Whatever Happened to the Mind?
Do you believe that your mind exists? Do you believe that the minds of other people exist as well? Of course we do. It’s common knowledge that every one of us has a brain–and a mind as well. But the mind’s existence is routinely ignored in the practice of modern psychiatry.
Our current mode of treatment–emphasizing neurobiological explanations and interventions to address emotional and behavioral problems–is frequently described as “mindless psychiatry.” It’s not meant to imply that my profession is stupid or crazy. Nearly all practicing psychiatrists are both intelligent, and perfectly sane. But modern psychiatry certainly seems to be mindless by design–driven by a belief system that willfully excludes the existence of the mind as a significant clinical entity. And it’s painfully obvious why we do so. It’s because of our history, our insecurity, our ignorance, and our corruption.
In 1808 a German medical professor named Johann Riel used Greek roots to coin the term “psychiatry,” which means “healing of the psyche.” The psyche itself is defined as “the human mind, soul, or spirit,” with no reference at all to the brain. Riel probably did so because he lived in a time when we had some grasp of the mind, but almost nothing was known about the functions of the brain. To this day psychiatry is defined as “a branch of medicine that is focused on mental, emotional, and behavioral disorders.” “Mental” is an adjective referring specifically to the mind–which in turn is defined in the Oxford dictionary as “the element of a person that enables them to be aware of the world and their experiences, to think, and to feel; the faculty of consciousness and thought.” But you won’t find any reference to the mind in the vast majority of published psychiatric research.
The history of psychiatry reveals a discipline whose focus has repeatedly swung back and forth between the two poles of our bipartite target organ–inclusively referred to as the brain-mind. Our modern treatment model claims to be driven by science–which is by definition the study of nature. However, our scientific understanding of the brain-mind is at this time limited to the anatomical and microanatomical features of the brain, and their associated physiological activities. What has escaped us is any credible explanation for the physiology of thought, and the composition of the mind.
In the face of these mysteries, contemporary psychiatry seems to have abandoned any contemplation of thought or mind–an ironic twist, given the obsessive level of attention that psychiatry gave to psychotherapy and various psychoanalytic theories up until the late 1970s. Much of this diversion was produced by an explosion of scientific knowledge that has been obtained in the last fifty years or so, thanks to advances in imaging and microbiological technologies–which have brought substantial leaps in our understanding of the microanatomy and chemical physiology of the brain.
But psychiatry’s shift to a more biological, brain-oriented practice wasn’t just the natural result of an expanding knowledge base. It was driven as well by:
-Mounting insecurities within our profession at large
-A promising relationship with the pharmaceutical industry
-The epic self-indulgence that preceded it, disconnected from science and medical convention.
The Psychoanalytic Era
In the absence of a sound neurophysiological knowledge base, psychiatry spent the first half of the 20th century indulging in hypothetical speculations about the nature of thought and mind. This era was jump-started by the psychoanalytical musings of Sigmund Freud, who achieved rock-star status in intellectual circles of the time. His candor about sexual issues broke through the Victorian propriety that had long prevailed, spawning a liberal movement that ultimately led to the sexual revolution of the Sixties. For better or worse, Freud was the public face of psychiatry for most of the 20th century. And within our profession, other psychoanalytic icons such as Carl Jung, Melanie Klein, Erich Fromm, Otto Kernberg, and Heinz Kohut (my personal favorite) emerged as well–each promoting their own conception of the mind, its maladies, and the right way to treat them.
But all of this “knowledge” was based on speculative interpretation of human behaviors, rather than scientific observation. Science is the study of nature–demanding the objective observation of natural phenomena, and driven by relentless self-doubt. In contrast, psychoanalytic theory thrived on the invention of intellectual models to explain all manner of human thought and behavior–without a shred of evidence to prove or disprove their existence. In contrast to the humility and self-doubt that drives proper science, psychoanalytic theory thrived on presumptuous proclamations from competing “schools” of psychoanalysis–detached from science and body.
When I first informed my father that I was going to pursue psychiatry as a specialty he flew into a rage, howling that he expected me to be “a real doctor.” This perception was shared by a broad swath of the general public, and many of our peers in other medical specialties as well. But by that time a revolution within psychiatry had already begun.
The Neo-Kraepelinian Revolution
Perhaps the greatest figure in psychiatric history was Emil Kraepelin–a German psychiatrist who oversaw an asylum in the late 19th century, and went on to cast a giant shadow over psychiatry into the 20th century. His greatest claim to fame was his rigorous observation and evaluation of the symptoms that patients presented upon their hospital admission. This work led him to identify both schizophrenia, and “manic-depressive illness”–now known as bipolar I disorder. He was driven to pursue this study so that he could predict the course of treatment, and thus inform family members what they should expect in the future. He found that those patients diagnosed with manic-depressive illness could be expected to eventually improve and return home–while those with schizophrenia would likely deteriorate slowly and steadily, to remain in the asylum for the rest of their lives. He also made note of patients that presented with blended symptoms of both of these disorders, now referred to as schizoaffective disorder.
Kraepelin’s stature grew beyond these discoveries, and he was certainly the most influential psychiatrist of his time. He unfortunately became a proponent of “degeneration theory” at a time when it was quite fashionable. It was an application of Darwin’s theory of evolution to human culture that led to a lot of unwarranted pessimism in the late 1800s–and in the next century inspired the Nazis’ Final Solution, well after Kraepelin’s death in 1926. It should be noted. however, that Kraepelin himself was quite taken with early psychology, stating in 1886:
Over the course of the last decade, psychology has become a natural science like any other, and therefore it has a legitimate right to expect that its achievements receive the same respect and recognition as other auxiliary disciplines that we use to construct our scientific house….Ever since psychology, thanks to its impartial investigation of the facts, has risen to the status of a natural scientific discipline, it has succeeded in creating strictly empirical research methods that might, upon further development, be applied to the difficult study of morbid mental states.
Over 120 years later, psychiatrists have yet to establish any gains in physiologically differentiating one psychiatric disorder from another. Instead we have diagnoses that are concocted in meetings of our trade association, the American Psychiatric Association–a political rather than scientific process, with no biological markers or established causation. In a history as dubious as ours, Kraepelin’s identification of those three disorders is still psychiatry’s most durable diagnostic achievement.
In the 1970s a group of academic psychiatrists at Washington University in St. Louis had become tired of the grip that psychoanalysis had over psychiatric practice, and set out to bring psychiatry back into the fold of proper medical practice. Kraepelin’s legacy was hijacked by fervent advocates of a biological model of psychiatry, justifying a more medication-oriented model of care. This “neo-Kraepelinian” movement began with the 1978 publication of an essay written by Gerald Klerman, entitled “The Evolution of a Scientific Nosology.” (Peculiarly, I found countless references to this essay online, but could not find any link to the actual essay. Don’t ask me why this is.) This essay presented a credo designed to turn psychiatry toward a more biological, less psychological model of care, driven by physical interventions such as medications and electroconvulsive treatment (ECT). The tenets of this model were listed as follows:
Psychiatry is a branch of medicine.
Psychiatry should use modern scientific methodologies and base its practice on scientific knowledge.
Psychiatry treats people who are sick and who require treatment for mental illness.
There is a boundary between the normal and the sick.
There are discrete mental illnesses. Mental illnesses are not myths. There is not one but many mental illnesses. It is the task of scientific psychiatry, as of other medical specialties, to investigate the causes, diagnosis, and treatment of these mental illnesses.
The focus of psychiatric physicians should be particularly on the biological aspects of mental illness.
There should be an explicit and intentional concern with diagnosis and classification.
Diagnostic criteria should be codified, and a legitimate and valued area of research should be to validate such criteria by various techniques. Further, departments of psychiatry in medical schools should teach these criteria and not depreciate them, as has been the case for many years.
In research efforts directed at improving the reliability and validity of diagnosis and classification, statistical techniques should be utilized.
I won’t argue with the fact that the psychoanalytic movement was rather sucked up into its own head, and indifferent to the early progress that was being made in our understanding of the brain. But the result of the Neo-Kraepelinian revolution was the substitution of a new biological belief system for the other–more driven by my profession’s own insecurities, than by convincing scientific evidence. In the absence of any biological explanation for the phenomenon of thought, this “credo” is a surprisingly frank admission of our more mundane concerns, as evident here:
1) Psychiatry is a branch of medicine.
That this was number one on their wish list is no surprise at all–but it has nothing to do with the actual science or treatment of mental illness. It is clearly motivated by desire for professional prestige and income, and the respect of their medical peers.
3) Psychiatry treats people who are sick and who require treatment for mental illness.
This point seems to me to be driven entirely by semantic concerns–again aimed at securing psychiatry’s status as a full-fledged medical specialty, by redefining the nature of psychiatric disorders.
4) There is a boundary between the normal and the sick.
This is perhaps the most grossly unscientific contention on this wish list. I think every one of us knows that people can be mildly depressed, intermittently anxious, somewhat dysfunctional, or even a little bit crazy. This dictum boldly declares that there is a boundary between us and them–without any clarification of what that means, why it should be observed, and the implications thereof. My 39 years of psychiatric practice, and 69 years of living, tell me that this is an arrogantly subjective statement which has nothing to do with either science or medical compassion.
5) There are discrete mental illnesses. Mental illnesses are not myths. There is not one but many mental illnesses. It is the task of scientific psychiatry, as of other medical specialties, to investigate the causes, diagnosis, and treatment of these mental illnesses.
This expresses some worthy ideals, but in retrospect is ironically naive. The ambiguities of psychiatric disorders resist our efforts to explain or categorize them. But that won’t stop us from trying to do so.
6) The focus of psychiatric physicians should be particularly on the biological aspects of mental illness.
The scientific method tells us to follow where nature leads us. Unfortunately, our scientific knowledge of healthy psychiatric function is still woefully incomplete, since we don’t really know how thought is generated. So focusing “particularly on the biological aspects of mental illness” remains a naive fantasy today.
7) There should be an explicit and intentional concern with diagnosis and classification.
The diagnosis of diseases in other medical specialties is based on a scientific understanding of normal physiology, and the observation of pathophysiology–how disease deviates from healthy function. Practically all psychiatric disorders are diagnosed in the absence of any physiological explanation for them–because there is way too much about normal brain function that we don’t understand. Psychiatric diagnosis continues to be a pale imitation of the medical model, because it lacks the critical element of established causation in our disorders.
8) Diagnostic criteria should be codified, and a legitimate and valued area of research should be to validate such criteria by various techniques. Further, departments of psychiatry in medical schools should teach these criteria and not depreciate them, as has been the case for many years.
A valid psychiatric diagnosis is often unattainable due to the ambiguities of psychiatric illness, and our limited understanding of psychiatric physiology. Rather than being defined by objective observations–such as lab values or other physical observations–psychiatric diagnosis is usually based solely on the patient’s superficial presentation, and their subjective report. As a result, the diagnosis of a patient can be readily skewed by a patient’s false report, or the psychiatrist’s subjective interpretation.
And by the way, psychiatrists in practice still depreciate the process of diagnosis, if for no other reason than for its persistently poor inter-rater reliability–i.e., the inconsistency of psychiatrists to agree on a diagnosis. I’ve heard the words “bullshit system” many times, and not just from my own lips.
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The thrust of this credo is not to scientifically examine psychiatric disorders and follow that process to wherever nature leads us–because the scientific nature of psychiatric disorders at that time was a dead end unknown to us, and it still is. It is instead the wish list of an insecure profession. Its guiding purpose is to place safety rails on psychiatric diagnosis and research to ensure that psychiatrists diagnose like real doctors, talk like real doctors, and treat disorders like real doctors–so we can be recognized by our peers as real doctors. As psychiatric critic DB Double aptly notes on his blog Paradigm Shift in Psychiatry:
This is a clear statement about the relationship between psychiatry and the rest of medicine. In many ways, it arises because psychiatry wants to gain the respect of the rest of medicine, rather than be seen as a vague discipline with less authority. It also has implications for non-medical practitioners who are viewed as subsidiary to the appropriate psychiatric professional–i.e. the medical doctor.
The neo-Kraepelinian model promised that psychiatrists would get to be seen as real doctors, and it has greatly succeeded in achieving that goal. It has also opened the door to the economic opportunities that are available to other medical specialties–most notably a fruitful relationship with the pharmaceutical industry. But it’s done so by shrouding ourselves in a cloak of disparate scientific findings that describe many of the countless functions of the brain–but deflect from our utter ignorance of both the mind, and the process of thought.
All of our limited discoveries are held together by a body of contrived pseudoscience designed to mislead not only the public, but ourselves as well–best illustrated by the Diagnostic and Statistical Manual of Mental Disorders, aka DSM, which has little basis in actual science. It is formulated every decade or so by our trade association, with the generous participation of commercial interests.
And the first casualty of this corrupted perspective has been the mind.
