Couch is a series about psychotherapy.
I have two offices, one for answers and another for questions. As a clinical psychiatrist, I begin my day in a room filled with soothing art and soft leather chairs, where my pharmaceutical prescriptions and psychological interventions are intended to meet the pressing needs of my patients. Here, I’m supposed to have answers, or at least that’s the hope.
Then, at some point near noon, I descend 12 floors, cross a cobblestone drive, pass into an old granite building and settle into a cubicle that overlooks Manhattan’s East River. Here, by a blackboard filled with arrows, scribbles and circles, and surrounded by hundreds of color-coded files and books, I do my work as a historian of psychiatry. It now becomes my job to critically pick apart the assumptions and beliefs of my own practice, my own field.
Two separate rooms, two different modes. Is that true? I was daydreaming recently, searching for a simple response to a question often asked of me — namely, how does my practice as a psychiatrist relate to my historical studies? — and that was what I first came up with.
Unfortunately, after but a moment of reflection, my neat division collapsed. In clinical psychiatry, perhaps more than in any other field, you incessantly ask questions, and the right question can often become an answer. “‘Not good enough’ for what?” may be all that is required from me to help a patient comprehend a sudden depressive turn. Likewise, historians, though driven by skeptical questioning, certainly can generate solid answers about what happened and why.
Better to say, then, that I inhabit two deeply related realms that have long been divided by mutual suspicion and conflict.
Consider this: Like most clinicians, I am eager for scientific progress, something new that will yield more clarity and provide my patients with faster or deeper relief. However, as I take stock of a new “neuroenhancer,” or the latest genetic correlation that may point to the cause of an illness, or a suddenly popular diagnosis, the historian in me senses ghosts beginning to stir.
Historians have shown that psychiatry has long suffered from the adoption of scientific-sounding theories and cures that turned out to be dogma. Perhaps the clearest example of such “scientism” was psychiatry’s embrace, in the early 19th century, of Franz Joseph Gall’s phrenology, in which all mental attributes and deficiencies were assigned to specific brain locales, evidence be damned. During much of the 20th century, psychoanalysis proposed far more conclusive answers than it could support, and today, the same could be said for some incautious neurobiological researchers.
These exaggerations are not merely academic errors. Over the years, scientism has persuaded mental doctors to do bad, even terrible things. Ice-pick lobotomies, refrigerator mothers, insulin shock: The list is not short. The most notorious example involved the father of psychiatric genetics, Ernst Rüdin, who during the Nazi era sought to cleanse the German population of so-called degenerative heredity through the sterilization and “euthanasia” of the mentally ill.
Much less extreme, everyday infiltrations of ideology can be discerned in the portraits that psychiatrists have drawn of their field. Most of these accounts have been self-serving affairs, in which the past was ravaged so as to justify present clinical certitudes. Nearly every generation has featured a proud practitioner who dismissed his predecessors and lifted the flag of victory, only to have it snatched away some years later. Since 1800, the end of history in psychiatry has come with the triumph of the asylum, followed by Romanic medicine, brain anatomy, genetics, psychoanalysis and, most recently, drugs like Prozac.
And so, as my morning sessions end and I cross over to my scholarly retreat, I am acutely aware that my present commitments as a doctor might undermine my capacity to fairly envision the past. Then I settle in before my archives and books and my troubles multiply.
For the past three decades, the reigning model among historians of my field has been dubbed “antipsychiatric.” Following the work of Michel Foucault, the fashion has been to argue that psychiatry emerged as a police arm of the modern state. Mental doctors were self-deluded or malevolent, their treatments cunning, at times barbaric, methods of control. Mental illness itself, they argued, was a false construct used to control dissidents, rebels and outcasts.
Some fine work along these lines has exposed the creation of bogus diseases that served to pathologize “wrong” behaviors, such as homosexuality. Researchers have shined light on the supposed madness of runaway slaves in antebellum America and political dissidents in the Soviet Union. They have also explored diagnostic fads, disappearing diseases like hysteria or sudden epidemics of ailments like attention deficit disorder.
However, this vein of research has been tarred by its own crude ideology. If scientism can falsely turn ethical and political issues into matters of disease, and grossly exaggerate what we know about the nature of mental illness, Foucault and his acolytes are prone to an antithetical failing: radical social constructionism. Madness, they would have us believe, whether it is schizophrenia, post-traumatic stress disorder or anorexia, is not grounded in any biological reality. Greedy commercial interests and a repressive society, they claim, have falsely transformed human differences and personal choices into psychiatric disorders.
Arguments of this sort can be morally compelling, for they appeal to the liberal ideal of toleration and argue for the civil rights of stigmatized minorities. However, no one is a Foucauldian in an emergency room. I was a medical resident in psychiatry when I first studied Foucault’s arguments, and I got the distinct impression that his “madness” was often just a metaphor with which to challenge authority, not much related to the shaking, hallucinating teenager that I would soon return to on the wards.
To me, Foucault and his followers seemed impossibly naïve, even complacent. Had they ever encountered severe obsessive-compulsive disorder or suicidal depression? Had they ever seen a manic patient take lithium and be restored? Psychiatrists might be blinded by their commitments as insiders, but this academic view seemed sustainable only by remaining on the outside looking in.
Over the years, in my dual roles as practitioner and historian, I have watched each camp become more strident, thanks in part to a lack of dialogue. Too often, psychiatrists dismiss the disturbing lessons from the past, while historians roll their eyes at the very possibility of progress in psychiatry. In these isolated worlds, scientism and radical social constructionism flourish.
Perched as I am between the disputants, lucky to be supported by a unique interdisciplinary institute and a group of like-minded colleagues, I have sought to reconcile my quarreling loves. It’s been a bit like marital therapy, in which profoundly intertwined partners mostly ignore each other, then occasionally pipe up to loudly dismiss each other’s perspective.
Amid such conflict, in my work with patients and in my writing, I do my best to explore contradictions, look for specifics amid abstractions, search for syntheses and, in the face of real uncertainty, advocate for polyphony, a multiplicity of explanatory perspectives. And I have come to distrust unstable dualities like mind or brain, artificial divisions like nature or nurture, and seductive dichotomies that should not end but merely begin an inquiry — such as having one office for answers and another for questions.
George Makari, a professor of psychiatry and director of the DeWitt Wallace Institute for the History of Psychiatry at Weill Cornell Medical College, is the author of “Soul Machine: The Invention of the Modern Mind.”