INTRODUCTION
To gauge the depths of psychiatry’s public image problem you need look
no further than the pages of New Yorker magazine, where for over fifty years
the profession has been an enduring target of their characteristically droll
cartoons. In bygone days the stereotypical psychoanalyst was portrayed as
aloof, eccentric, somewhat mercenary, but otherwise thoughtful or even
sympathetic—the butt of the joke was usually either the neurotic foibles of the
patient, or the clumsy ambiguities surrounding the remunerative aspect of the
therapeutic relationship. But in recent years this caricature has evolved into a
much uglier stereotype—a shallow and emotionally detached pill-pusher, a
shill for medications with no inclination to listen to patients, and no interest
in the fine points of human emotion. The medications themselves, e.g. the
already iconic Prozac, are treated with higher regard than are the doctors who
prescribe them.
This change in perception is the natural consequence of a revolution in
treatment that began in the 1970s—the emergence of biological psychiatry, in
which mental disorders are considered biological dysfunctions of the nervous
system, as the preeminent model of care. As medications have increasingly
become the mainstay of our treatment, knowledge and interest in the
psychodynamics of our patients have diminished, since they are deemed
irrelevant in the view of the prevailing dogma. It leaves psychiatrist and
patient with precious little to talk about, or listen to, during a treatment
session.
This transformation did not occur in a vacuum, but rather was ushered
in by a host of economic and sociological forces, not the least of which is the
context—to address not just the medication options available to them, but to
educate them regarding the stresses, psychodynamics, and lifestyle issues that
may be contributing to their illness. However, to do so requires a belief in
something other than the narrow dogma of biological psychiatry; the
willingness to speak frankly about our observations; and the ability and desire
to connect emotionally with our patients, if only for an hour or so. The same
approach can be continued into followup care, but it requires the application
of a multifactorial model of mental illness by a psychiatrist whose manner is
direct, emotionally engaged, and above all else, honest.
It’s on this issue of candor that I have my biggest beef with
contemporary psychiatry. Psychiatrists like to pretend nowadays that they
understand how the brain works, when really they don’t. But what’s even
more remarkable is that they don’t seem to understand how people work—
and I suspect that many don’t even ask themselves that question. In all my
psychiatric training, nobody ever told me that a person in a miserable
marriage could exhibit all the diagnostic criteria for major depression. And
that people in bad marriages typically lie about it, even if you ask them
outright. It took many years of clinical practice to discover these truths—but
before I could do it, I had to stop thinking of neurotransmitter receptor sites,
and start wondering why these patients didn’t get any better no matter what
medications I prescribed them.
Once I’ve figured out what the patient’s real problem is, there remains
the dilemma of what to do about it. Therapeutic neutrality dictates that I
should have no particular feelings or opinions on such a weighty issue as one’s
marriage. And maintenance of the therapeutic alliance could compel me to
avoid taking undue risks—such as telling a patient that by all indications their
spouse is incorrigibly narcissistic, and that the chances of improvement of the
patient’s mood are slim to none unless this issue is addressed—for fear that
the patient will take offense and be driven away from treatment. Both of
these guiding principles stand in the way of sharing my perception of the
truth, which is in fact the most valuable gift I have to offer a patient when
medications have proven worthless.
I‘m not the first to maintain that the effective practice of psychiatry
sometimes requires throwing out the book. But nowadays “the book” is a
corrupt falsehood worming its way into the popular ethos, promoting a
passive and disempowered role for patients that discourages their
constructive participation in treatment, hence undermining its efficacy. If the
real purpose of psychiatry is to relieve emotional distress rather than peddle
product, then it’s time to rigorously reexamine the intellectual underpinnings
of contemporary psychiatry to reaffirm their validity; because on the face of it,
psychiatry is not working as advertised. What we need is a new “book”, based
on the self-evident truths of psychiatric illness and its treatment, rather than
the pseudoscientific bromides that are currently dominating the conversation.
But don’t take my word for it. The case against biological psychiatry, as
it is currently marketed and practiced, can be made by the simple application
of reason to its principle contentions. And there’s already a well-established
process in place to discern fact from supposition, that requires only a
modicum of training and intellectual discipline—the scientific method.