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Out of Its MindReview - Out of Its Mind
Psychiatry in Crisis
by J. Allan Hobson
Perseus Books, 2001
Review by George Graham, Ph.D.
Mar 1st 2002 (Volume 6, Issue 9)

Some decades ago, we all knew what psychiatry was: it was ‘medicalized’ psychoanalysis. The discipline of psychiatry had excellent reasons for tethering itself to psychoanalysis. Surely any branch of medicine had to have its own distinctive domain. After psychoanalysis had identified its domain as the Unhealthy Unconscious, what remained left for psychiatry but to define itself as the treatment of the unhealthy unconscious? Furthermore, the tethering of psychiatry to psychoanalysis permitted patients -- or certain classes of patients – to be treated in a psychiatrist’s office, without having to visit disturbed inmates in asylums. Treatment was a matter of building a personal relationship with a patient who paid for services just as a victim of high blood pressure or diabetes paid for services.

Equally valuable, the psychoanalytic conception of psychiatry promised an account of therapeutic healing. Healing could be understood as the psychoanalytically guided illumination, management and control of unconscious forces – repression, Oedipal complexes, and so on.

Psychoanalysis failed. There were different reasons for failure – the inability to treat severe psychoses, the absence of determinate diagnoses, the incapacity to integrate with powerful and fertile results in neuroscience. But the conception of psychiatry as psychoanalysis lingered for a time after the failure of psychoanalysis because psychiatric medicine lacked a comparably compelling alternative approach. It seemed best to stick with psychoanalysis even though it had come apart. It appeared humane and compassionate and admirably tried to empower patients in their own care. But, alas, a crisis in psychiatry now has ensued.

Thus begins this multiply titled book.

Hobson is a professor of psychiatry at Harvard and perhaps best known for his work on the neurochemistry of dreams. Leonard is a freelance medical writer and Harvard graduate. Together they then lead the reader rather quickly to the proposition that forms the book’s first sub-title: psychiatry is in crisis. The crisis is constituted by the chaotic and post-psychoanalytic intersection of a number of large theoretical and social problems within the discipline. These include the following:

·                    identification and treatment mental illness

·                    scientific aspirations of psychiatry

·                    long-term patient care

·                    coping with HMO’s

·                    attraction, education, and training of psychiatrists

·                    mental illness among the homeless and prisoners

·                    rapport between psychotherapy and pharmacotherapy

Nor do these complete the list of critical issues.

Hobson and Leonard are certainly not the first to stand at the contentious and disorientating intersection of problems associated with psychiatry. However the Hobson and Leonard solution to the crisis (or better term given their view, ‘chaos’) in psychiatry– which I shall mention in a moment and which constitutes the second sub-title of a call for reform -- is simplicity itself.

Among theorists of the crisis/chaos in psychiatry, different writers propose different solutions, depending on which sub-crisis is for them the principle source of chaos. The issue of how to identify mental illness, for example, dominates discussions in the tradition of Thomas Szasz. However Szasz’s worries about the categorical mislabeling of problems of living as mental illnesses certainly is not for Hobson and Leonard the source of chaos. They are happy to acknowledge that conditions such as depression, panic disorder and the like are illnesses. Mental illness is real even if the word ‘mental’ itself is something of a categorical misnomer (see below). For Hobson and Leonard the principle cause of chaos is the absence of a proper sense within psychiatry of how to connect brain science with the theory and treatment of mental illness. Reform is to be achieved by forging that connection.

Simple or no, they offer a picture of how brain science should connect with both the theory and treatment of mental illness. They argue that psychiatry can only survive as a respected field in medicine if it becomes neuropsychiatric or ‘neurodynamic’, as they put it. On the view they outline, panic attacks, chronic anxiety, depression, and schizophrenia and so forth all emerge rightly to be classified as neurobiological/neurochemical illnesses. Psychiatry becomes neuropsychiatry because the unhealthy mind, somehow, just is the ill brain by another name.

“We need a mental health system led by psychiatrists who have a command of biomedicine and therapy; one that includes psychologists, therapists, counselors, social workers, and others assigned tasks corresponding to their skills.” (p. 213-214)

The central clauses are ‘command of biomedicine’ and ‘corresponding to skills’. The key to psychiatric medicine is biomedicine, brain science. General practitioners, counselors, and conventional pill-pushers tend to be inept at diagnosis and treatment. The neurodynamist/neuropsychiatrist should govern the mental health system.

Not governance by clinical psychologists, for clinical psychology is a creature of “bright ideas, human whim, or fashion” (p. 212). Neuropsychiatry is core – based in hard science, experimental accountability, and coherence with fertile and well-established theories in adjacent and overlapping domains, such as evolutionary psychology and biology.

Hobson and Leonard are not interested in the dialectics required to refine their theses (mentioned above) and to defend them against competitors. They are advocates. This is not a book with argumentative subtleties. But it is not wooden or pedantic either. The writing is lively and vigorous, bold in conception, and polemical in purport.

I would welcome a revealing unity into the stubborn diversity of illness types and treatments, but I fear that Hobson and Leonard’s forcing of the neuroscientific perspective onto psychiatry is too close-fisted to capture the ambiguity of the phenomena. Not just in the ambiguity it presents to clinical presentation, where the experience of mental illness takes place at the level of the whole person and not at the level of sub-personal regions of the brain, but more profoundly in the ambiguity it presents to our metaphysical picture of persons.

Hobson and Leonard’s talk of mental illness as all biology and chemistry is a simplistic physicalism about mental illness. If physicalism about mental illness is true it needs to be a more subtle doctrine than is offered in this book. It needs to incorporate both a reduction of the psychological to the neural and a form of autonomy for the psychological. Different conceptions of reduction and autonomy need to be explored, as they have been in very recent philosophy of mind.

Evidently, there are an indefinite variety of neurobiological and neurochemical configurations in the brain that are compatible with a diagnosis of depression, for instance. Hobson and Leonard make the assumption that there exists some final, uniquely true if prohibitively complicated neurobiological/neurochemical description of an illness like depression. This is an assumption that we should reject. Depression as such does not exist at the neurochemical/neurobiological level. It is an illness or disorder at the psychological level – at the level of feeling, motivation, cognition and behavior. Or better: it somehow exists at multiple levels. It is an illness of persons distributed across the layered world of the mind/brain.

Little or nothing of the ‘distribution’ of mental illness between levels appears in this book. Except for some tantalizing claims about one-directional causal commerce from bottom to upper levels, the idea is not explicitly approached. For Hobson and Leonard it’s all bottom-up. But if this book does not excite you with its reforms, or inspire you with its metaphysics, it will incite you to think about the ills of psychiatry and the alliance that is being and must be forged between psychiatry and basic neurobiological and neurochemical research. There is substantial room for disagreement with Hobson and Leonard about the trajectory, hypothesis space, and public policy impact of this alliance. But no one can deny its necessity and urgency. Not after reading this book. I recommend it.

 

© 2002 George Graham

 

George Graham is a professor of philosophy and of psychology at the University of Alabama at Birmingham. He is the co-author of When Self-Consciousness Breaks. This is his third review for Metapsychology.


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