# Psychiatry in Retreat: The Medical Beast Exposes Its Vitals **URL:** **By** Peter Breggin **Published:** May 1, 1979 --- “Psychiatry is being destroyed by the free market.” “Psychiatry’s Depression” read the banner headline on the cover of the April 2nd _Time_. Inside the magazine, the story itself was headlined with lackluster irony: “Psychiatry on the couch—To shake the blues, Freud’s disciples seek new directions.” What new direction? Psychiatry, for three hundred years the champion of the medical view of mankind, will become _more medical_, leave the garden variety of human complaints to bio-feedback, est, re-birthing and Transcendental Meditation, and focus its energy on so-called medical problems, on the seriously “mentally ill.” _Time_, for its part, is overcome with its own ambivalence. It freely admits that over-burdened psychiatrists “often dream of any easy way out: the miracle cure, a cheap drug or chemical for every mental illness,” even though “so far there has been no clear breakthrough.” _Time_ also acknowledges that the major tranquilizers used in mental hospitals “act as chemical restraints: they calm the schizophrenic but often turn him into little more than a zombie in the process.” The claim that these drugs have emptied the mental hospitals is also undone by reports that these same patients now languish “uncured” in other institutions or in urban slums, often returning in a revolving door process to the state mental hospitals. But, having shredded its own argument, _Time_ still sees the drugs as psychiatry’s only hope to lift itself from depression: “At the very least, the drugs may give psychiatry the bold new tools that will enable it to shake off its own current depression and fulfill the high hopes that Freud and his followers correctly held out for it.” The story is more ironic than the _Time_ editors intended. Remember that depression is a mental illness. To cure its illness, will psychiatry _take_ drugs? No, this is the kind of illness that is cured by _giving_ drugs. Thomas Szasz’s myth of mental illness is here displayed in its full splendor. Human problems must be declared biological and medical in their origin and cure, for without this medical mythology, psychiatry has little or no justification for its existence and will remain in the doldrums. The giving of medicine is not to cure the patient but to justify psychiatry’s identity—its prestige, power and income, all of which are on the decline. I recently gave a speech to the psychiatric staff of a large New York mental hospital, and one angry physician stood up to declare that “If what you say about the drugs is true—that they do nothing but disable the mind—then I would have to give up twenty-five years of knowing who I am.” Later another equally hostile psychiatrist challenged me: “Why would thousands of psychiatrists want to hide what you call the truth about the drugs?” I had only to remind him of the earlier psychiatrist’s contention that the de-mystification of psychopharmacology would ruin his lifetime identity. Undoubtedly, it would also ruin his status in the community and his income. _Time_ is right that psychiatry is in trouble. In its anguish it is returning to the womb of medical authority. Yet its medical origins and medical mentality are precisely the cause of its malaise. Psychiatry embraces its own illness, and may hasten its own demise far more rapidly than any of its critics had hoped. What is going on that psychiatry has reached an end-stage requiring a _Time_ cover story to announce in one mighty breath both its mental illness and its hoped-for drug cure? The assault on psychiatry has been more a guerrilla action than a war between contending authorities, with many disparate bands entering the fray. From within psychiatry itself, the most thunderous attack was launched in 1961 with the publication of Thomas Szasz’s _The Myth of Mental Illness_. Szasz struck at the twinchambered heart of the beast—involuntary treatment and its justification through the myth of mental illness. A decade later, again striking from within the profession, I published _The Crazy from the Sane_, and when this novel hardly sounded an audible “pop!”, I began a more direct professional and public assault on psychiatric technology, including psychosurgery, electroshock and the tranquilizing drugs used to subdue mental hospital inmates. As Szasz struck at the beast’s heart, I proceeded to pull its fangs and claws. Both the ideology and the technology of psychiatry found itself under assault by professionals for the first time in the history of the field. Organizations of former mental patients, and individual ex-inmates like Leonard Frank have begun to challenge psychiatry as their oppressor rather than their benefactor. Public interest legal groups have begun to chip away at the immunity which has protected psychiatry in its disregard for the well-being and civil liberties of those who come under its power. Within recent years, even state legislatures have got into the act, demanding that psychiatry adhere to prescribed procedures of informed consent, especially in the administration of its most obviously damaging therapeutics, such as psychosurgery and electroshock. ## Depressed by the free market It would be gratifying to imagine that the latest agonized cries from the body of psychiatry and its _Timely_ supporters were induced by yet another pre-meditated strike by those of us most directly involved in critizing psychiatry. But something much more fundamental is actually taking place. Psychiatry is being destroyed by the _free market_. How is this possible in a nation in which medical care is provided through state monopoly in the form of licensure, regulation and subsidy? The answer is provided in part by _Time_ itself: > Each day millions of Americans talk, scream, confront, jump, paint, dance, strip, tickle and grope their way toward emotional fulfillment. They are sampling one or more of the 200 or so therapies and countless pseudo therapies that are now being peddled in the U.S. as panaceas for unhappiness, anxiety or worse. At one end of this therapeutic spectrum are such exuberant exercises in self-help as biofeedback and Transcendental Meditation; at the other end, close-order drill for the psyche, like est. All but trampled by this stampede toward satisfaction lies the battered body of the medical speciality that once held the exclusive franchise for curing all maladies of the mind. Obviously it no longer does—one reason why psychiatry itself is now on the couch. _Time_’s lament over psychiatry speaks of Freud’s disciples abandoning the couch, but as the article itself observes, Fruedian psychoanalysis has never reflected the true nature of psychiatry. Of the nearly 30,000 psychiatrists in the United States today, fewer than 10 percent call themselves psychoanalysts. An American Psychoanalytic Association survey in 1976 disclosed that those who called themselves analysts actually treated fewer than five patients a week on the couch, a very low figure considering the tendency to see patients for much less time than the traditional five hours per week. If one considers the millions of patients treated by psychiatrists each year in hospitals, clinics and private offices, psychoanalytic patients reflect less than _one percent_ of the total patients treated. Many more patients are given electroshock each year than are given psychoanalysis, and still more are hospitalized in state and private hospitals where they are subdued with massive doses of mind-disabling and neurologically damaging tranquilizers. Even in routine psychiatric practice in surburban offices, far more patients are given occasional supportive interviews, group thearapy and drugs. In the public mind, and in the experience of a small group of intellectuals, psychoanalysis is psychiatry; in reality, psychiatry is a hodge-podge of institutions and practices, typically characterized by coercive hospital confinement and oppressive techniques and technologies. _Time_ supports a time-honored ruse in identifying psychiatry with “the couch” when it it far more accurately identified with the dungeon and the drug. _Time_ is correct, however, in observing that psychiatry has enjoyed an “exclusive franchise” over personal unhappiness, and that this monopolistic lock upon the public is now being broken. There is still a sufficient free market in this country for individuals to abandon the medical monopoly over psychological services and to seek out alternative approaches more to their liking and more easy on their pockets. But the psychiatric monopoly has the backing of the state, and it is busily attempting to regroup. Psychiatry has so much state support that it has been aptly dubbed America’s state religion. The most obvious form of support is the mandate from the state empowering the psychiatrist to treat patients against their will. In terms of the free market, this is a monopoly indeed. Not only does the provider control the production and distribution of the service, the provider can _make_ the consumer accept his services. On many occasions, patients are simply held against their will in private hospitals until their money or their insurance coverage runs out. But this financial advantage is but one of the many advantages accrued to psychiatry by involuntary treatment. The threat of involuntary treatment effectively controls hundreds of thousands of patients, and power to exercise commitment lends power and prestige to the profession and to individual practitioners. Similarly, the psychiatrist’s monopolistic influence is enhanced by his state-sanctioned role as legal expert in the courtroom, and his authority to make determinations of competency to stand trial, and competency to own and control property. The psychiatrist and psychiatry also benefit immensely from state support of the medical monopoly. Psychiatrists are licensed in individual states as practitioners of medicine, effectively establishing them at the top of the hierarchy of providers of psychological services. This status is reflected, for example, in the willingness of private insurers to pay psychiatrists a higher hourly fee than other providers of psychological services, and at times to make psychiatric supervision a requirement before non-medical providers can receive insurance payments for their services. Beyond this, psychiatry has benefited from such support of organized medicine as federal recognition of officially licensed medical schools as the only legitimate recipients of federal largesse. There is also an enormous amount of direct state support for psychiatric activities and psychiatric salaries. Huge state and federal investments in the state hospital system and the community mental health center network provide jobs and other emoluments for psychiatrists, and the majority of individual practitioners has some connection with these institutions. For a period of time, the federal government actually paid the training stipend for psychiatrists, in part by bringing about the present glut on the market. The Department of Health, Education and Welfare, as well as other federal agencies, provides research funds which support the salaries of many psychiatrists, and vastly add to their influence and prestige. Indirect state support has also come through the personal influence of leaders such as John F. Kennedy, who lent his enormous influence to the support of government funding for psychiatry, and, more recently, Rosalyn Carter, who has gone personally to the Congress on behalf of “mental health.” ## The marriage—and divorce—of psychiatry and psychoanalysis Psychiatry’s founder, Sigmund Freud, was aware and afraid of the medical monopoly, and in his _Autobiography_ and _The Question of Lay Analysis_ he argued that psychoanalysis was more akin to the ministry than to medicine, and that lay analysts should remain free of medical control. As Szasz has explained in _The Myth of Psychotherapy_, Freud wanted to feed his own voracious ego by franchising psychoanalytic institutes which would remain under his ideological control. A neuropathologist by training, Freud’s earliest studies on hysteria brought the wrath of organized psychiatry upon him, and he was forced to remove himself from any contact with psychiatric facilities or societies. Only after his success in gaining public approval was psychiatry’s appetite for psychoanalysis whetted. In Freud’s own lifetime, and against his wishes, psychiatry would begin the takeover of psychoanalysis. Partly it took place as psychiatrists became heads of institutes, and refused admission to non-physicians. Partly it took place through state monopoly, as non-medical psychoanalysts were threatened or charged with practicing medicine without a license. The Rockefeller Foundation played a crucial role in the unholy wedding of psychiatry and psychoanalysis by systematically funding psychiatric programs which promoted the inclusion of psychoanalysis. The goal was to give medical authority to psychoanalysis, and to lend intellectual validity to psychiatry. Thus in the 1930s psychiatry was already considered “depressed”; the cure in those days was not to give drugs but to hide under the mantle of psychoanalysis. The Rockefeller Foundation had an enormous impact, not only through direct funding, but through its influence, and within a decade many departments of psychiatry were headed by psychoanalytically trained physicians. This trend continued into the early ’60s until the decline of psychoanalysis and the resurgence of overtly biological psychiatry. Why did psychoanalysis decline, and with it the public’s overall respect for psychiatry? _Time_ would attribute the decline largely to competition from cheaper and more popular alternatives. But there are other free market forces involved as well. One is the stultification inherent in the monopoly process. The Psychoanalytic Institutes became a psychotherapy franchise largely protected from any competition by the medical monopoly. From the start of the psychoanalytic movement, the authoritarianism of Freud permeated these establishments, causing all innovators to be looked upon as “mentally ill heretics.” Entrance to and graduation from the Institutes required personal conformity to standards of psychological “normality” and ideological conformity to classical Freudianism, or at best, a thoroughly acceptable modern revision of Freudianism. The Institutes required a lengthy training analysis of several years, even if the candidate had already undergone a personal or therapeutic analysis, and required attendance at Freudian seminars. The candidate, though already a psychiatrist, had to endure these infantilizing years of further training and supervision. He also had to see his “training patients” at a fee below that which he could already earn as a psychiatrist, and he might have to sign pledges about not using a couch on his own until after graduation. By the early or mid-1960s when I became eligible for entering a Psychoanalytic Institute, these authoritarian demands had already put off many if not all free and autonomous spirits among young psychiatrists, and applications to the Institutes were on the wane. I myself opted not to enter an Institute. The stultifying effect of these monopolistic institutes can be seen in their products—the modern psychoanalists. They are generally a rigid, authoritarian and unimaginative lot. And the overall result of this stultification is an utter lack of worthwhile contributions to personality theory and psychotherapy in the last two decades. While the early stages of psychoanalysis produced many creative geniuses such as Jung, Adler, Reich and Horney, all of whom eventually broke with Freud and Freudianism, modern times have produced no revolutionary or even noteworthy intellectual contributions from within psychoanalysis. Those names that linger on as contributors to human thought—for example, Fromm, May or Erikson—are incorrectly identified in the public mind with psychiatry. They are “old-timers” from the non-medical era of psychoanalysis. The monopolistic relationship of psychiatry (and hence pyschoanalysis) to the federal government has also killed the development of psychoanalysis. The government could not easily justify the expenditures of vast sums of money for the support of the allegedly fat cats of psychoanalysis. Nor could it justify funding research or education for a treatment which affected only small numbers of patients, and which require great lengths of time. In reality, psychoanalysts were not highly paid by professional or medical standards, because they could not earn more than their fixed hourly fees and because the intensity of their concentration placed limits on the number of their work hours. The shocker, the drugger and the mental hospital psychiatrist could earn far more money. Nonetheless, government funds were channeled into hospitals and somatic psychiatry in an effort to find cost-effective treatments for large numbers of people. Private health insurers also spotted a bargain in shock, drugs and brief hospitalization, and found these methods more compatible with their medical orientation. To this day, private health insurers wage a constant battle against funding longterm psychotherapy. The specter of National Health Insurance has been correctly read by psychiatry as one more step in the direction of support for physical means of therapy, and has encouraged greater emphasis upon these techniques in the profession. Other forces within the profession of psychiatry and within society at large have accelerated the decline of psychoanalysis. Psychiatrists themselves are medically trained. Naturally they do not want to waste their years of training, and to discard the hard-won identity of physician. Psychoanalysis stands in such clear-cut opposition to medical and scientific viewpoints, despite Freud’s sometimes bizarre attempts to use a scientific language, that psychoanalysis has found it hard to attract adherents from within the medical-psychiatric community. In the pursuit of “science,” psychiatrists now lean toward simple-minded psychological theories such as behaviorism or toward vague, ill-defined biological explanations. Why haven’t psychiatrists been more willing to develop their own personal variations of therapy, such as Janov’s Primal Scream or Berne’s Transactional Analysis? This can be explained partly by the desire for a medical identity and partly by the dulling effect of the Psychoanalytic Institutes. The personality of the typical psychiatrist must also be taken into account. Who choses a career which requires four years of medical school, one year of internship, and a _minimum_ of three more years of psychiatric training? It is not an appealing route to creative, free spirits. And the experience itself is regressive and rigidifying, reinforcing these tendencies within the aging student. Tack on several more years of psychoanalytic training, and the result is crushing. As I describe in my novel, _The Crazy from the Sane_, the result of psychiatric training is a dependent, conforming, self-oppressive individual. This is one reason why psychiatrists have the highest known rate of suicide among all professionals who have been studied. ## The beast rolls over Today most directors of departments of psychiatry are biologically or behaviorally oriented; they are the most respected by their colleagues and the most honored with government funds. But while the _appearance_ of psychiatry has been changed by the expunging of psychoanalysis, the actual practice of psychiatry has changed very little. Throughout the history of psychiatry—some three hundred years long—involuntary treatments, biological theories of mental illness and somatic treatments have dominated the practice of the profession. Only psychologically sophisticed upper-middle-class patients are likely to receive any form of intensive psychotherapy, and they only if they know enough to select a psychiatrist who is willing and able to offer this form of treatment. A successful psychotherapy requires a participation of two well-motivated, intelligent, responsible persons—patient and therapist—and the combination is not an easy one to find. While the actual practice of psychiatry has varied little for the average patient over the past decade, the _public image_ of psychiatry has considerably declined with the gradual decline of psychoanalysis and intensive psychotherapy. Great numbers of the public do favor a viewpoint which promotes involuntary treatment and biological and behaviorial explanations of human conduct. But they favor these approaches for _other people_. They do not wish to think of _themselves_ as defective biological organisms in need of involuntary physical therapy. This is true even among psychiatrists. I remember during my first year of residency at Harvard’s Massachusetts Mental Health Center that every resident on my floor favored involuntary biological treatment for most of his or her patients, but chose voluntary psychotherapy for help with his or her own personal problems during the year. The nation’s intellectuals in particular may be willing to foist off oppressive therapies upon others, but will remain unwilling in most cases to think of themselves as candidates for these approaches. With the decline of psychoanalysis and intensive psychotherapy, what is left for the intellectuals to identify with on a personal level in psychiatry? Involuntary mental hospitalization? Behavorism? Pills? Electroshock? Psychosurgery? Surely the old-fashioned _New Yorker_ style jokes about psychiatrists and their couches will soon be replaced by more virulent criticisms of psychiatry and its technology. Psychoanalysis has been killed by its own monopolistic appetite, and by free market competition outside psychiatry. And psychiatry without psychoanalysis is a wolf without its sheep’s clothing. The decision by organized psychiatry to reembrace the medical image can only make the wolf more ominous and hasten the public’s withdrawal of its support. What we are witnessing, then, is the last dying gasps of an already moribund psychoanalysis, and the exposure of psychiatry for what it is—a medical monopoly which must justify itself on biological theories of human unhappiness and prove itself through the enforcement of oppressive medical technologies. This brings me back to an earlier metaphor: Szasz has been stabbing at the beast’s heart—involuntary treatment and the myth of mental illness—while I have been pulling its teeth and claws—drugs, electroshock and psychosurgery. Alone at first, we have been joined by increasing numbers of allies, some within the medical community. But in the midst of this growing attack, the psychiatric beast has decided to roll over and to display its most vulnerable underside—its biological guts. The medical beast, determined now to fight it out in its true identity, has doomed itself. Nothing but good can come from psychiatry’s increasing loss of public support. While the burgeoning therapeutic alternatives outside psychiatry have been ridiculed by the media as a part of the “me generation,” they reflect a genuine free market in psychological services. Furthermore, the very concept of a “me generation” has egoistic libertarian overtones. While many alternative therapies now in vogue have strongly authoritarian tendencies, none is backed up by state enforced involuntary treatment, and none produces brain-damage. They offer variety tailored to individual tastes, and their flaws reflect the marketplace and its buyers. In the meanwhile, libertarian alternatives are developing, as reflected in best-selling self-help books by libertarians, by Nathaniel Branden’s workshops, and by my own libertarian psychotherapy. Yet the very concept of “psychotherapy” is medical and continues to burden us. Can anyone think of a better term than “psychotherapist” to designate a professional conversationalist who specializes in talking about individual personal problems? Szasz has suggested the term “iatrologician,” but it is too cumbersome to survive in the marketplace. The person who coins a better term for psychotherapy or psychotherapist will further liberate us from the unholy marriage of psychiatry and psychoanalysis. _Peter Breggin is a psychiatrist in private practice in Bethesda, Maryland. His latest book,_ Electroshock: Its Brain-Disabling Effects, _will be published by Springer in the next few months._