Psychiatry’s foothold in contemporary art continues to strengthen— for good reason?

Freud’s Office by Edmund Engelman in 1938

Psychiatry has a complex past

He was a fearless thinker, a cunning linguist, a formidable scholar, and an often well-meaning if imbalanced physician. He was among the first to appreciate and to apply Darwin to human behavior in ways that are at times, to this very day, shockingly astute and productive. Despite his unfortunate derailments in the use of his own mind as a road map for the minds of others, those who have attempted to follow him in that peculiar cognitive behavior (and learn from his mistakes) often agree: he climbed like a giant standing on the shoulders of giants onto the most stunning, world-altering vistas in the history of human thought, particularly in the explanatory power offered by his formulations of the subconscious and the possibility of “subconscious conflict.” Sickening as it is to hear him say it, there is even a small parcel of truth hidden away in his disturbing belief that only he was capable of fully analyzing himself. We have been speaking about Sigmund Freud, of course.

Ultimately, even his most misguided thoughts proved to be incredibly efficacious in the stimulation of more useful theorems by other thinkers (e.g. Erik Erikson), serving as rich soil for much needed intellectual progress. In short, in the final analysis, it would not be completely outlandish to ascribe to Freud the nebulous title of “genius.”

The multi-faceted, and surprising Erikson

Freud was not the first or even the worst shyster in my field, which, for better or worse, has and always will attract those medical students with deep and potentially perilous appreciation for mental illness. Psychiatry has rarely been famous for its good works, only infamous for its controversial lemmas (e.g. the Oedipal complex), its half-baked integration into social institutions (e.g. over-zealous or unscrupulous guns for hire in the judicial system), its false claims of medical efficacy (e.g. the crippling motor side-effects of the first generation anti-psychotic medications; the dreaded frontal lobotomy), and its troubling history of diagnostic subjectivity (which is now improved with each iteration of the DSM). Perhaps for these reasons, psychiatry has been separate from the rest of medicine, so much to the point that most people do not know that all psychiatrists today are medical doctors with the same training as your surgeons, dermatologists, and general practitioners; nor is the difference between psychiatry and psychology popularly understood, much to the chagrin of both groups.

Psychiatry is looking good for a change

The past and the future of psychiatry have been elegantly and more engagingly described elsewhere. Those with curiosity on the subject will find Dr. Jeffrey Lieberman’s book, Shrinks, particularly enriching. I wish, however, to move away from those subjects toward an observation on the present.

Contemporary psychiatry feels stable, upstanding, and nearly wise. The strength of its trade relationships with neural science, chemistry, and genetics have surpassed (but hopefully will never replace) its old alliances with classics, anthropology, psychology, linguistics, philosophy, the visual arts, literature, poetry, and music. Its resemblance to the core medical disciplines is also increasing, so much so that criticism and derision of psychiatry by other physician groups may start to backfire as difficulties that are quite old to us begin to shed light on persistent, unresolved defects elsewhere in medicine.

With that being said, I cherish recent increases in the number of overt references to psychiatry in contemporary art, particularly in high production value polemical dramas such as AMC’s The Walking Dead.

Eastman (a forensic psychaitrist with hints of Buddhist self-mastery) instructs Morgan in the art of non-lethal self-defense

I was actually prompted to write this article by the most recent episode of Law and Order: Special Victims Unit (a program that has been critical of psychiatry on occasion). In the episode (S18.E04), widespread cultural illiteracy regarding Bipolar Disorder leads to unnecessary suffering for an Olympic pole vaulter and the ne'er-do-well sister of Detective Rawlins, who both discover within the language of psychiatry the ability to explain and solve the most fundamental and persistent difficulties of their lives.

Highly unexpected and surprisingly fitting, a psychiatrist has also recently become a major character in Longmire, as the love interest of the world’s most righteous cowboy sheriff.

Artists (e.g. television writers) are people who’s beliefs about what is missing in the world are too complex or controversial for typical speech. You could argue that they are people who intuit something so broadly important that a need develops to scream it from the mountain tops. In some cases, particularly in the case of painters, I think the artist’s proposed resolution is too complex even for conscious awareness, requiring more abstract methods of self expression. Or if you like, the artist is exactly the sort of beautifully eccentric, emotionally heightened person you’d expect to find in a psychiatrist’s waiting room. Perhaps it is no wonder then that there are more examples of support for psychiatry flooding into drama in recent months, either as the result of conspiracy or (more-likely) as a natural repercussion of steady progress in the efficacy of psychopharmacology, and broader cultural acceptance of it by artistic persons in the wake of its successes.

Is recent attention on psychiatry deserved or misplaced?

This is a matter of opinion and circumstance, and so I can only offer my own experiences for your consideration. As I progress through my residency training I find myself looking at the world through an entirely new lens. I feel much differently toward people: more accepting, less envious, more concerned, and (hopefully) more generous. For the first time in many years I am even beginning to feel that I must take better care of myself, rather than running myself ragged over unwelcome obstacles until I sink into the depths of despair, addiction, and even psychosis. I become appreciative of trite old adages at which I used to turn up my nose as hopelessly optimistic, and I see utility and truth in loving concepts in which I previously placed no stock. Much of this improvement I attribute to psychopharmacology.

So my personal experience is that psychiatry is the best thing that has happened to me in many years. Medication has made me a happier person, and as a result I make fewer bad decisions, and I am capable of more kindness. I am less likely to do or say things that are hurtful to others. The potential was always there, but I am only capable now that I have energy and interest to follow through.

I think I may be becoming a whole person again.

In my world, suffering is everywhere; I am surrounded by it at all times. It is my job to take all suffering seriously. I don’t reveal my current improvement to gloat, or because I am insensitive to the suffering of others, especially yours. I reveal my perception of self-improvement because I am more convinced than ever that many people in my life would have benefited from a psychiatrist at one time or another. Some of them desperately need one now. And, truthfully, I’m curious if the same is true for you, or the people in your life.

It is quite reliably difficult to convey to them, my long-standing friends and my own family, the ways in which they could benefit from psychopharmacology. And I think that I know why they (or anyone else for that matter) might have difficulty accepting my stance.

It took 5 miserable years on the fence about psychotropic medications in an environment in which I was surrounded by physicians, including psychiatrists, to become convinced of my need for them. In fact, for some of that time, I was already prescribing these medications to others. My hypocrisy knows no bounds. I forgive myself because I know that I had my reasons and I remember the things that stood in the way of giving psychiatry a chance.

The first barrier was my narcissistic belief that my situation and my brain were too special for treatment; also, I was fearful of handing my special brain over to someone who belonged to the least respected clan of physicians; thirdly, I had enormous biases against against psychiatry on the basis of its history, the way it had been discussed by people I trusted, and its many negative representations in art and other media; finally, I did not want to be identified or identify myself as a person with mental illness, because of its stigma, and because I did not appreciate: 1. how prevalent mental illness is and how many productive people can be said to have suffered from it, and 2. that if I had a mental illness, it wasn’t actually my fault.

Now I am convinced that psychiatry in practice bares very little resemblance to my old suppositions. In fact I think it may be the key to a better world.

How can psychiatry contribute to the creation of a better world?

I expressed previously that philosophy, a strong field in its own right, has always had a strong foothold in the minds of psychiatrists. I attribute this statistically significant cluster of interest in philosophy among psychiatrists to the philosophical agility required to successfully navigate the concepts of individual identity, and health (or normality) in the context of the practice of behavioral medicine. Psychiatry may require a naturally philosophical disposition. Additionally, because psychiatry existed as a medical art before neural science had matured to the point that strong physiological paradigms for complex neurological phenomena like emotion, cognition, memory, and sleep were available, psychiatry’s approach to research and development was necessarily mired in abstract computational rationalization (which is the special province of only two disciplines: mathematics and philosophy). Much like contemporary quantum mechanics, subatomic particle theory, and even astronomy to an extent, psychiatry relied heavily on limited data from a small number of empirical research tools, and as a result, heated debates, a cannon of leap froggy theoretician-heroes, and ample dead ends were just a fact of life.

I emphasize psychiatry’s special relationship with philosophy because there are threads from philosophy (and ancient religions) that have survived into many circles of contemporary psychiatry. One thread in particular is the concept of determinism, which is the axiom that all things that happen happen in the only way they can. Deterministic philosophy posits that the future is already decided because the laws of physics (however many there may be) govern predictably all temporal changes in matter and light, and that all changes within the things we call our “selves,” being fully composed of matter, are therefore fully subject to the immutable laws of physics. It’s a troubling thought for many people, but while it sends a chill down our spines it may also relieve us. Determinism removes the burden of culpability from human beings, and it recasts the emotion of guilt as an important evolutionary innovation that facilitated quid pro quo interactions between individual members of the species, creating enormous survival benefits in the form of social synergy.

The thing I like most about determinism, which relies heavily on the immutability of physical laws, is that it places the brain and our capacity for cognition in a very privileged position. So privileged, in fact, that it has evolved the capacity to lie to us about many aspects of our own nature. Where our location in space, our posture, even our eye-movements and facial expressions are operated mechanically through tension systems that can be very easily interfered with by opposing mechanical forces in accord with newton’s laws of motion and gravity, the human brain is subject to and operates on a very different set of physical laws, including Ohm’s Law, the principles of electromagnetism, and the thermodynamic/molecular-kinetic principles that govern all cellular processes. In a sense, in the realm of the organs, the brain is uniquely blind to and sheltered from direct mechanical forces by the skull, and through its specialized currency of electrical and chemical signaling (which is used in a similar fashion in the electrical conduction system of the heart), it gains the ability to isolate, code, and consolidate several kinds of mild vibrational, positional, kinetic, chemical, and photic information in the form of electrical signals, the patented mixture of which constitutes our experience of the world.

Additionally, through the poorly understood process of memory formation and retrieval, which probably relies upon a combination of low level electrical activity and structural plasticity in connections between individual neurons, a coded version of past sensory input is carried with us into the stimuli of the present, automatically informing our behavior by comparing the present moment to past moments in which we have been successful and rewarded, or punished. Incredibly, through experiential memory we are able to store abstract information about commonly occurring processes in the world; we are even able to communicate abstract information in canonized languages and symbols that are only meaningful to members of our own species who are already in possession of the requisite culturally-derived and experiential framework.

In fact, because so much of our memory is devoted to abstract, culturally-derived symbols, each of our brains has the opportunity to assess the validity of socially derived information against the flood of data obtained in our every day experiences. In this model, we own a portion of the culture of every person we will ever meet, and every person we have met has contributed something to our culture. Because we are in a constant state of communication with one another, whether we control that communication or simply experience ourselves as being in control of that communication, each of us is a vessel of information and experience that has some bearing on what the future will look like.

By changing the world around us faster than we are evolving genetically, the process we call “humanity” has become as much an economy of physical objects, sexual favors, and genetic material as it is an economy of symbolic information. And the breadth of the cultural influence that a person can have in the course of a lifetime will continue to grow at the rate of information technology. Simultaneously, it is predicted that rewards for broad cultural influence will decrease secondary to an increase in feasibility .

Finally, I like this model because it emphasizes something that many thoughtful psychiatrists believe very strongly about “bad” or “pathological” behavior, namely that it is no one’s fault. In the deterministic model, “bad” (for society) and “bad” (for the individual) behavior results from a set of experience-induced physiological deviations from normality, and since those deviations can be described in physiological terms, they can be considered a form of physical illness, the same as a myocardial infarction, and a pneumonia. In fact this is what is happening in neural science today: psychiatric illnesses are being recast in molecular, genetic, and neuroanatomical/physiological terms for the first time. And to the best of our understanding, those deviations that we consider illnesses appear consistently to arise from stressors that are external to the individual (in other words, stressors that arose in the individual’s culture, such as abuse, bereavement, and chemical or traumatic brain injury).

Suddenly, there is no culpability. Everyone, even the murderer, deserves our love. And is this not precisely what our most admired religious figures have wanted from us since time immemorial? We have arrived at the same conclusions, only we have used a far more empirically-based set of premises.

Meanwhile, we continue to have a prison system for people who do socially destructive (“bad”) things. In the psychiatrist’s secret view of the world, this is actually deeply distressing, because all of those individuals who are justly incarcerated on the basis of a good law (i.e. a law that promotes cooperation and enjoyable relationships between individuals, as well as equal survival and reproductive advantage for all) are necessarily considered to belong to the population of the mentally ill. Remember that if no one is culpable for bad behavior, then all bad behavior becomes the province of medical intervention to the extent that medical interventions exist. Simultaneously we can now say that we have good mechanistic (physiological) explanations for the way in which persistent suffering and stress induce neurological changes that facilitate the development of poor impulse control, psychotic beliefs, and anti-social behavior. As a result of these rational theories of mental illness and the empirical observation that many individuals in prison meet the criteria for a DSM diagnosis, we now have psychiatrists in most prisons. But a persistent challenge will lie in the ideological alignment of legislators, who protect society’s interests, and psychiatrists, who for all intents and purposes hold a professionally isolated perspective on the validity of the “antisocial-as-victim.”

The stigma of crime is not going anywhere any time soon, largely because our culture has not (and most-likely cannot) accept or carry to its conclusions a deterministic philosophy; a compassionate approach to antisocial behavior would seem to reward those who do unacceptable things; such a program would be counter-intuitive, not to mention expensive, and therefore it conflicts strongly with our biologically mediated and culturally accepted tendency toward self-interest; the expenses involved in a switch to compassion toward the mentally ill also conflicts with our rational fears of more pressing threats to social stability. Finally, determinism may run askew of our hard-wired and culturally ingrained perception of individual autonomy (i.e. the illusion of free will).

It is unlikely that the situation will change any time soon, and I would not encourage anyone to advocate for such a change, except perhaps in the context of serious research that illuminates the subject further. The reason is that psychiatry and neural science have yet to find pharmacological or other medical interventions for the entity known as “antisocial personality” (although a few intriguing strategies have been proposed). Just as it was irresponsible for Freud and others to push destructive theories before they’d received appropriate reality testing, for now it is irresponsible for medicine (and psychiatry in particular) to push for a sea change in ideology that concerns the functional treatment of individuals for whom the field still lacks viable treatment options.

But if positive representations of psychiatry continue, and if support for the field keeps pace with psychiatry’s improvements in therapeutic efficacy, truly rehabilitative prisons may be on the horizon; and the way we see and treat one another may achieve an ideal that few dreamed possible.