Out of Its Mind: Psychiatry in Crisis

by J. Allan Hobson, Jonathan Leonard

Should psychiatrists treat the mind or the brain? Battles about this have plagued psychiatry at least since the end of the nineteenth century, when Sigmund Freud rejected science in favor of psychoanalysis. But now, 100 years later, we find the pendulum has swung the other way-toward over-dependence on psychoactive drugs and depersonalized psychiatry. In this important book, Harvard psychiatrist J. Allan Hobson and science journalist Jonathan Leonard explore the roots of this trend and propose the development of a more balanced "humanistic" psychiatry that-while remaining wary of "pill-pushing"-embraces rather than shuns neuroscience. For as Hobson and Leonard demonstrate, neuroscience has revolutionized our understanding of the mind, has shed a bright light on mental ills, and now stands ready to bridge the gap between biomedicine and psychotherapy. This is a vital step, they assert, if we are to revive today's flagging over-drugged psychiatry, provide sound care for millions of the neglected mentally ill, and realize humanity's ancient dream of treating not just the mind or brain alone, but both together.

Genres: Mental Health

288 pages, Hardcover

First published May 1, 2001

About the author

John Allan Hobson is an American psychiatrist and dream researcher. He is known for his research on rapid eye movement sleep. He is Professor of Psychiatry, Emeritus, Harvard Medical School, and Professor, Department of Psychiatry, Beth Israel Deaconess Medical Center.

Reviews

[Ethan J · Rating 5 out of 5]

This well-researched, highly informative read is heartily recommended for anyone interested in the mental health field. Essentially, its authors argue for a reformed psychiatry that bridges the gap between psychology and brain science, a middle ground they call "neurodynamics." While at times the writing is less than stellar, the substance of the book is compelling. Showing the way forward for psychiatric treatment that utilizes both talk therapy and biomedicine, this book is just the right prescription for those who are baffled by the "split personality" of psychiatry today and determined to resolve it in the psychiatry of tomorrow.

[Dennis Littrell · Rating 4 out of 5]

Signaling a new psychology based on brain science

Hobson and Leonard believe that the fast evolving field of "brain science" will provide the foundation for a new psychiatry that will be enormously more effective than the old Freudian construct. They note that while Freudian psychology has failed, the new psychopharmacology that is replacing the "talk cure" is itself fraught with problems. As in T. M. Luhrmann's Of Two Minds: The Growing Disorder in American Psychiatry (2000), which might be compared with this volume, Hobson and Leonard believe that it is a combination of drugs and therapy that is needed.

The first part of the book recalls the old state asylums and the fifty-minute hours of the psychoanalysts and how that system managed the mentally ill, however poorly. Then came the destruction of that system at the hands of budget-minded politicians (e.g., the "let 'em sleep in the streets" Reaganites) and HMOs, thereby precipitating the current crisis. The authors emphasize however that the lack of a firm scientific foundation doomed the old psychiatry to extinction, regardless of financial considerations. They see brain science (e.g., neuroscience) as the hope of a new generation. I think they're right, but let's not hold our breath. Just reading their take on the current understanding of schizophrenia in Part Three is enough to dispel any notions we might have of a cure anytime soon.

Schizophrenia of course is the black beast of mental health. Nothing really works toward a cure. Therapy is practically useless, and the drugs prescribed tend mostly to sedate or mask symptoms and to have bad side effects so that the patient often stops taking them. If you go out into the streets of any city in this country and observe or talk to the homeless, you'll find that a substantial number of them are clearly schizophrenic as defined in DSM-IV. If you look at suicides or those attempting suicide you'll find that a significant percentage of them are depressed. Add the various anxiety disorders and you have psychiatry's big three, which the authors explore in chapters imaginatively entitled, "Anxiety and the Fear Machine," "Searching for Doctor Doom," and "The Land of Voices." Cure these and psychiatry may become as busy as the Maytag repair man.

In-between these two parts is Part Two on consciousness and the dream world. So we have Part One: the rise and fall of psychiatry, Part Two: the nature of consciousness, Part Three: the main mental disorders, and Part Four: the prescription. I can't say much about the prescription which includes "neurodynamics," their brave new psychology based on brain science, but I like their take on consciousness and their definition: "awareness of information processed by the brain." (p. 76) Implied in this definition is the fact that we are not in contact with "raw reality" but instead are limited to "information received, selected, translated into abstract neural codes, and processed by the brain." (p. 78) Hobson and Leonard realize that consciousness is a continuum, and that dogs and cats and even cockroaches have at least a rudimentary consciousness (see p. 81). They also make the nice point (p. 80) that consciousness is not the same as memory ...[or] thought... [C]onsciousness is awareness and awareness need not involve thought."

The text is readable up to a point. The part about how the brain works is difficult to follow if, like me, you are not readily familiar with the functions of the cerebellum, cerebrum, thalamus, hippocampus, etc., or can't tell them apart without a map. Fortunately the authors do provide a couple of drawings that help. I mention this as a failing on my part and as a reminder to myself that to be a really informed layperson today, an understanding of the structure of the brain and how its components work (in so far as we know) is becoming basic. This is just another example of how complicated our world has become, and how hopelessly lost are those whose world view scorns education for the absolute "knowledge" of fundamentalist religions or the discredited psychologies of bygone eras.

The authors however are not throwing out the baby of therapy with the bath water of the psychoanalytic construct. They are signaling the change from the "guesswork" of the old therapies to the new paradigm of brain science. I just hope that messieurs Hobson and Leonard realize that a reductionist and/or holistic look inside the black box of the brain needs to be allied with the study of behavior from an evolutionary point of view. Such an understanding would, for example, help the authors with their "genetic bug" theory of schizophrenia presented on pages 199-201. I think it would also help to explain the prevalence of depression and the bipolar disorder. Depression is painful and self-destructive, and the wild highs and lows of bipolar (the authors recall the example of Margot Kidder) highly dysfunctional. But if we look back into the prehistory we might see how such behavior developed in environments that were depressive and quickening by season. I am thinking of how being depressed and immobile during a cold winter may be a good survival strategy, while really going for everything like a frog in the bog in spring may also be effective. Perhaps the bipolar is an extreme adaptation (with some real reproductive value) that doesn't work well in the current environment, where the pain clearly outweighs whatever gain there might be. In this regard recall the phenomenon of seasonal depression. I know that personally when the days grow gray and short I am likely to take on a gray mood myself. Or take the example of dyslexia which is only a problem in the modern society. In the stone age it might have been a plus.

--Dennis Littrell, author of “The World Is Not as We Think It Is”