Psychiatry’s Solid Center

December 2, 2015

Most psychiatrists do not fit neatly into the biological or psychodynamic camps. Instead, like surgeons, they will implement tools that reduce the suffering and enhance the well-being of the patient.

Psychiatric disorders result from the complex interaction of physical, psychological, and social factors and treatment may be directed toward any or all three of these areas.

– Official Position of the American Psychiatric Association, 19781

If you invite the wrong group of psychiatrists to a dinner party, you may be in for some heated exchanges. (Hence, the old joke: “Two psychiatrists, three opinions.”) I’m talking about the minority of ideologues on both ends of the “biopsychosocial” continuum: on the one hand, the hard-core “biological psychiatrists” whose view of mental illness extends only to twisted molecules and misfiring neurons; and on the other hand, the “psychosocial” faction, whose only interest is in the psychodynamic and socio-cultural aspects of mental illness. It was this deep schism in psychiatry that was so vividly described in anthropologist Tanya Luhrmann’s classic book, Of Two Minds.2

I have been extremely fortunate in having been spared, for the most part, the procrustean worldviews of both factions. My psychiatric education was largely fostered by those in the great “solid center” of psychiatry-the pragmatic pluralists whose mantra was, “Do what it takes to ease the patient’s suffering-use whatever tools you need to help the patient get better.” Luhrmann’s analysis of the division within psychiatry didn’t fully appreciate that most psychiatrists do not fit neatly into the biological or psychodynamic camps. And critics of psychiatry who insist that the field has become exclusively “biological” are also missing the larger and more enduring picture.

[[{"type":"media","view_mode":"media_crop","fid":"42141","attributes":{"alt":"arrows-©Lightspring-shutterstock","class":"media-image media-image-right","id":"media_crop_4818779693756","media_crop_h":"0","media_crop_image_style":"-1","media_crop_instance":"4940","media_crop_rotate":"0","media_crop_scale_h":"134","media_crop_scale_w":"150","media_crop_w":"0","media_crop_x":"0","media_crop_y":"0","style":"float: right;","title":"arrows-©Lightspring-shutterstock","typeof":"foaf:Image"}}]]My teachers were deeply steeped in the psychoanalytic/object relations schools, and we residents received generous helpings of Kernberg and Masterson along with our Freudian repasts. But we were also instructed regularly in psychopharmacology and the medical aspects of consultation- liaison psychiatry. (One of my teachers, the late Dr Ellen Cook Jacobsen, was trained in both internal medicine and psychiatry.) At various points in my training, I ran a poetry therapy group on the inpatient unit and also co-edited a psychopharmacology bulletin with a more senior resident. I became a believer in pragmatic pluralism and psychiatry’s crucial role as a bridge between the medical sciences and the humanities. It’s always been that way for me, now going on 35 years in the field. Maybe that’s why I find it so troubling that many in the general public-and, indeed, many within the profession-see psychiatry as having pitched its tent squarely and solely in the “biological” camp.

This perception is not without some foundation, and there is no question that, in the 1990s, American psychiatry took a “biological turn” that has never fully swung back to the psychosocial end of the continuum. But to view today’s psychiatry as merely biology-based is to see it “through a glass, darkly.” When we look to the solid center of this profession, we see thousands of skilled clinicians, researchers, and teachers who are as comfortable with motives as with molecules. The solid center rejects the notion that we must choose between biology and psychology, between medication and psychotherapy.

As a broad generalization, those in the center conceive psychiatric “disease” as something that afflicts persons, not “minds” or “brains”-a point stressed by the late Dr Robert Kendell.3 Thus, the “mental versus physical” debates are seen as sterile and fruitless. Those following the “Middle Path” (to borrow a term from Buddhism) are preoccupied not with elaborate theories, but with relieving the suffering and incapacity of those who seek our help. Those in psychiatry’s solid center use the best established treatments to alleviate the patient’s illness-whether with “talk therapy,” medication, or both. What follows is a sketch of 3 exemplars of this holistic tradition-2 of whom, thankfully, are still very much with us.

Karl Jaspers, MD

Karl Jaspers (1883-1969) was truly a “Renaissance man,” beginning his academic career as a psychiatrist and then transitioning to philosophy in the 1920s. His psychiatric textbook, Allgemeine Psychopathologie (General Psychopathology, 1913)-written when Jaspers was barely 30 years old-is relevant and useful, even today.4 Jaspers was, above all, a “pluralist” when it came to psychopathology. As psychiatrist Dr Paul McHugh wrote in his introduction:

. . . Jaspers knew that some mental disorders derive from brain diseases, and therefore psychiatrists should be close allies with neurologists. But he also knew that mental distress could emerge as consequences of some conflict between an individual’s wishes and actual life circumstances, so psychiatrists should naturally share interests with . . . the social and cultural disciplines.4

Jaspers was also a “phenomenologist,” in the practical, clinical sense of that term. As McHugh notes, Jaspers believed that

. . . psychiatrists could achieve . . . an understanding of their patients’ mental life if they approached the task of inquiry without prejudice of theory, but rather, by attempting to gain from a patient a full description of his or her mental experience.

Following the lead of the German historian and psychologist Wilhelm Dilthey (1833-1911), Jaspers distinguished 2 modes of “explanation,” with respect to psychopathology.4-6Erklären refers to causal explanation based on “nature’s laws”-including, for example, biological causes. In contrast, verstehen refers to “understanding,” based on meaningful psychological connections. So, for example, if Mr Jones is extremely anxious and panicky, erklären might tell us, “Jones’s brain is exhibiting excessive electrical activity in the amygdala”-which may be perfectly true.7 But an understanding of Mr Jones’s anxiety-verstehen-would require us to know that he had just received a phone call from his employer telling him that he is being laid off immediately. These modes are not mutually exclusive, but complementary-and therein we find the practical, integrative task of the psychiatrist.

My colleague, Dr Nassir Ghaemi, has aptly termed Jaspers a “biological existentialist”-a term that would hardly be recognized in our current, polarized debates about psychiatry. As Ghaemi notes, Jaspers “. . . valued science and biology in medicine. His approach to spiritual and existential notions . . . built on, rather than negated, an appreciation for science.”

Eric R. Kandel, MD

Eric Kandel, MD, is the only psychiatrist (thus far) to have won a Nobel Prize-and, like Jaspers, Dr Kandel is a true Renaissance man. His research interests have spanned the territory from the molecular biology of long-term memory storage to the modernist artists of turn-of-the-century Vienna, where Kandel was born.8

In his classic book, Psychiatry, Psychoanalysis and the New Biology of Mind, Kandel shows that neurobiological and psychodynamic concepts are not mutually exclusive, but rather, complementary modes of understanding mind-brain relationships-akin to the complementarity of erklären and verstehen. Kandel does not eliminate the concept of “mind” at all, but asserts as a foundational principle that “. . . what we commonly call mind is a range of functions carried out by the brain.”9 (Ironically, Aristotle said much the same thing, over 2 millennia ago.) While Kandel believes that our genes play a fundamental role in the genesis of illnesses like schizophrenia, he avers that “multiple causality” is involved. By this he means that genetic abnormalities are influenced by “developmental and environmental factors.”

The sterile debate of “mind versus brain” is rendered irrelevant in Kandel’s framework for psychiatry. Thus, for Kandel, “. . . insofar as psychotherapy . . . is effective and produces long-term changes in behavior, it presumably does so through learning . . .”; and learning, in turn, involves alterations in the interconnections between nerve cells of the brain. Moreover, psychotherapy is capable of altering the expression of genes; hence, for Kandel, psychotherapy is a “biological” treatment in a fundamental sense. So much for the Manichaean dichotomy explored by Luhrmann.

Glen O. Gabbard, MD

I have been privileged to know Dr Glen Gabbard not only as an academic colleague and friend, but also as a mentor and role model. Readers of Psychiatric Times will recognize Dr Gabbard as the author of numerous books on psychodynamic psychotherapy, managing counter-transference, avoiding boundary violations, and many other professional topics. Perhaps less familiar are his books on Psychiatry in the Cinema (with Krin Gabbard) and on the psychology of The Sopranos. Clearly, Dr Gabbard is a man of many facets, but I have been most influenced by his holistic and non-dualistic approach to psychiatric disorders and their treatment. In a classic paper (2000) titled, “A Neurobiologically Informed Perspective on Psychotherapy,” Gabbard took aim at the divisive tendency to split psychiatry into 2 opposing ideologies:

Polarization of biological and psychosocial aspects of psychiatry has promoted a form of Cartesian dualism. Current knowledge of the interaction between biology and psychology makes it possible to consider a truly integrative approach to treatment.10

And, citing the aforementioned work of Dr Kandel, Gabbard continues:

. . . environmentally derived activity appears to drive the development of dendrites so that they conform to cognitive schemes for the construction of mental representations. Gene-environment interactions become a reverberating ‘hall of mirrors’ that cannot be easily dissected.

Gabbard goes on to cite studies in primates showing that “relational changes,” such as the separation of an infant monkey from its mother, can affect stress hormones and neurotransmitters in the infant.

Like Kandel, Gabbard knocks down the artificial wall between biological and psychosocial therapies:

. . . learning about oneself . . . in psychotherapy may in itself influence the structure and function of the brain . . . [moreover] medications have a ‘psychological’ effect in addition to their impact on the brain, and psychotherapeutic interventions affect the brain in addition to their ‘psychological’ impact.

I would add that even the act of prescribing psychiatric medication must be viewed in a psychodynamic context. As Metzl and Riba have noted:

. . . Symbolically speaking, medications convey a host of connotative implications that are difficult to recognize, let alone to quantify. These range from preconceived beliefs about drugs that patients carry with them into the examination room, to unspoken messages of nurturance at play when doctors prescribe (or choose not to prescribe) psychotropic medications . . . understanding the symbolic functions of the medications is as important as knowing their elimination half-lives or suggested dosing regimens.11

Conclusion

The British psychiatrist W. Alwyn Lishman-widely viewed as the dean of “organic psychiatry”-is quoted as saying this of psychiatry:

You have got to have a finger in every pie in psychiatry and be ready to turn your hand to whatever is the most important avenue: an EEG one day, a bit of talking about a dream another day. You just follow your nose. All psychiatrists should be all types of psychiatrist.12

Indeed, those who practice in this spirit of pragmatic pluralism- always aiming to reduce the suffering and enhance the well-being of the patient-are the “solid center” of psychiatry.

For further reading:

• Pies R. Can psychiatry and neurology “simply” merge? [letter] BJPsych Bulletin. October 1, 2015. http://pb.rcpsych.org/content/39/5/264.1.

• Pies R. Clinical Manual of Psychiatric Diagnosis and Treatment: A Biopsychosocial Approach. Washington, DC: American Psychiatric Press; 1994.

 

This article was originally posted on 10/7/2015 and has since been updated.

Note to readers: As with all of our blogs, the opinions expressed in this commentary are solely those of the author. Comments not followed by full names and academic titles will either be removed or heavily monitored. –Psychiatric Times

Disclosures:

Dr Pies is Editor in Chief Emeritus of Psychiatric Times, and a Professor in the psychiatry departments of SUNY Upstate Medical University, Syracuse, NY, and Tufts University School of Medicine, Boston. Dr Pies is author, most recently, of Psychiatry on the Edge, a collection of essays drawn from Psychiatric Times (Nova Publishing); and a novel, The Director of Minor Tragedies (iUniverse); and The Myeloma Year, a chapbook of poems and essays.

References:

1. Position statement on active treatment. Am J Psychiatry. 1979;136:753. http://www.psychiatry.org/File%20Library/Learn/Archives/Position-1978-Active-Treatment.pdf. Accessed October 5, 2015.
2. Luhrmann T. Of Two Minds: An Anthroplogist Looks at American Psychiatry. New York: Vintage; 2001.
3. Kendell RE. The myth of mental illness. In: Schaler JA (Editor). Szasz Under Fire: The Psychiatric Abolitionist Faces His Critics. Chicago: Open Court Publishing Company; 2004: 29-48.
4. Jaspers K. General Psychopathology, Vol 1. Translated by J. Hoenig and MW Hamilton. Baltimore: Johns Hopkins; 1997.
5. Wiggins OP, Schwartz MA. Karl Jaspers. In: Embree L, Behnke EA, Carr D, et al (Editors). Encyclopedia of Phenomenology. Kluwer Academic Publishers; 1997.
6. Ghaemi SN. On the Nature of Mental Disease. The Psychiatric Humanism of Karl Jaspers.Existenz. 2008(3):2.
7. Edwards SP. The amygdala: the body’s alarm circuit. The Dana Foundation. May 2005. http://www.dana.org/Publications/Brainwork/Details.aspx?id=43615. Accessed October 5, 2015.
8. Levine D. Alan Alda and Eric Kandel discuss science, psychiatry and the media. Elsevier. May 14, 2014. http://www.elsevier.com/connect/alan-alda-and-eric-kandel-discuss-science-psychiatry-and-the-media. Accessed October 5, 2015.
9. Kandel ER. Psychiatry, Psychoanalysis and the New Biology of Mind. Washington DC: American Psychiatric Publishing; 2005.
10. Gabbard GO. A neurobiologically informed perspective on psychotherapy. Br J Psychiatry. 2000;177:117-122.
11. Metzl JM, Riba M. Understanding the symbolic value of medications: a brief review. Prim Psychiatry. 2003;10:45-48.
12. Poole NA Interview with Professor William Alwyn Lishman. Psychiatrist. 2013;37:343-344.