Thursday, May 31, 2012

How I Became a Historian of Psychiatry: Gerald Grob

Gerald Grob, one of the great historians of psychiatry, has submitted his statement to the blog h-madness' series on "How I Became a Historian of Psychiatry." Having read much of Grob's work many years ago and been much impressed by his intelligence and good judgment, I was quite moved by this piece. I pass it along for those who don't regularly read h-madness.

Friday, May 18, 2012

Spitzer Apologizes

Psychiatry seems endlessly political. Having read Ronald Bayer's excellent chronicle of the story of homosexuality being read out of psychiatry's Diagnostic and Statistical Manual I was puzzled when I read the New York Times headline " Leading Psychiatrist apologizes for Study Supporting Gay 'Cure'." I was completely unfamiliar with the story it relates of Robert Spitzer's sponsoring and publishing a study on treating homosexuality in 2001.  The author of the article, Benedict Cary, suggests that it was Spitzer's anti-establishment impulses manifesting themselves again that led him to conduct the study. I found myself wondering if the study didn't express some  reservations that Spitzer still had about his advocacy for the de-medicalization of homosexuality. At the end of the article Spitzer, clearly thinking about his legacy in the history of psychiatry says of his apology: " You know, it's the only regret I have; the only professional one, … And I  think, in the history of psychiatry, I don't know that I've ever seen a scientist write a letter saying that the data were all there but were totally misinterpreted. Who admitted that and who apologized to his readers."  He might have added that it would be hard to find a psychiatrist turning 180 degrees from one politically controversial position to another -- not to mention in the wrong direction.

Wednesday, May 16, 2012

Diagnosing the DSM

Allen Frances' May 11, 2012 op-ed piece in the New York Times "Diagnosing the DSM" is a wonderful piece of common sense. He argues that we don't need to insist that psychiatrists are in cahoots with drug companies to see that conflicts of interests render the American Psychiatric Association incapable of developing a diagnostic manual that does not overreach and medicalize much of everyday life. His suggestion that some presumably neutral arbiter such as the National Institutes of Health should take on this task is worth discussion.
As it happens I was just rereading a wonderful essay by Peter Sedgwick in his 1982 book Psychopolitics, titled "Illness--Mental and Otherwise." While it is aimed at the anti-psychiatry theorists of the day, its central point is that all diagnosis, whether of mental or of physical disorders, involves value judgments. The great success of the DSM as well as its scientific pretentions make it clear that we must take Sedgwick's arguments seriously if we are going to have an honest debate over the reasonable limits of psychiatric diagnosis.

Tuesday, May 01, 2012

More on straitjackets

       In a  2006 post I wrote that the camisole de force was invented at the Bicêtre in 1790.  I recently realized that my source got that wrong. Most sources cite the same inventor, but give the date as 1770. In addition it seems that the strait waistcoat was in use at least by that date and probably much earlier. In 1772 David MacBride gives a detailed description of construction of the strait waistcoat, implying that it was well known in Britain by that time.
       By 1784, and perhaps as early as 1777, the very influential Scottish physician William Cullen in his First Lines of the Practice of Physick was praising the waistcoat not only as a means of restraint, but also as a remedy and even suggesting a physiological rationale for its benefit. This passage is so striking that it is worth quoting at length.

     "Restraining the anger and violence of madmen is always necessary for preventing their hurting themselves or others: but this restraint is also to be considered as a remedy. Angry passions are always rendered more violent by the indulgence of the impetuous motions they produce; and even in madmen, the feeling of restraint will sometimes prevent the efforts which their passion would otherwise occasion. Restraint, therefore, is useful, and ought to be complete; but it should be executed in the easiest manner possible for the patient, and the strait waistcoat answers every purpose better than any other that has been yet thought of. The restraining madmen by force of other men as occasioning a constant struggle and violent agitation is often hurtful. although there may be no symptoms of any preternatural fulness or increased impetus of blood in the vessels of the brain, a horizontal posture always increases the fulness and tension of these vessels, and may thereby increase the excitement of the brain."
      Philippe Pinel may have learned about the strait waist coat from Cullen when he translated this passage in 1785, incidentally using the term chemisette serrèe, suggesting that he was not yet familiar with the commonly used term camisole de force. In his Treatise on Insanity in 1800, Pinel argued that his use of the camisole de force was evidence that he subscribe to the same philanthropic principles as those of the York Retreat:
       We are doubtless without the advantages of Dr. [Thomas] Fowler's establishment in Scotland [actually the Retreat in York] with its expansive grounds and fine accommodations. But I can attest after two years of diligent observation that the same principles of philanthropy prevail in the management of the insane at Bicêtre. The attendants, under no pretext whatever, ever raise a hand, even in reprisal. Strait jackets [Gilets de force] and seclusion, for short periods, are the only punishments inflicted. When kind treatment or the imposing trappings of repression fail, a clever ploy sometimes produces unexpected cures [TAM. 1800, 65-6].

Defending Psychoanalysis in France

The dispute in France over the role of psychoanalysis in treating autism brought a defense of analysis in the Nouvelle Observateur [NO] from Elisabeth Roudinesco [ER] and Alain Badiou [AB].  I found one section of their comments of particular interest, not because it related to the issue of autism, but rather because it offered a social psychological interpretation of the plight of psychoanalysis. Here is my effort at a translation:
[ER]The dissatisfaction [of the relatives of autistic children] does not come from nowhere. However, all the critiques are not acceptable. For example, we are witnessing a new phenomenon: patients want to decide their treatments and consider in particular that their symptoms belong to their identity. [she uses the term boufées délirantes. I would paraphrase the CNRTL dictionary definition of this term as a sudden, short lived mental disturbance manifesting itself through hallucinations, sensory illusions and accompanied by mental confusion.] They do not see why they should be numbed by medication on the pretext that they hear voices. In which case one must listen to them. But we are going towards the patient as master of his destiny, and this is not desirable. Here again, psychoanalysts bear part of the responsibility, because by enclosing themselves in chapels they lose their authority. At bottom what has been lost in psychoanalytic societies is the position of master to the benefit of that of little chiefs [petit chefs].
[NO] What do you mean by “master?”
[ER] The position of master permits the transference: the psychoanalyst is “supposed to know” what the analysand is going to discover. Without that, trying to discover the origin of the suffering is almost impossible.
[NO] Is it really necessary to go through the restoration of the master?
[AB] The master is what helps the individual become a subject. Because if one admits that the subject emerges in the tension between the individual and universality, then it is evident that there is a need for mediation to advance on this road. And therefore the need for an authority. The crisis of the master is the logical consequence of the crisis of the subject, and psychoanalysis is no escape  from it. It is necessary to restore the position  of the master, but it is not true that one can do without it, even and especially from the perspective of emancipation.
[ER] When the master disappears, he is replaced by the chief, authoritarianism, and that ends always, sooner or later, in fascism- history has, alas, proved this.

I found this part of the interview interesting because it suggests that for psychoanalysis to be successful as an individual therapy and as a therapeutic institution the analyst must be accepted as a ‘master,. that is as one who is ‘supposed to know.’  While the priestly role of the doctor is an important part of many, if not most, areas of medicine, these remarks indicate that for psychoanalysis this role is the critical ingredient. Indeed, they seem to say that without the analyst being able to assume the role of master the process cannot occur. In a patriarchal society, such as the one Freud lived in, the doctor as a ‘master’ could be assumed. What the authors seem to be suggesting is that the challenge to psychoanalysis posed by such people as the relatives of ‘autistes’ is part of a larger challenge to patriarchal norms that may be occurring in France somewhat later that it did in the United States. This raises the question of what  role of the challenge to patriarchal norms in the United States has played in the decline in the fortunes of psychoanalysis.