Medicine over Mind

Mental Health Practice in the Biomedical Era

Dena T. Smith

• Publisher: Rutgers University Press
• Year: 2019
• Print ISBN: 9780813598666, 9780813598673
• eBook ISBN: 9780813598680
• Topic: Psychology
• Subtopic: Psychiatry & Mental Health
• Index: Psychology

We live in an era in which medicalization—the process of conceptualizing and treating a wide range of human experiences as medical problems in need of medical treatment—of mental health troubles has been settled for several decades. Yet little is known about how this biomedical framework affects practitioners' experiences. Using interviews with forty-three practitioners in the New York City area, this book offers insight into how the medical model maintains its dominant role in mental health treatment. Smith explores how practitioners grapple with available treatment models, and make sense of a field that has shifted rapidly in just a few decades. This is a book about practitioners working in a medicalized field; for some practitioners this is a straightforward and relatively tension-free existence while for others, who believe in and practice in-depth talk therapy, the biomedical perspective is much more challenging and causes personal and professional strains.

Chapter 1

From Meaning Making to Medicalization

The biomedical and psychodynamic approaches nurture two very different moral instincts by shaping differently the fundamental categories that are the tools of the ways we reason about our responsibilities in caring for those in pain: who is a person (not an obvious question), what constitutes that person’s pain, who are we to intervene, what intervention is good. These two approaches teach their practitioners to look at people differently. They have different contradictions and different bottom lines. Both have their strengths and their weaknesses. Each changes the way doctors perceive patients, the way society perceives patients, and the way patients perceive themselves.

—T. M. Luhrmann, Of Two Minds

Over the course of the late twentieth century a radical shift occurred in psychiatry. The Freudian, psychoanalytic, or psychodynamic talking cure that dominated psychiatric (and most mental health) practice ceded prominence to the biomedical model.1 This transformation felt like a paradigm shift. The movement toward evidence-based medicine and neuroscience involved a dismissal (some say a rejection) of most of the central features of the psychodynamic model and seemed to occur almost overnight. In many ways, however, the path toward biomedical psychiatry was a more gradual sea change in which long-lurking biomedical theories and treatments regained prominence in the field. Regardless, palpable contention characterized the field of psychiatry in the late twentieth century as practitioners battled for the future of a field now overwhelmingly under the influence of the biomedical model. There is no doubt that by the 1980s biological thinking and a focus on diagnosis transported psychiatry from a discipline that valued deep exploration of the psyche to one that advocates short-term, biomedical treatments.

While the history of late twentieth-century psychiatry is far too extensive to explore here and has been expertly recounted elsewhere (see especially Decker 2013; Horwitz 2002a; Shorter 1993), I address in the following pages the background for the conditions under which the doctors in this study practice. As such, I offer a glimpse into psychiatry in the psychoanalytic era and a brief foray into the story of how mental health troubles came under the purview of the biomedical model, with a focus on key ideas, principles of practice, and historical moments in each paradigm. Even more swiftly than it rose to prominence, the psychodynamic tradition—anchored in exploration of the relationship between analyst and analysand (patient), understanding of the unconscious, conflict and defense, and examination of the impact of early experience on the evolving personality—was relegated to the periphery of the field. The biomedical model in psychiatry is now settled and is the overarching framework within which mental health practitioners operate. In particular, psychiatrists today are mostly trained to diagnose discrete symptoms as mental disorder using the classificatory system detailed in the Diagnostic and Statistical Manual of Mental Disorders (DSM) and to prescribe medications as treatment for what are seen as heritable conditions based in neurobiology. This chapter focuses largely on psychiatry, although this story is relevant to other mental health fields, given psychiatry’s wide-ranging influence over diagnostic and treatment standards. Furthermore, the same forces that ushered in biomedical psychiatry—managed care, pharmaceuticals, evidence-based medicine, and shifting consumer desires—broadly impact mental health practitioners.

The Psychoanalytic Heyday: Exploration of the Psyche and the Meaning of Symptoms

Medical historian Roy Porter (1997, 516) describes Freudian psychoanalysis as having “changed the self-image of the western mind.” Though the psychoanalytic heyday was but a “hiatus” between early and current biological models (Shorter 1997), once psychiatry was awash in psychoanalytic principles, neither the field nor broader notions of the psyche and the self would be the same. Freud published The Interpretation of Dreams in 1900 and made his only trip to the United States in 1909 (to deliver a keynote speech at Clark University), yet his work didn’t influence American psychiatry until the 1920s and was not widely read until around 1940, one year after his death (Hale 1995; Lunbeck 1994). Freud’s ideas posthumously revolutionized American psychiatry and conceptualizations of mental illness more broadly, and by the 1950s both were firmly psychodynamic.

In post–World War II American culture, increasing secularism and social conservatism (especially surrounding sexuality) made for fertile ground in which psychoanalysis could take root. Combined with the rising antipsychiatry movement, the notion that therapeutic relationships could alleviate symptoms fueled a desire for a more humanistic way of understanding illness and the mind in general. The psychodynamic approach countered the biological thinking that dominated American psychiatry in the early 1900s, when the prevailing theories depicted mental illness as a brain disorder, which allowed for crude practices like lobotomy and primitive forms of electroconvulsive therapy, among other experimental practices, to be used regularly, with the goal of altering the physical properties of the brain.2 People who experienced psychiatric troubles were set apart from other members of society, often via isolation in state psychiatric facilities. Based on the notion that mental illness was not a drastically different state of being from normality, psychoanalytic theory presented a new language for understanding psychiatric conditions.

For Freud, good mental health was dependent on successful resolution of early psychosexual stages of development. Both dysfunction and healthier outcomes potentially emerged from progression through these universal stages; the latter were seen as proceeding in a biologically dictated order (oral, anal, phallic, etc.), but forward development could be derailed by the possible interplay of both external factors (e.g., trauma, overstimulation, deprivation, etc.) and internal dynamics (e.g., intense conflict over unconscious wishes). Mental life was viewed as dynamic, reflecting an ever-changing, active relationship between reality and mental forces, potentially leading to guilt, conflict, and symptom formation (Greenson 1995; Brenner 1974).

Freud conceptualized most of his patients’ symptoms as representing a neurosis;3 the creation of overt symptoms, designed to mask forbidden unconscious emotions and fantasies, was believed to protect the patient from the overwhelming anxiety that would result from emergence of such material into conscious awareness. This was the central concern of Freudian psychoanalysis (Brenner 1974). Neuroses were presumed to be the result of early psychic conflicts, rooted in psychological mechanisms such as fantasies and wishes, rather than purely in biological malfunctioning. Psychoanalysis was oriented toward the influence of past psychological conflicts on the present, and the assumption that the mind is ever changing, active, in motion—in short, a constant dynamic interplay between reality and mental forces, potentially leading to conflict and possibly to symptom formation. Problems, namely neurotic symptoms, emerged from conflictual wishes during childhood psychosexual stages. One could become “fixated” or stuck in a particular stage (e.g., the oral stage) and later develop a neurotic tendency in that vein (e.g., nail biting). These deviations could happen to anyone, as no one navigates childhood development entirely unscathed. Freudian psychiatry diminished the exoticism of psychiatric troubles by reconceptualizing them as inevitable reaction to the ubiquitous conflicts, wishes, and fantasies that arise in relation to everyday childhood experiences or trauma. In this way, Freudian theory was both universalist (everyone must go through these stages) and individualist (patients navigated these stages in unique ways). Freud conceptualized more severe psychiatric conditions, psychosis, on a continuum with neurotic symptoms, thus making their sufferers seem less worthy of the isolation of asylum settings. Yet because neurotic symptoms were more directly in the wheelhouse of psychoanalytic treatment, psychoanalysis shifted the attention of psychiatrists and laypeople alike away from psychotic illnesses like schizophrenia, which had been the focus of psychiatry through the early twentieth century (Porter 1997).

As a treatment, psychoanalysis sought to mitigate the influence of past psychological conflicts on present functioning. Targeting mostly patients with neurotic symptoms, the Freudian approach helped analysands situate their symptoms in a biographical context with the idea that examination of the patient’s verbal processes and reactions to the analyst could lead to recognition of unconscious conflicts and past (especially repressed) emotions and experiences. Over an extended period of time, the patient’s free associations and reactions to the analyst, in combination with the analyst’s interpretations of hidden fantasies, relational patterns, and defensive mechanisms, would lead to insight about unconscious processes; ultimately, new ways of thinking and experiencing self and others were expected to free people from their neurotic tendencies, whether phobias of insects or sexual inhibitions. In short, for Freudians, the gradual exploration and restructuring of ever-changing subconscious processes—present in all human beings at all times and within the context of the patient-analyst relationship—is the basis of psychoanalytic treatment. Establishing connections between present thought and behavior, unconscious processes required deep knowledge of patients, which was gained in extensive, in-depth treatment usually involving four to five sessions per week. The complexity of psychoanalysis is exemplified by longitudinal case studies that provide detailed information about individual patients’ life stories, character, and personality, as illustrated by Freud’s “Ratman,” “Wolfman,” and “Little Hans” (Freud [1940] 2003). The goal for the analysand, as described by the science writer Morton Hunt in his opus on the history of psychology, was “an awareness of one’s unconscious motives and the attainment of a state in which choices were determined by conscious ones” (1993, 186).

The Freudian model, already well established in Europe (with both fervent challengers and devout followers), rose to prominence in the United States because of a number of key figures in American psychoanalysis, perhaps most importantly Harry Stack Sullivan (Greenberg and Mitchell 1983). Freud’s contemporaries were divided as to what extent psychoanalysts should take culture into consideration when treating patients. Sullivan advocated for and advanced psychoanalytic techniques, but also vehemently disagreed with the lack of context in Freud’s drive theory.4 Most importantly, Sullivan pointed to an “underemphasis [of] the larger social and cultural context,” which, he argued, “must figure prominently in any theory attempting to account for the origins, development, and warpings of personality” (Greenberg and Mitchell 1983, 80). Sullivan’s work was heavily influenced by the pragmatist school, of which he was well informed during his years at the University of Chicago by both psychiatrists and social theorists such as George Herbert Mead, Charles H. Cooley, and Robert Park. An investigation of macro-social influences on individual-level phenomena abounded in the work of these theorists, who suggested that social structures were key factors in determining people’s life chances. There was, therefore, a deeply social bent to Sullivan’s work, especially in his focus on how interaction and relationships affected psychological function and troubles.

Sullivan’s attention to culture and context is a prime example of the deep divide between American psychoanalysts and early Biomedical Psychiatrists. Because Sullivan studied in the 1920s, he was familiar with American asylums at their peak. He spent much of his career studying schizophrenia, since the severe symptoms of this disorder (namely hallucinations and delusions) were likely to lead to treatment in institutional settings. At the time, Emil Kraepelin’s biological theory of schizophrenia dominated thinking in the field. Responsible for many of the earliest classifications of mental illness, Kraepelin is both lauded and denounced for his conceptualizations and measurements of specific mental illness categories with discrete symptom sets (Decker 2013; Horwitz 2002a; Kirk and Kutchins 1992). The Kraepelinian model made it more manageable to identify and treat patients’ symptoms. Many, including Sullivan, however, became critical of the Kraepelinian classification scheme; Sullivan went as far as to claim that the Kraepelinian approach was more about the researcher’s attempt to objectify and characterize the patient than to understand or make sense of the patient’s behavior.5 American psychiatry was fraught with debate between those in favor of discrete, rigid classification and those who supported a focus on experience and context, and much of this is echoed in debates about the perils and promise of the biomedical model that dominate psychiatry today.

A force in establishing the prominence of psychoanalysis in American psychiatry, Sullivan became one of the founding theorists and practitioners of American psychodynamic psychiatry. It is in great part due to his efforts that dynamic psychiatry was infused with such a strong opposition to the biomedical approach and that many American psychoanalysts were so concerned with interpersonal relationships. Sullivan was a powerful figure and successfully pushed psychiatrists to avoid conceptualizations of psychiatric symptoms as representations of biological malfunctioning. Though many early analysts were medical doctors, there was a heavier reliance on philosophy and theories of the mind than on diagnosis and biology; key figures in analysis were well trained in the philosophy of science and hoped to further their discipline by advancing theories on the etiology of mental disorders (Greenberg and Mitchell 1983). The emphasis on patients’ experiences was in line with the broader practice of American medicine. Psychoanalysis emerged during an era in which doctors had ongoing relationships with patients, as managed care had not yet impacted the doctor-patient relationship (Porter 1997). Though psychiatry has always been concerned with some form of diagnosis, psychiatrists in the 1950s and 1960s were rarely preoccupied with discrete classification. In the psychodynamic tradition, symptoms were a starting point but were located in the context of patients’ complex lives.

While illness classification manuals, such as the DSM, play a central role in psychiatry today, practitioners rarely consulted such manuals in the psychodynamic era (Kirk and Kutchins 1992). Even though DSM-II, the edition available for use from the 1960s until 1980, was written from a psychodynamic perspective, it was largely irrelevant to psychiatric practice, as illness categories in classic psychoanalysis were vague and not meant for acute diagnosis. DSM-II was divided into “neurotic” and “psychotic” categories, unmistakably Freudian terminology.6 One of a small number of conditions under the heading “neuroses, anxiety neuroses” was described in the following manner: “This neurosis is characterized by anxious over-concern extending to panic and frequently associated with somatic symptoms. Unlike phobic neurosis [a second neurotic category] … anxiety may occur under any circumstances and is not restricted to specific situations or objects. This disorder must be distinguished from normal apprehension or fear, which occurs in realistically dangerous situations” (APA 1968). DSM-II provided a vague, general outline of a condition, without a specific description of symptoms for identifying a disorder; the practitioner was responsible for contextualizing symptoms based on an intimate knowledge of the patient. Even though dynamic psychiatrists recorded symptoms, they were not concerned with objective classification. Light (1980, 180) aptly captures the dynamic tradition when he describes practitioners who search for “ ‘clues’ to the patient’s dynamics.” Psychiatrists sought to uncover how patients think and how past conditions affect present experiences, which meant discrete diagnosis was largely irrelevant.

Dynamic psychiatry revolutionized the way people viewed mental illness and provided society with a language and a forum for talking about and questioning the concept of abnormality. The spread of dynamic psychiatry was in no small part due to the emergence of what Horwitz (2002a) calls a “culture of psychotherapy.” This culture, however, depended on individuals who were educated and had ample incomes. Dynamic psychiatry offered freedom from repression, which was particularly appealing given post–World War II political and social conservatism, especially pertaining to sexuality. Jewish Americans, sexual minorities, and other oppressed groups were especially interested in the idea of psychological exploration, and artists, writers, and academics routinely sought the help of analysts for everything from difficulty with work and relationships to severe symptoms of depression. Despite its having been the dominant theoretical and treatment paradigm for but a moment, psychodynamic psychiatry had an immense impact on the mental health professions, and it flourished in the United States in the mid-1900s because of a pool of patients interested in and with the resources to afford its intensive treatment, as well as a range of cultural conditions that fostered an openness to its brand of treatment.

Enter the Biomedical Model

As the prevailing American political and social epistemologies shifted in the la...

Table of contents

• Cover
• Series Page
• Title Page
• Copyright
• Dedication
• Contents
• Introduction: Under the Influence of the Biomedical Model
• Chapter 1: From Meaning Making to Medicalization
• Chapter 2: Practitioner Portraits and Pathways to Practice
• Chapter 3: The Promise of “Imperfect Communication” and the “Prison” of Rigid Categorization: The DSM in Practice
• Chapter 4: Etiological Considerations and the Tools of the Trade: The Role of Medication and Talk Therapy in Practice
• Chapter 5: The Consequences of the Biomedical Model for Practice and Practitioners: Psychodynamic Therapy in a Biomedical World
• Conclusion: The Dangling Conversation—Ambiguity in Mental Health Practice
• Appendix: Notes on the Method and Sample
• Acknowledgments
• Notes
• References
• Index
• About the Author
• Series List