running on empty…

Posted on Sunday 28 April 2013

"My optimism is based partly on the extraordinary vitality of neuroscience and perhaps, even more important, on the emergence of remarkable new tools and technologies to identify the genetic risk factors for psychiatric disorders, to investigate the circuitry of the human brain, and to replace current animal models that have failed to predict efficacious new drugs that act by novel mechanisms in the brain."

One of the more helpful things I learned along the way in early psychiatry training was something called Crisis Intervention. It was an idea that came from the military experience during World War II. It was incorporated into the Community Mental Health Movement rhetoric of the late sixties and seventies, and then sort of sank under the waves of biology that swept over psychiatry in the 1980s. It was conceptualized as a preventive strategy. It’s origins were humble and based on a simple definition of crisis.

A crisis occurs when some important life trajectory is blocked. In such situations, emergency emotions are activated to focus attention on the problem. Normal coping mechanisms fail and more desperate mechanisms are engaged – fight, flight, etc. If they fail, the emotions escalate, and at some point, a crisis state appears. What is that? It’s when the problem is no longer whatever is trying to be accomplished and becomes the heightened emotions themselves. So the person on top of a burning building jumps, even though the ladder is being cranked into place. Or the soldier in the heat of battle climbs out of his foxhole and tears across the battlefield – an easy target.

In World War II, when a soldier showed signs of cracking on the front lines, they put him in a Jeep and took him out of the fray, gave him clean clothes, a good bed, some decent food, maybe a flick or a cocktail or two. Let him talk to a psychiatrist [usually some medic or doctor declared "psychiatrist" by lottery]. Three days later the Jeep took him back to his unit. It was a raging success, returning 82% to the lines whereas it had been 18% before. The soldiers went back to doing what soldiers do. They didn’t deteriorate or declare themselves mentally ill because they returned to function. They called it "combat fatigue." Those of us who treated these soldier’s children a generation later learned that there were enduring consequences, but even at that, the outcome was much better than after World War I where a generation was essentially lost.

The point of Crisis Intervention is not to solve the problem. People in crisis will do that themselves. The point is to keep them from doing the kinds of maladaptive crazy things people in the throes of a crisis state do just to feel better [and suffer the consequences in perpetuity]. So getting people off the front lines, liberal use of anxiolytics, and calm support are the first order of business. The next thing is to recognize that crisis states are caused by unsolvable problems, so one wants to hone in on the specific problem and reframe it into something more manageable. People can finally learn things that they’ve avoided learning for years because the crisis is so painful. And although people in crisis bring up every problem they’ve ever had when they’re in such a state, the point is to stay on the front burner, the problem at hand, and get the patient back into the stream of life as soon as possible. Crisis Intervention techniques are basic elements of any mental health worker’s skill set. I can’t imagine not knowing about Crisis Intervention.

Armed with our Crisis Intervention skills, what about Dr. Hyman’s crisis? Well, we can’t talk about that yet, because there’s another thing to consider when you think about doing Crisis Intervention. When dealing with a person in the throes of an emotional crisis, you pull out all the stops, go the extra mile, do almost anything it takes to get the patient’s emotional state out of the red zone. But there’s another kind of crisis – a manufactured crisis. People know that others respond generously to people in crises. We’ve watched that happen for two weeks in Boston. And there are people who manufacture crises to get what they want – sometimes unconsciously, sometimes on purpose. How can you tell the difference? Seasoned clinicians make that assessment quickly by experience, almost without thought. They’ve been taken for enough rides to have a sixth sense about these things.

One can say some things about how the old hands make that assessment. People in emotional crises come in many flavors, but they don’t lie and they don’t manipulate. And I’ve got to say that the people who are crying "Crisis!" here are doing both of those things. They start with the global burden of mental illness argument and portends of its rising incidence based on the fictive WHO predictions. They hide in the sheep’s clothing of concerned doctors without mentioning more unsavory motives. They focus on the empty pipeline as the precipitant of the crisis. Nothing acute there, we’ve known about it for years. The real precipitant is the exit of PHARMA from CNS drug development taking with them the generous financial contributions to academic departments, research, professional organizations, journals, the clinical research industry, and the KOL set. They claim to not understand why PHARMA would desert such a lucrative market knowing full well that PHARMA couldn’t get away with the things they did to make it so lucrative in today’s environment. There are just too many lies and manipulations for a genuine crisis.

And who is it crying wolf? They’re only the people who stand to lose when the PHARMA money goes away.  Of course we need for  basic neuroscience research to continue. Of course it’s reasonable to continue to try to understand basic pathophysiology of the mental illnesses of biological origin. Of course basic drug research is important. But we don’t need a continuation of the antidepressant and atypical antipsychotic story we’ve lived with for a quarter century. And we sure don’t need the academic/industry alliance that has accompanied it. This is a manufactured crisis.

But there is an actual crisis. The psychiatry that’s left behind is too heavily focused on psychopharmacology, is constrained and controlled by managed care, is operating at a low approval rating, and is strapped with a ruling class that thrived in, condoned, and wants to perpetuate a corrupted environment. It is, indeed, a time to learn things that have been avoided for a long time – but that’s not going to happen along the current path. Psychiatry’s real crisis isn’t an empty pipeline, it’s empty leadership…
    April 28, 2013 | 2:42 AM

    It seems that part of the crisis in leadership within psychiatry is that there is an glaring absence of the theory that lays in support of the practice. With this absence, we (psychiatrists, mental health practitioners, patients, the public), have been placed at the mercy of market forces that will never work in the best interests of our patients. I love this blog so much that it inspired me to start my own: Thank you for all your digging!

    Berit Bryn-Jensen
    April 28, 2013 | 2:46 AM

    Excellent! Excepting the extra costs, bureaucracy and constraints of the insurance industry in managed care, single-payer, publicly financed health care here, your diagnoses of the crisis in dominant bio-psychiatry is as I experience it in Norway.
    The Breivik case may be a turning point, as everyone who cared were witness to the shallow thinking and the power undergirding the reign of a too-close group of forensic bio-psychiatrists. The independence of the judges saved us from the folly of having a terrorist diagnosed with schizophrenia, sentenced to treatment in hospital.
    Power struggles are out in the open. Sunlight is indeed a powerful disinfectant!

    Bernard Carroll
    April 28, 2013 | 12:52 PM

    For Steven Hyman’s opinions to be credible, he should at least have a track record of success in translational science, as he calls it. He risks otherwise being discounted as a cynic who is just playing the game called the name of the game is to keep the game going. Evidence of his success in translational science is not apparent in his past work. Dr. Mickey is right about the leadership of our field. We need leaders who walk the walk, not just talk the talk.

    Richard Noll
    April 28, 2013 | 4:53 PM

    For the past sever days I read — and extensively re-read and marked up — my copy of a new book which arrived in the mail: Michael Alan Taylor’s Hippocrates Cried: The Decline of American Psychiatry (Oxford UP, 2013). This is the most thorough and nuanced critique of American psychiatry as it is today that I have read thus far. The problems with DSM, the pharmacological treatment algorithims, etc. are extensively documented by a true “insider” and add much to the discussion on this blog. However, as a non-psychiatrist, I was fascinated by the detailed indictment of how psychiatrists are trained and how this leads to the systemic problems we all experience. Taylor’s hope that psychiatry might move more in the direction of neuropsychiatry as he has practiced it seems a desirable direction if the specialty is to re-invent itself one more time before being handed over to the primary care physicians, clinical nurse specialists, physician’s assistants and clinical psychologists with prescribing priviledges. If this book had fallen into my hands when I was 20 years old I know what I would have been thinking: I would want to become a neuropsychiatrist.

    For those interested in another corner of the psychiatric profession that sees to be missing in all these portrayals of biological psychiatry as merely applied pharmacology, I strongly recommend that they read Taylor’s critical memoir.

    I would be curious as to the opinions of others who follow this blog, especially those of yiou who are psychiatrists, regarding Taylor’s views and your views of neuropsychiatry (which is a specialized board certification — another factthat had somehow escaped me all these years).

    April 28, 2013 | 5:04 PM

    Thanks for the reference. I haven’t read it, but I put the order in to Amazon. Sounds interesting.

    Welcome to the blogging world. Watch out. It’s an addiction…

    April 28, 2013 | 5:52 PM


    I very much look forward to your thoughts on the book. And, whether or not you share Dr. Fuller Torrey’s assessment that the message of the book is “Given his analysis, the ultimate integration of psychiatry and neurology is inevitable and should be most welcome.”

    And, whether you welcome it.

    April 28, 2013 | 6:31 PM


    In a related vein:

    Also relevant:

    What is sorely lacking in all of this are enough individuals in positions of prominence who have a sufficient level of understanding and respect for the varied ways in which we can know the brain/mind.

    As neuroskeptic points out, we now that it’s an Acting Brain! because the person in front of us is acting. Patterns of blood flow in the brain is not anymore “seeing the brain” than observing the acting behavior is “seeing the brain.” Both are abstractions in their own way. We’ve evolved over a long period of time to learn from each other and impact each other in ways that is unlikely to be matched by oversimplified interventions anytime soon. Future Think notwithstanding. I worry that this portion will be considered secondary in Dr. Taylor’s book. Or simply considered outside the purvue of medicine.

    At the same time it is equally absurd to ignore that a lot of why we do what we do is outside of easy and immediate awareness for us. We have not evolved to have ready access to a lot of that “why” and so additional tools, not simply restricting understanding and interventions to direct human interaction, need to be pursued.

    Sadly, there seem to be very few people in this current mental health era who experience genuine skepticism about their own deeply held beliefs.

    I really do look forward to your thoughts on the book.

    No matter how you slice it, it does seem that large swaths of psychiatry have transitioned from intellectual richness, but with frequent absurdities, to being less absurd but more intellectually impoverished.

    The DSMs wont bite the dust not because of the APA, but because most of the system either doesn’t care if psychiatry is intellectually impoverished or actually prefers it that way. Then there is the chorus of “It’s not science,” “It’s not medicine,” …etc. Or, it needs to become more like the rest of medicine, or become like neurology, or be taken over by prescribing psychologists, or be taken over by neuroscientists, or be replaced by primary care practitioners, or be done away with entirely …etc.

    Very few of the powers that be outside of psychiatry seem interested in psychiatry being a vibrant, sophisticated profession. Not even mentioning how many or few care about that within the profession.

    Richard Noll
    April 28, 2013 | 8:01 PM

    I suspect you will probably not be in agreement with Taylor’s views of psychoanalysis and its era of dominance in the 1960s and 1970s, but if you can get past those remarks his critique of the biological psychiatry that followed DSM and the introduction of Prozac certainly echoes many of your concerns. As Taylor admits in the book, he is now 72 years old and is horrified by what psychiatry — as a medical specialty — has become. I think the book is of most value by opening a window into a corner of the profession — neuropsychiatry — that offers another image of psychiatrists other than the DSM-skimming, prescription-writing doctors who either never learned, or quickly forgot, essential clinical medical skills that is being portrayed at present in the media and in the blogosphere.

    Professions rise and fall, and those that survive find ways to adapt. In an era of DSM and prescribing algorithims, it really is not so hard to learn to be a psychiatrist within our current managed health care system. Being a medical school-trained physician is really not that necessary anymore (as Carlat and others have noted). Primary care physicians and other non-physician professions have adopted much of that work and can be paid far less to do it within managed care networks. For psychiatry to remain as a distinct profession within medicine I suspect , as Taylor argues persuasively,it may have to narrow its jurisdiction to the sorts of conditions that might fall within the domains of neuropsychiatry, behavioral neurology and — yes — cognitive neuropsychology. As Taylor argues, there will indeed be a tipping point one day (perhaps after 2014 with the Affordable Health Care Act opens opportunities for PAs and clinical nurse specialists to step in because of a shortage of primary care physicians and psychiatrists).

    Apologies to all for the typos in my posts (past and future — I’m giving myself a blanket pardon). I write too fast for my own good.

    April 28, 2013 | 8:08 PM

    I would order Hippocrates Cried: The Decline of American Psychiatry if it were available in e-format or weren’t so expensive.

    I look forward to reading your blog and linking to it, matronimus. I’ve no doubt you can help to improve my opinion of psychiatric nurses as much as the psychiatric nurse I’m currently seeing, who is wonderful enough to have changed my mind after the one prior who was dumb as a doorstop. Life can be such a crap-shoot.

    The point of Crisis Intervention is not to solve the problem. People in crisis will do that themselves.

    The crisis, from where I’m sitting, includes psychosis. By resisting what I was expected to believe about myself and my psychosis, I was able to put myself back together on my terms, so that the psychosis was indeed transformative in the end. Sometimes, feeling terror and horror in its entirety— a terror and horror that you have no one to share with, one that you can not integrate into your life in a reasonable manner because everyone you know is completely divorced from it— is to be as insane as the horror itself.

    Now that I have experienced the true depth of my horror, I understand and respect just how much it has warped my personality and my outlook on life since it happened, and how it SHOULD, because life matters.

    I have spent my adult life doing everything in my power to maintain peace around me, but since I’ve recovered from my one psychotic episode, there is peace in me. With that peace, all the would haves, should havs, and self-condemnation has vanished. I’m me and it’s o.k. to be me, I feel no regret or self-blame for having been knocked back on my heels in response to a trauma so horrific that everyone on the planet and all sentient life was in immediate danger of extinction. There are so many levels of KNOWING and understanding. People who don’t know or understand what it is a person is suffering from psychically would be of more help if they could admit that they don’t know it and recognize that the content of the pain matters. Otherwise, what does matter? It’s nihilistic and dehumanizing to dismiss the content of mental/emotional suffering as nothing more than the symptoms of a biological malady.

    Richard Noll
    April 28, 2013 | 11:02 PM

    Good thing I granted myself a pardon for writing too fast . . . . My fingers did not type what my brain was thinking: fellowships in neuropsychiatry with board certifications in either psychiatry or both psychiatry and neurology is the fact I did not know.

    April 29, 2013 | 8:11 AM

    Richard Noll: Thanks for the recommendation. A number of years ago, as I was doing my own research in the broader field of medicine and its misconduct, I read Hippocrates’ Shadow: Secrets from the House of Medicine by David H Newman. This expose by an insider was eye-opening. Eventually, I discovered 1 Boring Old Man . . . and appreciate his in-depth exploration of the narrower field (psychiatry). When I first read Hippocrates’ Shadow, I not only shared the book with friends, but approached a doctor I know, recommending that this should be required reading for all first-year med students. Here we read about the misadventures of psychiatry . . . but it seems the current “business model” of medicine extends across ALL fields of medicine.

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