Psychiatry’s Mission Impossible
Most of my work is aimed at discrediting the current biological model of psychiatric treatment—which is supported by bad science, and corrupted by financial interests. But the sad truth is that psychiatry has always been inherently prone to such corruption—simply because its scientific challenges are so very daunting, and the public desire for successful intervention in psychiatric disorders is so desperate. So, before we begin to ponder psychiatry’s many sins against science, let’s first give full consideration to the peculiar challenges it faces as a medical specialty.
Psychiatry’s main anatomical focus is the brain—an organ entirely encased in bone. Underneath the bone are layers of fibrous tissue and fluid that cushion the brain, all of which are vulnerable to infection if intruded upon. The brain itself is a fabulously complex array of about a hundred billion nerve cells (neurons), each with numerous junctions connecting it to its neighboring cells. Cells communicate between each other across these nerve junctions (synapses) through the secretion of chemical messengers known as neurotransmitters. Each neuron has an average of about 7,000 synapses. There are over 100 different neurotransmitter agents identified in the human brain–each of which may have either an excitatory or inhibitory effect on the postsynaptic cell, depending on what kind of receptor protein it contacts in the cell membrane. The location of this intercellular communication is in the synaptic cleft, the microscopic space within the junction which is crossed by the neurotransmitters. Here the balance of neurotransmitters is constantly adjusted by the two cells through the processes of release, metabolism, and reuptake—which in turn are regulated by an elaborate feedback network incorporating input from other neurons as well.
In short, the raw circuitry of the brain is microscopic, profuse, and unimaginably complex. And every brain is unique!
The physiological tasks of brain cells are largely determined by their location within the brain—and the higher functions associated with thoughts and feelings are particularly inscrutable, since they occur within a microscopic assemblage of neurons acting in a meticulously coordinated fashion. Hence studies of brain cells in vitro (i.e. outside of the body in a laboratory medium) tell us little about their psychiatric function. This leaves us with the necessity of studying brain cells in vivo (in the living organism) to gain an accurate understanding of their function. But doing so would require passing a needle past the skull and through the surrounding nerve tissue, causing irreparable damage to the brain since neurons have little if any capacity for regeneration. This makes direct observation of living brain tissue ethically unacceptable—and even if it wasn’t, how many people would give informed consent to participate in such a study?
The other medical specialties (besides neurology, of course) focus on organ systems that are infinitely less complicated than the brain, more physically accessible, and able to withstand a needle biopsy without irreparable loss of function. Chemical markers associated with these systems are typically measurable in the peripheral blood, unlike those of the brain. Other intrusive diagnostic procedures such as endoscopy are available as well. Access to this sort of information allows physicians to be reasonably certain what’s going on inside the patient—a feeling dreadfully unfamiliar to any prudent psychiatrist.
Before one even contemplates these anatomical and physiological complexities, there is the conundrum of its duality—the brain in the corporeal world, the mind in the ethereal. Like astrophysics, neuroscience is an area of study that raises philosophical and spiritual questions, provoking the sort of controversies that are attendant to such concerns. In the realm of medical science, the brain-mind stands out as a uniquely remote wonder, a bottomless enigma that we’ve barely begun to crack. In point of fact, the secrets of the brain-mind constitute a last frontier far more scientifically daunting than astrophysics—which, after all, is just the study of a bunch of dumb particles that happen to be very far away. It’s only fair to acknowledge the onerous scientific challenges that psychiatric researchers confront in trying to penetrate this ironic, existential mystery.
Psychiatry’s sense of futility is further aggravated by the likelihood that once a psychiatric disorder does become treatable, it will be reclassified as a non-psychiatric disease. In the 19th Century a large proportion of asylum inmates were diagnosed with general paralysis of the insane (GPI)—a psychiatric disease characterized by manic symptoms or other behavioral problems, followed thereafter by the onset of dementia and progressive paralysis. It was noted that this presentation was more frequent in men, especially those with “debauched” lifestyles. Eventually this problem was identified as neurosyphilis, an advanced stage of syphilis that takes ten years or more to manifest itself in infected individuals. Once antibiotic treatments were developed it became a “medical” illness, and thus no longer the concern of psychiatrists. Similar paths were followed by epilepsy, the thiamine deficiency and hepatic encephalopathy associated with alcoholism, Parkinson’s disease, Huntington’s chorea, and other neurodegenerative diseases. It would seem that we are in part defined as a specialty by our ineffectuality, since any disease that can be readily treated becomes someone else’s responsibility. This sequence pretty much dooms us to persistent clinical failure–a reality of psychiatric practice that at times can be quite demoralizing.
With so much to prove to our patients and peers, and a dearth of reliable scientific information, psychiatry has time and again compensated for the deficiency of its knowledge base by simply making shit up. The unfathomable nature of our calling conveniently lends itself to grand fabrications—and when patients bring us uneasy questions about what we’re doing and how it works, almost any answer seems more satisfactory than yet another “I don’t know.” Consequently, psychiatry has been prone to spasms of radical reinvention over its history, as one brand of pseudoscience is replaced by another in a desperate attempt to cover up our gaping ignorance. These “breakthroughs” have generally swung between two opposing modes of characterizing psychopathology—either a biological orientation focusing on the brain, or a psychological orientation preoccupied with the mind.
At this time in psychiatric history, our understanding of the brain certainly exceeds our physiological understanding of the mind—which is nil. I’m completely forgiving of our ignorance in this regard. What I can’t forgive, however, is our refusal to acknowledge that ignorance in our clinical practice–and our vain, corrupt promotion of biological half-measures, as if they were clinically and ethically sufficient.
My contention is that in order to improve our success in psychiatric treatment, and to minimize the unintended harm we are inflicting, we need at last develop an eclectic array of interventions that address the eclectic nature of psychiatric disorders. Treatments that incorporate not only what we know about the brain, but what we know about the mind. We may not understand the underlying physiology of how the mind works, but we do have plenty of knowledge about how human beings work—and it’s foolish and inhumane to not make that sort of knowledge a necessary part of psychiatric intervention.
For thousands of years, people have been overcoming anxiety and depression by pursuing emotional growth. In my opinion, no psychiatric patient should be deprived of assistance in exploiting that innate capacity for meaningful, lasting improvement in the course of their treatment. I see nothing in our current model of care that acknowledges that capacity, much less utilizes it. I think it should be our duty to do so, if patient health is in fact our goal.
But there’s one major sticking point in my proposition—yet another quandary, one that impedes the aggressive funding of research to develop new models of psychotherapy for common psychiatric disorders:
