Mind Over Matter

For two decades, psychoanalysts have held fast to their slow, deep exploration of the psyche, reaping only scorn from the science-driven psychiatrists at Washington University. Good thing they didn't listen.

Hundreds more patients followed, each with his own Chinese box of memories and longings and fears. Moritz gained a kind of awe for the psyche's twists and turns, its ability to both protect and confound us. She guarded her patients' secrets fiercely, knowing all the while that this confessional seal was part of psychoanalysis' growing credibility problem. How could she do the kind of quantifiable, replicable research that science was demanding when her lab was the cobwebs inside her patients' minds?

Over the years, she watched with deep satisfaction as Wash. U. researchers exploded Freud's cruel speculations about cold, unreliable mothers who turned their children schizoid, pinpointed drugs to ease the torments of major mental illness without devastating side effects and traced genetic patterns of illnesses once blamed on warped character or early trauma. She also became active in the Eastern Missouri chapter of the American Psychiatric Association, working so closely with Wash. U. colleagues that the two sides grudgingly came to trust each other's good intentions. But they couldn't bridge the final abyss: the disagreement on how patients should be helped. The worldviews just didn't mesh. Wash. U. had created a standardized scientific vocabulary of classification; analysts treasured nuance and a fluid interplay between compartments. Wash. U. drew a straight line between mental illness and "problems of daily living" and focused on the former; analysts had seen "neuroticism" paralyze people and destroy their physical health as well. Wash. U. wanted to diagnose and relieve distressing symptoms; analysts wanted to share insight into their deepest causes.

When Moritz took over as director of the Institute in 1997, she placed unprecedented emphasis on research -- but psychoanalytic research was usually limited to comparisons of treatment outcomes or scrutiny of the therapy process itself. Patients weren't going to give up their confidentiality or jeopardize their own treatment to participate in a double-blind study, and, even if they did, the process would be so subjective and so variable that one couldn't generalize from it.

Wash. U. psychiatrists could generalize, by testing drugs, charting genetic traits and scanning brain mechanisms -- and that made the psychoanalysts look like high-priest wannabes, spoiled and self-indulgent and intellectually lazy. The image stung Moritz, who'd spent her entire life absorbing and clarifying and transforming other people's rage, agony, hatred, lust and muddle. "Nothing I have ever done is more fascinating, more completely absorbing, than this work," she says, leaning forward. "The trust that is involved is awesome. And the resiliency of people, even those who have been so scrunched down and constricted! I've seen spouses who've never had a moment of sexual pleasure in their lives; professionals who've sabotaged their own work for reasons they couldn't explain; people whose entire lives had to be rebuilt after a twist of fate destroyed everything. And, oh my God, the children. Grownups come to you with 40 years of issues, but children are right there in the beginning, and they take the analytic understanding and do handstands with it."


Friendless, the little girl spent every recess walking a perfect square around the school playground. At home, she went into tantrums if milk spilled or the schedule was broken, and she often begged her patient, loving, bewildered parents to kill her. Finally they brought her to Moritz.

Appointment after appointment, she let the child play.

"After my dying almost every day in fire, in rockets, in floods, she began more and more to focus on policemen and sirens and car smoke," recalls Moritz, "and she would put together, out of sheets of paper, massive highways that covered the floors of my room, everything perfectly done, Highway 40 with all its bridges. I went to her parents and said, 'Is there any chance that something happened on a highway to this child?' and they looked at each other and said, 'Oh my God. She was only 2; we didn't think she would remember.' She'd been in a car seat next to her dad, who was driving, and he had his first epileptic attack and jammed his foot on the gas, and the car went out of control. It was this idea that she had to be in charge of stopping the car, that she had to be the one who was making everything go right. And working this out made all the difference." Soon the child was playing kickball with the other kids, giggling uncontrollably. "It would have been all too easy to diagnose her with obsessive-compulsive disorder and give her drugs," concludes Moritz. "And drugs could have masked the symptoms for a long time."

Moritz has never opposed drugs; she gladly refers patients with biologically based illnesses such as schizophrenia to psychiatrists more skilled in the latest pharmacology, and as milder psychiatric meds have improved, she's become more willing to prescribe them for her own patients, especially early on, to lift a curtain of depression or anxiety long enough to reveal what's underneath. She's wary, though, after watching more and more psychiatrists try to solve existential angst with pharmaceutical stats. "We have run 3 million and eight people through these trials; all you have to do is increase the medication," she mimics in a pompous voice, "and when you get to the maximum of that one, you can change to a different family of drug, and for those who are 'resistant,' you can add an antipsychotic, you can add thyroid, you can add other drugs." Americans pay $10.4 billion a year for anti-depressants (a fivefold increase since 1993), yet depression, she remarks, is hardly ever a purely chemical problem. "People can be trapped in situations that undermine them and deplete their biochemistry. If you treat that symptomatically, you're not addressing the interrelationships of mind and brain and body. You can give them a false sense of happiness, perhaps, that covers over an inner emptiness and despair. But you haven't solved anything."

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