An “Even-Handed” History of Psychiatry as Damning as the “Polemics”?

Sandra Steingard, MD
13
1957

As I struggle to make sense of my field, I often reflect on its complex and confusing history. While I was not around when Emil Kraepelin and Sigmund Freud were developing their ideas, my career began when the so-called neo-Kraepelinians ousted the descendants of Freud from their perch at the top of American psychiatry. During my four years of medical school, the psychoanalyst chair of the school’s psychiatry department retired. His successor trained in psychoanalysis in the 1960s but went on to become a leading psychopharmacologist and was editor of the Journal of Psychopharmacology. This was when the DSM III was published. Although the modern era of psychopharmacology began when I was an infant, the Prozac era began just as I completed my training. Perhaps I suffer from the baby boomer misconception that our time was inimitable, but it seems as if my life as a psychiatrist has spanned an important period of transition. 

It is not surprising that when Mind Fixers was published several months ago, many colleagues and friends, knowing of my interests, sent reviews my way. Written by Anne Harrington, Harvard University Franklin L. Ford Professor of the History of Science, this book has garnered deserved attention, almost all of it positive. I was struck by the assertion that this book would be different from others in this field in that it would take a professional historian’s approach to understanding the changes that psychiatry has undergone since the days of Kraepelin and Freud. As Professor Harrington writes in her introduction:

“…I believe history matters…we do need history to understand how we came to be where we are now and therefore what might need to happen next. Heroic origin stories and polemic counterstories may give us momentary satisfaction by inviting us to despise cartoonish renderings of our perceived rivals and enemies…it is time for us all to learn and to tell better, more honest stories.”

This hit a nerve. I have been described by others as “passionate”; a colleague once suggested that I was too passionate to accurately analyze the scientific literature. Would Professor Harrington consider my perspective a “cartoonish rendering”? How would her book differ from others I have read? What would be revealed in a “more honest” story?

There are a number of excellent reviews so I will skip a detailed account of the general content of the book. The author was interviewed on Fresh AirThe New Yorker published a comprehensive review, and Los Angeles Review of Books has another excellent review. My own impression is closest to that of Gary Greenberg, who reviewed the book in The Atlantic. Most suggest that the even-handed tone of Mind Fixers might allow for better reflection on how to address the profession’s challenges.

I agree that this is a well-written book that highlights the major events in modern psychiatry. I was particularly pleased that she included the role of Freud and his followers in shaping modern psychiatry. I recommend it to anyone interested in this field.

Where she seems to differ from books that others might call polemics is that she does not attribute nefarious motives to psychiatrists or the psychiatric establishment. On the jacket cover, Steven Hyman, former NIMH director and current director of the Stanley Center for Psychiatric Research, commends her for her “fairness and even sympathy.” I would argue that it is her sympathy for the failings of the profession that has garnered her accolades from those who have less favorable views of other books that have covered similar territory.

So where does a sympathetic history lead us?

Her major thesis is that the evolution of psychiatry has not been the result of the oft-touted advances in science. She refers to this notion as an “actor’s category” which she explains in a Psychiatric Times interview as meaning “a way that people at the time talked about what was going on.” Rather, she argues, it was failure rather than success that gave way to change. Most new discoveries were due to serendipity. Kraepelin did not find brain pathology to explain the symptoms of the patients he so carefully characterized; this allowed the psychoanalysts to take over. It was their overreach that encouraged others to promote a more phenomenological approach. This was realized with the publication of the DSM III, however, its introduction did not yield explanatory causes for the disorders listed in the book. Modern psychopharmacology did not arise from some understanding of brain function or pathology. It was the other way around. The drugs are psychoactive and they were put to use. As more was learned about the effect these drugs had on neurotransmitters, explanatory hypotheses were generated. Even as scientific inquiry found these hypotheses wanting, this commonly called chemical imbalance theory was heavily promoted in pharmaceutical advertising and holds sway to this day in popular culture.

This book will be of value since its tone — as well as the robust academic credentials of the author — give it an authority that might help reformers. For despite the tone, the book offers a sobering view of the state of knowledge in psychiatry. She has chapters that outline the evolution in the modern era of the psychiatric conceptualization of three major disorders: schizophrenia, depression, and manic-depression. The narrative is not one of enlightened discovery yielding relief for those who suffer. Rather, each chapter comes to the conclusion that the robust research efforts of the past fifty years have led to far more questions than answers. She describes the creation of disorders to match available drugs and the massive expansion in indications for drugs that is clearly the result of marketing pressures rather than scientific discovery.

I agree with Gary Greenberg, however, that the price paid for neutrality, or sympathy, to use Hyman’s word, is that the author might “underplay the significance of the troubles she is reporting.” In some interviews, she talks of how her Harvard students influenced her. This was not just in their scholarship but in their sharing their personal travails. In the Psychiatric Times interview, she posits that her students who struggle “would be more apt to accept the help they need if it could be offered within a framework that did not pathologize them up front, but instead validated their experience and affirmed their resilience.”

I share that speculation but I worry that Professor Harrington underplays the ways in which the current model does more than fail to offer her students palatable help. The current model does harm. One of her students could have been Laura Delano, a Harvard graduate who not only sought help but was, by her own reckoning, a model patient. Her story has been detailed in The New Yorker and in Delano’s many blogs and website. The neutrality of the book underplays these harms. Are those among us who try to bring attention to this dismissed as polemicists?

Despite my worries that Professor Harrington might find my own perspective on psychiatry too polarized, I was heartened that to a large extent her suggestions for reform overlap significantly with my own. I was disappointed in her suggestion that psychiatrists confine their attention to “real illness,” mainly because that term gives an illusion of characterizing something that I am not sure actually exists. As pointed out by Dr. Awais Aftab, her Psychiatric Times interviewer, this suggests “that the complex causes of psychiatric conditions could be neatly divided into diseases and not diseases, as if this is a line carved in nature… It also assumes that there is some uncontroversial concept of disease in the rest of medicine on which psychiatry can rely.” Her response revealed the sophistication I would expect from a scholar of her accomplishments: “It was less about drawing a clean line in the sand between diseases and not diseases and more about suggesting that mental suffering is a larger category.” However, I worry that her language will reify a common misunderstanding among both supporters and detractors of psychiatry.

I fully support, however, her suggestion for a retraction of scope as well as giving away “some of its power to therapists, counselors, social workers, social service providers, and patient-run organizations.” While she believes this will take courage on the part of psychiatrists, she argues for an attitude of humility.

I have suggested an integration of two concepts, a drug-centered pharmacology with needs-adapted treatment (NAT), as a way to accomplish, at least in part, what Professor Harrington is suggesting. Joanna Moncrieff has made a distinction between disease-centered and drug-centered pharmacology. The former approach is what is most commonly used now — it suggests these are drugs that target specific diseases or disorders and correct the underlying pathology. A drug-centered approach acknowledges that these are psychoactive drugs that may have beneficial effects at times but not because they specifically target and correct a pathological process. In need-adapted treatment (Open Dialogue is a form of NAT) humility and uncertainty are core values. NAT offers the non-pathologizing, validating, and affirming approach that Professor Harrington speculates her students would welcome. Practitioners share expertise with everyone in the room. Rather than considering the person at the center of concern an object of therapeutic expertise, this person is a partner whose voice is respected and valued. This way of working allows clinicians to step back from a faulty diagnostic system. This approach might help to inoculate us from some of the hazards that are so nicely documented in Mind Fixers. Many of these ideas are elaborated upon in the book I recently edited, Critical Psychiatry: Controversies and Clinical Implications. I hope the contributors to my book are not dismissed as polemicists.

13 COMMENTS

  1. Sandy, I am glad you took time to read and review the book. I had seen the reviews and was wondering if it would be discussed here.
    I think it is a beginning crack but small and isolated in the elitist world of American academia. And thanks for the shout out to Laura. If the professor had true intelligence and creativity she would have co- authored the book with Laura.
    I still contend chemical treatment or maybe just say chemotherapy it fits in terms of bad side effects but is not even targeting bad cells to kill – is a band aid solution and now has morphed into a quasi legal solvo.
    The tools to treat humans in distress from trauma of all kinds in all configurations,or problematic withdrawal or a spiritual crisis or whatever are either few and far between, difficult in having, expensive, or hum labor intensive, or still nonexistent.
    So because of the expediency of pills or injections a dream for authortaritive administrators of all kinds. The perfect fit.
    So every professional is forced into this band aid approach and instead of helping folks, many times hurt is put upon other hurt.
    One can be a kind and compassionate professional but even then, one still has to play in the system and follow the systems rules. Some systems are less oppressive than others. But bottom line if one merely looks at the stats- the system ain’t working and folks are only getting worse.
    I would propose instead of a Physcians for Social Responsibility – remember that group? Psychiatrists Against Oppression and start actively being active not with books or papers but on your feet. The Benjamin Spock MD way.
    As a survivor even with First Amendment Rights to Free Speech if I choose to go out and protest if word gets out to the police or I act out of the margins- my very very strong fear is I will not just get picked up and arrested and charged like the Catholic protest at the Russell Building with elderly nuns and elderly lay folks- my fear- is – I will be pink slipped along with a violation charge.
    6 hours at a police station is nothing compared to days of forced medication.
    Because I live a Venn Digram life, I am not unopposed to working with dissident MH folks and can agree to disagree re the use of chemicals as long as we all agree band aid and things need to change.
    The issue with us survivors is our voices and power to be heard have been quashed in multiple levels. This is also true of any othered type culture or group of human beings these days.
    So a joint effort might be what Saul Alinsky’s ghost might say is all of our best chance at beginning whatever- change, transformation, or new entity type of support.
    There just needs to be some ground rules.
    As survivors we were abused and I do not say this lightly as a twenty year trauma involved LISW. The periods of my hospitalizations were the worst moments of my life and pure hell.
    The floors that I were on were so much much worse than any I had worked on as a staff member. They were nothing but prisons.
    So all survivors who have experienced this so called treatment will be angry and the anger can be scatter shot.
    Forgive us are legitimate anger and do not take it personally. It is what it is.
    What we ALL want is this never to be normal again and have the abuse stop.
    Then if this can be recognized let’s work together to stop things as they are.
    One needs voices st every state and local area and in a national context as well.
    And in Academia, in the board rooms, on Wall Street and in the streets.
    Your voice can be the shot heard round the world that opens up and allows our experiences to be heard and then possible ephinanies May come.
    It’s just too late to do the old ways- too much entrancement b so many powerful folk.
    Maybe just tumor board meetings – the oppsies when the medical model fails in situ? They do it for every other legitimate medical department. That would be one very small way of changing the mind set. Cracks before tanks maybe?
    As always just some barnstorming ideas.

    • So all survivors who have experienced this so called treatment will be angry and the anger can be scatter shot.

      Let’s not be too broad-brushed here — many AP survivors are extremely focused in our analyses and methodical in our strategies to expose and delegitimize psychiatry in the public consciousness. Further, we need not rely on academics or professionals to do this for us (though true allies are always welcome). And Catnight, be assured your contributions to this process via your comments are valuable and have been noticed by a number of us.

      Out of curiosity, do you you consider yourself anti-psychiatry at this point? Or are you still “critical”?

  2. I’m quite certain the editor of the DSM-IV called all the DSM disorders BS. “… there is no definition of a mental disorder. It’s bullshit. I mean, you just can’t define it.”

    https://www.wired.com/2010/12/ff_dsmv/

    And the head of the National Institute of Mental Health confessed all the DSM disorders to be scientifically “invalid” six years ago.

    https://www.nimh.nih.gov/about/directors/thomas-insel/blog/2013/transforming-diagnosis.shtml

    “this suggests ‘that the complex causes of psychiatric conditions could be neatly divided into diseases and not diseases, as if this is a line carved in nature…'”

    The two “most serious” DSM disorders, “bipolar” and “schizophrenia,” are illnesses created with the psychiatric drugs. As Whitaker pointed out, the ADHD drugs and antidepressants create the “bipolar” symptoms. Even the DSM-IV-TR pointed out it was malpractice to claim antidepressant induced mania is “bipolar.”

    “Note: Manic-like episodes that are clearly caused by somatic antidepressant treatment (e.g., medication, electroconvulsive therapy, light therapy) should not count toward a diagnosis of Bipolar I Disorder.”

    But our hubris filled psychiatrists took that disclaimer out of the DSM5. Rather than adding the ADHD drugs to that disclaimer. Which is what they should have done, if they had any ethics whatsoever. No ethics, but filled with hubris, DSM5 writers.

    The “schizophrenia treatments,” the antipsychotics/neuroleptics, create the negative symptoms of “schizophrenia” via neuroleptic induced deficit syndrome. And the antipsychotics create psychosis and the other positive symptoms of “schizophrenia” via antipsychotic induced anticholinergic toxidrome.

    https://en.wikipedia.org/wiki/Neuroleptic-induced_deficit_syndrome
    https://en.wikipedia.org/wiki/Toxidrome

    So I think there is actually “a line carved in nature…” All the DSM disorders are BS, none are real diseases. That is the “line carved in nature.”

    “Are those among us who try to bring attention to [the harm psychiatrists are doing] dismissed as polemicists?” Yes. The majority of “mental health” workers and doctors can’t handle the truth.

    Me: Can you stop stigmatizing and drugging the children?
    Pediatrician: “No, it’s just too profitable.”

    Psychiatry should give away “some of its power to therapists, counselors, social workers, social service providers, and patient-run organizations.” So long as the psychologists, therapists, counselors, social workers, and social service providers utilize the fraud based DSM for billing purposes, they will not be helping their clients. They will just continue to stigmatize and defame their clients.

    • I just want to point out that the RDoC is not something to be celebrated just because it rejects the DSM. A fundamental fatal flaw of the RDoC is that “mental disorders” exist as discreet entities and have a biological basis. Otherwise, it is little more than a pissing match over which disorders are legitimate and which are due to mission creep. The emerging data implicates the gut far more than the brain, but you wouldn’t know that by reading the RDoC’s agreed upon terms and calls for a “new nosology”.

      “A diagnostic approach based on the biology as well as the symptoms must not be constrained by the current DSM categories,

      Mental disorders are biological disorders involving brain circuits that implicate specific domains of cognition, emotion, or behavior,

      Each level of analysis needs to be understood across a dimension of function,

      Mapping the cognitive, circuit, and genetic aspects of mental disorders will yield new and better targets for treatment.”

  3. It seems to me that the diagnostic system hangs on largely due to payment systems that require labels to justify a level of severity of illness and need for more extensive intervention because we have a profit-driven healthcare system (something current Medicare for All campaigns fail to address). Not only that, we have a disability system that is strongly tied to diagnostic labels to determine severity of “illness”, and ability to earn taxable money. And a media that reinforces cultural notions of a special class of “mentally diseased” people that is really a veiled effort to justify increased policing, mass surveillance, and targeting of people for special lists because the NRA wants us to believe gun violence is solely caused by “crazy” people.

    We have a constitutional right to an education to prepare workers for our profit-driven economy, but there are no core rights to housing, healthcare and food, and our culture is so completely blinkered by notions of merit that not dying homeless and diseased in the streets is considered a right only of the able bodied and strong minded.

    Psychiatry currently serves to reinforce these notions (meritocracy) and until it’s willing to reconcile with its position as an enforcer of the profit-driven version of normality – and the (re)normalizing of debt bondage and serfdom – by pathologizing the normal response to trauma/adversity (at any age), there’s going to be little progress.

    We all do suffer under this system. Most of those of us who get labeled as SMI however have a history of trauma and have been punished by the system for our natural responses to it. My personal experience was that my traumas were blamed as the environmental influence that “triggered” the so-called genetic disease of “Bipolar” that conveniently manifested only after I’d been drugged with an SSRI for the somatic illness of “fibromyalgia” – the symptoms of which I now know to have been caused by Lyme disease. Talk about getting screwed at every step!

    Psychiatry as practiced in the West is a behavior control system with payment based on how sick the doctor can make the patient appear. This will not change until it is no longer profitable to disease the patient. The Finnish healthcare system is ranked among the best and most egalitarian in the world and the American system among the worst of developed countries. We need to look beyond psychiatry to understand why our American healthcare system is failing and the role psychiatry plays in maintaining the status quo for profit if we want to understand why the (zombified, in my opinion) disease model of “mental illness” refuses to die, even in the face of decades of evidence of its failure.

    • I largely concur with Auntie — the only “quibble points” for me would be the idea that “until” it does this or that psychiatry will be useless, or destructive, or whatever. This implies that there are things psychiatry could do to legitimize itself when there are in fact none, as the entire field is based on not only false but absurd premises. As one who generally rejects false hope, I imagine you still would agree that by definition psychiatry cannot be reformed.

  4. Thank you for this review Sandra Steingard. I ran into a copy of Anne Harrington’s book when visiting the library of another town and could only skim it.

    When she talks about a “sympathetic view” of psychiatry I ask myself “Sympathetic towards whom?”

    I am one of those who derived more harm than good from standard psychiatric treatments. Not psychotic till I took Anafranil for 3 weeks. Got diagnosed “Bipolar 2” and put on 3-4 drugs as a consequence.

    After 20 years I became chronically ill. Finally went off the drugs in secret with only online support. Forced to live on SSI even now thanks to IBD and nerve damage from long term drug use.

    It troubles me that Dr. Harrington wants to lock up swaths of people in institutions. Doc Torrey, our old friend, has gone on record saying we need to build more institutions. So is he admitting his magical pills are NOT 100% safe and effective after all?

    A lot of us have suffered long term iatrogenic damage already from drugs that drove us crazier than before we took them. Now they want to simply lock us up and throw away the key? 🙁

  5. Thank you Sandy for this interesting review. I am not sure I would find that much new in the book and I am sorry that she was not more critical. It is tragic that our field pathologizes normal human suffering. In the process, hope is extinguished and opportunities for healing the person and their network are lost in mirage of medication fixes. The voice of those of us with lived experience are being silenced more than ever in this era.I too continue to integrate medication with Open Dialogue, peer support, and Emotional CPR. But the ideology surrounding medication privilege it in a manner that makes it difficult for the other approaches to have equal influence.