Psychiatric illness and the politics of blame
© 1999 Canadian Medical Association
I was so much older then,
The shape of blame is round. It seeks its target with an arrogant certainty that often as not turns on itself.
Psychiatric problems are played out within the labyrinth of human volition and shame. Perhaps that is why the quest for their etiology raises the spectre of a witch-hunt. It is no coincidence that two recent books addressing the causality of psychiatric disorders use the word blame in their titles: Madness on the Couch: Blaming the Victim in the Heyday of Psychoanalysis, by Edward Dolnick, and Blaming the Brain: The Real Truth about Drugs and Mental Health, by Elliot Valenstein.
Both writers take to task the theorists and institutions who were or are prepared to reduce the mysteries of psychiatric illness to a dogmatic cause. In a mirrored symmetry, each challenges the opposing side of the mindbrain divide.
Dolnick's Madness on the Couch chastises post-Freudian psychoanalysts for their characterization and treatment of mental disorders, particularly schizophrenia. Dolnick sees Freud as a victim of his own theoretical parsimony, by which his ideas were drawn exclusively from his interpretations of patients' narrative recollections of childhood. However, he does acknowledge Freud's own reservations about the application of psychoanalysis to schizophrenia. It is more with Freud's heirs that he takes issue.
Using a journalistic approach, Dolnick, a science writer by trade, brings to life the personalities, therapeutic methods and aspirations of some of the most important figures in psychoanalysis during the 20 or so years that followed World War II. He presents these practitioners the boundlessly optimistic Karl Menniger; Freda Fromm-Reichmann, the intense inventor of the "schizophrenic mother"; and the bird-like and charismatic R. D. Laing, among others as well-meaning but ultimately misguided. More tragically, Dolnick asserts, theories of schizophrenogenic mothers and families, together with the treatment approaches that such explanations demanded, only served to rub salt in the wounds of patients and their loved ones. John Rosen, the founder of "direct analysis," which took its name from the technique of relating psychotic utterances directly to the unconscious, wrote in a 1953 paper entitled "The Perverse Mother": "A schizophrenic is always one who is reared by a woman who suffers from a perversion of the maternal instinct." R.D. Laing, a decade later, widened the ring from the mother to the family system: "Without exception the experience and behavior that gets labeled schizophrenic is a special strategy that a person invents in order to live in an unlivable situation." This view led Laing to a treatment that revelled in, rather than contained, the unfettered rambling word salads of schizophrenic thought disorder. With the advent of chlorpromazine therapy and of genetic studies, Dolnick claims, the walls collapsed around the psychoanalytic treatment of this disorder.
Valenstein begins where Dolnick takes leave. His account begins with the sentence "American psychiatry is said to have changed from blaming the mother to blaming the brain." Professor emeritus of psychology and neuroscience at the University of Michigan, Valenstein argues that the current biochemical models of depletions and imbalances of a few specific neurotransmitters in schizophrenia, depression and anxiety do not begin to fathom the complexities of a brain comprising 20 billion interconnecting cells communicating by means of more than a hundred different neurotransmitters. The biochemical case is overstated, he believes, primarily as a result of economic forces which, in the US, take shape in the profit dictates of HMOs and the relentless consolidation of the pharmaceutical industry. Pharmaceutical companies require a readily accessible but authoritative explanation of mental illness to support the marketing of their drugs both to physicians and, increasingly, to patients themselves. Similarly, HMOs are driven to restrict treatment to those options that appear, at least in the short run, to be the most expedient. Valenstein is concerned about the impact of these trends on the teaching and practice of psychiatry. A growing number of psychiatric residency programs, he laments, are providing inadequate psychotherapy training, and HMOs are reducing the role of the psychiatrist to that of drug dispenser. The net result is that patients become merely pieces of flawed chemistry to be put in order by the appropriate agent or combination of agents. No attempt is made to understand the problem or to offer treatment in a broader context.
These are cautionary tales. They tell us that today's gospel could well be tomorrow's lie, that the pendulum of opinion in the mindbrain debate, left unchecked, swings in extremes.
Why should this be so? The answer may lie in the nature of psychiatric and psychological problems themselves. Understanding difficulties and disorders in this domain goes to the existential core of what it is to be human. Are we agents of our own destiny, or are we driven by biology and fate? Are fear, depression and even madness within our control, or beyond it? What is our right mind? Where is the fault? Who is to blame?
Our sense of our humanity is always evolving, bound by the conflicting cultural currents within a society at a given point in time. Dolnick speculates that perhaps one of the reasons the post-war era so readily embraced the totality of psychoanalytical thought was a need to understand the evils that had been unleashed by World War II, which provided more than enough evidence of the death instinct that Freud had conceptualized. If thanatos could be understood, could it perhaps be tamed? Valenstein, for his part, examines the economic imperative. The resources and influences of large corporate structures within a consumerist culture are capable of moulding accepted opinion and determining what is valued.
The lesson is that societal context not insignificantly informs the illusory impartiality of science and medical practice. They do not sit in some rarefied, pristine atmosphere dealing with an absolute and constant truth. Rather, they are embedded in the fabric and history of the societies that generate them.
These books call on us to see beyond our own immediate period and locate ourselves on the trajectory drawn by the shifting coordinates of the mindbrain debate. These perspectives can only help us in advocating the most humane and balanced treatment possible for our patients.
Mark G. Leith, MD
Madness on the couch: blaming the victim in the heyday of psychoanalysis
Simon & Schuster, New York; 1998
352 pp. $35. ISBN 0-684-82497-3
Blaming the brain: