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Psychiatry’s Solid Center

“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, 1978[1]

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 world-views 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.”

Lurhmann’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.

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 Jacobson, 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.

A Bridge Between

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 or 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 vs. 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 three exemplars of this holistic tradition—two of whom, thankfully, are still very much with us.

Karl Jaspers

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 p. vii]

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.”[4, viii]

Following the lead of the German historian and psychologist, Wilhelm Dilthey (1833-1911), Jaspers distinguished two modes of “explanation,” with respect to psychopathology. [4,5,6]

Erklaren refers to causal explanation based on “nature’s laws”—including, for example, biological causes. In constrast, verstehen refers to “understanding”, based on meaningful psychological connections. So, for example, if Mr. Jones is extremely anxious and panicky, erklaren 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. [6]

Psychiatry’s Solid Center

This article originally appeared in:

Psychiatric Times

It is reprinted here with permission.


Ronald Pies, MD

Ronald Pies, MD, is Professor of Psychiatry and Lecturer on Bioethics & Humanities at SUNY Upstate Medical University, Syracuse, NY; and Clinical Professor of Psychiatry, Tufts University School of Medicine, Boston. His latest book is entitled, Don't Worry -- Nothing Will Turn Out All Right!: The Optipessimist's Guide to the Fulfilled Life. He is also the author of the essay collection, Psychiatry on the Edge (Nova Publishing); as well as the novel, The Director of Minor Tragedies (iUniverse) and the poetry chapbook, The Myeloma Year. He is a regular contributor to Psych Central.

 

APA Reference
Pies, R. (2015). Psychiatry’s Solid Center. Psych Central. Retrieved on December 11, 2018, from https://pro.psychcentral.com/psychiatrys-solid-center/

 

Scientifically Reviewed
Last updated: 6 Nov 2015
Last reviewed: By John M. Grohol, Psy.D. on 6 Nov 2015
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