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Madness on the Couch: Blaming the Victim in the Heyday of Psychoanalysis

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"Madness on the Couch" is not only a riveting read -- I consumed half of it at a single sitting -- but an important contribution to the history of medicine.

In chilling detail, Edward Dolnick documents those mid-20th century decades in which psychoanalysts used "talk therapy" to treat disorders like schizophrenia, autism, and obsessive-compulsive disorder and, in their unscientific quest for a cause, concluded that these conditions -- still largely unexplained but known to be the result of neural imbalances in the brain -- must have been the result of bad parenting. Most often, making a distressing family situation intolerable, they blamed the patient's mother.

Hindsight is a tricky tool in writing medical history. It is easy to marvel now, for example, how blithely many leading 19th century surgeons rejected germ theory to the bitter end, resisting for decades mounting evidence that their own bacteria-laden fingers and instruments were killing patients. Dolnick, to his credit, is sympathetic to context as he traces the psychoanalysts' path of reasoning, showing that -- within the elaborate framework of Freudian belief -- their wrongheaded conclusions often seemed entirely logical. Those were the days soon after World War II when the study of genetics, discredited by Nazi experimentation, was seldom pursued. And those were the days when the only therapeutic alternative for schizophrenia was lobotomy. ("What is going through your mind now?" asked one surgeon as he sliced through the lobes of the brain. "A knife," the patient replied.)

On the other hand, Dolnick argues, by the 1960s the testing of evidence for medical conditions by means of controlled experiments was well established. Yet many questions that should have raised red flags went disregarded by the psychoanalysts. If schizophrenia and autism are caused by bad mothers, for example, how come many mothers of schitzophrenics and autistics also have normal children? Brushing such questions aside, the pyschoanalysts relied on anecdotal stories. One eminent American psychiatrist constructed a whole career of influential teaching and writing ("We now know that the patient's family of origin is always severely disturbed") on an uncontrolled study of only 17 cases. Other pschoanalysts were scarcely more rigorous. "Ignorant of science and disdainful of it, they failed to follow up on leads they should have checked out," Dolnick says.

The history of effective medicine -- the era in which consulting a physician offers more chances of being successfully treated than not -- is barely more than a century old. "Madness on the Couch" illuminates a medical saga, played out within our own times, of how the best intentions can have the most disastrous effects. It is a brilliant and compelling book.

The madness in the title more properly should be assigned to the chair behind the couch. That is Dolnick's point: the shrinks themselves were mad. In their madness they blamed the parents for the illness of their children, particularly the mother. How did the schizophrenic get that way? He had a "schizophrenogenic" mother, typically a loveless woman who rejected the child while dominating it psychologically. How about autism? The victim of a "refrigerator mother" who withheld love from the child. The obsessive-compulsive disorder? Ditto, although here the patient was also singled out since the patient knew what he was doing, but just would not change.
Dolnick does a great job of chronicling the delusive mind set of the shrinks who fought tooth and nail against any sort of biological explanation of mental illness even though the evidence was clear. They clung like barnacles to their delusions that these diseases were psychological because, should they admit that they were physical illnesses, caused by something physically wrong in the brain, their fraudulent "talk therapy" would be seen as it really was, useless, and their entire professional lives would be exposed as a waste.

Dolnick begins with a studied demolition of Freud and psychoanalytic psychology. He exposes Freud's delusions about the causation of mental disease, about the nature of dreams, his obsessive belief in "symptoms as symbols," and especially his arrogant lack of scientific method. Dolnick shows how the "great" man bamboozled the psychiatric profession with his almost magical way with words, turning yes's into no's and vice versa as the situation required. The Freudian canon that sex was at the heart of every neurosis was so broad and varied that almost any convenient explanation could be found within. Soldiers suffering from shell shock would seem to be an exception, but no. Dolnick quotes Freud as arguing that "Mechanical agitation...[the hellish roar and rumble of trench warfare] must be recognized as one of the sources of sexual excitation." (p. 37)

Freud's ability to delude both himself and his colleagues is exemplified in the notorious case of Emma Eckstein who was operated on by Freud's friend, Wilhelm Fliess. She was suffering from "stomach ailments and menstrual pain" and "had problems walking." Fliess performed a nose operation but it did not go well. For one thing Fliess left some surgical gauze in Eckstein's nose. As she continued to hemorrhage Freud observed, "she became restless during the night because of an unconscious wish to entice me to go there; since I did not come during the night, she renewed the bleedings, as an unfailing means of rearousing my affection." (p. 47)

The crux of Dolnick's book, though, is not about Freud but about his followers, especially the psychoanalytic psychiatrists from what he sees as the heyday of psychoanalysis, roughly the middle third of the twentieth century. He expresses the central delusion of the therapists in these words, "The ranting of the schizophrenic on the street corner, the retreat of an autistic child behind invisible walls, the endless hand-washing of an obsessive-compulsive were not simply acts, but messages. They were, the therapists fervently believed, desperate if inarticulate cries for help. And now, for the first time, those cries could be decoded."

This self-serving delusion on the part of the shrinks is Dolnick's target and he hits it well, again and again. His technique is to describe in detail the latest Freudian disciple and his particular method of "treatment," how it is ballyhooed and how the psychiatrist himself is caught up in yet another wave of excitement and personal exultation. And then Dolnick gives the grim details, exposing the fake cures and nonexistent breakthroughs. Bruno Bettelheim in particular, who for decades covered up his lack of success in treating autism with attacks on parents ("All my life I have been working with children whose lives have been destroyed because their mothers hated them." p. 216) is exposed as a violent and hypocritical man obsessed with protecting and maintaining his turf.

In a particularly chilling chapter Dolnick recalls the progression of treatments from induced fever to electroshock to lobotomies. He describes the work of Dr Walter Freeman, who specialized in ice pick lobotomies in which an ice pick or similar tool is poked into the brain via the eye socket. Dolnick comments, "This was not merely driving without a map but barreling down the road with the windshield painted black." He quotes Freeman as asking a patient on the operating table, "What's going through your mind now?" The patient replied, "A knife." When the improvement of his lobotomized patients was short-lived, Freeman observed that "many patients had been too far gone to help. He had been wrong to call lobotomy a last resort; he realized now that it had to be used before it was too late." (p. 147)

In a final chapter on "Placing the Blame," Dolnick compares "the therapists [who] had only the best intentions...[to] American communists in the forties and fifties who sincerely wanted a better world but refused to acknowledge Stalin's crimes..." (p. 278) He asserts that "beyond hubris" the fault lay in two factors, one, the sense that when psychoanalysis failed it was "somebody's fault" unlike the sense in conventional medicine that when it failed it might be nobody's fault; and two, "a lack of respect for science." He adds that the therapists were simply "ignorant and disdainful" of science. (p. 286)

This "smugness and intellectual complacency" was "the besetting sin of psychoanalysis," according to Peter Medawar, who was astonished to find that psychoanalysts "seemed free of all such doubts" as most scientists in other disciplines normally encounter. (p. 287) I would add that psychoanalytic theory was like a new religion in the making. The analysts had experienced revealed truth and there was no confusing them with the facts. The sad result was "a tragedy" that "abounded in grief needlessly inflicted." (p. 278)

This book is an easy-to-read and thoroughly entertaining critique of psychoanalysis attempt to treat schizophrenia and autism through talk therapy. Though largely anedotal, Dolnick presents a strong case that psychoanalysis is speculation cloaked in scientific garb. Instead of utilizing a rigorous method of testing their hypotheses, psychoanalysts seek confirmation and try to fit observable phenomenon into their pre-existing schemata. The audacious arrogance of Freud and his followers made them immune to contrary evidence and resistant to other methods. Moreover, Dolnick suggests that psychoanalysis feeds into the self-aggrandizement of the psychoanalyst: they are the all-knowing interpreter of their patients; they are in the privileged position. With this sort of foundation, it is no wonder psychoanalysts were able to reck havoc on parents of schizophrenic and autistic children. Without any basis in fact but only through the deductions of their own schemata, psychoanalysts condemned parents for causing schizophrenia and autism. Some through willful fraud, others through self-delusionment distorted their own success rate. To admit mistakes, would render their enterprise vulnerable and knock them off the pedestal they place themselves upon.
I don't understand some of the criticism of Dolnick's tone as "sarcastic" and "depressing". Maybe Dolnick does have a bit of an axe to grind but what better service to grind an axe with than in these incidents. These psychoanalysts caused more problems than they solved. They condemned parents for something they weren't responsible for and gave these same parents a false sense of hope that they could help their children.

This book was more than I expected. Although it deals with a limited field of psychiatry, namely psychoses of schizophrenia, autism and OCD, as they relate to misuse of psychoanalysis in their treatment, the author gripped me from the start. I enjoyed the historical review of psychiatrists in the heyday of Freud, Jung, Adler, and was interested to learn of American counterparts in the mid 1900s. The description of case-histories was interesting, specifically the author's personal interviewing of these patients and patients families. In the ever evolving field of medicine, will we return to some of Freud's original theories? It will be interesting to follow. A new theory as to a possible treatment for autism using growth hormone, I believe, invites new debate. What does the author know and think about this newest treatment?

A meticulously documented expose of how the arrogance of the psychoanalytic profession led them to inflict terrible suffering on generations of patients and their families.

In some ways, what makes the book so shocking is its modesty: Dolnick leaves open the question of the ultimate validity of psychoanalysis per se, and points out that it is unfair to hold analysts to blame for not having the knowledge of the neurological underpinnings of condition such as autism, schizophrenia and OCD that we have now. However, his attitude is summed up movingly in his choice of epigraph for the book: Cromwell's plea to "think it possible you may be mistaken." On this, he builds a devastating case: psychoanalysts, having made up their minds (because it fitted their theories) that such conditions must be the result of deep psychological disturbances, refused to even consider that it was possible they might be mistaken, even in the face of mounting contradictory evidence and agonizing misery on the part of patients and families (although Dolnick doesn't mention it, at least one mother is known to have commited suicide after psychoanalysts convinced her that she had personally caused her son's autism through her unconscious hatred and coldness). Psychoanalysts, of course, are not the only ones to blame; Dolnick also notes how unquestioningly their theories were adopted and spread by the media.

In the end, though, what seems more damning than anything else is the fact that no psychoanalyst has ever apologized or admitted that they were in error. Predictably enough, Bruno Bettelheim, who compared parents of autistic children to concentration camp guards, died in old age still convinced he was right, and praised by other analysts as a genius and saint.

Edward Dolnick gives a compelling portrayal of the heyday of the "blame the victim" psychotherapy of the 50's and 60's. He starts, of course, with Freud and with psychoanalysis in particular. (Actually, although the jacket description cites "blame the victim", it should include "blame the mother".)

In that period it was decided that in many cases, Autism, schizophrenia and obsessive-compulsive could be explained by the faults and failing of the mother. That there was no physical reasons for these maladies; they were all the result of at best, faulty thinking by the victim and at worst, bad parenting, mainly by mothers.

Dolnick uses the actual words of the various therapists as well as their patients. Starting with Freud and his overweening emphasis and preoccupation with sex, he ranges from Frieda Fromm-Reichmann to Bruno Bettelheim (and his refrigerator mothers) with the many therapists in between. Although he starts with Freud, the real shame lies with the therapists that followed him and elaborated on his theories. They all delivered the scathing, harsh message to mothers and parents that they had driven their children mad. And sadly, that message was not challenged for more than a generation.

A compelling reminder to be skeptical about theories about mental issues and about absolute theories, in particular. A well-written, well-researched book.

This book is both exciting and reliable, two qualities that rarely are found together. I agree with the praise of all the newspaper reviews and all the customer reviewers (except for the one psychoanalyst who says he never read the book but goes on to say that anyone who dares to criticize Freud must have unresolved psychological problems! That kind of self-righteousness is EXACTLY what the book is about.)

The New York Times referred to Dolnick's "formidable array of strengths," and I agree. The book is lively and, in many places, shocking. This book kept me up late, eagerly reading to see what came next.

I have two autistic children, and I think this is a must-read book for others in my situation. It will help to give an overall sense of the history of autism, and the history of the perception and beliefs about autism, as well as other brain disorders. It is not simply another in a long series of attacks on Freud, but rather a careful examination of the various perverse and strained interpretations of Freud that give the "father of psychoanalysis" an unnecessarily tainted reputation. The great joy of reading this book is sharing in Bernard Rimland's ultimate validation of his belief in the biological basis of autism, and in his abilty as a parent of an autistic child to permanently shelve the idea of the "refrigerator parent".

This book taught me a great deal about the abuses of power on the part of Freud's followers as they treated and blamed the mentally ill and their families for what we now know are biological diseases. Edward Dolnick is an excellent writer, presenting his well-researched material in a clear and readable manner. While the author comes down strongly on the side of the biological in the nature vs. nurture debate, he does cite the various psychoanalysts for their "laudable ambitions," however harmful their impact. Also, I like Dolnick's style of humor to punctuate what otherwise could have been a rather hum-drum presentation.

This is a wonderful book about a shameful period in psychiatric medicine. You come away angry at this group of medical professionals whose wild claims for "cure" were never subjected to critical thinking or to rigorous scientific review. Not only was damage done to the individuals who suffered from schizophrenia, autism and obsessive compulsive disorder by looking for help where none was possible, but there was incalculable damage done to the families who were made to bear the burden of having caused the diseases of their children. Sadly, one isn't surprised at this after reading Dolnick's thorough and thoughtful introductory chapters on Freud and his followers. This book is well written by someone who has a real flair for explaining concepts and making academic arguments real to a lay reader.This is a wonderful book about a shameful period in psychiatric medicine. You come away angry at this group of medical professionals whose wild claims for "cure" were never subjected to critical thinking or to rigorous scientific review. Not only was damage done to the individuals who suffered from schizophrenia, autism and obsessive compulsive disorder by looking for help where none was possible, but there was incalculable damage done to the families who were made to bear the burden of having caused the diseases of their children. Sadly, one isn't surprised at this after reading Dolnick's thorough and thoughtful introductory chapters on Freud and his followers. This book is well written by someone who has a real flair for explaining concepts and making academic arguments real to a lay reader.