Does Psychiatry Have a Future?
PSYCHIATRY IS NO LONGER A PROFESSION confined as securely as its patients in warehouses of the unwanted. Asylums no longer haunt our imaginations, though the demise of Victorian museums of madness occurred essentially behind the backs of the profession, more the consequence of changes in social structures and shifts in public policy than of professional initiative. The abandonment of the mentally ill to euphemistically named “board-and-care” homes, to the gutter, and to the jail has been paralleled by the collapse of the once-dominant fraction of the profession that practiced public psychiatry. In the contemporary neoliberal environment, the stigmatized souls who suffer from major mental disturbances find few friends in the halls of government, and, perhaps unfairly, are seen as a standing reproach to a profession whose core constituency they once were.
Still in some ways a barely acknowledged stepchild of the larger medical enterprise, psychiatry has acquired a substantial presence in academic medicine and now dispenses remedies that, at first blush, look more like the therapies employed by mainstream medicine than they once did: no more insulin comas, surgical eviscerations, or destruction of the frontal lobes; and no more talk of sex and the id either. Talk therapy has been largely ceded to those who practice without medical credentials, and biology and pills have become the dominant ways in which psychiatrists explain and respond to mental disorders.
But the wager on biology is a bet whose payoff has been far more limited than its architects promised. Though the advances in basic science have been noteworthy, their bearing on the fate of the mentally ill has been slight. The neo-Kraepelinian revolution of the 1980s, named after the German psychiatrist who established the importance of descriptive psychiatry and authored the original distinction between dementia praecox (schizophrenia) and manic-depressive psychosis (bipolar disorder), was premised on granting a new prominence to questions of diagnosis, a categorical view of mental disorders that portrayed them as distinct and separable illnesses, sharply distinguishable from normality—and, in theory, from one another. Though serviceable for a time, resolving the public embarrassment of a profession unable to agree on how to label the problems it confronted or to distinguish reliably the mad from the sane, it privileged reliability over validity. By relying on a checklist of symptoms, it contained the seeds of its own destruction. “Illnesses” proliferated, inviting ridicule. Unexpectedly, as the commitment to biology and genetics proceeded, the distinctions between disorders crumbled, and the notion that such artificial constructs could identify distinct diseases became ever-more implausible.
The world of the Diagnostic and Statistical Manual (DSM) survives, but barely. For patients and their families, being able to put a name to their troubles provides a measure of reassurance, and for doctors it provides some guidance about how to proceed, illusory though that sense of mastery often proves to be. At the same time, this unwieldy edifice has been gnawed away from within and assaulted from without. It survives only because there is nothing to put in its place—and by dint of its crucial roles in securing reimbursement from insurers. The DSM provides the comfort of a diagnosis to which doctor and patient can cling—a reassurance not to be minimized—and it serves as the rationale for drug treatments and for the research programs that support the academic wing of the profession. But in the words of a prominent psychiatrist who played a vital role in constructing the third and fourth editions of the manual, “DSM diagnoses have given researchers a common nomenclature—but probably the wrong one.… DSM diagnoses are not useful for research because of their lack of validity.”1
Genetics and neuroscience have flourished within the confines of universities, but their therapeutic payoff has been minimal or nonexistent. This may change, but it is equally possible that those sponsoring these programs may tire of funding investigations that show few signs of producing practical advances.
Psychopharmacology has provided treatments that help some, but only some, patients to mitigate their symptoms without disabling side effects, and this is an advance not to be sneered at. But it is limited progress nonetheless, and that progress now seems to have stalled. In the words of the former head of neuroscience at Eli Lilly and Amgen, “Psychopharmacology is in crisis. The data are in, and it is clear that a massive experiment has failed: despite decades of research and billions of dollars invested, not a single mechanistically novel drug has reached the psychiatric market in more than 30 years.”2
Psychological interventions like cognitive-behavioral therapy and interpersonal therapy have provided relief for many patients suffering from anxiety disorders, eating disorders, post-traumatic stress disorder, and some forms of depression, but these therapies can do little for those with the most serious forms of disturbance. That, too, is progress as grateful patients attest, although many of those so treated discover that the relief doesn’t last. One wishes it were otherwise, but it is foolish to exaggerate how far our understanding and our capacities to intervene have advanced.
Meanwhile, the pharmaceutical industry, having extracted vast profits from the pills it has provided to treat a whole array of mental illnesses, seems to be abandoning the search for novel remedies and treatments.3 In the last ten years, GlaxoSmithKline has all but closed its psychiatric laboratories, AstraZeneca has essentially dropped internal research on psychopharmacology, and Pfizer has dramatically reduced its spending in the psychiatric arena. Perhaps these companies have been put off by the reputational damage some less-than-salubrious activities in this arena have brought. Or perhaps, more likely, not seeing any obvious path forward and finding therapies for other forms of pathology a more likely source of future profits, they decided to move on.4
What of the future? Professions derive their authority, legitimacy, and privileged place in the division of labor from their claims to possess unique and valuable specialized knowledge, combined with a capacity for action—cognitive and practical talents that render the problems they address susceptible to expert intervention.5 Within the medical universe, it is occasionally possible to obtain elevated status largely on a foundation of diagnostic skills and prognostic precision, even in the absence of effective means of intervening in the course of a disease. Neurology, for much of its history, occupied just such a niche. For its practitioners, diagnostic refinement went hand in hand with therapeutic impotence, and yet neurology enjoyed a relatively high status in the medical profession and among the public at large. More generally, however, medics are expected to combine an ability to identify the troubles they are called on to address with effective treatments. Where pain and suffering are concerned, stoicism is generally in short supply. Thus, like most of the rest of medicine, psychiatrists must present themselves as experts both at diagnosing the patients who seek their assistance and at alleviating their distress.
On both fronts, psychiatry is in trouble. Its diagnoses are an increasingly frail reed upon which to rest its claims to expertise. Making matters worse, its recipes for intervention in the most serious forms of mental illness are at best Band-Aids. Band-Aids are better than nothing, and the remedies we have are certainly better than earlier generations’ resort to surgical bacteriology or severing portions of the frontal lobes. Defenders of psychiatry (and of clinical psychology) may also rightly point to evidence of greater success in dealing with some of the milder and more widespread forms of mental distress. Yet the problems posed by the gravest illnesses are real and pressing, and the origins of psychosis and depression remain almost as obscure as ever. Meanwhile, the search for remedies remains desperate and frustrating.
IN THE YEARS AFTER THE SECOND WORLD WAR, the leaders of American psychiatry disdained biology and the brain and looked solely to the psyche—both to untangle the roots of mental disorder and to treat it. The hegemony of the “mind twist” crowd ended abruptly at the end of the 1970s. Since then, “brain spot” psychiatry has enjoyed an almost unchallenged supremacy, instructing us to see mental illness as brain disease.6
I think monism of both sorts is deeply misguided. As I noted in the opening pages of this book, I would be astonished if biology made no contribution to the genesis of many serious forms of mental disorder, unsatisfactory and frustrating as two centuries of effort to unravel that mystery have proved. Equally, though, I am convinced that madness cannot successfully be divorced from the cultural, social, and psychological matrix in which human beings exist. To deny that social factors play a major role in the genesis and course of mental illness is to blind oneself to an enormous volume of evidence, epidemiological and otherwise, that teaches us that the environment powerfully matters.
Of course, in a larger sense, this separation of the social and the biological is thoroughly misguided. To an extent unprecedented in any other part of the animal kingdom, humans’ brains continue to develop postnatally in ways heavily conditioned by the environment. Culture and society, on both a grand and a microscopic scale, interact powerfully with our lifestyle choices and biology, and in all sorts of complex ways the physical structure and functioning of our brains are shaped by psychosocial and other sensory inputs. Human plasticity extends far beyond childhood. As we now know, the very shape of the brain and the neural connections that develop within it—the biology that constitutes the physical-substrate underpinnings of our emotional and cognitive existence—are profoundly influenced by social and psychological stimulation, most crucially of all by the familial environment within which human beings grow. Thinking, feeling, and remembering are in a multitude of ways the product of complex networks and interconnections that form in the maturing brain. Developmental and environmental factors are crucial elements in determining whether someone becomes mentally ill and what forms their disturbance might take.
To think of the brain as an asocial or presocial organ is thus profoundly mistaken.7 So, too, is the crude parallel notion that mental illness—the breakdown of our cognitive and emotional life—is just brain disease. The obverse is surely also true: to dismiss any role for biological factors, and insist that only the mind or family matters, is to don a different set of blinkers. One self-imposed blindness is as bad as the other. Leon Eisenberg put it well: “Psychiatry is all biological and all social. There is no mental function without brain and social context. To ask how much of mind is biological and how much social is as meaningless as to ask how much of the area of a rectangle is due to its width and how much to its height.”8
Chemicals, even far better and more precisely administered chemicals than we presently possess, will never provide a wholly satisfactory answer to the riddles of mental illness or the challenges of responding to the personal and social disruptions that inevitably follow in its train. Developmental and environmental factors play a crucial role in the genesis and the character of mental disturbance, and addressing these dimensions of the problem requires a different, multifaceted approach. In the meantime, what remedies we have treat symptoms rather than cure, and they are wildly and unpredictably uncertain in their effects in any individual case. Perhaps advances in genetics will improve this situation, providing some means of predicting which medications will provide some degree of relief for a particular patient while avoiding a nasty constellation of side effects, but at present we are far from being able to do so with any degree of consistency. The prospects remain cloudy.
In any event, biological advances can take us only so far. For fortunate souls, the antipsychotics and the antidepressants that psychiatry at present relies on do provide some semblance of a solution to the devastating tragedy that otherwise envelops them. Palliative measures are assuredly better than nothing, so long as they do not bring in their wake new medically induced pathologies that outweigh the problems they began with. With time, too, just as they did before the psychopharmacological revolution and generally just as mysteriously, some mental illnesses remit. Depression lifts, mania subsides, even a diagnosis of schizophrenia is not always as unyielding a proclamation of one’s fate as is oftentimes assumed. But for far too many patients, such positive outcomes remain out of reach. Treatments are ineffectual or else bring in their wake a host of new and threatening pathologies. What then?
If we are to confront the challenges that mental disorders present to all of us, we shall have to take account of social and political realities. As we have seen, the decisions to confine the mentally ill to the madhouse and, more recently, to decant them into unwelcoming “communities” have drastically affected what it means to be mentally ill. Institutionalization and deinstitutionalization were both driven by powerful social and political imperatives. For practitioners and their patients, these are the larger matrices within which they live their lives.
We need a very different approach. The fixation on the biological has led to another kind of stasis. Neuroscientists and geneticists have used their command of academic departments of psychiatry to attract large amounts of funding for their research, and they have rewarded their sponsors with some useful basic science. The clinical utility of their work, however, has verged upon a nullity, and their dominance has created a remarkable gap between the worlds of academic and clinical psychiatry. The phenomenological and social dimensions of mental illness have all but disappeared as questions worthy of serious and sustained attention.9 That is an imbalance that has had profoundly negative effects on psychiatry and, more important, on the prospects of advancing the clinical care of patients and of achieving durable insights into the complexities of mental illness. If we are to obtain a better grasp of the boundaries, etiology, and the therapy of anomalous mental states, we must abandon a dogmatism that privileges either psyche or soma.
We should seek, in confronting madness, to avoid premature and uncritical enthusiasms and easy solutions. It would help enormously if psychiatry were to be more honest about the limits and imperfections of its knowledge, as well as less committed to a single approach to the problems with which it grapples. Humility and open-mindedness are deeply desirable qualities, but they are in short supply.
On the positive side, there are signs that some psychiatrists have begun to recognize the problems that confront us. Many of the criticisms of contemporary psychiatry in the closing chapters of this book rest, after all, on the findings of research being done in the field. Eventually, one must hope, the weight of evidence that the profession has gone astray will become too hard to ignore. Psychiatry has never been a monolith, and though there have been periods dominated by either the mind or brain, there have always been those who have resisted the dominant paradigm or who have found both kinds of reductionism difficult to swallow.
There is, however, a deeper difficulty that we confront as a society as we seek more effective responses to the problems of serious mental illness. The closing of asylums coincided with the abandonment of any serious public effort to ameliorate the sufferings of those gravely disabled by mental disturbances of all kinds. In a society that valorizes the market as a universal solvent, and that attributes failure to the shortcomings of the individual, those with serious mental illness face a harsh future. The malign neglect that has for nearly three-quarters of a century constituted public policy in this arena was not instituted at the behest of psychiatry, though with few exceptions the demise of public psychiatry drew little protest from within the ranks of the profession.
Dealing effectively with serious mental illness requires a major commitment to housing, supporting, and sheltering people who are incapable, for the most part, of providing for themselves. It necessitates serious engagement with research about the best ways to provide these things. Families, for perfectly understandable reasons, often find these burdens impossible to bear, and in other cases, patients flee their families. In either case, the alternatives are grim.
We ought to recoil from arrangements that condemn helpless and suffering human beings to the gutter and the jail, and stop pretending that chemistry is the sole and singular way forward. Those afflicted with serious forms of mental illness have been cast into the wilderness—a brutal and often fatal outcome for many with few resources of their own. These are people who lack the capacity to function in a neoliberal environment in which they are seen as little more than a drain on the public purse. Chronically dependent on the not-so-tender mercies of a shrinking welfare state, they are doubly stigmatized: for their illness; and because they show few signs of reform or recovery.
The idea that we bear a collective moral responsibility to provide for the unfortunate—indeed, that one of the marks of a civilized society is its determination to provide as a right certain minimum standards of living for all its citizens—has never enjoyed widespread support in the United States. Most Americans have long embraced an ideology far more congenial and comforting to the privileged, but one that also resonates among the masses: the myth of the benevolent “Invisible Hand” of the marketplace and its corollary, an unabashed moral individualism. There is little place (and less sympathy) within such a worldview for those who are excluded from the race for material well-being by chronic disabilities and handicaps—whether physical or mental, or the more diffuse but cumulatively devastating penalties accruing to those belonging to racial minorities or living in dire poverty.
The punitive sentiments directed against those who must feed from the public trough extend only too easily to people suffering from the most severe forms of psychiatric misery. Those who seek to protect a long-term mental patient from the opprobrium visited on the welfare recipient may do so by arguing that the patient is both dependent and sick. But I fear this approach has only a limited chance of success. After all, despite two centuries of propaganda, the public still resists the straightforward equation of mental and physical illness. Moreover, the long-term mental patient, in many instances, will not get better and often fails to collaborate with his or her therapist to seek recovery. Such blatant violations of the norms of self-care make it unlikely that people with severe mental illness will be extended the courtesies accorded to the conventionally sick. Those incapacitated by psychiatric disability all too often find themselves the targets of policy makers and pundits who would abolish social programs because they consider any social dependency immoral.
If our goal is a revival of a psychiatry that attends to the psychological, physical, and social dimensions of mental disorder, one must recognize just how difficult that transformation is likely to prove. For the professional elite in the academy, the pressures to secure grant money and build scientific careers make sustained interest in the social and psychological dimensions of mental disorder difficult and unattractive. Clinicians in private practice have few incentives to embrace this group of patients or to attend to these issues. But a far larger difficulty than these intraprofessional obstacles is the unpropitious nature of the larger political environment. Where is the political will to break with what has become the conventional wisdom about mental illness and its treatment? And where are the massive resources that would be required were we to take seriously the parlous situation of those whose lives have been devastated by serious mental illness, or address the multiplicity of their needs? Psychiatry faces a difficult way forward. So do we.
Madness remains, as it has for millennia, a mystery that stubbornly refuses to bend itself to the rule of reason. Yet, despite the obstacles, it is a riddle we must continue to strive to solve. Major mental illnesses constitute some of the most profound forms of human suffering. They are, as the historian Michael MacDonald once put it, at once the most solitary of afflictions and the most social of maladies.10 Small wonder some have been tempted to embrace the notion, as Shakespeare had it, that “diseases desperate grown, by desperate appliance are relieved, or not at all.”11 A seductive idea, but one we ought, at all costs, to resist.
In the words of Yogi Berra, “It’s tough to make predictions, especially about the future,” and I can claim no special talents as a prognosticator. It is all but certain, however, that the overwhelming social dislocations associated with the epidemic of COVID-19 will reemphasize the foolishness of neglecting the connections between the social environment and mental illness. Two groups at opposite ends of the age spectrum have had their lives disrupted in particularly powerful ways. Old people, already often living isolated and lonely lives, have been cut off even more extensively than they usually are from ordinary forms of social interaction, because they are the demographic group most vulnerable to serious illness and death if they contract the virus. Meanwhile, the young—both those in the critical years of schooling and social development and those seeking to launch independent lives and careers—have experienced massive losses that are likely to have lifelong effects. It would be astonishing if the social and economic devastation wrought by the pandemic does not contribute to more mental distress and breakdowns among those most exposed to its ravages, and preliminary data suggest that these consequences are already surfacing.12 The fear, isolation, job losses, and financial insecurity that so many have experienced have been reflected in a wide variety of survey data that show huge increases in reported levels of anxiety and depression.13 And while we know that “most people are resilient and will not succumb to psychopathology,” the psychosocial effects of these stresses can, in some cases, be expected to be profound and long-lasting, predisposing some people to heightened rates of mental disturbance for many years to come.14