Psychiatry on the Couch

Patient's name: Psychiatry.

Age: In middle years.

History: European born. After sickly youth in the U.S., traveled 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. Patient agrees with Norman Mailer: "It's hard to get to the top in America, but it's even harder to stay there."

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 overreliance on drugs.

Recommended treatment: Requires further study.

Prognosis: Problematic.

Each day millions of Americans talk, scream, confront, jump, paint, dance, strip, tickle and grope their way toward emotional fulfillment. They are sampling one or more of the 200 or so therapies and countless pseudo therapies that are now being peddled in the U.S. as panaceas for unhappiness, anxiety or worse. At one end of this therapeutic spectrum are such exuberant exercises in self-help as biofeedback and Transcendental Meditation; at the other end, close-order drill for the psyche, like est. All but trampled by this stampede toward satisfaction lies the battered body of the medical specialty that once held the exclusive franchise for curing all maladies of the mind. Obviously it no longer does--one reason why psychiatry itself is now on the couch.

The symptoms of psychiatry's ills are apparent enough. The U.S. has 27,000 psychiatrists in active practice, up from 5,800 in 1950. But now the bloom is off the therapeutic rose. Today only 4% to 5% of medical school graduates go into psychiatry, vs. 12% in 1970. Says one doctor: "Psychiatry is not where the action is."

Indeed, on every front, psychiatry seems to be on the defensive. Private groups with names like Alliance for the Mentally Ill are beginning to batter the profession and its hospitals with the same kind of malpractice suits that plague the rest of medicine. Many psychiatrists want to abandon treatment of ordinary, everyday neurotics ("the worried well") to psychologists and the amateur Pop therapists. After all, does it take a hard-won M.D. degree (a prerequisite psychologists do not need) to chat sympathetically and tell a patient you're-much-too-hard-on-yourself? And if psychiatry is a medical treatment, why can its practitioners not provide measurable scientific results like those obtained by other doctors?

Psychiatrists themselves acknowledge that their profession often smacks of modern alchemy--full of jargon, obfuscation and mystification, but precious little real knowledge. The Patty Hearst trial was a typical embarrassment--one battery of distinguished psychiatrists neatly explained that Hearst was ill, another insisted that she was not. To radicals, feminists and homosexuals, psychiatry is just one more villainous agent of the status quo. More than a century ago, an antebellum psychiatrist blithely explained that slaves who tried to escape from their masters were suffering from "dromomania," the runaway disease. How does the public know that 20th century psychiatry is not still retailing dromomania in more sophisticated guises?

As always, psychiatrists are their own severest critics. Thomas Szasz, long the most outspoken gadfly of his profession, insists that there is really no such thing as mental illness, only normal problems of living. E. Fuller Torrey, another antipsychiatry psychiatrist, is willing to concede that there are a few brain diseases, like schizophrenia, but says they can be treated with only a handful of drugs that could be administered by general practitioners or internists. He writes: "The psychiatrist has become expendable; he is left standing between the people who have problems in living and those who have brain disease, holding an empty bag." By contrast, the Scottish psychiatrist and poet R.D. Laing is sure that schizophrenia is real--and that it is good for you. Explains Laing: it is a kind of psychedelic epiphany, far superior to normal experience.

Even mainline practitioners are uncertain that psychiatry can tell the insane from the sane. In one experiment, Stanford's D.L. Rosenhan planted eight sane volunteers, one of them a psychiatrist, in public and private psychiatric wards scattered across the country and told them to behave normally. Many inmates quickly realized that the eight impostors were sane because the would-be patients kept taking notes. But the staff psychiatrists never did. Says Rosenhan: "Any diagnostic process that lends itself so readily to massive errors of this sort cannot be a very reliable one."

As is all too plain, psychiatry, especially analysis, is now suffering a bad case of mid-life blues. Whatever else the Freudian movement accomplished, it raised hopes dramatically, set the stage for the narcissistic excesses of today's Me Decade, and propagated the notion that mind science was on the brink of blowing away all mental ills. "Psychiatry was overtouted," says Psychiatrist and Author Robert Coles. "Then there was the disenchantment, not only of patients, but also, of course, professionals " Adds Robert Michels, head of Cornell Medical Center's Payne Whitney Hospital and Clinic: "The public's enthusiasm for psychiatry 20 years ago was based on an insane interpretation of psychiatry."

Freud's dazzling and complex theory of the mind--one of the great intellectual triumphs of all time--came along when American psychiatry was doing little more than warehousing the insane and performing the occasional crude Cuckoo's Nest lobotomy. Though most of Europe's intelligentsia remained unimpressed with Freud, a generation of largely Jewish disciples of the master, fleeing Hitler and the Nazis, spread the faith widely in the U.S. It quickly attracted the well-to-do, who could alford the treatment, and enticed the literati, who were smitten by the subtlety and symbolism of these fashionable excursions into the subconscious.

Throughout the 1940s and 1950s, psychoanalytic chic ran high, generating optimism about its potential that far outran Freud's. The master, of course, thought he had made a decisive breakthrough, but one destined to be modified by other discoveries, some of them biological and chemical. Psychoanalysis, he said, could do little for the seriously ill, such as schizophrenics and other psychotics, and even many neurotics should expect little more than transforming "hysterical misery into common unhappiness." Even that might not be achieved if the patient was too old and set in his ways.

Freudian psychoanalysts in particular, who account for only 10% of the nation's psychiatrists, have felt the common unhappiness of post-Freudian deflation. Freudian talk therapy is designed for the less seriously ill, precisely the constituency that has shifted toward quick Pop treatments. A 1976 survey by the American Psychoanalytic Association showed that the average psychoanalyst had 4.7 patients under treatment, down from 6.2 a decade earlier. Applications to the Freudian training institutes are also declining. When Psychoanalyst Herbert Hendin director of the Center for Psychosocial Studies in Montrose, N Y., applied to the prestigious Columbia Psychoanalytic Clinic for Training and Research a generation ago, more than 120 students competed for nine openings. "Now," he says, they're lucky to get twelve applicants for roughly the same number of spots."

In classical Freudian psychoanalysis, the patient, lying on the inevitable couch, meets with the analyst for an hour, three to five times a week. Whether the patient talks about problems, fears and dreams, or simply free associates--voicing any thoughts that come to mind--the theory is that his unconscious difficulties will gradually break through into conscious thought. The analyst is generally passive and silent, offering no advice and speaking only to prod the patient into uncovering more nuggets from the inner recesses of the mind. The key to the Freudian "cure" is transference--the analyst replaces some crucial figure in the patient's background, usually a parent--and the patient eventually re-experiences blocked emotions and frees himself of the past.

Forty years after Freud's death, the effectiveness of his therapy is still being debated, even among psychiatrists and psychologists who generally accept his theories and discoveries. (A sample panel discussion, scheduled for next month in New York City: "The Outcome of Psychotherapy: Benefit, Harm or No Change?") Psychoanalysts usually cite the "one-third" rule of thumb: of all patients, one-third are eventually "cured," one-third are helped somewhat, and one-third are not helped at all. The trouble is that most therapies, including some outlandish ones, also claim some improvement for two-thirds of their patients. Critics argue that many patients go into analysis after a traumatic experience, such as divorce or a loved one's death, and are bound to do better anyway when the shock wears off. One study shows improvement for people merely on a waiting list for psychoanalytic treatment; presumably the simple decision to seek treatment is helpful.

From its inception, psychoanalysis has been plagued by an elitist image. Most patients are middle and upper class, and even today only 2% are nonwhite. Analysts say that the treatment works best for the YAVIS (Young, Adaptable, Verbal, Intelligent and Successful). It also helps to be W (Wealthy). A psychoanalytic hour (actually it is now usually 45 to 50 minutes) costs from $20 to $100, with the average at $50, or $12,000 a year for the five-times-a-week treatment recommended by Freud. As a concession to economic reality, most American psychoanalysts see patients only once or twice a week, and some have begun to stress even more limited short-term therapy to cut expenses further. One sign of the times: Freudian Judd Marmor, a former president of the American Psychiatric Association, now recommends treatment limited to 20 or 30 sessions, with analysts abandoning their passive role to confront patients more and speed recovery. Marmor points out that even Freud complained that some psychoanalyses seemed interminable and made the patient emotionally dependent on the analyst. "A Cadillac may be a very fine car to drive," he says, "but it would be uneconomical to say we're dedicated to buying Cadillacs for every person in our society."

Shervert Frazier, a Harvard Medical School professor and psychiatrist in chief at McLean Hospital in Belmont, Mass., reports that no patients are psychoanalyzed at his hospital. Frazier, himself "a card-carrying psychoanalyst," sees his own patients for only as long or short a time as he deems necessary, some for as little as 15 minutes, others for 2 1/2 hours. Months may go by between visits, he says, but "when we see each other, these people really go to work."

That sort of dilution of the Freudian creed is already far advanced, and some critics predict that classical psychoanalysis will soon be extinct. The 1976 survey by the American Psychoanalytic Association showed that 70% of its members' patients were already receiving some kind of therapy other than psychoanalysis. Since there is no agreement on what works, Freudians--along with neo-Freudians, psychologists, counselors and Pop therapists--are all increasingly eclectic, borrowing bits and pieces of one another's methods. Even at hospitals still dominated by Freudian theory, psychiatric residents now get far more training in neurology, biochemistry, hypnosis and behavior modification than in such traditional gospel as the interpretation of dreams.

This scientific smorgasbord may indicate great creative ferment, or simply confusion, a hedging of bets against what will turn out to be the hot therapy of the 1980s. Psychiatry seems sure of one thing: it does not want to move in the direction of the pseudo therapies, although it occasionally profits from them. Says Miami Psychiatrist Paul Daruna: "Some Pop therapies generate business by stirring people up, jostling them about so they eventually turn to individual therapy." Still, many psychiatrists already feel underemployed, because they often fill many of the same functions as psychiatric social workers, nurses and related professionals. Not that these professionals do not perform valuable services for the mentally troubled; but none of them must endure four years of medical school or long residency in psychiatric wards.

In fact, during the 1960s and early '70s, many psychiatrists put some distance between themselves and organized medicine, identifying more with psychologists, sociologists and other social scientists than with their fellow doctors. Indeed psychiatry seemed almost ashamed of its medical origins, preferring to see itself as a softer, almost humanistic discipline. Along with this greening of psychiatry, the myth developed that it might be able to cure such serious social illnesses as drug abuse, delinquency and crime. Many psychiatrists even wondered why specialists of the human mind had to go to medical school at all. But all that has changed; now the catch phrase is, "Getting back to our roots in medicine."

At least one reason for such a move is an effort by psychiatry to retrieve its cloak of medical respectability at a time when the public is confusing it with charlatan therapies. Psychiatrists also are becoming more hard-nosed. They are increasingly convinced that their profession may not have the answers to profound political and social problems, and should perhaps restrict itself to getting measurable results with the truly sick. One current refrain: psychiatrists should become good team players, assisting other medical specialists in fulfilling their obligations to the sick. Many hospitals now have psychiatrists available for consultation on every kind of problem faced by doctors and their patients. Says Psychiatrist Daniel Asimus of Pasadena, Calif.: "Now is the time for us to train psychiatrists to be medically oriented, helping more people, not by direct therapy most of the time, but by assisting, consulting and advising the other professions."

By donning the medical waistcoat again, psychiatry also hopes to shed what Asimus calls its "freaky" image. As he explains it, even doctors have traditionally regarded their psychiatric colleagues as "a strange breed of people" who picked the specialty to work out their own hang-ups as much as those of their patients. Public misconceptions about psychiatry are still worse, including the cartoonist's idea that almost all psychiatry, rather than just traditional analysis, is done on a couch. For years psychiatrists have also been regarded as medicine's robber barons. In fact, as medical specialists go, they rank relatively low on the pay scale (average annual income: $47,565), far behind surgeons, $73,245, and only slightly above GPs $47,438.

More rankling still is the recent perception of male psychiatrists as sexual exploiters of their women patients. Though such behavior is clearly a violation of the Freudian ethic, which forbids any social contact between patient and doctor, to say nothing of the Hippocratic oath, there is clearly some fire behind the smoke. In Florida alone, nine psychiatrists last year were charged with sexual misconduct during therapy; in a recent poll of 500 psychiatrists, a medical journal found that a surprising 19% said that they approved of doctor-patient sex under some circumstances. The intimate relationships in therapy obviously make both patient and doctor more sexually vulnerable than in other professional relationships, but such deplorable indiscretions are found in all branches of medicine.

If psychiatry is trying to change its slightly tarnished image, it is also changing its attitudes. One of its favorite projects of the 1960s was the community mental-health movement. That plan to bring psychiatric services to the deprived went hand in hand with a consensus among psychiatrists that state hospitals should be emptied of all but the most intractable and dangerous hard-core patients. The hospitals were jammed and poorly funded in most states. The idea was compelling: since psychiatric hospitals could presumably do little more than store patients, those who responded to the new antipsychotic medication could be released to their families and treated as outpatients. Under the Community Mental Health Center Act of 1963, 647 local centers have been set up to treat such "deinstitutionalized" patients, and also to bring low-cost care to the rest of the public, particularly the poor.

While the scheme had successful aspects, it also brought new problems. Says Robert Michels: "Thirty years ago, 75% of all psychiatric treatment was conducted in hospitals. Today, 75% takes place in an outpatient setting. That's progress." Still psychiatric patients fill 40% of all hospital beds in the nation, and the number of mental patients in nursing homes, prisons and single-room occupancy residences is up. Says Payne Whitney's John Talbott: "We've merely shifted the mentally ill population, not decreased it."

Instead of emptying out, state hospitals are just as crowded--but with a higher percentage of untreatable patients. Many of these hapless people, in addition to their mental problems, are poor, infirm or alone and without any basic social skills to survive in the outside world. The drive to empty the hospitals may have gone as far as it can go. The readmission rate is up from 25% in 1960 to more than 65% today, which may indicate that too many have been released. As many as half of those discharged are now living alone, without the family support that psychiatrists think is essential for them to function. Says Talbott: "These poor patients are disorganized. They can't handle the bureaucracy. They just can't cope."

Sadly, many of them are now reduced to roaming the streets, annoying and frightening the citizenry. Some communities, even such liberal ones as Manhattan's Upper West Side, which has been flooded by thousands of deinstitutionalized patients, are beginning to cry out in anger. Says Manhattan Councilman An-.onio Olivieri, a liberal reformer: "The indiscriminate dumping of mental patients is creating new psychiatric ghettos in the cites. The policy is absurd." Psychiatrists are starting to share his concern. They fear that the increasing number of schizophrenics and other psychotics on the loose, particularly in the cities, may yet develop into an explosive political issue.

The community mental-health centers have their own headaches. Funding is short, and the goal of low-cost care is proving illusory. According to various estimates, each patient visit costs between $35 and $40, more than in private practice, for treatment that is generally of lower quality. Says Alan Stone, professor of law and psychiatry at Harvard: "Taking care of people well cannot be done in a less expensive way than just warehousing them, which was what we were doing before."

Meanwhile, the level of care at the state hospitals is getting worse. As storage centers for the hopeless, the hospitals are easy targets for cost-cutting state legislatures. Also, fewer first-rate psychiatrists want to work where the possibility of cures is so remote. Foreign psychiatrists, some of them unlicensed, have flocked to these institutions. Many, to be sure, do extremely competent work. Spanish-speaking doctors, for example, have been able to provide better levels of care for Hispanic patients. Nonetheless, the overall quality of these foreign doctors has raised a clamor for legislation by Congress that would stop the influx of poorly trained aliens. If it passes, the state institutions may be left with fewer psychiatrists of any kind. That could be calamitous; for even with these foreign-trained doctors, officials estimate that the nation will be short 9,000 psychiatrists by 1980. Right now there are 3,200 unfilled jobs for psychiatrists at the state hospitals.

In a modern version of the 19th century reform movement that broke up the old bedlams, the state hospitals are now under attack from groups formed to defend the rights of mental patients, among them the California Parents of Adult Schizophrenics and the Advocates for the Adult Mentally Ill in Seattle. Such groups have filed class-action suits charging that the hospitals are little more than snake pits. Lawyer Robert Plotkin of the privately funded Mental Health Law Project in Washington, D.C., says that conditions in the hospitals are "universally shocking," with inadequately trained doctors prescribing drugs that they know about only through drug-company leaflets.

Like many others in the reform movement, Plotkin thinks patients should not be medicated, restrained or even touched without their consent--unless the courts appoint a guardian to protect the patient from his doctor. Psychiatrists do not look with favor upon a Miranda-type situation that would involve reading deranged patients their rights before throwing them into a straitjacket. Warns Harvard Psychiatrist Alvin Poussaint: "If a patient refuses medication and is violent and tearing up the place, you may be subject to a lawsuit if you medicate him properly, or even if you restrain him by putting him in a room alone. What do you do?" More optimistically, other psychiatrists think the gains won by the patients' rights movement will force the states to pump badly needed money into their mental hospitals. Says Miles Shore, superintendent of Boston's Massachusetts Mental Health Center: "The standard of care enforced by the courts is one of the few defenses we have against Proposition 13."

The most common complaint of psychiatry is that it is expected to do more and more with less and less. According to various estimates there are 4 million Americans who are afflicted by serious mental illness, and many of them are getting no treatment at all. Indeed psychiatrists have every reason to sound depressingly plaintive. "We need more money, and we're simply not getting it," says Talbott. "Every other disease--cancer, kidney disease, hypertension--has a constituency. But the chronically mentally ill have no constituency. Everybody would just like them to disappear, their families, the press, even the medical profession."

Confronted by such overwhelming burdens, psychiatrists often dream of an easy way out: the miracle cure, a cheap drug or chemical for every mental illness that ever plagued man. So far there has been no clear breakthrough, although the prospects are improving. Doctors are finding great success in the use of lithium for control, if not cure, of manic-depression, the classic disorder of wild mood swings from mind-racing euphoria to deep despair.

Still, drug therapy has been essentially a holding action to stabilize the troubled. Tranquilizers such as Valium and Librium are good at reducing anxiety and tension, but they may interfere with thinking and can become habit-forming. The antidepressants, called tricyclics, are increasingly effective, but also can have adverse side effects. The stronger antipsychotic drugs like Thorazine are useful for handling schizophrenics, whose behavior is characterized by hallucinations and severely disordered thinking, as well as other forms of severe mental disorder. But while these chemicals produce a rapid return to normal, or at least socially acceptable behavior, in some patients, they also act as chemical restraints: they calm the schizophrenic but often turn him into little more than a zombie in the process. As Psychologist Steven Matthysse of the Mailman Research Center explains, while agitation and disordered thought diminish in the drugged patient, the drugs do very little to move the patient toward recovery or to help him relate to other people. Says Matthysse: "It's a sad thing, but a schizophrenic [on drugs] is very rarely motivated to do anything really consequential."

Though available drugs are still crude, pioneer work in brain research may lead to some astonishing new ones. A crucial discovery came when researchers located what are known as the brain's opiate receptors. These are the specific sites in the brain and spinal cord where such drugs as opium and morphine act. These and other recent discoveries open up the possibility of aiming artificial drugs at specific receptors, and perhaps duplicating the body's natural internal "drugs" that help keep normal people normal. Says Solomon Snyder, a psychiatrist and pharmacologist at Johns Hopkins University: "As a result of psychopharmacology, psychiatry has come from behind the other medical sciences to a position of leadership. We've got a whole new psychiatry."

Much of this new psychiatry centers on schizophrenia, the most disabling and puzzling of mental illnesses. There are dozens of contending theories to explain it. The leading behavioral one derives from Anthropologist Gregory Bateson's concept of the double bind, which holds that schizophrenia arises from a prolonged dose of conflicting instructions, as, say, when a mother tells a child not to eat sweets, yet is constantly rewarding it with candy. But studies of identical twins and adopted children by Biochemist Seymour Kety strongly suggest a genetic base for schizophrenia. According to Kety, the flaw, contained in the cells' DNA, the master genetic molecules, may possibly be transmitted by viruses. In any case, the new pharmacological researchers no longer regard schizophrenia as a single ailment but, like cancer, as a collection of different malfunctions. In schizophrenia, the common denominator is the brain, and many scientists are convinced that a neurotransmitter, or chemical brain-signal carrier, called dopamine is the prime culprit.

Researchers know that excessive doses of mood-elevating amphetamines, which greatly increase the amount of dopamine in the brain, can bring on psychotic symptoms identical to those of schizophrenia. Recent studies also have indicated that schizophrenics have 50% more dopamine in their brains than non-schizophrenics, and twice the number of dopamine receptors, the sites where the chemical locks into the central nervous system. One line of thinking is that some people are born with high dopamine levels, but that somehow an "environmental trigger," perhaps some life crisis, sets the stage for schizophrenia. But a growing opinion is that the sickness is entirely chemical. Says Matthysse: "I'd be surprised if family environment made the slightest difference."

The new breed of psychiatric researchers are also beginning to suspect the same thing about depression, the most common of mental complaints. Simple depression or temporary gloom, to be sure, may be a normal response to some unhappy experience in everyday life. But the enduring pathological kind of depression may well be entirely neurochemical. Says Wyeth Labs Psychopharmacologist Larry Stein: "The normal brain is damned adaptive. It may undergo a short-term depression when things are going bad, but it bounces back when things go well again." The serious depressive, on the other hand, he says, may be "suffering from the biology of his 'good-feeling machinery.' "

For those who fear that the new researchers are out to reduce all human emotions and problems to chemistry's atoms and molecules, Dr. Frederick K. Goodwin, chief of clinical psychobiology at the National Institute of Mental Health, has a tranquilizing message: "There is a chemistry of the human brain, but it acts in response to the environment." Goodwin also points out gently that brain research has not yet produced any new treatments for mental disease. In fact, the only early result expected from the research is agreement of existing antipsychotic and antidepressant drugs to eliminate side effects. Ross Baldessarini, a psychiatrist and biochemist at the Mailman Research Center, warns that chemical cures can easily be oversold, like psychoanalysis and community psychiatry. Says he: "We are not going to find the causes and cures of mental illness in the foreseeable future."

Nevertheless, the research has been impressive enough to start a rush in the direction of psychopharmacology. People with titles like biochemist, psychobiologist, neurophysiologist and psychopharmacologist are attracting scarce federal funds and replacing traditional psychiatrists as chairmen of hospital psychiatry departments. The field offers what psychiatry seems to have been yearning for all through the 1970s: scientific expertise, medical underpinnings and an escape from the troublesome subjectivity of the human mind.

"We will learn to think of ourselves, our personalities, as an orchestra of chemical voices in our heads," predicts Arnold Mandell, professor of psychiatry at the University of California at San Diego. "Psychiatry will become the most scientifically precise of medical specialties, relying not at all on subjective judgment." Jack Barchas, professor of psychopharmacology at Stanford, thinks the current exploits of his field are on a par with Einstein's revolutionary formulation E = mc^2. Says he: "The discovery of the neuroregulators may prove as important to humanity as that equation. We are on the edge of a new era." Also a Brave New World of mind-controlling drugs. Before long, according to some researchers, it will be possible to inject or extract chemicals to get almost any desired behavior, good or ill.

Undoubtedly, these rapidly opening biochemical avenues will place awesome powers in the hands of psychiatrists. The prospective drugs of the future could, of course, be used to create a Huxleian nightmare. But, in capable hands and under public scrutiny, they need not. At the very least, the drugs may give psychiatry the bold new tools that will enable it to shake off its own current depression and fulfill the high hopes that Freud and his followers correctly held out for it.

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