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.