Fallacies of Psychiatry

Nassir Ghaemi, MD, MPH


October 04, 2013

In This Article

The Solution

It's easy, in the abstract, to deny or denounce reductionism, whether biological or psychological; and it's easy, in practice, to keep doing it. The most common claim, when one is pressed, is that everything matters. So let's be "biopsychosocial." Let's try to combine all approaches. The problem with this eclecticism is that in practice, it ends up meaning that clinicians choose whatever they want to do, which usually means enacting whatever predilection they had to begin with. We pay lip service to biology, but we engage in psychological reductionism again, or vice versa.

This easy eclecticism is the theory of current psychiatry, if it can be called a theory. The practice of current psychiatry is the anarchic dogmatism which I've outline above in its biological and psychological forms.

Is there any solution which is neither anarchic nor eclectic? I've outlined my solution at length elsewhere[1,2]; I cannot fully convince readers here in a few hundred words more, but I hope the prior 1600 or so words convince them that my proposed solution deserves more careful attention. I can only provide the conclusions, without the documentation of the premises. So with that apology to the careful reader, I'll state my simple solution: science.

Now that may seem too simple, but let me clarify what I mean by science. Science doesn't mean biological reductionism, as many assume. Nor does it mean adding everything together in some holism. Science is by nature reductionistic; it takes something complex, and tries to test one aspect of it. It accepts only theories that are testable, preferably refutable, and not just confirmable.

In the case of psychiatry, scientific research might teach us that some diseases are basically biological (eg, schizophrenia, bipolar illness, and severe recurrent depression), and we are justified in being biologically reductionistic about them. And some clinical pictures are basically psychological in etiology (such as what used to be called "hysteria," today's PTSD), and some are social (for example, perhaps, "ADHD" in children raised in poverty who are neglected and have no behavioral structure in their lives).

These are not matters of opinion, which is not something you or I can decide. Scientific research will determine what is biological, psychological, and social, and here and there, that research might identify that 2 of those etiologies are almost equally relevant (as with personality traits in genetic studies); in those cases, we will be justified in being biopsychological.

In other words, our main problem in psychiatry is that we don't really submit to science; we just pay lip service to it, or we even disparage it. This is not surprising, given that our larger culture has developed an excessive distrust of science.[3] In psychiatry, the matter may be worsened by the fact that many persons (including me) are attracted to the mental health field because of personal humanistic predilections. Yet this is another cultural problem: We don't understand how one cannot be humanistic unless one is fully scientific. The 2 are treated as opposites, whereas they need each other. To be humanistic with persons who have psychiatric problems, it would be good to know whether they have diseases or not.

Either way, they deserve humanistic empathy and understanding as human beings. But it would be a terrible doctor who is extremely nice and misses a curable disease -- or one who diagnoses "diseases" that do not exist and prescribes drugs that then harm more than they help.