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Poised on the brink:
The social construction of a New Biological Psychiatry
You know the difference between a real science and a pseudoscience? A real science recognizes and accepts its own history without feeling attacked.
- Michel Foucault (1988)(1)
In Chapters 2 and 3 I reviewed historical oscillations in the practical and ideological management of the insane, showing how they have been repeatedly expelled from and reinducted into an ever-more encompassing system of psychiatric care. In this chapter I consider one aspect of the 'moral confinement' into which psychiatric patients have currently been readmitted, namely the presumed somatic aetiology of the major disorders. In particular I attempt to characterise the way in which present-day psychiatrists who subscribe to this ideology position themselves between past and future.
It is common cause that the past two decades have seen the rebirth in psychiatry of an enthusiasm for somatic explanations and the pharmacological management of mental disorders. The first of the new drug treatments came on the market in the late fifties, by the mid seventies 25% of National Health Service prescriptions in Britain were for psychiatric medications (Rose, 1986a), and by the early eighties, faced with the apparent success of drug therapies academic psychiatry had fully embraced a new biological orthodoxy.
Light (1982) describes how "within a short time the leading departments of psychiatry left their imitators and camp followers behind as they forged a new professional identity around advances in biopsychiatry" (p. 43), while Cockerham (1981), writing at about the same time, states: "Bolstered by recent biochemical discoveries, a current view in psychiatry is that the discipline is entering a new era, possibly making psychiatry one of the most scientifically precise of all medical specialties and ending its traditional dependence upon subjective judgments of and insights into the human mind" (p. 79-80). A review (Pincus, Henderson, Blackwood & Dial, 1993) of research articles published in the two leading American journals of general psychiatry, The American Journal of Psychiatry and Archives of General Psychiatry, showed that by the early nineties Clinical Psychobiology had become the largest(2) content category (25%), having risen sharply from 14.4% in 1969-70, while Social Science (12.8% to 10.2%) and Psychosocial Treatments (3.1% to 3.6%) remained more or less static.
Even psychiatrists who are not positively inclined towards biopsychiatry acknowledge its increasing predominance. Arthur Kleinman (1988), an anthropologically orientated psychiatrist, portrays the eighties as a "period of biological revanchism in psychiatry - when many psychiatrists seem[ed] to believe that understanding the biological basis of mental disorders is, if not around the corner, at most two or three streets away, and that such knowledge will be all the clinician needs to know to treat patients with schizophrenia and depression" (p. xi). He goes on to speak of how psychiatry "has been overtaken in the 1980s with a fervor for biological explanations" (p. 1) and complains that "academic psychiatry aims to become a version of high-technology internal medicine" (p. 140). The nineties, designated the 'decade of the brain' in psychiatry (Wallace, 1997), has been dominated by biological research and therapy, and there is widespread agreement that there has been a rapid expansion in understanding of the neurochemistry of the brain (Meador-Woodruff & Watson, 1997). Even at the start of the decade the American Psychiatric Association (APA) president already felt unsettled by "continuing excellent but unbalancing advances in brain biology" (Hartmann, 1992, p. 1137)(3).
These authors for the most part seem to assume that scientific advances constitute the driving force which has catapulted biopsychiatry into its currently 'unbalancing' preeminence. This is typical of 'insider' accounts of the development of science. Insiders tend to place much emphasis on the way in which scientific progress occurs through a process of verification, with incorrect theories replaced by correct ones on the basis of empirical evidence. Thomas Kuhn (1962), whose Structure of Scientific Revolutions has been enormously influential in casting doubt on such views, describes them as follows:
If science is the constellation of facts, theories, and methods collected in current texts, then scientists are the men who, successfully or not, have striven to contribute one or another element to that particular constellation. Scientific development becomes the piecemeal process by which these items have been added, singly or in combination, to the ever growing stockpile that constitutes scientific technique and knowledge. And history of science becomes the discipline that chronicles both these successive increments and the obstacles which have inhibited their accumulation (p. 1-2).
The kind of historiography which Kuhn seeks to debunk has been labelled Whig history, after a phrase used by the British historian Herbert Butterfield to satirise the tendency of some English constitutional historians to portray their field in terms of the continued broadening of human rights resulting from the struggle between forward-looking liberals and backward-looking conservatives (Brush, 1974). In medicine, Mishler, AmaraSingham, Osherson, Hauser, Waxler and Liem (1981) describe Whig histories as follows:
Many discussions of the history of medicine center ... on the history of ideas or on the history of people and events; they view medicine ... as the evolution and advance of important concepts and theories or as the product of key discoveries by researchers. ...These approaches tend to stay within medicine; in them its development is isolated from significant social forces outside the profession. Their implication is that the way medicine developed is the only way in which it could have developed, and - 'should' replacing 'could' - that medicine has been a constant advance of 'better' theory and practice (p. 244-245).
Since Kuhn, many philosophers, sociologists and historians of science have been active in criticizing such justificatory histories, and substituting more 'accurate' accounts of their own (cf. Woodward, 1986; and, for psychiatry, Allderidge, 1990; MacDonald, 1990; Miller, 1986; Scull, 1991b; Vandermeersch, 1991), but perhaps more interesting and logically prior to identifying the forces which 'really' shape science, is simply describing the rhetorical and other devices used by scientists themselves to construct the unfolding of their disciplines (Gilbert & Mulkay, 1984). Doing just that, Scull (1991b) describes the general form of Whig histories in psychiatry as follows:
Psychiatric history was here cast as a morality tale, a movement from the dark period when lunacy was not seen as a condition requiring medical treatment, through a drawn-out struggle in which the steady application of rational-scientific principles by people of good will produced halting and irregular but unmistakeable evidence of progress towards humane and effective treatments for those afflicted with the various forms of mental alienation - a process supposedly culminating in our present state of grace (p. 240).
The philosophical implications of describing science, and particularly psychiatry, in such constructivist terms will be considered in more detail in the next chapter. This chapter has the more limited aim of appraising the ways in which biologically oriented psychiatrists view the past and future of their profession. To distinguish the biopsychiatric movement which has flourished since the late fifties from previous periods of biological dominance in psychiatry, I label it the New Biological Psychiatry (NBP) and identify three distinctive features of the NBP's emerging historiography:
1. Scientific discovery is viewed as the primary mechanism of historical progression;
2. Psychiatry is presented as having only recently emerged from a period of superstition; and
3. The NBP has strongly millenarian overtones. (4)
The first characteristic is shared with science and medicine in general, while the second and third appear to be specific to the NBP. The chapter concludes with a consideration of the prospects for a new anti-biopsychiatry.
'Specific questions of fact': The logic of scientific discovery in psychiatry
In a lecture at London's Maudsley hospital(5), provocatively titled "Biological Psychiatry: is there any other kind?" Samuel Guze (1989), senior professor at a leading American medical school, spelled out the credo of the New Biological Psychiatry: All good psychiatry is necessarily biological. "Psychiatry, " said Guze, "is a branch of medicine, which in turn is a form of applied biology. It follows, therefore, that biological science, broadly defined, is the foundation of medical science and hence of medical practice" (p. 319). Political, religious and philosophical objections to this kind of reductionism are easily dismissed because they are not scientific and, in any case, can themselves be reduced to biology. "I believe," said Guze, "that continuing debate about the biological basis of psychiatry is derived much more from philosophical, ideological and political concerns than from scientific ones ... We will increasingly be thinking and discussing specific questions of fact and their interpretation rather than argue about ideological matters as substitutes for scientific discourse" (p. 322). Thus in the minds of some biopsychiatrists at least philosophy is lumped together with the presumably equally subjective and wordy enterprises of religion, ideology, politics and psychology, and opposed to the 'specific questions of fact' which is the realm of science.
This is Whig history at its best, and if it differs from scientific and psychiatric historiography in general, it is perhaps only in degree. In essence the story remains a tributary of the main medico-scientific tale in which enlightened doctor-scientists gradually, through the painstaking accumulation of facts, overcome the forces of intolerance and superstition. Classics of psychiatric historiography such as Zilboorg & Henry (1941) and Alexander & Sheldon (1966) give dramatic accounts of that great, mythical, upward sweep of humanism and science with which psychiatry has always wished to align itself. The New Biological Psychiatry simply believes even more firmly that an adherence to medical and scientific principles can guarantee for the discipline an ever-upward trajectory from past to future. The word 'progress' leaps out at one from the pages of biopsychiatric texts; it is used no fewer than five times on the first page of Trimble's (1988) authoritative handbook of biological psychiatry.
The irony is that biological psychiatry, perhaps more so than most branches of medicine, has progressed not through rational enquiry and evolutionary growth, but as a result of serendipitous discoveries. The following is an incomplete list of somatic treatments which, by common consent, were arrived at serendipitously:
Electroconvulsive treatment was introduced by Cerletti and Bini on the apparently mistaken theoretical grounds that psychosis and epileptic convulsions are mutually exclusive. Only when the treatment failed with schizophrenic patients, did they extend their trails to include those with affective disorders.
Cade (who afterwards styled himself as 'a little known psychiatrist with no research training'(6) ) stumbled on lithium treatment for mania in the course of testing his theory that manic patients are intoxicated by an excess of naturally-occurring substances (such as lithium) in the body. On observing lithium's sedative effects, Cade reversed his theory, now speculating that mania is caused by a lithium deficiency. However, this theory appears also to have been wrong, and as with electroshock, "the mode whereby it exerts its effects in psychiatry remains unknown" (Kiloh, Smith, & Johnson, 1988, p. 69). Colp (1989) tells another version of the story, namely that Cade thought mania was caused by an excess of natural metabolites (such as urea and uric acid) and that since lithium had been used in medical conditions in which these metabolites were elevated, he speculated that it might also help for mania. It was only when he injected guinea pigs with lithium that he noticed that it produced drowsiness and might for that reason be useful in mania. Cade (1949) himself said he wanted to see if uric acid would enhance the toxicity of urea, which he had injected into guinea pigs, apparently with the purpose of bringing about convulsions in the course of research on epilepsy. "The great difficulty was the insolubility of uric acid in water, so the most soluble urate was chosen - the lithium salt" (p. 350).
Chlorpromazine, the first major anti-psychotic, was first synthesised in 1883 by a chemist analysing chemical dyes, rediscovered in 1937 in the course of searching for a synthetic antihistamine to counteract allergic shock, tested in 1944 as an antimalarial drug, and in 1951 as a tranquilliser for surgical patients (where it was thought to induce "artificial hibernation"; Johnson, 1990). In 1952 Jean Delay and Pierre Deniker reported that CPZ affected mood, thinking processes, and behaviour in psychotics. It was consequently tried first on manic, and later on agitated schizophrenic patients. Iproniazid, the first of the monoamine oxidase inhibitors was initially used in the treatment of tuberculosis, where it was noticed to have mood-elevating properties. Imipramine, on the other hand, being an analogue of chlorpromazine, was on theoretical grounds expected to have value as an antipsychotic, and only when its clinical effects were found to be different from chlorpromazine was it tried on depressed patients. Moprobamate (Miltown), the first of the now notorious minor tranquillisers such as Librium and Valium, was stumbled upon in the course of animal-testing for new antibacterial drugs, where it was observed to relieve tension. And so on.
Of course attempts at linking the history of biological psychiatry to the logic of scientific enquiry differ in sophistication. Kiloh, Smith and Johnson's (1988) historical introduction to their standard text on physical treatments in psychiatry is possibly the most detailed account yet given by biopsychiatrists of the historical development of their discipline. Their technique is first to describe with great candour the various inhumane and senseless treatments which have been the province of biopsychiatry, and then to point out how each became discredited through rational scientific research.
Thus their readers learn how "the most pervasive and dangerous aetiological invention of the twentieth century" (p. 6), focal infection, and its treatment by the removal of teeth, tonsils, reproductive organs etc. reigned supreme until Kopeloff and Kirby demonstrated in a controlled study that more of the controls survived(7). Similarly, the insulin therapy vogue held sway, one is told, until Ackner and his colleagues published their double-blind controlled trial which showed that insulin coma was no more effective than barbiturate-induced coma. Acetylcholine treatment was long administered to schizophrenic and later neurotic patients, but fortunately Pare and others eventually carried out controlled trials in which they demonstrated that equal numbers improved on active treatment and placebo. Carbon dioxide was used in neuroses, anxiety states and hysteria with initial positive results, but "it was left to Hawkings and Tibbets ...to conduct a clinical trial" (p. 10) in which they demonstrated equal efficacy for inhalations of compressed air.
Another example of this kind of presentation is Colp's (1989) version of how chlorpromazine got to be an accepted drug: "In 1964, a double-blind study by the National Institute of Mental Health, which compared the clinical effects of placebos, chlorpromazine, and two other antipsychotics, when each was administered to hospitalized patients, scientifically demonstrated the effectiveness of the antipsychotics and established guidelines for the future clinical evaluation of psychoactive drugs" (p. 2141). However, Johnson (1990) has shown that the drug came to be used on a massive scale before any controlled studies had been done. Moreover, in their review, Wyatt, Apud and Potkin (1996) could find only nine studies that had ever been done comparing first hospitalisation schizophrenic patients given antipsychotic medications with a control group given other treatments. Even among these studies many were not carefully controlled and only two of the nine "found that patients initially given antipsychotic medications did significantly better than those given nonsomatic treatments" (Wyatt, Apud & Potkin, 1996, p. 362).
Kiloh, Smith and Johnson (1988) admit that scientific refutation was not always immediately followed by the clinical abandonment of a treatment (as for instance with the hard-to-eradicate treatment of focal infection) and that treatments may also have been abandoned simply because more convenient or apparently better treatments came along (as in the case of insulin coma treatment which got overtaken by reserpine and chlorpromazine). However, the overall implication is that it was primarily rational scientific research which has weeded out useless and harmful treatments.
This dressing up of the facts encourages practising psychiatrists to assume that convincing scientific refutation of the efficacy of any currently used treatment or theory will soon enough result in its abandonment by the psychiatric establishment. This is so not only for 'true believers', but also for those such as Charlton (1990) who are highly critical of the New Biological Psychiatry. Charlton believes that biological psychiatry is poised on the brink of a paradigm crisis, i.e. "when inconsistencies begin to build up, when good predictions are not forthcoming: when, in other words, things are not working as well as they used to" (p. 6). While there inevitably will be inconsistencies and failed predictions in the biopsychiatric literature, there is little evidence that this is leading to a loss of nerve.
An example is Mellon's (1989) review of genetic linkage studies in bipolar disorder. Once the great hope of biopsychiatric research, linkage studies have increasingly run into difficulties, leading Mellon to conclude that "after 20 years and approximately 30 studies, the status of the bipolar linkage field has not changed much" (p. 155) and that "lack of replication in the field has contributed to a growing skepticism about the usefulness and reliability of the linkage study approach in psychiatric illness" (p. 154). However, despite these devastating conclusions Mellon does not hesitate to add: "Yet it still holds great promise for answering basic questions of etiology and diagnosis" (p. 155).
Similarly Murray, Kerwin and Nimgaonkar (1988) suggest, from their review of the biology of schizophrenia, that "the reader may conclude that the neurochemical findings we have reviewed represent a meagre reward for 25 years of effort" and that the last decade has seen nothing more than "modest progress in understanding the biology of schizophrenia" (p. 176). Nevertheless they remain hopeful that the apparent confusion in the theorising about the neurochemistry of schizophrenia will soon be resolved by the discovery of "some primary but unknown abnormality" (p. 176) in the neurochemistry of schizophrenic brains. Wyatt, Apud an Potkin's (1996) review of the treatment of schizophrenia is equally unenthusiastic about the current state of play (treatments are 'at best palliative', genetic findings are 'tentative' and 'nonspecific'), but hopeful for the future: "Our knowledge continues to grow ... Improved care is on the horizon" (p. 366-367).
A final example: When Harrow, Goldberg, Grossman and Meltzer (1990) found that one of the most taken-for-granted 'facts' in psychiatry, the supposed prophylactic efficacy of lithium carbonate in mania, could not be demonstrated in clinical practice, they did not consider it necessary to question the idea of mania as a condition amenable to biological management or to suggest that the neurochemical theory (such as it is) of mania needs to be revised. Instead, their proposals were limited to practicalities: The use of alternate drugs such as carbamazepine should be explored and blood lithium levels should be monitored more assiduously.
In a closely argued and carefully documented study suggestively titled The structure of psychopharmacological revolutions, Healy (1987) demonstrated that "the catecholaminergenic hypotheses of depression and dopaminergenic hypotheses of schizophrenia(8) appear irrefutable. While apparently testable, negative evidence to date has had little effect and there is almost infinite scope to resist refutation" (p. 367). Much research in the field appears to operate on "the assumption that amines will be found to be deranged in the affective disorders despite the evidence ... that the original pharmacological basis for the expectation no longer warrants an exclusive focus on amines" (p. 359). He concludes that, like the Oedipal hypothesis in psychodynamic psychiatry, these hypotheses will never be refuted, no matter how overwhelming the weight of contradictory evidence, but will at best fade away as psychodynamic psychiatry faded away when research interest moved on to other fields.
'A strange antirational period': Discounting the recent past
A catalogue, such as that presented above, of how biological psychiatry has remained unmoved by 'specific questions of fact' prompts a sceptical response to claims by Guze (1989) and others that psychiatry has loosened itself from the fetters of philosophy and will henceforth operate along strictly scientific lines. A tendency to oversell the internal coherence of research work is not however by any means unique to biological psychiatry, and equally damaging accounts have been given for instance of biology (Meyers, 1990) and physics (Gross, 1991).
Like other scientific historiographies, that constructed to explain and justify biopsychiatry also locates speculative, philosophical and superstitious behaviour in the discipline's past, with rational and scientific approaches supposedly becoming more prominent as one approaches the present(9). Critical historians of science have argued that "preconceptions of science as necessarily antagonistic to superstition [have] resulted in a misperception of historical data" (Kirsch, 1980, p. 359), and that the passage of time has rendered practices such as a belief in demonology and witchcraft sufficiently exotic that it is easy to forget that they were once considered established fact by such scientific luminaries as Copernicus, Kepler, Napier, Boyle and Newton.
What is rather special about the New Biological Psychiatry, however, is that it places the era of superstition not in the sixteenth or seventeenth centuries, but only two or three decades away. The culmination of these superstitious tendencies was, so the story goes, the deinstitutionalisation debacle of the 1960s and 70s. Cancro (1989) speaks of "this strange antirational period of massive denial and grandiose expectations" (p. vii) and of the "near delusional beliefs" of those psychiatrists who participated in it. Deinstitutionalisation's failure appears to represent a powerful warning that to trivialise mental illness as anything other than a serious biological disease is to advocate the gross neglect of psychiatric patients. Thus Trimble (1988) feels compelled to explicitly warn fellow biopsychiatrists against again becoming "submerged and lost in a quagmire of new, old or revived psychological theorising" (p. xii).
To make things worse, psychiatry is presented as having lost its head not only for a decade or so after the 1960s, but for the better part of a century. The trouble started, as Trimble (1988) explains, with "psychological theorizing, which arose on the neoromantic tide of the turn of the century. This culminated in the psychoanalytic movement, which for a considerable time became synonymous with psychiatry" (p. xi). This 'considerable time' lasted from the 1920s until well into the 1970s, a fact which historians of the New Biological Psychiatry believe should be seen in the context of a much longer period of relative sanity: "this era has provided psychiatry with a legacy that it does not deserve, the main trend of the tradition for over 2000 years being medical and neuropathologically based" (Trimble, 1988, p. xi-xii). It is doubtful if any other scientific discipline, medical or otherwise, has had to admit to such a sizeable recent dip in what is usually presented as the steadily rising line of scientific conquest, and in this respect the New Biological Psychiatry clearly differs from psychiatry in general.
Another curiosity is that the main physical treatments in psychiatry, the treatments which have given biopsychiatry such a central place in everyday psychiatric practice, were instituted not before or after the 'strange antirational period', but while it was still in full swing: Electroshock in 1938, lithium in 1949, chlorpromazine in 1952, and imiprimine in 1958. Cancro (1989) explains this anomaly by presenting biopsychiatric research as an ongoing enterprise which, although periodically repressed, continued with the painstaking task of scientific knowledge accumulation:
The period was primarily dominated in America by psychoanalytic thinking. Biological studies were going on, but they were not in the mainstream. It was not until the mid-1950s, with the introduction of pharmacologically effective compounds, that American psychiatry began to move into the pantheon of medicine. Despite this scientific movement of the 1950s, the exuberance of the 1960s swept much of the previous rational enquiry and evolutionary growth aside (p. vii).
Is it true that psychiatry has just returned from a half-a-century long psychoanalytic detour in the course of which it lost contact with the grand old traditions of its biomedical past, or are both the detour and the grand old traditions New Biopsychiatric inventions?
That psychoanalysis had a certain prestige in psychiatry in the period from the 1920s to the 1970s, and that it in turn conferred a degree of prestige on the psychiatric profession, cannot be denied. However, it is clear that somatic views of mental illness were by no means discounted. Among the more horrific treatments advocated and administered by biopsychiatrists during the 'neoromantic' period are pre-frontal lobotomy, of which over 50 000 had been performed by the mid-fifties and hydro-therapy, which (in one of its variations) required that patients be kept tightly cocooned for up to four hours in sheets which were regularly drenched, first with cold and then with hot water. Then as now, it was only a small minority of hospitalised patients who were ever psychoanalysed. For the vast majority of hospitalised patients the facts of psychiatric life revolved around closed wards, restraint, and somatic treatment.
Two textbooks for lower-level psychiatric personnel published on the eve of deinstitutionalisation are suggestive of the sorts of things left out of biopsychiatric accounts of what we are asked to believe was a neoromantic/psychoanalytic interregnum. Rodeman (1956) starts her guide for American psychiatric aides with the following confident assertion, so very reminiscent of latter-day biopsychiatric statements: "The history of the care and treatment of psychiatric patients reveals that this care has progressed from abuse and punishment in the early days to the present-day care and treatment based on scientific knowledge and understanding of human behaviour" (p. 1). She goes on to advise aides to bear in mind that psychiatric patients perspire more than ordinary people, to never show either approval or disapproval of patients' behaviour ("remember always that he is ill and that his behaviour is a symptom of his illness"; p. 13), and so on. Much attention is given to the mechanics of preparing patients for insulin coma therapy and hydro-therapy, and aides are repeatedly urged to "reassure the patient and emphasize that this is a treatment," (p. 44) and to "avoid any details of the treatment which might frighten the patient" (p. 98). In case there are some aides who harbour doubts of their own, Rodeman is quick to reassure them: "It is not yet known how the insulin coma produces improvement in the patient, but improvement occurs in all aspects of his personality" (p. 97).
The second textbook, by Houliston (1955), matron at Crichton Royal Mental Hospital at Dumfries, was written for British psychiatric nurses, but the picture she paints is very similar. Confinement, seclusion, supervision of patients with 'tendencies to wander or escape' - these are presented as the stock in trade of a nurse's life in a mental hospital. Psychotherapy gets just more than a page, in which the reader is informed that it has two varieties: Suggestion and Persuasion. All-in-all Houliston is as confident as Rodeman that science is still carrying us all upwards and forwards and that things are much better now than they were in the bad old days: "The modern treatments available to mental patients include such things as electro-shock, insulin therapy, prolonged narcosis, hydro-therapy, occupational and recreational therapy, the various forms of psychotherapy, and prefrontal leucotomy, the brain operation recently introduced in psychiatry with success" (p. 7).
Rodeman and Houliston's textbooks were chosen for purposes of illustration, but are not unique. A similar ethos for instance pervades Ingram's (1949) Principles of Psychiatric Nursing and Altschul's (1957) Aids to psychiatric nursing, although Trick and Obcarskas' (1968) more recent Understanding Mental Illness and its nursing is perhaps not quite in the same category. A somatic orientation towards mental illness during the 'neoromantic' period is not confined to nursing texts either, as is demonstrated by the preface to the sixth edition of Henderson & Gillespie's (1944) Text-book of psychiatry in which they state that: "The dramatic successes attained by methods of physical treatment, such as those conducted by chemically or electrically induced convulsions and by surgical division of the white matter of the frontal lobes, have prompted us to add a special chapter on these triumphs of empiricism" (p. vii).
Interestingly, both Rodeman and Houliston have historical introductions in which psychiatry's imagined progression from superstition to science are mapped out. Houliston's historiography is particularly interesting in that she divides psychiatric history into various eras ('demonological', 'political' and so on), locating the then present firmly in the scientific era. Ironically this era is said to have started with the dawn of the twentieth century, just at the precise moment that Trimble (1988) sees the 'neoromantic tide' coming in.
If the story about psychiatry's neoromantic aberration is illusory, what then about the grand-old-tradition story? The short answer to this question is that, with the exception of clearly organic brain syndromes such as Alzheimer's disease and General Paralysis of the Insane (cerebral syphilis), which as early as 1822 was understood to be a physical disease and by 1909 "had moved from the stormy waters of psychiatry into the safe harbor of neurology" (Gilman, 1988, p. 211), the neurological basis of mental illnesses remains unexplicated. Similar views have been expressed by Kleinman (1988) and Kleinman and Cohen (1997). Kleinman (1988) states the case quite bluntly:
There is still, after more than 30 years of intensive biological investigation, no clear-cut understanding of the biology of schizophrenia ... This does not deter psychiatrists and those who write the advertisements for drug companies from asserting without any hesitation that schizophrenia is a biologically based disorder. This belief is a central tenet of professional orthodoxy (p. 188).
Trimble (1988) is probably correct in stating that the main trend in psychiatry over the past 2000 years has been neuropathological, but unfortunately there is little in this tradition, except for its general sentiment, which is of much use to modern biopsychiatry. Hippocrates and Galen may have set an example in their insistence that mental illness has a somatic origin, but their aetiological ideas concerning the correct mixture of phlegm, bile and so on now seem fanciful. The same goes for the seventeenth century British biopsychiatrist Thomas Willis, the details of whose theory relating to animal spirits circulating through the cortex are of course no longer accepted. The list goes on: Griesinger (insanity is caused by changes in circulation, nervous irritation or disturbed nutrition); Morel (insanity is a hereditary form of 'degeneration'); Foville (neuroses are localised nervous system diseases).
It is instructive to look at the original texts of some of these great figures from the prehistory of biopsychiatry, for instance that of James Prichard (1837). Prichard is mainly famous for creating the now-defunct disease of moral insanity "consisting in a morbid perversion of the natural feelings, affections, inclinations, temper, habits, moral dispositions, and natural impulses, without any remarkable disorder or defect of the intellect or knowing and reasoning faculties, and particularly without any insane illusion or hallucination" (p. 16). The great danger in moral insanity is that "persons labouring under this disorder are capable of reasoning or supporting an argument upon any subject within their sphere of knowledge that may be presented to them; and they often display great ingenuity in giving reasons for the eccentricities of their conduct, and in accounting for and justifying the state of moral feeling under which they appear to exist" (p. 21). A typical example of moral insanity would be a previously submissive adolescent girl who runs away from home or a housewife who questions her husband's authority; and for many decades after the publication of Prichard's book the concept of moral insanity was referred to by psychiatrists making commitment decisions in such cases.
Although it was accepted that social and psychological factors could play a role in moral insanity, at root it always had a physiological cause: the person's inherent 'temperament', a 'natural predisposition', or perhaps "some disorder affecting the head, a slight attack of paralysis, a fit of epilepsy, or some febrile or inflammatory disorder" (p. 21). And what is to be done about insanity, moral or otherwise? Prichard endorses the whole plethora of what now appear to be wilfully cruel and senseless treatments: bleeding, cold showers, purgatives ("no fact in medical practice has been longer established than the utility of purgatives in madness"; p. 195), emetics, digitalis, opium, mercury and the rotating chair.
'A thing of the past': Millenarian qualities of the New Biological Psychiatry
In his foreword to Kaplan and Sadock's Comprehensive Textbook of Psychiatry Robert Cancro (1989) refers to "this brief historical summary" (p. vii). However, the preceding two paragraphs are historical only in the sense that they rehearse the by now familiar idea of an irreconcilable difference between 'theological' intuition and rational science. Instead, pride of place goes to Neural Science (Chapter 1) and Neurology (Chapter 2), with history relegated to the last 21 pages of the two volume work.
This was not always the case. Stepping back a mere decade one finds that the third edition, published in 1980, opened with a lavishly illustrated historical chapter by George Mora, spread over 94 pages. By the fourth edition, five years later, this had been cut to 20 pages and moved to the end of the book, although the opening chapter still tackled 'theoretical trends' in psychiatry. The fifth edition, as mentioned, gets straight to business with Neural Science and Neurology; and the history chapter at the end, no longer by Mora, has degenerated into a lack-lustre catalogue of great men and their achievements. The most recent, seventh edition of Kaplan & Sadock (Kaplan, Sadock & Grebb, 1994) has no separate history chapter and opens with a full-colour guide to commonly prescribed drugs.
Why has history's shares, as reflected in the 'bible' of American psychiatry, dropped so precipitously over the past two decades(10)? At one level it is no doubt simply a matter of space. To accommodate the mass of new material being produced in fields such as brain imaging and neurochemistry it is only natural that 'old-news' items such as history and philosophy should be jettisoned. At another level it is an ideological shift which requires that psychiatry distances itself from aspects of its own history in order to 'make itself anew'. This is essentially the same conclusion as that arrived at by Foucault (1980), who asks:
Why should an archaeology of psychiatry function as an 'anti-psychiatry', when an archaeology of biology does not function as an anti-biology? Is it because of the partial nature of the analysis? Or is it not rather that psychiatry is not on good terms with its own history, the result of a certain inability on the part of psychiatry, given what it is, to accept its own history? (p. 192)
The gradual silencing of history's voice in the halls of biopsychiatry is not due to a loss of faith in the essentials of psychiatric historiography (progress through rational scientific discovery), but to a certain discomfort with regard to that history. There is little that the NBP can do with psychiatric history before 1955, except to warn against the dangers of unscientific theorising, or to show that for a very long time psychiatrists have believed in organic aetiologies and treatments of one sort or another despite the lack of empirical warrant.
For biopsychiatry the past is shrinking while the future is looming ever larger. The little history chapter at the end of the fifth edition of Kaplan and Sadock is called "Psychiatry: Past and Future", and from the 'future' section we learn:
The good news is that, because of progress both in scientific understanding and in clinical practice (all of which is likely to continue at the present brisk pace), the public will increasingly see mental illness as illness and psychiatrists as physicians who treat mental illness - more and more effectively. The stigma that was once attached to the psychiatric profession is likely to become, fairly soon, a thing of the past (Pardes, 1989, p. 2157).
Pardes may well be right. Popular magazines such as Time and Scientific American and television programs such as Beyond 2000 increasingly reproduce biopsychiatric orthodoxies regarding the aetiology and treatment of syndromes like schizophrenia and the major affective disorders. They also reproduce the promissory notes which biopsychiatrists almost routinely append to the end of their research reports. This is how, for example, Gershon and Rieder (1992) conclude their Scientific American article: "We expect our understanding of the biology of schizophrenia and mood disorders to expand dramatically, fuelled by the impressive advances in neurobiology, cognitive neuroscience and genetics" (p. 95).
Similar expressions of hope and expectation are very common in the professional literature. Some examples from genetic studies: "There is good evidence, especially from studies of twins and adopted children, that genetic factors are important in minor psychiatric disorders ... the recent tentative location of genetic sites associated with manic-depressive psychoses gives hope that such sites may also exist, and be found, for the cyclothymic and dysthymic traits" (Hare, 1991, p. 44). "Once a gene is identified a whole new era will begin" (Mellon, 1989, p. 155). "It seems likely that if major genes operate on schizophrenia, these will be identified in the next few years" (Murray, Kerwin & Nimgaonkar, 1988, p. 176). "We can be confident that, if genes of major effect are involved reasonably commonly in the aetiology of schizophrenia, they will be detected and localised during the next few years" (McGuffin, Owen & Farmer, 1995, p. 681).
Despite the passing of each successive 'next few years' the putative genetic mechanisms behind schizophrenia and other psychiatric disorders continue to remain elusive, and much the same is true concerning a viable theory of the neurochemical mechanisms involved, and of the effects of psychotropic medications (Wyatt, Apud & Potkin, 1996). Ingleby (1981) speaks of "the myth which helps to keep orthodox psychiatry on the move: the belief that what we need are simply more 'findings' - that round the corner lies some vital new fact which will settle the arguments once and for all" (p. 23). While persuasive evidence may yet become available in the 'next few years' (for instance from the human genome project), the New Biological Psychiatry has manoeuvred itself into a position where a post-millenarian scenario, in which it becomes evident that the arguments will not or cannot be settled, is at least conceivable.
'More than a science': The new anti-biopsychiatry
At the start of the chapter it was mentioned that not all psychiatrists and other mental health workers are equally comfortable with biopsychiatry's rampant successes. In an article in the British Journal of Psychiatry Robert Cawley (1993), emeritus professor of Psychological Medicine at the University of London, argues that psychiatry is more than a science - more even than an applied science - and that certain aspects of the assessment, management and prognosis of mental illness can therefore not be reduced to (or deduced from) scientific findings. Like other practitioners of a possibly embryonic new anti-biopsychiatry Cawley is circumspect in his criticism. A formula commonly used in this emerging literature is to start by acknowledging the achievements of biopsychiatry up front. Thus already in the second paragraph Cawley (1993) talks of "the neurosciences, in which we have seen staggering advances in the last couple of decades" (p. 154). Similarly, Gabbard (1992) in his rear-guard defence of psychodynamic psychiatry refers in the first sentence to the "remarkable discoveries from the neurosciences [which] fill the pages of our journals" (p. 991); Person (1989) starts his argument against mindlessness in psychiatry by admitting that "psychoanalysts cannot ignore the biological revolution that has occurred in academic psychiatry" (p. 182); Hartmann (1992) refers to "continuing excellent but unbalancing advances in brain biology" (p. 1137); while Wallace (1997) speaks of the "gargantuan literature" in the field of biopsychiatry and the "tremendous scientific and clinical fruit" (p. 92) borne by this branch of the discipline.
Such attempts to downplay differences occur throughout nominally critical texts now found in psychiatric journals. Cawley (1993) readily admits that psychiatry is a science, asking only that we don't forget that it is also more than a science, while Gabbard (1992), who argues not against biopsychiatry, but against "the 'either-or' polarization of the psychodynamic and the biological" (p. 991), strenuously attempts to blend the discourses of neuroscience, psychodynamics and behaviourism, as exemplified by the following:
Painful events, such as separations and losses, early in life may sensitize receptor sites, leading to vulnerability to recurrent depression in adulthood ... ideas and images associated with depressive states could ultimately act as conditioned stimuli capable of eliciting a major depressive episode without a concrete loss or external stressor in the environment (p. 992).
While speaking of subjective early childhood experiences and receptor sites in one breath may at first seem strange, it is a distinct possibility that an amalgamation of bio- and psycho- jargon may become common in psychiatric circles, with the language of neurology gradually taking on metaphorical meanings, particularly if a hard scientific understanding of mental disturbance continues to elude researchers.
Sensitive to the requirements of the times, Shevrin (1988) attempted to imbue psychoanalysis with neuroscientific respectability, and neuroscience with psychoanalytic meaning, using what might previously have been seen as absurd methods such as event-related potentials to prove the existence of the unconscious. Another example in this genre is Post's (1992) work, which attempts to straddle the gap between the literatures on psychosocial stress and neurological deficits in affective disorders, with formulations such as the following being common: "[social] stressors and the biochemical concomitants of the episodes themselves can induce the proto-oncogene c-fos and related transcription factors, which then affect the expression of transmitters, receptors, and neuropeptides that alter responsivity in a long-lasting fashion" (p. 999).
Abroms (1993) describes at length how he reconciles psychodynamic and biological approaches in his psychiatric practice, devoting entire chapters to topics such as "staging the treatment" and the "dynamics of drug therapy", pointing out, in terms reminiscent of moral treatment, that "therapists may have to work hard to become better attuned to the patient's special needs, to provide the support and tenderness that enlists cooperation, and the caring firmness that curbs rebellion" (p. 160). According to Abroms, without such precautions drug treatment may fail due to psychodynamic factors such as 'performance anxiety', 'castration anxiety', 'oral rage', the 'incest taboo', and 'fear of penetration'. A case study of "Carla, the lonely, divorced patient" ends as follows:
Her psychotic mother was so poisonous that Carla regarded all gifts of food or medicine emanating from a parental figure as bad milk. After much reassurance and insight, she was finally able to swallow her antidepressant and let it work (p. 169).
While most biologically oriented psychiatrists would perhaps balk at using this kind of formulation, they are happy to concede that the giving of medication has to be seen in a psychological and social context: "We are fully aware that current biological treatments work best when they are combined with psychosocial intervention, and expect that future biological treatments will also involve appropriate nonbiological considerations" (Wyatt, Apud & Potkin, 1996). In addition to suggesting that therapy might help pills to work, it is equally commonly suggested that the relationship between the two modes of treatment runs the other way around. Cooper (1989), for example, says that "in instances in which an underlying biologic malfunction is suspected, there is powerful warrant to attempt a biologic intervention that may then facilitate psychological interventions" (p. 209). Alternately a peaceful coexistence may be achieved by carefully demarcating separate professional and philosophical territories for mind and brain: "Psychoanalysis is a powerful instrument for research and treatment, but not if it is applied to the wrong patient population" (Cooper, 1989, p. 216).
Where the new anti-biopsychiatry offers alternatives to hard-core biopsychiatry these tend to be quite low-key and bland, a far cry from the strong medicine once prescribed by antipsychiatrists. Cawley's (1993) list of those aspects of psychiatry which are beyond science include, for example: individuality, subjectivity, self awareness, interpersonal processes, empathy and communication. Since, according to Cawley, these are the "six, and only six, crucial aspects of our discipline which are in principle unrelated to the basic sciences and yet are central to what we are doing" (p. 155), one must assume that such stocks in trade of antipsychiatry as free will, morality, and creative deviance are amenable to scientific treatment, not crucial aspects of psychiatry, or not central to what psychiatry is doing.
It may in fact be overstating the case to claim that such a thing as the new anti-biopsychiatry exists, even in embryonic form. The impression of important scientific advances having been made in the last three decades, and of even more important advances being imminent and inevitable, is so strong that all can now afford to be magnanimous in allowing diverse views a place in the psychiatric sun.
APA president Hartmann's (1992) appeal for a return to Engel's (1979) biopsychosocial model is perhaps more typical of the discourse one can continue to expect from psychiatry than the Guze's (1989) polemical biologism. Joseph English (1992), then APA president-elect, called for balance and tolerance in the mind-brain debate and praised the average psychiatrist as "the most tolerant of medical specialists" (p. 1142). This is the kind of middle-ground discourse where psychiatrists and psychiatric commentators have long been accustomed to meet. Both Arthur Kleinman (1988) and Sander Gilman (1988), neither of whom are anywhere near the psychiatric mainstream, can for instance be seen to be calling for much the same thing as the APA president: "The extreme relativism of some antipsychiatry anthropologists is as outrageously ideological as is the universalistic fundamentalism of some card-carrying biological psychiatrists" (Kleinman, 1988, p. 33); "I find the middle ground - where culture and biology reciprocally interact - the best vantage point from which to make sense of the cross-cultural data base and to avoid the excesses of its extremist neighbors" (Kleinman, 1988, p. 187). Or Gillman (1988):
Such writers as Thomas Szasz and R.D. Laing began to see mental illness as an artifact of society. Then the resurgence of a biologically oriented psychiatry in the past decade has led to the illusion that mental illness is simply an artifact of biology. Both views ignore the fact that the idea of mental illness structures both the perception of disease and its form (p. 18-19).
To the extent that a new anti-biopsychiatry might therefore exist, it is at most an attempt to tone down the shrillness of extreme biological positions, and to ensure that the baby is not thrown out with the bath water. At the same time, it provides a back door for psychiatry should the strong biological programme not deliver on its promises. Rather than a millennial religion, prone to falling apart when its prophesies are not fulfilled, the New Biological Psychiatry may have the capacity to expand back into psychosocial territory should this prove necessary. Wallace (1997) explains how such a feat could be justified:
A species-specific physiology, ethology, and ecology of Homo sapiens must encompass the image- and symbol-laden dimensions of both personal experience/ behavior and its sociocultural surround. In short, the naive and energy-wasting warfare between "biological" and "psychosocial" psychiatrists is founded on a breathtakingly constricted construct of human biology and on an unacknowledged "mind" - "body" split (p. 90).
Drob (1989) identified six possible ways for psychiatry to deal with theoretical diversity, of which three seem to describe the positions reviewed in this chapter: Relativism ("The emergence of a single dominant paradigm for psychiatry, if it occurs at all, will be determined by historical, economic, sociological, and other nonscientific factors", p. 63 - i.e. the traditional outsider historiographical position), commensurability (the best theory will win - i.e. the 'hard' biopsychiatric position) and reductionism (different modes of understanding can ultimately be translated into each other - i.e. the new anti-biopsychiatry or the 'soft' pro-biopsychiatric position).
A new scientific language for psychiatry, which may create the conditions for using apparently hard-edged neuroscience terms as metaphorical codes for mental concepts, is being forged not only as a by-product of projects such as Post's (1992) stress-deficit work, but also quite consciously in DSM-IV. Spitzer, First, Williams, Kendler, Pincus and Tucker (1992) describe their proposal for doing away with the term "organic mental disorders" in DSM-IV, arguing that psychiatry has now superseded the Cartesian mind/body duality, formerly reflected in "the two great divergent trends in psychiatry during the later part of the nineteenth century" (p. 240), viz. 'brain psychiatry' and psychodynamics. While the inclusion of 'organic mental disorders' in DSM-III and DSM-III-R may not be meant to imply that the other disorders are non-organic, Spitzer et al. are seriously concerned that such connotations may nevertheless exist:
The connotative meaning of the word 'organic' always returns to its historical roots, which imply a functional/structural, psychological/biological, and mind/body dualism ... These original dichotomies may have been valuable when we had little understanding of how the CNS functions, but they are at variance with the growing body of evidence of the importance of biological factors in the etiology of the major 'nonorganic' mental disorders (p. 241).
Spitzer et al.'s proposed solution is a trichotomy, classifying all disorders as either primary (e.g. schizophrenia proper), secondary (i.e. secondary to some non-psychiatric medical disorder, e.g. dissociative disorder due to epilepsy) or drug-induced (e.g. cocaine-induced erectile dysfunction). The beauty of this system, now by and large implemented in DSM-IV (which no longer uses the term "organic mental disorders"; Kaplan, Sadock & Grebb, 1994), is that it eliminates any remaining suggestion that the major psychiatric disorders are nonorganic, without on the other hand explicitly identifying them as necessarily organic. DSM-IV, as the official style manual of psychiatric discourse, has yet again moved along with the new biopsychiatric fashion, without having committed itself to an extreme biological view which may eventually prove untenable.
Throughout its history psychiatry, more so than the rest of medicine, appears to have been unable to operate without an attendant anti-psychiatry. As Dain (1989) points out, hostility to psychiatry even predates the establishment of psychiatry as a profession in 1844, and has often come from psychiatrists themselves - sometimes taking on a relatively benign (although influential) form as was the case for the group of psychiatrists around Clifford Beers at the turn of the century, and sometimes involving a thorough-going rejection of most of psychiatry's scientific and institutional basis, as was the case more recently with Szasz, Laing and company. As Rose (1986b) has argued, opposition to psychiatry has in fact been central to its modernisation.
From the current evidence it seems likely that the future new anti-biopsychiatry, if it is to be led by psychiatrists, will be of the Beers rather than the Szasz variety. However, it remains possible that the more radical challenge from outside psychiatry, particularly from ex-patient groups and their allies may gain in power. According to Parker and Burman (1993), who have worked extensively with groups critical of psychiatry, such groups are currently defining community-based treatment of mental illness as a thinly disguised device for regulation and control, much as has been done in Chapters 2 and 3, and the concerned academic's job should therefore be "to publicize the analyses presented by these groups rather than expropriate them, rather than presenting them as if they were ours" (p. 165).
Unfortunately, some patient and family lobby groups, such as SANE (Schizophrenia - A National Emergency), seem at present as likely to adopt conservative positions(11)
. Dain's (1989) gloomy prognosis perhaps best summarises the state of play:
What form both psychiatry and anti-psychiatry will take in the future is unclear. It is probably safe to say that short of achieving definitive knowledge about mental disorder and how to treat and prevent it and without the public will to care adequately for mentally disabled persons, both psychiatry and anti-psychiatry do have a future (p. 19).
1. In Martin (1988, p. 12)
2. 32 The second largest category was Diagnosis/nosology at 21.7%, with Psychopharmacology third at 17.1%.
3. 33 As early as the mid-sixties Alexander and Sheldon (1966) complained of the rising new biologism: "The role of the devil now has been taken over by brain chemistry. No longer a devil but a deus ex machina, a disturbed brain chemistry rather than the person's own life experiences, is responsible for mental illness. Whatever the cause of faulty brain chemistry may be, the new conviction is that the disturbed mind can now be cured by drugs and that the patient himself as a person no longer needs to try to understand the source of his troubles and master them by improved self-knowledge" (p. 14). From the late sixties the National Institute of Mental Health started targeting biopsychiatric research for nearly all its funding (Light, 1982).
4. 34 Birley (1990) labels the current somatic phase 'optimistic' or 'manic' organic theory, and cautions that it is liable to be followed by a pessimistic or depressive side.
5. 35 Later reprinted in Psychological Medicine.
6. 36 As quoted in Kiloh, Smith and Johnson (1988).
7. 37 In fact contradictory findings were repeatedly ignored or suppressed. See Scull (1990) for a detailed history.
8. Wallace (1997) terms it "the hallowed dopamine hypothesis" (p. 93).
9.39 As Colp (1989) puts it: "One comes away with a fresh appreciation of the great differences between ancient and modern - notably, the recent dramatic progress in the diagnosis and treatment of most psychiatric diseases" (p. 2143).
10. 40 As reflected also in psychiatric training: "The subject has been largely dropped from the Royal College of Psychiatrists' examination curriculum, has no academic base within the psychiatric establishment, and little following among the younger generation of more 'scientific' psychiatrists" (Turner, 1990, p. viii).
11. 41 A spokesperson for SANE is quoted (by Barham, 1992) as follows: "Never in the history of research into the workings of the brain has there been such hope that the cause or causes of this illness will soon be discovered. What is known is that schizophrenia is most likely to be a biochemical disorder of the brain". The advantages for patients and families in having conditions such as schizophrenia accepted as a 'real' disease are obvious.
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