Psychiatry, Psychology and Subjectivity

I continue to mull over the problems of diagnosis, the DSM, turf battles and how all of this relates to what I, as an ordinary clinician, do and think about my work. So today I want to talk about a couple of items that have attracted my interest in the last week and see if I can pull them together.

First is this terrific interview in Bookslut with Christopher Lane, who wrote Shyness: How Normal Behavior Became a Sickness. I think it highly unlikely that anyone within the mental health professions would have written this book. It takes someone outside who is willing to look at the issue without a particular professional axe to grind to do this. And the book is receiving a considerable amount of thoughtful attention, as I mentioned here and here. In this interview, Lane makes a very important point :

Another thesis you advance is that modern psychiatry has essentially "rebooted," deliberately going back to a kind of pre-Freudian indifference to subjective experience. Has the purging of subjectivity yielded significant fruit in treating mental illnesses?

The “rebooting” of modern psychiatry stemmed, I think, from a widespread effort to eliminate all trace of psychology from American psychiatry. This was not without serious intellectual and clinical consequences. Some of the psychiatrists responsible for this wholesale debunking of Freud, in particular, later twigged that they had thrown out the baby (in this case, interest in consciousness) with the bathwater. So in some cases they needed to start again almost from scratch: They had to find new ways to discuss perception that wouldn’t at the same time sound Freudian.

In my opinion, the whole exercise was immensely self-defeating for psychiatry. Experts pointed out at the time that it was rather arrogant to believe that one could simply trash 70 years of carefully argued analysis, itself tied to clinical experience, but few at the time were willing to listen. They were on a mission to turn psychiatry into a study of the brain, and thus a hard-boiled science. It’s unfortunate, then, that Ted Millon, one of their consultants, came forward in 2005 and told the New Yorker, “There was very little systematic research [informing DSM-III], and much of the research that existed was really a hodgepodge -- scattered, inconsistent, ambiguous.”

I’d say the “purging of subjectivity” from discussions about anxiety ended up impoverishing what we do know about anxiety, and have known for a very long time, which is that it crosses biology and perception, rather than being reducible to one or the other. Put another way, while the effects of anxiety are obviously biological -- a racing heart, sweaty palms, shortness of breath, and so on -- what triggers those effects is necessarily tied to consciousness.

I believe that Lane hits the nail on the head when he says:

"The “rebooting” of modern psychiatry stemmed, I think, from a widespread effort to eliminate all trace of psychology from American psychiatry."

Indeed this is a major effect of the turf battles.  Each of the two, psychology and psychiatry, needs some claim to uniqueness, some specialness of knowledge in order to claim space in the arena. Add to that the largely unconscious issues of esteem about whether or not either is a "real" science or "real" medicine and the ground is well prepared for what has happened. 

In psychology, subjectivity has long been suspect among behaviorists. I can remember one telling me in graduate school -- and this was over 35 years ago -- that self-report was unreliable and not worth gathering. And American psychiatry has never been especially hospitable to psychology -- it wasn't until 1988 that psychologists were admitted to psychoanalytic training in the US, and that only after a lawsuit forced the issue. 

In a curious way, the interests of modern psychiatry and clinical psychology have found common ground in their mutual desire to push subjectivity and the knowledge gained from years of research in psychodynamics out of consideration in treatment today. Each has embraced the so-called evidence-based model, concentrated research on outcome reports and on medication and short-term therapy to the exclusion of anything else. Add to this the push on the part of a significant segment of clinical psychologists to become prescribers and the two become ever more similar, though not, I believe, in the best interests of their patients.

And so we come to a post on ShrinkRap: What Good are Psychologists? which I freely admit rubbed me the wrong way. Just as it is hard for me to see it as a good thing that psychiatry has become so dominated by psychopharmacology, I can see it is hard for many, maybe most psychiatrists to see that psychologists have more to offer than tests. Given that there is precious little science involved in diagnosis or treatment, that basically what we do is apply what we know -- whether that is giving prescriptions for meds or offering psychotherapy -- claiming superior knowledge is a very shaky enterprise indeed. It's an old battle being fought here, stemming from the origins of psychiatry and clinical psychology and arising from their separate but similar inferiority complexes. 

I believe we are cursed by living in interesting times.
© Cheryl Fuller, 2018. All  rights reserved.