Posted on Monday 12 November 2012

What we call the beginning is often the end. And to make and end is to make a beginning. The end is where we start from…
T. S. Eliot, Little Gidding [1942]

The decision to reject one paradigm is always simultaneously the decision to accept another, and the judgment leading to that decision involves the comparison of both paradigms with nature and with each other. To reject one paradigm without simultaneously substituting another is to reject science itself…
Thomas Kuhn, The Structure of Scientific Revolutions [1962]

After singer Karen Carpenter died from anorexia nervosa, we were inundated with eating disorder cases, particularly those of us practicing on a college campus. I’d never actually seen a case before then, so I spent a lot of time in the library ‘boning up’ but didn’t find much. That summer, I was asked along with others to speak about the topic at our association meeting – organized by our new chairman, a prophet of the new DSM-III psychiatry. My presentation was largely examples from cases I’d seen. I talked about the difficulties in the transition from girl to woman in female adolescents, particularly in the ‘best little girls’ that my patients had been, essentially a talk about female identity formation. It wasn’t half bad. The new chairman began with the question, "How do we know that these girls aren’t vomiting to lower the dopamine levels in their spinal fluid?" and used the venue to discuss the need for more basic research in psychiatry.  I didn’t miss his point about "evidence," but I felt set up because I’d only reluctantly agreed, saying that all I knew was from cases. The library was empty.

And that’s how my very long final year in academic psychiatry went, day after day. Any mention of anything psychological evoked a discussion of the need for more research into the neurobiology of whatever we were talking about. It took me a while to get the point that all things psychological were seen as speculative. It wasn’t psychoanalysis, it was psychological causation itself. I had come to psychiatry having discovered that matters psychological were the central problems of many of the patients I saw. They had found me, not the other way around. The idea of abandoning the paradigm that had been such a light bulb in my career, changing my whole life direction was of no interest to me. All the new talk was about psychiatry as a medical specialty and where it was headed. I didn’t care much about psychiatry as a medical specialty. I cared about understanding the patients that showed up. Sounds kind of corny to say it, but it was the truth. So for me, it was time for another mid-course correction…

My point is that for whatever reasons [and there were many], psychiatry was abandoning the soft and speculative world of the psyche and moving into the world of hard data. I was born for the world of hard science and pursued it until I got to the place where I needed something more, so I sought out people who knew how to navigate on those open waters. I knew it was a speculative world filled with ambiguity and squishiness, but that was the world where the patients seemed to live. By the time the DSM-III came along, I was learning to live there too and finding a new way of looking at the terrain. But that’s about me, my conflict of interest statement. For the purposes of this post, the paradigm of psychological causation was the one being rejected. To me at the time, it was the baby in the bathwater of all the complaints about the power, the dogmatism, the speculation, and the fiscal drain of psychoanalysis. I agreed with many of those complaints myself, but what about the baby?

I picked my example above carefully from among a myriad of similar encounters because it illustrates two other things. The chairman’s counter-example ["vomiting to lower the dopamine levels in their spinal fluid"] was, of course, whimsy designed just to illustrate a point. But all the counter-examples were like that – some concrete biological explanation. The second thing is that they were all predicated on something in the future, something as yet undiscovered. The new "evidence-based" paradigm was invariably biological, and it existed in the imagined future. That year was my most difficult personal year ever because it required making a choice between two things that I saw as a false dichotomy. Both ways of thinking were sometimes right and both could be wrong – literally ‘different strokes for different folks’ in my book. I had embraced Adolf Meyer’s bio·psycho·social model for real [and still do]. I looked at a few other programs and had some offers, but what I discovered was that this was a national movement, not just something happening where I lived, and I had to make a choice – get on the bus and stay in academia or move on. I picked number two [though it felt once again like it picked me], and I absorbed my personal loss.

When I look back on it. It was clearly the only choice for me. Grieving actually works, even in the absence of treatment. A few hard and confusing years and then things get better, in fact get really good. I now know so much more about the political forces and massive external influences at work in those days. The point of this little confessional is that what happened back then was a paradigm shift in one sense – from psychological causation to hard biology. The temporizing DSM-III wasn’t so "non-etiologic" as advertised. But in another sense, it was an economic and political change masquerading as scientific debate. There’s no question at all that something needed to be done in those days. But paradigm shifts in science don’t come about for economic and political reasons. And this one missed Kuhn’s middle phrase, "and the judgment leading to that decision involves the comparison of both paradigms with nature and with each other" and came dangerously close to exemplifying his ending, "To reject one paradigm without simultaneously substituting another is to reject science itself." Much of what followed continued to be "economic and political change masquerading as something scientific" as in the ocean of corrupted clinical trials that poured from the academic/industrial complex that blossomed in the new psychiatry, many of which seemed to me to "reject science itself."

I suppose that the psychoanalytic establishment looked as bad to the pundits of the 1970s as the  academic/industrial complex and the APA/DSM-5 leaders look to me in the 2010s. If there’s a lesson in all of this, it’s that one really shouldn’t judge a science by its scientists alone. Some psychiatrists have behaved pretty badly in both eras. There are scientific problems on the table, and there are real economic and political problems, sure enough. But at the core, it’s our ethical problems that need to be addressed right now. The mentally ill still have both minds and brains that need our attention, and in the end, medicine is defined by its ethics, not by its economics, its politics, or its paradigms…

… And thirty years later, I still think the shoals of adolescent feminine development have more to do with eating disorders than spinal fluid chemistry. I’d now add that the changes in society in those thirty years have probably contributed to the fact that we seem to see fewer such cases – adding the social dimension back into the bio·psycho·social model from long ago …
    November 13, 2012 | 8:11 PM

    Hmm. . . Your world renown chairman thought that adolescent girls were vomiting to lower dopamine levels in their spinal fluid? Did he say whether this behavior was motivated consciously or unconsciously?

    November 17, 2012 | 2:09 AM

    There’s a good book called Crazy Like US by Ethan Watters about how the US is selling their model of psychiatry worldwide. One of the sections in it is about how China had a virtually zero rate of anorexia they starting girls to “watch out” for it. In Japan they didn’t have a word for mild depression so the marketing gurus came up with the term, “Cold of the soul.”

    Ivana Fulli MD
    November 26, 2012 | 8:30 AM


    I think that some people receiving neuroleptics are smoking (tabacco) themselves out of some of it.

    Nothing Freudian or whatever about it : their blood level decrease when they chainsmoke and so are the side-effects of the drug.

    I suppose it was the reasonning being the DA spinal fluid level: the women could feel better after vomiting, full stop.

    Although, the chosen example was eccellent on that score since the scope of vomiting is a very efficient prevention of weigh gain after alimentation…

    Ivana Fulli MD
    November 26, 2012 | 8:47 AM


    I wish your blog posts could be all reposted on “MAd In America” like Pr David Healy’s blog since what you write is needed to the readers of MIA as a link to that post http://www.madinamerica.com/2012/11/squishy/#comment-17816 and to another post http://www.madinamerica.com/2012/11/five-types-of-mental-health-advocates/#comment-17817 can attest.

    Thank you for your blog: i myself stpped wanting to become a neuropsychopharmacologist in 1986 after I designed a study who was published in The Lancet about female hormones and mood because none of my professors were interested on it after I suffered the greatest difficulties in finding a team wanting to do it because the biology oriented French academic psychiatrists did not believe in female Hormones and mood (in the end I used an emergency medicine team receiving suicidal attempts). I conceived that study when a research registrar in Oxford and had the shame to ask my supervisor to put my personal adress and not my professional one for a Psychological medicine publication on that subject since I couldn’t afford to make my boss at the time publicly responsable for it even in a very small way…

    This to add to the content of your post that , at least in France biological psychiatrists in the 80s were not exactly open minded and scientific even on biology- the monoamies theory has done a lot of bad things including making some PMT sufferers labelled bipolar -especially if the woman belong to the autistic spectrum and has difficulty with expressing feelings.

    Another characteristic of France is that the psychoanalysts never left power in the academic psychiatry -they cohabit with the monoaminergic simpletons – but they use a lot of drugs-at least for their public sector clients.

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