Mad Men and Ad Men- Extending the Bounties of Madness

by padraigcolman

Randall Jarrell’s wonderful book Pictures from an Institution was about an academic establishment not a mental hospital. Unlike his contemporaries John Berryman, Sylvia Plath and Delmore Schwartz, Jarrell  did not suffer a premature death as a direct result of serious mental disorder. He was not a member of the Mad Poets Society. He once shared accommodation with Robert Lowell, but Lowell’s bouts of mania were not contagious. Around the age of 50, Jarrell began to suffer a mild panic and depression possibly simply because of  the passing of the years.

Randall Jarrell

The medication prescribed to Jarrell made him behave eccentrically – on one occasion he tried to tip a waitress $1,500. He was hospitalized and tried to slash his wrists.  At the age of 51, he was killed by a car while taking an evening walk. The coroner deemed it an accident, but some have wondered it was suicide and poet Mark Ford referred to his “lonely, ambiguous death”.

Lowell wrote:

“Child Randall,

Greeting the car, and approving – your harsh luminosity”.

Robert Lowell

John Berryman

Sylvia Plath

Delmore Schwartz

Are there more mad people today or just more drugs?

The Sri Lanka Daily Mirror recently reported that 25% of Sri Lankans suffer from mental illness. I could not trace an authoritative source for this figure and  was puzzled because the item also said there was a shortage of  psychiatrists in Sri Lanka. If  psychiatrists are lacking, who was qualified to count and what were their definitions? Would there be even more mentally ill people if there were more psychiatrists to identify them and treat them? Is there really a problem or is this a case of what Mikkel Borch-Jacobson  has called “conceptual gerrymandering”?[i]

There are articles, for example one in the Lancet, [ii]which explain why there might be a high incidence of mental illness in Sri Lanka – the long-running war and the fear of terrorist acts, the tsunami, poverty. The high suicide rate is given as evidence of extensive mental illness.

In the world in general, are there more people today with mental illness than there used to be?  Are the stresses of modern life driving more people mad?

Marcia Angell has contributed a series of disturbing articles to the New York Review of Books about how the pharmaceutical industry uses “conceptual gerrymandering” to extend its market.[iii]

One in seventy-six Americans are so disabled by mental disorders that they qualify for social security. Mental illness is now the leading cause of disability in children, well ahead of physical disabilities like cerebral palsy or Down’s syndrome, for which the federal programs were created. A National Institute of Mental Health (NIMH) survey found that 46% of Americans met criteria established by the American Psychiatric Association (APA) for having had at least one mental illness within four broad categories at some time in their lives.

Definition, categorization, conceptual gerrymandering, treatment.

What constitutes “mental illness”? The categories included in the NIMH survey were “anxiety disorders,” including, among other subcategories, phobias and post-traumatic stress disorder (PTSD); “mood disorders,” including major depression and bipolar disorders; “impulse-control disorders,” including various behavioural problems and attention-deficit/hyperactivity disorder (ADHD); and “substance use disorders,” including alcohol and drug abuse. Most met criteria for more than one diagnosis. Of a subgroup affected within the previous year, a third were under treatment—up from a fifth in a similar survey ten years earlier.

Mortimer Ostow MD, wrote that the normal practice for psychiatrists when dealing with a new patient  was to complete a questionnaire, possibly by computer, the results of which would lead the psychiatrist to a code number and diagnosis in the current Diagnostic and Statistical Manual of Mental Illness (DSM). The psychiatrist would then refer to the three-volume handbook Treatments of Psychiatric Disorders. Treatment is primarily medication. As early as  the 1960s, Dr. Ostow was an advocate for extending psychotherapy in cases where patients had been medicated and discharged from mental health facilities. In 1965, he told members of the American Psychoanalytic Association that drug treatment by itself was often inadequate and that drugs ”remove the more florid symptoms of mental illness while leaving the disturbance itself untouched.”

Each new version of the DSM has included more mental illnesses than the previous edition it was replacing. In 1973, homosexuality per se was removed. RL Spitzer can take credit for that. He argued that what was at issue was a value judgment about heterosexuality, rather than a factual dispute about homosexuality.[iv] The controversy stirred by Spitzer’s paper did not prevent him becoming editor of DSM III. He is preparing a new edition for publication in 2013.

As long ago as 1984, George Vaillant, professor of psychiatry at Harvard Medical School,  wrote that the DSM represented: “a bold series of choices based on guess, taste, prejudice and hope”. Spitzer said in a 1989 interview: “I could just get my way by sweet talking and whatnot”. There are no citations of scientific studies to support its decisions.

Most of those deciding on what goes in the DSM have ties to the drug industry. A 2009 study showed that 18 out of 20 of the psychiatrists who wrote the American Psychiatric Association’s most recent clinical guidelines for treating depression, bipolar disorders, and schizophrenia had financial ties to drug companies.[v]

What’s in a Name? Were there bipolar people in the olden days?

Very few people had heard of bipolar disorder before 1980, when it was introduced in DSM III. (Thank you Robert Spitzer.)

We are told bipolar  is merely a new name for manic depression. This is not true –  muddle has been introduced by naming different types of bipolar disorder.

David Healy [vi]explains that the term ‘bipolar disorder’ was introduced in 1966 by Jules Angst (a wonderful name for a psychiatrist!) and  Carlo Perris. On the basis of 3,872 admission charts from the asylum at Denbigh, North Wales, between the years 1875 and 1924, Healy concludes that manic depression was rare. He arrives at a figure of ten cases per million each year, that is 0.001% of the general population. In 1994,  the US National Comorbidity Survey estimated that 1.3% of the American population suffered from bipolar disorder. Four years later, Angst estimated  5%: 5000 times higher than the figure suggested by Healy. There is now  a “bipolar spectrum”, which includes  a very accommodating “subthreshold bipolar disorder”.

Bipolar children?

On 13 December 2006, four-year old Rebecca Riley died from an overdose of the medication cocktail prescribed by her psychiatrist, Kayoko Kifuji. At the time of her death, she was taking Seroquel, a powerful antipsychotic drug, Depakote, a no less powerful anticonvulsant and mood-stabilising drug, and Clonidine, a hypotensive drug used as a sedative. How could Kifuji have prescribed a two-year-old psychotropic medications normally intended for adults suffering from psychotic mania? Apparently such things are now considered “normal”. Kifuji was cleared of any misconduct. Rebecca’s parents were convicted of murder.

The prevalence of paediatric bipolar disorder multiplied by a factor of 40 between 1994 and 2002. ‘Warning signs’ for parents are : ‘poor handwriting’, ‘complains of being bored’, ‘is very creative’, ‘intolerant of delays’, ‘curses viciously in anger’, ‘elated or silly, giddy mood states’.

In an interview with the Boston Globe, Janet Wozniak, director of the paediatric bipolar programme at Massachusetts General Hospital, stated her credo: “We support early diagnosis and treatment because the symptoms of bipolar disorder are extremely debilitating and impairing … It’s incumbent on us as a field to understand more which pre-schoolers need to be identified and treated in an aggressive way.”

Clearly Rebecca’s home circumstances were not conducive to a happy childhood but was there any hope that a toxic cocktail of powerful anti-psychotic drugs would improve her life? What of other children guilty of being silly or giddy?

Aggressive treatment

Treatment of people deemed by the professionals to be mentally ill has often been aggressive to the point of barbaric violence, including sending electric currents through the brain  or scooping out pieces with an ice-pick.

I  used to go to children’s Christmas parties at Barnwood House, near Gloucester, when I was around four or five years old, and my mother worked as an orderly there. I was puzzled that the high walls of Barnwood House had broken glass embedded in the top.

I later discovered that Barnwood House was a private mental hospital, generally for patients from affluent families. I recall that a relative of the Conservative minister Sir Reginald Manningham-Buller (known to his many enemies as Reggie Bullying-Manner) was a patient at Barnwood House when my mother worked there.

I have written elsewhere  about the travails of Ivor Gurney, poet, composer and musician. While researching for that article it sent a shiver down my spine to realise that I had met Ivor’s brother, Ronald who was a tailor in Gloucester, many times in the very house from which Ivor was forcibly taken to be incarcerated in Barnwood House. Gurney hated being in Barnwood House and tried to escape by jumping through a window. He was fortunate that he was not an inmate when it was the location for some pioneer work in “aggressive treatment”.

Ivor Gurney

Helen Thomas, the widow of Edward Thomas, a poet killed in the war, wrote: “Ivor Gurney longed more than anything else to go back to his beloved Gloucestershire, but this was not allowed for fear he should try to take his own life. I said ‘But surely it would be more humane to let him go there even if it meant no more than one hour of happiness before he killed himself.’ But the authorities could not look at it in that way.”

While in the trenches he dreamed about his beloved Gloucestershire. In the asylum he was again deprived of it.

Ivor Gurney’s first incarceration was in Gloucestershire. He  was an inmate at Barnwood House too early to benefit from the “most modern methods of treatment” of which the institution later boasted in its advertisements.

Barnwood House had a good reputation in Gurney’s time. I recall it in the 1950s as a rather forbidding redbrick building from the outside, the inside with long echoing corridors tiled in hygienic shiny white, the staff jolly Italian or brisk Icelandic women.

In 1939, Burden Neurological Institute at Stoke Gifford, near Bristol, formed links with Barnwood House. Gerald Fleming, the medical superintendent of Barnwood House and editor of the Journal of Mental Science, entered into collaboration with Frederic Golla and William Grey Walter from the Burden Neurological Institute. Five patients at Barnwood House were selected as guinea pigs for the new form of convulsive therapy. Barnwood house can proudly claim the first use of electroconvulsive therapy on patients in England.

“For the operator, only a small amount of training and experience is necessary, and knowledge of physics, though desirable on general grounds, is not essential….the apparatus is comparatively cheap and portable, and preparation of the patient need take no more than a minute.”

Barnwood and the Burden Neurological Institute co-operated again in 1941. Four certified patients at Barnwood House were also amongst the first in England to undergo prefrontal leucotomy. The operations were performed in April 1941 by surgeon Francis Wilfred Willway with a paperknife. None of the Barnwood House patients left hospital after the operations, but were described as more manageable and well behaved. Barnwood House then employed neurosurgeon Wylie McKissock to continue the leucotomy programme.

Aggressive treatment of mental illness has a barbaric history.  It has involved what Robert Penn Warren described as “high-grade carpentry work.” Not always high grade. Egas Moniz won the Nobel Prize “for his discovery of the therapeutic value of leucotomy in certain psychoses”. The procedure, also known as lobotomy, consists of cutting the connections to and from the pre-frontal cortex, the anterior part of the frontal lobes of the brain. “I would rather have a bottle in front of me than a frontal lobotomy”, says Randle McMurphy in the stage version of One Flew Over the Cuckoo’s Nest.  Dean Martin developed this further: “would rather have a free bottle in front of me than a pre-frontal lobotomy.” It was a mainstream procedure for more than two decades from 1935, prescribed for psychiatric (and occasionally other) conditions, despite general recognition of frequent and serious side-effects.

The American neurosurgeon, Walter Freeman, thought Moniz’s procedure too expensive and impractical for asylums without surgical facilities. After experimenting with an ice-pick from his kitchen,  Freeman developed  “transorbital” lobotomy, which  involved lifting the upper eyelid and placing the point of a thin surgical instrument under the eyelid and against the top of the eye socket. A mallet was used to drive the instrument  through the thin layer of bone and into the brain. The ice picks he started out with would occasionally break inside the patient’s head and have to be retrieved, so he had the very durable orbitoclast specially commissioned in 1948. In 1949, the peak year for lobotomies in the US, 5,074 procedures were undertaken, and by 1951 over 18,608 individuals had been lobotomised in the US.

In the US approximately 40,000 persons were lobotomized. In Great Britain, 17,000 lobotomies were performed, and Finland, Norway and Sweden had a combined figure of approximately 9,300 lobotomies. Scandinavian hospitals lobotomized 2.5 times as many people per capita as hospitals in the US. Sweden lobotomized at least 4,500 people between 1944 and 1966, mainly women. This figure includes young children. In Norway there were 2,500 known lobotomies.

In 1948, Norbert Weiner, the author of Cybernetics, said: “prefrontal lobotomy… has recently been having a certain vogue, probably not unconnected with the fact that it makes the custodial care of many patients easier. Let me remark in passing that killing them makes their custodial care still easier.”

Electroconvulsive therapy (ECT) was introduced in the 1930s for the treatment of mania. The aim of ECT is to induce a therapeutic clonic seizure where the person loses consciousness and has convulsions) lasting for at least 15 seconds. Although a large amount of research has been carried out, the exact mechanism of action of ECT remains elusive.

Ernest Hemingway committed suicide shortly after ECT at the Menninger Clinic in 1961. He is reported to have said to his biographer, “Well, what is the sense of ruining my head and erasing my memory, which is my capital, and putting me out of business? It was a brilliant cure but we lost the patient.”

The Drugs Don’t Work

Marcia Angell asks: “are we simply expanding the criteria for mental illness so that nearly everyone has one? And what about the drugs that are now the mainstay of treatment? Do they work? If they do, shouldn’t we expect the prevalence of mental illness to be declining, not rising?”

As a layman, I was shocked to discover how many drugs are prescribed for conditions quite different from the use they were designed for. In the trade this is called “off-label”. My wife has been prescribed strong anti-epilepsy drugs for her spinal condition. A fellow customer in a bar where  I used to lunch  had no arms. This was because his mother had been prescribed thalidomide, which had been designed as a mild sedative but was prescribed for morning sickness. Argentinian author Carlos De Napoli suggested the drug had been first developed by the Nazis as a possible antidote to nerve toxins. Documents from IG Farben, the German pharmaceutical firm, seem to confirm the existence of the product during the war and a connection  has been suggested between testing thalidomide and the Nazi death camps. Dr. Heinrich Mückter was one of those responsible for inventing Thalidomide. Sources suggest Dr. Mückter caused the death of hundreds of Polish prisoners in  wartime experiments to find a cure for typhus. Thalidomide  was withdrawn after one of the biggest medical tragedies of modern times – as many as 20,000 children were born with birth defects . Since then thalidomide has been found to be a valuable treatment for a number of medical conditions and it is being prescribed again in a number of countries, although its use remains controversial, including its testing in the developing world.

The drugs being prescribed freely today for the treatment of mental illness are derived from products initially developed to treat infections; their effect on mental states was discovered accidentally and no one knew  how they worked. Instead of developing a drug to treat an abnormality, an abnormality was postulated to fit a drug. Researchers found that these drugs blunted disturbing mental states by  affecting  certain chemicals in the brain.

Chemical imbalance has been the dominant theory over the past forty years. Gail Hornstein says: “You can’t see schizophrenia. .. No doctor who has given anyone an antidepressant has ever measured the level of a neurotransmitter in the patient’s body. There is no independent means by which to tell if someone has a ‘chemical imbalance.’ ” Big Pharma’s profits have been blessed by this theory – if mental illness is a chemical thing, pump in more chemicals. That theory became broadly accepted, by the media and the public as well as by the medical profession, after Prozac came on market in 1987 as a treatment for a  deficiency of serotonin in the brain. The number of people treated for depression tripled in the following ten years, and about one tenth  of Americans over the age of  six take antidepressants.

Irving Kirsch, a psychologist at the University of Hull in the UK, argues convincingly that the drugs do not work. [vii]  Kirsch’s 15 years of research led him to conclude  that the relatively small difference between drugs and placebos might not be a real drug effect at all. “It now seems beyond question that the traditional account of depression as a chemical imbalance in the brain is simply wrong.” Neurotransmitter function seems to be normal in people with mental illness before treatment. Patients diagnosed with psychiatric disorders do not suffer from any known “chemical imbalance.” Once they are given drugs their brains function abnormally.

Dr. Tim Kendall of the Royal College of Psychiatrists Dr. Peter Tyrer, the editor,  wrote in the same issue of the  British Journal of Psychiatry: “The spurious invention of the atypicals can now be regarded as invention only, cleverly manipulated by the drug industry for marketing purposes and only now being exposed.” The market for atypical antipsychotics is currently worth $18 billion – twice as much as it was for antidepressants in 2001.

Steve Hyman, a former director of the NIMH believes that long-term use of psychoactive drugs causes  “substantial and long-lasting alterations in neural function.” The brain’s compensatory efforts . SSRIs may cause episodes of mania, because of the excess of serotonin. Antipsychotics cause side effects that resemble Parkinson’s disease, because of the depletion of . Drugs are given to counteract the side-effects. More profit for the drug companies.

Some patients take as many as six psychoactive drugs daily. Researcher, Nancy Andreasen told  The New York Times, “The prefrontal cortex doesn’t get the input it needs and is being shut down by drugs. That reduces the psychotic symptoms. It also causes the prefrontal cortex to slowly atrophy.”

Freud’s Fraud

The “talking cure” employed in psychoanalysis might be thought preferable to aggressive physical methods such as surgery, ECT or powerful toxic drugs. This is very rarely used these days because the insurance companies are reluctant to pay for it. It is too time-consuming for psychiatrists to make a decent profit. Drugs are more profitable all round.

Also,  there is a growing body of opinion that Freud’s entire edifice is unscientific and based on delusion and falsehood.  Frederick Crews, who had been better known as a literary critic, published a series of articles in the New York Review of Books [viii]which caused quite a stir in the psychoanalytical profession. The articles together with responses and counter-responses were published in book form. Crews cites Malcolm Macmillan’s “exhaustive demonstration that Freud’s theories of personality and neurosis- derived as they were from misleading precedents, vacuous pseudo-physical metaphors and a long concatenation of mistaken inferences that couldn’t be subjected to empirical review – amount to castles in the air”.

Macmillan[ix] writes: “We are never told that the so-called discoveries are dependent upon methods of inquiry and interpretation so defective that even practitioners trained in their use are unable to reach vaguely congruent conclusions about such things as interpretation of a  dream or a symptom, let alone the basic clinical characteristics of infantile or perverse sexuality or the reconstruction of the early stages of an individual’s development.”

According to Crews, Freud’s therapeutic successes “appear to have been non-existent and he lied about them brazenly and often. It is hard to tell what was presented by patients as memories or as dreams and hallucinations; it is also difficult to separate Freud’s suggestions and interpretations from the patients direct and spontaneous statements. Freud’s theory of parapraxes is conceptually dubious and the book expounding it contains not one single satisfactory illustration. The validity of the technique of word association is undermined by the fact that Freud tended to take a nap while the patient was free- associating.

Freud himself was not averse to complicity in aggressive physical treatment. He administered cocaine and morphine to hysterics, endangering their health and compromising any inferences he might have drawn about the efficacy of the “talking cure”.

It was bizarre enough that Freud should claim that Emma Eckstein was “bleeding for love” for himself, thus confirming his theories about nasal-genital correspondence,  when she had persistent nose-bleeds. In fact, there was a half-meter of gauze left in her nose after Freud’s colleague Fliess had performed surgery on her in pursuance of Freud’s mad theory.  As Crews comments this incident “constitutes an entirely typical instance of Freud’s rashness in always preferring the arcane explanation to the obvious one”.

See also the work of Frank Cioffi and Allen Esterson.[x]

The Problem with Psychiatry

In his work generally, Niall McLaren[xi] focuses on difficulties with the field of psychiatry as a whole.  Going all the way back to Freud, there has been a lack of scientific rigour. McLaren believes that mental disorder is a reality but  sufferers are denied effective treatment because academic psychiatry has failed to provide practitioners with a consistent treatment programme. McLaren demonstrates that psychoanalysis is not scientific in nature.

Malcolm Macmillan has shown  that Freud’s theories of personality and neurosis- derived as they were from misleading precedents, vacuous pseudo-physical metaphors and a long concatenation of mistaken inferences that cannot  be subjected to empirical review- do not  provide a cure or even  prove authoritatively that an individual is actually mentally ill.

Extending the Bounties of Madness – Inventing Sickness to Sell ‘Cures’.

Expanding  and diluting the definition of manic-depressive illness to  include depression and other mood disorders, allows antipsychotic or anticonvulsant medications that were initially approved only for the treatment of manic states, to be foisted onto more people.

Healy concludes that “All available studies on the longer-term consequences of antipsychotics indicate that they probably reduce life expectancy.” Anticonvulsants are liable to cause kidney failure, obesity, diabetes and polycystic ovary syndrome. Atypical antipsychotics can cause significant weight gain, diabetes, pancreatitis, stroke, heart disease and tardive dyskinesia (a condition involving incapacitating involuntary movements of the mouth, lips and tongue). They can, in some circumstances, cause neuroleptic malignant syndrome, a life-threatening neurological disorder, and akathisia, whose sufferers experience extreme internal restlessness and suicidal thoughts.

I have witnessed these side-effects. A now-elderly lady, who is perhaps too gentle and innocent for this harsh world, became quite understandably sad at the harsh circumstances of her life. She was not mad or ill, just a little melancholy from time to time, for good reason. Her husband walked into the kitchen one day and told her that her mother had died. He added that he was leaving for another woman and taking the three children with him. The only time she saw the children after that was from a distance through a school fence. She had no income.  Inappropriate medication did not cure her unhappiness, it increased it. The medication was often  changed arbitrarily with disastrous effects. She was sent to the fearsome Angoda  mental hospital because she showed signs of dyskinesia and erratic behaviour directly caused by the ‘cure’. Now the medication has been altered and she is happy and perfectly sane.

There might be worthwhile risks in taking such toxic medications in cases of acute mania but not for depressed elders or hyperactive children.

What Works?

Interviewed in Sun[xii] magazine, Gail Hornstein argues that psychotic states vary in intensity and duration and people who are subject to them can have an insight into their own experience. “The challenge is to understand medication in a much more complex way, not oversimplifying people’s experiences and cramming them all into one box or another”. Hornstein does not dismiss the efficacy of medication, but believes that the number of people who benefit “is far smaller than drug-company advertisements or ardent proponents of biological psychiatry make it seem”.

She said that two World Health Organization research projects had indicated that outcomes for schizophrenic patients were better in “developing” countries. “Two hypotheses have been put forward to explain these findings. One is that developing countries don’t use medications over the long term because they can’t afford it. Without long-term medication, patients don’t become chronically disabled. The other hypothesis is that people in developing countries are more likely to be cared for at home and be a part of their community, rather than being isolated or sent away to a hospital, and this helps them recover”.

When we were sharing a house with a paranoid schizophrenic, one thing that occurred to both my wife and myself was that there is  indeed a continuum of mental states. Some of the behaviour of this person who had been labelled and treated as mentally ill was not a great deal different from that of people, including ourselves, who are labelled “normal”. So many friends have phobias and superstitions. People who live alone can enjoy their own company so much they cease to care about how their behavior looks to others. Families develop bizarre rituals and private languages that can seem odd to the uninitiated.

That is not to say that the invention of a ‘bipolar spectrum’ in order to sell more drugs is helpful. It is, rather an indication that empathy is in order. There but for the grace of God.

While incarcerated in a mental hospital Ivor Gurney wrote to his friend Marion Scott: “Last night I wrote to Dr Vaughan Williams to get me Death, for this I cannot endure. Rescue me to something. For Death I long for. There is no reason I should not be released from this confinement- these rules”

Gurney knew he was troubled, but he also believed he was not mad.  He begged for help, but it was not forthcoming.  “Rescue me while I am sane,” he pleaded in a letter to Marion Scott written shortly after he was first admitted to Barnwood House.

Gurney’s biographer, Michael Hurd muses: “It is hard, though, to discount the suspicion that Gurney’s mind might have righted itself had he not been locked away. Fifteen years in a lunatic asylum may well have destroyed what in other circumstances might have been saved.”

Gurney did not receive the “benefits” of ECT, anti-psychotic drugs or psychoanalysis but even those who do today may have something destroyed which in other circumstances might have been saved.

 


[i] Mikkel Borch-Jacobsen. Which came first, the condition or the drug? London Review of Books. Vol. 32 No. 19 · 7 October 2010

[ii] Nayanah Siva. Sri Lanka struggles with mental health burden. Lancet. Volume 375, Issue 9718, Pages 880 – 881, 13 March 2010.

[iii] Marcia Angell NYRB Vol. XLVIII 11 and 12.

[iv] The diagnostic status of homosexuality in DSM-III: a reformulation of the issues. RL Spitzer American  Journal of Psychiatry 1981; 138:210-215

[v] What is Wrong with the DSM? History of Psychiatry March 2004 15: 5-25 R.V.Cooper@lancaster.ac.uk

[vi] Mania: A Short History of Bipolar Disorder by David Healy. Johns Hopkins, 296 pp, £16.50, May 2008, ISBN 978 0 8018 8822 9

[vii] Irving Kirsch: The Emperor’s New Drugs: Exploding the Antidepressant Myth. Basic Books

[viii] Frederick Crews et al. The Memory Wars: Freud’s legacy in disrepute. NYRB 1995 New York.

[ix] Malcolm Macmillan, Freud Evaluated: The completed arc. North-Holland 1991

[x] Frank Cioffi Freud and the Question of Pseudoscience (1998)  and Allen Esterson Seductive Mirage: An Exploration of the Work Of Sigmund Freud (1993).

[xi] McLaren, Niall (2009). Humanizing Psychiatry. Ann Arbor, MI: Loving Healing Press. pp. 145–147. ISBN 978-1-61599-011-5.

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