1 Boring Old Man

Beginning in the 1950s around the time that the psychotropics were introduced, there was increasing opposition to this arrangement. Within psychiatry, there was resentment about the power wielded by the analysts, both by biological psychiatrists and by the non-psychoanalytic psychotherapeutic disciplines, many begun by analysts who changed their minds – Thomas Szazs, Aaron Beck, etc. But it wasn’t until the 1980s when the psychologists sued successfully that this stranglehold was broken, and analytic institutes began to train people from all disciplines as Freud had suggested decades earlier. All of this happened around the time of the DSM-III which ended the analysts influence over the diagnostic manual and the American Psychiatric Association. Now, thirty years later, psychoanalysis has changed radically and is increasingly populated with a mix of mental health and academic disciplines, much more along the lines of the Europeans.

As someone trained in those days, being a psychoanalyst was hardly a plus as a psychiatrist. Many, like me, left academic psychiatry for private practice. Others dropped their affiliations with analysis and stayed in psychiatry as part of the ‘new psychiatry’ ushered in by the DSM-III. The point of talking about this is that this had a potent impact on what has happened thereafter. In this country, the analysts were the representatives of "the mind" in psychiatry, and when they left or were extruded, the specialty quickly became increasingly focused on "the brain." There were a jillion other things involved. The coming of managed care moved psychiatrists in practice into a limited role – prescribing medications, primarily as a cost effective maneuver, and "talk therapy" moved into the realm of other disciplines who charged much less. About that time, along came Prozac et al, and with the drugs an influx of pharmaceutical money into academic psychiatry that was desperately needed to fund training. The down side of that move is well known to all of us and the subject of more blogs than this one. But the point here is that there was no large segment of psychiatry focused on the mind – just the brain and the medications that effected it. Thus, with the coming of the DSM-III, Psychiatry lost its mind.

In fact, in spite of the influence of the analysts in psychiatry, there aren’t and weren’t that many analysts. Training is long and expensive, only worth the effort if you get hooked, and really wanted to do it. Many drop out along the way. It was much more important as an influence than a fact but, in this country, the analysts were heavily over-represented in academia. Many psychiatrists practiced Psychodynamic Psychotherapy – a therapy patterned on some of the broad principles of psychoanalysis, but much more limited in scope [the style portrayed in the series "In Treatment"]. And even Psychodynamic Psychotherapy gradually evaporated in most psychiatric programs with the focus on neuroscience, evidence-based medicine, and the realities of third party payments. Psychiatry iterated towards the model called by NIMH Director Tom Insel "Clinical Neuroscience."

Somewhere in all of that confusing collage of forces, there was another gradual change. Psychiatry lost its soul. The only way I understand that is through my own eyes, so that’s the story I’ll tell, often alluded to here before. I was a happy research-type Internist cruelly yanked from my chosen path by the US Air Force [or at least that’s how it felt at the time] and sent off to be a practicing Internist on a base on a heath in Europe – having really never intended to practice in the first place. I loved it to my surprise. When I sat down and thought about it, it was the people and their stories. Most patients seen by an Internist on a large Air Force Base have physical symptoms, but their problems were in their lives [75% by my count]. I learned to ask about that, and they told me, but then I was dead in the water. After reading a few Psychiatry texts, all of Freud, and others – I applied to do a psychiatry residency. Six months into that program, I identified the people who talked about what I’d come to learn and they were the analysts. Before that, I didn’t even know there was such a thing. I started my analytic program while still a psychiatric resident, and that was that. Had I picked a psychiatry residency elsewhere where there was no such possibility, I would’ve likely been satisfied with learning Psychodynamic Psychotherapy, but that’s not what happened.

Through all of that, I got what I came for – the tools I didn’t have as an Internist to understand the tangles of the minds and lives of the patients I saw. Mission Accomplished. So, I stayed on in academics and was moving right along until whatever I’d become [mostly a Psychodynamic Psychotherapist] abruptly went out of fashion, and I found myself opening an office [where I had plenty to do]. I would never have said that the psychoanalysts carried the soul of psychiatry, and I still don’t believe that. Many of the best and brightest I know weren’t analysts. But somewhere in all of that, psychiatry began to become something else – more detached, more medical. The journals and meetings moved away from cases and focused on groups – diagnostic groups, clinical trials, new pieces of biology. It was just different, and I felt increasingly alien – more at home in the world of other disciplines. At psychiatry meetings, I was a stranger in a strange land. I’m not slightly convinced that the majority of psychiatrists want things to be like they are now, at least not the ones I know. Many of the practitioners I know still do therapy, though much less, and spend a lot more time doing "med checks."

Here’s the punch line. What’s really wrong with the DSM-5 effort is that it’s being put together by a subset of psychiatrists that have gained the same kind of over-representation the analysts had thirty years ago. They’re creating a brain-as-organ version of a diagnostic system that’s mindless sure enough, but worse than that – it has no soul. They’ve lost the vital connection with the individual people that drew me to the specialty in the first place, and they’ve connected instead to an organ – the brain. That approach is doomed by definition.  If successful, it will be incorporated by the other "organ" specialties like Neurology or Internal Medicine. If they fail, as they’re doing now, they will destroy something that doesn’t really need to go anywhere.