1 Boring Old Man

In this blog, I’ve spent no small amount of time going over the 1980 DSM-III and the forces that went into its creation. Just a thumbnail recap. In 1974, Dr. Melvin Sabshin became the Medical Director of the American Psychiatric Association. He had formerly been chairman at the University of Illinois. Besides wanting to put psychiatry in the mainstream of scientific medicine as he says above, he was interested in defining Normality and in removing the psychoanalytic influence from psychiatry [the ideology he referred to]. On arrival, he teamed up with Robert Spitzer who was a nosologist with the same interests. Spitzer was closely allied with the neoKraepelinians in Saint Louis who were outspoken advocates of a purely biological psychiatry. There are accounts of how all of this came together throughout this blog and elsewhere, including Dr. Sabshin’s "insider" book above. My point for right now is that a small subgroup within psychiatry radically changed the specialty using the power of the American Psychiatric Association, its Medical Director Dr. Sabshin, and the Task Force leader Dr. Spitzer.

^{For most of the DSM-III disorders, however, the etiology is unknown. A variety of theories have been advanced, buttressed by evidence – not always convincing – to explain how these disorders came about. The approach taken in DSM-III is atheoretical with regard to etiology or pathophysiological process except for those disorders for which this is well established and therefore included in the definition of the disorder. Undoubtedly, with time, some of the disorders of unknown etiology will be found to have specific biological etiologies, others to have specific psychological causes, and still others to result mainly from a particular interplay of psychological, social, and biological factors.}
^{DSM-III Introduction – page 7.}

 

There’s an real irony in this story. The psychoanalysts who fled Hitler’s Europe and came to America were from a particular group known as the Ego Psychologists. That particular group had expanded Freud’s psychoanalysis into a general human psychology and established institutes here that trained only psychiatric physicians. Neither thing happened in Europe, so there was a big split in psychoanalysis [called the Atlantic Ocean]. Drs. Sabshin and Spitzer weren’t the only psychoanalytically trained psychiatrists who had a beef with the arrogance and rigidity of the American Psychoanalytic Association – both its structure, its scope, and its dogma. I expect many were like me – enduring that part to learn what was valuable, then going our own way. But there were plenty like Drs. Sabshin and Spitzer who saw the APsA influence as something that had to go. But to stick to the thread, one could make a similar Venn diagram about psychoanalysis circa 1960 with the American Ego Psychologist psychoanalysts claiming dominion over what Jaspers called Personality Disorders when their legitimate domain was a much smaller inner circle.

This story is usually told in one of two ways. In one version, Drs. Sabshin, Spitzer, and the group in Saint Louis used the power of the American Psychiatric Association to liberate psychiatry from its psychoanalytic captivity [the DSM-III revolution] – reclaiming its rightful medical roots. In the other rendition, the Saint Louis neoKraepelinians used the disaffected Drs. Sabshin and Spitzer along with the power of the American Psychiatric Association to take over American psychiatry for the neurobiologists – a coup d’état. I expect there are an number of variations in-between. And if you add in the forces of managed care, the pharmaceutical industry, the place of government in medical care, the rise of other mental health disciplines, changes in medicine in general, and the myriad of other things that shape human history, one might have an infinite regress – the stuff of legend. My point here is not how it happened, it’s about the consequences.

The psychoanalysts, particularly the ones active in the American Psychiatric Association, didn’t put up much of a fight. Things needed to change in psychiatry and psychoanalysis no matter how it came about. Some analysts changed their spots. Others retreated to their Institutes and grumbled. Whatever the case, there was no place in an academic department for people like me, so I went into practice to be the psychotherapist/psychiatrist I’d set out to be – working in the smaller circle where I fit just fine. But there is something from my experience of all of this that bears on the present. When the DSM-III revolution arrived in Atlanta, I couldn’t open my mouth about anything without hearing about evidence-based medicine and the quackery of psychoanalysis.

A story: The day I decided to quit academics, I was a training director leading a curriculum committee meeting. My earlier job had been directing the Grady Hospital Psychiatric Emergency Room called the CIS [Crisis Intervention Service]. If you’ve ever worked in such a place, you know there wasn’t any psychoanalysis going on there. It was filled with acutely psychotic people, suicidal people, homicidal people, just about anyone out of control on the streets of Atlanta. It was just my cup of tea and I taught the residents a course on Crisis Intervention. As I listened to the committee question whether I should continue to teach such a course, being that I was an analyst in training and all, I could actually feel steam coming out of my ears – but maintained my composure. The next topic was a course on the supportive management of Schizophrenic patients taught by one of our senior faculty, the head of Child Psychiatry. It was a brilliant course, based on his experience as a young man before the primacy of the neuroleptics. You guessed it, he was an analyst too and the same discussion ensued – something about analyzing Schizophrenia [a thought I’m sure never crossed his mind]. That afternoon, there was a death in my family and I was gone for two weeks. On returning, I promptly gave up my tenure and resigned, though I suspect the feeling was mutual.

Psychological thinking was out, at least where I was, when I was there. You can hear that story two ways. We were both psychoanalysts. But more to the point, we were both teaching courses on management of psychological illness – crisis intervention and supportive care of the chronic mental patients. Neither topic was psychoanalytic, but they weren’t biologic. I expect my experience was not typical, but it wasn’t atypical either. Academic psychiatry seemed to rapidly medicalize as in become scientific, but not in the sense of the care of the sick. And Dr. Spitzer’s claim of becoming atheoretical was more in form than substance – biology and neuroscience had become the new kings. I hasten to add that generalizing from my experience would be a mistake. What happened was more a trend than in bas relief as it was for me – which was in one specific place with one specific me.

• Dr. Sabshin wrote, "How could a professional organization engineer a scientific revolution that changed its core? According to conventional wisdom, organizations respond; they do not initiate." The answer is simple. They take the driver’s seat, concentrate the power over the course of the history, and run the show. I suppose an analogy might be what we call the War Powers Act in our government. They did just that. Whether that was right or wrong is history. The contemporary part is that the American Psychiatric Association never let go of that power – to this day [and into tomorrow]. It’s trivial to reiterate that absolute power corrupts absolutely, but in this case it’s true. That’s why so many of us don’t belong anymore.
• The second major consequence of that DSM-III revolution is well known to you if you’re reading this blog. There were a few deus ex machina, outside forces that opportunized on the new state of affairs and found hungry and willing allies within the new psychiatry – one was the pharmaceutical industry. They had a feeding frenzy pouring needed dollars into psychiatry in return for, well, you know what the return was. In a large segment of psychiatry, particularly academic psychiatry, "scientific" and "evidence-based" came to mean pharmaceutical drug trials, and the rest is history – a history of some of the most corrupt science the field of medicine has ever known. Jaspers’ domain, Personality Disorders, became a medication target range [the mile or so from my new office was the department I had left where Dr. Charles Nemeroff came to lead a few years later].
• Dr. Sabshin wrote, "… psychiatry had to adopt a genuine committment to science rather than to ideology. It needed to change the profession fundamentally if it was to become a respected part of medicine. To accede to pressures without radical modifications of the field would not have convinced others that the profession had changed. A new strategy was essential! Producing the DSM-III stated emphatically that psychiatry in America chose an evidence-based practice rather than ideology." Other physicians don’t think about what psychiatrists do that much, if at all. The audience being addressed here was more the third party carriers who were breathing down psychiatry’s throat at the time, with Dr. Sabshin’s own vision of psychiatry thrown in for good measure [aka ideology]. Best I can tell, he was a well meaning guy, as was Dr. Spitzer. Unfortunately, their "scientific" and "evidence-based" psychiatry was mostly lacking the kind of science and evidence they were talking about. And that was the beginning of what I call FutureThink – talking enthusiastically about the unrealized future as if it were just around the corner, rather than merely speculation aka ideology [and often they talked about it as if it were already here].