10/28/15

Positively NOT Psychiatry

© lightwise | 123RF.com

© lightwise | 123RF.com

Positive psychiatry is a growing phenomenon within the profession of psychiatry. And Dr. Dilip Jeste, a former APA President, seems to be the primary “evangelist” for the positive psychiatry movement. The theme for his year as APA President in 2012 was: “Pursuing Wellness Across the Lifespan.” He said positive psychiatry was the future of psychiatry.  In a Psychiatric News article for June of 2012, Jeste said: “I believe that, as the medical field begins to appreciate the value of positive psychosocial factors in the prevention and management of pathology, positive psychiatry will increasingly take a central stage within medicine and health care.”

David Rettew, a child psychiatrist, wrote of his invitation by Dr. Jeste, to speak at a symposium on Positive Psychiatry at the 2015 annual conference of the American Psychiatric Association (APA) held in Toronto. He was excited by the opportunity and sees positive psychiatry as an opportunity for his profession to become “physician experts in mental health,” as opposed to their current emphasis on mental illness. Dr. Rettew noted that for too long, psychiatry has had two primary interventions: psychotherapy and medications. “Expanding our efforts into domains of wellness gives us so many more avenues to help children and families thrive.”

Jeste is also one of the editors of Positive Psychiatry: A Clinical Handbook, which was just released in June of 2015. Dr. Rettew is one of the contributing authors to that work. Jeste, Barton Palmer (co-editor of Positive Psychiatry), Rettnew, and Samantha Boardman (contributor to Positive Psychiatry) coauthored an article in the June 2015 issue of the Journal of Clinical Psychiatry, “Positive Psychiatry: Its Time Has Come.” They noted how psychiatry has traditionally focused on the diagnosis and treatment of mental illnesses. However, trying to find what causes mental illness and developing “safe and effective treatments” has not been enough to fulfill “the enormous potential of psychiatry to promote human welfare.”

The time has come to integrate positive mental health into psychiatric practice, training, and research and to expand psychiatric expertise to encompass the full spectrum of mental functioning.

Instead of an emphasis on managing mental disorders, Jeste et al. said positive psychiatry is a science and clinical practice that seeks to promote well-being through “assessment and interventions aimed at enhancing behavioral and mental wellness.” As a branch of medicine, positive psychiatry is rooted in biology and seeks to decipher the biological underpinnings of positive psychosocial characteristics (PPCs). “And eventually promote health and well-being through psychosocial/behavioral and biological interventions.“

Positive psychiatry traces its immediate influence to the positive psychology movement that was pioneered by Milton Seligman in the later 1990s. In his presidential address to the American Psychological Association in 1998, he called for “a reoriented science that emphasizes the understanding and building of the most positive qualities of an individual.” These qualities include: optimism, courage, work ethic, future-mindedness, interpersonal skills, the capacity for pleasure and insight, and social responsibility. Similarly, Jeste et al. pointed to how a growing body of research shows that higher levels of PPCs, such as resilience, optimism, and social engagement are associated with objectively measured better health outcomes. You can watch a TED talk given by Seligman, “The New Era of Positive Psychology,” where he describes positive psychology.

Possible biomarkers for positive mental health were noted by Jeste et al. They were: allostatic load, telomere length, oxidative stress, neuroinflammation and immune function. The authors then ran through the “association” of several positive psychological characteristics (PPCs) with biological factors. Jeste et al. believed that by strengthening the development of positive traits through psychotherapeutic, behavioral, social and biological interventions, “positive psychiatry has the potential to improve health outcomes and reduce morbidity as well as mortality.”

Instead of being narrowly defined as a medical subspecialty restricted to the management of mental illnesses, psychiatry of the future will develop into a core component of the overall health care system. Psychiatrists will thereby more explicitly reclaim their role as physicians in addition to their roles as mental health professionals. Clearly, much more work is needed to make positive psychiatry a norm in psychiatric practice, but it is time to start that process.

I’m troubled by the rhetoric of the so-called “positive psychiatry” movement. On the one hand, it is encouraging to hear an eminent psychiatrist like Dr. Jeste call for attention and research into positive psychological traits. Psychiatry has concentrated on the prevention and management of pathology, while it largely ignored positive psychological traits like resilience, optimism and self-efficacy and how important they are in preventing and managing pathology. This next quote, taken from the Jeste et al. article, succinctly captures both what encourages me and sends chills up my spine: “The time has come to integrate positive mental health into psychiatric practice, training, and research and to expand psychiatric expertise to encompass the full spectrum of mental functioning.”

The time has come to consider positive mental health in psychiatry. However, the expansion of psychiatric “expertise” and the authority that will accompany such expertise in modern society is not a positive outcome for society. It has disturbing social and political dimensions that were foreseen and noted by psychiatrist Thomas Szasz over fifty years ago. In his 1977 work, The Theology of Medicine, he said:

In the scientific-technological concept of the state, therapy is only a means, not an end: the goal of the therapeutic state is universal health, or a least unfailing relief from suffering. The untroubled condition of man and society is a quintessential feature the medical-therapeutic perspective on politics: conflict among individuals, and especially the individual and the state, is invariably seen as a symptom of illness or psychopathology; and the primary function of the state is accordingly the removal of such conflict through appropriate therapy—imposed by force if necessary. (Thomas Szasz, The Theology of Medicine, p. 128)

If we value personal freedom and dignity, we should, in confronting the moral dilemmas of biology, genetics, and medicine, insist that the expert’s allegiance to the agents and values he serves be made explicit and that power inherent in his specialized knowledge and skill not be accepted as justification for his exercising specific controls over those lacking such knowledge and skill. (Thomas Szasz, The Theology of Medicine, p. 17)

It seems that within “positive psychiatry,” psychiatrists are seeking to not only maintain their hegemony over preventing and managing pathology, but expand it to “encompass the full spectrum of mental functioning.” There has been a growing concern with the failed promises of psychiatry, such as the identification of biological or genetic cause in the “mental illness.” Critiques of DSM diagnosis have come from within psychiatry from individuals such as Allen Frances and Thomas Insel. Frances was the chair for the DSM-IV. Insel is the Director of the National Institute of Mental Health (NIMH). In Saving Normal, Frances’s critique of the DSM-5 and the medicalization of everyday life, he said: “Unfortunately, the DSM approach has been far too influential—dominating the filed in a way we never intended.” Insel announced before the publication of the DSM-5 that the NIMH would be “reorienting its research away from DSM categories” (see “Psychiatry Has No Clothes”).

It was encouraging to hear Dr. Rettew acknowledge how psychiatry has been having an identity crisis. He alluded to the dominance psychiatry had as “skilled therapists” when it was ruled by psychoanalytic thought. But there is another way to see the consequences of the “explosion of neuroscience” and the “promise of medications.” Just as the reliability and validity of psychiatric diagnosis was effectively questioned, and from within and outside psychiatry, and psychiatrists faced losing their social status and power, they reframed diagnosis along purely biological guidelines and aligned themselves with the pharmaceutical industry.

As Rettew said: “Recent research has revealed that many of the risks of medications may have been under appreciated while the benefits somewhat overblown.”  He noted how neuroscience research has been impressive, but lacking immediate clinical applications. Despite the promise that these results may eventually help improve early identification and facilitate effective treatment with a variety of disorders, “in reality there remains a large number of dots to connect before that actually happens.”

Positive psychiatry seems to be about maintaining hegemony in the face of another serious challenge to its authority. It is not humbly admitting the limitations of a purely biochemical explanation for human behavior, it’s just “kicking the can” of research further down the road. The reductionism of the medical model is still at the heart of how positive psychiatry views psychopathology. Biology is still the “root” of positive psychiatry. Jeste et al. said:

As a branch of medicine, positive psychiatry is rooted in biology and seeks to decipher biological underpinnings of PPCs [positive psychosocial characteristics] and eventually promote health and well-being through psychosocial/behavioral and biological interventions.

Jeffery Liebeman, the president of the APA immediately after Dr. Jeste, has published a book, Shrinks, that purports to tell the story of how psychiatry overcame its dubious past. Lieberman seems more willing to acknowledge the still dominant medical model in psychiatric diagnosis and treatment.  With regard to the field of psychiatry, he said: “Ever since the very earliest psychiatrists began conceiving of disturbed behaviors as illnesses (and even long before), they held out hope that direct manipulation of a patient’s brain might one day prove therapeutic” (Shrinks: The Untold Story of Psychiatry, p. 160).  With regard to diagnosis, he said: “The DSM-III turned psychiatry away from the task of curing social ills and refocused it on the medical treatment of severe mental illnesses.” (Shrinks, p. 147)

Research into the impact of positive psychological characteristics on mental functioning and psychopathology is certainly a good thing, but it is positively NOT psychiatry that should have a controlling, leading role in that research. Its seemingly positive and hopeful view of the future is based upon seeing humanity as biological machines. While not I don’t think this would lead to the dystopian future, like that portrayed in the Terminator movies, the rise of the biological machine would be just as apocalyptic.  For an alternative way of doing psychiatry, see “Psychiatry Is Not Neurology.”