Psychiatry and Its Discontents

Is psychiatry in crisis? Andrew Scull thinks that it is. So too does the former head of the National Institute of Mental Health, Thomas Insel. 

As it happens, and to descend a few rungs, life would probably be better if we saved the word “crisis” for real crises. Calling something a crisis evokes images of Hurricane Sandy bearing down on us. 

Even if we accept that America is in some very serious trouble, that the social contract has been sundered, and that appalling behavior had become the order of the day, blaming it on psychiatry is a bit facile. While we would have seriously preferred that young Salvador Ramos, along with the other mass murderers out there, had been committed involuntarily to psychiatric institutions, the fault, dear readers, lies in the culture at large, a culture, as I said yesterday, that has broken the American family and that has diminished and demeaned and derided and defamed fathers.

To imagine that psychiatry or any mental health professional can instantly solve this problem is naive. I would say the same about gun control and locked schools. The problem is bigger than all that.

Anyway, rather than read Scull’s book, I refer to Stephen Eide’s review in the City Journal. I found it through Maggie’s Farm, via one Dr. Joy Bliss. I will note a point that Dr. Bliss made and that even I have made before. We too often fail to distinguish between brain diseases like schizophrenia, metabolic disorders like bipolar illness and more everyday conditions, like depression, anxiety and narcissism.

Without making these distinctions, we are, as it were, flying blind. We too, with Scull, would like to know where mental illness comes from and how to cure it. For the record, Scull is a sociologist. Nuf said.

Now, I will simply review a couple of salient points. Scull apparently makes much of the movement to deinstitutionalize mental illness. Surely, our failure to commit young homicidal maniacs to psychiatric institutions is part of the fallout of this policy. True, some psychiatrists were behind the movement, but many were not. It was more leftist politics than effective treatment.

I would note that one reason we thought it was a good idea was the advent of new therapeutics, from neuroleptic drugs to certain types of antidepressants. When drugs like Thorazine and Anafranil were introduced they produced remarkably positive effects. The problem was that in order for them to work patients needed to take them. And many patients who were let go from psychiatric institutions did not take them. There was also the problem of the side effects, like tardive dyskinesia, which have not until recently been treatable. 

Eide summarizes Scull’s point:

Deinstitutionalization began slowly at first, in the 1950s, but the pace accelerated around 1970, despite signs that all was not going according to plan. On the ground, psychiatrists noticed earlier than anyone else that the most obvious question—where are these people going to go when they leave the mental institutions?—had no clear answers. Whatever misgivings psychiatrists voiced over the system’s abandonment of the mentally ill to streets, slums, and jails was too little and too late.

And then, more pertinent for my own personal consideration, is the fact that Freudian psychoanalysis, the therapy of choice until relatively recently, has now fallen into desuetude.

Eide explains:

The Freudians normalized therapy in America and provided crucial intellectual support for the idea that mental health care is for everyone, not just the deranged. Around the same time as deinstitutionalization, Freud’s reputation, especially in elite circles, was on a level with Newton and Copernicus. Since then, Freudianism has mostly gone the way of phlogiston and leeches. 

That happened not just because people decided the psychoanalysts’ approach to therapy didn’t work but also because insurance wouldn’t pay for it. Insurance would, however, pay for modes of therapy that were less open-ended than the “reconstruction of personality that psychoanalysis proclaimed as its mission,” more targeted to a specific psychological symptom, and, most crucially of all, performed by non-M.D.s.

One suspects that this paragraph refers to the advent of cognitive and behavioral therapies, which have largely supplanted psychoanalysis. In Great Britain the National Health Service will only pay for those treatments, because they have demonstrated their effectiveness.

But, then apparently Scull most clearly despises the pharmaceutical industry. I myself have known psychiatrists who were working with psychotic patients before the advent of neuroleptics and antidepressants. They would strongly disagree.

Scull loathes the drug industry and only grudgingly allows that it has made improvements in the lives of mentally ill Americans. 

He divides up the vast American drug-taking public into three groups: those for whom they work, those for whom they don’t work, and those for whom they may work, but not enough to counter the unpleasant side effects. He argues that the last two groups are insupportably large.

True enough, sometimes the drugs work. Sometimes they do not work. After all, people rushed out to take Prozac because the psychoanalytically oriented treatments that they had been undergoing were decidedly ineffective. 

And, it is worth mentioning, though I like to think that Scull has done so, that among the best new treatments for depression is conditioning exercise. This was discovered by scientists and it does not produce obscene profits for the drug manufacturers.

Eide summarizes Scull’s concepts:

Scull believes that psychiatry is in crisis because the most recent generation failed to deliver on its three defining promises: the promise to identify the biological (genetic or neurological) roots of mental illness, the promise to establish a definitive typology of mental illnesses (presented in the Diagnostic and Statistical Manual of Mental Disorders), and the promise to develop an array of effective medications for the mind. Psychiatry’s best and brightest participated in these efforts. Biological research, in particular, benefited from billions in federal funding. Americans, too, take more medication than ever. But decades on, psychiatry doesn’t seem to have much more of a handle on mental illness than when these initiatives launched.

As it happens, many purveyors of medication have made it seem that we all needed to take just another pill. But many psychiatrists are extremely grateful that these medications exist. 

And yet, the more salient issue, is that psychiatry did not cause America’s problems and is not likely to be the solution. As we saw during pandemic lockdowns, enforced desocialization produced spikes in severe psychiatric disorders. It did so especially among the most vulnerable, the young. These children do not just need a pill. They need to get their lives back.

We Americans bear some responsibility for the policies implemented by the politicians we elected. And we ought to recognize that our inability to produce a cohesive society is perhaps the most significant causal factor in the manufacture of mental distress.