Why is psychiatry?

Somebody asked for a "user's manual for a brain," hoping I knew of a path to what he called "24/7 bliss." Sorry mate, the Buddha was right. This world is a world of pain, if you wanted bliss, you should have got off two stations ago. Always beware of people offering bliss, keep your hand on your wallet while they're talking. I offered a few suggestions along the line of "You're not responsible for what people do to you but you are responsible for how you react to it," and he asked an important question: "Why doesn't psychiatry see any of this as useful?" By coincidence, I've spent the last week writing on the influence of positivism in modern psychiatry. "What's that?" he asked. A good question. In fact, a critically important question as positivism has determined the form of modern psychiatry without anybody realising it.

Wherever you go in the world, regardless of how sophisticated the people are, they all recognise the same few sorts of mental trouble. They understand that some children are slow to learn and never become independent (intellectual handicap); people can lose their wits after a head injury or infection; old people slowly lose their memories; some teenagers develop crazy ideas and hear voices; some people go crazy from drink or drugs; some people are frightened when there's nothing to be frightened of; and others seem to be grief-stricken all the time; while there are people who are just born trouble-makers. That's the folk classification of mental disorder. What comes next is the cause.

Here, there are only three options. It's either something supernatural, like possession states or spells or bad stars and such like; or it's something physical, like bad diet, bad teeth, allergy or constipation; or it's a moral/mental thing. There are people all over the world who firmly believe in the supernatural theory of mental disorder (see Youtube for hits such as "Casting out demons for beginners." On the other hand, don't bother). They wear amulets and have all sorts of rituals and incantations to fill the day but the difference is that they tend to look after the mentally troubled in their villages. They cast out the devils but here in the sophisticated West, we cast out the mentally-troubled.

Next, we have the equally ancient notion of physical causes of mental disorder. It is one of the enduring human beliefs that there is something you can add to or subtract from the diet that will cure all manner of ailments and woes. The Romans were strong on physical causes of mental problems and had a range of treatments such as forced vomiting, purging or various nasty concoctions for people to drink, or heating or cooling people. A few rounds of that treatment tended to quieten most people so the plebs were quite happy with it.

Finally, there is the moral/mental option. In order to have a mentalist theory, you need to have a theory of mind. For most of human history, and most people today, that's easy: the mind is the spiritual thing that hides between my ears and looks out of my eyes. It's me, myself. If it goes wrong, then it must be something I've done or I'm responsible for, and I must make amends. This was the Greeks' forte, the idea of the fatal moral flaw that destroyed the hero, especially hubris, over-weaning pride. The person wants something he's not allowed to have, or refuses to do something she's supposed to do, or doesn't show Right Attitude. Finally, the gods get sick of it and hurl a thunderbolt to let the troublemakers know who's boss.

Each of those options led to a program of treatment. If it's supernatural, call in the priest, or the local witch who was probably cheaper and knew all sorts of mysterious things that you wouldn't want the priests to know about. Even in cultures where the dominant religion is rational and conservative, people never actually give up their old ideas. The new religion sits on the bedrock of folk beliefs but never quite eliminates them: think of Christmas trees and Easter bunnies, which have absolutely nothing to do with the Sermon on the Mount.

The idea that people are the source of their own mental troubles is more complex and has taken many forms over the centuries. Lack of self-discipline or self-indulgence has a lot to do with it, especially sexual indulgence, and led to the widely-held notion of "masturbatory insanity." There was a classic paper from a British psychiatrist in 1962 which has been revisited just a few months ago (link here). Psychiatrists really believed this and Andrew Scull has given it a section in his recent and commendable history of psychiatry, Desperate Remedies. However, it took its modern form with the work of the Viennese psychiatrist, Sigmund Freud.

It's impossible to summarise Freud's psychoanalytic theories in a few sentences; suffice it to say he assembled a hugely complex mental apparatus which explained normal mental function and abnormal mental function and then dictated treatment. We also can't underestimate Freud's impact on Western thinking during the last century. Many of his technical terms have entered common language, such as "acting out," "unconscious," "anal compulsive," "catharsis" and so on, but mostly misunderstood.

Psychoanalysis had a huge influence on American psychiatry and the second edition of their Diagnostic and Statistical Manual, DSM-II, issued in 1952, was full of psychoanalytic concepts. The trouble was, they couldn't be standardised, and psychiatry became a complete mess. Poor people went to the mental hospitals where they got drugs, ECT and strait jackets, while the rich visited their analysts five times a week for an hour of the talking cure. However, there was only one problem: nobody could prove any part of Freud's work. You either believed it was true, or you didn't, and that was no basis for science. Psychiatrists wanted it both ways. They wanted to keep psychoanalysis as a (lucrative) medical specialty, but they also didn't use any part of their medical training in their work.

Finally, there is the idea that it's all physical, not enough blood going to the brain, or too much, they could never work that out, or some sort of dietary or bowel toxin, or too many or not enough of different chemicals. In Mind Fixers: Psychiatry's Troubled Search for the Biology of Mental Illness, Anne Harrington has described this in gruesome detail.

So in Western psychiatry, the battle lines were drawn. On one side were the physicalists who put brains under microscopes and tried different drugs and poultices and so on, not to overlook bleeding, purgation and scalding. They were sure mental disorder was due to a disturbed brain, and often said this: "Mental disease is brain disease." And they were convinced they had the science. On the other were the mentalists who talked in airy-fairy terms of Oedipal complexes and penis envy and all sorts of arcane stuff. Needless to say, the two sides were talking past each other. Finally, the physicalists won the battle, but not by proving their case. What happened was a revolution in the philosophy of science, called positivism.

The history of this doctrine, because that is what it is, is too long and complicated to bore you with. Throughout the nineteenth century, there was a growing move to cut all the superfluous junk from science, to strip it down to its bare essentials so that all that was left was what could be proven by observation: "If we can't see it and can't measure it, then it doesn't exist." And minds, as everybody knew, can't be seen or measured. So they had to go. But that wasn't done in an open debate in psychiatry. In 1929, a group of physicists, mathematicians and logicians in Vienna (again) published a pamphlet outlining what they saw as the proper conduct of science.

Known as the Vienna Circle, they were enormously influential but science was already well down that path anyway. Physics, chemistry, biology and thus medicine were racing ahead; only psychiatry was wandering around with the mentalist pixies. If psychiatry wanted to remain part of medicine, it had to toe the party line. If it wanted to be seen as a rational science, it had to get rid of all talk of minds, mental events, egos, defence mechanisms and, above all, unconscious drives: if it's unconscious then, by definition, it can never be observed or measured. So it came to this: if psychiatrists wanted to be seen and paid as specialists, they had to become good physicalists and dump the mental bit. There was no battle: "Stand and deliver, the money or the mind!" "Er, we'll keep the money thanks, shall we put the mind in this bin?"

Back to the question: "Why doesn't psychiatry see any of this (mental stuff) as useful?"

A: Because they don't have a theory of mind, and the only way they can keep their jobs is by defining all mental disorder as a physical disorder of the brain that needs physical treatment such as drugs, ECT and brain surgery. That keeps them firmly in the medical camp rather than being stabled with psychologists and social workers and nurses, and they get all the benefits that flow from it, such as being able to prescribe and order tests and have people locked up and being treated respectfully in courts. Without those benefits, life would be too horrible to contemplate.

The price of power was to give up the notion that there was any meaning or point in talking about minds. For psychiatry, that was a small price to pay because if you have to treat your patients as sentient beings, you have to be nice to them. You can't boss them around and order them to take this ghastly treatment or stay in this horrible place and be treated as insane and stripped of human rights. But the problem was that damned Vienna Circle a hundred years ago who said:

There are consequently no questions which are in principle unanswerable, no problems which are in principle insoluble. What have been considered such up to now are not genuine questions, but meaningless sequences of words.

Questions such as "What is the nature of mind? Of unconscious motivation? Where are ego defences?" couldn't be answered by observation so, by their rule, they aren't real questions, just "meaningless sequences of words" and out they went. Trouble is, there are practically no psychiatrists who know this. They are all completely indoctrinated in positivist science from Day 1 at primary school, and they think that the idea of a mental life belongs in the rubbish bin of history. Plus the fact that they actually like being kings of the castle.