SPIEGEL Interview with Jerome Kagan: 'What About Tutoring Instead of Pills?'
Part 2: 'Psychiatrists Should Ask What the Causes Are'
SPIEGEL: Should one just wait to see whether depression will go away by itself?
Kagan: That depends on the circumstances. Take my own case: About 35 years ago, I was working on a book summarizing a major research project. I wanted to say something truly important, but I wasn't being very successful. So I went into a textbook-type depression. I was unable to sleep, and I met all the other clinical criteria, too. But I knew what the cause was, so I didn't see a psychiatrist. And what do you know? Six months later, the depression had gone.
Kagan: Psychiatrists would say I was mentally ill. But what had happened? I had set myself a standard that was too high and failed to meet that standard. So I did what most people would do in this situation: I went into a depression for a while. Most depressions like that blow over. But there are also people with a genetic vulnerability to depression in whom the symptoms do not pass by themselves. These people are chronically depressed; they are mentally ill. So it is important to look not just at the symptoms, but also at the causes. Psychiatry is the only medical profession in which the illnesses are only based on symptoms
SPIEGEL: and it seems to discover more and more new disorders in the process. Bipolar disorders, for example, virtually never used to occur among children. Today, almost a million Americans under the age of 19 are said to suffer from it.
Kagan: We seem to have passed the cusp of that wave. A group of doctors at Massachusetts General Hospital just started calling kids who had temper tantrums bipolar. They shouldn't have done that. But the drug companies loved it because drugs against bipolar disorders are expensive. That's how the trend was started. It's a little like in the 15th century, when people started thinking someone could be possessed by the devil or hexed by a witch.
SPIEGEL: Are you comparing modern psychiatry to fighting witches' hexes in the Middle Ages?
Kagan: Doctors are making mistakes all the time -- despite their best intentions. They are not evil; they are fallible. Take Egas Moniz, who cut the frontal lobes of schizophrenics because he thought that would cure them
SPIEGEL: ... and received a Nobel Prize for it in 1949.
Kagan: Yes, indeed. Within a few years, thousands of schizophrenics had their frontal lobes cut -- until it turned out that it was a terrible mistake. If you think of all the people who had their frontal lobes cut, being called bipolar is comparatively harmless.
SPIEGEL: It's not entirely harmless either, though. After all, children with this diagnosis are being subjected to a systematic change in their brain chemistry through psychoactive substances.
Kagan: I share your unhappiness. But that is the history of humanity: Those in authority believe they're doing the right thing, and they harm those who have no power.
SPIEGEL: That sounds very cynical. Are there any alternatives to giving psychoactive drugs to children with behavioral abnormalities?
Kagan: Certainly. Tutoring, for example. Who's being diagnosed with ADHD? Children who aren't doing well in school. It never happens to children who are doing well in school. So what about tutoring instead of pills?
SPIEGEL: Listening to you, one might get the impression that mental illnesses are simply an invention of the pharmaceutical industry.
Kagan: No, that would be a crazy assertion. Of course there are people who suffer from schizophrenia, who hear their great-grandfather's voice, for example, or who believe the Russians are shooting laser beams into their eyes. These are mentally ill people who need help. A person who buys two cars in a single day and the next day is unable to get out of bed has a bipolar disorder. And someone who cannot eat a bite in a restaurant because strangers could be watching them has a social phobia. There are people who, either for prenatal or inherited reasons, have serious vulnerabilities in their central nervous system that predispose them to schizophrenia, bipolar disease, social anxiety or obsessive-compulsive disorders. We should distinguish these people from all the others who are anxious or depressed because of poverty, rejection, loss or failure. The symptoms may look similar, but the causes are completely different.
SPIEGEL: But how are you going to distinguish between them in a concrete case?
Kagan: Psychiatrists should begin to make diagnoses the way other doctors do: They should ask what the causes are.
SPIEGEL: The problems you describe are not new. Why do you believe psychiatry is in a crisis at this specific time?
Kagan: It's a matter of the degree. Epidemiological studies are saying that one person in four is mentally ill. The Centers for Disease Control and Prevention in Atlanta recently announced that one in 88 American children has autism. That's absurd. It means that psychiatrists are calling any child who is socially awkward autistic. If you claim that anyone who can't walk a mile in 10 minutes has a serious locomotor disability, then you will trigger an epidemic of serious locomotor disabilities among older people. It may sound funny, but that's exactly what's going on in psychiatry today.
SPIEGEL: Do you sometimes feel ashamed of belonging to a profession that you think wrongly declares large parts of society to be mentally ill?
Kagan: I feel sad, not ashamed but maybe a little ashamed, too.
SPIEGEL: Over 60 years ago, when you decided to become a psychologist, you wanted "to improve social conditions so that fewer people might experience the shame of school failure and the psychic pain of depression," as you once put it. How far did you get?
Kagan: Not very far, unfortunately, because I had the wrong idea. I thought family circumstances were crucial to being successful in life. I thought that, if we could help parents do a better job, we could solve all these problems. That's why I chose to be a child psychologist. I didn't recognize the bigger forces: culture, social standing, but also neurobiology. I really thought that everything was decided in the family, and that biology was irrelevant.
SPIEGEL: Over time, you've come to realize that the bond between a mother and her child is not so important after all.
Kagan: That's right, though one must remember that the mother's role was not emphasized until quite recently. Sixteenth-century commentators even wrote that mothers were not suited to looking after children: too emotional, overprotective. But when the bourgeoisie increased in the 19th century, women didn't have to go out and work anymore. They had a lot of time on their hands. So society gave them an assignment and said: "You are now the sculptress of this child." At the same time, middle-class children didn't have to contribute to their family the way peasants' children did. They were not needed and therefore ran the risk of feeling worthless. But when a child doesn't feel needed, it needs another sign. So love suddenly became important. And who gives love? Women. Eventually, John Bowlby came along and romanticized maternal attachment.
SPIEGEL: Bowlby, the British psychiatrist, was one of the fathers of attachment theory. Do you consider his hypotheses to be wrong?
Kagan: People wanted simple answers, and they longed for a gentler conception of humanity, especially after the horrors of World War II. This fit the idea that only children who are able to trust their mothers from birth are able to lead a happy life.
Kagan: Unfortunately, even though we already disproved this in the 1970s. Nixon was president at the time, and Congress was toying with the idea of national day care centers. Along with two colleagues, I got a big grant to study the effect of day care on a group of infants. The children in the control group were looked after at home by their mothers. At the end of 30 months, we found that there was no difference between the two groups. Nonetheless, to this day, 40 years later, people are still claiming that day care centers are bad for children. In 2012.
SPIEGEL: Professor Kagan, we thank you for this conversation.
Interview conducted by Johann Grolle and Samiha Shafy
- Part 1: 'What About Tutoring Instead of Pills?'
- Part 2: 'Psychiatrists Should Ask What the Causes Are'
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