Thursday, January 28, 2010

Thomas Kuhn, Paradigms, and Psychiatry

Haters of the word, paradigm, have Thomas Kuhn to blame. His seminal 1962 publication, The Structure of Scientific Revolutions, is a regular on all manner of Top 100 lists for books that rocked the world. In my line of work, you can’t browse a website for five seconds before being paradigmed to death.

My latest close encounter was an online book by Todd Finnerty PsyD on the fine points of Depressive Personality Disorder (see recent blog post). Dr Finnerty thoughtfully summarized Kuhn’s main points, which, together with Wikipedia and other sources, spares me from having reread Kuhn (which I did read way back in college).

Here’s the basics:

Forget about the quest for knowledge being an objective inquiry governed by scientists rationally sifting through the facts. That may be their intention, but in reality they are operating within their own particular conceptual frameworks (paradigms) that govern how they think. Thus, if you are living in an era where the ruling paradigm features the earth at the center of the universe, then your typical 15th century Polish heliocentric firebrand named Copernicus is going to come across as a raving lunatic (okay, make that solartic).

Ironically, says Kuhn, the 15th century scientific community, such as it was, was perfectly correct in rejecting Copernicus, as Ptolemy’s model of the universe still proved a superior predictor of observable planetary motion. Only later, with Galileo and others building on Copernicus, did Ptolemy (pictured here) and his world come crashing down.

During a period of normal scientific development, researchers are working off a shared set of general beliefs, which frees them up for working on specific problems. Anomalous findings either get dismissed or folded into the paradigm. But anomalies have a way of accumulating like unwanted snow. The old guard has a legitimate role as keepers of the paradigm, but history is not on their side.

According to Kuhn, the old and new paradigms are so different that they are “incommensurable.” In essence, there is no common ground by which a scientist working within a new paradigm can prove her point based on the assumptions of the old.

For an example of worlds in collision: At the 2004 American Psychiatric Association Annual Meeting, I heard Jack Barchas MD of Cornell University and a pioneer in the field of how biochemistry and behavior interact, recount how as a young investigator an early mentor challenged one of his ideas on these grounds: “How is this justified in the writings of Freud?”

Not surprisingly, Freud soon became to psychiatry what Ptolemy became to astronomy. But was Freud getting a raw deal? At the following year’s APA, I heard Nobel Laureate Eric Kandel MD state:

“A major need of psychiatry in the future is to put the psychotherapeutic arm of psychiatry on the same solid biological footing as the pharmacological aspect of psychiatry."

Dr Kandel was very much moved by Kay Jamison who said if it wasn’t for lithium she would be dead, but that it was really psychotherapy that gave her a coherent view of her life, that allowed her to tie the various strings of her life together.

"We’re in a fantastic phase of psychiatric thought," Dr Kandel concluded. The biology of the mind is the central scientific challenge of the twenty-first century. Molecular genetics and molecular biology, he said, have given us insights that would have been inconceivable 20 or 30 years ago. These advances will revolutionize psychiatry, but hardly eliminate it. Instead, psychiatry will synthesize with molecular biology into what he describes as "the new science of the mind."

Paradigms, paradigms, paradigms.


Anonymous said...

I am at a very well-endowed university and opted for the full-force insurance plan. There is someone to prescribe me drugs and there is somebody to help me read generic Buddhist self-help (all in 15 minutes flat). All well and good, but I need a shrink. A symptom of the present paradigm?

Willa Goodfellow said...

This is ridiculous, John -- read my info on facebook!

In medicine, the paradigms dictate the treatments. Unsuccessful treatments do not challenge the paradigm; they simply are problems to be solved within the existing paradigm. Unacceptable side effects lead to the task of finding/eventually creating new meds with less severe side effects, not lessening the reliance on meds.

A friend asked, "Why is there a 'battle' against cancer, but other diseases aren't addressed this way?" I think the paradigm of cancer cells as "foreign invaders" and "no prisoners taken" in the crusade led to cancer treatments that eventually caused terminal patients to rebel and fight their case in court, where they won. So that paradigm changed, as oncologists had to examine their relationships with their patients and their personal feelings about death.

Over in psychiatry, we're still using the war paradigm. The goal is complete elimination of symptoms, and again, no prisoners taken. As the sales reps for Zyprexa famously said, "Would you rather have a fat, happy patient or a skinny, miserable one?" Again, the experiences of patients are anomalous findings. And again, patients have begun the push-back, with the recovery paradigm. I have to learn how to manage my symptoms, not drug myself into a stupor to eliminate them.

However, we are severely disadvantaged in the courts. Part of what cancer patients had to do was convince judges that they were not mentally ill! Our next best weapon is noncompliance, which removes from us one of our basic strategies in the recovery paradigm.

Maybe this needs to turn into my OWN blog post!

John McManamy said...

Yes, Willa. This is definitely blog-worthy. :) What makes my job so fascinating is that I am seeing paradigms rocked every which way. For instance, what got me started on this piece was reading something that challenged us to think of our depression in terms of personality rather than simply illness.

My piece was framed in terms of psychiatrists coming up with their own paradigm, but the deeper issue - which both you and I have cottoned onto - is that psychiatry itself may be an outdated paradigm.

I used the example of brain science challenging basic psychiatric assumptions. You used the example of the recovery movement. Either way you look at it, psychiatry is being knocked off its pedestal, no longer THE authority as to what makes us tick or in how to win back our lives.

The literature I come across today - popular and medical - is very different than what was taken for granted when I first started writing about my illness back in 1999. I don't know how it's all going to shake down, but if we keep losing funding for research and treatment maybe it won't matter.

Willa Goodfellow said...

Well, one of my themes is that the funding issues WILL drive this issue, and will continue psychiatry's fall, because psychiatry has no economic engine other than imbursement for services and research grants. The recovery paradigm, on the other hand, has an economic engine that runs on commitment, passion and compassion. On my hopeful days, I think that will get us to a better place. Eventually.

John McManamy said...

Funny thing, Willa. Psychiatry has been too stupid and prideful to seek advocacy partnerships with patients. Seldom, if ever, are we at the same table together petitioning our legislators etc for increased funding for treatment and research. If psychiatry were willing to team up, then there might be an economic engine. But psychiatrists have to be the big know-it-alls in their relationships with patients, even ones who can help them.

I have had personal experience with them. They're response? Smart patients are anomalies. Ignore them. Definitely a fucked up paradigm they are operating under.

Anonymous said...

I think the book Beyond the Brain written by Stanislav Grof, more than any other book in the field shows where the next paradigm shift in psychiatry and psychotherapy will be. And as it is normal for a true paradigm shift, it is nowhere near what everyone expects.

It's quite a demanding read, but I think you might like it John. Well... you might not like it, but it will definitely get you thinking ;)

John McManamy said...

Hi, Anonymous. Very good point. Paradigm shifts come out of the blue, which means being blindsided by total surprises.

Re Grof - I came across his thinking back in the 80s and just went to Wikipedia to refresh me. I touch on my "rebirthing" experiences in this piece:

I think rebirthing is the poor man's holotropic breathing. I'm a firm believer that we get stuck in our day to day ruts that we need to get out of. So I strongly encourage personal voyages of discovery (but within limits - for instance no psychedelics).

But if the Wikipedia entry is correct and I'm interpreting it right, part of what Grof is stating reflects an outdated paradigm that is making a dangerous comeback.

This is a hippie-dippie view that romanticizes serious mental illness. I am all for seeing our various ills in a positive light (indeed, I draw a lot of flack for this), but I am intimately close to the sheer destructive power of the brain quitting on us.

The Wikipedia article stated that Grof does not distinguish between psychosis and states of higher consciousness/awareness. I totally reject this. Psychosis reflects a major breakdown in brain function. Higher awareness is the complete opposite - greatly enhanced brain function.

But there is a link that needs further exploration, which I have touched on here in my pieces on creativity. I'm oversimplifying, but here goes: The creative mind has a way of taking in more info, feelings, senses and connecting them up without losing rational control. This borders close to psychosis and may even overlap with it, but it is not the same. In psychosis, the brain becomes overloaded and/or stuck and the rational mind loses control.

John Nash is a good case study in this. At a certain point in his life, he lost control of his beautiful mind and by his own admission lost 25 years of his life. He also says his brain went on strike.

I strongly suspect that those who romanticize mental illness have very limited real world experience with serious mental illness. But yes I am aware that our western mindset is also locking us into a different paradigm. I am looking forward to doing one or two or three pieces based on Ethan Watters recent NY Times piece, The Americanization of Mental Illness.

I am also looking forward to exploring the issue in relation to my friend Tom Wootten's new book, who simultaneously comes across to me as a visionary genius and an out-of-touch fool who has no idea what he's talking about (I hope to explore both facets of my view of Tom in a positive way that encourages us to see things in new ways).

There is a lot of ground for fruitful discussion here, and because there are so many twists and turns no two people are going to have the same opinions. Likewise, no one owns the truth. The truth is something we are all searching for, but we always wind up having to settle for a paradigm.

Let the conversation begin ...

Anonymous said...

Hi John,

Wikipedia article is somewhat incorrect in stating that Grof does not distinguish between psychosis and states of higher consciousness/awareness. He does and his explanation for this is somewhat covered with what you already said.

According to his research, psychosis can have a purely organic cause and causes a breakdown in brain function BUT it can also have a purely mental/spiritual origin without any associated biological brain disorder (i.e. disease).

He compares this to computers; if a computer (brain) breaks down, you'll get an error on screen. You won't start to see a totally new operating system or software on it. Similar with psychosis. If one has a (biological) brain disorder, you'll experience e.g. thinking, memory, orientation problems. You won't start to see visions of heavenly realms and angels coming down to you while you engage in a meaningful dialogue with them. The former is a disease. The later (according to Grof any many older spiritual traditions of the world) can be a spiritual experience with great potential for healing.

This also somewhat relates to the article by Ethan Watters in NY Times you mention. My thinking which I again borrowed from Grof (being a great fan of his as you can notice by now), is that when psychosis in not clearly organic in nature (and I mean as a clear disease, not a 'disorder' of unknown biological origin), suppressing it with psychotropic medication can often simply freeze the process which never gets resolved. If on the other hand, the process is allowed to be completed (in a safe and structured setting), the psychosis often gets spontaneously resolved. And I think that can be one of the reasons, why non-western methods of healing often have better results that western type methods (e.g. medication) does.

I'm not saying psychotropic medication are not useful in many cases. They are. But I think current psychiatric paradigm which is more or less biologically oriented and treats all unusual experiences as brain disorders is missing something really substantial not only in its world view but also in huge potential these new methods can bring for healing psychiatric 'disorders'.

Just my two cents ;)


John McManamy said...

Hi, Marko. Extremely interesting, and many many thanks for taking the time to break this down for me and my readers. I'm on a steep learning curve with psychosis and am benefiting from all points of view. I am looking forward to raising the issue in future blog posts (including my critique of Tom Wootton in progress) and seeing where the conversation goes.

This is part of a journey that began with me looking at mania in a different way (as something that should not necessarily be medicated out of us), which then moved on to depression (I wrote my Living Well book while depressed).

Certainly, there is nothing good about the brain breaking down, whether it manifests as mania, depression, or psychosis. But then come the types of nuances you raise.

I suppose the issue boils down to this: How can we think and feel and perceive in highly aware and original ways without losing control? Without undermining our ability to function in life. The very meaning of depression, mania, and psychosis presumes we have in fact lost control, that we are beyond reason.

But there is a growing body of opinion saying, not necessarily.

Fascinating stuff. You can see why I love my job. Looking forward to hearing from you again.