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Taking a narrative turn in psychiatry
Perspectives
The art of medicine Taking a narrative turn in psychiatry
Private Collection/Costa/Leemage/The Bridgeman Art Library
A little over 30 years into its life journey, modern scientific psychiatry seems to be heading into a dark wood. Last year the US National Institute of Mental Health (NIMH) withdrew its support for the Diagnostic and Statistical Manual (DSM), which has often been called the “bible of psychiatry”. Pharmaceutical companies are to some extent pulling back from psychiatric research and drug development. Activists, journalists, and academics from various perspectives are criticising psychiatric research, diagnoses, and treatments. Psychiatry, it seems, has gone astray from the road it set out on during the late 20th century and now seems to be veering into Dante’s “arduous wilderness”. All of this is personal for me; modern scientific psychiatry emerged around the same time I became a psychiatrist. In 1980, just a few years before I entered my residency at George Washington University, the American Psychiatric Association published—with much fanfare—the third edition of DSM. Leading psychiatrists at the time hailed DSM-3 as a revolutionary book that would lead to considerable modernisation of psychiatric diagnoses and treatment. It heralded a major shift away from psychoanalysis towards a more scientific approach to psychiatry. Unconscious conflicts, childhood traumas, and talk therapy gave way to broken brains, neurochemical
Inferno, Canto 2, The darkening sky of the first night, illustration after Gustave Doré in The Divine Comedy by Dante Alighieri
22
imbalances, and psychopharmacological treatments. It seemed this tide of “modernisation” would go on indefinitely: more drugs would be developed, there would be more advances in neurological research, and the wave of scientific psychiatry would keep flowing forward. Instead, 34 years after the “revolutionary” DSM-3 was published, psychiatry has run into doubt, criticism, and uncertainty. It is important to note that when the NIMH withdrew support for psychiatry’s diagnostic manual, including the most recent DSM-5, it also questioned the validity of DSM categories. NIMH researchers are now trying to reorient research efforts to develop an entirely new set of categories for mental difference and suffering that is more directly connected to observable laboratory measures—a process that the NIMH estimates could be 10 years or more in the making. Not only has the NIMH cast a vote of no confidence against DSM, pharmaceutical companies seem to some extent be pulling back their research and development of psychopharmacological drugs. Although the pharmaceutical industry is not exactly “in” the field of psychiatry, it has been intertwined with the specialty for the past few decades. Indeed, many critics of psychiatry argue that it was the power of pharmaceutical promotion that solidified the current consensus in psychiatry. Without resources for research and marketing from one of the world’s most profitable industries there is a drying up in the pipeline for psychiatric medications and, perhaps more important, a reduced funding source for the current consensus in psychiatry. Psychiatry is also facing increased calls for reform from people with lived experience, peer specialists, anthropologists, sociologists, philosophers, social activists, attorneys, and journalists. This criticism is reminiscent of the protest around psychiatry during the 1960s and 1970s, which in part stimulated the birth of scientific psychiatry in the first place. While their opinions naturally vary, today’s critics share a belief that the current system of psychiatric care needs to be vastly improved and, many would argue, transformed. Few of these voices are “against” psychiatry, but all lament psychiatry’s near-exclusive turn to pharmaceutical treatments in the past few decades. Biology and medications are part of psychiatric treatment, research, and education, they argue, but the question remains, how much and in what proportion? For most contemporary critics, psychiatry’s current biological focus results in excessive preoccupation with only a portion of the variables relevant for mental health. What do these signs of doubt and instability mean for the future of psychiatry? Are we hearing the sounding of the www.thelancet.com Vol 383 January 4, 2014
Perspectives
death knell? Or will this tough passage through the current dark wood lead eventually, as it did for Dante in The Divine Comedy, to newer and more enlightened places? Modern psychiatry is going through a midlife crisis; will it come out renewed and transformed on the other side? It is certainly possible that modern scientific psychiatry will restabilise itself. The Psychiatric Genomics Consortium, for example, has used large genetic databases to find shared genetics among major psychiatric disorders. In addition, last year the Obama administration endorsed a new brain activity map project, Brain Research through Advancing Innovative Neurotechnologies (BRAIN). The BRAIN initiative will be comparable to the Human Genome Project in its capacity to shape future research and will likely have sufficient successes to attract the pharmaceutical industry back into psychiatry. But mapping the brain is a long-term project, and while it will have successes, these will be piecemeal and disconnected for some years to come. Before psychiatry rushes in to “save” its bioscientific self, however, it seems this moment offers an opportunity for self-reflection and deeper understanding of the process of psychiatric meaning-making. Psychiatry can take advantage of its current instability to take a bird’s-eye view of how all the possible models of mental difference are created and propagated—whether biological, psychoanalytic, cognitive, creative arts, family, recovery, or biopsychosocial, just to name a few. If we step back from the particulars, we can see that all these models work through root metaphors that structure our understanding and perception by foregrounding and backgrounding different variables. These root metaphors become models through systematic development in a research and treatment community and, from there, seep out of the clinic to join other cultural tools that people use for storytelling about mental health problems. Such a deeper understanding of how mental health models are used for meaning-making is already developing in psychiatry under the banner of narrative, narrative theory, and narrative psychiatry. During the period in which psychiatry has been relentlessly pursuing science, the humanities and the social sciences have seen an explosion of research in narrative and narrative theory. This narrative ferment, recently picked up within psychiatry, offers not only a way for psychiatry to reconnect with the larger university beyond the sciences, but also a deeper reflection about the way psychiatry makes meaning and constructs its models. The implication of narrative for psychiatry is that there are many ways to tell the story of mental health problems— not just one right way and many other wrong ways. All the models of psychiatry can work as potential tools for storytelling about mental disorders. No matter which model or combination of models one uses, the process of healing involves an initial set of problems that the person www.thelancet.com Vol 383 January 4, 2014
is unable to resolve. Through clinical dialogues, patient and psychiatrist use one or more models to bring additional perspectives to patient problems, allowing patients to understand them in new ways. The perspectives vary greatly depending on the models used. The metaphors of broken brains, unconscious conflicts, cognitive distortions, and family dysfunctions differ greatly. But, from the vantage point of narrative theory, all of these perspectives, when used for storytelling, allow the possibility of reworking the initial story into a new one. Having a new story can allow new degrees of flexibility for understanding past and present troubles and provides new strategies for moving into the future. None of this means the end of a biological model, psychiatric medications, or emergent neuroplastic training practices. Just the opposite. The biological model is now, and will remain, a critical tool for understanding and intervening in psychiatric troubles. This will only become truer as we move into a brave new world that maps out biological markers for our mental traits and processes. Taking a narrative turn does not mean abandoning the biological model or any other. A narrative turn says all the models are valuable if used self-reflexively in dialogue with patients and in the service of recovery. Ultimately, it is the patient’s choice which model or combination of models best fits their goals and desires. Our task as psychiatrists is to help navigate the process and the options. This kind of narrative self-reflexivity helps us remember that our allegiance is to our patients—not our models. Recovery, not loyalty to models, is the goal. Finally, and to me equally important, as a specialty we need narrative to tell our own stories. Like our patients, I would argue that psychiatry is not exclusively bound to a biological model as the only way to understand ourselves. When the NIMH announced that it would abandon DSM, it also unequivocally reasserted the biological model, telling us that “mental disorders are biological disorders”. We need not accept such a dogmatic story of psychiatry. Psychiatry has an opportunity in this time of instability to more consciously shape its professional identity. I would suggest that as we navigate the current wilderness, some of the most valuable questions for individual psychiatrists and the field as a whole are narrative questions. Where have we been in the past? Where are we now? Where will we go in the future? All of these questions are to some extent about narrative identity—about who we want to be as practitioners and as a profession. I do not think they can be answered by science alone. We must locate ourselves in a story to make sense of them and to plot our way forwards.
Bradley Lewis Gallatin School of Individualized Study, New York University, New York, NY 10012, USA [email protected]
Further reading Angel M. The illusions of psychiatry. New York Review of Books. July 14, 2011 Friedman RA. A dry pipeline for psychiatric drugs. New York Times Aug 19, 2013 Hamkins S. The art of narrative psychiatry: stories of strength and meaning. Oxford: Oxford University Press, 2013 Insel T. National Institute of Mental Health. Directors blog: transforming diagnosis. April 29, 2013. http://www.nimh.nih.gov/ about/director/2013/ transforming-diagnosis.shtml (accessed Dec 10, 2013) Lewis B. Narrative psychiatry: how stories can shape clinical practice. Baltimore: John’s Hopkins University Press, 2011
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The art of medicine Taking a narrative turn in psychiatry
Private Collection/Costa/Leemage/The Bridgeman Art Library
A little over 30 years into its life journey, modern scientific psychiatry seems to be heading into a dark wood. Last year the US National Institute of Mental Health (NIMH) withdrew its support for the Diagnostic and Statistical Manual (DSM), which has often been called the “bible of psychiatry”. Pharmaceutical companies are to some extent pulling back from psychiatric research and drug development. Activists, journalists, and academics from various perspectives are criticising psychiatric research, diagnoses, and treatments. Psychiatry, it seems, has gone astray from the road it set out on during the late 20th century and now seems to be veering into Dante’s “arduous wilderness”. All of this is personal for me; modern scientific psychiatry emerged around the same time I became a psychiatrist. In 1980, just a few years before I entered my residency at George Washington University, the American Psychiatric Association published—with much fanfare—the third edition of DSM. Leading psychiatrists at the time hailed DSM-3 as a revolutionary book that would lead to considerable modernisation of psychiatric diagnoses and treatment. It heralded a major shift away from psychoanalysis towards a more scientific approach to psychiatry. Unconscious conflicts, childhood traumas, and talk therapy gave way to broken brains, neurochemical
Inferno, Canto 2, The darkening sky of the first night, illustration after Gustave Doré in The Divine Comedy by Dante Alighieri
22
imbalances, and psychopharmacological treatments. It seemed this tide of “modernisation” would go on indefinitely: more drugs would be developed, there would be more advances in neurological research, and the wave of scientific psychiatry would keep flowing forward. Instead, 34 years after the “revolutionary” DSM-3 was published, psychiatry has run into doubt, criticism, and uncertainty. It is important to note that when the NIMH withdrew support for psychiatry’s diagnostic manual, including the most recent DSM-5, it also questioned the validity of DSM categories. NIMH researchers are now trying to reorient research efforts to develop an entirely new set of categories for mental difference and suffering that is more directly connected to observable laboratory measures—a process that the NIMH estimates could be 10 years or more in the making. Not only has the NIMH cast a vote of no confidence against DSM, pharmaceutical companies seem to some extent be pulling back their research and development of psychopharmacological drugs. Although the pharmaceutical industry is not exactly “in” the field of psychiatry, it has been intertwined with the specialty for the past few decades. Indeed, many critics of psychiatry argue that it was the power of pharmaceutical promotion that solidified the current consensus in psychiatry. Without resources for research and marketing from one of the world’s most profitable industries there is a drying up in the pipeline for psychiatric medications and, perhaps more important, a reduced funding source for the current consensus in psychiatry. Psychiatry is also facing increased calls for reform from people with lived experience, peer specialists, anthropologists, sociologists, philosophers, social activists, attorneys, and journalists. This criticism is reminiscent of the protest around psychiatry during the 1960s and 1970s, which in part stimulated the birth of scientific psychiatry in the first place. While their opinions naturally vary, today’s critics share a belief that the current system of psychiatric care needs to be vastly improved and, many would argue, transformed. Few of these voices are “against” psychiatry, but all lament psychiatry’s near-exclusive turn to pharmaceutical treatments in the past few decades. Biology and medications are part of psychiatric treatment, research, and education, they argue, but the question remains, how much and in what proportion? For most contemporary critics, psychiatry’s current biological focus results in excessive preoccupation with only a portion of the variables relevant for mental health. What do these signs of doubt and instability mean for the future of psychiatry? Are we hearing the sounding of the www.thelancet.com Vol 383 January 4, 2014
Perspectives
death knell? Or will this tough passage through the current dark wood lead eventually, as it did for Dante in The Divine Comedy, to newer and more enlightened places? Modern psychiatry is going through a midlife crisis; will it come out renewed and transformed on the other side? It is certainly possible that modern scientific psychiatry will restabilise itself. The Psychiatric Genomics Consortium, for example, has used large genetic databases to find shared genetics among major psychiatric disorders. In addition, last year the Obama administration endorsed a new brain activity map project, Brain Research through Advancing Innovative Neurotechnologies (BRAIN). The BRAIN initiative will be comparable to the Human Genome Project in its capacity to shape future research and will likely have sufficient successes to attract the pharmaceutical industry back into psychiatry. But mapping the brain is a long-term project, and while it will have successes, these will be piecemeal and disconnected for some years to come. Before psychiatry rushes in to “save” its bioscientific self, however, it seems this moment offers an opportunity for self-reflection and deeper understanding of the process of psychiatric meaning-making. Psychiatry can take advantage of its current instability to take a bird’s-eye view of how all the possible models of mental difference are created and propagated—whether biological, psychoanalytic, cognitive, creative arts, family, recovery, or biopsychosocial, just to name a few. If we step back from the particulars, we can see that all these models work through root metaphors that structure our understanding and perception by foregrounding and backgrounding different variables. These root metaphors become models through systematic development in a research and treatment community and, from there, seep out of the clinic to join other cultural tools that people use for storytelling about mental health problems. Such a deeper understanding of how mental health models are used for meaning-making is already developing in psychiatry under the banner of narrative, narrative theory, and narrative psychiatry. During the period in which psychiatry has been relentlessly pursuing science, the humanities and the social sciences have seen an explosion of research in narrative and narrative theory. This narrative ferment, recently picked up within psychiatry, offers not only a way for psychiatry to reconnect with the larger university beyond the sciences, but also a deeper reflection about the way psychiatry makes meaning and constructs its models. The implication of narrative for psychiatry is that there are many ways to tell the story of mental health problems— not just one right way and many other wrong ways. All the models of psychiatry can work as potential tools for storytelling about mental disorders. No matter which model or combination of models one uses, the process of healing involves an initial set of problems that the person www.thelancet.com Vol 383 January 4, 2014
is unable to resolve. Through clinical dialogues, patient and psychiatrist use one or more models to bring additional perspectives to patient problems, allowing patients to understand them in new ways. The perspectives vary greatly depending on the models used. The metaphors of broken brains, unconscious conflicts, cognitive distortions, and family dysfunctions differ greatly. But, from the vantage point of narrative theory, all of these perspectives, when used for storytelling, allow the possibility of reworking the initial story into a new one. Having a new story can allow new degrees of flexibility for understanding past and present troubles and provides new strategies for moving into the future. None of this means the end of a biological model, psychiatric medications, or emergent neuroplastic training practices. Just the opposite. The biological model is now, and will remain, a critical tool for understanding and intervening in psychiatric troubles. This will only become truer as we move into a brave new world that maps out biological markers for our mental traits and processes. Taking a narrative turn does not mean abandoning the biological model or any other. A narrative turn says all the models are valuable if used self-reflexively in dialogue with patients and in the service of recovery. Ultimately, it is the patient’s choice which model or combination of models best fits their goals and desires. Our task as psychiatrists is to help navigate the process and the options. This kind of narrative self-reflexivity helps us remember that our allegiance is to our patients—not our models. Recovery, not loyalty to models, is the goal. Finally, and to me equally important, as a specialty we need narrative to tell our own stories. Like our patients, I would argue that psychiatry is not exclusively bound to a biological model as the only way to understand ourselves. When the NIMH announced that it would abandon DSM, it also unequivocally reasserted the biological model, telling us that “mental disorders are biological disorders”. We need not accept such a dogmatic story of psychiatry. Psychiatry has an opportunity in this time of instability to more consciously shape its professional identity. I would suggest that as we navigate the current wilderness, some of the most valuable questions for individual psychiatrists and the field as a whole are narrative questions. Where have we been in the past? Where are we now? Where will we go in the future? All of these questions are to some extent about narrative identity—about who we want to be as practitioners and as a profession. I do not think they can be answered by science alone. We must locate ourselves in a story to make sense of them and to plot our way forwards.
Bradley Lewis Gallatin School of Individualized Study, New York University, New York, NY 10012, USA [email protected]
Further reading Angel M. The illusions of psychiatry. New York Review of Books. July 14, 2011 Friedman RA. A dry pipeline for psychiatric drugs. New York Times Aug 19, 2013 Hamkins S. The art of narrative psychiatry: stories of strength and meaning. Oxford: Oxford University Press, 2013 Insel T. National Institute of Mental Health. Directors blog: transforming diagnosis. April 29, 2013. http://www.nimh.nih.gov/ about/director/2013/ transforming-diagnosis.shtml (accessed Dec 10, 2013) Lewis B. Narrative psychiatry: how stories can shape clinical practice. Baltimore: John’s Hopkins University Press, 2011
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