The Danger of Dogma

When a clinician\'s theoretical framework becomes more important than the patient in front of them, the framework has become a problem. The history of psychiatry offers no clearer illustration of this than the case of Rafael Osheroff.

There is an old saying — attributed to Maslow, though the sentiment is older — that if all you have is a hammer, everything looks like a nail. I have thought about that aphorism many times over the course of my career, and never more than when I consider what happened to Rafael Osheroff at Chestnut Lodge in 1979.

When I began my psychiatric residency at Timberlawn Hospital in Dallas in 1978, psychoanalysis still dominated academic psychiatry. Many department chairs were analysts. The prevailing doctrine held that psychiatric symptoms were surface expressions of deep intrapsychic conflict, and that treating the symptom — relieving the depression, quieting the anxiety — was not only insufficient but potentially harmful, because it might foreclose access to the underlying cause. Modern pharmacotherapy was in its infancy, and in some quarters it was viewed with frank suspicion. Medication that could produce relief without insight was described, in the language of the time, as superficial and cheap.

Timberlawn described its own approach as eclectic, which was a meaningful distinction at the time. But the broader culture of academic psychiatry was not eclectic. It was, in the truest sense of the word, dogmatic.

Rafael Osheroff was a forty-one-year-old nephrologist who admitted himself to Chestnut Lodge in Maryland in January 1979, seeking relief from a severe depression. Chestnut Lodge was a prestigious institution, deeply committed to the psychoanalytic tradition. His treating psychiatrist reframed his biological depressive symptoms as a personality disorder — narcissistic pathology — and treated him exclusively with intensive psychoanalytic psychotherapy. His requests for antidepressants were refused. Medication, the staff believed, was contrary to the Lodge's philosophy.

Over the following seven months, Osheroff deteriorated. He lost forty pounds. He paced relentlessly. He could not sleep. A case conference contemplated years of further inpatient treatment. He was eventually declared legally incompetent. His mother, alarmed by what she saw, removed him from the Lodge and transferred him to Silver Hill Hospital in Connecticut. There, a physician prescribed Thorazine and Elavil. Within three weeks, his agitation resolved and his depression lifted. He was discharged that November.

Osheroff subsequently sued Chestnut Lodge — not for administering harmful treatment, but for withholding effective treatment while persisting with an approach that was not working. The case settled before final adjudication, but its influence was lasting. Gerald Klerman's 1990 paper in the American Journal of Psychiatry framed the case as establishing the psychiatric patient's right to effective treatment. It is widely credited with accelerating the decline of psychoanalytic dominance in American psychiatry and with strengthening the movement toward evidence-based standards and informed consent about treatment alternatives.

I think about this case not as a historical curiosity but as a standing warning. The clinicians at Chestnut Lodge were not incompetent or indifferent. They were, by the standards of their training and their institution, doing what they believed was right. That is precisely what makes the case so instructive. Dogma does not announce itself as dogma. It presents as conviction, as expertise, as fidelity to a coherent theoretical framework. The problem is not the framework itself — psychoanalytic thinking has contributed enormously to our understanding of the mind — but what happens when the framework becomes more important than the patient.

I am not immune to this. I have formulated patients as depressive, or as hypomanic, and only upon further reflection — sometimes after a treatment trial that produced an incomplete response — begun to seriously entertain the diagnosis of ADHD. When I have then initiated a careful medication trial, the results have sometimes been striking: not only improved attention and executive function, but improved mood, reduced anxiety, better relationships, better performance at work. The ADHD had been there all along, generating symptoms that fit neatly into other diagnostic categories. I had been looking for nails.

ADHD is frequently undiagnosed in adults, and frequently undertreated even when it is diagnosed. The impairments are real and consequential — failures in school, chronic difficulties at work, relationships that fracture under the accumulated weight of forgotten commitments and emotional dysregulation. These are not minor inconveniences. They are the conditions of a person's life.

The lesson I draw from Osheroff — and from my own clinical experience — is not that any single diagnostic framework is wrong, but that no framework should be held so tightly that it prevents us from seeing what is actually in front of us. Psychiatry has moved, over the decades since Chestnut Lodge, toward greater empiricism and greater humility. That movement is worth protecting. The patient's right to effective treatment depends on the clinician's willingness to remain genuinely open — not just in principle, but in practice, case by case, when the evidence points somewhere unexpected.