Thursday, September 13, 2007

Concept: Psychoanalysis and American Psychiatry.

Up until now I've offered a one-sided criticism of psychoanalysis, all the way back to its roots in Freud and Jung. I always took the angle that Freud was a gifted observer who formed some highly faulty models of psychology based on speculation as to how the human brain worked. This I am willing to stand by. In other ways, however, I have to reevaluate my opinion. Many of my friends in the arts and critical fields rely heavily on psychoanalysis. I've been more skeptical, but my criticism has been kind of free-floating; I haven't read broadly enough for my opinion to be as informed as I thought it was. Now I am coming to the further conclusion that, not only were Freud and Jung's ideas fundamentally flawed, but they did not serve to improve the fields of psychiatry. Psychology, perhaps. Psychoanalysis certainly contributed the notion that careful discussion and analysis of the cause of a disorder could be therapeutic. This was possibly useful for the society at large. But for those with mental disorders (roughly 1-2% of the population), and especially in America, psychoanalysis was a disaster.

Emil Kraepelin was born in northern Germany in February 1856, less than four months before Freud. By the time he was thirty he'd compiled a set of empirical studies to publish the first edition of his book Psycologie which would go on to be published in nine editions. The differences in methodology and results are difficult to go into here, but Kraepelin discovered that psychotic forms of mania and depression were manifestations of a single spectrum of disoders (bipolar disorder). More importantly, he used longitudenal studies to combine superficially divergent symptoms into a definition of "madness" as dementia praecox or premature senility. In its American form, this condition is known as schizophrenia. Kraepelin revolutionized psychiatry by defining the terms of a more rigorous inquiry and setting the groundwork for establishing prognosis. He identified a genetic component to these conditions, but also believed in limited penetrance. At the time, he was recognized as the master of his field, but who learns the name of Kraepelin in high school? I took a semester of Psychology in high school and the Humanities and Sociology sequences at the University of Chicago. I never heard about Kraepelin until assigned to work on his bio at work.

The book I'm working on doesn't give a complete account of the posthumous dismantling of Kraeplin's legacy. He was a German nationalist (as opposed to Freud, who fled the Nazis) and monarchist, staunchily opposed to socialism and, while he died in 1926, before the rise of the Nazi party, an advocate of eugenics during his lifetime. It stands to reason that his legacy might have (deservedly?) floundered in the postwar climate. But that never hindered Werner von Braun in the postwar era. It was probably, more than anything else, the pro-psychoanalytic stance of prominent American psychiatrists that shouldered Kraepelin's studies aside. And frankly, this trend had been going on since the turn of the century (eg. Adolph Meyers, Eugen Bleuler). The psychoanalytical angle went something like:

The problem of psychoses would be simple and perspicuous if the ego's detachment from reality could be carried through completely. But that seems to happen only rarely or perhaps never. Even in a state so far removed from the reality of the external world as one of hallucinatory confusion, one learns from patients after their recovery that at the time in some corner of their mind (as they put it) there was a normal person hidden, who, like a detached spectator, watched the hubbub of illness go past him.

It's very poetic. I can easily understand the appeal to writers and literary types. However, it is not provable, is almost not disprovable, and is dangerous to consider as a science. Why? Because science is not science if it lacks a mechanism to confront error and subjectivity. That is, to scrutinize hypotheses for signifiant bias. As a result, the mid-20th century psychiatric literature is littered with references to "schizophrenogenic mothers" and "narcissistic neuroses," concepts which are not only patently (and demonstrably) wrong, but which lead to equally misguided treatment. It is not, I think, coincidental that this was the also the era of lobotomy and chemical convulsive therapies, solutions that were, in many ways, both less humane and hardly more scientifically sound than the surprise baths and bed saddles of the 19th century. Nor did the psychoanalyically informed therapies – group therapy and mass deinstitutionalization – have a positive effect on contemporary prognoses. This is largely why there are so many homeless schizophrenics today.

The psychoanalytical approach to psychiatry held out through the seventies before giving up the ghost. The model of schizophrenia that we use today is derived almost directly from Kraeplin. Certainly this has continued to have been revised, and many concepts (autointoxication, degeneration theory) have been discarded. But diagnostic and progress in treatment is made through revision; an advantage that psychoanalysis substantially lacked.

In short, before working on this assignment, I felt that Freud was a gifted genius whose work helped build psychiatry, but whose persistent influence is damaging to the arts. Now I feel that Freud was a gifted genius whose persistent influence is damaging to the arts, but was perhaps even more damaging to psychiatry.

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