Before coming into psychiatry in the mid 1970s, I read the contemporary Freedman and Kaplan’s Comprehensive Textbook of Psychiatry. It said that Adolf Meyer was the Father of American Psychiatry, and I saw him primarily as a historical figure. He introduced the work of Emil Kraepelin to the US. He brought Freud and Jung to America for a famed symposium at Clark College. His wife and collaborator, Mary Brook Meyer, was the “first American social worker.” But he made unique contributions of his own. I rarely think about what Adolf Meyer was talking about in his time. I’m referring to what’s called Meyer’s bio·psycho·social model. I guess I heard that so many light years ago that I haven’t lingered to parse his meanings for a while. It just became a part of me.

bio·

^{At first glance, the bio· part seems obvious. We’ve heard about nothing but bio·, bio·, bio· in psychiatry for the last twenty-five years, so I shouldn’t have much to add. bio· is important! We get it. But thinking for Adolf, he had a lot more in mind than just Tom Insel’s version of bio·. I think he’d include things like sex, aggression, survival, affiliation, nurture, attachment, grief, physical illness, disability, etc. – things innate or sometimes acquired. Maybe I’ll forgo speaking for Meyer and just say that I’d include those things.}

psycho·

In my first career, I had a love affair with hard science [still do], but fate put me in the situation of practicing medicine. I couldn’t have done it without my medical training of course, but I quickly learned something that had escaped me in a busy residency. What doctors do is take care of people, and for me that came to mean more than just applied science advice. When I realized it had a lot to do with helping people with the tangles in their minds, their subjectivity rather than my objective view of them, I changed directions – never much looking back except for an occasional nostalgia for the comforting clarity that hard science can sometimes bring.

I have no apologies for my later psychoanalytic training, any more than I have for reading Meyer’s Commonsense Psychiatry, or Kraepelin, or the existentialists, or the psychologists, or the philosophers, or the ethologists, or Woolf’s Mrs. Dalloway, or Aaron Beck, or the countless other things that pertain to the private mental lives of human beings – the psycho· part. Those things I mentioned are just the maps that get us oriented when we visit new places, but they don’t tell us what it’s like to be there. That’s why the methods of statistics don’t work very well with subjectivity – because all minds and lives are so subtly different. Leaving out the psycho· and only thinking about the bio· [neuroscience] seems to me like unscrewing the back of this computer and looking at the chips or reading through the software code to figure out what this blog post is about. Whether you like it or not, on the side of your mind, you’re thinking about some version of my life and experience or your own life and experience, our minds, not the brain’s circuitry. The only real question is whether you’re using your map, or thinking about mine.

It’s easy to criticize theories about the psycho· aspect of Meyer’s trinity. The theories are only models that have a similar relationship to the mind as model airplanes have to the jumbo jets that carry us through our skies. That’s what I like about Meyer – he didn’t much deify theories. He just highlighted the importance of the individual’s whole life history and subjectivity in understanding the mind and its pain. I can’t even imagine an alternative. The psychiatry of the modern variety seems mindless – and I frankly find that hard to relate to.

social

What Meyer was talking about was taking the patient’s social milieu into account in formulating an approach to the person – the broad social and the intimate. The social worlds of the soldiers I saw in the military living in a foreign country, the Black charity patients in downtown Atlanta, the urban educated  in my office practice, and the rural Appalachians I now see live in different social universes with differing cultures, mores, and life experiences. Those differences matter a lot. And their intimate social experiences though similar across cultural lines have an infinite variability. Like the psycho· piece of Meyer’s model, the social has been put on the back burner. To deny that individual and group social context has something to do with mental illness and is not in the purview of psychiatry is to me as un-medical as losing the mind altogether.

Research Domain Criteria – RDoC
NIMH – Director’s Blog
by Thomas Insel
March 06, 2012

^{In contrast to these changes in the rest of medicine, for the past century mental disorders have been considered "behavioral," implying that an exclusive focus on symptoms could yield a precise diagnosis. Problems with this narrow approach to diagnosis began to emerge as research demonstrated the inescapable heterogeneity underlying diagnostic labels such as depression or schizophrenia. Even attempts to subdivide these categories by considering additional symptoms, such as anxious depression, failed to give reliably better prediction of treatment response…}

Looking into the inescapable heterogeneity was rewarding, even at my embryonic level understanding, but it takes time. You have to ask, and you have to know what to ask, and you have to do a lot of listening. Some doctors don’t want to do that, and I don’t blame them for that. They see their field in a specific way – no heart problem ergo not my problem. I was never able to do that, so I decided to become an inescapable heterogeneity doctor – because that was the most interesting and challenging thing of all. That part was like House on television. At about that point, I found an ancient copy of Common Sense Psychiatry in the base hospital library – a collection of Meyer’s lectures and papers published in 1948. I can’t even remember a lot of what he said in the specific, except that it was something of an outline about how to listen and how to tease out what mattered in a story.

And so my own Diagnostic Manual became something like this. There were the medical conditions and brain diseases that caused mental symptoms – they came first. If the problem is hypothyroidism or a brain tumor, that’s the diagnosis. Then there are the Psychiatric Diseases like Schizophrenia and Melancholia. If one of those is present, that’s the diagnosis. And then there are people struggling with their inescapable heterogeneity and they’re all different, and my job was to jump in and see what I could find. And Adolf Meyer was a powerful influence for me in learning how to do that. I don’t recall specifics from Meyer because that wasn’t the point – it was the way he thought about people and the way he approached understanding them that mattered.