The Evolution of Psychiatry in America

When it comes to the history of psychoanalysis and psychiatry in the United States, to paraphrase Luce Irigaray, one never stirs without the other. While Freud sent Theodore Reik across the ocean to promote lay analysis, A.A. Brill, president of the New York Psychoanalytic Institute, was preparing to divorce the International Psychoanalytic Association. Brill, driven by a fear that psychoanalysis might be seen as quackery and so discredited, sought to guarantee that the only people allowed to practice psychoanalysis in America were medical doctors. Then came the Anschluss: humanitarian efforts were made to bring the very-same IPA members the Americans sought to separate from onto American soil.

This is a pretty well known tale–told by Gay, Hale, Roazen and others; enter Orna Ophir’s book, On the Borderland of Madness: Psychosis, Psychoanalysis and Psychiatry in Postwar USA (Routledge, 2015), offering a much needed explanation of how psychoanalysis in America lost its patina.

This intellectual history closely studies, via a reading of key journals, the way two professions, for years dancing in close embrace, began to fall out of step. In the same way that the birth of a child with developmental disabilities can reveal a cleavage in what was once thought to be a secure marital bond, debates over the treatment of psychosis led to the eventual separation of two longstanding bedfellows: psychiatry and psychoanalysis.

Ophir pieces together the confusing, and previously untold, tale of how psychoanalysis came to be marginalized–and what role psychosis played therein, for its role was key. To carry the conflicted parent metaphor a little further, when a child suffers from psychic distress one member of a couple might seek to understand that suffering in genetic terms while the other spouse might examine the kind of care shown that child: the story of psychiatrically influenced psychoanalysis and non-psychiatrically influenced psychoanalysis line up similarly.

While it is commonly known that the release of new medications to treat psychotic pain beginning in the late 1950s, and the birth of community psychiatry in the 70s, and of course the release of the anti-psychodynamic DSM-III in the 80s all played a role in arguments for the superfluity of analytic treatment for psychosis, Ophir argues that psychoanalysis got sidelined because American psychoanalysts, given their long-standing embrace of psychiatry, were duly handicapped. How to let go of the safety-net of psychiatry–that which is deemed irrefutable, scientific and biologically bound–and still survive was their question.

Using ideas from the sociology of the professions/knowledge, Ophir argues that analysts engaged in jurisdictional turf wars that the treatment of psychosis brought to the fore. In a profession largely populated by psychiatrists, during a time when psychosis came to be largely seen as a brain disorder rather than a defense or a remnant of pre-oedipal disturbance, analysts had to decide which side they were on. Analytic clinicians, attempting to stay relevant, began to employ the language of psychiatry, supporting what Ophir calls “the neosomatic revolution” only to find that by doing so, they had thrown out the (psychotic) baby with the bathwater.

Discursive shifts, be it in politics or a profession, have deep impacts–(when we hear analysts using the language of brain as opposed to mind we are in the presence of the data produced by that impact) and we see proof of this today: very, very few analysts treat psychosis.

As in most every divorce that involves children, custody is not usually distributed evenly. Ophir tells the story of how analysts handed over their psychotic patients ...

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