10.4/The Interior Life/The Private Life

The Couch and the Capsule: Mental Health as Lived Practice, 1989–2001

The Occupational Hazard

A comparable discretion, administered on a longer clock, governed the other institution the same masthead’s staff depended on. Every June, an analyst practicing on the Upper West Side sent each patient in current treatment a typed letter, single-spaced, on the analyst’s own letterhead, announcing the weeks in August the practice would be closed. The letter usually named a colleague’s telephone number to call in an emergency. Six weeks was the ordinary length of the gap, sometimes bleeding a few days into September; the patient read the letter standing at a front door or a desk, copied the dates into a calendar, and went on with June. Analysts on the Upper West Side left in this way more or less as a body, so that the neighborhood’s whole apparatus of fifty-minute hours emptied out at once and the patients of a hundred separate practices were, for six weeks, without the one appointment the rest of the year had been arranged around.² What the letter did not supply was a reason a patient could use out loud. “My analyst is in Wellfleet” was a sentence a person could say at a dinner party without further explanation, and the sentence covered a great deal: the migraine that arrived in the gap and had nowhere to be reported, the ill-advised affair begun in the second week of August, the resignation letter drafted and not sent until the analyst’s return made it possible to discuss first.

The exodus was not a symptom of neglect; it was closer to the opposite, a structural fact the four-times-a-week order had always required, the fifty-minute hour’s summer counterpart. Manhattan in this period supported a denser concentration of practicing analysts than any other city on earth, trained at institutes that clustered on the same ten blocks where their graduates then hung a shingle: the New York Psychoanalytic Institute, on East Eighty-Second Street since 1931; the William Alanson White Institute, founded in 1943 at 20 West Seventy-Fourth Street by Erich Fromm and Harry Stack Sullivan among others; the Columbia University Center for Psychoanalytic Training and Research; the Institute for Psychoanalytic Training and Research.³ A patient who left one of these buildings in July and did not return until September had, in effect, been handed the same summer recess her analyst’s own training analyst had been handed a generation earlier — the practice replicating itself down through the calendar as faithfully as it replicated itself down through technique.

Four Times a Week

The prestige form, in 1989, was still the couch: four sessions a week, forty-five to fifty minutes each, the analyst seated out of the patient’s sightline, free association without an agenda, no notes taken during the hour itself. Candidates training at the New York Psychoanalytic Institute or the William Alanson White Institute underwent this exact regimen themselves, as patients, for years before the institute certified them to practice it on anyone else, which meant the four-times order was not merely a clinical preference but a professional class’s own initiation rite, passed down essentially unchanged from the 1940s.² The fifty-minute hour — paid for a full sixty minutes, run for fifty, the last ten reserved for the analyst’s own notes — was a unit of billable time no other profession in the city used, and a patient in four-times analysis was, without much exaggeration, buying roughly three and a half hours of an analyst’s attention every week for years running.

By 1989, four-times-weekly treatment was already a minority practice even among the analysts who had trained to deliver it; most patients, and most of the small number of insurance plans that covered psychotherapy at all, tolerated once or twice a week. The prestige attached to the fuller schedule regardless, and a senior figure on a magazine’s editorial floor who kept it rarely said so plainly. “I see somebody” was the sentence that did the work instead, understood by anyone who needed to understand it and opaque to anyone who did not.

The analysts themselves clustered by neighborhood, and the neighborhood told a prospective patient something about the treatment before the first appointment did. The Upper West Side — the West Seventies through the West Nineties, Central Park West, West End Avenue, Riverside Drive — held the densest concentration of psychoanalytic offices in North America, a direct inheritance of the training institutes clustered in the same ten blocks. The West Village and Chelsea supported a different practice, gay-affirmative in orientation and increasingly built, through the 1980s and into the 1990s, around the specific demands of the AIDS years. The Upper East Side ran more medication-forward and more hospital-affiliated, less committed to the couch than to a diagnosis a chart could carry. Park Slope, across the river, arrived only with the decade itself, staffed by a newer wave of analysts trained in the feminist currents of the 1970s, charging lower fees to a clientele of young families the Manhattan institutes had rarely served.

The popular picture of the New York analysis — the patient supine, the analyst silent, a wisecrack landing somewhere inside the fifty-minute hour — left out most of what a real course of treatment actually consisted of. A working analysis in this period meant long silences that produced nothing in particular that week, a scheduling dispute over a missed Tuesday, a January letter announcing the coming year’s rate increase, the specific discomfort of running into one’s own analyst at a Zabar’s checkout on a Sunday, a dream about the analyst reported to nobody including the analyst, and a plateau in the third or fourth year in which nothing seemed to be happening at all. This was the part of the arrangement patients rarely mentioned outside the room and rarely saw depicted anywhere: not a cure delivered on a schedule but a slow, administered, at times tedious relationship that ran for years and cost, in a full four-times course, what a second car or a child’s tuition might have cost, with no guarantee of outcome attached to any of it.²

A patient in four-times-weekly treatment at the $150 figure the New York Times cited repeatedly through the mid-1990s as its standard high-end rate was paying on the order of $30,000 a year, a sum closer to a second car’s annual cost than to any ordinary discretionary expense, almost always out of pocket.⁴ The institute clinics were the fee structure’s other end. NYPSI, the William Alanson White Institute, and the Postgraduate Center for Mental Health all ran low-fee services in which a candidate still under supervision treated a patient for a fraction of a senior analyst’s rate, and an editorial assistant earning twenty-two thousand dollars a year could be, and often was, in once-weekly treatment with a candidate at thirty dollars a session — a real and common arrangement inside a profession whose public face was the Park Avenue hour.³

The List of Three Names

Nobody consulted a directory to find a therapist in this period; there was, in the ordinary sense, nothing to consult. The path ran through people: a trusted friend named her own analyst, or asked that analyst directly, and received back a short list — three names, typically one woman, one man, one psychiatrist who could prescribe if it came to that — with the assurance that any of the three would be appropriate. The third name on the list mattered more with each passing year of the period. A referring analyst who could not prescribe knew, from her own practice, that a certain fraction of her referrals eventually wanted medication in addition to, or instead of, the hour on the couch, and a workable list needed a psychiatrist on it for exactly that reason, regardless of whether the patient asking for names knew yet that she was one of them. The name itself arrived on a napkin, a Post-it, the back of a subscription-renewal card, and the chain that produced it was tight enough that two colleagues who had never discussed the subject with each other could turn out to be seeing analysts two doors apart on the same prewar hallway on West End Avenue, each one’s presence in the building a fact the other never learned.

The discretion this system demanded was itself a professional craft, separate from the clinical work going on inside either office. An elevator shared with someone else’s analyst, a waiting-room encounter timed so that one patient’s exit did not overlap a colleague’s arrival, a nod in a hallway that acknowledged nothing — these were skills a patient in this world learned within a session or two of starting treatment, without anyone teaching them directly.

The list itself was never written down anywhere a stranger could find it, and its currency was trust rather than credential: a name carried no professional listing beyond a shingle by the building’s buzzer, and it traveled only as far as the referring friend’s own confidence in it. A friend’s account of feeling understood counted for more than any hospital affiliation printed on a letterhead, and a single bad session — a comment felt as careless, a silence felt as indifference — could quietly end a name’s use for years, with no complaint filed anywhere and no record of why the name had stopped being passed along.

The New Regime

Three forces pressed against the four-times order across the years that followed, and by 2001 all three had done more to reshape it than any single event had. Managed care, spreading through the early 1990s, compressed reimbursable psychotherapy into a fixed annual allotment — eight sessions on one plan, twelve or twenty on a better one — tied to a diagnostic code and a standard of “medical necessity” that classical psychoanalysis, unmeasurable by design and by definition not tied to any illness with a treatment endpoint, did not meet; cognitive behavioral therapy, delivered in a dozen or twenty sessions with an outcome a claims adjuster could read on a form, became the model insurers were willing to pay for instead. Selective serotonin reuptake inhibitors, arriving from the drug side of the same decade, raised a question that had not previously had a clean answer: whether three years on a couch or six weeks on a capsule addressed the same difficulty, and whether a patient needed to choose. And the generation entering treatment after 1989 arrived, on the whole, wanting instruction rather than interpretation — a shift the four-times order, built on the patient’s own free association rather than the analyst’s advice, was not designed to satisfy.⁶

By 2001, the typical educated New Yorker in treatment was seeing a psychologist once a week in psychodynamic therapy, paying somewhere between $150 and $200 a session and splitting the cost between out-of-network insurance reimbursement and cash, and — increasingly — seeing a separate psychiatrist for a medication check that ran fifteen minutes and cost less per visit but answered to no other appointment on the calendar.⁷ The four-times order had not disappeared. It had become one option among several, no longer the form a serious patient was assumed to be moving toward.

The vocabulary available for naming any of this moved with the practice itself. In 1989, a forty-year-old on a magazine’s editorial floor described the trouble as “a rough patch” or “not sleeping,” and “seeing a psychiatrist” still meant the couch and the analytic frame rather than a prescription pad; medication, when it came up at all, meant a tricyclic or an older compound, a serious drug with a serious side-effect profile reserved for an illness serious enough to name. By the middle of the decade, “depression” and “anxiety disorder” had entered ordinary office conversation in a way they had not been sayable a few years earlier. By 2001, one colleague might ask another, without much preamble, what she was taking — the working assumption no longer whether a person was managing something pharmacologically but which drug it happened to be, a shift in the professional class’s own vocabulary that ran well ahead of any change in the vocabulary available to the rest of the city.

The Prescription Encounter

The other route into treatment required no analyst’s referral at all, and by the middle of the decade it was, for many people, the only route taken. It began, typically, at the end of an annual physical, in a half-sentence offered almost as an afterthought — not sleeping well, feeling low — to an internist who had perhaps thirty patients still to see that day. The internist wrote a prescription for twenty milligrams of fluoxetine on a standard pad, without a referral, without a formal depression scale, often without a scheduled follow-up, and sent the patient out with a two-week sample box from a desk drawer.⁸ Retail cost without insurance ran, by the era’s pricing, somewhere in the neighborhood of seventy-five to eighty dollars a month at the starting dose, rising if the dose increased.⁹ The patient filled the prescription at a pharmacy where the pharmacist knew a first name, and took the first capsule on an ordinary morning because the printed leaflet warned of nausea and breakfast seemed the safer time.

The same capsule sat inside a class geography that chemistry alone did not explain. Eighty dollars a month approached five percent of pre-tax income for an editorial assistant earning twenty-two thousand dollars a year — not an impossible sum, but a felt one, weighed against rent and the cost of the subway. For a magazine’s most senior editors the identical figure was absorbed, unremarked, into a monthly expense report. The drug was the same drug wherever it was taken; the arithmetic around obtaining it, filling it every month, and explaining its cost to nobody in particular was not.

Nothing happened for roughly three weeks, and this was the part almost nobody explained adequately in advance. The literature’s own onset window was real; patients who quit in the second week, certain the pill was inert, were not wrong about what they had felt so far, only wrong about how long the trial was supposed to run. What arrived afterward, for those who stayed on it, rarely announced itself as elation. It arrived, in the vocabulary that developed to describe it, as a floor where there had been none — not happiness exactly, but the specific dread that had opened every morning failing, for the first time in memory, to show up first. Whether a person told anyone at the office changed by year. In 1994, the capsule was taken alone, with tap water, at a bathroom sink between meetings, and mentioned to nobody; by 1998, an editor might mention it in passing at her own desk; by 2001, it required no more preface than mentioning a dentist’s appointment.

What Nobody Adequately Warned

The complaint that took longest to reach the patient information sheet was the one most people eventually discovered for themselves, in bed, with someone else. Reduced desire and delayed or absent orgasm affected a substantial minority of patients on the new antidepressants — later, more careful studies put the range at roughly thirty to fifty percent depending on how directly patients were asked — and in the early 1990s this was folklore passed between patients rather than a labeled warning; the manufacturers’ own labeling did not catch up to what patients already knew until Zoloft’s revision in 1996, two years after the fact had entered ordinary conversation among people comparing capsules.¹⁰

A second complaint took even longer to enter the conversation, because it was harder to describe as a complaint at all. Patients on the new drugs sometimes found that the worst of a mood had lifted along with a portion of everything else — an inability to cry at a piece of music, or a good sentence, that had reliably produced tears before, a narrowing of the emotional register that read, depending on how a person weighed it, as either a fair trade or a specific and precise loss. Nobody at a magazine wrote a memo on the subject. It surfaced instead as a private, undiscussed observation: a colleague noticing, alone, that a photograph or a paragraph that used to do something to her no longer quite did, and being unable to say for certain whether the drug or the accumulated relief was responsible.

The capsule did not travel alone. A psychiatrist managing a patient’s baseline mood on an SSRI frequently prescribed a second drug for acute anxiety on top of it, and by the middle of the decade clonazepam — sold as Klonopin, approved by the Food and Drug Administration in 1975 for seizure disorders and granted a specific indication for panic disorder only in 1996 — had acquired a reputation among prescribers as the more “responsible” benzodiazepine, longer-acting and less euphoric than Xanax, better suited to daily maintenance than to acute rescue.¹² Zolpidem, approved in December 1992 and sold as Ambien, arrived marketed as a sleep aid without a benzodiazepine’s dependency profile, a claim the drug’s own side-effect record did not fully bear out; by the late 1990s it had become, within the professional class this account concerns, the ordinary sleeping pill.¹³

The Body the Magazine Would Not Photograph

The fashion-adjacent floor of a magazine office in this decade ran on a form of selective blindness distinct from anything happening in a consulting room. A recognizable share of the women on the editorial and photo staffs, and of the assistants beneath them, were visibly underweight, and the office as a body did not remark on it, for a structural reason nobody needed to say aloud: the aesthetic the magazine sold to its readers was thinness itself, and to comment on a colleague’s body was to comment on the product. A quieter restroom near the executive offices — single stalls, better sound insulation, lighter traffic than the production floor’s — served a use the louder restroom did not, and everyone on the floor who needed to know which one it was already knew. On the days that restroom was itself too visible, the floor below, the after-hours gym, or the basement near the loading dock did the same work; a magazine tower of this size in Midtown offered enough anonymous plumbing that no single supervisor ever had cause to notice a pattern that ran, in fact, across the whole building.

The condition affected women in more than nine cases out of ten in the clinical samples of the period, and within Manhattan magazine publishing specifically it ran overwhelmingly white, college-educated, and single, concentrated in the early twenties through the middle thirties. The profile was not the debutante’s version popular imagination preferred but the assistant’s: a salary in the low twenty-thousands, a shared walk-up apartment, an editor she answered to who was thinner than she was, a model in the pictures she captioned or printed who was thinner still than the editor. The same aesthetic held at every level of the masthead, from the cover down to the assistant who answered the phone, and the thinness expected at one level was never quite matched by the level just below it.

The Renfrew Center, the country’s first residential treatment program built specifically for eating disorders, had opened outside Philadelphia in June 1985; an outpatient branch opened in New York, on West Forty-Seventh Street, in 1994, giving the city’s own patients a treatment option that did not require the trip to Pennsylvania that a decade of New Yorkers had made before it.¹ An editor who went inpatient before 1994 used the same cover story described earlier in this chapter and returned eight to fifteen pounds heavier; the recovery, within a year, often did not hold.¹ The deepest difficulty in treating an eating disorder inside this particular office was structural rather than clinical: recovery produced a body the institution’s own pages did not print, so that the cure, however successful by any medical measure, failed the one aesthetic the job existed to enforce.

A related and largely separate behavior moved through the same floor without any name the office could say aloud. Cutting, most often concealed on the upper thigh or the inside of the upper arm, or a cigarette burn on the wrist mistaken, when it was noticed at all, for an accident near a stove — these left marks a long sleeve covered for most of the year, and a long sleeve in July, on an office floor with no air conditioning to blame it on, was the one sign that required no clinical vocabulary to read, only an attention nobody on the floor was in the habit of paying.