a thought…

Posted on Sunday 12 May 2013

There was a time – it was a long time ago, maybe 40 years ago – when I could think whatever I wanted to think. I could use a jillion models – be doctor medical model at 8AM, psychoanalytic at 9AM, cognitive behavioral before lunch, and throw in a little existentialism in the afternoon. It was like a toolbox filled with a lot of wonderful ways to think about the problems before me and my job was to bring whatever I could find to help until I found what really mattered – some shared way of understanding that my patient and I could use to make some headway. And in conferences we’d argue back and forth, the various different kinds of us, about what was right and wrong, which was all in fun because there wasn’t any right or wrong just different cameras on the same set, then we’d all go to the pub and be human together. It was an exciting time for me. I miss it – always have.

Then in the 1980s, that all changed. Because I was a psychiatrist, I was supposed to be a biologist. Well, I am a biologist, but that’s just a piece of what I am and what patients needed from me. And because I was a psychoanalyst, I was supposed to be … psychoanalytic, but that’s just a piece of what I am too and what patients needed from me. And so on and so on through the toolbox. And worse, I wasn’t supposed to meander from tool to tool until I found the one[s] that fit that patient on that day, I was supposed to have some consistent evidence-based position that could be validated by some third party to prove I wasn’t a charlatan or a I-don’t-know-what-but-it-was-a-bad-thing. I wasn’t up to it. I’d spent a long time refining my skills at doing it the other way which was some hard work, so I went off on my own and did what I’d learned to do until I retired. I’m so glad I did that.

Now it’s coming full circle. The psychologists are saying that the medical model psychiatrists are off the deep end. The biologists  are at war with each other over which biology is the correct biology. The humanists are after the robots. The analysts have learned to be quiet, but you can bet they’re thinking their thoughts. I’m sure all the existentialists in France and elsewhere are off being existential together. I know a lot of very talented and competent mental health types who come from a wide variety of backgrounds but they are unified by a few simple things – a deeply ingrained practice ethic, a suitable awe for the marvelous and monstrous variability in human beings, a genuine curiosity, broad training and life experience, and humility. If they can’t help you, they’ll at least be able to help you find someone who can.

When I think back on things, the most helpful piece of my training in mental health was becoming a hard science Internist first. The reason is that I knew a secret my psychiatric colleagues didn’t know. The hard science medicine I left was no more precise and assured than the loosy-goosy psychiatry I went to.  Sure there were more tests, more precise diagnoses, more drugs. But there was the wall of physical disease beyond which you couldn’t go. Once you found it, that was the end of the road. With mental illness, there’s no wall. Even with the worst cases of our most devastating illnesses, there’s still something that can be done, even if it is only a small thing. You may not find it, but it’s not because it’s not there.

So in one way, it makes me sad to read all these battles flying back and forth precipitated by the release of the DSM-5. On the other hand, it reminds me of those days long ago when we fought with each other to learn from each other. I’ve missed that more than I knew. And it makes me feel hopeful that what’s up ahead will be a toxic environment for the know-it-all psychiatric KOLs that have so contaminated our world [and detracted from the contributions of biologists with good sense], and their pharmaceutical marketing colleagues, and the opportunistic Managed Care types whose job it has been to keep us from doing ours. Right now, I hope right thinking psychiatrists of all flavors, psychologists of all flavors, social workers, counselors, etc. can brace themselves for a long-needed realignment that is consistent with our shared task. It won’t happen any time soon. We’ve been lost in the wilderness too long for that. But the wind blowing in the trees is at least encouraging to this old man…
    May 12, 2013 | 5:41 PM

    What’s missing is the voices of the patients. After refusing medication enough to be conscious, a patient dealing with a first episode of psychosis will be told that getting well means accepting the biological explanation of the resident doctor’s choice and the medication of his choice. The current paradigm doesn’t even allow a person to talk about the psychological impact of having experienced psychosis for the first time. This is too dehumanizing, domineering, and controlling to merit the name of “help.” Once psychiatry, as an institution, dismisses the patient, they are little more than an instrument of social control that justifies it’s abuse and belittling of patients with what can only be described as a “loose hypothesis” of the origin of mental illness that ignores everything in the patient’s life, and flatters the anemic work of biological psychiatry entirely too much. Anyone who wants to think of themselves as something more than an instrument to support the overarching superiority complex of the psychiatric profession and to address their own real problems and limits is “lacking insight.”

    If the KOLs and other figureheads in psychiatry want to respect patients any less, they’ll have to herd patients into pens, give them shots, then herd them out the door with a big bill for their services and a label that can ruin their lives.

    May 12, 2013 | 6:07 PM

    I’m not certain the task is “shared”.

    I appreciate what Robert Stolorow, Ph.D. has to say on the subject of the DSM… The diagnoses themselves causing invalidation, objectification and re-traumatization! –


    Conventional psychiatry based its diagnoses and treatments upon nothing scientific, nothing “biological”. And millions of people have been gravely injured.

    I don’t see this as an opportunity for psychiatrists and mental health professionals (social workers, counselors, psychotherapists) to come together with a common goal. This is a time for a clean break from the profession… to let it die.

    This is *not* the time to hold hands and sing ‘Kumbaya’.
    The truth (of injury and death) has yet to be told and truly *heard* .
    Amends have yet to be made.
    The force of dangerous treatments have yet to be replaced by safer and more effective treatments.


    May 12, 2013 | 6:14 PM

    Dr. Robert Stolorow remains one of the brighter lights I’ve ever followed – always a force to be reckoned with. I still count his “Faces in the Clouds” from long ago among the most important books in my early thinking, and he has continued to shine for all these years…

    May 12, 2013 | 6:18 PM

    Excellent post. That hope and faith thing I asked about earlier, a fine reply!

    May 12, 2013 | 8:52 PM

    At least in the old days we used to take the time to have multidisciplinary conferences where a patient’s presenting symptoms, life situation, psycho-social stressors and circumstances, medical-neurological co-morbidities, and life/developmental history were discussed by the various medical, psychiatric, psychological, and social work providers. The relative contributions of each factor or set of factors assessed by the various medical and non-medical providers to the patient’s symptoms or distress were discussed and debated. Alas, it was difficult to assign a “metric” or “number” to these debates, as patients often revealed themselves to be complicated and besieged by complex internal and external forces interacting in no small measure with their past. But I bet the patient got better as a result of such intensive scrutiny of the study of his or her life.These days it seems there is no time, rhyme or reason to do that. God only knows why.
    I am guilty of being irreverent at times in my posts on this wonderful blog. Yeah I posted the nonsense about bio-babble-bullshit-biological psychiatry that someone took offense to; and rightly so. But as Bill Maher might say, “Oh I kid!” I am just pissed off at the biological reductionist conceptions of human suffering (note to Duane I didn’t say mental illness, but I might have) that have dominated this field for the past 30 years. I truly hope that the fighting between between the biologists, psychologists, and sociologists will usher in a new creative synthesis, and point the way to future NIMH-funded research to help the suffering souls among us. Insel’s RDoC push may help to a degree; but can he at least try to seduce the Pharma companies he is so obviously in love with to come up with a pill to treat poverty, racism, sexism, social disintegration, unemployment, urban decay, the effects of family dissolution, as well as good old anxious and depressive fallout from id-ego-superego conflict?

    May 12, 2013 | 9:56 PM


    You didn’t say “mental illness”, but you might have.

    Yeah, but you didn’t.
    And that’s a great place for a dialogue to begin!


    May 13, 2013 | 4:31 AM

    One of the main reasons for the battles between schools in mental health may be political. Powerful institutions continue to hold privileged knowledge and tend to impose the prevailing models. Students and clinicians are indoctrinated to these prevailing models, theories, and techniques. So, the pressure is on to align with particular schools of thought in order to advance in academic programs, attain employment, and obtain third-party insurance reimbursement. But I think there’s reason for hope. Meanwhile, the various fields in mental health have s shifted from an emphasis on divergence between models to an emphasis on convergence and common change factors. For most of the 20th century, models have emphasized their differences. This is why there have been so many battles within mental health. And it’s been a good thing. Like the free market system, this competition challenged the proponents of each approach to work at improving their model to distinguish itself from the others. Recently, however, mental health has begin to shift its emphasis to areas of convergence, confluence, integration, and a focus on how we are similar. I think theoretical orthodoxy is definitely fading away.

    May 13, 2013 | 11:53 AM
    May 13, 2013 | 12:02 PM

    Mules don’t know how to push carts.

    May 13, 2013 | 2:39 PM

    I graduated MD Emory ’85 and have been a psychiatrist in Montgomery since 1989. I would like to have your comment reprinted in the Alabama Psychiatric Physicians Association newsletter, “The Freudian Slip.” I though it was spot on, and request your permission. I have enjoyed your blog for some time.

    Dave Harwood

    berit bryn-jensen
    May 14, 2013 | 2:59 AM

    The wind in the trees may be coming from Vestre Lappland and the teams of Open Dialogue and other places were therapeutically minded people listen and keep listening – to the Patient and her/his family and important others, who will and can help, to get at the heart of what’s the matter. No Mr know-it-all-KOL monologue to stear things in predetermined directions.
    The Finnish psychologist Jaakko Seikkula has taught many to listen and include the people who may know things of importance to assist the person at the centre, the Patient, without whom nothing is discussed. Nothing about us without us.

    May 14, 2013 | 5:22 AM

    The wind in the trees is also from the increased volume of the many voices coming from survivors and (ex)patients and sadly too-late enlightened family members like me, who trusted that some bio-psych shrinks were healers, not wreckers.
    Cudos to Wiley, and to dr Mickey.

    May 15, 2013 | 9:03 AM

    I stole your post (with attribution) and put it on Shrink Rap. I hope you don’t mind. I had to google “KOL.” Thank you so much. ~Dinah

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