Psychiatry in Crisis: At the Crossroads of Social Sciences, the Humanities, and Neuroscience

By Vincenzo Di Nicola and Drozdstoj Stoyanov

The field of academic psychiatry is in crisis, everywhere. It is not merely a health crisis of resource scarcity or distribution, competing claims and practice models, or level of development from one country to another, but a deeper, more fundamental crisis about the very definition and the theoretical basis of psychiatry. The kinds of questions that represent this crisis include whether psychiatry is a social science (like psychology or anthropology), whether it is better understood as part of the humanities (like philosophy, history, and literature), or if the future of psychiatry is best assured as a branch of medicine (based on genetics and neuroscience)? In fact, the question often debated since the beginning of modern psychiatry concerns the biomedical model so that part of psychiatry’s perpetual self-questioning is to what extent it is or is not a branch of medicine. This unique and bold volume offers a representative and critical survey of the history of modern psychiatry with deeply informed transdisciplinary readings of the literature and practices of the field by two professors of psychiatry who are active in practice and engaged in research and have dual training in scientific psychiatry and philosophy. In alternating chapters presenting contrasting arguments for the future of psychiatry, the two authors conclude with a dialogue between them to flesh out the theoretical, research, and practical implications of psychiatry’s current crisis, outlining areas of divergence, consensus, and fruitful collaborations to revision psychiatry today. The volume is scrupulously documented but written in accessible language with capsule summaries of key areas of theory, research, and practice for the student and practitioner alike in the social and human sciences and in medicine, psychiatry, and the neurosciences. 

• Language: English
• Publisher: Springer
• Release date: Feb 3, 2021
• ISBN: 9783030551407

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© Springer Nature Switzerland AG 2021

V. Di Nicola, D. StoyanovPsychiatry in Crisishttps://doi.org/10.1007/978-3-030-55140-7_1

1. Introduction: Prospectus and Leitmotifs

Vincenzo Di Nicola¹, ²   and Drozdstoj Stoyanov³

(1)

University of Montreal, Montrea, QC, Canada

(2)

The George Washington University, Washington, DC, USA

(3)

Medical University of Plovdiv, Plovdiv, Bulgaria

Keywords

Crisis of psychiatryKnowledge (epistemology)Being (ontology)Psychiatry’s critical gapsDisciplines vs. subdisciplines

1.1 Prospectus: Crisis? What Crisis? – Psychiatrists on Psychiatry –Vincenzo Di Nicola

When we announced our project on the crisis in psychiatry, we received three kinds of comments and reactions. There are two extremes and a complex middle ground full of nuances and revisions.

Crisis? What crisis?

This first reaction reminds me of the 1975 album by the English group Supertramp with the album cover of a guy in a deckchair and an umbrella surrounded by a destitute post-industrial environment. These folks are naïve optimists or the reformed cynics who have found religion in positive psychology.

Psychiatry has always been in crisis

This is espoused by a surprising number of thoughtful psychiatrists, including Tom Burns (2006) in his brief introduction to psychiatry: Psychiatry has always been controversial and never had a Golden Age … when everyone was in agreement (Burns 2006, p. 131). Burns is of the opinion that protests notwithstanding none of us truly believe that psychiatry is just like any other branch of medicine and that this difference generates conflicts and crises. Some of these folks are cynics who dismiss the possibility of a scientific, rational, or even a clinically meaningful psychiatry.

In between these extremes, there are radically different opinions as to the nature and extent of the crisis:

Psychiatry lost its way

Another opinion is that we have lost our way in North American academic psychiatry. Some believed that the wrong path was psychoanalysis with its oversold promise as psychodynamic psychiatry. In the 1970s and 1980s, mainstream academic American psychiatry adopted the DSM (APA 1980) project along with George Engel’s (1977, 1980) biopsychosocial (BPS) model. Outside the academic mainstream, a seeming endless number of new paths were offered through this thicket with revolutionary rhetoric: systems theory and family therapy, social and transcultural psychiatry, community psychiatry, cognitive therapy and its avatars, and of course psychopharmacology and the biological revolution. The rhetoric was as overheated as it was naive. In the 1970s, Salvador Minuchin announced that family therapy would take over psychiatry in 20 years (Malcolm 1978). To use the language of family therapy, these reframings or redefinitions were not so radical. If you scratch most other kinds of therapists, you will find some version of Freud’s theory or practice of psychoanalysis underneath, either in disguise or in reaction. In this sense, these new paths were not so much revolutions as attempts to bring psychiatry back to its roots. Not a revolution but a rebranding of the field in the Anglo-American world as behavioral psychiatry, family psychiatry, community psychiatry, social and transcultural psychiatry, biological psychiatry, or a psychiatry based on cognitive theory and therapy. In much of Europe, there was phenomenological psychiatry and its aliases or antipsychiatry and its alliance with community and humanistic psychiatry. Now almost forgotten is the Pavlovian psychiatry of the former Soviet Union and the nations under its scientific and social influence.

As for the DSM, we do not need to jettison nosology but to improve it, and as for the BPS model, we need more, not less theory. One of us (Di Nicola) has spent much of his career on other paths – child and adolescent psychiatry, social and transcultural psychiatry, community psychiatry, and family psychiatry and relational therapies. Unfortunately, while they are stimulating and intrinsically valuable, opening up space for orphaned experiences of children, families, communities, and cultures in mainstream academic psychiatry, these approaches do not provide a complete account of the mind and its relations (that is to say, a psychological theory), nor do they offer a comprehensive model for all of psychiatry (that is to say, a theory of psychiatry).

Now, while this may have created fragmentation and even mutual incomprehension among the different practitioners on these new paths, a much more radical alternative has appeared.

Psychiatry as neuroscience, psychiatric illness as brain disorders

This is not a rebranding exercise or a return to psychiatry’s roots but a complete reset, accompanied by a radical departure and a new research paradigm taking, predictably, a new name. In the 1990s, the USA announced the Decade of the Brain and what was heretofore alienation in the nineteenth century, psychiatry in most of the twentieth century, and more recently behavioral or mental health, came under the rubric of neuroscience, just as academic psychology morphed from behavioral psychology to cognitive psychology to cognitive neuroscience. The mantra of this new approach is that mental disorders are brain disorders. This group exhorts us to pay more attention to the brain.

This approach inspired a dual intellectual temptation for one of us (Stoyanov) who recounts his scientific journey in an Excursus in Part One: "One was the identity theory of mind as a particular form of reductive physicalism and the other was functional MRI (fMRI) as a method to deliver empirical evidence in its support" (See Stoyanov et al. 2012, 2013, 2014). For different reasons, we came to parallel conclusions about the limits and false promises of biological reductionism in psychiatry.

Besotted by what Raymond Tallis (2011) labeled Neuromania, these are the psychiatrists who want to jettison everything we have done in the last two centuries to found what they call a scientific psychiatry. (See "Excursus: Slouching Towards an Impoverished Language of Psychiatry). Think Thomas Insel and the Research Domain Criteria (RDoC) during his tenure at NIMH. The version of this in academic psychology is evolutionary psychology – or what Tallis (2011) calls Darwinitis." So there we have it – Neuromania and Darwinitis – the Tweedledum and Tweedledee of biological reductionism in psychiatry and psychology today.

Excursus: Slouching Towards an Impoverished Language of Psychiatry

The problem with jettisoning the past completely for a new language of psychiatry was articulated clearly by linguist Noam Chomsky (1972) in his critique of BF Skinner’s behavioral encomium, Beyond Freedom and Dignity (Skinner 1971). Briefly, Chomsky argued that when Skinner uses behavioral descriptions, we translate them into the language of the mind, elaborated over the last few centuries (arguably since the Enlightenment). Now, a transitional generation would understand behavioral descriptions by referring back to the older language using mental terms and references to the subjective inner life of the mind, yet if Skinner and behaviorism would succeed to the point of dominating psychology and our understanding of human behavior, eventually we would not have this other language that philosopher of mind Jerry Fodor (1975) called mentalese. And as a result, we would have an impoverished language of human psychology. In both philosophical and psychological terms, our very experience would become impoverished for lack of naming, elaborating, and sharing our inner mental states. The alexithymia that was bemoaned in the psychotherapy literature about a constrictive form of concrete and operational thinking would become a social and cultural phenomenon of word failure, that Di Nicola (1997, 2001) described in his review of language and therapy. This constriction is a direct consequence of behavioral and biological reductionism and represents the greatest threat to the theory and practice of psychiatry and why it is in crisis, bordering on collapse.

If the work of Nobelist in Medicine Eric Kandel (2005) is the greatest hope for neuroscience and the mind being understood through the brain, there are also those of us in psychiatry and beyond (among them, noted child psychiatrist and family therapist Maurizio Andolfi, philosopher Jerry Fodor, developmental psychologist Jerome Kagan, and geriatrics researcher Raymond Tallis) who decry the diminishing attention to the mind and its relational aspects along with the misguided biological reductionism of mind equals brain and biological evolution as the explanation for the social and cultural aspects of being human.

1.2 Leitmotif I: The Crisis of Psychiatry as a Crisis of Knowledge – Drozdstoj Stoyanov

My overall statement is that psychiatry is in a crisis of knowledge (which may well have a counterpart in, or result from, an ontological crisis). The main components of any psychiatric knowledge would consist of taxonomy – terminology and nomenclature – and methods. The first component is projected onto a crisis of identity and the second component onto a crisis of confidence. Psychiatric taxonomy in the post-DSM-III (APA 1980) era has been proven to generate more problems than solutions, both on conceptual and empirical levels. In my view, this is rooted in the mode of escape from theoretical foundations of psychiatry, as proposed by logical positivism.

Psychiatry has always been inevitably engaged in theoretical debates such as the mind-brain problem and escaping from them into instrumental quantifications of the human narratives was a fatally flawed choice. Those theoretical debates come back to life regardless of whether we clinicians want them or not since they are relevant to our fundamental activities: diagnosis and treatment. As far as methods are concerned, I believe that the persistence of an explanatory gap between nomothetic and ideographic methods has caused complete misunderstanding in the dialogue across disciplines. Each discipline adheres to its epistemic monologue, comprised of a terminology and a methodology of its own. What represents the main problem, in my view, is the issue of translation, that is, the creation of manuals to translate data/information across various disciplinary matrices, so that stable bridge or law-like connections may be established between them.

The take home message of my contribution is that we need to aspire to cognitive pluralism, inter-domain translation, and synergy in order to induce change in psychiatry on a meta-theoretical level and overcome the current crisis.

Excursus I: Inter-theoretical Reduction and Nagelian Laws

Ernest Nagel (1961) postulated that there exist law-like cognitive structures within and between different scientific matrices, which exist in order to establish bridges to connect notions, explanatory mechanisms, and regularities. This concept has been criticized as being heavily reductionist over the second half of the twentieth century. However, in my view, the plethora of modern psychiatric theories (psychodynamic, behavioral, biological, etc.) which claim to have offered the ultimate explanations of mental health and disorder in fact are either utilitarian or authoritarian approaches which can encompass just a small portion of the explanandum, or what needs to be explained. The instrumentalist biopsychosocial model (Engel 1977, 1980) also turned to be inefficient in terms of a better understanding of mental disorder since it is deprived of any conceptual foundation. In order to capture the entire complexity of human being and mental suffering in particular we need all those theoretical models to complement each other in a rather synergistic manner than excluding each other as they do at present. To achieve synergy, we may benefit once again from the Nagelian inter-theoretical model of analytic equivalences in a more or less updated version, where explicit reduction to basic sciences is avoided.

Here, Di Nicola and I have one major territory for dispute – Nagelian laws actually exclude any ontological commitments! Nagelian laws were meant originally as reductive. However, reduction was implied on two levels. One is homogeneous, where the terms and vocabulary of the reduced and reducing theory share more or less the same meaning. In that case, the reduction is essentially instrumental and methodological and does not concern ontological matters, that is, the matters of whether or not the observed and described phenomenon exists or not (Nagel 1961, 339.)

The other is heterogeneous, where different meanings are assigned in the reduced and reducing theory. In that case, ontological reduction applies in order to impose basic explanatory vocabulary and mechanisms on higher order phenomena, by practically eliminating them (which would be the relevant stance of eliminative materialism). That would be the case with the so-called social neuroscience, where most complex social and cultural interactions are reduced to neurochemical and neurophysiological mechanisms.

However, when interpreted in the context of the neuroscience-psychiatry dialogue, the reduction will be assumed rather to be homogeneous, since the two groups of disciplines share approximately the same meaning of the employed terminology. For instance, molecular neuroscience and psychiatry share the term depression as clinical condition, which means they have conventional agreement about its definition.

Excursis II: Identity Theory of Mind Versus Eliminative Materialism

We assume that various stances in the mind-brain debate underlie the main diagnostic and therapeutic methods in psychiatry. While biological pharmacotherapy is largely expanded on the basis of eliminative materialist views, psychotherapy is endorsed on an implicit level by the dualism and perhaps, the dual-aspect monism. In fact, the crisis of confidence means that we no longer believe in our clinical evaluation methods, or in our therapeutic ones. This undermines our expert statements and their legal authority as well. I tend to believe that returning to type and token identity theories of mind might be useful. Actually, token identity is far less radical form of physicalism than epiphenomenalism or eliminative materialism for instance. As it has been stated in the seminal papers of Ullin T. Place (2004), identity might be regarded as compositional where components of lower level phenomena are incorporated in the hierarchy of the higher order ones without any ontological claims at elimination (Churchland 1981), instead of de re identity where one phenomenon is overruled by higher level phenomenon.

Excursus III: Utilitarianism as Opposed to Validity

The atheoretic utilitarian classifications led to various issues with validity and therefore to a crisis of professional identity. In their influential paper Kandel and Jablensky (2003) argue that validity has been replaced with utility in psychiatry. In this view, further elaborated by Zachar and Jablensky (2015) and Jablensky (2016), there are missing natural boundaries, anchored in neurobiology to distinguish different mental disorders, which is essential for the crisis in psychiatry. The crisis of identity entails such highly controversial queries as, Are panic disorders any more psychiatric diagnosis or maybe they belong to the domain of clinical psychology? or, Is Alzheimer disease a psychiatric diagnosis or it is the subject of neurology? In effect, the penultimate query raised at psychiatry from an identity perspective, is Is psychiatry a legitimate medical discipline or an artifact of neurology? Parnas and Henriksen (2016) address the problem of phenomenological continuity in psychiatric diagnosis. One study (Frederiksen et al. 2016) has compared the changes in psychiatric diagnoses in leading academic departments under the different updates of the conventional classifications. It turned out that interdepartmental heterogeneity and variability of diagnoses and the internal department homogeneity have not been improved over more than 30 years, from ICD-9 to ICD-10. This means that conventional classifications do not achieve the purpose they are designated to, that is, unification and harmonization of diagnostic