Effective Psychiatric Therapy, Jeffrey Deitz, MD
Welcome to the Effective Psychiatric Therapy blog, which I am excited to write and edit for PsychCentral.com. With so much information and misinformation about psychiatry flooding the internet, I will do my best to anchor Effective Psychiatric Therapy in facts and clinical observation, free from commercial bias and the ebb and flow of public opinion.
In Greek mythology, Psyche was the beautiful but mortal princess of the soul who stole Eros’s heart from Aphrodite. After many misfortunes and turns of fate, Psyche married Eros and became immortal. Thus, when Plato first discoursed on psychology, he was really pondering the soul, a concept the great religions had already considered. Psychology eventually morphed into the study of the mind and later-day philosophers debated the mind-body question, that is could the mind and soul be explained solely on the basis of physical existence, or was the mind somehow beyond science. Mind-body dualist Rene Descartes argued that mind and soul were separate, whereas today’s mind-body physicalists posit, “Mind is what brain does.” Although many people reject that notion as a reductionist attempt to reduce imagination, will, and emotion to mere electrical activity in neural networks, I disagree. As neuroscience advances, clinician and researcher can’t help being awed by the beauty and complexity of the mind/brain.
Even were we able to map Beethoven’s brain processes as he transformed music, a transcript of Beethoven brain activity while composing could never translate into the majesty of his Chorale Symphony. Like Psyche, the brain is a beautiful, incredibly adaptive and resilient organ, as long as it is not damaged irreparably by trauma or toxins, or starved by anoxia or hypoglycemia. One essential caution about the brain: the word processor now transcribing my finger strokes into words functions regardless of whether it is cold, overworked or feeling unappreciated. The human computer differs; our brains are emotion-sensitive: depressed brains skew data towards the negative. Stressed-out brains are often too keyed up to consider alternative coping strategies. Higher level brain functions like sustained attention, judgement and reason, can be severely compromised, even knocked offline, when the brain is intoxicated, malnourished or sleep-deprived.
As for the dictionary, Psychiatry’ definition is a mouthful: “the field of medicine concerning the Diagnosis and Treatment of Mental Disorders.”
Let’s start with, “The field of Medicine…”:
There is no escaping the medical model inherent in Psychiatry. Medicine is about health and illness, not about normalcy and abnormality. Cardiology studies the cardiovascular system and its diseases. Neurology takes on the nervous system and its diseases. Yet, by definition, Psychiatry concerns disease; it’s no wonder some people feel that visiting a psychiatrist is admitting something is wrong with them! Although many, myself included, would prefer that Psychiatry’s definition expand to include the study of normal mind/brain functioning and its disorders, psychiatry’s definition is grandfathered in and deeply entrenched. One of the goods doctors do is differentiate health from disease—just think of how relieved you would feel if a trusted medicine man reassured you that the lump in your neck came from strep throat, not the Hodgkin’s disease that killed Uncle George!
The medical model differs in attitude: binge-drinking on college campuses may be normal but it is definitely not healthy. Nor is teenagers’ attachment to their smartphones; or single mothers’ worrying about money or seniors obsessing about loneliness.. On the other hand, psychological pain is not necessarily pathological, either: grief can be excruciating without being abnormal; depressive affect after being dumped by one’s fiancee or turned down for a promotion can be devastating.
The second part of psychiatry’s definition: “…that concerns diagnosis…”
Given the 900+ diagnoses in the latest Diagnostic and Statistical Manual of Mental Disorders, I can understand why people might worry that every unpleasantness of the human condition could be pathologized into a mental disorder. I’ve been asked in court whether I believe in the DSM, as if it were scripture. DSM attempts to describe unhealthiness, regardless of how it came about. The biggest problem with DSM is that inclusion and exclusion criteria are decided by committee, not by microscope or tissue culture. Real people have overlapping symptoms, and diagnosticians, which nowadays include non-psychiatrist MD’s, PhD psychologists, licensed clinical social workers, advanced practicing nurses and nurse practitioners, frequently differ about the diagnosis. No wonder so many people look at DSM like a new textbook whose validity is questionable even before they read the introduction! Psychiatric diagnosis is subjective. The science of psychiatry has a long way to go.
Third part of definition: “…and treatment…”
The word treatment implies pathology. Assuming psychopathology has been diagnosed, just about every mental health practitioners would feel a need to respond, even if they might disagree about diagnosis. Even though the natural history of depressive episodes is that 50% remit spontaneously in 6 to 18 months, no reasonable professional would advise a severely symptomatic person to check back in a year to see how his depression is progressing. They would intervene, with the understanding that effective treatment would hasten the episode’s remission.
Are problems in living pathological? Not necessarily. I hold that psychopathology exists when there is a serious, non-self-limited period of compromised mind/brain functioning: that is a disruption of the basics like eating and sleeping, cognition and judgement and impulse control, or dysregulation of emotions like anxiety and depression.
Effective treatment for psychiatric disorders includes a huge range of therapies with profound neurobiological implications: Psychotherapy exerts a powerful effect on the brain; so does exercise therapy, nutritional therapy, psychiatric medications, drug-counseling and 12-Step programs, even transcranial magnetic stimulation to electroconvulsive therapy. No matter which therapy or combination thereof is prescribed, every regimen should be personalized and delivered by experts in their metier.
We treat patients, not family problems or neurotransmitter dysregulations. The person on the other side of the room is a human being, and good psychiatric care touches the soul and addresses the human need for compassionate understanding and care.
Finally, the fourth part of the definition: …”mental disorders…”
Mental, derived from the Latin root “mentalis,” of the mind entered common parlance in the middle ages. There would be no problem had not the word become so distorted and bastardized over the centuries with stigmatizing, degrading connotations. Going forward, Effective Psychiatric Treatment will define mental disorder as “a brain—based disturbance of cognition, behavior and emotion.”
So now that the field under study is defined, let’s get on with the business of describing Effective Psychiatric Treatment. Psychiatry is an exciting and evolving field. I urge readers and professionals to share their comments and reactions which I promise to post and comment upon.
See you soon.
JD
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