In a recent NY Times article, Nobel-Prize winning neuroscientist Eric Kandel responded to recent claims that psychiatry is a pseudoscience. The gist of the negative side of the argument is that: 1) psychiatry is not a real science because we do not know exactly how the biological processes of the brain give rise to thoughts and feelings - and that such knowledge is essential for psychiatry to be a real science; and 2) compared to fields like chemistry and physics, with many established facts, psychiatry is excessively dominated by theory, and consists of research findings that seem to only apply to a portion of people with a given diagnosis and that are often difficult to reproduce (including those based in 'hard science' fields such as genetics). Kandel disagrees with these positions. He notes that psychiatry is moving ever closer to an understanding of how brain processes lead to psychological experiences, and that this will continue to accelerate with further advances in genetics, brain imaging, and other technologies. Moreover, he gives revealing examples of progress towards understanding both the biological bases of specific psychiatric conditions, as well as how basic psychological processes (e.g., memory) are altered by these conditions. He also notes that the effectiveness of both pharmacological and psychological interventions can be studied in a rigorous fashion.
To Kandel's points I would like to add a few others that I think will be of interest to the readership of this NAMI NJ newsletter. First, science is not defined by what is being studied, or by how many years a field of study has existed. Rather, it is defined by the extent to which the scientific method is used. The scientific method refers to the belief that we increase our knowledge of how the world works by developing theories and specific hypotheses, and then testing these in a systematic fashion that, over many studies, either rules out alternative explanations for the observations (or 'findings'), or leads to the rejection of the hypothesis and the development of new ones. This is what distinguishes science from other 'ways of knowing' such as faith or intuition. Viewed in this way, the relevant question here is whether psychiatry builds on its knowledge base through carefully-designed research studies vs. through untested ideas, appeals to authority, tradition, or other methods. The answer to this is that it is clear that progress in psychiatry involves much science, as evidenced by the thousands of research studies (many of which are of very high quality) published every year that build upon past findings, and that affect how we understand mental disorders and how we treat them. Importantly, even while there is still much we do not understand about how brain processes lead to conscious experience (although much progress has been made in this regard), we can nevertheless continue to generate evidence towards answering "the ultimate question" as posed by Gordon Paul: "What treatment, by whom, is most effective, for this individual with that specific problem, under what set of circumstances." Indeed, knowledge regarding this issue continues to accumulate.
Does this mean that every decision made in psychiatry is based on universally accepted facts? No. There are still many areas that need to be researched further so that we understand the causes of mental disorders better and so that we can develop more effective treatments. Given the relatively young age of psychiatry compared to other fields, and given how complex the brain is, it is possible at this point to focus either on how far we have to go, or on how far we have come. The debate noted above essentially reflects these 2 different viewpoints. Because psychiatry is continually developing its knowledge base, it would benefit consumers and families to educate themselves as much as possible about the evidence in support of (or against) any intervention that is recommended to an identified consumer, as well as about the pros and cons of other available options.
Second, it is very important to understand that what is practiced clinically does not always reflect what is known through scientific studies. This problem is not unique to psychiatry, although it definitely characterizes this field. An often-cited report from the Institute of Medicine several years ago identified gaps of 10 to 20 or more years, typically, before scientific findings affect clinical practice. Moreover, even when new findings (e.g., that a new type of cognitive-behavioral therapy is effective for reducing delusional thinking) are known by clinicians, it is often difficult for this to affect clinical practice at agencies due to lack of funding, which limits opportunities for staff training, or for clinicians to have the time to conduct the interventions, or to receive appropriate supervision. These are some of the reasons why it is critical for NAMI NJ members and others to advocate (to state mental health offices and to politicians who decide how much funding is allocated for services) that the best available evidence-based interventions be offered at mental health centers.
Third, although we are learning much about the brain, there is a bias in the research field, and among the general public, to overemphasize the importance of studies using brain imaging and new technologies, and to minimize the importance of studies of psychological theories of psychiatric symptoms, or of psychological treatments. Several research studies have now shown that when an article has brain images created from functional magnetic resonance imaging (fMRI) data, readers are more likely to assume that the findings are important, even when the study is poorly designed and the results are relatively meaningless. The over-eagerness to find biological causes of, and solutions to, psychiatric problems in this country stands in contrast to what is happening in other countries (such as the UK and other European nations), where there is a much greater emphasis on psychological understanding of how beliefs and experiences lead to symptoms, and how psychological treatments can be helpful. This is not to say that biology is less important than has been claimed. Better understanding of the brain and how it affects experience, and vice versa, is critical for advancing psychiatry. However, it is equally important to study psychological questions (e.g., how a person's beliefs about themselves affect whether or not they develop depression after a serious life stress). Because of this, and because of the data on effectiveness of psychological interventions, I suggest that no consumer be satisfied when medication is offered to them as the only solution for psychiatric symptoms - unless data can be provided demonstrating that outcomes for a given condition are as good or better when only medication is used.
In his article, Kandel suggested that mind and brain are inseparable. In essence, creating the experience of the mind is part of what the brain does. However, progress towards a truly scientific psychiatry will only occur to the extent it should when both sides are understood.