my own nostalgia…

Posted on Tuesday 29 March 2011

As a kid, I had something of a fixation on phrases. I remember musing on "old sayings." They sounded wise to me, and I wondered things like "how old do they have to be to qualify as ‘old sayings’?" or "if I can come up with one right now, how old will I be when it becomes a real ‘old saying’?" The latter became a moot question because I couldn’t come up with one. Another phrase was "the good old days." I had some serious thinking to do about that one because it was pretty clear that there was something awry. If the "good old days" were so "good," why did things change? Why didn’t they just stay "good." In my case, the "good old days" they were talking about were the Depression years and the World War Two years, and from those stories they were telling, I could tell that they were hardly "good" [in the sense I understood the word]. Much later, I read Archibald MacLeish’s play, J.B., and  the lines "If God is God, He is not Good. If God is Good, He is not God" and I felt comforted that I wasn’t the only little boy who ever wondered about these great paradoxes [I decided Archibald must’ve spent some time musing in a cherry tree just like I did].

I don’t miss the point of nostalgia. What’s good about the "good old days" isn’t always the "old days" themselves. It’s how we felt in those days – like that television show – "The Wonder Years." Now I’m of sufficient age to realize that my own "good old days" included the Civil Rights War in my part of the world, the Cold War in the whole world, the tumult of the 1960’s, Viet Nam, etc. And I feel nostalgia just like those big people in my cherry tree years [that cherry tree might be on the top of my nostalgia list]. Another thing on that list would be my Psychiatry Residency in the mid-1970s. I want to say some things about those years, but I know full well that while they may have been "wonder years" for me, there was a lot that was anything but "good" going on in Psychiatry at the time.

I came to Psychiatry as a thirty three year old Internist who had gotten "hooked on the mind" while practicing medicine in the Air Force in England. I had become interested in Analysis, and Psychiatry was the route to psychoanalytic training. But I found Psychiatry fascinating too, particularly Schizophrenia. I’d finally ended up doing something that was a "fit" for me and those years were the best learning years of my life. I don’t think I even realized that we were playing with a short hand. It was just the cards that we were dealt at the time.

The rhetoric of the day was that medication was the key to freeing the patients from the overcrowded State Hospitals to live productive lives in society. By the time I came along, the community resources had dried up, so for a lot of those patients, they had been freed to live under bridges, in shelters – revolving through the now overcrowded "stabilization units" if their illness became noisy. The promise of the medications was true for some, but nowhere near numbers to justify the rhetoric.  And it kept getting worse. By the mid-1980s, I was Director of Training on the faculty, and we finally pulled the residents from the State Hospitals altogether  They couldn’t keep the patients long enough to even "stabilize" them, and we just didn’t want to teach the residents to participate in that kind of practice.

In the time I was a resident, the placement of residents in Public Mental Health hospitals and outpatient clinics was the major funding source for our program. Later, as a Residency Director, I watched that support evaporate. To make matters worse, training grants were fading, and placements in private hospitals disappeared as they closed in response to Managed Care. We were hanging on as best we could [by a thread]. Then we got a new Chairman, a Biological Psychiatrist who talked endlessly about research [meaning drug research]. I didn’t recognize the Department after only a year, so I gave up my tenure and left. It was mutual. I didn’t fit what the new regime wanted to do [nor did I want to].

So, although those years were the "good old days" for me in terms of learning and finally ending up doing the right thing for me to be doing, being a Psychiatrist/Psychoanalyst, it was a very disillusioning time to be in Psychiatry as a specialty. It was much later that I came to understand the subtext of that new emphasis on "drug research." Now it’s obvious. It was a way to finance a training program and a department in a time when older funding was evaporating. And now, twenty-five years later, it’s clear why the drug companies were willing to be so generous with their grant and faculty support. I guess Psychiatry was on the block, and the Pharmaceutical Industry bought up a portion of the distressed property on the courthouse steps. That sounds melodramatic as I say it, but it’s just what happened where I was [and lots of other places].

Looking back, the Department I entered had been built on the upside of the Community Mental Health initiatives of the Kennedy era and was staffed, in part, by Psychoanalysts founding a fledgling Analytic Institute in Atlanta. I came into the story as those "good old days" were waning. At the end, the new powers above me were catching the next wave of Biological Psychiatry, and the funding that came with it. I wish I’d known all of that back then. It wouldn’t have been half as confusing and disheartening as it felt at the time. I was lucky in that I had been a fairly visible figure in the Department and had no trouble filling a rewarding practice quickly. The Analytic Institute was a success, so I got to be involved in its coming of age, even in a time when analytic practice in general suffered. So I’m not nostalgic about the state of Psychiatry when I came on the scene. I’m nostalgic about all the things I got to see and learn. It was an eclectic time – analysts, biologists, community psychiatrists, crisis interveners, group therapists, trauma experts, some existentialists, a few hippie experiential types. Even in the fading light of the era, it was still exciting and creative – lots of people wrestling with the problem of mental illness. It prepared me well for the difficult patients I saw later in my practice.

The way I see it now, it was high time for a paradigm shift in Psychiatry. The Analysts and other psychotherapy disciplines had had their day in the sun, and the Biologists were due a turn. They’d earned it with the advances in psychopharmacology – antipsychotics, lithium, antidepressants, biological markers, etc. That’s the way things work in science – ebb and flow. But something happened that wasn’t consistent with the way things are supposed to work. In a short period, Psychiatry became only neuroscience – in the specific, only drugs. Was it Managed Care? Insurance? Competition from other disciplines in Mental Health? I guess that’s what we all thought was happening. Those things were certainly understandable factors, but there was another gigantic force that a lot of us didn’t see clearly. The Pharmaceutical Industry had taken the helm. If not the helm, at least the compass. It was a Deus ex Machina:
    A deus ex machina [pronounced /ˈdeɪ.É™s É›ks ˈmɑːkiːnÉ™/ or /ˈdiː.É™s É›ks ˈmækɨnÉ™/, DAY-É™s eks MAH-kee-nÉ™] [Latin for "god out of the machine"; plural: dei ex machina] is a plot device whereby a seemingly inextricable problem is suddenly and abruptly solved with the contrived and unexpected intervention of some new event, character, ability, or object… Aristotle criticized the device in his "Poetics", where he argued that the resolution of a plot must arise internally, following from previous action of the play…

The change in Psychiatry was more than a paradigm shift. Suddenly, people were talking as if the problem of mental illness had been solved. Mental illnesses were entities treated with drugs. The only growing edge of Psychiatry was discovering the as yet undiscovered drugs that held the key. They didn’t even talk about what caused the illnesses or what they represented. They talked about drugs or the other novel biologic interventions that worked in their treatment. All that other old stuff was obsolete – not evidence based – meaningless.

I said it wasn’t a proper "paradigm shift." If it wasn’t that, what was it? I guess it was a coup d’état. So there’s something else I’m really nostalgic for. I miss the days when we didn’t act like we knew things we didn’t know. We talked, and argued, and changed our minds. We wondered what Shizophrenia is, why it happens. We worried about the lives of the chronic schizophrenic patients and where they lived, what their lives were like. We worried a ton about Tardive Dyskinesia. We tried to get our minds around the loose genetic factors in Manic Depressive illness and Schizophrenia. Analysts were excited about the possibility of Biological Markers and Biologists knew what Narcissism was. We figured out how wrong our predecessors had been about homosexuality. We argued with the Psychologists and then went out for drinks together. We thought about a lot of mental illness as "hurting in your mental" rather than as things with initials. We knew what we didn’t know and wrestled with what we did know. New things like obsessive people getting better on SSRIs poked holes in what we thought about obsessional people and we had to rethink the whole story. And then there were some people who were depressed because they were angry, just like we’d always thought. The dialog was alive, relevant, collegial, open-ended instead of key opinion leaders talking about the same things over and over. And most of us knew the names and doses of the drugs, but not which company manufactured them. We sure didn’t need a public database to see which drug company paid which Psychiatrist to give what traveling dog and pony show with company slides [because it would’ve been empty]. And we’d never even heard of ghostwriting. I miss those days a lot. They really were my "good old days."

I know we won’t go back there. And I don’t know where we’re going. But I also know that we can’t stay where we are…
    March 29, 2011 | 2:30 PM

    Point taken.

    Bruce Hart
    March 30, 2011 | 12:57 AM

    “First, do no harm”, the most important tenet of the Hypocratic Oath. Unfortunately, psychiatric medicine is no longer abiding by this first principle. Psychiatry has evolved into just another Big Business that is looking for ways to increase profits via expansion of its patient base and of its regimens of drug-based therapy. If you give someone medication for a disease that does not have an identifiable cause, you are at best a pseudo-scientist and at worst a drug dealer. We live in extremely volatile economic and political times and medication is being presented as the sole remedy for a variety of very real and contrived illnesses, for which we have little or no real understanding. Drugs are now employed as a means of merely controlling behavior, not curing anything. In fact, the vast majority of anti-psychotics are merely sedatives and tranquilizers for a population that is perceived as having little or no control over their lives. It is painful to watch people suffer the arrogance and unfettered power of the welfare state. I pray that God will raise up courageous men and women to counter this misguided and horribly destructive paradigm that we have in place.

    March 30, 2011 | 11:28 AM

    All’s I got to say is that if Gen. Washington spent his time ponderin in his cherry tree about stuff rather than choppin it down, well he might have manumitted first chance he got and shaped the founding documents of this U.S. of A. through force of will and conviction – could’ve spared Tom Jefferson no end of anxieties and untold millions no end of blood and pain!

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