The Medicification of Psychology

Discussion

• The story as an allegory: 
  
  Three tragedies befell poor Johnny. The first was the cancer that obstructed his bile flow, explaining all his symptoms. The second was the misdiagnoses that wasted precious time and allowed his cancer to grow. This, in turn, caused the third and likely the most lethal tragedy, his loss of faith in the medical system, which deprived him of his only chance at survival – surgery. 
  However, you’d be relieved to hear that the second tragedy that struck Johnny is very unlikely to occur in real life. Why this is the case, is the very heart of our allegory. This story is a critique not of medicine, but of psychology, by showing how medicine would function if it functioned like psychology. 
  
• The structure of medical knowledge:
  
  Medical knowledge is structured in such a way that diagnostic testing and treatment plans traverse the boundaries of medical specializations. This is because, while the story is fictional, bilirubin is very real, and it crosses organs systems; generated in the blood, absorbed by the liver, and secreted through the biliary tracts into the intestines. This is called the physiology of bilirubin metabolism, and it is taught to and agreed upon by all doctors, regardless of their specialty. Therefore, all doctors presented with jaundice will order tests to check the integrity of the red blood cells, the functioning of the liver, and the patency of the biliary tracts. 
  
  Physiology, the study of the normal functioning of the human body, just like pathophysiology, the study of abnormal functioning, forms the terminological scaffolding that organises all medical knowledge, and glues together all specialties, placing them on a continuum of medical care. Describing the inner processes of the human body, these fields use a terminology, a super-lexicon, that is biologically based and unequivocal. The importance of this terminology to the understanding of inner bodily processes is equivalent to the importance of language to human knowledge. Without it, proper communication and cooperation among specialist physicians are impossible, making Johnny’s tragedy the rule rather than the exception.   
  
• The structure of psychological knowledge:
  
  Psychological knowledge boasts a formidable pedigree, descendent of names like Carl Roger, B F Skinner., and Sigmund Freud. These psychological superstars aren’t so famous today because they contributed to psychology, but because they still make up psychology! Unlike conventional sciences, or “hard” sciences, theories and insights in psychology don’t build upon one another to form a universally accepted model of the human mind, the equivalent of physiology to medicine. Instead they grow in parallel, creating, at best, schools that offer a unique perspective on human behavior and mind, using unique terminology, and resulting in unique therapeutic methods. However, the fate of most psychological insight that remains terminologically isolated from newer trends, is to be buried on a shelf in a library collecting dust, perhaps to be taught anecdotally. 
  
  It is generally accepted that there are eight schools in psychology today, sometimes called “approaches” or ”perspectives” to alleviate the sense of fragmentation. Among the most famous ones are psychodynamic, cognitive, and humanistic psychology. Each has its separate terminology, practices and even practitioners. For instance, a poor soul with severe sadness may resort to three psychologists and be met with unique interpretation, terminology, and treatment plans. 
  A psychodynamic psychologist may blame a dysfunctional relationship with the mother as the root cause of his suffering, and discern that repressed rage from his unmet childhood needs is being transferred onto his spouse, causing the tension and heaviness weighing him down. The therapist may not divulge his analysis, and instead dive into the patient’s childhood and relationship with his mother, and slowly guide his patient into the realization that will sever the pathological channel of transference and end the tyranny of the past over the present. 
  
  A cognitive psychologist may blame the distorted beliefs the patient holds about the future, and discerns that an extremely negative and unfounded view of the future is paralyzing him in multiple areas in his life, suffocating him with a necklace of closed doors. The psychologist will try to reflect this to the patients, and dissolve the negative thought patterns with evidence from the patient’s previous successes. The psychologist will attempt to instill in the patient a heightened mindfulness to these thoughts, to catch them as soon as they arise, and consciously replace them with more adaptive ones. 
  
  A humanistic psychologist on the other hand doesn’t blame or pathologise. But instead reframe the patient’s suffering in positive terms, for instance, as stunted growth and potential. The psychologist will place the patient, and not the problem, at the center of the therapy, and offer an endless stream of human empathy and compassion, to propel the patient forward towards self-actualization. 
  
• On pluralism of perspectives vs fragmentation of knowledge:
  
  Why should pluralism be a cause for lament when it can be a cause for celebration? If in modern democracies, pluralism of views and lifestyles infuse society with diverse and vibrant colors, why should it be any different in psychology? Multiple perspectives can shed an even more illuminating light on the human condition, one that is infinitely complex and calls for humility in embracing the different perspectives. In this sense, the variety of schools in psychology can be viewed as different tools used to deconstruct the human mind, and human suffering. Just as a cardiologist and a dietician can both offer beneficial and valid view points on a patient’s heart attack, so too can a humanistic and psychodynamic psychologist, for instance, when it comes to a patient’s excessive sadness. 
  
  This framing of pluralism can be tempting to embrace. After all, what stringent fanatic wouldn’t want to “democratize” or “liberalize” psychology? But liberalizing truth is nationalizing it, expropriating it from the hold of evidence and logic. In a healthy society the public must use the truth but not own or control it. A cardiologist and dietician do offer different perspectives of the same problem – the heart attack – but their perspectives are not alternative but continuous, and are bridged by an unequivocal definition of cholesterol and the process through which it accumulates in and clogs a patient’s artery. Converging on the same terms and model of both normal physiology and pathophysiology allows them to communicate and cooperate, tackling the patient’s problem through a multilayered approach. A healthy diet, a cholesterol lowering drug, and a catheter balloon that mechanically dilates a clogged artery all synergize to halt a lethal sequence of events at every turn. If an ambulance gets stuck in traffic, medicine would cut car production, enhance public transport, and if that fails bring a SWAT team to clear out a lane.
  
  This is not the case in psychology, which, as it stands today, is starving for cholesterol. In its stead, psychology boasts terms such as transference, distorted beliefs, and stunted growth, and while each can provide us with valuable insight, they remain stricken with fluid and ever debated definitions. This is why they cannot be integrated into the same model that explains sadness or any other symptom. Till this day, they belong to separate schools of psychology with mutually exclusive models of the human mind. Psychodynamic, cognitive, and humanistic psychotherapists cannot reach an integrative explanation of the patient’s problem with different sets of terminologies, just as three writers cannot write a common story using three different languages. This lack of communication and cooperation, as alluded to in the story of poor Johnny, is not a benign phenomenon. At best it causes confusion and wasted resources, and at worst a lack of faith in the well meaning psychologist and an untreated psychological “cancer.”  
  
• The root of the difference 
  
  A physician faced with a clinical deterioration with no diagnosis may resort to cutting the patient open and excising a piece of the malfunctioning organ, to put under a microscope and give a name to the disease, a face to the enemy. This is one advantage medicine has over psychology – direct visualization. 
  
  But this last resort is rarely resorted to. In the majority of cases, as in the case of Johnny, the patient turns to the physician with a symptom – Jaundice, for example. The physician, equipped with knowledge of the inner workings of the human body – physiology – derives from it several possible pathologies or “glitches” that may explain the symptom. For example, the physician will conclude that based on the physiology of bilirubin it must be a problem with the red blood cells, the liver, or the biliary tract. The physician will then go on to test surrogate markers, indirect measures that correlate with certain pathologies. For example, the physician will measure the levels of enzymes that rise with breakdown of red blood cells, or liver cells, and order an ultrasound to measure the diameter of the biliary tract, which will be dilated if there is a blockage. Essentially, medicine attempts to use knowledge of the inner processes (e.g. bilirubin metabolism) to account for symptoms (e.g. jaundice); to use physiology to account for phenomenology; to use the hidden to account for the seen.
  
  In psychology it is the other way around. The first pioneering psychologists such as William James and Sigmund Freud, and later ones such as Abraham Maslow all tried to construct models of the human mind based on their experience with patients – to construct models of the hidden processes of the mind based on symptoms, the psychological equivalent of physiology based on phenomenology. This is supposedly an empirical approach, meaning to base one’s conclusions on observed evidence. But observations in psychology, if not based on unequivocal knowledge, can be a monumental pitfall. To illustrate this point, picture a man dragging a tree log; one observer may observe a man lighting a fire to keep warm; another may observe a man building a wooden hut; and yet another may observe a violent assailant dragging his murder weapon. Observations are achingly subjective, and tend to reveal more about the observer than the observed.   
         
  Of course psychology is much more sophisticated than it once was. Nowadays it boasts state of the art brain imaging techniques, hormonal studies, and even dips its hands into genetics. But these techniques are used as surrogate markers to existing models, with existing terminology. Even with advanced technological methods, it is difficult to prove or falsify, indeed make any meaningful change to a theory, if the definitions aren’t agreed upon. It is impossible to break a model if the terms it is built from are fluid.  
  
• Moving forward:
  
  Medicine is not a science, but a scientific practice, and it is advancing at an astonishing rate. Medicine is not the study of disease – that would be pathology. It is not the study of drugs either – that would be pharmacology. Yet medicine builds upon the terms and models offered by these fields of study, and many others, to develop a practice, not infallible, to investigate and alleviate suffering. To develop this practice, medicine employs the scientific method, to develop theories, test, falsify or prove, and then integrate the new knowledge. Every advancement in pharmacology, pathology, and even physics and chemistry, are harvested by medicine and put into practice through new techniques of investigating and alleviating patients’ suffering. 
  
  This is not the case in psychology, despite the fact that it is still heralded as science. It makes limited use of advancements in other fields and the knowledge it produces doesn’t accumulate in the way medical knowledge does. Many of the theories in psychology are introduced, discussed enthusiastically, researched academically, accumulate discrepancies and embaffelling questions, evoke frustrating disillusionment, and fade quietly on a shelf.
  
  This isn’t a fatal flaw, just a dead end, and to move forward we must turn back. This doesn’t mean to disregard all the insight that has accumulated over the years, but learn from medicine and base observations and insights on the rigid terms of hard sciences. Only using the firm infrastructure of the hard sciences can psychology translate its insight into a single language and join together all the bits and pieces. This channel is my humble attempt to begin this process.