Psychiatry Has an Identity Crisis, and It’s a Problem for Patients

Over the past one hundred years, psychiatry has moved from Freudian philosophy of the theoretical concept of unconscious conflict and somewhat dated ideas of human development (Oedipus and Electra Complexes) toward a pharmaceutical orientation. Is “penis envy” normal in women who live in a misogynistic society?

In the new wave of medical/psychiatric thinking and training, residents in psychoanalytic training programs panicked. I saw this first-hand as worried young men asked out loud what they were to do now.

Where were they to finish their training if the hospital where they were now training was suddenly shifted to biopsychiatry? How could they switch to a medical model from the one in which they were currently involved? But didn’t they go to medical school with a medical model?

As a result, residents left and tried to re-orient themselves and their careers. And insurance reimbursement came into play. One analyst asked me if health insurance companies would pay for psychoanalysis. I had no idea.

Psychiatry transitioned from one of multiple weekly one-hour (or 50-minute) therapy sessions over years (what did Woody Allen say?) to one of consultation, diagnosis, prescription, and referral to a psychotherapist. No longer would psychiatrists be involved in psychotherapy. The prescription pad was their instrument of change.

A man with whom I am well-acquainted suffers from chronic, often debilitating panic attacks resulting from severe childhood trauma in a highly dysfunctional household. The mother beat the father with a frying pan, but he never touched her because he was raised to respect and never strike women. She attempted to set the house on fire, and the children suffered lifelong anxiety.

Referred to a new psychiatrist, the man, at the end of their first appointment, asked naively, “When do we schedule our therapy sessions?”

Without missing a beat, the nonplussed young woman psychiatrist responded, “I’m a psychiatrist. I’ve refilled all your prescriptions.” Nothing more was offered, and he received the name and number of a psychologist. What was the patient to think?

Where is psychiatry headed in the future as science marches on and attempts to find the biological basis of all behavior and abnormality? The questions have been asked by psychiatrists like Dr. Thomas Szasz, who wrote “The Myth of Mental Illness,” Dr. Allen Frances, who wrote “Saving Normal,” and Dr. David Viscott, who had a successful radio show.

In some of his statements about psychiatry, Dr. Francis is quite bold. “Psychiatry is certainly not alone in its overreaching — we are just a special case of the bloat and waste that characterize all of US medicine. Commercial interests have hijacked the medical enterprise, putting profit before patients and creating a feeding frenzy of overdiagnosis, over testing, and over treatment. We spend twice as much on healthcare as other countries and have only mediocre outcomes to show for it. Some of our citizens are harmed by too much medical care, others by shameful neglect. Medicine and psychiatry both stand greatly in need of taming, pruning, reformulation, and redirection.”

A few decades ago, Dr. Szasz wrote similarly about the behavior that psychiatry called mental illness and misused the terms in their nosology to create a special mystique. Neuroses and anal-retentive still hang in there today.

Where do we stand currently regarding our understanding and treatment of mental illness? Providers often use medications off-label, and these cause damage. Do we even know what mental illness is, or are we so highly dependent on the DSM-5 that we cannot see normal in its varied iterations? I applaud Dr. Martin Seligman for his emphasis on the positive aspects of human behavior, not psychopathology.

In addition, the DSM is behavioral in its diagnoses. There are no medical indications in it, nor is any medical testing recommended. Behavioral features and differential diagnoses are offered, but no medical illnesses that I can find in it. Why would only medications be prescribed? I’m sure objections can be raised here.

And the same book used to diagnose, the DSM, is revised periodically to include more mental illnesses. An excellent example was provided in Dr. Frances’ book, where a psychiatrist wanted to include “psychosis risk syndrome.” What would that have done to how many patients?

The questions are serious and must be constantly asked because people’s lives depend on what is provided to them by medical professionals. Once given a diagnosis, you might as well put a large, somewhat invisible letter on the person’s head, as in The Scarlet Letter. The stigma is long-lasting.

Arrogance has no place in medicine because it can cause more harm than the most dangerous poisons — it poisons the mind to reason and innovative thinking.