Curious Chronological Convergences: An Anniversary, Osheroff’s Victory, and Pfister’s Award

Chestnut Lodge, Phillip Reed/Peerless Rockville Historic Preservation Ltd

Psychiatric Times is celebrating its 40th anniversary this year. It was “born” in 1985, when psychiatric theory and practice were less evolved and very different than they are today. At Psychiatric Times’ inception, Psychiatric News, published by the American Psychiatric Association (APA), still held center stage. In due time, the popularity of these 2 seminal publications reversed, and Psychiatric Times became—and remains—the world’s most read psychiatric publication, serving as both an essential resource and news platform as well as a forum for psychiatric clinicians.

Curiously, 2 other seemingly unrelated events occurred around that time: The landmark Osheroff v Chestnut Lodge lawsuit was settled out of court in 1987 after several years of legal deliberation. Although it was never adjudicated in a court of law, this widely discussed lawsuit by a physician-turned-patient-turned-plaintiff nevertheless changed the standards of psychiatric treatment. Around the same time, in 1983, a lesser-known event occurred, one that contrasts with psychiatry’s pro-science shift that was spurred on by the Osheroff settlement and by the publicity generated by this controversial case.

The APA instituted the annual Oskar Pfister Award, which honors outstanding contributions in the field of religion and psychiatry. Named for the ordained minister who used psychoanalytic principles in his work and discussed religion with Freud, a devout atheist, the award is funded by the Association of Professional Chaplains and the Harding Foundation. The recipient receives a monetary prize and a plaque at the annual APA conference, where they deliver a lecture on their chosen topic. Although many psychiatrists may be unfamiliar with this accolade, it is telling that the award was set in motion when psychiatry itself was shifting gears, primarily, but not solely, in response to the Osheroff case, which privileged evidence over opinion. Viewed in this context, the Oskar Pfister Award invites us to reexamine the distinctions between science and religion and to consider how these distinctions pertain to psychiatric theory in general and psychoanalysis specifically.

Osheroff v Chestnut Lodge

Raphael J. Osheroff, MD, had been a successful nephrologist who owned and operated several dialysis centers before he admitted himself to Chestnut Lodge, a much-storied bastion of psychoanalysis, in hopes of relieving the unabated depression that had plagued him for 2 years. Encouraged to seek hospitalization by his psychiatrist, the renowned psychopharmacologist Nathan Kline, MD, and pressured by his then wife, Osheroff selected Chestnut Lodge because he was impressed by Joanne Greenberg’s memoir of her treatment there (I Never Promised You a Rose Garden; 1964). This pseudonymously published, semi-autobiographical book had become a cult classic among 1960s-era adolescents before producer Roger Corman made it into a celebrated film in 1977.¹

Sadly, the outcome of Osheroff’s treatment at the Lodge was not as salubrious as Hannah’s (in the memoir), Deborah’s (in the film), or Joanne Greenberg’s in real life. Osheroff’s mental and medical conditions deteriorated during his 7-month stay at Chestnut Lodge, where he was treated with daily psychoanalytic sessions only, sans psychopharmacology. Osheroff reportedly paced relentlessly, slept little, and lost 40 lb. His analyst nevertheless pressured him to regress in a futile attempt to peel away his maladaptive personality traits that presumably propelled his outward symptoms. Rather than recovering, this previously successful kidney specialist experienced a worsening of his mental and physical health. He lost control of his dialysis centers and, eventually, his entire medical practice. He also lost his wife along the way, as well as his relationships with his sons.

After the Lodge ignored Osheroff’s mother’s last-ditch recommendations to add psychotropic medications, his mother arranged his transfer to Silver Hill Hospital, which had a different approach to treatment. There, his symptoms remitted after a mere 3 weeks of medications. After being treated with higher doses of tricyclic antidepressants combined with a phenothiazine, he was discharged in 3 months.

Now divorced and recovering, Osheroff attempted to recapture his prior professional success and proceed with his life. He was never rehospitalized and did not attempt suicide, but his story did not have as happy an ending as one might wish. Writing for The Guardian on October 11, 2022, reporter Rachel Aviv elaborates on the convoluted events that followed.²

Represented by Philip Hirschkop, one of the most prominent civil rights attorneys in the US and a former Green Beret, Osheroff filed suit against the Lodge. The Maryland Health Care Arbitration Panel ruled for Osheroff, but legal proceedings lingered for years before the suit was finally settled in his favor without being adjudicated by a court of law. Psychiatrist Peter D. Kramer, MD, author of the best-selling book Listening to Prozac (1993), one of the century’s most important psychiatry-related books, later compared the cultural and clinical significance of Osheroff v Chestnut Lodge to Roe v Wade.²

Shifts in psychiatric practice were spurred in large part by the much-quoted testimony provided to the panel by psychiatric luminaries such as Gerald L. Klerman, MD, who subsequently published an influential journal article, “The Psychiatric Patient’s Right to Effective Treatment: Implications of Osheroff v Chestnut Lodge.”³ Klerman opined that the case’s central issue was not psychotherapy vs psychopharmacology, but rather, “opinion versus evidence.” His article implies that issues related to ethics and doctors’ obligations to patients are as important as clinical decisions that dictate treatment.

Osheroff’s legal case attracted national attention mainly through the all-star cast, which included Klerman (Harvard professor; director of research at Massachusetts General Hospital); William Potter, MD, PhD (chief of psychopharmacology, National Institute of Mental Health); Frank Ayd, MD (professor of psychiatry who pioneered the use of chlorpromazine); Donald Klein, MD (professor of psychiatry, Columbia University Vagelos College of Physicians and Surgeons; director of New York State Psychiatric Institute); and more. These titans implicitly indicted traditional psychoanalytically based psychiatry when they testified on Osheroff’s behalf. Several well-known psychiatrists testified in support of the institution’s treatment plan, and some posited other explanations for Osheroff’s clinical improvement.² One psychiatrist wondered if Osheroff’s mood had improved because a dalliance with a female patient at Silver Hill increased his self-confidence.

Osheroff’s case proved that psychiatry was a house divided. Civil war waged as Alan A. Stone, MD, a former APA president, attributed Osheroff’s recovery to a better therapeutic alliance with his new psychiatrist rather than to medications. Stone told Aviv that “no psychiatric malpractice lawsuit has attracted more prominent expert witnesses than Ray’s.... The case became ‘the organizing nidus’ around which leading biological psychiatrists ‘pushed their agenda.’”²

Klerman’s succinct statement became a rallying cry in psychiatry: “The issue is not psychotherapy versus biological therapy but, rather, opinion versus evidence.”^3,4 The ramifications of that statement cannot be emphasized enough. In essence, Klerman recapitulated the philosophical concept of epistemology without using that opaque term. With that single-sentence pronouncement, the hallowed walls of psychoanalysis came tumbling down. The case was debated by medical professionals, legal scholars, plus the public at large. It became a prime topic of discussion in psychiatric training programs and psychiatric journals. The mainstream media, such as the New York Times,⁵ explored its significance.

A Paradigm Shift

A sea change in psychiatry followed Osheroff’s lawsuit and the debates it catalyzed. Evidence-based medicine became the buzz phrase in psychiatry. The catechism voiced by devotees of “St Sigmund” frayed at the edges. In time, Frieda Fromm-Reichmann, MD’s theory of “schizophrenogenic mothers” who spurred schizophrenic breaks in their progeny likewise vanished from acceptable psychiatry vocabularies and moved to history of psychiatry seminars.

In hindsight, this paradigm shift in psychiatry was not as sudden as it seemed. Psychiatry was already changing course and veering into turbulent waters in the very year that Osheroff entered Chestnut Lodge in 1977. That year, the APA’s then-president, Melvin Sabshin, MD, urged psychiatrists to “return to their medical roots.” DSM-III appeared in 1980.⁶ Intended to encourage a more scientific psychiatry, DSM-III delineated diagnoses carefully, omitting the metaphorical language of psychoanalysis. Osheroff filed suit 2 years after the manual’s publication. The suit concluded in 1987. The 1990s were dubbed the “Decade of the Brain.”

The Lodge stayed afloat for another decade before it officially closed in 2001 after having been sold to CPC Health in 1997. The latter-day Lodge was partly a victim of managed care’s shortened stays, which made its practice model financially unsustainable. Although the Lodge prescribed medications to almost all patients in the aftermath of Osheroff’s victory, its overall adherence to treatment techniques that did not withstand the test of time and lacked the endorsement of evidence-based medicine sealed the fate of this historic institution.¹

About a year after Osheroff’s death, almost to the day, Psychiatric Times published “The Humanities and Psychiatry: The Rebirth of Mind,”⁷ an article by James L. Knoll IV, MD, then–editor in chief. Knoll links the late 20th-century gyrations in psychiatric approaches to Osheroff v Chestnut Lodge. This author’s article, “A Belated Obituary: Raphael J. Osheroff, MD,” appeared in Psychiatric Times on June 28, 2013.⁸

The Oskar Pfister Award

How does psychiatry’s privileging of scientific evidence over opinion or intuition relate to the religious sentiment underlying the Oskar Pfister Award, which arose around the same time as the case? To push the question even further, can we compare religion with science? How are the 2 disciplines similar, and how do they differ?

In short, religion seeks to prove itself true, whereas science strives to prove itself false and to promote newer theories as it discards outdated data. Religion is based on belief, regardless of how hard theologians have striven to add scientific explanations for events related to religion. Science, in contrast, depends upon experimental and possibly inferential proof.

By designating an award for endeavors related to the overlap between religion and psychiatry, the APA implicitly moved religion away from the arena of scientific psychiatry, and rightly so. In doing that, the organization moved religion into its own realm without marginalizing its importance. Indeed, religious belief, as well as religious affiliation, have historically been shown to be safeguards against suicide, for example. A few religions endorse suicide and see it as honorable, but those religions are in the extreme minority.

Spirituality, which has become increasingly popular in America, is more difficult to quantify than measurable acts, such as church/synagogue/mosque/temple attendance or membership or the practice of various religious rituals. Still, despite spirituality gaining increased attention, it has not outpaced religious affiliation, as only 33% of Americans describe themselves as “spiritual” whereas 47% identify as “religious.”⁹

Contrarily, orthodox and unwavering psychiatric ideology, retained in the face of evidence to the contrary, has been compared with religion, as implied by epithets such as St Sigmund. And would we want to worship false gods? Probably not.

Dr Packer is an assistant clinical professor of psychiatry and behavioral sciences at Icahn School of Medicine at Mount Sinai in New York, New York.

References

1. Greenberg J. I Never Promised You a Rose Garden. New American Library; 1964.

2. Aviv R. Psychiatry wars: the lawsuit that put psychoanalysis on trial. Guardian. October 11, 2022. Accessed April 4, 2025. https://www.theguardian.com/society/2022/oct/11/psychiatry-wars-psychoanalysis-antidepressants-rachel-aviv

3. Klerman GL. The psychiatric patient’s right to effective treatment: implications of Osheroff v. Chestnut Lodge. Am J Psychiatry. 1990;147(4):409-418.

4. Oldham JM. Psychodynamic psychotherapy for personality disorders. Am J Psychiatry. 2007;164(10):1465-1467.

5. Shuchman M, Wilkes MS. Dramatic progress against depression. New York Times. October 7, 1990. Accessed April 4, 2025. https://www.nytimes.com/1990/10/07/archives/dramatic-progress-against-depression.html

6. DSM History. American Psychiatric Association. Accessed April 4, 2025. https://www.psychiatry.org/psychiatrists/practice/dsm/about-dsm/history-of-the-dsm

7. Knoll JL IV. The humanities and psychiatry: the rebirth of mind. Psychiatric Times. March 15, 2013. https://www.psychiatrictimes.com/view/humanities-and-psychiatry-rebirth-mind

8. Packer S. A belated obituary: Raphael J. Osheroff, MD. Psychiatric Times. June 28, 2013.

9. Jones JM. In U.S., 47% identify as religious; 33% as spiritual. Gallup. September 22, 2023. Accessed April 4, 2025. https://news.gallup.com/poll/511133/identify-religious-spiritual.aspx