The Medicalization of Woe

Talk is Not Enough: How Psychotherapy Really Works
by Willard Gaylin, M.D.

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Prior to Freud psychiatry only recognized what we now call the major psychoses. These patients were irrational and bizarre, different from the rest of us. "Crazy," "lunatic," "insane," were words interchangeably used by layman and physician. Freud began to elaborate an entire new group of illnesses, still not clearly defined as mental illnesses, which he labeled the psychoneuroses, that is, psychological disturbances caused by irritation or inflammation of the nerves. These were mental illnesses characterized by clear-cut symptoms - phobias, obsessions, paranoias, and the like - occurring in a normal (not insane) person.

In so doing, Freud destroyed the absolute dichotomy between sane and insane. The symptom neuroses suggested that one need not be totally crazy to demonstrate crazy patterns of behavior. Normal people like his friends and himself could have isolated pieces of behavior that were "crazy."

This began a process that led to an increasing array of mental disorders that, without preconception or intention, paved the way for a continuum from healthy to sick. The on-off light switch had been replaced by a dimmer, or rheostat. Once the process was started, the elaboration of mental illnesses was rapid, and the distinction between the healthy and the ill was blurred and eventually obliterated.

While Freud was continuing to catalog the whole new species of symptom neuroses, a colleague was formulating a definition of mental illness that involved no symptoms at all! Wilhelm Reich was interested in the structure of character or personality. It occurred to him that one did not have to have bizarre and irrational symptoms to be defined as mentally ill; the very character of the individual could be so damaged as to reduce his capacity for work or pleasure. He affirmed, in psychological terms, Heraclitus's observation that "a man's character is his fate."

Reich's theory was a pioneering piece of work that anticipated the direction of modern psychiatry. Today, particularly in ambulatory or office psychotherapy, the vast majority of patients do not have traditional psychological symptoms; rather, they suffer from what we call "character disorders": they can't succeed at work, they can't fall in love, they can't make permanent attachments, they're afraid of competition, they are overly aggressive or too timid, excessively seductive or painfully shy.

Freud, meantime, had begun to elaborate a general theory of neurosis that could encompass such disparate behaviors as paranoia and compulsiveness, delusion and hysteria. Beyond just explaining diverse mental symptoms, this ambitious theory would lay the foundation for understanding normal character traits, attitudes, cultural beliefs, and the very institutions of society. Freud's general theory would come to be called the libido theory. Here, all mental illness was seen as a function of something gone awry with the developing sexual instinct. In order to define what went wrong, he had to elaborate a "normal" development for human beings. Just as one assumed a normal physical progression of the infant from sitting up to crawling to standing, from infancy to puberty to maturity, so one could assume a traditional normal psychosexual evolution.

By setting a standard scheme of development, Freud allowed for mental illness to be explained in terms of the absence of expected normal functioning, as well as in terms of malfunctioning. The patient did not have to demonstrate any aberrancy; he could simply be missing that which we assumed normal people must possess to qualify for a definition of health. Significant omissions became part of the definition of mental illness. The failure to be able to achieve orgasm would be defined as a mental illness, as would the failure to be able to maintain an erection in an adult relationship.

These changing standards expanded the population of the mentally ill far beyond the original group of psychotic patients. By definition the mentally ill now included those with psychoses, symptom neuroses, significant omissions from normal behavior, and character disorders.

The next large group of patients to be added to the population of the mentally ill emerged from the research of physicians concerned with basic physiology and internal medicine rather than psychiatry. Modern medicine began to see links between emotional states and the emergence of physical conditions: hives, neurodermatitis, diarrhea. In addition, emotions were implicated in the onset of what had been formerly seen as purely physical diseases: asthma, ulcerative colitis, migraine headache, peptic ulcer, hypertension. These would come to be called psychosomatic diseases or conditions. Here we had a group of patients who were "mentally" ill, with no mental symptoms; nothing now had to be wrong with your mental functioning for you to be included in the population of the mentally ill.

Some of the early theoreticians of psychosomatic medicine became heady with the opportunity of explaining physical symptoms in terms of psychodynamic causes. They slipped into a disastrous habit of looking for a specific dynamic, or force, for each disease. The silly season arrived and almost sank the ship before the voyage began. I recall reading a psychiatric paper that explained a peptic ulcer as being the "bite of the introjected [swallowed up] mother," whatever that was supposed to mean. More sophisticated researchers began to be aware that mental processes played a part in, but did not have to be the exclusive cause of, psychosomatic diseases. Today we understand how complicated the interplay is between emotion and body functions.

The layman always understood this. The diarrhea that occurred the night before the examination was not seen by the student as some unlucky accident compounding his anxiety about the examination, but rather the product and proof of that anxiety. We knew that we sweated when we were nervous, flushed with embarrassment, often wet our pants with terror or even excitement. But now exact research studies would enable people to understand the mechanisms by which an emotion could provoke a physical reaction. Anger could trigger an increase in hydrochloric acid secretion in the stomach, thus being, if not the sole cause, a contributing factor in a peptic ulcer. We know that specific allergies are due to specific antigens. We can demonstrate this by creating the symptoms in our patients with minute doses of these allergens. We also know that emotions can precipitate the very same allergic responses.

The more sophisticated we become in our knowledge of human physiology, the more we erase the mind-body dichotomy from human medicine. We know that emotions can trigger hormonal releases, changing blood chemistries that act on such end organs as bronchi, lungs, the colon, or the skin to produce symptoms.

This brutally abbreviated "history" of the evolution and expansion of the definition of mental illnesses is presented not for scholarly purposes, but merely to demonstrate why the ranks of the mentally ill have seemed to increase so precipitously. People aren't more neurotic than they once were. Society is not causing the population of the mentally ill to increase. We are changing the definitions.

By narrowing the amount of impairment necessary to define a person as mentally ill, we have broadened the population of the mentally ill. So much so that by the mid-twentieth century, major researchers could do epidemiological studies of the Upper East Side of Manhattan and discover that over 70 percent of the population had evidence and traits of mental distress. Admittedly, the Upper East Side of Manhattan is a peculiar location, but I suspect that these same researchers could have gone into any community and found the same proportion of mental problems.

Psychiatry had now captured 75 percent of the population as a potential constituency. But the net was still not fine enough. What about the 25 percent that eluded our grasp? The mental hygiene movement took care of them.

The mental hygiene movement emerging in midcentury was part of the increased interest in preventive medicine. If we now understood normal psychological development as we understood normal physical development, why should we wait for the deterioration of function or the development of symptoms? Why not act prophylactically, thus guaranteeing healthy development by insuring a proper psychosocial environment?

We had arrived at a point where almost everyone was a little sick and even the healthy could benefit from some psychological guidance. Everything would eventually become a form of mental illness, every failure, even a lack of success - a bad marriage, a disobedient child, antisocial behavior, ennui, mere unhappiness. This being the case, all sorts of problems that formerly might have been directed to ministers, counselors, friends, relatives, correctional officers, teachers, lovers, or parents could now be directed to psychiatrists. If all of these behaviors were a form of sickness, shouldn't they be treated by a doctor? In the beginning it worked just that way. The medicalization of misery led to an expanding population of psychotherapists who were psychiatrists, i.e., doctors.

So now "patients" were consulting with their "doctors," seeking "cures" for "illnesses" - miseries - that were never before perceived of as medical. We had engineered the medicalization of woe.

About the Author

Willard Gaylin, M.D., is the author of fifteen books, including Feelings, The Killing of Bonnie Garland, and The Rage Within. He is Clinical Professor of Psychiatry at Columbia College of Physicians and Surgeons and cofounder of the Hastings Center, the preeminent institute for the study of ethical issues in the life sciences. For more than thirty years he has been a leading theoretician, educator, and practitioner in the field of psychotherapy and psychoanalysis.