By Joel Paris
University of Toronto Press, 2005.
Review by Tony O'Brien
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 20th 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 19th 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.