"Where there is no gift, there is no art, then it may be possible to destroy a work of art by converting it in a pure commodity. Such, at any rate, is my position. I do not maintain that art cannot be bought and sold; I do maintain that the gift portion of the work places a constraint upon our merchandising.” Lewis Hyde, The Gift (1979)
Los Angeles, January 2012. Allan is a new patient at our outpatient clinic. In the space of a month he has lost his job, his health insurance, and after a fight with his wife, his home. He is 32 and is suffering from, he explains, “PTSD, bipolar disorder and ADHD”. He wants me to renew the medications he has been taking for the last few years: a mood stabilizer, an antidepressant, two antipsychotics and one tranquilizer.
Option 1: He signs the papers authorizing me to treat him; I quickly read the medical and psychological questionnaire completed by the admissions social worker; I check the absence of major psychiatric symptoms or worrisome side effects; I renew the prescriptions given by my previous colleagues, preferably for three months, and document the visit in my computer. The procedure takes fifteen or 20 minutes; the patient gets what he wants and the administrator is satisfied. All is for the best in the best of all possible worlds in the land of managed care.
Option 2: I try to get a sense of who he is. I explore his history, symptoms, treatments and responses. I discuss medication and the risks and consequences of hasty and simplistic diagnoses and their pharmacological corollaries. The patient is initially surprised and worried that "I would refuse to prescribe”, but then he relaxes. He talks about his "legal" use of cannabis. I ask him what he really wants and where he sees himself in five years. I clarify the difference between bipolar and borderline diagnoses, and their respective treatments. At the same time, I give him the address of a website run by patients. I tell him about our support groups for trauma victims. With his consent, I contact the social worker in charge of emergency shelters and the staff responsible for Narcotics Anonymous. At the end of the consultation the patient says that, in fact, he doesn’t take his medication regularly. Together, we discuss a treatment plan (that he signs) and the part he is supposed to play in it. He thanks me with enthusiasm, explains in detail the medication that he is “really taking” and asks if he can see me in two weeks. The entire encounter takes less than 45 minutes.
I watch him leave, thinking about the psychoanalyst’s neutrality, about so many psychiatric patients in jail and in the streets, about Jack Nicholson in One Flew Over the Cuckoo's Nest, about the role of the psychiatrist in a team, about the changes in cultures and practices...
I think of my last twenty years of practice . . .
Belgium, 1992. I complete my psychiatric residency. Five years of training gives me, among other things, a good psychodynamic foundation and an exposure to a range of psychiatric medications, including the newest ones being touted as, ironically, both scientific and miraculous. In my heart there is an eagerness to learn more, a penchant towards borderline pathology and a desire to relieve souls in suffering.
Since then I have journeyed through very different places: from hospitals and private practice in the European system of universal healthcare (albeit only for its citizens), to the streets, prisons, outpatient services and psychiatric emergency rooms of Los Angeles, a multicultural jungle, and a place where extremes either collide or else ignore each other completely.
Although I was a young psychiatrist convinced of the effectiveness of psychotherapy, there was definitely something thrilling in the ‘Decade of the Brain’ and its ’intelligent molecules’, which were presented as having no serious side effects. Not only would they be a cure for debilitating chronic illnesses but the molecules themselves (or the imbalance thereof) would be the long-awaited scientific explanation of mental illness itself. Suddenly, my new profession, whose ethics were so often questioned (remember the Gulag and lobotomies) and challenged as to its ‘real’ scientific value (Popper and psychoanalysis), acquires the seal of scientific respectability.
Almost overnight, the psychiatrist-prescriber becomes the expert of the new sciences of chemical imbalance, methodical classifications of illnesses and evidence-based treatment. The new science of human consciousness has arrived, a modern discipline where pesky existential questions seem obsolete. In the euphoria of the late twentieth century, pharmaceutical companies and psychiatrists discover one another and embark on a risky love affair. Lavish international conferences are organized during which prestigious panels of experts attempt to give concrete meaning to the inexplicable and in doing so propel the exponential expansion of the market base of the drug industry.
Clinicians (of which I am one) and academics, in a surprising moment of "méconnaissance intéressée” in the words of Derrida, do not seem (or want) to be aware of the potential conflicts of interest in this thrilling adventure. Very quickly, both international psychiatric research and physician’s education become more and more dependent on money from pharmaceutical lobbies.
In medical school, psychotherapy starts to look outmoded. Young doctors are amazed (and perhaps reassured) by the molecular and genetic versions of human passions, and build themselves a new identity, that of the psycho-pharmacologist. The psychosocial model in force in the mental health community no longer seems to apply to a ‘modern’ psychiatry. In libraries, Freud and Frankl are taken off the medicine shelves and end up in the literature department with Albert Camus and Jean Paul Sartre.
At the same time, other voices are speaking up – those of the mental health patients themselves and their families. As part of the wave of civil rights movements that were rushing through America in the 1960s and ‘70s, patients and former patients, some calling themselves "Survivors of Psychiatry", demand an active role in their own care. “Nothing about us without us", is their war chant. Under their influence, terminology changes, too. The word ‘patient’, with its implication of suffering and passivity gives way to ‘users’, ‘clients’, and ’consumers’ in keeping with the more active participation of a patient in his or her own treatment. Importantly, this new terminology is also more in sync with a capitalist world where ‘care’ becomes more than ever an object of consumption with profit its underlying goal.
It is into these turbulent waters that I dove when, in 1999, I came to the United States to continue my interest in borderline personality disorders (BPD). Curiously, in these times of medical exhilaration, this group of patients seems to balk at any reductionist classification. BPD doesn’t respond to the “pill-to-heal-everything” approach. BPD patients’ long resistance to both psychiatric and psychoanalytic treatment has earned them a history of rejection and disqualification, the alleged reason being that these patients are difficult, manipulative, or worse, not really sick. It appeared as if only a categorical diagnosis or a treatment validated by modern science could bestow on these sufferers the seal of authenticity.
In my new American reality, I am on the frontlines observing how theoretical, political and social contexts can affect the expression or the occurrence of a symptom, its recognition and what we choose to do (or not do) about it. With BPD patients in particular, the fact that there is no pill to treat them encourages some ER staff members to discharge them swiftly without really addressing their issues. Verbal complaints and “scratches” that may lead to necessary treatment in my previous home of Belgium will generally bring disdain in a US emergency room, where much deeper self-mutilations is required in order to hold the patient long enough to initiate therapeutic engagement . So, the self-inflicted wounds of Otto Kernberg’s and Marsha Linehan’s patients in the US somehow appear more threatening and bloodier than the ones I observed in my small European country. It seems necessary to shout louder in the US in order to have our healthcare system decide finally to take care of you.
Social and political contexts also influence the writing of a prescription. An antipsychotic medication identified as “very safe” in Belgium, might suddenly bring a lawsuit in the United States, due to the fact that a rare side-effect is emphasized in a ‘Black Book’, a tome sold primarily to lawyers.
During my second residency, I was lucky enough to be trained in cognitive and behavioral therapies (CBT). Contrary to the naïve and/or arrogant belief of the psychoanalytical circles in which I did my original training, I realized how well these techniques can work and how easily teachable they are. I have been impressed by the willingness of practitioners of cognitive therapy to prove the effectiveness of their methods, thus gaining ‘scientific’ legitimacy and resulting financial reimbursement.
Forced to question my theories and techniques, I discovered research that suggests that, for a majority of conditions treated in psychotherapy, all the major modes of psychological treatment produce similar outcomes . In fact, this research suggests that only 8% of the variance is due to the type of therapeutic technique, while 70% is due to the overall effect of treatment itself, such as the factors of empathy, a good working relationship between the therapist and his or her client etc. The residual 22% of the variance remains unexplained.
Fascinated by these oddly un-‘modern’ results, I felt reassured in my belief that the individual caregiver’s role is central to the therapeutic process. After all, isn’t modern psychiatry but a new iteration of the age-old combination of witches and wardens?
While the paths of neuroscience and psychology may seem to diverge, an expert interested in both disciplines, Eric Kandel, is trying to force a dialogue between them. In the early 2000s, armed with his recent Nobel Prize for research in neuroplasticity, he proposed a “biological” legitimacy to psychotherapeutic techniques . He has helped us to understand how environment affects the development of our brains as much or more than a chemical molecule does.
If only something biological gives legitimacy to a ‘modern’ treatment, then we must recognize that the interaction between two human beings is also a biological treatment , because it affects our brain’s function and development. For example, the environment may affect the way our genome is translated into proteins, building blocks of cellular receptors essential to our learning mechanisms .
Along this line, researchers have started studying the interactions between the modalities of attachment and molecular genetics , and a new Society of Neuro-psychoanalysis has been created. In borderline patients, neuro-imaging studies have discovered abnormalities specific to their struggles . This is apparently what is needed for science to finally recognize them as real patients.
In November 2004, given the disastrous build-up in the streets and prisons of patients with serious psychiatric problems and the financial and human cost that accompanied it, California voters approved a new tax for millionaires. The money is to develop ambulatory programs for these ‘consumers’ left out of the American dream. As a newly appointed UCLA professor, I was hired to be part of one of these multidisciplinary teams, whose motto is "Whatever it takes”.
Far from plush psychiatric couches and magical pill factories, I abruptly dive into the belly of a modern city. Not far from the dazzle of the Walt Disney Concert Hall, I discover a world of misery where drugs and violence reverberate with the hallucinations and melancholy of over 50,000 wandering homeless souls – a barbaric world in the midst of the country of the Aristocats, so celebrated for its technological miracles and neuroscientific research.
The first goal of our team (four social workers, two nurses and one psychiatrist per 100 patients) is to “engage” people identified as suffering from, among other ailments and social problems, major psychiatric disorders for which to date, “nothing had worked”. These are people who had been what we call “frequent fliers”, who cycle in and out of emergency rooms, jails and homeless shelters. Our fundamental rule is to meet them "wherever they are”, literally and figuratively. For example, we try to provide shelter and clothing before trying to sell the benefits of an intramuscular injection that they might have been refusing for years. The program’s goals were defined through scores of meetings with patients, their families and the many political and social groups that reflected the diversity of citizens of Los Angeles.
Our objective is to give to these individuals not only a proper treatment but a dignity as well. We aimed to give them an active role in society and perhaps even a job within a couple of years, which seemed extravagant to me at first. We don’t force the patient in these directions; he or she has to agree to all the aspects of his or her treatment. They are in control. One of our huge advantages is the relative lack of time constraints for our work, and a budget that can cover the costs of housing, clothes, a meal at a fast food restaurant or dental expenses. The undertaking is complex and the results have been sometimes successful, sometimes not.
One memorable example is that of Leonora, 45 and originally from Kenya. She is strong, intelligent and most often in a good mood. During the seven years since her immigration to the United States, she has worked as a nurse attendant. Six months ago, she walked off her job, confiding to a colleague that she had been contacted by an important man for an extraordinary mission. Without an income she soon ended up homeless and eventually in prison for having assaulted a police officer who tried to dislodge her from a street corner where she had been living. When she told the sergeant that for five years, she’d been carrying the six children of a “healer” in her womb, he wanted to take her to the psychiatric emergency room, but she fought back, denying she had a mental illness and demanded to be treated like any other American citizen. She was remanded in custody where a psychologist classified her as schizophrenic and a judge referred her to our service.
When I meet with Leonora for the first time, it is behind bars. After a long negotiation, Leonora accepts our team’s help, which is also her ‘get-out-of-jail-free’ ticket, but she makes the demand that she not be forced to take medications. Of necessity, we agree, and rapidly find her a board and care facility. Before long, she gets back her dignity, femininity and creativity. She sews an African tunic from a discarded piece of fabric, and her colorful pieces of jewelry become the pride of the occupational therapy department of the board and care. In order not to endanger her pregnancy, she refuses heavy work and all medications. The gynecological examination doesn’t detect any fetuses, but Leonora does not believe in American science. She is clearly engaged with us, always greets me with a smile and we have long chats about her family, about Africa, and about the difficulties of immigration. When I gently confront her with the fact that her husband, the healer, doesn’t seem to be showing us any signs of life, she either bursts out laughing or gets angry at my ignorance of sacred things. At times, her anger is so threatening the board and care sends her to the emergency room, where she is confined to the hospital.
Usually, her charm and negotiating skills quickly convince the representative of the court of the unfairness of her internment and she is released to her board and care. But a problem arises unexpectedly. In order to continue to benefit from her therapeutic housing, Leonora must agree to take a psychotropic medication. Leonora, by her own logic, refuses to swallow a molecule that could hurt her babies and she is eventually kicked out of the board and care. Without work or money, she soon goes back to the sidewalks. For several months we meet her in the street at places that she determines. One day she is not there.
Fifty years after Michel Foucault , we are far away from the era of "the great confinement." US capacity for inpatient psychiatric services has declined dramatically since 1965, from approximately 500,000 to less than 50,000. Since 1995, California alone has lost 40 psychiatric wards or hospitals, representing nearly a 22% drop. Experts estimate a need for a minimum of 50 public psychiatric hospital beds for every 100,000 people. In 2010, California had 17 psychiatric inpatient beds for every 100,000 residents .
Private inpatient psychiatric capacity held relatively stable during the early 1990s but has declined sharply as insurance reimbursement levels have shrunk. Although some would argue that psychiatric services are still profitable for hospitals, they are usually less profitable than other inpatient services such as general medicine and surgery. One of the consequences of the lack of resources and poor reimbursement is that in the last few decades the average length of stay has gone from 421 days to just four or five. In this context, “hospital treatment" can be considered an oxymoron. Whereas an “acute day” (defined as a patient presenting behavior either self-destructive or aggressive to others) is reimbursed at approximately $900 per day for a hospital stay, an “administrative day” pulls in more like $200. Therefore, as soon as a patient is “calmed down” through the use of “meds”, psychiatrists are pressured to discharge them as quickly as possible because the reimbursement level has plummeted. Note that the label of “acute day” is justified typically by “behaviors” either self-destructive or aggressive to others, whereas intense internal suffering without outrageous “acting out” does not justify adequate reimbursement for inpatient care.
The situation is even worse in emergency rooms where psychiatrists are caught between law enforcement officers who pour a steady stream of social despair and agitation into the ER, and management, who are concerned mostly about cost and liability linked to emergency room overcrowding. Under constant pressure, psychiatrists are given the mandate of kicking out sub-acute ‘consumers’ as swiftly as possible without really being given the time or means to provide proper treatment. A drugged-into-submission patient is still sick, but he must be discharged. The catch-22 for the psychiatrist is that if a patient kills him or herself, or hurts somebody else after being released too quickly, it is the physician signing the chart who will be the one held accountable. Being responsible with neither the authority nor the means (time, space, personnel) to function properly, is a recipe for disaster and burnout. From “agents of confinement”, psychiatrists have now been given the thankless and dehumanizing role of hospital bouncer.
Compassion and finesse are no longer necessary; actually they are contraindicated for the job. For staff to feel better about their new inhumanity, it is the patients who are blamed – called malingers, drug addicts, or “a bunch of bums who need to grow up!” "After all, it's their choice!” is a classic line of the overwhelmed emergency room staffer, be it nurse, nurse attendant, social worker or psychiatrist. Shifting from the frame of mind of triage (the process of determining the priority of patients' treatments) to one of moral judgment may be one of the only ways for the caregiver-bouncer to avoid the crushing feelings of guilt and helplessness experienced from kicking out these patients. How else can we feel when, without resources and treatment facilities to which to refer these patients, our only ways of helping, besides providing mostly unwelcomed medications, are to dole out bus tokens and a list of shelter and outpatient clinic phone numbers to patients who have no home and no phone?
In California, it is the court, not the psychiatrist who has the authority to impose an involuntary hospitalization or a pharmacological treatment without the patient’s consent. This has changed due to growing patients’ rights advocacy. A decision to keep a patient longer than three days against his or her will is made by a representative of the court who comes to the hospital to meet with the patient, his or her advocate, and the psychiatrist. It is justified only in the case of imminent danger to the patient themselves, society and/or a total inability of the patient to “take care of him or herself”.
In this context, modern-day psychiatrists are left without the original framework of their profession, which was developed in the structure of an asylum or hospital. By removing both the ability and responsibility related to involuntary treatment, society has transformed the doctor’s working conditions without necessarily preparing him or her for the change. Psychiatric residents are trained in the hyper-technical compartmentalization of symptoms and their correlative pharmacological solutions, but the practitioner is no longer taught tools (therapy, ethics, etc.) to confront the complexities of the human condition in a more sophisticated way. Today, in most medical schools, residents are still fed theories relating to chemical imbalances of the brain long after this model has been demonstrated as incorrect . Psychiatric residents are generally taught that schizophrenia, for example, is an incurable disease for which medication will be required until the patient’s last breath, even though multiple studies have shown that at least 30% of patients labeled schizophrenic will eventually have a pill-free, ‘normal’ life . Another matter not addressed in medical school is the myth that patients do what physicians ask and will tell us honestly what they have done. In fact less than 25% of patients take their medications as prescribed.
Once in the field, if a young psychiatrist has the courage to keep his or her eyes open, he or she realizes that the world of mental illness is, for the most part, unclassifiable, unpredictable and much more difficult to treat than it is in an article in The New England Journal of Medicine.
September 2007, South Central Los Angeles, a place where gangs are the law. A social worker and I, both of us Caucasian and somewhat nervous, park our car near the fence of a gloomy looking two-story building. In the common area of a filthy rooming house lounge a dozen predominantly African-American men, in transition from the streets, prison, drug rehabilitation facilities and hospitals. The place does not meet the legal criteria for a licensed halfway house, hence the palpable chaos, but it accepts people who no one else accepts: arsonists, sex offenders and patients rejected by licensed board and cares. On the ground floor, a surly giant of a man is preparing a huge pot of potatoes. He constitutes the staff. On the second floor, curled up in a half-empty room, our new patient, Daniel, looks at us with suspicion. We know from the referral papers that he had worked for five years as a mailman until, in 2003, a bout of paranoid psychosis cost him his job, housing, and after using methamphetamine, his freedom. When he sees us, he shouts with a threatening voice that he is not sick and that he does not want social services. From a safe distance, we offer our help. Better housing? Clean clothes? After a few minutes, he asks us to leave, but agrees to a future visit.
It takes many months, but gradually we get to know one another and Daniel finally accepts housing, a parka, therapy and, later, four milligrams of risperidone. Gradually, he is “himself” again, gets off of hard drugs and, after two years is able and willing to go back to school. In October 2011, he received a degree as a pharmacy technician and he is now looking for work. He is not really convinced of his diagnosis of schizophrenia. Recently, negotiating a decrease of his antipsychotic medication, Daniel told me that his "paranoia" was probably due to his use of methamphetamines. He added that the day we first met him, he, a member of the Bloods gang, had been housed in the middle of Crips territory, the enemy gang. With good reason he feared for his life, and was furious at the decision of social workers from the unit where he was briefly hospitalized, to “dump him there”. He added with a smile that at that time, he thought that we were just plain stupid. As to his urgent request to decrease his medication, which certainly has some basis (was his paranoia solely drug- and circumstance-induced?), I am hesitant. We decide to lower the risperidone. How far shall we lower it? What will be the outcome? We will have to wait and see. As Daniel says on leaving my office, "after all Doc, this is MY life".
During my six years in the trenches, I discovered the incredible resilience of some patients previously branded as difficult, and their surprising outcomes due to (but sometimes in spite of) our treatment. I have worked side by side with other mental health workers, who have shared their enthusiasm, compassion, time, and often some their own money. I have been moved by the kindness of several sheriffs and by the genuine love that some board and care owners have given to these lost strangers. But I have also observed all too often the bleak mantle of indifference under which it seems so easy to hide those for whom we assume there is nothing we can do.
Daniel, Leonora and many other patients have forced me to question and sometimes to set aside some of the knowledge upon which I built my identity as a therapist and psychiatrist. Working 24/7 to help patients stay in the community (and not in institutions) when some of them are often on the verge of an act of violence against themselves or others, is exhausting – especially when done without the support provided by the structure and staff of an inpatient unit. In moments of powerlessness and fear, and at times against a background of absurdity, I read Viktor Frankl and Donald Winnicott. I am looking for comfort in the Consolation of Philosophy and in the idea of "radical acceptance" so important in dialectical behavior therapy. I am dismayed by the lies, excesses and costs of the unhealthy collusion between the world of academic medicine and the pharmaceuticals lobbies . I worry just as much about the resulting loss of credibility that risks eroding trust in our profession and the fact that patients may no longer be willing to use medications that could change, or even save their lives17. The possible swing of the pendulum against medication may not necessarily bring a better balance.
In the media recently, two healthcare professionals have added an inspiring perspective to the field by coming out of the closet of shameful psychiatric labels and sharing the lessons of their own descent into the hell of mental illness. Elyn Saks, Professor of Law and Psychiatry at the University of Southern California (USC) outlines, in a remarkable book, the story of her daily struggle with schizophrenia . She stresses the importance of a judicious combination, at least for her, of psychoanalysis and drug therapy. She describes the horror of psychiatric detention, the torment of the side-effects of drugs that were given against her will, the black hole of psychosis, and the despair. But she also reminds us that “we who struggle with these disorders can lead full, happy, productive lives, if we have the right resources” . Similarly, in June 2011, in order to give hope to patients who have lost it, Marsha Linehan shared her own story in a moving New York Times interview. She describes her own struggle with mental illness and psychiatry, and the vagaries of the long road traveled between an erroneous diagnosis of schizophrenia and becoming the originator of dialectical behavioral therapy , one of the most effective treatment methods for borderline personality disorders.
To add to my internal wonder, a close friend has described to me recently how switching to gluten-free diet has interrupted a cycle of psychosis for which he could have been lobotomized fifty years ago . Clearly we do not have to listen very hard to realize the limits of our knowledge.
Faced with the blinders-off reality of daily fieldwork, I have to give up the belief that 'scientific' theories are all-powerful. They are, after all, no more than science’s translations of current social beliefs – sometimes very useful, but never really comprehensive or exact.
That said, getting rid of psychiatry, and closing psychiatric hospitals, will not eliminate mental illness. The steady increase of the mentally ill homeless and incarcerated is a daily reminder of the limits of the anti-psychiatry discourse. The recovery model has given hope to many in the mental health field, so we do not like to be reminded of those who suffer in places we cannot see them or help them. What about the many patients suffering from the devastating consequences of brain damage from head injuries, or chronic drug and alcohol use, or early dementia, who are warehoused in the few remaining state hospitals because they are too sick to live independently or stay with their families? Many of these facilities are unprepared, unequipped and underfunded for such care.
A colleague of mine has described these extremely sick patients as “at times so severely disturbed that they lick the walls and floor, or compulsively flip light switches up and down to the point that they develop blisters or the like”. How will our society provide real asylum to these people who have been sacrificed upon the altar of patients’ rights and budget cuts, and who have no real hope for a better future or miraculous treatment. How can we re-think psychiatry?
A Postmodern Psychiatry
Philosophically, I struggle to make sense of the challenges that my profession confronts me with every day – by witnessing the almost unbearable moral and physical misery of our fellow human beings, and our inability to change a non-working system. But, I am also confronted with the miracle of daily acts of kindness. Turning to a phenomenological approach, I try to find sense and strength in the thoughts offered by Emmanuel Levinas (1906-1995), a Lithuanian-born philosopher who was influenced by the work of Heidegger as well as by his own experience in Nazi concentration camps. At the core of Levinas's philosophy are his descriptions of the encounter with another person: the face-to-face relationship. The fundamental intuition of Levinas's philosophy is the non-reciprocal relation of responsibility. We do not choose to be responsible. Responsibility arises before we begin to think about it, by the approach of the other person. For Levinas, the irreducible relation of the face-to-face, the encounter with another, is a privileged phenomenon in which the other person's proximity and distance are both strongly felt. Looking at the other’s face is to be confronted with the idea of infinity, that is to say having the thought of what we cannot think of, having the idea of the limitation of what we can know. Staring at someone (“devisager” in French, literally "de-facing" someone, or staring) is, for Levinas, to annihilate a person’s face by reducing it to a set of material qualities (a shape, a color etc). This reductionist way of viewing the other can be found for instance in some well-intentioned charitable/paternalistic ways of reducing the other to a caricature and taking away from them the depth of their reality as full human being. This reductionist approach gives the other the identity we label him/her with (“homeless”, “schizophrenic”, “gay”). By distancing us from the other – by reducing others to what we imagine about them – such "charity" makes us feel better. But on the other hand, “the ethical relationship – the encounter with the abyss of what we cannot know or do – overwhelms us”.
It may be to avoid being overwhelmed that society, through psychiatry among other systems, catalogs fellow human beings into rigid categories, leading to our limited number of “evidence-based treatments”. If these treatments do not work, the patient, more often than the treatment, is questioned. The patient is consequently described as “resistant”, “non-adherent”, “difficult” or “not engaged in his or her recovery process”.
Humility is not a core attribute of western science, which sometimes has the tendency to blame whatever it cannot control or understand, rather than questioning its own limitations. The current need to attach a scientifically-correct (in the sense of politically-correct) account to every emotional/psychiatric suffering dehumanizes the discipline itself. An illustration of this danger is what has happened as the narrative of the cause of mental illness has changed from something psycho-social in origin to its becoming a “brain disease”. The original idea was that a scientific explanation would lower the stigma of a psychiatric disorder. Research suggests, however, that this charitable attitude (think again of Levinas) causes the opposite of the expected effect. We tend, in fact, to treat the sufferer more harshly when his or her problem is described in the new terminology of "disease", almost as if these biological abnormalities make the sufferer belong to another species.
Two British colleagues offer an alternative to this Enlightenment belief in the omnipotence of science, which modern psychiatry and some psycho-social schools of thought have pushed to the extreme. They present a "Postmodern Psychiatry" – not as a rejection of theoretical approaches, but as a way to question the claim of total and universally valid knowledge. They are inspired by the proposal of Gilles Deleuze who defines a theory as one element in a toolbox. In this box, it is urgent to re-introduce the tools of ethical, philosophical and relational thinking; concepts that have been prematurely removed from medical school coursework.
Rethinking psychiatry must entail a greater understanding of the character of the “healer” as well as identifying the human qualities that make a good therapist (shaman, healer or psychiatrist) regardless of the theories he or she is using. What qualities can best transform the person seeking help? Let us recall Wampold’s research: 70% of the overall effect of psychotherapy seems related to factors such as the degree of collaboration and trust between patient and therapist (therapeutic alliance), empathy, etc. rather than to the technique or theory employed. We must therefore identify and preserve these qualities that are so necessary for the effective exercise of our mental health professions, such as the effort to be fully present with the other without memory or desire (as explored by Wilfred Bion ) and the possibility of an encounter à la Levinas. Psychoanalysis, perhaps more than any other western technique, has ventured into the observation of the inter-relational process, both conscious and non-conscious. But how to quantify the alpha function defined by Bion ? How can we measure love or hatred in counter-transference?
We cannot “guideline” our imagination or the free associations which are at work behind an interpretation that we share with a patient. How can we predetermine the exact moment to say something? We cannot write a manual for the creativity required to come up with an enlightening metaphor or for when and how to change the intensity of our glance. Without enough time to get to know the other, to hear the melody of our communications or to understand the expression of the elements unique to a human-to-human encounter such as inspiration and generosity, we risk losing the essential ingredients of our profession which foster new emotional learning.
Unfortunately, mental healthcare is evolving quickly in the opposite direction. It gets more and more defined by guidelines and manuals, evidence-based techniques and computerization. The risk is the transformation from a supportive structure into evidence-based straightjacket.
The challenge is to embrace progress without becoming its brainless and heartless devotee. One of the new directions is the development of tele-psychiatry, a term that at first seemed paradoxical to me because of my humanistic approach to psychiatry. How to convey the warmth and intimacy necessary to build a trustful environment through a webcam and computer screen? But our human species has amazing ways of adapting, and if not everybody is convinced by this computerized relationship, this fast growing practice is welcomed by geographically isolated populations and by patients who would otherwise never seek help in a clinic for crazy people.
But the advances and challenges of our 21st century do not stop at tele-psychiatry. In 2011, researchers at USC’s Institute for Creative Technologies (ICT) , New York-Presbyterian Hospital/Weill Cornell Medical Center and the Emory University School of Medicine were awarded an $11 million, four-year grant from the US Department of Defense to test different ways to treat post-traumatic stress disorder (PTSD), including the use of “virtual-reality exposure therapy”. “Virtual-reality exposure therapy” uses three-dimensional graphics (with the support of goggles and earphones) to gradually immerse the patient into digital scenes simulating the traumatic or phobia-inducing event. Similar technology is also developing avatars or virtual mentalhealth agents, so that a soldier, for example, who is reluctant to share his or her vulnerability to a real human therapist, instead is offered a computer-generated counselor who can receive confidences and provide basic advice anonymously.
Don’t get me wrong. Despite my humanistic tendencies, I heartily embrace certain appropriate tools of science. I imagine that the vision of goggles and earphones in a therapist’s office may raise eyebrows, but in an attempt to integrate modernism and tradition, let’s try to put this idea in a 21st century context. For certain types of phobias or traumatic memories, the idea of "re-programming” our brain through virtual simulation makes sense. Neuroscientific research recently provided us with ways to understand how some therapeutic practices may be successful in changing the way we are thinking or remembering. Each time we bring to consciousness the memory of a particular situation, we activate a complex network of neuronal connections. Within this new context (determined by where we are, who we are talking to and our new physiological state, etc.) we can re-record the old memories that are now associated with a new array of neuronal connections created by this new context (and which importantly are lacking other, perhaps more traumatic ones). The brain now has a new updated recording of the initial event, changed by the new symbolic and emotional associations, conscious and non-conscious, that we just experienced. Researchers suggest that it is possible that this process creates not an additional memory, but a singular brand new one whose biological trace has replaced the old one. An obvious limitation of the technological exploitation of this hypothesis is that, even with extremely advanced machinery, there is an infinite gap between the way we can recreate a virtual representation of an “event” and a human-to-human experience.
In any case, we can imagine how this type of technology might be offered sooner than later by our health organisations for legitimate reasons (easy access) or to save money on salaries.
Our society has to be cautious and thoughtful about the direction of the future of mental healthcare. Those who – in the name or under cover of science – decide to embrace indiscriminately every new mental health technique with the same enthusiasm they clung to a belief in chemical imbalances need to be aware that doing so may risk losing the essential human component in psychiatry. Even if Deep Blue has finally prevailed over Kasparov, it is not tomorrow that an avatar with a tender heart will linger after its shift is over to hold the hand of a dying man.
Technology has taken over our lives to the extent that it has to make me wonder: are we really irreplaceable? How can I control my anxiety? Take a pill? Identify and alter dysfunctional cognitions? Undertake a virtual reality assessment? Or simply check my new smart phone app?
I need to talk to someone! And I’m probably not the only one. ≈©
This article is available as a Wild Culture Press Kindle ebook, Rethinking Psychiatry: From Locked in to Locked Out. The ebook edition includes responses to Bernadette's original piece (first published in The Journal of Wild Culture on January 3, 2014, from a range of professional experts, kickstarting a timely debate about the very nature of psychiatry.
DR. BERNADETTE GROSJEAN is a native of Belgium, where she received her M.D. and her first psychiatric training (1992). After a visiting fellowship at Cornell in 1997 with Professor Otto Kernberg, world expert in the field of borderline personality disorder (BDP), she made the decision to re-train in psychiatry in the United States (2001-2005). She is now Associate professor of Psychiatry at Geffen School of Medicine at UCLA. www.bgrosjean.com
All images by Alex Widdowson. alexwiddowson.tumblr.com
A sobering look at our field over 20 years. For me, going back 40 years, would just add to decline, I'm afraid.
Indeed, the relationship and engagement can still be the key. For me, Martin Buber is my Levitas. The "I-Thou" relationship then becomes holy.
Hi Dr. Grosjean,
I am a PGY-3 psychiatry resident in Florida, and I felt your article was very pertinent to my experience so far in psychiatry. I am training in an era where residents have an added undiscussed job of making revenue in order to prevent loss of residency positions given the upcoming funding cuts for residency training, and I feel that I constantly struggle with taking the easy route and refilling scripts or really figuring out what I can do to help patients achieve their own goals instead of mine. At our program, every patient seen by a trainee must also be seen by an attending during the visit, so it is often very difficult to fit everything into our time slot, but your article encouraged me to at least consider spending a few extra moments on their goals for recovery. I also thought your discussion about how inpatient psychiatry has drastically changed as I constantly struggle with how my role can really assist those in recovery versus just meeting the demands of insurance companies. Thanks so much for sending this out, I forwarded it along to several of my fellow residents as well!
Thanks Bernadette, I appreciate your article I think the importance of the therapeutic relationship has been relagated to a second class role to symptom criteria, medication management and evidence based practices. We hear talk about maintaining "fidelity to the model of evidence based practices." What about fidelity to the client and their goals and recovery, fidelity to the therapeutic relationship? What if in a given moment the most helpful interaction a client could benefit from is silence in the presence of their clinician, or some brief eye contact and an encouraging smile. As far as I know these are not evidence based practices and like you say, neither is their timing. I agree that new technologies will eventually help save money and help certain clients. I hope we don't lose something essential.
Wonderful article that put into words in a very eloquent manner a number of different thoughts and impressions about our mental health system in United States. This is the third system that I am working in after being trained in India, then retraining in England and coming over to US.
I traverse the biological and Psychosocial spectrum being a trained psychiatrist and certified cognitive therapist with particular interest in the most seriously ill.
This perhaps is the most broken system and needs a lot of people ( critical mass) with your kind of thinking to bring about a change at the highest level. Psychiatrist should be more than a medical doctor to be able to use oneself as the therapeutic agent as much as or if not more than using agents such as medication. Psychiatrist should be more than a family member or a friend in being able to provide the safety of therapeutic encounter to let the patients most difficult to express thoughts and beliefs to spring forth. In the process a Psychiatrist should consider oneself to be previleged that a patient is allowing them to visit the deep recesses of their psyche and experience their humanity from psychologically close proximity. They are allowed into those recesses of their mind that they did not allow anyone before.
However to build this type pf relationship requires time, patience and is not going to be done in a short time. This is where the system fails us all time and again. It is so rare for us to work in a system such as Assertive community treatment teams where you have the luxury of seeing a patient as often as needed for as long as needed. These kind of programs are like oases in a desert of fragment, dehumanized care where the needs of system are more paranount than the reason why the system exits in first place.
Thanks again for your thoughts and hope to see more of your thoughts and observations.
Narsimha R Pinninti
Professor of Psychiatry, UMDNJ-SOM
We all know technology always upgrades through years, months, weeks or even in a single day. I also definitely agree that with technology it will not only save money but will also save lives of many people. Love, trust and care are also one of the best ways to save this problem, but when the case is about drug abuse/alcohol abuse, there are places or treatment centers like drug rehabilitation, alcohol rehabilitation and even intervention that will surely help. Don't you agree that this is fair enough to help those people who need treatment?