Joel Paris’s account of the rise
and fall of psychoanalysis within North American academic psychiatry provides
an interesting and informative overview that touches on many current issues in
psychiatry. The book is highly readable, and accessible to both general and
specialist audiences. Written from the point of view of a practicing psychiatrist
committed to a biological model of his discipline, the book could be expected
to provide a full frontal assault on interpersonal and social models. Instead The Fall of an Icon provides a
reasonably balanced overview. Paris does make the claim, familiar amongst
biological psychiatrists, that the brain will ultimately yield up its secrets,
and that psychiatry will assume its rightful place amongst the family of
medical specialisms. But this claim is tempered with an acknowledgement of the
role that psychoanalysis has played in the development of modern psychiatry,
and a plea for more research into its effects. Threaded throughout the book,
are Paris’s reflections on his own career in psychiatry, beginning in the
1950s. Thus some key events in the past half-century are seen through the prism
of a practitioner’s experience as a clinician, researcher, and academic.   

The
Fall of an Icon is divided into three sections, documenting the periods of
the dominance of psychoanalysis, challenges to its status, and its subsequent
decline to its current marginal position within mainstream academic psychiatry.
These days the teaching of psychoanalysis is confined to a few major centers is
the US and Canada.  Paris has an
extensive knowledge of the key players in this century long drama, and the book
is sprinkled with autobiographical details, personal anecdotes, and
illustrations from Paris’s long period of familiarity with psychiatric
literature. The story of psychoanalysis is reflected in Paris’s own career. Although
he was always a sceptic, Paris has been a recipient and practitioner of
psychoanalysis, a teacher of its methods, and ultimately a critic of its
claims. As an author Paris is generous in disclosing his own beliefs at
different times, some of which he has had cause to revise. It helps in
accepting his analysis that his current views reflect his own struggles with
the orthodoxies of his time. Amongst the others who ‘made the shift’ is Robert
Spitzer, the research psychiatrist who was subsequently influential in
development of the DSM III and its later versions.

The main purpose of The Fall of an Icon is to trace the
historical place of psychoanalysis in academic psychiatry, and its decline as
decisive influence, especially since the development of the DSM III. The book
begins with psychoanalysis firmly in place in the early 20^th
century, and charts its rising, then waning influence since. Paris is Canadian,
and so is well placed to take an objective view of developments in the US,
Canadian psychiatry having been substantially influenced by events taking place
south of the border. Paris moves through the decades of the last century,
recounting the factionalised nature of academic debate, and the power politics
of the academy, and providing some intriguing case study illustrations along
the way. One such case study is that of Raphael Osheroff, a neurologist who was
admitted to the (then) analytically focused Chestnut Lodge for treatment of
depression following the death of his wife in the early1980s. Such a case
should provide an exemplar of dynamic psychiatry, but after months of
unsuccessful psychoanalytic treatment Osheroff’s family had him discharged from
Chestnut Lodge. When Osheroff subsequently responded to antidepressants, he
sued for failure to provide proper care. The case was settled out of court,
with the defense sticking to its psychoanalytic guns, claiming that Osheroff’s
improvement was due to a better therapeutic relationship with his treating
doctor.           

Also noted is the change in focus
of journals of psychiatry since the 1960s. The American Journal of Psychiatry and the relative newcomer Archives of Psychiatry and Neurology
both began to set exacting standards of scientific rigor in considering
submissions; both also began to consign psychoanalysis to the book review
section or to relatively minor case reports. As both journal are voices of
mainstream psychiatry this change is not surprising. But it seems more
plausible to think that publication trends are influenced by the same political
agendas that drove psychiatry towards a biological model than to think that
scientific articles are inherently more meritorious. Academic departments are
increasingly driven by publication impact factors which
contain an inherent and self-fulfilling logic of their own. There is also the
possibility that publication patterns are influenced by the economic power of
the pharmaceuticals industry. Publication cannot be taken to represent anything
more than one more artifact of the politics of psychiatry.

Although asserting that the rise of
biological psychiatry has rightfully supplanted the non-scientific enterprise
of psychoanalysis, Paris is also aware of limitations to the current science of
psychiatry. These limitations are considerable, and important. Paris makes the
useful point that the purpose of the DSM is as much to provide a common
language as to provide a foolproof guide to treatment. He is also skeptical of
the categories of the DSM, and shows some common ground with Mary Boyle
who has criticized diagnostic psychiatry’s obsession with reliability at the
expense of validity. Paris notes that:

"We don’t know if [the DSM’s] categories are
real, and reliability has trumped validity" (p. 87) 

Psychoanalysis has faced
considerable critique on the grounds of its scientific status, and Paris adds
his support to this body of criticism. Like many other critics, Paris cites Popper’s
criteria for science, although Popperian critique of psychoanalysis, especially
as it relates to the issue of falsifiability, has critics of its own. But the
main problem for Paris is that in refuting the claim of psychoanalysis to
scientific status, he comes close to falling foul of those very criticisms in
his insistence that the unraveling of the biological basis for mental illness
is only a matter of time. If the biological theory of mental illness really is
a scientific theory, it must in principle be falsifiable. But you sometimes get
the impression that it is not. Not only are there issues of the validity of the
categories of the DSM, but there is a sense that any problems biological theory
encounters are not problems of the conceptual foundations of the theory; they
just represent a need for further research. Some discussion in terms of Kuhn’s
model of scientific change would have been interesting. Science is embedded in
politics anyway, and the decline of psychoanalysis was as much a political as a
scientific revolution. In the slowest section of an otherwise compulsively
readable book, Paris details the machinations of professorial appointments in
American and Canadian universities. It is notable that he offers a comparison
with the rise to power of Mikhal Gorbacov, an example of political rather than
scientific revolution.

Paris’s analysis notwithstanding,
there remains another position open to analysis. That is, to argue that madness
requires an interpretive, rather than scientific theory. So much of the
evidence of the effectiveness of treatments in psychiatry points towards the
influence of the relationship between therapist and client as a crucial
variable that it is hard to accept Paris’s argument that questions of treatment
options will ultimately be decided by greater understanding of the brain. Paris
is aware of these arguments, and chapter three contains a summary of the work
of Jerome Frank.

The
Fall of an Icon is a history as much as anything else, and yet in writing
history the choice of a starting point is crucially important. Late in the book
Paris recalls a statement attributed to Edward Shorter, to whom The Fall of an Icon is dedicated. In his
History of
Psychiatry, Shorter is quoted as saying that there was no
psychiatry until the early 1900s. In fact Shorter’s book of that title covers a
much longer period, including the development of the first biological
psychiatry in the 19^th century. Paris, too, cites the influence,
then neglect of Kraepelin, the German empirical psychiatrist who had little
time for Freud. Some acknowledgement that biological models of psychiatry had
been promulgated before and during the period of psychoanalysis would have
provided Paris’s work with a more contextualized account of the development of
neuroscience and pharmacology. The determination to establish a medically
legitimate discipline of psychiatry is a recurrent theme, rather than the
resolution of its history.  

Psychoanalysis remains an important cultural
influence in western societies. It is somewhat ironic that while students of
cultural studies and literature continue to read Freud and the neo-Freudians,
psychoanalysis is something of a footnote within the discipline that gave birth
to it. But is hard to imagine modern psychiatry, even at its most biological
extreme, completely abandoning its psychoanalytic legacy. Psychoanalysis gave
us a new way of listening to what people say about their distress. Its emphasis
on language and communication seems more important than ever in the face of
biological reductionism and the complexities of problems people present to
mental health services.   

©
2005 Tony O’Brien

Tony O’Brien is a lecturer in
mental health nursing at The University of Auckland, New Zealand

Categories: Psychoanalysis, MentalHealth