Out of Its Mind: Psychiatry in Crisis: A Call for Reform

Perhaps my expectations for this book were too great. Hobson is a respected professor of psychiatry at Harvard Medical School who has made contributions to our understanding of sleep and dreams. And the blurbs on the dust jacket were very promising: “A brainy book about the mind,” “eye opening and scintillating.”

Unfortunately, Hobson’s collaboration with science writer Jonathan Leonard is a disappointment. I must confess that the conflicting and distinctive voices of the two authors of this book are disconcerting. It is as though they could not agree on the authorial tone of the text. Whatever the reason, even the case histories given as examples lack clinical verisimilitude, and there are troubling oversimplifications of the science and everything else.

The authors’ enterprise was to describe and explain the crisis in the theory and practice of psychiatry and to offer a remedy. In my opinion, however, the first sentences of the acknowledgment indicate how their project went awry. They refer to their efforts to construct not a “Tower of Pisa” but an “Eiffel Tower” so as to scan the broad landscape. This analogy (typical of the prose style) explains why instead of building a book on Hobson’s own solid expertise, the scientist and the science writer went around interviewing leading figures in the various subdisciplines of psychiatry. As a result, sections of this “overview” recount material that has been described (more convincingly) by those who have actually worked in the subspecialty and written books directed, like this one, at the general reader. I have in mind, among others, Descartes’ Error by Damasio (1), The Emotional Brain by LeDoux (2), The Antidepressant Era by Healy (3), and Mood Genes by Barondes (4). Other sections reveal a woeful ignorance of health policy and medical economics.

The best sections of the book deal with Hobson’s lifelong interests, e.g., the problem of consciousness and sleep and the “dance of dreams.” Here one finds an ambitious attempt to present and explain the current scientific background (neuroanatomical and neurochemical) of the mind-brain problem. But even that writing is marred by a forced cleverness that annoys more often than it enlightens. In other places the authors are snide and brash: “Not all of the new psychiatric residents are hopeless” (p. 214). “And HMO [administrators] get paid plenty, because you can’t hire competent people to do a nasty job like depriving others of health care benefits unless you pay them well” (p. 219).

Yes, psychiatry is in a crisis: morale is low, psychoanalysis is dead, managed care is a disaster, treatment resources are inadequate, psychopharmacology is not an exact science, and the brain is incredibly interesting. Unfortunately, the authors’ account of all this brings no new insight or clarity, and despite their lofty vantage point they seem not to recognize that all of medicine is now afflicted with some of the same ailments.

The authors are upbeat and propose a call for reform. They base that reform on a new psychology—“neurodynamics,” a bottom-up psychology based on brain science. They suggest that we can now go back to Freud’s original scientific project—a theory of the mind based on our knowledge of the brain. Unfortunately, their overview demonstrates how far we still are from the knowledge base necessary for a bottom-up psychology. The brain is awe-inspiring in part because the more we understand about it the more we realize how much of it remains a mystery. As a scientific matter I would suggest that understanding the pathophysiology of cancer will be a simpler task than understanding “neurodynamics.” We can expect a cure for cancer long before our science reduces the mind to the brain.

I know and admire Allan Hobson, so I can only hope that his general readers will find more here than I did.