Perennial medicine and changing technologies

Adolescent Psychiatry,  2002  by Rakoff, Vivian M

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I must ask for your forgiveness, because much of this chapter sounds like History of Psychiatry 101-a history you all know. But starting with a historical review is the only way I could think of to respond to a very kind invitation to try to make sense of what I think is our contemporary dilemma-how to retain direction and a sense of ourselves in spite of health maintenance organizations in the United States and government agencies in my part of the world and in spite of competing therapeutic interests, which advertise various treatment modalities as the ultimate elixirs for all that ails us.

In this chapter, I attempt to trace the essential historical thread in the nature of the socially recognized healer, which has to be plucked back into the contemporary tapestry of multiple therapies and expanding technologies so that we can both understand where we are at present and preserve our age-old direction. I discuss how much of psychiatry in the past two centuries has been driven by metaphors derived from science and technology in other fields in ways that have sometimes been helpful but often been harmful to patients. Last, I point out how the ongoing medical tradition of the healer offers a much needed corrective to the excesses of scientism. Attempting to do all this in a short chapter is a bit like writing War and Peace on the head of a pin. This is perhaps to the good, if the effect is similar to that of hearing one of Father Guido Sarducci's speeches-the audience may be left retaining a few things after a long talk.

THE SEPARATE TRADITIONS OF THE MIND AND THE BODY

It has always been the theme of healing therapeusis that we exist subjectively as human beings in two very different modes-the psychological experiences we like to call "mental" and the physical experience of the body. I am certainly not going into the problem of the mind-body dichotomy here, but just let me say that, in spite of our belief that we have transcended this dichotomy, there is a sense in spontaneous speech and in our journals that Cartesian dualism is still very much in place, as though human beings were divided into a physical realm (now called the "biological") and a numinous, mental domain (in which time and space are collapsed, and people exist in some kind of pure form), and that these two kinds of existence do not transcend the barriers between them.

The history of the psychiatry of the late 19th century and of the entire 20th century, which is really our history, has seemed like a horse race between the two parallel stories of body and mind. Knowledge that pertains to the healing of mind-related disorders is suffused with two complicated traditions of theory and research-neurobiological and psychosocial. So separate have these traditions been that they indeed have seemed totally autonomous. At times, they have even seemed not to be two modes of intellectual discourse but two competing theologies engaged in a battle for the human soul, each claiming ultimate truth. One could conclude that they were not even addressing the same entity, the simple human being.

At the end of the 19th century, the mind-body dichotomy was approached using a model that had recently gained dominance in European medicine-the theory of general pathology. As is universally taught in medical schools, the point about the theory of general pathology is that, no matter what the insult is to the body, it responds in a predictable series of healing responses-a cascade of physical events beginning with general inflammatory responses and progressing toward healing and scarring and, eventually for the fortunate, survival. This kind of understanding of general pathophysiologic processes underlying diseases led to the abandonment of the multiplicity of diagnoses that had long plagued medicine-abandonment of a situation in which every separate little disease and disorder had a name and etiology unto itself. There followed a heroic attempt to look at the brain-mind in the same way and to apply the same kind of rigorous thinking about the body to the psyche. There were attempts to impose a similar discipline on the conceptualization of psychological functioning, psychiatric disorders, and mental decompensation in the hope that this kind of ordered thinking would lead to more rational therapeutics.

Attempts to Unite Mind and Body

The most notable thinker to develop a unitary hypothesis in our field was Freud. He began by looking for the neurological substrate of the mind-developing neural stains in Brucke's rigorous Viennese laboratory in attempts to see what made the mind work. Freud then went off to study with Charcot. In Charcot's Salpetriere, he encountered psychological disorders without clear physical causes-the "hysterics" and sufferers from posttraumatic hysterical "railroad spine" were clearly responding to hidden mental processes. Their physical symptoms were not explicable in terms of anatomical lesions. The careful histologic study of physical neurology was no guide to these maladies. At the same time, a physical model of mental processes was being elaborated by Kraepelin's and Bleuler's work on schizophrenia, and Pavlov in Russia was constructing a psyche in terms of the exciting new field of electrical communications-wire connected to wire, neural circuits plugged in as predictably as the newly discovered machinery and telephones that were beginning to be the metaphor of all functioning in Europe.