Since insight-oriented verbal psychodynamic therapy has importantly expanded, refined, and modulated the thinking of the Viennese neurologist, and is notably more sophisticated than a century (and half-century) ago, it sure would be helpful to ban the lazy words Freud and Freudian from all journalistic and lay discourse. This even as the insights of psychoanalytic thinking prove ever solider by the day, in this age of mentally imbalanced political leaders.
15
One of the questions that the use of medications in psychiatric disorders raises is: is consciousness nothing more than the sum of our biological, neurological, and chemical processes, or is it something more? Put another way, are we transcendent and mysterious beings greater than the sum of our parts or are we little more than meat that talks? One of the positive things about traditional psychiatry was its profound respect for our fundamental mysteriousness and complexity. Using medications is fine but it’s not enough.
12
@Mark Siegel The first and most important question that the use of medications in psychiatric disorders is:
do the meds afford the patient relief from their symptoms and an ability to live a somewhat normal life?
The right medication makes it possible for someone suffering through their mental illness to have some lucidity and sense of humor about the question you pose. No medication, or the wrong medication, makes such navel gazing irrelevant to a person who cannot get out of bed, work, engage in basic hygiene, or refrain from suicide, self-harm, or acting on delusions.
I promise you, most folks with active, serious mental illness want less mystery and more answers. Consistent treatment, with the right meds, by an active and engaged shrink and a complementary talk therapist are predicates to someone wondering if they're neurochemicals or ensouled or what have you.
As one doc I knew said, "It doesn't matter if it's personality, pathology, or trauma if you want to kill yourself all the time. First, you have to stop wanting to kill yourself. Everything else can wait."
49
Many Americans foolishly ascribe infallibility to their medical professionals. My brother fell victim to this fallacy. While depressed over a mistaken perception that he failed as a parent, he allowed a quack to prescribe a potent antidepressant, one that required regular 6-week check-ins. These check-ins never happened; the quack simply ignored them. Thus, my brother developed mood swings, hallucinations, and other mental issues, from which he has yet to recover, years after stopping the rotten drug. We need to realize that many doctors, psychologists and psychiatrists especially, are often doing little more than blind guess-work. We have to partner with them, challenge them, and dump them for a better doctor, if necessary. None of them are infallible.
39
@PW Read Dr. Breggin's book Psychiatric Drug Withdrawal.
6
We should also remember that our brains are constantly changing as a RESULT of our psychological experiences (neuroplasticity). Psychological stress changes the brain, learning anything changes the brain, and other mental habits also change the brain. This is something we need to tap into in the future instead of introducing compounds (psychiatric drugs) to change the brain in random ways.
Additionally, psychiatric drugs probably work for some people some of the time, only due to ‘expectations’ (i.e., the placebo effect). Placebo effects can be very powerful - check out the article titled “The Placebo Effect, Digested – 10 Amazing Findings” by C. Jarrett (published in the BPS Research Digest).
9
@kdn
You are wrong to attribute everything to placebo. An antidepressant was very helpful to me for about a year. Then it was not, slowly. There are clearly drugs of all kinds that alter moods quite potently. This effect is not due to placebo, tho some part may be for some people.
Anti-anxiety medications? very helpful, but also must be used sparingly.
We just do not know everything, and meanwhile people who are suffering want relief. And need it. But it is never just drugs that are the answer--they are a short-term answer. The answer lies within the sufferer and how this person processes the changes they are experiencing within their environment.
10
Mental illness or wellness still remains largely subjective, based on observations of patients and on- going self study for those afflicted and hoping to feel better. Depression remains a killing disease. Options for treatment are better than they were years ago but the improvements seems to be incremental. Brain studies, biofeedback and other "cutting edge" therapies are available but are still considered specialized care, not covered by insurance and not readily available to those suffering. Until we give mental health the same priority we do our physical health, with the resources able to help maintain it, psychiatry will remain marginalized as a part of medicine.
35
In the past, people spent months on psychiatric wards. Now, they are fortunate to have a few days paid for by their insurance companies, or we all pay through Medicare or Medicaid. Chronic mental illness is not going away. But, Psychiatric wards are not a profit center for hospitals, and insurance companies do not want to cover it.
The lack of mental health insurance coverage means the majority of the psychiatric drugs are being distributed by primary care physicians. Medicines are lused by some people because very few paitents have insurance that will cover therapy. What some may see as "bogus " use of therapy may be life saving for the patient.
There is room for debate about the use of medications and mental health care. But surely our skyrocketing death rate of suicide , and major increases of depression and anxiety among young people is a cry for more help not less.
35
Psychiatry should be abolished and removed from the medical school curriculum.
7
@Edward
Your comment indicates that you've never lived next door to a mentally ill person...quite the "adventure."
25
Mental health has its seat in early childhood, and in failures of attachment, some malign, some inadvertent. If you deeply know the story of a person you will come to understand why they suffer and why they act as they do. Failures in attachment cause functional/ structural and neurotransmitter issues as well (triggers, PTSD, cortisol).
This became obvious to me when I began working with Foster Youth, who have very painful childhoods and suffer a high number of mental illnesses. Injuries to the spirit and not enough comfort or attention are very damaging to tiny kids.
45
@Megan
Megan, this is an excellent comment and really appreciate your thoughts about this. And I fully agree.
Deeply knowing the story of a person...enables one to come to understand their suffering, and perhaps why they act the way they do. We need much more effective treatments and help that are based in this knowing.
It is also not only failures of attachment, it is failures of respectful inclusion in communities and societies. The most extreme version of this is slavery. Racism and other forms of identity-based marginalizations or even violence...are way--too--frequent examples.
Thank you for your wonderful comment.
18
Like the rest of society lately, the field of mental health has been reduced to warring tribes: biological psychiatrists overselling "neurobiology," versus psychotherapy advocates deriding psychiatrists as mindless pill-pushers. The field will show evidence of maturity when each side realizes the other has a lot to offer, and their own is not a panacea.
I look forward to reading Harrington's book. My field needs serious critique without condemnation, and with some appreciation that the problems we treat are difficult.
38
@Steven Reidbord MD
Indeed the problems are difficult, and dis-eases are not a single entity. Depression, for example, is a host of processes. These need to be unpacked and understood, and that is time will spent with those in your profession. 15 minute, laughable med checks won't do it.
11
...all that mantra about the biological origin of mental illness will be over one of these days...then there will be an article in this newspaper (or whatever people use to get information about the world in the future) saying that millions of innocent people (including children) were severely damaged for the rest of their lives by the big Pharma and the thousands of psychiatrits who forgot about the complexity of our human soul ...readers will be scandalized for that..it happens all the time in this field... You will see
11
When I was an investigator for a criminal defense attorney, I was surprised how often I came into contact with psychiatrists. Somehow these geniuses could not bring up their own children to avoid serious criminal behavior, including murder. In more than one case, mom or dad, abetted by destroying evidence. The other psychiatrists were expert witnesses who could find some mental illness that would mitigate the crime. They might have to go really far out on a limb, but you get the justice you pay for.
8
Over-use of psychotropic drugs is the problem. Lack of biological markers for mental illness justifies lack of public trust in the pharmaceutical industry and the so-called doctors who prescribe these powerful drugs. They do not cure. They merely stabilize a patient, who is then expected to continue to take the drugs without end - and with no real cure ever being provided. The drugs have side effects that the industrial medical complex (pharmaceuticals and doctors) expect patients to tolerate in pursuit of "mental health." When dosages taken by a patient vary, which may happen for a wide variety of reasons, the patient reacts, with side effects becoming more pronounced, or the patient becoming ill even to the point of having psychotic episodes – the so-called “off his drugs” syndrome. Understanding that mental illness lacks biological markers, the question begs to be asked: are the psychotropic drugs causing mental illness that becomes a self-fulfilling prophecy yielding profits for doctors and pharmaceutical companies? Such drugs may be justifiable in a limited number of cases, but the widespread drugging of America raising health care costs for all is ridiculous. For further reading, see Breggin, Psychiatric Drug Withdrawal (2013).
12
From page 82 of Inborn Metabolic Diseases Saudubray et. al. eds.
'Inborn errors of metabolism [IEM] frequently present with psychiatric diseases in adolescents or adults. Since psychiatrists' awareness of these rare disorders is low, IEM presenting with a pure psychiatric illness are often missed."
*****************
MY COMMENTS:
Mental illnesses are symptoms.
There are many IEM that produce these symptoms. Although each IEM may be rare there are many such IEM so collectively they are not rare.
That is why any patient presenting with severe mental illness must have a full MEDICAL evaluation by a MEDICAL doctor knowledgeable about IEM.
12
I'll have to read this, it sounds fascinating. I am not a clinician, but I am the administrator of a program that provides a Medicaid-funded mental health service. And I have to say, I don't see a pathway to reform.
The process of diagnosis has become completely entangled within the framework of billing codes, eligibility and "access to care" standards. I go to county meetings and listen to officials prattle on for hours about numbers and technical minutiae without mentioning actual well-being once. I know there are therapists who give bogus or ill-reasoned diagnoses just so their clients are eligible to receive therapy. And don't get me started on the DSM.
Lifting billing and profit off of this entire superstructure like pulling off a cobweb would solve the issue, but industry lobbyists will never allow it. They want to keep Medicaid byzantine and difficult to access, and they want to keep private health care larded with profitable billing codes.
Equal health care for all--including not being able to pay more for better care--is the real solution, but it would take a revolution to get there.
71
@sedanchair
from what I have been told about coding - especially for mental health - the system is entirely arrayed against the provider and patient, designed as a barrier to treatment - or at least to payment for treatment.
Nothing that requires more time be spent on coding, billing and rebilling than on patient contact is a reasonable system - it isn't even a coldly efficient system. It wastes what resources are available.
11
The most difficult part will be understanding and evading the "prevailing prejudices" of TODAY. The reviewer indulges in the comfort of a Hegelian dialectic of ever greater perfection with our current time being smarter, more advanced than those biased and prejudiced practitioners of the 1960s or 1900s. That is, at base, the hubris of a certain set of scientists (and historians) who feel they have transcended such human considerations. Science attempts as best they can to explain and improve the human condition; while some may view their attempts as barbaric, historical context matters. To err is human, to forgive is divine.
5
This is why every new 'breakthrough' in biological psychiatric treatment just makes me roll my eyes. Yes, medications help. But they are nowhere *near* the miracle cures they've been sold as. I've seen catatonic depressives essentially "come back to life" with medications, or even electroconvulsive therapy, but the relapse rates of all the psychiatric illnesses are hideous.
It's the same story over and over: any treatment works fairly well for about 6-12 months, then seems to stop working. And the natural course of mental illness itself tends to wax and wane. So it's hard to tell if some depression or anxiety disorders would get better on their own without medical interventions, or not.
Severe mental illnesses, such as schizophrenia and bipolar disorder, have proven to be sensitive to such medications as antipsychotics and lithium, both of which have been around for over 50 years. Even antidepressants have been around for nearly that long. All the new drugs that are developed tend to be variations on the themes discovered several generations ago. The only differences tend to be in the severity of the side effects, not the therapeutic effects.
I tell *everyone* that medications alone are never enough. Therapy is essential to long-term improvement in psychiatric illnesses. But so many practitioners (and patients) are convinced that if they find the right 'cocktail', the meds will do the work for them. It's a delusion, and a dangerous one.
53
They’re looking for the right type of garlic to undo hexing- or the right combo of garlic and silver- its not going to happen, and “therapy” will not help any of the potions to work. The entire approach has to be scrapped, and start over.
3
@Liz Yes. The right meds create the mental breathing room to address the underlying causes, in order to do the work in therapy to eliminate triggers, develop coping mechanisms, and learn to detect relapses/new onsets. The right therapist will help the patient through the grieving process of accepting that there is no cure, and will help them get to the point of understanding that mitigation and maintenance are things of value and are worth living for.
12
We need parallel studies of the minds of psychiatrists - as a group they appear to be remarkably detached, self-congratulatory and self-involved - reluctantly dispensing patience to their patients. Don't hold your breath on them making a virtue of modesty and building trust based on authenticity.
23
Psychoanalysis is a moral science as well a body of ideas about dreams and the structure of the mind. It values autonomy, being free to decide the future course of one's life, as free as possible of irrational fear, envy, and anger. Freud once said that the purpose of psychoanalysis is to free people from neuroses so they can deal with the ordinary unhappiness of life.
As apparently Prof. Harrington argues, drugs should be reserved mostly for severe mental disorders, such as schizophrenia and psychotic depression or mania.
Therapies like Skinnerian behavioral therapy work against autonomy, freedom, and moral responsibilty.
To borrow the title of a popular book by Harry Browne, psychoanalysis allows you to find freedom in an unfree world.
7
@Diogenes: I beg to differ. Psycho*therapy* is indeed extremely valuable - especially cognitive-behavioral therapy (CBT). Freudian psychoanalysis, however, is a pseudoscience that's about as valid as astrology (read Karl Popper, who pointed out that none of its theories were falsifiable) and your claim that "Skinnerian" behavioral therapy "works against autonomy, freedom, and moral responsibility", is spurious. Stringing emotionally-laden words doesn't make the claim true.
CBT, in fact, emphasizes that you can't change what happened in the past, but that you must take responsibility for your cure - which turns out to be somewhat harder than talking away while lying on a couch. Indeed, CBT is the only approved psychotherapy for PTSD.
The idea that CBT patients are like B.F. Skinner's lab rats pulling levers in cages for rewards is bogus.
7
@PMN
It strikes me that statements like "Freudian psychoanalysis is a pseudoscience.." is emotionally laden. Citing authorities, such as Karl Popper, are not evidence of your claim. Popper's conjecture and refutation model has been been subject to powerful attacks by more recent philosophers, who argue that it does not account for scientific progress.
The main point of my post is that is that psychoanalysis is a moral science in that it allows the patient to determine his or her own future, to experience freedom and autonomy, even for example in determining when to end one's life if pain and suffering become too severe.
Your post makes several claims, but provides little evidence.
3
This is one reason why the field of clinical social worker has ballooned so precipitously, with LCSW's representing the majority of mental health care providers in the U.S. Social workers have been ahead of the curve in terms of understanding the holistic causes of mental health issues (their bio-psycho-social-spiritual influences). However, many social workers are as loyal to the DSM-5 as psychiatrists, partly because of the prestige that diagnostics imparts on the practitioner as "expert" (whether the practitioner is conscious of this motivation or not). Harrington's views aren't new. The medical model approach to mental health has been widely questioned for well over the last decade (in medicine, psychology, anthropology, and popular culture) but it's always heartening to see it given another public platform. There are many other paradigms for understanding human behavior (sociologists have plenty that aren't biologically oriented) but the western obsession with empiricism often stands in the way of our own growth.
15
Once -a long time ago-psychiatry forgot that the brain and mind were so speak in the same head! Freud "forgot" he was trained as a neurologist and became an analyst. Although many important contributions were made, the dichotomy of analysis yielded -inevitably- to a new dichotomy of bio-chemical interventions.
Although unmentioned in this book review, modern psycho-dynamic psychiatry has sought to reunite treatment of the mind and brain i.e. both talk therapy and bio-chemical interventions are important. Dichotomous thinking is in no ones interest.
37
@Michael Kaplan
You might add "body" to the mix; it's not as if we're just a brain in a vat. There's a lot of interplay going on, most of which we're still not aware of or willing to address.
31
@Michael Kaplan
I agree (and mainly practice psychodynamic therapy myself). But Freud didn't forget he was a physician. His "Project for a Scientific Psychology" (1895) was an attempt to explain the mind using the science of the time. He abandoned this effort, realizing the technology of his day wasn't up to it. Although we've advanced a great deal in the 125 years since, we too should tamp down the hubris of pretending we know more than we do... while still doing the best we can with the technology of OUR day.
21