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September 4, 2007
Why did Tiebout omit mention of Marty Mann's homosexuality?
by Ron Roizen
Dr. Harry Morgan Tiebout (1896-1966)
Tiebout was Mann's psychiatrist. He was also the psychiatrist who interpreted Alcoholics Anonymous to the contemporary psychiatric profession. Kurtz (1991. p. 107) termed Tiebout, "A.A.'s first psychiatric friend." Tiebout both treated and studied alcoholics, and he published a number of seminal papers on the translation of AA's concepts and practices into psychodynamic terms. He was one of the early psychiatric crafters and protagonists on behalf of a disease conception of alcoholism (see Tiebout, 1945) -- the great theme of the social movement that Marty Mann led. Astonishingly, as well, he employed Mann, qua alcoholic patient, as a kind of paradigmatic alcoholic exemplar and case study in AA's deflating personality effects. He included a case description of Mann in his earliest paper on AA's approach to alcoholism (Tiebout, 1944).1
It may be said therefore that a complex thicket of professional, institutional, and personal relationships surely existed between Mann and Tiebout.
Tiebout on Mann
A curious aspect of Tiebout's handling of Mann's case in his 1944 paper is that he never mentioned Mann's homosexuality?2
Here is how Tiebout described an unnamed Mann in his 1944 paper (p. 468):
My first encounter with the group [i.e., AA] came through the medium of a 34-year-old woman patient who had been under my care at Blythewood for several months. She had been a chronic alcoholic for many years and, despite intelligence, family position and early successes, had literally hit the gutter, after a steady decline in her fortunes had left her all but penniless. Although no patient ever wanted to get well more desperately or cooperated more wholeheartedly in a treatment program than she, the results were very unsatisfactory. Finally, it became clear that she possessed a character structure which, despite her best efforts and mine, persisted unshaken and was clearly responsible for the continuance of her drinking. One day a copy of "Alcoholics Anonymous," while yet in multilith form, came into my hands. I read it, and found it contained a most accurate description of the character problem I had been facing in my patient. In an effort to jar her a bit, I gave her the book to read. To my surprise, she was so greatly impressed that she arranged to go to an Alcoholics Anonymous meeting and very shortly became an active and successful member of the group. Even more surprising was the discovery that, with the process of assimilation of that program, her character structure, which had been blocking any help, dissolved and was replaced by one which enabled its possessor to remain dry.There is more about Mann and her apparent character transformation in the remainder of Tiebout's article but nowhere is homosexuality noted. How might we interpret this seeming omission?
Did Tiebout perhaps not know that Mann was gay? Could Mann have concealed her lesbianism even after "several months" (see above) of inpatient treatment?
Homosexuality was, to be sure, more likely to be deeply shrouded in the late 1930s than it is today. Yet, and in so long a treatment experience, wouldn't the tell-all ethos of psychiatry have penetrated any shields Mann may have maintained?
Moreover, it cannot be entirely excluded that Mann was actually under treatment for her homosexuality, whether wholly or in part, at Blythewood.
On the other hand, if Tiebout knew of Mann's sexual orientation, how then might he have justified omitting its mention in a paper in the American Journal of Psychiatry?
Might Tiebout have felt that homosexuality was not a salient factor in Mann's alcoholism or problematic "character structure"? There is evidence to support this possibility in Tiebout's writings on alcoholism. For example, in a 1951 paper published in the Quarterly Journal of Studies on Alcohol, Tiebout employed two medical metaphors in explaining and justifying treating alcoholism as a primary disorder and chief focus of therapeutic efforts. The first metaphor was fever. "Nowadays," wrote Tiebout,
no one treats a fever. One looks for the causative agent and treats for that, knowing that the fever will subside if its cause can be eradicated. Occasionally, however, the fever gets out of hand and becomes in and of itself a threat to the patient's life.3The direct psychiatric treatment of alcoholism, Tiebout argued, was analogous to the direct treatment of fever when the patient's condition so required.
Yet the fever metaphor's capacity to explain Tiebout's omission of Mann's lesbianism in his 1944 paper is hedged about with difficulties. First of all, we cannot be sure that Tiebout saw the treatment of alcoholism through the fever-like metaphor he articulated in 1951 back in 1943-1944, when he was writing about Mann's case. Second, as a psychiatrist well aware of the Freudian tradition, it can be imagined that Tiebout felt an obligation to his psychiatric readership to report Mann's lesbianism. The Freudian view regarded alcoholism as an consequence of arrested psychosexual development and repressed homosexuality. Moreover, Tiebout's view of Mann's alcoholism emphasized a problematic character structure, both as the ultimate causal source of her excessive drinking and as a barrier to his therapeutic efforts. Even if Mann's homosexuality could be safely regarded as irrelevant ot her alcoholism, could homosexuality be equally safely regarded as irrelevant to her character structure?
How can we know, at this remove, why Tiebout either would not have known about Mann's lesbianism or would have chosen not to mention it in his case description of Mann in 1944?
I suggest that the content of Tiebout's account of Mann in his 1944 paper was probably a product of both Tiebout's interest and involvement with the nascent AA movement and, as well, the outcome of negotiation with Mann over how her case should be described.
Mr. William Wilson also became a patient of Tiebout and Wilson's case was also described in Tiebout's 1944 paper. Yet Wilson's case was handled in an unconventional manner therein. Wilson was treated partly as an example of AA's therapeutic approach, as Mann had been, and also partly as an authority on alcoholism. Moreover, Wilson was referred to by name in Tiebout's paper (Mann, it will be recalled, was not named).
Tiebout began his paper's narrative with a direct reference to Wilson:
Alcoholics Anonymous is the name applied to a group of ex-alcoholics, who, through a therapeutic program which includes a definite religious element, have successfully combated alcoholism. The group stems from the efforts of one man, Mr. William Wilson, who in 1934 found an answer to his drinking problem in a personal religious experience. This experience he was able to translate into terms which were meaningful for others. Since then, many alcoholics have become sober by using his approach.This special use of Wilson in the article and the naming of Wilson in the text would have obliged Tiebout, I believe, to clear the manuscript's content with Wilson himself.
The anonymous use of Mann may not have harbored the same obligation.4 Mann -- at the time of the article's preparation and publication, at least -- was not as well known as Wilson, either to the general public or within AA. Tiebout may have felt that few readers of the American Journal of Psychiatry would be able to recognize Mann from his case description. Mann's rise to fame and the widespread diffusion of her recovery story had not happened yet.
The need for Tiebout to clear his talk and paper with Wilson would have meant that Mann's case would be put before Wilson's eyes. Wilson would have known Mann's case well enough to recognize her in Tiebout's description. Showing the article's manuscript to Wilson also might have led to Wilson showing the article around to other AA members, thus exposing it to a still larger set of potential AA readers who would be able to recognize Mann's case in the paper.
It follows, therefore, that Tiebout would have known that Mann's anonymity was not well protected in his article. It futher followed that Tiebout would have felt an obligation to omit from his paper any aspects of Mann's case that he knew she would not want included.
And so, in this somewhat roundabout way, Tiebout's use of Mann and Wilson in his 1944 paper created obligations that may have limited the content of his exposition, thus requiring that Mann's homosexuality go unmentioned in his clinical description.
1 Two additional alcoholic patients were described in Tiebout's 1944 paper: William Wilson (of AA) and "...a man in his early forties" who had contact with AA but was not described as a long-term member. The importance of Wilson's presence in the paper will be discussed below.
2 On Mann's homosexuality, see Brown and Brown (2001), particularly pp. 142 et seq.
3 Incidentally, Tiebout credited Jellinek for the fever analogy.
4 Human subjects protections were not as rigorous and well defined in the mid-1940s as they would become twenty years later after the publication of Beecher's (1966) celebrated article.
© 2007 Ron Roizen
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