The Empty Couch
by Joan Acocella
In one of the psychiatric wards where T. M. Luhrmann did research for her new book, "Of Two Minds: The Growing Disorder in American Psychiatry" (Knopf; $26.95), there was a patient who enjoyed going into the common room in the evening and telling the other patients how she tortured animals: "She told them that she liked to stick pins into rats’ eyes and listen to them squeal, that she would chop them up and drink their squirting blood." Once she had all the other patients crying, she would go back to her room and turn in for the night. When the attending doctor spoke to her about this, he did not try to find out if she actually tortured animals, let alone why. He just told her to stop disrupting the ward." 'If you feel like you want to harm animals.., and you need some help controlling those thoughts, tell us,’ he said. ‘Otherwise, don’t tell us, because no hospital can legally discharge you if you do.’ "She stopped, and, in keeping with the current trend toward short hospitalization, probably soon went home. This was a "biomedical" ward, as are most psychiatric units these days, and in such a place the doctors no longer explore with you why you think and act as you do. Biomedical psychiatrists regard mental disorders as "heart attacks in the brain" (Luhrmann’s phrase), and they no more expect you to explain such an event than if you had had a heart attack in the heart. On admission to the hospital, you are swiftly diagnosed and medicated. Then, once you have stopped threatening suicide or hearing voices - a process that takes maybe five to ten days - you are given a bottle of pills and discharged. Chances are you will be back soon.
For about a decade now, since the introduction of Prozac, in 1988, and the articles and books on it in the early nineties, the general public has known about the split between psychodynamic and biomedical psychiatry which in outpatient terms means the choice, when depression or anxiety returns, of either going back to the psychotherapist for another year or getting your regular doctor to give you a prescription for Prozac or Xanax. People also know, if they have read the Time and Newsweek articles—and maybe Peter Kramer’s 1993 “Listening to Prozac,” which has sold more than half a million copies in the United States alone—about the philosophical implications of the two approaches: how on the one, psychodynamic hand, you are in large measure stuck with your fate but also responsible for it, and how on the other, psychopharmacological hand, you don’t have a fate, you have a system of neurotransmitters, for which you are not responsible and with which you aren’t stuck, since, thanks to drugs, you can adjust it. To partisans of the psychodynamic view, the new, drug-based psychiatry is taking the morals, the dignity, the truth out of human life. To the drug doctors, all that is being eliminated is the junk pile of unexamined assumptions descended from Sigmund Freud.
“Of Two Minds” addresses the controversy differently. Luhrmann, a professor of anthropology at the University of California at San Diego, comes to psychiatry the way Margaret Mead went to Samoa. That is, she approaches it as a culture, a collection of beliefs and practices which young people are socialized into. She follows a number of psychiatrists-to-be through their training and watches how they get “processed” by the contingencies of their culture—how, in the end, what is called theory is actually a canny balancing of conviction with the need to survive. In the process she provides a more nuanced treatment of the moral and philosophical issues than any previous discussion I know of.
As Luhrmann sees it, almost everything about psychiatric trainees’ experience pushes them into the biomedical camp. Medical school, to start with, teaches them to separate their feelings from their patients, and the psychiatric residency drives that lesson home. Residents are given lectures and training in psychotherapy, but there is a none too subtle deëmphasis of that part of their education in favor of the biomedical work of diagnosis and medication. Then they graduate and take jobs in places that, increasingly, have nothing to do with psychotherapy. Luhrmann spent a week studying an institution she calls San Juan County Hospital, in northern California. On its psychiatric unit there were two women married to God, and another, pregnant with her ninth child—her previous eight were living with relatives or in foster homes—who called herself Shirley Temple. (“Look,” she would say, pinching her arms, “the hospital hasn’t helped. I’m still black.”) One man, on arrival at the hospital, reported that he had no hallucinations, “except for the Devil.” His problem was that he hadn’t taken food or drink for six days. This was his fourteenth admission. Many of the other patients were also what the staff called “frequent fliers”—a fact that was unquestionably due in part to the conditions in which they lived on the outside. Most were poor; many, upon release, used crack or alcohol to control their symptoms.
The staff tried to address these people’s “psychosocial” problems; they held meetings with them to talk about substance abuse and living skills, but in the eight days that was the average length of admission there was little they could do. Luhrmann says she once ran such a meeting. When the patients spoke, “which was not so often, they talked about how it was more difficult to get to one prison than to another and how when their son came home on probation they really hoped he wouldn’t keep a gun in his car the way he had last time.” If social problems are hard to solve in a week, emotional problems don’t have a chance. The man who was starving himself reported that his father had died three weeks earlier: “Several times he started a sentence with ‘My father’ but couldn’t complete it.” The resident who admitted him did not draw him out; she didn’t have time. The purpose of the unit was simply containment, for the sickest patients in their sickest periods, and once they were discharged they were not supposed to return too soon. Those who keep coming back may find themselves taking a vacation courtesy of the local authorities. ”In southern California,” Luhrmann reports, “patients would show up in the psychiatric emergency room and explain that they had been in Minnesota or Illinois and had gone to the bus station and a nice man from the county mental health had bought them a bus ticket to San Diego, which they thought they’d like to visit.”
Many writers who take on the current state of our psychiatric hospitals side with the patients, and demonize the psychiatrists. The wonderful thing about Luhrmann’s book is that she demonizes no one. Young psychiatrists, she says, start out idealistic (even more so these days, when managed care has reduced their earning power). Then they start cutting their losses. Diagnosis, which they begin doing as residents, is the first lesson in hospital Realpolitik. Diagnosing means looking at a person who typically presents a complicated, ambiguous picture-—"They’re sad, they’re not sleeping too well, their wife just left them,” as one resident summarized it—and, within a matter of minutes, marking him down as having one of the conditions listed in the American Psychiatric Association’s “Diagnostic and Statistical Manual of Mental Disorders,” or D.S.M. These conditions, in keeping with the so-called medical model—which holds that psychological disorders are like, or are, organic disorders—come described as consisting of certain “symptoms,” which add up to a certain “syndrome.” Then, again in keeping with the medical model, the psychiatrist prescribes medication. These actions have good short-term results. The patient, given the medication, settles down. The insurer, given the diagnosis (it is required), pays for the treatment, thereby keeping the hospital out of bankruptcy. So young psychiatrists go on doing these things, and as they do they come to look for symptoms that fit D.S.M. diagnoses, and for which medications are available. Then they go to work in hospitals where there is no time to do psychotherapy, so why bother even thinking about the matters that psychotherapy addresses—hope, discouragement, truth or untruth to oneself? Thus psychiatrists learn to work within the biomedical system, and to believe in it, if they don’t want their lives to be anguish. Touchingly, Luhrmann reports that many of them haven’t learned, and that their lives are anguish. They know what it is that they are ignoring, and they feel they have broken trust with their patients. “They feel like bad people.”
Where did the biomedical approach come from? From Hippocrates, at the latest. For a couple of millennia now, the pendulum of psychiatry has been swinging between organic and psychological/spiritual explanations. In the late nineteenth century organic causation was the dominant theory. Then it was shoved aside by Freud. Psychoanalysis took a while to conquer the United States, but once it did, after the Second World War, its dominance was unquestioned, and its arrogance breathtaking. Schizophrenia, autism, and numerous other disorders were blamed on the mother, with no evidence, just utter certainty. The public accepted this, to the great disadvantage of patients, not to speak of mothers. Then, gradually, it was shown that schizophrenia had a strong genetic component, that autistic children had demonstrable neurological deficits, and so on. In other words, biomedical theory rose because there was science to support it. It also had humanitarian appeal: if mental disorders were biological, patients shouldn’t be blamed for them, shouldn’t be stigmatized. That the return of the biomedical approach also occurred within the context of the despiritualization of our society after the sixties, that it fit in so well with the abandonment of any value that was not commercially profitable (as psychotherapy apparently was not, and drugs were): these facts were noticed by some but, in the re-scientific atmosphere of those times, they did not amount to a strong argument.
It was in the late seventies that the first generation of convinced biomedical psychiatrists got out of school. Still, many of them felt that psychological disorders involved both organic vulnerability and learning, and that, whatever the cause, most patients needed both biological and psychological treatment. (Even if a disorder is wholly biological, patients need psychological therapy to repair the consequences—their wrecked marriages, their hiatus-filled résumés.) So in most wards some psychiatrists gave drugs, some gave psychotherapy, and the system chugged forward.
Then came managed care. Luhrmann is so fair that she is even fair to managed care. By 1990, she notes, expenditures on health care in the United States had exceeded six hundred billion dollars, more than twelve per cent of the gross national product. Something had to be done, but what was done was brutal, above all in mental health. (General medical benefits dropped by 7.4 per cent, but mental-health benefits were cut by half.) In the mid-nineteen-nineties, Luhrmann re-visited a large teaching hospital where she had done field work a few years earlier. The experience, she says, was like “coming back to a tree-lined London neighborhood after the Blitz.” Services had been reduced to a minimum. Psychotherapy was gone altogether, except for certain, very circumscribed groups. (For example, trauma patients. Is this why therapists are now so interested in psychological trauma, and so likely to diagnose it?) Most patients don’t have a prayer of discussing their dead fit her, or even their living circumstances. In all this slash-and-burn, it is not clear that there has been any substantial cost saving, for with the elimination of psychotherapy—and the stepped-up speed of discharge—readmission rates have risen. Especially important in the financial picture, it seems, is the provision of outpatient psychotherapy, as the Champus Insurance Company, for example, discovered when it expanded outpatient psychiatric coverage between 1989 and 1992. It “gained a net saving of $200 million because its customers’ hospitalization rate dropped sharply. For every dollar spent on psychotherapy, four dollars were saved.” There are few things more expensive than hospitalization, and, strange to say, it can be prevented in many cases by a little talk once a week with an interested person.
"Of Two Minds” concentrates on inpatient care, but there is a parallel crisis going on in outpatient treatment, and that is the subject of “ProzacBacklash: Overcoming the Dangers of Prozac, Zoloft, Paxil, and Other Anti-depressants with Safe, Effective Alternatives” (Simon & Schuster; $25), by the Harvard Medical School psychiatrist Joseph Glenmullen. Twenty million people are now on Prozac, not to mention the millions who are taking other SSRIs (selective serotonin reuptake inhibitors), such as Paxil and Zoloft. Meanwhile, insurance support for outpatient psychotherapy has been cut off at the knees. In Glenmullen’s view, this constitutes an outrage, not just because people need psychotherapy but because the drugs that have replaced it are potentially dangerous.
There’s a saying among psychiatrists that you should always prescribe a new drug right away, “while it still works”— in other words, while the doctor and the patient still believe in it, thus giving it the placebo effect—because many popular medications, once they hit the market, enter what Glenmullen calls the “10-20-30” cycle. After ten years, people start noticing problems with the drug, problems that the manufacturer vigorously denies. After twenty years, the problems become clearer, and physicians start sounding the alarm. After thirty years, the regulatory agencies step in, and often the drug is withdrawn from the market. Surprise—by then the patent has expired, and the manufacturer no longer has a financial interest in the drug. But the company has a new drug, said to be newly effective, newly free of side effects, and the 10-20-30 cycle begins again. This has happened many times, but only in accelerated cases—for example, the recent fen-phen scandal—does it seem to get noticed by the press, and hence by the public.
Prozac, too, is running a shorter cycle. (The new, “improved” version is already in the works.) By 1994, the psychiatrist Peter Breggin and his wife, Ginger Ross Breggin, had published “Talldng Back to Prozac,” in which they claimed that the drug was having dire side effects. Glenmullen’s book is in some measure just an update, but in the intervening six years more research has accumulated, and some of it is frightening.
By “Prozac backlash,” Glenmullen does not mean the response of the public; he means the response of the brain— above all, of the dopamine system—to what the SSRIs are doing to the serotonin system. A number of studies have found that about sixty per cent of SSRI users experience sexual dysfunction: decreased libido, decreased arousal, delayed orgasm. (Or, in rare cases, they may have a “paradoxical” response. A 1989 paper in the Journal of Clinical Psychopharmacology described the case of a woman who, upon having her Prozac dose increased, began experiencing spontaneous orgasms for most of each morning, a circumstance that, not surprisingly, was said to be “interfering with normal activity.”) Another complication is that some people, when suddenly put on a high dose of Prozac—for years, the manufacturer marketed the capsules in only one dose, a high dose (twenty milligrams), so as to make the drug simpler for primary-care physicians to prescribe, thus cutting out the specialist, thus pleasing the H.M.O.s—have committed suicide or homicide. Pharmaceutical companies have done what they could to minimize such findings. (The literature enclosed with Prozac still states the incidence of sexual side effects as two to five per cent of depressed patients taking the drug.) And they have had the help of many supposedly independent psycho-pharmacologists publishing research on the SSR[s—or not publishing it, if the drug company, having funded the study, doesn’t like the findings. According to Glenmullen, the only reason we know about the widespread sexual difficulties of SSRL users is that the research was paid for by the manufacturers of Serzone and Wellbutrin, competing, non-SSRI antidepressants that had lesser sexual side effects. (Don’t change your prescription. Glenmullen reports that, at least in the case of Wellbutrin, gains in the short run may peter out in the long run: “I have now seen a number of patients who lost interest in sex, even developed an aversion to it, after being on Wellbutrin long-term.”)
That’s not the end of the side effects. There are also motor problems: tics, muscle spasms, agitation. In patients on SSRLs Glenmullen has seen “fly-catcher tongue-darting” and “chewing-the-cud jawing.” Others have seen “involuntary pelvic thrusting.” Interestingly, these symptoms resemble the motor abnormalities that began to develop in hospitalized schizophrenics after the introduction of the so-called major tranquilizers, such as Thorazine, in the fifties. Because those problems developed only slowly and were often masked by the very drugs that caused them, the extent of the damage did not become clear for years. Now we know that between twenty and thirty per cent of patients on major tranquilizers develop tardive dyskinesia, a Parkinson’s-like movement disorder. In about half of those cases, tardive dyskinesia is irreversible; the symptoms do not go away when the patient is taken off the drug. Considering the tics and spasms that are turning up in SSRJ takers—on which, it should be added, there seem to be no good figures yet (Glenmullen says things like “Mild to moderate spasms may affect as many as 10 percent of patients”)— some doctors are worried that Prozac and its cousins may likewise be causing “silent brain damage,” the effects of which will not become clear for years, perhaps not until the patient reaches old age.
A recent issue of Brain Research reported on a study in which rats were given high doses of either Prozac or Zoloft for four days. Afterward, their brain cells showed “swollen axon terminals, thick axons and corkscrew-like profiles.” Corkscrew-like profiles! The drug doses, it should be said, were very high, ten to a hundred times the therapeutic dose for human beings. On the other hand, the rats took the drugs for only four days, whereas millions of human beings have been on SSRIs for years. Madhu Kalia, who directed the study, says, “We don’t know if the cells are dying.... These effects maybe transient and reversible. Or they may be permanent.” If they are permanent, and turn up in human beings as well as in rats, the law courts are going to be an interesting sight in thirty years. Unlike the hospitalized schizophrenics who developed tardive dyskinesia, the ad executives taking SSRLs have good lawyers.
Glenmullen’s book is not the sort of bend-over-backward balanced assessment that Luhrmann’s is. (One of the blurb writers compares it to “The Jungle.”) Yet one is inclined to listen to him, because he is not a one-solution man. Indeed, he prescribes SSRIs. Like many cautious psychiatrists, he uses them to relieve depression to the point where the patient can do something about its source. He tells patients that medication is just a crutch, that they need psychotherapy, that if they don’t find out what’s causing the depression it will never go away. (He cites the research showing that although drugs and psychotherapy are about equally effective against depression in the short term, people who rely on drugs alone are far more likely to relapse. Incidentally, the same is true for anxiety disorders.) He seems to have an unclouded faith in short-term psychotherapy. In the cases he recounts, the patients soon cough up the underlying reason for their troubles, and talk about it, and get better, usually in less than a year. But these people may not be atypical; mild to moderate depression is one area where short-term psychotherapies have had remarkably good results. Apart from his insistence that SSRIs should not be dispensed without psychotherapy, Glenmullen believes that they should be given to far fewer patients. Doctors are now prescribing them for weight problems, premature ejaculation, back pain, PMS, failed romances, nail biting. Increasingly, SSRIs are also being given to children, whereas, to quote a 1996 review article in the Journal of Nervous and Mental Disease, “The evidence is unanimous that antidepressants are no more effective than placebos in children with symptoms of depression.” In Glenmullen’s view, seventy-five per cent of people on SSRIs can either go off the drug or dramatically reduce their dose. In any case, they should read this book.
For many people of my generation, especially women, psychotherapy is not so much an issue as a history, a language in which they learned to speak of themselves, and of life. This fact has been widely deplored. Psychotherapy, people say, has taught women to think of themselves as victims. It has made them narcissistic, turned them in on their own minds rather than out into the world, where the men seem to be living. True enough, of some therapies. In others, women—and men—have learned to stop being victims, and to act in the world. That was the case with Emily Fox Gordon, the author of “Mockingbird Years: A Life In and Out of Therapy” (Basic; $24). The title is a little scary; this is not just another “woman’s memoir but a memoir of the couch, the tears. Yet “Mockingbird Years” is a beautiful book, and very tough-minded.
Gordon was born in the late forties to a father who was an economist—he became the Director of the Budget in the Kennedy and Johnson administrations—and a mother who, in Gordon’s view, was even more gifted: artistic, imaginative, subtle. She was also, Gordon felt, embarrassed by her chubby, emotional, underachieving daughter. By the age of eleven, Gordon had begun her voyage through psychotherapy, a long story (six therapists) that is a sort of capsule history of psychodynamic treatment in the postwar period. First she was sent to orthodox psychoanalysts who, faithful to the Freudian rule, put her on the couch and remained silent for most of the hour, as did Gordon. (Fifty minutes of silence. For a pre-adolescent. The parents paid for this.) Then she began a sit-up therapy, which, however, came to an abrupt end when Gordon was dumped by a boyfriend and responded, as she unsentimentally recounts, by scratching at her wrists with a pair of nail scissors. That was it—she was judged suicidal, and sent to Austen Riggs, a famous institution in Stockbridge, Massachusetts, where, diagnosed as having “schizoid personality disorder with borderline trends,” she spent three years. She is very funny on the subject of Riggs. Now and then, she says, something interesting would happen. Once, for example, a man inserted a number of hard-boiled eggs into his rectum and then laid them, publicly, in the hall. But mostly the place was just boring: elderly outpatients “shuffled up and down Main Street, stopping for the lunch special at the drug store, ducking into the library for a nap.
At Riggs, however, Gordon was eventually assigned to a man who became the lodestar of her youth, the existential therapist Leslie Farber. Existential therapy, almost forgotten today—it was echt sixties—focused on patients’ responsibility for their lives, and on the “authenticity” of the patient-therapist relationship. Farber, Gordon says, treated her like a moral agent—a revelation to her. He also, in keeping with the non-Freudian rules of “authenticity” kept loose boundaries. He told her about his childhood, his marriages. He offered not a cure but a friendship, and when, after a few years, he left Riggs and moved to New York, she went with him, and got gummed up in his life, hanging out in his kitchen, becoming friends with his wife, looking after his children. Like many of the experimental treatments of the sixties, this ended badly. Though Farber had permitted her intrusions, he finally lost patience with them and bawled her out. In considerable disrepair; she left him soon afterward. She married and went back to school. Eventually she returned to therapy—with “Dr. B.,” whom she describes as an “ordinary” man, not like the deep-browed Farber— and stayed for seven years. Dr. B. had no truck with existentialism. This was the eighties, and the rule of therapy was empathy. Dr. B. wound her in love and compassion; she, resisting him all the way, unwound herself, and emerged as a writer.
Gordon has a low opinion of psychotherapy. She says what the others say: victimization, narcissism. Therapy, she writes, taught her to view herself as “saucer-eyed and frail,” as opposed to the “blunt and caustic person” she knew she was. It corrupted her morally: “I wasn’t interested in being happier, but in growing more poignantly, becomingly, meaningfully unhappy.”
She says all this, yet she is a walking refutation of it—above all, of the moral indictment. Good writing is itself a moral virtue. Wit, complexity and detail are its outward signs, and “Mockingbird Years” shines with them. One could search the whole of confessional literature and be hard put to find a less self-serving portrait of a writer’s childhood than the one Gordon gives us. Her father, she says, was a “disastrous parent,” and, she immediately adds, “worse than he deserved to be.” Mostly, it seems, he was just busy with his work, and emotionally blind, as men were supposed to be in those days. As for the artistic mother, this is a deeper matter. The mother is the book’s great character. Gordon writes:
When she bathed my brother and me, she floated birthday candles anchored in halved walnut shells in the bathtub. She turned off the lights, lit the candles, and stood smoking a cigarette in a shadowy corner of the bathroom as we sat in the midst of a small shining armada.
Even as the shadows engulf her, the mother is always haloed in light. On a vacation in Puerto Rico, the family goes for a boat ride:
The water was full of tiny phosphorescent creatures; a hand or foot dipped into it came out glowing and glittering. My mother found this fascinating; again and again, as my father sat at the rudder, she lowered her hand into the water, held it up loosely in front of her eyes, and gazed at it. . . . She would often do something similar at the dinner table in Washington, holding up her graceful, aging hand so that it was framed by the nimbus of the candle flame, turning it this way and that and marvelling as if it had been transformed into the head of a swan.
By then Gordon recognized the gesture as a sign not just of her mother’s poetic nature but of the fact that she was an alcoholic. The portrait is almost Southern.
In 1961, Gordon recalls, her family went to a reception at the White House. She wore “a black-and-white checked shirtwaist with oversized pink rosette buttons” which her mother had ordered from the “chubbette” section of the Sears catalogue. When, in the receiving line, she got to L.BJ., he leaned down from his great height, “took my hands in his large ones,” and said, “How do you do, my little cotton-tailed bunny rabbit?” This is funny—the big, kind, corny Texan romancing the fat little girl—but it is also stabbing, for that is what she needed: to be someone’s bunny rabbit. (Alas, it’s what we all need.) She didn’t get it; instead she got therapy, whose attempts to compensate she now regards as false and demoralizing. But if therapy gave her the strength to write that scene plainly, factually, with no tears—or just ours—then it taught her something. Gordon is not a great thinker on psychotherapy. She’s still hung up on Farber (the one who was mean to her, natch), and her condescension to Dr. B., the one who cleaned up after Farber, the one whose love and pity she pushed away—thereby, I believe, conquering self-love, self-pity—is painful to witness. But she is a thrilling writer. Dr. B. should be proud. Good for you, Dr. B.! The heck with Farber!
What do we think about psychotherapy? I don’t mean for inpatients. (They clearly need it; their lives are wrecked.) I mean for outpatients, the walking wounded—us. For some it’s damaging. Even when it’s good, it’s very expensive, but compared with the church and family of yesteryear, whose loss it is trying to make up for, it’s a bargain. (In the church you tithed, gave ten per cent of your income. As for the family, it kept women at home. What was the cost of that?) And when it is good, it is something hard to find in life, a moral dialogue. Gordon says Farber taught her that talk could be “treated not as a means to a therapeutic end, but as the central source of moral meaning itself” That’s very existential of her; but the truth is that a talk about moral meaning cannot not be therapeutic, if by therapy we mean not just symptom relief but a chance for a serious life. The matters that people discuss in psychotherapy—whether they are really answerable for their lives, whether they should place their own welfare over another’s—are the things that people in the Bible were trying to decide. They are the big questions, right? For patients in serious distress, pills are useful, but they cannot provide, don’t aim to provide, what psychodynamic therapy has at its core. Luhrmann summarizes it: “a sense of human complexity, of depth, an exigent demand to struggle against one’s own refusals, and a respect for the difficulty of human life.”
This essay was originally published in The New Yorker on May 8, 2000, and is reprinted with permission.
*This autobiographical information was supplied by the author at the time this paper was contributed to the Academy Library. This information may not be current.