Monday, April 24, 2006
By David Kaiser, M.D.
December 1996, Vol. XIII, Issue 12
As a practicing psychiatrist, I have watched with growing dismay and outrage the rise and triumph of the hegemony known as biologic psychiatry. Within the general field of modern psychiatry, biologism now completely dominates the discourse on the causes and treatment of mental illness, and in my view this has been a catastrophe with far-reaching effects on individual patients and the cultural psyche at large. It has occurred to me with forcible irony that psychiatry has quite literally lost its mind, and along with it the minds of the patients they are presumably supposed to care for. Even a cursory glance at any major psychiatric journal is enough to convince me that the field has gone far down the road into a kind of delusion, whose main tenets consist of a particularly pernicious biologic determinism and a pseudo-scientific understanding of human nature and mental illness.
The purpose of this piece is not to attempt a full critique or history of this occurrence, but to merely present some of the glaring problems of this movement, as I believe significant harm is being done to patients under the guise of modern psychiatric treatment. I am a psychiatrist trained in the late 1980s and early 1990s, and I use both psychotherapy and medications in my approach to patients. I state these facts to make it clear that this is not an antipsychiatry tract, and I am speaking from within the field of psychiatry, although I find it increasingly impossible to identify with this profession, for reasons which will become clear below.Biologic psychiatrists as a whole are unapologetic in their view that they have found the road to the truth, namely that mental illnesses for the most part are genetic in origin and should be treated with biologic manipulations, i.e., psychoactive medications, electroconvulsive treatment (which has made an astounding comeback), and in some cases psychosurgery. Although they admit a role for environmental and social factors, these are usually relegated to a secondary status. Their unquestioning confidence in their biologic paradigms of mental illness is truly staggering. In my opinion, this modern version of the ideology of biologic/genetic determinism is a powerful force that demands a response. And when I use the word ideology here, I mean it in it's most pernicious form, i.e., as a discourse and practice of power whose true motivations and sources are hidden to the public and even to the practitioners themselves, and which causes real harm to the patients at the receiving end.
Biologic psychiatry as it exists today is a dogma that urgently needs to be unmasked. One of the surest signs that dogmatists are at work here is that they rarely question or attempt to problemitize their basic assumptions. In fact, they seem blissfully unaware that there is a problem here. They act in seeming unawareness that they are caught up in larger historical and cultural forces that underwrite their entire "scientific" edifice.These forces include the medicalization of all public discourse on how to live our lives, a growing cultural denial of psychic pain as inherent in living as human beings, the well-known American mixture of a historicism and belief in limitless scientific progress, and the growing power of the pharmaceutical and managed care industries. These self-proclaimed visionaries, oblivious to all of this, boast of real scientific progress over what they consider to be the dogma of psychoanalysis, which had up until recently reigned as psychiatry's premier paradigm.
Now, it is not my intention to defend psychoanalysis, which had its own unfortunate excesses, although I do use psychoanalytic principles in the kind of psychotherapy I do. However, it is quite clear to me that the grandiose claims of biologic psychiatry are wildly overstated, unproved and essentially self-serving. Biologic psychiatry has had its successes, particularly with recent antidepressants like Prozac and newer antipsychotic medications such as Clozaril. Medications can effectively improve depression, relieve severe anxiety, stabilize serious mood swings and lessen psychotic symptoms. These successes are real in that they improve the quality of life of patients who are genuinely suffering. But in reality, i.e., the reality of treating patients, medications have profound limitations. I know that if the only tool I had in treatment was a prescription pad, I would be a poor psychiatrist. The center of treatment will always need to be listening to and speaking with the patients coming to me. This means listening seriously to what they say about their lives and history as a whole, not merely listening for which symptoms might respond to medications. Although it seems astounding that I would have to state this, biologic psychiatrists as a whole really only listen to that portion of the patient's discourse that corresponds to their biologic paradigms of mental illness. It is the nature of dogma that its practitioners hear only what they want to hear.
So what are the limitations of biologic psychiatry? First of all, medications lessen symptoms, they do not treat mental illness per se. This distinction is crucial. Symptoms by definition are the surface presentation of a deeper process. This is self-evident. However, there has been a vast and largely unacknowledged effort on the part of modern (i.e., biologic) psychiatry to equate symptoms with mental illness.
For example the "illness" major depression is defined by its set of specific symptoms. The underlying "cause" is presumed to be a biologic/genetic disturbance, even though this has never been proven in the case of depression. The errors in logic here are clear. A set of symptoms is given a name such as "major depression," which defines it as an "illness," which is then "treated" with a medication, despite the fact that the underlying cause of the symptoms remains completely unknown and essentially untreated. I have seen repeatedly that, for example, in the case of depression, once medications lessen the symptoms, I am still sitting across from a suffering patient who wants to talk about his unhappiness. This process of equating symptoms with illnesses has been repeated with every diagnostic category, culminating in perhaps one of the greatest sophistries psychiatry has pulled off in its illustrious history of sophistries, namely the creation of the Diagnostic and Statistical Manual (currently in its fourth incarnation under the name DSM-IV), the bible of modern psychiatry.
In it are listed all known "mental disorders," defined individually by their respective symptom lists. Thus mental illnesses are equated with symptoms. The surface is all there is. The perverse beauty of this scheme is that if you take away a patient's symptoms, the disorder is gone. For those who do serious work with patients, this manual is useless, because for me it is simply irrelevant what name you give to a particular set of symptoms. It is an absolute myth created by modern psychiatry that these "disorders" actually exist as discrete entities that have a cause and treatment. This is essentially a pseudo-scientific enterprise that grew out of modern psychiatry's desire to emulate modern medical science, despite the very real possibility that psychic pain, because of its existential nature, may always elude the capture of modern medical discourse and practice.
Despite its obvious limitations, the DSM-IV has become the basis for psychiatric training and research. Its proponents claim it is a purely phenomenological document stripped of judgments and prejudices about the causes of mental illness. What in fact it has done is the defining and shaping of a vast industry of research designed to validate the existing diagnostic categories and to find ways to lessen symptoms, which basically has meant biologic research. Virtually all of the major psychiatric journals are now about this, and as such I find them useless to help me deal with real patients. Patients are suffering from far more than symptoms. Symptoms are the signs and clues to direct us to the real issues. If you take away the symptoms too quickly with medications or suggestion, you lose the opportunity to help a patient in a more profound way. As an aside, modern psychiatrists, because they have forgotten or dismissed the real power of transference, vastly underestimate the extent to which symptom reduction is caused by mere suggestion. Not that patients should be left to suffer needlessly from what are often crippling symptoms. Relief from symptoms is a part of treatment. Modern psychiatry would have us believe that this is all treatment should be. Meaning, desire, loss and death are no longer the province of the psychiatrist. In this process patients are reduced to something less than fully human, as they become an abstract collection of symptoms without meaning to be "managed" by technicians called psychiatrists.
This is in the service of medical progress and enlightened scientific thought. The biologic psychiatrist will not make the mistake of imposing their value systems on patients like in the bad old psychoanalytic days. This is, of course, a sham. Modern psychiatry now foists on patients the view that their deepest and most private ills are now medical problems to be managed by physician-psychiatrists who will take away their symptoms and return them to "normal functioning." This is more than a bit malignant.
One of the dominant discourses that runs through the DSM-IV and modern psychiatry in general is the equating of mental health with "normal" functioning and adaptation. There is a barely concealed strain of a specific form of Utopianism here which blithely announces that our psychic ills are primarily biologic and can be removed from our lives without difficulty, leaving us better adapted and more productive.What is left completely out, of course, are any notions that our psychic ills are a reflection of cultural pathology. In fact, this new biologic psychiatry can only exist to the extent it can deny not only the truths of psychoanalysis, but also the truths of any serious cultural criticism. It is then no surprise that this psychiatry thrives in this country presently, where such denials are rampant and deeply embedded.
I am constantly amazed by how many patients who come to see me believe or want to believe that their difficulties are biologic and can be relieved by a pill. This is despite the fact that modern psychiatry has yet to convincingly prove the genetic/biologic cause of any single mental illness. However, this does not stop psychiatry from making essentially unproven claims that depression, bipolar illness, anxiety disorders, alcoholism and a host of other disorders are in fact primarily biologic and probably genetic in origin, and that it is only a matter of time until all this is proven. This kind of faith in science and progress is staggering, not to mention naive and perhaps delusional.
As in any dogma, there is no perspective within biologic psychiatry that can effectively question its own motives, basic beliefs and potential blind spots. And thus, as in any dogma, there is no way for the field to curb its own excesses, or to see how it might be acting out certain specific cultural fantasies and wishes. The rise and fall of biologic determinism in a culture likely has complicated and interesting causes, which are beyond the scope of this paper. A few comments will have to suffice.This is a culture increasingly obsessed with medical science and medical health as a sign of virtue. It is not surprising that our psychic ills would be pulled into this dominant medical discourse, essentially medicalizing our specific forms of psychic pain. It seems to me that modern psychiatry, in step with a culture which created it, assumes any suffering to be unequivocally bad, an impediment to the "good life" of progress, productivity and progress. It is now almost heresy in psychiatry to say that perhaps suffering can teach us something, deepen our experience, or point us to different possibilities.Now, if you are depressed or anxious, it has no real meaning, because as a biologic illness similar to say diabetes, it is separate from the world of meaning and merely is. Now any thoughtful person knows that something as fundamental as depression has meanings such as loss, facing mortality, unlived desires, lack of power or control, etc., and that these meanings will continue to exist even if Prozac makes us feel better. There is much more to life than feeling better or living without pain, and only a superficial and pathologic culture would need to deny this. Yet conclusions such as "depression is a chemical imbalance" are created out of nothing more than semantics and the wishful thinking of scientist/psychiatrists and a public who will believe anything now that has the stamp of approval of medical science.
It seems to me that modern psychiatry is acting out a cultural fantasy having to do with the wish for an omniscient authority who, armed with modern science, will magically take away the suffering and pain inherent in existing as human beings, and that rather than refusing this projection (which psychoanalysts were better able to do), modern psychiatry has embraced the role wholeheartedly, reveling in its new-found power and cultural legitimacy.
I would be remiss if I left out the obvious economic factors in psychiatry's movement toward the biologic. Pharmaceutical corporations now contribute heavily to psychiatric research and are increasingly present and a part of psychiatric academic conferences. There has been little resistance in the field to this, with the exception of occasional token protest, despite its obvious corrosive and corrupting effects.
It is as if psychiatry, long marginalized by science and the rest of medicine because of its "soft" quality, is now rejoicing in its new found legitimacy, and thus does not have the will to resist its own degradation. The fact that drug companies embrace and fund this new psychiatry is cause enough for alarm. Equally telling is a similar embrace by the managed care industry, which obviously likes its quick-fix approach and simplistic approach to complicated clinical problems.
When I talk to a managed care representative about the care of one of my patients, they invariably want to know what medications I am using and little else, and there is often an implication that I am not medicating aggressively enough. There is now a growing cottage industry within psychiatry in advocating ways to work with managed care, despite the obvious fact that managed care has little interest in quality care and realistic treatment approaches to real patients. This financial pressure by managed care contributes added pressure for psychiatry to go down a biologic road and to avoid more realistic treatment approaches.
What this means in real terms is that psychotherapy is left out. There has thus been a triple partnership created between this new psychiatry, drug companies and managed care, each part supporting and reinforcing the other in the pursuit of profits and legitimacy. What this means to the patients caught in this squeeze is that they are increasingly overmedicated, denied access to psychotherapy and diagnosed with fictitious disorders, leaving them probably worse off in the long run.It is quite depressing to listen to the discourse of modern psychiatry. In fact, it has become embarrassing to me. One gets the strong impression that patients have become abstractions, black boxes of biologic symptoms, disconnected from the narratives of their current and past lives. This pseudo-scientific discourse is shot through with insecurity and pretension, creating the illusion of objectivity, an inevitable march of progress beyond the hopeless subjectivity of psychoanalysis. Psychotherapy is dismissed and relegated to nonmedical therapists.
I actually have no objections to real science in the field, if, for example, it can help me make better medication decisions or develop newer and better medications. But in general biologic psychiatry has not delivered on its grandiose and utopian claims, as today's collection of medications are woefully inadequate to address the complicated clinical issues that come before me every day. This is all not terribly surprising given what I have outlined in this piece. There will be no substitute for the difficult work of engaging with patients at the level of their lived experience, of helping patients piece together meaning and understanding in the place of their pain, fragmentation and confusion.
Patients these days are not suffering from "biologic illnesses." What I generally see is patients suffering from current or past violence, traumatic loss, loss of power or control over their lives and the effects of cultural fragmentation, isolation and impoverishment that are specific to this culture at this time. How this manifests in any individual is absolutely specific; therefore, one should resist any attempt to generalize or classify, as science forces us to do. Once you go down the route of generalization, you have ceased listening to the patient and the richness of their lived experience.
Unfortunately what I also see these days are the casualties of this new biologic psychiatry, as patients often come to me with many years of past treatment. Patients having been diagnosed with "chemical imbalances" despite the fact that no test exists to support such a claim, and that there is no real conception of what a correct chemical balance would look like. Patients with years of medication trials which have done nothing except reify in them an identity as a chronic patient with a bad brain. This identification as a biologically-impaired patient is one of the most destructive effects of biologic psychiatry.
Modern psychiatrists seem unaware of what psychoanalysts know well, namely how powerful are the words that a patient hears from an authority figure like a psychiatrist. The opportunity here for suggestion, coercion and manipulation are quite real. Patients are often looking to psychiatrists for answers and definitions as they struggle with questions such as who am I or what is happening to me. Of course we all struggle with these questions, and the human condition is such that there are no definitive answers, and anyone who comes along claiming they have answers is essentially a fraud.Biologic psychiatry promises easy answers to a public hungry for them. To give a patient nothing but a diagnosis and a pill demonstrates arrogance, laziness and bad faith on the part of the psychiatrist. Any psychiatrist needs to be continually aware of the very real possibility that they are or can easily become agents of social control and coercion.The way to resist this is to refuse to take on the role assigned through cultural fantasy, namely the role of omniscient dispenser of magical potions. As a whole modern biologic psychiatry has enacted this role with particular vigor and enthusiasm. At the level of individual patients this means a growing number of overdiagnosed, overmedicated and disarticulated people less able to define and control their own identities and lives.
At the level of our culture this has meant an impoverishment of the discourse around such questions as what is wrong with us, as "scientific" answers replace more potentially fruitful and truthful psychological and cultural questioning. If psychiatry is to regain any semblance of legitimacy and integrity, it must strip itself of false and hubristic scientific claims and humbly submit itself to the urgent task of listening to individual patients with patience and intelligence. Only then can we have any real sense of what to say back to them.The sole philosophic basis for this new psychiatry is the championing of empiricism above all other measures of truth. Something is valid only if it can be demonstrated through experimental method, otherwise it is disregarded or relegated to "subjective" experience, which is presumed to be inferior. Now, of course, this dominance of empiricism is not limited to psychiatry, and one can easily trace the invasion of the experimental method of the "hard" sciences into the "soft" or social sciences.
On a larger cultural level this can be detected in the public's infatuation with "studies," statistics and so on. This hegemony of empiricism over other ways of thinking and knowing represents an unprecedented modern achievement which has thoroughly infiltrated the cultural psyche, to the point now where the average person believes easily the claims of the biologic psychiatrist.
Now as is clear from my views already expressed, a social science dominated by empiricism is a vulgar science, and there is a vast tradition in philosophy from Plato to Nietzsche which in my view irrefutably demonstrates this. However this is well beyond the scope of this piece. Suffice it to say that modern psychiatrists, like all "scientists" these days, have no time for the basic philosophic questions that have engaged the most brilliant minds of the past. Who needs questions about virtue when there is important data to collect? These biologic psychiatrists never think to ask themselves whether their own precious methods are perhaps standing on very shaky ground, say their own disavowed prejudices about what constitutes the good life.Empiricism is one way of knowing, but certainly not the only or best way. Biologic psychiatrists often use the standards of empiricism to answer their critics, in effect saying that their claims are scientifically "proven" and thus unassailable, clearly a tautological argument. I would further add that in my view many of the claims of biologic psychiatry do not even hold up to their own standards of empirical science, for example their claims about the biologic and genetic basis of many mental illnesses.
In my view, the methods of experimental science are inappropriate and misplaced when it comes to understanding the complexity of the human psyche, as they can only objectify the mind and remove subjectivity from the heart of human experience, thus creating an abstract entity in place of a human mind. It is no wonder that psychiatry declared the 1980s the decade of the brain instead of the decade of the mind. In their pursuit of the human brain they have quite literally lost their minds.
One way to unmask the dogma that is biologic psychiatry is to ask the question what kind of human being is being posited as desirable, "normal," or not disordered. Judging by the DSM-IV, it would be a person not depressed or anxious, without perversions or sexual "dysfunction," in touch with "reality," not alienated from society, adapted to their work, not prone to excessive feeling states and generally productive in their life pursuits. This is, of course, the bourgeois ideal of modern culture. We will all fit in, produce and consume and be happy about it. Anyone who dissents by choice or nature slips into the realm of the disordered or pathologic, is then located as such by medical science and is then subject to social management and control.
Now, psychiatry has always provided this social function, as admirably shown by Foucault and others. I would submit, however, that modern psychiatry, under the guise of medical and "scientific" authority and legitimacy, has surpassed all past attempts by psychiatry to identify and control dissent and individual difference. It has done this by infiltrating the cultural psyche, a psyche already vulnerable to any kind of medical discourse, to the point where it is a generally accepted cultural notion now that, say, depression is an illness caused by a chemical imbalance.
Now when a person becomes depressed, for example, they are less able to read it or interpret it as a sign that there may be a problem in their life that needs to be looked at or addressed. They are less able to question their life choices, or question for example the institutions that surround them. They are less able to fashion their own personal or cultural critique which could potentially lead them to more fruitful directions. Instead they identify themselves as ill and submit to the correction of a psychiatrist, who promises to take away the depression so they can get back to their lives as they are. In short, the very meanings of unhappiness are being redefined as illness. In my view this is a dismaying cultural catastrophe. I do not mean to suggest that psychiatry is solely to blame for this, given how wide a cultural shift this is. However, I do think that psychiatry has not only not resisted its role here, but actually has fulfilled it with considerable hubris.Thus in my view the whole phenomenon of biologic psychiatry is itself a symptom or acting out of a larger, underlying cultural process. Unhappiness and suffering are not seen as resulting from real cultural conditions; for example, the collapse of traditional institutions and the ever increasing hegemony of rampant consumerism in American culture. Nor is suffering seen in the context of what it means to exist as a human being in any historical period. Historical and existential discourse about unhappiness is increasingly supplanted by medical discourse, and biologic psychiatry has served as one of the major mouthpieces for this kind of pseudo-scientific and frankly pathetic medical discourse about what ails us.
I am increasingly astonished about how unable the average patient is now to articulate reasons for their unhappiness, and how readily they will accept a "medical" diagnosis and solution if given one by a narrow-minded psychiatrist. This is a cultural pathologic dependence on medical authority. Granted, there are patients who do fight this kind of definition and continue to search for better explanations for themselves which are less infantilizing, but in my experience this is not common. There is a frightening choking off of the possibility for dissent and creative questioning here, a silencing of very basic questions such as "what is this pain?" or "what is my purpose?" Modern psychiatry has unconscionably participated in this pathology for its own gain and power. It is a moral, not scientific issue at stake here, and in my view this is why many astute Americans rightfully distrust this new psychiatry and its Utopian claims about happiness through medical progress.
So what kind of psychiatry am I advocating here? First of all, I think it is unclear whether the field can extricate itself from its current infatuation with technology and its own power to use it. When one reads psychiatric journals now, one senses a dangerous giddiness about the field's "discoveries" and "progress," which in my view are wildly and irresponsibly overstated. All the momentum, which is mainly economically driven, is pushing psychiatry toward further biologism.
Having said this, what I am advocating is a psychiatry which devotes itself humbly to the task of listening to patients in a way that other medical practitioners cannot. This means paying close attention to a patient's current and past narrative without attempting to control, manipulate or define it. From this position a sychiatrist can then assist the patient in raising relevant questions about their lives and pain.The temptation to provide answers or false solutions should be absolutely avoided here. Medications are used judiciously for lowering painful symptoms, with considerable attention paid to the psychological effects of medication treatment. Diagnosis should play a secondary and small role here, given that little is known about what these diagnoses actually mean. Above all suggestion, coercion, normalization and control need to be assiduously guarded against, as these are natural temptations that arise out of the dynamics of power that exist between psychiatrist and patient.
A more humane psychiatry, if it is even possible in today's cultural climate, must recognize the powerful potential of the uses and abuses of power if it is not to become a tool of social control and normalization. As I have outlined in this piece, these abuses of power are by no means always obvious and self-evident, and their recognition requires rigorous thought and self-examination. The psychiatrist plays a particular role in cultural and individual fantasies, and an intelligent psychiatrist must be aware of the complexity of these fantasies if he is to act in a position outside these projections and fantasies. This requires real moral awareness on the part of a psychiatrist who wishes to act intelligently. What I am advocating for in outline form as stated previously are the minimal requirements necessary for the field of psychiatry to reverse its current degradation. What is essential at this time is for psychiatrists and other clinicians to speak out against the ideology known as biologic psychiatry.
Dr. Kaiser is in private practice in Chicago, and is affiliated with Northwestern University Hospital