatment of psychotic patients. Analyzing and synthesizing major developments in this critical and clinical field, Orna Ophir discusses how leading theories redefined what schizophrenia is and how to treat it, offering a fresh interpretation of the nature and challenges of the psychoanalytic profession. The book also considers the internal dynamics and conflicts within mental health organizations, their theoretical paradigms and therapeutic practices.

Opening a timely debate, considering both the continuing relevance and the inherent limitations of the psychoanalytic approach, the book demonstrates how psychoanalysts reinterpreted their professional identity by formalizing and disseminating knowledge among their fellow practitioners, while negotiating with neighboring professions in the medical fields, such as psychiatry, pharmacology and the burgeoning neurosciences. Chapters explore the ways in which psychoanalysts constructed – and also transgressed upon – the boundaries of their professional identity and practice as they sought to understand schizophrenia and treat its patients. The book argues that among the many relationships psychoanalysis sustained with psychiatry, some weakened their own social role as service providers, while others made the theory and practice of psychoanalysis a viable contender in the jurisdictional struggles between professions.

Psychosis, Psychoanalysis and Psychiatry in Postwar USA will appeal to researchers, academics, graduate students and advanced undergraduates who are interested in the history of psychoanalysis, psychiatry, the medical humanities and the history of science and ideas. It will also be of interest to clinicians, health care professionals and other practitioners.

1 Freud’s dual view of schizophrenia (1894–1940)

“Finally I confessed to myself that I do not like these sick people, that I am angry at them to feel them so far from me and all that is human.”

(Freud 1928 in Gay 1998, p. 537)

The unique and intriguing paradox inherent in the psychoanalytic approach to schizophrenia is that while it seeks to deepen an understanding of psychosis in general and schizophrenia in particular, it also assigns itself a reduced role in treating schizophrenic patients. This stance is at least partly due to the jurisdictional struggles that have historically occurred between psychoanalysis and the medical professions, especially psychiatry and neurology, which held social and cultural control over the treatment of mental ailments. The roots of this struggle can be traced back to Freud’s own efforts to professionalize psychoanalysis and to his writings on psychosis and schizophrenia.

As part of the institutionalization of psychoanalytic knowledge, Freud sought to appropriate for psychoanalysis areas of treatment that, during his time, were under the control of psychiatry and neurology. Thus, in his efforts to ensure a place for psychoanalysis among the trusted methods of healing, he sought to explain all pathological conditions (including psychosis and schizophrenia), using his newly formulated psychoanalytic theory. Although Freud is better remembered for assigning modest aims to psychoanalysis – a method of cure to merely turn neurotic misery into common unhappiness (Freud 1893, p. 305) – a very different ambition is evident in his lesser known writings. In a letter to his lover (and later wife), Martha Bernays, about his future plans, Freud wrote, “… and I will cure all the incurable nervous cases …” (June 20, 1885 in Gumbrich-Simitis 2011). Because the onus was on psychoanalysis to prove its superiority to the already established fields of psychiatry and neurology, Freud offered a theoretical explanation of schizophrenia and asserted that psychoanalytic theory could explain even the most psychotic condition. However, since schizophrenic patients presented an ever-looming threat of incurability to a young profession in need of proving its efficacy, the “father of psychoanalysis” did not like these patients and did not assume them to be part of the psychoanalytic clinical endeavor (Freud 1928 in Gay 1998).

Even though some of Freud’s patients turned out to be psychotic (one even exhibiting signs of schizophrenia), Freud refused to diagnose them as such, openly insisting that such patients were indeed unable to be treated by psychoanalysis. It seems that in its pursuit of jurisdiction in the mental health field, psychoanalysis included schizophrenic patients, but did so only in theory, excluding these individuals from clinical psychoanalytic treatment.

The jurisdictional struggles of psychoanalysis

One of the most important statements Freud made about the struggle between psychoanalysis and the medical professions to control mental health appeared in his book, titled The Question of Lay Analysis (1926). This was written in response to the failed attempt by the Viennese government to enact legislation against charlatanism and quackery. The government’s actions were largely an attempt to shut down the popular practice of Theodore Reik, a Viennese analyst who was not a trained or licensed physician. According to Winter (1999), it was through writing this text that Freud took a strategic step in developing psychoanalysis as a profession, by defending those analysts who were not medical doctors but who were adequately trained in the art and science of psychoanalysis. Freud sought to convince the public (both laypeople and professionals) that medical training was not an essential component of analytic expertise. He argued that psychoanalytic understanding is a field of knowledge unto itself and that it cannot be properly practiced by those who are not wholly engrossed in it. Conversely, those who acquired psychoanalytic knowledge through rigorous training in psychoanalytic institutes, through guidance from older and experienced analysts or from years of handling actual cases under the watchful eye of skilled senior analysts were no longer laymen in the field of psychoanalysis (Freud 1926, p. 228).

In his attempt to popularize the perception of psychoanalysis as superior to psychiatry, Freud argued that having psychoanalytic knowledge was better than having medical expertise alone in the treatment of mental illnesses. A qualified analyst, in his opinion, would have a broad knowledge of the history and culture of the field, derived from the analyst’s feeling “at home” in many disciplines and enjoying expertise in multiple academic fields. In Freud’s opinion, doctors who attempted analysis without receiving appropriate psychoanalytic training were the laymen and thus should seek psychoanalytic training to achieve true competence, regardless of a national or state conferral of a medical degree (Freud 1926). In this same text Freud also warned that psychoanalysis should not be “swallowed up” by medicine,

to find its last resting-place in a text-book of psychiatry under the heading “Methods of Treatment”, alongside of procedures such as hypnotic suggestion, autosuggestion, and persuasion, which, born from our ignorance, have to thank the laziness and cowardice of mankind for their short-lived effects.

(p. 248)

In commenting on the competition between psychoanalysis and the medical professions over the control and treatment of mental illnesses, the Cambridge-based historian of psychoanalysis, John Forrester (1985), argued that psychoanalysis capitalized on an opportune moment in medical history in which the relative professional authority of medicine was weakened. The psychoanalytic movement used this opportunity to advocate its clinical technique and expertise. Psychoanalysis, as presented by Freud, was marketed as being superior to these medical professions in the field of mental health, and, like surgery, psychoanalysis was said to be able to effectively cure a disease rather than simply diagnose it. The package that Freud presented, therefore, was the most complete in terms of what a profession can offer: a personal and personalized service of a trained specialist who could mediate the demands of society, the family and the individual. Based on that claim, the psychoanalytic technique had to prove itself to be a more effective cure than what was being offered by its competitors. Thus, Freud could not afford to analyze schizophrenic patients because they threatened to contradict his principle of cure (“where Id was, there shall Ego be,” or “Wo Es war, soll Ich werden”) (1933, p. 80). His renunciation of schizophrenic patients left them under the care of medicine, especially psychiatry and neurology, the two professions that treated them somatically. Another reason schizophrenic patients were excluded from psychoanalysis was because it was largely done in private practices, not in medical institutions, where schizophrenic patients were treated.

Aside from garnering public recognition and appreciation of its expertise, a profession must target its services to a specific clientele. Towards this end, Freud took two steps: first, he created a new jurisdiction for psychoanalysis – the “personal problems” of those in the educated, upper middle-class social circles he traveled in. Second, he challenged medical doctors by setting his professional sights on the “hysterical” clientele whom he declared suffered from reminiscence (Winter 1999). He attempted to eject psychiatry and neurology from this jurisdiction by asserting that these disciplines did not truly understand hysteria, and that they, in this regard, were laymen. Freud’s categorical assertion that only psychoanalysis could adequately treat hysteria not only attacked the process of psychiatric diagnosis; it went beyond hysteria and questioned the fundamental capability of the medical field, which specialized in bodily ailments, to treat mental disorders. Nonetheless, although Freud questioned psychiatry’s ability to render psychological treatment generally, he seemingly did not attempt to claim jurisdiction over psychotic and schizophrenic patients.

In what may have been an additional attempt to distance psychoanalysis from neurology and psychiatry, Freud did write about these disorders, and even coined the term “paraphrenia” to describe the phenomenon that Emil Kraepelin, the father of modern scientific psychiatry, psychopharmacology and genetic psychiatry, referred to as “dementia praecox,” and which the Swiss psychiatrist Eugen Bleuler called “schizophrenia.” And although Freud used these terms interchangeably and was not overly impressed with psychiatric nosology, in a letter to Carl Jung he criticized the psychiatric term: “I write paranoia and not dementia praecox because I regard the former as a good clinical type and the latter as a poor nosographical term” (Freud 1908, p. 121).

Despite the fact that he applied his theoretical framework to psychotic patients in his struggle with psychiatry over professional jurisdiction, Freud clearly did not want to treat psychotic patients in his clinical practice. In 1913, in his paper “On Beginning the Treatment,” Freud suggested that analysts provide a “trial period” of two weeks when beginning treatment with a new patient to ascertain whether he or she is suitable for analysis – namely, if he or she did not exhibit any hint of psychotic tendencies. In such cases, Freud recommended that such a patient (suffering from paraphrenia) would not be an ideal candidate for analysis and should not be treated with his method. When Freud defined the jurisdiction of psychoanalysis, he targeted first the educated, upper-middle classes who suffered from personal conflicts and life stressors. Only secondarily did he include hysterical clients whom he attempted to wrest from the psychiatric camp. Finally, Freud also declared who could not be helped by psychoanalytic treatment, and he purposefully left individuals suffering from schizophrenia within the domain of medical professionals by dint of their inability to be effectively cured by psychoanalysis.

Freud’s treatment of psychotic patients

Nonetheless, among Freud’s patients were a number who were later diagnosed as psychotic, as well as one diagnosed with schizophrenia. Further, among Freud’s writings is a collection of unpublished clinical articles on a number of these patients. In some of these articles, Freud focuses on applying the psychoanalytic method and practice to the treatment of these psychotic and schizophrenic patients. David Lynn (1993), a psychiatrist at Harvard University who examined the entire corpus of Freud’s 133 cases, identified one as a case of paranoia and ten as cases of psychosis, despite Freud’s own explicit recommendations against treating schizophrenics through psychoanalysis. Lynn’s conclusions were based on a perusal of hospital files, interviews with psychiatrists, a discussion by Freud in 1927 in his paper “Fetishism” and Freud’s correspondence with Oskar Pfister, a psychoanalyst and Swiss priest, about his analysis of a young psychotic man. As Lynn (1993) noted that the patient, A.B., from a wealthy American family, was diagnosed by Bleuler as suffering from mild schizophrenia. After five years of treatment with Freud, he was hospitalized and diagnosed with chronic paranoid schizophrenia and remained there until his death. Lynn posited that Freud’s conflicting stance regarding the treatment of schizophrenics, and particularly his treatment of the young American man, can be viewed from three different perspectives, each associated with different implications for the psychoanalytic treatment of this patient group:

1. Freud as a pessimistic doctor who felt remote from his schizophrenic patient and wanted to terminate his contract with him;
2. Freud as an optimistic psychoanalyst who sought to understand the patient through concepts such as resistance, repression and catharsis through analytic revelation; and
3. Freud as a humanist with a personal style of thinking, who believed that even if the patient’s behavior is “far from normal,” his personality is “worth any amount of trouble” (Freud 1925 in Lynn, p. 68).

Lynn’s article concluded that Freud’s recommendation of setting a trial period of treatment before deciding whether to accept a person in psychoanalysis was established, not to disqualify psychotic patients, as Freud argued, but rather to explore the interaction between analyst and patient. Freud’s affection for A.B., said Lynn, is what prompted him to continue with his analysis, despite the patient’s psychotic symptomatology. While A.B. was not ultimately cured with psychoanalysis and actually deteriorated over the years (culminating in his spending his final years in a psychiatric hospital), it was Freud’s analysis, according to Lynn, that prevented him from an even earlier institutionalization. Lynn is unclear whether A.B.’s decline was due to the fact that Freud terminated treatment in 1930 or that the deterioration was the cause of termination. In any case, despite his own recommendations, even Freud selected his patients not so much based on diagnosis, but rather on his personal interests and rapport. His famous “Wolf Man” patient, although diagnosed by Freud as an obsessive neurotic, exhibited delusional thinking, which would fulfill today’s diagnostic criteria for schizophrenia. His psychotic symptoms did not stop Freud from analyzing him (Muslin 1991; Lang 1997).

The libido theory of schizophrenia

Despite Freud’s reluctance to use psychoanalysis to treat psychosis and schizophrenia, he wrote extensively about these illnesses. In the 1890s he viewed neuroses and psychoses as defenses against repressed memories. He saw schizophrenia as defending against severe forms of conflict and unacceptable desires. For the early Freud the difference between psychosis and neurosis was based on the types of defenses being used, as well as the degree to which patients could process their unacceptable desires.

Freud’s libido theory of schizophrenia was published in 1911 in his essay on Judge Daniel Paul Schreber, titled “Psycho-Analytic Notes on an Autobiographical Account of a Case of Paranoia (Dementia Paranoides).” Freud used the judge’s personal account, Memoirs of My Nervous Illness (1903/2000) – which included a description of his psychosis and hospitalization, his delusional attitude towards his psychiatrist, Dr. Paul Flechsig (who Schreber alleged committed “soul murder”) and his erotic relationship with God – to form theories about psychosis and schizophrenia.

Freud continued to theorize about paranoia and schizophrenia even after he wrote his famous notes on Schreber (Freud 1914, 1915a), and in three specific works (1916, 1917, 1922) he claimed there could be one theory to explain the clinical phenomena of schizophrenia. In these papers Freud developed a theory that claimed that sexual and libidinal energy progress from autoeroticism in early childhood (during which a child’s body, especially his mouth, anus and genitals, are the source of sexual satisfaction), to narcissism (in which the entire body or self of the child becomes the object of sexual desire) and eventually to a love object (represented by a significant person or caregiver in the child’s life). During development, certain amounts of sexual energy may be left behind and may create fixations as a result. Fixation is a condition in which the libidinal energy remains invested in one of the first two stages of development (autoeroticism or narcissism) and, therefore, is not fully available to be invested in other people, objects or ideas (as is necessary for cathexis, which requires attachment to an external object).

At this stage of Freud’s theory, the phenomenon of experiencing the “end of the world,” as described by Schreber and numerous other schizophrenic patients, was a projection of the inner catastrophe, accompanied by the libidinal withdrawal (regression) from the world and its objects. According to Freud, megalomania, manifesting in Schreber as a delusion that God impregnated him to create a new race of people, was a libidinal regression from the world in which one invested oneself entirely in the self rather than the external world (Freud 1911). Due to the nature of libidinal regression, the schizophrenic patient was perceived by Freud as being unable to establish transferential relationships and thus incapable of transferring his libidinal energy from himself to the analyst (Freud 1915a). Since transference plays such a crucial role in the psychoanalytic process, psychotic and schizophrenic patients were, not surprisingly, considered to be poor candidates for psychoanalytic treatment (Freud 1917).

In two 1915 essays, Freud filled in a gap in his theory of schizophrenia by explaining the processes of schizophrenic thinking (Freud 1915b, 1915c). In these articles he developed the notion of reduced cathectic capacity and distinguished between cognitive representations of an object and cognitive representations of the word for that object, suggesting that with schizophrenia, both cognitive representations of the object and the word for that object undergo decathexis. In their attempts to “recover,” schizophrenics connect to an object by using its verbal representation. However, they then find themselves committed to and confined by the word in which they invested their energy, as opposed to the object itself, and so they treat words as if they were objects themselves (Freud 1915a).

Although Freud had already formulated his theory of aggression in “Beyond the Pleasure Principle” in 1920, its application to sch...

Table of contents

• Cover
• Title
• Copyright
• Contents
• Acknowledgments
• Introduction
• 1 Freud’s dual view of schizophrenia (1894–1940)
• 2 Ravens in white coats: The medicalization of American psychoanalysis (1909–1954)
• 3 Psychoanalysis, psychopharmacology and community psychiatry (1954–1970)
• 4 The “dopamine hypothesis” and evidence of genetic factors in schizophrenia (1971–1980)
• 5 The emperor’s new clothes: DSM-III and the abandonment of psychodynamics in favor of the biomedical model (1980–1990)
• 6 The last battle of psychoanalysis? The Decade of the Brain (1990–2000)
• 7 The many faces of Schreber as the face of American psychoanalysis (1954–2000)
• Epilogue
• Index