1 Boring Old Man

When I was a young person, I think I conflated science and truth, just like some people equate religion and truth. Then I got to be a scientist, and learned that truth was an elusive concept – what’s true today is simply waiting for tomorrow’s exceptions. Then I got to be a psychoanalyst, and I began to understand how much our own experience colored what we thought and saw in the world. Later, I saw the relativity of psychoanalysis – what the analyst sees is likewise colored by his/her experience as well. One might just throw up one’s hands and scream. "What’s the point? Every time I get some solid footing, there it goes, slip-slipping away!"

Fortunately, some smarter-than-me people looked at this same set of phenomena and found a way to live with it comfortably. Some were religious leaders or philosophers who saw the problem as being hubris – our overvaluing the human mind – Buddhists, Existentialists. Some were scientists like Albert Einstein who explained things in a very simple way – all things are relative, depending on where you stand to look at them. When he realized that the great Isaac Newton’s laws didn’t work for tiny particles, or huge celestial bodies, or light – he recalled two things from his childhood. He remembered an old man who told the story of having fallen from a roof. "It wasn’t like I was falling. It was like the ground was coming up at me!" the old man said. And Einstein recalled that when he sailed on the lake, the wind came from a different direction when he was sailing than when he lowered the sail and sat still. So what we see depends on our point of reference – ergo, his theory of relativity.

Some other smarter-than-me people generalized these ideas in a philosophy of science, the study of paradigms – people like Thomas Kuhn and Michael Polanyi. They looked at the idea that scientific "truth" ran out of juice after a time in a simple way. They re-framed scientific theories as "paradigms" – ways of explaining things. A new explanatory paradigm goes through a heyday where it is extended far and wide. Then exceptions begin to appear – places where the paradigm doesn’t seem to work. Out of the morass, someone [like Einstein] comes up with a new paradigm that explains the exceptions, and we’re off on a new cycle. They use terms like paradigm ascendancy, paradigm shift, and paradigm exhaustion. What happens to the old paradigm? It’s still around. The carpenter working on your roof is a Newton guy – gravity is trying to pull him off of the roof. That’s called paradigm competition. Einstein’s notion that space-time is distorted in the region of large bodies just has no application in the roofing industry.

I came into my field at the end of a period when American Psychiatry had been dominated by the psychoanalysis of Sigmund Freud. It’s what I was interested in and wanted to study. But there was a new paradigm gathering steam – Biological Psychiatry. Drugs had been discovered that altered the major syndromes we treated – antipsychotics for Schizophrenia, lithium for Mania, antidepressants for the depressed, stimulants for kids with attentional problems. These were major breakthroughs for previously untreatable conditions. So my main interest was in a paradigm that was on the back end of a paradigm shift. At the time [the early 1980’s], I didn’t really understand the problem. I didn’t see any conflict between trying to understand problems of the Mind as a psychoanalyst/psychotherapist and learning to use the drugs that worked on the Brain as a physician/psychiatrist – two different things, both interesting. But that was a naive position I came to learn.

I didn’t know that my predecessor psychoanalyst colleagues had tried to push psychoanalysis into areas where it didn’t fit or didn’t work. More important, I didn’t understand that the psychoanalysts had held the seats of power in academic psychiatry for a long time and looked down on the biologists and the other psychotherapeutic disciplines like psychology and social work. I came along at a time when another paradigm [biological psychiatry] was on the ascendancy. So I went into private practice and taught in our psychoanalytic institute – both of which were fine places for me to be. And I watched from the side as my former Department of Psychiatry became increasingly "biologized" under the leadership of a Chairman named Dr. Charles Nemeroff – the guy I’ve been periodically writing about these last few days.

I wrote all those paragraphs as an introduction to make several distinctions. Biological Psychiatry is reaching the phase of paradigm exhaustion. That certainly doesn’t mean it’s going away. Some of the forward strides have been truly remarkable [for example the SSRI’s, the use of anticonvulsants in Psychiatry]. But a lot of the current research money is being frittered away looking at small differences in drugs and chasing hypothetical biological treatments that are frankly somewhere in left field. The influence of the for-profit Pharmaceutical industry is disgusting [speaking of Dr. Nemeroff who is on the leading edge of that piece of corruption]. One of the forces that propelled psychopharmacology into the forefront is that it offers a quick fix as an alternative to the more subjective interventions like psychotherapy. That dichotomy is still in flux, particularly with the coming revolution in cost effective health care delivery.

I don’t personally know how it’s going to play out in the long run. All the techniques used in more traditional medicine to find the balance between cost containment and effective care – things like DRG’s – are notoriously ineffective in Mental Health. Likewise, Psychiatrists deal with disorders that don’t go away – like Schizophrenia, Manic Depressive Illness, and Personality disorders. How that’s all going to fit into a health-care system is as debatable as it has always been, but there’s one thing that’s very clear right now. The heyday of people like Dr. Charles Nemeroff who have co-opted scientific research into service of the profit-driven world of Wall Street Pharmaceutical Manufacturers has passed its prime. The rotten apples have to go away now. We can at least be thankful for that. And the system that has partially sustained that perversion of scientific research [the National Institute of Mental Health for example] needs to be put under a very high resolution microscope…