1 Boring Old Man

Back then, psychiatry could and did contain an eclectic menagerie of orientations, as did most other mental health disciplines, just in differing proportions. Unlike the rest of the world, in the US almost all psychoanalysts were psychiatrists due to some political quirk from another time. Most behaviorists and psychometrists were psychologists – dating from their origins in academic psychology. And clinical psychology was the home for the majority of the various experiential and existential psychotherapies left over from the grooviest of the nineteen-sixties. It was the time of "deinstitutionalization" when the mental hospitals were emptying largely as a result of the coming of the antipsychotic medications, so the traditional medical psychiatrists were no longer on the grounds of the institutions. We were all medical psychiatrists. It was the era of the Community Mental Health Movement, so most of us were trained in Mental Health Centers and Crisis Intervention Centers where disciplines blurred. We mixed, worked together, and married with little foreknowledge that this domain would all but disappear in the form we knew it in the not too distant future. There were anti-psychiatrists on all sides, primarily focused on the question of civil commitment [involuntary hospitalization] and prejudice [homosexuality as a disease].

If I had heard the sound of distant drums, it would have come from two directions. First, I was directing a training program, and we were literally starving. Our residents had previously been paid by the clinics and the hospitals where they worked, and those sources of funding were evaporating little by little as private hospitals  cut back or closed and the federal and state money was drained from public facilities. So one drum beat was money. The other drum-beat came from Saint Louis, where a Psychiatry Department was insistent that psychiatry was a distinct medical specialty – that we should return to our true medical roots – white coats and hard science. The commingling of orientations and disciplines was also eroded with the coming of managed care and the competition for the healthcare dollar.

I liked the way I found it when I showed up in the mid-seventies. We argued, debated, collaborated, and socialized. It was a vibrant intellectual culture of the kind I missed from college days. Whatever the discipline, we were all sure we were absolutely right, but didn’t take such things so seriously and the cross-pollination enhanced the experience – we all learned from each other. I paid almost no attention to the DSM-III Revision process, had no inkling that the future would see it as a key turning point in the history of mental health treatment. It was published in 1980, and within five years, I was starting a private practice across town far from the academic career I assumed I would always be a part of. But I’ve said more than enough about that in this blog along the way. The point for the moment is that the Saint Louis version of psychiatry swept the country like the storms sweeping across the country last night.

It is ironic that organized psychiatry was such a big part of the revolution of 1980, creating a book the became the "bible" for mental health, used by all disciplines for coding and the sea of paperwork that came from the parallel revolution in reimbursement practices – DRGs, evidence-based medicine, managed care, pre-approvals, provider panels, etc. My own response to all of that might be summed up by a Dicken’s moniker – the Artful Dodger. I pretty much ignored it all. I doubt that I could do that now [a point often made by my daughter, a Psychologist, given to periodic moaning about paperwork and matters reimbursement]. The irony is that in creating the definitive tome of Mental Disorders, psychiatry itself became the opposite of eclectic – dyslectic? Psychiatrists became medical doctors, using medical methods, doing medical research, talking medical talk. Psychiatry lost its mind and became brain-obsessed. But that’s another topic I’ve had more than enough to say about over the months in this blog. The irony was that psychiatry created the presumably all encompassing system for mental illnesses, but itself became increasingly a specialty with a very narrow focus – neuroscience, medical treatments, medications.

It is coming to a head now, again around the issue of a diagnostic manual effort – the DSM-5 Revision. The conflict is infinitely clear, and currently centered inside the specialty of psychiatry. Organized psychiatry has gravitated to the land of neuroscience as its only real focus, but has been unable to let go of the all inclusive domain of mental illness. It comes down to which diagram works?

And the answer just isn’t that hard. I don’t think all psychiatrists agree that psychiatry equals clinical neuroscience or mental illness equals brain disease even if the reality of reimbursement makes it lean that way. But this is mainly a problem at the top – and that’s what the top thinks.

So the DSM-5 Task Force’s Clinical Neuroscientists are merrily putting together a diagnostic classification that purports to define all mental illness in the context of the brain like the diagram on the left. And we sit out here incredulous, saying, "why won’t they see it’s not going to work?" – as if they are stubbornly refusing to listen. But I’m beginning to think that it’s not that they won’t listen, but rather that they can’t. They are so committed to their world of receptors, brain pathways, clinical drug trials, neuroimaging, drug-pipelines, etc. that they’ve lost sight of what mental illness even really means. So the great irony is that the pathway mapped out by the framers of the DSM-III Revision has lead the American Psychiatric Association exactly where it intended, but failed to notice that in doing so, they were forfeiting the very right that they were so boldly claiming. The bubble has burst, but they haven’t heard it yet.