Postmodernism: The Risk to Western Tradition and Psychiatry By Herbert S. Sacks, M.D. APA President

The continuing debate engulfing the humanities involves intense academic concerns about race, gender, and social class, together with dogmas subsumed under the buzzword "postmodernism." The historic trends in American psychiatry during the past 20 years reflect inexact parallels.

Radical curricula changes in the humanities have abandoned much of the Western tradition in our universities, setting off fireworks in learned journals and campuses across the country. Western tradition has been beset by accusations of sexism and racism by an academic elite who have made a case for non-Western modern theory, historically attuned and politically correct. The elite charges that the canon (a mean term used by postmodernist warriors to describe Western thought) makes for moral insensitivity and clinging to ancient ideas in a changing world. But examination of the ideas of postmodernists reveals intellectual clichés, reworked concepts going back to the 18th century, and nature-versus-nurture debates using arcane and euphemistic constructivist terminology to obscure the essential arguments.

The postmodernists have entrapped themselves in doctrines that may limit informed access of women and minorities to the literature and social thought of the Western tradition, disparaging humanism and driving students away from the liberal arts. The new orthodoxy has contributed to the dramatic decline of undergraduate majors in the humanities over the past two decades.

Inexact Parallels in Psychiatry

We have seen an explosion of information in the neurosciences and psychopharmacology in the past 25 years that has brought relief to many of our suffering patients. Research on neurophysiological correlates of behavior has illuminated brain alterations derived from psychotherapeutic effects. The past predominance of department chairs, psychodynamically and psychoanalytically oriented, has been supplanted, in many cases, by neurobiologically trained chairs, many of whom strive to sustain eclectic departments. However, there are departments in the country where psychotherapy teaching, informal and thorough going, is nonexistent or marginal. In eclectic departments, there is an auction of sorts for valuable curricular time, a marketplace of competing goods, where psychotherapy proponents don't do well against advocates of evidence-based science.

Psychotherapy, at its best, is systematic, rooted in a hundred years of literature and theory that is subject to continuing revision. My friend, Albert Rothenberg, in the book The Creative Process of Psychotherapy (Norton, 1988), reminds us that our best psychotherapists are aesthetic in their appreciation of intensity, narrative, and leaps of understanding. Those of us invested in psychodynamics are accused of lacking a scientific basis in our work. But the aesthetic perspective itself is amenable to careful scientific study and analysis, and indeed, the process of psychotherapy is a creative experience sharing features of the creative process in the arts, music, and sciences. (See the program on Day of Creation at APA's 1998 annual meeting in Toronto; an article about the program begins on the facing page.)

Psychotherapy, done by our best people, is rigorous, consistent, and logical. Remember that these best people have been exposed to intense training, sophisticated individual supervision, literature seminars with requirements of accountability, and continuing cases. Often these best people have entered treatment themselves to deal more effectively with their own vulnerabilities, and not for an intellectualized didactic experience.

With surging neurobiological advances and a proportionate decline in psychotherapy training in many academic health centers, we are graduating from our training programs many residents who, while possessing fine skills and talents, often don't incorporate healing procedures that have underlyingly the strong moral and aesthetic values of personal dignity and freedom, a respect for uniqueness and choice, and an emphasis upon imagination and the deployment of intuition. My experience participating in ABPN examinations in the past years gives some credence to my claim. But I would concur with them that the oral examination-time limited, focused, and associated with the high anxiety of the candidates-doesn't give clear proof of my hypothesis.

Earlier, I expressed concern that the ascent of the evidence-based scientific establishment with its neurobiologic infrastructure will yield a corresponding decline in psychotherapy strengths in our training programs. A Weltanschauung (world outlook) which elevates evidence-based science and does not integrate it with clinical wisdom will lead us into a cul-de-sac. Entrapped by a science-based dogma, a new orthodoxy may emerge where psychotherapy will become the canon, seen as clinging to ancient ideas in a changing world, accused of being unscientific. In the worst-case scenario, our humanistic, intuitive, and aesthetic sensibilities will give way to formulaic approaches to the treatment of the mentally ill. (Is polypharmacy, for instance, a prodromal symptom of what's to come?)

Gary Tucker and Nancy Andreasen in the American Journal of Psychiatry in the past two years have warned how our focus on symptoms, narrowed by the contribution of the DSM series, has detracted from our attention to the patient's narrative, which is central to our work. This challenge to good patient care is synergized by the impact of managed care and its stepchild, case management, which dilute medical responsibility and invade our ethos and historic antecedents. Managed care's dehumanizing business strategies are designed to make us into formulaic and fungible professionals serving the cause of corporate profit maximization.

Let me know what you think. Fax me at (202) 682-0432.