Psychiatry

Sigmund Freud introduced psychoanalysis into the United States in 1909 through his lectures at Clark University in Worcester, Massachusetts. By the 1940s, psychoanalysis and its proponents were having a powerful, controversial impact on American psychiatry. "Dynamic" therapies, such as psychoanalysis, focused on changing patients' motivations rather than on altering their cognitions or behavior. By the 1940s, dynamic therapies were prestigious and were greatly enhanced by the emigration to the United States of prominent German psychoanalysts fleeing Hitler. Dynamic therapies were treatments of choice for those who could afford them, but early on the medical tie between psychoanalysis and psychiatry was determined by James Jackson Putnam (1846–1918), the founder of psychoanalysis in the United States. Putnam was in disagreement with Freud over the necessity that psychoanalysis have a medical base. Although psychiatry emerged as a branch medicine in the first half of the nineteenth century in the Western world, the United States remains the only country in the world to require medical training for the practice of psychoanalysis—in countries other than the United States, one can be a psychoanalyst without medical training, without being a psychiatrist. Although the beginnings of psychosomatic medicine are attributed to the German physician Johann Christian August Heinroth (1773–1843) in 1818, its roots in America were distinctly psychoanalytic and psychodynamic (Scully, et al 2000, p. 136).

One of the first tasks given to psychiatry was to classify mental disorders. Psychiatry began to be applied to those living outside institutions, as well as to those in hospitals, workhouses, and sanitariums. In Great Britain, psychiatry applied specifically to medicine, while in its earliest manifestations in North America it covered the work of other mental health professionals such as clinical psychologists and social workers.

Psychiatry developed in the 1920s and 1930s in the Unites States as a practice characterized by the use of electroshock treatments and frontal lobotomies for those people kept in mental hospitals. Only in the 1940s and 1950s would antipsychotic drugs such as Thorazine begin to be used in treatment of the severely mentally ill. Indeed, in the decades since, psychiatry has evolved as a pharmacological and biological set of treatments for distressed individuals. Even in the twenty-first century, psychiatrists still use electroconvulsive therapy as a last resort for those in extreme distress. The basis for deciding what treatment to pursue followed the social and historical contingencies of science. As a science, psychiatry privileged the most immediately effective treatment methods, comparing a patient's behavior before and after treatment. Women in particular were treated by surgeries in which their ovaries or breasts were removed to cure "neurotic" diseases. It was thought that such surgical treatments could cure patients via the sympathetic arc syndrome (Shorter 1992).

The history of psychiatry's development is, however, often difficult to trace. Elliot Valenstein's Great and Desperate Cures is perhaps the most extensive publicized account of twentieth century biological therapies. Indeed, the early sparse history of psychiatry is told more through medical records than through literature on the subject. To quote Michel Foucault, "The new methods of power [were] not ensured by right but by technique, not by law but by normalization, not by punishment but by control" (1979, p. 9). Hydrotherapy, electroshock therapy, and lobotomy were all practices approved by contemporary science. So disturbing were the treatments of the early twentieth century that the 1960s and 1970s saw the beginning of antipsychiatric movements.

"Psychiatric Education after World War II" cites the power and omnipresence in clinical practice of psychoanalysis up through the 1950s (Scully et al. 2000). In 1951, a conference was held at Cornell University to focus on the role of psychiatry in medical education. While the medical knowledge required was neuroanatomy, neuropsychology, and neuropathology, the "new" science of psychiatry was based on psychodynamics. The thrust was to correctly diagnose patients, to differentiate between normal, neurotic, psychopathic, psychotic, and intellectually defective behavior (Scully et al 2000). Since World War II, a great number of changes have occurred in psychiatry. There has been a great effort to increase the number of psychiatric training programs focusing on neuroanatomy and neuropathology. Still, psychoanalytic theory and practice were seen as the highest goal to be obtained. Most departmental heads of psychiatry departments remained psychoanalysts.

By the late 1970s, however, a reaction against psychoanalysis occurred. Schisms developed in departments between those oriented toward brain and those oriented toward mind. The 1990s were marked by the increased use of medical treatments for mental illness; mental asylums and hospitals themselves were largely abolished in the 1960s and 1970s due to cost efficiency concerns (Ragland-Sullivan 1989). At the beginning of the twenty-first century, many of the severely mentally ill end up in the prison system.

In the 1990s the role of the psychiatrist became less clear so far as managed care programs took over much of the practice previously overseen by psychiatrists. Managed care chose the psychiatrist to be used and specified only a few sessions that would be paid for. Indeed, medical insurance tended to cover only care by psychiatrists—not psychologists or social workers—and only for short-term treatment. Although psychoanalysis always tried to close the gap between psyche and soma (mind and body), the swing of the pendulum toward psychiatry as a specialty differentiated it from the rest of medicine and constantly risked obscuring its foundation, psychoanalysis (Ragland-Sullivan 1988).

The contemporary orientation of psychiatry derived from World War II, the effect of which was to bring medicine and psychiatry ever closer (Lipsett 2000). Indeed, one cannot study psychiatry as practiced in the United States in the twenty-first century without reference to its key manual, the Diagnostic and Statistical Manual of Mental Disorders. The disorders listed in the manual have become reality paradigms and inform medical and pharmaceutical recommendations for cure. Yet, cure does not seem to be the goal of the DSM system, but rather continued maintenance of stable behavior via medication. Insofar as the DSM, like the empirical scientific method on which it relies, opposes variables of behavior (its positive data) to a control (some concept of a correct or normal reality to attain), it is far from psychoanalyst Jacques Lacan's (1901–1981) theory that scientific proof itself depends upon the function of exceptionality as structurally necessary to explain a phenomenon after the fact (Ragland 2007). Although psychiatry from its beginnings argued that mental disease was an illness of the nerves (Shorter 1992), Freud's revolutionary find rested on the discovery that symptoms of psychic suffering could be made to disappear, or transform themselves into "better" symptoms, upon treatment by talking.

The history of the Diagnostic and Statistical Manual as created by the American Psychiatric Association reflects the practice of psychiatry itself. The manuals started as a census-taking venture in search of families whose military members could not be found, but to whom compensation was owed. The DSM evolved slowly as a manual that listed "disorders," defined in relation to no particular theory. Rather, the first three manuals were eclectic, even apologetically so. Freudian diagnostic categories, such as obsession and hysteria, remained intact in the first three manuals, alongside object relations theories and various kinds of psychotherapies. But with the DSM-III-R (1987), the manual became more aggressive and began to call the myriad disorders cited as themselves the "disease" at issue. The DSM goes from the paralysis cited as characteristic of hysterics in the nineteenth century to the "chronic fatigue syndrome" of contemporary medicine (Shorter 1992).

Changing his depiction of psychiatry in Blaming the Brain: The Truth about Drugs and Mental Health (1998), Valenstein says that the DSM-II and the World Health Organizations's International Classification of Diseases, eighth edition (ICD-8) "were both published in 1968, but it wasn't long before these manuals were widely criticized. The criteria were found to be ambiguous, and several studies made it clear that diagnostic labels were often being used arbitrarily. The criteria for diagnosing schizophrenia, for example, varied between institutions and between countries" (1998, p. 157).

The ICD-10 manual was published in 1992, and the DSM-IV manual in 1994. Valenstein goes on to say that:

All of the diagnostic and statistical manuals have been atheoretical and basically descriptive in nature. The authors were frank to admit that the cause of mental disorders, except for those involving obvious brain damage, were not known…. The large group of specialized consultants working on the later DSM editions split different symptoms into distinct disorders, which often simply reflected the specialized interests of the consultants, rather than any compelling scientific rationale."

                                  (1998, p. 158)

In the DSM, paradigms of disorders to be treated by psychiatry have become medical and pharmaceutical descriptions of behaviors, without addressing the meaning of the symptoms. The point of the medical method of treatment does not, indeed, focus on cure, but on controlling disorders rather than treating their causes. For example, the DSM describes pedophilia as involving sexual activity with a prepubescent child, generally thirteen years or younger. The pedophile will be sixteen years or older and at least five years older than the child. There are exclusive types of pedophiles who are attracted to only one type of child. The nonexclusive type can sometimes be attracted to adults. They believe that the child derives sexual pleasure from them, or that the child is sexually provocative to them. These themes are popular in their pornography as well. Children may be in their own family or outside it. Except for those engaged in sadism, pedophiles usually care about the child's needs to assure his or her affection. This DSM description is, then, reduced to diagnostic criteria that merely restate the description given, but in an outline form (DSM-IV, pp. 527-528). The DSM IV-TR does reference fantasies.

The DSM discusses female sexual arousal disorder in two pages, describing it in relation to its onset—lifelong versus acquired. This disorder is, in brief, "a persistent or recurrent inability to attain, or to maintain until completion of the sexual activity, an adequate lubrication-swelling response of sexual excitement." It is not only a medical condition, but an interpersonal dysfunction (DSM-IV, p. 500). Hysteria, which was treated in long sections in earlier manuals, has become in the DSM-IV three pages analyzing histrionic personality disorder, which is crossed diagnostically with borderline, antisocial, narcissistic, and dependent personality disorders (pp. 655-658).

Because these categories of disorder are not treated as symptoms, the DSM implies that no meaning causes a given disorder, and, thus, cannot be found in order to unravel the symptom and the suffering caused by it. Psychiatry, thus, increasingly treats and allays symptoms, instead of addressing their causes. To speak of a symptom as a psychoanalyst instead of a psychiatrist implies that meaning functions via displacement and substitution.

Lacan, a medical doctor and psychiatrist who practiced psychoanalysis, criticizes the logical positivism lying at the base of DSM concepts of disorder. Logical positivism seeks to elaborate and classify knowledge based on positive facts available to the conscious mind and observable in behavior. Gone is the unconscious or unconscious desire as the cause of a symptom that might be unraveled through the language and identifications that produced the symptom in the first place, thus alienating a person in language and by the separations or cuts that make humans lacking, less than whole. Insofar as logical positivism lies at the base of conscious knowledge and of the practice of psychiatry, it provides an inadequate framework for qualifying or quantifying mental health or any other attribution of meaning whose proof lies outside the obvious.

Insofar as suffering from sexuality lies at the traumatic base of human suffering—itself a difficult thing to assume for anyone—one will not be enlightened by the DSM, which describes "mental disorder": "no definition adequately specifies precise boundaries for the concept 'mental disorder … nevertheless, it is useful to present a definition of mental disorder that has influenced the decision to include certain conditions … as mental disorders and to exclude others" (DSM-IV, p. xxii). Each mental disorder is, then, described as a "clinically significant behavioral or psychological syndrome or pattern … associated with present distress … or disability…. There is no assumption that each mental disorder is a discrete entity with sharp boundaries (discontinuities) between it and other mental disorders, or between it and no mental disorder" (p. xxii).

Not all psychiatrists have been happy with these new medicalized guidelines of the DSM system. Indeed, Don R. Lipsett argues in "Psyche and Soma: Struggles to Close the Gap," that the respect for the individualistic nature of each patient is abandoned "for the sake of not merely rapprochement with medicine, but perhaps even absorption into medicine" (2000, pp. 179-180). Further, Lipsett argues that although the efforts of many neuroscientists and psychopharmacologists have shed much light on the multiplicity of ways in which the brain functions and potentially connects with the mind, we are reminded that any conceptualizing that veers too much toward the brain runs the risk of evolving into a "mindless" psychiatry.

The authors of the DSM-III declare that their language does not classify persons, only disorders. By changing the language of the DSM-III, which still used adjectives such as "schizophrenic," the DSM-III-R describes, rather, "a person with schizophrenia." The authors have subterraneously shifted the theoretical bias of the 1980 Manual, which still equated a person with his or her kind of suffering, to delineate the person as separate from that which causes his or her suffering. In the earlier formulation, the person is not a suffering being, but is a disorder. In this change of language from that used in the 1980 DSM-III, the American Psychiatric Association has changed the assumptions about symptoms by gradually exchanging the concept of "mental disorder" for a concept of physical disorder.

Although psychiatry has become increasingly concerned with gender, including the treatment of homosexuals and lesbians as nonpathological orientations to sexuality, there is no mention of homosexuality or heterosexuality in the DSM-IV, although it mentions gender disorder and lists several medical dysfunctions under "sexual dysfunctions."

The medically based American Psychiatric Association has imputed a largely biological set of causalities to psychological symptoms. This reflects the American Psychiatric Association's long and gradual swing towards more biological, empirical, and medicalized disorder categories. For example, in 1918 the Statistical Manual for the Use of Institutions for the Insane had twenty-two categories of disorders, twenty of them disorders with organic causes. Because nomenclatures used in 1918 no longer applied to the patients being seen who were not veterans, the American Psychiatric Association came up with its new system of nomenclature in DSM-I, published in 1952. Many psychiatrists regard the DSM as a great advance over the early statistical manual, especially in so far as the word organic is not used. Ensuing editions of the DSM continued to revise categories and nomenclature, a revision process that has been conservative and driven by empirical research. Removing categories was shunned in favor of adding categories. The issue of what might constitute a category is as large as the question of what empirical itself means.

This version of American psychiatry is a world apart from Lacanian psychiatry, wherein psychoanalysis works with the subject as desiring, as lacking at the point of desire that first alienated him into the language of the Other, and separated him from partial Ur-objects-cause-of-desire. Here desire is the inverse face of a lack-in-being because the first social desire is to please the other; desire is not only structurally based on lack, but is also creative of alienation into someone else's desire. Lacan's challenge to the DSM system is radical and total. He argues that trauma lies in assuming an alienated identity in the first place, one in which the taking on of identity as sexuated is at stake. He argues that the cause of dis-order is the cause of suffering itself, which comes from an alienated desire that we take on as our own unconscious language, unconscious language being concrete language that functions as the major tropes of language—metaphor (substitution) and metonymy (displacement). Not only do we suffer from living out someone else's desire, we suffer from the losses that form the subject as itself divided between being and having, between unconscious knowledge and conscious perceptions. The differential categories Lacan evolves are a return to Freud, albeit a radical rereading of Freud. The DSM-III claims that "for most of the … disorders … the etiology is unknown. Many theories have been advanced and buttressed by evidence … attempting to explain how these disorders come about. The approach taken in the DSM-III-R is atheoretical," say the authors (DSM-III-R, p. xxiii).

Instead of seeing categories of disorders as listed in the DSM, Lacan taught that the taking on of sexuality as identity involves a trauma regarding being divided from the mother, who is the first Other to both sexes. In learning difference one from the other, each boy and girl is "castrated" or found lacking in terms of being a whole self. This search for completion is a structure that compels humans to search and suffer throughout their lives. This is directly opposite from the DSM's lack of a theory of cause. Depending on how one takes on sexual difference, the Lacanian clinic posits four differential categories: the normative masquerade, the psychoses (paranoia, schizophrenia, manic-depression), the perversions (sadism and masochism), and the neuroses (hysteria and obsession). Each one is tallied by an individual's response to sexual difference that is not gender based, but based on an interpretation of a given masculine or feminine that marks their experience with the lack of being whole. The normative person represses the sexual difference; the neurotic denies it; the perverse subject repudiates it; the psychotic forecloses it. Given these broad categories, each subject, then, goes his or her own very particular way in living out his or her sexuation. The order of the particular is Lacan's fourth category of knowledge, the other three being the real (trauma and sexuality), the symbolic (language and culture), and the imaginary (identifications and narcissism). The fourth is the symptom or sinthome. This order is that of the Oedipal paternal metaphor, rewritten since Freud, to include one's interpretation of the mother's unconscious desire vis-à-vis the Father's name signifier, which is a function that acts as a third term in separating the early mother-infant symbiosis, not a person per se. Thus, cognitive or undifferentiated somataform disorders are not at issue, but the unconscious formations of an Ideal ego, of a fundamental fantasy, of loss at the start of being, of desire as interfaced with lack. And sexuality and sexuation lie at the center of being, not some disembodied disorder that is not even labeled as a symptom.

see also Eating Disorders; Krafft-Ebing, Richard; Lacan, Jacques; Pedophilia; Psychoanalysis.

BIBLIOGRAPHY

American Psychiatric Association. 1980. Diagnostic and Statistical Manual of Mental Disorders-III. 3rd edition. Washington, DC: Author.

American Psychiatric Association. 1987. Diagnostic and Statistical Manual of Mental Disorders-III-R. 3rd revised edition. Washington, DC: Author.

American Psychiatric Association. 1994. Diagnostic and Statistical Manual of Mental Disorders-IV. 4th edition. Washington, DC: Author.

Bettleheim, Bruno. 1983. Freud and Man's Soul. New York: Knopf.

Braslow, Joel T. 1997. "Introduction to the Psychiatric Body." In Mental Ills and Bodily Cures: Psychiatric Treatment in the First Half of the Twentieth Century. Berkeley: University of California Press.

Foucault, Michel. 1979. Discipline and Punish: The Birth of the Prison, trans. Alan Sheridan. New York: Vintage Books.

Gregory, Richard L., ed. 1998. The Oxford Companion to the Mind. New York: Oxford University Press.

Lacan, Jacques. 1988. The Seminar. Book 1: Freud's Papers on Technique (1953–1954), ed. Jacques Alain-Miller, trans. John Forrester. Cambridge, UK: Cambridge University Press.

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Ragland-Sullivan, Ellie. 1989. "Attitudes envers la psychanalyse dans les hôpitaux am(ricains d'aujourd'hui," trans. F. Sauvagnat, ed. R. Wartel, R. Broca, F. Sauvagnat, and D. Cremniter in Phénom(nes et structures dans le champs des psychoses. Paris: GRAPP, pp. 183-189.

Ragland, Ellie. 2007. "The Discourse of Science, the Imaginary Axis, and a Concept of the Differential from the Perspective of Lacan's Psychoanalytic Topological Logic." In Proving Lacan: Psychoanalysis and the Evidentiary Force of Disciplinary Knowledge, ed. Ellie Ragland and David Metzger.

Scully, James H, Carolyn B. Robinowitz, and Rand James H. Shore. 2000. "American Psychiatric Education after World War II." In American Psychiatry after World War II: 1944–1994, ed. Roy W. Menninger and John C. Nemiah. Washington, DC: American Psychiatric Press.

Shorter, Edward. 1992. From Paralysis to Fatigue: A History of Psychosomatic Illness in the Modern Era. New York: Free Press.

Valenstein, Elliot S. 1979. Great and Desperate Cures: The Rise and Decline of Psychosurgery and Other Radical Treatments for Mental Illness. New York: Basic Books.

Valenstein, Elliot S. 1998. Blaming the Brain: The Truth about Drugs and Mental Health. New York: Free Press.

                                                Ellie Ragland