In recent years, psychiatry and psychoanalysis have been drifting apart. As has been stated, psychiatry is losing its mind as it concentrates on chemistry and biology. This is a pity, because it is always good to have a mind.
Psychoanalysis' unique contribution is its adherence to the belief that patients' behavior, attitudes and feelings are meaningful even when they appear to be most irrational. The intrapsychic focus stresses unconscious motivation, which means that the causes of emotional disturbances frequently stem from inner sources. To some degree, it assumes that patients are the masters of their own destiny, that they are not just the hapless victims of cruel circumstances. This means that, in most instances, there is a potential for control and this leads to the hope that emotional equilibrium can be established.
Moving away from the intrapsychic focus takes us into the realm of biology and neurochemistry, areas that are making significant advances. Unfortunately this movement has led to a polarization between the inner workings of the mind from a psychological perspective and external traumas as they impact on the brain. The brain and the mind have once again become separated, leading to a Cartesian dualism that in the past had been considered naive and anachronistic.
History is repeating itself. In the first decade of this century, psychodynamic explorations and the intrapsychic origin of emotional disorders were gaining acceptance by psychoanalysts and some prominent psychiatrists. Patients suffering from what was then called general paralysis of the insane or paresis, a sizable group of hospitalized patients, brought forth considerable primary process material and were being studied from a psychological perspective. The hopes these pursuits engendered were abruptly shattered when the Japanese bacteriologist Noguchi discovered the organism treponema palidum, a spirochete, to be the causative agent of what proved to be syphilis of the brain and the cause of general paresis. The efforts of investigators intensified in their pursuit of organic causes for other emotional entities, particularly psychoses. Their biological orientations led to the discovery of electric and insulin shock therapies.
Nevertheless, there was a slow and gradual ascendancy of psychodynamic thinking reaching its apogee shortly after the end of World War II. Then something similar to Noguchi's discovery happened; chlorpromazine was synthesized. Now we had a monumental breakthrough, a magical cure for psychoses, that rivaled the importance of penicillin and reinforced the search for organic etiologies. Since then there has been a continuous outpouring of drugs that are more or less effective in controlling behavior and symptomatic expression.
Psychopharmacological, somatic, behavioral and cognitive approaches assume a simple linear etiological sequence. They may achieve symptomatic control and restore functioning, but changes are restricted to the surface of the personality and ignore the subtle aspects of deeper psychic elements. Improvement, if it occurs, is often at the expense of the patient's fundamental humanity and the obliteration of autonomy.
Decline of Western Civilization
The decline of the intrapsychic focus seems to be associated with a certain notable deterioration of Western civilization. Most inner cities have become jungles, as murder, rape and incest are so commonplace that most of us are no longer shocked by the prevalence of such crimes. There has been a notable increase in the divorce rate, the number of dysfunctional families as well as many reported cases of sexual and physical abuse. Many of our elementary and high schools are in shambles, and the pursuit of learning and aesthetic goals has in many segments of our society practically disappeared.
Reflection, introspection, contemplation and even empathy have been shoved aside in favor of action which often escalates to violence. Ours is a materialistic concrete society, and our approaches to mental illness seem to be a reflection of the decline of values as exemplified by current mechanistic outlooks.
Today, problems have to be quickly resolved with computer-like speed. Subtle complexities are avoided, and solutions with "how-to" clarity and simplicity are eagerly sought.
Medicine and mental health are to a large measure in the hands of laymen or, more aptly stated, businessmen. Their motives are based on profits rather than healing and humanistic values. To some degree they have succeeded in infusing their values into our profession as evidenced by the many doctors who seek simple cause-and-effect sequences and quick cures.
Untrained and lay practitioners have also invaded our areas of endeavor, leading to an abundance of simplistic procedures and sheer incompetence when dealing with sensitive, vulnerable psyches that are immersed in misery and desperately seeking help. In many instances they are met with a mechanistic approach and formulaic procedures.
What most therapeutic approaches have in common is that they do not have an intrapsychic focus. In fact, in some cognitive therapies the inner life of the psyche is assiduously avoided. Their aims are limited to behavioral control.
Our therapeutic perspective aimed at behavioral manipulation should not be taken for granted. Some clinicians are concerned about "psychiatry losing its mind" as well as the violence and insanity that keeps escalating in our society which, in some ways, may be connected with the decline of the intrapsychic focus.
Although many patients are products of their culture and seek instant relief, there are others who cannot accept superficial solutions and do not want to relinquish symptomatic adaptations until basic issues are resolved.