In April 1979 a cover-story in Time Magazine, always a sensitive indicator of American public opinion, was entitled ‘Psychiatry on the Couch’. The verdict was unequivocal, even though expressed in the form of a mock-clinical formulation:
History: European-born. After sickly youth in the US, travelled to Vienna and returned as Dr Freud’s Wunderkind. Amazing social success for one so young. Strong influence on such older associates as Education, Government, Child-Rearing and the Arts, and a few raffish friends like Advertising and Criminology.
Complaint: Speaks of overwork, loss of confidence and inability to get provable results. Hears conflicting inner voices and insists that former friends are laughing behind his back ...
Diagnosis: Standard conflictual anxiety and maturational variations, complicated by acute depression. Identity crisis accompanied by compensatory delusions of grandeur and a declining ability to cope. Patient averse to the therapeutic alliance and shows incipient over-reliance on drugs.
Recommended treatment: requires further study.
America-watchers who are aware of the role assumed by psychiatry in American cultural life during the post-war era might well be puzzled by so disillusioned a judgment. In no other country, after all, has the impact of the subject been so great and the American Psychiatric Association, numbering more than thirty thousand members and fellows, has grown to be immeasurably the largest and most influential professional organisation of its type in the world.
A closer reading of the Time article shows that it is not so much psychiatry – ‘psychological medicine’, as it is often called in this country – as psychoanalysis, ‘Freud’s Wunderkind’, whose claims are being questioned. In his study of Freud and the Americans, Nathan Hale has traced in some detail the origin and development of a long-standing love-affair which inevitably affected the medical profession in the post-war era. The profound doubts which have been expressed about the scientific validity and therapeutic value of psychoanalytical theory and practice were bypassed, and a whole generation of psychiatrists was trained on the assumption that the forces and motivations of human behaviour had at last been established. The resulting stereotype of the psychiatrist has become all too familiar, both in the fantasy world inhabited by the Hollywood shrink and in the fictional characters of American writers from Scott Fitzgerald to Erica Jong. It is an image manifestly different from the one with which the millions of British television viewers, glued weekly to the soap-operatic events taking place in Maybury Hospital, were presented in the person of Dr Edward Roebuck: a recognis – ably shabby figure, fallible but well-meaning, doing his troubled best to help, counsel and advise his patients.
Now the American consumer appears to have rumbled what Sir Peter Medawar has termed the most stupendous confidence-trick of the 20th century. To be sure, the numbers of mentally sick and worried well have not diminished. They are still in search of help, but they are turning more and more to drugs, to biofeedback, towards new ways of living and away from the one-to-one, let’s-talk-about-me psychotherapy which was so much in vogue during the fat years of the Fifties and Sixties. A seemingly limitless demand was then met from various quarters, prominent among them the departments of psychiatry in the medical schools. How this was effected is the subject of Donald Light’s book.
Light is a medical sociologist who sets out to examine ‘what kinds of people choose to become psychiatrists, how their training experience alters their sense of illness, treatment and responsibility, how they cope with suicidal patients, and how they overcome the uncertainties of their work’. His method is that of the participant observer, a role which he succeeded in establishing in the psychiatric residency training programme of a university hospital in the late Sixties in order to record and illustrate what he calls ‘the professional transformation of self’. He presents a disturbing picture of the process of indoctrination. The trainee physician, educated in the mould of a traditional medical school with its strong biological approach to disease, finds himself confronted by patients whose disorders cannot be explained in mechanistic terms and who appear to be resistant to most forms of treatment. His teachers, by contrast, are less concerned with medical models than with the inculcation of the tenets and value-systems of psychoanalytical theory and practice. Slowly the young doctors begin to enunciate what is expected of them. They learn to accept the staff’s view of their patients as extensions of themselves: ‘The line between patient’s and resident’s psyche became blurred in the resident’s mind.’ Gradually they internalise a different view of their own function: ‘I’m not sure psychiatry can do that much for the mentally ill patient, but after watching a lot I’m convinced it can really help the healthy patient. With healthy neurotics, it can make them really healthy people.’
The author traces the evolution of this metamorphosis through the observation of his subjects’ routine tasks, giving numerous illustrations on the way. Here is one of his examples, a ward discussion (‘DOC’, incidentally, is an abbreviation for ‘doctor on call’):
Head nurse: Miss X pushed a newly set window out in the ladies’ room.
Chief: You mean she didn’t have to smash it? (Jauntily punches his fist into other hand.)
Head nurse: Yes. The putty had not hardened.
Patient’s doctor: That sound like a compromise. (Laughs around the room.)
Chief: Did you speak to her?
Doctor: I tried, but she didn’t want to.
DOC last night: Last night I saw her. She gave the perfect Blumbergian interview, without Blumberg. (Chuckles in room.) How she was lonely, and lost and sad. It was the classic pre-suicidal speech.
Chief: That’s a young, adolescent girl giving the perfect speech for the doctor, just what we want to hear. And then the day you stop listening they cut their wrists.
DOC: Well, I listened.
Chief: And got no sleep. I learned at the end of being DOC to be a meanie. Otherwise you get no sleep. (General laughter.)
The Dr Blumberg in question is a pseudonym for the clinical director, a man for whom the sole objective of training is to acquire expertise in psychotherapy, ‘the process of feeling oneself into the patient’s dilemma to discover the painful experience, ideas and affects avoided by the fragmented ego’. At times he is like a character in a Woody Allen scenario:
A resident presented a case familiar to Dr Blumberg. He had recommended bringing up transference issues, and the patient had begun to talk about her feelings for her old therapist. The resident had asked her if she had similar feelings for him, and she said no. ‘You planted seeds,’ said Blumberg, ‘and they will grow up.’ The resident stopped presenting, wordlessly staring up at Blumberg. Blumberg continued, ‘Pretty soon she’ll be talking about you.’
The author’s message is clear, then, though the points are scored in unnecessary detail, with too much jargon and without the stylistic elegance which renders the studies of Erving Goffman so persuasive. And, like all exercises in microsociology, a preoccupation with the trees tends to be accompanied by a myopic perception of the forest. In particular, by concentrating on a single institution, Light does inadequate justice to the winds of change that were blowing, albeit softly, in the outside world, from which most medical schools are not as hermetically-sealed as he suggests. The medical student of today is the physician of tomorrow: he keeps an eye on the social and economic climate of opinion in which he is to practise and is usually well aware of the relevance of his training experience to his future professional activities. This emerged clearly from the survey of 15 centres in North America, including the one described in this book, which I conducted 20 years ago with the aim of assessing psychiatric training programmes in order to evaluate their possible relevance for the United Kingdom. The general picture certainly included a widespread awareness of the need to master psychoanalytical theory and practice, but there was even then an uneasy awareness of things to come. ‘We’ve got to take care not to find ourselves stuck out on a Freudian limb in twenty years’ time,’ commented one of my resident-interviewees in 1961 and time has proved him right. It is not merely, as Light suggests, that ‘bio-psychiatry’ has superseded the earlier paradigm: there have been many other forces at work, including a new understanding in the USA of the limitations of laissez-faire medicine and of the need for medical audit, as well as a growing awareness of those intrinsic defects of training programmes which were to lead the American Psychiatric Association in the late Seventies to call for a ‘de-emphasis on psychoanalytic orientation’.
In sum, the subject calls for a broader framework than Light provides. Writing about medicine more than a hundred years ago, Oliver Wendell Holmes commented that ‘professedly founded on observation, it is as sensitive to outside influence, political, religious, philosophical, imaginative, as is the barometer to the changes of atmospheric density. Theoretically, it ought to go on its own straightforward inductive path, without regard to changes of government or to fluctuations of public opinion. But there is in fact a closer relation between the Medical Sciences and the thought of the time than would at first be suspected.’ This is an early statement of a truth which has since been widely acknowledged and much elaborated by observers within and, increasingly, outside the medical orbit, not least by last year’s Reith Lecturer, who exaggerated its force by describing medicine as an essentially political enterprise, with psychiatry as a prime example. Colin Blakemore, one of his Reithian predecessors, has recently written on ‘The Future of Psychiatry in Science and Society’, pointing out that ‘psychiatry is public property. It is, like no other area of medicine, thought about, agonised over, discussed and criticised by people who have no direct contact with it as a medical discipline either as practitioners or sufferers.’ Hence the wider interest of this book, though the British reader will stick with Dr Roebuck if he wants a more accurate picture of psychological medicine in this country.
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