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INTRODUCTION

To gauge the depths of psychiatry’s public image problem you need look
no further than the pages of New Yorker magazine, where for over fifty years
the profession has been an enduring target of their characteristically droll
cartoons. In bygone days the stereotypical psychoanalyst was portrayed as
aloof, eccentric, somewhat mercenary, but otherwise thoughtful or even
sympathetic—the butt of the joke was usually either the neurotic foibles of the
patient, or the clumsy ambiguities surrounding the remunerative aspect of the
therapeutic relationship. But in recent years this caricature has evolved into a
much uglier stereotype—a shallow and emotionally detached pill-pusher, a
shill for medications with no inclination to listen to patients, and no interest
in the fine points of human emotion. The medications themselves, e.g. the
already iconic Prozac, are treated with higher regard than are the doctors who
prescribe them.
This change in perception is the natural consequence of a revolution in
treatment that began in the 1970s—the emergence of biological psychiatry, in
which mental disorders are considered biological dysfunctions of the nervous
system, as the preeminent model of care. As medications have increasingly
become the mainstay of our treatment, knowledge and interest in the
psychodynamics of our patients have diminished, since they are deemed
irrelevant in the view of the prevailing dogma. It leaves psychiatrist and
patient with precious little to talk about, or listen to, during a treatment
session.
This transformation did not occur in a vacuum, but rather was ushered
in by a host of economic and sociological forces, not the least of which is the

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concurrent rise of Big Pharma as a formidable patron. But although the


pharmacological industry is an obvious culprit, psychiatry’s rash embrace of
this biological model has been driven as well by our own historical self-doubt.
Over the entire course of its existence, two nagging insecurities have dogged
this profession—the fundamental unknowability of its subject matter, and its
desire for legitimacy as a medical profession. Biological psychiatry has
proven to be a seductive remedy for both of these problems.
The enigmatic interrelationship of brain and mind has been pondered
for centuries, even put forward as the divine spark that separates man from
the other animals. Formidable physical, physiological, and even ethical
obstacles impede our ability to definitively observe and understand the
operations of the brain, which even in its fabulous complexity is the relatively
simple hardware end of our sophisticated “personal computer”. The higher
operations that generate our thoughts and conscious behaviors are a function
of the mind—our virtual software operating system with its attendant
programs and database—which, as Bill Gates will tell you, is where the real
money is. The challenge of grasping all of these unknowns is clouded even
further by a vast degree of individuation from one person to the next—six
billion different brain/mind units, none of them constructed or programmed
quite like the other.
Our glaring inability to explain mental illness has never dissuaded
psychiatrists from giving it a shot anyway. The history of psychiatry is littered
with well-intended but half-baked theories, lurching from biological to
psychological and back again, all of them ultimately debunked. Recent
advances in technology over the past three decades have indeed led to
significant gains in our understanding of brain physiology, and in turn have
improved the quality of our medications. However, our longstanding

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compulsion to explain the unknowable has once again led us to overreach—to


take a little bit of scientific knowledge and run with it, vastly exaggerating our
degree of understanding in order to project certitude where there is in fact
none. Our embrace of medication-oriented theory and practice has been
reinforced by the increased esteem we have gained from other physicians,
who are sitting up and taking notice of us now that we talk about
neurotransmitters and prescribe drugs that work. In the meantime our
academic institutions have been generously rewarded by the pharmaceutical
industry for being its handmaiden. Thanks to biological psychiatry, we have
finally earned the right to sit at the table with the cool kids.
Despite what some would have you believe, this newfound wealth and
popularity has not been the product of good, sound science. Biological
psychiatry has ascended on the strength of its technology, strictly defined as
the application of scientific knowledge to commercial or industrial objectives.
Meanwhile science itself—the systematic study of the physical world, using
the scientific method to differentiate truth from supposition—has fallen by the
wayside, a victim of the corrupting influence of money and prestige.
Strict adherence to scientific principles would require an unsparing
reexamination of some of biological psychiatry’s most hallowed assumptions
by its greatest beneficiaries, the institutions of academic psychiatry, who have
to date exhibited little inclination to risk derailing their own gravy train.
Instead they have constructed a sort of alternate pseudoscientific reality,
driven by a diagnostic system that defines disorders based on superficial
observations rather than the identification of actual disease states. Although
this may be a necessary evil given the vagaries of psychiatric illness, it has
nonetheless facilitated the rampant expansion of nominal pathology to
include much of what used to be considered human passions, foibles, and

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individual quirks—and spawned a new frontier of clinical indications for


pharmaceutical intervention.
At this point you might leap to the conclusion that I disapprove of
psychiatric medications, when in fact almost all my patients are on
pharmacotherapy. That’s because I share the New Yorker’s evident belief that
our medication is the best thing that contemporary psychiatry has to offer.
What I do object to is almost every other facet of the biological model of
practice: its paternalistic inclination to pathologize human emotions; its self-
imposed ignorance of psychodynamics; its economically and scientifically
corrupt research apparatus; its amorality and spiritual vacuity; and most
especially, the elaborate body of misinformation that has been created to
promote pharmacotherapy, without regard to the destructive effects of these
myths on our patients and the therapeutic process.
We are living in an impatient age that demands the quick fix, whether
one exists or not. Biological psychiatry is based on a pipe dream: the false
hope that extremely complicated human situations can be boiled down into
simplistically defined disease states, and will respond to efficient, cost-
effective treatments that will become even more efficient and cost-effective
over time. It ignores the fact that psychiatric illness occurs in the context of
the human condition, with all the dreadful tragedies and nuances that this
phrase implies. Technology and its partner, bureaucracy, strive to fit
psychiatric patients (like any other problem) into categorical boxes, on the
assumption that this will facilitate their rehabilitation. Unfortunately for this
worldview, the case could be made that the single best definition of a
psychiatric patient is “one who will not fit into a box.” It’s my contention that
the effective practice of psychiatry requires the acceptance of this fact, a
determined effort to understand not just the symptoms but the story of the

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patient, and the imaginative utilization of an eclectic variety of interpersonal


tools to supplement our medications.
All of this sounds a little bit like I’m suggesting that psychiatrists should
go back to doing analytically-oriented psychotherapy—only I’m not.
Psychoanalysis was a rich man’s (or woman’s) game, a woefully inefficient
model of care lacking any semblance of cost-effectiveness, and hence
inappropriate for consideration in the democratized market of psychiatry
today. Its inherent inefficiency was rooted in three of its guiding principles:
the process of free association, allowing the patient to direct the course of
treatment; the maintenance of therapeutic neutrality, i.e. a passive,
nonjudgmental, and emotionally anonymous demeanor allowing the patient
to project their own concerns onto the therapist’s blank slate; and cultivation
of the therapeutic alliance, the partnership of the patient’s “healthy” side with
the therapist. These tenets have persevered through the history of classic
analysis and most of its offshoots, but the considerable investment of time
they require contributed to the decline of the analytic model of practice.
Of course with the advent of biological psychiatry, the process of free
association (and hence patient-directed treatment) went out the window,
since nothing could be more irrelevant in this model of care than a patient’s
rambling thoughts about anything. The other two principles have persisted,
but in altered form. Since the demise of its intended purpose of facilitating
projection, therapeutic neutrality has evolved into more of a standard of
professionalism than a clinical tool, ensuring the bland acceptability ofthe
practitioner to the widest possible consumer base. Meanwhile, maintenance
of the therapeutic alliance (i.e. the avoidance of provocation that might
disrupt treatment) now seems to be driven primarily by fear of a formal
complaint or lawsuit, rather than the dedication to clinical progress that

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originally impelled it. Both conventions have become manifestations of


defensive medicine, in which the goal of clinical improvement is significantly
compromised by the fear of potential malpractice litigation or other negative
reaction on the part of the patient.
In short, contemporary psychiatry has utterly rejected the humanistic
values of inquisitiveness, empathy, and introspection that characterized
psychoanalysis, in its conviction that they are inefficient and irrelevant—and
yet has co-opted a couple of its more inefficient traditions for reasons that
have little to do with clinical efficacy, and a lot to do with the mediocre goal of
not upsetting anyone. In doing so, it has effectively thrown out the baby, and
kept the proverbial bathwater. As they now function, both conventions have a
chilling effect on frank communication within what is already a chilly
relationship. And when combined with the easy evasions of biological
psychiatry—“Here, let’s try this new medication”—the chances for any candid
exploration of complicated emotional issues approach nil.
So what am I proposing as an alternative? Well, as I see it, medication
is now an essential part of psychiatric practice, the most compelling
justification for our existence as a discipline. Psychologists and clinical social
workers can perform longterm psychotherapy as well or better than we do,
and at less expense (assuming that we want to maintain our current
advantage in pay scale). Where we clearly excel is in our familiarity with
psychiatric medications, which enhances our value to patients, other
physicians, and other disciplines. The authority to hospitalize patients
enables us to manage more difficult cases, which also contributes to our
utility. But among all their attendant privileges, there is one that places the
psychiatrist in the catbird seat of the mental health system: the definitive
diagnosis of mental illness.

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This authoritative role emanates largely from the acquiescence of the


court system, insurance companies, and government agencies—all of whom
regard a psychiatrist’s opinion as the last word on all questions diagnostic—
rather than being indicative of any inherent expertise. In fact, our diagnostic
system is already dumbed-down enough to assure its idiot-resistance, and can
be reliably implemented by any reasonably intelligent person with a limited
amount of training. However such a determination would lack the
imprimatur of being issued by a psychiatrist, who holds the prestige and legal
authority that is uniquely conferred by a medical license.
I think most of us today are falling short in our execution of this
diagnostic function, by failing to recognize and exploit the linchpin role we
hold in the assessment and disposition of the patient. Enabled by the
biological model, we habitually neglect any of the thornier issues that might
be contributing to the patient’s complaints—or if too obvious to ignore, they
are summarily referred for psychotherapy, so that other professionals can
provide the time and attention that we’re unwilling to give. The deficiency of
such an approach is its failure to acknowledge that many of these patients will
never actually make it into therapy, for a variety of reasons—often lack of
insurance coverage, but also due to fear, lack of motivation, work schedule,
transportation issues, availability of a therapist, or failure to understand the
necessity of doing so. When we see a patient in evaluation, it is often their
first confrontation with the mental health system, and it may be their last as
well.
Many patients still expect us to have a unique understanding of their
feelings, and are surprised to find how biologically and medically oriented
psychiatry is today. We are given a golden opportunity in such circumstances
to help the patient understand their psychiatric problems in a broader

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context—to address not just the medication options available to them, but to
educate them regarding the stresses, psychodynamics, and lifestyle issues that
may be contributing to their illness. However, to do so requires a belief in
something other than the narrow dogma of biological psychiatry; the
willingness to speak frankly about our observations; and the ability and desire
to connect emotionally with our patients, if only for an hour or so. The same
approach can be continued into followup care, but it requires the application
of a multifactorial model of mental illness by a psychiatrist whose manner is
direct, emotionally engaged, and above all else, honest.
It’s on this issue of candor that I have my biggest beef with
contemporary psychiatry. Psychiatrists like to pretend nowadays that they
understand how the brain works, when really they don’t. But what’s even
more remarkable is that they don’t seem to understand how people work—
and I suspect that many don’t even ask themselves that question. In all my
psychiatric training, nobody ever told me that a person in a miserable
marriage could exhibit all the diagnostic criteria for major depression. And
that people in bad marriages typically lie about it, even if you ask them
outright. It took many years of clinical practice to discover these truths—but
before I could do it, I had to stop thinking of neurotransmitter receptor sites,
and start wondering why these patients didn’t get any better no matter what
medications I prescribed them.
Once I’ve figured out what the patient’s real problem is, there remains
the dilemma of what to do about it. Therapeutic neutrality dictates that I
should have no particular feelings or opinions on such a weighty issue as one’s
marriage. And maintenance of the therapeutic alliance could compel me to
avoid taking undue risks—such as telling a patient that by all indications their
spouse is incorrigibly narcissistic, and that the chances of improvement of the

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patient’s mood are slim to none unless this issue is addressed—for fear that
the patient will take offense and be driven away from treatment. Both of
these guiding principles stand in the way of sharing my perception of the
truth, which is in fact the most valuable gift I have to offer a patient when
medications have proven worthless.
I‘m not the first to maintain that the effective practice of psychiatry
sometimes requires throwing out the book. But nowadays “the book” is a
corrupt falsehood worming its way into the popular ethos, promoting a
passive and disempowered role for patients that discourages their
constructive participation in treatment, hence undermining its efficacy. If the
real purpose of psychiatry is to relieve emotional distress rather than peddle
product, then it’s time to rigorously reexamine the intellectual underpinnings
of contemporary psychiatry to reaffirm their validity; because on the face of it,
psychiatry is not working as advertised. What we need is a new “book”, based
on the self-evident truths of psychiatric illness and its treatment, rather than
the pseudoscientific bromides that are currently dominating the conversation.
But don’t take my word for it. The case against biological psychiatry, as
it is currently marketed and practiced, can be made by the simple application
of reason to its principle contentions. And there’s already a well-established
process in place to discern fact from supposition, that requires only a
modicum of training and intellectual discipline—the scientific method.

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