Legal, Ethical, and Professional Issues in Psychoanalysis and Psychotherapy
The Neurosciences, Prescription Privileges, and A Little Bit of Sugar Still Don’t Make The Medicine Go Down
Patrick B. Kavanaugh, Ph.D.
Author’s Note: This year the spring meetings of Division 39 were organized around the theme Evolving Domains: Psychoanalyis in Dialogue with Science, Culture, and Technology. The following article is based on comments made at a symposium at which Drs. Johanna Tabin (Chicago) and Bertram P. Karon (Lansing) addressed the question: In our highly technocratic and rapidly changing culture, what role, if any, do medications play in the analytic process?
Certain fundamental questions are inseparable from considering the role of medications in a psychoanalytic discourse. Namely: What is the basic nature of the person? How does one understand the human mind? and What is psychoanalysis? How we might answer these and other such questions speaks to our core beliefs, values, and ways of thinking about people and life. And ultimately, our answers are inextricably linked with the philosophical beliefs and values by which we understand and interpret the so-called mentally ill of our society.
Organized psychology and psychoanalysis readily answer these questions in something like the following way: What is the basic nature of the person? The basic nature of the person is rooted in evolutionary biology with mental functions dependent on a somatic substrate in the central nervous system. How does one understand the human mind? Mind is a function of the physiological processes of the brain; mind is inextricably linked to a somatic substrate in which for every psychological event there is an underlying brain event. And, What is psychoanalysis? If psychoanalysis is what our psychoanalytic institutions profess it to be then psychoanalysis in this country is a medicalized way of thinking with conceptions of people signified in the various structures of diseases, disorders, and deficiencies. Infused with this medical ideology, DSM-IV stands in the analytic community as a monument to our shared communal preoccupations with pathology, diagnosis, treatment, and curative factors. And in this paradigm, it has become almost axiomatic that for the more severe mental illnesses notions of treatment and curative factors begins with the prescription of medications.
Our psychological institutions understand and interpret people in very specific ways. And this understanding and interpretation is premised on a dualistic construction of the person which, in turn, structures the research objectives and political agenda of their institutional discourses. For example, in much of our current research a Cartesian construction of mind and body is assumed; research then focuses on the mysteries of their connectivity. In such research, the person is constructed as agent in clinical practice and as organism in scientific research. Person as agent engages in those activities that involve conscious choice; person as organism exists by means of physiological processes (Gedo, 1999).
This dualistic construction of the person places conceptual primacy with organismic realities such as observable physiological processes; it advances the notion that mind is to conscious choice as body is to unconscious process. In such a dualistic framework, the content of delusions or hallucinations is understood as related to personal experiences while the mental chaos of schizophrenia is related to imbalances in brain chemistry. Premised on this understanding of mind-body connectivity, research in the neurosciences during the ‘80’s and ‘90’s produced the current generation of anti-psychotic drugs, the more-improved atypicals such as Clozaril, Risperdal, and Geodon. These drugs target the dopamine saturated regions of the brain and control erratic dopamine surges. And the political agenda? For many in the psychological community, only the political question remains: How long before prescription privileges enable the psychologist, psychoanalytic or otherwise, to prescribe medications for mental illness amongst the underserved and underprivileged?
An excitement grows in the psychological community as the medical model of psychology in dialogue with a bio-chemical imbalance model makes it possible for the psychologist to provide humanistic interpretations addressed to the psychic conflicts of the mind (the content of delusions and hallucinations) while prescribing anti-psychotic drugs for the biochemical imbalances of the body (brain chemistry). And the tradition continues in which every psychological proposition blends the compassion of humanism with the rigors of science. With the recent securing of prescription privileges by psychologists in New Mexico, it won’t be long now! Soon people will be able to Talk to Someone Who Cares and be medicated while doing so.
We Can Do It Better, at least according to the APA’s marketing slogans.... But what is it, exactly, that we are going to be doing that’s better? Two separate questions need to be addressed by the psychological community. First, irrespective of the psychologist’s theoretical orientation, What is the therapeutic effectiveness of the atypicals? And a second question for the analytic practitioner, What is the effect of medications on the analytic process?
If a bio-medical model of psychology or psychoanalysis is advanced as an empirical and causal science of mind, then its scientific propositions must be held to—and meet—the evaluative standards of both medicine and science. There is a growing body of literature in the scientific community, however, that unequivocally asserts that the research underlying the atypicals is scientifically and medically unacceptable; that the nature of the triangulated dialogue between our psychological institutions, the neurosciences, and the pharmaceuticals has been economically—and ethically—corrupted; and, that the role of the atypicals in the treatment of severe mental illness is a form of medical fraud. These are pretty strong indictments. And they seriously raise the question, Is the dialogue between our psychological institutions, the neurosciences, and the pharmaceutical corporations developing into tomorrow’s version of an Enron in the psychological community?
Recently reviewed by Louis Berger, Ph.D. for Psychoanalytic Psychology (Vol. 18, No. 1, 184-187), Elliot Valenstein’s Blaming the Brain: The Truth About Drugs and Mental Health (New York: Free Press, 1998) raises some very disturbing questions for the psychological community. Or, at least it should. Valenstein is Professor Emeritus of Psychology and Neuroscience at the University of Michigan who considers some of the socio-political factors that led in a very short period of time to the notion that chemical events in the brain are “not only the cause of mental disorders, but also the explanation of the normal variations in personality and behavior” (p. 184).
In his review of the literature, Valenstein notes a recurring general pattern of scientifically and medically unacceptable work; concludes that the evidence and arguments supporting the claims about the relationship between brain chemistry to psychological problems and personality and behavioral traits are far from compelling and are most likely wrong; and, asserts that the suspect claims, beliefs, and practices arose and are maintained by various self-serving groups for economic and emotional reasons). Berger notes that the theoretical and, ultimately, the practical difficulties that mind-brain dualisms are likely to introduce into any body of thought where they play a foundational role cannot be overemphasized: “the problems inherent in a dualistic framework should make suspect any proposed plans or proposals to ‘integrate’ psychoanalytic and biological thinking” (italics added, p. 187).
Why is it that the treatment for madness is likely to do much better when provided by a shaman with witch-doctor potions in such countries as India and Nigeria than when provided by a mental health professional with medical-doctor anti-psychotic medications in the United States? Why have outcomes for Americans with schizophrenia actually worsened over the past twenty-five years, the dialogue of psychology with the neurosciences notwithstanding? "Schizophrenics in the United States currently fare worse than patients in the world's poorest countries, and quite possibly worse than asylum patients did in the early 19th century.... What are the secrets of care--beyond not keeping patients regularly medicated--that help so many people in those countries get well?" (italics added) (Whitaker, 2002, p. 289).
After exhaustive research of medical records, historical and government documents, and numerous interviews, medical journalist Robert Whitaker echoes Valenstein’s view of the research studies during the eighties and nineties as scientifically and medically unacceptable. And further, he asserts that the nature of the relationship between the pharmaceutical companies and research scientists was corrupted by the politics and economics of research, resulting in studies being skewed to prove that the new anti-psychotic medications were more effective than the old. Published earlier this year, Whitaker’s Mad in America: Bad Science, Bad Medicine, and the Enduring Mistreatment of the Mentally Ill concludes with this rather sharp admonishment to mental health professionals:
As citizens, professionals, and a community of scholars we might do well to move past the political rhetoric of Talk to Someone Who Cares and We Can Do It Better and begin to rigorously question our received biologic assumptions, knowledges, and wisdoms. There is so much we do not know in our understanding of people and life and yet about which we act as if we are so certain. And that which we think we do know appears to be well-founded on bad science which generates bad medicine.
A psychoanalytic discourse is one of the most significant voices in our highly technological culture to speak with the complexity and uniqueness of the individual. And this includes speaking with the person with a so-called severe mental illness. At this year’s Division 39 spring meetings, Drs. Johanna Tabin and Bertram Karon presented their collective thinking and experiences in working with the so called mentally ill. Citing extensive empirical data, they called into question the scientific nature of psychotropic drugs and their effectiveness as therapeutic agents; spoke to some of the possible communications when we participate in either prescribing psychoactive drugs or referring an individual for an evaluation for medications; and, were in agreement that schizophrenic people are best treated without medication if the analyst, the person, and the setting can tolerate the anxieties attendant to such an endeavor. Their understanding and interpretation of the basic nature of people, of mind, and of psychoanalysis contrasts sharply and radically with the more bio-chemical and medical points of view. Further, the position was advanced that in working with the more dramatic forms and expressions of madness, we are working with intricately complex social phenomena that makes sense, is understandable, and can be translated in meaningful ways in a sense-making discourse of the non-sense making of being human. Empirical and clinical evaluations strongly suggest that it is time for the psychological community to question our institutional(ized) assumptions and rethink our traditional answers to some fundamental questions about...the basic nature of human being and...mind--political rhetoric and economic motivations notwithstanding.
This essay first appeared in the June 2002 issue of the Michigan Society for Psychoanalytic Psychology newsletter, the MSPP News. It is reprinted here by permission of the author. For a copy of the references in this paper, contact the author at 248-626-6460.
During the past 35 years, Dr. Kavanaugh has worked extensively with people with so called severe mental illnesses at various inpatient units, residential treatment facilities, day treatment programs, and in the private practice of psychoanalysis in Farmington Hills, Michigan.
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