Part 4: What Psychiatrists Don’t know About Hard Problems
I have been trying to argue that Christians have been guilty of not appreciating the spiritual nature of mental illness. We unwisely and unnecessarily assume that complex problems are beyond our capabilities, entrusting the most troubled people in our culture exclusively to psychiatrists. Of course, psychiatrists have a role to play. The problem I’m concerned with is the exclusive role that Christians have given them.
In previous posts I’ve tried to address some reasons why Christians do this. I think another reason that we cede ground to psychiatrists is because we believe they possess a level of knowledge and expertise that they do not actually have. In his book, Unhinged: The Trouble with Psychiatry—A Doctor’s Revelations about a Profession in Crisis, Psychiatrist, Dr. Daniel Carlat, describes two different appointments with two separate women named Linda and Carol. Linda and Carol each struggle with depressive symptoms, and he prescribes a different medication to each one. As he reflects on his appointments with and advice to these women he explains all the things he did not do during his sessions with them. I want you to read Dr. Carlat’s very frank reflection. I will follow it up with three quick observations.
I didn’t tell Linda that, despite my training at Harvard’s Massachusetts General Hospital, I have no idea how Lexapro works to relieve depression, nor does any other psychiatrist. Like the Zoloft I had given Carol, while Lexapro increases levels of serotonin in the nerve synapses, there is no direct evidence that depression is a disorder of reduced serotonin. The term “chemical imbalance” is commonly used by laypeople as a shorthand explanation for mental illness. It is a convenient myth because it destigmatizes their condition—if the problem is a chemical imbalance, it is not their fault. Psychiatrists go along with his shorthand, because it gives us something to say when patients ask us questions about pathophysiology. After all, no doctor wants to admit ignorance about the very problems he or she is trained to manage.
I did not tell Linda that psychotherapy might work just as well as medication for her, and that I had decided on medication in part because I received little training in therapy during my three years of psychiatric residency. Like many psychiatrists, I don’t do psychotherapy because I can’t do psychotherapy.
I did not ask Linda to have her blood drawn, nor did I send her for a brain scan. Diagnosis in psychiatry proceeds exactly as it did a century ago—by asking a series of questions and analyzing the responses. Patients often ask us for a “diagnostic test.” They hear media reports about PET scans, EEGs, and computerized tests of attention. Both psychiatrist and their patients are quick to embrace these talismans of hard science, but, unfortunately, psychiatric diagnosis continues to lag far behind the rest of medicine. Because of this, the DSM-IV, our diagnostic manual, has taken on the dimensions of a holy book in the field. Every ten years or so, a new edition is published, and the landscape of psychiatry changes. But, as I’ll show later, the new diagnoses are based on votes of committees of psychiatrists, rather than neurobiological testing. Because diagnosis in psychiatry is more art than science, the field is vulnerable to “disease mongering,” the expansion of disease definitions in order to pump up the market for medication treatment.
Finally, I did not tell Linda that I was often visited by a pharmaceutical representative, from Forest Pharmaceutical, the maker of Lexapro, who would bring me my favorite drink from Starbucks and sandwiches for my receptionist. The rep had told me that Lexapro was the best tolerated of all SSRIs, and I knew that there is no convincing evidence that this is true, but her visit accomplished its objective, which was to plant Lexapro uppermost in my mind. And I, in turn, prescribed it to Linda.
First, notice how decidedly un-medical Dr. Carlat’s meetings with Carol and Linda were. He admits that he did none of the medical testing you would expect with other diagnoses. He also admits a level of ignorance that would be unacceptable with other diagnoses. Carlat is honest in the context of the rest of his book that this reality is not unique, but common.
Second, notice how unsure Carlat was about the effectiveness of the treatment he prescribed. He is not sure if it will work, how it will work, or whether something else might work more effectively.
Third, one treatment option that he expressly avoided was psychotherapy. Carlat, he admits, does not do psychotherapy, because he cannot do psychotherapy.
Not Criticism, but Praise
I am not criticizing Carlat. On the contrary, I am grateful for his honesty. I find it refreshing. One of the refreshing realities about it is how encouraging it is for Christians who are interested in helping the Lindas and Carols of the world.
We do not need to live in fear that we are the ignorant ones in the midst of a culture full of psychiatric sages. The reality is that we live in a world full of people struggling with problems of enormous magnitude, and everybody is confused about how to help. There is literally no person who has plumbed the depths of the problems in living that plague so many.
In the midst of all of our collective ignorance there is at least one thing we Christians know. To say it better, there is one Person that we know. We know the One who formed Linda, Carol, and every other messed up person. We worship the One who loves the broken with an everlasting love. We are united by faith to the One who knows how to shed His light in the midst of the darkest despair. His name is Jesus.
At the end of the day we biblical counselors may not know a lot about the specifics of brain chemistry. We may not have a lot of information about which medications are the most helpful for really troubled people. When we admit that reality, we are admitting the same thing that the most well-trained psychiatrists admit when they’re honest.
In the midst of the chaos and confusion Christians are the only people who know for sure that there is something helpful we can do. We can look every troubled person in the eye and cut through the pain, repeating the same words our Christ gave us to say in Matthew 11:28-30:
Come to me all who labor and are heavy laden, and I will give you rest. Take my yoke upon you and learn from me, for I am gentle and lowly in heart, and you will find rest for your souls. For my yoke is easy, and my burden is light.