1 Boring Old Man

The Dictionary of Disorder
^{How one man revolutionized psychiatry}
The New Yorker
by Alix Spiegel
January 3, 2005

^{In the mid-nineteen-forties, Robert Spitzer, a mathematically minded boy of fifteen, began weekly sessions of Reichian psychotherapy. Wilhelm Reich was an Austrian psychoanalyst and a student of Sigmund Freud who, among other things, had marketed a device that he called the orgone accumulator—an iron appliance, the size of a telephone booth, that he claimed could both enhance sexual powers and cure cancer. Spitzer had asked his parents for permission to try Reichian analysis, but his parents had refused—they thought it was a sham—and so he decided to go to the sessions in secret. He paid five dollars a week to a therapist on the Lower East Side of Manhattan, a young man willing to talk frankly about the single most compelling issue Spitzer had yet encountered: women. Spitzer found this methodical approach to the enigma of attraction both soothing and invigorating. The real draw of the therapy, however, was that it greatly reduced Spitzer’s anxieties about his troubled family life: his mother was a “professional patient” who cried continuously, and his father was cold and remote. Spitzer, unfortunately, had inherited his mother’s unruly inner life and his father’s repressed affect; though he often found himself overpowered by emotion, he was somehow unable to express his feelings. The sessions helped him, as he says, “become alive,” and he always looked back on them with fondness.}

Wilhelm Reich‘s early book, Character Analysis, was an erudite and classic description of personality disorders. Thereafter, he became increasingly crazy – migrating to New York where he established Orgone Therapy a conflation of sexual energy and cosmic forces. He created the Orgone Box [Accumulator] where one sat to experience this sexual energy, and later a built a cloudbuster that focused the energy on the clouds to make rain. Reich died while serving time in prison for  fraud. In whatever illness he developed along the way, Reich took Freud’s early ideas about the importance of instinct and psychic energy literally, and built a delusional system around it.

^{Spitzer first came to the university as a resident and student at the Columbia Center for Psychoanalytic Training and Research, after graduating from N.Y.U. School of Medicine in 1957. He had had a brilliant medical-school career, publishing in professional journals a series of well-received papers about childhood schizophrenia and reading disabilities. He had also established himself outside the academy, by helping to discredit his erstwhile hero Reich. In addition to his weekly sessions on the Lower East Side, the teen-age Spitzer had persuaded another Reichian doctor to give him free access to an orgone accumulator, and he spent many hours sitting hopefully on the booth’s tiny stool, absorbing healing orgone energy, to no obvious avail. In time, he became disillusioned, and in college he wrote a paper critical of the therapy, which was consulted by the Food and Drug Administration when they later prosecuted Reich for fraud. At Columbia Psychoanalytic, however, Spitzer’s career faltered. Psychoanalysis was too abstract, too theoretical, and somehow his patients rarely seemed to improve. “I was always unsure that I was being helpful, and I was uncomfortable with not knowing what to do with their messiness,” he told me. “I don’t think I was uncomfortable listening and empathizing—I just didn’t know what the hell to do.” Spitzer managed to graduate, and secured a position as an instructor in the psychiatry department [he has held some version of the job ever since], but he is a man of tremendous drive and ambition—also a devoted contrarian—and he found teaching intellectually limiting. For satisfaction, he turned to research. He worked on depression and on diagnostic interview techniques, but neither line of inquiry produced the radical innovation or epic discovery that he would need to make his name.}

Somehow, reading about Spitzer’s history helped me condense my own objections to the DSM-III. I’m going to try to articulate why it bothers me [but I may end up sounding as crazy as Wilhelm Reich]. It has to do with the overvaluation of words, language, theory. The place to start is how I understood my own psychoanalytic training. Psychoanalysts as clinicians are essentially listeners, listening to other people think out loud. Over the years, countless analysts have come up with ways to understand what they hear – called metapsychology – the "theories" of psychoanalysis. Even the best of them are often in conflict with others. They’re nothing more than that – models created by smart people who listened carefully. None of them will ever be "true" and they bear the same relationship to real people that model airplanes have to 747s. They’re pointers in trying to understand the actual person in front of you, nothing more. That’s why they were such a lousy way to organize psychiatric diagnosis. If they help in a given case, great. If not, try listening another way. Some find this mumbo jumbo. Some of us find it endlessly fascinating. But psychoanalytic theory is no basis for building an objective diagnostic classification – a point now accepted by almost everyone. And there’s nothing more boring than an analyst who has landed on some theory as the final answer to mental life and begins expounding jargon.

^{Spitzer labored over the DSM–III for six years, often working seventy or eighty hours a week. “He’s kind of an idiot savant of diagnosis—in a good sense, in the sense that he never tires of it,” Allen Frances says. John Talbott, a former president of the American Psychiatric Association, who has been friends with Spitzer for years, says, “I remember the first time I saw him walk into a breakfast at an A.P.A. meeting in a jogging suit, sweating, and having exercised. I was taken aback. The idea that I saw Bob Spitzer away from his suit and computer was mind-shattering.” But Spitzer’s dedication didn’t always endear him to the people he worked with. “He was famous for walking down a crowded hallway and not looking left or right or saying anything to anyone,” one colleague recalled. “He would never say hello. You could stand right next to him and be talking to him and he wouldn’t even hear you. He didn’t seem to recognize that anyone was there.”}

^{Despite Spitzer’s genius at describing the particulars of emotional behavior, he didn’t seem to grasp other people very well. Jean Endicott, his collaborator of many years, says, “He got very involved with issues, with ideas, and with questions. At times he was unaware of how people were responding to him or to the issue. He was surprised when he learned that someone was annoyed. He’d say, ‘Why was he annoyed? What’d I do?’ ” After years of confrontations, Spitzer is now aware of this shortcoming, and says that he struggles with it in his everyday life. “I find it very hard to give presents,” he says. “I never know what to give. A lot of people, they can see something and say, ‘Oh, that person would like that.’ But that just doesn’t happen to me. It’s not that I’m stingy. I’m just not able to project what they would like.” Frances argues that Spitzer’s emotional myopia has benefitted him in his chosen career: “He doesn’t understand people’s emotions. He knows he doesn’t. But that’s actually helpful in labelling symptoms. It provides less noise.”}