Shrinks (7 page)

One day at work, Moses abruptly began to have difficulty speaking. Soon he was stuttering. He became confused and disoriented. By the end of the day, he had become entirely mute. He opened his mouth but no sound came out, only guttural rasps. This disturbing change in behavior prompted his colleagues to whisk him off to the emergency room.

The doctors immediately presumed Moses had experienced a stroke or seizure, the usual suspects when someone suddenly becomes confused and unable to speak. They ordered a complete neurological workup, including a CT scan and an EEG. To their surprise, the tests came back completely normal. Without any evidence of a physiological abnormality, the problem was presumed to be psychiatric, and Moses was referred to me.

At first, I suspected some form of malingering—perhaps he was faking symptoms to get sick leave or collect disability insurance—but there was no evidence to support this hypothesis. Moses’s muteness extended to all areas of his life, even when he was home with family and friends. I recommended that he be placed on medical leave and scheduled a follow-up visit. When he arrived at my office, I told him that I would like to perform a diagnostic procedure called an amytal interview. This was an old procedure that involved administering a moderate dose of a short-acting barbiturate intravenously. It relaxes and disinhibits the patient and thus can act as a kind of truth serum. Moses nodded his consent.

I brought him into a treatment room, placed him on a gurney, and filled a syringe with amobarbital. Inserting the needle into his vein, I slowly began to inject the liquid medication. In less than a minute he began to speak, at first in a garbled and childlike fashion, then clearly and coherently. He explained the jam he was in at work and declared that he didn’t know what to do. After recounting all the details of his dilemma, he abruptly fell asleep. When he awoke a short while later, he was once again unable to speak, but the “truth serum” had confirmed my guess: His muteness was a conversion reaction. (The latest edition of the
Diagnostic and Statistical Manual of Mental Illness
contains a formal diagnosis for conversion disorders that is largely based on Freud’s conception.)

After missing work for a few weeks, Moses was informed that he was being transferred to another department and would no longer work for his former boss or be responsible for the cardiology division’s finances. Within a few days of this news, Moses fully regained his ability to speak. Freud, I think, would have been pleased with the outcome.

By defining mental illness as conflicts between unconscious mechanisms—conflicts that could be identified, analyzed, and even eliminated—Freud provided the first plausible means by which psychiatrists could understand and treat patients. The appeal of Freud’s theory was enhanced by his spellbinding skills as a speaker and his lucid and compelling writing. Surely this was the leader that psychiatry had been yearning for, someone who could boldly lead the field into the new century and back into the good graces of their medical brethren.

Instead, Freud ended up leading psychiatry into an intellectual desert for more than a half century, before eventually immersing the profession into one of the most dramatic and public crises endured by any medical specialty. How did this happen? Part of the answer lies with individuals like Elena Conway and Abigail Abercrombie—patients suffering from debilitating illnesses.

Part of the answer lies within Freud himself.

Chapter 2

Down the Garden Path: The Rise of the Shrink

Psychiatry enables us to correct our faults by confessing our parents’ shortcomings.

—L
AURENCE
P
ETER

Sigmund Freud was a novelist with a scientific background. He just didn’t know he was a novelist. All those damn psychiatrists after him, they didn’t know he was a novelist either.

—J
OHN
I
RVING

A Coffee Klatch

Like the smart phone, Freud’s exciting new conception of the mind was embraced so universally that it became difficult to remember what life was like before it arrived. Freud made mental illness seem fresh, comprehensible, and intriguing. But unlike smart phones—which were adopted rapidly after their introduction—the influence of psychoanalytic theory spread slowly.

A better comparison for Freud’s theories might be video teleconferencing, a technology that was completely shrugged off by the public when it was first introduced in the 1970s, though it finally caught on decades later on the heels of the Internet and mobile devices. So how did psychoanalytic theory grow from the idiosyncratic conjectures of an unknown neurologist to become as commonplace as Skype? It all started with an evening coffee klatch.

A Small Circle of Colleagues

In the autumn of 1902, Freud sent postcards to four local physicians, inviting them to his row house apartment in the Berggasse district of Vienna, a drab, uninspiring middle-class Jewish neighborhood. One postcard read: “A small circle of colleagues and supporters would like to give me the great pleasure of coming to my place one evening a week to discuss topics of interest to us in psychology and neuropsychology. Would you be so kind as to join us?”

Freud’s book
The Interpretation of Dreams
had been published less than two years earlier, but the book hadn’t made much of a splash, or even a ripple. Its very modest print run of six hundred copies was languishing at booksellers. Nevertheless, a handful of physicians were sufficiently intrigued by Freud’s decryption of the workings of the mind to strike up an admiring correspondence with him. One of these early enthusiasts was Wilhelm Stekel, a vivacious and outspoken general physician and a writer of plays and poems. Stekel volunteered to become one of the very first patients to be psychoanalyzed by Freud and went on to become a psychoanalyst himself. In the midst of his therapy, Stekel advanced a history-altering recommendation: Freud should hold a discussion group to talk about his ideas.

The fact that exactly four people were invited to Freud’s first coffee klatch hints at the deflating initial lack of interest in his work. Stekel was the first invitee. Two others were Freud’s childhood friends (Max Kahane and Rudolf Reitler). The fourth was Alfred Adler, the only recruit with any meaningful influence in the medical field at the time. Adler was a Socialist physician who enjoyed the camaraderie of groups and felt completely at home among the working classes. He dressed and carried himself like a blue-collar laborer and had published an occupational health book for tailors.

Together with Freud, these four men formed the nucleus of what would eventually become an international movement. The group decided to meet in Freud’s dark and tiny living room every Wednesday evening, prompting the name for their little clique: the Wednesday Psychological Society. Despite these humble beginnings, according to Stekel, the earliest meetings featured “complete harmony among the five, no dissonances; we were like pioneers in a newly discovered land, and Freud was the leader. A spark seemed to jump from one mind to the other, and every meeting was a revelation.”

The society soon began to attract nonphysicians, including an opera producer, a bookseller, an artist, and a novelist. Meetings followed a prescribed routine. The men would gather around an oblong table in Freud’s Victorian-styled parlor at 8:30 p.m. sharp. Presentations commenced at 9:00 p.m. Names were drawn from an urn to determine the order of the speakers. After the formal talks, there was fifteen minutes of socializing. Cigars and cigarettes were laid out on a table and smoked in great quantities. Black coffee and cakes were served and hungrily devoured. Max Graf, an Austrian musicologist who joined the society in 1903, described the mood: “There was the atmosphere of the founding of a religion in that room, and Freud himself was its new prophet.”

The last and decisive word of each meeting was left to Freud. The minutes of one meeting, during which the members debated the role of incest in neurosis, report how Freud closed the session by “telling of a disguised form of the dream of incest with the mother. The dreamer is in front of the entrance to a house. The dreamer goes inside. He has the vague recollection of having been in there once before. It is the mother’s vagina, for this is the place where he has been once before.”

Initially, meetings of the Wednesday Psychological Society mainly focused on the theoretical and social implications of Freud’s ideas. But the members of the society soon became eager to apply this new theory to alleviate the suffering of those who were mentally disturbed. Since Freud believed that most psychiatric problems resulted from inner psychic conflicts, he developed an ingenious and highly original method to relieve these conflicts.

Freud’s “talking cure,” as he called it, derived from two distinct forms of therapy he had been exposed to during his early career. The first was hypnosis. As part of his neurological fellowship under Jean-Martin Charcot in 1885, Freud learned to use hypnosis with patients suffering from hysteria, which at the time was a vaguely defined condition consisting of volatile and unmanageable emotions. Freud marveled at how hysterical symptoms often seemed to dissipate after a hypnotic session. He gradually came to believe that it might be possible to adapt hypnosis into a more methodical form of talk therapy (or
psychotherapy
, in the vocabulary of psychiatry).

Freud’s talking cure also had roots in the methods of Viennese physician Josef Breuer, who mentored the young Freud in the late 1880s and set him up with his first medical practice. As Breuer’s protégé, Freud observed that when one of Breuer’s young female patients (known to history as Anna O) rambled aimlessly to Breuer about whatever thoughts came into her mind, her psychiatric symptoms diminished or disappeared. Anna referred to this process of uninhibited speech as “chimney sweeping,” while Breuer called it the “cathartic method.” Freud combined Charcot’s hypnosis and Breuer’s cathartic method with his evolving psychoanalytic theory to fashion the first systematic form of psychotherapy, which he dubbed
psychoanalysis
.

Psychoanalysis was conceived as a method of probing patients’ unconscious minds to identify their hidden conflicts. During psychoanalysis, Freud encouraged patients to free-associate, speaking about anything that came to mind. Since Freud viewed dreams as an invaluable source of information about unconscious conflicts (he famously called them the “royal road to the unconscious”), he also encouraged patients to share details of their dreams during psychoanalysis. The great benefit of psychoanalysis, Freud insisted, was the fact that hypnosis worked on only about one-third of patients, while psychoanalysis worked on everyone.

Freud’s psychoanalytic method came to define many of the traditional forms of psychiatrist-patient interactions that continue to this day, including frequent therapy sessions, the 45-or 50-minute session, guided communication with the patient, and a comfortable therapist’s office with a couch or overstuffed armchair. Psychoanalysts usually sat behind their patients, a technique that was carried over from Freud’s earliest days when he sat behind patients while hypnotizing them so that he could press their foreheads while solemnly urging them to remember events blocked from their consciousness.

The clinical practice of the unobservable therapist later acquired a theoretical justification through the concept of
transference
. During psychoanalysis, the therapist was to become a blank slate, remote and aloof and removed from view, in order to facilitate the patient’s projection of past relationships onto the therapist. This was believed to induce the eruption of revelations from the unconscious, like submitting oneself to the Oracle of Delphi.

While contemporary psychiatrists no longer stay hidden from their patients’ view, the Freudian concept of transference has endured as one of the cornerstones of modern psychotherapy and is taught to every psychiatric resident, clinical psychology grad student, and social worker trainee. For Freud, the tools of transference, dream interpretation, and free association were all designed to achieve the ultimate goal of psychoanalysis: “to make the hidden visible.”

Think about this approach to treating mental illness for a moment. If you suffered from depression, obsessions, schizophrenia (like Elena Conway), or panic attacks (like Abigail Abercrombie), then—according to psychoanalytic theory—the best way to relieve your symptoms was to unearth the hidden psychic conflicts generating your pathological behavior. To dig up these conflicts, the psychoanalyst, like the biblical Joseph, might interpret the cryptic significance of your dreams. If you refused to talk about your dreams—if, instead, you wanted to talk about what could be done to prevent you from committing suicide if your depression took hold again—the psychoanalyst would interpret this desire to switch topics as “resistance” that needed to be worked through.

As the popularity of psychoanalysis and the number of its practitioners grew, some of Freud’s protégés wanted to push psychoanalysis in new directions and began to propose new ideas about mental illness and the mind that were quite different from Freud’s own. Perhaps some psychic conflicts were not linked to sex at all? Might there be a cosmic significance to the unconscious? What about
four
parts to the mind, instead of three?