The Smug Style in American Psychiatry

I’ve been reading Anne Harrington’s new book, Mind Fixers, which is about the long and complicated history of psychiatry’s search for a clear biological basis for mental illness. The book doesn’t argue that there is no such basis—Harrington acknowledges that overwhelming evidence that genetics and neurochemical factors have an outsize role in determining who becomes ill and how their illness progresses—but she does argue, convincingly, so far, that the actual history of the century-and-a-half battle between medicalized psychiatry and (in the broadest sense) psychoanalysis has defined vastly more by politics, ideology, and blasé confidence than it has by much progress for either side.

In her introduction, Harrington characterizes the mid-20th century “biological revolution” in psychiatry—when, more or less, the Freudians were replaced by the MDs as the dominant force in mental health treatment—like this:

By 1988…psychiatry’s transformation into a biological discpline seemed complete. That fall the psychiatrist Samuel Guze gave a lecture at London’s Maudsley Hospital provocatively titled “Biological Psychiatry: Is There Any Other Kind?” His answer was implied in the title: of course not. Psychiatry was a branch of medicine, and all medicine was “applied biology”, end of story. “I believe,” he concluded, “that continuing debate about the biological basis of psychiatry is derived much more from philosophical, ideological, and political concerns than from scientific ones.”

All this added up to nothing less than a palace revolution in American psychiatry, an astonishingly rapid 180-degree turnaround in understanding and approaches to ailments of the mind. Why did it happen? What caused an entire profession to reorient itself so quickly and so completely?

For the psychiatrists who heralded these developments in the 1980s, the answers seemed clear. In the late nineteenth century, they believed, the field of psychiatry—especially in German-speaking Europe—had actually been on the right track. Under the leadership of Theodor Meynert and Emil Kraepelin, it had pursued a robust biological research program. Unfortunately, the Freudians had come along, turned everyone’s heads, and led the field into a scientific wasteland for more than half a century. Finally, however, exciting developments in neuroscience, genetics, and psychopharmacology had changed things. Irrefutable evidence that mental disorders were brain diseases had emboldened a new generation of biological psychiatrists to overthrow the Freudians and to bring back the brain as the primary object of psychiatric research, diagnosis, and treatment. It was a simple explanatory story, one with clear heroes and villains, and above all a satisfying happy ending.

The only trouble with this story is that it is wrong—not just slightly wrong but wrong in every particular.”

When I was a political writer, I was probably best known for making versions of this argument about Democratic Party wonk culture. The particulars varied, but my central claim was that over the course of the late 20th century, as Democratic liberalism had begun to dominate elite cultural spaces in the United States, technocrats and wonks began to conceive of themselves as people whose claim to leadership was not predicated on superior ideological or moral commitments so much as a general claim to competence itself. Liberalism, I used to say, now conceived of itself not as a competing vision for society among many — or even a particular vision inflected and shaped by the historical and economic conditions which gave rise to it — but as a kind of political superego, committed only to the rational apprehension and application of facts by diligent, hard-nosed stewards. Political challenges, and even defeats—whether by the religious right in the 1990s, or by the resurgent left in the last decade—were consequently regarded not as peer challenges from rival political factions made on equal footing, but as what Richard Hofstader once called “irritable mental gestures”: misguided, philosophically and ideologically motivated flailing against the scientific rationalism of liberal wonk-kings, who have no ideology, or philosophy, only facts and a desire to apply them.

When I made these critiques, I wasn’t taking issue with the usefulness of facts or rationality or even policy-wonkery as components of a successful political regime. But I pointed out, over and over again, that this confidence in competence-in-general had become an end-in-itself. Liberalism-in-particular got hollowed out. The crime bill, welfare reform, the abandonment of unions, the replacement of a universal health care plan with the Heritage Foundation’s 1990s market-based solution, the whole of the Clinton 2016 campaign: not only was liberalism standing for less and less beyond its own claim to a monopoly on empirical reason, but because it no longer regarded itself as one ideology among many, it had begun to misunderstand its failure to win all political contests. Everyone else, they thought,—whether on the left or the right must just confused and mistaken, victims of bad-faith con men. Alternative ideologies were simply lacking in the kind of realism and seriousness required to actually run the world. How could anyone put those people in charge? How could these idiots be winning? It must be that the voters hadn’t yet seen the right charts… As I said over and over, the irony was that this liberal self-conception was itself an ideology. It was just the kind of crippled ideology that cannot recognize itself as such. “Pure ideology”, as Marx might say.

But until I read Harrington’s introduction, I hadn’t thought to apply the same framework to psychiatry. It makes sense: psychiatry, like politics, is a young field of study. The last century has seen incredible advances in our ability to detect and analyze the underlying causal mechanisms at work, but, as in political science, the field remains too young to offer much more than a recognition of these mechanisms, and some initial attempts to understand them. The gulf between the adoption of scientific/rationalist attitude, and any serious, concrete results that might one day result from the application of that attitude, became a space into which the ideology of competence could flourish. We don’t know anything yet, it says, but we’re the Kinds of People Who Know Things. So you better trust us. Everybody else is just playing stupid games.

I don’t want to deny that the “biological revolution” in psychiatry has yielded tangible results for quite a lot of patients. The confirmation — or, at least, preliminary confirmation — that mental illness results from biological and chemical malfunction has become an essential talking point in destigmatization efforts, particularly for people like me who suffer from the more bizarre, obnoxious, and frightening pathologies. The development of mood stabilizers and antipsychotic medications have allowed hundreds of thousands of people who would otherwise have spent their lives in institutions to live at home and in communities. They have allowed many more—perhaps millions, including me—to live relatively normal lives that simply could not be maintained without medical assistance. For the schizophrenic, schizoaffective, bipolar, and majorly depressed, these advances have been the equivalent of the invention of wheelchairs, insulin, and effective HIV medication. But for all these benefits, there’ve also been consequences. A singular obsession with transforming psychiatry into a medical domain has shut out those problems which would benefit from more psychological approaches. For every person like me who has received life-saving medication for one kind of mental illness, there are scores of inattentive children, and justifiably-anxious citizens, and people who just need to talk through their problems, who have been pathologized, medicated, and told to stay away from that hokey pseudo-intellectual “talk therapy” garbage.

It’s also worth considering that, as Harrington points out elsewhere in her introduction, nearly all of the great medical advances in psychiatry preceded the so-called “biological revolution” of the 1970s and 80s. New drugs, new treatment methods, even new research into genetic and biological factors took place and had their most essential triumphs, back when medical psychiatry and psychoanalysis were still considered genuine rivals. Back when both still needed concrete proof that their approach worked best. The story is largely the same with technocratic liberalism: all of the triumphs, the New Deals and Great Societies, which allegedly demonstrate the superior efficacy of pragmatic reformism, came about when American liberalism still understood itself to be locked in a genuine political contest with both the left and the right. Once the wonks and rationalists come to consider the matter settled, come to consider themselves above the petty ideological squabbles of ideologues and Freudians, progress tends to halt. Competence becomes the end in itself. The only task left is middle-management: budget tweaks and entitlement reform and medication dosage adjustments. Meanwhile, the sectors of society who resent this new order—whether they be out of work coal miners, or the kinds of patients whose disorders are, perhaps, environmental or historical, and who would therefore benefit from more talk therapy and less over-prescription, grow more and more resentful and mistrustful of the wonk-stewards of the world, and more prone to reject even the foundational notion that rational study, applied with sufficient humility and imagination, is one of the best ways we know to make any progress at all.