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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]

Eric R. Kandel

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 erklaren 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, p. 39]. (Ironically, Aristotle said much the same thing, over two 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.” [9, p. 46].

The sterile debate of “mind vs. 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…”; [9, p. 39] 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

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 this paper 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” [ 10 ] Gabbard took aim at the divisive tendency to split psychiatry into two 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.” [10]

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.” [10]

I would add that even the act of prescribing psychiatric medication must be viewed in a psychodynamic context.

As Metzl and Riba (2003) 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.

References

1. http://www.psychiatry.org/File%20Library/Learn/Archives/Positio-1978-Active-Treatment.pdf

2. Luhrmann T: Of Two Minds: An Anthroplogist Looks at American Psychiatry. New York, Vintage, 2001.

3. Kendell RE: The myth of mental illness. Chapter 1 in: Szasz Under Fire, edited by J.A. Schaler, Open Court 2004, pp. 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 Volume 3, No 2, Fall 2008

7. Edwards SP: The Amygdala: The Body’s Alarm Circuit.
http://www.dana.org/Publications/Brainwork/Details.aspx?id=43615#sthash.qNSs7T2O.dpuf

8. http://www.elsevier.com/connect/alan-alda-and-eric-kandel-discuss-science-psychiatry-and-the-media

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. Primary Psychiatry. 2003;10:45-48

12. Poole NA Interview with Professor William Alwyn Lishman. Psychiatrist 2013; 37: 343-44
For further reading:
Pies R: Can psychiatry and neurology ‘simply’ merge? [letter] BJPsych Bulletin 1 October 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.

Galaxy image available from Shutterstock

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 October 15, 2019, 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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