New Evidence Said to Challenge Psychiatry’s Basic Paradigms

Psychiatry is at a crossroads, according to Patrick Bracken, M.D., Ph.D., clinical director of the West Cork Mental Health Service in Ireland, at APA’s annual meeting in San Francisco in May.

“Accumulating evidence challenges the current paradigm underlying psychiatric thinking and practice,” said Bracken. The problem lies deeper than just “too many drugs.”

“Psychiatry faced three great quests over the last 30 years—the quest for valid classification systems, the quest for biological and psychological causal pathways in mental illness, and the quest for technological treatments used independently of context—and all are falling apart in front of our eyes,” he maintained.

Bracken faults the profession’s adherence to what he calls the “technological paradigm,” an approach to understanding psychiatric symptoms and diagnoses mainly as broken mechanisms or processes that need fixing.

“These faulty cognitive or emotional processes are modeled in universal causal terms, separated from context,” said Bracken. “This technical approach pushes nontechnical, nonspecific aspects of mental health to the margins.”

Psychiatry is not like cardiology, he said. The mind is not simply another organ of the body, but encompasses relationships, values, and meaning.

However, the technological paradigm today guides training, service delivery, and research. Perhaps 95 percent of papers published in psychiatry fall into that category, he said.

The treatment of depression serves as an example. Antidepressant medications seem to work for about 60 percent to 70 percent of patients, yet little is known about their mechanism of action. “But how the treatment is carried out is as important as which drug is used,” he stated.

Furthermore, while cognitive-behavioral therapy (CBT) is a recommended treatment for depression, studies show that specific features of CBT can vary and still benefit patients.

“CBT works,” he said. “But what matters is the quality of the relationship between the patient and therapist, whether the patient feels respected, and whether the encounter is meaningful.”

Thus, in Bracken’s view, psychiatry needs to move beyond its current technological paradigm.

“The public and our medical colleagues are looking at us and asking, what’s going on?” he said. “For three decades, we’ve been telling them that the classification systems are going to be gotten right, the neuroscience is going to be there, that we’ve got the new psychopharmacology.”

But that promise is unfulfilled, he believes. “Unless we grapple with the fundamental paradigmatic issues and actually look at what the science is telling us, we are going to be made irrelevant.”

Nevertheless, medical knowledge and expertise will remain relevant and vital to overcoming mental illness. “A post-technological psychiatry would not get rid of the theories and treatments we use today but would start to develop a primary discourse out of which choices could be made about what we search for and prioritize, what training our professionals should have and, crucially, what kinds of services we want to deliver,” he said. ■