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
Letter of Resignation from the American Psychiatric Association
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