Image credit: Alex Widdowson ©2012
Belgium, 1992. I completed my psychiatric residency. Five years of training gives me, among other things, a good psychodynamic foundation and an exposure to a range of psychiatric medications, including the newest ones being touted as, ironically, both scientific and miraculous. In my heart there is an eagerness to learn more, a penchant towards borderline pathology and a desire to relieve souls in suffering.
Since then I have journeyed through very different places: from hospitals and private practice in the European system of universal healthcare (albeit only for its citizens), to the streets, prisons, outpatient services and psychiatric emergency rooms of Los Angeles, a multicultural jungle, and a place where extremes either collide or else ignore each other completely.
Although I was a young psychiatrist convinced of the effectiveness of psychotherapy, there was definitely something thrilling in the ‘Decade of the Brain’ and its ’intelligent molecules’, which were presented as having no serious side effects. Not only would they be a cure for debilitating chronic illnesses but the molecules themselves (or the imbalance thereof) would be the long-awaited scientific explanation of mental illness itself. Suddenly, my new profession, whose ethics were so often questioned (remember the Gulag and lobotomies) and challenged as to its ‘real’ scientific value (Popper and psychoanalysis), acquires the seal of scientific respectability.
Almost overnight, the psychiatrist-prescriber becomes the expert of the new sciences of chemical imbalance, methodical classifications of illnesses and evidence-based treatment. The new science of human consciousness has arrived, a modern discipline where pesky existential questions seem obsolete. In the euphoria of the late twentieth century, pharmaceutical companies and psychiatrists discover one another and embark on a risky love affair. Lavish international conferences are organized during which prestigious panels of experts attempt to give concrete meaning to the inexplicable and in doing so propel the exponential expansion of the market base of the drug industry.
Clinicians (of which I am one) and academics, in a surprising moment of “méconnaissance intéressée” in the words of Derrida, do not seem (or want) to be aware of the potential conflicts of interest in this thrilling adventure. Very quickly, both international psychiatric research and physician’s education become more and more dependent on money from pharmaceutical lobbies.
In medical school, psychotherapy starts to look outmoded. Young doctors are amazed (and perhaps reassured) by the molecular and genetic versions of human passions, and build themselves a new identity, that of the psycho-pharmacologist. The psychosocial model in force in the mental health community no longer seems to apply to a ‘modern’ psychiatry. In libraries, Freud and Frankl are taken off the medicine shelves and end up in the literature department with Albert Camus and Jean Paul Sartre.
At the same time, other voices are speaking up – those of the mental health patients themselves and their families. As part of the wave of civil rights movements that were rushing through America in the 1960s and ‘70s, patients and former patients, some calling themselves “Survivors of Psychiatry”, demand an active role in their own care. “Nothing about us without us”, is their war chant. Under their influence, terminology changes, too. The word ‘patient’, with its implication of suffering and passivity gives way to ‘users’, ‘clients’, and ’consumers’ in keeping with the more active participation of a patient in his or her own treatment. Importantly, this new terminology is also more in sync with a capitalist world where ‘care’ becomes more than ever an object of consumption with profit its underlying goal.
It is into these turbulent waters that I dove when, in 1999, I came to the United States to continue my interest in borderline personality disorders (BPD). Curiously, in these times of medical exhilaration, this group of patients seems to balk at any reductionist classification. BPD doesn’t respond to the “pill-to-heal-everything” approach. BPD patients’ long resistance to both psychiatric and psychoanalytic treatment has earned them a history of rejection and disqualification, the alleged reason being that these patients are difficult, manipulative, or worse, not really sick. It appeared as if only a categorical diagnosis or a treatment validated by modern science could bestow on these sufferers the seal of authenticity.
In my new American reality, I am on the frontlines observing how theoretical, political and social contexts can affect the expression or the occurrence of a symptom, its recognition and what we choose to do (or not do) about it. With BPD patients in particular, the fact that there is no pill to treat them encourages some ER staff members to discharge them swiftly without really addressing their issues. Verbal complaints and “scratches” that may lead to necessary treatment in my previous home of Belgium will generally bring disdain in a US emergency room, where much deeper self-mutilations is required in order to hold the patient long enough to initiate therapeutic engagement . So, the self-inflicted wounds of Otto Kernberg’s and Marsha Linehan’s patients in the US somehow appear more threatening and bloodier than the ones I observed in my small European country. It seems necessary to shout louder in the US in order to have our healthcare system decide finally to take care of you.
Social and political contexts also influence the writing of a prescription. An antipsychotic medication identified as “very safe” in Belgium, might suddenly bring a lawsuit in the United States, due to the fact that a rare side-effect is emphasized in a ‘Black Book’, a tome sold primarily to lawyers.
During my second residency, I was lucky enough to be trained in cognitive and behavioral therapies (CBT). Contrary to the naïve and/or arrogant belief of the psychoanalytical circles in which I did my original training, I realized how well these techniques can work and how easily teachable they are. I have been impressed by the willingness of practitioners of cognitive therapy to prove the effectiveness of their methods, thus gaining ‘scientific’ legitimacy and resulting financial reimbursement.
Forced to question my theories and techniques, I discovered research that suggests that, for a majority of conditions treated in psychotherapy, all the major modes of psychological treatment produce similar outcomes . In fact, this research suggests that only 8% of the variance is due to the type of therapeutic technique, while 70% is due to the overall effect of treatment itself, such as the factors of empathy, a good working relationship between the therapist and his or her client etc. The residual 22% of the variance remains unexplained.
Fascinated by these oddly un-‘modern’ results, I felt reassured in my belief that the individual caregiver’s role is central to the therapeutic process. After all, isn’t modern psychiatry but a new iteration of the age-old combination of witches and wardens?
While the paths of neuroscience and psychology may seem to diverge, an expert interested in both disciplines, Eric Kandel, is trying to force a dialogue between them. In the early 2000s, armed with his recent Nobel Prize for research in neuroplasticity, he proposed a “biological” legitimacy to psychotherapeutic techniques . He has helped us to understand how environment affects the development of our brains as much or more than a chemical molecule does.
If only something biological gives legitimacy to a ‘modern’ treatment, then we must recognize that the interaction between two human beings is also a biological treatment , because it affects our brain’s function and development. For example, the environment may affect the way our genome is translated into proteins, building blocks of cellular receptors essential to our learning mechanisms .
Along this line, researchers have started studying the interactions between the modalities of attachment and molecular genetics , and a new Society of Neuro-psychoanalysis has been created. In borderline patients, neuro-imaging studies have discovered abnormalities specific to their struggles . This is apparently what is needed for science to finally recognize them as real patients.
Image credit: Alex Widdowson ©2012