Psychiatric Tribalism

December 1, 2007
William S. Appleton, MD

Volume 24, Issue 14

"Positive Psychology: A More Direct Route To Happiness" (Psychiatric Times, September 2007) brought to mind that no one asks an internist to which school of medicine he or she belongs.

"Positive Psychology: A More Direct Route To Happiness" (Psychiatric Times, September 2007) brought to mind that no one asks an internist to which school of medicine he or she belongs. Only in psychiatry and psychology are such questions raised, and they are often accompanied by deeply held beliefs that "I'm positive; you're negative"; "I'm deep, dynamic, and analytic; you're superficial and preachy"; and "My cures are lasting; yours are temporary." The wise clinician is dynamic, analytic, supportive, positive, gives drugs when necessary, and belongs to no school. Many professors claim to know the correct way to diagnose and treat and call it evidence-based; eg, Mr Tal D. Ben-Shahar, the popular lecturer with an audience of 800 plus Harvard students, and Prof Martin Seligman, who has conducted randomized controlled trials and says he can prove the value of positive psychology.

Psychotherapy wars are just the beginning of psychiatric tribalism-there are also psychopharmacologists; proponents of first, second, and third nerve cell messengers; and the experts on each neurotransmitter. Drug companies are frantically searching for new agents to cure persons with serious illnesses, those in pain, and even those who are merely unhappy.

A committee of 1000 experts is about to recarve mental disorders and to publish their conclusions in the fifth edition of the DSM. When Congress expands laws and alters the tax code, at least it does not claim to be scientific.

Everyone in mental health is presumably trying to help, but pious fighting, whether in the mental health or political arena, is destructive.

There are a spate of recent books denouncing God and praising science that laud evidence over faith. It is time to practice humility and to face the fact that after centuries of effort, severe mental illness is not curable, and the rest of human misery will not be eliminated by fish oil, transcranial magnets, the modulation of glutamate receptors by LY2140023, or psychotherapists. Humility means we can all try but should not feel superior to others who help. It is the mental health worker and clinician on the front line who do the most good.

We all hope research will continue and may someday provide answers. Presently, and unfortunately, the targets of the investigators remain surrounded by fog. What is severe mental disorder and how can we define it? To do so might help focus curative efforts, unless we get lucky and fix it without knowing how. Aspirin worked for years before its relief of pain and fever could be explained. Perhaps there is a plant out there in some shrinking rain forest that will relieve severe mental disorder and human misery. Until then, no professor has reason to look down on any other or on the frontline clinician or mental health worker. While we should not abandon the academy or the laboratory, we must redouble our outreach to patients and study them closely to find answers. That is how chlorpromazine, lithium, and the first antidepressants were discovered.