Letter to a Foreign Psychiatrist: Page 2 of 2

Letter to a Foreign Psychiatrist: Page 2 of 2

So, my first suggestion: live beyond DSM. See it as a tool, a fallible tool, a mostly (but not completely) false tool. Look for the few places where it is based on solid research, and build on those parts. But put it aside as a central approach to clinical treatment: there it fails.

That’s the bad; here’s the good. In 1989, I was in Madrid for 4 months working in a psychiatric hospital, the first in that city run by an American health company. The doctors there read the American journals and had begun to prescribe this new-fangled drug called fluoxetine, and they actually considered possible biological causes of mental illness. Other hospitals in Spain mainly used Spanish versions of Freudian and Germanic ideas to “explain” mental conditions; treatments were varied and random. Psychotherapies of dubious efficacy abounded; somatic treatments were old and dangerous: insulin coma therapy was still in use, and I saw ECT given in non-surgical rooms with only brief intravenous benzodiazepine treatment but no muscular blockers or other anesthesia. The seizure happened as the body writhed and the arms and legs shook rhythmically. It might have been good for the brain, but it was terrible for the body. In short, psychiatry in Europe was old-fashioned, non-scientific, and either dangerous or benignly useless.

The strength of European psychiatry is attention to phenomenology: to the careful understanding and description of patients’ experiences. The weakness of European psychiatry is therapeutic randomness. American psychiatry, for all its faults, pays some attention to scientific testing and, for all its overuse of drugs, has some truly effective medications (preeminently, lithium).

The strength of American psychiatry is acceptance (at times) of the verdict of scientific testing and the use of treatments that are sometimes truly effective. The weakness is an extreme “pragmatism” that has produced a nosology based on opinion, enforced by a cultural monopoly of influence.3 This pragmatism has also led to an extreme, shoot-from-the-hip psychopharmacology in which, above all else, one must “do something” that “works” while in reality what one does hardly works.2

Can you combine both? Can you be non-American enough to truly value signs, symptoms, and experiences in a clinically sound nosology, not one based on the economic and social wishes of professional leaders? And can you be American enough to test your ideas scientifically and base your treatments on those scientific tests?

Being foreign can be an advantage. Only an outsider sees assumptions that insiders take to be self-evident. But simple criticism fails. Turn your vision inward, and ask yourself what assumptions your country has and what beliefs your teachers are imposing on you, complacently and without sound basis. Truths are sol­itary things, and they move away when approached; they are not passed around simply from teacher to student, or from America to the world, like a plate of cookies. Search for truths where no one else is; that’s probably where you’ll find them.




1. Andreasen NC. DSM and the death of phenomenology in America: an example of unintended consequences. Schizophr Bull. 2007;33:108-112.

2. Ghaemi SN. Volks­wagen psychopharmacology. Psychiatric Times. June 1, 2011. Accessed March 1, 2013.

3. Ghaemi SN. Couch-pragmatism. Psychiatric Times. August 18, 2010. Accessed March 1, 2013.

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