Perhaps the most destructive notion in modern conceptualizations of mental and emotional illness is that these are purely diseases of the brain and that therefore direct manipulation of brain physiology represents both a necessary and sufficient cure. David Healy, like Thomas Szasz and R. D. Laing before him, provides a bracing tonic that should assist the field in moving beyond the simplistic philosophies that currently guide, and significantly undermine the effectiveness of, modern mental health treatments.

     In his book The Creation of Psychopharmacology, Healy (2002) convincingly argued that psychiatry fell prey to the seductions of the pharmaceutical industry in large part because of a need to be fully accepted as a true member of the medical tribe. If mental disorders have demonstrable organic etiologies and demonstrable organic cures, then psychiatry could shed the uncertain legacy of its psychodynamic past and become a legitimate branch of medicine. Certainly this search for acceptance as a bona fide medical specialty did much to influence the wholesale adoption of pharmacotherapy by modern psychiatry, but factors more subtle, and more clearly linked to the underlying schemae that guide psychiatric training, are equally at play.

     A decade ago, Pies (1991) asserted that psychologists could never be trained to administer psychotropic medications because their intellectual heritage was rooted in logos (knowledge) rather than iatros (treatment). This is a rather bizarre argument on the face of it, flying as it does in the face of the long history of psychology in the clinical arena. But the argument becomes even more absurd when one examines the damage that wholesale adoption of allopathic medical cures has brought to psychiatry at the beginning of the 21st century. If modern psychiatry is, as Pies believed, a proud representation of a history of iatros, then psychologists should heave a collective sigh of relief that we have avoided these unfortunate antecedents.

     We would, however, go further to assert that the training of psychologists, based as it is on the understanding of the scientific method, and emphasizing a holistic perspective, actually confers some immunity to psychologists, which will likely protect us from making the same mistakes of physicians. Hence we would disagree with Pies, and say that psychologists' training in logos actually better prepares us to administer psychotropic medication in the irrational world of psychopharmacology as characterized by Healy. Simply stated, our grounding in the scientific method makes us more skeptical than psychiatrists, and hence more likely to critically evaluate the evidence of safety, efficacy and effectiveness of psychopharmacological agents before we will prescribe them to our patients.

     Sigmund Freud, despite his own training in neurology, once tartly observed that analysts should be neither priests nor doctors. This opinion reflected his discomfort over the incongruities of extensive allopathic medical training of psychiatrists who would not, under a dynamic model, be expected to rely on medical treatments. The impracticability of balancing the medical and psychological training of psychiatrists has, then, been recognized for many years, and, up until the recent past, this remained a lively and contentious debate among educators of psychiatrists. But it is clear that those who do not follow the allopathic medical model have lost. Because the fundamental training of psychiatrists is allopathic medicine, and because they have foresworn appropriate training in non-medical and non-allopathic methods of treating mental distress, the medical model has triumphed. This is most regrettable, because there is little evidence that the medical model, when applied to the treatment of mental illness, has resulted in improvements in patient care. If modern psychiatric treatment can be said to have improved, much of the variance here is likely accounted for by the abandonment of inhumane and ineffective treatments. Here we are speaking of early somatic cures and prolonged institutionalization, (We acknowledge that the flight from the asylum was at least in part assisted by the development of antipsychotic agents like chlorpromazine, however, societal shifts demanding more humane treatment of the mentally ill was likely the driving force). , Thus, improvements in psychiatric treatment cannot be said to have improved as a result of the development of truly effective cures. Psychotropic drugs palliate (and this is not a bad thing in spite of the protestations of psychologists opposed to prescriptive authority) but they do not cure. Our thinking about psychotropics becomes dangerously muddled when we regard them as curative agents. This leads to unfortunate clinical practice and a misallocation of resources seeking the "magic bullet". Thus did psychiatry fall prey to the Sirens of the pharmaceutical industry.

     While the influence of the pharmaceutical industry on psychiatry is indisputable, both psychiatry and psychology are influenced by cultural factors far more subtle than the marketing of psychotropics. Attitudes towards mental illness, the compensability of such illnesses via the disability system, the success of lawsuits regarding the infliction of mental distress, and the expansion of legislation mandating parity for the treatment of psychological and physical disorders are examples of the cultural factors influencing our conceptualizations of, and treatments for, mental illness. The expansion of diagnostic categories for mental distress under the DSM system has led to the unsupportable belief that we can provide increasingly specific treatments for increasingly specific diagnostic subtypes. Both psychologists and psychiatrists persist in this belief in spite of history that clearly demonstrates the susceptibility of the social sciences to fads in both diagnosis and treatment - fads that, as Healy argues, are often influenced by the marketing strategies of pharmaceutical firms.

     So let us be pragmatic. Our science, like that of any other discipline, is less precise than we would like and less exact than we pretend it to be. But psychologists cannot wait for the perfection of a cure before we adopt it in clinical practice. Psychotropics, though their effects are usually nonspecific and their mechanisms of action incompletely understood, remain useful adjuncts in the treatment of many mental disorders. If we recall that they are simply that - adjuncts - we will not fall prey to misguided optimism as to their curative powers. If we accept their limitations, and at the same time strive to understand the mechanisms of nonspecific or placebo responses and attend carefully to this literature, we will have developed at least partial immunity to the seduction of the pharmaceutical industry and may indeed be able to lay claim to a truly psychological model of pharmaceutical service provision.

Reference

Healy, D. (2002). The Creation of Psychopharmacology. Boston (MA): Harvard University Press.

Pies, R. W. (1991). The "deep structure" of clinical medicine and prescribing privileges for psychologists. Journal of Clinical Psychiatry, 52, 4-8.


Address correspondence to the first author at Center for Psychological Studies, Nova Southeastern University, 3301 College Ave, Ft. Lauderdale, FL 33314

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