Body: | Psychiatry: Chemical imbalances are mythical
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Dr. David Kaiser
Against Biologic Psychiatry
Psychiatric Times
December, Dec. 1996, Vol. XIII, Issue 12
Against Biologic Psychiatry
By David Kaiser, M.D.
December 1996, Vol. XIII, Issue 12
As a practicing psychiatrist, I have watched with growing dismay and
outrage the rise and triumph of the hegemony known as biologic psychiatry.
Within the general field of modern psychiatry, biologism now completely
dominates the discourse on the causes and treatment of mental illness, and
in my view this has been a catastrophe with far-reaching effects on
individual patients and the cultural psyche at large. It has occurred to me
with forcible irony that psychiatry has quite literally lost its mind, and
along with it the minds of the patients they are presumably supposed to
care for. Even a cursory glance at any major psychiatric journal is enough
to convince me that the field has gone far down the road into a kind of
delusion, whose main tenets consist of a particularly pernicious biologic
determinism and a pseudo-scientific understanding of human nature and
mental illness.
The purpose of this piece is not to attempt a full critique or history of
this occurrence, but to merely present some of the glaring problems of this
movement, as I believe significant harm is being done to patients under the
guise of modern psychiatric treatment. I am a psychiatrist trained in the
late 1980s and early 1990s, and I use both psychotherapy and medications in
my approach to patients. I state these facts to make it clear that this is
not an antipsychiatry tract, and I am speaking from within the field of
psychiatry, although I find it increasingly impossible to identify with
this profession, for reasons which will become clear below.
Biologic psychiatrists as a whole are unapologetic in their view that they
have found the road to the truth, namely that mental illnesses for the most
part are genetic in origin and should be treated with biologic
manipulations, i.e., psychoactive medications, electroconvulsive treatment
(which has made an astounding comeback), and in some cases psychosurgery.
Although they admit a role for environmental and social factors, these are
usually relegated to a secondary status. Their unquestioning confidence in
their biologic paradigms of mental illness is truly staggering.
In my opinion, this modern version of the ideology of biologic/genetic
determinism is a powerful force that demands a response. And when I use the
word ideology here, I mean it in it's most pernicious form, i.e., as a
discourse and practice of power whose true motivations and sources are
hidden to the public and even to the practitioners themselves, and which
causes real harm to the patients at the receiving end.
Biologic psychiatry as it exists today is a dogma that urgently needs to be
unmasked. One of the surest signs that dogmatists are at work here is that
they rarely question or attempt to problemitize their basic assumptions. In
fact, they seem blissfully unaware that there is a problem here. They act
in seeming unawareness that they are caught up in larger historical and
cultural forces that underwrite their entire "scientific" edifice.
These forces include the medicalization of all public discourse on how to
live our lives, a growing cultural denial of psychic pain as inherent in
living as human beings, the well-known American mixture of ahistoricism and
belief in limitless scientific progress, and the growing power of the
pharmaceutical and managed care industries. These self-proclaimed
visionaries, oblivious to all of this, boast of real scientific progress
over what they consider to be the dogma of psychoanalysis, which had up
until recently reigned as psychiatry's premier paradigm.
Now, it is not my intention to defend psychoanalysis, which had its own
unfortunate excesses, although I do use psychoanalytic principles in the
kind of psychotherapy I do. However, it is quite clear to me that the
grandiose claims of biologic psychiatry are wildly overstated, unproved and
essentially self-serving. Biologic psychiatry has had its successes,
particularly with recent antidepressants like Prozac and newer
antipsychotic medications such as Clozaril. Medications can effectively
improve depression, relieve severe anxiety, stabilize serious mood swings
and lessen psychotic symptoms. These successes are real in that they
improve the quality of life of patients who are genuinely suffering. But in
reality, i.e., the reality of treating patients, medications have profound
limitations. I know that if the only tool I had in treatment was a
prescription pad, I would be a poor psychiatrist. The center of treatment
will always need to be listening to and speaking with the patients coming
to me. This means listening seriously to what they say about their lives
and history as a whole, not merely listening for which symptoms might
respond to medications. Although it seems astounding that I would have to
state this, biologic psychiatrists as a whole really only listen to that
portion of the patient's discourse that corresponds to their biologic
paradigms of mental illness. It is the nature of dogma that its
practitioners hear only what they want to hear.
So what are the limitations of biologic psychiatry? First of all,
medications lessen symptoms, they do not treat mental illness per se. This
distinction is crucial. Symptoms by definition are the surface presentation
of a deeper process. This is self-evident. However, there has been a vast
and largely unacknowledged effort on the part of modern (i.e., biologic)
psychiatry to equate symptoms with mental illness.
For example the "illness" major depression is defined by its set of
specific symptoms. The underlying "cause" is presumed to be a
biologic/genetic disturbance, even though this has never been proven in the
case of depression. The errors in logic here are clear. A set of symptoms
is given a name such as "major depression," which defines it as an
"illness," which is then "treated" with a medication, despite the fact that
the underlying cause of the symptoms remains completely unknown and
essentially untreated. I have seen repeatedly that, for example, in the
case of depression, once medications lessen the symptoms, I am still
sitting across from a suffering patient who wants to talk about his
unhappiness. This process of equating symptoms with illnesses has been
repeated with every diagnostic category, culminating in perhaps one of the
greatest sophistries psychiatry has pulled off in its illustrious history
of sophistries, namely the creation of the Diagnostic and Statistical
Manual (currently in its fourth incarnation under the name DSM-IV), the
bible of modern psychiatry.
In it are listed all known "mental disorders," defined individually by
their respective symptom lists. Thus mental illnesses are equated with
symptoms. The surface is all there is. The perverse beauty of this scheme
is that if you take away a patient's symptoms, the disorder is gone. For
those who do serious work with patients, this manual is useless, because
for me it is simply irrelevant what name you give to a particular set of
symptoms. It is an absolute myth created by modern psychiatry that these
"disorders" actually exist as discrete entities that have a cause and
treatment. This is essentially a pseudo-scientific enterprise that grew out
of modern psychiatry's desire to emulate modern medical science, despite
the very real possibility that psychic pain, because of its existential
nature, may always elude the capture of modern medical discourse and
practice.
Despite its obvious limitations, the DSM-IV has become the basis for
psychiatric training and research. Its proponents claim it is a purely
phenomenological document stripped of judgments and prejudices about the
causes of mental illness. What in fact it has done is the defining and
shaping of a vast industry of research designed to validate the existing
diagnostic categories and to find ways to lessen symptoms, which basically
has meant biologic research. Virtually all of the major psychiatric
journals are now about this, and as such I find them useless to help me
deal with real patients. Patients are suffering from far more than
symptoms. Symptoms are the signs and clues to direct us to the real issues.
If you take away the symptoms too quickly with medications or suggestion,
you lose the opportunity to help a patient in a more profound way. As an
aside, modern psychiatrists, because they have forgotten or dismissed the
real power of transference, vastly underestimate the extent to which
symptom reduction is caused by mere suggestion. Not that patients should be
left to suffer needlessly from what are often crippling symptoms. Relief
from symptoms is a part of treatment. Modern psychiatry would have us
believe that this is all treatment should be. Meaning, desire, loss and
death are no longer the province of the psychiatrist. In this process
patients are reduced to something less than fully human, as they become an
abstract collection of symptoms without meaning to be "managed" by
technicians called psychiatrists.
This is in the service of medical progress and enlightened scientific
thought. The biologic psychiatrist will not make the mistake of imposing
their value systems on patients like in the bad old psychoanalytic days.
This is, of course, a sham. Modern psychiatry now foists on patients the
view that their deepest and most private ills are now medical problems to
be managed by physician-psychiatrists who will take away their symptoms and
return them to "normal functioning." This is more than a bit malignant. One
of the dominant discourses that runs through the DSM-IV and modern
psychiatry in general is the equating of mental health with "normal"
functioning and adaptation. There is a barely concealed strain of a
specific form of Utopianism here which blithely announces that our psychic
ills are primarily biologic and can be removed from our lives without
difficulty, leaving us better adapted and more productive.
What is left completely out, of course, are any notions that our psychic
ills are a reflection of cultural pathology. In fact, this new biologic
psychiatry can only exist to the extent it can deny not only the truths of
psychoanalysis, but also the truths of any serious cultural criticism. It
is then no surprise that this psychiatry thrives in this country presently,
where such denials are rampant and deeply embedded.
I am constantly amazed by how many patients who come to see me believe or
want to believe that their difficulties are biologic and can be relieved by
a pill. This is despite the fact that modern psychiatry has yet to
convincingly prove the genetic/biologic cause of any single mental illness.
However, this does not stop psychiatry from making essentially unproven
claims that depression, bipolar illness, anxiety disorders, alcoholism and
a host of other disorders are in fact primarily biologic and probably
genetic in origin, and that it is only a matter of time until all this is
proven. This kind of faith in science and progress is staggering, not to
mention naive and perhaps delusional.
As in any dogma, there is no perspective within biologic psychiatry that
can effectively question its own motives, basic beliefs and potential blind
spots. And thus, as in any dogma, there is no way for the field to curb its
own excesses, or to see how it might be acting out certain specific
cultural fantasies and wishes. The rise and fall of biologic determinism in
a culture likely has complicated and interesting causes, which are beyond
the scope of this paper. A few comments will have to suffice.
This is a culture increasingly obsessed with medical science and medical
health as a sign of virtue. It is not surprising that our psychic ills
would be pulled into this dominant medical discourse, essentially
medicalizing our specific forms of psychic pain. It seems to me that modern
psychiatry, in step with a culture which created it, assumes any suffering
to be unequivocally bad, an impediment to the "good life" of progress,
productivity and progress. It is now almost heresy in psychiatry to say
that perhaps suffering can teach us something, deepen our experience, or
point us to different possibilities.
Now, if you are depressed or anxious, it has no real meaning, because as a
biologic illness similar to say diabetes, it is separate from the world of
meaning and merely is. Now any thoughtful person knows that something as
fundamental as depression has meanings such as loss, facing mortality,
unlived desires, lack of power or control, etc., and that these meanings
will continue to exist even if Prozac makes us feel better. There is much
more to life than feeling better or living without pain, and only a
superficial and pathologic culture would need to deny this. Yet conclusions
such as "depression is a chemical imbalance" are created out of nothing
more than semantics and the wishful thinking of scientist/psychiatrists and
a public who will believe anything now that has the stamp of approval of
medical science.
It seems to me that modern psychiatry is acting out a cultural fantasy
having to do with the wish for an omniscient authority who, armed with
modern science, will magically take away the suffering and pain inherent in
existing as human beings, and that rather than refusing this projection
(which psychoanalysts were better able to do), modern psychiatry has
embraced the role wholeheartedly, reveling in its new-found power and
cultural legitimacy.
I would be remiss if I left out the obvious economic factors in
psychiatry's movement toward the biologic. Pharmaceutical corporations now
contribute heavily to psychiatric research and are increasingly present and
a part of psychiatric academic conferences. There has been little
resistance in the field to this, with the exception of occasional token
protest, despite its obvious corrosive and corrupting effects.
It is as if psychiatry, long marginalized by science and the rest of
medicine because of its "soft" quality, is now rejoicing in its new found
legitimacy, and thus does not have the will to resist its own degradation.
The fact that drug companies embrace and fund this new psychiatry is cause
enough for alarm. Equally telling is a similar embrace by the managed care
industry, which obviously likes its quick-fix approach and simplistic
approach to complicated clinical problems.
When I talk to a managed care representative about the care of one of my
patients, they invariably want to know what medications I am using and
little else, and there is often an implication that I am not medicating
aggressively enough. There is now a growing cottage industry within
psychiatry in advocating ways to work with managed care, despite the
obvious fact that managed care has little interest in quality care and
realistic treatment approaches to real patients. This financial pressure by
managed care contributes added pressure for psychiatry to go down a
biologic road and to avoid more realistic treatment approaches.
What this means in real terms is that psychotherapy is left out. There has
thus been a triple partnership created between this new psychiatry, drug
companies and managed care, each part supporting and reinforcing the other
in the pursuit of profits and legitimacy. What this means to the patients
caught in this squeeze is that they are increasingly overmedicated, denied
access to psychotherapy and diagnosed with fictitious disorders, leaving
them probably worse off in the long run.
It is quite depressing to listen to the discourse of modern psychiatry. In
fact, it has become embarrassing to me. One gets the strong impression that
patients have become abstractions, black boxes of biologic symptoms,
disconnected from the narratives of their current and past lives. This
pseudo-scientific discourse is shot through with insecurity and pretension,
creating the illusion of objectivity, an inevitable march of progress
beyond the hopeless subjectivity of psychoanalysis. Psychotherapy is
dismissed and relegated to nonmedical therapists.
I actually have no objections to real science in the field, if, for
example, it can help me make better medication decisions or develop newer
and better medications. But in general biologic psychiatry has not
delivered on its grandiose and utopian claims, as today's collection of
medications are woefully inadequate to address the complicated clinical
issues that come before me every day. This is all not terribly surprising
given what I have outlined in this piece. There will be no substitute for
the difficult work of engaging with patients at the level of their lived
experience, of helping patients piece together meaning and understanding in
the place of their pain, fragmentation and confusion.
Patients these days are not suffering from "biologic illnesses." What I
generally see is patients suffering from current or past violence,
traumatic loss, loss of power or control over their lives and the effects
of cultural fragmentation, isolation and impoverishment that are specific
to this culture at this time. How this manifests in any individual is
absolutely specific; therefore, one should resist any attempt to generalize
or classify, as science forces us to do. Once you go down the route of
generalization, you have ceased listening to the patient and the richness
of their lived experience.
Unfortunately what I also see these days are the casualties of this new
biologic psychiatry, as patients often come to me with many years of past
treatment. Patients having been diagnosed with "chemical imbalances"
despite the fact that no test exists to support such a claim, and that
there is no real conception of what a correct chemical balance would look
like. Patients with years of medication trials which have done nothing
except reify in them an identity as a chronic patient with a bad brain.
This identification as a biologically-impaired patient is one of the most
destructive effects of biologic psychiatry.
Modern psychiatrists seem unaware of what psychoanalysts know well, namely
how powerful are the words that a patient hears from an authority figure
like a psychiatrist. The opportunity here for suggestion, coercion and
manipulation are quite real. Patients are often looking to psychiatrists
for answers and definitions as they struggle with questions such as who am
I or what is happening to me. Of course we all struggle with these
questions, and the human condition is such that there are no definitive
answers, and anyone who comes along claiming they have answers is
essentially a fraud.
Biologic psychiatry promises easy answers to a public hungry for them. To
give a patient nothing but a diagnosis and a pill demonstrates arrogance,
laziness and bad faith on the part of the psychiatrist. Any psychiatrist
needs to be continually aware of the very real possibility that they are or
can easily become agents of social control and coercion.
The way to resist this is to refuse to take on the role assigned through
cultural fantasy, namely the role of omniscient dispenser of magical
potions. As a whole modern biologic psychiatry has enacted this role with
particular vigor and enthusiasm. At the level of individual patients this
means a growing number of overdiagnosed, overmedicated and disarticulated
people less able to define and control their own identities and lives. At
the level of our culture this has meant an impoverishment of the discourse
around such questions as what is wrong with us, as "scientific" answers
replace more potentially fruitful and truthful psychological and cultural
questioning. If psychiatry is to regain any semblance of legitimacy and
integrity, it must strip itself of false and hubristic scientific claims
and humbly submit itself to the urgent task of listening to individual
patients with patience and intelligence. Only then can we have any real
sense of what to say back to them.
The sole philosophic basis for this new psychiatry is the championing of
empiricism above all other measures of truth. Something is valid only if it
can be demonstrated through experimental method, otherwise it is
disregarded or relegated to "subjective" experience, which is presumed to
be inferior. Now, of course, this dominance of empiricism is not limited to
psychiatry, and one can easily trace the invasion of the experimental
method of the "hard" sciences into the "soft" or social sciences.
On a larger cultural level this can be detected in the public's infatuation
with "studies," statistics and so on. This hegemony of empiricism over
other ways of thinking and knowing represents an unprecedented modern
achievement which has thoroughly infiltrated the cultural psyche, to the
point now where the average person believes easily the claims of the
biologic psychiatrist.
Now as is clear from my views already expressed, a social science dominated
by empiricism is a vulgar science, and there is a vast tradition in
philosophy from Plato to Nietzsche which in my view irrefutably
demonstrates this. However this is well beyond the scope of this piece.
Suffice it to say that modern psychiatrists, like all "scientists" these
days, have no time for the basic philosophic questions that have engaged
the most brilliant minds of the past. Who needs questions about virtue when
there is important data to collect? These biologic psychiatrists never
think to ask themselves whether their own precious methods are perhaps
standing on very shaky ground, say their own disavowed prejudices about
what constitutes the good life.
Empiricism is one way of knowing, but certainly not the only or best way.
Biologic psychiatrists often use the standards of empiricism to answer
their critics, in effect saying that their claims are scientifically
"proven" and thus unassailable, clearly a tautological argument. I would
further add that in my view many of the claims of biologic psychiatry do
not even hold up to their own standards of empirical science, for example
their claims about the biologic and genetic basis of many mental illnesses.
In my view, the methods of experimental science are inappropriate and
misplaced when it comes to understanding the complexity of the human
psyche, as they can only objectify the mind and remove subjectivity from
the heart of human experience, thus creating an abstract entity in place of
a human mind. It is no wonder that psychiatry declared the 1980s the decade
of the brain instead of the decade of the mind. In their pursuit of the
human brain they have quite literally lost their minds.
One way to unmask the dogma that is biologic psychiatry is to ask the
question what kind of human being is being posited as desirable, "normal,"
or not disordered. Judging by the DSM-IV, it would be a person not
depressed or anxious, without perversions or sexual "dysfunction," in touch
with "reality," not alienated from society, adapted to their work, not
prone to excessive feeling states and generally productive in their life
pursuits. This is, of course, the bourgeois ideal of modern culture. We
will all fit in, produce and consume and be happy about it. Anyone who
dissents by choice or nature slips into the realm of the disordered or
pathologic, is then located as such by medical science and is then subject
to social management and control.
Now, psychiatry has always provided this social function, as admirably
shown by Foucault and others. I would submit, however, that modern
psychiatry, under the guise of medical and "scientific" authority and
legitimacy, has surpassed all past attempts by psychiatry to identify and
control dissent and individual difference. It has done this by infiltrating
the cultural psyche, a psyche already vulnerable to any kind of medical
discourse, to the point where it is a generally accepted cultural notion
now that, say, depression is an illness caused by a chemical imbalance.
Now when a person becomes depressed, for example, they are less able to
read it or interpret it as a sign that there may be a problem in their life
that needs to be looked at or addressed. They are less able to question
their life choices, or question for example the institutions that surround
them. They are less able to fashion their own personal or cultural critique
which could potentially lead them to more fruitful directions. Instead they
identify themselves as ill and submit to the correction of a psychiatrist,
who promises to take away the depression so they can get back to their
lives as they are. In short, the very meanings of unhappiness are being
redefined as illness. In my view this is a dismaying cultural catastrophe.
I do not mean to suggest that psychiatry is solely to blame for this, given
how wide a cultural shift this is. However, I do think that psychiatry has
not only not resisted its role here, but actually has fulfilled it with
considerable hubris.
Thus in my view the whole phenomenon of biologic psychiatry is itself a
symptom or acting out of a larger, underlying cultural process. Unhappiness
and suffering are not seen as resulting from real cultural conditions; for
example, the collapse of traditional institutions and the ever increasing
hegemony of rampant consumerism in American culture.
Nor is suffering seen in the context of what it means to exist as a human
being in any historical period. Historical and existential discourse about
unhappiness is increasingly supplanted by medical discourse, and biologic
psychiatry has served as one of the major mouthpieces for this kind of
pseudo-scientific and frankly pathetic medical discourse about what ails
us.
I am increasingly astonished about how unable the average patient is now to
articulate reasons for their unhappiness, and how readily they will accept
a "medical" diagnosis and solution if given one by a narrow-minded
psychiatrist. This is a cultural pathologic dependence on medical
authority. Granted, there are patients who do fight this kind of definition
and continue to search for better explanations for themselves which are
less infantilizing, but in my experience this is not common. There is a
frightening choking off of the possibility for dissent and creative
questioning here, a silencing of very basic questions such as "what is this
pain?" or "what is my purpose?" Modern psychiatry has unconscionably
participated in this pathology for its own gain and power. It is a moral,
not scientific issue at stake here, and in my view this is why many astute
Americans rightfully distrust this new psychiatry and its Utopian claims
about happiness through medical progress.
So what kind of psychiatry am I advocating here? First of all, I think it
is unclear whether the field can extricate itself from its current
infatuation with technology and its own power to use it. When one reads
psychiatric journals now, one senses a dangerous giddiness about the
field's "discoveries" and "progress," which in my view are wildly and
irresponsibly overstated. All the momentum, which is mainly economically
driven, is pushing psychiatry toward further biologism.
Having said this, what I am advocating is a psychiatry which devotes itself
humbly to the task of listening to patients in a way that other medical
practitioners cannot. This means paying close attention to a patient's
current and past narrative without attempting to control, manipulate or
define it. From this position a psychiatrist can then assist the patient in
raising relevant questions about their lives and pain.
The temptation to provide answers or false solutions should be absolutely
avoided here. Medications are used judiciously for lowering painful
symptoms, with considerable attention paid to the psychological effects of
medication treatment. Diagnosis should play a secondary and small role
here, given that little is known about what these diagnoses actually mean.
Above all suggestion, coercion, normalization and control need to be
assiduously guarded against, as these are natural temptations that arise
out of the dynamics of power that exist between psychiatrist and patient.
A more humane psychiatry, if it is even possible in today's cultural
climate, must recognize the powerful potential of the uses and abuses of
power if it is not to become a tool of social control and normalization. As
I have outlined in this piece, these abuses of power are by no means always
obvious and self-evident, and their recognition requires rigorous thought
and self-examination. The psychiatrist plays a particular role in cultural
and individual fantasies, and an intelligent psychiatrist must be aware of
the complexity of these fantasies if he is to act in a position outside
these projections and fantasies. This requires real moral awareness on the
part of a psychiatrist who wishes to act intelligently. What I am
advocating for in outline form as stated previously are the minimal
requirements necessary for the field of psychiatry to reverse its current
degradation. What is essential at this time is for psychiatrists and other
clinicians to speak out against the ideology known as biologic psychiatry.
Dr. Kaiser is in private practice in Chicago, and is affiliated with
Northwestern University Hospital
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