On the Borderland of Madness

When it comes to the history of psychoanalysis and psychiatry in the United States, to paraphrase Luce Irigaray, one never stirs without the other. While Freud sent Theodore Reik across the ocean to promote lay analysis, A.A. Brill, president of the New York Psychoanalytic Institute, was preparing to divorce the International Psychoanalytic Association. Brill, driven by a fear that psychoanalysis might be seen as quackery and so discredited, sought to guarantee that the only people allowed to practice psychoanalysis in America were medical doctors. Then came the Anschluss: humanitarian efforts were made to bring the very-same IPA members the Americans sought to separate from onto American soil. This is a pretty well known tale--told by Gay, Hale, Roazen and others; enter Orna Ophir's book, On the Borderland of Madness: Psychosis, Psychoanalysis and Psychiatry in Postwar USA (Routledge, 2015), offering a much needed explanation of how psychoanalysis in America lost its patina. This intellectual history closely studies, via a reading of key journals, the way two professions, for years dancing in close embrace, began to fall out of step. In the same way that the birth of a child with developmental disabilities can reveal a cleavage in what was once thought to be a secure marital bond, debates over the treatment of psychosis led to the eventual separation of two longstanding bedfellows: psychiatry and psychoanalysis. Ophir pieces together the confusing, and previously untold, tale of how psychoanalysis came to be marginalized--and what role psychosis played therein, for its role was key. To carry the conflicted parent metaphor a little further, when a child suffers from psychic distress one member of a couple might seek to understand that suffering in genetic terms while the other spouse might examine the kind of care shown that child: the story of psychiatrically influenced psychoanalysis and non-psychiatrically influenced psychoanalysis line up similarly. While it is commonly known that the release of new medications to treat psychotic pain beginning in the late 1950s, and the birth of community psychiatry in the 70s, and of course the release of the anti-psychodynamic DSM-III in the 80s all played a role in arguments for the superfluity of analytic treatment for psychosis, Ophir argues that psychoanalysis got sidelined because American psychoanalysts, given their long-standing embrace of psychiatry, were duly handicapped. How to let go of the safety-net of psychiatry--that which is deemed irrefutable, scientific and biologically bound--and still survive was their question. Using ideas from the sociology of the professions/knowledge, Ophir argues that analysts engaged in jurisdictional turf wars that the treatment of psychosis brought to the fore. In a profession largely populated by psychiatrists, during a time when psychosis came to be largely seen as a brain disorder rather than a defense or a remnant of pre-oedipal disturbance, analysts had to decide which side they were on. Analytic clinicians, attempting to stay relevant, began to employ the language of psychiatry, supporting what Ophir calls "the neosomatic revolution" only to find that by doing so, they had thrown out the (psychotic) baby with the bathwater. Discursive shifts, be it in politics or a profession, have deep impacts--(when we hear analysts using the language of brain as opposed to mind we are in the presence of the data produced by that impact) and we see proof of this today: very, very few analysts treat psychosis. As in most every divorce that involves children, custody is not usually distributed evenly. Ophir tells the story of how analysts handed over their psychotic patients to psychiatrists during tense negotiations. Like many a spouse after a divorce, analysts worried about their ability to rebuild their (professional) lives. Ophir reminds us however that the children jettisoned do come back to haunt the parent that let them slip away. And just as that parent might say, "but I always loved you", the child only sees proof of neglect. Then, alas, that parent starts to lose sleep. S/he make mistakes, perhaps falls ill, even dies (broken-heartedly) from the internal stress--witness the shaky state of the field today and you can find an apt corollary. Indeed, most American psychoanalytic institutes graduate candidates who have never worked with psychotic individuals. Additionally they have been taught the language of dissociation, of external trauma, self-states, coupled with a healthy dose of dislike for the death instinct on the side--all of which work well when conceiving of the non-psychotic patient but perhaps less so with a person in one's office responding to command hallucinations, riddled with delusions. Writes Ophir of the psychoanalytic shunning of psychosis and its impact on the profession, "...the nature of the repressed is to return," and "the nature of what is split off and expelled is to become ever more persecutory. If psychoanalysis is to survive it must reconnect with the edges of experience ... with the death instinct and catastrophic inferno where many schizophrenic patients exist." It is not enough, according to Ophir, (and I wholly agree) to produce theories that elaborate upon the psychotic core or dissociated self-states in otherwise neurotic individuals--(as has become symptomatically common after the custody arrangement regarding the treatment of psychotic people was finalized)--while never treating persons actually suffering from psychosis. For psychoanalysis to remain relevant, Ophir suggests, it may be time to go back to family court to revisit the custody arrangement.

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Tracy D. Morgan is the founding editor and host of NBIP, a psychoanalyst in practice in NYC trained also as an historian, she writes about many things.