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

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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 While I expected a detailed and scholarly review, much of the historical content is limited by experience from one hospital and one delivery system in Massachusetts.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.

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.

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.

Out of its Mind - psychiatry in crisis, a call for reform is a compelling account of the daunting problems facing America's treatment of the mentally ill. The authors begin by describing the inadequacy of treating the mentallly ill by drug therapy and deinstitutionalization and the inadequacy of traditional Freudian psychoanalysis. They then explore the science of the brain and what it offers in illuminating the dark corners of what we know as the mind. Lastly, they make recommendations for reform to bring together our newly acquired knowledge to create "a psychology linking the brain and mind and showing how biomedicine and psychotherapy should work together." This is an inspiring book and though the scientific section is not light reading, the authors' compassion and rational analysis make this vital reading. It will take many informed citizens to ensure that our politicians commit the funds to bring this new synthesis to fruition and to the lasting benefit of the mentally ill!
Read it!

It's a well-written book full of interesting information and illuminating insights. My main problem was figuring out who it is addressed to. It is written with a journalist as co-author, so I assume the writers did not want to limit readership to other psychiatrists. It is certainly not a self-help book. It might be useful to some-one with a mentally ill family member, but such a person would be better off going to the NAMI web site.
The first part is an excellent history of the decline and fall of psychoanalysis and of the last 50 years of American psychiatry. Then comes a short account of neurophysiology in some technical depth. The object seems to be to show that psychiatrists are real doctors and real scientists. The authors tread on philosophical ground with their theories of consciousness. It's "for every twisted thought a twisted molecule" stuff.
Part three consists of cases vignettes of panic disorders, of bipolar disorder and of schizophrenia.
Finally come recommendations, but who are the recommendations being made to? They seem to be talking about things "we" should change. Who is this "we"? Sometimes it's as if they were talking to a group of state legislators, the Secretary of HHS, the United States Congress or the American Council on Graduate Medical Education. I suspect it is largely directed at a readership of psychiatrists. A problem (if you can call it a problem) that they discuss is the fact that the new anti-depressant and anti-psychotic drugs have become so free of side-effects and so easy to use that there is not as much for psychiatrists to do. Primary care doctors and RN's and (in New Mexico) psychologists can prescribe them. That leaves psychotherapy, but why would psychiatrists be any better at that than somebody without an MD? It's an interesting question but a full answer would need need hard evidence. As it is, many of the assertions are subjective.
Coming back to some particular points, I wondered why,in the description of management of a patient with auditory hallucinations and delusions, no mention was made of the evidence-based techniques other that drugs. The strictures about foreign psychiatrists are not supported by valid evidence. Anti-psychotic drugs were invented in France, the use of lithium in Australia, and anti-depressants in Switzerland. How good is the evidence that specific brands of psychotherapy such as cognitive-behavioral or interpersonal are really different?

Having lived through the Freud to R.D. Laing Thorazine generation watching the disintegration of the system of psychiatric care, it is interesting to read this account of the subsequent fate of the profession and of renewed efforts to reconstitute some form of order from a great disorder. We have reached the age Freud predicted, in which knowledge of the brain would challenge the reign of psychoanalysis and allow a new foundation for both the study of psychology and the treatment of psychiatric disorders. Without agreeing per se to the new perspective offered,as such, the attempt to establish some new compassionate form of care in this psychiatrist ...patient bedlam gets an automatic if provisional endorsement, somebody do something, anything might be better than what just passed. The book also reviews briefly the considerable advances of neuro-psychiatric research and the new models of mind and brain. The viewpoint of the reductionist, fruitful as it is limited, will, one might think, sooner or later evoke the challenges of yesteryear in a new form, but these advances have changed the basics to the degree that a passing age seems-is-an age gone by. It is also true that reductionist psychology is uniquely limited in its perspective, acknowledges nothing whatsoever of the ancient heritage of man as visible in, say, the Buddhist tradition, and does this dogmatically, treating dissenters as mad. So, the cuckoo's nest issues are never too far away. The technocratic definition of man might turn a Foucauldian page on issues of madness and civilization. What is man?

A lot has happened in the field in the decade since OOIM was written. And much of it reflects the two main thrusts here: failing to help the least capable patients and the rise of neuropsychology.

Psychiatry and the care of the mentally ill are still in a sorry state ten years later, but books like OOIM have had =some= impact. Save for the diehards, most in the field accept the unified biopsychosocial model of pathology these days. The problem is that the diehards run the show (and dominate the treatment teams and schemes) in many facilities.

Surprisingly (to some, anyway) it's quite often the influence of the HMOs and their insistence upon "evidence-based treatment" that's helping to change matters. These days, there are many books written for HMO, as well as clinician, readership (see the "Compact Clinicals" series, for example) describing the results of statistical research into the most effective treatment algorithms.

Many of the new "meta-therapies" (e.g.: dialectical behavioral, acceptance and committment) are combinations of medicinal, psychodynamic, cognitive and behavioral methods built as much upon the results of brain function mapping and understanding of concepts like neurochemical transmission, excitoxocity and neural plasticity as they are on increasingly better grasp of the merry-go-round of thought, emotion and behavior.

One thing Big Medicine continues to roll over and die at, however, is understanding that patients need one product first and foremost: hope. Too many "care" providers provide everything but in the world of "fill out these forms, take these tests, and we'll get to you when we can" that continues to be "the way it is" in big city health care.

Having considerable experience in the trenches with homeless military veterans (see Dealing with the Homeless Mentally Ill in the New Depression at [...]), however, there's still a lot to be done to move further along the paths suggested in OOIM.

A Harvard psychiatry professor explains one key aspect of what is wrong with psychiatry - its fragmented method of patient care - and correctly calls for straightening the system out, but he wrongly both accepts the usefulness of the harmful drugs commonly used and sees answers to psychiatry's problems in the limited area of brain research in which he has been involved.

The authors posit that "brain science", and applications flowing therefrom, will solve psychiatry's "crisis." The explanation of brain science, with its focus on consciousness, is unpersuasive. The authors disengenuoulsy fail to mention that studies of the brain, including the magic touchstone, the genome,have failed to explain how the brain and mental illness are related--perhaps the only cogent analysis focuses on neurochemical transmitters.
The authors seems to want an eclectic approach to the mentally ill patient. Often this grab-bag method is nothing more that throwing mud at a wall and seeing what sticks. Right now, for severe mental illness (Schizophrenia, Major Depression, some forms of manic depession) the only effective treatment is medication. My hunch is that medication is underutilized with disorders such as Narcissism, Borderline, Anxiety disoders, ocd. Although the authors won't come out and say it directly, it sems quite clear that they prefer drugless treatment, probably for philosophical reasons, rather than for lack of efficacy of drugs...