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Munich, R.L. (1999). Madness on the Couch: Blaming the Victim in the Heyday of Psychoanalysis: Edward Dolnick. New York: Simon & Schuster, 1998, 368 pp., $25.00. J. Amer. Psychoanal. Assn., 47(3):939-943.

(1999). Journal of the American Psychoanalytic Association, 47(3):939-943

Madness on the Couch: Blaming the Victim in the Heyday of Psychoanalysis: Edward Dolnick. New York: Simon & Schuster, 1998, 368 pp., $25.00

Review by:
Richard L. Munich

Madness on the Couch is a scathing indictment of the application of psychoanalytic theory and technique to patients with schizophrenia, autism, and obsessive-compulsive disorder. Although the book's subtitle focuses on patients, a substantial amount of space is used to implicate dynamically oriented psychiatry in blaming families in the etiology of these disorders. Edward Dolnick's book has already been featured on National Public Radio, and several exchanges about it have appeared on the American Psychoanalytic Association members' page on the Internet.

The cohort of dynamically sophisticated psychiatrists trained in the three decades between 1955 and 1985 will find this well-written book especially poignant. It was during this span of time that the limitations of the psychodynamic approach for these patients were becoming clearer, yet no compelling alternative etiologies were available. The often impressive efficacy of psychotropic medications was vitiated by their perplexing and at times crippling side effects. Many of the more pernicious symptoms were untouched by medication, and cognitivebehavioral, psychoeducational, and rehabilitative techniques were in their infancy. Nevertheless, the therapists who chose to work with these very difficult patients were regularly achieving certain intangible results: (1) establishing a more or less supportive and nonthreatening contact and treatment alliance with otherwise resistant patients; (2) assisting in the decoding and delineation of inchoate and bizarre mental phenomena; (3) recognizing the early signs of inevitable decompensations and guiding stricken patients to safe havens; (4) helping families and significant others cope with the considerable strain attending the disorders; and (5) occasionally helping the fortunate patient achieve a version of community reintegration and tenure. Far from considering their efforts curative, most of these therapists assumed that beginning with one of these patients meant something more palliative and a commitment of several years, if not a lifetime. Far from unraveling the mysteries of disordered thinking or stereotypic behaviors, these therapists saw themselves an assisting patients with the considerable problems in living that come with these illnesses. The anecdotal literature that chronicled these modest results never considered measuring quality of life.

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