A Criticism of Biological Psychiatry
The model of psychiatry known as biological psychiatry is increasingly the dominant paradigm in mental health in the United States. Biological psychiatry is characterized by the belief that mental disorders are to be understood as a biological phenomenon. The implications of this belief will be explored in this chapter, specifically in relation to the Lacanian definition of psychosis, and it will be shown that the limitations of biological psychiatry are so profound as to create a situation which is in practice potentially harmful to psychotic patients.
The popularity of biological psychiatry is visible in the anecdotal observation that, since the invention of antipsychotic medications in the 1950’s, pills are more and more the treatment of choice for mental distress. However, this more recent change in technique is linked to a thread with a longer history. The quintessentially human wish for an unassailable position. Freud (1926) tells us that science is “not a revelation,” that it “lacks the attributes of definiteness, immutability and infallibility for which human thought so deeply longs.” Although today’s science is different than that of a hundred years ago, and its position in human society is also different, his statement remains valid. We often turn to science for answers, perhaps even more so now than in Freud’s time, especially answers to questions that have been categorized as medical, but it is at times worth questioning that categorization, which I will do later in this chapter. Recent events have given rise to the opportunity for an even greater medicalization of the popular perspective on psychiatric symptoms and disorders. On April 29th, 2013, the director of the National Institute of Mental Health, Thomas Insel, publicly criticized the soon-to-be published Diagnostic and Statistical Manual of Mental Disorders, 5th edition (DSM-5) as lacking objectivity and touted the benefits of the Research Domain Criteria project (RDoC), which “incorporates genetics” and assumes that “mental disorders are biological disorders.” The treatment model of biological psychiatry is one which attempts to reach a position from which the treatment of patients can be systematized and universally applied: an objective and scientific position. The DSM has been using a checklist approach to diagnosis for over 30 years, the current incarnation of which, the DSM-5, stands strong in its continued determination to use only observable phenomena such as behaviors, complaints, and symptoms to determine diagnosis and thus treatment. Insel also remarked in his blog post of April 29th that “symptoms alone rarely indicate the best choice of treatment” and I strongly agree, although I suspect for very different reasons than his. I doubt that Thomas Insel would put much stock in the way a patient bestows meaning on their own experience, but that is precisely where Lacanian psychoanalytic theory would have us look when symptoms themselves are not enough. When recontextualized within psychoanalytic theory, Insel’s statement does not imply the striving towards objectivity he intended, but rather a loosening of the hold of objectivity.
The reduction of mental illness to brain disease inherent in the position of biological psychiatry treats the question of meaning with a violent hand. Science takes away our responsibility as subjects, a question that Lacan addresses in Science and Truth (1966). If mental disturbance is caused by genetic and chemical factors, there is no space for a human subject to emerge, and move towards taking responsibility. Stijn Vanheule criticizes the DSM-5 from a related perspective. He uses concepts from the philosophy of Frege to delineate a particular lack in the DSM-5 regarding its utility for psychotherapeutic goals. He goes so far as to say (Vanheule, 2012) that the assumption that psychiatric disorders are brain diseases is a view of diagnosis that is “not workable for psychotherapy” and that this approach neglects “precisely what psychotherapy should focus on.” He writes that in fact the priority should be to focus on what is unique and person-specific about a symptom, not what is common to other patients with similar symptoms. In particular, he indicates the value of focusing on how a particular patient relates to their own symptom, and what it means to them. These are perspectives that biological psychiatry is unable to take into account.
In practice, of course, individual psychiatrists may propose psychotherapy as well as prescribing psychotropic medication to treat a given patient. Although most likely only a small minority of psychiatrists would consider themselves to be pure adherents to biological psychiatry, we are still duty-bound to look beneath the surface of the assumptions made by this model, and the logical extremes of following its guidelines. The fact that psychotherapy is very much secondary within the framework of biological psychiatry has an impact that must be examined. Since biological psychiatry is increasingly dominant as a point of view, and its language is the language of science, it is often assumed to be a professional and complete response to the question of mental illness, when in fact it is lacking, like any other model. This chapter will propose a criticism of the archetypal biological psychiatrist. Furthermore, the focus here will be limited to the problems of working with patients who are psychotic according to the model of diagnosis proposed by Jacques Lacan.
According to Lacan (Evans, 1996) the psychotic subject is essentially excluded from the symbolic order of experience. The Symbolic Order is a larger concept, whose definition will not be attempted in this chapter, but for our purposes it is most important to note that it is strongly linked with how meaning is assigned to the world around us. Following a Lacanian definition of psychosis, the practice of biological psychiatry constitutes no less than a violation of the human rights of the psychotic subject, for whom the world of the signification is so fragile. In cases of psychosis the assignment of meaning is more rigid and idiosyncratic, whereas meaning for normal neurotic subjects is decidedly flexible and metaphoric. Otherwise stated, for psychotic subjects there is a “hole in the symbolic” (Fink, 1997) upon which it is possible to exert pressure in a manner that risks further erosion and destabilization. This can be done by taking a position with respect to the patient that would require them to accept the doctor’s view of the existence of hidden layers of symbolic meaning in the patient’s dreams, words, acts, or creations. This position is also described as an attempt to occupy a symbolic position in which a doctor would “situate himself in a tertiary position in a relationship based on...” a dyadic model (Lacan trans. Fink, 1997) and the psychotic lacks the tools to operate in this tertiary mode. Fink translates Lacan’s name for this threatening and paranoiagenic position as the “One-father” and says that by taking this position, it is possible to trigger a psychotic break, or worsen a psychotic episode. In French, Lacan’s name for this position is the “Un-père” which also carries connotations of imperativity, due to the similarity in the sound of the spoken words; the one-father commands. Unfortunately, psychiatrists often do something very close to what Lacan advises against, especially our archetypal biological psychiatrist, who might tell a patient that their delusional beliefs are invalid or incorrect and authoritatively command the patient to enact an a treatment: “you are hearing voices, and they are not real, and this means you are schizophrenic, and so you should take Risperdal.” For the psychiatrist to directly indicate and emphasize latent layers of meaning (or lack thereof) is an unethical act which is fundamentally ignorant of its consequences.
The increasingly biological model of psychiatry implies a basic act which is deeply problematic. If the doctor unilaterally defines the illness as a chemical imbalance and mandates a specific treatment without leaving space for the patient’s own perspective, there is great risk to the patient’s mental health and stability. Lacan tells us that psychosis mitigates the subject’s capacity to navigate symbolic phenomena, and that is precisely what the doctor proposes in making the assumption and the statement that psychosis is an issue of malfunctioning “brain circuits” (Insel, 2013) and bad genes. One might argue that even a biological psychiatrist could take a more delicate approach, and while perhaps believing that the disorder in question was simply a brain disease, would yet decline to tell the patient this view, and instead prescribe a treatment while awkwardly avoiding such complex questions. Why would a biological psychiatrist do such a thing? If it is simply out of an effort towards politeness or manners, then it is a superficial facade that must surely crumble in the face of any intense questioning, which will undoubtedly arise when the proffered treatment induces such severe potential side effects as diabetes and permanent tremors of the hands and face. If it is not politeness, but a more stable position involving guiding principles, then we are no longer in the realm of biological psychiatry. A doctor whose method acknowledges the possibility of impacting the patient’s stability via words alone has moved beyond the brain disease model, if perhaps unconsciously and in an internally inconsistent way.
Psychoanalytic treatment of psychotic patients, and specifically a treatment that follows Lacanian ethical guidelines, allows for the possibility of addressing symptoms and promoting increased stability while respecting human subjectivity. Darian Leader, a British psychoanalyst and author says:
“...the radical revision in diagnostic procedures that characterized the biological psychiatry of the 1980s... effectively removed the problem of meaning from the study of psychosis. The drugs acted on the visible, disruptive symptoms of psychosis, and over time the actual ‘illness’ that they were supposed to treat became redefined in terms of the effects of the drugs. Rather than seeing the drug as the key to the lock of the illness, the illness was defined as whatever would fit that key... what mattered was what symptoms they had rather than ... what they made of them.”
The Lacanian diagnostic model offers only three main diagnoses: Neurosis, Psychosis and Perversion, along with a few subcategories. A diagnosis within this model is based not on observable symptoms and behaviors, like the DSM-5, but on internal psychic structure, gleaned only from hours of sitting with an individual patient, and even then held lightly. This is not efficient or objective work, and it is not a model we can apply universally to every patient who walks through the door, rather we must specifically listen for the singularity of each human subject. Learning more about the patient’s internal psychic structure is what will indicate a better choice of treatment, not genetics, and the treatment grounded in these efforts is one which is humane to a far greater degree, and cleaves more strictly to the dictum of “do no harm,” than the world of psychotropic medications with drastic side effects and mediocre primary effects. Leader (p. 28) says: “By dulling the person’s mental abilities, the drug treatments threatened the ability of the psychotic subject to build self-generated defences against their experience of madness.” I am not, by any means, advocating a total abandonment of the medical model or of psychiatric medications. There are undoubtedly many patients with whom I have been able to do some level of productive work that would have been impossible without the intervention of pharmaceutical drugs. I propose instead a treatment that provides space for the patient to elaborate their own experience without being explicitly invalidated. Moncayo (2008) puts it well, locating the problem not in empiricism itself, but rather describing a “ tyrannically positioned” scientism that “determines practice guidelines” without taking account of human subjectivity.
Psychotic patients are very often treated as less than human within psychiatric institutions. Simply put, their fundamental human rights are violated, specifically their freedom of thought. They are told, in no uncertain terms, that their beliefs and their experience of the world is less than valid and that if they do not not change their beliefs they will not be healthy enough to be released from hospitals where they are kept against their will. Clearly, in situations where a patient’s beliefs seem likely to create a dangerous situation, there is a careful calculation to be done, which takes into account the risk of danger as well as the violence being done by detaining a patient against their will. However, the beliefs themselves are often used as a reason to begin or maintain a treatment that is itself dangerous to the patient. At times patients are expected to conform to standards that have little to do with their ability to function in the world, despite the often-cited relativistic definition of mental illness in terms of functionality. I have heard a psychiatrist say ‘we need to put some different thoughts in his head’ regarding an anxious and preoccupied patient. I have heard a psychiatrist say that he will simply try a variety of medications and see which one works best before giving a diagnosis, indicating the degree to which DSM-5 diagnosis is intertwined with the pharmaceutical industry. Treatment in acute care psychiatric hospital settings in the United States is necessarily limited in scope due to the length of stay, and increasingly dictated by health insurance and other external factors related only tangentially (if at all) to the patient's psychic well-being. This is not a context conducive to anything resembling psychoanalysis. This type of institutional treatment is all too frequently directed by a (possibly unconscious) push towards normalization, which lends itself easily to a shift towards coercion and psychic, if not physical, violence.
One of the forms of violence is seen when the psychiatrist takes the position of arbitrator of objective reality rather than listen, and allow the psychotic patient to elaborate his or her own subjective position, even though it may be drastically different than that of the doctor. Doctors are taught to provide “reality checks” and improve the “reality orientation” of psychotic patients. Although these terms may be used to describe treatment that is less violent, from the perspective of Lacanian psychoanalysis there is no objective reality to which the psychiatrist or psychoanalyst has recourse. In fact, Lacan writes in his seminar on psychosis (Seminar III) that it would perhaps be better to eliminate the idea of objective reality in evaluating psychosis and instead focus on treatment. Fink (1997) says the priority should be psychical reality not objective reality, and puts it thus: “No matter how well trained, a therapist is not an arbiter or judge of what is real and what is not... The all-too-common view that it is the therapist’s job to lead the patient to see reality clearly is a colossal piece of ideology that instates the therapist as the master of reality and knowledge (usually designed to legitimate the therapist in serving some kind of “normalizing” function).” If a doctor believes that s/he knows objectively which of the patients beliefs are delusional and thereby false, that doctor has taken a position which leads perilously towards a violation of the right to freedom of thought. I am arguing here for a kind of treatment of psychotic patients that does not place the collective doctoral ego, as represented by the illusion of objectivity, above the health of the patient.
Perhaps it is worthwhile to examine the reasons a psychiatrist might have to take on a position of authority over the psychic reality of a patient. Firstly, we cannot rule out sadism as a component of the violence we see in biological psychiatry. In his article The Question of Lay Analysis, Freud writes about his choice of studying medicine: "I have no knowledge of having had any craving in my early childhood to help the suffering humanity. My innate sadistic disposition was not a very strong one, so that I had no need to develop this one of its derivatives..." (1926, p. 253). As I said earlier, it is important to question the inclusion of mental disorders within the category of disorders treatable by the medical profession. There is no inherent reason to assume that a state of anxiety or confusion is a question of simple biology. I would argue even further that it would be valuable to question the priority of the biological aspect of most forms of illness faced by doctors. There are factors beyond the body that have great influence upon the body. Certainly it would be comforting to know that a psychosis was curable by a pill, and that there was, in fact, a “normal” state to which a psychotic patient could be returned. Granted, some are more different than others, but there is no threshold for a normal mental state and there is ever so much more to psychosis than medical science and brain disease can address. This leftover ‘more’ is unsettling and it is easy understand something of the anxiety generated by being open to the possibility that an entire profession is based on a misunderstanding and miscategorization. The reason for this miscategorization is primarily a deficit in our collective ability to accept that which is not like us. The efforts to compress the complexity of psychosis gloss over a vital encounter with difference. It is so much more palatable to see oneself as knowing an answer than it is to wrestle with the possibility that there is no reachable answer that completely addresses the question. The dreadful reality of this difference can be linked with sexual difference. Although I will not elaborate those links in detail here, the examples that follow will evince the patriarchal aspects of past theories and interventions. There is a clear trace left on the history of mental health treatment that speaks to struggles with gender difference and issues of power. The concept of hysteria has a long and troubled history, and evokes for many the phenomenon of men labeling women, and an essential intolerance of difference. Whether or not the word hysteria still has value is a larger question, but its history begins with the ancient Greek conception of the “wandering womb.” Treatments for hysteria have included the attempted removal of difference by surgical hysterectomy. Various sexual-themed treatments for hysteria, including intercourse, pregnancy, childbirth, and vibrators to induce orgasm, show a misguided attempt to address this difference. Moving beyond hyteria, the lobotomy (as a treatment for certain diagnoses) was perhaps an act that declared a preference for destroying personhood as opposed to encountering the varieties of personhood. Antipsychotic medications may represent a more sophisticated treatment, but even the name of this category of medications betrays something of a miscategorization. Darian Leader (2012) questions: “is it an accident that today’s drugs are not labelled ‘anti-psychosis’ but, precisely, ‘anti-psychotic’, as if it is the psychotic person themself that needs to be eliminated?” It is natural to be afraid of what one does not understand, but it is something else to try to colonize it. An ethical encounter with psychosis requires a genuine acknowledgement of difference, which many seem not to be capable of. The doctor who fails to encounter the difference in a psychotic patient becomes something of dictator. How can the patient’s fundamental human rights be respected if there is no space for difference?
In proposing that the treatment provider should sustain a place for the radical difference of the patient, perhaps we can also question how the psychotic patient positions the doctor. Psychosis has long been anecdotally described as a situation in which the boundaries between self and other become blurred. Although this may not appear to be a well developed theoretical construct, it has the ring of truth, and leads to useful formulations. In fact, a psychotic patient may be, to varying degrees, incapable of sustaining a place for the difference of the other. When the doctor fails to tolerate the difference their psychotic patient represents, we could see this as, at least in part, a response to the way the patient is positioning the doctor. This is not to excuse the doctor’s failure, but an attempt to understand the relation. In this view, the doctor’s personhood is not acknowledged, and then s/he denies the patient’s personhood in return. This type of relation is of the order of the imaginary, according to Lacanian theory; a symmetrical relation that is “ego-to-ego” and stands unmediated by the influence of the symbolic order. Writing about the attempt to understand, Fink (2010) writes: “Situated within the Lacanian register or dimension of the imaginary, the process of understanding can be seen to reduce the unfamiliar to the familiar, to transform the radically other into the same, and to render the analyst hard of hearing.” The question of how to bring about the influence of the symbolic order in a treatment of psychosis is beyond the scope of this chapter, but a psychoanalyst of psychotic patients must have other options than simply to mirror the relation that is offered to them. An essential part of the ethical treatment of a psychotic patient is the ability to sustain a space for them that they are not furnishing for us. To be sure, these challenges are different than those encountered in the treatment of illnesses that are not ostensibly psychiatric or psychological in nature. This difference is part of what requires the treatment of psychosis to be categorized not simply as a an illness treatable by medical science.
Not only does the treatment that fails these requirements risk a crisis, but it also represents an active attack on the patient’s efforts towards health. Freud (1911) tells us that “The delusional formation, which we take to be the pathological product, is in reality an attempt at recovery, a process of reconstruction.” It is possible to treat psychotic patients in such a way that their own efforts towards reconstruction are given priority in directing the treatment, and many psychotic patients will not be able to productively engage in any kind of therapy that does not leave space for their guidance. In fact, in psychoanalysis, the visible symptoms of psychosis are often seen as a creative response to psychotic experiences as opposed to the symptoms being directly representative of the illness itself. Leader (2011) also refers to Freud in writing that “delusion is less problem than a solution... [it] is not a primary symptom of psychosis but an attempt at self-cure: it is ‘found applied like a patch over the place where originally a rent had appeared in the ego’s relation to the external world... the clinician must recognize that so many of the phenomena of psychosis are not the sign of some deficit but, on the contrary, a path towards creation.” It is precisely where the delusional belief has manifested that we must follow the lead of the patient and learn from them, and support their unique solution insofar as it provides a stabilizing effect. This begins with simply allowing the psychotic patient a place to elaborate his or her own subjective position. I direct the reader to Darian Leader’s “On Madness” for a more detailed description of various modes of stabilization. Many thoughtful and creative attempts have been made to establish ethical treatments for psychotic patients outside of institutions. One such notable effort is the “388” clinic in Quebec City, which implements Lacanian theory.
In conclusion, the logical extreme of biological psychiatry is a positivist scientism focused purely on observable, empirical data, and this does not leave room for some of the most important aspects of human experience, whereas psychoanalysis contains the theoretical capability to specifically address these extremely complex phenomena. When referring to certain trends towards empirical research, Fink (in Dent, 2011) says: “The unconscious is immediately ruled out in the very construction of such studies.” Although the specific position of the unconscious for psychotic patients is under debate, his statement is an indication of the insensitivity of the tools of science when directed towards the objects of psychoanalytic study. The fact remains that efforts to know objective reality are inherent in this medical model and they mitigate the psychiatrist’s ability to avoid taking what is effectively an authoritarian position. The doctor who dictates the reality of the patient by taking a position of knowledge and authority with regard to the meaning of symptoms risks further destabilizing the psychotic subject. This overt and aggressive denial of the subjective experience of another human being would be unthinkable if the patient were not psychotic. A patient who enters treatment for a non-psychiatric condition is not required to change their belief system. On the other hand, we could argue that patients who search out treatment for purely biological illnesses (to the degree we accept such a construction) are in fact asking for a belief system, whereas psychotic patients are very often required to participate in treatment without their consent. The act of treatment consistent with the model of biological psychiatry has a shocking nature when seen from the perspective of Lacanian psychoanalysis. The following quote from Fink (2007) describes something of the horror therein: “...trying to have a chess piece land on a certain square on a chessboard when that square has simply been cut out of the board.”
References
Dent, L. (2011). Lacan in the United States: An Interview with Bruce Fink. Contemp. Psychoanal., 47: 549-557.
Evans, D. (1996) “Dictionary of Lacanian Psychoanalysis”
Fink, B. (1997). A clinical introduction to Lacanian psychoanalysis. Cambridge, MA & London: Harvard University Press
Fink, B. (2007). Fundamentals of Psychoanalytic Technique: A Lacanian Approach for Practitioners. New York: Norton.
Fink, B. (2010) Against Understanding: Why Understanding Should Not Be Viewed as an Essential Aim of Psychoanalytic Treatment, J Am Psychoanal Assoc 2010 58: 259
Freud, S. (1926) "The Question of Lay Analysis"
Insel, T. (2013) http://www.nimh.nih.gov/about/director/2013/transforming-diagnosis.shtml
Lacan, J. (1955) Seminar III: The Psychoses
Leader, D. (2012) “What is Madness?”
Moncayo, R. (2008). Evolving Lacanian perspectives for clinical psychoanalysis. London, England:Karnac Books.
Vanheule, S. (2012) "Diagnosis in the field of psychotherapy: A plea for an alternative to the DSM-5.x"
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