Has our current concept of psychiatry outlived its useful purpose? Yes, says just about everyone.
HATERS of the word, paradigm, have Thomas Kuhn to blame. His seminal 1962 publication, The Structure of Scientific Revolutions, is a regular on all manner of Top 100 lists for books that rocked the world. In my line of work, you can't browse a website for five seconds before being paradigmed to death.
Paradigms - The Basics
Forget about the quest for knowledge being an objective inquiry governed by scientists rationally sifting through the facts. That may be their intention, but in reality they are operating within their own particular conceptual frameworks (paradigms) that govern how they think. Thus, if you are living in an era where the ruling paradigm features the earth at the center of the universe, then your typical 15th century Polish heliocentric firebrand named Copernicus is going to come across as a raving lunatic (okay, make that solaratic).
Ironically, says Kuhn, the 15th century scientific community, such as it was, was perfectly correct in rejecting Copernicus, as Ptolemy's model of the universe still proved a superior predictor of observable planetary motion. Only later, with Galileo and others building on Copernicus, did Ptolemy and his world come crashing down.
During a period of normal scientific development, researchers are working off a shared set of general beliefs, which frees them up for working on specific problems. Anomalous findings either get dismissed or folded into the paradigm. But anomalies have a way of accumulating like unwanted snow. The old guard has a legitimate role as keepers of the paradigm, but history is not on their side.
According to Kuhn, the old and new paradigms are so different that they are "incommensurable." In essence, there is no common ground by which a scientist working within a new paradigm can prove her point based on the assumptions of the old.
Biological Psychiatry Unseats Freud
For an example of worlds in collision: At the 2004 American Psychiatric Association Annual Meeting, I heard Jack Barchas MD of Cornell University and a pioneer in the field of how biochemistry and behavior interact, recount how as a young investigator an early mentor challenged one of his ideas on these grounds: "How is this justified in the writings of Freud?"
Not surprisingly, Freud soon became to psychiatry what Ptolemy became to astronomy. But was Freud getting a raw deal? At the following year's APA, I heard Nobel Laureate Eric Kandel MD state:
"A major need of psychiatry in the future is to put the psychotherapeutic arm of psychiatry on the same solid biological footing as the pharmacological aspect of psychiatry."
Dr Kandel was very much moved by Kay Jamison who said if it wasn't for lithium she would be dead, but that it was really psychotherapy that gave her a coherent view of her life, that allowed her to tie the various strings of her life together.
"We're in a fantastic phase of psychiatric thought," Dr Kandel concluded. "The biology of the mind is the central scientific challenge of the twenty-first century. Molecular genetics and molecular biology, he said, have given us insights that would have been inconceivable 20 or 30 years ago. These advances will revolutionize psychiatry, but hardly eliminate it. Instead, psychiatry will synthesize with molecular biology into what he describes as "the new science of the mind."
Challenging the Biological Psychiatry Paradigm
I first posted the above on my blog, Knowledge is Necessity, in Jan 2010. In a comment, Willa challenged the notion of psychopharmacology on a solid biological footing, noting that in medicine "the paradigms dictate the treatments." Unsuccessful treatments, she said, do not challenge the paradigm. "They simply are problems to be solved within the existing paradigm." Thus unacceptable side effects induce researchers to find new meds rather than lessening the reliance on meds.
In response to my second posting later in the year, Tony added that every FDA medication in essence carries the warning that says: "We have no idea how this stuff works, but it does... kinda, sorta a little better than a placebo..."
Obviously, we have a lot of frustrated and very well-informed patients challenging the biological psychiatry mindset in the form of the recovery movement. Had psychiatry come up with new meds that worked a lot better than the old ones, with practitioners smart enough to work with us, the current paradigm might be more secure right now.
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Mark added another twist to this, of transpersonal psychiatry (that expands on Freud and Grof and others) vying for attention with the new brain science. In Mark's words:
My personal view is that the biological researchers are trapped by their paradigm to look only at the brain. They cannot conceive the possibility of mental disease having any other source than the physical matter of the brain itself. By their paradigm, they not only believe that but refuse to look at any other evidence which would point to the contrary.
He concludes: "The race is on. Let the best emerging paradigm win."
Toward a Grand Unified Theory
Mark's post really got me thinking. Are the various paradigms-in-waiting mutually exclusive? Or do we see a grand unified theory on the horizon? My bets are on the latter. Here's how I see it:
To my knowledge, every brain scientist is operating off a genes-environment paradigm, which takes into account both biology and how we respond to the world around us. In the old days, psychiatry distinguished between biological causes to mental illness (such as neurosyphilis) and what they saw as maladaptive reactions to stress and interpersonal relations.
This harkens back to the old mind-brain distinction. Since we lacked the tools to see into the brain, the first DSM of 1952 classified depression and schizophrenia and bipolar and the like as "reactions" rooted in neurosis or psychosis or personality rather than biology.
Biological psychiatry tipped over that Freudian paradigm, but in the process lost track of the fact that there was a lot of validity to Freud and his followers. Our behaviors are indeed shaped by our environment and buried traumas. The catch was that the only known therapy of the day - psychoanalysis - did not work for serious mental illness. Thus a paradigm ripe for tipping.
A New Model of the Brain
The biological psychiatry paradigm naively assumed we could simply find something wrong in the brain and fix it, with no regard to environment, without being able to pinpoint cause and effect. Thus an antidepressant for depression, a mood stabilizer for bipolar, and so on. The catch was that even magic bullets are problematic if someone has to contend with an abusive relationship or a toxic work situation.
The new brain science has broken down the mind-brain distinction. We now know that some of us inherit vulnerable brains that are prone to breaking down under stress, which in turn manifests as various forms of illness episodes and maladaptive behaviors. Those with more resilient genes are far more likely to take stress in stride. This new brain science validates the "diathesis-stress" hypothesis advanced during the seventies.
These discoveries cut across all psychiatric diagnoses and blur the categorical distinctions, spurring researchers to dig deeper into underlying causes (endophenotype) rather than the outer symptoms of phenotype. This demands a new approach to diagnostic psychiatry, which is more likely to come from outside the field rather than from within.
The new brain science has also revealed that the brain is plastic, capable of reshaping itself. In essence, the brain is software rather than hardware, and we can change the software to make us more resilient and better able to adapt to whatever life may throw our way. It also works the other way - that sustained stress and trauma can change our software for the worse.
Likewise, we can change our environment. If we know, for instance, that we have a genetic predisposition to alcoholism, we learn to avoid situations that put us at risk.
We now have a new model of the brain interacting with the environment and vice-versa, each capable of change, each capable of changing the other. Thus we see the beginnings of a grand unified theory waiting for the next Einstein, where Freud and biological psychiatry are reconciled, along with ancient precepts. Mind and brain are one, leading to new insights into behavioral causes and effects and possible treatments and therapies and self-help tools. This is already well underway.
Those operating within the current paradigm, who simply expect brain science to validate biological psychiatry can be regarded as intellectual dinosaurs. Their days are numbered, but they won't go down without a fight. As the physicist Max Planck once said, "Science advances one funeral at a time."
Some form of Kandel's new science of the mind will emerge and maybe it will no longer be called psychiatry. But this new paradigm, like all paradigms, will only be a temporary placeholder, awaiting a newer paradigm to unseat it, such is the nature of scientific discovery. Absolute truth will always elude us. The best we can do is proceed on the facts as we know them, with an assist from inspired speculation. This will yield us the best approximation of reality. That is, until a better one comes along.
Reviewed July 11, 2016
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