The Old Questions:
The Psychiatric Diseases were identified by Kraepelin a century ago and have remained essentially unchanged since that time, through many classifications [see a mere catalogue?…]. These Kraepelinian Illnesses were universally accepted as Diseases, probably biological in the minds of most. The borders with other people were distinct – both diagnostically and literally as most were in asylums back when, at least for some of the time. About that same time, Freud began to treat a different group of people who had symptoms and behaviors that he thought were generated by the mind and life. Over time, many other conditions were added to the mix by the psychologists, social workers, military psychiatrists, etc. This second group were generally thought to exist in people with an intact central nervous system. They were probably psychological and the borders with other [normal] people were indistinct. Except in crisis circumstances, they lived among us.
Beside the questions of proof of treatment efficacy, the third party carriers were driven nuts by the indistinct borders of these latter conditions, and the psychoanalysts were of absolutely no help in defining these boundaries more crisply. So along came the DSM-III with its evidence-based medicine aiming to firm up the boundaries with its objective criteria. One Old Question was Why did they ablate the distinction between the Kraepelinian Psychiatric Diseases with definite borders and the second poorly delineated group? They all became just Disorders. And in one glaring instance, they destroyed that distinction within a major diagnostic entity – Major Depressive Disorder. Melancholia and Depressive Neurosis ran together, becoming a subtyping issue implying a groundless and unjustifiable continuity.
Another Old Question: While the DSM-III claimed to be non-etiologic, it was really something more than that – anti-psychologic is the only term I can think of. The Disorders known to be Brain Diseases are identified as such, but there was no place for psychological causation. So, why did all mental illness become not psychologic? Nobody thinks that all mental illness is non-psychological – not psychiatrists, psychologists, playwrights, social workers, neighbors, authors, psychoanalysts, physicians, mailmen, me, or you. Nobody…
The New Question:
Well, my new question certainly isn’t Why did psychiatry become nothing but neuroscience and psychopharmacology? The answer to that one is kind of obvious. What other choice was there? And it’s not Did Melvin Sabshin, Robert Spitzer, and Allen Frances plan on their DSMs leading to the primacy of psychopharmacology, the union of PHARMA and academic psychiatry that resulted, and the debacle of the recent DSM-5 process? I think not, particularly in light of the reaction of Spitzer and Frances to the DSM-5 Task Force. But my question is How did things become so damned corrupt in psychiatry? so quickly? Was that inevitable? And I think that’s a pretty good question…
The coming of the DSM-III created a void – actually several. First, it created an ideology void. Being non-psychological was hard work in a specialty that had been so psychological before. There was Aaron Beck, another recovering psychoanalyst who had developed Cognitive Behavior Therapy [AKA "evidence based psychotherapy"], but few others in the psychological realm. The psychopharmacology front was populated, but stalled after a brilliant surge in the 1950′s. But there was another void. Many of psychiatry’s best and brightest were the psychoanalysts, up and down the ranks, who drifted to their own worlds in the years that followed – a brain drain. So there was a fresh new milieu but it was relatively unpopulated, working on re-forming itself – looking for a direction. Not psychoanalysis just isn’t much of an identity.
I think I might have happened on another force for later corruption in psychiatry in those days after the DSM-III reading Sabshin’s book. Once it was done, psychiatry needed something to organize its new non-psychological persona. People were eager to jump on band wagons a little too quickly, a bit uncritically. We were new to that much hard science and grasped at anything that looked good enthusiastically. As long as I’m using historical analogies, why not use one close to home? The Carpetbaggers flowed into prominence in the field and their misadventures were allowed by people who might have known better in a more mature scientific environment, might have raised red flags earlier. And, by the way, psychiatry was broke, so the pharmaceutical money looked real good. We grew us a crop of KOLs that were unlike the leaders of the past. Some of them made a great noise and lead us down a garden path.
Something else. I expect the people behind what I’m trying to talk about next would say it was the right thing and it had to be done, or that it was the only possible method, or some other rationalization for "the ends justify the means." They might even be right about that. But it really was "sneaky." The "Psychoanalysis had to go!" agenda wasn’t explicit, but was embedded in other language – scientific language, economic language, scapegoating. Scapegoats may always earn their fate at some level, but the simplification and polarization in the scapegoating process extracts a price. In this case, I suspect the price was a lot of latter-day "sneakiness" that has actually poisoned our waters.
- Well, it’s over. That’s all I have to say about the election. But while I was watching, I had a thought about these last several posts about the years around 1980 when I was young in psychiatry and way less aware of the future, or for that matter, the contemporary present, than I knew. One of my favorite authors [when I can tolerate his world] is Cormac McCarthy, author of the book made into the powerful film, "No Country for Old Men" – a favorite movie [when I can tolerate watching it]. I don’t have the kind of dark disillusionment that pervades McCarthy’s work about much of anything, but I feel the sense of the title line, No Country for Old Men, in both the election and in the story of psychiatry. A long personal history can be a burden…