Fault lines in the debate over mental illness

01 November 2013

Srinivas* was referred to the psychiatric ward of Gandhi Hospital in Secunderabad after a failed suicide attempt—the third time in three years that he had tried to take his life. He was diagnosed with clinical depression and put on therapeutic medication, drugs that would work on the delicate network of synapses in his brain to stimulate the production of neurotransmitters such as serotonin and norepinephrine—chemicals that help transmit impulses between neurons and play a role in the regulation of the body’s many mechanisms. The psychiatrist asked him to return for a consultation three weeks from then.

The three weeks were a trial, both physically and mentally. Srinivas felt queasy much of the time; he couldn’t sleep, and he had a constant dull headache. The doctor had warned him in passing of some side effects, but he didn’t know how long they would last. The anxious atmosphere at home and the increasing sense of distance from his parents didn’t help much. He showed up at the hospital a few days into the medication and asked to see his doctor. Instead, he was referred to a part-time counsellor. Over several sessions with the counseling psychologist, he came to understand that the medication was necessary, that the side effects would abate over time, and that there were ways in which to move his life forward.

His story wasn’t unusual: a broken romantic relationship, low self-esteem, and difficulties in articulating his needs and problems to his parents. These problems, the counsellor felt, had to do with those relational dynamics and his inability to handle them.

This was one of the rare cases where psychiatry and psychology were applied in a complementary manner to deal with a mental health issue, bringing together the science and art of dealing with the demons of the mind. While the medication was necessary to activate the production of what some call “happy hormones”, the counseling helped him gain perspective and build in him the inner strength to look at his life more positively.

But where exactly does the locus of mental illness lie? In that vague, unfixable entity called the mind? Or in the cellular composition of brain tissue? Can it be better addressed by considering the biochemical basis of life and its constituents or by understanding the social and cultural dynamics that construct and constrict an individual’s life? Does one electronically prod and diagram the convolutions of that intricate tissue, one of the last frontiers of medical science, or listen and watch as an individual life unfolds through narration and description? Are the causes understood within the chapters of biology, by reading personal history, or by examining the existential reticulum of society, polity and culture?

Historians would point to René Descartes and the acceptance of the mind-body duality as the point of separation between these two applied sciences of the mind—psychiatry and psychology. The first is born out of biology and medicine, a belief system that holds that disease has a physical basis, one that can be identified, isolated and observed, given the right tools. The second is born out of a philosophical tradition of enquiry, of a focus on the invisible and the immaterial side of being, the idea of self, the soul and its struggles to find balance in a material world. To which of these disciplines does the health of the mind belong, then? If the mind is merely an extension of the body—a function of the brain, so to speak—then it may be treated with the tools of biological medicine. But if it is beyond the body, then what might the tools of healing be? It is in the application of these sciences to the healing of mental illness that a variety of confusions become apparent—regarding the locus and cause of disease, the path and form of treatment.

PSYCHIATRY AS A BRANCH OF MEDICAL PRACTICE has had a long journey from the restraint-based mental asylums of the pre-Victorian era to the sanatoria informed by psychoanalytic theory to the early twentieth century clinics where electroconvulsive therapy became one of the infamous means of taming the rebellious brain. This was followed by the discovery of a range of antipsychotic drugs, heralding a new era of treatment based on pharmacotherapy. In a pithy history of the discipline in The Lancet (10 April 2010), Andrew Scull of the University of California at San Diego notes that these drugs gave psychiatrists a “therapeutic modality that was easy to dispense and closely resembled the magic potions that increasingly underpinned the cultural authority of medicine at large”. The availability of medications allowed psychiatric treatment to move outside institutions and in a way gave more autonomy to patients and their families. At the same time, it also resulted in reducing mental illness to something that was a biochemical problem, one which could be easily addressed with the support (and, some would say, collusion) of the pharmaceutical industry.

These developments in psychiatry—first institutionalization as a mechanism and then the excessive dependence on drugs—led to considerable social criticism in the early part of the 20th century, dubbed the “anti-psychiatry” movement, fuelled by intellectuals like Michel Foucault and R D Laing in Europe and Thomas Szasz in the United States. The unquestioned assumption that ‘reason’ underlay ‘normalcy’ in thought and behavior—an outcome of the Enlightenment—was attacked. This served to bring back some credibility to the role of the “talking cure” which had been discredited following the rise of the “biomedical” model and which now became the preserve of the newer science of psychology.

SIGMUND FREUD MIGHT BE THE FATHER OF PSYCHOANALYSIS and widely credited with the introduction of the “talking cure” but the discipline of psychology is thought to have been formalized with the setting up of a laboratory by German physiologist Wilhelm Wundt at the University of Leipzig in 1879, to study human behavior. Wundt used a method called “introspection” to break down thoughts and reactions into units that could be related to the most basic sensations and perceptions. Taken further and formalized by Edward Tichener, one of his students, this came to be known as the structuralist school of psychology. Psychology then travelled to North America where the understanding of behavior was placed within the context of the social environment, growing into the functionalist school. Human consciousness was conceptualized as something that existed as a continuous flow, which could not be broken down according to a structuralist formula. This approach to understanding the mind influenced studies on memory and behavior, and informed the experimental work that began to characterize the psychology of the early 1900s. The first half of the twentieth century was dominated first by Freud and Carl Jung and their work on the unconscious, while the middle years of the 1900s gave themselves over to the study of developmental psychology and cognition, marked by thinkers such as Jean Piaget and Abraham Maslow. Psychology was attempting to integrate ideas about intelligence, behavior and the brain in ways that raised complex questions about nature and nurture, biology and spirituality, mind and matter.

By the 1950s, the discipline already has several subfields and many divergent schools of thought, from the heavily positivist ideas of the behaviourists and those who believed that the workings of the mind could be tested and coded in a scientific manner, to those who, like Maslow, believed the understanding of the mind as an art required a more philosophical and humanistic approach.

The latter half of the twentieth century saw psychology subjected to similar criticisms as psychiatry in its reductionist view of the human mind, in its trying to fit the mind into the structure of the brain, and place responsibility—and blame—on the illness on individual factors. This fueled the move towards a more open, socially and culturally sensitive approach to understanding and dealing with human thought and behavior. Positive psychology, for instance, is a direct outcome of this move, with its focus on building the capacity in people to better respond to their life contexts.

SRINIVAS' DRUG THERAPY was a direct consequence of the biochemical basis of psychiatry, while the counsellor’s approach was almost classical cognitive-behavior therapy, or CBT, on which much of today’s psychology is based.

The boundary between psychology and psychiatry is neither clean nor clear, but messy and blurred, rent in places by knowledge from contributing fields of knowledge, bridged by technology in others. Neurobiology, cognitive science, genetics, as well as sociology, theology and (once again) philosophy make connections with both the medical and the social science and render the divide debatable.

In the world of ideas, of journals and academic conferences, there is considerable comingling and sharing of knowledge. Take, for instance, the Journal of Philosophy, Psychology and Psychiatry (published by Johns Hopkins University), which encourages crossover thinking. But as Philip John, a senior psychiatric consultant from Kerala notes, in an article in the Indian Journal of Psychiatry (2010, vol. 52), “professional contest and personal vanity” still mark the boundary debates between the two professions. While John recognizes the importance of developing an approach to mental health that allows a melding of ideas and approaches across the spectrum, from chronic insanity to the ‘worried well’, in the real world, most practitioners of the two sciences to a large extent still work in different worlds, and with different world views.

Diana Monteiro, a Hyderabad-based counseling psychologist, adds that the forcing of mental health practice into a medical model creates a need among clinical psychologists to “appear equivalent” to psychiatrists. “There’s a tendency for both professions to look down on the other side, with a reluctance to refer patients to each other,” she says.

The resistance to the biomedical understanding of mental health resurfaced last month with the publication of the newest edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM 5) in the United States. Ashok Mysore, professor of psychiatry at St John’s Medical College in Bangalore, calls this an “extension” of the process of operationalisation of definitions of disorders that began with DSM 3 in 1980 that was “predicated on the philosophy of logical positivism”, as it focused on “empirical evidence” as the basis for categorizing disease. DSM 3 for the first time had introduced a system of classification and identification of mental illnesses that drew upon explicit diagnostic criteria without reference to the ‘cause’ or in medical terms, ‘aetiology’ of disease. The DSM 5 further systematizes the classification. The British Psychological Association, in response to DSM 5, has called for a rethinking of the approach to defining mental illness, moving away from relating it to biological—even genetic—causes and taking into account social and cultural contexts within which people live their lives.

The truth is, both professions are crucial to the management of mental illness and mental health. In India, mental health disorders account for close to one-sixth of all health problems. There are 0.4 psychiatrists and 0.2 psychologists per 100,000 Indians, a grossly inadequate number, given the scale and scope of mental health problems in the population. Policy makers call for a “therapeutic alliance” in the field of mental health, comprising a range of professions and representing a variety of approaches.

S N Chaudhry, neurosurgeon and member of the governing body of the Delhi-based Vidyasagar Institute of Mental Health and Neurosciences (VIMHANS), says that psychiatry is one of the most poorly treated specialisations in early medical training across India. “Very little attention is paid to mental health in the basic MBBS programme, with those who go into it later receiving an education focusing almost entirely on diagnosis and pharmacotherapy,” he says. “Training in psychology, on the other hand, happens through the Arts or Social Sciences Faculty in most universities, and there is limited and widely varying exposure to the clinical aspects of mental health until the MPhil level.”

This divergent approach to education has deepened the schism between practitioners. “The average MA in psychology has no ability to deal with mental illness,” observes Chaudhry. On the other hand, the average psychiatric practitioner in India approaches all mental health problems as psychosis.

Chaudhry emphasizes that it is extremely important to distinguish between psychosis, which has a physiological basis and mental health issues. “Only 1 per cent of patients actually have psychosis—which requires medical treatment.” This would include conditions such as mood disorders, schizophrenia and clinical depression. For the rest, it is the psychologist who holds the key to treatment, through a combination of counseling and psychotherapy. Chaudhry also indicates that the biggest growth for services is in areas such as child/adolescent issues, lifestyle management, family and relationship counseling, and substance abuse rehabilitation—all of which are more appropriately handled by psychology than psychiatry.

Monteiro points out that despite this, one is more likely to find a larger crowd in a psychiatric clinic than in a counsellor’s office. “The psychiatrist is usually the first stop when someone has a mental health problem,” she says. This could be even something as simple as stress and anxiety leading to sleep deprivation. “And very, very few psychiatrists will refer them to a psychologist.”

“I’d say that 75 per cent of my patients see a psychiatrist, and in most cases that has been their first stop,” says Monteiro. “But in fact, 95 per cent need to see a psychologist first and perhaps only 5 per cent—the severe cases—need a psychiatrist.”

There’s another catalyst for the medicalization of mental health, according to Ashok Mysore. “The more legalities are associated with the practice of healthcare, the more it forces us into a medical model.” The legal system demands clear definitions of mental disorder, thus forcing practitioners to look for symptoms in a manner akin to a checklist. “After all, you can [legally] hold medical practice accountable for errors with defining or managing the change in a person’s mental state. One cannot be reliably faulted for pinning responsibility for altered mental states on contexts such as society or culture.”

Most people seeking medical care want quick treatment, and, so the doctor who can prescribe a pill to make the illness go away is always preferred—hence the preference for the psychiatrist. With extremely effective drugs becoming available, pharmacotherapy is the first line of treatment. “But hardly ever does a doctor tell the patient what the drug is for, and how long they will need to use it,” she adds.

Chaudhry’s approach at VIMHANS has been to ramp up the presence of psychologists. “It’s also a question of economics,” he says. “A psychiatrist sees 3-4 patients in an hour, while a psychologist can see one patient an hour, just because of the nature of the interaction.” This naturally translates into psychological counseling being the more expensive service, and therefore is more difficult to sustain. At VIMHANS, involving this group in education and research has helped mitigate the financial challenge.

On the other side, psychiatric practice and training in most parts of the world has expanded to include psychotherapy and counseling—in a way, going back to its origins. “One has to remember that the chemicals now available to treat psychoses are no more than three or four decades old,” says Chaudhry. “It was because there were no medicines to treat these disorders that Freud tapped into the subconscious as a method of addressing them.”

It has taken a new generation of psychiatrists to recognize the importance and complementary value of psychology and therefore adjust their own approaches to treatment to make the most of this potential synergy. Combined clinical meetings and case discussions have helped overcome some of the disciplinary distrust. “It’s been a gradual evolution,” says Chaudhry. “Our psychiatrists are now better able to demarcate those patients who would benefit from a psychologist’s intervention.” The clinical psychologists at VIMHANS now have close to 40 per cent referrals (with the remaining walk-ins), a four-fold jump from 8 years ago, when barely 10 per cent of the patients were referred for psychological counseling.

It’s also important to acknowledge the role of public perceptions in granting status to one discipline over another. Chaudhry cites the examples of complementary fields like cardiology and cardiac surgery, neurology and neuro surgery. It’s the surgical disciplines that seem to provide the miracle solutions, and therefore acquire greater cachet in the public mind. “The social workers and psychologists actually handle the bulk of mental health issues but psychiatrists receive the greater credit,” he says. This is because they come in at a point when disease becomes severe, and therefore calls for more drastic—and more visible—measures.

The therapeutic alliance is particularly important in such cases. As Monteiro explains, “I have seen a fair number of people who got put on anti depressant or anti mania drugs who I thought were quite normal and experiencing a normal reaction to a life stressors.”

“I think the relationship between the psychiatrist and psychologist is very important, to keep communication open about what each thinks is normal or not,” continues Monteiro. “When the psychiatrist has explained his thinking to me I was able to understand why he thought it was abnormal and vice versa. This takes of course a good relationship between the two.”

Places like VIMHANS and the Bangalore-based NIMHANS / St John’s where such an approach exists, are still the exception rather than the rule in India, and the professions still do not occupy a common service delivery platform. The situation is compounded by the divisions within the field of psychology, which has a variety of overlapping subspecializations, ranging from abnormal to developmental to organizational to social to counseling psychology. “I’d say the boundary tensions within psychology are more pronounced than that between psychology and psychiatry,” says Mahati Chittem, associate professor of health psychologist at the Indian Institute of Technology, Hyderabad. She points to the overlaps between health psychology, counseling psychology and positive psychology, all subspecialties that focus on enabling individuals to handle mental and emotional stress, but arising from different sources or contexts. Clinical psychologists, whose purview has been abnormal behavior, sometimes stray into providing counseling for instance.

BACK IN THE LABORATORIES and hallways of research there are exciting realignments and crossovers that are creating new knowledge, understandings that do not fit easily into any one box yet have implications for a variety of areas. Work on neurotransmitters and chemical receptors in neurobiology holds promise for the development of new psychotherapeutic drugs, something that the field has been waiting over three decades for. Illnesses such as depression have benefited from pharmacological intervention—ipronazid, for instance, has helped many people who struggle with chronic depression. Other illnesses continue to challenge researchers, particularly since testing psychotropic drugs cannot follow the same animal model trajectory that other drug testing does. Symptoms such as despondency may not quite manifest in similar ways in mice! Scientists are also beginning to look at different approaches to drug discovery that bypass animal testing, instead going back to directly observable effects on humans in what are called “fast-fail” trials. In these experiments, the attempt is to link specific symptoms (observable behaviours) to particular regions of the brain.

Inputs from other fields such as neuroimaging and cognitive sciences are also helping build pictures of how the brain works in conditions like autism spectrum disorder. Such pictures are beginning to show, for instance, that differences in patterns of neural connections may indicate some forms of schizophrenia. The University of Hyderabad’s Centre for Neural and Cognitive Sciences brings together linguists, philosophers, developmental psychologists and computer scientists to understand the process of cognition. Combined with neuroimaging, these disciplines help map brain activity and impulse transmission during acts such as reading, speaking or taking in visual stimuli. Studies on adolescents, among others, has provided interesting insights into key emotional, cognitive and social changes taking place at this phase of development. In fact, much of the “new research” in this shifting field is now under the large umbrella of neurotechnology—an interdisciplinary space that combines health sciences, bioengineering, cognitive science, genetics and biotechnology. Prof Bapi Raju of the University of Hyderabad notes that until recently, the debates at the cognitive science-philosophy interface concerning the nature of the mind and consciousness had not had any direct impact on the practice of either psychiatry or psychology. “Neuroimaging perhaps offers us a way to facilitate that dialogue,” he says. “We are in a position to study brain activity ‘in vivo’ so to speak, in conditions as varied as dyslexia and schizophrenia,” he continues, noting that in doing so, “we are mindful of the fact that we are making the big assumption that consciousness has a neural manifestation.” His excitement is visible as he speaks of the opportunity afforded by such technologically-aided collaborations to gain a better understanding of how (for instance) talk (as in psychotherapy) can actually have an impact on brain chemistry.

Barack Obama, in his 2013 State of the Union address, flagged a new research initiative called BRAIN (Brain Research through Advancing Innovative Neurotechnologies) aimed at revolutionizing our understanding of the human brain. This initiative hopes to build “dynamic pictures of the brain” that will ultimately “shed light on the complex link between brain function and behavior”.

There is a danger, however, that the application of technologically-driven science could push the study of the mind—that opaque entity that is lodged in the brain—back into the realm of that which is physically visible, its processes subject to modeling and mapping using an algorithmic approach, that one kind of reductionism is replaced by another. Mapping all 100 trillion neural connections in the brain may not quite lead us to ‘seeing’ the workings of the mind. As Robert Burton, author of A Skeptic’s Guide to the Mind says, there is no way to understand how the brain converts the electrochemical impulses into subjective experience.

But one might say that attempting to understand the workings of intelligence is only a few steps away from drawing the boundaries of normal and abnormal cognition. The use of advanced imaging to note the patterns of brainwaves might tell us that something is happening within the innermost reaches of our brains but its interpretation is still embedded within a cultural and social context. Similarly, genetics and neurobiology are producing new knowledge that feed into the epidemiology of disease, but this again returns us to the basic rift in disciplines, one of interpretation of physical/biological phenomena and how one defines the pathology of mental illness. However, it is interesting that the focus of this understanding is aimed at understanding “brain disorders” rather than “mental illness”, and perhaps this is where the disciplinary divide will ultimately come to rest. Will understanding how the brain works also provide insights into how the mind reacts to situations? What tips the balance between health and illness when it comes to the mind? Is it “thinking” as mapped via neuroimaging or “feeling” tracked through neurotransmitters? How does one interact with the other? And at what point does something move from minor aberration to pathology?

One of the major criticisms against the newest DSM is the expanded range of mental states to be classified as disorders, including temper, grief and worrying. It would seem that psychiatry has narrowed the range of the normal and expanded its own playing field, in labeling as pathologies states that most people experience at one time or another in the course of a lifetime. At the same time, critical scholars have suggested through systematic meta-analyses that such conditions as ‘premenstrual syndrome’ have no biological basis and may instead be products of a process of socialization.

SRINIVAS' STORY ENDED HAPPILY ENOUGH. The antidepressants, despite their side-effects, did help restore a biochemical balance in due course. And while the chemicals were doing their job, the psychological counseling helped him map out the things that were causing him distress, building within him the coping skills that would help him handle the challenges without breaking down.

So, has his body been healed, or has his mind?

The truth about mental illness or mental health, most likely, lies somewhere in the space between the biological and the socio-cultural. As Simon Wessely, Member of the Royal College of Psychiatrists notes in The Guardian, it is “about biology, but it [is] also about psychology, and sociology, ethics, politics and much else.”

Usha Raman Usha Raman is a journalism teacher, writer and editor based in Hyderabad.

Keywords: psychology psychiatry mental illness