A New Paradigm for Psychiatry
Answering the call from the UN
Posted Feb 26, 2017
In Robert Whitaker’s article from last December, “INTAR 2016: A Global Call for a New Paradigm” he wrote that by the end of the conference, this gathering of representatives from the World Health Organization, the United Nations, and the International Disability Alliance had “embraced a common thought: a new global health narrative was needed, one that could replace the failed ‘medical model’ that dominates mental health today.”
This call for a new paradigm reflects the awareness that the paradigm of pharmaceutical psychiatry has failed. Pharmaceutical psychiatry replaced the older, psychoanalytic model. There have been many gifted analytic therapists – illuminating writers like Fairbairn, Winnicott, and Harry Stack Sullivan – as well as important understandings about attachment. And there have been many excellent teachers. Nonetheless, psychoanalytic theories are off-base, Byzantine, incomprehensible, and significantly wrong (I have also written extensively about these problems). Psychoanalytic theories had become dehumanizing and reductionistic, perpetuating a ‘we-they’ dynamic that violated the essential respect and care for our patients.
I have been a practicing psychiatrist for forty-three years. During this time I have dedicated myself to my craft: intensive psychotherapy. I am not a recovering pharmacological psychiatrist. I have been opposed to psychiatric drugs my entire career. Over time, a new paradigm for psychiatry has coalesced.
Such a paradigm needs to explain human struggle and how and why suffering occurs. It requires an appropriate treatment approach that heals pain and shows why and how it works. It needs to be consonant with contemporary neuroscience, and to be comprehensive regarding human behavior. The approach I will describe is consistent with the nature of consciousness itself, with the neuroscience of the brain, with child development, human relatedness, and attachment.
The theory is ‘The play of consciousness in the theater of the brain.’ The treatment is ‘The psychotherapy of character.’ Consciousness is organized as a living drama in the theater of the brain. This ‘play’ is a representational world that consists of a cast of characters, who relate together by feeling, as well as scenarios, plots, set designs and landscape. It is how the brain represents reality and how consciousness is organized in the brain. Our adult characters are formed as our individual genetic temperament is shaped by our experience. (see – (“The Nature-Nurture Question”).
All psychiatric symptoms come from plays that are written as a result of deprivation and abuse, i.e., trauma. They are not biochemical. Trauma can be generated by abusive or depriving parents, sexual abuse, physical abuse, bullies, loss, deaths, separations, divorce, war experience, etc. Through later trauma, we write new plays which can override the original one, and generate a darker play. This then becomes our new prism through which we experience the world.
Psychotherapy is the process by which one mourns the pain of trauma, allowing for a new play to be written that is grounded in authenticity and love. Psychotherapy must honor the inviolable boundaries of respect in order for it to be safe for the necessary explorations of pain, abuse, deprivation, and love. Within the safe emotional holding of the therapeutic relationship, the patient is able to mourn his problematic play. Symptoms and suffering reflect an adaptation to a toxic emotional environment. Psychotherapy generates a literal rewriting of the play in the brain. This is the process by which real brain change actually takes place. (see – “The Art, the Science, the Wisdom of Psychotherapy”).
Of course, everything is processed biochemically in the brain. But this is just mechanistic. A problematic emotional adaptation gets altered by the processes of psychotherapy which is then reflected in the brain. Psychiatric symptoms are not brain diseases. Depression is not a chemical imbalance generated in the synapses between neurons. Chemicals do not cause depression.
We need to give special attention to the psychotic worlds: paranoid schizophrenia, catatonia, hebephrenia, schizo-affective schizophrenia, manic-depression and paranoid state. I will quote from my book:
“In the psychotic worlds, there is an additional disruptive dimension to deprivation, abuse. In the context of major emotional deprivation, the damage to these plays derives from an unmanageable limbic nuclear rage. The cortex cannot encompass this powerful rage in a cohesive way. It fragments the cohesion of the intactness of the play itself and the intactness of the self persona. When the self and its primal play flies apart, it generates a state of terror, the dimensions of which are far more powerful than regular anxiety. This terror/rage is the central characteristic of all of the psychotic character worlds. It is the worst and most unbearably frightening state of all potential human experience.
Although the self and the plays are fragmented, consciousness continues its ongoing process of neuronal mapping, reflecting this new experience. Consequently, the cortical imagination now writes new plays that are anchored in this limbic rage/terror experience. Disrupted plays of a fragmented self and terror-filled feeling and other-worldly plots are written and inhabited. The feeling of these other-worldly plays are captured by words like awe, dread, or horror. There is an another tragic feature of schizophrenia—the Humpty-Dumpty factor.”
Often, once the plays and the self are fractured, they cannot fully be put back together again. This can lead to chronic states with some disability.
As a result of the fragmentation, what would be regular thoughts in an intact play are experienced as literal, heard voices in the plays of paranoid schizophrenia. These auditory hallucinations are given form by the cortical imagination, as voices of other-worldly figures who generate terror and awe, or command voices.
In manic depression, the central feature is that limbic feeling cannot be contained by the ruptured play. It spins out of control without limits. Manic flights of feeling should not to be romanticized. A patient in a manic psychosis can be quite humorous in his early mood-elevated phases. It feels ebullient. Like all mood states, it is contagious, and manic people make us laugh. It, however, always escalates out of control, and, in its final and inevitable form, shows itself to be a terror/rage state.
Manic-depression is now called bipolar, which I consider to be dehumanizing and mechanistic, like two poles of a battery. Mania is a very serious and debilitating psychotic character world, which always generates some disintegration of the personality and results in repeated hospitalizations throughout life.
Not medicating a patient with schizophrenia in today’s world sounds like a novel event, a new movement. But it is not. There has only been drugging since the 1950’s. Schizophrenia has been with us always. There has been a great deal of experience with the psychotherapy of schizophrenia. One of the best approaches came from Harry Stack Sullivan at Chestnut Lodge. He took the treatment outside of the medical model and created a respectful and safe environment, where people could have psychotherapy in a caring manner. I have written about Geel, a town in Belgium where for centuries the townsfolk adopted individuals with schizophrenia to live out their lives as respected members of their families. Also keep in mind that there is an acceptance that there is often some disability present. (see – “Reflections on Geel.”)
Another important piece of knowledge that has been lost due to drug psychiatry is that when a patient presents with an extremely acute and flagrant psychosis, this ordinarily predicts a good recovery. It is counterintuitive that a longer term, quieter, chronic psychosis is actually more problematic. It used to be old news that people can recover from a first break and do very well. Old knowledge has been lost.
Psychotherapy of the psychotic worlds is no different from psychotherapy with anybody else. There are times where a judicious use of drugs may help people in a state of terror and fragmentation. But even with a potential use of drugs, drugs are never the treatment. Psychotherapy is the treatment. The writing of the play is trauma-based, and the trauma needs to be mourned. I do not pretend to have the final answer as to why the play gets fragmented. There may or may not be some kind of genetic susceptibility. To be clear, I am absolutely saying that schizophrenia is not a brain disease. It is a human process. I have been through this journey with people many times. We need to respect and reach, care and engage in a purely human way.
The play of consciousness is a unified field theory which not only includes psychiatry, it is consistent with neuroscience (as it must be), dreams, myths, religion, and art. The ‘play’ encompasses the ineffable human mysteries – birth, death, and the disparity between our ordinary sense of self and our intimation of a deeper authenticity. It includes, as well, the dark side of our nature. Human consciousness and human nature are one and the same. The creation of our inner play by the brain is the consummation of our Darwinian human evolution. This universal paradigm reflects a consonance of science and art.
I suggest that this paradigm needs to be the foundation of all the helping professions: psychiatry, psychology, social work and others. We should dedicate our resources to this enterprise. What is important is the quality of the practitioner, not his degree. The medical model is not germane. The education of therapists should be done on a mass scale to meet the needs of our society. From beginning to end, all of psychiatry is a human process, nothing more and nothing less.