Psychiatry and Anti-psychiatryRead Now
After losing the copy that I was reading a year ago, I finally got another one and have now read Gary Greenberg's The Book of Woe, which is an account of how the latest edition of the Diagnostic Statistical Manual, the DSM-5, was written. As probably everyone who reads this blog is aware, the DSM is a handbook published by the American Psychiatric Association which presents a comprehensive list of all mental disorders, as well as a clinical description of the symptoms for each disorder. But at just under 1000 pages, the latest edition is way too bulky to be called handy and is not nearly as scientific or authoritative as the APA would have people believe. Greenberg gives an amusing account of the the politics and feuds that led up to the publication of the manual, which makes their efforts seem less like medical science and more like psychiatric follies. But he is careful not to present the DSM committee as a cabal of evil shrinks intent on diagnosing us all as mentally ill in order to sell drugs and enrich both themselves and pharmaceutical companies. They are, rather, mostly concerned, if somewhat clueless professionals who want to relieve people of their mental suffering. But since the publication of the DSM-3 some forty odd years ago, psychiatry made a fateful turn and has adhered to a disease model of mental illness that has continuously tried to eliminate any nebulous mental or experiential factors from its understanding of mental illness. Unfortunately, as the incidence of mental illness has soared over the past forty years, the attempt to ground psychiatric treatments in the diagnosis of some identifiable physical pathogen has proven entirely fruitless. This approach has, however, led to vastly increased sales of psychopharmaceuticals which have enriched both psychiatrists and pharmaceutical companies. It may also account for the reluctance of psychiatry to admit to its failure and try another tack. For it is never easy to admit to failure, but it is much more difficult to do so if it means losing such great lucrative rewards. Given its potential for scientific, as well as financial corruption, the close alliance between psychiatry and Big Pharma deserves the closest scrutiny and Greenberg's book offers yet another persuasive case about its dangers. But if psychiatry--which has always been the branch of medicine that deals with mental illness--has failed so signally in finding either cause or remedy for madness, does this mean that the bio-medical approach should be abandoned altogether? The question deserves serious consideration.
To mainstream psychiatry, however, even to entertain such a question is to fall into the camp of anti-psychiatry. We might recall that the term anti-psychiatry was first coined more than forty years ago by R.D. Laing's colleague David Cooper, a radical psychiatrist from South Africa who did indeed want to see the profession destroyed (Laing himself detested the term and never took such an incendiary position). But nowadays anybody outside of the psychiatric consensus who dares to express criticism of it is likely to be branded an anti-psychiatrist. This includes serious critics like Robert Whitaker and Richard Bentall, as well as less reputable ones from Scientology. It almost goes without saying that Greenberg has been slapped with the label because of The Book of Woe. But by dismissing him so automatically psychiatry is refusing to engage in the serious argument that lies at the heart of the book. What is the role that medicine should play in the treatment of mental and emotional suffering? A true anti-psychiatrist (though like Laing, he, too, hated the term), Thomas Szasz, argued that mental illness is a myth that is based on a category error and that what psychiatry called mental illnesses were actually "problems in living". But that is not what Greenberg believes. As a practising psychotherapist, he knows that when people feel depressed, confused, agitated and bewildered, they feel sick and want to be free of their suffering. But the question remains: are they suffering from some biologically based malady?
Unfortunately, there is no simple answer to this question. As Greenberg points out, unlike other, more diagnosable physical ailments, the symptoms of a mental disease constitute the disease itself and do not point to an underlying pathogen or physical condition that gives rise to them. The symptoms of depression, for example, merely indicate that a person suffering them is depressed. Although the dream of psychiatry has always been to devise something like a simple blood test that would detect clear bio-chemical markers for mental illness, researchers have been unable to devise any such test and have found no markers and no magic bullets for madness. But psychopharmaceutical drugs do have effects, sometimes positive, even life saving ones. Every therapist has encountered someone who has been rescued from the maelstrom of a suicidal depression by the timely administration of anti-depressant medication. And sometimes medication can stabilise a client so that psychotherapy can take place or become more effective. But medication can also have terribly negative side-effects and if psychiatry is to be condemned for anything, it is for minimising them and overselling the benefits of drugs. Its error appears to spring from a dogmatic belief that the only effective treatment of mental illness can be medical and any other approach can be safely ignored. A consequence of this belief is that it will always keep the self experience of the patient at arm's length from the psychiatrist. As Emil Kraeplin, the father of psychiatry once decreed, psychiatrists should have no more empathy for their patients than surgeons have for theirs. Ever since the publication of the DSM-3, psychiatry has been all too faithful to his tenet of heartlessness.
Of course, not all psychiatrists feel this way and many of the greatest psychotherapists and psychological theorists have also been psychiatrists. No less a figure than Freud--the father of psychotherapy, as well as a psychiatrist-- believed that medical training could actually act as an impediment to becoming a good psychotherapist. His reasoning was diametrically opposed to Kraeplin's as he believed that the detached objectivity that the physician should cultivate would prevent the development of the empathic understanding that is so essential to psychotherapy. But Greenberg notes that medicine has always been at least as much an art as it is a science and that much of its effectiveness depends on the intuitive skills of the physician, as well as the medical knowledge that he draws on. A good doctor not only has a sound grasp of medical practice; he also knows how to apply it to the individual needs and particular circumstances of each of his patients. If this principle applies in medicine, it applies even more strongly in psychotherapy where theoretical knowledge is provisional at best and the empathic bond between therapist and client is perhaps the single most important factor in the success of therapy. How ironic that by increasingly focussing on the physical factors of mental distress, psychiatry has turned its attention away from the relationship between doctor and patient where the best prospect of healing lies.
None of this, however, presents an argument for the claim that medicine has no place in the treatment of mental illness. And as research into the brain and neurological functioning progresses, it is reasonable to suppose that better treatments will be found for dealing with the distress of mental illness. But perhaps psychiatry stands to gain even more by regaining its interest in the experiences of its patients and putting more emphasis on the therapeutic relationship.
For LeonRead Now
My friend Leon Schlamm died suddenly a couple of weeks ago. He had just come through a rather long, difficult period of poor health, but after quitting smoking on his doctor's advice he seemed to be doing quite well. A mutual friend had spoken to him a few of days before he died and they made tentative plans for a meeting. But then, just as he was about to pin down the appointment, he received news that Leon had been rushed into hospital. I don't know the details of Leon's final hours, but I understand that death came fairly quickly after he was hospitalised. At sixty seven, he was really too young to die, especially as he was enjoying his retirement as a lecturer in Religious Studies at the University of Kent. I first met Leon at Kent nine years ago when, as a mature student, I applied for a place in the MA programme in the Study of Mysticism and Religious Experience that he and Peter Moore had convened. The MA programme--which is now in younger hands--emphasises the psychology of religious experience over more theological or sociological concerns, which suited my interests perfectly. Leon and I also hit it off immediately as we had read many of the same books and found we usually shared the same opinions about them. But there was another, deeper reason for our friendship. Leon's academic speciality was C.G. Jung. In fact, Leon didn't just study Jung; he was a passionate Jungian (he was spending his retirement in close reading of Jung's Red Book, Liber Novis, for personal, rather than academic interests). As much as anything else, it was our great admiration for Jung that revealed our affinity for each other.
Because I have no formal training as a psychotherapist in analytical psychology, I am not able to call myself a Jungian. Even so, apart from Buddhism, no other school of psychology influences my thought and practice quite so deeply. So I call myself a crypto-Jungian to acknowledge my debt to Jung without claiming any credentials as a member of that elite guild. Yet, in spite of its great influence and wide renown, Jung himself remains a controversial figure who does not command universal respect. Many Freudian psychoanalysts, especially of earlier generations, could never forgive his break from Freud. But even to critics of other orientations, he is often regarded as little more than a crank whose spiritualistic views spoiled his claim to be a reputable psychological scientist. In fact, the early Jung was a ground breaking clinical psychologist whose research into psychological types is still used in such standard psychological tests as the Myers-Briggs. But after his split from Freud and suffering his creative illness (which was, in fact, nothing less than a psychotic breakdown) Jung seemed less the clinician and more of a visionary. This altered his reputation irrevocably and made him into the figure who still divides opinion so sharply. It isn't just that his ideas about archetypes and the collective unconscious took him into places that clinical psychology could not and dared not go. Nor is it his often unclear, sometimes even cryptic style of writing. It is also that his approach to the psychology of religion, which did take religion seriously, did not do so in terms that pleased many theologians or religious believers. Indeed, even in Religious Studies at Kent there were some members of the department who regarded Jung with scorn that matched any Freudian's. But none of this made Leon question Jung's genius. Like all Jungians I have known (my two psychotherapists were both Jungians), Leon was well apprised of Jung's faults and shortcomings.
It is now widely recognised that Jung was very much a man of his culture and times and his wide learning and sometimes narrow prejudices contributed to his world view. After nearly a century of critical scholarship, Jung's personal and professional shortcomings have been well documented. As a scholar and student of mythology, his science and anthropology now seem dated, as well as Eurocentric. Even worse, his questionable association with the Nazis before WW II showed his alarming willingness to dance with the devil. The idea, however, that Jung himself was a Nazi or that he had any admiration for Hitler or his movement is simply false (in an interview conducted in the 1930's, for example, he said that Hitler was a vacant personality who was leading Germany into the abyss). In fact, notwithstanding his somewhat racialist, if not racist views (the collective unconscious was, after all, first called the racial unconscious) Jung could be described as something of semitophile who, from the first, always had many Jewish admirers and followers (in fact, Leon himself was Jewish). There is also the troubling matter of Jung's rather complicated relationships with women, particularly his female patients, most notably Toni Woolf (who was involved in a menage a trois with Jung and his wife, Emma) and Sabina Spielrein. Having had affairs with both women, Jung claimed that they each matched his ideal anima and exerted an attraction that was as much spiritual, as it was romantic. In fact, both women possessed formidable intellects that Jung truly admired and Wolff in particular was an important collaborator in the development of many of his ideas. But Jung took liberties with his female patients that was no more acceptable then than it would be now. Yet, at least to his admirers, his achievements remain indisputable, no matter what his transgressions.
As a scholar, Leon had a somewhat different view of Jung than mine as a therapist. He was more interested in Jung's ideas about spiritual experience, whereas it is Jung's approach to psychotherapy and his understanding of individuation that has made him so important for me. The idea of individuation can be summarised easily enough. It is coming to terms with the unconscious forces and influences in one's life in an ongoing process of becoming oneself. But note that slippery word "unconscious" and the unfathomable depth that it conceals. One of my favourite quotes by Jung begins to suggest its depth of meaning: "The unconscious really is unconscious", he said in a famous interview with the BBC. What I think he meant by this is that unlike the Freudian idea of the unconscious, which regards it as a hidden mechanism of desire that has been made comprehensible by psychoanalytic theory, Jung saw the unconscious as progressively more unknowable the more deeply it is plumbed. At root, the unconscious connects to nothing less than the infinite mystery of being. But in the course of ordinary living we are scarcely aware of it and most of us may have little inkling that it influences us at all. Yet on the force of certain, usually traumatic experiences anyone can be plunged into an unconscious depth that reveals the provisional and constructed nature of conventional reality. Although this can be psychologically destabilising as well as terrifying, it also holds a potential for higher self development. Individuation, as Jung conceived it, must involve both psychological conflict and the discovery of the inner resources to deal with it. Discovering and developing such inner resources is much of what Jungian psychotherapy is all about.
In our last meeting together, I was trying to persuade Leon to start up a discussion group on Jung. "Let me think about it," he replied. Although he was enjoying the freedom his retirement was giving him, I thought that the prospect of having regular discussions on the subject to which he had devoted so much of his life would be irresistible to him. Moreover, it was in small groups of like-minded people where he seemed to express himself most freely. And I would have benefited from the stimulation that his conversation always gave me. When I first met Leon I had the feeling that he had been a friend long before I knew him. Now that he is gone, I will miss the deeper friendship that might have developed.