If I closed my eyes, it would have been easy to imagine that I was visiting a peaceful city park. The sounds of birdsong and children’s laughter rang in the air, and the odor of freshly cut grass filled my nostrils. But the sweet smells and soothing sounds belied the horror of the place where I actually stood—inside the wrought iron gates of Auschwitz-Birkenau, the Holocaust’s most infamous concentration camp. Today the camp is a museum, and there is an eerie dissonance between the tranquility of its sprawling grounds and the mass murders that were carried out here almost 70 years ago. Like many visitors to Auschwitz, I experienced powerful emotions—a mixture of revulsion, anger, and a deep empathy for the millions of souls who suffered and perished there. I also felt a discomfiting sense of doubt about the goodness of humanity, including my own.
As a psychiatrist, however, I also have rational side. Like most of my colleagues, I am aware of the connection between political violence and an elevated risk of depression and anxiety disorders.1 My visit to Auschwitz made this connection tangible, and it raised questions about my profession that made me uneasy. Psychiatrists increasingly emphasize biological principles in their understanding and treatment of mental illness, but seeing physical evidence of the Holocaust made me wonder how well the biomedical model applies to the sequelae of psychological traumas like genocide. Genocide and lesser forms of political violence are still rampant, and psychiatrists are increasingly called on to treat the victims. Does biology really provide us with the best tools to help them? Could our focus on biology actually hurt the survivors? These are easy questions to ignore in everyday clinical life, but for me, visiting Auschwitz imbued them with a sense of reality and urgency.
I will confess that I am skeptical of biological psychiatry—the belief of many psychiatrists that mental illness is best understood and treated using a biological approach. My doubts are not fueled by any distrust of science—I recognize the tremendous contribution biology has made to psychiatry, both in understanding diseases like schizophrenia and bipolar disorder, and in bringing about effective somatic treatments that have become the mainstay of our profession. Rather, I fear that for many psychiatrists and patients alike, a one-sided approach to understanding mental illness—biological or otherwise—may sound the siren call of easy answers and inevitably lead to moral consequences.
Some will object that the term “biological psychiatry” is disingenuous because psychiatry is actually based on Engel’s venerable biopsychosocial model.2 While it is true that psychiatrists must pay homage to the biopsychosocial model to pass their board exams, a perusal of any respectable psychiatry journal will demonstrate that in research and clinical practice biology is king. As an example, I recently overheard a well-known genetic researcher expounding to a group of psychiatry residents that “the more we stick with biology, the better off we will be.” I hope that trainees do not heed this ill-conceived advice. One need only examine the psychiatric consequences of genocide to see what a terrible mistake this would be.
The nature and magnitude of the mistake may not be obvious to a privileged class of professionals living in a stable Western democracy. There, a dogmatic theoretical emphasis on biology may prove harmless in clinical settings, where the exigencies of clinical interaction ensure that some amount of attention will always be paid to social and psychological concerns. However, psychiatry’s role in society extends far beyond the clinic to influence public attitudes toward mental health and illness the world over3 and, in many parts of the world, social injustice and political violence rule the day just as they did in occupied Europe. In these spheres, biological dogmatism is not benign if it leads the public to abandon moral outrage in favor of a disease model for understanding the psychiatric consequences of social injustice and political violence.
This may sound like catastrophizing, but there is evidence that the public has begun to accept this view. For example, a prominent mental health consumer group proclaims on its Web site that “mental illnesses are biologically based brain disorders.”4 I reflected on this idea as I walked past pits that held the ashes of incinerated prisoners, hastily buried before advancing liberation forces arrived. I remembered some elderly Holocaust survivors I had seen as a medical student rotating through psychiatry. Some suffered from depression, others from posttraumatic stress disorder; all suffered from memories of the Holocaust, and there were many others like them in the clinic where I worked. How would they react if they were told that their painful memories were the result of brain disease?
I understand that describing mental illness as brain disease may reflect a well-intentioned effort to de-stigmatize mental disorder and legitimize its treatment as a medical illness. However, it also suggests that biological explanations are the final word on psychiatric illness. Walking among the ash pits, this would be a difficult claim to believe. No doubt that anxiety has biological correlates, but in a concentration camp it is worth asking whether biology is the most appropriate explanatory principle. If a prisoner at Auschwitz were shot in the head, one could accurately describe the victim’s injury in terms of “genes plus environment”—but to do so would be worse than insensitive and rather beside the point.