‘Words are the physicians of the mind diseased.’
Aeschylus, Prometheus Bound
A recent essay in the press described a case of Obsessive Compulsive disorder encountered in Azad Kashmir. The writer expressed her distress at the entirely ‘biological’ i.e. medical treatment of the disorder by local practitioners leading to poor results and significant harm to the patient. The author, to her credit, attempts to broaden the understanding of the illness utilizing psychotherapeutic methods employed by leading lights in the field of Psychiatry and Psychology including Carl Gustav Jung, Frieda Fromm Reichman and others. However, her analysis lacked a consideration of what might be generically termed ‘environmental’ factors, more specifically the socio-economic and religious factors at work in the genesis of Obsessive Compulsive disorder and other mental illness. The title of this essay comes from an experiment conducted by American Psychologist David Rosenhan in 1972. The experiment tested the validity of psychiatric diagnosis by having a group of normal, non-mentally ill individuals pose as psychiatric patients to gain admission into a psychiatric hospital and also tested the ability of mental health professionals to detect the truly mentally ill from amongst a group of people of people who were not ill. The experiment concluded that it was difficult to distinguish the ‘sane’ from the ‘insane’ in that setting. It also concluded that the whole process of diagnosing patients lent itself to ‘massive errors’.
This experiment has a direct bearing on all patients treated anywhere with the treatments currently at our disposal. The method of Freud, Psychoanalysis, which formed the basis of the theories of Jung, Reichmann, Kernberg, Adler, Klein and a generation of psychotherapists, posits that psychopathology or mental illness results from unconscious conflicts and desires usually originating in a person’s childhood. This method focuses largely on ‘intra-psychic’ processes i.e. feelings, desires and impulses generated by a person’s own mind to the exclusion of the outside environment. The most trenchant critiques of this method have been made by other schools of thought that tend to focus more on outside influences. These include cognitive behavior therapy, gestalt therapy etc.
A Freudian approach neglects some crucial factors. Why is it that all over the world, not just in Pakistan but in the USA, UK and Western Europe the psychotherapeutic method is being abandoned in favor of biological interventions i.e. medications? The answer to this question requires some historical perspective. Psychoanalysis was born in the ferment of the last years of the 19th century. This was a time of great upheavals in Europe with wars, revolutions and counter revolutions. The first Russian revolution was to follow in 1905, followed a few years later by the First World War and then the October revolution in Russia which resulted in the formation of the first workers republic, the USSR. Freud’s theories, which counseled a ‘looking inward’ rather than towards the existing social and material conditions gained rapid popularity in the ruling circles of the day and in fact, his most loyal patients belonged to the upper classes of the time. After World War II, the governments of the USA and Western Europe provided generous benefits to their workers including mental health benefits for long term therapy including psychoanalysis. This was a way of weaning them away from ‘dangerous’ ideologies like Socialism, at that time the ruling philosophy of a large part of the world’s population, soon to be joined by China. The USA could afford to do this because it had emerged as one of the world’s two remaining superpowers after the war with an intact infrastructure, a huge balance of payments credit and a highly industrialized economy. In contrast, Europe was in ruins and the German, English and Japanese empires had been destroyed. The massive aid plan to rebuild Europe, known as the Marshall plan, was also an attempt to forestall a ‘revolution from below’ by workers fed up with wars and slaughter.
This was the background against which psychoanalysis received a major boost in popularity especially in America. Starting in the 1970s however, the economies of the Western countries including USA slowed and profits began dropping again. The reasons are beyond the scope of this article but it led to a series of efforts, continuing to this day, of taking back the gains made by the working class in most of the twentieth century. This is why all of the ‘welfare’ provisions of years past are under attack including higher pay, pensions, social security and healthcare. A consequence of this last is the shift from psychotherapy, which is labor intensive and less profitable, to medications which generate much higher profits for both the medical establishment as well as drug companies. This is not an isolated phenomenon, as mentioned. It goes hand in hand with efforts to roll back all social welfare provisions including spending on healthcare, infrastructure, education, mass transportation, clean water etc
In a country like Pakistan with a limited industrial base and a largely agrarian economy, a focus on biological interventions for mental illness serves the same purpose. It helps to mask the most significant causes of mental illness, poverty, lack of education and social and educational inequality. This is also a significant, and often neglected, reason for the rise of religious fundamentalism. Social injustice, poverty and lack of economic opportunities lead inevitably to frustration and anger which can breed anxiety, depression and other kinds of mental illness or, if directed ‘outwardly’, lead to anger and hatred. This can easily push a person towards religious fundamentalism as a perceived ‘solution’ to these problems. Economic ruin and the resultant social upheaval was exactly what made the rise of Hitler’s Nazi party possible after the First World War
There is no doubt that the mental health needs of large parts of the population in Pakistan are neglected and that this leads to untold suffering. However, the struggle to provide more efficient and meaningful care to those in need cannot be conducted in isolation. It must be part of a larger struggle to reform society as a whole in a just and humane manner. Only then can one see real, meaningful changes occurring in people’s mental health.
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The author is a Psychiatrist practicing in Arkansas, USA. He can be reached at ahashmi39@gmail.com
