Healing the Soul in the Age of the Brain: Why Medication Isn’t Enough

Philosophers, scientists, psychiatrists, and psychoanalysts are taken up with the study of the mind in relation to the body-brain as never before. This area of study is not a cohesive field of expertise but a battleground of data and ideas as well as values and egos. For those in the materialistic camp, the mind is the behavior of the brain, end of story. As one of them has said, “Mind is matter” (1). For them, all that is needed is time before the “explanatory gap” between these two domains is satisfactorily bridged and the brain mechanisms of mind phenomena are expounded. For instance, a neural mechanism has now been proposed for the mental operation known as “denial,” which before had been conceptualized purely in psychological terms (2). There are many who oppose this optimism, and they, too, come from several fields of expertise (3), but the fervent and cogent arguments of the so-called mysterians have been quickly countered with arguments equally heated and convincing (4). And the battle rages on.

In psychiatry, this controversy has been echoed in the question of whether the increasing efficacy of psychoactive medication and the promise of gene therapy will render psychotherapy obsolete. For some, this possibility represents a conceptual vindication and a blessing; for others, it is dehumanizing and misguided. Those trying to contain health care costs or sell medications have enjoyed the biological boom as much as their pill-pushing has been decried by those who champion psychosocial interventions. Managed care and the pharmaceutical industry can be blamed for only so much, however. The truth is that, before their zeal to save dollars and their greed, there was what psychoanalysts call “resistance.” Religious and spiritual leaders, healers, and physicians alike have long noted the struggles of their disciples and patients to emulate their practices or adhere to their recommendations. Well before the fluoxetine fad, quick fixes were seldom in want of followers.

Enter Frattaroli, a psychiatrist and a psychoanalyst, who has written an impassioned, ambitious, and complex apologia for psychoanalysis and psychoanalytic psychotherapy. He comes with a promise of clarity and finality in an area where there seems to be so much obfuscation and suspense. The subtitle of the hardcover version of the book (Becoming Conscious in an Unconscious World) is different from that of the paperback version (Why Medication Isn’t Enough). The intended readership of this remarkable book is the general, educated public, but psychiatrists can valuably read it, including those in training. Although the final result is uneven, there is plenty in this book warranting thoughtful consideration.

In six sections and 18 chapters, the author strives to expose group forces underlying intellectual conformism, offer his own interpretation of Cartesian epistemology, champion a model for diagnosis and treatment that corrects the drawbacks of the medical model, pay homage to his teacher Bruno Bettelheim, delve into the philosophy of science and the implications of quantum mechanics, provide an intimate and candid account of the psychotherapeutic process, suggest an answer to Freud’s changing views on the mental apparatus and symptom formation, and refute materialism while lamenting the demise of certain values, which plagues society at large as much as contemporary psychiatry.

Psychoanalysts may value particularly Frattaroli’s discussion of the repetition compulsion and the superego as the “I that stands above.” Psychiatric educators may consider the tragic story of the young man with psychosis in chapter 2, “The Technocrat and the Cowboy,” as required reading for medical students and residents. Clinical psychiatrists will appreciate the fine distinctions in formulating clinical cases throughout the book. The author is at his best in discussing patients, both as a therapist and as a writer. His prose can be beautiful and moving. In discussing ideas, however, his eloquence often becomes grandiloquent.

Frattaroli, never shy to use the words “soul” and “spirit” and ever ready to offer an exegesis of the Book of Genesis or Buddhist enlightenment, bravely endorses the philosophy of dualism, out of favor these agnostic days in academic circles. Readers with religious convictions, therefore, may wonder why he stops short of ever using the “G” word in discussing psychoanalytic views on religious beliefs or the transpersonal and supernatural implications of dualism.

There is disagreement on the use of medication in psychoanalysis (5–7). Even psychoanalysts who agree with Frattaroli on this issue, however, may object to statements such as, “All mental illnesses—personality disorders as well as symptom disorders—are caused by inner conflict” (p. 215). Clinicians who work with disenfranchised individuals suffering severe, chronic mental illness with comorbid disorders such as medical conditions, substance disorders, and cognitive impairment may become exasperated with these types of provocative statements throughout the book.

Some philosophers of the mind, neuroscientists, and biological psychiatrists are likely to be dismissive of this book. Frattaroli the polemist is often too eager to make a straw man out of their complex and far from monolithic fields. Most disappointed will be those who are seeking bridges between psychoanalysis and affective and cognitive neuroscience. This omission is all the more unexpected because Glen Gabbard, who played an important role in the genesis of the book, has welcomed neuroscience findings to show how psychotherapy affects the brain and speculated why it does so (8).

Those who find that this review discourages them from reading the book need to know that it reads like a novel. The last chapter brings climax and closure to the book in an unexpected way. This chapter ushers the book away from the genre of intellectual contest into a sort of intellectual memoir. It is here where Frattaroli ultimately succeeds in creating a touching example of how intertwined the life and the ideas of an individual can be. And how dualism can be in the soul of the beholder.