Psychiatry and Its Discontents

A recent column by George Makari has caused a bit of a stir in what remains of the psychoanalytic ecosphere. Makari is both a practicing psychiatrist and a student of the history of psychiatry and he attempts to explain how he conducts two kinds of practice.

That seems more like the hook than the substance of his article, so I will leave it to the side.

His first point, a point I have often made, is well worth emphasizing. The history of psychiatry is littered by pseudo-scientific theories that have served no useful clinical purpose. These have failed because they were driven more by ideology than of scientific fact.

Among them is Freudian psychoanalysis:

Historians have shown that psychiatry has long suffered from the adoption of scientific-sounding theories and cures that turned out to be dogma. Perhaps the clearest example of such “scientism” was psychiatry’s embrace, in the early 19th century, of Franz Joseph Gall’s phrenology, in which all mental attributes and deficiencies were assigned to specific brain locales, evidence be damned. During much of the 20th century, psychoanalysis proposed far more conclusive answers than it could support, and today, the same could be said for some incautious neurobiological researchers.

Ideology is driven by ideas. It cherry picks the facts that support its positions and ignores or tries to explain away the rest. Frank Cioffi once offered an anecdote supposedly about J. Edgar Hoover. When Hoover ordered surveillance on someone who was suspected of being subversive, he would admit of two results. Either the facts demonstrated that the man was a subversive or, if they did not, the man was labelled a “cunning subversive.”

Makari sees the same process at work when people write biographies, or hagiographies of psychiatrists and psychoanalysts. He does not mention the notion of saintliness or that these biographies fall well within the tradition of the lives of the saints. We owe the introduction of saintliness to Jacques Lacan.

Makari writes:

Much less extreme, everyday infiltrations of ideology can be discerned in the portraits that psychiatrists have drawn of their field. Most of these accounts have been self-serving affairs, in which the past was ravaged so as to justify present clinical certitudes. Nearly every generation has featured a proud practitioner who dismissed his predecessors and lifted the flag of victory, only to have it snatched away some years later. Since 1800, the end of history in psychiatry has come with the triumph of the asylum, followed by Romanic medicine, brain anatomy, genetics, psychoanalysis and, most recently, drugs like Prozac.

As I said, the notion that psychoanalysis is idea-driven, not fact-driven ought to have been well established by now. Makari does not mention that Lacan, for example, never considered psychoanalysis to be a science and declared that anyone who promoted it as a therapy was scamming his patients.

Naturally, Lacan’s followers were happy to repress Lacan’s truth. But their master understood perfectly that Freud was proposing an ideology and that its true destiny was to become a pseudo-religion. See my book, The Last Psychoanalyst.

One can, just for fun, recall a statement by Nobel prize-winning biologist Peter Medawar, from 1975:

… psychoanalysts will continue to perpetrate the most ghastly blunders just so long as they persevere in their impudent and intellectually disabling belief that they enjoy “a privileged access to the truth.” The opinion is gaining ground that doctrinaire psychoanalytic theory is the most stupendous confidence trick of the twentieth century; and, to borrow an image I have used elsewhere, a terminal practice as well—something akin to a dinosaur or a zeppelin in the history of ideas: a vast structure with radically unsound design and with no posterity.

Obviously, Medawar was looking at psychoanalysis as a clinical practice. And yet, if it is not a clinical practice but a stealth way to indoctrinate people in a radical leftist ideology, we are dealing with an altogether different beast.

One understands that some people continue to insist that psychoanalysis is perfectly consonant with the values practiced by liberal democracy. As Lacan might have said, such people understand nothing of Freud.

Makari sees the influence of the radical left in antipsychiatry, movement that apparently has infected the minds of historians of psychiatry. For reasons that escape me Makari credits it to Michel Foucault.

True enough, in  a book called Madness and Civilization Foucault declared that the cultural production of madness was driven by the ideological needs of Western civilization, of capitalism and liberal democracy.

And yet, if one is going to talk about antipsychiatry one ought to mention that the man who named it a was a British psychiatrist named David Cooper, in conjunction with R. D. Laing and a number of other figures in the psychiatric world.

I will mention in passing that I knew Foucault and occasionally discussed these matters with him. I never heard him claiming any great interest in antipsychiatry, except to the extent that his good friend Gilles Deleuze was associated with Felix Guattari, director of a psychiatric clinic called Clinique de la Borde. 

The clinic offered every known psychiatric treatment within a context that was called institutional psychotherapy. Deleuze and Guattari collaborated on a book called the Anti-Oedipus that made a bit of a stir in the 1970s. The one thing that the clinic and its two sister clinics did not offer was: psychoanalysis. (I will mention in passing that all of the directors of all the clinics were in analysis and in supervision with Lacan.)

During the 1970s, the founding father of antipsychiatry, David Cooper was at times in residence at La Borde. True enough, Guattari made a lot of noise about the antipsychiatry, but he was shocked one day to hear a pharmaceutical representative tell him that his clinic ordered as much psychiatric medication as the psychiatric hospitals. One might add that when the clinic was founded in 1953, they had precious few medications to offer. The result was very ugly, indeed. No serious psychiatrist associated with the place doubted the value of the new medications when they became available.

As it happened the antipsychiatry did exercise some influence over the patients at La Borde, generally in persuading them not to take their medication. One day the medical director and owner of the clinic, Jean Oury announced, when one of his patients had committed suicide, that the antipsychiatry had killed one of his patients. The true story is more complex than you would glean by reading a book by Foucault.

Those facts, to give you a context for Makari’s reflections on the influence of Foucault and the antipsychiatry on the practice of psychiatry in France.

Yet, Makari is quite correct to see that the field of psychiatry continues to suffer from ideological blinders. He might have mentioned that this is not an accident. Ideologues and culture warriors have very often used psychiatry and especially psychoanalysis to advance a culture and political agenda.

In Makari’s words:

For the past three decades, the reigning model among historians of my field has been dubbed “antipsychiatric.” Following the work of Michel Foucault, the fashion has been to argue that psychiatry emerged as a police arm of the modern state. Mental doctors were self-deluded or malevolent, their treatments cunning, at times barbaric, methods of control. Mental illness itself, they argued, was a false construct used to control dissidents, rebels and outcasts.

As I said, only Lacan had the intelligence to dispense with the notion that Freudian theory was a science. One might say, as I have suggested, that he had to do it to save the theory from drowning in its lies.

Makari continues:

However, this vein of research has been tarred by its own crude ideology. If scientism can falsely turn ethical and political issues into matters of disease, and grossly exaggerate what we know about the nature of mental illness, Foucault and his acolytes are prone to an antithetical failing: radical social constructionism. Madness, they would have us believe, whether it is schizophrenia, post-traumatic stress disorder or anorexia, is not grounded in any biological reality. Greedy commercial interests and a repressive society, they claim, have falsely transformed human differences and personal choices into psychiatric disorders.

In any event I cannot imagine where Makari got the idea that Foucault’s followers were running antipsychiatry programs in psychiatric clinics, but at least we can allow him his say:

To me, Foucault and his followers seemed impossibly naïve, even complacent. Had they ever encountered severe obsessive-compulsive disorder or suicidal depression? Had they ever seen a manic patient take lithium and be restored? Psychiatrists might be blinded by their commitments as insiders, but this academic view seemed sustainable only by remaining on the outside looking in.

Perhaps Laing and Thomas Szasz were doing such things, but at La Borde, which was as radical a place as there was, whose leaders believed that the future of psychiatry lay in practices that were being developed in China during the Cultural Revolution, no clinician voluntarily deprived a patient of medication or any other form of psychiatric treatment. If anything, the patients were overmedicated and overtreated.