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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 ahistoricism 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.... 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 resentation 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... 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....
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....
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.... 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. ... 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....
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....
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. ... 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....
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 psychiatrist can then assist the patient in raising
relevant questions about their lives and pain ... Diagnosis should play
a secondary and small role here, given that little is known about what
these diagnoses actually mean....
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
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