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Minefield of the Soul
by Robin Roger

"The history of psychiatry is a minefield," writes Edward Shorter, the Hannah Professor of the History of Medicine at the University of Toronto. "Both the revisionists and neo-apologists such as myself risk being blown up by uncharted pieces of evidence.many surprises may lie in store for us all."
This coy disclaimer makes little sense. New pieces of evidence may always catch historians short, and if they know this is possible, then they can't really be surprised. And if there is the possibility of a fatal misstep, shouldn't Shorter move tentatively and gingerly through his field? In fact, he hikes energetically through the minefield of psychiatric history. His goal is not only to tell the story of psychiatry, which needs updating in the wake of new pharmaceutical and genetic advances, but also to reveal where other historians have gone astray.
"Many of the psychiatric historians who came of age in the 1960s and 1970s have constituted a kind of lost generation in that they have chosen to pursue puffs of smoke, displaying no interest in the question of just what happens historically to make mind and brain go awry. If we wish to tell the history of psychiatry empathically, we must deal with the story of illness rather than arguing that it is a non-story or that it is unknowable."
Thus Shorter sets out to write two books, one about psychiatry, the other about the field of psychiatric history. Any writer who exposes the distortions and falsehoods of ideology is to be commended, and Shorter's criticisms are sometimes welcome correctives, even though they are only a minor note in his symphony.
Shorter argues that to truly document psychiatry, mental illness has to be understood in detail. Looking carefully at mental disease and its causes, he brings science and history together in a substantive way. Unfortunately, he believes that a genuine history of psychiatry should only study such mental illnesses as can be easily defined as disease entities or somehow quantitatively measured. This allows him to overlook a vast range of human miseries and to condemn those branches of the discipline that try to treat them. Shorter holds that genuine mental disease, such as schizophrenia and psychosis, deserves treatment, but that whiny posturing dysphoria, which is human unhappiness pretending to be depression, does not: ".quotidian anxiety and sadness,.obsessive traits of behaviour and the misfiring personality types.are the lot of humankind."
This is a rather sweeping statement for a historian to make. As he sees it, if people are functional, their suffering is not true illness. If it were, they would not be functional. Somehow Shorter has been able to measure suffering and prove to his satisfaction that functional people feel less pain than dysfunctional victims of completely debilitating mental diseases such as psychosis. The "worried well" ought to find other ways to cope, and leave the unwell to the shrinks. This is something like saying that people with headaches should chew tree bark and leave the neurologists for the brain tumours. Headaches can be minor symptoms or major ones, and the same goes for mental anguish. Room has to be left for a spectrum of mental distress other than those that can be linked to a gene or a chemical deficiency.
For example, there is that bedevilled group of individuals who, for lack of a better term, are known as "borderline", meaning that they hover between neurosis and psychosis. Shorter may see these people as the "worried well" because they function in society much like everyone else, though they struggle with ravaging forces such as suicidal thoughts, substance addictions, volatile relationships, and paranoid fears. These "misfiring" personalities are destructive of themselves and others, and often end up needing a great deal of medical attention. Are borderline personalities simply part of the lot of humankind, or can they be returned to a healthier mental status? One study, the Menninger Foundation Psychotherapy Research Project, looked at this and other questions over a thirty-year period, and found that psychoanalysis could indeed help these severely troubled people, in a lasting way.
Medical science also devotes considerable effort to supporting and promoting healthy development in order to prevent illnesses later on. Hearing problems in children are treated aggressively so that they will not suffer a delay in their speech development, which cannot be completely corrected if the proper initial development does not take place. Emotional development can also go awry, with results that are sometimes ignored until adulthood. Psychotherapy studies have shown that when these problems of arrested development are treated, the results are lasting because development goes back on track. In other words, psychotherapy can have a preventative benefit. It may be impossible to express in a statistic how many psychological problems are prevented, just as we cannot know how many hearing aids and speech therapists we won't need if we put tubes in infants' ears, but the treatment is effective nonetheless.
Shorter sidesteps the grey and murky aspects of human mental illness in an effort to prove that psychiatrists are simply buttering their bread by treating neurotics in their cosy consulting rooms instead of slogging it out in the asylums. It may well be true that our culture has encouraged the merely unhappy to turn to psychiatrists for hand-holding, but it does not follow that psychiatrists who treat neurotics are simply snake-oil salesmen who are creating turf for themselves. Or that the father of all snakes is Sigmund Freud, the progenitor of psychoanalysis, for which Shorter saves his most withering sarcasms.
Although Freud is the most cited twentieth-century thinker (in any academic field), Shorter summarizes his thought in one sentence: "Freud's psychoanalysis said that repressed childhood sexual memories and fantasies caused neurosis when reactivated in adult life." And psychoanalytic technique in another: "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 earlier childhood attitudes)."
He goes on to dismiss one of society's most enduring and pervasive treatments, using some spectacularly broad strokes-particularly in his depiction of European Jewry, pre- and post-Holocaust.
George Orwell once observed that no matter what you said about Jews in public, you were bound to get in trouble for it. Beyond that he did not tread. Shorter not only treads over European Jewry, he dances on its grave, explaining why the potent combination of high-strung Jewish sensibilities and Hitler's defeat made North America prone to psychoanalytic contamination.
According to Shorter, Freud had "privileged access to a group of patients who were especially needy in psychological terms: middle-class Jewish women in families undergoing rapid acculturation of West European values." And later on, he pronounces that "it would be hard to imagine a therapy less appropriate for the needs of people with serious psychiatric illnesses." "History moves in odd ways," says Shorter. "What ultimately converted a chic 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."
Psychoanalysis "may have appealed to Jewish women in particular. Perhaps these cloistered but well-read and highly curious women.were simply more self-reflective, more psychologically minded than the women of the non-Jewish lower-middle classes below them who worked alongside their husbands in shops, or the women of the nobility above, busy with the social whirl of the salon."
A nuanced thinker like Shorter must know that there were also Jewish women working alongside their husbands in the shops. (For that matter, they often ran the shop while brow-beating their husbands, who slacked off to read holy texts.) And that the cloistering was later than the Holocaust, because it took time for immigrants to acquire the funds necessary to gild their wives' cages, and then it consisted more of decorating, fundraising, and socializing than of reading. But Shorter makes many peculiar observations about Jews. "The American Jews had not experienced the trauma of emigration. Yet they too had arrived as outsiders.." He implies that it was only the Jews caught short by the Holocaust who struggled with adjustment in America, overlooking the fact that each community of Jews who arrived had initially left to get away from some external threat, and that the struggle to find bearings takes more than a generation and expresses itself in many kinds of distress.
Nobody would deny that Freud was influenced by his background, his community, and his clientele, but it takes intellectual chutzpah to conclude that psychoanalysis was tailored to fit the psyche of the Jewish European Princess. Or that their American counterparts took over when it reached New York. Jewish refugees did play a large role in the dissemination of psychoanalysis in North America, and Jewish neurotics did buy the product. The questions are, to what degree should these facts be stressed, and how do they bear on the validity of psychoanalysis and related therapies? If it had no validity, and only spoke to Jews, it would be about as widespread as Jewish delicatessens: able to survive, but not to grow. Psychoanalysis and bagels have become mainstream phenomena, which suggests they both have some virtue independent of their ethnicity.
Whether or not psychotherapy can help the mind and brain that goes awry is more of a debate than Shorter would like to suggest. He refers to Hans Eysenck's forty-five-year-old study which argued that the efficacy of psychotherapy and spontaneous remission were about the same, but does not consider the critical question of research design or measurement, which has been growing increasingly complex and sophisticated in the subsequent half-century. Eysenck's conclusions have been seriously challenged by other studies which have identified non-comparable comparison groups, arithmetical errors, and other flaws. In fact, a revisiting of Eysenck using a more nuanced technique suggests that spontaneous remission does indeed occur, but that psychotherapy can bring about relief in fifteen weeks while waiting to get better usually involves two years. If Shorter were depressed or anxious, which would he choose? The many dubious alternatives to psychotherapy which are described in this book, including insulin coma therapy, lobotomy, electroconvulsive therapy, and CIA-sponsored deep-sleep depatterning, all make free associating on a couch look like a safer bet. The only genuine progress Shorter can see has been in the finding of genetic components to brain diseases such as schizophrenia, and in the invention of drugs to treat diseases. The popularity of "cosmetic psychopharmacology", through which we are currently living, with the advent of Prozac and similar drugs, is the latest episode in psychiatry's continuing march of folly. Once again, Shorter takes the whiners to task for lining up at the prescription counter the way they flocked to the consulting room. Workaholics and other neurotics are not in the "historic tradition of the agonized and the inconsolable, for real psychiatric disease causes terrible pain and disablement." In the final analysis, Shorter finds biological psychiatry preferable to psychodynamic, and sees them as clearly opposed. But he overlooks current work on the interrelatedness of our biological dispositions and our psychic response to experience. Neuro-psychologists have been studying the impact of emotional development on brain development in infants, discovering that when emotional deprivation occurs in the first year, the very substance of the brain is affected. Our wires can short-circuit if the proper growth is not stimulated through external nurturing input. Our psyches are biological, our biology is influenced by our psyches. And this appears to continue throughout life. One study looked at obsessive-compulsive patients after ten weeks of cognitive behavioural treatment and found that those who had improved clinically showed brain changes on their orbital cortex, caudate nucleus, and thalamus. A partnership between psychotherapists and biological psychiatrists may be feasible, and far preferable to the split that Shorter thinks is inevitable.
Given the disdain with which Shorter regards garden-variety neurotics, and his insistence that they are not legitimately unwell, he might have been better off writing an even shorter book on the history of schizophrenia and psychosis and a second volume on the more elusive conditions that disturb humankind. To write the second history would require the empathy he calls for at the outset of this book, which he appears to withhold from most of humanity.

Robin Roger is editor of the alumni magazine for University College, University of Toronto.


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