CONVERSATIONS IN CRITICAL PSYCHIATRY

Dr Anne Harrington is the Franklin L. Ford Professor of the History of Science at Harvard University, Director of Undergraduate Studies in History of Science, and Faculty Dean of Pforzheimer House, a resident community of Harvard College. For six years, she was also Co-Director of Harvard’s Mind, Brain, Behavior Interfaculty Initiative (with psychologist Jerome Kagan, PhD). Her 2019 book Mind Fixers explores the history of psychiatry's tumultuous search for the biological foundations of mental illness. She also is the author of three other books, including The Cure Within, and Reenchanted Science, and many historical articles; and she served as the editor of such interdisciplinary volumes as The Placebo Effect, So Human a Brain, and The Dalai Lama at MIT.

I got interested in Dr Harrington's ideas after reading Mind Fixers. She offered a stimulating and thought-provoking historical perspective on the evolution of biological psychiatry from the German histopathologists to the present time. The history itself is fascinating, and she wonderfully weaves together events and figures scattered across space and time to create a coherent narrative. She also teases out the implications of this history for the future of psychiatry, and it is this critical and interpretative aspect of the book that I find to be the most valuable. In this interview, I engage Dr Harrington in an in-depth conversation regarding her historical understanding of psychiatry.

Awais Aftab, MD: I would like to commend you on your excellent book Mind Fixers. To write a good critical history of psychiatry one must walk a fine line: you have to poke holes in the establishment narrative without legitimizing the antipsychiatry story. I think you handled it very well. Was this something that weighed on your mind as you were writing the book?

Anne Harrington, DPhil: I did think about this issue, and my position was very clear. There are good historical reasons why psychiatry has so many discontents. But there are also at least as good historical reasons to resist the frequent moves made by anti-psychiatry critics to demonize the entire enterprise. In writing Mind Fixers, I wanted to make clear both the reasons to resist demonization and equally the reasons for the polemics and polarizations. I thought it was important to try to do this because, whatever else we think needs to happen, I think psychiatry and its publics need to find new ways to repair trust-on all sides. And I am persuaded that one way to repair trust is by helping all the stakeholders become clearer about how the field actually arrived at its present moment.

Aftab: You describe in detail how psychiatry has gone through multiple paradigm shifts and has overthrown one way of thinking for another every few decades. People tend to see these paradigms as failures, and they did fail in the sense that all of them aspired to-and failed to-be the “theory of everything” in psychiatry. Yet, in another sense, each paradigm taught psychiatry something, and there has been progress.

For instance, German psychiatry may have failed, but Kraepelin provided an influential framework for thinking about classification (not to mention the discoveries made with regards to the pathology of neurodegenerative diseases and dementias). Freudian psychoanalysis may have failed, but psychoanalytic theory also contained valuable truths about our minds-without which any comprehensive and meaningful understanding of psychological suffering is incomplete. The age of DSM may be nearing its demise, but it successfully launched an era of research whose fruits will outlive the DSM.

Would you agree with this story of progress despite failed revolutions?

With every new chapter in the field, there is a risk that we don’t just become smarter, but also more ignorant. Reading against the grain can be a very effective way for every field-not just psychiatry-to better recognize its implicit biases and blind spots.

Harrington: From a historian’s perspective, it only makes sense to speak of progress, or to imagine psychiatry learning from each of these eras, if it can be shown that new generations are, in fact, being taught to respect and reflect on what can be learned from projects and approaches that are now deemed overall to have largely failed. We cannot assume this will happen automatically. On the contrary, it is my impression that every time the field has decided it is in the throes of a revolution, the perspectives of rivals tend to get starved of oxygen.

People become more knowledgeable about some things and more ignorant about other things. Research dollars get allocated in ways that reflect new priorities. Textbooks get rewritten in ways that emphasize the new orthodoxies. Training programs get revamped. We saw this happen when the Freudians were largely in charge in the three or four decades after World War II. And we saw it happen again in the 1980s and 1990s after a new medically minded generation largely hostile to psychoanalysis secured the pole position.

This way of engaging with the past is, of course, not inevitable. The American Psychiatric Association, for example, could mount a whole new program in what we might call salvage psychiatry-or they could simply work to instill a greater historical consciousness in their trainees. No surprise if I say that I think that would be a good thing!

Aftab: Contemporary psychiatry sees Kraepelin as this heroic figure whose legacy has been reclaimed, and you rightly show that there is much in Kraepelin’s thoughts (such as his views on degeneration) that modern psychiatry would find problematic, if not odious. If Kraepelin could be resurrected in flesh and blood, what would he think of the DSM and the notion that it is neo-Kraepelinian? Would he be proud of his legacy?

Harrington: This is the kind of question that, for generations, many psychoanalysts also asked about themselves-or, more often, about rival schools of psychoanalysis they saw as deviating from orthodoxy and with which they were quarreling. What would Freud think?

While it is not the kind of question that most historians ask, some critics of various versions of the DSM have sometimes done something a little similar: they have invoked Kraepelin’s original project as part of a larger criticism of various decisions made by so-called neo-Kraepelinians. You call yourselves neo-Kraepelins, the argument has gone, but Kraepelin would have been horrified by what you are doing! You can see these kinds of rhetorical moves being made at various points in the 1980s and 1990s, for example, in heated debates over whether the DSM authors had chosen to circumscribe manic depression or bipolar disorder too narrowly.

Aftab: Another fascinating thing for me was the realization that psychiatrists are the children of a marriage between the asylum doctors (alienists) and the nerve doctors (who were mostly trained as neurologists). How did neurologists lose this big, lucrative market of treating “bad nerves” to psychiatrists? Was it because the psychoanalysts proved to be better at understanding and dealing with these bad nerves?

Harrington: Not exactly. What I think happened is that by the early 20th century there was a growing consensus that the kind of patients who had once tended to visit “nerve doctors”-like patients with low energy, vague aches and pains, chronic insomnia, digestion problems, etc.- were not literally suffering from an overtaxed nervous system. They were, instead, suffering from emotional problems.

As this conviction took hold, the once time-honored tool kit of nerve doctoring-massage, water cures, nerve tonics, and especially electrical stimulation-no longer looked credible. Nerve doctors needed to figure out a way to reinvent themselves. Some became psychotherapists, and some even became psychoanalysts! As the wonderful historian and psychiatrist Henri Ellenberger wrote back in 1970 (in the context of a discussion about the decline of exorcism as an accepted treatment), “Curing the sick is not enough; one must cure them with methods accepted by the community.”1

It would be a mistake to assume that, this being so, all the patients who might previously have sought help from a nerve doctor now sought assistance from a psychoanalyst. They did not. There were not enough psychoanalysts to go around, they tended to be concentrated in a small number of urban centers, and the ideas of psychoanalysis had not yet become a fixture of mainstream American popular consciousness.

Instead, for many years, people with what most clinicians judged to be emotional problems were more likely to see their family doctor. They would generally not talk about having depression or suffering from an anxiety disorder. They also would generally not talk about their unconscious conflicts or repressed feelings. Instead, they would complain of “feeling run down,” “feeling blue,” suffering from insomnia, or this or that chronic physical problem.

For a long time, we also see a lot of these patients still were using the officially obsolete language of bad nerves, though perhaps now more metaphorically than before. They might talk about being nervous, about their nerves being shot, and about being on the verge of a nervous breakdown. And, of course, we still sometimes use that kind of language, generally without any real awareness of its historical origin. Similarly, we generally do not think about the fact that when we talk about someone being good humored, or sanguine, or say that a particular situation makes our blood boil, we are unwittingly invoking the archaic language of humoral theory!

Aftab: At the conclusion of your book, you mention that pharmaceutical companies have been abandoning psychiatric drug development. But since your book was written, there has been a flurry of new medications approved. For example, esketamine for treatment-resistant depression and brexanolone for postpartum depression. Psychedelics like psilocybin and ecstasy are being studied for depression in cancer patients and posttraumatic stress disorder. Several other compounds are in development. If you were to re-write the book today, would you still say that pharmaceutical companies are abandoning the field of psychiatry?

Harrington: You are right that these developments all happened in a flurry as my book was already in production and, in the end, I could only insert a footnote that flagged their potential importance. I have to say that these developments are still so new that I do not feel I can talk in an informed way about what they will mean. I have read some of the industry reports, the lively and somewhat contentious general press coverage, and some online testimony from patients involved in clinical trials. It seems clear that these new drugs have felt like a godsend to some people who have not been well helped before. It also seems that the story to come is likely to turn out to be complicated.

I asked a psychiatrist friend of mine who has his finger on the pulse of these kinds of issues if he thought that developments like the recent FDA approval of esketamine for treatment-resistant major depression signaled the beginning of a changed trend within the industry. Were we now seeing a significant swing back to mental health R&D? For what it is worth, his response was no, he did not think so. That could change, but so far, he thought most of the companies did not yet see a sustainable path forward in this area for themselves. And so, they are waiting and watching.

Aftab: You write in Mind Fixers that some people with mental afflictions are “suffering from a real illness” and “others are (almost certainly) not.” You also note: “Mental suffering takes many forms and has many causes, only some of which have roots in disease.” This assumes that the complex causes of psychiatric conditions could be neatly divided into diseases and not diseases, as if this is a line that is carved in nature. This is an assumption of which I am increasingly skeptical. It also assumes that there is some uncontroversial concept of disease in the rest of medicine on which psychiatry can rely. Medicine does not have a coherent philosophical notion of disease any more than psychiatry does.

Harrington: The comment that I made there was in the context of asking whether a take-no-prisoners approach to biological psychiatry has shown itself to always best serve the complexity and range of mental suffering that burden individuals-all of whom need and deserve help. It was less about drawing a clean line in the sand between diseases and not diseases and more about suggesting that mental suffering is a larger category than mental disease with multiple causes and with multiple downstream effects. Even in the absence of absolute certainty, it was a plea for a more intellectually generous, pluralistic approach to care. I think it is possible to lead with questions about the spectrum of suffering without denying the important philosophical issues you raise. In fact, insisting on the vexed nature of the boundary between disease and non-disease is a useful way to avoid a situation in which patients are preemptively sorted into categorical bins in ways that risk overlooking something important.

I also do not think this is a particularly controversial or philosophically fraught perspective. I think that most clinicians, even in an age of medication and biological thinking, appreciate that not all forms of mental distress are necessarily signs of a brain disease or some other medical condition. Even the DSM III, the book that we most associate with the biological turn in psychiatry, had a section of so-called V-codes or “conditions not attributable to a mental disorder.” A big problem, though, is that it became very difficult to make much use of that category, simply because most insurance companies decided early on to not reimburse clinicians for working with people who had been given a V-code.

Finally, I agree that categorical distinctions between disease and not-disease vex medicine more broadly and in ways that suggest other specialties have their own unfinished conversations about the relationship between physical suffering and physical disease. Today we live in a world, for example, in which many patients with no overt symptoms of disease are nevertheless treated with prescription drugs on the basis of their numerical deviation from certain assumed (and sometimes changing) norms of healthy physiological functioning. On the other side, we live in a world-one that I myself explored in an earlier book, The Cure Within-in which many patients suffer from ill-defined symptoms of physical distress for which their primary care physician or internist is repeatedly unable to find any physical cause. They fiercely resist being told this, because saying they do not have a disease signals to them that their suffering is not real, that they are making it up, and that they are not deserving of care. Ironically for our purposes, they also often resist this because it leads them (and sometimes their clinicians) to conclude that their problems are psychiatric rather than really medical.

Aftab: You mention in Mind Fixers, “The suffering of those who are not really ill in any meaningful medical sense can still be acute. I have only to look at the struggling students I teach and advise to know how true this is.” Could you perhaps comment more on your experience with such students, and the insights you have gained from that?

Harrington: In one of my roles at Harvard, I oversee a residential community of some 400 undergraduates. Sometimes they struggle. Sometimes bad things happen to them. They realize they are gay and are afraid to tell their parents (or they do tell them, and their parents disown them). They live through the tragic suicide of a friend or roommate. They are racially targeted. They experience a sexual assault. There is serious illness within their family back home, and they feel helpless. Or maybe they just take a course load that overwhelms them, or they fail academically in some other way and fear they have let everyone down. When they suffer from distress, hopelessness, or anxiety, they need and deserve help. Is a narrow medical approach likely to best serve them?

If is, of course, possible that in some cases their life challenges have triggered a true disease process. There is a great deal we still do not know about how the brain responds to adversity. Very likely, though, many of them are basically biologically healthy individuals whose mental distress is nevertheless real and who, in some cases, might even benefit from a short-term course of medication. One of the things I have come to believe strongly from watching and caring for students like these is that many would be more apt to accept the help they need if it could be offered within a framework that did not pathologize them up front, but instead validated their experience and affirmed their resilience.

Aftab: I think we don't appreciate the ways in which developments in psychiatry are reflective of developments in larger social thinking. People seem to think that diagnostic expansion and medicalization of distress has happened almost unilaterally. As if psychiatrists were sitting in their isolated conference rooms and were trying to decide what behaviors to call disorders and then reveal those diagnoses to an unsuspecting public. The reality is that psychiatrists feel an imperative to call something a disorder only when people increasingly show up to the clinics and seek help for those problems. The current debates over internet gaming disorder, porn addiction, sexual addiction, and so forth are happening precisely because people are increasingly seeking help. Medicalization is a sort of a dialogue that happens between society and physicians. Psychiatrists have little to no power to medicalize something if society is not ready to consider it a medical condition.

Harrington: There has been quite a lot of attention paid within my field to the dialogical process of medicalization. One approach that has been influential was originally developed by the philosopher Ian Hacking, PhD. He suggested that psychological categories, including many categories of mental disorder, are not inert but interactive-that is to say that the people to whom they are applied may have a point of view about them, may embrace them, may change them, and may resist them.2,3 Because of this, people in my field have looked at ways that interactive classifications (including those which abound in psychiatry) are apt to be more unstable and porous to changing cultural and social norms than are classifications imposed onto inert objects. Rocks neither resist nor embrace their classifications; people can and (sometimes) do.

A good way to see this in action is to consider the 1970s story of the depathologizing of homosexuality. For decades (not just during the psychoanalytic years), the orthodox position within psychiatry was that homosexuality was a mental disorder. Why did this change? It changed not so much because of internal dissent within the field (though it is worth giving a big shout out to the work of psychologist Dr Evelyn Hooker in the 1950s), but because a critical mass of gay activists decided they were no longer willing to accept having their identities and behaviors pathologized.

Aftab: The idea that the time period from 1980 until the present has been the age of biological psychiatry is a fiction in many ways. I personally would call it the age of DSM. DSM does not explicitly endorse biological reductionism. It is remarkably agnostic about etiology. The closest thing to a conceptual framework that psychiatry trainees get taught is the biopsychosocial model, which may lead to an eclecticism in practice but is decidedly not reductionistic. I think a lot of people hoped that the DSM would usher in an era of biological psychiatry, but that is different from seeing it as a biological revolution by itself. How did this false narrative emerge?

Harrington: I would rather call the 1980s biological revolution an actors’ category, a way that people at the time talked about what was going on. And the well-known radical changes to the DSM in 1980 were indeed a critical part of what was really going on, but-as I explore in my book-I don’t see it as the only relevant event. Schizophrenia, depression, and bipolar disorder (among others) all underwent their own kind of biological revolution in the 1970s and 1980s, and the DSM was not the only or even the major factor I see driving those more disease-focused stories.

As for your point about what kind of book the DSM really was: You are right that the architects of the DSM always insisted that their project was a descriptive one and that they were agnostic about etiology. Nevertheless, when it was published, DSM-III was pretty much universally understood to be, a bellwether sign of the field’s pivot away from the old Freudian approaches and a return to a medical model, not an invitation for a new “big tent” era in psychiatry. In the end, virtually all efforts to validate its syndromes focused on trying to find new ways to link them to genetics, neuroanatomy, neurochemistry, developmental neuroscience, and cognitive neuroscience.

Today, looking back, it seems pretty clear that all those hopes that the DSM specifically would help usher in a new era of successful biological research were not realized. This is why, more than 30 years later, National Institutes of Mental Health Director Dr Tom Insel could say bitingly that “biology never read that book.”4 But the fact that he could say such a thing also makes clear just how many biological hopes were invested in this allegedly agnostic book.

Aftab: You recommend that psychiatry “could decide to return to being something like what it was more than a century ago-that is, a profession concerned principally with the most severe forms of mental illness.” I don’t really see that as happening, and I am personally not sure it’s the best solution either. The Pandora’s box has been opened, and I fear it won’t close. I do agree with you, though, that we need much more honesty and psychiatry needs to become genuinely pluralistic in its framework. I would like to think that if we could usher in an era of pluralism, that might temper some of the profession’s worst instincts.

Harrington: I am a deep believer in pluralism, too, but I believe that a road to true pluralism will require the courage to share power. In other words, alongside becoming less reductionist, the field also could consider becoming less hegemonic. And by that I simply mean that more efforts could be made to flatten hierarchies, lift all boats, cooperate across professions and disciplines, and acknowledge the expertise of many. Psychiatry is a branch of medicine and, as such, its purview should be generous but not all-inclusive. So, I have suggested that the field would be stronger and serve patients better if it functioned as one part-the medical part-of a cooperative ecosystem of mental health experts.

Aftab: Any words of advice for psychiatry trainees and young psychiatrists?

Harrington: My answer might surprise you, but it is an answer that you might expect from an historian rather than a clinician! It is to try sometimes to read the literature, including textbooks, against the grain. That is to say, do not just read to absorb the information being offered, but look also for possible gaps, contradictions, or incidental references to factors or issues that are not pursued, and then ask why not. This comes back to the point I made earlier: with every new chapter in the field, there is a risk that we don’t just become smarter, but also more ignorant. Reading against the grain can be a very effective way for every field-not just psychiatry-to better recognize its implicit biases and blind spots.

Aftab: Thank you!

Dr Aftab is a geriatric psychiatry fellow at University of California San Diego in La Jolla, CA, and he has been actively involved in initiatives to educate psychiatrists and trainees on the intersection of philosophy and psychiatry. He is also a member of the Psychiatric Times Advisory Board. He can be reached at awaisaftab@gmail.com.

Conversations in Critical Psychiatry is an interview series aimed to engage prominent individuals who have made meaningful criticisms of psychiatry and have offered constructive alternative perspectives to the current status quo. It is Dr Aftab’s hope that these discussions will stimulate a much-needed debate in the psychiatric community.

The opinions expressed in the interviews are those of the participants and do not necessarily reflect the opinions of Psychiatric Times.

Disclosures:

Dr Aftab and Dr Harrington have no relevant financial disclosures or conflicts of interest to report.

References:

1. Ellenberger HF. The Discovery of the Unconscious: The History and Evolution of Dynamic Psychiatry. New York: Basic Books; 1970.

2. Hacking I. The Looping Effect of Human Kinds. In: Sperber D, Premack D, and Premack AJ, eds. Causal Cognition: A Multidisciplinary Debate. Oxford: Clarendon Press; 1995.

3. Hacking I. The Social Construction of What? Harvard University Press; 1999.

4. Belluck P, Carey B. Psychiatry’s guide is out of touch with science, experts say. New York Times. May 6, 2013. http://www.nytimes.com/2013/05/07/health/psychiatrysnew-guide-falls-short-experts-say.html. Accessed June 1, 2019.

This article was posted online ahead of print on June 27, 2019, with the title The Structure of Psychiatric Revolutions, and has since been updated. -Ed