But the clash was not fully over. In a rebuttal letter to the editor, Klerman asked: “Why doesn’t psychodynamic psychiatry attempt to be scientific?” He concluded that “psychoanalysis is now on the defensive intellectually and scientifically. . . . My dominant feelings about psychoanalysis are frustration and disappointment.”11
Beyond dichotomy: rising to the challenge
And so what can be said, 2 decades later, about the outcome of this “important historical moment of transition in modern psychiatry”? Did Klerman’s proposals, in fact, have “serious consequences for the innovation, diversity, and independent thought essential to scientific progress in psychiatry”? After Osheroff, and particularly during the “decade of the brain,” the schism widened between “a reductionist scientific method, as manifest in evidence-based medicine, and that of a narrative form of knowledge derived from clinical experience.”5 The dualism was outlined rather comprehensively by anthropologist T. M. Luhrmann10 in her book Of Two Minds: The Growing Disorder in American Psychiatry. Luhrmann concluded that neither the biomedical nor psychodynamic approach “mirrors” the reality, but each provides a different and valuable way of approaching mental illness.
It can be argued that the greedy reductionism of scientific psychiatry inexorably wrapped itself around the brainstem of psychiatry, threatening to squeeze the life out of the art of psychiatry. Despite the best intentions of the biopsychosocial model, it can be argued that the practice of psychiatry, particularly from Osheroff forward, deteriorated into a de facto biological reductionism (R. Pies, personal communication, October 15, 2012). Should psychiatry be faulted for taking this path? While opinions may be divided on this issue, it should be noted that psychiatry was merely following the lead of medicine generally.
Although the biopsychosocial model has been heavily critiqued in recent decades, many would argue that it was never meant to “discover” neuropsychiatric pathology. Rather, it is a philosophy of clinical care and a practical clinical guide for the application of psychiatric knowledge to needs of individuals.12 As for the way in which biological psychiatry allowed its knowledge to become subservient to the pharmaceutical industry, one is left to wonder if this was not part of the serious consequences dreaded by Stone.
Despite Klerman’s indictment, psychodynamic psychiatry has managed to survive as a viable model for clinical practice. And why might this be? The humanities search for truths about the human condition, just as science searches for truths about physical matter. Truths do not dissolve so easily. Freud13 noted: “In the end the most cutting truths are heard and recognized especially after the injured interests and affects aroused by them have exhausted themselves.” In fact, Freud anticipated the perennial fate of psychoanalytic thought. Who among us wants to be told that we are each the author of our own story, be it comedy, tragedy, or other? This is a painfully bright sun to stare directly into, and Freud13 was fully aware of this: “I must put a damper on your expectations. Society will not hasten to furnish us authority. Society must remain in a state of resistance towards us because we assume a critical attitude towards her. We inform her that she herself plays a great part in the causation of the neuroses.”
2. Shapiro SJ. The “Hart-Dworkin” Debate: A Short Guide for the Perplexed. February 2, 2007. U of Michigan Public Law Working Paper No. 77. http://dx.doi.org/10.2139/ssrn.968657. Accessed January 24, 2013.
3. Annas G. Doctors, patients, and lawyers—two centuries of health law. N Engl J Med. 2012;367:445-450.
4. Stone AA. Law, science, and psychiatric malpractice: a response to Klerman’s indictment of psychoanalytic psychiatry. Am J Psychiatry. 1990;147:419-427.
5. Robertson M. Power and knowledge in psychiatry and the troubling case of Dr Osheroff. Australas Psychiatry. 2005;13:343-350.
6. Klerman GL. The psychiatric patient’s right to effective treatment: implications of Osheroff v Chestnut Lodge. Am J Psychiatry. 1990;147:409-418.
7. Malcolm JG. Treatment choices and informed consent in psychiatry: implications of the Osheroff case for the profession. J Psychiatry Law. 1986;14:9-106.
8. Snow CP. The Two Cultures: And a Second Look. New York: Cambridge University Press; 1963.
9. Furedi F, Kimball R, Tallis R, Whelan R. From Two Cultures to No Culture: CP Snow’s ‘Two Cultures’ Lecture Fifty Years On. London: Civitas; 2009.
10. Luhrmann TM. Of Two Minds: The Growing Disorder in American Psychiatry. New York: Alfred A. Knopf; 2000.
11. Klerman GL. The Osheroff debate: finale. Am J Psychiatry. 1991;148:387-390.
12. Borrell-Carrió F, Suchman AL, Epstein RM. The biopsychosocial model 25 years later: principles, practice, and scientific inquiry. Ann Fam Med. 2004;2:576-582.
13. Freud S. The future chances of psychoanalytic therapy. Selected Papers on Hysteria and Other Psychoneuroses. http://www.bartleby.com/280. Accessed January 24, 2013.
14. Perry JC, Bond M. Change in defense mechanisms during long-term dynamic psychotherapy and five-year outcome. Am J Psychiatry. 2012;169:916-925.
15. Gerber AJ, Kocsis JH, Milrod BL, et al. A quality-based review of randomized controlled trials of psychodynamic psychotherapy. Am J Psychiatry. 2011;168:19-28.
16. Gabbard GO. Long-Term Psychodynamic Psychotherapy: A Basic Text. 2nd ed. Arlington, VA: American Psychiatric Publishing, Inc; 2010.
17. Shedler J. The efficacy of psychodynamic psychotherapy. Am Psychol. 2010;65:98-109.
18. Douglas CJ. Studying the efficacy of psychodynamic psychotherapy. Am J Psychiatry. 2011;168:649-650.
19. Vaillant G. Lifting the field’s “repression” of defenses. Am J Psychiatry. 2012;169:885-887.
20. Dennett DC. Facing Backwards on the Problem of Consciousness. November 10, 1995. http://ase.tufts.edu/cogstud/papers/chalmers.htm. Accessed January 24, 2013.
References1. National Endowment for the Humanities. National Foundation on the Arts and the Humanities Act of 1965 (P.L. 89-209). http://www.neh.gov/about/history/national-foundation-arts-and-humanities-act-1965-pl-89-209. Accessed January 24, 2013.