The Humanities and Psychiatry: The Rebirth of Mind

What place do the humanities have in psychiatry? One might as well ask: What place does the mind have in the brain? What place does clinical experience have in medicine? What is the utility of the empty space within the vessel? The term “humanities” is broad and includes “the study and interpretation of . . . language . . . literature; history; jurisprudence; philosophy . . . ethics . . . [and] aspects of social sciences. . . .”¹

Is any of this relevant to everyday psychiatric practice?

The humanities are a variety of academic disciplines that focus on the human condition with analytic and sometimes speculative methods. This is in contrast to the empirical methods of the natural sciences. The humanities are required, primarily because science alone cannot answer the question of what it means to be human. In truth, neither can the humanities. Science and the humanities are like the yin and yang of our intellectual explorations into the human condition-one is necessary for (and contains) the other.

As a student of “psychiatry and the law” as well as of psychodynamic psychotherapy, the question of the relevance of the humanities to psychiatry has always seemed too obvious to me. Yet in this particular age, I realize I am obligated to back up my claim that we should focus on anything beyond the randomized controlled trial. Here I admit bias, because the study of law reveals a potent mix of social sciences and humanities, in so far as it focuses on the “relation between legality and morality.”²

Forensic psychiatry has occupied a distinctly hybridized place in the annals of medical jurisprudence for some 2 centuries. Students of both law and medicine are quickly led to the conclusion that both are “critical tools for improving health and well-being on a global level, and each profession is more effective when the two work together.”³ Thus, the value of mixing science with the humanities, at the proper time and place, seems evident, insightful, and farsighted.

In this article, I focus on the importance of the humanities to psychiatry, via the perennial conflict between biological psychiatry and psychodynamically oriented psychiatry. I hope to use a humanist approach to show that these “two cultures” depend on each other for balanced progress in the field.

The Battle for Psychiatric Knowledge

Had I not done a fellowship in forensic psychiatry, I would not likely have knowledge of what Alan Stone, MD, called “an important historical moment of transition in modern psychiatry.”⁴ Stone was referring to the case of Osheroff v Chestnut Lodge that settled out of court in the mid-1980s [for a pdf, please click here]. For a case that set no official legal precedent, it rocked the foundations of psychiatry: it was a “showdown between two forms of knowledge in psychiatry-evidence-based medicine and clinical experience.”⁵

In brief, Dr Osheroff was a 42-year-old nephrologist who was admitted to Chestnut Lodge in 1979. At that time, Chestnut Lodge had “played an important role in the modern history of psychiatry in the US. [It was] one of the major centers of theory and clinical practice in intensive individual psychotherapy” based on psychoanalytic therapy.⁶ Psychotherapy pioneers such as Harry Stack Sullivan and Frieda Fromm-Reichmann served, at various times, as consultants at Chestnut Lodge.

Dr Osheroff had a number of psychosocial stressors, was in his third marriage, and suffered periods of depression and anxiety. He had been treated with TCAs and individual therapy, with moderate improvement; he had difficulty with adhering to treatment. For about 7 months, he was treated at Chestnut Lodge exclusively with psychoanalytically oriented therapy. Dr Osheroff deteriorated significantly, and symptoms of a severe agitated depression developed. His family intervened and had him transferred to Silver Hill Hospital, where he was treated with a TCA and an antipsychotic. He improved and was discharged after approximately 3 months.

The contrast between the approaches of the two hospitals represented the dichotomous thinking prevalent in psychiatry. While Silver Hill focused on Dr Osheroff’s biological depression, Chestnut Lodge focused on long-term change by treating his underlying personality disorder. After his recovery, Dr Osheroff sued Chestnut Lodge, alleging, among other things, negligent diagnosis, negligent treatment, and failure to obtain full informed consent by not disclosing and discussing alternative treatments.⁷

The Two Cultures

Surely, the concept of dualism and dichotomous thinking goes back to unknown ages. But about 53 years ago, at the University of Cambridge, a highly respected scholar, C. P. Snow, delivered a lecture that would powerfully capture the tension between 2 types of thought: science and art. His Rede Lecture, “The Two Cultures,” gave open expression to the “gulf of mutual incomprehension” between 2 scholarly approaches that function as pillars of intellectual progress.⁸ The dichotomy was that of scientists against what Snow called the “traditional” community (or literary intellectuals). Snow seemed somewhat disparaging of traditionalists who could readily quote Shakespeare yet remained ignorant of the second law of thermodynamics.

The dichotomy constructed by Snow is a stark one and allows us to more clearly distinguish the 2 types of thought. For example, while the second law of thermodynamics is “specialized knowledge, useful or irrelevant depending on the job,” Shakespeare’s writings are a form of “self-knowledge” in terms of their capacity to “provide a window into the soul of humanity.”⁹

Snow was taken to task 2 years later by a member of the traditional community-F. R. Leavis, who was a distinguished English professor and literary critic at Cambridge, and thus one of the elite literati.⁹ Leavis’s rebuttal, “The Significance of C. P. Snow,” was a withering ad hominem attack. Leavis also suggested the concept of a third realm where important knowledge existed-not in physical reality but in human minds as a collaborative body of work. The practice of medicine has been referred to as both an art and a science. Arguably, it is the medical specialty of psychiatry that bridges this gap rather conspicuously. Psychiatry’s integration of the humanities with science could be considered both its strength and its weakness. Much like other hybrid fields (eg, economics, political science), psychiatry is the quintessential “third culture.”⁵

Clash of the Psychiatric Titans

Some 30 years later, the Snow-Leavis debate was recapitulated in psychiatry. This was a clash of psychiatric titans carried out in the pages of the American Journal of Psychiatry in 1990. Arguing from the corner of science was one of the most eminent biological psychiatrists of the time-Gerald Klerman, MD. Klerman had been a psychiatric expert retained by Osheroff and spoke with experience of the case as well as with his recognized authority in American psychiatry. Representing the corner of traditional psychiatry, and thus psychoanalytically informed psychiatry, was Alan Stone, MD, whose undisputed authority in both law and psychiatry provided the balanced matchup for Klerman.

Klerman’s opening salvo was powerful to the point of authoritarian: he proclaimed that there should be a legally recognized “right to effective treatment.” He invoked the scientific powers made famous by Archie Cochrane, stressing the centrality of the randomized controlled trial (RCT) and that “the issue is not psychotherapy versus biological therapy but, rather, opinion versus evidence.”¹⁰ In fact, Klerman seemed prepared to annihilate all forms of treatment that had not been supported by an RCT. Leveling his psychiatric authority down on all “lesser” forms of knowledge, he warned: “practitioners and institutions who continue to rely on forms of treatment with limited efficacy will be on the defensive and at possible jeopardy for legal action.”⁶

Stone’s response was as powerful as Klerman’s but differed in style. Stone began by refuting Klerman’s notions about the law. It was Stone’s opinion that Klerman should have limited himself to stating that using exclusively psychoanalytic treatment for Osheroff was not clinically acceptable-a point with which Stone agreed. However, Stone was very concerned about Klerman’s threat to dictate a “universal rule set by one school of psychiatry for the others.” He went on to point out that the Osheroff case was more complex than “the pills worked.”⁵

Stone questioned the very nature and reliability of efficacy research in psychiatry and followed with a suggestion that there may have been more to Osheroff’s improvement than mere medications. Stone warned that Klerman’s edicts would “repudiate the traditional commitment of both the law and psychiatry to diversity” and could become “detrimental, even to the aspirations of ‘scientific psychiatry.’” Stone revealed his motivating intent as freedom-in particular, the freedom to consider both science and the humanities, which seems to be necessary for psychiatry to avoid a scientific dictatorship.

But the clash was not fully over. In a rebuttal letter to the editor, Klerman asked: “Why doesn’t psychodynamic psychiatry attempt to be scientific?” He concluded that “psychoanalysis is now on the defensive intellectually and scientifically. . . . My dominant feelings about psychoanalysis are frustration and disappointment.”¹¹

Beyond Dichotomy: Rising to the Challenge

And so what can be said, 2 decades later, about the outcome of this “important historical moment of transition in modern psychiatry”? Did Klerman’s proposals, in fact, have “serious consequences for the innovation, diversity, and independent thought essential to scientific progress in psychiatry”? After Osheroff, and particularly during the “decade of the brain,” the schism widened between “a reductionist scientific method, as manifest in evidence-based medicine, and that of a narrative form of knowledge derived from clinical experience.”⁵ The dualism was outlined rather comprehensively by anthropologist T. M. Luhrmann¹⁰ in her book Of Two Minds: The Growing Disorder in American Psychiatry. Luhrmann concluded that neither the biomedical nor psychodynamic approach “mirrors” the reality, but each provides a different and valuable way of approaching mental illness.

It can be argued that the greedy reductionism of scientific psychiatry inexorably wrapped itself around the brainstem of psychiatry, threatening to squeeze the life out of the art of psychiatry. Despite the best intentions of the biopsychosocial model, it can be argued that the practice of psychiatry, particularly from Osheroff forward, deteriorated into a de facto biological reductionism (R. Pies, personal communication, October 15, 2012). Should psychiatry be faulted for taking this path? While opinions may be divided on this issue, it should be noted that psychiatry was merely following the lead of medicine generally.

Although the biopsychosocial model has been heavily critiqued in recent decades, many would argue that it was never meant to “discover” neuropsychiatric pathology. Rather, it is a philosophy of clinical care and a practical clinical guide for the application of psychiatric knowledge to needs of individuals.¹² As for the way in which biological psychiatry allowed its knowledge to become subservient to the pharmaceutical industry, one is left to wonder if this was not part of the serious consequences dreaded by Stone.

Despite Klerman’s indictment, psychodynamic psychiatry has managed to survive as a viable model for clinical practice. And why might this be? The humanities search for truths about the human condition, just as science searches for truths about physical matter. Truths do not dissolve so easily. Freud¹³ noted: “In the end the most cutting truths are heard and recognized especially after the injured interests and affects aroused by them have exhausted themselves.” In fact, Freud anticipated the perennial fate of psychoanalytic thought. Who among us wants to be told that we are each the author of our own story, be it comedy, tragedy, or other? This is a painfully bright sun to stare directly into, and Freud¹³ was fully aware of this: “I must put a damper on your expectations. Society will not hasten to furnish us authority. Society must remain in a state of resistance towards us because we assume a critical attitude towards her. We inform her that she herself plays a great part in the causation of the neuroses.”

Although a bit slow to produce, psychodynamic psychiatry did listen to Klerman because it has attempted, to the best of its ability, to subject its approach to the scientific method.^14-16 In applying scientific methods to psychodynamic psychiatry, more important lessons have been learned. For example, nonpsychodynamic therapies may be effective, in part because more skilled practitioners use techniques that have long been central to psychodynamic theory and practice.¹⁷ Real-world clinical practice is often very different from the conditions of most RCTs (eg, patients commonly bring more than one illness to therapy), and psychiatrists find themselves employing a mix of evidence-based treatments with other empirically supported approaches and a good measure of creativity.^18,19

Conclusion

Should providence be with psychiatry, the next swing of the pendulum will not be so wild as to threaten to suppress an entire form of knowledge. Yet, this may be too much to ask, since progress often requires the most frustrating and convulsive upheavals. It does seem encouraging for psychiatry that over 2 decades since Klerman proclaimed psychoanalysis a disappointment, we find both it and its progeny alive and well.

Biological psychiatry has made truly impressive progress, yet it remains the case in 2013 that “biological psychiatrists do not hold the panacea for serious mental disorders,”⁷ particularly when standing on the lone pillar of science. The art of medicine remains a critical foundational structure in psychiatry, and both pillars are necessary for the stability of the field. One might say that the humanities and/or psychoanalytic thought helps provide science with the relevant questions on which to focus its “piecemeal work.”²⁰ Put another way: the humanities provide the wonder, which science then illuminates.

It is sometimes the case that older theories are not proved false-rather, the very progress they contributed to now shows their limits. This incremental progress is a “gradual accumulation of truth; or truth is approached by successive approxi-mations.”⁹ Pure science, in isolation, cannot tell us why we should undertake a certain act, such as attempting to relieve human suffering. It can only yield for us the most logical method of accomplishing, for good or ill, “what we have already decided to do.”⁹ In 2009, Chestnut Lodge was to be renovated when, sadly, it burned to the ground. One hopes that from the ashes of this symbolic edifice, arises a rebirth of a balanced, progressive psychiatry that fights for the benefit of its patients.

References

1. National Endowment for the Humanities. National Foundation on the Arts and the Humanities Act of 1965 (P.L. 89-209). Accessed January 24, 2013, http://www.neh.gov/about/history/national-foundation-arts-and-humanities-act-1965-pl-89-209

2. Shapiro SJ. The “Hart-Dworkin” Debate: A Short Guide for the Perplexed. February 2, 2007. U of Michigan Public Law Working Paper No. 77. Accessed January 24, 2013. http://dx.doi.org/10.2139/ssrn.968657

3. Annas G. Doctors, patients, and lawyers-two centuries of health law. N Engl J Med. 2012;367:445-450.

4. Stone AA. Law, science, and psychiatric malpractice: a response to Klerman’s indictment of psychoanalytic psychiatry. Am J Psychiatry. 1990;147:419-427.

5. Robertson M. Power and knowledge in psychiatry and the troubling case of Dr Osheroff. Australas Psychiatry. 2005;13:343-350.

6. Klerman GL. The psychiatric patient’s right to effective treatment: implications of Osheroff v Chestnut Lodge. Am J Psychiatry. 1990;147:409-418.

7. Malcolm JG. Treatment choices and informed consent in psychiatry: implications of the Osheroff case for the profession. J Psychiatry Law. 1986;14:9-106.

8. Snow CP. The Two Cultures: And a Second Look. Cambridge University Press; 1963.

9. Furedi F, Kimball R, Tallis R, Whelan R. From Two Cultures to No Culture: CP Snow’s ‘Two Cultures’ Lecture Fifty Years On. Civitas; 2009.

10. Luhrmann TM. Of Two Minds: The Growing Disorder in American Psychiatry. Alfred A. Knopf; 2000.

11. Klerman GL. The Osheroff debate: finale. Am J Psychiatry. 1991;148:387-390.

12. Borrell-Carrió F, Suchman AL, Epstein RM. The biopsychosocial model 25 years later: principles, practice, and scientific inquiry. Ann Fam Med. 2004;2(6):576-582.

13. Freud S. The future chances of psychoanalytic therapy. Selected Papers on Hysteria and Other Psychoneuroses. Accessed January 24, 2013. http://www.bartleby.com/280

14. Perry JC, Bond M. Change in defense mechanisms during long-term dynamic psychotherapy and five-year outcome. Am J Psychiatry. 2012;169:916-925.

15. Gerber AJ, Kocsis JH, Milrod BL, et al. A quality-based review of randomized controlled trials of psychodynamic psychotherapy. Am J Psychiatry. 2011;168:19-28.

16. Gabbard GO. Long-Term Psychodynamic Psychotherapy: A Basic Text. 2nd ed. Arlington, VA: American Psychiatric Publishing, Inc; 2010.

17. Shedler J. The efficacy of psychodynamic psychotherapy. Am Psychol. 2010;65:98-109.

18. Douglas CJ. Studying the efficacy of psychodynamic psychotherapy. Am J Psychiatry. 2011;168:649-650.

19. Vaillant G. Lifting the field’s “repression” of defenses. Am J Psychiatry. 2012;169:885-887.

20. Dennett DC. Facing Backwards on the Problem of Consciousness. November 10, 1995. Accessed January 24, 2013. http://ase.tufts.edu/cogstud/papers/chalmers.htm