Tuesday, July 21, 2015

The Unending Crisis of Psychiatry

Just noting another article by another psychiatrist bemoaning that his field is "in crisis." I have been reading about this crisis in identical terms for most of the past twenty years. The crisis can be described in several different ways, viz: is psychiatry about the physiology of the brain or the state of the soul? is it another branch of pharmacology, or is treating mental problems different from treating infections? should we be finding ways to make therapy work better, or discarding it as mumbo-jumbo and looking to do everything with drugs and electric currents? are psychiatrists scientists or humanists, or perhaps priests?

Has anyone read a book or article lately by a psychiatrist who loves his or her work and thinks the field is in great shape?

Thirty years ago there was a raft of books by people very excited about the potential of new drugs like Prozac and lithium, certain that our growing knowledge of the brain would soon lead to miracle cures of mental problems. I'm not hearing very much along those lines these days. ("Anyone who thinks otherwise should remember the Decade of the Brain, which ended 15 years ago without yielding a significant clue about the underlying causes of psychiatric illnesses.") Certain drugs do help some people, but in my experience only those patients whose problems originate from simple physical causes -- e.g., a severe deficit  of some pituitary hormone -- are ever cured by drugs.

Therapy also seems to help some people, but sometimes at the cost of making them insufferable bores who talk constantly about themselves. The whole point of therapy is to pay very close attention, at an almost obsessive level, to your own mind and how it works; but a humanistic psychologist might say instead that what people really need in life is to stop obsessing about their own minds and involve themselves more fully in the world. Anthropologists will tell you that this obsession with the mind of the individual is a western, modern thing, and that in most of the world people think about themselves much more as units in a family, a village, and a society. And that, furthermore, many of our psychological problems may be caused precisely by focusing too much on our own minds; why else would more Americans suffer from crippling anxiety than people living in war-torn states like Lebanon or Ukraine? Toss our ongoing fight about who should pay for health care into the mix, and you get a lot of misery and confusion. Because of  doubts about the efficacy of therapy and fights over who should pay for it, the number of Americans receiving it has declined greatly in recent years.

All of this has left me, as my readers know, feeling detached and skeptical about psychiatry. I never know what advice to give anyone with psychological difficulties, since I am ambivalent about all the options. I have sometimes recommended therapy or drugs, although without any great conviction. In my heart I think that what would most help troubled people is more fulfilling lives, but that is of course a ridiculous thing to recommend to anyone, especially some one too depressed or anxious to take even a small step outside routine. I also think that our psychological difficulties point toward something very wrong with our society that I would like to fix. But since we evolved to live in small communities beset by shortages and threatened with violence, I am at a loss to suggest what sort of modern world might really be suitable for us. Except that we could all use more friends, stronger communities, more support in times of hardship, and a stronger sense that we are all in this together.


G. Verloren said...

"why else would more Americans suffer from crippling anxiety than people living in war-torn states like Lebanon or Ukraine?"

It sounds bizarre, but when you're living in warzones, you actually acclimate somewhat to the insanity and the suffering. You don't suffer "anxiety" about what might happen, because it constantly is happening and you're too busy coping with more pressing needs and concerns. You don't have time to feel anxious about the future, because your every waking moment is spent concerned with the present.

On the flipside, it is when things change and conflicts come to an end that people start to suffer from anxiety. Without the constant pressure to just keep moving, keep coping, keep surviving, the mind has time to reflect and to worry. Consider PTSD among veterans, with many of them becoming lost without the focusing pressures of constant conflict - they actually want to get back into the war, where things are "simpler", where things "make sense", where they don't have to lie awake at night alone with their unoccupied minds.

Anyway, psychology as a field isn't suffering from any great crisis, but merely from disappointment. People got their collective hopes up that we'd make bigger and better advances than we have thus far achieved, and now that things aren't quite panning out the way they were "meant" to, people are naturally not terribly confident or optimistic about the field.

And yet, psychology is still our best tool in combatting mental illness. Or rather, our best set of tools. No one focus works for every case. Some people respond well to drugs, while others simply don't. Therapy does wonders for certain individuals, but nothing for others. The humanist approach of community and interaction with the world always seems to at least help somewhat, but it isn't always possible to achieve.

Despite their shortcomings, we need to understand and value all three approaches, and reserve them as options in every case. And we should also keep an open mind in regards to other approaches entirely as well. There is no one magic bullet, no miracle pill, that will work all the time for everyone. Like archeology, psychology is most definitely not an exact science.

Shadow Flutter said...

Well, Marcia Angell, Senior Lecturer in Social Medicine at Harvard Medical School and former Editor in Chief of The New England Journal of Medicine, doesn't think much of the state of psychiatry. She uses three recent books criticizing the field as a launching pad to hit hard. Worth the read, in my opinion. Would be interested in your thoughts.

A long read but worth it. Two articles, back to back, in the NYB.



David said...

I confess I don't get what all this emphasis on community is about. My impression is that, many (I would say most) members of close, traditional communities spend most of their time either a) gossiping and engaging in petty quarrels and resentments or b) protecting themselves from gossip, petty quarrels, and resentments. In such a case, it seems to me "community" is an antidote not so much to psychological problems as a force for discouraging people from talking about them or displaying them, or perhaps encouraging people to deal with them by venting their hostility on their neighbors.

John said...

Shadow Flutter: I love those essays by Angel; I wrote about them here:


My main thought looking back is to re-emphasize that this whole subject is confusing for all of us and upsetting to the people who work in mental health. What I mean by "crisis" is the attitude of people like Kirsch and Carlat, who feel like their profession has been hijacked by drug companies out for profits and insurance companies looking for a cheap fix, so that people are drugged instead of helped. I don't think they are necessarily right, because I know so many people who have been helped by medications, but they certainly express a widespread unease about mental health in modern America.

John said...


By "community" I don't mean a village, I mean a circle of friends one can interact with and have to dinner parties. The opposite of loneliness, which is the besetting social problem of modernity.

I am turning over in my mind the notion that strong communities of the traditional sort reduce the reported rate of mental illness because people lie and conceal it to keep face. Surely that would in some instances be very bad, viz., the closet alcoholic who ruins his family rather than get help. But there is a widespread notion that the way to become a certain sort of person is to act the part with conviction until it becomes real. Might it be possible that acting like a sane, normal person might help some people become sane and normal? Do traditional communities impose their roles by just this mechanism?

David said...

"Might it be possible that acting like a sane, normal person might help some people become sane and normal?"

I think this probably does happen to some degree in many cases. On the other hand, there is the problem of: how could you tell? People would show what they want their neighbors to see. It would be like trying to report on the nation's attitude toward work by using what people say in job interviews.

It's also worth remembering that in traditional small communities, a portion of the population ended up living (and often dying young) as disgraced failures and outliers. I would say that part of the abiding hostility to psychiatry (which I do not mean to imply you're sharing in) stems from a discomfort that, instead of saying someone is a disgrace who shamed their family, psychiatry says they suffer from anxiety disorder.

In any case, I imagine social pressure's "cure" rate was probably similar to psychiatry's, and the cures were probably about as final. And would you say the social cost was less?

John said...

Given the choice, I would opt for modernity and freedom -- in fact I have. That would be partly because I share modern psychology's notion of what is good for the soul; I find the social roles and identities imposed by traditional societies fascinating but, at a personal level, almost incomprehensible.

But as harsh as traditional communities could be, they had features that I think we miss, and I think that is a big part of why all our wealth and freedom have not made us that much happier.