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Prozac on the Couch PRESCRIBING GENDER IN THE ERA OF WONDER DRUGS
By JONATHAN MICHEL METZL
DUKE UNIVERSITY PRESS Copyright © 2003 Duke University Press
All right reserved.
Chapter One INTRODUCTION: THE FREUD OF PROZAC
The history of contemporary American psychiatry is often written with the presupposition of a paradigm shift. Psychoanalysis was the power structure of the profession through the 1950s and into the 1960s. Analysts chaired the country's leading academic psychiatry departments and headed important grant-making institutions. A psychoanalyst served as a brigadier general in the army. And psychoanalysts dominated the American Psychiatric Association's 1951 Committee on Nomenclature and Statistics. Their presence helped shape the first postwar national classification of psychopathology, the DSM-I, published in 1952. The manual was filled with psychoanalytically inflected disorders such as psychoneurosis, conversion, displacement, and other terms that assumed presenting symptoms, and, indeed, personality itself, to be the result of early-life conflicts that were mapped onto the unconscious psychical apparatus for the remainder of life. As a result, analytic concepts affected the ways in which all psychiatrists, analysts and nonanalysts alike, conceptualized mental disease.
Somewhere in the 1970s, accordingto this narrative, American psychiatry began to change when a series of randomized, often placebo-controlled clinical research studies reported the success of biological psychiatry and psychopharmacology. Scientific findings laid bare neural pathways that exposed the inner workings of the mind. Psychogenetics, evoked potentials, and the discovery of key neurotransmitters ushered in the creation of an "objectifiable, biological" psychiatry that eschewed the role of early-life experience to identity formation and instead looked beneath these constructs to the level of the anatomic substrate. Split-brain research found that each hemisphere of the brain specialized in mediating certain functions, thereby demonstrating that what Freud (himself a neurologist) had mistaken as the "unconscious" was in fact the domain of a new neuroscience. "Music appreciation and the comprehension of puns and jokes" were, thereby, discovered to come, not from a repressed unconscious, but rather from the governance of a nondominant, wholly observable cerebral hemisphere. And, most important, biological mental illnesses were treated, not only with psychotherapy or psychoanalysis, but primarily with tranquilizers, benzodiazepines, antidepressants, and other forms of psychotropic medication.
It then follows that, as a direct result of these events, present-day academic psychiatry often rejects its psychoanalytic origins. To be sure, psychoanalysis and psychotherapy are still widely practiced by clinicians who also prescribe medications, and many voices within psychiatry now tout the importance of "combination" therapy-an arrangement in which psychiatrists prescribe medications while non-M.D. therapists provide therapy. Yet evidence points to the fact that biological psychiatry has replaced psychoanalysis as the dominant paradigm in the field. Psychoanalysts rarely hold leadership positions in academic psychiatry departments or major funding organizations. The DSM-IV emphasizes immediately observable criteria of illness. Leading journals such as the American Journal of Psychiatry (AJP), Archives of General Psychiatry, and Biological Psychiatry employ genetics, structural and functional neuroimaging, neurochemistry, and other methods in order to demonstrate the commonly held belief that mental illness has a constitutional, "biological substrate." These conditions are then treated with psychotropic medications-antidepressants, anxiolytics, antipsychotics, and mood stabilizers-that correct imbalanced levels of neurotransmitters within the central nervous system and inhibit or stimulate mood, affect, or behavior accordingly. Finally, the notion that personality and identity result primarily from early-life experiences is often called into question by contemporary psychiatric researchers. Gender identity, for example, is frequently defined in structural rather than developmental terms. As the academic psychiatrists Peg Nopoulos and Nancy Andreasen write, "Modern day advances in brain imaging technology minimize if not eliminate social and environmental confounders [of sex difference] and suggest the existence of a substrate of biological sex differences in brain-behavior relationships." In other words, the social environment is no longer considered a primary source of information when brain-imaging technology can determine sex differences.
The notion that these events represent a paradigm shift from psychoanalytic to biological sensibilities suffuses the ways in which the recent history of psychiatry is understood in contemporary academic writing and in many histories of psychopharmacology. True to Thomas Kuhn's analysis in The Structure of Scientific Revolutions, the success of pharmacological treatments for mental illness, modern-day advances in brain-imaging technology, and discoveries in psychogenetics are widely assumed to have catalyzed "a community's rejection of one time-honored scientific theory in favor of another incompatible with it," causing "a subsequent shift in the problems available for scientific scrutiny." For example, Loyd Rogler describes the events of the 1970s as causing a "paradigm shift in psychiatry," in which new diagnostic presuppositions and treatment options "became largely discontinuous with previous formulations." Similarly, the psychiatrist Michael Stone describes a "biological revolution in psychiatry" between 1970 and 1997, leading to an environment in which mental illness, personality, and even object choice are "now realized to be primarily constitutional rather than psychodynamic in nature." The former Johns Hopkins psychiatry chair Paul R. McHugh writes in "The Death of Freud and the Rebirth of Psychiatry" that "as psychiatry becomes more coherent ... psychiatrists can present themselves to the public just as physicians and surgeons do, and no longer as practitioners of a mystery cult, condescendingly proposing crude, sexualized ideas about human nature." Likewise, the neuropsychologist Eliot Valenstein's critique of contemporary psychiatry is constructed on the assumption that psychiatry has undergone a "shift from blaming the mother to blaming the brain": "The value of this [psychoanalytic] approach and the theory underlying it is now widely questioned, if not totally rejected, by most mental health professionals. Today, the disturbed thoughts and behavior of mental patients are believed to be caused by a biochemically defective brain, and symptoms are not 'analyzed' but used mainly as the means of arriving at the diagnosis that will determine the appropriate medication to prescribe." Finally, the historian Edward Shorter prefaces his argument that psychiatry has moved "from Freud to Prozac" in the latter half of the twentieth century with the contention that "a revolution took place in psychiatry," in which,
old verities about unconscious conflicts as the cause of mental illness were pitched out and the spotlight of research turned on the brain itself. Psychoanalysis became, like Marxism, one of the dinosaur ideologies of the nineteenth century. Today it is clear that when people experience a major mental illness, genetics and brain biology have as much to do with their problems as do stress and their early childhood experiences. And even in the quotidian anxieties and mild depressions that are the lot of humankind, medications can now lift the symptoms, replacing hours of aimless chat. If there is one central, intellectual reality at the end of the twentieth century, it is that the biological approach to psychiatry-treating mental illness as a genetically influenced disorder of brain chemistry-has been a smashing success. Freud's ideas, which have dominated the history of psychiatry for the past half century, are now vanishing like the last snows of winter.
In this book, however, I challenge the notion that biological psychiatry replaced psychoanalysis. I question the binary that Shorter, Valenstein, Nopoulos and Andreasen, McHugh, and other academic psychiatrists, anthropologists, and historians of psychopharmacology assume exists between these two modes of treatment and explore the stakes in their rejection of Freud. No doubt, many important and beneficial changes have taken place in the profession of psychiatry over the past half century, leading to very real changes in the diagnosis and treatment of mental illness. Moreover, even the American Psychiatric Association has come to realize clinical interactions to be more complicated than an often-artificial division between biological substrates and environmental confounders. Yet arguments such as Shorter's serve a purpose: asserting that a biological approach to a person's problems has replaced "aimless chat" about early-life experiences, or dismissing social and environmental factors as "confounders," effaces the ways in which socially, environmentally, and culturally produced tensions and anxieties play a part in even the briefest or most prescriptive clinical encounters. Psychoanalysis knew this very well. Concepts such as transference and countertransference, for example, are contingent on the notion that the expectations that doctors and patients bring into an examination room shape the content of their interaction. To claim that such considerations have vanished, or are replaced by pharmaceuticals, often works to the contrary, reinforcing preexisting hierarchies surrounding the positions doctor and patient while making it more difficult for psychiatrists and other health-care workers to think critically about the implications of the treatments they prescribe.
I should state at the outset that I am not a structuralist, an essentialist, or even a psychoanalyst. Rather, I am a psychiatrist who trained in a residency program that put a great deal of emphasis on chemical and neurophysiological definitions of mental illness. I now work in a university-run outpatient psychiatry clinic and, thus, spend much of my life writing prescriptions for medications similar to those described above. I believe in, and have seen firsthand, the many ways in which psychotropic medications ease pain and suffering and often help people lead happier, more productive lives. I also believe that the success of these medications has vastly improved the reliability, efficiency, and even the quality of the treatments that psychiatrists can offer their patients.
Yet I am made constantly aware of the inaccuracy of the belief that biology has replaced psychoanalysis, or that medications and talking cures work on entirely different axes, whenever a woman comes to my office requesting a prescription for Zoloft after seeing an advertisement in Marie Claire magazine; or whenever a male patient tells me that he believes that, owing to her strange behavior, which has ruined their intimate relations, his wife requires Valium, lithium, or Haldol; or whenever I find myself thinking that Effexor might help a woman patient cope with the depression that she experiences as a result of marital stress even though I know that her husband's attitude is largely to blame for her emotional state; or even at times when a woman requests medication to help her cope with intense feelings of sadness during her menstrual periods, a condition defined in the DSM-IV as premenstrual dysphoric disorder, for which fluoxitine is now a known indication. At issue in these moments is not the question whether medications may or may not be helpful in this particular case-they may be, or they may not be. Rather, there is the clear possibility that the patient and I may not be talking about medications at all, at least not about those medications prescribed, bought, sold, or ingested. These interactions suggest that psychotropic medications are imbued with expectation, desire, gender, race, sexuality, power, time, reputation, countertransference, metaphor, and a host of important factors that a putative paradigm shift from interaction to prescription tacitly eliminates from psychiatry's purview. At these moments, I and other practitioners of psychiatry have much to learn from the "social environment" because social and environmental "confounders" accompany patients into the examination room. More important, these confounders also help shape psychiatry itself, and psychiatry is revealed to be a part of the same social environment when it looks back at patients or thinks about itself and its place in the world. In these instances, medications convey a host of multiple meanings often occluded by an emphasis on the replacement of talking cures with prescribing cures. And the notion of a paradigm shift works to efface the ways in which biological psychiatry generally, and psychopharmacology specifically, often functions in many of the same ways as psychoanalysis. Assuming a move from Freud to Prozac, in other words, precludes the awareness of Freud as Prozac.
I argue that the biological revolution in psychiatry needs to be read socially, environmentally, historically, and, indeed, psychoanalytically if we are to understand how a narrative claiming change-and specifically a changed notion of the relevance of gender-also risks reinventing and rearticulating the same gender hierarchies for which psychoanalysis was widely critiqued. To understand how this process has taken place, however, is to consider the possibility that psychotropic medications accrue meanings in both medical and popular cultures, meanings that then come back to inform clinical practice. My project shifts the origins of the "biological revolution" to American popular culture in the 1950s and then explores the interrelation between popular and medical, or psychoanalytic and biological, sensibilities as they appear in representations of psychotropic medications in American print culture between 1955 and 2002. My specific focus is, in fact, the castrating mothers, shrunken fathers, and other psychoanalytically inflected representations that appear and reappear in pharmaceutical discourse, contrary to all explicit claims.
Over the course of this fifty-two-year period, as electrophysiology gave way to lactate infusion and neuroreceptor binding (which were in turn replaced by positron-enhanced neuroimaging), the terminology of psychiatry claimed to minimize, if not eliminate, social and environmental confounders while suggesting the existence of biological substrates in brain-behavior relations. Yet the sharp divide between the biological and the social/environmental explanations seems an inadequate means of understanding, for example, how in 1956 a Cosmopolitan article reported the research of Dr. Frank Ayd in "curing" frigid women with tranquilizers ("after treatment, frigid women who abhorred marital relations responded more readily to their husbands' advances"), or how a 1970 advertisement in the Archives of General Psychiatry introduced Jan, the unmarried "psychoneurotic" lesbian who "needs" Valium in order to find a man, or how Peter Kramer describes the process whereby his patient "Mrs. Prozac" meets her husband after beginning treatment. These and other sources bring to the fore how psychoanalytic assumptions helped shape the construction of biology and how, as a result, psychoanalytic and biological models were often similarly employed in maintaining traditional gender roles, even as the language for defining symptoms underwent drastic revision. I ultimately argue that these sources reveal the ways in which psychotropic medications often redeploy all the cultural and social baggage of the psychoanalytic paradigms, but without the awareness of gender, and its socially constructed dimensions, that those Freudian paradigms reveal and, in my view, render problematic.
Excerpted from Prozac on the Couch by JONATHAN MICHEL METZL Copyright © 2003 by Duke University Press. Excerpted by permission.
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