A journey through 20th-century psychiatry with Joseph Wortis

Joseph Wortis was 28 years old when he engaged with Freud, then 76, in an analysis that lasted for 4 months. Their sessions together marked a transition for 20th-century psychiatry, though one that wouldn’t manifest until later. Wortis became one of the drivers of the biological psychiatry movement that displaced psychoanalysis from its central position in American psychiatry, introducing new biological approaches, and founding the journal Biological Psychiatry that served as the movement’s focal point.

Wortis was born in New York in 1906 to European Jewish parents and was a precocious student with wide-ranging interests. He completed his undergraduate degree at New York University and then travelled to Europe, deciding to study for his medical degree in Vienna rather than take up a position at Yale (Halmi, 1995). He returned to New York after he had completed it and was working as an intern at the Bellevue Hospital when he was offered an unusual fellowship.

The fellowship had been endowed by a wealthy widower, whose husband had been tormented by his same-sex attraction and ended his life by suicide. She was keen that more research was undertaken to better understand the difficulties her husband had faced and asked two men prominent in American mental health – psychologist Havelock Ellis and psychiatrist Adolf Meyer – to recommend someone who might undertake training and research in the area. Ellis, who had met Wortis when he was a student in Europe, put Wortis’ name forward (Wortis, 1954). Wortis accepted eagerly. He discussed with Ellis what training he might do with the fellowship funds, and they agreed that a return to Vienna to undertake an analysis with Freud would be a good place to start.

Back in Vienna, Wortis approached the analysis with an inquisitive mind – open to the experience but sceptical, and by no means in awe of Freud, who was almost 50 years his senior and at the peak of his fame. In Wortis’ account, they started with a discussion about the analysis’s terms and payment. He had $1600 available to him from his fellowship funds, and they agreed to 4 months of five-sessions-a-week therapy at $20 per session (Wortis, 1954).

Wortis attended the sessions diligently over the ensuing months. He was at times sceptical about Freud’s attempts at interpretation: the way he dismissed some dreams as unimportant and how ‘he would wait until he found an association which would fit into his scheme of interpretation and pick it up like a detective at a line-up who waits until he sees his man’ (Wortis, 1940). Freud appears to have accepted Wortis’ criticisms with equanimity and to have conceded the provisional nature of many of psychoanalysis’ tenets.

While Wortis was in Vienna, with time on his hands outside of the hour each day he spent with Freud, he had taken a real interest in the insulin coma therapy that had been developed locally by psychiatrist Manfred Sakel as a treatment for schizophrenia. He expressed his interest to Freud, who was sympathetic to it, saying he found no incompatibility between biological and psychological approaches (‘psychoanalysis had never claimed there were no organic factors in the psychoses’) (Wortis, 1940).

Other than discuss his dreams in the analytic sessions, Wortis and Freud talked extensively about psychiatry and research, and Freud seems to have freely offered his opinions on subjects ranging from Americans (he was disparaging), the virtue of old people (‘the older you get the worse you become’), and his colleagues – some of whom he expressed bitterness towards and others nostalgia (Wortis, 1940). We know this detail because straight after each session Wortis would take himself to a nearby café and write down what he recalled from it, later publishing his notes as a brief paper (Wortis, 1940) and then as a book (Wortis, 1954).

The analysis ended as scheduled, without Wortis having been converted to psychoanalysis’ cause (and nor did he pursue research in sexology, as his fellowship had intended). He returned to New York to continue his training, helping to introduce insulin coma therapy to the United States and translating Sakel’s writing on the treatment (Peimer and Silver, 1996). He became evermore invested in exploring biological approaches to mental illness, working at various academic centres in New York (and for a brief time at the Johns Hopkins Medical School in Baltimore). He was appointed as the founding editor of Biological Psychiatry in 1959, which he helmed until 1992. He died 3 years after standing down from the editorship, at the age of 88.

If Wortis’ journey in psychiatry seems to be a straightforward one, illustrating the profession’s transition from a discipline with psychoanalysis at its foundation to one supported by neurobiology, that would miss some of the nuances in Wortis’ approach. His thinking was broad and encompassed strands of thought that have also become more prominent over the past 50 years.

Wortis was a strong believer in the social determinants of mental illness, which he did not see as being in opposition to biological causes. One of his major criticisms of psychoanalysis, for example, was that he saw it as detaching a person from their social milieu. As he puts it to an interviewer,

Well, psychoanalysis emphasizes individualism. Everything comes from within you: how you behave is a result of your past, your instinctive drives, and so on … It enormously emphasizes the subjective and plays down the social. (Dufresne, 1996)

Wortis saw psychoanalysis’ emphasis on a person’s past, without much concern for the nature of their current social environment, as undermining the social determinants of their predicament. As he said to Freud during his analysis, ‘A neurosis seems to me to amount to a discrepancy between the individual and his environment. Isn’t it possible to help a patient sometimes by changing the environment?’ To which Freud responded, ‘But that is not a doctor’s business’ (Dufresne, 1996).

Wortis lived according to his beliefs. He identified as a Marxist and was for a short time a member of the Communist Party, appearing before a US Senate subcommittee in 1953 in their investigation of supposed communist infiltration of educational institutions. He defied the committee by refusing to answer any questions (Dufresne, 1996). The experience, he believed, hampered his career; he found it difficult to obtain research grants after his appearance and his rise through the academic ranks stalled. He took up a position for a time working with children with intellectual disabilities and lectured on the influence of social class on child development (Peimer and Silver, 1996).

These two strands of Wortis’ interests continue to dominate much of the psychiatric literature today, and he exemplifies how they need not be mutually exclusive: the social environment must at some level, after all, exert its effects via the nervous system. But the dominance of these pillars at either end of the biopsychosocial spectrum, epitomised by Wortis’ approach, also exposes a weakness. The middle – the subjective experience that forms the ‘psycho’ of biopsychosocial – has been excluded. With the waning influence of psychoanalysis, academic psychiatry has shown less interest in the experiential, phenomenological nature of mental ill health.

But subjective distress is the main currency we deal with as clinicians, and accounts that focus on receptors, neural pathways and brain networks will only ever be partial. So too will accounts that focus only on poverty, social marginalisation and under-resourcing. For all Wortis’ strengths, his focus on these perspectives – and his dismissal of psychoanalysis – relegated subjective experience to a place outside the frame. But it really should be part of it, and reintegrating this perspective will be one of the challenges for 21st-century psychiatry.