Golden Age of Psychiatry [Original Research]
H. Taynen, MD, FRCPC
Private practice Burlington, ON, Canada
[emedpub – Psychiatry and Mental Health: Vol 1:1] [Date of Publication: 08.25.2011]
ISSN 2231-6019

August 25, 2011 at 10:31 AM

We live in a materialistic world.  Economies are based on consumption.  Status is measured by wealth.  Success in life is gauged by how early we retire from work that may have had no real meaning apart from making money to retire.  The arts go unfunded.  Education has been reduced to job training from its once lofty place of learning for the joy of learning and for the advancement of human culture.

Above all, the miraculous accomplishments of science and technology so much impress the public that the leaders in this field have instant authority as the bearers of knowledge.  When a scientist says “we now know” — all listen — as we once did to bishops.

In this environment, psychiatry works to establish a solid, well-founded identity that keeps it squarely in the medical profession.  The truth is that psychiatry lies somewhere between neurology and psychology, encompassing both.  It also borders on and borrows from such subjects as biochemistry, biology, genetics, sociology, political science, history and religious studies.  Psychiatry may be difficult to define because it is among the most comprehensive areas of study we know, requiring a holistic mind that is skeptical of “either/or”and at home in “both/and”.

Eisenberg (1), followed by Lipowski (2), warns against the “mindless” or “brainless” practice of psychiatry, the fundamental either/or for our profession.  Up to 1950 we were brainless.  Since then we have become mindless.  Could there be a Golden Age of psychiatry upon us, leading out of the techno-biological Dark Ages we have sunk into and bringing us to a profession which is both a science and an art, serving both human suffering and the evolution of consciousness?

Today, there is a “chemical imbalance” in psychiatry — an imbalance towards neurochemistry.  We are held back by a hypertrophic materialism that sees human problems exclusively in mechanically physical and behavioural terms, devoid of meaning.  With the best of intentions, we create diagnostic entities and deem them to be “illnesses” and “disorders” when we have no actual physiological basis for using these terms.  As Joel Paris argues (3), all we can honestly refer to on the basis of the available information is syndromes — collections of features that cluster into an apparent event, the cause of which is mainly unknown.  “Dropsy” was such a syndrome before the various medical causes ofpedal edemawere discovered.

Scientific materialism has influenced the public to believe–without actually saying so–that almost all human problems are primarily genetic.  Those phenomena that are truly genetic just emerge, with no apparent external cause.  The trouble is that those phenomena that are unconsciously generated also just emerge.  Too often, the spontaneous emergence of phenomena such as mood changes, anorexia, obsessive-compulsive symptoms and gender dysphoria is taken as evidence or even proof that theyare genetically determined.  Thereby the problem implicitly has no meaning or worse, the meaning is explicitly disavowed.  Consider a few examples.

The single-parent mother in a family of four teenagers, all taking SSRIs, says on TV, “We are so grateful to our psychiatrist.  Before we met him we thought we had problems.  Now we know we have Dysthymia”.  The mother and the doctor are happy — sort of; the drug company is happy — for sure; and the real problems in this hornet”s nest of a family situation are left to fester because they are medically deemed not to exist or to be secondary and trivial.  Similarly, when I once asked a young female patient on 200 mgm of sertraline what was her concern, she said, “I’m unhappy because I have depression”.  This is an understandable statement in light of her thorough indoctrination in the medical-illness model.  When, however, I asked her if she thought she might be depressed because she was unhappy about something, her medical orientation held sway and she could not understand the question.  She also would not let me anywhere near a consideration of her over-ripe attachment to her mother (effect or cause?)

An anorexic young woman is told that she has a hormonal disorder.  The observable psychodynamic fact that ingestion is all that remains in her life over which she feels she has any control, is ignored.   It is allowed to sink below the surface and out of view.  We become oblivious of such things as we are oblivious of gravity–though we live with it constantly.

A young woman in Europe recently has offered to make herself the “poster girl” for eating disorders by having photos of her nude, skeletal body published in the media.  Journalists seem to understand the mind better than many psychiatrists.  They prominently display her history as the daughter of a troubled single mother who refused to let her little girl play outside for fear that fresh air and sunlight would make her grow.  The girl, online casino now severely anorexic, explicitly remembers the moment at which she decided not to eat in order not to grow so that her mother would be happy and love her.  Could anyone looking at this call anorexia nervosa a primary hormonal disorder?

A young man with “OCD”, safely reassured that he has a known “disorder” which is caused by a malfunctioning brain, has his intrusive thoughts and compulsive checking thankfully well controlled by SSRIs.  After months of psychotherapy he arrives at a dreadfully real fundamental — the conscious and present intention to murder his tyrannical father.  Being brave, he does not flee and there is an insight.  He suddenly says, “But wait.  I could never really, actually do that”.  No one told him this; he saw it himself.  Before allowing the feeling to be conscious, he unconsciously feared that the urge would become action and this terrifying possibility had to be unconsciously contained, obsessively and compulsively, through exhaustive checking– clearly a functional mental defence mechanism, which would be mediated by but not caused by the brain.  The patient now evidently has a normal brain because his “OCD” is gone.  It is the software that is the problem, not the hardware—or at least not primarily the hardware.

A less dramatic example is that of a woman, also struggling in adulthood to emerge from a conflicted attachment to a tyrannical mother,has OCD symptoms that, though they persist, are well controlled by SSRIs.  She routinely notices if she carries out the cognitive exercise of asking herself “who do I want to kill?”that the intensity of her compulsions distinctly lessens.  In my own clinical practice, I have never encountered an OCD patient who did not have a tyrannical parent.

An interesting point to notice in connection with the current scientific materialism that largely prevails in psychiatry (scientism) is that only certain types of evidence are regarded as acceptable.  Only “quantifiable data” serve as a basis for the requisite practice of “evidence-based psychiatry”—as objective.  Subjective observation—observing the observable–and especially case studies– are simply inadmissible as though in a court of law obviously incriminating evidence is ruled out to protect the legal system.  The clinical examples I have given simply do not constitute evidence because they are not quantifiable, measurable elements in a controlled, double-blind statistical study.  A “tyrannical parent” is clinically obvious to the naked eye, though unmeasurable.

Where genetic heritability is concerned, the genetic component in psychiatric disorders is usually surprisingly low.  This is not an attempt to diminish its importance. That would be “brainless”.  In major depression, for example, heritability studies run between 20-40% in women and less in men (4).  For OCD, studies range from 26-33%.  The concordance rate for schizophrenia in monozygotic twins is only 42%–far higher than first-degree relatives (10%) and the general population (1%) but not the 100% we find in cystic fibrosis.   This may have to do with a clearer diagnosis in medical disorders but not entirely.  The psyche, the mind, is functionally dealing with the proximity of others, consciously and unconsciously.  It is appealing and perhaps unprovable—and therefore inadmissible—that genetic vulnerability is necessary and not sufficient in the genesis of any psychiatric syndrome.  I am fond of what a child psychiatrist once poignantly told me, “If you have a child who is genetically vulnerable to depression and you give that child the attention they need, there is no genetic vulnerability” (personal communication G. Shomair). “Prove it or I won’t listen”, says the irrational materialist.

The rubric of the “resilient child” is a subtly employed to judge children affected by traumatic events as in some way inferior.  What is worse, the fact that many children are not affected as badly as others by traumatic events which cannot in themselves be scientifically equated to each other, is used as “proof” that childhood development has no effect on human psychopathology — or to be more precise, it cannot be “proven” and therefore has no valid evidence-based role to play in understanding what has happened to people.  This is like claiming that since father-daughter incest does not always result in gross pathology, it does no harm.

It is generally acknowledged — this much at least is safe — that the combination of medication and psychotherapy is regularly demonstrated, scientifically, to be more effective than either alone.  The trouble with this, it seems, is that what is meant by psychotherapy in such discussions has little to do with insight or developmental meaning.  Instead it is CBT which avowedly has no interest in meaning or interpersonal therapy which has an emphasis on counselling.  The difference between counselling, which is didactic, and insight work, which heals through discovering the meaning of things, is apparently not relevant.  Studies confirming the benefits of short-term therapy, which is valued over longer-term work, focus on symptom relief and regard dependency is a deplorable side effect.  The fact is that in long-term psychotherapy the benefits far exceed symptom resolution, which is a rather automatic early phenomenon, and the dependency that generates is worked through developmentally such that the patient emerges into a true independence rather than the false ‘counter-dependence’ they began with.  Where short-term and counselling and long-term insight-work are concerned, it is the difference—in good hands—between a pop tune and a symphony.  How is classical music doing these days?  It seems to require an attention span we no longer have.

Those who work to reduce human suffering for present and future generations through psychological work are trivialized and marginalized as elitists entertaining themselves with the “worried well”.  While it is a vital social value that as much as possible be done for those who suffer most, it is also true (both/and) that in-depth psychological workwith high-functioning patients—those who suffer silently– has far-reaching benefits that are not visible to the casual observer. The markers are not located in gross pathology and aberrant behaviour.  The fact is that the religious principle– “the truth will make you free”–actually works on a daily basis in thousands of offices the world over.  It has no status, however, because it cannot be proven statistically.  It can only be observed.All that is subjective is not false.  Otherwise a mother’s intuitive sensitivity to her infant would have to be discounted as illusion when, in fact, it has a real and critical role.  Without the element of psychological insight as part of our profession, we are left with scientific materialism—at its worst irrational materialism—and no art of healing.  We are no longer healers; we are technicians.

In a public discussion, Nobel laureate Eric Kandel said that “insight is a biological treatment” (Charlie Rose Brain Series, PBS, 2010).  The brain is a plastic organ, unlike any other.  As the brain affects the mind, the mind affects the brain — brain function and brain morphology.  Insight changes the brain as medications also change it through neurogenesis and by modifying brain activity–mind and brain; neuron and psyche.  We might also say left brain and right brain; left wing and right wing.  Psychiatry challenges its members to be specialists in the holistic.

Materialistic psychiatrists allow the public to think that brain activity, as seen on imaging studies, is revealing the cause of mental phenomena.  People accept this without knowing that mental phenomena are reflected in brain activity as much as the brain may cause mental activity.Is the visualized brain activity the cause of mental phenomena or the effect of them?  The deepest point of difficulty for scientific materialism is the prospect that the brain does not cause consciousness as a meaningless neurochemical reaction but that consciousness may exist apart from the brain, which mediates it.  Those who think that a lightbulbcauses light know nothing of electricity.  We must at least say of the assertion that the brain causes consciousness that it is not necessarily more valid than the opposite claim–that the brain mediates consciousness, already existent apart from anything materialistic.

In the Golden the Age of Psychiatry we need a kind of intelligence that sees both the brain and the mind and realizes that though it cannot be seen, consciousness is real.  In a materialistic world of things, consciousness is the only thing that is not a thing.  Psychiatry is the study of its expression through and its interaction with–the brain.

References:

  1. Eisenberg L. Mindlessness and Brainlessness in Psychiatry. British J Psychiatry 1986;148: 497-508.
  2. Lipowski ZJ.  Psychiatry: Mindless or Brainless, Both, Neither? Canadian J Psychiatry 1989; 34: 249-254.
  3. Paris J. Prescriptions for the Mind.  Oxford University Press, 2008.
  4. Jang KL. The Behavioural Genetics of Psychopathology, Lawerence Erlbaum Associates, 2005.
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