Couch, Clinic, Scanner

Sigmund Freud went on record about the benefit patients might expect from his therapy. No miracles of personal fulfillment were on offer. It counted as success, he wrote, to transform “neurotic misery into ordinary human unhappiness.” What today’s self-improvement marketers call “living your best life” would nonetheless involve facing death, taxes and certain unwelcome holiday gatherings.

The expression “neurotic misery” may seem trivializing (at one point Freud referred to it as “hysterical misery,” which sounds even worse), but that was not the intent. In Freud’s case studies, the suffering that drove people to consult him is palpable. The grand conceptual edifice of psychoanalysis was an attempt to solve the riddle of that suffering’s origins. As David Hellerstein recounts in The Couch, the Clinic, and the Scanner: Stories From Three Revolutionary Eras of the Mind (Columbia University Press), a full initiation into psychoanalytic practice still conferred prestige in the early days of his own psychiatric career. While in residency training at the Payne Whitney Clinic in Manhattan between 1980 and 1984, he had to decide whether to undergo a training analysis: investing one hour a day, five days a week, on a couch and revealing every thought, impulse or image that went through his mind as a senior analyst listened in near-perfect silence.

In common parlance, “psychoanalyst” and “psychiatrist” are taken as interchangeable, but strictly speaking the former is a variety of the latter. (Both are required to hold an M.D., at least in the United States.) A psychoanalyst has been certified as such by a psychoanalytic institute after a training analysis, which often runs for years; in principle, you could trace the lineage of any given psychoanalyst back to someone analyzed by Freud himself. To a skeptic, this may sound less like rigorous scientific training than an initiation into Freemasonry. “All through residency training,” Hellerstein recalls, “we joke[d] about the foibles of our professors and supervisors as proof to the adage that psychoanalysis doesn’t cure your neuroses, it just frees you to brag about them.”

Now a professor of clinical psychiatry at the Columbia University College of Physicians and Surgeons, Hellerstein integrates the personal essays he has published over the years into a memoir of the upheavals in his profession. The authority of psychoanalysis, already waning at the start of his career, went into free fall in the wake of the third edition of the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Illness, published in 1980.

Offering a codified set of diagnostic categories with criteria for evaluating symptoms, the DSM-III was a catalyst for developing targeted forms of treatment—including psycho-pharmaceuticals. Patients still struggling with chronic depression after years of talk therapy reported feeling the leaden mood lift within days of starting the right medication. None of the personal history or inner conflicts beneath the symptoms would come to light, and the pills might grow less effective over time. But there was a reduction in suffering (Freud’s goal, remember) while the pharmaceutical industry always had a new pill that might help.

The author frames the late 1980s through the mid-’90s as the period when “the clinic” replaced “the couch” as the definitive site for his profession’s efforts to alleviate psychic misery. And unlike the psychoanalytic institutes, in his view, the clinic also allows for gathering data and evaluating forms of treatment. His chapters on working in hospital psychiatric departments are full of stories of people in dire condition who do not improve until someone on staff provides the right combination of personal attention and treatment modality.

But the advances on the clinical front are made under pressure from institutional and economic forces. “It is not just New York, we soon realize,” he writes. “It is a national thing. A shakeup—or shakedown—of the health care system. Disruption, like what banks and investment firms have been going through since the early 1980s. Some people say that word with glee, as if it is a good thing to shake things up, make everything more efficient, leaner, with less redundancy, to strip everything to the basics and then strip some more. Except with us, it is not only vice presidents and analysts being laid off: patients’ lives are at stake.”

Having developed (as he puts it) the persona of a researcher as well as that of a healer, Hellerstein finds himself drawn to using magnetic resonance imaging and other tools to map the organic layer of psychological phenomena—what goes on in the brain as someone daydreams, recalls a trauma or practices a stress-reducing technique. He regards “the scanner” (neuroscientific modeling) as the emerging center of gravity for progress in psychiatry, with the potential to foster treatments specific to the individual patient. He reports that patients coming to his office wondering “if they can have a brain scan to find out what is wrong with them, the way that a cardiac catheterization could show what is wrong with the arteries of their heart. No, we’re not there yet.” But someday, with adequate funding …

One of Hellerstein’s objections to couch-era psychiatry is that few people could afford to invest the time and money required for psychoanalysis. And his enthusiasm for the clinical phase of his career seems to be worn down somewhat by the deleterious impact of “managed care,” with its unrelenting pressure to “do more with less.”

So it seems as if his more recent optimism about the scanner as a diagnostic tool ought to come with a bit of caution. Enormous sums are required for basic research—and undoubtedly will be, in turn, for psychiatric application. Last year I suffered a head injury from slipping on ice. Three or four minutes in an MRI machine cost $13,000. Somehow this did not induce agoraphobia, but my insurance might not cover neurological scanning if it did. From his vantage point as a researcher, Hellerstein has grounds to believe in progress. But his experience as a clinician might warrant more concern for how many people will benefit from it.