The Banana Peel Project

According to research published in the latest issue of the American Medical Association’s Archives of General Psychiatry (65[8], August 2008), the past ten years have seen a tremendous decline in applied psychotherapy, a change which the authors attribute directly to “a corresponding increase in those [psychiatrists] specializing in pharmacotherapy–changes that were likely motivated by financial incentives and growth in psychopharmacological treatments in recent years” (962).  Although the study was made available only yesterday, dozens of commentators have already praised the authors for quantifying what had until now been a primarily impressionistic understanding of the tensions between psychotherapy and psychopharmacology.  Some have highlighted the extent to which the study shows that managed care and the increasing availability of psychopharmaceuticals have influenced psychiatrists’ methods of treatment.  Others (including the study’s authors) have wondered aloud whether this change is necessarily negative, or whether it represents a qualitative shift in the nature of psychiatric care in the 21st century.

According to the authors:

Some psychiatrists view the ability to provide psychotherapy along with medication treatment as a core aspect of the practice of psychiatry.  However, we found that psychiatrists who strongly favor psychotherapy tend to prescribe medications for only slightly more than half of their patients, and a growing group of psychiatrists who prescribe medications for the large majority of patients appear to shun delivery of formal psychotherapy altogether (969-70).

They identify this shift as a generational struggle between older psychiatrists who continue to embrace the model of “integrated care”–in which the combinationof medication and psychotherapy is understood to be the most effective (and least costly) strategy for treating patients–and younger psychiatrists with very different ties to patient populations, fellow mental health professionals, and the pharmaceutical industry (969).

It’s not always productive to think about psychotherapy and psychopharmaceuticals as inherently contradictory psychomedical strategies.  On one hand, strategies based on the integrated care model recognize the importance of including both in any treatment program.  Yet these approaches reinforce the notion that psychoanalysis and clinical psychology has little or nothing to offer biomedical research–that mind and brain are two different things that require different approaches and afford different means of access.

This idea that culture and biology lie in two distinct domains is increasingly being challenged by feminist cultural critics and scientists.  It is extraordinarily productive to understand the ways in which psychoanalytical or psychotherapeutic models of mental illness and treatment inform and are informed by biomedical understandings of the brain, and likewise to recognize that the biological sciences have always sought to address problems raised by more psychological appraoches.

For example, in his quite well-written analysis of pharmaceutical advertisements from the 1950s to the 1970s, Prozac on the Couch, psychiatrist Jonathan Metzl points out that psychiatry’s embrace of psychopharmaceuticals emerged in a way that reinforced–rather than contradicted–classical Freudian understandings of gender.

In a similar vein, Elizabeth Wilson reveals in Psychosomatic that Freudian psychoanalysis owes a great deal to neurological theories of mind and brain.  Rather than standing in opposition to each other, she writes, psychoanalysis and the biomedical models at the core of psychopharmaceutical research share a great deal.  By pointing to the way in which Freud’s attention to the “malleable actuality of neurological matter” (24) influenced his understanding of the inextricability of mind and body, Wilson identifies a key connection between contemporary psychotherapy and the “neurochemical selves” of modern psychopharmacology (Nikolas Rose discusses the neurochemical self in his spectacular 2007 book, The Politics of Life Itself).

The AGP article identifies an incredibly significant shift in the way in which psychiatric professionals understand and treat mental illness.  But while we trace these changes, we must also be careful not to falsely assume that we are witnessing an epochal, unavoidable, or catastrophic cultural transformation.  Psychopharmaceuticals reinforce as well as rearrange our understandings of the mind and the brain–the mind is revealed in its chemical complexity just as chemicals are revealed in their organic vitality.  Psychiatry and psychotherapy need not be seen as fundamental opposites, one good and the other evil, but rather as collaborative and constitutive components of the same process.