The Crisis of Present-Day Psychiatry: The Loss of the Personal

(The following is the first of two articles adapted by the authors from lectures given at the University of Zurich upon receiving the 1998 Dr. Margrit Egnér-Stiftung prize-Ed.)

Let us begin with an example. Suppose I am traveling from the United States to Switzerland, anticipating skiing with my son in the Alps. My anticipation becomes vivid and lively. I recall excitement mixed with joy at rapidly soaring down the mountainside, and I am now quite anxious to re-experience this thrilling adventure with my son-eager to be heading down the mountain with him. Later, as we stand on the crest of a deep and winding slope, the speed, thrill and admixture of danger and adventure will infuse my being.

If, in this condition of excitement and joy, my body were connected to a monitor and tested, it would register certain physiological patterns that might be identical to those of an anxiety attack. So, from one point of view, my anticipation of a thrilling ski adventure could be mistaken for an anxiety attack. This point of view would, of course, have to disregard my subjective experiences, which are those of a person filled with joyful excitement.

Granted, in colloquial English we say, "I am anxious," but in this case it is meant in the sense of "I am anxious to meet my son." This anxiety is of joyful expectation, just the opposite of morbid anxiety. Indeed, if the only categories at one's disposal were pathological categories, my organic condition would have to be classified as an anxiety attack.

Therefore, in order to misinterpret my condition as an anxiety attack: 1) my condition must be decontextualized, i.e., my personal situation-that of a man traveling to go skiing with his son-would have to be disregarded and my organic condition alone considered; and 2) the decontextualized organic condition must be viewed as falling under some pathological classification system. If taken, these two steps would categorize my state as an anxiety attack.

In the modern climate of thought, the first step-ignoring the person's subjective experiences-is easy enough to take. Indeed, this would be viewed as required for a strictly scientific test. Science itself demands that subjective experience be disregarded and organic reality alone examined. Only in this way, the modern mind assumes, is a truly objective result reached.

The second step does not appear to follow as easily from the proclivities of the modern mind, however. But it does easily follow the modern specialization of the sciences. As they more precisely isolate specific provinces of reality, some sciences have focused on pathological conditions, leaving the study of healthy states to other disciplines. For example, American psychiatry has become determined to define mental disorders as thoroughly as possible, and it has indeed made some progress in this regard. But American psychiatrists rarely study mentally healthy people.

This concern with the pathological and neglect of the healthy is part of the specialization and resulting fragmentation of the sciences in Westernized countries. The increasing precision with which scientists study those aspects of the world in which they are interested focuses on ever more restricted dimensions of reality. One result is that the various sciences, now so many and so specialized, have little contact with one another. This is certainly true of the disciplines that study human life-too many and too vast to be comprehended by a single mind. For example, psychiatrists, in order to treat mental disorders, must study psychopathology, neurophysiology, psychopharmacology, behavioral therapy and psychotherapy, as well as a variety of medical disciplines. Hence, while psychiatrists know the special sciences peculiar to their field, they are disinclined to study philosophy, humanities and social sciences.

The other force that leads psychiatrists to ignore philosophy, humanities and social sciences is the remedicalization of psychiatry. Today, most American psychiatrists emphasize the fact that they are physicians, i.e., practitioners of a medical specialty. As they see it, psychiatry is simply one specialty within medicine, on a par with cardiology, orthopedics and gynecology. In order to validate this claim, psychiatrists increasingly strive to practice psychiatry the way other doctors practice their specialties. Hence it is thought to be desirable if the diagnostic manuals, treatment procedures and outcomes testing in psychiatry resemble as closely as possible those of the other medical specialties. In order to see how we have arrived at this predicament in psychiatry, let us take a few historical steps back, returning to the birth of psychiatry during the Enlightenment.

Psychiatry was born in the 18th century as part of the Enlightenment, a period when people, inspired by the new scientific spirit, were able to view mental disturbances as illnesses rather than as the result of sin or witchcraft. Mental problems were thus conceived in causal terms rather than moral or religious ones. Although the mechanisms within the individual producing these disturbances were unknown, the mere conception of these disturbances as due to causal mechanisms revolutionized our understanding of them. But this mechanistic conception of mental problems did not exist, as it does today, in theoretical isolation. Like all science at that time, this view formed merely one subsidiary branch of an all-encompassing metaphysical view that included social, political, religious and moral conceptions. To see this clearly, one must grasp the overall character of the Enlightenment.

The Enlightenment perpetuated and reinvigorated the Renaissance ambition of a universal philosophy of reason in whose light human beings could shape themselves and their entire social world. This universal discipline bore the name philosophy. However, the sciences at this time were part of philosophy-the two had not yet been distinguished. René Descartes reformulated the age-old belief that all the sciences were but branches of the tree of philosophy. Therefore, this universal philosophy included physics and mathematics as well as the sciences of the human mind, society and politics (Husserl, 1970).

Moreover, in its all-embracing unity, this universal philosophy included political and moral values. Its ultimate ideal was to be life-guiding and action-directing, with no distinction between daily life and philosophical reason. Life-including the collective, social life-should be shaped by philosophical reason. Nothing less than the reformation of the entire society under the guidance of a normative rationality was the aim of these thinkers. Hence the value-ideals of the French and American Revolutions-liberty, equality and universal human rights-were designed to guide this political and social reformation. The idea of value-free scientific knowledge still lay a century in the future.

When Enlightenment thinkers, like Dr. Benjamin Rush in America, took psychiatry (yet to be named) as their subject matter, they applied to a delimited group of phenomena a universally broad philosophical system that encompassed every kind of reality. While the illness was perceived from a mechanistic point of view, the patient was still seen as a human being with human rights deserving of inclusion in the full privileges of universal humanity. Hence physicians were able to regard mental disturbances as illnesses like other natural diseases; yet they still were able to see patients as potentially capable of living in a moral community. This vision at least provided the ideal for their treatment, which physicians called moral treatment. In moral treatment, mental patients were unchained; with the goal of integrating patients into daily life, psychiatrists dressed them in proper clothing, took meals with them, engaged in ordinary social interactions with them and sometimes even married them (Bockoven, 1972; Zilboorg, 1941).

Even during the Enlightenment, however, forces were at work that would eventually undermine this grand conception of a universal philosophy. The Enlightenment ideal declined partially because of the advances in knowledge steadily accruing in physics, anatomy and other natural sciences, which were bought at the price of specialization. As researchers began to specialize in separate fields, and as knowledge grew, specialists in one field became unable to keep abreast of advances made in other fields, bringing an end to universal understanding.

Philosophy continued to exist, of course, but in philosophy it was difficult to show the progressive advancement of knowledge so obvious in the natural sciences. Philosophers such as Georg W.F. Hegel still sought to integrate human knowledge and values into one single system of thought, but these all-encompassing systems were espoused by only a few. As a result, philosophy, now conceived as distinct from science, became intellectually discredited. And so it stands today-except that the separate sciences receive even more respect, and philosophy receives even less.