Psychiatry wars: the lawsuit that put psychoanalysis on trial
Before entering Chestnut Lodge, one of the most elite psychiatric hospitals in the US, Ray Osheroff was the kind of charismatic, overworked physician we have come to associate with the American dream. He had opened three dialysis centres in northern Virginia and felt within reach of something “very new for me, something that I never had before, and that was the clear and distinct prospects of success,” he wrote in an unpublished memoir. He loved the telephone, which signified new referrals, more business – a sense that he was vital and in demand. “Life was a skyrocket,” he wrote.
But when he was 41, after divorcing and marrying again quickly, he seemed to lose his momentum. When his exwife moved to Europe with their two sons, he felt as if he had ruined his chance for a deep relationship with his children. His thinking became circular. In order to have a conversation, his secretary said, “we would walk all the way around the block, over and over”. He couldn’t sit still long enough to eat. He was so repetitive that he started to bore people.
His new wife gave birth to a baby boy less than two years after their wedding, but Ray had become so detached that he behaved as if the child wasn’t his. He seemed to care only about the past. He felt increasingly overwhelmed by the stress caused by professional rivals, and he sold a portion of his business to a larger dialysis corporation. Then he became convinced he had made the wrong choice. After finalising the sale, he wrote: “I went outside and sat in my car and I realised that I had become a piece of wood.” The air felt heavy, like some sort of noxious gas.
Ray felt that he had carefully built a good life – the kind he had never imagined he could achieve but, on another level, felt secretly entitled to – and with a series of impulsive decisions, had thrown it away. “All I seemed to be able to do was to talk, talk, talk about my losses,” he wrote. He found that food tasted rotten, as if it had been soaked in seawater. Sex was no longer pleasurable either. He could only “participate mechanically”, he wrote.
When Ray began to threaten suicide, his new wife told him that if he didn’t check into a hospital, she would file for divorce. Ray reluctantly agreed. He decided on Chestnut Lodge, which he had read about in Joanne Greenberg’s bestselling 1964 autobiographical novel,I Never Promised You a Rose Garden, which describes her recovery at the Lodge and serves as a kind of ode to the power of psychoanalytic insight. “These symptoms are built of many needs and serve many purposes,” she wrote, “and that is why getting them away makes so much suffering.”
During Ray’s first few weeks at the Lodge, in 1979, his psychiatrist, Manuel Ross, tried to reassure him that his life was not over, but Ray would only “pull back and become more distant, become more repetitive,” Ross said. Ross concluded that Ray’s obsessive regret was a way of staying close to a loss he was unable to name: the idea of a parallel life in which “he could have been a great man”.
Hoping to improve Ray’s insight, Ross interrupted Ray when he became self-pitying. “Cut the shit!” he told him. When Ray described his life as a tragedy, Ross said, “None of this is tragic. You are not heroic enough to be tragic.”
At a staff conference a few months after he arrived, a psychologist said that after spending time with Ray, she had a pounding headache. “He is like 10 patients in one,” a social worker agreed.
“He treats women as if they are the containers for his anxiety and are there to indulge him and pat his hand whenever he’s in pain,” Ross said. “And he does that with me, too, you know? ‘You don’t know what pain I’m in. How can you do this to me?’”
Ross said that he had already warned Ray: “With your history of destructiveness, sooner or later you are going to try to destroy the treatment with me.” Nevertheless, Ross was confident that if Ray “does stay in treatment for five or 10 years, he may get a good result out of it”.
“Five to 10 years is about right,” another psychiatrist said.
At the Lodge, the goal of all conversations and activities was understanding. “No single word used at the hospital is more charged with emotional meaning, or more slippery in its cognitive implications,” Alfred Stanton, a psychiatrist, and Morris Schwartz, a sociologist, wrote in The Mental Hospital, a 1954 study of the Lodge. The hope of “getting better” – by gaining insight into interpersonal dynamics – became its own kind of spirituality. “What occurred at the hospital,” the authors wrote, “was a type of collective evaluation in which neurosis or illness was Evil and the ultimate Good was mental health.”
Dexter Bullard, the director of Chestnut Lodge for nearly 40 years, believed that the Lodge could do what no other American hospital had done: psychoanalyse every patient, no matter how far removed from reality they were (as long as they could pay the admission fee). The possibilities of pharmacology did not interest him. His goal was to create an institution that expressed the ethos of the analyst’s office. If a patient appeared beyond the realm of understanding, the institution had failed – its doctors weren’t trying hard enough to see the world through the patient’s eyes. “We don’t know enough yet to be able to say why patients stay sick,” Bullard told a colleague in 1954. “Until we know that, we have no right to call them chronic.”
The “queen of Chestnut Lodge”, as people called her, was Frieda FrommReichmann, a founder of the Frankfurt Psychoanalytic Institute who lived on the grounds of the Lodge in a cottage that had been built for her. She described loneliness as the core of mental illness. It was such a deep threat, she wrote, that psychiatrists avoided talking about the phenomenon, because they feared they would be contaminated by it, too. The experience was nearly impossible to communicate; it was a kind of “naked existence”.
Fromm-Reichmann and other analysts at the Lodge were described as “substitute mothers”. Younger therapists vied for their attention, working through what they called sibling rivalries. The doctors, all of whom had undergone analysis themselves, felt that they had been incorporated into one household – as one psychiatrist put it, they were “part of a dysfunctional family”. As patients walked down the hallway to their appointments, others shouted, “Have a good hour!” Alan Stone, a former president of the American Psychiatric Association (APA), described the Lodge as “the most enlightened hospital in North America.” He told me, “It seemed like Valhalla, the residence of the gods.”
At the time, faith in the potential of psychology and psychiatry seemed boundless. The psychological sciences provided a new framework for understanding society. “The world was sick, and the ills from which it was suffering were mainly due to the perversion of man – his inability to live at peace with himself,” declared the first director of the World Health Organisation, a psychiatrist, in 1948. The psychologist Abraham Maslow said: “The world will be saved by psychologists – in the very broadest sense – or else it will not be saved at all.”
At the Lodge, Ray began walking eight hours a day. Breathing heavily through pursed lips, he paced the corridors of the Lodge. He calculated that he walked about 18 miles a day, in slippers. A nurse wrote that he frequently bumped into people but “doesn’t even seem to realise he had physical contact”.
As he paced, Ray recalled the lavish vacations that he and his wife had enjoyed. They dined out so frequently that when they entered their favourite restaurants they were immediately recognised. The motion of his legs became a “mechanism of self-hypnosis in which I would concentrate on the life I once had”, Ray wrote. His feet became so blistered that orderlies at the Lodge took him to a podiatrist. His toes were black with dead skin.
After half a year, Ray’s mother visited him at the Lodge and was alarmed by his deterioration. His hair had grown to his shoulders. He was using the belt of his bathrobe to hold up his trousers, because he had lost 18kg (almost three stone). Ray had once been a prodigious reader, but he had completely stopped. He was also a musician, and, although he had packed sheets of music in the suitcase he brought to the Lodge, he almost never looked at the pages. When a nurse called him Dr Osheroff, he corrected her: “MrOsheroff.”
Ray’s mother asked the Lodge to give him antidepressants. But to the Lodge psychiatrists the premise of this form of treatment – to be cured without insight into what had gone wrong – seemed superficial and cheap. Drugs “might bring about some symptomatic relief”, Ross, Ray’s psychiatrist, acknowledged, “but it isn’t going to be anything solid in which he can say, ‘Hey, I’m a better man. I can tolerate feelings.’” Ross concluded that Ray was simply searching for a drug that would buy him the “return of his former status” – an achievement that, Ross believed, had always been illusory.
Disappointed by the Lodge, Ray’s mother decided to transfer him to Silver Hill, a hospital in New Canaan, Connecticut, that had embraced the use of antidepressants. Ray’s new psychiatrist at Silver Hill, Joan Narad, immediately prescribed him two medications: Thorazine, to calm his agitation and sleeplessness, and Elavil, discovered in 1960. Her impression of him, she said, was as a “vulnerable person who desperately wanted a relationship with his boys”.
On Ray’s first evening at Silver Hill, he gave a nurse his wedding ring. “I don’t need it anymore,” he said. The next morning, he called his mother and said: “This institution and a lot of pills can’t change things.” He felt like he was “floating in space in no definite direction”. On his seventh day, he told the nurses he wished to change his name and disappear somewhere. On his eighth day, he said: “I give myself another year or two to live. I hope to die quickly of a coronary in my sleep.”
After three weeks there, Ray woke up in the morning, sat in an armchair, and drank a mug of steaming coffee. He read the newspaper. Then he called his psychiatric aide into his room. “Something is happening to me,” he told her. “Something has changed.”
He felt a “terrible sadness”, an emotion that he realised had previously been inaccessible. He hadn’t seen his sons in almost a year, and he started to cry – the first time he had done so in months. He thought he had already been grieving his separation from his sons, but now he realised that what he had been experiencing wasn’t anything as alive as grief: it was “beyond feeling”, he wrote. “It is a total absence of feeling.”
Within two weeks, Ray seemed to have regained his sense of humour. A nurse wrote that he had “a warm, sensitive aspect to his disposition – especially towards his children”. Narad, his psychiatrist, said: “A new human being began to emerge.”
Ray began spending time with another patient, a woman his age. With a day pass from the hospital, Ray took a bus to downtown New Canaan, bought a bottle of champagne, and knocked on the woman’s door. They spent the night together. “The act of making love,” he wrote, “was not so much sexual or biological, but it was an act of defiance, a reaching out, a groping, a grabbing back of our humanness.”
Ray began to spend hours reading in the hospital’s psychiatric library. He was shaken by a 1975 memoir, A Season in Hell, by Percy Knauth, a former New York Times correspondent who was suicidal until he took antidepressants. “Within a week the miracle began to happen,” Knauth wrote. “For the first time in more than a year I felt good!” He added, “There is little doubt that I had been suffering from a norepinephrine imbalance,” which was at the time a theory for the source of depression, one that has since been largely discarded.
The chemical-imbalance theory of depression was first described in 1965 by Joseph Schildkraut, a scientist at the National Institute of Mental Health, in what became the most frequently cited paper in The American Journal of Psychiatry. Reviewing studies of antidepressants and clinical trials in both animals and humans, Schildkraut pro-
posed that the drugs increased the availability of the neurotransmitters dopamine, norepinephrine and serotonin – which play a role in the regulation of mood – at receptor sites in the brain. He reasoned backwards: if antidepressants worked on those neurotransmitters, then depression may be caused by their deficiency. He presented the theory as a hypothesis – “at best a reductionistic oversimplification of a very complex biological state”, he wrote.
Nevertheless, the theory gave rise to a new way of talking about the self: fluctuations in brain chemicals were at the root of people’s moods. The framework redefined what constituted selfknowledge. This was “a shift in human ontology – in the kinds of persons we take ourselves to be”, the British sociologist Nikolas Rose later wrote.
At Chestnut Lodge, Ray had been lacking in insight, but at Silver Hill, where a different model of illness prevailed, he was an eager student of his condition. He began working on a memoir. To research the book, he read medical literature on depression, a disease he now saw as “exquisitely curable”. He felt relieved by the idea that the past two years of his life could be explained with one word.
Ray was discharged from Silver Hill after three months of treatment. It had been nearly a year since he had lived outside the confines of an institution. He returned to an empty house. His wife had decided to divorce him, and she had already moved out with their son, taking most of the furniture. His other sons were still in Europe.
Ray showed up unannounced at his dialysis clinic. Patients embraced him and shook his hand; some of the nurses kissed him. But newer employees, hired while Ray had been away, kept their distance. Word had spread that he had been in a mental institution. In the break room, the head nurse described Ray as a “lunatic” and “incompetent”. A secretary observed that he asked rudimentary questions about how to work a dialysis machine. A colleague who had been running Ray’s business in his absence was upset that Ray had failed to complete his treatment at the Lodge. He assumed that Silver Hill had merely done a “patch-up job”. He quit and opened a competing practice in the same building. Many of Ray’s patients and employees migrated there, too.
News of Ray’s illness – and the rift with his colleague – spread throughout the medical community, and he stopped getting referrals. Sometimes, he didn’t have enough patients to fill a day of work. Separated from his sons and barely working, Ray felt as if he had lost the “trappings that identified me as a person existing in the world”.
In 1980, the year after he was released from Silver Hill, Ray read the entire Diagnostic and Statistical Manual of Mental Disorders. The third edition, DSM-III, had just been published. The first two editions had been slim pamphlets, not taken particularly seriously. But for the new version, a committee appointed by the APA tried to make the manual more objective and universal by cleansing it of psychoanalytic explanations, like the idea that depression is an “excessive reaction” to an “internal conflict”.
Now that medications had been shown to be effective, the experiences that gave rise to a condition seemed less relevant. Mental illnesses were redefined according to what could be seen from the outside – a checklist of behavioural symptoms. The medical director of the APA declared that the new DSMrepresented a triumph of “science over ideology”.
The clinical language of DSM-III relieved Ray’s sense of isolation – his despair had been a disease, which he shared with millions of people. He was so energised by the new way of thinking about depression that he scheduled interviews with leading biological psychiatrists as research for his memoir, which he titled A Symbolic Death: The Untold Story of One of the Most Shameful Scandals in American Psychiatric History (It Happened to Me).
Ray sent a draft of his memoir to the psychiatrist Gerald Klerman, who had recently stepped down as the head of the US federal government’s Alcohol, Drug Abuse and Mental Health Administration. Klerman had written disparagingly of what he called “pharmacological Calvinism” – the belief that “if a drug makes you feel good, it’s either somehow morally wrong, or you’re going to pay for it with dependence, liver damage, chromosomal change, or some other form of secular theological retribution”. Ray said that Klerman told him that his manuscript was “fascinating and compelling”.
Emboldened by Klerman’s approval, Ray decided to sue Chestnut Lodge for negligence and malpractice. He argued that, because the Lodge failed to treat his depression, he had lost his medical practice, his reputation in the medical community, and custody of his children. Ray’s friend Andy Seewald told me that Ray often compared himself to Ahab in Moby-Dick. “The Lodge was his white whale,” he said. “He was searching for the thing that had unmanned him.”
In the lawsuit, the 20th century’s two dominant explanations for mental distress collided. No psychiatric malpractice lawsuit has attracted more prominent expert witnesses than Ray’s, according to Alan Stone, the former president of the APA. The case became “the organising nidus” around which leading biological psychiatrists “pushed their agenda”, he told me.
At a hearing before an arbitration panel, which would determine whether the case could proceed to trial, the Lodge presented Ray’s attempt to medicalise his depression as an abdication of responsibility. In a written report, one of the Lodge’s expert witnesses, Thomas Gutheil, a professor of psychiatry at Harvard, observed that the language of the lawsuit, much of which Ray had drafted himself, exemplified Ray’s struggle with “‘externalisation’ – that is, the tendency to blame one’s problems on others”. Gutheil concluded that Ray’s “insistence on the biological nature of his problem is not only disproportionate but seems to me to be yet another attempt to move the problem away from himself: it is not I, it’s my biology.”
The Lodge’s experts attributed Ray’s recovery at Silver Hill at least in part to his romantic entanglement with a female patient, which gave him a jolt of self-esteem.
“It’s a demeaning comment,” Ray responded when he testified. “And it just speaks to the whole total disbelief in the legitimacy of the symptomatology and the disease.”
The Lodge lawyers tried to chip away at Ray’s description of depression, arguing that he had shown moments of pleasure at the Lodge, such as when he had played piano.
“The sheer mechanical banging of ragtime rhythms on that dilapidated old piano on the ward was almost an act of agitation rather than a creative pleasurable act,” Ray responded. “Just because I played ping-pong, or had a piece of pizza, or smiled, or may have made a joke, or made googly eyes at a good-looking girl, it did not mean that I was capable of truly sustaining pleasurable feelings.” He went on, “I would say to myself: ‘I am living, but I am not alive.’”
Manuel Ross, Ray’s analyst from the Lodge, testified for more than eight hours. He had read a draft of Ray’s memoir and he rejected the possibility that Ray had been cured by antidepressants. He was not a recovered man, because he was still holding on to the past. (“That’s what I call melancholia as used in the 1917 article,” he said, referring to Freud’s essay Mourning and Melancholia.)
Ross said that he had hoped Ray would develop insight at the Lodge. “That’s the true support,” he said, “if one understands what is going on in one’s life.” He wanted Ray to let go of his need to be a star doctor, the richest and most powerful in his field, and to accept a life in which he was one of the “ordinary mortals who labour in the medical vineyard”.
Ray’s lawyer, Philip Hirschkop, one of the most prominent civil rights attorneys in the country, asked Ross: “As an analyst, do you have to sometimes look inside yourself to make sure you’re not reacting to your own feelings about someone?”
“Oh yes,” Ross said. “Oh yes.”
“You who’ve locked yourself into one position for 19 years with no advancement in position other than salary, might you be a little resentful of this man who makes so much more money, and now he’s here as your patient?” Hirschkop asked.
“That’s possible, sure,” Ross said. “You have to take that into account – there’s no question about that. I think that’s your own kind of psychological work that you do on yourself. Am I being envious of this? Or am I describing the grandiosity just out of envy and spite? But I don’t think I was doing that.”
“Would you infer, fairly, that someone who locked themself into the same job for 19 years might lack some ambition?”
“No, Mr Hirschkop,” Ross said. “I like the work I’m doing. I find it continually stimulating.”
On 23 December 1983, the arbitration panel concluded that Chestnut Lodge had violated the standard of care. The case could proceed to trial. Joel Paris, a professor of psychiatry at McGill University, wrote that “the outcome of the Osheroff case was discussed in every academic department of psychiatry in North America”. The New York Timeswrote that the case shook “the conventional belief, held even by some doctors, that chronic depression is not an illness, but merely a character flaw”. According to The Philadelphia Inquirer, the case could “determine to a great extent how psychiatry would be practiced in the United States”.
But shortly before the case was to go to trial, in 1987, Chestnut Lodge offered to settle. By then, Ray was dating a high-school classmate, who was the widow of a psychoanalyst. She didn’t like the way Ray’s case pitted one school of psychiatry against the other. “It’s much too simplistic,” she told me. “One school does not supplant the other.” Ray decided to settle the case and move on.
The country’s most prominent psychiatrists continued to treat the case as psychoanalysis’s final reckoning. The psychiatrist Peter Kramer, the author of the landmark book Listening to Prozac, later compared the case’s significance to Roe v Wade. As Psychiatric Times put it, the case represented a “showdown between two forms of knowledge”.
Ray’s doctor at Silver Hill, Joan Narad, told me that she was pained by the conclusions people drew from Ray’s story. “The case was used to increase polarity,” she said. The APA held a panel on Ray’s case at its annual conference in 1989, and Ray showed up with his oldest son, Sam, with whom he had reunited, to watch. Narad was there too, and she showed Sam pages of Ray’s medical records. “I told him, ‘I just want you to know that your father tried to reach you – he loved you and was desperate to see you,’” Narad said.
But Sam and his younger brother, Joe, did not forgive their father. They believed he had latched on to the wrong explanations for why his life had gone off course. “My father had this gregarious, kind, brilliant side to him, but he never addressed his problems,” Joe told me. “He kept telling the same repetitive story.”
After Ray’s case, the Lodge began prescribing medication for nearly all of its patients. “We had to conform,” Richard Waugaman, a Lodge psychiatrist, told me. “It wasn’t always about whether it was going to help the patient. It was about whether it would protect us from another lawsuit.”
The Lodge doctors felt chastened by a long-term study, published in 1984 in the Archives of General Psychiatry, that followed more than 400 patients who had been treated at the Lodge between 1950 and 1975. Only a third of schizophrenic patients had improved or recovered – roughly the same percentage of patients shown at that time to recover in any treatment setting. At a symposium attended by 500 doctors, the study’s co-author Thomas McGlashan, a psychiatrist at the Lodge, announced: “The data is in. The experiment failed.”
For years, most patients at the Lodge had their care covered through private insurance plans, but in the early 90s, managed care came to dominate the insurance industry. To contain costs, insurance companies required doctors to submit treatment plans for review and show evidence that patients were making measurable progress. Long, elegant narratives of patients’ struggles were replaced by checklists of symptoms. Mental healthcare had to be treated as a commodity, rather than as a collaboration.
The doctor–patient relationship, which the Lodge viewed as an enchanted bond, was remade by the language of corporate culture. Psychiatrists became “providers” and patients were “consumers” whose suffering was summarised with diagnoses from the DSM. “Madness has become an industrialised product to be managed efficiently and rationally in a timely manner,” wrote the anthropologist Alistair Donald in his 2001 essay The Wal-Marting of American Psychiatry. “The real patient has been replaced by behavioural descriptions and so has become unknown.”
As older analysts retired, the Lodge hired a new generation of doctors and social workers who were more enthusiastic about medications. But Karen Bartholomew, the former director of social work there, told me it was frustrating when staff members, dismissing the psychiatry of earlier eras, said: “We’re so much better now.” Increasingly, she said, patients showed up at the Lodge “on five or six different medications, and who knows what’s working at that point?”
In 1995, the Lodge was sold to a community-health nonprofit organisation that soon drove it into bankruptcy. By the late 90s, the buildings at the Lodge were falling apart. A psychiatrist at the Lodge recalled that one of her patients was on the third floor of the hospital when honey dripped on to her face. On the ceiling were beehives.
By the hospital’s final day, 27 April 2001, only eight patients remained. The Lodge, like many mental asylums in the country, was eventually abandoned. A local paper described the property as a gathering spot for “ghost hunters”, driven by “tales of the paranormal and other hauntings”. Then, in the summer of 2009, for reasons that were never determined, the Lodge’s main building burned to the ground.
After settling his lawsuit, Ray had moved to Scarsdale, New York, with his new wife, but, after a few years, he felt that the relationship had “no content”, and he got another divorce. In a draft of his memoir, Ray modified his definition of depression: “This is not an illness, it is not a sickness – it is a state of disconnection.” He had started seeing a psychoanalyst again. He referred to this analyst as the “good father” (whereas Ross, he wrote, had been the bad one). Ray believed that if the Lodge had treated him with medications he might have never needed therapy, but now, he wrote, he had “lost the framework on which to build anything”.
Following the collapse of his marriage, Ray moved to New Jersey, to live with another former high school classmate, even though he found her tiresome and bland. He worked at a nephrology clinic, but, after a year, his contract wasn’t renewed, and he “began to float around in entry-level positions”, as he described it in a letter. “Can you imagine what it would be like to be ashamed to have your children see you this way – that you would want to run away from them?”
When Ray visited his oldest two sons, he overwhelmed them with a repetitious account of how Chestnut Lodge had derailed his life. He also gave them new revisions of his memoir. “The book, the book,” Joe said. “That’s all he wanted to talk about.” When Sam’s first child was born, Ray showed up with a revised draft of his memoir and seemed more interested in discussing his writing than in meeting his granddaughter. Sam said that his father told him: “The memoir is going to blow people away. They’re going to make a movie of this.” He and Joe stopped returning their father’s calls. Ray’s youngest son was already estranged.
The memoir swelled to 500 pages. The early drafts had been textured and vibrant. But after three decades of revision, there was something oppressive and dishonest about the writing, a tale of revenge. Perhaps the only improvement was Ray’s portrait of his own father, who had been absent in early drafts. Now he revealed that his father may have abused him.
In each draft, Ray searched for an overarching theory that would explain
why the life he had wanted had ended 40 years too early. One theory was that he was a man with a chemical imbalance. Another was that he was a boy deprived of a paternal model: “Underneath all of this,” he wrote, “is there not the theme of the son in search of the father? Not the loss of a business. The loss of the father.” A third was that he suffered from a kind of chronic loneliness – a condition that he characterised, quoting Fromm-Reichmann, as “such an intense and incommunicable experience that psychiatrists must describe it only in terms of people’s defences against it”.
“So what does this story add up to?” Ray asked. “How can I define myself? Who is Ray Osheroff now?” He had been taking psychiatric medications for three decades, but he still felt rootless and alone. “There is a painful gulf between what is and what should have been,” he wrote. He was an “unremedied man”. Two different stories about his illness, the psychoanalytic and the neurobiological, had failed him. Now, he was hopeful that he would be saved by a new story, the memoir he was writing. If he just framed the story right or found the right words, he wrote, he could “finally reach the shore of the land of healing”.
Adapted from Strangers to Ourselves: Stories of Unsettled Minds by Rachel Aviv, published by Harvill Secker on 20 October and available at guardianbookshop.co.uk
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