Burn us at the stake: Comments on a Commentary by Edward Shorter
A Commentary by Toronto based historian of psychiatry, Edward Shorter, PhD has just been published in Psychiatric Times. Dr. Shorter’s provocative comments often but not always miss the mark, but nowhere are they more offensive, misinformed and misguided than in his attack on the biopsychosocial model and on psychoanalysis, which he compares to witchcraft. He asserts that the mental health system would benefit if both of these were dropped.
Dr. Shorter sees the medical model as the answer and the biopsychosocial model as the problem, and joins those who see a bright future in finding biomarkers for mental disorders. Here he is entitled to his own opinion, but not to his own facts, and the facts do not support replacing the biopsychosocial model with a biomedical one. It is “both/and” rather than “either/or,” biology and psychosocial. After all, despite much searching, no reliable biomarkers for mental disorders have been found (including the dexamethasone suppression test referred to by Shorter), and the search has been compared to that for the Holy Grail. The Genome Wide Association Studies that explore genetic underpinnings of common mental disorders like depression have taught us that heritability of depression is complex, with no genes and only one single nucleotide polymorphism (SNP) associated with depression—and that one SNP is located in what the researchers acknowledge is a “gene desert.” Meanwhile, Tully has shown us that mothers who are depressed during childrearing tend to have depressed children whether the children share maternal genes or are adopted. In schizophrenia over 125 potential genetic loci have been found, but what has become clear is that genes alone are not the answer. Environmental (aka psychosocial) factors matter a great deal. I addressed this kind of assault on the biopsychosocial model recently in a book review of Nassir Ghaemi’s On Depression. Genetics in psychiatry has given way to a paradigm-shifting focus on gene-by-environment interactions—so called epigenetics. And I would suggest that “epigenetics” is another way of saying “biopsychosocial”—biology and genes interact in complex ways with environmental psychosocial factors--both adverse and positive experiences. Relationships matter. I appreciate that a non-clinician like Shorter would like the answers to be simple, medical, and genetic, but the science isn’t moving in that direction—just as in the last century the appealing simplicity of Newtonian physics ultimately had to give way to the complicated truth of the theory of relativity. Space and time, like people, are complex and context dependent.
Shorter’s attack on psychoanalysis is particularly puzzling though not unfamiliar, again a stance shared by Ghaemi, but likening psychoanalysis to witchcraft? Kernberg and his group that developed and demonstrated the efficacy of Transference Focused Psychotherapy for borderline patients are a coven of witches? Fonagy and Bateman for their work on Mentalization Based Therapy are also designated as practitioners of witchcraft? And what about incoming Riggs medical director/CEO Andrew Gerber’s publication of a meta-analysis of over 90 studies of psychodynamic psychotherapy showing that psychodynamic therapy works? Or Leichsenring and Rabung’s meta-analysis of 23 studies of Long Term Psychodynamic Psychotherapy (LTPP) demonstrating that the average patient receiving LTPP for complex and persistent major depressive disorder was better off than 96% of patients receiving other treatments? Why does Shorter overlook these studies or the assertion of Nobel Prize winning neurobiologist Eric Kandel that psychoanalysis is the most nuanced and sophisticated theory of mind we have? Dr. Shorter’s historian colleagues long ago taught us a painful lesson from the seventeenth century. That is, when we fear something and don’t understand it, we are at risk to call it witchcraft—and, if we get lost enough in fear and ignorance, we may burn its practitioners at the stake—much to our own eventual shame and mortification. This kind of prejudice has no place in our field, and those blinded by it certainly deserve our respect as fellow humans, but not our admiration for their ideas.
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