Out of Its Mind: Psychiatry in Crisis: A Call for Reform [Paperback]

J. Allan Hobson (Author), Jonathan Leonard (Author), Jonathan A. Leonard (Author)

Book Description

Publication Date: May 2002 | ISBN-10: 0738206857 | ISBN-13: 978-0738206851

While millions of patients with severe mental illnesses are neglected, those charged with caring for them are engaged in a troubling debate: Who should treat these patients-and how? On one side are psychoanalysts, on the other are pill-pushing psychiatrists. And on the fringe are neuroscientists, who are learning volumes about the brain but whose discoveries have largely been ignored. Truly, psychiatry is in crisis.In this important book, Harvard psychiatrist J. Allan Hobson and medical journalist Jonathan A. Leonard explore the roots of this predicament and propose, for the first time, the development of a more balanced approach to treatment-neurodynamics-that bridges the worlds of biomedicine, therapy, and neuroscience. Written with passion and informed by decades of experience, Out of Its Mind shows a clear path to reviving psychiatry, providing sound care for millions, and realizing humanity's ancient dream of treating not just the mind or brain alone, but both together.

Editorial Reviews

Amazon.com Review

Prozac and all its cousins haven't helped psychiatry as much as their manufacturers claim. In Out of Its Mind, Harvard psychiatrist J. Allan Hobson and science writer Jonathan Leonard argue that the field is reaching a crisis in the struggle between biological treatments and psychoanalytic methods and that a synthesis is badly needed. Calling his approach "neurodynamic," Hobson advocates a broad understanding of each patient's unique situation, including genetic and physiological factors, as well as social qualities like family history. Hardly revolutionary, but given the resistance of HMO culture to any treatment that's not simple and cheap, the paradigm will require aggressive, concerted efforts to implement.

The book is half history of psychiatry, half utopian plan of action. The authors first examine the strengths and weaknesses of both treatment modes and, unsurprisingly, find problems with uncritical acceptance of one over the other. The current mess, including a 90 percent reduction in hospital beds and a wild emphasis on pill-pushing, is a direct result of the successful pharmaceutical treatments devised in recent decades. Hobson and Leonard ask for broader education for psychiatrists and other professionals, to include what might be called holistic methods--wrapping up nature and nurture to better treat ill people. Out of Its Mind will appeal to both nontechnical readers and those directly involved in mental health and guide them toward the emerging synthesis. --Rob Lightner --This text refers to an out of print or unavailable edition of this title.

From Publishers Weekly

It isn't quite true that the lunatics have taken over the asylum, but that might be preferable to the current state of psychiatry, at least according to this provocative and alarming study by noted Harvard Medical School faculty member Hobson and science writer Leonard. Not only is psychiatry underfinanced, but due to HMOs' disregard for patients' basic mental health needs and the profession's increasing tendency to treat mental problems with pharmaceuticals rather then look at deeper causes, as well as a lack of community services, two million Americans suffer from "severe but untreated mental ills." Many of these individuals are warehoused in nursing homes or prisons, while "the plight of the severely disordered homeless on our streets has become a socially indefensible disgrace." Several concise chapters examine how psychiatry wound up in such a sorry state, and include an informed and incisive discussion of the profession's evolution from the rise of asylums and the invention of psychoanalysis to the emergence of the more radical psychoanalytic theories of R. D. Laing, the birth of the HMO and the impact of brain science. Hobson and Leonard offer concrete remedies for what ails mental health care today, such as a complete overhaul of psychiatric training, better working relationships between mental hospitals and other social service agencies and the bringing of key elements of mental hospital treatment to prisons. While some of the proposals are practical, others are more utopian. Yet this powerful book is convincing in its call for reform.

Copyright 2001 Cahners Business Information, Inc.

--This text refers to an out of print or unavailable edition of this title.

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Product Details

• Paperback: 304 pages
• Publisher: Basic Books (May 2002)
• Language: English
• ISBN-10: 0738206857
• ISBN-13: 978-0738206851
• Product Dimensions: 8.9 x 6.2 x 0.8 inches
• Shipping Weight: 13.6 ounces (View shipping rates and policies)
• Average Customer Review: 3.4 out of 5 stars  See all reviews (9 customer reviews)
• Amazon Best Sellers Rank: #1,052,606 in Books (See Top 100 in Books)

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25 of 30 people found the following review helpful:

1.0 out of 5 stars Sad commentary, sad conclusions, August 23, 2001

By A Customer

This review is from: Out Of Its Mind: Psychiatry In Crisis (Hardcover)

A learned and distinguished colleague gave me a book review of Out of Its Mind: Psychiatry in Crisis. My desire to read the book stemmed from the glowing report of how the book outlined the rise, the fall, and a plan for reformation of psychiatry.

The introduction of the book offered many challenges to psychiatry that were intriguing: difficulty recruiting quality students, a major internal rift (between "brain science" and psychotherapy), and a strong need for an integrated delivery service for chronic suffers. While I expected a detailed and scholarly review, much of the historical content is limited by experience from one hospital and one delivery system in Massachusetts. Overgeneralizations abound and there are significant inaccuracies about psychology and the practice of psychotherapy. Enormously complex issues, such as consciousness and brain chemistry, are reduced to oversimplified concepts that are best suited for Oprah. Finally, personal opinion interfered with any sense of objectivity.

Although my review sounds poor, it unconscionably becomes worse. Rather than looking specifically at ways to reform its ranks and deal with managed care, the authors attack psychology.

"[C]linical psychology, directed at therapeutic treatment of the human mind, lacks psychiatry's medical model and hard science base. That's critical today, because much of what we know about treating mental ills is medical. The drugs are medical. The knowledge of brain chemistry and brain structures relating to both drugs and the nature of mental illness is medical. But psychology is not medical, and in fact is well known as a refuge for intelligent people who are uncomfortable with hard science. So it is not geared toward understanding hard science, supervising medical personnel, or even coordinating with pill pushers. And despite its promising array of emerging graduates, it cannot reasonably be expected to bridge the gap between our growing scientific knowledge and sound treatment."

Some of these statements are patently untrue and diminish psychology's role in treatment. There are many studies that show equal effectiveness between psychotherapy and medication for the treatment of Major Depression, Panic Disorder, Generalized Anxiety Disorder, and Obsessive Compulsive Disorder.

The diatribe continues with the authors' reasons that neurology is incapable of rising to the challenge of integrated care. In the end, the authors merely state that psychiatrists are the best trained to help those needing emotional and behavioral treatment. As for solutions, the author's contend that psychiatry's survival depends on creating enthusiasm for those entering the field and needing more money for treatment rather than the poor performance of managed care.

The brief shining moment occurs when the authors acknowledge that psychoactive substances are not the only answer.

"The [psychotropic] drugs help, all right, but they are limited. They don't always work, they don't cure anything, they often reduce but don't eliminate the target symptoms, they affect the whole person's brain chemistry, they have nasty side effects, and they definitely don't work if the patient doesn't take them."

The unfortunate conclusion is that we need more psychiatrists who can understand the patient in his or her entirety, has the time to establish "a sound therapeutic relationship", and coordinate necessary support services. Amazingly, this is what many psychologists do.

The sad irony is that Out of its Mind: Psychiatry in Crisis is just that, a metaphor of how psychiatry is in crisis and plagued with an overly simplistic conceptualization of human emotion, behavior, and effective treatment. The text offers no creative solutions on how to rectify its difficulties. The text languishes in the old rhetoric criticizing orthodox forms of psychoanalytic practice while abandoning any sustained or comprehensive approach to reforming a field dedicated to serving others. If Dr. Hobson is a leader in psychiatry, the book has uncovered one reason psychiatry has lost its way.

7 of 8 people found the following review helpful:

3.0 out of 5 stars "Neurodynamics"? Why not "Biopsychosocial"?, August 9, 2002

By 

John A. Mozzer (Los Angeles, California) - See all my reviews
(REAL NAME)   

This review is from: Out of Its Mind: Psychiatry in Crisis: A Call for Reform (Paperback)

Hobson and Leonard appear to be over-extending themselves. I do not believe that abstract theories about consciousness, and attempts at giving practical advice to society regarding psychiatric care, belong in the same book. The authors attempt to demystify mental illness; in reality, mental illness remains a mystery.

More importantly, explain to me what is original about their "neurodynamics" model, compared to the "biopsychosocial" model first proposed for medicine and psychiatry in 1977? (See Engel GL: The need for a new medical model: a challenge for biomedicine. Science 1977; 196:129-36.)

Both paradigms emphasize the need to simultaneously recognize the significance of biological, psychological, and social factors in the care of people with mental illness. A PubMed search reveals that the biopsychosocial approach to treatment has been discussed in psychiatric journals throughout the 1980's and beyond.

Hobson and Leonard needed to do more homework. They could have written about the biopsychosocial paradigm in two or three chapters, covering a period subsequent to the period when psychoanalysis ruled. If the biopsychosocial approach has not been implimented like it should be in psychiatric care, that could have been the essence of their book.

A new buzzword, "neurodynamics", is not necessary.

9 of 11 people found the following review helpful:

4.0 out of 5 stars Signaling a new psychology based on brain science, March 16, 2002

By 

Dennis Littrell (SoCal) - See all my reviews
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This review is from: Out Of Its Mind: Psychiatry In Crisis (Hardcover)

Hobson and Leonard believe that the fast evolving field of "brain science" will provide the foundation for a new psychiatry that will be enormously more effective than the old Freudian construct. They note that while Freudian psychology has failed, the new psychopharmacology that is replacing the "talk cure" is itself fraught with problems. As in T. M. Luhrmann's Of Two Minds: The Growing Disorder in American Psychiatry (2000), which might be compared with this volume, Hobson and Leonard believe that it is a combination of drugs and therapy that is needed.

The first part of the book recalls the old state asylums and the fifty-minute hours of the psychoanalysts and how that system managed the mentally ill, however poorly. Then came the destruction of that system at the hands of budget-minded politicians (e.g., the "let ‛em sleep in the streets" Reaganites) and HMOs, thereby precipitating the current crisis. The authors emphasize however that the lack of a firm scientific foundation doomed the old psychiatry to extinction, regardless of financial considerations. They see brain science (e.g., neuroscience) as the hope of a new generation. I think they're right, but let's not hold our breath. Just reading their take on the current understanding of schizophrenia in Part Three is enough to dispel any notions we might have of a cure anytime soon.

Schizophrenia of course is the black beast of mental health. Nothing really works toward a cure. Therapy is practically useless, and the drugs prescribed tend mostly to sedate or mask symptoms and to have bad side effects so that the patient often stops taking them. If you go out into the streets of any city in this country and observe or talk to the homeless, you'll find that a substantial number of them are clearly schizophrenic as defined in DSM-IV. If you look at suicides or those attempting suicide you'll find that a significant percentage of them are depressed. Add the various anxiety disorders and you have psychiatry's big three, which the authors explore in chapters imaginatively entitled, "Anxiety and the Fear Machine," "Searching for Doctor Doom," and "The Land of Voices." Cure these and psychiatry may become as busy as the Maytag repair man.

In-between these two parts is Part Two on consciousness and the dream world. So we have Part One: the rise and fall of psychiatry, Part Two: the nature of consciousness, Part Three: the main mental disorders, and Part Four: the prescription. I can't say much about the prescription which includes "neurodynamics," their brave new psychology based on brain science, but I like their take on consciousness and their definition: "awareness of information processed by the brain." (p. 76) Implied in this definition is the fact that we are not in contact with "raw reality" but instead are limited to "information received, selected, translated into abstract neural codes, and processed by the brain." (p. 78) Hobson and Leonard realize that consciousness is a continuum, and that dogs and cats and even cockroaches have at least a rudimentary consciousness (see p. 81). They also make the nice point (p. 80) that consciousness is not the same as memory ...[or] thought... [C]onsciousness is awareness and awareness need not involve thought."

The text is readable up to a point. The part about how the brain works is difficult to follow if, like me, you are not readily familiar with the functions of the cerebellum, cerebrum, thalamus, hippocampus, etc., or can't tell them apart without a map. Fortunately the authors do provide a couple of drawings that help. I mention this as a failing on my part and as a reminder to myself that to be a really informed layperson today, an understanding of the structure of the brain and how its components work (in so far as we know) is becoming basic. This is just another example of how complicated our world has become, and how hopelessly lost are those whose world view scorns education for the absolute "knowledge" of fundamentalist religions or the discredited psychologies of bygone eras.

The authors however are not throwing out the baby of therapy with the bath water of the psychoanalytic construct. They are signaling the change from the "guesswork" of the old therapies to the new paradigm of brain science. I just hope that messieurs Hobson and Leonard realize that a reductionist and/or holistic look inside the black box of the brain needs to be allied with the study of behavior from an evolutionary point of view. Such an understanding would, for example, help the authors with their "genetic bug" theory of schizophrenia presented on pages 199-201. I think it would also help to explain the prevalence of depression and the bipolar disorder. Depression is painful and self-destructive, and the wild highs and lows of bipolar (the authors recall the example of Margot Kidder) highly dysfunctional. But if we look back into the prehistory we might see how such behavior developed in environments that were depressive and quickening by season. I am thinking of how being depressed and immobile during a cold winter may be a good survival strategy, while really going for everything like a frog in the bog in spring may also be effective. Perhaps the bipolar is an extreme adaptation (with some real reproductive value) that doesn't work well in the current environment, where the pain clearly outweighs whatever gain there might be. In this regard recall the phenomenon of seasonal depression. I know that personally when the days grow gray and short I am likely to take on a gray mood myself. Or take the example of dyslexia which is only a problem in the modern society. In the stone age it might have been a plus.