Spitzer Apologizes

Psychiatry seems endlessly political. Having read Ronald Bayer's excellent chronicle of the story of homosexuality being read out of psychiatry's Diagnostic and Statistical Manual I was puzzled when I read the New York Times headline " Leading Psychiatrist apologizes for Study Supporting Gay 'Cure'." I was completely unfamiliar with the story it relates of Robert Spitzer's sponsoring and publishing a study on treating homosexuality in 2001.  The author of the article, Benedict Cary, suggests that it was Spitzer's anti-establishment impulses manifesting themselves again that led him to conduct the study. I found myself wondering if the study didn't express some  reservations that Spitzer still had about his advocacy for the de-medicalization of homosexuality. At the end of the article Spitzer, clearly thinking about his legacy in the history of psychiatry says of his apology: " You know, it's the only regret I have; the only professional one, … And I  think, in the history of psychiatry, I don't know that I've ever seen a scientist write a letter saying that the data were all there but were totally misinterpreted. Who admitted that and who apologized to his readers."  He might have added that it would be hard to find a psychiatrist turning 180 degrees from one politically controversial position to another -- not to mention in the wrong direction.

Diagnosing the DSM

Allen Frances' May 11, 2012 op-ed piece in the New York Times "Diagnosing the DSM" is a wonderful piece of common sense. He argues that we don't need to insist that psychiatrists are in cahoots with drug companies to see that conflicts of interests render the American Psychiatric Association incapable of developing a diagnostic manual that does not overreach and medicalize much of everyday life. His suggestion that some presumably neutral arbiter such as the National Institutes of Health should take on this task is worth discussion.
As it happens I was just rereading a wonderful essay by Peter Sedgwick in his 1982 book Psychopolitics, titled "Illness--Mental and Otherwise." While it is aimed at the anti-psychiatry theorists of the day, its central point is that all diagnosis, whether of mental or of physical disorders, involves value judgments. The great success of the DSM as well as its scientific pretentions make it clear that we must take Sedgwick's arguments seriously if we are going to have an honest debate over the reasonable limits of psychiatric diagnosis.

More on straitjackets

       In a  2006 post I wrote that the camisole de force was invented at the Bicêtre in 1790.  I recently realized that my source got that wrong. Most sources cite the same inventor, but give the date as 1770. In addition it seems that the strait waistcoat was in use at least by that date and probably much earlier. In 1772 David MacBride gives a detailed description of construction of the strait waistcoat, implying that it was well known in Britain by that time.
       By 1784, and perhaps as early as 1777, the very influential Scottish physician William Cullen in his First Lines of the Practice of Physick was praising the waistcoat not only as a means of restraint, but also as a remedy and even suggesting a physiological rationale for its benefit. This passage is so striking that it is worth quoting at length.

     "Restraining the anger and violence of madmen is always necessary for preventing their hurting themselves or others: but this restraint is also to be considered as a remedy. Angry passions are always rendered more violent by the indulgence of the impetuous motions they produce; and even in madmen, the feeling of restraint will sometimes prevent the efforts which their passion would otherwise occasion. Restraint, therefore, is useful, and ought to be complete; but it should be executed in the easiest manner possible for the patient, and the strait waistcoat answers every purpose better than any other that has been yet thought of. The restraining madmen by force of other men as occasioning a constant struggle and violent agitation is often hurtful. although there may be no symptoms of any preternatural fulness or increased impetus of blood in the vessels of the brain, a horizontal posture always increases the fulness and tension of these vessels, and may thereby increase the excitement of the brain."

 
      Philippe Pinel may have learned about the strait waist coat from Cullen when he translated this passage in 1785, incidentally using the term chemisette serrèe, suggesting that he was not yet familiar with the commonly used term camisole de force. In his Treatise on Insanity in 1800, Pinel argued that his use of the camisole de force was evidence that he subscribe to the same philanthropic principles as those of the York Retreat:

       We are doubtless without the advantages of Dr. [Thomas] Fowler's establishment in Scotland [actually the Retreat in York] with its expansive grounds and fine accommodations. But I can attest after two years of diligent observation that the same principles of philanthropy prevail in the management of the insane at Bicêtre. The attendants, under no pretext whatever, ever raise a hand, even in reprisal. Strait jackets [Gilets de force] and seclusion, for short periods, are the only punishments inflicted. When kind treatment or the imposing trappings of repression fail, a clever ploy sometimes produces unexpected cures [TAM. 1800, 65-6].

       

Defending Psychoanalysis in France

The dispute in France over the role of psychoanalysis in treating autism brought a defense of analysis in the Nouvelle Observateur [NO] from Elisabeth Roudinesco [ER] and Alain Badiou [AB].  I found one section of their comments of particular interest, not because it related to the issue of autism, but rather because it offered a social psychological interpretation of the plight of psychoanalysis. Here is my effort at a translation:
[ER]The dissatisfaction [of the relatives of autistic children] does not come from nowhere. However, all the critiques are not acceptable. For example, we are witnessing a new phenomenon: patients want to decide their treatments and consider in particular that their symptoms belong to their identity. [she uses the term boufées délirantes. I would paraphrase the CNRTL dictionary definition of this term as a sudden, short lived mental disturbance manifesting itself through hallucinations, sensory illusions and accompanied by mental confusion.] They do not see why they should be numbed by medication on the pretext that they hear voices. In which case one must listen to them. But we are going towards the patient as master of his destiny, and this is not desirable. Here again, psychoanalysts bear part of the responsibility, because by enclosing themselves in chapels they lose their authority. At bottom what has been lost in psychoanalytic societies is the position of master to the benefit of that of little chiefs [petit chefs].
[NO] What do you mean by “master?”
[ER] The position of master permits the transference: the psychoanalyst is “supposed to know” what the analysand is going to discover. Without that, trying to discover the origin of the suffering is almost impossible.
[NO] Is it really necessary to go through the restoration of the master?
[AB] The master is what helps the individual become a subject. Because if one admits that the subject emerges in the tension between the individual and universality, then it is evident that there is a need for mediation to advance on this road. And therefore the need for an authority. The crisis of the master is the logical consequence of the crisis of the subject, and psychoanalysis is no escape  from it. It is necessary to restore the position  of the master, but it is not true that one can do without it, even and especially from the perspective of emancipation.
[ER] When the master disappears, he is replaced by the chief, authoritarianism, and that ends always, sooner or later, in fascism- history has, alas, proved this.

I found this part of the interview interesting because it suggests that for psychoanalysis to be successful as an individual therapy and as a therapeutic institution the analyst must be accepted as a ‘master,. that is as one who is ‘supposed to know.’  While the priestly role of the doctor is an important part of many, if not most, areas of medicine, these remarks indicate that for psychoanalysis this role is the critical ingredient. Indeed, they seem to say that without the analyst being able to assume the role of master the process cannot occur. In a patriarchal society, such as the one Freud lived in, the doctor as a ‘master’ could be assumed. What the authors seem to be suggesting is that the challenge to psychoanalysis posed by such people as the relatives of ‘autistes’ is part of a larger challenge to patriarchal norms that may be occurring in France somewhat later that it did in the United States. This raises the question of what  role of the challenge to patriarchal norms in the United States has played in the decline in the fortunes of psychoanalysis.

The Wall

Although the controversy over Sophie Robert's documentary film "The Wall: Psychoanalysis put to the test for autism" has been going on for a while, I first learned about this week when I ran into an article in the Nouvelle Observateur titled "Faut-il brûler la psychanalyse ?" in which Elisabeth Roudinesco and Alain Badiou defend psychoanalysis. Frustrated with reading this I learned that in January 2012 The New York Times published an article "A French Film Takes Issue with the Psychoanalytic Approach to Autism," which reviews the controversy quite clearly. However, clicking on the link to the Youtube version of the film in the article, I found that it had been removed from Youtube. This act of censorship  got me interested in finding a way to view the film. Indeed several sites no longer had the film available. I did find one site where the film is available. As a document in the history of psychiatry, it is well worth viewing. It reminded me of the controversies over psychoanalytic theories of Tourette Syndrome that Howard Kushner describes so well in his book A Cursing Brain? Histories of Tourette Syndrome.

Rabbi's Little Helper

Psychiatry has long been accused of being an agent of social control. It appears that a new chapter to this story is being written in Israel.  A few weeks ago Haaretz published  "Rabbi's Little Helper," which related stories of people being taken to psychiatrists by their rabbis for medication, presumably in the hopes that their behavior will better conform to community standards. Today Haaretz published a follow-up titled  "Psychiatric drugs become talk of the ultra-Orthodox community.

Biology vs. Psychology in the 1920s

     Some years ago, while rummaging around in a room full of psychiatric hospital records from the 1920s, I ran across the verbatim typescript of a memorable case conference. During this period two perspectives on understanding patients were actively competing. Psychoanalytic ideas were still relatively new and attempting to explain all sorts of phenomena that had previously been explained biologically. At the same time new biological treatments were infusing biologically oriented psychiatrists with new confidence. At this hospital the ambitious medical director had recruited a number of young clinicians from each of these perspectives. The case presented on that day was a middle aged man who had been treated with mercury some ten years earlier for symptoms of general paresis of the insane. Now he was admitted to the hospital for symptoms of depression with some suspicion that his general paresis had returned. In the days before penicillin, general paresis, which is a form of tertiary syphilis was a common frightening cause of madness and death. Its early psychiatric manifestations were quite variable, though most often they were mood related--mania and depression. While severe dementia eventually dominated the clinical picture, symptoms of dementia were, in the early stages, often subtle and easy to miss.
      Why was this man depressed? The medical director posed this question to his young new staff somewhat in the manner of a professor presenting a question to a class. A lively discussion broke out. The  biologically oriented psychiatrists noted that  mood symptoms were common in such cases of general paresis. The psychoanalytically oriented psychiatrists argued that the sexual nature of the disorder ws producing guilt and that was leading to the symptoms of depression. The discussion went on for some time without resolution since the two perspectives were incommensurable. Eventually the medical director asked that they simply review the facts of the case.  After some further discussion, he pointed out that ten years earlier the patient had thought himself cured of syphilis and free from the possibility of general paresis. Now, perhaps, the patient was able to subtle signs of dementia in himself and understood what was in store for himself. "Isn't that," the medical director concluded, "reason enough to be depressed."
       Reading that case many years ago, I thought about how ideological arguments have the power to distract psychiatrists from what is staring them in the face. Over the years that I have practiced psychiatry, i have often had occasion to recall the lesson of that case conference.

Her Name is Sabine

This is a beautiful, tragic documentary film directed by the actress Sandrine Bonnaire. It uses home movie footage of her sister Sabine along with footage made when Sabine was a resident of a group home for people with serious psychiatric and neurological disabilities. The contrast between the images of the hauntingly beautiful adolescent Sabine and the obese, drooling, anxiety ridden and occasionally violent woman that her sister found  after her five years residence in a psychiatric hospital is profoundly moving. The film also answers a question that I have had for years since seeing Sandrine Bonnaire in the Agnes Varda film Vagabond. I wondered how Bonnaire had 'found' the hauntingly beautiful character she plays. Her Name is Sabine certainly gives a clue to an answer to that question.
I should add that Sabine is described in publicity for the film as 'autistic.' As I recall, someone who I took to be a psychiatrist in the film describes her as a 'psychoinfantile character with autistic features.' [I may not remember this exactly] While I thought that schizophrenia was a reasonable diagnosis for Sabine [especially as she seems to be receiving clozapine treatment], I found it interesting that schizophrenia is not mentioned in the film. I wondered if this was due to stigma or diagnostic peculiarities in France.

Teenager’s Path and a Killing Put Spotlight on Mental Care

I suppose this article got to the first page of the New York Times today to give us a preview of what this era of more budget cuts and no new taxes will be like. There are, of course, many unfortunate consequences of lowered funding for mental health services. It takes stories like this to bring attention to the situation. What will it take to produce better services? During the late nineteenth and early twentieth centuries mental health services for the seriously mentally ill deteriorated for nearly a century.

Sigmund Freud’s Cocaine Years

This New York Times review by Sherwin Nuland of Howard Markel's book titled  AN ANATOMY OF ADDICTION: Sigmund Freud, William Halsted, and the Miracle Drug Cocaine  sound as though Markel's book manages to treat the cocaine addiction of two famous people with both clinical and historical intelligence -- a remarkable achievement. I look forward to reading the book.

Ugandans with Mental Illness Learn to Fit In

This story reported by Joanne Silberner and funded by a Rosalynn Carter Fellowship for Mental Health Journalism describes a program for helping people in Uganda with mental illness find employment. In a market economy, community acceptance is based on the ability to work and bring money home to the family. This story focuses on community efforts in Africa to supplement psychiatric treatment with vocational programs. The emphasis of this story is on how programs that promote work for the mentally ill are especially important in African communities. The suggestion seems to be that things are different in the United States.  In my experience, however, all that seems different in this country is that vocational programs for the mentally ill have a very low priority. Would that there were more effective programs promoting work for the mentally ill in the United States.

It's all in the Head

The Neue Galerie in New York currently has a wonderful exhibition of twenty busts by the 18th century sculptor Franz Xaver Messerschmidt (1736–1783). The article "It's all in the Head" by 

Willibald  Sauerländer  in the New York Review both places Messerschmidt's work in its historical context [to the extent that such strange and original work can be placed] and offers a well placed jab at the psychoanalytic reductionism that presumed  [and perhaps still presumes] to explain everything.