The century of psychoanalysis? - Porter - 2002 - Article

What can be said about science and psychiatry?

Psychiatry has often had two goals, namely understanding mental disorders through a scientific perspective, and healing mental disorders. Sometimes, there has been more an emphasis on one than on the other goal. For example, in the nineteenth century, for many psychiatrists, the emphasis was on creating a true scientific enterprise for their discipline, alongside other biomedical sciences such as neurology and pathology. They wanted to be different from non-scientific fields, such as mesmerism and spiritualism. Thus, there was a strong emphasis on creating a scientific basis for psychiatry. John Hughlings Jackson for example, told Herbert Spencer to use evolutionism as the basis for his account of the nervous system. Henry Maudsley also used a Darwinian basis to look at psychiatry. Freud was also fan of Darwin, and wanted to achieve a ‘Copernican’ revolution in his field. Also, German Emil Kraepelin wanted to make psychiatry more scientific.

Kraepelin became an important figure for psychiatry. For example, he became a professor at university of Heidelberg. He created descriptive clinical psychiatry and psychiatric nosology. According to him, his patients were ‘symptom carriers’. According to him, the course of the illness was best to understand the nature of the disease, in contrast to only looking at the symptoms that the patients had. He innovated psychiatry, by creating disease concepts and classifications. He created a model of a degenerative condition, namely dementia. He based this on Morel’s ‘deménce précoce’ and hebephrenia (psychosis in young people). He distinguished dementia from manic-depressive psychoses.  According to Kraepelin, dementia praecox was a precursor of schizophrenia, and patients were describes as having ‘atrophy of the emotions’ and ‘vitation of the will’. Because he was interested in the course of the disorders, he tracked his patients’ entire life histories in a longitudinal perspective. The prognosis, the outcome of the disorder, was a very important point. Kraepelin was also fan of Wundt, and thus of experimental psychology. Thus, he pioneered psychological testing of psychiatric patients. Another colleague of Kraepelin, Alois Alzheimer, created the speciality of ‘psycho-geriatrics’. All of this lead to the creation of a Munich-clinic-inspired centre, such as the hospital created by Henry Maudsley in South London. This hospital was created to be a research centre. Heredity was an important concept in Kraepelin’s work. He was also positive about he outcomes of psychiatric disorders. Therefore, something called ‘Pinelian optimism’ arose. However, later this lost support. One German asylum doctor even commented:  “we know a lot, but we can do only little”. Later, a psychiatric politics emerged that was very pessimistic, and that even stated that mentally ill people were not worth living. For example, in the 1930s, the Nazi psychiatry thought that schizophrenics should be eliminated, similar to their ideas about Jews. Thus, between January 1940 and September 1942, there was a run called ‘the final solution’, in which 70.723 mental patients were gassed.

What was psychodynamics?

In reaction to pessimism and asylum psychiatry, there were new dynamic styles of psychiatry launched. For example, Franz Anton Mesmer’s therapeutic ideas, and the Enlightenment were the roots of these dynamic psychiatry. This raised questions about the will, the unconscious, and the unity of the person. All Cartesian ideas were disregarded, and people became to think that ‘man was not master in his own house’. Using mesmeric techniques, Nancy Liébault and H.M. Bernheim made hypnotism a diagnostic device for hysteria. According to them, only hysterics could be hypnotized. But, later it became clear that this was not a scientific method.

Who was the conquistador of the unconscious?

Sigmund Freud was born to a middle-class Jewish family from the Czech Republic. He was trained in Vienna in medicine and physiology. He was specialized in clinical neurology, and he was a supporter of Darwin’s ideas. He was also a supporter of Ernst Brücke’s ideas, and he brought a materialist approach to the study of humans. He thought that the mind was all in the brain, and he disregarded religion, calling it an illusion. He worked closely together with Josef Breuer, and he was interested in hypnotic states, hysteria, and neuroses. Breuer once told Freud about a patient called ‘Anna O.’, who suffered from hysterical symptoms. He told Freud that he treated Anna with hypnosis, and that this helped to vanish her symptoms.

Later, when Freud worked under Charcot in Paris, Charcot told Freud that hysteria had a sexual side. Later, Freud and Breuer together published a book called ‘Studies on Hysteria’, in which Freud described that neurosis stemmed from early sexual traumas. For example, the hysterical female was said to have experience ‘seduction’, which is the term for sexual abuse by the father. According to Freud, repressed memories of this abuse later would get to the surface, in the form of hysterical symptoms. This was thus called the ‘seduction theory’. Three years later, he went public during a lecture in Vienna and told the listeners about his ideas.

However, one year later, Freud confessed to Wilhelm Fliess that he no longer believed in neurotica (the seduction theory). According to Freud, who was now very interested in autobiographical dreams and self-analysis, his patients’ seduction stories were just fantasies, which originated from their erotic wishes. Therefore, he created a new theory, namely that of infantile sexuality within the Oedipus complex. Thus, the two key concepts in psychoanalysis were the unconscious and Oedipal sexuality.

Well, how could this shift in Freud’s thinking be explained? Orthodox Freudians thought of this as Freud having a ‘Eureka-moment’, in which he suddenly saw the light. Others, critics of Freud, thought of this as Freud having lost his nerves, and thought that the abandonment of the seduction theory was actually a mistake, and even a betrayal. Why a betrayal? Well, if they were really abused, then Freud would disregard their stories, calling them liars.

Freud later distanced from Breuer, who was a fan of hypnotic techniques. He also broke with Fliess. He advanced the fundaments of psychoanalysis, by including unconscious mental states, the repression of these states, and the neurotic consequences. He also outlined the techniques of ‘free association’ and ‘dream interpretation’, which were two methods for overcoming resistance and for uncovering hidden unconscious wishes. He also introduced the idea of ‘therapeutic transference’. During the Great War, Freud applied his ideas to shellshock and other war-related neuroses. According to him, the soldiers that displayed paralysis and loss of speech, sight, and hearing, suffered from conversion hysteria. Later, he elaborated his theory by including the notion of developmental phases, the conflict between eros and death, and his ideas about the ego, superego, and id. He also created theories about the origins of incest, about patriarchy and monotheism. He also introduced the idea of ‘Freudian slips’, which refer to that someone unintentionally speaks something that he or she did not want, and that this reveals his or her true, subconscious feelings.

Freud’s ideas were very important for the twentieth-century views of the self. The funny thing is, Freud viewed himself as a natural scientist, but his theories and ideas were not of this nature, at all.

What can be said about the psychoanalytical movement?

In Switzerland, ‘depth psychiatry’ emerged. At the Zürich psychiatric hospital, Eugen Bleuler used psychoanalytic theories of ‘schizophrenia’, which he based on Kraepelin’s dementia praecox. He defined schizophrenia by delusions, hallucinations, and disordered thought. According to Bleuler, schizophrenics are ‘strange, puzzling, inconceivable, uncanny, incapable of empathy, sinister, and frightening’. However, these ideas were overshadowed by the ideas of Carl Jung, who developed the ‘analytical psychology’, which was less sexual and a more realistic view of the unconscious.

Carl Jung was the son of a pastor, and he was trained in medicine. He became Freud’s ‘favourite son’, and gained a reputation of the ‘crown prince’ of psychoanalysis. However, with the publication of his book ‘The Psychology of the Unconscious’, Jung challenged many of Freud’s theories, and the sexual origin of neuroses the most. After two years, they split. According to Jung, his analytic psychology provided a better view of the psyche compared to Freud’s. He also introduced personality types, such as the ‘extravert’ and the ‘introvert’. According to Jung, a healthy balance of opposites was good, as well as a balance between thought, feeling, and intuition. Jung introduced the idea of the ‘collective unconscious’, which refers to latent memories of mankind’s ancestral past, which are passed down from generation to generation by some kind of Lamarckian mechanism. His study of dreams, art, and anthropology fascinated him with archetypes and myths, which he believed to shape the collective unconscious and experience. He described all of these ideas in his book ‘Man and His Symbols’.

In France, there was another psychodynamic tradition. Pierre Janet created theories of personality development and mental disorders which dominated French dynamic psychiatry. He also focused on the unconscious, and created descriptions of hysteria, anorexia, amnesia, and obsessional neuroses, and of their treatments using hypnosis, suggestion, and other psychodynamic techniques. He suggested to treat hysteria with ‘psychological analysis’, because he thought hysteria was related to ‘subconscious fixed ideas’.

Freud’s ideas were also received well in America. For example, Alfred Adler, who is best known for his ideas about the ‘inferiority complex’ (which refers to that someone is very aggressive, because of neurosis), was one of these recipients. After working together with the ‘master’ Freud, he broke with him, and created his own theory, described in ‘The Nervous Character’. He described his ideas about the relationships between the individual and the environment, and he stressed the need for social harmony as a means to avoid neurosis.

A lot of Jewish researchers flee from Europe, and went to the United States. Therefore, the United States became the key location for psychoanalysts. Thus, it is not surprising then that America was heavily psychoanalytically oriented. Psychoanalysis also spread to the United Kingdom. There was however some resistance there, but psychoanalysis still claimed some space. The British psychoanalyst Ernest Jones became close friends with Freud and he published the first book in England about psychoanalysis. Anna Freud, Freud’s daughter, also lived in England together with her father after the Nazi occupation in Austria. There was a lot of debate about infant/mother relations.

What was ‘the shock of the new’?

Freud was seen as ‘the conquistador of the unconscious’. At the same time, the medical treatment of the mentally ill innovated, by therapeutic innovations. Some innovations were effective, many were dubious, and a few were simply dangerous. For example, the effects of bacterial infections on brain pathology were identified, such as syphilis. Julius von Wagner-Jauregg found that counter-infection with artificially induced malaria was effective against mental disorders. This led him to win the Nobel prize in 1927. Wagner-Jauregg was a fan of Faradization (electric shock) for the disorder called ‘shell shock’. Also, sleep therapies with the use of sleep medication was introduced. Insulin-induced coma had been introduced against diabetes, and against schizophrenia. Even though it was dangerous, it seemed to have some benefit.

Ladislaus Joseph von Meduna also developed a shock treatment against epilepsy. He used a drug called Cardiazol or Metrazol, which produced seizures which were so violent that patients’ bones sometimes broke. According to Meduna, epileptiform seizures were beneficial to schizophrenic patients. Later, based on this idea, Ugo Cerletti began to use electric shocks (ECT) to alleviate severe depression.

Psychosurgery also became popular from the 1930s on. Egas Moniz for example, stated that obsessive and depressive symptoms could be alleviated by using leucotomy, which involved a surgical removal of connections between the frontal lobes and the rest of the brain. These ideas were received well in the United States, for example by Dr. Walter Freeman, who was a neurologist. Using a cocktail-cabinet ice-pick inserted via the eyes, Freeman conducted a lot of lobotomies in a week, sometimes 3600 in one week. Before these ideas were criticized, around 18.000 patients in the U.S. had undergone lobotomy.

However, before this, lobotomy seemed to be very beneficial. Some lobotomized patients were discharged from institutions and became well adjusted. Lobotomy was said to ‘turn the troublesome into quiet, placid, uncomplaining persons who showed little concern about their troubles’.

What was the chemical revolution?

In the 1940s, penicillin was introduced. It was one of the innovations of psychopharmacology. It was introduced as a treatment for manic-depression. There were also other anti-psychotic and anti-depressant drugs introduced, such as the phenothiazines (chlorpromazine, named ‘Largactil’ or ‘liquid cosh’), and Imipramine (against depression). These medicines helped a lot of patients to maintain a life in the outside world, even though it was under continuing medication. William Sargant, a British psychiatrist, supported these drugs and thought it was the best way to treat patients, and he also thought that this would help to eliminate mental illness, by the year 2000. Diazepam, a tranquillizer, became the world’s most often prescribed medication In the 1960s. In 1970, one in five women were using minor tranquillizers. By 1980, American doctors were prescribing ten million prescriptions a year for anti-depressants, mostly tricyclics such as Imipramine. Prozac, which was introduced in 1987 and which raised serotonin levels (and creates a good feeling), was prescribed a lot against depression. Currently, central nervous system drugs are at the top of the medicines the most sold in the USA. Even though these medicines have reduced the amount of people institutionalized, they come with a lot of side effects, and the long-term effects are often unknown. Thus, there are a lot of ethical and political questions with regard to this kind of treatment of mental disorders.

What is anti-psychiatry?

Thus, psychotropic drugs seemed to offer hope, because they helped to reduce the amount of people institutionalized. Since there were a lot of European and American psychiatrists who were against asylum, this was great. These psychiatrists did not like asylum, because there were a lot of problems in the day-to-day management of the English asylums. Also, the segregation of the ‘mad’ from the ‘normal’ did not make any sense. Psychiatrists even came to the conclusion that the greatest proportion of mental disorders was not to be found in the asylum, but in the community at large. Thus, mental disorders became to be seen as extremities of normal conditions. These ideas had big implications, and led to a shift from the institutional provision to the needs of the patient. By the end of the twentieth century, the psychiatric hospital and psychoanalysis faded. There was also an explosive growth visible in certain psychiatric conditions, such as in post-traumatic stress disorder (PTSD). This lead to the introduction of clinical psychology and cognitive therapy.

However, most psychiatrists were still using the ideas of Kraepelin, and described and taxonomized mental disorders. In 1952, The Diagnostic and Statistical Manual of the American Psychiatric Association was published. In 1980, there was a revised version, which mapped the following categories of mental disorders: disorders of childhood (hyperactivity, anorexia, autism), disorders with known cause (disease of old age, disorders that are drug-induced), disorders of schizophrenia (disorganized, catatonia, paranoia, undifferentiated), paranoid disorders, affective disorders, anxiety disorders, somatoform disorders, dissociative and personality disorders. In 1994, the DSM-IV was published, and created a trend towards a more organic orientation. The DSM is revised every few years, and there is always a lot of debate about terminologies and ideas. For example, in 1975, homosexuality was removed from the DSM. I wonder what else will change in 20 years.