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Psychiatry After Freud

The Vital Balance

by Karl Menninger, by Martin Mayman, by Paul Pruyser
Viking, 531 pp., $10.00

The Revolution in Psychiatry

by Ernest Becker
Free Press, 276 pp., $5.50

It is not easy to work up much enthusiasm over the state of psychoanalysis since Freud ceased writing. Gone are the days when excitement ran high over the “revolution” released by the impact of Freud’s discoveries. To some they promised a great liberation; to others they posed a great threat. Now the general feeling is more cautious, more sober, and more tired. Psychoanalysis has settled down as part of the Establishment; and neither the hopes of some nor the fears of others have come to pass. It used to be said that Freud marked the beginning of a new age in the study of man. In historical perspective. I think, he is more likely to be viewed as a voice from the past.

There have been two main trends in the development of psychoanalysis: post-Freudian and anti-Freudian. The authors of The Vital Balance are post-Freudians. The anti-Freudian reaction began with Jung and Adler, and was followed by the social revisionists (Horney, Fromm, etc.). The latest branch set up by the anti-Freudians is known as “existential analysis.” The Revolution in Psychiatry falls into this general category.

The post-Freudian trend consists, partly, in mopping-up operations, partly—as in the case of The Vital Balance—in shifting the focus of psychoanalytic work to an analysis of “the ego and its mechanisms of defense.” Ego-psychology serves several functions. In one sense. It is a strategic retreat before the anti-Freudians. The latter have been ego-psychologists all along, either because they revised Freud’s libido theory beyond recognition (Jung) or because they discarded it altogether (Adler, Sullivan, Fromm, and the existentialists). The literature of ego-psychology in post-Freudian psychoanalysis shows a similar trend. The rise of ego-psychology corresponds to a decline of libido theory. The libido theory tends to be modified or reduced; in fact, it may be whittled down to a point where the literature of ego-psychology becomes indistinguishable from anti-Freudian revisionism.

This is not true of The Vital Balance: on the contrary, its authors belong to the dwindling number of post-Freudians who accept the basic outline of Freud’s theory of instincts, with love and hate being separate and contrary drives. Thus there are other reasons for a shift to ego-psychology. The concept of the ego was a weak link in Freud’s topology of the psyche, for it was asked to do an impossible job. It was supposed to account for all the adaptive and adjustive functions of the self on the one hand, and for its autonomous, self-regulative functions on the other. It was, on the one hand, the product of “socialization.” and the seat of “self-identity” on the other. That’s asking too much. Post-Freudian psychoanalysis tends to be conformist—i.e., to make its peace with the reality-principle prevailing in society—when it is enamored by the ego as an instrument of adjustment; it tends to be receptive to existential revisions (as in the case of Erik Erikson) when it is puzzled by the autonomous functions of the ego in the life of young Luther or in the “neurotic personality of our time.”

Finally, the ego occupies a central place in psychoanalysis because it is the locus of mental illness. A weak ego is the source of psychic disorganization. More specifically, the ordinary and “normal” defenses used by everybody in order to cope with the vicissitudes of life fail to work in the case of individuals whose ego is damaged. Hence, these individuals must call up extra defenses, “coping devices,” as the Menninger authors call them, in order to reinforce the ego and to preserve some sort of “vital balance”—another word for homeostasis—in the economy of the psyche. They pay for the “abnormal” defenses they need by developing progressively serious symptoms of mental disorder.

Such, in brief, is the conceptual schema (along Freudian lines) employed in The Vital Balance. In addition, the Menninger authors develop several ideas of their own. It is of general interest, for example, that they join the campaign against psychiatric jargon and classifications. Here are some of their arguments: Classifying mental diseases is at best a matter of taxonomic convenience; at worst, the use of technical jargon “disguises essential ignorance and incompleteness of knowledge.” The Vital Balance includes an impressive 70-page appendix reviewing different and discarded systems of classifications throughout the history of psychiatry. In place of the labels most fashionable today, the Menningers propose a “unitary,” “holistic,” or “humanistic” concept of mental illness. This means that all varieties of mental disturbance, ranging from mild nervousness to extreme psychosis, are subsumed under the general category of a poorly functioning ego. Five types of “dysorganization” are distinguished, and it is shown how the ordinary classifications of mental illness can be accommodated and reinterpreted in this over-all schema. By implication, it is also shown, I think, that there is no qualitative difference between mental health and illness. Defenses are needed in either case. Thus the difference is either due to quantitative factors (i.e., the number and strength of extra defenses needed) or due to social factors (i.e., whether or not the defenses are socially acceptable). This consequence should please people who are tired of the gospel of “mental health” preached by post-Freudian psychoanalysis.

There is another reason for opposing the passion for naming in psychiatry. Labels are misleading in two respects: They suggest that a mental illness is a specific and identifiable entity, which it isn’t. Moreover, they suggest that a patient has or does not have a mental illness, in the sense of having or not having some physical characteristic—where as an illness is much more like a state of being. “Disease is nothing but life under altered conditions,” as Virchow said. Applied to mental illness, this concept is close to an existential point of view; for it suggests (1) that illness may be a legitimate way of life despite pain and suffering, and (2) that we may learn more about it by understanding the “value” it has in the way of life chosen by the individual than by explaining it in terms of specific causes relating to his childhood. (There is so much good sense here that I am sad to add parenthetically that the Menninger authors also worry about technical terms, e.g., anal or genital, because they think such language offends decent people. I thought this is how the righteous felt fifty years ago.)

The Revolution in Psychiatry adds another volume to the field of existential analysis. It is not a good case for its cause. In order to learn why existential thinkers are anti-Freudian, one should read the original sources in the field, Husserl, Heidegger, Sartre, or Binswanger, not Mr. Becker.

He too is opposed to labels. He develops a unitary and humanistic concept of mental illness, derived from a general theory of action. Man is the sum of his acts, as Goethe observed long before Sartre. Human action, however, ever, takes place in a special environment: for man is also the symbol-marking and symbol-responding animal par excellence. From birth to death he acts against a background of symbolic meanings mediated in society. The norm of human action, according to this view, would be to integrate these meanings so that the individual can act appropriately and satisfactorily and so that he can acquire what Mr. Becker calls a sense of self-value. In mental illness this normal patterns breaks down because the individual constructs his own system of meaningful symbols. This private language “saves” his pattern of action—though on a progressively reduced and disordered scale. He is sick—or “stupid,” as Mr. Becker says—because his behavior is cut off from the system of symbolic meanings which mediate the field of action in the social world. In short, mental illness is a failure of language, and there may be degrees of linguistic failure corresponding to different states of mental disturbance.

There is little to quarrel with in this conceptual schema. Whatever else it is, mental illness surely is a failure of action and communication. What is so confusing about The Revolution in Psychiatry is that it muddles up the central issue in the existential revolt. Thus one of Mr. Becker’s mottoes is taken from The Myth of Mental Illness by Thomas Szasz: “The task is to redefine the problem of mental illness so that it may be encompassed under the general category of the science of man.” Well and good—the only trouble is that an existential analysis has nothing to do with psychoanalysis nor with science. The founders of the movement are quite clear on this point, but Mr. Becker is not. He wants to say that “Freud’s place in the history of science is as secure as Newton’s” and then, in order to make sure that it isn’t, he dishes up all the red herrings about psychoanalysis all over again, Freud’s reductionism, scientism, and his alleged “pansexual obsession.”

Perhaps it’s time to get this issue straight and indicate briefly why an existential analysis is neither psychoanalysis nor science. First of all, it is an ego-psychology exploring the field of conscious phenomena only. Whether existential analysis go back to Heidegger or to Sartre, they have no use for the unconscious. There is a lengthy critique of the concept in Being and Nothingness: yet. whatever psychoanalysis was or may be, it is nothing without the unconscious and the theory of repression on which Freudian analysis of the unconscious rests. In this respect, the existential revolt is not post-Freudian, but pre-Freudian; it is not “post-scientific,” as Mr. Becker says, but antiscientific—the simple reason being that existential analysts are phenomenologists.

A phenomenological method is antiscientific because it is not interested in discovering the causes of human behavior, but in describing the structure of meanings in human experience. The distinction between causes and meanings is obvious. The meaning of a friendship is different from the cause and effect relations that enter into it. Again, what an illness means in the life of the individual is different from a scientific explanation of its causes. Yet the business of science is to explain, and an explanation is based upon the discovery of causal relations. Thus the explanation of an illness differs from a description of its meaning in the life of the individual.

Phenomenologists think it is more important in a study of man to describe meanings than to discover causes. Why they think so I cannot discuss here: but The Revolution in Psychiatry is still-born because Mr. Becker—partly misled, I think, by trying to superimpose Dewey upon an existential analysis—consistently scrambles up meanings with causes and description with explanation. Thus, for him. meaning in the psychological sense is a knowledge of “cause and effect sequences,” which it isn’t, and when he has given a description of depressive behavior, he thinks he has explained it. In the revisionist literature of psychoanalysis, this confusion is as old as the Jungian archetypes.

There is a final trend that deserves attention in a review of post-Freudian affairs. The emergence of an ego-psychology also coincides with a surprising return to ideology in psychiatry. Here post-Freudians and anti-Freudians meet. Both have adopted a pastoral (even sermonizing) language that is completely out of tune with Freud and the early radicalism of psychoanalysis. Thus the two works under discussion also conclude on a high ideological level—Mr. Becker on the theme of love and art in the life of man, the Menninger authors on the Christian trinity. Faith, hope, and love are the great “intangibles” in psychiatric treatment. In fact, reading The Vital Balance is a strange experience because its authors seem to put the case for therapy, perhaps unintentionally, into grave jeopardy. I was amazed to learn that “the treatments which have been so dramatically effective in psychiatry have had nothing to do with a discovered or a theoretical etiology, for the most part.” It is difficult to say, of course, how much ground is covered by the last escape clause, but the general impression one derives from the Menninger volume is that a little tea and sympathy is the most effective therapy.

In other words, there is no necessary correlation between theory and therapy. It may help to work with a good theory, but chance and charity may do more than any theory. To put it crudely, therapy may be needed only by those who cannot find hope and love anywhere else but on the couch. But if the pragmatic test fails because other methods can cure just as well or better, on what grounds do we decide the “value” of psychoanalytic theory? Or was psychoanalysis always more than a medical theory? If, as Freud thought, it occupies a position “between medicine and philosophy,” then it is easier to resolve this puzzle. Disagreements—in theory and in therapy—are never decided on the basis of scientific tests only because they always involve differences in philosophy as well.

Both volumes under discussion, finally, raise high hopes for the future of psychiatry. Mr. Becker’s book is dedicated to a society in which “psychiatry will be an agent of social change rather than a shelter from social confusion.” This is a beautiful sentiment, but I don’t see any trends anywhere that would make it a realistic estimate of the social situation. The Menninger authors fall back upon a self-image of the psychiatrist who holds “the keys to the door of happiness and the answer to the mystery of adjustment.” I know this belief is very popular, but it is pure magic just the same. Happiness may be a mystery eluding everybody; adjustment is not. It’s normal.

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