Shrinks

by Jeffrey A. Lieberman

  The book won him instant fame, especially among young people who were embracing countercultural values and challenging traditional forms of authority. By the mid-1960s, students flocked to study with him at SUNY. He began publishing articles and giving lectures advocating a new approach to psychotherapy. The true and worthy goal of an analyst, Szasz contended, was to “unravel the game of life that the patient plays.” Psychiatrists, therefore, should not assume that there is something “wrong” with odd behavior, a message that resonated with a generation adopting other anti-authoritarian slogans such as “Turn on, Tune in, Drop Out” and “Make Love, Not War.”

  Szasz’s views amounted to a form of behavioral relativism that viewed any unusual behavior as meaningful and valid if viewed from the proper perspective. Szasz might say that Elena Conway’s decision to accompany the sleazy middle-aged stranger to his apartment was a valid expression of her plucky personality and her admirable willingness to not judge someone by his appearance, rather than impaired judgment caused by an arbitrary “illness” that doctors called “schizophrenia.” Szasz wanted to completely do away with mental hospitals: “Involuntary mental hospitalization is like slavery. Refining the standards for commitment is like prettifying the slave plantations. The problem is not how to improve commitment, but how to abolish it.”

  Szasz’s ideas helped give birth to an organized activist movement that questioned the very existence of the profession of psychiatry and called for its eradication, and The Myth of Mental Illness became its manifesto. Szasz’s final betrayal of his profession came in 1969 when he joined L. Ron Hubbard and the Church of Scientology to found the Citizens Commission on Human Rights (CCHR). Explicitly drawing upon Szasz’s arguments, the CCHR holds that “so-called mental illness” is not a medical disease, that psychiatric medication is fraudulent and dangerous, and that the psychiatric profession should be condemned.

  Szasz served as inspiration for others who doubted the value of psychiatry, including an unknown sociologist named Erving Goffman. In 1961, Goffman published the book Asylums, decrying the deplorable conditions in American mental institutions. Since the population of asylums was near its all-time high, there was little question that most of these institutions were oppressive, overcrowded, and bleak. What was Goffman’s response to this indisputable social problem? He declared that mental illness did not exist.

  According to Goffman, what psychiatrists called mental illness was actually society’s failure to understand the motivations of unconventional people; Western society had imposed what he called a “medical mandate over these offenders. Inmates were called patients.” Goffman wrote that his goal in investigating mental institutions was “to learn about the social world of the hospital inmate.” He intentionally avoided social contact with the staff, declaring that “to describe the patient’s situation faithfully is necessarily to present a partisan view.” He defended this overt bias by claiming “the imbalance is at least on the right side of the scale, since almost all professional literature on mental patients is written from the point of view of the psychiatrists, and I, socially speaking, am on the other side.”

  The urge to propound theories of human behavior is a basic human impulse we all frequently indulge in; this may be why so many psychiatric researchers feel compelled to throw aside the theories and research of previous scientists in order to articulate their own Grand Explanation of mental illness. Despite the fact that Goffman was trained in sociology (not psychiatry) and had no clinical experience whatsoever, the urge for propounding his own Grand Explanation of mental illness soon overtook him.

  Individuals diagnosed with mental illness did not actually have a legitimate medical condition, insisted Goffman, but were instead the victims of society’s reaction to them—what Goffman termed “social influences,” such as poverty, society’s rejection of their behavior as inappropriate, and proximity to a mental institution. But what if a person was convinced that something was wrong with her, as in the case of Abigail Abercrombie and her panic attacks? Goffman replied that her perceptions of her racing heart, her sense of imminent doom, and her feeling of losing control were all shaped by cultural stereotypes of how a person should behave when she is anxious.

  As Szasz and Goffman were rising in prominence, another antipsychiatry figure emerged on the other side of the Atlantic: the Scottish psychiatrist R. D. Laing. While Laing believed that mental illness existed, like Goffman he placed the source of illness in a person’s social environment, especially disruptions in the family network. In particular, Laing considered psychotic behavior an expression of distress prompted by a person’s intolerable social circumstances; schizophrenia, to his thinking, was a cry for help.

  Laing believed that a therapist could interpret the personal symbolism of a patient’s psychosis (shades of Freud’s dream interpretations) and use this divination to address the environmental issues that were the true source of the patient’s schizophrenia. To successfully decode a patient’s psychotic symptomatology, Laing suggested that the therapist should draw upon his own “psychotic possibilities.” Only in that way could he comprehend the schizophrenic’s “existential position”—“his distinctiveness, and differentness, his separateness and loneliness and despair.”

  The ideas of Szasz, Laing, and Goffman formed the intellectual underpinnings of a burgeoning antipsychiatry movement that soon joined forces with social activists such as the Black Panthers, Marxists, Vietnam War protesters, and other organizations that encouraged the defiance of the conventions and authority of an oppressive Western society. In 1968, the antipsychiatrists staged their first demonstrations at an annual meeting of the American Psychiatric Association. The following year, at the APA meeting in Miami, delegates looked out the window to discover an airplane circling overhead pulling a banner that read “Psychiatry Kills.” Every year since then, APA meetings have been accompanied by the bullhorns and pickets of antipsychiatry protests, including the 2014 meeting in New York, over which I presided.

  Despite the kernels of truth in the antipsychiatry movement’s arguments in the 1960s and 1970s—such as their quite valid assertion that psychiatric diagnosis was highly unreliable—many of their claims were based on extreme distortions of data or oversimplifications of clinical realities. The most elaborate antipsychiatry critiques tended to emerge from ivory tower intellectuals and political radicals who lacked any direct experience with mental illness, or from clinical mavericks who operated on the fringes of clinical psychiatry… and who may not have even believed the ideas they were touting.

  Dr. Fuller Torrey, a prominent schizophrenia researcher and leading public spokesperson for mental illness, told me, “Laing’s convictions were eventually put to the test when his own daughter developed schizophrenia. After that, he became disillusioned with his own ideas. People who knew Laing told me that he became a guy asking for money by giving lectures on ideas he no longer believed in. Same with Szasz, who I met several times. He made it pretty clear he understood that schizophrenia qualified as a true brain disease, but he was never going to say so publicly.”

  The antipsychiatry movement continues to harm the very individuals it purports to be helping—namely, the mentally ill. Aside from Laing, the leading figures of antipsychiatry blithely ignored the issue of human suffering, suggesting that a depressed person’s misery or a paranoid schizophrenic’s feelings of persecution would dissipate if we merely respected and supported their atypical beliefs. They also ignored the danger that schizophrenics sometimes presented to others.

  The eminent psychiatrist Aaron Beck shared with me one example of the true cost of such ignorance. “I had been treating a potentially homicidal inpatient who made contact with Thomas Szasz, who then put direct pressure on the Pennsylvania Hospital to discharge the patient. After he was released, the patient was responsible for several murders and was only stopped when his wife, whom he threatened to kill, shot him. I think that the ‘myth of mental illness’ promulgated by Szasz was not only absurd but al
so damaging to the patients themselves.”

  State governments, which were always eyeing ways to cut funding for the mentally ill (especially state mental institutions, usually one of the most expensive line items in any state budget), were only too happy to give credence to antipsychiatry arguments. While purporting to adopt humane postures, they cited Szasz, Laing, and Goffman as scientific and moral justification for emptying out the state asylums and dumping patients back into the community. While legislators were able to save money in their budgets, many patients in these asylums were elderly and in poor health and had nowhere else to go. This ill-conceived policy of deinstitutionalization directly contributed to the epidemic of homelessness, many of whom were mentally ill, and the rapid growth of the mentally ill population in prisons, which persists to this day. Insurance companies also readily accepted the antipsychiatrists’ argument that mental illness was simply a “problem in living” and not a medical condition and therefore treatment for such “illnesses” should not be reimbursed, leading to even more cutbacks in coverage.

  The final and most enduring professional blow that resulted from the antipsychiatry movement was an assault on psychiatry’s near-monopoly of therapeutic treatment. Since the core argument of the antipsychiatry movement was that mental illness was not a medical condition but a social problem, psychiatrists could no longer claim they should be the sole medical overseers of mental health care. Clinical psychologists, social workers, pastoral counselors, new age practitioners, encounter groups, and other lay therapists leveraged the antipsychiatrists’ arguments to strengthen their own legitimacy as providers for the mentally ill, diverting increasing numbers of patients from medically trained psychiatrists. Soon, proliferating numbers of self-styled therapists without any license at all began carving up the mental health care market. The most ominous and aggressive of these non-medical alternative therapies was the Church of Scientology, a quasi-religious system of beliefs created by the science fiction writer L. Ron Hubbard. Scientology holds that people are immortal beings who have forgotten their true nature and past lives. They condemn the use of psychiatric drugs, instead encouraging individuals to undergo a process of “auditing” whereby they consciously re-experience painful or traumatic events from their past in order to free themselves from their harmful effects.

  Each of the rival groups espoused its own theories and methods, but all shared a common conviction articulated so emphatically by the antipsychiatrists: Mental disorders were not bona fide medical illnesses and therefore did not need to be treated by physicians. The Conways, who brought their schizophrenic daughter Elena to see me, are an example of those who embrace the arguments of the antipsychiatrists, favoring holistic treatments over medical ones.

  By the mid-1970s, American psychiatry was being battered on every front. Academics, lawyers, activists, artists, and even psychiatrists were publicly condemning the profession on a regular basis. The 1975 movie One Flew Over the Cuckoo’s Nest, based on Ken Kesey’s 1962 hit novel, came to symbolize the surging sentiment against psychiatry. This Academy Award–winning film was set in an Oregon state mental institution where the main character, a charismatic and mischievous rogue played by Jack Nicholson, was hospitalized for antisocial behavior. Nicholson leads a boisterous patient rebellion against the tyrannical authority of the psychiatric ward, Nurse Ratched, who cruelly reasserts control by forcing McMurphy to undergo electroshock treatment and then having him lobotomized. While the story was intended as a political allegory rather than an antipsychiatry polemic, the film emblazoned the image of a morally and scientifically bankrupt profession upon the public’s mind.

  Surveying the situation in the early 1970s, the American Psychiatric Association warned its members, “Our profession has been brought to the edge of extinction.” The Board of Trustees called an emergency conference in February of 1973 to consider how to address the crisis and counter the rampant criticism. Everyone agreed that there was one fundamental problem central to all of psychiatry’s troubles: It still had no reliable, scientific method for diagnosing mental illness.

  Chapter 4

  Destroying the Rembrandts, Goyas, and Van Goghs: Anti-Freudians to the Rescue

  Physicians think they do a lot for a patient when they give his disease a name.

  —IMMANUEL KANT

  Unfortunately for us all, the DSM-III in its present version would seem to have all the earmarks for causing an upheaval in American psychiatry which will not soon be put down.

  —BOYD L. BURRIS, PRESIDENT OF THE BALTIMORE WASHINGTON SOCIETY FOR PSYCHOANALYSIS, 1979

  An Unlikely Hero

  There was little in the early life of Robert Leopold Spitzer to suggest he would one day be a psychiatric revolutionary, but it wasn’t hard to find indications of a methodical approach to human behavior. “When I was twelve years old I went to summer camp for two months, and I developed considerable interest in some of the female campers,” Spitzer tells me. “So I made a graph on the wall of my feelings towards five or six girls. I charted my feelings as they went up and down over the course of summer camp. I also recall being bothered by the fact that I was attracted to girls that I didn’t really like very much, so maybe my graph helped me make sense of my feelings.”

  At age fifteen, Spitzer asked his parents for permission to try therapy with an acolyte of Wilhelm Reich. He thought that it might help him understand girls better. His parents refused—they believed, rather perceptively, that Reich’s orgonomy was a sham. Undeterred, Spitzer snuck out of his apartment and secretly attended sessions, paying five dollars a week to a Reichian therapist in downtown Manhattan. The therapist, a young man, followed Reich’s practice of physically manipulating the body and spent the sessions pushing Spitzer’s limbs around without talking very much. Spitzer does remember one thing the therapist told him. “If I freed myself of my crippling inhibitions, I would experience a physical streaming, a heightened sense of awareness in my body.”

  Seeking that sense of “streaming,” Spitzer persuaded a Reichian analyst who possessed an orgone accumulator to allow him to use the device. He spent many hours sitting within the booth’s narrow wooden walls patiently absorbing the invisible orgone energy that he hoped would make him a happier, stronger, smarter person. But after a year of Reichian therapy and treatments, Spitzer grew disillusioned with orgonomy. And, like many zealots who lose their faith, he became determined to unmask and expose his former orthodoxy.

  In 1953, during his final year as a Cornell University undergraduate, Spitzer devised eight experiments to test Reich’s claims about the existence of orgone energy. For some trials, he enlisted students to serve as subjects. For other experiments, he served as his own subject. After completing all eight experiments, Spitzer concluded that “careful examination of the data in no way proves or even hints at the existence of orgone energy.”

  Most undergraduate research never reaches an audience wider than the student’s own advisor, and Spitzer’s study was no exception; when he submitted his paper debunking orgonomy to the American Journal of Psychiatry, the editors promptly rejected it. But a few months later he received an unexpected visitor to his dorm room: an official from the Food and Drug Administration (FDA). The man explained that the FDA was investigating Reich’s claims of curing cancer. They were looking for an expert witness to testify about the effectiveness of Reich’s orgone accumulators—or lack thereof—and they had obtained Spitzer’s name from the American Psychiatric Association, the publisher of the American Journal of Psychiatry. Would Spitzer be interested? It was a gratifying response for an aspiring young scientist, though in the end Spitzer’s testimony was not needed. The incident demonstrated that Spitzer was already prepared to challenge psychiatric authority using evidence and reason.

  After graduating from the New York University School of Medicine in 1957, Spitzer began his training in psychiatry at Columbia University and psychoanalysis in its Center for Psychoanalytic Training and Research, the most influential psychoanalytic
institute in America. But once Spitzer started treating his own patients using psychoanalysis, he soon became disillusioned once again. Despite his ardent efforts to properly apply the nuances and convolutions of psychoanalytical theory, his patients rarely seemed to improve. Spitzer says, “As time went on, I became more aware that I couldn’t be confident I was telling them anything more than what I wanted to believe. I was trying to convince them they could change, but I wasn’t sure that was true.”

  Spitzer soldiered on as a young Columbia University clinician, hoping that he would encounter some opportunity to change the course of his career. In 1966, that opportunity arrived in the Columbia University cafeteria. Spitzer shared a lunch table with Ernest Gruenberg, a senior Columbia faculty member and the chair of the Task Force for the DSM-II, which was under development. Gruenberg knew Spitzer from around the department and had always liked him, and the two men enjoyed an easy and lively conversation. By the time they finished their sandwiches, Gruenberg made the young man an offer: “We’re almost done with the DSM-II, but I still need somebody to take notes and do a little editing. Would you be interested?”

  Robert Spitzer, the architect of DSM-III. (Courtesy of Eve Vagg, New York State Psychiatric Institute)

  Spitzer asked if he would be paid. Gruenberg smiled and shook his head. “Nope,” he replied. Spitzer shrugged and said, “I’ll take the job.”