Madness on the Couch: Blaming the Victim in the Heyday of Psychoanalysis

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In the golden age of "talk therapy," the 1950s and 1960s, psychotherapists saw no limit to what they could do. Believing they had already explained the origins of war, homosexuality, anti-Semitism, and a host of neurotic ailments, they set out to conquer one of mankind's oldest and fiercest foes, mental illness. In Madness on the Couch, veteran science writer Edward Dolnick tells the tragic story of that confrontation.

It is a vivid, compelling tale that is told here for the ...

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Riverside, New Jersey, U.S.A. 1998 Hardcover New 0684824973. 368pp----DESCRIPTION: In the golden age of "talk therapy, " the 1950s and 1960s, psychotherapists saw no limit to ... what they could do. Believing they had already explained the origins of war, homosexuality, anti-Semitism, and a host of neurotic ailments, they set out to conquer one of mankind's oldest and fiercest foes, mental illness. In Madness on the Couch, veteran science writer Edward Dolnick tells the tragic story of that confrontation. It is a vivid, compelling tale that is told here for the first time. Dolnick focuses on three battles in an epic war: against schizophrenia, autism, and obsessive-compulsive disorder. Schizophrenia, the most dreaded mental illness, strikes its young victims without warning and torments them with hallucinations and mocking voices. Autism claims its victims even younger, at age one or two, and locks them away, cut off from the rest of us by invisible walls. Obsessive-compulsive disorder strikes at any age and e Read more Show Less

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Overview

In the golden age of "talk therapy," the 1950s and 1960s, psychotherapists saw no limit to what they could do. Believing they had already explained the origins of war, homosexuality, anti-Semitism, and a host of neurotic ailments, they set out to conquer one of mankind's oldest and fiercest foes, mental illness. In Madness on the Couch, veteran science writer Edward Dolnick tells the tragic story of that confrontation.

It is a vivid, compelling tale that is told here for the first time. Dolnick focuses on three battles in an epic war: against schizophrenia, autism, and obsessive-compulsive disorder. Schizophrenia, the most dreaded mental illness, strikes its young victims without warning and torments them with hallucinations and mocking voices. Autism claims its victims even younger, at age one or two, and locks them away, cut off from the rest of us by invisible walls. Obsessive-compulsive disorder strikes at any age and entraps its hapless victims in endless rituals.

Inspired by their hero, Freud, but bolder even than he, psychoanalysts set out to vanquish those enemies. Armed with only words and the best of intentions, they achieved the worst of outcomes. The symptoms of disease were symbols, these therapists believed, and diseases could be interpreted, like dreams. The ranting of a schizophrenic on a street corner, the retreat of an autistic child from human contact, the endless hand-washing of an obsessive-compulsive were not simply acts but messages. And the message psychoanalysts decoded and delivered to countless families was that parents themselves — through their subtle hostility — had driven their children mad. That verdict was not overturned formore than a generation.

Clear, dramatic, and authoritative, Madness on the Couch uses the voices of therapists as well as those of patients and their loved ones to describe the controversial methods used to treat the mentally ill, and their heartbreaking consequences. We see the leading lights of psychotherapy at work, including tiny, grandmotherly Frieda Fromm-Reichmann; gawky Gregory Bateson, either a genius or a charlatan, depending on whom one asked; and birdlike R. D. Laing, a slender figure with dark, deep-set eyes and the charisma of a rock star. We meet, too, scientists and family members who fought the reigning dogma of the day. Bernard Rimland, for example, set out to refute the claim that autism was caused by "refrigerator" parents whose coldness had turned their children into zombies. Rimland's only "credential" in his battle with the experts was the fact that his son was autistic.

A gripping tale of hubris, arrogant pride, and terrible heartbreak, Madness on the Couch combines the immediacy of superb joumalism with the depth of scrupulous history. It shows us convincingly that in attempting to cure mental illness through talk therapy, psychoanalysis did infinitely more harm than good.

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Editorial Reviews

Books & Culture: A Christian Review
If you read only one book about Freud's "legacy," make it this one...
Journal of the American Medical Association
Psychoanalysis is no different from any other theoretical construct in medicine. Unfortunately, some constructs are misapplied by true believers. Time separates the useless and marginal from the valuable. Scientific rigor and intellectual honesty, therefore, have the call on the future. To reflect upon Madness on the Couch will be provocative, cleansing, and convincing and could be part of a course for every resident in psychiatry.
Publishers Weekly - Publisher's Weekly
Extensively researched but depressingly mean-spirited, journalist Dolnick's debut chronicles the American midcentury's full-out embrace of psychoanalysis and willingness to apply it with impunity. Theorists such as Frieda Fromm-Reichmann, R.D. Laing and Bruno Bettelheim broadened Freudian theory to treat not only anxiety and neurosis, Dolnick explains, but also more severe mental illnesses such as schizophrenia, autism and obsessive-compulsive disorder. As Dolnick shows, these neo-Freudians quickly came to dominate the psychiatric industry. They shared with ur-Freudianism an emphasis on talk therapy for even the most disturbed patients and, most damningly in Dolnick's eyes, a vision of the home as nest of pathology; it was in this era that the term "refrigerator mother" was coined to designate the mother of a schizophrenic. Today, these theories have receded into the background of psychiatry because of their apparent clinical inefficacy and the emergence of powerful (but hardly problem-free) drug therapies. In an ill-focused j'accuse, Dolnick, a contributing editor of Health magazine, charges the neo-Freudians with sloppy science, moral laxness and intellectual infirmity. Above all, he faults them for "hubris," because they failed to conduct double-blind experiments in testing theories (although in the epilogue he admits that such trials were not even invented until 1948, nor widely in use until long after). He also pins the blame for an entire generation's demonization of domestic life squarely on the shoulders of this small band of therapists. In sentence after sentence brimming with accusatory hauteur, Dolnick shifts his moral critique from anecdote to anecdote, now sympathizing with the patients, whose symptoms he details with distasteful breathiness, now with the hard-working but sadly befuddled psychoanalysts in the trenches, and now with the unfairly blamed parents. While this book can be seen as yet another case of hindsight Freud bashing, it lacks the intellectual subtlety that would make it a genuine contribution to such historical revisionism.
Library Journal
A contributing editor to Health magazine, Dolnick slams psychiatry's efforts to cure mental illness in the '50s and '60s.
Booknews
A highly critical account of the misguided attempts on the part of some members of the psychiatric profession of the 1950s and 60s to attribute mental illnesses such as schizophrenia, autism, and obsessive-compulsive disorder to cold, contradictory, or otherwise unwholesome parenting. The author incorporates the personal stories of parents who endured criticism for making their children sick, only to find themselves vindicated when the biological origins of these conditions were identified.
Books & Culture: A Christian Review
If you read only one book about Freud's "legacy," make it this one...
Derek Bickerton
[Dolnick] brings to his task a formidble array of strengths....[the] narrative moves smoothly and effortlessly, never lingering too long on any topic yet never leaving a topic until its full significance has been explored....the book is a delight to read. -- The New York Times Book Review
Kirkus Reviews
A very important, sobering study of psychiatric overreach during a quarter-century (roughly 1948-73) in treating three psychotic or near-psychotic illnesses: schizophrenia, autism, and obsessive-compulsive disorder. Dolnick, a veteran science and health journalist (formerly with the Boston Globe), notes how prone to "parent bashing" leading psychiatric and psychoanalytic theorists were during this period. Thus, Frieda Fromm-Reichmann coined the term 'schizophrenic mother' in 1948, and Gregory Bateson (more an anthropologist than a psychologist) in the mid-1950s alluded ominously to parents of schizophrenics placing their children in highly anxiety-provoking, unresolvable dilemmas termed "double binds." Bruno Bettelheim, who for many years was seen as a pioneer and kind of national guru in the treatment of autism, wrote in 1981, "All my life I feel I have been working with children whose lives have been destroyed because their mothers hated them." Theorists also often based their absolutist, increasingly widely held conclusions, that parents had caused the illnesses and that mental-health professionals alone could cure then, largely through talk therapy, one of the most unscientific of methods. Sometimes they worked with ridiculously small study samples, as in the case of psychiatrist Theodore Lisz, who wrote for many years about schizophrenic patients after studying all of 17 upper-class New England families. Ultimately, of course, their theories and practices proved almost entirely wrong; psychoanalysis was found to be largely useless in treating the severer mental disorders. In addition, the discovery and effective employment of psychotropic medication, beginning withthorazine in 1952 and culminating with Prozac during the 1990s, demonstrated that severe, and many lesser, emotional and mental disorders are largely rooted in biological imbalances, not in individual or familial psychological dynamics. Dolnick provides valuable information on Freudian, non-Freudian, and contemporary theories about the three illnesses he examines and on how long-held views gradually were debunked during the late 1960s and '70s, and he writes in a tremendously engaging and informative manner. This cautionary tale of pseudo-scientific hubris my well be not only the yearþs best book on a mental-health topic, but also one of the most compelling works of its kind in this decade.
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Product Details

  • ISBN-13: 9780684824970
  • Publisher: Simon & Schuster
  • Publication date: 1/28/1997
  • Pages: 368
  • Product dimensions: 6.41 (w) x 9.56 (h) x 1.08 (d)

Meet the Author

Edward Dolnick, a contributing editor of Health magazine, is the former chief science writer for The Boston Globe. His articles have also appeared in The Atlantic Monthly, The New York Times Magazine, and many other publications. He lives in Chevy Chase, Maryland.

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Read an Excerpt

Madness on the Couch
Blaming the Victim in the Heyday of Psychoanalysis


By EDWARD DOLNICK

Simon & Schuster

Chapter Five

The Mother of the
"Schizophrenogenic Mother"

We think of a schizophrenic as a person who has had serious traumatic experiences infancy in early at a time when his ego and its ability to examine reality were not yet developed.
--Frieda Fromm-Reichmann

    At night, when the mental hospital grew quiet, the tormentors emerged. They were plain as day to their victim -- plain as devils, really -- but he alone could see or hear them. Night after night, he leapt from his bed, terrified, pleading for mercy in a melange of English, French, German, and Hebrew, scrambling atop the bureau in a frenzied attempt at escape, retreating from there to the desk, to the chair, to the bed again, to the bureau, all the time jabbering in a torment of fear. Trailing behind him, struggling to make her own way across the furniture, was the slower, clumsier figure of a tiny middle-aged woman. She was Frieda Fromm-Reichmann, one of America's most renowned psychiatrists. She did not see any phantoms, she tried to reassure her patient as she, too, switched from language to language, but if and when she caught sight of them, she would do her best to protect him.

    In the battle against schizophrenia, Fromm-Reichmann was in the front lines. She made an unlikely warrior. Only four feet ten, plump, down-to-earth, she looked like a grandmother sent over from central casting. A German Jewish refugee, she had come to the United States in 1935. There she spent her career at Chestnut Lodge, a renowned private mental hospital in the suburbs of Washington, D.C., devoted to the psychoanalytic treatment of psychotic patients. She had originally been hired for two months, as a summer replacement, but those two months stretched to twenty-two years, ending only with Fromm-Reichmann's death from a stroke in 1957.

    By that time, she was known throughout the psychiatric community as a wise and kindly therapist. But she was more than that. For venturing to take on madness in its most virulent form, and for emerging victorious, the diminutive Fromm-Reichmann had earned a towering reputation. The psychiatrist Robert Coles, himself a moral exemplar for a later generation, spoke for his peers when he lauded her as a "hero." The best-selling novel I Never Promised You a Rose Garden, published in 1964, spread her reputation to the general public. Written by a former patient, Joanne Greenberg, it portrayed Fromm-Reichmann as the savior who had delivered her from schizophrenia. Fromm-Reichmann was "Clara Fried," remarkable in equal measure for her brilliance and her empathy. "After you know her for a while," one of the novel's bedazzled psychiatrists remarks, "you'll find out that with little Clara Fried, brains are only the beginning."

    But Fromm-Reichmann left a complex legacy. On the one hand, she confronted schizophrenia head-on -- as we have noted, even Freud had blinked when he looked at schizophrenia -- but indomitability was only half the story. Equally important, she introduced an essential new element into the schizophrenia picture. This new element was blame, and it would come to dominate the canvas.

    Schizophrenia was not an organic condition, Fromm-Reichmann argued, despite the contrary views of the nineteenth century's most eminent psychiatrists. Nor did she devote a great deal of time to Freud's speculations on the psychological origins of schizophrenia, though she dutifully paid them homage. Fromm-Reichmann's view was simpler, and it would soon become gospel, passed along and embellished by a series of distinguished disciples over the course of the 1950s and '60s. The message was that schizophrenia was man-made. To be precise, it was woman-made. A schizophrenic was shaped by human hands, as much a product of human craft as a reed basket or a clay pot. In the case of schizophrenia, Fromm-Reichmann proclaimed, those shaping hands belonged to mother.

    From her medical school days, Fromm-Reichmann had found herself drawn to treating schizophrenics. Unflappable and unafraid, she insisted on seeing patients alone, even the paranoid and violent ones. To bring along an aide for protection, she insisted, would be disrespectful to her patients. Successful treatment was not a matter of adhering to particular techniques or doctrines, she believed, and she disdained "technical rules." What was crucial was "the basic attitude of the individual therapist toward psychotic persons. If he meets them as strange creatures of another world whose productions are not understandable to `normal' beings, he cannot treat them. If he realizes, however, that the difference between himself and the psychotic is only one of degree and not of kind, he will know better how to meet him."

    Madness could be understood just as dreams could be, but virtuoso displays of intellectual acrobatics were not Fromm-Reichmann's style. A schizophrenic patient who was "aloof, detached, and uncommunicative," for example, might simply be "protecting himself from additional fear and potential hostility." "It is certainly not an intellectual comprehension of the schizophrenic but the sympathetic understanding and skillful handling of the patient's and physician's mutual relationship that are the decisive therapeutic factors," she declared. (Italics in original.)

    It was a philosophy that was easier to espouse than to enact. It took eighteen months, for example, before one patient at Chestnut Lodge would stop shouting, "You dirty little stinking bitch" and "You damned German Jew; go back to your Kaiser?" and "I wish you had crashed in that plane you took!" Fromm-Reichmann was not one to posture, and she told such stories not to portray herself as noble or long-suffering but in passing, on the way to some other point. In trying to sort out her own "irrational" fear of one patient, for example, she noted that "it is true that she threatened repeatedly to hit me or to throw stones at me," but she also pointed out that the threats had never materialized. Indeed, "very little actually happened except for a few slaps in my face."

    Her fellow therapists marveled at the imperturbability of this "well-brought-up, refined, upper-middle-class, German Jewish lady," as one of them described her, no matter the behavior that confronted her. "One day, during a therapeutic hour, as this patient (mute, as usual) was sitting with Dr. Fromm-Reichmann in her office," a colleague recalled, "she noticed that he was fingering his genitals with one hand that was crammed deep into the pocket of his trousers. It was also plain to her that he had an erection. She pondered this situation for a moment, then said to him, `If it will make you feel any better, please go ahead.' Whereupon the young man unzipped his fly and proceeded to masturbate, while Dr. Fromm-Reichmann sat quietly across from him, her eyes down, her hands clasped in her lap."

    Fromm-Reichmann would "sit in a patient's urine with him to show there was no difference between them," another colleague recalled. "Or a patient would give his feces as a gift, and she would take them."

    Small wonder that those psychiatrists willing to take on schizophrenia were more often hailed by their peers than emulated. Schizophrenic patients were hard to reach, quite likely poor and disheveled, and perhaps violent. Treatment was likely to be prolonged, difficult, and, worst of all, unsuccessful. What psychiatrist would not prefer a succession of grateful ladies and gentlemen in business attire, who kept their appointments, paid their bills, and eventually moved along?

    But to think of schizophrenia as simply a difficult disease is to understate the point woefully. It is relatively common, more prevalent than Alzheimer's disease or multiple sclerosis, and its horrors moved even the experts to shake their heads in awe. They rattled off the bare facts easily enough -- schizophrenia affected about one person in a hundred; it tended to strike between ages seventeen and twenty-five; it afflicted men and women in equal numbers, although men fell ill at a younger age -- but even in austere medical journals, they sometimes interrupted their measured prose with a more heartfelt passage.

    "Schizophrenia is the cancer of psychiatry," one authority declared, and its victims were "in truly terrible trouble." Another called the disease an "awesome holocaust" that left in its wake a trail of "tragic human debris."

    It is a holocaust that we, safe at home, can scarcely imagine. In truth, the challenge is even greater than it first appears. Illness is a foreign country, it has been observed, and we read travelers' tales of their journeys there with mingled fear and fascination. But mental illness is unlike cancer or heart disease or many other afflictions, since it directly affects the way its victims perceive the world. The result is that the very people who know madness best -- the natives of this strange land, so to speak -- may scarcely be able to describe it in terms the rest of us can grasp.

    On the other hand, we cannot do without such guidance. We can imagine ourselves paralyzed or blind or deaf, perhaps, but almost by definition we cannot think clearly about what it would mean to think chaotically. How to imagine being caught in seething white water if all we have ever known is a gently burbling stream?

    And so we turn to the natives. Listen to Carol North, for example, in a passage from Welcome, Silence, her memoir of schizophrenia. One day North happened to see a piece of glass from a broken Coke bottle:

There was a message here. I was supposed to use the glass edge to rip away the flesh of my feet to get a view of the machines inside, which would provide a parallel view into the workings of the Other Dimensions. ... Although the connection was subtle, I was astute; I could see the master plan here ....
    Eagerly I sat down and began to carve into the top of my foot with a piece of green glass. It wasn't easy, because the glass was so rough. I was surprised at the toughness of my skin. I made several gouges, not even slicing through the long tendons running the length of the top of my foot. A few drops of blood oozed forth, then the wounds just sort of lay there doing nothing. I poked around in them with my finger, trying to get beneath the skin edges to probe into the machinery inside, but the skin was tenacious and hung tightly to my underlying flesh. I pulled the wounds as far open as they would stretch, but I couldn't see any machines inside. The humming stopped. I had missed my chance.

    That strange tone, that "juxtaposition of lunacy and sanity," in the words of the psychiatrists Paul Wender and Donald Klein, is telltale. A person brain-damaged in a car crash, say, might be damaged across the board. In contrast, the schizophrenic's mind is a hodgepodge, a surrealist painting that mixes the most bizarre hallucinations and delusions with the most everyday of images. A schizophrenic might believe that he sees dragons climbing out of the walls and yet be able to read the morning newspaper.

    Even a lifetime of familiarity does not tame the onlooker's sense of eeriness. "My son is crazy and he's not crazy," says Irma Cardozo-Freeman, a professor of literature and folklore at Ohio State University and the mother of a fifty-year-old schizophrenic. "I can't explain it. He can sit down and write an essay without an irrational thought in it, and yet he's irrational. Not always, but most of the time. He thinks Mick Jagger and Miles Davis talk to him through the radio. Sometimes," she concludes wearily, "I think my son is possessed."

    Poignantly, there may be stretches of insight and self-awareness. I recall one schizophrenic man, first diagnosed at age eleven and forty-seven at the time I met him during one recent winter. He lived alone in a single room, the thermostat set to eighty, his mattress in the center of the room and surrounded by teetering stacks of newspapers and books and mounds of dirty clothes. He was able to function on his own -- indeed, he was quite bright -- but he lurched from topic to topic and spoke in a peculiar singsong, some words long and drawn out and then whole phrases rattled-off-at-high-speed-and-squeezed-into-a-single-breath. "A psychiatrist told me once," he recounted as matter-of-factly as if he were commenting on the weather, "that I would always come across like a phonograph record that someone had left lying in the sun."

    Despite the odds, there are many firsthand accounts of insanity. The best are vivid and compelling, though the mere act of providing an understandable description imposes an artificial order, just as a dream recounted to someone else never has the sweep and taken-for-granted strangeness of the original.

    The dream analogy is almost unavoidable. Like elements in a dream landscape, for instance, mundane fragments of a schizophrenic's world can suddenly take on a hypnotic vividness. "Environmental stimuli constantly bombarded my senses with unrelenting, nearly unbearable intensity," Carol North recalled. "I spent hours marveling at the texture of the bricks on the buildings, at the intricate moving patterns of the moonlight on the river, at the folds of bark on trees, at designs dancing over the ballroom carpet in the [student] Union, even at the fine weave in my jeans. These were no ordinary designs and patterns; they were pregnant with meaning."

    A recovered schizophrenic named Norma MacDonald recounted a similar sensory bombardment. "The walk of a stranger on the street could be a `sign' to me which I must interpret. Every face in the windows of a passing streetcar would be engraved on my mind, all of them concentrating on me and trying to pass me some sort of message." Often the messages were more overt. Carol North had been tormented by strange voices since she was six years old. She believed that everyone heard voices; no one talked about them, she assumed, because voices, like bodily functions, were private. In time, North's voices became almost incessant, "chattering away nonsensically, like people at a cocktail party in the next room." Later still, by the time North was seventeen, the voices were issuing her orders to kill herself.

    Voices are a mark of schizophrenia, but they are only a part of the pain the disease inflicts. Patients are haunted by delusions -- false beliefs, like the conviction that the CIA is tracking one's every move -- and by hallucinations--voices, for one thing, as well as imaginary but utterly convincing nightmare mirages. "I could find no rest," a patient named Renee complained, "for horrible images assailed me, so vivid that I experienced actual physical sensation. I cannot say that I really saw images; they did not represent anything. Rather I felt them. It seemed that my mouth was full of birds which I crunched between my teeth, and their feathers, their blood and broken bones were choking me. Or I saw people whom I had entombed in milk bottles, putrefying, and I was consuming their rotten cadavers. Or I was devouring the head of a cat which meanwhile gnawed at my vitals. It was ghastly, intolerable."

    Almost in passing, as if it was scarcely worthy of singling out, Carol North described feeling "my skin turning gray and starting to slide off my forearms right there in the psychiatrist's office," and "molten blobs of thoughts [that] slipped off my skin and splatted onto the carpet in neat little paths."

    Look at a particular patient struck by schizophrenia and there is no dodging questions about where this strange disease came from. Why had it appeared when it did? Had it been lurking somewhere, unrecognized?

    Now consider not an individual patient but the history of the disease itself, and the same baffling questions arise. Did schizophrenia suddenly appear, or has it plagued mankind from the beginning? Look in the Bible and in Hippocrates and in dozens of other ancient texts and you find vivid descriptions of leprosy and epilepsy and a host of other illnesses. Where is schizophrenia? Today it is one of the most widespread mental illnesses, present in every culture in the world. Could a disease with such devastating and flamboyant symptoms really have been overlooked? And if it did suddenly appear out of nowhere, why then? Why there?

    The historical record is dotted with tantalizing, but equivocal, descriptions of diseases that sound as if they might have been schizophrenia. One sixth-century writer describes a woman who believed that she truly held the fate of the world in her hands -- unless she kept her fingers rigid, she feared, the world would be destroyed. In about the year 1000, the Persian physician Avicenna described a young prince who had become convinced he was a cow and begged to be killed "so that a good stew may be made from my flesh." In France in the fourteenth century, King Charles VI (Charles the Mad) suffered from the delusion that his legs were made of glass and that they might break at any moment.

    Strangely, there are no undisputed accounts of schizophrenia until the nineteenth century. Then, suddenly, there were two accounts in the same year, 1809, one by an English asylum-keeper and the other by a French physician. These early observers were especially struck by the disease's early onset, in adolescence. "In the interval between puberty and manhood," wrote John Haslam, superintendent of London's Bethlehem Hospital (the word "bedlam" comes from "Bethlem"), "I have painfully witnessed this hopeless and degrading change, which in a short time has transformed the most promising and vigorous intellect into a slavering and bloated idiot." New or not, this disease suddenly seemed to be everywhere. It became a scourge, and the embodiment of insanity.

    Frieda Fromm-Reichmann seemed an unlikely authority on such a daunting disease, but she was more formidable than she looked. Despite her grandmotherly facade, she was a zealous and highly disciplined worker, fueled by endless cigarettes and countless cups of coffee. The sense of duty had been implanted early. Fromm-Reichmann had been raised in a stern household, the oldest of three daughters, and the declared favorite of an imperious, never-to-be-crossed mother. The children grew up quiet, well mannered, neat, conscientious. Expectations were high; rebellion was unthinkable. "We had a wonderful, carefree childhood," the third daughter, Anna, recalled in her old age. "We were allowed to learn anything we wanted."

    Frieda, her mother's perfect child, excelled from the start, in her lessons and later at the University of Konigsberg, where she was one of only a few female students among hundreds of males. Though she devoted her life to an enterprise that Freud had deemed impossible, she insisted that she was no rebel. No disciple of Freud was more devout than she was, Fromm-Reichmann maintained, and she delighted in proclaiming Freud's trailblazing genius. With schizophrenia, it was not so much that Freud had gone astray as that he had, for once, sold psychoanalysis short.

    The great man's mistake was understandable, in Fromm-Reichmann's eyes. After all, nearly all his patients had been merely neurotic rather than psychotic. Freud had declared that schizophrenia was untreatable essentially because the patient was too disturbed to establish a working relationship with the therapist. Here was the key error, and Fromm-Reichmann spelled out the intellectual mistake that had led Freud astray.

    He had noted, correctly, that schizophrenics were "withdrawn, detached, and sometimes aggressively hostile," but he had misunderstood what he had seen. This retreat into a private world was not a primary, defining feature of schizophrenia. Instead, it was "a secondary result of very early serious warping of their relationships with the people significant in their environment in infancy and childhood."

    This was a message that carried enormous hope -- contrary to Freud, schizophrenic patients were not beyond help. The withdrawal from reality was only a symptom, a kind of mental wound. Schizophrenics had been hurt by the world, but they had come into it intact. The damage had come later.

    And so it could be undone. The key was a therapist with the patience and stamina to undo the patient's lifelong "warping." Identification between patient and therapist was possible. In an account of her own therapeutic successes at Chestnut Lodge, Frieda Fromm-Reichmann put the essential point in italics: "The schizophrenic has, above all, to be cured of the wounds and frustrations of his life before we can expect him to recover." The analyst Edith Weigert (who had analyzed Seymour Kety, the scientific director of the National Institute of Mental Health) described Fromm-Reichmann's technique in a bit more detail. She made it sound routine. Perched in her rocking chair and looking her patient squarely in the face, Fromm-Reichmann sat and listened, without judgment, without prejudice, without preconceptions. "Sooner or later the schizophrenic patient experienced that he was no longer alone, that here was a human being who understood, who did not turn away in estrangement or disgust," Weigert wrote. "This rare moment of discovery-unpredictable and unforeseen, like a gift of grace -- sometimes became a turning point in the patient's life. The gates of human fellowship were opened -- and thereby the slow way to recovery was opened also."

    This was a claim that was easy to assert but difficult to demonstrate. Fromm-Reichmann and Weigert and other psychotherapists talked blithely of cures and recovery, but they provided no evidence to back those claims. This is especially troubling because schizophrenia is a slippery disease. The problems begin at the beginning, with diagnosis. Even today, schizophrenia can be diagnosed only on the basis of symptoms -- hallucinations, delusions, severe apathy, and so on -- rather than on the basis of a blood test or a brain scan or any other objective measure that yields an indisputable label. The diagnosis is still made as it was a century ago, essentially by checking off boxes on a form.

    As a result, psychiatrists can disagree on whether a given patient is schizophrenic in the first place. Solomon Snyder, one of the most renowned of present-day psychiatrists, declares emphatically that even Fromm-Reichmann's prize patient, the author of I Never Promised You a Rose Garden, was not schizophrenic at all. "Anyone who has ever worked with schizophrenics for even a few weeks," Snyder insists, "knows that neither Vonnegut [Mark Vonnegut, author of The Eden Express, a first-person account of madness] nor Deborah in Rose Garden was schizophrenic."

    More confusing still, schizophrenia follows an unpredictable course. Even in the early years of this century, when there were essentially no treatments of any sort for schizophrenia, the rule of thumb was that one-third of all patients recovered, one-third improved, and one-third did not improve. This should have been an observation that made every psychiatrist cautious about making bold claims. Its plain meaning was that anecdotes and case histories were not enough. Any therapy that anyone dreamed up would be able to claim some successes.

    Fromm-Reichmann claimed that her approach to therapy derived from Freud's, but it was not quite so. As we have seen, Freud almost never dealt with schizophrenic patients. In spite of his amateur standing, however, he believed he had seen to the heart of the disease, thanks to an extraordinary patient he had never met. Daniel Paul Schreber was a German judge who spent thirteen years of his life in mental hospitals. The second and longest hospitalization began when Schreber was fifty-one and stretched nearly nine years, from 1893 until 1902. During those nine years, Schreber kept meticulous notes, and in 1903 he published a first-person narrative called Memoirs of My Nervous Illness.

    Schreber's "nervous illness" would be called paranoid schizophrenia today, and he told a remarkable, if barely comprehensible, tale. Schreber was assaulted by voices and other hallucinations and plagued by delusions -- he spoke with the sun, he was tormented by vampires, his body was gradually being transformed into a woman's. For years, he believed, God had directed a series of "rays" toward him; the rays had produced an endless number of painful effects that Schreber called "miracles." He had grown accustomed to this bizarre assault, he wrote, but "even now the miracles which I experience hourly are still of a nature to frighten every other human being to death."

    The aim of the book was to invite qualified scientists to examine Schreber so that they could see for themselves that his body was in fact changing itself from male to female. "What other people think are delusions and hallucinations," Schreber explained, were real changes, unprecedented in the course of human history and proof that God's powers were even greater than had been previously understood. Telling his story, Schreber believed, would spread these new religious truths and would "in the highest degree act fruitfully and as a blessing to mankind."

    Freud read Schreber's book in 1910 and published an essay on his case the following year. This was Freud's first report on a hospitalized mental patient. His argument was complex and, characteristically, explained not only Schreber's case but that of every (male) paranoiac. How to account for the paranoid schizophrenic's belief that the world is conspiring against him? That obsessive fear stems from the patient's unconscious homosexuality. Unable to acknowledge the proposition "I love him," the paranoiac protests too much and insists instead, "I hate him." This proposition, in turn, is unacceptable, because it forces the patient to see himself as poisoned by hate, and so it is transformed by one final twist into "He hates me." Voila!

    Fromm-Reichmann hailed Freud's insights, but in fact her approach to schizophrenia came closer to that of her friend and mentor Harry Stack Sullivan. Celebrated in the 1920s and '30s as one of America's best psychiatrists, Sullivan is nearly forgotten today. He was an odd character -- a college dropout, an alcoholic, a big spender who skipped out on his father's funeral to avoid being stuck with the bill. He could be "as tender as a pat of butter," one bemused colleague recalled, "or as maliciously attacking as an enraged cobra."

    Sullivan was a tall, thin, melancholy figure, "a lonely person from his earliest childhood," in the words of one of the speakers at his memorial service. Perhaps as a result, his psychological theories took as their central theme the hazards of dealing with other people. Where Freud had concentrated on conflicts within the individual, Sullivan emphasized the interactions between his patient and other people. "The individual is simply not the unit to study," in one commentator's summary of Sullivan's views, for the same reason that "an animal in a cage rather than its natural habitat" is not the right subject for a student of wildlife.

    Sullivan may have suffered bouts of schizophrenia himself -- he claimed this experience as the source of his insight into the disease -- but some biographers suspect he invented these stories. At any rate, he put his theories into practice beginning in 1929, at Baltimore's Sheppard and Enoch Pratt Hospital. There he organized a six-bed ward for young male schizophrenics, sealed off from the rest of the hospital.

    Sullivan chose the patients from among the hospital's population of schizophrenics, chose the six aides who dealt with them, and then gave this select staff detailed instructions on how to deal with their charges. The idea, simple verging on banal, was that the patients had fallen ill because of bad relationships with others and could therefore be restored to health by good relationships. The key was in choosing aides who were sensitive, kind, friendly, and, above all, trustworthy. This down-to-earth, optimistic, can-do strategy, with its emphasis on coping in the present rather than on resurrecting the past, Sullivan declared, was characteristically "American."

    The results were extraordinary. Sullivan claimed that about 80 percent of his patients had improved, though he was vague about defining "improvement." (This was not necessarily evasiveness. Sullivan's prose was always obscure and often impenetrable. "Intimacy," he declared, in one representative passage, "is that type of situation involving two people which permits validation of all components of personal worth.")

    Sullivan had begun his therapeutic career by deciding which bits of Freudian furniture to chuck overboard and which to hang on to. In treating schizophrenics, even many of the basics were unceremoniously rejected. Though he believed that dreams were akin to psychoses, he deemed dream analysis too risky for patients with such a flimsy attachment to the real world. To ask for free associations from a patient who heard werewolves talking to him was to throw gasoline on a fire.

    Nor did other classical Freudian techniques seem useful to Sullivan. The therapist could not sit out of view in near-total silence, for example, content to reflect his patient's remarks back to him. (Fromm-Reichmann sat next to her patients, not behind them like Freud, so that they could see one another.) The fifty-minute hour, too, was abandoned as too restrictive. The therapist might be obliged to engage her patient for hours at a time. Making matters still more difficult, these deeply disturbed people, unlike neurotics, did not see their therapist as an ally. Having fled the world in favor of a self-created one, they resisted all efforts to bring them back. "Like the animal in the woods fleeing before a predatory foe," the psychiatrist John Rosen declared in a 1952 essay, "the patient fights with all the skill of his instincts."

    Therapy sessions were frequently unrewarding, resembling nothing so much as bleak scenes from Beckett. Schizophrenic speech was a "word salad," with recognizable bits tossed together any old way. Or schizophrenics talked "ragtime," careening at high speed through some idiosyncratic encyclopedia. Sometimes they did not talk at all. "In working with these patients," one of Fromm-Reichmann's colleagues explained, "the therapist eventually gets to do some at least private mulling over of the possible meanings of a belch, or the passage of flatus, not only because he is reduced to this for lack of anything else to analyze, but also because he learns that even these animal-like sounds constitute forms of communication in which, from time to time, quite different things are being said, long before the patient can ... say them in words."

    Fromm-Reichmann herself did not go quite so far in interpreting her patients' words and silences. She did insist, however, on the value of the "symptoms as symbols" approach. For four years, while still in Europe, she and her then husband, Erich Fromm, had run a private psychoanalytic hospital where they had worked closely with Georg Groddeck, perhaps the greatest advocate of the disease-deciphering school. Fromm-Reichmann remained a devoted admirer of Groddeck throughout her life. He had "a profound influence on her thinking and work with psychotics," one colleague noted, and she insisted that her students study Groddeck's writings and be prepared to discuss them. Fromm-Reichmann dedicated her only book, Principles of Intensive Psychotherapy, to her four "teachers," the German psychiatrist Kurt Goldstein and Freud, Sullivan, and Groddeck.

    Well before Frieda Fromm-Reichmann came along, psychiatrists had made sporadic attempts to pin the blame for schizophrenia on something that had gone wrong in the family. In 1934, for example, one group of investigators reported that "in a series of 45 unselected [i.e., random] cases maternal over-protection or rejection was present in sixty percent of the cases." But the studies were hard to credit. Most involved tiny numbers or unrepresentative populations, and all were marred by vagueness and an almost total lack of methodological rigor. One 1936 study focused on kings and found that twice as many insane as sane kings had lost their fathers early in life. In 1940, a psychoanalyst reported on four female schizophrenics she had treated. All four suffered, she said, from having had cold, sadistic mothers and soft, indifferent fathers who were merely "imitation" parents.

    Then, in 1948, the parent-blaming idea surfaced again. This time it came with a celebrity endorsement. Writing in Psychiatry, a journal founded by Harry Stack Sullivan, Frieda Fromm-Reichmann published a paper called "Notes on the Development of Treatment of Schizophrenics by Psychoanalytic Psychotherapy." She began with her familiar claim that, contrary to Freud, schizophrenics could be treated by talk therapy. Then, almost in passing, in one short phrase tacked on the end of a long sentence, Fromm-Reichmann coined a phrase that would reverberate for a quarter-century.

    "The schizophrenic is painfully distrustful and resentful of other people," she wrote, "due to the severe early warp and rejection he encountered in important people of his infancy and childhood, as a rule, mainly in a schizophrenogenic mother." That phrase "schizophrenogenic mother" -- literally, schizophrenia-producing mother -- would be taken up as the drumbeat accompanying psychiatrists into battle against the enemy. For decades, it would sound in the ears of parents who felt that they were the enemy.

    Less than a year later, with people's ears perked up, Psychiatry carried an article amplifying Fromm-Reichmann's remark. Here bad mothers would not be dismissed in a phrase. This time they would be poked and prodded at leisure.

    The new paper, written in awkward English by a Viennese-educated psychiatrist named Trude Tietze, bore the innocuous title "A Study of Mothers of Schizophrenic Patients." Unlike Freud, who had focused all his attention on the schizophrenic himself, Tietze drew back and took a broader look. With that new perspective, everything fell into place. What suddenly appeared, Tietze realized, was not simply an individual with problems of his own but an individual caught up in a family beset with problems.

    It was a paper with a tremendous influence, and it merits a close look. Tietze, at Baltimore's Johns Hopkins Hospital, had interviewed the mothers of twenty-five adult, hospitalized schizophrenics. They were, Tietze made clear at once, a very peculiar bunch. "All the mothers were tense and anxious people who tried to conceal their anxiety, some with more success than others. They described themselves as `nervous,' `high-strung,' `shaking inside,' and `always anticipating impending disaster.'" None had ever been hospitalized for mental illness or even seen a psychiatrist, but "all of the mothers were fundamentally insecure people, who could feel relatively secure only if they could control the situation."

    Despite their similarities, Tietze wrote, the mothers differed in key ways, especially in their dealings with Tietze herself. Five of the women "openly tried to dominate the situation by over-demanding behavior. They remained superficially friendly and polite but were very hostile and resented the psychiatrist." The larger group, seventeen mothers, "appeared docile and submissive, smiling, yet not laughing, their fleeting smile often changing to a frozen grimace." But Tietze soon realized that they, too, resisted her questioning. "Their friendliness and effervescence were superficial and they tended to hide their anxiety and keep the interviewer at arm's length."

    Here, barely into her paper, Tietze adopted an adversarial tone that grew steadily more marked as she went along. She seemed especially irritated by the larger, eager-to-please group. The mothers apparently did not know they were acting strangely -- "they seemed quite unaware of their own hostility and of the unconscious motivation of their behavior" -- but Tietze was determined not to be taken in by their performance. "Once their superficial smiling front was broken through," she wrote, "one was appalled by the emotional emptiness one found. There was a lack of genuine warmth."

    To demonstrate this two-facedness, Tietze rattled off a long list of particulars. "These mothers `cooperated' to the letter with the psychiatrist; they kept their appointments, snow, rain, or hail. They were always on time, always apologetic of taking so much of the doctor's time, always profusely thanking at the end of the interview. They tried in every possible way to ingratiate themselves and to make the best possible impression on the doctors. They acted like `model patients.'" But Tietze saw through their little game. "They went, however, only through the motions -- of themselves they gave little."

    Tietze's indictment continued:

They tended to become solicitous about the interviewer whenever an opportunity presented itself. They frequently commented on the hard life of a psychiatrist; if it was raining and they did not see rubbers or an umbrella in the office, they expressed their concern lest the doctor catch a cold. Every holiday was remembered with a sweet lime card, and they frequently placed little notes or presents on the doctor's desk. They never directly asked for any favors; they would ask exactly how long they should visit their children and would carry out any suggestion to the letter, thus often reducing advice to absurdity. Their attitude was: "You are the doctor and you know best."

    It does not seem an outlandish attitude for mothers whose children were victims of an overwhelming and mysterious disease, but Tietze would have none of it. "They did not seem to be aware of the burden and responsibility they put on the physician," she complained. "By their seeming surrender in what looked like a dependent relationship they dominated the situation in a subtle way and put the psychiatrist under some strain."

    Her irritation grew plainer. These mothers, supposedly so eager to help, seemed not to grasp what Tietze was after. "It was impossible to obtain accurate data in regard to onset and completion of toilet training of their children," Tietze reported. "The prevailing reaction of the mothers to this question was a mixture of amazement and irritation." Nor were they forthcoming about their own private lives. "The majority of mothers were reluctant to discuss their sex life with the psychiatrist," Tietze observed.

    When the mothers did volunteer personal information, Tietze refused to take at face value what sounded remarkably like maternal devotion. "The children were uniformly described as `placid, lovable, cuddling babies,'" she acknowledged, but in the same sentence she explained away this behavior: the babies' "helplessness and complete dependency on their mothers seemed to have been a source of considerable gratification."

    Even the way these women had responded to their child's illness struck Tietze as misguided. "The acute onset of the psychosis came as an unexpected shock to the mothers, who suddenly felt that they had lost their children," she wrote. "They felt defeated and utterly frustrated and made frantic attempts to retrieve their children. Five mothers spontaneously stated that they would rather see their schizophrenic children dead than insane."

    Another observer might have seen that maternal shock and despair as predictable. These were, after all, parents whose once-healthy children were in the chronic ward of a mental hospital where they would likely live out their lives, victims of a disease that had descended without warning. Death, these parents may have felt, would at least have ended their child's suffering.

    Tietze took a different view. The key to the children's illness was their mothers' "rejection." These "sick" women had never had an instinctive rapport with their sons and daughters. "It is this intuition or empathy with the child that appears to be missing or inadequately developed in the relationship of the mothers here under discussion to their schizophrenic children," she wrote.

    That lack was crucial. Now Tietze explained why she had focused so much attention on the mothers' attempts to control their interviews with her. Such manipulativeness was not simply irritating; it was literally maddening. "It is the subtly dominating mother who appears to be particularly dangerous to the child," Tietze reported. "Her methods of control are subtle and therefore do not provoke open rebellion as undisguised domination may. The children exposed to this form of subtle domination under the disguise of maternal love and sacrifice are deprived of any outlet of their aggressive impulses."

    By scrutinizing her twenty-five subjects, Tietze believed she had found a universal pattern. "All schizophrenic patients who were in good enough contact to reality and who formed a reasonably good relationship with their psychiatrist expressed a feeling of rejection by their mothers."

    It was an extraordinary paper, and it had an extraordinary impact. Almost immediately, it was hailed as "the most thorough-going research into the nature of parent-child relationships in schizophrenia," and even after a decade it remained "perhaps [the] best known" of what was by then a flood of articles on schizophrenogenic mothers.

    Nonetheless, a close reading makes clear that this was an intellectually shabby performance. Tietze never acknowledged, let alone sorted out, a crucial chicken-and-egg question -- were these children schizophrenic because their mothers were overanxious and overbearing, or were the mothers frantic and jumpy because their children were schizophrenic?

    In addition, though she took every opportunity to hammer home her view that rejection by the mother was at the heart of schizophrenia, Tietze dismissed seemingly contradictory evidence without discussion. She wondered, for example, if children who became schizophrenic had been welcome additions to the family. She found, presumably to her surprise, that "definitely unwanted siblings of the schizophrenic patient, who himself was planned and wanted, turned out to be the best adjusted members of the family." That odd finding, which might well have brought matters to a screeching halt, turned out not to merit even a raised eyebrow, Tietze was on to other matters in the very next sentence.

    The paper's most serious weakness was another sin of omission. Tietze carried out her study without a "control" group -- a comparison group of mothers that would have let her sort out whether the strange behavior she saw was something peculiar to those who had raised schizophrenic children. "In order to arrive at valid conclusions," she acknowledged blithely, "it would be necessary to compare the twenty-five mothers of this series with a control group consisting of mothers who have never produced a schizophrenic child." Necessary or not, Tietze plowed ahead. "To obtain such a control group," she noted simply, "met with insurmountable difficulties."

    She decided to make a different comparison. Working from the assumption that bad mothers produced mentally ill children, Tietze tried to sort out what made some mothers more dangerous than others. She looked at her twenty-five women and divided them into two groups. Group A consisted of all those mothers whose healthy children outnumbered their schizophrenic children. These mothers, perhaps, had some redeeming qualities. Group B was a grimmer bunch. It was made up of all those mothers whose only child was schizophrenic, or who had one schizophrenic child and one healthy one. (Two of the twenty-five mothers had two schizophrenic children; those two women were in Group B.)

    That odd comparison, the only one that Tietze undertook, "revealed no significant quantitative or qualitative differences" between the two groups of mothers. The question why some children became schizophrenic and others "escaped" their fate, Tietze acknowledged, "remains still open."

    Tietze had not been a major figure in psychiatry, and she did not become one. But the snowball she threw started an avalanche. Within a year or two, the idea of the "bad mother" had become a commonplace that scarcely required demonstration. A 1951 paper on male schizophrenics, in the American Journal of Psychiatry, captured the matter-of-fact tone. "There is a common belief in the field of mental hygiene," the authors declared in the paper's first sentence, "that mothers of schizophrenic boys are `overprotective, oversolicitous, domineering, overanxious, and/or rejecting.'" So unremarkable was this observation that it did not even rate a footnote. In two years, an untested claim had become something that "everyone knew."

    Psychiatrists rushed to endorse the new insight, delighted that someone had finally unraveled the greatest riddle confronting them. Psychiatry had finally found a way to help schizophrenics -- since the disease was caused by parental misdeeds, it could be treated by helping patients come to terms with their upbringing. But this was a discovery with theoretical implications at least as great as the practical ones. For everyone recognized that talk therapy was too expensive, too difficult, and too slow a treatment to transform the lives of the nation's 1 million-plus schizophrenics.

    The excitement was that the thing could be done at all, not that it could be done on a mass scale. If a meticulous craftsman had succeeded, after years of labor, in building an antigravity machine, it would have been churlish to ask how much it would cost to put one in every garage. Psychoanalysis had built its antigravity machine.

    Where medicine had been baffled for more than a century, where even the greatest names in psychiatry's pantheon had thrown up their hands in bewilderment, Freud's descendants had proved triumphant. Psychoanalysis had done the undoable. This was not merely good news for a particular group of patients; it was good news for psychoanalysis, a validation of this modern therapy in its confrontation with an implacable foe.

    Paper after paper spelled out the new doctrines. One could read lists of the traits of the schizophrenogenic mother. She was "guileful and potentially deceitful," "self-indulgent," "irritable," "sarcastic and cynical," "ostentatious," and "exhibitionistic." She was "characterized by a thorough-going Machiavellianism which is employed in the service of a rather unlikable egocentricity. Other people, and this includes her child, seemingly exist only to serve her own ends and are consequently manipulated and exploited -- or ignored."

    The vogue lasted for decades. In a survey of the medical literature produced between the late 1940s and the early '70s, the psychiatrist John Neill counted more than seventy-five papers on schizophrenogenic mothers, as well as numerous books and book chapters. The idea that mothers produced schizophrenia in their children enjoyed "enormous popularity," Neill wrote, and was "standard practice" on both sides of the Atlantic. Over the course of the same decades Neill found only two cautionary articles, both by the same author.

    Not surprisingly, parents were not as taken by the new theories as the psychiatrists were. In Tietze's 1949 paper, for example, she had noted that when the project began, "the immediate response of all [the] mothers was one of curiosity, optimism, and appreciation of the interest taken in their children and themselves." But the mothers soon had their hackles up. "Their enthusiasm ... waned when the meaning of interpersonal relationship and its implication dawned on them."

    Tietze paid little heed. She had expected mothers to try to wriggle out from under the burden of blame. Who would rush to embrace the painful truth that she had caused her child's illness? The sicker the child, Tietze found, the harder the mother fought to resist the truth. "Those mothers whose children had been irretrievably withdrawn for years and who had little hope for recovery," she wrote, "were reluctant to accept the importance of environmental influences and preferred to believe in constitution and heredity as etiologic factors."

    There was little difference, Tietze's tone implied, between such a misguided mother and a toddler who "preferred to believe" in Santa Claus or the Easter Bunny. But not all psychiatrists were as dismissive as Tietze. There was a risk, a few writers acknowledged, that what began as devotion to patients could become an attack on parents. That would be unfortunate, everyone agreed -- after all, these parents had been done wrong by their parents, and so on up the line -- so there was no point in assigning blame.

    But if it was a mistake, they went on, it was a natural, understandable, forgivable one. To side with patients against the parents who had victimized them, Fromm-Reichmann's protege Don Jackson observed, was a "warmly human error."

    Ironically, it was Fromm-Reichmann's undeniable warmth that gave the notion of the schizophrenogenic mother much of its staying power. Modest, wise, experienced, Fromm-Reichmann was as far from mean-spirited as a person could be. Her aim was to relieve pain, not to score ideological points or hand down indictments. If even she saw parents as culprits, it was hard to imagine that they were not guilty as charged.

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Table of Contents

PROLOGUE In Search of El Dorado

PART ONE: FREUD

CHAPTER ONE The Gospel According to Freud

CHAPTER TWO The Power of Conviction

PART TWO: THE HEYDAY OF PSYCHOANALYSIS

CHAPTER THREE The High Ground

CHAPTER FOUR Hope and Glory

PART THREE: SCHIZOPHRENIA

CHAPTER FIVE The Mother of the "Schizophrenogenic Mother"

CHAPTER SIX Dr. Yin and Dr. Yang

CHAPTER SEVEN From Bad Mothers to Bad Families

CHAPTER EIGHT Ice Picks and Electroshocks

CHAPTER NINE The Tide Turns

PART FOUR: AUTISM

CHAPTER TEN A Mystery Proclaimed

CHAPTER ELEVEN The Buchenwald Connection

CHAPTER TWELVE The Scientists

CHAPTER THIRTEEN The Parents

CHAPTER FOURTEEN Parent-Blaming Put to the Test

EPILOGUE Current Theories of Autism

PART FIVE: OBSESSIVE-COMPULSIVE DISORDER

CHAPTER FIFTEEN Enslaved by Demons

CHAPTER SIXTEEN Freud Speaks

CHAPTER SEVENTEEN The Biological Evidence

PART SIX: CONCLUSION

CHAPTER EIGHTEEN Placing the Blame

NOTES

BIBLIOGRAPHY

ACKNOWLEDGMENTS

INDEX

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First Chapter

We think of a schizophrenic as a person who has had serious traumatic experiences in early infancy at a time when his ego and its ability to examine reality were not yet developed.

- Frieda Fromm-Reichmann

At night, when the mental hospital grew quiet, the tormentors emerged. They were plain as day to their victim -- plain as devils, really -- but he alone could see or hear them. Night after night, he leapt from his bed, terrified, pleading for mercy in a mélange of English, French, German, and Hebrew, scrambling atop the bureau in a frenzied attempt at escape, retreating from there to the desk, to the chair, to the bed again, to the bureau, all the time jabbering in a torment of fear. Trailing behind him, struggling to make her own way across the furniture, was the slower, clumsier figure of a tiny middle-aged woman. She was Frieda FrommReichmann, one of America's most renowned psychiatrists. She did not see any phantoms, she tried to reassure her patient as she, too, switched from language to language, but if and when she caught sight of them, she would do her best to protect him.

In the battle against schizophrenia, Fromm-Reichmann was in the front lines. She made an unlikely warrior. Only four feet ten, plump, down-to-earth, she looked like a grandmother sent over from central casting. A German Jewish refugee, she had come to the United States in 1935. There she spent her career at Chestnut Lodge, a renowned private mental hospital in the suburbs of Washington, D.C., devoted to the psychoanalytic treatment of psychotic patients. She had originally been hired for two months, as a summer replacement, but those two months stretched to twenty-two years, ending only with Fromm-Reichmann's death from a stroke in 1957.

By that time, she was known throughout the psychiatric community as a wise and kindly therapist. But she was more than that. For venturing to take on madness in its most virulent form, and for emerging victorious, the diminutive Fromm-Reichmann had earned a towering reputation. The psychiatrist Robert Coles, himself a moral exemplar for a later generation, spoke for his peers when he lauded her as a "hero." The best-selling novel I Never Promised You a Rose Garden, published in 1964, spread her reputation to the general public. Written by a former patient, Joanne Greenberg, it portrayed Fromm-Reichmann as the savior who had delivered her from schizophrenia. Fromm-Reichmann was "Clara Fried," remarkable in equal measure for her brilliance and her empathy. "After you know her for a while," one of the novel's bedazzled psychiatrists remarks, "you'll find out that with little Clara Fried, brains are only the beginning."

But Fromm-Reichmann left a complex legacy. On the one hand, she confronted schizophrenia head-on -- as we have noted, even Freud had blinked when he looked at schizophrenia -- but indomitability was only half the story. Equally important, she introduced an essential new element into the schizophrenia picture. This new element was blame, and it would come to dominate the canvas.

Schizophrenia was not an organic condition, Fromm-Reichmann argued, despite the contrary views of the nineteenth century's most eminent psychiatrists. Nor did she devote a great deal of time to Freud's speculations on the psychological origins of schizophrenia, though she dutifully paid them homage. Fromm-Relchmann's view was simpler, and it would soon become gospel, passed along and embellished by a series of distinguished disciples over the course of the 1950s and '60s. The message was that schizophrenia was man-made. To be precise, it was woman-made. A schizophrenic was shaped by human hands, as much a product of human craft as a reed basket or a clay pot. In the case of schizophrenia, Fromm-Reichmann proclaimed, those shaping hands belonged to mother.

From her medical school days, Fromm-Reichmann had found herself drawn to treating schizophrenics. Unflappable and unafraid, she insisted on seeing patients alone, even the paranoid and violent ones. To bring along an aide for protection, she insisted, would be disrespectful to her patients. Successful treatment was not a matter of adhering to particular techniques or doctrines, she believed, and she disdained "technical rules." What was crucial was "the basic attitude of the individual therapist toward psychotic persons. If he meets them as strange creatures of another world whose productions are not understandable to 'normal' beings, he cannot treat them. If he realizes, however, that the difference between himself and the psychotic is only one of degree and not of kind, he will know better how to meet him."

Madness could be understood just as dreams could be, but virtuoso displays of intellectual acrobatics were not Fromm-Reichmann's style. A schizophrenic patient who was "aloof, detached, and uncommunicative," for example, might simply be "protecting himself from additional fear and potential hostility." "It is certainly not an intellectual comprehension of the schizophrenic but the sympathetic understanding and skillful handling of the patient's and physician's mutual relationship that are the decisive therapeutic factors," she declared. (Italics in original.)

It was a philosophy that was easier to espouse than to enact. It took eighteen months, for example, before one patient at Chestnut Lodge would stop shouting, "You dirty little stinking bitch" and "You damned German Jew; go back to your Kaiser!" and "I wish you had crashed in that plane you took!" Fromm-Reichmann was not one to posture, and she told such stories not to portray herself as noble or long-suffering but in passing, on the way to some other point. In trying to sort out her own "irrational" fear of one patient, for example, she noted that "it is true that she threatened repeatedly to hit me or to throw stones at me," but she also pointed out that the threats had never materialized. Indeed, "very little actually happened except for a few slaps in my face."

Her fellow therapists marveled at the imperturbability of this "well-brought-up, refined, upper-middle-class, German Jewish lady," as one of them described her, no matter the behavior that confronted her. "One day, during a therapeutic hour, as this patient (mute, as usual) was sitting with Dr. Fromm-Reichmann in her office," a colleague recalled, "she noticed that he was fingering his genitals with one hand that was crammed deep into the pocket of his trousers. It was also plain to her that he had an erection. She pondered this situation for a moment, then said to him, 'If it will make you feel any better, please go ahead.' Whereupon the young man unzipped his fly and proceeded to masturbate, while Dr. Fromm-Reichmarm sat quietly across from him, her eyes down, her hands clasped in her lap."

Fromm-Reichmann would "sit in a patient's urine with him to show there was no difference between them," another colleague recalled. "Or a patient would give his feces as a gift, and she would take them."

Small wonder that those psychiatrists willing to take on schizophrenia were more often hailed by their peers than emulated. Schizophrenic patients were hard to reach, quite likely poor and disheveled, and perhaps violent. Treatment was likely to be prolonged, difficult, and, worst of all, unsuccessful. What psychiatrist would not prefer a succession of grateful ladies and gentlemen in business attire, who kept their appointments, paid their bills, and eventually moved along?

But to think of schizophrenia as simply a difficult disease is to understate the point woefully. It is relatively common, more prevalent than Alzheimer's disease or multiple sclerosis, and its horrors moved even the experts to shake their heads in awe. They rattled off the bare facts easily enough -- schizophrenia affected about one person in a hundred; it tended to strike between ages seventeen and twenty-five; it afflicted men and women in equal numbers, although men fell ill at a younger age -- but even in austere medical journals, they sometimes interrupted their measured prose with a more heartfelt passage.

"Schizophrenia is the cancer of psychiatry," one authority declared, and its victims were "in truly terrible trouble." Another called the disease an "awesome holocaust" that left in its wake a trail of "tragic human debris."

It is a holocaust that we, safe at home, can scarcely imagine. In truth, the challenge is even greater than it first appears. Illness is a foreign country, it has been observed, and we read travelers' tales of their journeys there with mingled fear and fascination. But mental illness is unlike cancer or heart disease or many other afflictions, since it directly affects the way its victims perceive the world. The result is that the very people who know madness best -- the natives of this strange land, so to speak -- may scarcely be able to describe it in terms the rest of us can grasp.

On the other hand, we cannot do without such guidance. We can imagine ourselves paralyzed or blind or deaf, perhaps, but almost by definition we cannot think clearly about what it would mean to think chaotically. How to imagine being caught in seething white water if all we have ever known is a gently burbling stream?

And so we turn to the natives. Listen to Carol North, for example, in a passage from Welcome, Silence, her memoir of schizophrenia. One day North happened to see a piece of glass from a broken Coke bottle:

There was a message here. I was supposed to use the glass edge to rip away the flesh of my feet to get a view of the machines inside, which would provide a parallel view into the workings of the Other Dimensions....Although the connection was subtle, I was astute; I could see the master plan here....

Eagerly I sat down and began to carve into the top of my foot with a piece of green glass. It wasn't easy, because the glass was so rough. I was surprised at the toughness of my skin. I made several gouges, not even slicing through the long tendons running the length of the top of my foot. A few drops of blood oozed forth, then the wounds just sort of lay there doing nothing. I poked around in them with my finger, trying to get beneath the skin edges to probe into the machinery inside, but the skin was tenacious and hung tightly to my underlying flesh. I pulled the wounds as far open as they would stretch, but I couldn't see any machines inside. The humming stopped. I had missed my chance.

That strange tone, that "juxtaposition of lunacy and sanity," in the words of the psychiatrists Paul Wender and Donald Klein, is telltale. A person brain-damaged in a car crash, say, might be damaged across the board. In contrast, the schizophrenic's mind is a hodgepodge, a surrealist painting that mixes the most bizarre hallucinations and delusions with the most everyday of images. A schizophrenic might believe that he sees dragons climbing out of the walls and yet be able to read the morning newspaper.

Even a lifetime of familiarity does not tame the onlooker's sense of eeriness. "My son is crazy and he's not crazy," says Irma Cardozo-Freeman, a professor of literature and folklore at Ohio State University and the mother of a fifty-year-old schizophrenic. "I can't explain it. He can sit down and write an essay without an irrational thought in it, and yet he's irrational. Not always, but most of the time. He thinks Mick Jagger and Miles Davis talk to him through the radio. Sometimes," she concludes wearily, "I think my son is possessed."

Poignantly, there may be stretches of insight and self-awareness. I recall one schizophrenic man, first diagnosed at age eleven and forty-seven at the time I met him during one recent winter. He lived alone in a single room, the thermostat set to eighty, his mattress in the center of the room and surrounded by teetering stacks of newspapers and books and mounds of dirty clothes. He was able to function on his own -- indeed, he was quite bright -- but he lurched from topic to topic and spoke in a peculiar singsong, some words long and drawn out and then whole phrases rattled-off-at-high-speed-and-squeezed-into-a-single-breath. "A psychiatrist told me once," he recounted as matter-of-factly as if he were commenting on the weather, "that I would always come across like a phonograph record that someone had left lying in the sun."

Despite the odds, there are many firsthand accounts of insanity. The best are vivid and compelling, though the mere act of providing an understandable description imposes an artificial order, just as a dream recounted to someone else never has the sweep and taken-for-granted strangeness of the original.

The dream analogy is almost unavoidable. Like elements in a dream landscape, for instance, mundane fragments of a schizophrenic's world can suddenly take on a hypnotic vividness. "Environmental stimuli constantly bombarded my senses with unrelenting, nearly unbearable intensity," Carol North recalled. "I spent hours marveling at the texture of the bricks on the buildings, at the intricate moving patterns of the moonlight on the river, at the folds of bark on trees, at designs dancing over the ballroom carpet in the [student] Union, even at the fine weave in my jeans. These were no ordinary designs and patterns; they were pregnant with meaning."

A recovered schizophrenic named Norma MacDonald recounted a similar sensory bombardment. "The walk of a stranger on the street could be a 'sign' to me which I must interpret. Every face in the windows of a passing streetcar would be engraved on my mind, all of them concentrating on me and trying to pass me some sort of message." Often the messages were more overt. Carol North had been tormented by strange voices since she was six years old. She believed that everyone heard voices; no one talked about them, she assumed, because voices, like bodily functions, were private. In time, North's voices became almost incessant, "chattering away nonsensically, like people at a cocktail party in the next room." Later still, by the time North was seventeen, the voices were issuing her orders to kill herself.

Voices are a mark of schizophrenia, but they are only a part of the pain the disease inflicts. Patients are haunted by delusions -- false beliefs, like the conviction that the CIA is tracking one's every move -- and by hallucinations -- voices, for one thing, as well as imaginary but utterly convincing nightmare mirages. "I could find no rest," a patient named Renée complained, "for horrible images assailed me, so vivid that I experienced actual physical sensation. I cannot say that I really saw images; they did not represent anything. Rather I felt them. It seemed that my mouth was full of birds which I crunched between my teeth, and their feathers, their blood and broken bones were choking me. Or I saw people whom I had entombed in milk bottles, putrefying, and I was consuming their rotten cadavers. Or I was devouring the head of a cat which meanwhile gnawed at my vitals. It was ghastly, intolerable."

Almost in passing, as if it was scarcely worthy of singling out, Carol North described feeling "my skin turning gray and starting to slide off my forearms right there in the psychiatrist's office," and "molten blobs of thoughts [that] slipped off my skin and splatted onto the carpet in neat little paths."

Look at a particular patient struck by schizophrenia and there is no dodging questions about where this strange disease came from. Why had it appeared when it did? Had it been lurking somewhere, unrecognized?

Now consider not an individual patient but the history of the disease itself, and the same baffling questions arise. Did schizophrenia suddenly appear, or has it plagued mankind from the beginning? Look in the Bible and in Hippocrates and in dozens of other ancient texts and you find vivid descriptions of leprosy and epilepsy and a host of other illnesses. Where is schizophrenia? Today it is one of the most widespread mental illnesses, present in every culture in the world. Could a disease with such devastating and flamboyant symptoms really have been overlooked? And if it did suddenly appear out of nowhere, why then? Why there?

The historical record is dotted with tantalizing, but equivocal, descriptions of diseases that sound as if they might have been schizophrenia. One sixth-century writer describes a woman who believed that she truly held the fate of the world in her hands -- unless she kept her fingers rigid, she feared, the world would be destroyed. In about the year 1000, the Persian physician Avicenna described a young prince who had become convinced he was a cow and begged to be killed "so that a good stew may be made from my flesh." In France in the fourteenth century, King Charles VI (Charles the Mad) suffered from the delusion that his legs were made of glass and that they might break at any moment.

Strangely, there are no undisputed accounts of schizophrenia until the nineteenth century. Then, suddenly, there were two accounts in the same year, 1809, one by an English asylum-keeper and the other by a French physician. These early observers were especially struck by the disease's early onset, in adolescence. "In the interval between puberty and manhood," wrote John Haslam, superintendent of London's Bethlehem Hospital (the word "bedlam" comes from "Bethlem"), "I have painfully witnessed this hopeless and degrading change, which in a short time has transformed the most promising and vigorous intellect into a slavering and bloated idiot." New or not, this disease suddenly seemed to be everywhere. It became a scourge, and the embodiment of insanity.

Frieda Fromm-Reichmann seemed an unlikely authority on such a daunting disease, but she was more formidable than she looked. Despite her grandmotherly facade, she was a zealous and highly disciplined worker, fueled by endless cigarettes and countless cups of coffee. The sense of duty had been implanted early. Fromm-Reichmann had been raised in a stern household, the oldest of three daughters, and the declared favorite of an imperious, never-to-be-crossed mother. The children grew up quiet, well mannered, neat, conscientious. Expectations were high; rebellion was unthinkable. "We had a wonderful, carefree childhood," the third daughter, Anna, recalled in her old age. "We were allowed to learn anything we wanted."

Frieda, her mother's perfect child, excelled from the start, in her lessons and later at the University of Königsberg, where she was one of only a few female students among hundreds of males. Though she devoted her life to an enterprise that Freud had deemed impossible, she insisted that she was no rebel. No disciple of Freud was more devout than she was, Fromm-Reichmann maintained, and she delighted in proclaiming Freud's trailblazing genius. With schizophrenia, it was not so much that Freud had gone astray as that he had, for once, sold psychoanalysis short.

The great man's mistake was understandable, in Fromm-Reichmann's eyes. After all, nearly all his patients had been merely neurotic rather than psychotic. Freud had declared that schizophrenia was untreatable essentially because the patient was too disturbed to establish a working relationship with the therapist. Here was the key error, and Fromm-Reichmann spelled out the intellectual mistake that had led Freud astray.

He had noted, correctly, that schizophrenics were "withdrawn, detached, and sometimes aggressively hostile," but he had misunderstood what he had seen. This retreat into a private world was not a primary, defining feature of schizophrenia. Instead, it was "a secondary result of very early serious warping of their relationships with the people significant in their environment in infancy and childhood."

This was a message that carried enormous hope -- contrary to Freud, schizophrenic patients were not beyond help. The withdrawal from reality was only a symptom, a kind of mental wound. Schizophrenics had been hurt by the world, but they had come into it intact. The damage had come later.

And so it could be undone. The key was a therapist with the patience and stamina to undo the patient's lifelong "warping." Identification between patient and therapist was possible. In an account of her own therapeutic successes at Chestnut Lodge, Frieda Fromm-Reichmann put the essential point in italics: "The schizophrenic has, above all, to be cured of the wounds and frustrations of his life before we can expect him to recover." The analyst Edith Weigert (who had analyzed Seymour Kety, the scientific director of the National Institute of Mental Health) described Fromm-Reichmann's technique in a bit more detail. She made it sound routine. Perched in her rocking chair and looking her patient squarely in the face, Fromm-Reichmann sat and listened, without judgment, without prejudice, without preconceptions. "Sooner or later the schizophrenic patient experienced that he was no longer alone, that here was a human being who understood, who did not turn away in estrangement or disgust," Weigert wrote. "This rare moment of discovery -- unpredictable and unforeseen, like a gift of grace -- sometimes became a turning point in the patient's life. The gates of human fellowship were opened -- and thereby the slow way to recovery was opened also."

This was a claim that was easy to assert but difficult to demonstrate. Fromm-Reichmann and Weigert and other psychotherapists talked blithely of cures and recovery, but they provided no evidence to back those claims. This is especially troubling because schizophrenia is a slippery disease. The problems begin at the beginning, with diagnosis. Even today, schizophrenia can be diagnosed only on the basis of symptoms -- hallucinations, delusions, severe apathy, and so on -- rather than on the basis of a blood test or a brain scan or any other objective measure that yields an indisputable label. The diagnosis is still made as it was a century ago, essentially by checking off boxes on a form.

As a result, psychiatrists can disagree on whether a given patient is schizophrenic in the first place. Solomon Snyder, one of the most renowned of present-day psychiatrists, declares emphatically that even Fromm-Reichmann's prize patient, the author of I Never Promised You a Rose Garden, was not schizophrenic at all. "Anyone who has ever worked with schizophrenics for even a few weeks," Snyder insists, "knows that neither Vonnegut [Mark Vonnegut, author of The Eden Express, a first-person account of madness] nor Deborah in Rose Garden was schizophrenic."

More confusing still, schizophrenia follows an unpredictable course. Even in the early years of this century, when there were essentially no treatments of any sort for schizophrenia, the rule of thumb was that one-third of all patients recovered, one-third improved, and one-third did not improve. This should have been an observation that made every psychiatrist cautious about making bold claims. Its plain meaning was that anecdotes and case histories were not enough. Any therapy that anyone dreamed up would be able to claim some successes.

Fromm-Reichmann claimed that her approach to therapy derived from Freud's, but it was not quite so. As we have seen, Freud almost never dealt with schizophrenic patients. In spite of his amateur standing, however, he believed he had seen to the heart of the disease, thanks to an extraordinary patient he had never met. Daniel Paul Schreber was a German judge who spent thirteen years of his life in mental hospitals. The second and longest hospitalization began when Schreber was fifty-one and stretched nearly nine years, from 1893 until 1902. During those nine years, Schreber kept meticulous notes, and in 1903 he published a first-person narrative called Memoirs of My Nervous Illness.

Schreber's "nervous illness" would be called paranoid schizophrenia today, and he told a remarkable, if barely comprehensible, tale. Schreber was assaulted by voices and other hallucinations and plagued by delusions -- he spoke with the sun, he was tormented by vampires, his body was gradually being transformed into a woman's. For years, he believed, God had directed a series of "rays" toward him; the rays had produced an endless number of painful effects that Schreber called "miracles." He had grown accustomed to this bizarre assault, he wrote, but "even now the miracles which I experience hourly are still of a nature to frighten every other human being to death."

The aim of the book was to invite qualified scientists to examine Schreber so that they could see for themselves that his body was in fact changing itself from male to female. "What other people think are delusions and hallucinations," Schreber explained, were real changes, unprecedented in the course of human history and proof that God's powers were even greater than had been previously understood. Telling his story, Schreber believed, would spread these new religious truths and would "in the highest degree act fruitfully and as a blessing to mankind."

Freud read Schreber's book in 1910 and published an essay on his case the following year. This was Freud's first report on a hospitalized mental patient. His argument was complex and, characteristically, explained not only Schreber's case but that of every (male) paranoiac. How to account for the paranoid schizophrenic's belief that the world is conspiring against him? That obsessive fear stems from the patient's unconscious homosexuality. Unable to acknowledge the proposition "I love him," the paranoiac protests too much and insists instead, "I hate him." This proposition, in turn, is unacceptable, because it forces the patient to see himself as poisoned by hate, and so it is transformed by one final twist into "He hates me." Voilà!

Fromm-Reichmann hailed Freud's insights, but in fact her approach to schizophrenia came closer to that of her friend and mentor Harry Stack Sullivan. Celebrated in the 1920s and '30s as one of America's best psychiatrists, Sullivan is nearly forgotten today. He was an odd character -- a college dropout, an alcoholic, a big spender who skipped out on his father's funeral to avoid being stuck with the bill. He could be "as tender as a pat of butter," one bemused colleague recalled, "or as maliciously attacking as an enraged cobra."

Sullivan was a tall, thin, melancholy figure, "a lonely person from his earliest childhood," in the words of one of the speakers at his memorial service. Perhaps as a result, his psychological theories took as their central theme the hazards of dealing with other people. Where Freud had concentrated on conflicts within the individual, Sullivan emphasized the interactions between his patient and other people. "The individual is simply not the unit to study," in one commentator's summary of Sullivan's views, for the same reason that "an animal in a cage rather than its natural habitat" is not the right subject for a student of wildlife.

Sullivan may have suffered bouts of schizophrenia himself -- he claimed this experience as the source of his insight into the disease -- but some biographers suspect he invented these stories. At any rate, he put his theories into practice beginning in 1929, at Baltimore's Sheppard and Enoch Pratt Hospital. There he organized a six-bed ward for young male schizophrenics, sealed off from the rest of the hospital.

Sullivan chose the patients from among the hospital's population of schizophrenics, chose the six aides who dealt with them, and then gave this select staff detailed instructions on how to deal with their charges. The idea, simple verging on banal, was that the patients had fallen ill because of bad relationships with others and could therefore be restored to health by good relationships. The key was in choosing aides who were sensitive, kind, friendly, and, above all, trustworthy. This down-to-earth, optimistic, can-do strategy, with its emphasis on coping in the present rather than on resurrecting the past, Sullivan declared, was characteristically "American."

The results were extraordinary. Sullivan claimed that about 80 percent of his patients had improved, though he was vague about defining "improvement." (This was not necessarily evasiveness. Sullivan's prose was always obscure and often impenetrable. "Intimacy," he declared, in one representative passage, "is that type of situation involving two people which permits validation of all components of personal worth.")

Sullivan had begun his therapeutic career by deciding which bits of Freudian furniture to chuck overboard and which to hang on to. In treating schizophrenics, even many of the basics were unceremoniously rejected. Though he believed that dreams were akin to psychoses, he deemed dream analysis too risky for patients with such a flimsy attachment to the real world. To ask for free associations from a patient who heard werewolves talking to him was to throw gasoline on a fire.

Nor did other classical Freudian techniques seem useful to Sullivan. The therapist could not sit out of view in near-total silence, for example, content to reflect his patient's remarks back to him. (Fromm-Reichmann sat next to her patients, not behind them like Freud, so that they could see one another.) The fifty-minute hour, too, was abandoned as too restrictive. The therapist might be obliged to engage her patient for hours at a time. Making matters still more difficult, these deeply disturbed people, unlike neurotics, did not see their therapist as an ally. Having fled the world in favor of a self-created one, they resisted all efforts to bring them back. "Like the animal in the woods fleeing before a predatory foe," the psychiatrist John Rosen declared in a 1952 essay, "the patient fights with all the skill of his instincts."

Therapy sessions were frequently unrewarding, resembling nothing so much as bleak scenes from Beckett. Schizophrenic speech was a "word salad," with recognizable bits tossed together any old way. Or schizophrenics talked "ragtime," careening at high speed through some idiosyncratic encyclopedia. Sometimes they did not talk at all. "In working with these patients," one of Fromm-Reichmann's colleagues explained, "the therapist eventually gets to do some at least private mulling over of the possible meanings of a belch, or the passage of flatus, not only because he is reduced to this for lack of anything else to analyze, but also because he learns that even these animal-like sounds constitute forms of communication in which, from time to time, quite different things are being said, long before the patient can...say them in words."

Fromm-Reichmann herself did not go quite so far in interpreting her patients' words and silences. She did insist, however, on the value of the "symptoms as symbols" approach. For four years, while still in Europe, she and her then husband, Erich Fromm, had run a private psychoanalytic hospital where they had worked closely with Georg Groddeck, perhaps the greatest advocate of the disease-deciphering school. Fromm-Reichmann remained a devoted admirer of Groddeck throughout her life. He had "a profound influence on her thinking and work with psychotics," one colleague noted, and she insisted that her students study Groddeck's writings and be prepared to discuss them. Fromm-Reichmann dedicated her only book, Principles of Intensive Psychotherapy, to her four "teachers," the German psychiatrist Kurt Goldstein and Freud, Sullivan, and Groddeck.

Well before Frieda Fromm-Reichmann came along, psychiatrists had made sporadic attempts to pin the blame for schizophrenia on something that had gone wrong in the family. In 1934, for example, one group of investigators reported that "in a series of 45 unselected [i.e., random] cases maternal over-protection or rejection was present in sixty percent of the cases." But the studies were hard to credit. Most involved tiny numbers or unrepresentative populations, and all were marred by vagueness and an almost total lack of methodological rigor. One 1936 study focused on kings and found that twice as many insane as sane kings had lost their fathers early in life. In 1940, a psychoanalyst reported on four female schizophrenics she had treated. All four suffered, she said, from having had cold, sadistic mothers and soft, indifferent fathers who were merely "imitation" parents.

Then, in 1948, the parent-blaming idea surfaced again. This time it came with a celebrity endorsement. Writing in Psychiatry, a journal founded by Harry Stack Sullivan, Frieda Fromm-Reichmann published a paper called "Notes on the Development of Treatment of Schizophrenics by Psychoanalytic Psychotherapy." She began with her familiar claim that, contrary to Freud, schizophrenics could be treated by talk therapy. Then, almost in passing, in one short phrase tacked on the end of a long sentence, Fromm-Reichmann coined a phrase that would reverberate for a quarter-century.

"The schizophrenic is painfully distrustful and resentful of other people," she wrote, "due to the severe early warp and rejection he encountered in important people of his infancy and childhood, as a rule, mainly in a schizophrenogenic mother." That phrase "schizophrenogenic mother" -- literally, schizophrenia-producing mother would be taken up as the drumbeat accompanying psychiatrists into battle against the enemy. For decades, it would sound in the ears of parents who felt that they were the enemy.

Less than a year later, with people's cars perked up, Psychiatry carried an article amplifying Fromm-Reichmann's remark. Here bad mothers would not be dismissed in a phrase. This time they would be poked and prodded at leisure.

The new paper, written in awkward English by a Viennese-educated psychiatrist named Trude Tietze, bore the innocuous title "A Study of Mothers of Schizophrenic Patients." Unlike Freud, who had focused all his attention on the schizophrenic himself, Tietze drew back and took a broader look. With that new perspective, everything fell into place. What suddenly appeared, Tietze realized, was not simply an individual with problems of his own but an individual caught up in a family beset with problems.

It was a paper with a tremendous influence, and it merits a close look. Tietze, at Baltimore's Johns Hopkins Hospital, had interviewed the mothers of twenty-five adult, hospitalized schizophrenics. They were, Tietze made clear at once, a very peculiar bunch. "All the mothers were tense and anxious people who tried to conceal their anxiety, some with more success than others. They described themselves as 'nervous,' 'high-strung,' 'shaking inside,' and 'always anticipating impending disaster.'" None had ever been hospitalized for mental illness or even seen a psychiatrist, but "all of the mothers were fundamentally insecure people, who could feel relatively secure only if they could control the situation."

Despite their similarities, Tietze wrote, the mothers differed in key ways, especially in their dealings with Tietze herself. Five of the women "openly tried to dominate the situation by over-demanding behavior. They remained superficially friendly and polite but were very hostile and resented the psychiatrist." The larger group, seventeen mothers, "appeared docile and submissive, smiling, yet not laughing, their fleeting smile often changing to a frozen grimace." But Tietze soon realized that they, too, resisted her questioning. "Their friendliness and effervescence were superficial and they tended to hide their anxiety and keep the interviewer at arm's length."

Here, barely into her paper, Tietze adopted an adversarial tone that grew steadily more marked as she went along. She seemed especially irritated by the larger, eager-to-please group. The mothers apparently did not know they were acting strangely -- "they seemed quite unaware of their own hostility and of the unconscious motivation of their behavior" -- but Tietze was determined not to be taken in by their performance. "Once their superficial smiling front was broken through," she wrote, "one was appalled by the emotional emptiness one found. There was a lack of genuine warmth."

To demonstrate this two-facedness, Tietze rattled off a long list of particulars. "These mothers 'cooperated' to the letter with the psychiatrist; they kept their appointments, snow, rain, or hail. They were always on time, always apologetic of taking so much of the doctor's time, always profusely thanking at the end of the interview. They tried in every possible way to ingratiate themselves and to make the best possible impression on the doctors. They acted like 'model patients'" But Tietze saw through their little game. "They went, however, only through the motions -- of themselves they gave little."

Tietze's indictment continued:

They tended to become solicitous about the interviewer whenever an opportunity presented itself. They frequently commented on the hard life of a psychiatrist; if it was raining and they did not see rubbers or an umbrella in the office, they expressed their concern lest the doctor catch a cold. Every holiday was remembered with a sweet little card, and they frequently placed little notes or presents on the doctor's desk. They never directly asked for any favors; they would ask exactly how long they should visit their children and would carry out any suggestion to the letter, thus often reducing advice to absurdity. Their attitude was: "You are the doctor and you know best."

It does not seem an outlandish attitude for mothers whose children were victims of an overwhelming and mysterious disease, but Tietze would have none of it. "They did not seem to be aware of the burden and responsibility they put on the physician," she complained. "By their seeming surrender in what looked like a dependent relationship they dominated the situation in a subtle way and put the psychiatrist under some strain."

Her irritation grew plainer. These mothers, supposedly so eager to help, seemed not to grasp what Tietze was after. "It was impossible to obtain accurate data in regard to onset and completion of toilet training of their children," Tietze reported. "The prevailing reaction of the mothers to this question was a mixture of amazement and irritation." Nor were they forthcoming about their own private lives. "The majority of mothers were reluctant to discuss their sex life with the psychiatrist," Tietze observed.

When the mothers did volunteer personal information, Tietze refused to take at face value what sounded remarkably like maternal devotion. "The children were uniformly described as 'placid, lovable, cuddling babies,'" she acknowledged, but in the same sentence she explained away this behavior: the babies' "helplessness and complete dependency on their mothers seemed to have been a source of considerable gratification."

Even the way these women had responded to their child's illness struck Tietze as misguided. "The acute onset of the psychosis came as an unexpected shock to the mothers, who suddenly felt that they had lost their children," she wrote. "They felt defeated and utterly frustrated and made frantic attempts to retrieve their children. Five mothers spontaneously stated that they would rather see their schizophrenic children dead than insane."

Another observer might have seen that maternal shock and despair as predictable. These were, after all, parents whose once-healthy children were in the chronic ward of a mental hospital where they would likely live out their lives, victims of a disease that had descended without warning. Death, these parents may have felt, would at least have ended their child's suffering.

Tietze took a different view. The key to the children's illness was their mothers' "rejection." These "sick" women had never had an instinctive rapport with their sons and daughters. "It is this intuition or empathy with the child that appears to be missing or inadequately developed in the relationship of the mothers here under discussion to their schizophrenic children," she wrote.

That lack was crucial. Now Tietze explained why she had focused so much attention on the mothers' attempts to control their interviews with her. Such manipulativeness was not simply irritating; it was literally maddening. "It is the subtly dominating mother who appears to be particularly dangerous to the child," Tietze reported. "Her methods of control are subtle and therefore do not provoke open rebellion as undisguised domination may. The children exposed to this form of subtle domination under the disguise of maternal love and sacrifice are deprived of any outlet of their aggressive impulses."

By scrutinizing her twenty-five subjects, Tietze believed she had found a universal pattern. "All schizophrenic patients who were in good enough contact to reality and who formed a reasonably good relationship with their psychiatrist expressed a feeling of rejection by their mothers."

It was an extraordinary paper, and it had an extraordinary impact. Almost immediately, it was hailed as "the most thorough-going research into the nature of parent-child relationships in schizophrenia," and even after a decade it remained "perhaps [the] best known" of what was by then a flood of articles on schizophrenogenic mothers.

Nonetheless, a close reading makes clear that this was an intellectually shabby performance. Tietze never acknowledged, let alone sorted out, a crucial chicken-and-egg question -- were these children schizophrenic because their mothers were overanxious and overbearing, or were the mothers frantic and jumpy because their children were schizophrenic?

In addition, though she took every opportunity to hammer home her view that rejection by the mother was at the heart of schizophrenia, Tietze dismissed seemingly contradictory evidence without discussion. She wondered, for example, if children who became schizophrenic had been welcome additions to the family. She found, presumably to her surprise, that "definitely unwanted siblings of the schizophrenic patient, who himself was planned and wanted, turned out to be the best adjusted members of the family." That odd finding, which might well have brought matters to a screeching halt, turned out not to merit even a raised eyebrow. Tietze was on to other matters in the very next sentence.

The paper's most serious weakness was another sin of omission. Tietze carried out her study without a "control" group -- a comparison group of mothers that would have let her sort out whether the strange behavior she saw was something peculiar to those who had raised schizophrenic children. "In order to arrive at valid conclusions," she acknowledged blithely, "it would be necessary to compare the twenty-five mothers of this series with a control group consisting of mothers who have never produced a schizophrenic child." Necessary or not, Tietze plowed ahead. "To obtain such a control group," she noted simply, "met with insurmountable difficulties."

She decided to make a different comparison. Working from the assumption that bad mothers produced mentally ill children, Tietze tried to sort out what made some mothers more dangerous than others. She looked at her twenty-five women and divided them into two groups. Group A consisted of all those mothers whose healthy children outnumbered their schizophrenic children. These mothers, perhaps, had some redeeming qualities. Group B was a grimmer bunch. It was made up of all those mothers whose only child was schizophrenic, or who had one schizophrenic child and one healthy one. (Two of the twenty-five mothers had two schizophrenic children; those two women were in Group B.)

That odd comparison, the only one that Tietze undertook, "revealed no significant quantitative or qualitative differences" between the two groups of mothers. The question why some children became schizophrenic and others "escaped" their fate, Tietze acknowledged, "remains still open."

Tietze had not been a major figure in psychiatry, and she did not become one. But the snowball she threw started an avalanche. Within a year or two, the idea of the "bad mother" had become a commonplace that scarcely required demonstration. A 1951 paper on male schizophrenics, in the American Journal of Psychiatry, captured the matter-of-fact tone. "There is a common belief in the field of mental hygiene," the authors declared in the paper's first sentence, "that mothers of schizophrenic boys are 'overprotective, oversolicitous, domineering, overanxious, and/or rejecting.'" So unremarkable was this observation that it did not even rate a footnote. In two years, an untested claim had become something that "everyone knew."

Psychiatrists rushed to endorse the new insight, delighted that someone had finally unraveled the greatest riddle confronting them. Psychiatry had finally found a way to help schizophrenics -- since the disease was caused by parental misdeeds, it could be treated by helping patients come to terms with their upbringing. But this was a discovery with theoretical implications at least as great as the practical ones. For everyone recognized that talk therapy was too expensive, too difficult, and too slow a treatment to transform the lives of the nation's 1 million-plus schizophrenics.

The excitement was that the thing could be done at all, not that it could be done on a mass scale. If a meticulous craftsman had succeeded, after years of labor, in building an antigravity machine, it would have been churlish to ask how much it would cost to put one in every garage. Psychoanalysis had built its antigravity machine.

Where medicine had been baffled for more than a century, where even the greatest names in psychiatry's pantheon had thrown up their hands in bewilderment, Freud's descendants had proved triumphant. Psychoanalysis had done the undoable. This was not merely good news for a particular group of patients; it was good news for psychoanalysis, a validation of this modern therapy in its confrontation with an implacable foe.

Paper after paper spelled out the new doctrines. One could read lists of the traits of the schizophrenogenic mother. She was "guileful and potentially deceitful," "self-indulgent," "irritable," "sarcastic and cynical," "ostentatious," "characterized by a thorough-going Machiavellianism which is employed in the service of a rather unlikable egocentricity. Other people, and this includes her child, seemingly exist only to serve her own ends and are consequently manipulated and exploited -- or ignored."

The vogue lasted for decades. In a survey of the medical literature produced between the late 1940s and the early '70s, the psychiatrist John Neill counted more than seventy-five papers on schizophrenogenic mothers, as well as numerous books and book chapters. The idea that mothers produced schizophrenia in their children enjoyed "enormous popularity," Neill wrote, and was "standard practice" on both sides of the Atlantic. Over the course of the same decades Neill found only two cautionary articles, both by the same author.

Not surprisingly, parents were not as taken by the new theories as psychiatrists were. In Tietze's 1949 paper, for example, she had noted that when the project began, "the immediate response of all [the] mothers was one of curiosity, optimism, and appreciation of the interest taken in their children and themselves." But the mothers soon had their hackles up. "Their enthusiasm...waned when the meaning of interpersonal relationship and its implication dawned on them."

Tietze paid little heed. She had expected mothers to try to wriggle out from under the burden of blame. Who would rush to embrace the painful truth that she had caused her child's illness? The sicker the child, Tietze found, the harder the mother fought to resist the truth. "Those mothers whose children had been irretrievably withdrawn for years and who had little hope for recovery," she wrote, "were reluctant to accept the importance of environmental influences and preferred to believe in constitution and heredity as etiologic factors."

There was little difference, Tietze's tone implied, between such a misguided mother and a toddler who "preferred to believe" in Santa Claus or the Easter Bunny. But not all psychiatrists were as dismissive as Tietze. There was a risk, a few writers acknowledged, that what began as devotion to patients could become an attack on parents. That would be unfortunate, everyone agreed -- after all, these parents had been done wrong by their parents, and so on up the line -- so there was no point in assigning blame.

But if it was a mistake, they went on, it was a natural, understandable, forgivable one. To side with patients against the parents who had victimized them, Fromm-Reichmann's proégé Don Jackson observed, was a "warmly human error."

Ironically, it was Fromm-Reichmann's undeniable warmth that gave the notion of the schizophrenogenic mother much of its staying power. Modest, wise, experienced, Fromm-Reichmann was as far from mean-spirited as a person could be. Her aim was to relieve pain, not to score ideological points or hand down indictments. If even she saw parents as culprits, it was hard to imagine that they were not guilty as charged.

Copyright © 1998 by Edward Dolnick

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