How can psychiatrists make room for both mind and brain in their practice? What have psychiatrist become, and what should they be? These and related questions are discussed in one of Joel Paris' latest books, Prescriptions for the Mind.
Accessible to anyone with an interest in the field, Prescriptions for the Mind provides a knowledgeable consideration of today's psychiatry by the experienced clinician, researcher and teacher Joel Paris. Reflecting on the changes in his own field, Paris highlights the dynamics between the intense development in neurobiological research and the merits of talk therapies. Resisting an anti-psychiatry view, the author nevertheless points out the flaws of his field. There is, however, a well-preserved wish in this veteran psychiatrist to improve the treatments of mental illnesses, and a strong belief that in time, we will do so.
As the basic elements of psychiatry, neuroscience and psychotherapy have not yet found a way to cooperate optimally. The first part of the book is devoted to the strengths of these fields, as well as the dysfunctional relationship between them. Paris wonders why psychiatrists no more provide or prescribe psychotherapy -- it is clearly an effective method to treat psychological symptoms. Also, even if neuroscience is an essential part of psychiatry, it does not exlude the need for empathic relating, nor does it fully explain the mind. Neuroscience alone will not save us.
The second part of the book revolves around problems of diagnosis. The current diagnostic system categorizes mental illnesses according to symptoms, not cause or process of disease. The purpose of the DSM system is to make it possible for clinicians to classify and communicate psychiatric disorders with as little confusion as possible. Unfortunately, however, we do not know a lot about them. "In reality, psychiatrists are treating conditions that they barely understand. Our diagnoses are, at best, rough and ready, and do not deserve the status of categories in other specialties" writes Paris in the introduction of the book. The rest of the second part revolves around issues such as fuzzy boundaries, "shoe-horning" patients into diagnoses, "bipolar imperialism", and "psychiatry's problem children", a.k.a. ADHD, PTSD, and personality disorders.
Part three focuses on which kind of psychiatric practice is most efficient, how to increase patients' access to care, and what the role of the psychiatrist could be in the future. The need for a unified method, which means bringing together the therapeutic ingredients that really work into effective treatments of psychiatric disorders. Paris wants to combine the traditional psychoanalytic method of "listening with the third ear" with more recent research findings about the psychotherapeutic process, such as briefer courses of treatment. He suggests a revivial of the traditional method of talking and listening, a treatment that has been scientifically tested and proved to be efficient, without a return to the analytical couch. He does not have a lot of affection for the trends in thinking and treatment that continually sweep the psychiatric world, nor does he believe in authoritarianism and tradition; thus, what he hopes for are psychiatrists who keep their eyes on their mission and their mind on evidence-based care.
One of the reasons reading Paris is refreshing is the coexistence of three important perspectives in an imperfect world: respect for old school thinking, a sober understanding of the limitations of the present, and keen anticipation of future changes. The current state is better than the past, but the shunning of psychotherapy combined with an infatuation with genes, brain scans and medication is not the answer to yesterday's mistakes. "To make further progress, we need to adopt a broader model, one that does not reduce the mind to molecules" (198), writes Paris in the last part of Prescriptions for the Mind.
This last part, "Outlook", focuses on the training of psychiatrists, psychiatry's social dimension, and the future of psychiatry. "I look forward to a psychiatry that is neither brainless nor mindless but focuses on what is true and on what helps patients" (208). Thus the author summarizes his motto, and it is easy to agree with him. Throughout the book, Paris discusses the changes he has seen in the field during the years he has been studying and practicing psychiatry, and his understanding of the processes that influence the development is clear, deep, humanistic and realistic. But there is also passion for the discipline and a genuine desire to help those who are affected in practice, which makes the reading even more inspiring and rewarding.
Oftentimes, ideas about the future can be tiresomely unbelievable. Fabulously enough, Prescriptions for the Mind is not science fiction, but rather like a Michael Haneke-production, sprinkled with optimism.
© 2009 Minna Forsell
Minna Forsell is a psychologist, recently graduated from the University of Stockholm. She currently works in a psychiatric health care center in Volda, Western Norway.