The 90-year divide
Nearly a century ago, rival approaches to psychiatry fractured the profession. The grand argument is far from over.
Clara Thompson had been one of the top psychiatrists on the staff of Adolf Meyer, selected by him to tend to his private patients when he was away. He had been her mentor, both in the clinic and in her personal life, and a few years earlier had written a glowing recommendation for her. Now Meyer, director of the Henry Phipps Psychiatric Clinic at Johns Hopkins, was contemplating how to fire her. As he sorted through the events that had occurred over the summer of 1925, beginning with the suicide of one of his private patients, Meyer wrote notes to himself in his neat, meticulous script. Thompson had created "an inadmissible situation," he said. Against his explicit wishes, she had entered into Freudian psychoanalysis with Joseph Thompson, a most "unsavory character." (The two Thompsons were unrelated.) Joseph Thompson had lured her over to his office down the street from the clinic, and now she was taking patients from Phipps there as well. It was a clear "misuse of her position," showing "lack of judgment," Meyer wrote in his notes.
To Meyer, who was concerned about the increasing influence of Sigmund Freud, Clara's defection amounted to a "division of allegiance and separation of an analytic camp." Known as the dean of American psychiatry, Meyer had spent his career carefully developing his theory of psychobiology, which rejected the dualism of mind and body to focus on the whole person. He believed in a "commonsense" approach to psychiatry, rooted in close observation of a patient's behavior, physical symptoms, and life story. Leaving behind psychobiology, Thompson had championed Freudian theory, which was much more mind-oriented and held that all symptoms of mental illness could be traced to hidden conflicts in the unconscious. She advocated that not only patients but also their doctors—like Meyer—would benefit from intensive analysis. Meyer firmly rejected such an idea; he saw no purpose in dwelling in what he called "the cesspool of the unconscious."
These strong positions of nearly a century ago bred conflicts that still divide psychiatry. The divisions, which had serious repercussions at Phipps and affected the careers of both Thompson and Meyer, live on in the current controversy over the revision of the Diagnostic and Statistical Manual of Mental Disorders, the psychiatrist's bible known colloquially as the DSM. In the heat of that debate are Johns Hopkins psychiatrists Paul McHugh and Phillip Slavney, who have raised serious questions about the DSM's approach in their textbook, The Perspectives of Psychiatry, and in the May 17 issue of the New England Journal of Medicine. Psychologist René J. Muller, A&S '75 (PhD), goes further: He has proposed scrapping the DSM altogether and replacing it with a classification system based on Meyer's ideas.
The fundamental questions confronted by psychiatrists in the 1920s remain unresolved today. Encountering a new patient, what does a doctor see? A set of symptoms requiring treatment? A life story waiting to be revealed? And what scientific evidence backs up any approach?
As a young man in Switzerland, Meyer initially trained as a neuropathologist. Unable to find professional opportunities in Europe, he immigrated to the United States where he landed at the Illinois Eastern Hospital for the Insane, at a time when people suffering from mental disorders were warehoused and forgotten. There he examined slides of brain tissue taken from autopsies, hoping to discover an organic source of mental illness. Years later, doctors discovered that almost a third of the "insane" patients inhabiting asylums actually suffered from tertiary syphilis. But Meyer could find no anomalies.
When his mother was hospitalized in Zurich for severe depression, Meyer railed against the hopelessness associated with mental illness and turned his attention to an intense examination of living patients. He left neuropathology for the budding field of psychiatry, using his medical background and wide-ranging, eclectic reading to probe all aspects of the mind, delving into Greek history for anything useful, as well as the pragmatic philosophy of the day, including that of his contemporary William James and social reformers Jane Addams and Julia Lathrop. Making his way through the ranks of American institutions, he arrived at the pinnacle of his career when he was appointed the first professor of psychiatry at Johns Hopkins Hospital in 1908. The next year, he was named psychiatrist-in-chief, and in 1913 presided over the opening of the Phipps Clinic.
At Johns Hopkins, his theory of psychobiology came into practice. "What is of importance to us is the activity and behavior of the total organism," he wrote. It is unlikely, he said, that "we should ever come to distinguish sharply between mind and body in our field, because, after all, we face one large biological problem, the disorders and actual diseases of biological organisms." Meticulous record keeping marked his scientific approach, which he described as based on facts that might include anything that made a difference in a patient's life, as revealed in the patient's attitudes, activity, and behavior. Every aspect, from family history and physical ailments to jobs and recent actions, was recorded in chronological order on detailed, standardized life charts. "It is 'the story' that counts in a person," he said. Meyer's ideas revolutionized the field from the development of psychiatric case histories to the establishment of psychiatric training programs.
By 1909, Meyer was one of the luminaries invited to give a talk at a conference at Clark University in Massachusetts. There he met Freud, who was presenting his ideas on psychoanalysis in the United States for the first time. Initially open to Freud's ideas, Meyer remarked on the "indisputable importance" of the new theory. However, he predicted that many in the medical establishment would object to the Freudian focus on sex. Furthermore, Freud required psychiatrists to dig into the unconscious mind to make interpretations through analysis of dreams and slips of the tongue and word associations. "Not everybody is a born detective. Not everybody can venture upon the ground of rather delicate constructions and interpretations," Meyer cautioned.
The Phipps was a grand testimony to Meyer's own vision. He had spent four years planning the 88-bed clinic, which he had designed to be the latest in research as well as practice, and for private as well as public patients. In the old system, patients were committed by law to asylums for what often amounted to a life sentence. At Phipps, patients could walk in voluntarily and find humane treatment. They could stroll the interior gardens, play basketball, or receive a variety of hydrotherapy treatments in the elegant Queen Anne-styled building.
One of the bright young medical students who flocked to work at the Phipps in the early years was Clara Thompson. Brilliant but troubled, Thompson had graduated in 1920 from the School of Medicine and begun a residency at the Phipps. Colleagues at the hospital described her as "lonely," "embittered," and "in considerable distress," according to Sue Shapiro, a New York therapist who has written about Thompson. Like Meyer, Thompson had grown up in a small town in a religious household. Her parents belonged to a strict Baptist sect, where dancing and sexual relations before marriage were condemned as the work of the devil. For refusing to go to church and other sins, Thompson later would be estranged from her mother for 20 years. She was eventually analyzed by the Hungarian psychoanalyst Sándor Ferenczi; in The Clinical Diary of Sándor Ferenczi, translator Michael Balint, an associate of Ferenczi, identified her as "DM," a patient who was grossly sexually abused by her father. (Thompson never publicly acknowledged this.)
When Thompson was at the Phipps, it was not unusual for psychiatrists to treat one another. Soon she entered therapy with her chief. In Meyer, known for his gentle, incisive questions, she found both a challenging professor and father confessor. Meanwhile, as she practiced his psychobiological approach to psychiatry, she rose in his estimation, becoming a favorite on his staff.
Without effective medications or brain imaging, psychiatrists often could do little to influence the outcome of a mental disease. Meyer was open to any approach that could be shown to be effective. He shunned simplistic diagnoses for a thorough understanding of the patient's life story. "You have to know your cases, and if you do, the name of the illness will be of a secondary matter," he wrote. According to Meyer's records, kept on hundreds of note cards, up to 19 percent of the patients who left the clinic were listed as "recovered," and up to 64 percent "improved," depending on the diagnosis.
Meanwhile, other psychiatrists were claiming grand cures using the new psychoanalytic method pioneered by Freud. By the 1920s, many young students of psychiatry, including Thompson, were swept up in a frenzy over Freud. She had first become exposed to psychoanalysis in 1918, when she worked as an intern at St. Elizabeth's Hospital in Washington, D.C., at the time a hotbed of Freudian thought in the United States. To the outside world, Meyer retained a professional openness to psychoanalysis. But at best, he viewed it as only one of many theories that were subsumed by his overarching psychobiology. Meyer "attempted to incorporate psychoanalysis within what he saw as his own broader psychobiological approach—at the cost of modifying Freud's ideas almost beyond recognition," notes Ruth Leys, a Johns Hopkins professor of humanities who has written extensively on Meyer.
Inside the Phipps Clinic, Meyerian psychobiology ruled. Meyer mistrusted the cultlike claims of Freud's disciples. Residents on Meyer's staff soon learned that if they had an interest in Freudian concepts, they had best keep it to themselves. They were expected to use Meyer's odd terminology, with words like ergasia, a Greek term for self that many privately ridiculed. Meyer deplored the use of psychoanalytic interpretations over facts and shunned the Freudian emphasis on sex.
His opposition to analysis intensified when, in January 1925, psychoanalyst Joseph Thompson (known as "Snake" for his interest in herpetology) set up shop in Baltimore at 800 N. Broadway, just a few blocks from Phipps. When Thompson wrote to him asking for patients under his care "who might not be recovered"—implying that he could cure Meyer's failures—Meyer coolly refused to help him. Meyer also turned down his request to give a public lecture at the clinic on psychoanalysis. He was infuriated when Clara decided to enter psychoanalysis with Joseph.
To Meyer, Joseph Thompson appeared to be one of those Freudian converts who preached an end to the world's problems while blinded to the possible ill effects of psychoanalysis. Meyer had consulted his colleague A.A. Brill, the translator of Freud and Carl Jung in New York, about Thompson. "Brill considers [Thompson] a crazy person, insane and dangerous," Meyer recorded in his notes. Thompson affects "a very peculiar cast which leaves no doubt of his eccentricity." Thompson, who had served in the U.S. Navy's medical corps, wore his uniform constantly as an assertion of authority, with a green scarf fastened by a gold pin in the shape of a snake. Having grown up in Japan as the son of a missionary, he had served as a spy with cartographer Andrew Seoane during the Philippine insurrection of 1909 and 1910, charting Philippine invasion routes along the Japanese coast for the U.S. military.
Meyer distrusted Thompson, but the analyst did have respectable credentials. A graduate of the Columbia University College of Physicians and Surgeons, he was vice president of the Washington Psychoanalytic Association. On one point, however, Meyer was correct: Thompson's zeal for Freudian psychoanalysis, which Thompson equated to the discoveries of Copernicus and Darwin. Publishing in the United States Naval Medical Bulletin, Thompson suggested that 50 percent of all people ill in hospitals—all people, not just mental patients—could be cured by psychoanalysis.
As Meyer privately seethed about Clara's analysis with Thompson, her classmates noted a positive change in her demeanor. The two Thompsons clearly had a strong rapport. "They were seen dining together, or walking arm in arm, talking animatedly," according to psychiatrist Maurice Green. Rumors, later denied by Clara, soon began to circulate that they were having an affair.
The antagonism between the psychobiological and psychoanalytical camps, represented by Meyer on the one hand and Joseph Thompson and Clara Thompson on the other, festered during the summer of 1925, beginning with the suicide of one of Meyer's private patients in late May. James Baker, a 46-year-old Princeton University graduate, was found dead "in a room at the institution," reported a Baltimore newspaper. "His throat had been cut with a razor blade and there were five gashes in his right wrist. The wounds, according to police, were self-inflicted." Suicide was rare at the Phipps. According to Meyer's records, there were 16 between 1913 and 1940. Doctors made every attempt to guard against danger. On admission, patients' razors, mirrors, keys, and other potentially sharp implements were confiscated. Patients were monitored and their behavior noted carefully by round-the-clock nurses. Yet despite reports of his worsening mental state, Baker had managed to harm himself. What had happened? Albers Harken, the psychiatrist on duty at the time of the suicide, refused to hand over his case files. A native of Holland who spoke little English, Harken had experienced problems adjusting to Meyer's demand for extensive note taking. As the conflict over the suicide embroiled the Phipps staff, Harken, who was seen more often in the company of Clara Thompson and Joseph Thompson at the psychoanalytic office on Broadway, grew defiant. F.I. Wertheimer, psychiatric resident, wrote to Meyer during the summer that Harken had been "openly insubordinate" to three other members of the staff. Meyer decided to terminate Harken's appointment two months early.
As Meyer departed for his summer vacation, Esther Richards, associate psychiatrist, wrote to him about the growing tension at the Phipps. By July, Wertheimer and Harken were not speaking, and on at least one occasion, nearly got into a fistfight. The Maryland Commission for Mental Hygiene was investigating the suicide, Richards reported. "Sorry to interrupt your holiday" with these "volcanic eruptions," Richards wrote, but Harken, claiming he was owed pay, now threatened to use "legal means to defend himself."
When Meyer returned in the fall, the battle lines between himself and his former star pupil were deep and unbridgeable. Clara had been spending three or four afternoons a week at Joseph Thompson's office. Even worse, against clinic policy, she had taken patients from the Phipps and treated them with psychoanalysis, charging $100 a month, as Meyer noted in early fall. "Analytic séances with patients in her own room with burning of incense," he fumed in his notes. The final blow occurred when one of the patients Thompson had been treating outside the clinic attempted suicide in October. According to Meyer's notes, Thompson had telephoned him to see if the patient could be admitted to the Phipps, "provided she could be his physician. I declined and referred her to the hospital. She did not report to me that night—only telling others I had declined help without saying why and how."
Thompson's career at Johns Hopkins ended with a terse letter tendering her resignation on October 23, 1925. She had secured a job in the Department of Neurology's outpatient clinic. Meyer wrote to Warfield Longcope, Johns Hopkins Hospital's president, to block the appointment. "In addition to matters which would have made continuation of service impossible, she has since June treated several patients of the clinic for a fee of $100 a month at the office of a clever but unsavory psychoanalyst. . . . She is bright but unduly free of some of the traits we would like to consider obligatory," Meyer wrote.
Four years later, Thompson sought reconciliation with Meyer, admitting her naïveté and mistakes while still making a case for psychoanalysis. Meyer's point of view is clear in a letter he sent to Thompson on December 10, 1929. "These are to the best of my knowledge the facts and the motives of whatever I had a share in with regard to a frankly distressing experience, but not one governed by 'emotional tension,' at least not on my part," he wrote. "I no doubt have often said and felt that I have had bad experience with a number of devotees of psychoanalysis. Why should I not look for a less seductive type of formulation?" In a letter dated December 15, Thompson maintained that psychoanalysis had offered her a personal and professional transformation: "As to psychoanalysis—I am convinced (and I think I have given other methods a fair trial) that in the hands of a well-trained person who has his own problems well understood, it can do more therapeutically than any other method. So I have tried to become well trained & well analyzed & I think to the improvement of both myself & my efficiency. But I think all psychiatrists would be more effective in a therapeutic method if they were themselves analyzed and had their own personality difficulties smoothed out."
When Meyer returned in the fall, the battle lines between himself and his former star pupil were deep and unbridgeable.
Clara's analysis with Joseph Thompson proved not to offer the relief she sought. She continued to pursue variations of psychoanalysis, spending the summers of 1928 and 1929 in analysis with Sándor Ferenczi in Budapest; she moved there to work with him in 1931. Eventually labeled a "Neo-Freudian," she became a leader in interpersonal psychiatry and adapted Freud's theories to better meet the needs of modern women. A founder and executive director of the William Alanson White Institute of Psychiatry, Psychoanalysis, and Psychology in New York City, she worked as a therapist and teacher there until she died in 1958.
Soon after Thompson resigned, Harken sailed for Curaçao and was never heard from again. Joseph Thompson, frustrated by fractious infighting in the Freud camp, ended up in San Francisco as a psychoanalyst breeding Burmese cats. After his death in 1950, Meyer faded into relative obscurity as Freudian theories rose to dominance in the 1950s and 1960s. The innovations he had pioneered became an integrated part of the profession, but few recognized Meyer as the innovator.
Going on 90 years later, the fundamental rift in psychiatric practice that divided Meyer and Thompson has not been resolved. At least two fundamental questions—What causes mental illness? How best to treat mental illness?—still await definitive answers. When the first edition of the DSM appeared in 1952, many psychiatrists welcomed it as providing a more scientific basis to chart the incidence and prevalence of mental illness. But by its 1980 revision, the scope of the DSM had expanded to a lengthy list of symptoms to be used in the diagnosis of all kinds of mental disorders. According to critics like McHugh and Slavney, the DSM sidestepped the disputes over explanatory theories of psychopathology and became something akin to a naturalist's field guide that "offered no way of making sense of mental disorder." Their recent article in the New England Journal of Medicine continues, "[The DSM's] emphasis on manifestations persuades psychiatrists to replace the thorough 'bottom-up' method of diagnosis, which was based on a detailed life history, painstaking examination of mental status, and corroboration from third-party informants, with the cursory 'top-down' method that relies on symptom checklists."
At least two fundamental questions—What causes mental illness? How best to treat mental illness?—still await definitive answers.
Psychologist René Muller, author of the 2007 book Doing Psychiatry Wrong: A Critical and Prescriptive Look at a Faltering Profession, uses stronger terms: "The DSM got it wrong. It's been a disaster. You get somebody having the worst day of their lives and they are branded as schizophrenic or bipolar disorder on the basis of the DSM. Those are heavy-duty labels. [Doctors] neglect to look at the interior—why is this person doing this?" Following discussion with McHugh on the DSM's failures, Muller is now working to create what they consider a better method for diagnosing and classifying mental disorders that makes more systematic Meyer's ideas of psychobiology. "The reason he's not known is that he never did set up a system," Muller says. "Meyer didn't think diagnosis was as important as plugging into the reasons why people did what they did and trying to help them readjust to their life circumstances."
Like Meyer, McHugh and Slavney believe diagnosis is secondary to knowing the case history. In their textbook, The Perspectives of Psychiatry, they call for a blend of approaches according to the needs of the patient. Reflecting Meyer's theories, they write, "[A] cause is . . . anything that makes a difference in the evoking or sustaining of a disorder." While McHugh recognizes the DSM as important and entrenched as a reference work, he proposes adding categories for causes, or "perspectives," as a way of evaluating patients rather than focusing on symptoms. These "perspectives" include brain diseases, personality dimensions, motivated behaviors, and life encounters.
David Kupfer, chair of the task force charged with DSM revision at the American Psychological Association, responds that the four perspectives represent "a theoretical ideal that, unfortunately, does not fit well with current constraints on psychiatric practice or methods of reimbursement. In the best of all possible worlds, all psychiatrists would have the time to approach patients from this vantage point. However, today's reality is that this can rarely happen, particularly in public systems of care. The well-trained psychiatrist working in such a system of care will draw on these perspectives while using the DSM to efficiently arrive at a reliable diagnosis that should lead to appropriate treatment."
Yet Kupfer sounds like Meyer as he advocates "a comprehensive patient assessment. Clinicians should always consider not just the symptoms listed in the manual's diagnostic criteria but the presenting complaint as stated by the patient, the patient's past psychiatric history and response to any previous treatments, his or her developmental history and family background, and any family psychiatric history."
Long after Adolf Meyer pondered how to fire Clara Thompson, psychiatry still has not solved the mind-body conundrum or come to an agreement on how best to treat patients. In a recent grand rounds session at the School of Medicine, McHugh posed the question: "What is madness?" He quoted sources ranging from the characters in Hamlet to the current issue of the New York Review of Books before concluding, "We are still asking that question."