Mind Games: American Culture and the Birth of Psychotherapy (review)

Eric Caplan. Mind Games: American Culture and the Birth of Psychotherapy. Medicine and Society, no. 9. Berkeley and Los Angeles: University of California Press, 1998. xiii + 242 pp. $35.00; £27.50.

Eric Caplan's account of the birth of medical psychotherapy in America is as much a work of historical archaeology as it is a narrative. Caplan discovers fragments of historical skeleton embedded in different layers of the postbellum American cultural landscape. Chapter by chapter he unearths and assembles them like pieces of a puzzle, until they emerge as an entity we recognize as an ancestor of the species "psychotherapy" with which we (think we) are familiar.

Caplan's first substantive chapter exhumes the medical and legal controversies surrounding railway spine and finds that railway surgeons--of all unlikely medical groups--developed and carried forward a psychogenic theory of this disorder against the prevailing current of somatic etiology. Next he dusts off the well-worn gem of neurasthenia, but he observes it closely and carefully and discovers new facets: this functional nervous disorder did not in itself promote a psychological approach to its cause or its treatment; rather, the "therapies designed to combat neurasthenia were products of American medicine's growing fidelity to the somatic paradigm" (p. 45). Yet with his characteristically keen sense of historical irony, he concludes:

That efforts to treat neurasthenia had little direct impact on the emergence of what came to be known as psychotherapy is a point frequently missed by historians. The same cannot be said of the unwitting impact of those efforts, however. . . . in the longer term the largely futile efforts to treat neurasthenia by somatic means caused a number of prominent physicians to reconsider some of their most cherished assumptions regarding the relationship between mind and body. (p. 60)

Caplan completes his historical reconstruction with chapters on the religious movements that popularized ideas about the role of the mind in disease and thereby prepared the soil of American culture for medical psychotherapy. He tracks the medical debates surrounding these movements, dissecting out the multiple and complex responses of elite physicians and rank-and-file practitioners. In the end, he has laid bare a subtle and sophisticated historical process--incremental, undramatic, nonlinear--that can be viewed and appreciated in its richness and depth.

Unfortunately, Caplan dresses this process in the ill-fitting garb of polemical positions that do not do justice to his own meticulous historical work. He rightly sees himself as redressing imbalances in the historiography of American psychotherapy, but this leads him to set up simplistic dichotomies and assert untenable positions. From the outset, he takes up the banner for the specifically American determinants of American psychotherapy (as against the significance of European influences), as well as for the preponderance of socioeconomic causes over "internalist" factors in the medical profession's eventual adoption of psychotherapy. Yet in the body of his book he is forced to qualify and backpedal to the point of rendering these causal claims virtually meaningless. He cannot avoid repeated references to "the frequently overlapping Euro-American medical-cultural discourses regarding neurasthenia, railway spine, hysteria, and mind cure" (p. 118). The causal importance of economic motives--i.e., the profession's need to "compete effectively in a rapidly expanding mental-medical marketplace" (p. 6)--is asserted but unsupported by the evidence. For example, after describing a New York neurologist's public change in position regarding the Emmanuel movement, Caplan writes: "Why the change of position? The answer to this question, I suspect, concerns the threat of competition from nonmedically trained 'psychotherapists'" (p. 137). I suspect! The various controversies, delays, and changes in position among physicians that Caplan describes in such detail would seem to be as explicable by the demands of medical theory and practice as by his suspicion--assumption--about their motives. But such assertions, like the misleading title "Mind Games," seem more a...