The Crisis of Present-Day Psychiatry: The Loss of the Personal

(The following is the first of two articles adapted by the authors from lectures given at the University of Zurich upon receiving the 1998 Dr. Margrit Egnr-Stiftung prize-Ed.)

Let us begin with an example. Suppose I am traveling from the United States to Switzerland, anticipating skiing with my son in the Alps. My anticipation becomes vivid and lively. I recall excitement mixed with joy at rapidly soaring down the mountainside, and I am now quite anxious to re-experience this thrilling adventure with my son-eager to be heading down the mountain with him. Later, as we stand on the crest of a deep and winding slope, the speed, thrill and admixture of danger and adventure will infuse my being.

If, in this condition of excitement and joy, my body were connected to a monitor and tested, it would register certain physiological patterns that might be identical to those of an anxiety attack. So, from one point of view, my anticipation of a thrilling ski adventure could be mistaken for an anxiety attack. This point of view would, of course, have to disregard my subjective experiences, which are those of a person filled with joyful excitement.

Granted, in colloquial English we say, "I am anxious," but in this case it is meant in the sense of "I am anxious to meet my son." This anxiety is of joyful expectation, just the opposite of morbid anxiety. Indeed, if the only categories at one's disposal were pathological categories, my organic condition would have to be classified as an anxiety attack.

Therefore, in order to misinterpret my condition as an anxiety attack: 1) my condition must be decontextualized, i.e., my personal situation-that of a man traveling to go skiing with his son-would have to be disregarded and my organic condition alone considered; and 2) the decontextualized organic condition must be viewed as falling under some pathological classification system. If taken, these two steps would categorize my state as an anxiety attack.

In the modern climate of thought, the first step-ignoring the person's subjective experiences-is easy enough to take. Indeed, this would be viewed as required for a strictly scientific test. Science itself demands that subjective experience be disregarded and organic reality alone examined. Only in this way, the modern mind assumes, is a truly objective result reached.

The second step does not appear to follow as easily from the proclivities of the modern mind, however. But it does easily follow the modern specialization of the sciences. As they more precisely isolate specific provinces of reality, some sciences have focused on pathological conditions, leaving the study of healthy states to other disciplines. For example, American psychiatry has become determined to define mental disorders as thoroughly as possible, and it has indeed made some progress in this regard. But American psychiatrists rarely study mentally healthy people.

Psychiatry and the Specialization of the Sciences

This concern with the pathological and neglect of the healthy is part of the specialization and resulting fragmentation of the sciences in Westernized countries. The increasing precision with which scientists study those aspects of the world in which they are interested focuses on ever more restricted dimensions of reality. One result is that the various sciences, now so many and so specialized, have little contact with one another. This is certainly true of the disciplines that study human life-too many and too vast to be comprehended by a single mind. For example, psychiatrists, in order to treat mental disorders, must study psychopathology, neurophysiology, psychopharmacology, behavioral therapy and psychotherapy, as well as a variety of medical disciplines. Hence, while psychiatrists know the special sciences peculiar to their field, they are disinclined to study philosophy, humanities and social sciences.

The other force that leads psychiatrists to ignore philosophy, humanities and social sciences is the remedicalization of psychiatry. Today, most American psychiatrists emphasize the fact that they are physicians, i.e., practitioners of a medical specialty. As they see it, psychiatry is simply one specialty within medicine, on a par with cardiology, orthopedics and gynecology. In order to validate this claim, psychiatrists increasingly strive to practice psychiatry the way other doctors practice their specialties. Hence it is thought to be desirable if the diagnostic manuals, treatment procedures and outcomes testing in psychiatry resemble as closely as possible those of the other medical specialties. In order to see how we have arrived at this predicament in psychiatry, let us take a few historical steps back, returning to the birth of psychiatry during the Enlightenment.

The Enlightenment and the Origins of Modern Psychiatry

Psychiatry was born in the 18th century as part of the Enlightenment, a period when people, inspired by the new scientific spirit, were able to view mental disturbances as illnesses rather than as the result of sin or witchcraft. Mental problems were thus conceived in causal terms rather than moral or religious ones. Although the mechanisms within the individual producing these disturbances were unknown, the mere conception of these disturbances as due to causal mechanisms revolutionized our understanding of them. But this mechanistic conception of mental problems did not exist, as it does today, in theoretical isolation. Like all science at that time, this view formed merely one subsidiary branch of an all-encompassing metaphysical view that included social, political, religious and moral conceptions. To see this clearly, one must grasp the overall character of the Enlightenment.

The Enlightenment perpetuated and reinvigorated the Renaissance ambition of a universal philosophy of reason in whose light human beings could shape themselves and their entire social world. This universal discipline bore the name philosophy. However, the sciences at this time were part of philosophy-the two had not yet been distinguished. Ren Descartes reformulated the age-old belief that all the sciences were but branches of the tree of philosophy. Therefore, this universal philosophy included physics and mathematics as well as the sciences of the human mind, society and politics (Husserl, 1970).

Moreover, in its all-embracing unity, this universal philosophy included political and moral values. Its ultimate ideal was to be life-guiding and action-directing, with no distinction between daily life and philosophical reason. Life-including the collective, social life-should be shaped by philosophical reason. Nothing less than the reformation of the entire society under the guidance of a normative rationality was the aim of these thinkers. Hence the value-ideals of the French and American Revolutions-liberty, equality and universal human rights-were designed to guide this political and social reformation. The idea of value-free scientific knowledge still lay a century in the future.

When Enlightenment thinkers, like Dr. Benjamin Rush in America, took psychiatry (yet to be named) as their subject matter, they applied to a delimited group of phenomena a universally broad philosophical system that encompassed every kind of reality. While the illness was perceived from a mechanistic point of view, the patient was still seen as a human being with human rights deserving of inclusion in the full privileges of universal humanity. Hence physicians were able to regard mental disturbances as illnesses like other natural diseases; yet they still were able to see patients as potentially capable of living in a moral community. This vision at least provided the ideal for their treatment, which physicians called moral treatment. In moral treatment, mental patients were unchained; with the goal of integrating patients into daily life, psychiatrists dressed them in proper clothing, took meals with them, engaged in ordinary social interactions with them and sometimes even married them (Bockoven, 1972; Zilboorg, 1941).

Even during the Enlightenment, however, forces were at work that would eventually undermine this grand conception of a universal philosophy. The Enlightenment ideal declined partially because of the advances in knowledge steadily accruing in physics, anatomy and other natural sciences, which were bought at the price of specialization. As researchers began to specialize in separate fields, and as knowledge grew, specialists in one field became unable to keep abreast of advances made in other fields, bringing an end to universal understanding.

Philosophy continued to exist, of course, but in philosophy it was difficult to show the progressive advancement of knowledge so obvious in the natural sciences. Philosophers such as Georg W.F. Hegel still sought to integrate human knowledge and values into one single system of thought, but these all-encompassing systems were espoused by only a few. As a result, philosophy, now conceived as distinct from science, became intellectually discredited. And so it stands today-except that the separate sciences receive even more respect, and philosophy receives even less.

The Modern Period and the Sciences

Before looking more closely at the state of psychiatry today, let us lay bare some of the factors that made this increasing scientific specialization and diversification possible. In order for scientists to carve out a distinct domain of reality for scientific investigation, they must perform certain acts of abstraction. Scientists must consider the properties of one domain of reality alone and disregard other realities, sometimes even other properties of the same reality. For a physicist to study, for example, the electrical currents moving through a microphone, the fact that the microphone is a cultural tool with a particular social function and value must be disregarded. Of course, the function it performs for speakers and audiences may remain somewhere in the back of the physicist's mind. But this background awareness does not constitute any part of the scientific understanding of electricity. The science of electricity has abstracted from the social functions of the objects through which the electricity moves. To abstract from certain aspects of reality, then, is to systematically disregard those aspects of reality.

The field investigated by a particular science can be defined and understood only by abstracting from and disregarding those aspects of reality studied by other sciences. It is this systematic disregarding that separates the fields of science from one another. Of course, connections are sometimes made between fields. But this only produces other specialized scientific fields like psycholinguistics or sociolinguistics. The history of science in the modern period has been the history of the division of reality into disparate regions by the growing specialization and separation of the sciences (Husserl, 1970).

In numerous ways philosophy has served as the handmaiden to this increasing specialization and separation. One of the ways it has done so is by finding metaphysical justifications for the abstractions that the sciences have made. For example, since the natural sciences systematically abstract from the values things have, they are said to be value-free or value-neutral. Although this abstraction was probably originally motivated by the need to liberate science from religious and political control, it purified nature for characterization in mathematical terms.

Philosophy aided this abstraction by constructing a metaphysical dualism that strictly separated mind (where values were relocated) from body, thereby excluding values from the external world, confining them within the inner domain of consciousness. This mind/body dualism, in fact, served extremely well as a device for ridding nature of whatever properties the various sciences sought to disregard: It was always possible to resituate those properties within the inwardness of the mind, thereby denying their presence in the outer world. It was accordingly easy for modern philosophy to help the emerging science of biology, for it allowed this science to abstract from the teleology of organic beings by restricting all teleology to consciousness alone. In this way, living beings could be conceived as determined solely by the same kind of efficient causality that governed the rest of nature (Jonas, 1966).

The Equivocal Face of Present-Day Psychiatry

Now we return to the present in which psychiatry, we contend, has entered a crisis. This present-day crisis of psychiatry, we admit, is peculiar because, while numerous psychiatrists recognize psychiatry's critical condition, many others believe the field has never been in finer shape. Those who contend that psychiatry is doing quite well will point pridefully to refined diagnostic instruments like the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, and its many specialized handbooks, algorithms and tests. More proudly still, they will list the vast array of fourth-generation drugs that so effectively relieve many symptoms that previously defied therapy. And the practical efficacy of these drugs, they will say, can now be explained through our rapidly mounting knowledge of the biologic and genetic mechanisms involved in the pathogenesis of mental disorders.

For the first time ever, they will boast, psychiatry now equals the other specialties of medicine in the scientific rigor of its research and knowledge, the reliability of its diagnoses, and the safety and efficacy of its treatments. Thus, through these rapid advances, psychiatry has attained the scientific status that makes it as respectable as any other branch of medicine.

Since many psychiatrists herald this newly acquired elevated rank among the sciences, how can we claim that psychiatry has entered a period of crisis? We claim this because we think psychiatry has managed to acquire this appearance of a respectable science only by dangerously fragmenting its conception of the patient.

The following represents the crisis of present-day psychiatry:

• Psychiatry lacks a conception of healthy mental life; i.e., it lacks an understanding of psychological normalcy. As a result, most aspects of patients' lives are perceived in pathological terms. Indeed, the very term phenomenology is today assumed to mean psychopathology.
• Psychiatry lacks adequate conceptions of the many disorders of which it speaks. It has forsaken all serious attempts to understand the patient's experiences, deeming any such attempt unscientific. As a result, it has reduced mental disorders to a list of observable symptoms.
• Psychiatry lacks therapies appropriate for mental disorders due to this lack of conceptions. Thus, treatment procedures have become simplistic and reductionistic; therapies are now primarily pharmacological and behavioristic.

In the briefest terms, psychiatry, a firstborn child of the Enlightenment, is in crisis today because its conceptions of mental illness and patients are too restricted and abstract. Present-day psychiatry lacks an adequate understanding of its patients and of itself as a healing discipline. It is necessary to at least return to the aspiration of the Enlightenment image of psychiatry as part of a comprehensive theory of human life, nature and society. In other words, psychiatry needs again to find its place within a universal philosophy of humanity that forms the basis for both the sciences and ethics.

• The Dangers of a Psychiatry in Crisis

It was not that long ago that we witnessed the frightening misuses to which psychiatry can be put when it lacks an understanding of itself and its patients. In both Nazi Germany and the Soviet Union, psychiatry was used as an instrument of the greatest collective crimes against humanity the world has known. It should be emphasized that in these totalitarian regimes, psychiatry was not simply one of the instruments for state crimes, it was a very important instrument.

Psychiatry could serve such demonic political purposes because its understanding of patients was insufficient to distinguish between mental illness and mental health. Consequently, perfectly normal people could be classified and treated as mentally ill. Mental illness meant nonconformity to social or political categories, while mental health meant conformity to those categories (Beer, 1997; Lifton, 1980; Gluzman, 1989; Savenko and Vinogradova, 1996).

Currently, in the United States, there is no adequate conception of mental health. By default, then, mental health comes to mean social conformity. For children this means conformity to the expectations of parents, teachers, school counselors and other adult authority figures. Mental health in adults means conformity to society's expectations.

There exist large numbers of mental health experts or professionals-social workers, clinical psychologists, psychiatrists and so on-who are prepared to misdiagnose nonconformity as a mental disorder. Such misdiagnoses occur readily when the only categories that mental health professionals possess are categories of pathology, and when the criteria for mental pathology are as simplistic and reductionistic as they are today.

The social and political forces at work in America today remain, of course, very far from those in Hitler's Germany or Brezhnev's Soviet Union. But from our vantage point, the condition of psychiatry in the United States today is not that far from what it was in those countries. The crisis we have described entails psychiatry's lack of any firm grounding in a humanitarian and ethical understanding of the people it treats. Without this understanding, psychiatry could easily become the pawn of a variety of external forces.

Indeed, it is already becoming the pawn of these external forces: In 1998, managed care companies and health maintenance organizations began transforming psychiatry to serve their economic aims. Under this transformation, American psychiatry has fallen into a further reductionism: Economic constraints now lead clinicians and researchers to regard patients from very limited perspectives.

The fact that managed care organizations have significantly reduced the amount of time psychiatrists may spend with their patients is an indication of how this happens. For example, a psychiatrist's first contact with a patient is often restricted to thirty minutes; follow-up sessions are even more restricted. These severe restrictions threaten even the possibility of nonmedication-centered approaches, simply because they may be more time-consuming. Moreover, few funding organizations have an interest in proving their effectiveness.

On the other hand, pharmaceutical companies are eager to pay for research showing the effectiveness of their medications. As a result, there are far more investigations of pharmacotherapy than of other approaches. Moreover, medications are quick and easy for the clinician to prescribe, easy for the patient to take and usually successful in reducing the patient's symptoms. In this way, biological psychiatry has justified the limitations on time and money imposed by managed care corporations. These corporations, conversely, by referring to the published research, deny payment for nonmedication-centeredapproaches.

The result is that patients' problems are treated as primarily chemical imbalances in the brain. In this way, managed care businesses lead psychiatrists to practice medicine as if biological psychiatry sufficiently explained mental disorders. Biological psychiatry thus assumes a prominent role in present-day psychiatry, not because its hypotheses have been scientifically proven, but because clinicians must think in its terms in order to practice within the limits imposed by managed care companies. Consequently, psychiatric treatment and research move more and more toward a reductionistic conception of the patient.

This relationship between managed care companies and biopsychiatry arises from an elective affinity between the two. The sociologist Max Weber borrowed Johann Wolfgang von Goethe's phrase elective affinity to signify a noncausal process in which two sets of interests seek one another out and reinforce one another (Weber, 1958). In this example, managed care corporations do not actually dictate psychiatric approaches. Psychiatrists still are free to choose their individual treatment plans and research projects. But these choices must be made within the restrictions on time and payment imposed by managed care companies. As a result, psychiatrists increasingly perceive an affinity between the needs of their patients and the provisions of biopsychiatry. Thus, managed care companies have created working conditions for physicians in which the only reasonable thing for psychiatrists to do is conform to the treatment and research programs of biological psychiatry.

The impact of managed care on the basic direction of psychiatric practice and research illustrates the alarming malleability of psychiatry today. Psychiatry is in crisis because it has lost its moorings to an ethically grounded vision of the patient that is sufficiently holistic to appreciate human personhood in its full breadth.

References:

• References 1.Beer MD (1997), History of the psychiatric profession and its institutions. Current Opinion in Psychiatry 10:412-418.
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  4.Husserl E (1970), The Crisis of European Sciences and Transcendental Phenomenology; An Introduction to Phenomenological Philosophy. Evanston, Ill.: Northwestern University Press.
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