All medicine should be bio/psycho/social. Illness is never just a biological phenomenon -- more than 80 percent of health outcomes are determined by economic, social, and behavioral factors.
And the psychosocial part is especially important in psychiatry. As Hippocrates pointed out 2,500 years ago, it is more important to know the patient who has the disease than the disease the patient has.
In recent years, psychiatry has embraced what a former president of the American Psychiatric Association has despairingly called a "bio/bio/bio" model. The enormous research budget of the National Institute Of Mental Health has been totally invested in biologically reductionist brain and genomic research.
Pat Bracken is an Irish psychiatrist and philosopher who would like to put the mind and soul back into psychiatry. Pat writes:
"I believe that psychiatry finds itself in a pernicious position. Pharma has used its financial power to mould psychiatry into something that serves corporate needs, not the best interests of patients. And the massive investment in genetic and neuroscience research has yielded practically nothing of clinical value for our patients.
In fact, we have gone backwards. The narrow focus on biological research has led to a profound neglect of the social, cultural and psychological dimensions of mental illness. In the United States, where Pharma has had most influence and the perverse payment system has operated, there is evidence that, to a large extent, psychiatric care has become equated with the provision of a DSM diagnosis and a prescription.
The New York Times carried a story in 2011 in which a psychiatrist spoke of having to train himself not to get too close to his patients and 'not to get too interested in their problems'. His role was simply to check the diagnosis and adjust meds.
The reductionism that now dominates psychiatric theory and practice is ideological in nature: it does not stand up to conceptual challenge and is not supported by the results of empirical investigation. Its dominance is sustained through finance from Pharma allied to a professional quest to be more 'medical' than the rest of medicine.
What we have to grasp is that when we put the word 'mental' in front of the word illness, we are doing something important. We are delineating a territory of human suffering that is primarily about relationships, meanings and values. And, while we cannot experience anything without a functioning nervous system, a knowledge of the brain will not help us a great deal in understanding the nature of this territory.
The brain is a necessary, but not a sufficient cause of human experience. We are embodied beings but we are also encultured. We grow to become human in the midst of language, culture, history and relationships with others. These shape the way we experience ourselves and how we encounter the world around us and cannot be reductively explained in biological terms.
The demand that psychiatry should simply become a 'clinical neuroscience' is nothing more than an assertion of dogma and is not based on a genuinely questioning scientific approach to the sort of problems that face us.
We need to nurture the development of a psychiatry that sees relationships, meanings and values as its primary focus. I have used the word 'hermeneutic' to describe this.
How to get there is the challenge. Evidence-based medicine (EBM), with its focus on controlled studies and meta-analyses, has not proved robust enough in protecting psychiatry, and medicine in general, from corruption. It has been said that EBM itself is 'broken.'
With our colleagues from other medical disciplines we will need to develop a much deeper form of critical appraisal. I believe that any profession that has power in the lives of ordinary people should seek to critically reflect on its own history, assumptions, values and practices in an organized and sustained way. A mature profession should not be afraid of this. We need practitioners who are trained to question and to doubt, to challenge their teachers and to see financial ties to third parties as an aberration.
On a more positive note, our discipline has a rich history of grappling with conceptual issues before the rise of 'neuromania' and the DSM. The work of Karl Jaspers stands out in this area but many of our predecessors struggled to develop a theory and a practice of psychiatry that was not reductionist. The great Swiss psychiatrist, Medard Boss, for example, sought to develop a specifically hermeneutic psychiatry in the post World War II era. We do not have to re-invent the wheel. A growing movement of critical psychiatry is now emerging as a positive force for change within the profession (www.criticalpsychiatry.co.uk).
I believe that we need to develop a practice that is centered on relationships and we need to acknowledge the limitations of a diagnosis-guided practice in our field. This is not anti-medical but simply an acceptance that mental health work demands something different. We need to nurture negotiation skills in our trainees and encourage them to engage with the growing consumer movement in a positive and non-defensive way. We need to accept that psychiatry has done a great deal of harm to many of its patients and professional arrogance should be stigmatized and fought against. We need to nurture doubt, questioning and critical reflection in our academic and clinical practice.
A hermeneutic psychiatry would be one where doctors, patients, carers and other professionals struggle together to determine what research, teaching and service models are appropriate. I also believe that we should struggle to shed the power to order coercive interventions. This is not to say that sometimes people need to be cared for safely and even against their will, but there is no scientific or moral reason why the medical profession should be in charge of this.
I do not claim to have an answer to all the problems of psychiatry but the following moves will be essential if we are to find a cure for our current ills: 1) collaborate with other doctors who are struggling to free medicine of Pharma corruption, 2) find ways of working positively with, and learning from, the growing international consumer movement, 3) balance our involvement with the biological sciences with an equal involvement with the humanities and social sciences, 4) nurture the development of a clinical discourse that is centered on relationships, meanings and values, 5) seek to shed the coercive powers that are now invested in us and promote an open debate about how people can be looked after safely through times of crisis."
Thanks, Pat. We must get back to treating the whole person, not just his brain circuits. The brain is involved in all we do and what we are, but it is also itself influenced by our psychology and social context.
And we must equally counter those who err in recommending an opposite and equally extreme psychosocial reductionism. Mindless psychiatry and brainless psychiatry are equally misguided and harmful.