This third installment in my series on sloppy thinking in psychiatry addresses something a little more subtle than “chemical imbalance” or polypharmacy. It is the growing vision, well represented by this recent editorial in Current Psychiatry, that the only salvation for the field lies in embracing the language and practice of neuroscience. With “chemical imbalance” discredited, attention has turned to functional brain imaging and genetics as our last and best hope to retain a shred of dignity as a medical specialty. Dr. Nasrallah’s editorial goes further than most, arguing that we need a new name for psychiatry: Psyche is an “archaic concept” that “has outlived its usefulness and needs to be shed.” Likewise, our “brilliant future anchored in cutting-edge neuroscience” will be hastened by renaming the major mental illnesses, calling psychotherapy “verbal neurotherapy,” and by embracing the language of “brain repair.” But it’s not all a matter of terminology: “The disastrously dysfunctional public mental health bureaucracy must be abandoned and transformed into ‘brain institutes,’ in all states, similar to cancer centers or cardiovascular institutes, where state-of-the-art clinical care, training, and research are integrated.”
I share the sentiment, really I do. Wouldn’t it be great to see shiny Brain Institutes cropping up all over, replacing those sad, underfunded public mental health clinics? Wouldn’t we hold our heads higher if our business cards promised “verbal neurotherapy” and “brain repair”? We could call ourselves medical doctors without a hint of doubt or insecurity, sit proudly at the hospital cafeteria table with the other doctors — you know, the surgeons and cardiologists and such — and charge higher fees as a premier medical specialty instead of our current status as mental health “primary care.” There’s a lot to recommend this vision; where do I sign up?
Unfortunately, there is nowhere to sign up. This is a pipe dream. Psychiatry isn’t clinging to archaic language about the psyche out of nostalgia. It’s the best we have. ”Verbal neurotherapy,” while technically a valid description of psychotherapy, is absurd hand-waving. By the same token, taking a vacation is “locational neurotherapy.” We aren’t going to gain anyone’s respect by dressing up our current practices in pseudoscientific jargon.
Nor are we withholding “behavioral neuroscience” from our patients now. In addition to the verbal neurotherapy, i.e., psychotherapy, that forms the mainstay of my practice, I also offer pharmaceutical neurotherapy, advice regarding nutritional and exercise neurotherapies, discussion of various occupational and relational neurotherapies — I even suggest an occasional locational neurotherapy. I simply lack the hubris, or perhaps it’s the marketing genius, to call it that.
When scientists develop safe, effective psychiatric treatments based on neuroplasticity and neuroprotection I’ll happily offer them to patients (or refer patients to centers where such treatments are available). When my Election Day ballot includes a measure to upgrade public mental health facilities to state-of-the-art Brain Institutes, you can count on my vote. I’m not holding my breath.
Kidding aside, there is nothing sloppy or ill-advised about incorporating neuroscience into psychiatry. Nor is it a new idea. From prehistoric trepanning to Freud’s 1895 “Project for a Scientific Psychology” (pdf of a 2004 review), from the introduction of neuroleptics in the 1950s (modern commentary here) to the “decade of the brain” in the 1990s, psychiatry has nearly always paid homage to the neural underpinnings of behavior. The only obvious exception was the heyday of psychoanalysis, from about 1950 to 1980. Otherwise, we use the best neuroscience we have at the time. The real problem, of course, is that we ask more of our neuroscience than it can deliver. Trepanning probably didn’t help, Freud abandoned his “project,” neuroleptics caused major side-effects and failed to allow patients to return to the community, and the “decade of the brain” turned many psychiatrists into drug-doling technicians. Science keeps improving, and I’m sure we’ll see good things emerge in the coming years. However, progress will occur at its own pace, and no amount of wishing or envisioning will make it happen any faster.
It is sloppy thinking to imagine that behavioral neuroscience is something new and revolutionary. The real revolution in psychiatry, if it ever happens, will be the integration of careful neuroscience, psychology, sociology, and other disciplines to elucidate and benefit our lived experience. This integration will incorporate, not supplant, our higher level understandings of psychology and psychodynamics. When psychiatry is ripe for the “creative destruction” of polarized thinking and choosing sides, it will be stronger than the sum of its parts, and will have finally reinvented itself into something we can unequivocally be proud of.
And yet again, photo courtesy of Petr Kratochvil.