1

AN INSECURE PROFESSION

In my second year of residency at San Antonio I trained in psychiatric

consultation, providing assessment and treatment to patients who were
identified as having psychiatric difficulties while hospitalized on other
medical services. Problem-solving has always been what I enjoy most about
my job, and the identification and resolution of issues on the consultation
service challenged me to develop a variety of skills that were not necessarily
employed in individual treatment.
At the beginning of the rotation the director of the service, Dr. David
Fuller, taught us that consultations often arose from the complaints of the
medical treatment team rather than from the patient. For example, the
psychiatrist might be consulted to assess a patient for aberrant behavior, but
eventually find that the appropriate intervention was to provide direction and
reassurance to the nursing staff in dealing with a patient who just happened
to have a particularly nasty disposition. Another consultation might require
the psychiatrist to provide counseling to a particularly intrusive family
member who was interfering with treatment. Because the initial consultation
request might be misleading, Dr. Fuller encouraged us to keep an open mind
regarding the motivation behind the consultation, reminding us that we were
being asked to intervene because somebody had a problem and needed our
help—it just might not be the patient. His contention was that “There is no
such thing as an inappropriate consult”—a maxim that is not entirely true, but
nonetheless useful in promoting the maintenance of a positive and helpful
attitude for nearly all situations.
My enthusiasm for the work apparently gained me some consideration,
and I developed a collegial relationship with some of the non-psychiatric

©Paul Minot 2011

 2

physicians. In the course of friendly conversation one revealed to me that

psychiatrists were commonly referred to as “spooks”—as in, “That patient’s
weird. Let’s get a spook to look at him.” I was more amused than upset, but
immediately knew that it wasn’t at all meant to convey respect for my
specialty. On reflection it may have referenced the detachment from “real
medicine” that psychiatrists frequently displayed at the time (around 1983,
when the biological model was just taking root); their tendency to appear and
disappear on the medical units with little interdisciplinary communication;
and/or their myriad personal eccentricities (since psychiatrists are generally
quirkier than other doctors). It may have even hinted at some implicit
hostility toward psychiatric patients, whose behavioral foibles and self-
destructive tendencies were not suffered easily by other physicians. At any
rate, it brought home the fact that within the medical community there were
many different types of doctors—and then there were psychiatrists.
Psychiatry’s rash embrace of the biological model in the years since then
has generally been attributed to the considerable financial influence of the
pharmaceutical industry. Certainly this was a driving force, as it’s unlikely
that so many psychiatrists would have changed their clinical thought and
practice if there wasn’t a lot of money at stake. But another contributing
consideration was psychiatry’s abiding status as the red-headed stepchild of
medical specialties, struggling for a secure sense of its professional identity in
the midst of “real doctors” who are dealing with more tangible clinical
problems.
Time and again psychiatry has responded to this deficit by hitching its
wagon to half-baked theories, capriciously overreaching its scientific grasp in
a desperate attempt to validate both its treatment philosophy du jour, and its
right to stand shoulder to shoulder with other medical specialties. This

©Paul Minot 2011

 3

inconstancy is evident from even a cursory review of its history—but the effort
required to get at that history is itself confirmatory of psychiatry’s low self-
esteem. When I was in residency a fair amount of the curriculum was
devoted to the discoveries and theories of past luminaries, particularly those
of the psychoanalytic movement. Now that the recent swing to the biological
model has made those figures largely irrelevant, the history of psychiatry has
been banished for the most part to arcane corners of academic medicine—or
seized upon by its critics in the antipsychiatry movement, who revel in the
follies that have been perpetrated over the years in the guise of treating
mental illness.
The challenge of producing an authoritative and politically neutral
history of psychiatry has even merited its own book, a scholarly collection of
essays entitled Discovering the History of Psychiatry (Oxford University
Press, 1994). In its introductory chapter, editors Roy Porter and Mark Micale
observe that “in no branch of history of science or medicine has there been
less interpretive consensus.” They go on to state:

From its earliest days, psychiatric medicine has been marked by

the persistence of competing, if not bitterly opposing, schools.
Most noticeably, the field since the eighteenth century has been
convulsed by a deep, dichotomous debate between the somatic
and mentalist philosophies of mind…. Moreover, for professional
purposes, each generation of practitioners has written a history
that highlights those past ideas and practices that anticipate its
own formation and consigns to marginal status competing ideas
and their heritages. In this process, individual figures and texts—
indeed, entire historical periods and bodies of knowledge—have at

©Paul Minot 2011

 4

times been omitted from the historical record. With an intensely

subjective subject matter, complex multidisciplinary origins, and
insecure and shifting epistemological base, porous disciplinary
boundaries, and a sectarian and dialectical dynamic of
development, it has thus far proved impossible to produce
anything like an enduring, comprehensive, authoritative history of
psychiatry.

The selective suppression of history that is noted here by the authors

smacks of an Orwellian design to reinforce the current “truth” and consign
dissent (and dissenters) to oblivion. However, I doubt that its real purpose is
to restrain consideration of psychoanalytic theory, since it seems unlikely that
advocates of the biological model would feel at all imperiled nowadays. (After
all, they have Prozac and managed care on their side; the analysts don’t.)
Rather I believe that contemporary psychiatrists are embarrassed by the
theories that once held sway in psychiatry—and threatened by the larger
questions they raise about the durability of “truth” in our line of work.
So what exactly is it that psychiatrists are trying to hide? Well,
fortunately there is at least one comprehensive (yet readable) overview
available—A History of Psychiatry: From the Era of the Asylum to the Age of
Prozac (Wiley, 1997), by noted medical historian Edward Shorter—and I have
cribbed from it shamelessly. Mr. Shorter does a good job of recounting the
many twists and turns taken by psychiatry over the centuries, and I highly
recommend the book to anyone who needs more thorough documentation of
just how undisciplined this alleged discipline has been in the past.
But before we begin to ponder psychiatry’s many sins against science,
let’s first consider the peculiar challenges it faces as a medical specialty. Its

©Paul Minot 2011

 5

main anatomical focus is the brain—an organ entirely encased in bone.

Underneath the bone are layers of fibrous tissue and fluid that cushion the
brain, all of which are vulnerable to infection if intruded upon. The brain
itself is a fabulously complex array of about a hundred billion nerve cells
(neurons), each with numerous junctions connecting it to its neighboring
cells. Cells communicate between each other across these nerve junctions
(synapses) through the secretion of chemical messengers known as
neurotransmitters. There are over 100 different neurotransmitter agents
identified in the human brain, each of which may have either an excitatory or
inhibitory effect on the postsynaptic cell depending on what kind of receptor
protein it contacts in the cell membrane. The location of this intercellular
communication is in the synaptic cleft, the microscopic space within the
junction which is crossed by the neurotransmitter, where the balance of
neurotransmitters is constantly adjusted by the two cells through the
processes of release, metabolism, and reuptake—which in turn are regulated
by an elaborate feedback network incorporating input from other neurons as
well. In short the raw circuitry of the brain is microscopic, profuse, and
unimaginably complex.
The physiological tasks of brain cells are largely determined by their
location within the brain—and the higher functions associated with thoughts
and feelings are particularly inscrutable, since they occur within a
microscopic assemblage of neurons acting in a meticulously coordinated
fashion. Hence studies of brain cells in vitro (i.e. outside of the body in a
laboratory medium) tell us little about their psychiatric function. This leaves
us with the necessity of studying brain cells in vivo (in the living organism) to
gain an accurate understanding of their function. But doing so would require
passing a needle past the skull and through the surrounding nerve tissue,

©Paul Minot 2011

 6

causing irreparable damage to the brain since neurons have little if any
capacity for regeneration. This makes direct observation of living brain tissue
ethically unacceptable—and even if it wasn’t, how many people would give
informed consent to participate in such a study?
The other medical specialties (besides neurology, of course) focus on
organ systems that are infinitely less complicated than the brain, more
physically accessible, and able to withstand a needle biopsy without
irreparable loss of function. Chemical markers associated with these systems
are typically measurable in the peripheral blood (unlike those of the brain);
other intrusive diagnostic procedures such as endoscopy are available as well.
Access to this sort of information allows physicians to be reasonably certain
what’s going on inside the patient—a feeling with which any prudent
psychiatrist would be dreadfully unfamiliar.
In point of fact, the secrets of the brain constitute a last frontier more
scientifically daunting than astrophysics—which, after all, is just the study of a
bunch of dumb particles that happen to be very far away. Before one even
contemplates its anatomical and physiological complexities, there is the
conundrum of its duality—the brain in the corporeal world, the mind in the
ethereal. Like astrophysics, neuroscience is an area of study that raises
existential and spiritual questions, and provokes the sort of controversies that
are attendant to such concerns. In the realm of medical science the brain
stands out as a uniquely remote wonder, a bottomless enigma that we’ve
barely begun to crack. So let’s just acknowledge beforehand the onerous
scientific challenge that is confronted by psychiatric researchers.
This predicament is aggravated by the likelihood that once a psychiatric
disorder does become treatable, it will be reclassified as a non-psychiatric
disease. In the 19th Century a large proportion of asylum inmates were

©Paul Minot 2011

 7

diagnosed with general paralysis of the insane (GPI)—a psychiatric disease

characterized by manic symptoms or other behavioral problems, followed
thereafter by the onset of dementia and progressive paralysis. It was noted
that this presentation was more frequent in men, especially those with
“debauched” lifestyles. Eventually this problem was identified as
neurosyphilis, an advanced stage of syphilis that takes ten years or more to
manifest itself in infected individuals. Once antibiotic treatments were
developed it became a “medical” illness, and thus no longer the concern of
psychiatrists. Similar paths were followed by epilepsy, the thiamine
deficiency and hepatic encephalopathy associated with alcoholism,
Parkinson’s disease, Huntington’s chorea, and other neurodegenerative
diseases. It would seem that we are in part defined as a specialty by our
ineffectuality—since any disease that can be readily treated becomes someone
else’s responsibility. This sequence of events pretty much dooms us to clinical
failure, which is a pretty darned demoralizing state of affairs. (No wonder we
have a complex!)
Another distinguishing characteristic of psychiatric disorders is that
they typically present with behavioral symptoms—which inevitably drags us
into the murky arena of will. Nearly all patients who go to a non-psychiatric
doctor for a medical complaint are doing so on their own volition, for
symptoms that are unequivocally imposed on them by disease. Relief of these
complaints typically entails the administration of medication, but it may also
call for changes in lifestyle or entry into a rehabilitation regimen, all of which
require motivation and compliance on the part of the patient in order to
ensure efficacy of the treatment. In most cases the complaint that initially
drove him to seek help—pain, fear, or some other sort of discomfort—will
continue to act as an external motivator, prodding the patient to comply

©Paul Minot 2011

 8

despite his resistance. Sure, the patient may refuse to follow through—but
not without persistence of his physical distress, and the knowledge of what he
ought to be doing to relieve it.
The motivation to pursue treatment of a psychiatric disorder is rarely
that simple. At one extreme you have patients who are involuntarily
committed by court order to psychiatric treatment—usually because of
behaviors that are dangerous to the patient or to others (i.e. risk of suicide or
assault), though sometimes due to unmanageable behaviors that are
peculiarly disruptive to society (as I will explore later). Even those who come
into treatment without such a court order may have other extenuating
circumstances coercing them into treatment, such as the demands of a
spouse, job difficulties, or legal concerns (e.g. child custody litigation,
probation, or a recent arrest)—which is often a recipe for treatment failure
due to their lack of earnest investment in the process. Patients who are
internally motivated for treatment are often conflicted, struggling with
feelings of guilt, shame, or fear arising from their need to pursue help, or
perceived dependency on medications. Those seeking help for depression
often succumb to the lack of motivation that is associated with that disorder,
skipping medication doses and/or missing appointments—or have difficulty
making the lifestyle changes (e.g. sobriety, diet, personal hygiene) that would
be beneficial in alleviating their symptoms. Patients struggling with mania
often chafe when confronting the drudgery of reconstructing their lives, and
are tempted to stop their meds so they can fly back into the fantasy world of
their illness. In short, the issue of patient will arises over and over again in
the treatment of psychiatric disorders.
Consequently, psychiatrists regularly struggle to attain the degree of
authority and trust within the clinical relationship that is necessary to

©Paul Minot 2011

 9

motivate treatment compliance—a problem largely unfamiliar to other

medical specialties. In my first year of residency I spent several months in a
neurology rotation under the supervision of a rather cocky senior resident.
Near the end of my rotation I ran into him at a party, where he proceeded to
chide me for going into psychiatry since “in a few years neurologists will be
treating all your patients.” I fired back, “Are you kidding? You guys will
never be able to stand working with patients that don’t do what you tell them
to!” Little did I know at the time the enduring truth implied in that drunken
utterance—that the practice of psychiatry is indeed defined by the patient
management challenges inherent to treating disorders of behavior.
With so much to prove to our patients and peers, and a dearth of
reliable scientific information, psychiatry has time and again compensated for
the deficiency of its knowledge base by simply making shit up. The
unfathomable nature of our calling conveniently lends itself to grand
fabrications—and when patients bring us uneasy questions about what we’re
doing and how it works, almost any answer seems more satisfactory than “I
don’t know”. As a consequence psychiatry has been prone to spasms of
radical reinvention over its history, as one line of pseudoscience is replaced by
another in a desperate attempt to cover up the gaps in our comprehension.
As previously noted, two competing schools of thought—one biological,
the other psychosocial—have struggled for ideological control of psychiatry
since its conception. Always the more covetous of medical legitimacy,
biological proponents have had to vie with the many obstacles that impede
study of the brain, and make do with the limited technical means available to
them. In the 18th and 19th centuries speculation on the cause of psychiatric
disorders was largely focused on anatomy, since most of their information
came from the study of cadavers. The dearth of hard science invited the

©Paul Minot 2011

 10

ruminations of doctors with large egos but limited clinical qualifications—

such as Theodor Meynert, a notable neuropathologist at the Vienna asylum
who had the brass to begin lecturing on psychiatry in 1868, even though he
had no apparent interest in patients, saw little hope in treating them, and by
all accounts preferred the company of microscopes and brain sections.
The resultant theories now seem coarsely simplistic, and often
childishly wrongheaded. In 1755 Oxford graduate Charles Perry described
“hysteric passion” as a common and incapacitating “nervous disorder” among
women that was caused by “errors and defects in our accretions and
secretions”, and boasted that he was able to treat it “with uncommon success
and effect.” Soon afterward French and English psychiatrists were diagnosing
female patients with nervous “vapours” which allegedly arose from the uterus,
and had the power to “derange all the functions of the brain” according to
Joseph Daquin in 1787. By 1812 Benjamin Rush (proclaimed “the father of
American psychiatry” by the American Psychiatric Association in 1975)
affirmed that “the cause of madness is seated in the blood-vessels of the brain,
and it depends on the same kind of morbid and irregular actions that
constitute other arterial diseases.” Complete and utter ignorance of basic
neurophysiology seems to have been no hindrance to the expression of
authoritative opinion on the subject.
French psychiatry was dominated in the 19th Century by the charismatic
presence of Jean-Martin Charcot—a brilliant neurologist who is credited with
identifying multiple sclerosis, amyotrophic lateral sclerosis (aka ALS or “Lou
Gehrig’s disease”) , and numerous other neurological disorders. In the 1870s
he turned his energies to advancing his personal notion of “hysteria”, an
assortment of neurotic symptoms that he believed to constitute an inheritable
disease associated with unidentified changes in nerve tissue. He promoted

©Paul Minot 2011

 11

this concept by performing public lectures, the highlight of which was his
dramatic demonstration of hysterical symptoms in female subjects that he
hypnotized on stage. These presentations became a national sensation, and
led his theories to gain widespread acceptance among psychiatrists
throughout Europe—only to be debunked after his death in 1893.
An infinitely more regrettable innovation of French psychiatry was the
concept of degeneration. At the time nearly all psychiatrists believed
psychiatric disorders to be directly inheritable. In 1857 a French physician,
Benedict-Augustin Morel, proposed that something even more insidious was
happening in the psychiatrically impaired, advancing the pre-Darwinian
notion that acquired characteristics (such as alcoholism and moral turpitude)
could be genetically incorporated and passed on to the next generation. The
anticipated result would be a steady accumulation of inherent psychiatric,
constitutional, and even moral dysfunction in subsequent generations,
leading in turn to an overall deterioration of the human race. The
“degenerate” offspring of such defective bloodlines were said to “recapitulate
in their bodies pathological organic characteristics of a number of previous
generations“; and any such individual is “not only incapable of becoming part
of the chain of transmission of progress in human society, he is the greatest
obstacle to this progress through his contact with the healthy portion of the
population.”
This dystopian vision apparently had broad appeal, spreading rapidly
throughout the European psychiatric community and into other intellectual
circles. It was the first manifestation of social Darwinism, generating a
climate of fear that these “natural processes” would result in the downfall of
civilization. Another French psychiatrist, Valentin Magnan, fanned the
flames by declaring that society was in a “hereditary struggle for life”, and

©Paul Minot 2011

 12

grimly proposing that society “combat it with a rigorous form of social

hygiene.” A popular bestseller in the 1890s, Max Nordau’s Degeneration,
analyzed the allegedly degenerate characteristics of modern art, music, and
literature. Although degeneration theory fell into disfavor among
psychiatrists early in the next century, its allure persisted among
antidemocratic circles in Europe, eventually spawning the genocidal policies
of Hitler’s Nazi regime.
But the more immediate effect of degeneration theory was that it was
very bad for business. People with psychiatric complaints began to suppress
their symptoms, and avoided psychiatrists for fear of being branded with a
stigmatizing diagnosis. Likewise family members resisted taking family
members in for care, because of the legitimate fear that their whole family
might bear the stain of being “degenerate” carriers of what was perceived to
be inheritable disease. Having thus succeeded in undermining the economic
viability of their own profession, psychiatry was forced to figure a way out of
the corner into which they had painted themselves.
The answer was the adoption of a nonscientific euphemism, “nerves” or
“nervous disease”, for the low-intensity psychiatric disorders that were the
bread and butter of office-based practice. Never mind that this appellation
deceptively implied that the origin of such complaints existed in the
peripheral nervous system, rather than the brain. In order to avoid the stigma
of psychiatric illness and ensure their participation in treatment, it was an
acceptable compromise to tell patients what they wanted to hear rather than
the perceived truth. Such disorders were typically attributed to overwork,
“stress”, or “humoral imbalances”, despite the widely held (but unspoken)
belief among psychiatrists that they were genetic or constitutional in nature.

©Paul Minot 2011

 13

The definitive “nervous” diagnosis emerged in 1869, when a New York

electrotherapist, George Miller Beard, “discovered” (i.e. contrived)
neurasthenia—a disease entity attributed to physical exhaustion of the
nervous system brought on by the stresses of modern living. It embraced a
vast grab bag of symptoms, including dyspepsia, headaches, insomnia,
weakness, dizziness, fainting, anesthesia, menstrual irregularities, and wet
dreams. Beard’s proposed mechanism was that “the central nervous system
becomes dephosphorylized, or perhaps, loses somewhat of its solid
constituents.” This wispy stab at science was apparently enough for the
psychiatric community, as the diagnosis became widely accepted in both
America and Europe.
Clinics and hospitals embraced the new paradigm by changing their
names—institutions previously designated “for the insane” were now “for
nervous disease”. However, the continued presence of “degenerate”
psychiatric patients in such institutions continued to inhibit use of these
facilities by those who could afford other options. In 1875 Silas Weir Mitchell
proposed the definitive treatment for neurasthenia, the rest cure. This
regimen called for the patient to be isolated from stress and excessive
stimulation, with special diets (such as the popular “milk diet”) and a melange
of physical therapies that might include water therapy, electrotherapy, and
massage. This cure could be delivered at private clinics or sanitariums, but
the definitive environment for treatment were the spa clinics that sprung up
on both sides of the Atlantic. Many of the patients were upper class women,
providing an enthusiastic (and lucrative) clientele for “nerve doctors” and the
facilities to which they referred patients. It was a classic win-win scenario—
after all, who doesn’t like rest? And who doesn’t like spas?

©Paul Minot 2011

 14

A notable effect of the “nervous” branding of psychiatric disorders was

that it opened the door for neurologists to treat psychiatric complaints. The
office practice of psychiatry was shepherded into being by neurologists, since
most psychiatrists of the time were affiliated with the asylums. It was
neurologists who observed that the success of these “cure” models depended
in large part on a rigorously structured regimen that was imposed under the
benign authority of an administering physician, which had a powerful effect
on its largely female clientele. The suspicion grew that the primary
therapeutic benefit arose from the act of submission itself, suggesting that
these disorders were more functional (i.e. psychological) than organic. If so,
this powerful doctor-patient relationship could be moved out of the
sanitariums and spa clinics into the more cost-effective environment of the
doctor’s office. This led to the emergence of psychotherapy and hypnotherapy
—ironically promoted by neurologists rather than psychiatrists—and to the
eventual ascendance of one neurologist who would come to dominate
psychiatry for half a century.
The vogue for spa treatment peaked around 1900, waning as the
number of overtly psychiatric patients at these facilities increased, which
considerably diminished the euphemistic cache’ of “nervous disease”. The era
stands as a compelling illustration of just how far psychiatry was willing to
compromise its scientific credibility in response to commercial
considerations. Remarkably, neurasthenia still appears on the World Health
Organization’s official list of diseases, the ICD-10, since it continues to be
used in Asia as a culturally acceptable diagnosis in order to avoid the stigma
of mental illness.
Although the historic focus of neurology had previously been organic
disease, the persistent stigmatization of psychiatrists offered neurologists a

©Paul Minot 2011

 15

steady flow of paying customers seeking help for “psychoneurosis”.

Numerous theories were proposed, and different therapeutic approaches were
explored including hypnosis. In Vienna Sigmund Freud was impressed by
how many sexual issues were emerging in his psychotherapy practice
(treating many young female patients), and he began to develop a body of
theory that gave a primacy to sexuality never before contemplated. This
naturally courted controversy and derision—but also stimulated a lot of
interest and discussion. He successfully cultivated an intellectual following in
and around Vienna that grew to become an international movement, while
laying the foundation for a new treatment model known as psychoanalysis.
As a social revolutionary I revere Sigmund Freud. His frank discussion
of sexuality cut through Victorian repression and propriety like a buzzsaw,
and changed our world forever. Freud’s ideas triggered a seismic shift of
Western culture away from repressive decorum toward candor and sexual
freedom, ushering in the acknowledgement and celebration of sexuality in art
and media. He made invaluable contributions as well to the evolution of
psychological theory and treatment, such as delineating the role of the
unconscious in human behavior and developing the technique of free
association. His definitions of the id, ego, and superego, his observation of
psychological defenses, and much of drive theory in general are still useful
concepts that facilitate the exploration and discussion of psychological
problems.
But as a scientist, Freud was an utter disaster. He was hopelessly in
love with his own opinions, lacking the humility to entertain doubt of his
interpretations. He was stubbornly fixated on sexuality as causation, which
made him a better revolutionary but a lousier theoretician. Since his
hypotheses were ill-suited for examination using the scientific method, he had

©Paul Minot 2011

 16

free rein to build consensus in the psychiatric community through a

combination of personal charisma and sheer chutzpah. His intellectual
domination of psychiatry was imposed by the coercive abuse of
psychoanalytic terminology to attack his opponents, dismissing criticism of
his theories as psychological “resistance” or “denial”. This technique was
emulated by his legion of followers, who managed to sustain a cultish ideology
for decades that was virtually impervious to rigorous reexamination.
To illustrate the absurdity of some of Freud’s ideas, I offer for your
consideration the concept of penis envy. According to Freud’s psychosexual
development theory—which, strictly speaking, should be referred to as a
hypothesis—children of both sexes first exhibit a libidinal focus on the genital
area during the phallic stage of development, occurring from age 3 to 6.
Freud proposed that the penis becomes the organ of primary interest for both
sexes, triggering a series of events that result in different outcomes for each
gender due to their differences in anatomy. These events constitute the
Oedipal complex in boys, characterized by castration anxiety; while in girls
they are referred to as the Electra complex, the context within which penis
envy arises and is then resolved.
Freud proposed that at the beginning of the phallic stage the girl
develops her first sexual impulses, which are directed toward her mother. She
then realizes that she does not have the requisite anatomical equipment for
that sexual relationship, and comes to desire a penis and the power that it
represents—hence experiencing penis envy. The solution is to obtain a penis,
leading her to develop a sexual desire for her father, an urge that impels the
elimination and replacement of her mother. The girl concurrently blames the
mother for her apparent castration, which she presumes is retaliation for
daring to compete with her mother for her father’s attentions. Eventually the

©Paul Minot 2011

 17

girl begins to identify with and mimic her mother in order to be a better
replacement, but this in turn leads to fear of further retaliation. All this
tension is at last relieved utilizing the psychological defense of displacement,
through which the girl transfers her discomfiting attraction from her father to
the more attainable and acceptable object of men in general.
I don’t know about you, but I lost count of the number of intuitive leaps
attempted by Freud within this one hypothesis. The scientific method calls
for observation and testing to confirm a hypothesis, but my bet (and hope) is
that Freud never directly questioned a sample of 3- to 6-year-old girls to
explore what feelings they had about their absent penis—much less all the
other areas of conjecture here. What’s most baffling, however, is that this
bizarrely tortuous conceit was not the idiosyncratic delusion of some crackpot
on the fringe, but a core tenet of the analytic canon, advanced by the man who
was the reigning figure of American psychiatry for most of the 20th Century.
When psychiatrists conferred with each other on individual cases penis envy
would be discussed as a matter of course, and rarely if ever questioned as a
clinical entity. Meanwhile, the coeval cultural phenomenon of “penis
narcissism”—the preferential allotment of wealth, power, and personal
freedom to those fortunate enough to be born with a penis—went entirely
unnoticed by the (predominantly male) psychoanalytic community. Go
figure….
Untethered by the scientific demand for objective verification, and
inspired by Freud’s example, psychoanalysts ran rampant with half-baked
theories to explain the inner workings of the mind and the pathogenesis of
psychiatric disease. One of the more reckless of these speculations was Frieda
Fromm-Reichmann’s proposal in 1948 that the degenerative neuropsychiatric
disease known as schizophrenia was caused by a “schizophrenogenic

©Paul Minot 2011

 18

mother”—a hypothesis that in retrospect appears transparently motivated to

justify the use of psychotherapy to treat this disorder. According to Fromm-
Reichmann, such a mother was domineering and overprotective, yet
emotionally rejected the child, triggering the eventual rise of psychosis as the
child became “painfully distrustful and resentful of other people”. This
supposition was accepted and reiterated by the psychiatric community for
decades, maligning a generation of mothers who probably felt bad enough
having a schizophrenic child without being told they were to blame for their
misfortune. Eventually this hypothesis was debunked by actual scientific
research, apparently because somebody felt that such a charge merited
investigation rather than mere assertion.
Meanwhile, Melanie Klein proclaimed that the origins of psychosis were
in the first six months of life. Klein proposed that in order to develop
properly the infant has to split its world into good and bad objects, because
doing so prevents the perception by the infant that good is being destroyed by
the bad. Integration of good and bad is anticipated in normal development
once the child matures to a point that it is able to safely tolerate ambivalence
and conflict. However if the needs of the baby are not met promptly on a
regular basis because the mother is not there to fulfill them, the absence of the
good object is experienced as the bad object. In fantasy the baby attacks the
bad object, and in turn fears that the bad object will retaliate. As a result the
baby grows up feeling persecuted, and develops chronic paranoia in dread of
the bad object’s inevitable revenge.
Cleverly, Klein had managed to concoct a hypothesis that noone can
ever prove or disprove.
Countless volumes of academic literature were filled with such
propositions during the psychoanalytic era. These suppositions carried on

©Paul Minot 2011

 19

psychiatry’s established tradition of making shit up, now refined to

stratospheric new heights of convoluted audacity. They arise from the same
brand of “science” that brought us the theory of intelligent design—the
conviction that something must be true because it sounds good, feels right,
and supports my existing world view. Except intelligent design is more
elegant and firmly grounded in reality.
So how could this sort of poppycock have risen to prominence in a
century notable for huge leaps in scientific progress? Well, the biggest
contributing factor was Freud’s rock star status in American popular culture.
Freud had been on the money in confronting the stultifying sexual repression
of the Victorian era, and clarifying the role of the unconscious in human
behavior. These concepts had a profound cultural impact over and above his
influence as a clinician, spilling over into art and literature. He single-
handedly inspired the surrealist movement, and overtly Freudian references
can be found in Hitchcock movies and other popular media of the era. To this
day Sigmund Freud is probably the only psychiatrist that most lay people can
name.
His ideas were an object of fascination among the chattering classes–
who not only elevated his stature, but made up much of the psychoanalysts’
natural consumer base. Never before had psychiatry experienced such social
cache’. For better or worse, psychiatry was publicly branded by Freud’s
preeminence—so when paying patients came into a psychiatrist’s office
expecting Freudian therapy, they were likely to be obliged. And if
psychiatrists could get their rambling speculations published and discussed
without having to do the grunt work of actual research, it would be hard for
anyone with a healthy ego to resist.

©Paul Minot 2011

 20

Freud’s impact was not only cultural and clinical, but commercial as
well. Before Freud the practice of psychiatry was primarily based in the
asylum, where the severely ill could be safely housed and “treated”. Emerging
from neurology to address low-intensity psychiatric complaints in an office-
based practice, Freud revolutionized our profession. As historian Edward
Shorter states, “Psychoanalysis was the caisson on which American psychiatry
rode triumphantly into private practice”—rescuing psychiatrists from the
asylums, and creating the practice model that has endured even into this
medication-oriented era.
However, it’s worth noting that two centuries of psychiatric research
prior to the advent of psychoanalysis had produced little of lasting clinical
value. As I noted earlier, the obstacles to understanding the brain and its
functions are formidable, and prior to the 20th Century the available
technological means were simply not up to the task. Unfortunately the early
pioneers in the field tended to have more gumption than wisdom, consistently
overestimating their level of understanding and generating a succession of red
herrings disguised as theories, that merely waylaid earnest scientific study
rather than advancing it. Over this entire period there was only one major
psychiatric figure whose discoveries remain clinically relevant today—a
German psychiatrist who was humble enough to know the limits of his means,
to appropriately narrow his focus, and to strictly adhere to the scientific
method.
That man was Emil Kraepelin, head of the university psychiatric clinic
in Heidelberg, who over the course of the 1890s carried out methodical
research of patients who were admitted for severe psychiatric illness.
Kraepelin was a notably independent and plainspoken figure for his time. He
came into the profession with a psychological orientation, and was offended

©Paul Minot 2011

 21

by the rude indifference his teachers often demonstrated toward patients. He

rejected the biological fixation of most of his peers, since their extensive
anatomical study had already proven fruitless in identifying the causes of
psychiatric illness. He decided early on that the technological means
available made it impossible to speculate regarding causation in these cases,
accepting this limitation rather than leaping to uninformed conclusions.
Instead he concentrated his research on the bedside observation of patients
over an extensive period of treatment, with a focus on identifying predictors
of disease course. He did so in hope of identifying discrete diagnostic entities,
so they could be further studied—but also saw it as a clinical priority, since
loved ones so often wanted to know whether patients would improve and
when. As Kraepelin stated:

The doctor’s first task at the bedside is being able to form a

judgment about the probable further course of the case. People
always ask him this. The value of a diagnosis for the practical
activity of the psychiatrist consists of letting him give a reliable
look at the future.

With this goal in mind, he gathered extensive data regarding these

patients, analyzing his findings in an attempt to “cut nature at the joints” and
identify specific disease states. He noted that patients presenting with
psychosis shared many common symptoms, but had wildly differing courses
of their disease. After prolonged study, he observed that patients with a high
degree of affective (i.e. emotional) content had episodes that swung in a
cyclical patter, with full recovery of function between these episodes. He

©Paul Minot 2011

 22

called this condition manic-depressive illness, a disorder now technically

designated as Type I Bipolar Disorder.
Patients lacking this affective content, on the other hand, trended
toward a degenerative course of illness that was unremitting, exhibiting what
he described as “a peculiar destruction of the internal connections of the
psychic personality, with the most marked damage of the emotional life and
volition.” He coined the term dementia praecox for this condition—which
was later renamed schizophrenia, after it became clear that the degree of
cognitive impairment was insufficient to warrant the term “dementia”.
Although he came to believe that schizophrenia was neurodevelopmental in
origin, he maintained a healthy respect for the non-biological aspects of the
psyche, touting the therapeutic benefits of meaningful activity (especially
farming and gardening) in treatment of the mentally ill.
But Kraepelin was a singular exception in a psychiatric legacy that was
littered with debunked theories, dead ends, and downright quackery. By the
dawn of the 20th Century, the entirety of psychiatric research had culminated
in the exportation of medical diseases (like neurosyphilis and multiple
sclerosis) to other specialties, and the identification of two actual psychiatric
diseases that had no known causation or treatment—the only durable
psychiatric knowledge to date. In a demoralized state after nearly destroying
itself with the “degeneration” debacle, it’s little wonder that psychiatry latched
on to Freud’s confident authority and public stature.
As it turned out, psychoanalysis was much more effective for treating
the worried well than the truely ill. Attempts to apply psychoanalysis to the
asylum population failed miserably, and outpatients who were unresponsive
to analysis were often labelled “resistant” or even “bad patients”.
Furthermore it was cost-ineffective, especially in the macroeconomic sense,

©Paul Minot 2011

 23

since the type of patients who were most likely to participate and respond to
psychoanalysis were those most likely to be able to maintain employment as
well. In the 1950s psychiatric medications began to improve by leaps and
bounds, emerging eventually as a more cost-effective treatment option
applicable to a larger proportion of the patient population, including those
who were the sickest.
Even if it flunked science (and economics), psychoanalysis certainly
deserves an A for effort. In analysis, diagnosis was a demanding process that
took place over weeks, months, even years, as ever deeper thoughts and
feelings were revealed in the course of therapy. As convoluted and speculative
as a diagnostic formulation might be, it was an earnest attempt to understand
the patient’s personality and problems, and to communicate a patient’s story
without gross oversimplification—and hence inherently respectful of just how
complicated any human being really is. Old school analysts have been some
of the most passionate critics of biological psychiatry’s crass reductionism—
which is not surprising, given that there always was an element of romance to
psychoanalysis that impelled many of its practitioners.
But there’s simply no place for romance in science, since that inevitably
entails attachment to an idea you may have to dispose of later. Most of the
figures cited in this chapter were true believers, passionately attached to their
own ideas or those of their mentors. Any of them who lived long enough saw
their cherished doctrines crushed by whatever passed for “progress” in that
era. The notable exception was Kraepelin, a scientist rather than a believer,
whose discoveries have accordingly endured to this day.
Contemporary psychiatry has good reason to be ashamed of its history.
But if the apparent neglect of its checkered past is by design, I suspect there
are deeper motives beyond mere embarrassment. Over the years we have

©Paul Minot 2011

 24

habitually underestimated our scientific task, and overplayed our clinical

hand. Having finally achieved a tenuous foothold on medical legitimacy, it’s
natural to assume that we might be threatened by a history that challenges
that stature. The new technologies are indeed powerful, and the resultant
treatments are undoubtedly more effective than ever before. But it would be
foolhardy to overlook psychiatry’s established proclivity for bending science
to its will—and to discount the very real possibility that our current dogma is
just the latest manifestation of that regretful tendency.

©Paul Minot 2011