Some decades
ago, we all knew what psychiatry was: it was ‘medicalized’ psychoanalysis. The discipline of psychiatry had excellent
reasons for tethering itself to psychoanalysis. Surely any branch of medicine had to have its own distinctive
domain. After psychoanalysis had
identified its domain as the Unhealthy Unconscious, what remained left for
psychiatry but to define itself as the treatment of the unhealthy
unconscious? Furthermore, the tethering
of psychiatry to psychoanalysis permitted patients — or certain classes of
patients – to be treated in a psychiatrist’s office, without having to visit
disturbed inmates in asylums. Treatment
was a matter of building a personal relationship with a patient who paid for services
just as a victim of high blood pressure or diabetes paid for services.

Equally
valuable, the psychoanalytic conception of psychiatry promised an account of
therapeutic healing. Healing could be
understood as the psychoanalytically guided illumination, management and
control of unconscious forces – repression, Oedipal complexes, and so on.

Psychoanalysis
failed. There were different reasons
for failure – the inability to treat severe psychoses, the absence of
determinate diagnoses, the incapacity to integrate with powerful and fertile results
in neuroscience. But the conception of
psychiatry as psychoanalysis lingered for a time after the failure of
psychoanalysis because psychiatric medicine lacked a comparably compelling
alternative approach. It seemed best to
stick with psychoanalysis even though it had come apart. It appeared humane and compassionate and
admirably tried to empower patients in their own care. But, alas, a crisis in psychiatry now has
ensued.

Thus
begins this multiply titled book.

Hobson is a professor of
psychiatry at Harvard and perhaps best known for his work on the neurochemistry
of dreams. Leonard is a freelance
medical writer and Harvard graduate.
Together they then lead the reader rather quickly to the proposition
that forms the book’s first sub-title: psychiatry is in crisis. The crisis is constituted by the chaotic and
post-psychoanalytic intersection of a number of large theoretical and social
problems within the discipline. These
include the following:

·                   
identification and treatment mental illness

·                   
scientific aspirations of psychiatry

·                   
long-term patient care

·                   
coping with HMO’s

·                   
attraction, education, and training of psychiatrists

·                   
mental illness among the homeless and prisoners

·                   
rapport between psychotherapy and pharmacotherapy

Nor do these complete the list of critical issues.

Hobson and Leonard are certainly
not the first to stand at the contentious and disorientating intersection of
problems associated with psychiatry.
However the Hobson and Leonard solution to the crisis (or better term
given their view, ‘chaos’) in psychiatry– which I shall mention in a moment and
which constitutes the second sub-title of a call for reform — is simplicity
itself.

Among theorists of the
crisis/chaos in psychiatry, different writers propose different solutions,
depending on which sub-crisis is for them the principle source of chaos. The issue of how to identify mental illness,
for example, dominates discussions in the tradition of Thomas Szasz. However Szasz’s worries about the
categorical mislabeling of problems of living as mental illnesses certainly is
not for Hobson and Leonard the source of chaos. They are happy to acknowledge that conditions such as depression,
panic disorder and the like are illnesses.
Mental illness is real even if the word ‘mental’ itself is something of
a categorical misnomer (see below). For
Hobson and Leonard the principle cause of chaos is the absence of a proper
sense within psychiatry of how to connect brain science with the theory and
treatment of mental illness. Reform is
to be achieved by forging that connection.

Simple or
no, they offer a picture of how brain science should connect with both the
theory and treatment of mental illness.
They argue that psychiatry can only survive as a respected field in
medicine if it becomes neuropsychiatric or ‘neurodynamic’, as they put it. On the view they outline, panic attacks,
chronic anxiety, depression, and schizophrenia and so forth all emerge rightly
to be classified as neurobiological/neurochemical illnesses. Psychiatry becomes neuropsychiatry because
the unhealthy mind, somehow, just is the ill brain by another name.

“We need a mental health system
led by psychiatrists who have a command of biomedicine and therapy; one that
includes psychologists, therapists, counselors, social workers, and others
assigned tasks corresponding to their skills.” (p. 213-214)

The central clauses are ‘command
of biomedicine’ and ‘corresponding to skills’. The key to psychiatric medicine is biomedicine, brain
science. General practitioners, counselors,
and conventional pill-pushers tend to be inept at diagnosis and treatment. The neurodynamist/neuropsychiatrist should
govern the mental health system.

Not governance by clinical
psychologists, for clinical psychology is a creature of “bright ideas, human
whim, or fashion” (p. 212).
Neuropsychiatry is core – based in hard science, experimental
accountability, and coherence with fertile and well-established theories in
adjacent and overlapping domains, such as evolutionary psychology and biology.

Hobson and Leonard are not
interested in the dialectics required to refine their theses (mentioned above)
and to defend them against competitors.
They are advocates. This is not
a book with argumentative subtleties.
But it is not wooden or pedantic either. The writing is lively and vigorous, bold in conception, and
polemical in purport.

I would welcome a revealing unity
into the stubborn diversity of illness types and treatments, but I fear that
Hobson and Leonard’s forcing of the neuroscientific perspective onto psychiatry
is too close-fisted to capture the ambiguity of the phenomena. Not just in the ambiguity it presents to
clinical presentation, where the experience of mental illness takes place at
the level of the whole person and not at the level of sub-personal regions of
the brain, but more profoundly in the ambiguity it presents to our metaphysical
picture of persons.

Hobson and Leonard’s talk of
mental illness as all biology and chemistry is a simplistic physicalism about
mental illness. If physicalism about mental
illness is true it needs to be a more subtle doctrine than is offered in this
book. It needs to incorporate both a
reduction of the psychological to the neural and a form of autonomy for the
psychological. Different conceptions of
reduction and autonomy need to be explored, as they have been in very recent
philosophy of mind.

Evidently, there are an
indefinite variety of neurobiological and neurochemical configurations in the
brain that are compatible with a diagnosis of depression, for instance. Hobson
and Leonard make the assumption that there exists some final, uniquely true if
prohibitively complicated neurobiological/neurochemical description of an
illness like depression. This is an
assumption that we should reject. Depression as such does not exist at the
neurochemical/neurobiological level. It
is an illness or disorder at the psychological level – at the level of feeling,
motivation, cognition and behavior. Or
better: it somehow exists at multiple
levels. It is an illness of persons
distributed across the layered world of the mind/brain.

Little or nothing of the
‘distribution’ of mental illness between levels appears in this book. Except for some tantalizing claims about one-directional
causal commerce from bottom to upper levels, the idea is not explicitly
approached. For Hobson and Leonard it’s
all bottom-up. But if this book does
not excite you with its reforms, or inspire you with its metaphysics, it will
incite you to think about the ills of psychiatry and the alliance that is being
and must be forged between psychiatry and basic neurobiological and
neurochemical research. There is
substantial room for disagreement with Hobson and Leonard about the trajectory,
hypothesis space, and public policy impact of this alliance. But no one can deny its necessity and
urgency. Not after reading this
book. I recommend it.

 

©
2002 George Graham

 

George Graham is a professor of
philosophy and of psychology at the University of Alabama at Birmingham. He is the co-author of When
Self-Consciousness Breaks. This
is his third review for Metapsychology.

Categories: Philosophical, MentalHealth, Ethics

Tags: Psychiatry, Mental Health Policy and Advocacy