Mind Games: American Culture and the Birth of Psychotherapy / Edition 1 available in Paperback
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Mind GamesAmerican Culture and the Birth of Psychotherapy
By Eric Caplan
University of California PressCopyright © 2001 Eric Caplan
All right reserved.
The truth is that medicine, professedly founded on observation, is as sensitive to outside influence, political, religious, philosophical, imaginative, as is the barometer to the changes of atmospheric density. Theoretically it ought to go on its own straightforward inductive path, without regard to changes of government or to fluctuations of public opinion. But ... actually there is a closer relation between the medical sciences and the conditions of society and the general thought of the time, than would at first be suspected.
Oliver Wendell Holmes (1891)
My original intention was to write a history of the image of the psychotherapist in the United States. Such a work, I believed, would offer a number of significant insights concerning both American medicine and American culture. But in preparing a background chapter for that project, I soon discovered that a vital secondary source was not merely difficult to locate but impossible to find—that is to say, it did not exist. Much to my dismay I came to the conclusion that no one had yet written a history of the origins of psychotherapy in the United States. I do notmean to suggest that no work has been done on the subject. On the contrary, I was able to compile an extensive bibliography of valuable secondary sources examining both the history of institutional psychiatry and the history of psychoanalysis. Absent from virtually all of this literature, however, is any serious effort to explain the origins of psychotherapy.
In a nation that currently employs tens of thousands of licensed psychotherapists and perhaps an equal, if not greater, number of unlicensed practitioners, it struck me as odd that no historian had tackled this subject.1 Indeed, throughout the past five years of research and writing I have remained continually fearful that someone might point me to a book or an article that explores this topic. In many respects the discovery of such a work would come as a welcome relief since, like many young historians, I suffer from the perverse fear that a subject that has not already been addressed may in fact be a subject not worth addressing at all, particularly when that subject is so large.
Over time I have come gradually to realize that the absence of a book on this topic is largely attributable to a widely held, though often unstated, conception of what is meant by psychotherapy—namely, virtually any method of healing that does not rely on somatic agents. There are several problems with this definition. The most obvious is one of semantics. Shamanism is not psychotherapy. But there are far more substantive issues as well. I shall mention just one: the issue of anachronism. Whereas no historian would dare suggest that a medieval nostrum employed to treat mania constitutes a crude form of psychopharmacology, a substantial number have made analogous claims regarding psychotherapy and such practices as mysticism, faith healing, even crystal therapy. Proponents of this position interpret psychotherapy in functional rather than historical terms. In so doing they neglect to consider the meaning that these healers and their patients might have attached to these esoteric and diverse practices. Worse still, such an ahistorical rendering of psychotherapy, to say nothing of mysticism, faith healing, and crystal therapy, fails to address what is in fact distinct about each of these systems of healing. Moreover, it leaves unanswered the most salient question about the late-nineteenth- and early-twentieth-century origins of the practice: Why, after decades of resistance, were mainstream physicians finally willing to embrace a system of mental therapeutics?
In the discussion that follows I argue that questions concerning the American origins of psychotherapy—by which I mean the deliberate and systematic effort to relieve nervous and mental symptoms without recourse to somatic agents—are best framed within the context of American medicine and American culture. My work rests on the proposition that an understanding of the invention of American psychotherapy requires not only a thorough grounding in the relevant medical and cultural matrices but also an awareness of the interaction betweenthe two. This observation—as I hope is evident by the Holmes quotation that precedes my analysis—is neither novel nor surprising. It is, however, crucial to the story that I tell.
As late as 1907 Americans knew little of psychotherapy. The word itself was virtually nowhere to be found.2 Talking cures were not talked about. Despite growing medical and cultural awareness of mental suffering, few physicians made any effort to treat such states by appealing to the mind.3 Those who did frequently incurred the wrath of their colleagues. In a little-read book on the subject of psychology applied to medicine, David Wells captured the prevailing attitude of his medical colleagues regarding psychotherapy: "It takes courage and self-reliance to openly advocate and practice it."4 Courage? Self-reliance? Why such trepidation? In our own therapeutically aware, talk show-driven age, Wells's fear seems bizarre indeed. But in 1907, when he offered these remarks, such circumspection was not only understandable, it was professionally imperative. For more than three decades American physicians—particularly those who specialized in the treatment of nervous and mental disorders—had scoffed at anything even remotely resembling mental therapeutics. Mind was to medicine what vinegar was to oil. The two did not mix well.
Prevailing neurological theory held that mental states were merely concomitants of physical states. Proponents of this doctrine, known as psychophysical parallelism, interpreted psychical symptoms as signs of some underlying but not yet discernible physical lesion.5 Wounded minds were products of wounded bodies. Diseases fell into two categories: structural and functional. The former implied a known cause; the latter, an unknown cause. As a prominent neurologist explained, "Whatever the microscope can see, we call structural—what the microscope cannot see, we call functional."6 The therapeutic implications of this position were clear. Because all symptoms, be they physical or mental, were attributable to physical irregularities, mental therapies could never hope to address the root of the problem. Successful therapies needed to be aimed at the body, not the mind. How such therapies might produce a positive mental outcome remained unclear. What mattered is that they did. As celebrated Philadelphia neurologist S. Weir Mitchell proclaimed, "You cure the body, and somehow find that the mind is also cured."7
In the context of this rigorously materialistic framework, psychotherapy seemed, at best, superfluous and, at worst, thoroughly misguided. The overwhelming majority of American physicians, regardless of their school or specialty, had ceased even to consider the possibility that psychological factors might play a role in exciting, maintaining, or treating mental and nervous disorders. Such views were not without a cogent foundation. As the respective discoveries of the microscopic organism responsible for syphilis and the nutritional deficiency responsible for pellagra soon revealed, materialistic agents did indeed have the capacity to generate a wide array of nervous and mental symptoms that no system of mental therapeutics, no matter how sophisticated it might be, could possibly hope to relieve.8
But it was not somatic ideology alone that prevented specialists in nervous diseases from considering psychotherapy. Practical concerns were equally significant. Of these, perhaps none was more important than the desire of American physicians to maintain a sense of professional and scientific credibility. In the final decades of the nineteenth century this meant, among other things, avoiding at all costs anything that even remotely resembled the practices of their nonmedical rivals. In large measure this reluctance lay at the core of mainstream medicine's antipathy to mental therapeutics.9 That is to say, many late-nineteenth- and early-twentieth-century American physicians eschewed mental healing precisely because it already occupied a prominent position in the larger culture.
Fearing that any association in the public mind with such unsavory characters as Christian Scientists, faith healers, and proponents of the New Thought might compromise their hard-won professional standing, American physicians were understandably reluctant to adopt what many rightly considered the identical methods of their lay rivals. As Harvard psychologist Hugo Münsterberg explained, "Physicians do not like to touch a tool that has been misused so badly."10 Indeed, the decision to invoke the word psychotherapy was in part an effort to address this latter issue. In a fascinating admission, Boston neurologist Richard C. Cabot wrote, "Psychotherapy is a most terrifying word, but we are forced to use it because there is no other which serves to distinguish us from Christian Scientists, the New Thought people, the faith healers, and the thousand and one other schools which have in common the disregard for medical science and the accumulated knowledge of the past."11
As Cabot's remarks make clear winning professional support for psychotherapy would require a long and arduous battle. American physicians who promoted the clinical use of mental therapeutics confronted substantial opposition—particularly from the ranks of their professional colleagues. To meet this resistance they had to address two separate but related issues. First, they had to establish a cogent scientific and theoretical rationale for addressing their therapies to the mind rather than to the body. Against the backdrop of prevailing somatic theories of disease, to say nothing of compelling clinical and laboratory evidence, this task was particularly arduous. Second, and perhaps even more daunting, they had to address an even more practical concern—that of distinguishing their "scientific psychotherapy" from the disreputable methods to which their more somatically inclined colleagues frequently and not implausibly compared it.12
In the face of such obstacles what one historian has recently referred to as the "sudden appearance" of psychotherapy in the United States soon after the turn of the century is surprising, to say the least.13 Previous historians have traced this transformation in medical attitudes to the role of elites. In perhaps the most respected interpretation of this medical-cultural episode, Nathan G. Hale, Jr., relying on Thomas Kuhn's model of scientific revolutions, has argued that beginning in the mid-1880s a small cohort of prominent neurologists, psychiatrists, and psychologists began to argue "that the somatic style, as then defined, had exhausted its actual possibilities."14 Building on Hale's analysis, George Drinka has declared, "[In] placing less emphasis on the brain and giving new credence to personal emotions, ideas, and symbols, a few doctors inched toward a more subtle comprehension of how to listen to human sufferers, how to feel compassion for their symptoms, how to confront their pain."15
But rather than adding clarity to their respective analyses, Kuhn's model of scientific revolution needlessly constricts Hale's and Drinka's otherwise trenchant observations by compelling them to assume that which they need first to prove—namely, the presence of a crisis in the somatic paradigm. But the facts do not necessarily point to such a conclusion.16 Indeed, while a number of physicians did in fact isolate several cracks in its foundation, the somatic paradigm proved to be more durable and adaptable than either these authors or those who have built on their arguments suggest.
In the pages that follow I argue that the birth of psychotherapy in the first decade of the twentieth century had little to do with a crisis in the somatic paradigm. On the contrary, the medical embrace of psychotherapy was only partially attributable to internal medical affairs. Farmore significant was a host of nonmedical factors that impinged directly on the practice of medicine. Of these, some of the more prominent were a growing legal and popular recognition of accident-induced traumatic neuroses, a begrudging recognition that somatic therapies could not by themselves explain the results they yielded, a rapidly expanding indigenous mind-cure movement and with it the creation of a new type of "patient," and, finally, a mainstream pastoral healing movement that physicians realized they could ignore only at their own peril. Psychotherapy emerged at considerable odds and in the face of considerable opposition—much, indeed most, of which was generated by the medical profession itself. Its arrival signified a begrudging acceptance on behalf of both medical elites and rank-and-file physicians that their allegiance to the somatic paradigm compromised their capacity both to treat effectively and to compete effectively in a rapidly expanding mental-medical marketplace.
A contemporary observer of the American medical and cultural landscape during the final decade of the nineteenth century would be hard-pressed to locate any signs of the emergence of modern "psychotherapy." Prior to the medical revolution of the late nineteenth century the capacity of physicians to distinguish with any certainty the respective roles of material and mental factors in sickness and in health was virtually nonexistent. Both medical theory and practice were, in the words of Charles E. Rosenberg, "necessarily and ubiquitously 'psychosomatic.'"17 The extent to which either the mind or the body contributed to a particular disease was impossible to discern.18 Each no doubt played a role, and the responsible physician endeavored to treat both accordingly.
The work of the great nineteenth-century neuroscientific and bacteriological pioneers destroyed this holistic medical paradigm. Out of its ashes emerged not one but two competing theories of disease—each of which had its origins in the older psychosomatic order. One was psychological, the other somatic.19 Whereas the latter quickly achieved dominion across the entire medical spectrum, the former remained a potent cultural influence.20 In contrast to previous generations of physicians, somatically inclined medical doctors of the late nineteenth century focused primarily on material factors. Earlier in the century a physician might explain the presence of an illness by appealing to nonmaterial agents, but by the 1870s doing so was out of the question.
Physicians no longer considered mental and behavioral symptoms on their own terms and for their own sake. On the contrary, they now interpreted such clues only insofar as they enabled them to infer "the [diseased] physical conditions [of the central nervous system] implied by the psychical states."21 Support for this somatic perspective increased substantially soon after Robert Koch's 1876 discovery of the microbe responsible for anthrax and the subsequent acceptance of germ theory.22 In keeping with the somatic zeitgeist, many physicians, including those who specialized in the treatment of nervous disorders, abandoned their preoccupation with what might be considered psychosocial factors.23
Jettisoning the mind from medicine in no way signified declining interest in nervous and mental symptoms, however. If anything, the opposite was true. That is to say, somatically inclined physicians devoted an unprecedented amount of attention to the psychical symptoms of those for whom there existed no clearly discernible anatomical or organic irregularities. What they did not do, however, and what distinguished them from physicians of an earlier generation, was to consider the possibility that psychosocial factors might play a role in the healing process. Instead, they relied almost exclusively on somatic therapies. Rest cures, diet cures, electrical cures, and water cures abounded. Indeed, during the final three decades of the nineteenth century only a tiny minority within the American medical community gave credence to the possibility that mental healing, either by itself or in conjunction with one of many available somatic therapies, offered much hope. Despite a growing medical recognition of mental suffering, few physicians displayed any concomitant commitment to mental therapeutics.
Paradoxically, acceptance of the somatic paradigm proved to be a critical precondition for the advent of an epistemologically meaningful conception of "psychotherapy."24 Simply put, what came to be known as psychotherapy was inconceivable within the context of mid-nineteenth-century psychosomaticism. Its implausibility was attributable not to the practical or theoretical limitations of this holistic paradigm but rather to its expansive scope. After all, what need was there to explain that which was readily assumed—namely, a correspondence between mind and body, on the one hand, and environment and health, on the other? With the ascension of the somatic paradigm this logic no longer held, and psychical factors came to be regarded merely as the products of certain yet-to-be-determined neurophysiological processes. Without this profound theoretical reorientation the emergenceof psychotherapy would have been inconceivable. In making this claim I do not mean to suggest that prior to the late nineteenth century physicians were oblivious to the role of mental factors in healing. On the contrary, the role of the mind (and of the body) was ubiquitous—but by default rather than design. In all but the most obvious ailments there was no possible way for a physician to disentangle the mental from the physical components of a particular disease.
The moral therapy practiced in nineteenth-century European and American asylums provides a splendid illustration of this phenomenon.25 That both moral therapy and psychotherapy share certain assumptions regarding the impact of environmental, experiential, and behavioral phenomena cannot be denied.26 But more significant than the apparent similarities between these two therapeutic systems is their fundamental difference.27 Moral therapy was the therapeutic complement to the expansive environmental ethos that pervaded Jacksonian America and post-Enlightenment Europe. By way of contrast, psychotherapy was a highly contested response to the science-engendered materialism of the late nineteenth and early twentieth century that had no brief for mental considerations.
Having shared my findings with several scholars and many well-read friends, I have begrudgingly accepted the fact that those reading a book about the origins of psychotherapy in the United States expect, indeed demand, to find Sigmund Freud occupying a prominent place in this story. They will be disappointed—though I hope not for long. Odd as this may sound, Freud has little role to play in this early chapter in the history of American psychotherapy. Prior to 1910 there are virtually no references to his work in American medical periodicals and none whatsoever in popular cultural sources.28 Simply put, the primary factors that compelled physicians in the United States to embrace psychotherapy had little to do with ideas emanating from Vienna or, for that matter, from any other European city. American doctors had little reason to look across the Atlantic. The germs of psychotherapy could be found much closer to home.
In the chapters that follow I seek to explain the causal paths linking culture, profession, and knowledge in the formation of psychotherapy in the United States. The invention of American "psychotherapy," as I make clear, was not simply an internal medical affair but rather the product of a host of interlocking social and cultural discourses endemicto late Victorian America.29 Where my analysis departs from others that have acknowledged the cultural dimensions of American psychotherapy is in its capacity to locate discrete nodal points at which medicine and culture actually intersect. By focusing on specific "medical-cultural" discourses such as railway spine, industrial liability, functional nervous disorders, psychical research, mind cure, and pastoral counseling, I reveal the extent to which psychiatric theory itself and, more particularly, the practice of psychotherapy have been shaped by influences that on the surface appear to have little or no relationship to professional medicine. Moreover, I demonstrate that on the eve of Freud's historic visit to the United States in September 1909, mental therapeutics was already integrally woven into the fabric of American medicine and culture.
This work is composed of six chapters, each of which examines a distinct element in the formation of American "psychotherapy." The first examines the medical-legal controversy generated by the proliferation of railway accident-induced traumatic neuroses during the late nineteenth century. Here I argue that almost half a century before the shell shock experienced by veterans of the First World War legitimized the existence of psychoneuroses, several European and American physicians had explored the possibility that certain traumatic experiences might induce otherwise healthy, hereditarily untainted men and women to take on the symptoms of a wide variety of physical ailments that had no apparent somatic basis.
The second chapter assesses the cultural and medical significance of neurasthenia, a functional nervous disease commonly believed to affect upper-class men and women. I argue that prior to 1900 virtually all medical therapies designed to treat so-called functional nervous disorders were somatically based. Although common sense suggests that there might be some causal relationship between the discovery of functional nervous/psychical diseases and the advent of psychological therapies, little evidence exists in support of this position.30 Of the more than two hundred books and articles concerning the treatment of neurasthenia that appeared in the 1906 issue of the Index Catalogue of the Library of the Surgeon-General's Office, a paltry sixteen were included under the heading, "Treatment by Hypnotism," and only four of the sixteen were published by American authors.31 Moreover, in contrast to previous scholars who focus almost exclusively on the cultural components of neurasthenic discourse, I concentrate instead on its medical features and, in so doing, reveal the profound somatic bias that informed both the medical and the cultural response to this disease. In addition, I establish that certain elite physicians, deducing from the variegated experiences of a wide array of somatic treatments, began to speculate that a single factor, the psychical element, might be common to them all.
In the third chapter I focus on what William James termed the "mind cure movement" and explore its impact on American religion, medicine, and culture. I argue that because of its unique ideas concerning the capacity of mental therapies to cure all diseases, the American mind-cure movement differed substantially from other nineteenth-century health reform and antimaterialist campaigns. Moreover, I suggest that the movement not only tapped into but also stimulated the growth of a huge and potentially limitless market of "nervous" men and women who, for a variety of reasons, possessed great faith in the potential efficacy of nonsomatic therapies—thereby enticing and antagonizing different factions within the American neurological and psychiatric communities.
In the fourth chapter I explore the impact of the somatic paradigm on late-nineteenth- and early-twentieth-century psychiatry and neurology. I argue that the ascendance of the somatic paradigm did not completely abolish medical interest in psychological matters. During the 1890s, when the neurological critique of asylum psychiatry had finally succeeded in convincing most American asylum superintendents of the need to consider the role of physiological factors alone in diagnosing and treating insanity, elites within the American neurological profession were just beginning to call attention to the role of mental factors in certain functional nervous disorders.
Within less than two years this scenario had changed dramatically. The reason for this change is the subject of my fifth chapter. Here I provide a case study of the first popular psychotherapy movement in the United States, the Boston-based Emmanuel movement, which lasted from 1906 to 1910. This church-sponsored psychotherapy venture was the primary agent responsible for the efflorescence of psychotherapy in the United States. Whereas decades of vigorous internal professional debates had failed to generate a consensus among American physicians regarding the scientific legitimacy and clinical efficacy of mental therapeutics, in two short years the Emmanuel movement forced the American medical community to confront squarely and publicly a subject that it had long avoided. In the final chapter I consider briefly the impact of psychoanalysis and other psychiatric modalities that have marked the landscape of twentieth-century psychiatry and culture.
Excerpted from Mind Games by Eric Caplan Copyright © 2001 by Eric Caplan. Excerpted by permission.
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