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Analyze This, Pronto

Review of “Out of Its Mind: Psychiatry in Crisis,” by J. Allan Hobson and Jonathan A. Leonard

Out of Its Mind, by J. Allan Hobson and Jonathan A. Leonard

Hippocrates, in the fifth century B.C., declared that mental illness was a medical problem based on an organic dysfunction of the brain, which could best be addressed with oral remedies. Plato argued fiercely against Hippocrates, described mental illness as a philosophical problem, maintained that character was determined by early experience rather than by biology and believed that cure was to be achieved through reasoned discourse; he dismissed doctors who addressed themselves to the subject as “mere artisans.” The divide shifted slightly in the Middle Ages: after Augustine, some saw mental illness as a religious problem, and thought that madmen were possessed and in need of exorcisms; others thought that crazy people suffered from illness and needed sympathy and medical intervention. The split in modern psychiatry — between the brain scientists and the humanists, and hence between those who favor medication and those inclined toward introspection and talking therapies — is hardly the novelty that recent commentators, including the authors of Out of Its Mind, would have us believe. It is an expression of a mind-body duality that is one of the eternal problems of Western self-perception.

Now, however, not only is the division particularly acute, but also, dishearteningly, one side seems to be winning. There are two reasons for this. First, we have had such visible progress in the domain of psychomedication that the rest of our knowledge tends to be overshadowed by the new technology. Second, we are in the era of the H.M.O., and economic pressure favors the least expensive treatment, which is medicine, prescribed as rapidly as possible. Because the medications are so advanced now, we are probably giving effective treatment to a lot of people for whom there simply was no effective treatment 25 years ago. But we have lost caretaking skills, and are in consequence neglecting and abandoning a tremendous number of people who might once have had the support they require to function.

J. Allan Hobson and Jonathan A. Leonard set out to catalog the things that are going wrong and then to write a prescription for fixing them all. While they’re at it, they run through a layman’s guide to modern brain science, some personal theories about the definition of psychosis, a bit of grandstanding social theory and an appreciation for particular clinics where Hobson worked. It’s hard to disentangle this macramé of material, but Hobson, a professor of psychiatry at Harvard Medical School, and Leonard, a medical writer, do get at most of the really crucial problems with psychiatry today.

As they lay it out, students are by and large interested either in personality, in which case they become psychologists, or in the technical workings of the brain, in which case they become neurologists. Psychiatry, where these two interests meet, is a second-rate enterprise in which middling professionals patch together prescription plans on the basis of 15-minute interviews. Meanwhile, not only the medicine but also the humanism has become more and more technical, as communication skills have steadily declined. Many psychiatrists wave the flag for their pet methodologies, whether group therapy or cognitive-behavioral therapy or interpersonal therapy or psychopharmaceutical intervention or psychoanalysis.

But as Hobson and Leonard point out, patients are highly individual, each requiring an individual program of care drawn from multiple branches of learning and negotiated and maintained through extended interaction. Though some patients receive both therapy from a psychologist and medication from a psychiatrist, there is generally no meaningful coordination. These problems are acute for patients with mild to moderate illness. For patients with severe illness, they are worse than acute. Institutionalization, though overused in the past, is now underused, and the psychiatrists who work with refractory cases in mental hospitals are undertrained and undervalued. And in many instances, the effect of the patients’ rights movement has been to abandon to illnesses people whose symptoms include an inability to make sound choices.

While these are the problems that most concern Hobson and Leonard, the bulk of their book is given over to a review of modern brain science. They hit on some interesting things. Hobson has in the past done important work on dreams, and, unsurprisingly, he is at his best when he writes on dreams here. He proposes that psychotic states are waking dreams — not simply in the metaphoric sense, but in terms of a symmetry in the literal scheme of brain processing. He carries his comparison a long way, but the principle is well argued and helps to sort out certain puzzling aspects of psychosis. Around this strong material, he and Leonard have spun a story of the brain that is not unintelligent. It is, however, sometimes nearly unintelligible, blending as it does personal research, universally acknowledged truths, received wisdom, radical statistics and some far-fetched concepts that appear spun out of thin air. This stuff comes flying at you, and it’s up to you to figure out what is what; in the course of nearly 300 pages, the authors provide 19 endnotes. While a decision to provide no endnotes would be misguided, the decision to provide 19 seems almost madcap, the mark of an ostentatious disdain for the separation of one’s private theories from objective reality. Nonetheless, Hobson is an excellent scientist, and a close reader can take from this book a coherent, if sometimes eccentric, picture of how the brain relates to the mind. This is a rare and precious accomplishment.

The book ends with a set of proposals for improving the state of modern psychiatry. Much of what Hobson and Leonard propose is wonderful. To start with, in education, they would create undergraduate courses for pre-meds that bring together psychology and brain science in a neurodynamic approach; for social justice, they would send psychiatric residents to the unidentified mentally ill people in homeless shelters; and for sustained high standards, they would increase the growing number of mandatory outpatient treatment programs. Unfortunately, in today’s medical climate, this is a bit like proposing a Middle East peace deal that demands that both sides beat their guns into plowshares and their grenades into pruning hooks. Still, we need books like this. We need righteous indignation at policies that are causing enormous unnecessary suffering, the wasting of huge quantities of money and the undermining of a civil society.