Prozac on the Couch: Prescribing Gender in the Era of Wonder Drugs

Reviewer: Elizabeth Bromley, MD, MA

Disclosures

August 11, 2003

Introduction

By Jonathan Michel Metzl
Duke University Press
Copyright 2003
275 pages
ISBN 0-8223-3061-X
$24.95 hardcover

Were it not in dialogue with such a serious and timely project -- namely, attending to the sociocultural implications of modern psychopharmacology -- Prozac on the Couch: Prescribing Gender in the Era of Wonder Drugs would be a fun, critical read of popular images of anxious women. Author Jonathan Michel Metzl, MD, PhD unpacks psychiatric prescribing and rewrites psychiatric history from a novel perspective. However, the author's delivery is too jargonistic for the professional audience to whom its conclusions would be most relevant.

In his first book, Metzl, a psychiatrist and gender studies scholar, has written a cultural history of psychiatric therapeutics. Using the imagery of pharmaceutical ads, the popular press, and professional journals, he argues that a biological psychiatry centered on the dispensation of pills is no less involved in the reification of social norms or the enforcement of gender relations than the dynamic psychiatry it claimed to replace. Identifying similarities in the social function of psychiatric therapies from the 1950s to the present, he argues that it is inaccurate to imagine "that medications and talking cures work on entirely different axes" (p. 5). He claims that because "psychotropic medications are imbued with expectation, desire, gender, race, sexuality, power, time, reputation, countertransference, metaphor, and a host of important factors," psychiatry's purview remains similar, despite changes in its therapeutics (p. 5). Finally, he wants to demonstrate that "a narrative claiming change also risks reinventing and rearticulating the same gender hierarchies for which psychoanalysis was widely critiqued" (p. 6).

Metzl uses a series of case studies to demonstrate the continuities buried under the rhetoric of a paradigm shift. He argues that, between the 1950s and the 1970s, changes in the iconography of pharmaceutical ads mirrored changes in psychiatric practice. Psychiatrists disappeared: "In their stead appeared representations of ... capsules and tablets that grew ever larger throughout the era, assuming an agency once the sovereign domain of men"(p. 56). In the clinic, as well, pills took over the effective position of the psychiatrist. Pills assumed, to the same problematic degree, the role of "defending the sanctity of relationships between men and women against the forces of depression" and other mental ills (p. 36).

Metzl examines news magazines and popular print sources announcing the discovery of the tranquilizer Miltown (meprobamate) between 1954-1960. In these popular sources, he finds evidence that psychoanalysis was "unable to treat the anxiety caused by women's discontent" which "threaten[ed] to rupture civilization's progress narrative" (p. 27). Women as "free radicals" threatened social stability, causing an anxiety psychiatry could not cure by talk therapy alone (p. 122). Miltown emerged, then, as a "restorative cure," (p. 27) able to "bind" cultural anxiety, but with more success than psychoanalysis.

Metzl reads ads from 1964 to 1997 to show that pharmaceuticals continued to enforce normative, "psychoanalytic" relationships. In the 1960s, they controlled the angry, married woman who threatened doctorhood; and in the 1970s, Valium treated the unmarried woman who served as "the marker of pathology and abnormality" (p. 143). That "problematic connections between mothers and pharmaceuticals from popular culture in the 1950s" become marketing techniques in later decades indicates to Metzl the continued remnants of psychoanalytic thought in medicalized psychiatry (p. 27). Similarly, autobiographical narratives of treatment with Prozac (for instance, Persimmon Blackbridge's novel Prozac Highway) demonstrate the essential continuity between Freudian ideas about gender development and antidepressant treatment.

In short, Prozac on the Couch is a psychoanalytic interpretation of psychiatric prescribing, using (mostly) popular sources as data points. Those readers who are intellectually inclined enough to be comfortable with the language, theory, and methodology may not find the argument surprising. Yet, clinicians who find the themes compelling might grow impatient with the presentation. The point is that psychiatric practice is and always will be an activity that involves gender, social norms, and culture-mediated distress. Even as the location of inquiry moves toward the biological, and the predominant therapeutic mode is medicalized, the practice of psychiatry is stuck within a web of culture and social relationships. Further, psychiatry, even when strictly biological, must, in part, operate through power, a situation with different significance for men vs women.

To appeal to a wider audience, the argument could be presented with less jargon and more caution. For instance, terms like Freudian and psychoanalytic are used in an academic, not a clinical sense. Any mention of relationships or gender (particularly a "binaried" notion of gender [p.17]) in contemporary clinical parlance is interpreted as a remnant of a psychoanalytic legacy, not a simple pronoun in an illness narrative. Mothers, daughters, married or single women, sons or husbands are discussed as "psychoanalytic categories," (p. 14) not the social roles through which psychiatrists engage their patients. Such relabeling will sound simplistic to clinical psychoanalysts, and inexact to historians of science.

Further, the book makes bold statements with little evidence or contextualization. Metzl takes the disappearance of the psychiatrist from pharmaceutical ads as evidence of a vital change in the psychiatrist's role. Yet, a more thorough survey of advertising may reveal that all ads became more iconographic in the last five decades, or that nonpsychiatric medical ads also featured fewer surgeons and internists. This begs the question of how ad sampling was performed, and whether, on a quantitative level, Metzl's assertion is true at all. Some readers will also disagree with his interpretation of images in pharmaceutical advertisements, which are at times elaborate.

His central theses also deserve more substantiation. Metzl posits a crisis of psychoanalysis in the 1950s based on the proliferation of popular presentations of anxiety and psychotherapeutic communication. These sources do not, to this reader, obviously denote a crisis, and could indicate the opposite. In a similar manner, mass-market representations of psychiatry are used to substantiate claims about the identity of the profession itself. Using popular sources to track professional priorities may be familiar to cultural theorists who question the separateness of high and low culture. However, it may bother practitioners, who notice differences between popular and professional representations of psychiatry.

Ultimately, Prozac on the Couch relies on a strawman argument that in American psychiatry, biology claimed to have replaced and invalidated psychoanalysis. Metzl wants to question how thorough this coup was, arguing for continuity within psychoanalytic and biological therapeutics. Yet, he continually portrays them as opposing forces. For instance, he says that the presence of a wedding ring in pharmaceutical ads provides "evidence for my larger claim that certain specific gender tensions continued to exist in psychiatric diagnoses and treatments, even as psychiatric language claimed that they did not" (p. 157). Does current psychiatric rhetoric claim gender is no longer of interest? Do neuroscientists really argue that marital status is molecular? Whether psychopharmacologic rhetoric aims to render relationships and culture obsolete could be an inquiry in itself, not a fact with which to begin. However, Metzl's repetition of a simplistic dichotomy reminds the reader that without exaggerating the ideologic discontinuity of the biological and the psychoanalytic, he would have no counterargument to make about their similarities.

Nonetheless, Prozac on the Couch has important things to say about the meaning of psychiatric practice. Metzl warns that when biological psychiatrists ignore their social function, they risk reinforcing norms and the status quo, rather than furthering liberation. He reminds practitioners that psychiatry necessarily concerns "dialectics of selves and others and the intersubjective imputation and recognition of constitution and consciousness," (p. 198) even when it is structured by the task of prescription writing. The "repression" of our psychoanalytic past "renders [psychiatry] less aware of the cultural categories and categorical manipulations" it engages (p. 158). Finally, in Prozac on the Couch, Metzl tells an interesting story of how psychoanalysts defined psychiatric problems, and thereby opened a space for pharmaceuticals. To the extent that "tranquilizers ... became treatments for clearly psychoanalytic problems," what endures in the encounter between a psychiatrist and a patient, despite vicissitudes in rhetoric, deserves further exploration (p. 108).

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