Another question must be cleared before we can proceed to the exposition of the new—cultural—approach to mental illness. This is the question why the currently accepted approach is not sufficient. That it is not sufficient is generally agreed, and its practitioners (among the clinicians and researchers alike) represent the great majority of its critics.

Depression, manic-depression, and schizophrenia have been the focus of the psychiatric profession since its very inception over two centuries ago, but none of them as yet has a cure, and all three still remain causally unexplained: We do not know what causes them. The common conviction in the field is that these diseases are biological (especially within the research community, which has an obvious vested interest in the ultimate triumph of the biological explanation), but even those committed to this position admit that no empirical proof of the biological causes of these major diseases exists at this point—after more than two hundred years of searching for it and billions of dollars expended on this search.

In the past century the biological lead most consistently followed has been the genetic one. Its advocates repeatedly expressed the belief that very soon a specific gene or a group of genes causing one of these diseases will be found, and these assurances have succeeded in convincing the general public that they were found already. However, researchers were once and again disappointed, and none of the mental illnesses in question was traced to a genetic origin. Nevertheless, the belief (which, like any belief, does not need evidence to persist) that depression, unipolar and bipolar, and schizophrenia, are biological in their origin continues to guide research, and the unproven presupposition of biological causes necessarily leads to biological treatment. As the rates of these devastating diseases increase—and statistical studies consistently show that they do—this means that more and more people not only remain without a cure, but are potentially mistreated.

The common explanation for the failure of psychiatry to explain, and thus provide a cure for, the illnesses within its expert purview is that we simply do not know enough about the biological mechanisms involved, be they the genetic system or the brain, and the common prescription is that we should study them even more assiduously (and get even more money in grants).

The possibility is never raised that the root cause (and therefore treatment) of these diseases may not be biological at all. It is important to remember that even Freudian psychoanalytic tradition that in the past century has been the only alternative to the dominant medical approach, assuming a universal structure of human consciousness, however affected by individual life experiences, in the end reduces mental processes to biology.

This biological bias permeates the field, reaching as deep as the diagnostic categories themselves. The three diseases we distinguish today—depression, manic depression, and schizophrenia—were in the 19th century seen as one disease, varying in severity and complexity and characterized both by abnormal affect (bipolar, though with depression more common than mania) and abnormal thought processes. Psychiatrists in the 19th century were almost without exception clinicians; their knowledge and understanding of mental pathology was based on their experience with and observation of their patients and their symptoms.

This changed in the end of the 19th century, when the prestige of pure scientific research skyrocketed, especially in biology as a result of the publication of Darwin’s Origin of the Species, and careers in academic medicine, completely separated from medical practice (including in psychiatry), became not only possible, but more advantageous than those in medical practice. This was especially so in Germany, where academic positions traditionally carried a far greater prestige than practical professions and theory was more highly valued than practice, in general. So, not unexpectedly, a German professor of psychiatry, whose clinical experience was rather limited, Emil Kraepelin, embarked on a theoretical organization of the field, inventing a whole new vocabulary for talking about this particular mental disease, with numerous Latin, and therefore scientifically-sounding, categories within it.

This psychiatric nosology (i.e., basically, language) was based more on logical connections between names of diseases, than on the observation of symptoms and their connections, but it united those who knew it into an exclusive professional community and invested them with the prestige of a scientific discipline.

In the first place, Kraepelin decided to separate the affective and thought-related symptoms of the mental disease he appointed himself to classify into two distinct diseases, affective disorders, on the one hand, and thought disorders, on the other; thus depressive illnesses (later further separated into manic-depression and unipolar depression) and schizophrenia emerged as two independent diagnoses, each with its own community of experts and research agenda.

Kraepelin, who worked in the end of the 19th century and early 20th century, was dedicated to the biological perspective on mental disease, and insisted that the two diseases, affective and schizophrenia, are traced to separate genetic sources, even though almost nothing was known about genetics at that time. As a result, family history was included as one of the symptoms in the psychiatric diagnosis. (Imagine if diagnosing whether a patient suffers from a heart disease or diabetes depended on whether he/she had heart disease or diabetes in the family.) In addition, Kraepelin presupposed that affective diseases and schizophrenia differ in their course and outcome, with affective diseases capable of gradual improvement and schizophrenia necessarily leading to the complete deterioration of intelligence. These presuppositions have been repeatedly proven wrong, and yet they continue to guide psychiatric training, practice, and research.

The explanation of the consistent failure of psychiatry to find the causes of and cure the most devastating illnesses within its purview lies in this early, empirically unwarranted, commitment of the psychiatric profession to the biological paradigm, a commitment which is instead based on career-enhancing considerations of social prestige. The questioning of the biological paradigm and a search for a new approach are, therefore, entirely justified.

Liah Greenfeld is the author of Mind, Modernity, Madness: The Impact of Culture on Human Experience

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Response to “The State of Psychiatry Today” is a reply by David Rettew M.D.

About the Author

Liah Greenfeld, Ph.D.

Liah Greenfeld, Ph.D., is a professor of sociology, political science, and anthropology at Boston University.

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