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

In this insightful study, Jonathan Metzl, a practicing psychiatrist and women's studies professor, provides a gender-focused, poststructuralist, psychoanalytic rereading of the much-ballyhooed "biological revolution" in late twentieth-century American psychiatry. His target is the widely held notion that psychiatry underwent a paradigm shift beginning in the 1970s, when frustration with psychoanalysis's outdated gender stereotypes combined with a new body of neuroscientific and psychopharmacologic knowledge and technologies, led to the replacement of psychoanalysis with biological psychiatry. Metzl's revision of this story takes an ironic twist: Despite biological psychiatry's claims to the contrary, he suggests, psychoanalysis persists as its thinly repressed unconscious, evident primarily in the remnants of postwar American psychoanalytic gender ideology that can be found hidden beneath the surface of its supposedly gender-neutral, scientific discourse.

Metzl first provides a close reading of American psychiatry's main professional journal, the American Journal of Psychiatry, from the 1950s through the 1990s. He argues that the journal articles and advertisements should be read alongside one another, because they together reveal a parallel shift: the initial prominence and then disappearance of the male psychiatrist as the symbolic agent of clinical potency and authority, and his subsequent replacement by equally masculine-gendered pharmaceutical products. According to Metzl, the symbolic target of these phallic agents remains consistent: the pathological female patient.

Metzl next turns to popular media, where he finds that from the advent of the tranquilizer Miltown (meprobamate) in the late 1950s, sources have consistently portrayed psychiatric medications as treatments for the same deviations from contemporary female gender norms that psychoanalysis had stigmatized—deviations such as "frigidity," ambivalence over marriage, female infidelity, female participation in the workforce, and, most notoriously, "momism," the supposedly emasculating effect of overbearing mothers on their vulnerable sons. Beginning in the 1960s, these sources added the unmarried adult woman and the enraged feminist to the stock of pathologized stereotypes, while in the 1990s, discourse focused on a new gender ideal: the attractive, professionally productive woman who is nonetheless reassuringly anchored to family, children, and heterosexual marriage.

Moving on from professional and mass market media, Metzl ends with an analysis of Prozac (fluoxetine) as a character in literary accounts, both fictional and nonfictional, from the late 1990s. Here he uncovers a typical trajectory reminiscent of romantic plot lines: nearly religious enthusiasm ("salvation"), followed by violent disillusionment, eventually giving way to reconciliation or resolution. He partly uses this to celebrate a new, more liberated model of female patienthood available to contemporary America: the empowered health care consumer able to appropriate technologies for her own counterhegemonic ends, while still struggling with the power of mainstream idealizations.

Despite its insights, however, Prozac on the Couch turns out to be a somewhat narrow account of American psychiatry's late twentieth-century trajectory. Social, economic, and even intellectual factors indispensable to understanding this period—factors such as the transformation in health care financing and insurance, the explosive growth of the pharmaceutical industry and its increasing influence on the medical profession, the changing role of government, the remarkable civil libertarian challenge to psychiatric authority, the dismantling of the nineteenth-century asylum system, the rise of and backlash to the drug culture—are mentioned only in passing. Metzl would likely argue that these topics have been adequately covered elsewhere, but his slighting of them in favor of gender ideology makes the book less valuable to those not already familiar with the relevant literature.

Even within the domain of gender ideology and representational politics, Metzl could have done still more with the historical record. Psychopharmaceutical advertising is a broader source of stereotypes, fantasies, and fears—some of them frankly contradictory—than he acknowledges, particularly regarding the multiple competing representations of men, masculinity, race, illness, and normality, as well as of women and femininity. Clearly Metzl knows this. In demonstrating this awareness, he reproduces an advertisement from the 1970s in which a grotesque caricature...