Out of Its Mind by J. Allan Hobson and Jonathan Leonard
Out of its Mind: Psychiatry in Crisis
by J. Allan Hobson and Jonathan Leonard
Perseus. 288 pp. $26.00
In 1895, Sigmund Freud, then thirty-nine and known primarily for his work in neuropathology and clinical neurology, set out to “furnish a psychology that shall be a natural science”—in other words, to build a brain-based psychology on the same epistemological footing as biology, chemistry, and physics. Within a few years, however, having decided that too little was known about the brain, he shelved his project as impractical. By the time he published The Interpretation of Dreams in 1899, Freud had distanced himself from neuroscience, preferring to concentrate on psychological theories that could be expressed in abstract terms. Thus was psychoanalysis born.
Freud’s modern sympathizers maintain that he always knew, and even hoped, that advances in neuroscience would someday render his psychological speculations obsolete. Whether or not they are correct about this, the idea of brain-based psychology was slow to catch on among psychoanalysts, the inheritors of Freud’s legacy. After all, prior to the advent of psychoanalysis, psychiatric medicine meant little more than ministering to the legions of mentally ill who were warehoused in asylums; the Freudian paradigm restored hope—and glamor—to the discipline. The cost, however, was that psychiatry lost touch with its empirical foundation, and hence with the rest of biologically-based medicine. As J. Allan Hobson and Jonathan Leonard argue in Out of Its Mind, the eventual result was the decline of psychiatric medicine and a long period of confusion about how mental illnesses should be treated.
In the 1950’s, Hobson and Leonard show, doubts began to grow about the efficacy of psychoanalysis. At a moment when relatively few could afford it, psychoanalysis was both time-intensive—requiring as many as five sessions a week—and incredibly expensive. In the meantime, empirical evaluations were suggesting that the “talking cure” yielded nothing, whereas psychoactive medications could result in fantastic progress. Rival approaches mushroomed, some of which, like “therapeutic touching” and the invocation of “natural forces,” bordered on the occult.
Under the combined weight of these trends, psychoanalysis finally collapsed in the early 1970’s. But there was no theoretical paradigm to take its place. Psychiatrists were thus left, in Hobson and Leonard’s telling, with the remnants of Freudian psychology and an ever-expanding arsenal of psychoactive drugs, many of which had uncertain modes of action and unknown side effects. Meanwhile, social pressure had shut the doors of mental hospitals, whose patients were being decanted into communities that lacked the services and facilities to deal with them. Many of the mentally ill, either released from institutions or kept from entering them in the first place, ended up homeless or imprisoned. This situation persists today.
Not surprisingly, Hobson and Leonard regard our current system as in urgent need of repair. Their own approach picks up where Freud left off: the time is ripe, as they see it, to reunite psychiatry with “brain science,” which in the past several decades has reaped an extraordinary harvest of knowledge about the mind and its disorders.
Toward this end, about a third of Out of Its Mind is given over to a lucid and informative summary of what is known about the neurobiological basis of normal and pathological consciousness. This discussion is flavored strongly by Hobson’s own comprehensive theory of conscious states, built over the course of decades of research into the neurochemistry of sleep and dreaming. The intent throughout is to demonstrate that brain science can be used in productive ways to understand and treat psychiatric illnesses.
Out of Its Mind concludes with what Hobson and Leonard style a “call to arms,” essentially laying out the framework for a new psychiatry. They call their approach “neurodynamic,” emphasizing both its grounding in neuroscience and its emphasis on strong therapeutic relationships between psychiatrists and patients. This latter aspect is crucial, they hold, not least as a corrective to the prevailing and dangerously inaccurate view of drugs as a psychiatric cure-all. The book ends with concrete proposals that range from changes in the content of undergraduate and medical education to a national network of mental-health centers with affiliated community services.
A prerequisite for turning over American psychiatry, one would think, is drawing a picture of it as it actually is. In this, Hobson and Leonard unfortunately fall short. The story they concentrate on telling is mostly that of large, state-backed psychiatric hospitals like the Massachusetts Mental Health Center, a Harvard-affiliated facility where Hobson works. Undoubtedly these institutions have suffered a decline in prestige and funding over the past few decades, and despite some innovative strategies—like introducing psychiatric care to homeless shelters—they generally lack for patients and equipment. It is also true that psychiatrists in health-maintenance organizations (HMO’s) have been trapped in dungeons of prescription-writing, with fewer opportunities for meaningful patient contact than even the asylum wardens of decades past.
There are brighter spots, however, that Hobson and Leonard say little about. Just a few miles from Hobson’s citadel of benign neglect is McLean Hospital, a psychiatric institution that has fared much better in an era of biomedicine and managed care. McLean, not Mass Mental, is now Harvard’s primary psychiatric teaching facility, with various residential and outpatient treatment programs as well as state-of-the-art research in neuroscience laboratories. True, McLean is a private hospital, and historically a rather exclusive one at that. All the same, its success as an already existing model of the neurodynamic approach belies the rather dismal picture of psychiatry painted in Out of Its Mind.
Nor is McLean an isolated example. Much of the research discussed in this book was conducted by physician-scientists at similar institutions who have long embraced a brain-based approach to psychiatry. Hob-son and Leonard do not say much about this, although they do mention with approval a rather obscure journal called Neuro-Psychoanalysis, intended, as its title implies, to bridge the gap between analysts and neuroscientists. But there are also more widely read journals, like Biological Psychiatry, Cognitive Neuropsychiatry, and the Journal of Neuropsychiatry and Clinical Neuroscience, that already embody the scientific side of what Hobson and Leonard call “neurodynamics.”
Still, if Hobson and Leonard’s call for a brain-based psychiatry is not particularly revolutionary, they do make a few trailblazing moves. Most important is their recognition that clinical psychology—the “talking cure” side of psychiatry—needs to be revamped so that drug treatment can be satisfactorily integrated with it. Not only would this free psychiatrists from at least some of their HMO-related travails, it would go a long way toward ending the expensive and ineffective revolving-door treatment of the mentally ill.
Hobson and Leonard distill the neurodynamic approach into a couple of clearly enunciated core principles: that drugs and therapy are mutually reinforcing, and that many mental ills should be viewed as chronic diseases, generally amenable to treatment.1 But they do not stop there, instead venturing into the realm of public policy. There, real problems arise.
For example, the authors lament the “barbaric” laws that in most states bar the involuntary commitment of the mentally ill, attributing this to the public distrust of psychiatry and the misguided fears of “civil libertarians.” Sweeping aside these concerns, they hail the recent trend toward increased outpatient commitment as a way of ensuring that psychiatric care reaches those who truly need it.
No doubt laws against commitment often hinder efforts to treat seriously ill people who lack insight into their own condition, and it may be time for legislatures to revisit those laws in light of the difficulties they have caused. At the same time, however, the ethical and political ramifications of involuntary commitment are much thornier than Hobson and Leonard seem willing to admit. One need not invoke the example of the Soviet Union (or of contemporary Cuba), where opposition to the regime was deemed a medical pathology and political dissidents were locked up in psychiatric hospitals, to envision instances in the United States where the line between sound psychiatry and social engineering might easily become blurred. Could “racism” be identified as a disease, for example? Or “homophobia,” as homosexuality was until recently? To believe that sound science will guard against abuses is a Utopian delusion; sound science has not prevented the zealous overprescription of psychotropic drugs like Ritalin and Prozac.
Similar caveats apply to Hobson and Leonard’s recommendation for expanding mental-health services within the prison system. Some mentally ill people are indeed in prison because there is nowhere else for them to go. As Hobson and Leonard note, this situation is far from ideal either for the inmates, who do not receive proper care and are often mistreated, or for the criminal-justice system, which is not generally equipped to deal with psychiatric cases. Their solution is to set up a parallel system of penitentiary “psychiatric wings” for the mentally ill, in effect “bring[ing] the mental hospital to the prison.”
Leaving aside the cost of such reforms (Hobson and Leonard think they would ultimately be cost-effective), we are again faced with practical questions about how to separate “the mad” from “the bad.” The authors acknowledge that care must be exercised, but they sidestep a legal and scientific minefield. Researchers are already using brain-imaging techniques in an effort to discern what is different about the brains of psychopaths. Whatever they uncover will no doubt be pressed into serving one side or the other of a debate over how to view psychopathy: as a disease amenable to treatment, or as a marker of incorrigible criminality.
These serious reservations noted, Out of its Mind remains an important and timely book. Hobson and Leonard are surely right about the need to rehabilitate psychiatry, especially public psychiatry, by putting it on a sound empirical footing; until this happens, the social costs of mental illness are only likely to worsen, and more and more people with mental disorders will suffer poor and sporadic treatment. Despite their incautious proposals for institutional reform, moreover, there can be no doubt that such reform is needed. Even if “neurodynamics” merely gives a name to a movement that has been in the making for several decades, it may still serve as a rallying-cry for a new approach to mental health—which would be all to the good.
1 For a fuller discussion of developments in this area, see “Romancing Depression” by Paul R. McHugh in the December 2001 COMMENTARY.