American Psychiatry Scholarship: The Pendulum Maintains its Momentum

Abstract

In the last year or two there has been a surge in American psychiatric scholarship and a small sampling of the contributions helps to identify the diversity of the field and future directions in it. According to Nicholas Rasmussen and Jonathan Metzl, among other medical historians, psychiatric practice in the United States should be conceptualised ‘as more diverse and eclectic, and less polarised’ than previous accounts had argued. 1 In short, the biological versus psychodynamic schism in psychiatry was far more complicated than once thought. Even more recently, the work of the sociologist of medicine Martyn Pickersgill on changing discourses of social personality disorders confirmed that while the ‘pendulum metaphor’ in histories of psychiatry has a certain heuristic importance, it obscures continuity amongst psychiatrists and psychiatric discourses, and reduces a complex set of theories and practices to a simplistic either/or binary. 2 Yet, what becomes immediately clear is that while the ‘pendulum metaphor’ has not been entirely transcended, the intellectual firmament in the history of psychiatry is shifting and a diversity of distinctive approaches is readily apparent. The pendulum, that is, continues to swing, just in different directions. For, as authors investigate specific diagnoses and illnesses (depression), societal units (the family) and broader structures (DSM-III), others are taking an unapologetically cultural approach to the history of psychiatry. Lawrence Samuel, for instance, offers an overview of psychoanalysis in American popular culture. Having written previous books about Freud on Madison Avenue and The American Dream, Samuel is well qualified to delve into how psychoanalysis infiltrated art, adverting and the average American’s everyday lexicon. As he presents his case, he builds on the work of John Burnham, Philip Cushman and Eli Zaretsky 3 and attempts to describe how America’s ‘national quilt’ has been woven using a unique psychoanalytic loom (p. xiii). The close tie between psychoanalysis and American society was, he argues, a process of continual negotiation, one typified by ‘waxing and waning’, just as the pendulum metaphor suggests (p. x). More specifically, though, Samuel outlines that psychoanalytic tenets and practice were slowly mediated (and then re-oriented) by extant national characteristics, including personal improvement and productivity. Over time, psychoanalytic ideas demonstrated a tremendous resilience and, of late, have ‘enjoyed a renaissance of sorts’ (p. xxv). Of his fellow Americans, he writes, ‘We’ve all been “shrunk”’ (p. ix). The goal of Samuel’s book is not to rehash the struggle between biological psychiatry and psychoanalysis, but rather to situate the general ‘trajectory of psychoanalysis in American cultural history’ (p. x). He suggests that scholars of various stripes have under-appreciated the role of psychoanalysis in American popular culture and he targets a wide audience. Shrink, then, ought to be regarded as a corrective, albeit one that purposely ignores the intellectual, institutional and technical aspects of its subject matter. As such, it eschews historical records ‘tucked away in musty boxes of archives’ and does not ‘follow the revisionist history vogue’ to ‘turn the field upside down’ (pp. x–xi). Instead, Samuel is attempting to broaden the conversations in psychiatric scholarship and the result – which focuses on actors like Marilyn Monroe and Marlon Brando – is a lively book that is both breezy and entertaining. Edward Shorter, by contrast, places a spotlight on a single mental illness, specifically the concept of depression. To begin, Shorter’s book, How Everyone Became Depressed, adopts a positivist approach to the diagnosis and treatment of mood disorders. Even as he makes crystal clear that the classification system ‘is a jumble of non-disease entities, created by political infighting within psychiatry, by competitive struggles in the pharmaceutical industry, and by the whimsy of regulators’, his book is most certainly not a ‘diatribe’ (p. 3). Rather, his aim is to showcase how ‘illnesses of body, mood, and mind were once understood’ and thus chart the gradual (and global) shift from nerves to depression. He ably accomplishes this in thirteen punchy, accessible chapters that focus on, among other topics, ‘Fatigue’, ‘Anxiety’, ‘Drugs’ and ‘Nerves Redux’. In doing so, the book positions the evolving concept of depression within the ebb and flow of German and, later, American psychiatric wisdom during the late nineteenth century to the present day. Shorter argues that the conception of two depressions – that is, melancholia and non-melancholia – has given way over time to a broad, catchall definition of depression for which antidepressants are prescribed often and inappropriately. This, he writes, is ‘an appalling failure of a scientific discipline’ and it is time for a ‘turn-around’ (p. 196). As he makes this persuasive case about depression, he ably demonstrates the mediated nature and cyclicality of American psychiatry over the past sixty years. Gary Greenberg’s The Book of Woe advocates substantive change in psychiatry, although the scope and tone is significantly different from Shorter’s. With a pugnacious, muckraking style, Greenberg places a bulls-eye squarely on the Diagnostic and Statistical Manual of Mental Disorders. The book, he writes, is an attempt to ‘understand ourselves’ and ‘relieve suffering’, even if this results in a sort of reductionism that ‘insults our sense of ourselves as unfathomably complex and even transcendent’. Worse still, he argues, the DSM represents the ‘desire to control, to manipulate, to turn others’ vulnerabilities to our advantage’ (p. 25). Thus, the consequence of these two impulses meeting is that ‘commerce – and often bullshit – will prevail’ (p. 25). Greenberg, a practising psychotherapist and author of two previous books, Manufacturing Depression and The Noble Lie, proceeds to critique the field of psychiatry using an ahistorical, first person approach. He provides an illuminating insider account of the personalities, politics and pitfalls involved in creating DSM-5. The Book of Woe, which is immensely readable and devoid of both theory and archival research, could accurately be situated within the increasing body of literature censuring the medico-corporate complex and questioning the vast influence of psychiatry in Americans’ lives. In recent years, such well-respected authors as Daniel Carlat, David Healey and Allen Frances, among others, have delivered devastating accounts of the failures in psychiatry. 4 And as valuable as these works may be, they often rely on uncomplicated narratives directed at a popular audience. This is the case with Greenberg’s fascinating tell-all story of DSM and the field of psychiatry in the 21st century. Similarly, Hannah Decker provides a polarised view of psychiatry in her history of the DSM-III, but her intention is not castigate the profession. Her book, The Making of the DSM-III: A Diagnostic Manual’s Conquest of American Psychiatry, instead positions the APA’s manual and its methodological transition in the late 1960s as the pivotal moment in the pendulum’s swing from psychoanalysis to a more scientifically based study of the mind. DSM-III was constructed, she writes, at a time ‘when so much was up in the air and unsettled’ (p. xxii). Decker begins with the anti-psychiatry movement of the late 1960s, illustrating an era disenchanted by the failing American war in Vietnam and the subsequent disintegration of carefully built Cold War dichotomies. Having established her backdrop, Decker then focuses on, as she sees it, the revitalisation of American psychiatry led by APA Chair Dr Robert Spitzer, who placed an emphasis on scientific objectivity and method, empirical research, and the construction of stronger psychiatric classifications and nomenclature within the manual. This empirical ‘swing’, according to Decker, was just another example of the ‘cyclical nature of psychiatric progress’ (p. xix). Thus, the book’s portrayal of the contestation between psychoanalysis and scientific methodology (along with the increasingly global influence of the DSM and the APA in the early 1980s) aligns with the conception of a pendulum swing in the field of psychiatry and offers a fascinating, although largely orthodox account of the period. The Making of DSM-III is an ambitious book. With her background in history and psychiatry at the University of Houston, Decker attempts to provide a text that satisfies an extensive audience (pp. xxi–xxii). In addition to an encyclopaedic presentation of psychiatric theory, the history of the APA’s manual from 1952 to 1983, and the primary historical players within the APA, she provides an institutional history, mixing archival documents with interviews, personal anecdotes, and pictorial essays of members of the APA. More specifically, some of the core strengths of her book include the character studies and individual histories of Spitzer and other members of the APA Task Force; although, it should be noted, Decker presents a multi-faceted perspective that transcends history of the ‘great man’ variety. The result is a comprehensive study of the structure and development of American psychiatry and DSM-III. Decker’s book succeeds in providing a wide-ranging and useful reference for scholars of psychiatry, medical history and the general public. By contrast, Deborah Weinstein’s history of the development of family therapy in postwar America is a more tightly focused study. Devoted to a specific type of psychiatric practice, The Pathological Family: Postwar America and the Rise of Family Therapy nevertheless addresses the diverse influences on American psychiatry as a whole during the 1950s and 1960s. Weinstein presents post-war psychiatry and family therapy as a microcosm of the larger Cold War and its politics. While not an entirely novel approach, 5 Weinstein’s concise and lively study locates the power of the family in the American post-war culture of normalcy, and ably details the rise of the psychiatric perspective of the family as a ‘unit of disease’ (pp. 14–15). In addressing the family and state through the lens of therapy, Weinstein draws together subjects that have been previously viewed separately: American culture and intellectual life, psychiatry’s increasing focus on family life, and the history of scientific observation. She draws upon certain cultural elements of the 1950s and 1960s, such as film and television representations of ‘normal’ and ‘healthy’ families, and the text effectively combines the history of culture, post-war society and psychiatry. 6 Consequently, Weinstein reveals ‘many of the tensions that defined postwar America in a new way’ (p. 2) and how the stronger influences of the social perception of health and normalcy affected modern psychiatry through the postwar development of family therapy. A major strength of the book is its use of gender amid a psychiatric profession that was, as Decker phrased it, ‘up in the air’ and ‘unsettled’ (p. xix). Weinstein’s portrayal of family therapy illustrates how, as a discipline in the throes of transition from the individualistic practice of psychoanalysis to a group environment, psychiatry took on a variety of epistemological and methodological influences. According to Weinstein, beyond the transition from psychoanalysis to scientific methodology, psychiatry underwent a gender shift. Psychoanalysis, a typically male-dominated field, was supplemented by more ‘female’ disciplines, such as sociology and anthropology. This was significant, because it indicated a deeper, subtler and underplayed evolution within the field of psychiatry, one that related to social and cultural shifts during the mid-twentieth century. In the introduction of Edward Shorter’s influential 1997 book, A History of Psychiatry, he writes that his subject was a ‘minefield’. In his view, both revisionists and neoapologists (as he described himself) were in perilous terrain, because their interpretations risked being ‘blown up’ by new evidence. Even as he rejected the revisionist orthodoxy in psychiatric scholarship, Shorter noted, ‘many surprises may lie in store for us all’. 7 He was undoubtedly correct, since, over ten years later we are witnessing intriguing scholarship related to DSM, culture and psychiatry, discrete psychiatric diagnoses, and the family unit in psychiatry. Thus, even though the pendulum metaphor continues to act as a guide, and rightfully so, a small selection of books in 2013 confirms that abundant surprises certainly lay ahead.