Reviewed here: Prescriptions for the Mind, by Joel Paris; Doctoring the Mind, by Richard Bentall
In Prescriptions for the Mind, McGill University psychiatrist Joel Paris contends that psychiatry has moved so far toward drug therapy that talk therapy, tarred by the decline of psychoanalysis, has been marginalized. Once a mainstay of any psychiatrist's identity, training in talk therapy is now more likely to be viewed as career suicide. Paris laments this folly, arguing that psychotherapy should remain a useful part of every psychiatric practice.
To make his case, Paris advances a number of charges against drug therapy that are frankly devastating. He reminds us that psychiatry rarely deals with causes of illness, only with their signs and symptoms. There are no “biological markers,” such as blood tests or brain scans, that could objectively and decisively prove a given disorder. Indeed, psychiatry uses the fudge word “disorder” precisely because it cannot legitimately speak of “disease” at all. “Only a few psychiatric diagnoses,” Paris writes, “have been fully validated; the rest are makeshifts in the absence of something better.”
Prescriptions for the Mind: A Critical View of Contemporary Psychiatry
, by Joel Paris, Oxford University Press, 247 pages, $32.95
Psychiatry's handbook of mental disorders, the Diagnostic and Statistical Manual ( DSM ), is an obvious locus for skepticism. On the one hand, given the confusion about terminology before 1980, the DSM-III and DSM-IV at least provide a common language so that psychiatrists can better communicate with each other and with insurance companies. On the other hand, diagnostic categories are so “irredeemably fuzzy” and broadly defined that psychiatrists end up confusing “the human condition” with pathology. Consequently, prevalence rates have at times risen absurdly. Here is Paris at his best: “Perhaps the main reason for the large number of diagnoses in psychiatry is that we do not understand any of them.”
Out of sheer desperation, then, psychiatrists often mistake the makeshift, pragmatic and provisional categories of the DSM for reified truths. The result is a psychiatry with dubious scientific bona fides that ignores the merits of therapeutic talk and over-prescribes drugs in “shotgun” fashion.
By contrast, Paris advocates an “evidence-based” psychiatry committed to whatever works. Clearly, he is no enemy of drug therapy, which includes a handful of significant treatments. As for psychotherapy, Paris follows the available evidence and recommends short-term therapies focused on the present. Beyond that, he is unable to advocate any particular talk therapy, since evidence reveals that there isn't a lot of difference among any of them. At bottom, we are left with the efficacy of the “healing relationship” between therapist and patient – and the goal of a psychotherapy unified in the future.
Like the illnesses psychiatry diagnoses, the profession is subject to its own discourse
Over all, Paris is very good at punching holes in the scientific pretensions of contemporary biomedical psychiatry. But he doesn't always hold his own belief in talk therapy up to similar doubt – and for good reason. Despite his devastating criticisms, Paris is certainly not out to devastate psychiatry. He is careful to reject the “broadside attacks on the DSM ” and characterizes some criticism of psychiatry's influence as “paranoid.”
Yet on the basis of his own work, I am more convinced than ever that broadside attacks deserve a hearing. Moreover, I'm doubtful that an evidence-based talk therapy reduced to the bare bones of empathic relationships is much for psychiatry to celebrate. Not when so many others have taken over the practice of talk therapy. And not when the greatest promise for psychotherapy lies, as with drug research, in a distant and perhaps idealized future.
As for the present, if it is true that “anyone can come up with a list of criteria written in ‘ DSM -ese' that will be no better and no worse than the ones we have been living with since 1980,” then perhaps we are no worse off with clinical psychologists, fringe therapists or even philosophers doling out prescriptions for the mind. I wonder how slippery Paris intends this slope to be.
Paris speaks knowingly about the “system” in psychiatry, which is laudable. He could, however, say more about the discourse of power in psychiatry. In this respect, power is not just “the influence of psychiatry on society.” It works the other way around, too, implicating a profession dedicated to science in large part, Paris says, because of a collective desire for the “respect, prestige and certitude” bestowed upon doctors. Real doctors – the kind who prefer white coats to sports coats. Paris's diagnosis is nonetheless pitch-perfect: identity crisis. Like the illnesses psychiatry diagnoses, the profession is subject to its own discourse.
