I often use the word cloistered to describe my twenty years between retiring and leaving an academic position [that I had thought would be my career] to go into practice. It wasn’t exactly a choice. There was a new psychiatry arriving like a tsunami – one now well known to us. And there was an old psychiatry that I was a part of but would’ve been glad to have been a part of changing. It took me a few months to figure out that there wasn’t a middle [at least that’s how it felt], and so to the next twenty years – cloistered. As it turned out, it was the best of times. I often apologize for being so oblivious to the invasion of the pharmaceutical industry. Looking back, it was so obvious, particularly in Atlanta at Emory in a Department I was still a part of. I saw the PHARMA, but I didn’t see the money, or the corruption. I can only conclude that my blindness was garden variety denial – I didn’t want to see it. I now know that some decent people, old friends, got caught up in the dark side of that story. Who wanted to know that?
But that’s not all I missed. There was a case, Osherhoff v. Chestnut Lodge, that was apparently center stage around the time I left academia, but I only heard about it a few days ago reading in the Psychiatric Times [A Belated Obituary: Raphael J. Osheroff, MD]. 
Chestnut Lodge was a legendary sanatorium where patients with severe mental illness were treated with intensive in-patient psychoanalytic psychotherapy. The approach was not part of the mainstream of psychoanalysis which focused more on outpatient treatment of the less disturbed, but "the Lodge" was legendary none-the-less – staffed at times by legends like Harry Stack Sullivan, Frieda-Fromm Reichmann, Otto Will, and Harold Searles. Its history spanned the era of the introduction of psychiatric medications. The case involved a Dr. Rafael Osherhoff, an Internist with a history of episodes of anxious depression as an adult, three marriages, and a contemporary depressive episode treated with both psychotherapy and tricyclic antidepressants as an outpatient with variable results. In 1979, he was hospitalized at Chestnut Lodge and treated with psychoanalytic psychotherapy and no medication for a diagnosis of Narcissistic Personality Disorder. His condition worsened with an agitated depression and a 40 pound weight loss. After 7 months, his family moved him to another hospital where he received a Tricyclic Antidepressant and a Phenothiazine Antipsychotic. Within weeks, he improved and was discharged after 3 months with a diagnosis of Manic Depressive Illness, Depressed Type. He sued Chestnut Lodge in 1982 for negligence and damages.
by Gerald Klerman.American Journal of Psychiatry. 1990 147[4]:409-418.
Although Osheroff v. Chestnut Lodge never reached final court adjudication, the case generated widespread discussion in psychiatric, legal, and lay circles. The author served as a consultant to Dr. Osheroff and testified that Chestnut Lodge failed to follow through with appropriate biological treatment for its own diagnosis of depression, focusing instead on Dr. Osheroff’s presumed personality disorder diagnosis and treating him with intensive long-term individual psychotherapy. The author suggests that this case involves the proposed right of the patient to effective treatment and that treatments whose efficacy has been demonstrated have priority over treatments whose efficacy has not been established.
by Alan Stone.American Journal of Psychiatry. 1990 147[4]:419-427.
The Osheroff litigation, which is central to Klerman’s paper, ended in an out-of-court settlement. The author states that there is no legal precedent for the so-called right to effective treatment and that the case history was a much more complicated clinical scenario than Klerman reports. He concludes that there is neither in the law nor in the clinical facts a sound or certain basis for Klerman’s conclusions or for the sweeping policy reforms and standardized clinical procedures he urges. Although they are directed against traditional psychoanalytic psychiatrists, Klerman’s proposals could have serious consequences for the innovation, diversity, and independent thought essential to scientific progress in psychiatry.
Chestnut Lodge. I completely agree with the clip from Dr. Stone on the right. But saying that the evidence base for biological psychiatry essentially makes traditional psychiatry intrinsically harmful crosses my eyes as much today as it would’ve in 1990. Even though I feel today as I would’ve felt in 1990 that this man’s depression was likely biological. In fact, the DSM-II diagnosis – Psychotic Depression is one that I’m still not sure should’ve been jettisoned.
Psychiatric TimesBy James L. Knoll IV, MDMarch 15, 2013…Klerman’s opening salvo was powerful to the point of authoritarian: he proclaimed that there should be a legally recognized “right to effective treatment.” He invoked the scientific powers made famous by Archie Cochrane, stressing the centrality of the randomized controlled trial [RCT] and that “the issue is not psychotherapy versus biological therapy but, rather, opinion versus evidence.” In fact, Klerman seemed prepared to annihilate all forms of treatment that had not been supported by an RCT. Leveling his psychiatric authority down on all “lesser” forms of knowledge, he warned: “practitioners and institutions who continue to rely on forms of treatment with limited efficacy will be on the defensive and at possible jeopardy for legal action.”
Stone’s response was as powerful as Klerman’s but differed in style. Stone began by refuting Klerman’s notions about the law. It was Stone’s opinion that Klerman should have limited himself to stating that using exclusively psychoanalytic treatment for Osheroff was not clinically acceptable—a point with which Stone agreed. However, Stone was very concerned about Klerman’s threat to dictate a “universal rule set by one school of psychiatry for the others.” He went on to point out that the Osheroff case was more complex than “the pills worked.”
Stone questioned the very nature and reliability of efficacy research in psychiatry and followed with a suggestion that there may have been more to Osheroff’s improvement than mere medications. Stone warned that Klerman’s edicts would “repudiate the traditional commitment of both the law and psychiatry to diversity” and could become “detrimental, even to the aspirations of ‘scientific psychiatry.’” Stone revealed his motivating intent as freedom—in particular, the freedom to consider both science and the humanities, which seems to be necessary for psychiatry to avoid a scientific dictatorship…
Should providence be with psychiatry, the next swing of the pendulum will not be so wild as to threaten to suppress an entire form of knowledge. Yet, this may be too much to ask, since progress often requires the most frustrating and convulsive upheavals. It does seem encouraging for psychiatry that over decades since Klerman proclaimed psychoanalysis a disappointment, we find both it and its progeny alive and well.
Biological psychiatry has made truly impressive progress, yet it remains the case in 2013 that “biological psychiatrists do not hold the panacea for serious mental disorders,” particularly when standing on the lone pillar of science. The art of medicine remains a critical foundational structure in psychiatry, and both pillars are necessary for the stability of the field. One might say that the humanities and/or psychoanalytic thought helps provide science with the relevant questions on which to focus its “piecemeal work.” Put another way: the humanities provide the wonder, which science then illuminates.
It is sometimes the case that older theories are not proved false—rather, the very progress they contributed to now shows their limits. This incremental progress is a “gradual accumulation of truth; or truth is approached by successive approxi-mations.” Pure science, in isolation, cannot tell us why we should undertake a certain act, such as attempting to relieve human suffering. It can only yield for us the most logical method of accomplishing, for good or ill, “what we have already decided to do.” In 2009, Chestnut Lodge was to be renovated when, sadly, it burned to the ground. One hopes that from the ashes of this symbolic edifice, arises a rebirth of a balanced, progressive psychiatry that fights for the benefit of its patients.
Re: “Biological psychiatry has made truly impressive progress, yet it remains the case in 2013 that ‘biological psychiatrists do not hold the panacea for serious mental disorders,’ particularly when standing on the lone pillar of science.”
I have a quick question: What progress?!
Re: the “relationship between science and the humanities.”
What science?!
Duane
The profession’s talk about science is delusional!
Psychiatry wouldn’t know what to do with real science.
It’s had no training or experience in the area of science!
Duane
Very interesting post. Does illuminate my concern that even the providers polarize as much as the rest of the population does. But, isn’t that human behavior at its most annoying. Fail at one extreme and then just rush to the opposite side and fail again, this “pendulum perspective” only bashes people.
Eclectic perspective is what I embrace. Shame many in the field just chose a side, not a whole. One reason managed care succeeded.
It’s refreshing to see someone acknowledging “the pendulum perspective,” Joel. I find that to be a disheartening habit of mind. It’s so entrenched in our
culture, that it can be difficult, if not impossible, to get a person to think about an issue outside of the frame it’s presented in and to look for another approach to a problem or another discussion about a problem. It seems that once a frame is given (by media) that Americans take a side of the rope and insist that the only game is tug-o-war.
The diminishing funding for the liberal arts and humanities worries me for the reason that Dr. Knoll addresses. Meta-thinking is essential to the sciences and to civilization. I see a lot of writing on the internet that suggests that the writers do not have that “theory of mind” thing down yet— people thinking like three year-old toddlers (and many of them are armed).
The idea that if someone is well trained in scientific theory and technical aspects of their field that they are thinkers is just wrong. Perhaps it’s widespread, but definitely in U.S. culture, a person who is intelligent in a science or math is often assumed to have a universal intelligence. Linus Pauling is a prime example of how a truly great scientist can become a crank.
We as a people should understand this and not encourage people with one kind of intelligence— no matter how phenomenal it is— to think that they are any less prone to ridiculousness than anyone else.
I was indeed one of the experts in the case of Osheroff v Chestnut Lodge. The public debate between Gerald Klerman and Alan Stone that followed the Osheroff hearing was a tiresome, ego-fueled distraction from the essential issues in the case. Gerald Klerman’s political posturing was unnecessary. The Osheroff case was not about the efficacy and regulation of psychotherapy. The Osheroff case was a straightforward medical malpractice case involving negligent assessment and diagnosis, which led to obstinately misguided treatment. I should know. I testified at the Maryland Health Claims Arbitration of Dr. Osheroff’s complaint in November, 1983 and I reviewed the entire record. My testimony described how Chestnut Lodge Hospital was negligent in failing to diagnose Dr. Osheroff’s bipolar disorder despite clear references to manic features in the referral letters; in failing to recognize his protracted mixed bipolar state for months on their inpatient service; in failing to record even the most elementary mental status examination and symptom profile of his depression; and in failing to appreciate the significance of the nihilistic depressive delusions that were described in the record. That is what the case was really about, not about the politics of psychotherapy versus drug therapy for generic “depression”. The sheer incompetence of the Chestnut Lodge psychiatrists and of their clinical care system was breathtaking.
Per Bernard Carroll’s above comment, I can only say
WOW!
Yes, Bernard Carroll’s experience and comments on this specific case perfectly illustrates the problem of problems being inappropriately framed and fought over to an end that doesn’t advance anything, but further muddies the issues instead.
I’m curious Bernard, if you think that there might have been a perceived difficulty in pursuing medical malpractice, false imprisonment, intentional infliction emotional distress for forced regression for the same settlement or if the “right to effective treatment” was more likely a product of a trouble mind and tilting at windmills (authoritatively) on the part of Klerman or an idle threat to raise the stakes?
Wyley: I had the impression that Gerald Klerman was pleased to find a case that he could turn into a cause célèbre against doctrinaire psychoanalysis so soon after DSM-III appeared. Indeed, he appeared so intent on that objective that he didn’t register the obvious bipolar aspects of Raphael Osheroff’s illness. To that extent he risked messing up Osheroff’s claim through pursuing his own doctrinaire agenda. The case for a claim of negligence was much stronger with the bipolar diagnosis, as well as the psychotic features, than it could have been with Klerman’s arguments.
Ah— a crusade. We should all have a crusade alert to prevent overwrought wastes of time and resources. Perhaps our adversarial system of law encourages polarized battles that distract so many from the value of putting one’s head down and earnestly pulling the plow (doubts and all), and from having tolerance for ambiguity in the face of change.