Where's the Wisdom in Psychiatry?

with Paul Minot MD

psy·che      /ˈsīkē/
noun   1. the human soul, mind, or  spirit

Throughout its history psychiatry has swung back and forth between two opposing models of assessment and treatment. One is biological, focused on the obscure physiology of the brain; the other is psychological, focused on the even hazier functions of the mind. Each school of thought has competed for dominance of our profession, indifferent to the obvious truth that psychiatric health depends on proper functioning of both the brain and the mind. Any qualified psychiatric assessment would require a full understanding of both these entities,  and  a treatment model that included an eclectic array of tools. But we’ve yet to see any such model, because of three perennial contaminants in the evolution of psychiatric practice–ignorance, pride, and commerce.

These three driving forces continue to drive psychiatry into a clinical dead end. Our ignorance is scientific: To date we have no confirmed explanation as to how the brain and mind intersect, because the brain-mind is locked inside the skull, and is unimaginably complex. Our persistent inability to master our assigned organ system has driven us to chronic insecurity as a medical specialty–which has led us down many strange paths in the past, and culminating today in our fawning embrace of medication-oriented treatment. This new direction has been accompanied by our ironically brazen neglect of the psyche–defined as the human mind, soul, or spirit…but also known as “that thing that psychiatrists are supposed to treat.” This most recent swing in orientation has been quite financially rewarding for psychiatry, which is not unusual for the profession. Throughout its history, psychiatry has never turned away from any treatment model that has demonstrated its marketability–since much of psychiatric treatment has historically been provided to the poor and downtrodden.  And we’ve never had more paying customers than we have in this current biological era, now that we’re able to deal in pills–or as we psychiatrists like to think of it, “real medicine.” The benefits of modern medication-oriented psychiatry have even included fulfillment of our long-awaited dream–elevation of our specialty to the status of “real doctors” in the eyes of our peers. The modern model of psychiatric treatment has undoubtedly been very good for psychiatrists. 

But all that good stuff hasn’t changed the inherently eclectic nature of psychiatric illness. It was the cultural impact of psychiatry’s first and only rock star, Sigmund Freud, that made psychoanalysis all the rage in the first half of the 20th Century–but psychoanalysis eventually declined in popularity because it was time-consuming and hence expensive, and also not broadly effective. The medications that have taken its place are certainly much less time-consuming, less expensive, and more applicable to a broad array of patients than psychoanalysis was. But their efficacy is not that impressive, their risks and long term side-effects not well understood. Psychiatric medications are now often prescribed in brazen disregard of all that we do not know about our patients–under the vain assumption that our limited scope of interest, and our limited tools, are all that we need. Because, after all, that’s entirely consistent with community standards of care nowadays–it’s what we get paid to do.

This current neglect of the psyche is in my opinion indefensible–not just because it’s so damned demeaning to our patients and ourselves, but also because its reasoning has no firm basis in science. The physiological nature of thought remains an utter mystery to us all–but that doesn’t mean that it doesn’t exist, and  that our patients are mere biological entities. They have thoughts, affections, strengths, weaknesses, hopes, fears, struggles, and goals that are just as real as our own. Such abstractions are contributory to most if not all psychiatric disorders, but aren’t usually taken into consideration while we’re treating those pesky “symptoms.”

Back in the day, some of these symptoms used to be called “feelings”. Psychiatrists and patients alike were instructed to listen to them–not just squelch them with medications. Modern psychiatrists may lay claim to an understanding of human thought and behavior, of happiness and healthy function–but they aren’t expected to explore these issues in any depth whatsoever in their practice.  Modern psychiatry thinks it is smart, but exhibits no appreciation of wisdom–which, according to Socrates, begins with the humility of knowing and appreciating what you don’t know. By that timeless measure, contemporary psychiatry has no freaking clue.

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