1 Boring Old Man

In my last post, I was not completely fair, in that Tom Insel’s article was written in the salad days of 2005, before we all knew the extent to which the Pharmaceutical Industry had permeated the Psychiatric hierarchy with the resulting scandalous perversion of our scientific dialog. It was happening, but most of us weren’t so aware as we are now. In my defense, the version of the paper on the NIMH site  cited by the Wired article was undated and I assumed it was a more recent production. The piece above references his original JAMA article from 2005 when it was first published. I only discussed the very end of his piece as a way of balking at his equation that Psychiatry equals Clinical Neuroscience. I know that’s what he and his cohorts want, but I’m not sure it’s a justifiable wish. I left out the penultimate section [Training in Clinical Neuroscience] last time because I wanted to think about it a bit before responding. I’m certainly not opposed to training in neuroscience, but he’s suggesting more than just that.

My salad days,
When I was green in judgment, cold in blood…
                ^{Shakespeare’s Antony and Cleopatra}

It’s not 2005 anymore. Since then, a lot of Insel’s cohort has fallen off the wall [as documented on this blog and elsewhere]. They weren’t attacked from within Psychiatry so much. They met their fate out in the world – in the Courts, in the Press, in the Halls of Congress. And it wasn’t because of allowing their naive science to rest on their wished-for future results instead of results in the present, they were busted for corrupt ties to the Pharmaceutical Industry. Lots of Psychiatrists. Lots of connections. And that problem is hardly resolved.

"The study of unconscious processes, motivation, or defenses, while at one time the sole province of psychoanalytic therapies, is now also in the domain of cognitive neuroscience."
"The need for a sophisticated understanding of interpersonal relationships along with the use of evidence-based, nonpharmacological treatments [from psychoeducation to cognitive behavioral treatments] will be the tools of the effective healer in the future as much as in the past."
"The separation of psychiatry from other medical specialties has contributed to the stigma of those who treat mental disorders as well as those who have them."

^{The recognition that mental disorders are brain disorders suggests that psychiatrists of the future will need to be educated as brain scientists. Indeed, psychiatrists and neurologists may be best considered clinical neuroscientists, applying the revolutionary insights from neuroscience to the care of those with brain disorders.}

"The study of unconscious processes, motivation, or defenses, while at one time the sole province of psychoanalytic therapies, is now also in the domain of cognitive neuroscience."
"The need for a sophisticated understanding of interpersonal relationships along with the use of evidence-based, nonpharmacological treatments [from psychoeducation to cognitive behavioral treatments] will be the tools of the effective healer in the future as much as in the past."

^{Redefining the foundation of psychiatry as clinical neuroscience also accelerates the integration of psychiatry with the rest of medicine. The separation of psychiatry from other medical specialties has contributed to the stigma of those who treat mental disorders as well as those who have them. Even beyond stigma, this separation has led to inadequate care. The recent scientific recognition of the importance of effective treatments of mental illnesses in cardiovascular disease and diabetes mandates the incorporation of psychiatry into truly integrated and effective treatment teams.}

At the time, I was in an Air Force Regional Hospital, and I had five Psychiatrists to choose from. Two were career Air Force Psychiatrists who mostly were in the business of getting people out of the military who were too sick to be there. When they consulted, they left me a diagnosis and usually a recommendation for medications, neither of which helped me or my patient. Another was a funny guy trained in the Sixties in California. His hip, experiential ways didn’t fit the military dependents I was treating. They thought he was crazy ["You know what that guy said to my wife? He said she had a flower in her that she wouldn’t let bloom. What’s wrong with that guy? She thought he was coming on to her!"]. Then there was a fast-track Academic from the North-East who was headed for a career in ECT research.  My patients thought he was arrogant and were mad at me for consulting him. Finally, there was a thoughtful Child Psychiatrist, not an Analyst, but someone who knew the mind [as well as all that other stuff]. He would come by after hours and talk to my patients in privacy. They appreciated his coming as did I. Some just went home, a few continued to see him. But he was the one we needed. So I just kept the patients around until he was on call for Psychiatry.

That’s the way it has remained to this day. My medical colleagues in the clinics where I now work bring me lots of people.  I close the door and do what I went back to training to learn how to do. They mostly aren’t neuroscience cases nor are they usually candidates for the evidence-based, nonpharmacological, psychoeducational and cognitive behavioral treatments. They’re just people who need to talk to someone who will listen and try to bring some understanding to bear on their situation about how life and the mind can cause a whole lot of hurt. And when I comb around to make referrals which I am often called on to do, I try to be sure to send people to practitioners who have a full range of skills rather than a devotion to just one way of thinking – people who know about the revolutionary insights from neuroscience and the formerly revolutionary insights about mental life.