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|Year : 2015
: 57 | Issue : 1 | Page
|Psychiatrists need a Freud-chip in their psyche to be well-rounded
James T Antony
Department of Psychiatry, Jubilee Mission Medical College and Research Institute, Kerala, India
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|Date of Web Publication||7-Jan-2015|
|How to cite this article:|
Antony JT. Psychiatrists need a Freud-chip in their psyche to be well-rounded. Indian J Psychiatry 2015;57:4-8
Since the celebration of the "decade of the brain" commenced in 1990, the mind-set of many psychiatrists has tilted considerably, to become almost totally "biological." Though we have nice concepts like "eclecticism," which can provide the right kind of "theory-hat" to tackle tough clinical situations, even the word hardly gets mentioned in professional circles these days! and quietly, mental health care has switched over to a kind of "split treatment:"  The psychiatrist addresses things biological, the clinical psychologist would administer his few panaceas like cognitive behavioral therapy (CBT) and counseling to almost everyone and as for other mental health professionals, they pursue their narrow tracks, in solitude!
We have totally forgotten Adolf Meyer, who taught us the usefulness of studying psychiatric disorders as "reaction-types" and about the need to integrate psycho-social factors with biological ones, while trying to understand sick persons. Even a simple, practical stance like "bio-psycho-social approach,"  does not appeal to many present-day practitioners! With regards to "psycho-dynamic formulation," which could enable every clinician to have a holistic understanding of his patients, it is no more viewed as useful by most psychiatrists. Even in institutions rated as centers of excellence, trainees are no more taught the basics of dynamic theories. And for many in the profession, psychotherapy means just behavior therapy and its offshoots!
The old holistic approach of physicians toward patients slowly started to change with the arrival of "reductionism." When at a conceptual level, one could "split" any "entity" including "man," into small compact components and study each "part" intensely, researchers gained many fascinating insights. With rapid growth in its basic sciences, medicine or rather "medical science" advanced in leaps and bounds. And by the end of the 19 th century, doctors could cure many illnesses that were scourges for mankind since ages!
However, medical practice as a whole had to pay a price for all such fabulous advances: From then onwards doctors started to view patients as some sort of "machines needing repair," rather than fellow human beings in distress. Later, when "specialization" became a central feature of the entire Medicare scenario, this cold, "machine-view" about human beings worsened further.
We have another idea, again a contribution by Rene Descartes that radically changed the thinking of medical practitioners. In a rather ingenious manner, he divided "Man" into two portions, "body" and "soul." Such a division at a conceptual level was made by Descartes to bring about a truce to a then prevailing tussle between the powerful church on the one side and the slowly emerging "scientific medicine" on the other. Descartes "decreed" that doctors must confine themselves to the job of treating the "body," while priests were given the right to "treat" disorders of the "soul!"
This Cartesian dichotomy continues to strongly influence the thinking of everybody including doctors, even today. , It has inflicted serious harm to health care systems all over the world, in many ways. We have, for example, many "religious healers" who seriously believe they have a "God-given" right to treat psychiatric patients! later, when "mind" became the new "scientific" term for two words, "psyche" and "soul," and when psychology emerged as the new science of mind, many psychologists too started to think in the same fashion, like priest-healers: Treating an "independent entity" or that particular "part" of "man-machine" called "mind," is their exclusive right!
When such a "machine model" became the very center-piece of medical "wisdom," even great "authorities" in medicine started to teach students that they must distance themselves from mundane social and emotional issues of patients! A classic example of this trend is the famous Flexner report (1910)  of the United States, which is viewed even today by many as a sort of "scripture" that guides medical education. Flexner exhorts: "The primary purpose of the modern medical school was the education of students and the study of diseases, not the care of the sick!" 
With such teachings, the entire medical field started to follow a new principle: Study diseases intensely and treat them vigorously, but distance one-self from social and emotional issues of patients! When Kraepelin, with his nosological approach, put psychiatry on par with the rest of medicine, psychiatrists too started to copy that popular attitude. As a result, medical practice as a whole became cold and institutionalized, and even the manner in which human beings were viewed got totally fragmented. At that point in history, medical practice as a whole needed an original thinker to re-discover its old holistic and humane traditions. A theory was needed to go beyond the machine-model of Descartes and Newton and also to transcend a crude and artificial "body-mind dualism."
At the beginning of the 20 th century, though many theories from "gestalt" to "general systems" came up, it was "psychoanalysis," formulated by Sigmund Freud that had a great appeal to intellectuals across all fields. And when psychoanalysis became part of it, psychiatry attained a new stature as the one medical specialty where doctors strived for an "inside knowledge" about their patients. It once again started to persuade practitioners to view their patients with empathy and a caring attitude.
Even in 1968, when Diagnostic and Statistical Manual of Mental Disorders Second Edition (DSM-II)  arrived, Freudian psychoanalysis was its main theoretical underpinning. The ability of the clinician to craft a "psychodynamic formulation" was the bench-mark of his clinical sensitivity. And having a psychotherapeutic attitude toward patients was the very essence of "clinical acumen" for a psychiatrist!
But today, the pendulum has, once again, swung back. It is as though the dazzle of new sciences and technology is blurring the vision of everybody. With fabulous advances in areas such as molecular genetics, imaging technologies, organ transplantation and so on, most doctors are no more capable of viewing their patients in a holistic manner. Their thinking has become totally reductionistic. Most specialist doctors of the present time are not sensitive enough to at least suspect, if not perceive, any distressing human predicament that is outside the narrow, rigid boundaries set by their particular sub-specialty!
In psychiatry too, a paradigm shift has taken place in the thinking of many. A good section of "biological psychiatrists" are keen to explain all illnesses in a "medico-pathological-explanatory model," like it is done in main-stream medicine! For them, it is as though one can understand human predicaments completely, merely if one knows the underlying "bio-chemistry" of "experiences"!
In this kind of thinking, the "mind" is conceptualized in an altogether new, over-simplified, and restrictive manner: Namely, only whatever is revealed by imaging machines and researches in molecular biology is "mind;" all other concepts, insights and theories, about human experiences and predicaments that have been taught to us by great doyens of the past, do not mean anything!
Today, various integrating and holistic views of Freud and others are forgotten or are being deliberately discarded by clinicians. Once again, the conceptualization of human beings has moved back, to the old Cartesian machine-model view. And medical professionals are once again in the grip of "reductionism;" perhaps even more badly than our forefathers were, before the arrival of Freud!
An equally important reason why psychiatrists are distancing themselves from integrative theories these days is the tremendous stature and influence that DSM-III  has acquired. While this manual, which arrived in 1987, is useful to ensure a better reliability of psychiatric diagnosis, it quietly persuaded psychiatrists to distance themselves from all dynamic theories; just practice a "descriptive psychiatry!". By discouraging clinicians from making any "inferences" regarding patients' predicaments or making "psychodynamic formulations," it has transformed many clinicians into somewhat insensitive human beings.
A more damaging effect of DSM-III and its later versions  is that these manuals strongly persuade clinicians to become "theory-neutral" or "a-theoretical!"  To understand the extent of this damage, one needs to give some serious thought to the manner in which the thinking process actually takes place in human beings. At the very core level, our thinking is "deterministic" in nature.  This means that to maintain equilibrium, the human "mind" has to always find a "cause" or "reasons behind" its experiences, especially those that are "threatening." This deterministic thinking is an attribute that even our "primitive" forefathers of prehistoric times had! When nature manifested in its furious and frightening ways with lightning or thunderbolts, they used to have an explanation to dispel their fear and remain at ease: "God is angry; that is why he is sending thunderbolts to punish!"
What DSM-III has sought to achieve with its "a-theoretical" stance is to shut off this universal human quest to "know" the "cause" behind one's experiences! Here the authors of the manual have failed to realize that such a banishment of "theory" is just not possible because it goes against the very nature of Man. Here a profound statement by Levine that "nothing is as practical as a good theory"  is quite relevant. Also as Kernberg (1987) has wisely stated, "all observations of clinical phenomena depend upon theories, and when we think that we are forgetting about theory, it only means we have a theory of which we are not aware." 
The point for all of us to remember is that our deterministic mind would not allow us to remain "a-theoretical," at any time, even if someone teaches us to be so. We would quietly take in one theory or other, without even being aware that we are doing so! And this is exactly what happens in the case of large sections of present-day psychiatrists. Even though they succeed in distancing themselves from dynamic theories, based on the influence of DSM, they continue using some theory, just the way they were doing all along, right from their days as fresh medicos.
Today, we live in an age, when many fabulous advances are making people blind admirers of science and technology. For many psychiatrists, their fascination is to be known as "clinical scientists" or "evidence-based clinicians."
With this narrow objective, they are keen to craft a medico-pathological theory, making use of whatever new findings are available from neurosciences. But the problem here is that while many ideas from fields like imaging or molecular research are quite fascinating, they lack enough explanatory power, to deal with the kind of clinical data we have in psychiatry. One may say that though data from well-conducted studies qualify as "scientific," they lack the explanatory power that would satisfy the deterministic mind of the clinician.
Many times, a psychiatrist would have tumultuous sessions with a patient that would be like a voyage in the turbulent sea. In such situations, a rudder in the form of a "theory that explains" would be necessary to keep the clinician on track. In the absence of a theory, he would either be totally shattered or more often, his defense mechanisms would force him to keep an "emotional distance" from the patient. In both situations, the clinician would fail to pick many subtle, soft, and nontangible clinical signs; the net result would be that even the diagnosis of many common psychiatric disorders would be missed!
On the other hand, when supported by a good dynamic theory, a psychiatrist would be able to relate with his patients quite well. He could start with empathy and build a genuine rapport. As for the patient, he is enabled to trust the doctor and bring out with ease many of his delicate and closely guarded thoughts, feelings, fears, fantasies, dreams, jealousies, ambitions, humiliations, insults, and pains! And the doctor would discern the "meaning" of many symptoms and treatment could commence quite professionally.
The point here is that a "biological" psychiatrist, while on the lookout for objective signs, would fail to have the empathy required to perceive the subjective experiential world of his patient!
Hence, while concepts from neurosciences are fascinating, the kind of expectations that many entertain about them is quite disproportionate! May be mega-research projects like the Connectome project in the Unites States or the human brain project in Europe are also fuelling this enthusiasm. But one suspects that the present optimism betrays a lack of a clear comprehension about certain basics. First, we have the inherent complexity of the human nervous system with its 100 billion neurons; each of which has around 10,000 synapses. It is not in the realm of possibility to have a clear understanding of important brain functions, at least in the foreseeable future.
Second, in the absence of a dynamic theory, one would not be able to pick up those innumerable traits and symptoms that a patient manifests. And even if for the sake of discussion it is admitted that all subtle and soft signs are picked, one cannot make an explanatory theory making use of all such signs. Further, if one attempts to connect all these to the concepts known so far in neurosciences, it would not succeed; it would still leave huge gaps all over.
Hence, while a synthesis of the behavioral, biological, and brain imaging, which is being attempted by many investigators all over the world,  is certainly a brave venture, it is not likely to yield satisfactory results. Bridging brain pathology and phenomenology is a great dream but indeed quite a distant one. Knowing about an individual's genotype will not predict behavior but would only inform us of her vulnerabilities and potential actions.
One must reconcile to a situation that in psychiatry, where a "scientific theory," based purely on "formulated scientific data" in line with a "medico-pathological" approach like in mainstream medicine, is not possible just yet. "Hardcore" biological psychiatrists should accept this fact. It is most welcome that psychiatrists integrate research findings from neurosciences into the total corpus of their knowledge. But for the present, it would be more realistic to limit this exercise to the clear objective of linking up known pathophysiology with possible psycho-pharmacology.
Linking such biological data with subjective experiences of patients is not yet in the realm of what is possible in our times. In this situation, to imagine that one could give up all dynamic theories would be preposterous. While wanting to be "evidence-based" is a fine idea for new-millennium psychiatrists, to imagine that with isolated ideas from biological studies one can explain or understand complex human predicaments would be totally inappropriate.
But at the same time, if a clinician with dynamic orientation approaches even a tough clinical situation, he would have the wisdom to understand the patient's real predicament. The difference here is that he has a theory with enough explanatory power or in other words a "hermeneutic" theory. Nobody needs to be apologetic about making use of a "hermeneutic" theory, during their clinical work. Even in pure sciences like physics, the starting point for extending the frontiers of knowledge is a hermeneutic theory, formulated by an original thinker. Later, only when data emerge from experiments designed as per such a theory or from observations in other situations, a scientific formulation would be possible. Only then would it be possible to make a well-knit scientific theory based on actual data.
Sigmund Freud is the original thinker who first crafted a hermeneutic theory to explain, interpret and understand human nature in a comprehensive manner, which he named psychoanalysis. Soon, it became the core body of knowledge in psychiatry and with its efforts to understand the predicament of patients, it occupied the center-stage among all psychological theories that dealt with human nature. It not only aided clinicians to understand manifest features, but for those who pursued it and probed further, it enabled them to gain deep insights and even discern the "meaning" of patients' predicaments. It could transcend the narrow, "biological-medical model" and empower clinicians to think in an integrated, holistic manner.
Most importantly, psychoanalysis and other dynamic theories could inspire doctors even now, to re-invent age-old virtues of their profession. These days, the kind of problems for which people consult psychiatrists has changed considerably. Unlike in olden days, many do it to sort out their relationship problems, rather than to get treated for typical clinical syndromes. Even in those who consult for typical syndromes, the clinical picture would be colored considerably by their personality characteristics. While handling such situations, only with insights from dynamic theories a psychiatrist would be able to craft effective remedies.
There are many more situations, where only psychotherapy, based on a deep dynamic understanding about the patient is likely to yield results. It has been stated that the unique capacity of the psychiatrist to provide combined psychotherapy and pharmacotherapy will maintain a special robustness to the discipline in both its practice and research. 
Weissman  has rightly stated that genetic replicas of each of us would not create copies of any of us. He has also mentioned about 10 analytical concepts from the 20 th century, which will be critical for new millenium psychiatrists to understand the thoughts, feelings, and actions of their patients.
But it would not be enough or even practical for psychiatrists to study these important concepts in isolation. It is necessary for all psychiatrists to have an understanding of at least the basics of various dynamic theories. A foundation for this can be laid by learning the basic postulates of Sigmund Freud and also by studying about the manner in which he went on to formulate a dynamic theory. An orientation on various core concepts that were developed by other important dynamic theorists is also required.
This basic understanding has to be taken forward, by acquiring a reasonable working knowledge on three currently popular schools of psychoanalysis, namely, ego psychology, object relations theory, and self-psychology.  With such a foundation, a trainee must administer dynamically oriented psychotherapy, under supervision. At the end of such a training, he should have a clear idea about situations where dynamic therapy is required and also must acquire the confidence and know how to carry out the same, independently.
We must be conscious of the fact that treatments such as counseling and CBT do not go deep enough into any dynamic aspects of human existence. If psychiatrists of the early 21 st century confined their professional work to the administration of these currently "popular" interventions, plus prescribing a few molecules from their basketful of "wonder drugs," it would be a huge disappointment. It is time we do something, lest future generations judge that psychiatry of our times was just one more "calling" that went only "skin-deep," while addressing complex human predicaments!
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Dr. James T Antony
Department of Psychiatry, Jubilee Mission Medical College and Research Institute, Thrissur - 680 005, Kerala
Source of Support: None, Conflict of Interest: None