Liah Greenfeld Ph.D.

The Modern Mind

Psychiatry

A Bloggers’ Quarrel

On the State of Psychiatry, Again

Posted Nov 03, 2013

A fellow blogger, Dr. David Rettew, who usually abstains (as he tells us) from commenting on other bloggers’ contributions, was so strongly provoked by my recent post on the current state of psychiatry that on this occasion he could not abstain. A reader identified as Thomas, who left three comments on Dr. Rettew’s site, has already answered his main claim against the points I raised, so I could leave my cause rest in the hands of this thoughtful champion, to whom I am grateful. But I am flattered by Dr. Rettew’s recognition of how provocative – that is how new – my argument is and would like to continue the dialogue that he initiated, using this opportunity to stress that my intention is to make psychiatry better able to help its patients, rather than to undermine it and “throw the baby out with the bath water.”

I would go further and suggest to Dr. Rettew that the agreement between our positions is probably far greater than the disagreement and that, had he read what I wrote carefully and thoughtfully, he would not be offended by my post. What proves that he did not read my post that way, but rather allowed his emotions to blind him? For starters, he misspells my name. More importantly, he did not notice – though I have stated this explicitly in the opening paragraph of the post – that it was only one of a continuous series of posts, focused on one particular point in an extensive argument which was the subject of many earlier posts and was to be further exposed in the posts to come. How could Dr. Rettew be certain that his objections were not met before and would not to be met later? Were he not blinded by emotion, I am sure he would give me – as his fellow blogger – the benefit of the doubt and, rather than assume that I was ignorant of the development in psychiatry in the past half-a-century, seriously engage with my argument regarding the insufficiency of the biological paradigm (and I said “insufficiency,” not “uselessness,” meaning that it was not enough and not that it should not be taken into consideration). Were he to seriously engage with my critique, I’ll repeat, he would read the other posts in the series, consult the book on which the series is based, and find all his objections both foreseen and answered.

Let me proceed to Dr. Rettew’s five specific objections:

1) Dr. Rettew finds fault with my statement that "no empirical proof of the biological causes of these major diseases exists at this point,” believing that, saying this, I claim that mental functioning can be “nonbiological.” But, of course, I claim no such thing. Nothing in human life can be unbiological by the definition of life itself and for the simple reason that we experience everything through our body. Moreover, I am talking specifically about causes (or agents) of the major psychiatric diseases, not about their expression. In fact, against social constructionism, I insist on their biological reality. And I think it is extremely important to finally find the causes – whatever they are – of these devastating diseases which express themselves biologically. It must also be stressed that my argument concerns only schizophrenia, manic depression and unipolar depression, diseases identified (in the most authoritative psychiatric sources) as those “of unknown etiology” and “of uncertain organic origin”; this identification clearly signifies that there is no proof of their biological causes, isn’t it? Dr. Rettew for some reason mentions autism, but this developmental disorder is entirely irrelevant to the discussion.     

2) Dr. Rettew finds fault with my statement that the “empirically unproven presupposition of biological causes necessarily leads to biological treatment [and therefore] possible mistreatment.” Dr. Rettew quotes only the middle part of this sentence and takes it out of context. He then responds to it by saying: “Psychiatry recognizes the importance of non-medication treatment because of the overwhelming research that things like psychotherapy are just as “biological” as a drug. Think about it a minute. How could it be otherwise?” The gist of my argument is precisely that cultural influences, just like psychotherapy, would necessarily have biological effects – how could it be otherwise, indeed? – and that, therefore, it is essential that we do not exclude culture from the areas in which we look for the causes of psychiatric diseases.

3) Dr. Rettew finds fault with my discussion of Emil Kraepelin, whose firm, though empirically unwarranted belief in genetic origins of schizophrenia and affective disorders led to the fact that “family history was included as one of the symptoms in the psychiatric diagnosis.” Dr. Rettew says that “it is misleading to report something a century ago as though it is still happening. . . Nobody makes a diagnosis simply based on family history. Do psychiatrists use family history? Sure...” Should I leave this without further comment? 

4) Dr. Rettew’s fourth objection should be quoted in full, because it provides a key to his emotional reaction. He writes: “We study biology based on ‘career-enhancing considerations of social prestige.’ Now it gets a little personal. Like all professions, psychiatrists include people with a wide variety of personalities, motivations, and attitudes. The vast majority, including those involved in biological research, are deeply committed to the welfare of people and improving mental health. Blanket statements that disparage a large group of dedicated professional are irresponsible, offensive, and just wrong.” This is a reaction to the following statement in my post: “… in the end of the 19th century, … 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….Kraepelin, who worked in the end of the 19th century and early 20thcentury, 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…. [His] 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…”

As can be seen, I said nothing about the motivations of the biologically-inclined psychiatrists of our day. I made an empirically supported sociological statement about the early commitment of the psychiatric profession. There is no need to see red and no need to take offence. Professions have a history; this history has a formative effect on their characteristic practices. This does not at all imply that professionals of later generations share the motivations of the founders whose commitments proved central in the process of professionalization (i.e., turning certain activities into a social institution).

5) “Finally,” writes Dr. Rettew, “what solution is being suggested in this post to this ‘biology ran wild’ situation? As I mentioned in the beginning, a point about the importance of culture is fine, but making it at the expense of turning an entire field into a caricature is an easy and cheap way to go about it.” In fact, I began the post found so wanting with a sentence: “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.” This was the promise to offer the solution in the following posts. (If Dr. Rettew did not jump the gun, I probably would have started discussing it today.) But it has already been offered in my book. Please, Dr. Rettew, read it. Consider my causal explanation of schizophrenia, manic depression, and unipolar depression. Perhaps you’ll agree with me; perhaps you’ll be able to offer me some constructive criticism. We are allies in the same battle, after all, and serious engagement with each other’s views can only benefit both of us.  

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

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