Perspectives
by Peter D. Kramer, M.D.
January 1996

Finding Ourselves

Writers are always grateful for new outlets and, with them, new audiences. But with new audiences comes the possibility of being mistaken. Just who is looking in, and what are they seeing? This problem--identifying the self, locating the other--is in any case the central problem of modern psychiatry. At least I see it that way.

Others would disagree. E. Fuller Torrey, a psychiatrist and advocate for the seriously mentally ill, has suggested that, in the era of neurobiology, psychiatry must focus exclusively on such disorders as schizophrenia and leave mental health to the social scientists. Under this paradigm, welcome to many policy makers, psychiatry will merge with neurology, departments of mental health will be folded into departments of health, and the science (or art) of mind will be replaced by the science of brain.

Limiting psychiatry's focus to severe mental illness is the new liberal, humane position. It has political merits: adopting it would result in a shift of resources to the gravely disabled. But it is worth recalling that only a few years back, the liberal, humane stance held that people-and health and illness-exist on a spectrum; severe illness was seen as an exaggeration of the anxiety and depression that color all lives. That view had the advantage of highlighting the premise, set forth by the greatest American psychiatrist, Harry Stack Sullivan, that we are all more human than otherwise.

For the moment, opinion favors the medical model. Certain disorders, such as autism, schizophrenia and manic depression, may turn out to have discrete causes, so that neurosis and the psychoses may prove to be as distinct as asthma, pneumonia, cystic fibrosis and so on--different in kind, not degree. But research is likely to show that quite minor disorders--chronic low levels of anxiety and depression-have biological and even genetic underpinnings. Normal conditions, such as personality styles, may well prove "physiological" in one or another way. The focus on a biology may not narrow the scope of psychiatry. As for the line between health and illness, some ailments of the mind may prove hard to corral, tougher to delineate than ailments of the lung.

Biological research may well find new areas of continuity, new spectra. Why is it that the medications we call antidepressants affect such diverse conditions, even conditions we ordinarily consider to be opposites: impulsivity and compulsiveness, anxiety and depression, bulimia and morbid obesity, agitation and apathy? Is it likely that anyone will discover a valid dividing line between depression, the illness, and melancholic temperament, the normal trait? Or even, to choose the most severe disorder, between schizophrenia and extreme eccentricity? (I am thinking here of some odd but productive characters in the new book by David Weeks and Jamie James, Eccentrics: A Study in Sanity and Strangeness).

The future shape of psychiatry is not apparent. In the face of the individual patient, adequate models may be as complex as any psychiatrists wrestle with today. The constant questions are how this person, with this individual history and this body and this social circumstance, exists as a mixed product of nature and nurture, and how this person can be helped to change. That help, I suspect, will continue to include empathy, interpretation, confrontation, and other tools central to psychotherapy-tools used incidentally, rather than technically, in the rest of medicine.

The import of psychiatry tends to be broad. When Freud highlighted sexual repression as a cause of hysteria, he produced a critique of his culture. The focus, a decade or two ago, on narcissism had similar range, as will today's debates over posttraumatic stress, sexual abuse, and false memory. The proposition that mental illness is narrowly "biological" will inevitably spill over into ways we experience the ordinary self . How we conceptualize psychiatry tells us something about who we are, as do the way we use medication, and the value we place on empathy. It is this sort of question, really a receding series of questions, that has long interested me. What does psychiatry tell us about who we are, and what can we learn from the observation that we are a society in which psychiatry tells us that?

My recent book, Listening to Prozac, was often misunderstood to be about a medication. From my point of view, it is a book about the self, a book that asks that series of questions about the nature of self, cultural demands on the self, our difficulties in locating self and other. These, in any event, are the questions I find compelling--part of who I am, as a writer. I hope that this column will pursue them, these questions of what psychiatrists see and how that vision affects the way we, as members of our culture, find our selves today.