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

The premise of this book is that the biochemical revolution in psychiatry, which displaced Freudianism from its central role in treating mental illness in the United States, is itself in need of psychoanalyzing. Metzl is not the first scholar to interrogate the complicated psychological world of psychiatric drug treatment, but his book distinguishes itself by its strong interest in Freudian analytic schemas as opposed to any of a myriad interpretive possibilities. This creates a stumbling block for his work, since he is at once dedicated to Freudian analysis and highly critical of it. Prozac on the Couch, provocative and engaging, is also at times frustrating and somewhat handicapped.

This psychoanalysis of psychopharmacology focuses largely on women, and most explicitly on mild forms of mental disturbance. Metzl is most interested in the tendency to pathologize the extremes of normal social behavior, and he argues throughout the book that psychiatry and psychiatric pharmaceuticals are used to restrain female sexuality. Making women marriageable, in his analysis, is a major task of contemporary psychiatry. Married women, or women en route to marriage, stand as the norm of the healthy psyche; women who refuse marriage, who intimidate or belittle men, figure as the irrational unconscious erupting to disturb the tranquil, male-dominated domain of civilization.

In Metzl's interpretation, Freudian theory identified the superego with the father and the unconscious with the mother; he argues that this constituted "the working order, not just of the individual, but of the larger environment in which he lives and works" (p. 78). According to the Freudian model, the mother/unconscious needs to be renounced and repressed in order for civilization to prosper. The irruption of the repressed maternal into the conscious world causes dislocation, panic, and, above all, anxiety.

Metzl argues that the psychopharmaceutical revolution never cut itself free from the psychoanalytic obsession with anxiety-provoking free females. Drawing on psychiatric literature, pharmaceutical advertisements, and popular journalistic accounts of psychiatry, he produces a cultural history from the era of Miltown, through Valium, to Prozac. Throughout he seeks to demonstrate that the Freudian paradigm of gender relations endures—unacknowledged and nonetheless powerful—in the age of wonder drugs.

Metzl is neither an antipsychiatry psychiatrist nor an antidrug psychiatrist, although his book has provoked strong criticism from defenders of the establishment. My chief complaint is not that Metzl's criticism is too radical, but that it is in fact in thrall to the very Freudianism it seeks to banish from psychiatry. He never gives us an alternative to the Freudian father/superego, mother/unconscious, and his interpretations of women are filtered through this distorting lens. Hence, his sometimes absorbing and adroit presentation of examples is hamstrung by an interpretive paradigm that is no broader than that which he seeks to criticize. I found myself asking, So, do women not suffer mental illness? Is Metzl arguing that marriage is always pathological? That single women are always neurotic? Or that any woman who wants to marry is willfully engaged in her own subjection? He never accounts for the broader realities of heterosexual female desires, including desires for sex and careers, but also for children and families, and the very real difficulties encountered as individual women seek to reconcile these competing desires in their lives. Finally, I found it more than vaguely objectionable that he acknowledges strong female agency only as a kind of masculine pretense made possible by Prozac (p. 189). In sum, Metzl overestimates the power of Freud, and underestimates the importance of history, which can provide us with powerful lessons of navigating or challenging gender roles, and of women possessed of strong characters unaided by Prozac.

Despite these criticisms, Prozac on the Couch would make a provocative addition to courses in the history of psychiatry, in women's studies, and in broader courses on the social study of sciences. If practicing psychiatrists have the patience to read this...