Monday, November 05, 2018

Camille Claudel, 1915

This beautiful, haunting and poignant film takes place in an asylum for the insane during a few days in 1915.  The sculptor Camille Claudel, already in the asylum for many years, waits for a rare visit from her brother, the philosopher Paul Claudel.The backstory of how she came to be there is only alluded to. The film Camille Claudel (1988) provides a graphic depiction of that. This film focuses on the experience of a woman who has been abandoned by her family and lives in an environment that feels like a prison to her. The contrast between her intelligent and sensitive bearing and the behavior of the other inmates may seem exaggerated, but having spent many hours on a back ward of an American state hospital, I found it painfully familiar. The film is about loneliness. The contrast between Camille's  demeanor before and after she learns that her brother is going to visit  conveys her agony more forcefully than the moments where she breaks down into tears. Her brother's self absorption and indifference to her suffering locks the door that confines her. The slow pace of the film makes it hard to sit through, but succeeds in drawing the viewer into Camille's life.  The performance by Juliet Binoche as Camille is simply riveting.

Saturday, October 29, 2016


Last evening I watched the 2006 Lauren Greenfield film "Thin." Afterwards I read as many of the reviews and comments as I could find online. Virginia Heffernan's New York Times review, which referred to the film as  “One Flew Over the Cuckoo’s Nest” for women, certainly captured my reaction to the movie. I was also taken with the number of women who posted statements expressing gratitude for the treatment they received at this facility. Having practiced psychiatry for forty years and read the critics from Foucault on, I think it is fair to say this kind of polarization is present, not only with regard to inpatient treatments for anorexia, but for all psychiatric treatments. What should one make of such polarized views of a psychiatric treatment?
I think this is a question that has deep historical and philosophical roots.
On the same day that I saw 'Thin' I happened to be reading a wonderful book by Brian Nance, "Turquet de Mayerne as Baroque Physician." I was particularly interested in his description of the change in the relationship between the concepts of sign and symptom that occurred during the nineteenth century. While I was taught in medical school to accept the term sign as referring to objective finds and symptom as referring to subjective experience. In the late 16th and early 17th century, when Turquet de Mayerne was practicing this was not the case. "A signum was something," Nance points out, "indicative of any hidden process or event taking place in the body while a symptoma was produced specifically by a disease [Nance, 2001, 72]." For Turquet de Mayerne signs and symptoms had equivalent epistemological status. For us the data given by  signs clearly trumps the evidence produced by symptoms.
As I see it this shift in the relative epistemological weights of signs and symptoms indicates a shift in the weighting of the knowledge produced by the observations of doctors in relation to the knowledge produced by the experience of patients. This shift has profound implications. It is baked into every encounter between a medical professional and a patient.
Most of the time we take this for granted. The doctor reads the x-ray and the patient accepts the results.
In psychiatry this is more complicated. While a psychiatrist's observations may be called signs, they are not so obviously of greater epistemological value than a patient's observations of his/her inner life. While Freud certainly had no doubts about whose observations were worth more in his consulting room, to their credit, psychoanalysts have made real efforts to level the field.
When one speaks about an inpatient treatment facility for a disorder with manifest and serious issues of self-deception such as anorexia the gap in the value given to what therapists see and what patients say grows.
As I see it, much of the Cuckoo's Nest quality of the treatment portrayed in 'Thin' arises from the acceptance of this distinction between the treatment team's perspective and that of the patients. I have worked in facilities that bear some resemblance to the one portrayed in the film.  I can remember the struggle between wanting to believe that I knew best and accepting what the patient said at face value. The 'sicker' the patient the easier it was to opt for the former and dismiss the patient as 'deluded.'
I think that this is a struggle that is unavoidable in contemporary psychiatry. For individual therapists working with relatively healthy patients it is fairly easily resolved. For people working in institutions, like the one depicted in the film, with sicker patients the pull to doctor-knows-best is and will remain hard to resist.
We can criticize the treatment shown in 'Thin,' but we should not forget that some of what we object to in that treatment is simply baked into our way of offering medical care. And we shouldn't forget all the women who say that they found this treatment helpful. Perhaps some of the empathic capacities of the caregivers managed to break through the cultural grip of our ideas about medical knowledge.

Friday, November 20, 2015

William Harvey: Rage and Heart Disease

Reading Walter Pagel's book New Light on William Harvey I ran across a case described by Harvey. Pagel writes "How much insight Harvey had into the deep interlocking of psychic and somatic aspects of the causation of disease is best shown in a case report…"

"I knew another stout man, who did so boyl with rage because he had suffer'd an injury, and receiv'd an affront by one that was more powerfull than himself, that his anger and hatred being increas'd every day (by reason he could not be reveng'd) and discovering the passion of his mind to no body, which was so exulcerate within him, at last he fell into a strange sort of a disease, and was torur'd, and miserably tormented with great oppression and pain in his heart, and brest, so that the most skilfull Physicians prescriptions doing no good upon him, at last, after some years, he fell sick of the Scorbutick disease, pin'd away, and dyed.
This man only found ease as oft as his brest was prest down by a strong man, and was thump'd and beaten down as they do when they mould bread: his friends thought he was bewitch'd, or possess'd with the Devil." [The Anatomical exercises of Dr. William Harvey, London, 1653, 63]

Monday, October 19, 2015

Sydenham's 'Equine Therapy'

While reading Kenneth Dewhurst's book Thomas Sydenham (1624-1689): His Life and Original Writings, (University of California Press, 1966) I ran across an amusing instance of what appeared to me to be a psychological treatment:
"Riding long journeys on horseback was one of Sydenham's favourite remedies ... After attending a … (wealthy patient) for several months without alleviating his symptoms, Sydenham frankly told him that he was unable to render any further service. But he added that a certain Dr. Robertson of Inverness had performed several remarkable cures in this particular malady. Armed with Sydenham's letter of introduction, the patient set out for Inverness where he lost no time in seeking Dr. Robertson. to his dismay he learned that there was no physician  of that name in the city, nor had there ever been one in the memory of anyone there. Returning to London the gentleman vented his indignation of Sydenham for having him on such a long and fruitless journey. "Well," inquired Sydenham, "are you in any better health?"
     "Yes, I am not quite well, but no thanks ty you."
     "No," added Sydenham, "but you may thank Dr. Robertson for curing you. I wished to send you on a journey with some objective interest in view. I knew it would be of service to you; in going you had Dr. Robertson and his wonderful cures in contemplation, and in returning, you were equally engaged in thinking of scolding me." [pp. 53-4]

If anyone knows of other instances of the therapeutic effects of such deceptions, I would be interested in learning about them.

Sunday, June 21, 2015

Neuro: The New Brain Sciences and the Management of the Mind

Neuro: The New Brain Sciences and the Management of the Mind by Nikolas Rose and Joelle M.Abi-Rached looks at the development of the neurosciences historically. They stress that a number of technological and conceptual developments in recent years have changed not simply what we know about the brain, but the 'style' with which we think about the brain and its relationship to our personhood. New technologies of visualization [pet scan, fmri] which offer the idea that the nervous system is plastic, and that is capable of change and growth have led to technologies for changing brains. They have also led to a self-help industry focused on brains, 'neurobics.' They suggest that while much has changed, not much has changed. Essentially they argue that the psy disciplines have been re-outfitted as 'neuro' without much being added to our understanding of what matters in human life. While they do take science seriously they offer a wise warning against hype.

     I found their review of developments in the neurosciences helpful for someone like myself, who hasn't been following things too closely. Sharing their views about what we've gotten from the 'psy' industry I was sympathetic to their skepticism about the burgeoning 'neuro' field.


Wednesday, February 25, 2015

Pathologist of the Mind: Adolf Meyer and the Origins of American Psychiatry

I have been interested in Adolf Meyer since my training as a psychiatrist forty years ago. While one might say that Meyer, who was the most influential American psychiatrist in the first half of the twentieth century, is the forgotten psychiatrist of the twenty-first, his teachings were still in the air in the 1970s. But they were just in the air. Freudian theories and treatments were what we were taught. Trying to find out just what Meyer thought and did was difficult, not just because his writings were not a part of our curriculum, but because his writings were impenetrable.
Many thanks are now due the historian Susan Lamb for writing a lively and lucid account of Meyer's most creative period-- the twenty years before the World War I. She provides a chapter on his life and influences and another on his concept of psychobiology. She also uses a day in the life of a typical patient at the Phipps Clinic that Meyer ran to show how every detail of a patient's life was used in a therapeutic effort. She then provides two lengthy case histories the show the implications of Meyer's ideas. These are beautifully presented and really gave me a sense of how psychiatrists thought about patients in the early years of the twentieth century. She ends with a chapter that tries to relate Meyer's ideas to issues that psychiatrists and others struggle with today.
Now I finally feel that I understand Meyer and the many ways that breathing that Meyerian air in my youth influenced my life.

Perhaps I wasn't clear. The title of Susan Lamb's book is Pathologist of the Mind: Adolf Meyer and the Origins of American Psychiatry, (Johns Hopkins University Press, 2014)

Tuesday, December 23, 2014

The Invention of Nostalgia

The Invention of Nostalgia
Lawrence Raab
Before 1688 nostalgia didn't exist
People felt sad and thought about home,
but in 1688 Johannes Hofer, a Swiss doctor,
made up the word. It wasn't what he himself
was feeling, but a malady he'd observed

in soldiers posted far from home.
Leeches and opium were the cure,
and if those failed, a return to the Alps.
Therefore: homesickness, nostalgia's symptom,
the way your stomach felt that first nitht

at summer camp, though if you cried
so hard you had to leave, later
you probably found yourself thinking,
They'd be swimming now, they'd be having lunch.
And you felt sad in a different way.

Imagine how many places you can't
go back to, how much it hurts
to want what's lost--all those days,
the ones that have left
their cloudy picture in your mind.

and the smell of certain rooms, the light
through trees at a certain hour, a time
before the first time you felt it,
like all the years before 1688
when no one had the right word to turn to.

Lawrence Raab is author, mostly recently of "Visible Signs: New and
Selected Poems"

Sunday, September 07, 2014

Erving Goffman's Asylums

While still in college and working as a volunteer at a 5,000 bed state hospital, I read Erving Goffman's Asylums. His descriptions of St. Elizabeth's Hospital matched what I was observing each Saturday afternoon during the 3 or 4 hours that I spent with a few of the 200 men housed on  a so-called Cottage Ward.  I  accepted Asylums as the gospel. Recently I read a short article titled "Erving Goffman's Asylums and Institutional Culture in the Mid-twentieth Century United States" by the historian Mathew Gambino, which takes a second look at Goffman's classic book. Gambino reviews materials, such as a patient edited newspaper, that were available to Goffman. Where Goffman saw indoctrination, Gambino hears the voices of patients. Even after more than fifty years he was able to locate statements by patients that suggested that they were quite active in shaping their lives at patients. Indeed, Gambino points out that for all the time Goffman spent as a participant-observer at St. Elizabeth's, he presented no interviews with patients. The difference in orientation between Goffman and Gambino suggests an evolution in our attitudes towards the mentally ill. While Goffman saw the patients  as victims, Gambino asks us to consider these patients as agents.  This does not suggest to me that we simply rewrite the history of asylum treatment in the United States. At the very least there is no way that I can erase my experiences with patients at a state hospital in the 1960s. It does suggest that when we write about the mentally ill  we should not forget that they are people struggling not only with their illnesses, but with the institutions that shape their lives. Gambino's article should be required reading in classrooms where students are asked to read Asylums.

Wednesday, July 30, 2014

The Weariness of the Self

The Weariness of the Self: Diagnosing the History of Depression in the Contemporary Age
Alain Ehrenberg
(McGill-Queens University Press, 2009)

It appears that we live in the midst of an epidemic of an illness that we call Depression. Looking back to my training as a psychiatrist in the early 1970s, the diagnosis of Depression was usually limited to states that were so disabling that a person could not work, was at risk of suicide, often needed hospitalization and was usually treated with tricyclic antidepressants or ECT. There was a diagnosis of Neurotic Depression that was milder and was always treated with psychotherapy. Our current epidemic is usually explained by two factors: first, the Diagnostic and Statistical Manual of 1980 which eliminated Neurotic Depression and created a vaguely defined category called Major Depression and second, the advent of Prozac, an easy to take medication that was effective for a broad range of symptoms. 
Ehrenberg takes a different tack. He traces the history of depression focusing on two models. The conflict model, initiated by Freud, sees people as whole, but divided by conflict. Transgression and guilt are the forces that drive it, especially in France where Lacan's version of psychoanalysis is dominant and about which Ehrenberg is writing. The key term in the second model is deficiency. Following the social and cultural changes of the 1960s, he argues, transgression and guilt were no longer dominant concerns. She, and Ehrenberg is religious about using that pronoun, can do anything she wants. Now what matters is feeling inadequate, that is to say deficient. Depression is no longer about conflict and guilt, but about feeling inadequate and deficient. Medications like Prozac help with this by allowing people to feel more capable. Ehrenberg seems nostalgic for the old days when conflict reigned and psychoanalysis was popular. He seems to hold the view that feeling better because of a chemical effect is not authentic. Nonetheless, because he sees the changes as cultural, and social he does not make case for going back to the old days. 

What to make of a book like this. It was certainly confusing at times, especially because most of his references are to twentieth century French psychiatry about which I am not very familiar. The broad idealistic/Foucauldian perspective where cultures change without clearly marked material causes is hard to follow. Nonetheless, posing a contrast between a view of human nature centered on the idea of conflict and one centered on a notion of deficiency is quite refreshing. It isn't a matter of a biological/psychological dichotomy. Ehrenberg is clear psychotherapies, going back to Janet, can be based on a deficiency model. Indeed as I think about discussions of psychotherapy in recent years it seems to me that these were often based on the premise that the patient was somehow injured and in need of repair, not that 'she' was in conflict about how to live. The medications and the psychotherapies that we use are consistent with one another in how they view human nature. In this regard it seems to me that Ehrenberg is onto something and that this book was worth reading.

Wednesday, February 19, 2014

The Prisoner of Stress

Having seen Scott Stossel's book My Age of Anxiety” (Knopf) in a bookstore, I was interested in reading Louis Menand's review. Menand, as usual, goes beyond simply giving his opinion about the book under review. In this case he has written an interesting essay on the many meanings of anxiety. Is it an illness? Is it due to unconscious conflicts? Is it an existential condition? Is it due to stressors? None of the above or all of the above. Is it even 'somthing'? In the course of the review he sketches a brief history of our current ideas about and methods for treating anxiety. While he doesn't mention Andrea Tone's book The Age of Anxiety: A History of America's Turbulent Affair with Tranquilizers, I would suggest it as a good place to get a fuller description of this history.  

In the end Menand seems to take an agnostic position about theories of anxiety. His final word leaves room for both biology and psychology. He writes "As a species, we lucked out: natural selection gave us minds, and that freed us from the prison of biological determinism. We can put our genetic assets to positive account if and as we choose, and sometimes we have to try to do the same thing with our genetic deficits. " Not a bad approach to something we may not be able to avoid.

Wednesday, January 09, 2013

The Science of Sex Abuse

         This week's issue of the New Yorker has an article by Rachel Aviv on the medicalization of sex abuse crimes. It is well researched, well written and worth reading. She focuses the piece around the story of a man named John, who was drawn to child pornography on the internet, then to a chat room and finally to a rendezvous with undercover police officers. She describes his time in prison and on probation, his relapse, and his re-incarceration. The heart of the article is about the use of civil commitment to keep John "in treatment" after finishing his prison sentence. She describes civil court hearings, psychiatric testimony and life in the treatment facility where John winds up. Aviv is particularly interested in the fact that while John has not harmed anyone [other than indirectly through his support for the child pornography industry], the judicial system seems almost unable to release him for fear that he might assault a child. She discusses the psychological tests and psychotherapy which contribute to the view that John is a risk.  Since the advent of the internet and the emergence of internet child pornography there has been a virtual epidemic of cases like that of John. As yet, however, as I read Aviv, we don't  have a way to distinguish those men who will assault children from those who won't, nor do we have effective means of stopping such men from indulging in pedophile fantasies. As she describes it this creates  a catch 22 situation that leaves men like John to spend years in involuntary treatment. Aviv quotes psychiatrists who deplore the profession being used to medicalize what they regard as a criminal issue. But, of course, there are also those psychiatrists who make a living testifying in civil court and running involuntary treatment programs.

Friday, December 28, 2012

Laura's Law

In case you missed it the PBS News Hour had an interesting piece on court ordered outpatient treatment. California has a new law allowing for court ordered outpatient psychiatric treatment for psychiatric patients thought to be dangerous. The law, which is named for a young woman who was killed by a paranoid patient, hasn't been funded. The state, in its wisdom, is leaving this to localities. So far only one county has done so. The piece gives various people an opportunity to speak for and against the law, but doesn't say anything about those few states that have such a law. From my limited experience working in a state that allows for court ordered outpatient treatment I would say that it is neither as helpful nor as harmful as as the two sides quoted in this story suggest. It would be interesting to know whether there is data on how such laws work.