By Caleb Gardner, MD. Referenced article originally published in The New England Journal of Medicine.
Last fall I co-authored an article “Medicine and the Mind: The Consequences of Psychiatry’s Identity Crisis”, in which, among other things, I hoped to express some concern that American psychiatry might, in effect, be neglecting nuance and psychological complexity and losing touch with certain fundamental insights about the mind. In the article, we suggest that the practically exclusive emphasis of contemporary academic and clinical psychiatry on psychopharmacology, symptom-checklist diagnoses, and a biochemical perspective on mental health and illness is problematic. At the same time, we try to make it clear that this in no way means that medications are not important and powerful tools, or that biological research should be abandoned. First and foremost a clinical endeavor, psychiatry must be primarily concerned with whatever effective, lasting, practical help it can offer. If the proliferation of diagnoses and medications in the past half-century or so had led to equally widespread, convincing clinical improvement, that would be one thing. But it is far from apparent that that is the case.
On the one hand, amid a variety of pressures and influences, the practice of simply matching a diagnosis with a medication seems increasingly standard. On the other hand, as time passes, the limitations of current biological treatments (as well as their benefits) have become clearer to a variety of clinicians and researchers. Consequently, some have questioned what kinds of problems should fall under the purview of modern psychiatry. Allen Frances worries that varieties of normal experience are being pathologized and medicalized, and Anne Harrington seems to suggest that psychiatry narrow its scope to the kinds of illnesses that have more manifestly biological or biochemical qualities, illnesses which, presumably, might best respond to the biological and biochemical treatments now available, and which responses might be most usefully classified and evaluated by the quantitative, aggregative methods of clinical research. Such a constriction of scope would not be an exclusively clinical matter, however. Intended or not, it would also be an acknowledgement of a self-imposed limitation of what the field proposes to endeavor to understand about the mind and about the ways that change might be brought about in treatment.
Sometimes a rigidly quantitative, algorithmic approach to treatment is promoted as more scientific or evidence-based. Yet throughout all clinical medicine, to a greater or lesser extent, there is a tension between what we know about people in general, and what we learn about a specific individual. In psychiatry, not only are the unknown regions particularly vast to begin with, but the clinical problems themselves are inherently intertwined with a person’s subjective experience, making the presenting and ongoing expression of that experience an essential source of evidence by which treatment should be guided. To put it another way, unbiased, well-designed clinical trials are an important source of a certain kind of information, while the words and gestures and silences used to communicate inner experience are an important source of another kind of information. It would follow, then, that neglecting the complexities and contradictions of individual experience would be a step away from, rather than toward, scientific rigor in the hospital, clinic, and consulting room.
There is clearly a part of our inner life, probably a very large part, that takes place outside of everyday, conscious awareness. Meanwhile, emotion, cognition, and somatic experience are deeply intertwined, and drag their ancient roots around with them. We remember things we don’t know we remember, and we have ways of knowing things without knowing that we know them. None of this is particularly new information, though fields from literature to neuroscience are continuously coming up with new ways of describing and thinking about such things. There is much that we don’t understand, and much that we can never hope to understand in the way that we understand other organ systems. And yet, for all of us, the state of these invisible processes makes a big difference in everyday life. Rather, they are everyday life, and a psychiatry that avoided that fact would be a diminished thing indeed.
Caleb Gardner, MD, graduated from the Cambridge Health Alliance psychiatry residency program in 2019 and is currently a psychoanalytic candidate at BPSI.
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