on history 1

Posted on Friday 25 January 2013

Those who do not remember the past are condemned to repeat it …       
George Santayana

It’s pretty easy to criticize medicine, but psychiatry is particularly vulnerable because of its position at the subjective edge. Forty years ago, when I changed specialties, my friends had heart to heart talks with me, trying to help me understand that I’d taken leave of my senses – that I should let the impulse pass. I had no choice but to list my internal medicine mentors as references on residency applications. Years later, when I directed our training program, I ran across my own file. Those reference letters all ended with a softly phrased "taking leave of his senses" comment or two [I guess I’m still on leave]. Like I said, psychiatry is easy to criticize.

I realized that my fellow residents had chosen psychiatry in medical school – primarily on hospital wards. I hadn’t and would’ve ranked  that experience below most any other rotation. My interest developed in the course of internal medicine practice, realizing that many of the patients I saw may have come for help with physical symptoms, but the real problem was "supratentorial" [a doctor code word for "in the mind"]. Without actually noticing it happening, that’s where my interest was drawn. It wasn’t the major psychiatric illnesses – it was what the term "neurosis" means. So when I got to residency training, the major mental illnesses were brand new and very alien – at least early on during those hospital rotations. Being something of a history buff, I actually read the parts of the texts about psychiatric history most people skipped over, and spent idle hours in the library in the dusty old books section.

I enjoyed reading about Sigmund Freud, Emil Kraepelin, Eugen Bleuler, Adolf Meyer, Harry Stack Sullivan – the usual suspects. But I also found people like António Egas Moniz [prefrontal lobotomy], Ugo Cerletti [seizure therapy eg ECT], and Manfred Sakel [insulin coma therapy] pretty intriguing [see for review…].  I came along at the very end of the asylum era, but I saw plenty enough to understand why such radical treatments were seen as breakthroughs when they were introduced. Moniz was awarded a Nobel Prize for a treatment that is now only portrayed as abuse from films like One Flew Over the Cuckoo’s Nest, Frances, or Shelter Island [Moniz was shot in 1939 by a "disaffected patient" and paralyzed for life]. It was compelling but difficult reading. I had one foot in a world where desperate mental illness was part of my daily life, and one foot out, disquieted by the desperateness of the old treatments – some forgotten, others still shrouded in suspicion.

What I took from that reading had to do with a topic well known to any practicing physician – Therapeutic Zeal. It’s the danger behind the Hippocratic Oath’s injunction to "Do No Harm." These radical treatments were introduced for the devastating, often fatal illnesses only seen behind the walls of Asylums and State Hospitals. But with some successes, they were increasingly applied in patients with less debilitating illness or diagnoses. That’s what Therapeutic Zeal means, becoming too invested in treating and overlooking the dangers. In the case of lobotomy, Rosemary Kennedy, the younger sister of JFK, was a prime example. As best I can tell, her diagnosis was moderate mental retardation. In her early twenties, she was treated with lobotomy for behavioral problems. The consequences of the treatment became an additional lifelong disability, lasting until her death at age eighty-six – a tragedy.

Some medications are visibly miraculous – Vitamin B12 in a case of pernicious anemia; insulin with diabetic coma; amytal in a catatonic patient; morphine with any number of things. The neuroleptic drugs that grew from the thorazine of the early 1950s can be equally dramatic in the face of florid psychosis, but it didn’t take me long to realize that I’d arrived in another period of Therapeutic Zeal in psychiatry. The State Hospitals, originally built as a reform movement, had become overcrowded human warehouses. So when a treatment for psychosis came along [thorazine and friends], it became incorporated as an essential ingredient in the move to empty the hospitals [part benevolent, part cost-cutting]. A helpful but non-curative treatment should’ve looked like the solid line in the graph, but the dashed line is what happened. So the primo goal was emptying the hospitals and the only way to do it was long-term meds – by ignoring many of the toxicities. Initially, community resources filled in some of the gap, but then that money went away. Neuroleptics are no cure for Schizophrenia. They treat acute symptoms, eliminate some of the devastating deterioration of the disease, and closed the hospitals, but they cause an illnesses all their own. Fortunately, patients often stop them, so they’re used intermittantly. And unfortunately, our jails and prisons have replaced the institutions of old and many chronic patients show the neurological signs of overmedication. Therapeutic Zeal struck again.

I had come because I wanted to learn more about psychotherapy, and did psychoanalytic training as well. I had no illusions of curing the world or of spending my days with only a few patients. I wanted to know more about the mind and I was more than pleased with learned. At the time, the body psychoanalytic was trapped between its method and modern reality, coming out badly in the 1980 revolution as the target of a campaign against the Therapeutic Zeal [and cost] of psychoanalysis [there’s that phrase again]. Exploratory psychotherapy is a major undertaking, neither for routine use nor for the zealous. Like everything in this post, it’s a limited treatment that doesn’t play well outside it’s rational indications. It was my cup of tea, but I didn’t have illusions or delusions about it, so I was pleased with the results.

None of these stories make a bit of sense outside the context of their history – how they came to be, how they came to grief when overextended by Therapeutic Zeal and the narcissism of their proponents. There are economic and social components to each piece of the story independent from the medical worth. And personally, I find solace and perspective in knowing that history – just as I had discovered how much the history of my patients related to their manifest problems. I am a medical physician too, and I know that the same kinds of limitations are as much a part of internal medicine as they are in psychiatry – Therapeutic Zeal is no less dangerous. I don’t talk about it much, but I’ve personally found psychiatry more rewarding than I found my earlier career. In medicine, the excuses were better – chronic or incurable illnesses. In psychiatry failure is more personal, but the problems are fascinating, and the rewards are frequent, even if often less than desired.

Yet with my abiding interest in the history of medicine and psychiatry, and something almost like a hobby preoccupation with the shoals of Therapeutic Zeal, I was totally unprepared for what happened in psychiatry in these last thirty years – so unprepared that I didn’t even really see a lot of it happening. And somewhere in there, we lost a lot of our own history – or at least our history as it actually happened…

History is a vast early warning system …       
Norman Cousins
    Bernard Carroll
    January 25, 2013 | 3:10 PM

    Thank you for these reflections… they are a useful counter to what we might call therapeutic counter zeal. By that I mean a preoccupation with the limitations of treatments, to the point where their potential benefits are dismissed. Your ability to take a nuanced view is refreshing. Many of the therapeutic counter zealots reached their advocacy positions through personal or family misadventure, so their positions are perfectly understandable, though incomplete. It helps to remember that many new treatments were introduced for the intractable and devastating disorders that you call showstoppers. The people who introduced them may have been proven wrong or misguided in the eye of history, but they were not knaves or fools.

    The hostility of the therapeutic counter zealots today gets a lot of its momentum from the crass commercialism of modern treatment research and drug development – where expansion of the market for profit rather than for professionally recognized and justified need is the driving force.

    January 25, 2013 | 9:59 PM

    It has long seemed obvious to me that the historiography of any given discipline should be not only required academically, but should be emphaphized as necessary to understanding that field.

    Henry Hall
    January 25, 2013 | 10:29 PM

    It is horrendous to realize that, after all this time, horrific therapeutic zeal still continues to ruin lives, through psychiatry, of people who have no psychiatric disorders but are merely (you might say) at conflict with society.

    For example, the standard treatment in 1962 for transsexualism was in-patient ECT and Thorazine.

    The DSM-5 still proposes going forward that transsexualism is a mental disorder when it clearly is not. Thus blackmailing people who need somatic medicine to allow psychiatric diagnosis to be perpetrated upon them. And holding somatic medical treatment hostage to compliance with despicable psychiatric social prejudice even absent any and all mental disorder.

    No wonder the DSM-5 will be widely boycotted by medical professionals.

    January 25, 2013 | 10:46 PM

    history and historiography. Due to all the bogus studies, deconstructing the last thirty years is going to be a herculean task.

    berit bj
    January 26, 2013 | 6:55 AM

    Historians and critically minded professionals are already doing decontruction. I would recommend the The British historian David Wooton’s short book Bad Medicine, Doctors doing Harm since Hippocrates and Roy Porter’s deeply dug volumes. Robert Lifton’s work The Nazi Doctors is a must, as is recent books by British psychiatrist Joanna Moncrieff. on psychopharmacology, some pros. more con, most of all listening, obesrvant, honest, careful, maybe like dr Mickey et al?

    An honest history of psychiatry and lobotomy must include the shocking rates of death, around half the victims in some places in the early years. The critics were vocal, some hospitals, read doctors, in Norway never performed the procedure eagerly touted by an early KOL, dr Odegard, the leading doctor at Gaustad asylum, resulting in the largest proportion of operations relative to population anywhere were performed here., An unknown number of unnamed patiensts are buried in a grave nearby at Riis church, a formal ritual of remembrance is performed once a year by members of our NGO named WeShallOvercome.
    Of course, the Nobel Prize to Moniz should have been revoked, as the report by a former Brown University professor, as the utterly premature Nobel Peace Prize to an American president still at war. Oslo was under siege when the Obamas were here, unlike when president Mandela deservedly was honoured.

    Psychiatry deserves the critism levelled at it today. The crass commersialism is only the latest twist of a very dark tale where the victims voices could have been heeded if the doctors had been humane enough to recognize shared humanity.

    January 26, 2013 | 9:32 AM

    Thanks for writing about the value and importance of “looking back.” Like Wiley, above, I believe a knowledge of history (in any field) should be a prerequisite to going forward.

    Your focus on psychiatry is paralleled in many fields. You know I am interested in diabetes, and I note the similarities you present. An unwillingness to acknowledge failure, opinion leaders whose opinions seem to be more informed by a pharma paymaster than real science, the obsession about blockbusters and latest-greatest medications and treatments.

    I find it eerie how often I read your article and find substituting ‘diabetes’ for ‘psychiatry’ is on point. Thanks for your thoughtful pot-stirring.


    January 26, 2013 | 11:01 AM

    But what of the adage “the more things change, the more they stay the same”? What disturbs me having only practiced 20 years now is seeing how much we leap onto a “breakthrough” drug or other intervention, only to find it has equal poisons and placebo effects once applied to the general population.

    I am equally disturbed how so many alleged mentors and senior providers have done nothing to challenge the intrusions by insurance and big pharma. I have painfully learned that too many of our colleagues are inherently selfish and patriarchal in attitude to a profoundly detrimental level.

    And boy, has the APA been the poster child for this observation.

    This post is appreciated. Again, I envy your opportunity to practice as trained for as long as you were able. I wrote an open letter to people involved in mental health at my blog, perhaps too many questions, but, better to ask than stay silent, eh?

    January 26, 2013 | 11:13 AM

    Joel, you state:
    I am equally disturbed how so many alleged mentors and senior providers have done nothing to challenge the intrusions by insurance and big pharma. I have painfully learned that too many of our colleagues are inherently selfish and patriarchal in attitude to a profoundly detrimental level.

    I’m one to paint doctors with a very broad brush of selfishness & arrogance. But in more thoughtful moments, I realize that many of them are caught up in the maelstrom of today’s complicated society and literally do not have the time to fight the battles we think need fighting. E.g., I have been very angry for a very long time at endocrinologists (diabetologists) who failed to wave the “proceed with caution” flag when the latest-greatest rDNA insulin was foisted upon the diabetic population. But while some could have spoken out–at the very least for moderation–many were considering the very real threat offered by pharma that the old tool (natural insulin) WOULD BE removed from the marketplace. They could have joined the battle to retain a needed tool, but would that have taken needed time to realign their patients with the tsunami of biotech offerings and found they were merely tilting at windmills–leaving patients in a vacuum.

    I’m a black-and-white type of person; age is teaching me a great deal about the various shades of gray.

    berit bj
    January 26, 2013 | 12:22 PM

    I did not understand any goings on, lots of painful, harmful coercive harm being done (Norway is top of European tables), contributing to the downward spiral of one of my children, until I started asking questions and was brusquely put in my (silly, ignorant, subservient mom) place by the leading KOL, whom I remember as a kingpin of a little facist empire. As a (then) politician I think I understood something about power, the message given by this brutality was: Keep out. Shut up. Leave it (a young son) to us.
    Instead I found a kindred spirit in a female doctor I met while researching someting I thought unrelated, the politics of everyday violence. We started an NGO, I started reading history of medicine and psychiatric textbooks, have never stopped, and have been in a process of steep, unending learning since. It took two years to force the removal of a couple of local tyrants and ideologues of bio-psychiatry. But we saw then that there’s a huge crowd infected by the sickness of greed for easy money and power, the collective ethical failures embodied in APA, NAMI and their clones in too many locations .
    There is much to rejoice and be thankful for in this world, but also more cynicism and cruelty than I knew in my former, sheltered existence. It’s been a watershed of revelations.
    I’m thankful for the 1BOM-blog and the many good comments.. Unaccustomed to this mode of communication, I apologize for any faux pas unintentionally committed. I have much to learn, will try tand watch my step.

    January 26, 2013 | 2:50 PM

    Oh yeah. How many “you silly little woman” looks have I gotten from male psychiatrists? As soon as their pay goes down, women will fill the ranks.

    January 26, 2013 | 4:14 PM

    berit bj
    You’re doing fine…

    Actually, the women are already there – a majority in many classes of trainees…

    January 27, 2013 | 2:18 PM

    As an injured patient, I have a hard time seeing psychiatry as mostly good. Perhaps the doctors here can help me with this.

    It took me 4 years to find a psychiatrist who took my iatrogenic injury seriously. In that time, I talked to about 20, mostly affiliated with UCSF psychiatry, some big names, and a half-dozen non-psychiatrists.

    Among the psychiatrists, only 2 were at all able to conduct an intelligent conversation with me. The others were pompous and condescending, particularly repellent traits when combined with a lack of knowledge.

    Mind you, the subject was a common adverse effect of antidepressants (withdrawal syndrome) that they should have all known about, being they prescribe the drugs at least several times a day and sometimes several times an hour.

    Those are the statistics: One knowledgeable psychiatrist out of 20 (the other gets points for compassion, but he was still clueless).

    I was fortunate in that I had extraordinarily generous health insurance that mostly covered even the out-of-network doctors. Most patients don’t have the financial resources or stamina to search out 20 doctors. When I finally found my extraordinary psychiatrist, I was so disheartened about the profession I almost could not bring myself to talk to him.

    I took my sheaf of journal articles to show him, the same collection that the others had ignored. He told me to put them away, he was already familiar with them. I could have wept. He saved my life (such as it is).

    Every day, people add their stories to my site at http://tinyurl.com/3o4k3j5 Read 10 or 12 of them yourself.

    You will see they are ordinary people, with ordinary problems, being made ill by ordinarily clueless psychiatrists (and other doctors) all over the world, in patterns that repeat over and over: Misdiagnosis, overprescription, ignorance of adverse effects, ignorance of what “tapering” means.

    It’s not a random sample, it’s skewed in a lot of ways, but given my personal experience and what I see reported by these people (who come to my site because they cannot find knowledgeable medical care anywhere), I can’t help but conclude a good psychiatrist is very, very difficult to find.

    I can understand why psychiatrists want to believe their profession is doing mostly good, but from my perspective, this isn’t what’s happening. Perhaps psychiatrists see what they want to see in their patients, and what they want to see is effective treatment. This can be quite different from the patient’s point of view. See http://wp.rxisk.org/monicas-story-the-aftermath-of-polypsychopharmacology/ :

    “So he said something suggesting what happened to me isn’t the norm. That he sees medications working wonders all the time. I challenged him like this, “Dr. M, when you were treating me you thought I was one of your successes, right?” He said, “Yes.” And I responded with, “Well, you were wrong. My life was miserable. I lived in a drugged haze. I slept and worked because that is all I had time to do. I had no passion for what I did and I just lived by going through the motions, flat and empty. My life was hell. I liked you and you needed to believe that I was okay…I tried to please you like a “good patient.” Still if you’d paid attention you know that I was always asking to be put on disability.”

    January 27, 2013 | 3:09 PM

    Glad you found a psychiatrist who was knowledgeable. Would you consider it appropriate to name that one (NOT the other 19). I’d be curious to understand more about his/her characteristics. If not, then that would be completely understandable. Either way, did he/she express their view on why they had come to take these issues more seriously in patients when his/her colleagues did not? Was that from the literature or primarily from his/her own clinical experience?

    January 27, 2013 | 3:32 PM

    I can’t give his name out generally because he would be swamped with requests. He’s already very busy.

    His characteristics are that he’s an independent thinker — he saw through SSRIs and hasn’t prescribed them for 10 years. He recognized the prevalence of pharma propaganda early on.

    He’s also a sleep specialist and thinks good sleep is important to general health. As soon as he saw antidepressants fractured sleep, that made him suspicious.

    He doesn’t shrug off the obvious hormonal effects of psychiatric drugs, such as sexual dysfunction, either.

    He seems well-versed in the adverse effects literature and, like Dr. Mickey, does his own statistical fact-checking.

    He does prescribe other psychiatric drugs, very cautiously, when needed, at the lowest effective dosages, disregarding the nonsensical “therapeutic dosages” promulgated by the drug companies. Having focused early on the role of the glutamatergic system in insomnia and anxiety, he’s an expert in the use of lamotrigine.

    He maintains patients on drugs only until symptoms are relieved, closely monitoring and adjusting dosage, as he believes the nervous system is dynamic (what a concept) and the indication for chemical intervention is temporary.

    He’s also a very compassionate person. He considers the doctor-patient relationship a collaboration in healing. He’s eclectic and uses non-drug methods, such as supplements, as well (but he doesn’t follow the naturopath party line either).

    January 27, 2013 | 4:02 PM

    Also — how could I forget to mention — he noticed people were coming in who had suffered iatrogenic damage from psychiatric drugs and developed protocols to treat it.

    As I said, he’s very busy.

    January 27, 2013 | 8:17 PM

    It is good to know Altostrata found the physician to help. But what I sense many at sites like this seem to ignore when I raise the point over and over is simply this: What do you do when over 50% of people, not only the patients but fellow providers, be it other physicians, therapists, and patients not only cling to this failed biochemical imbalance model, but are quick to harass you as a dissenter if not just bail on you after standing your ground on pushing for a multifactorial approach to care interventions.

    Many of you type away how doctors are to blame, but it is time to stand back and see the bigger picture: society has bought the lie, and just scapegoating a profession isn’t going to gain healing and proper perspective. No, it is time for creative people to find creative ways to stop the liars, the profit mongers, the charlatans, and the sheep of the public to stop demanding quick fixes.

    The most effective way to stop a proverbial tank of this magnitude is to make a crater that will plunge it into a hole and be trapped. Money, power, and leadership devoid of respect for followers is at least slowed with legal action.

    It is time to charge the minions selling this failed philosophy with felonies. Even civil actions strictly for the sake of recouping money is not effective. Threatening to jail people gets attention. And it will need legal hawks who are committed to a cause, not a payout.

    And like this is going to happen. Well, if you as a collective who want real change for the better agree with this perspective, time to mobilize. When reckless physicians, out of control pharma, insensitive managed care, and clueless associated providers see there are real consequences, well, like rats on a sinking ship, they will flee.

    That is what I have learned with history. Oh, and by the way, I have done my time as a whistleblower and found out how ungrateful the masses are, so please do not ask me to take another bullet, turn the cheek. I have a family to feed, I do what is right, and I’ll support a cause but will not run it again.

    It is time to see who really cares, and who just wants to point fingers.

    January 27, 2013 | 8:39 PM

    I don’t know how my doctor does it, Joel. He must be a master diplomat. He speaks his truth and yet is still very well respected among his peers. He knows they’re wrong but doesn’t confront them with it. He’s known as the go-to guy when they screw someone up so badly they don’t know what to do next.

    He’s not a firebrand, just a hard-working principled clinician.

    January 27, 2013 | 9:11 PM

    That does not jive with me. You can’t speak truth among psychiatrists and be respected. Sorry, that is the reality it is in 2013. I hope you are paying full attention.

    I am the first to say I am not right all the time, but, boy, when I am right and it is about the profession being wrong, I kinda know how It feels to be ostracized and marginalized. That is what the profession does to protect itself.

    January 27, 2013 | 9:20 PM

    I guess he doesn’t care about being ostracized and marginalized as long as he gets more referrals than he can handle.

    berit bj
    January 28, 2013 | 3:24 PM

    Yes, dr Hassman.
    To be ostracized and marginalized from one’s community or group is so destructive that people may get sick, committed and die early, feared even by Sigmund Freud, backstepping on the controversial theory of sexual abuses, perhaps remembering the fate of dr Semmelweiss, expelled from the medical community, died in an asylum after successfully having demonstrated that skyrocketting rates of deadly puerperal fever in the maternity wards could be reduced by doctors washing their hands…
    A wellknown psychiatrist in this country wrote a book in which he – very carefully, diplomatically – set out ideas towards a more patientfocused, less abusive psychiatry, stopping well ahead of the most contetious issues. When I critized him in public for fundamental omissions, he answered – in a private conversation – that he’d been wiped out by his colleagues if he’d gone further.
    Which tells me that the castle is crumbling from the inside.

    January 28, 2013 | 4:09 PM

    As was pointed out to me by a nonpsychiatrist colleague years ago, the Freudian based psychiatrists are basically a cult, and they have zero tolerance for dissent nor alternate points of view. True from my experiences these past 20 plus years with colleagues older thajn 60 who are excessively psychodynamic in orientation.

    How ironic one of psychiatry’s main nemesis is Scientology, an equally rigid and inflexible system that I think fears us the most for exposing it for what it is, a cult, that is not interested in educating and enlightening, just controlling and disrupting any who stand in it’s way.

    Yeah, sort of what the powers that run the APA and academic psychiatry have been doing since the windfall of “biochemical imbalance” kicked in.

    Thanks for what I interpret as something supportive of my earlier comment.

    berit bj
    January 28, 2013 | 7:17 PM

    Correctly interpreted, dr Hassman.
    Of scientology I know next to nothing, but see no need of any new church, new cults or new national organizations..
    I do see the need for organizing, but not on a large scale, rather small, loosly connected groups, guerillas in broad daylight, supporting common goals of democratic and humane attitudes to diversity, demanding transparency from all who have private or professional or political stakes in outcomes. National organizations need more money, and are thus more easily corrupted, as demonstrated by NAMI and other big Mental Health NGOs . All it takes, (to transform the world), is one dedicated person, and then 12, like incorruptable lion mothers, born to defend the children

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