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Human Nature Review 2004 Volume 4: 47-52 ( 1 January )
URL of this document http://human-nature.com/nibbs/04/healing.html
Healing the Soul in the Age of the Brain: Becoming Conscious in an Unconscious World
By Elio Frattaroli
Reviewed by Christian Perring, Ph.D., Department of Philosophy, Dowling College, Idle Hour Blvd, Oakdale NY 11769, USA.
In Healing the Soul in the Age of the Brain, Elio Frattaroli presents an extended argument against the medical model of treatment for mental disorders and especially focuses on the limitations of psychotropic medications. His theoretical perspective is deeply rooted in psychoanalysis and he argues for a psychotherapeutic model of treatment. Many of his criticisms of mainstream psychiatry will be familiar to those aware of the history of psychiatry of the last fifty years. Furthermore, the well-known concerns about the evidential basis of psychoanalysis are directly applicable to the claims of Frattaroli. The battle-lines in those arguments are extremely well-entrenched, and have been defended more eloquently and concisely by other writers. (Those wanting to investigate the literature might do well to start with the recent publication, The Freud Encyclopedia, which provides many perspectives on the value of psychoanalysis.)
The central question for potential readers of this book is whether Frattaroli has anything new to add to the debate. He does have some interesting ideas which he argues for at great length, but his argument is riddled with implausible and unsupported claims as well as incorrect interpretations of philosophers and scientists. The book is written in a popular style, with many lapses into discussion of Frattaroli's personal and professional experiences, long discussion of some particular cases, and finishes with a detailed account of the process of writing and revising the text of the book itself, including his email exchanges with his editors.
Frattaroli was a student of Bruno Bettelheim, to whom he refers as "Dr. B." The particular brand of psychoanalysis that Frattaroli defends derives from Bettelheim's teachings. Frattaroli puts great emphasis on the idea that "the end is always the beginning," with which he suggests that the taking a psychological rather than a medical approach to a patient is more open-ended and open-minded. Bettelheim recommended taking an "I-Thou" attitude toward a patient rather than a dehumanizing "I-It" attitude. Frattaroli also explains that "falling down is good," which he calls the quest philosophy. On this view, the goal of treatment is to facilitate the maturational process that is already inherent in the patient's symptom, and symptoms are where growth happens. He argues that the medical model fails to recognize people's souls and offers at best an incomplete treatment. He claims that the best treatment will enable patients to become conscious. By this, he seems to mean becoming aware of one's unconscious, or possibly, moving from a state of alienation to becoming fully human. While Frattaroli's ideas are not precisely expressed, it is clear that his psychoanalytic stance is saturated by a humanistic existentialism.
One of the early chapters, titled "The Technocrat and the Cowboy," serves as a gripping introduction to Frattaroli's concerns about the medical model. He presents in detail the case of a patient he calls "Bill." Bill was a young reporter who was admitted to the psychiatric unit of a community hospital after he had aimed a shotgun at his fiancée's head while she slept and claimed that she was the devil and that God had instructed him to kill her. Frattaroli treated him with both medication and psychotherapy. The anti-psychotic drug, haloperidol, calmed Bill down, but Frattaroli suspected that it simply suppressed a psychotic process that was still active within Bill. Bill wanted to be discharged urgently, and didn't seem to be facing the seriousness of the fact that he had nearly committed a murder. They discontinued the medication to see what would happen, but Bill did not become psychotic again. Nevertheless, Frattaroli retained an uneasy feeling in the pit of his stomach that Bill's issues were unresolved. In his experience, "two months is about the average time it takes for a hospitalized patient to become engaged in treatment," yet with current health care policies, it is almost unknown for psychiatric patients to stay in hospital for that length of time unless a court mandates their hospitalization. Frattaroli was very reluctant to discharge Bill from hospital because he suspected Bill was still a danger to himself or others, but he did not have any firm evidence for this. He turned to two colleagues for help in making a decision. The Technocrat was a firm believer in the Medical Model and seemed to base his treatment recommendations on the contents of diagnostic manuals, and after assessing Bill, recommended that Bill be released from hospital so long as he agreed to take lithium and engage in supportive psychotherapy. The Cowboy was far more unconventional, and confronted Bill with the violence of his nearly killing his fiancée and the powerful emotions that must have been motivating such an action. Bill reacted defensively and angrily to the Cowboy, and this reaction confirmed in Frattaroli's mind that Bill still had strong feelings that he was unwilling to share. He recommended long-term hospitalization for Bill to the rest of his family. Bill's father refused and, with the assistance of the Technocrat, managed to get Bill discharged on medication. Six weeks later Bill killed himself, even though he had been taking his pills.
The themes in this case recur throughout the book. Frattaroli often argues that using medication alone does not get to the heart of a patient's problems and indeed can make treatment more difficult because it masks revealing symptoms. While Frattaroli is not against the prudent use of medication for some psychological problems -- he reveals at the end of the book that he himself occasionally uses anti-anxiety drugs before public speaking -- he believes that it often used without enough thought about the ways it affects the healing path of the patient.
However, one does not need to be an adherent of the medical model in order to be unconvinced by Frattaroli's claims for psychoanalysis. When constraining the freedom of adults, we need to have good evidence that there is good reason. Furthermore, while managed care may be bureaucratic and it may often make short-sighted and poor policy decisions, it is nevertheless clear that we do not have unlimited resources for health care, and both hospitalization and psychoanalysis four or five times a week are both extremely expensive. We need to have some kind of management of health care resources, and the only rational way to make those decisions is to base them on the available evidence. The evidence for the therapeutic effectiveness of psychoanalysis is weak. It may be that the evidence for the long-term effectiveness of medication is also open to question, but if so, this simply shows the poor evidential basis for psychiatric treatment in general, and does not provide independent support for the use of psychotherapy. In the case of Bill, Frattaroli's implication that hospitalization and psychoanalysis would have kept Bill alive has some intuitive plausibility but of course, there is no objective evidence to support the view.
The most interesting and original part of Frattaroli's argument aims to address the scientific status of psychoanalysis. He proposes using a principle of complementarity when trying to understand mental illness. He borrows this idea from quantum mechanics and the work of the physicist Niels Bohr on wave-particle duality. The basic idea here is that in some experimental situations, subatomic entities behave like waves and in others they behave like particles. Frattaroli draws a parallel with the dual perspectives of the Psychotherapeutic Model and a neuroscientific understanding of a person's emotional life. He defends the scientific status of psychoanalysis through criticism of the crude positivism of the medical model, and he argues that there are other routes to knowledge than laboratory measurements. He proposes that through putting together the experience of a therapist and a patient together, we can achieve objective scientific knowledge.
This is certainly an intriguing and even a promising approach in principle, but Frattaroli fails to provide any clear way to distinguish his approach from pseudoscience. What he does give is an extended discussion of one patient, Mary, over 94 pages. He gives the impression that he believes that this careful analysis constitutes an argument for the psychoanalytic conclusions he reaches. Without going into detailed criticism, it is not feasible to make a case that the argument fails, so I will simply state my opinion that it is based on a plethora of dubious assumptions.
Frattaroli tends to undermine his own credibility with rather wild interpretations of some philosophical positions, especially that of Descartes, and inaccurate depictions of those whom he takes to be his opponents, especially Peter Kramer. He claims, citing no secondary literature, that in his famous Cogito, ergo sum argument, Descartes has been widely interpreted as providing a logical sequence of thoughts (mental contents) giving a syllogism. Frattaroli provides the alternative interpretation that, "With a shock of recognition, Descartes caught himself in the act and existential moment of questioning. In the immediacy of that distilled awareness of himself as consciousness in process, he recognized that he was listening to a soul, the still center and spiritual essence of his personal experiencing" (pp. 15-16). Later he claims that from reading Descartes' Principles of Philosophy, "it is pretty clear that he was thinking of body and soul not as fundamentally different kinds of thing, but as fundamentally different kinds of experience" (p. 352). If Frattaroli is right, then every major interpreter of Descartes up to now has been fundamentally mistaken. Frattaroli cites Descartes' late work The Passions of the Soul as evidence for his interpretation. It is true that this work does raise interesting interpretive questions about Descartes' thought, and there is academic debate about the extent to which his later theories are compatible with his more famous earlier work. What is clear is that Frattaroli provides no real justification for his revisionist account of Descartes' philosophy, but he does convey a sense that his own agenda tends to dominate his approach to the ideas of other thinkers, and this reduces the reader's respect for his scholarly abilities.
Of course, whether or not Frattaroli has given a correct interpretation of Descartes makes no difference to his claims about the current state of psychiatry. But when it comes to his discussion of Peter Kramer's views about psychopharmacology, Frattaroli's abilities to fairly represent the ideas of others are more crucial. It is clear that he dislikes Kramer's view, labeling it as shallow philosophy and a threat to psychotherapy, but his main negative reaction to Kramer is due to his perception that "it promotes a compelling rescue fantasy that competes directly" with Frattaroli's own. The perception of Kramer as enthusiastic proponent of the widespread use of antidepressants may have been fueled by the fact that his book Listening to Prozac was a bestseller and may have helped the enthusiastic reception of the drug in the 1990s. Frattaroli characterizes the debate as a choice between healing the soul and a quick fix, and he portrays Kramer as proposing psychopharmacology as a replacement for psychological insight.
However, careful attention to Kramer's writing in Listening to Prozac and his earlier book Moments of Engagement shows that his view is in fact far more complex than suggested by Frattaroli. The latter book is in fact an outstanding discussion of the both positive and negative psychodynamic issues involved in the interaction when a psychiatrist prescribes medication, and the process of "listening to Prozac" is precisely one where patients gain psychological insight about themselves when they start taking psychotropic medicines. Frattaroli's account of the psychological effects of the prescription of medication is in fact far cruder and more simplistic than Kramer's. Concerning psychodynamic treatment, Kramer is a strong advocate of the power of a probing investigation of a patient's emotional conflicts, although he is far less wedded to a particular theoretical perspective than is Frattaroli. But maybe the most interesting difference between these two psychiatrists is that while Frattaroli is an advocate of his complementarity thesis, emphasizing the incompatibility of psychological and biological approaches, Kramer makes a fascinating argument for the necessity of the eclectic integration of different approaches (See "When it works," in Kramer, 1989). It is eclectic because there is no grand unified theory of psychiatry, but rather a psychiatrist has to use the different kinds of knowledge and treatment that are available to him or her with sensitivity to their possible interactions. Kramer optimistically suggests that it is possible for a psychiatrist to create a tailored therapy "which weaves seamlessly together the therapies it integrates" (1989, p. 175). Had Frattaroli paid attention to this aspect of Kramer's writing and assessed it carefully, he might have been able to make a stronger case for his own proposal of complementarity.
It is worth noting that Frattaroli's faith in the power of psychoanalysis extends to rather risky empirical claims. One of his most surprising claims against the medical model is that the changes brought by medication are only temporary while the changes created by psychoanalysis are irreversible. This seems to be a claim that should be capable of straightforward empirical testing, but Frattaroli provides no evidence for it. As a universal claim, it is obviously false, since there have been many cases in which changes created through psychoanalysis have been short-lived. As a statistical generalization, it is possible that the changes brought by psychological insight and genuine resolution of emotional conflict are longer lasting than those caused by medication, and this is certainly a claim that should be investigated.
Frattaroli's adherence to psychoanalysis is bound to alienate many psychiatrists and a good many psychologists more convinced of the efficacy of cognitive-behavioral approaches. However, whether or not one shares his Freudian sympathies and despite the sloppy scholarship, his broad-ranging evaluation of the philosophical issues behind clinical treatment is stimulating. While Healing the Soul in the Age of the Brain is a deeply flawed book, it nevertheless raises issues of crucial importance for modern psychiatry and there is not enough discussion of these issues within the current literature. It is a book that should not be ignored, but rather should spur impassioned response and further debate.
Edward Erwin (Editor). The Freud Encyclopedia: Theory, Therapy and Culture. New York: Routledge, 2002
Peter D. Kramer. Moments of Engagement: Intimate Psychotherapy in a Technological Age. New York: Viking, 1989.
Peter D. Kramer. Listening to Prozac: A Psychiatrist Explores Antidepressant Drugs and the Remaking of the Self. New York: Viking, 1993.
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© Christian Perring.
Perring, C. (2004). Review of Healing the Soul in the Age of the Brain: Becoming Conscious in an Unconscious World by Elio Frattaroli. Human Nature Review. 4: 47-52.