Prozac on the Couch

by Jonathan Michel Metzl
Duke University Press, 2003
Review by Jennifer Hansen, Ph.D. on Oct 27th 2003

The back story to Prozac on the Couch: Prescribing Gender in the Era of Wonder Drugs is a shrink who thinks too much--and that's a good thing! Jonathan Michel Metz is a psychiatrist who pursued a Ph.D. in American Studies at the University of Michigan. This book grows out of his disseration, entitled "The Freud of Prozac, Tracing Psychotropic Medications through American Culture, 1950-2001," and situates him in the emerging cultural dialogue about Prozac and gender. Currently, he is the director for the Program of Culture, Health and Medicine and the University of Michigan, a program committed to cross-disciplinary exchange over issues of health.

Profound cultural questions about gender and normalcy gnaw at Metzl, questions that might get in the way of a routine psychiatric practice. Metzl's work in American Studies, however, has equipped him with a variety of theoretical tools (drawn from the humanities) for diagnosing what is wrong with psychiatry, particularly its unconscious gender expectations. Metzl frames his book with several epigraphs from Sigmund Freud, Luce Irigaray, and an excerpt from a research article on the "Improvement from Transcranial Magnetic Stimulation." These epigraphs invite us into a psychoanalytic session, in which Metzl has put psychiatry on the couch. Metzl's goal is to bring to light the psychiatric profession's deeply buried beliefs about men and women insidiously operating in its overt practices.

Adam Phillips, a translator of Freud's ideas, tells us that Freud viewed psychoanalysis as analogous to cleaning out a cavity filled with pus in order to help along the patient's healing process. Phillips writes "The operation, Freud suggests, is not the cure; it is only the prelude to the cure" (Phillips 1993, 1). Likewise, Metzl's intention is to finally scrape out the pus-filled cavity of psychiatry in order to futher help the profession heal itself of its unhealthy attitudes toward women (as well as people of color and the poor). The first step in the healing process, for Metzl, is to point out what is not said, what goes unchallenged in current psychiatric practice. We need to read psychiatric texts differently, we need to look again at pharmaceutical advertisements, and we need to hear the psychiatrist's own unconscious slips.

Metzl teaches us how to see differently. Upon completing Metzl's book, one can no longer read the findings of the "Transcrainal Magnetic Stimulation" innocently (one of the early epigraphs). In this study of the effectiveness of "transcranial magnetic stimulation" as a therapeutic for depression, we should ask why all the patients were women, ages 41-66. We should also be suscipious that all of them are very depressed. Finally, we should be deeply concerned that the psychiatrists seem unable to help them. About his own clinical experience, Metzl confesses to us that

. . . whenever a woman comes to my office requesting a prescription for Zoloft after seeing an advertisement in Marie Claire magazine; or whenever a male patient tells me that he believes that, owing to her strange behavior, which has ruined their intimate relations, his wife requires Valium, lithium, or Haldol; or whenever I find myself thinking that Effexor might help a woman patient cope with the depression that she experiences as a result or marital stress even though I know that her husband's attitude is largely to blame for her emotional state . . . there is the clear possibility that the patient and I may not be talking about medications at all . . . These interactions suggest that psychotropic medications are imbued with expectation, desire, gender, race, sexuality, power, time, reputation, countertransference, metaphor, and a host of important factors that a putative paradigm shift from interaction to prescription tacitly eliminates from psychiatry's purview" (5).

The practice of psychiatry is full of unstated, and perhaps unconscious expectations of what we should expect from women and men.

Metzl's central claim is that the paternalism and misogyny of the psychoanalytic era stubbornly outlives the paradigm shift in psychiatry toward a neuroscientific view of mental illness. In the first two chapters: "The Freud of Prozac" and "The Name of the Father, The Place of Medication," Metzl outlines the transition in psychiatry from the reign of psychoanalysis (and its male practitioners) to the new era of Prozac (a period spanning the mid-1950s to the present). He declares that "the replacement of men with medications," took place during the late 70s and early 80s. To tell this story (history), Metzl (a) examines drug advertisements, (b) articles in popular magazines about women's sexuality, (c) scholarly articles in Psychiatric journals aimed at discrediting the merits of psychoanalysis and touting the cost-effectiveness of psychopharmacology, and (d) theoretical tools such as Foucault's notion of body disciplines (in this case pharmaceutical discipline). This is a "multi-factorial" approach to the etiology of psychopharmacology. While many "serious" medical historians may dispute these facts, Metzl's aim is not to the "official story," but rather to expose what is "not said" or unconscious. To unearth these stubborn prejudices, hiding from the cruel scrutiny that may accompany their emergence into conscious discourse, Metzl has to scrape and dig.

What is objectionable to this history, one can and will argue, is that it does not offer sufficient evidence that psychiatry is a sexist profession. Some clinicians may get lost in the often esoteric, and abstruse jargon of the theoretical tools that Metzl uses. If critics make it through the theoretical analyses, they may still demand more proof that the advent of new antidepressants, such as SSRIs, are part of a long-standing project to control women's sexuality.

Indeed, Metzl's claims are provocative. In chapters three and four, "Anxiety, the Crisis of Psychoanalysis, and the Miltown Resolution," and "The Gendered Psychodynamics of Pharmaceutical Advertising," Metzl offers evidence that psychiatry clearly has been out to control women's sexuality. For example, he looks at self-help articles from the 50s addressing female frigidity. In these self-help articles, one sees, especially retrospectively from the partial success of feminism, the many medical disorders "invented" to comprehend why women don't want to sleep with their husbands. Rather than examine larger social issues and women's role in an overtly sexist (misogynistic) culture, doctors found ways to swiftly contain and neutralize the threat that female emancipation might pose to the social order. Moreover, Metzl points out that during the 1950s-70s (an era of Miltown and Valium as treatments to housewife anxiety), the only authority on women's moods and experiences were the men, the psychiatrists. Metzl observes, "the voices of real women never appear in the magazines and journals announcing Miltown's success" (113).

In moving now to the era of Prozac, Paxil, Effexor, Zoloft etc. we are no longer struck by the authoritative claims of male psychiatrists, but rather the claims of the pharmaceutical industry. No longer do psychiatrists even figure in drug advertisements (and popular self-help pieces). Psychopharmacology has practically usurped the role and power of the male psychiatrist. However, we should not assume that this move to the "scientific" bases of psychiatry, rooted now in neuroscience, means that the unconscious desire to control female sexuality has disappeared. It hasn't disappeared, according to Metzl, its just gone underground and thereby has become more difficult to discern. One symptom that the psychiatry and women are always threatened by a return of the repressed is in the very fact that psychiatry so enthusiastically embraces neuroscientific approaches to mental illness (and, cocomitantly psychopharmacology). For example, in characterizing and early article in Newsweek on "How Tranquilizers Work," Metzl points out the controlling impulses (brought on by deep ambivalences and insecurities about earlier psychiatric approaches) at the heart of this paradigm shift. He writes "Even the deepest and most troubling impulses are rendered rational and knowable . . . the article connects biological and psychoanalytical assumptions that the unseen can be made visible and rational through the act of uncovering, whether by verbal interaction or by newly emerging technology" (110). Psychiatry's overcoming of psychoanalysis is actually the result of psychoanalytic assumptions that the unknowable can be rendered knowable, that the unseen can be made visible. What is also crucial to this making visible the invisible is, for Metzl, the deep need to control when humans (or, perhaps more precisely, men) are confronted with ambiguous situations.

While psychiatry may no longer hold emasculating mothers responsible for male (and thereby cultural) dysfunction, nonetheless the psychiatrists are still "punishing" mothers. If we look carefully at the new antidepressants advertisements we see mothers--better able to function as wives and mothers thanks to the intervention of SSRIS. The men may not be visible in these ads, insofar as we are not able to point fingers at controlling male psychiatrists, but their fears linger. The upshot of this paradigm shift in psychiatry is that its trickier to charge psychiatry with misogyny. The men have hidden behind "rational and knowable"--uncontestable--proof that women are mad, and mothers need medication for society to function better.

In the final chapter, "Prozac and the Pharmacokinetics of Narrative Form," Metzl shows us how powerfully the psychopharmacological age has taken hold. Earlier in the book, Metzl points out how rarely psychiatrists let women speak, and how rarely the popular culture listens to their complaints. The Prozac age has further obscured women's voices. The narratives and memoirs that women write about their trials with Prozac, according to Metzl, present women fully consumed by Prozac and its false promises. They have adopted the language of psychopharmacology, which means that the represent themselves as becoming what the masculinized culture wants them to become. Metzl examines several Prozac narratives--memoirs of women put on Prozac. These Prozac narratives do not wholly embrace Prozac as the answer to their trauma, mostly because at a certain point the medication stops working (or at least it doesn't work very well.) What doesn't seem to be in these memoirs, however, is a larger critique of the historical and political circumstances in which Prozac has emerged and the relationship of women (and/or femininity) to these times.

Metzl argues that the reason the narratives fail to account for the social context that these female Prozac protagonists are struggling against is that the psychiatric (psychopharmacological) discourse speaks in a "presentist" mode. That is, because psychiatry no longer searches for the etiology of mental disorder within the patient's history (past experiences), but rather posits these illnesses as wholly neurochemical (preexisting or mostly independent of life events--albeit exacerbated by life events), then those afflicted no longer attempt to understand their suffering within the arc of their life. Moreover, moving from psychoanalysis--which always dealt with history--to neuroscience--which deals only with an "eternal" present, psychiatry shuts itself off from understanding its current practices in terms of its past behavior or experiences. Hence, in Prozac narratives and psychiatric practice we are presented with a text without context.

Metzl ends his book with this observation: "The challenge for psychiatry, as it struggles with the implications of what it was and what it will become, is to develop a theory of itself and of its own complex constitution. Psychiatry needs to expose its own synapses and dendrites with the same vigor and which it has exposed those of its patients and, in so doing, develop a perspective--indeed, a biological perspective--on the ways in which its perceptions and projections shape its own interactions" (198). This is precisely the account that Metzl has begun in this book. He gives the reader quite a lot to think about; perhaps, he gives the reader too much to think about.

My hope is that Metzl will continue to write, but take pieces of this large project and carefully present his arguments in a language that will infiltrate and impact the very profession he criticizes. While many psychiatrists should read Metzl's book, I fear they won't because it will speak to them in a language (mostly because of the theoretical tools that Metzl relies upon) that they reject from the outset. Metzl may need to take a more insidious approach if he truly wants to transform psychiatry, namely, he needs to speak to psychiatrists in a language they will listen to and show them why their practices persist in promoting deadly gender and racial stereotypes. Metzl clearly has a great deal of material, both from his clinical practice and from his theoretical work in American Studies, to regularly contribute to a debate within Psychiatry (and, by extension, the larger culture).

Works Cited

Phillips, Adam. 1993. On Kissing, Tickling, and Being Bored: Psychoanalytic Essays on the Unexamined Life. Cambridge, MA: Harvard University Press.

Jennifer Hansen is an Assistant Professor of Philosophy at Gettysburg College. She has recently published, along with Ann Cahill, The Continental Feminism Reader (Rowman and Littlefield). She also is the managing editor of Studies in Practical Philosophy. She can be contacted at jhansen@gettysburg.edu.

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