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 Air, The 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.