1 Boring Old Man

How the community mental health movement, the coming of managed care, the rise of the other mental health disciplines, the problems funding psychiatric training, the abuses that Dr. Szasz talks about, the paradigm battles within the specialty itself, the changing attitudes towards social welfare programs, the neuroleptic medications becoming available, and many other things all came together in those years is a whole shelf of books, many yet to be written – maybe even an entire section in the library. In retrospect, I find it even hard to define the problem in those days – it seems like it was problems. I can’t even remember what was going right back then.

One of my annoying hobbies is coming up with  quips [like never accept an invitation to go crazy]. Once, years ago, I was scheduled to give a lecture on Systems Theory. I read and read, but when I gave the lecture in my head, it was way beyond boring. Then I came up with an axiom that brought it out of the doldrums. It was this: a system is only composed of parts when it’s not working. I talked about flying to work on my magic carpet, and how when it started sputtering, it suddenly became a machine with parts and dials etc. It seemed to work and became a standard part of the course. Well back in the 1970s, psychiatry was sputtering badly and all the parts were screaming and pointing – each detailing the deficiencies and misbehaviors of the other parts without looking in the mirror. It wasn’t a bit pretty. And it wasn’t resolved by analysis, consensus, or an assessment of the needs of the mentally ill.

We all know how it came out. Psychiatrists would become primarily medication doctors, seeing patients briefly and prescribing medications. Therapy would be delivered in metered doses by other, less expensive disciplines. We would radically medicalize our diagnostic scheme [DSM-III]. The analysts and psychotherapists among us would remove themselves to the general pool of psychotherapists. Academic and Organized Psychiatry would become allied with the Pharmaceutical industry [who would finance that which needed financing]. The psychiatric literature and meetings would morph towards matters neuroscientific and psychopharmacologic.

While it left out our historical attention to the plight of the chronically mentally ill except for medication, the solution was apparently a functional compromise, because the noise died down and the system began to glide along again. We extruded another traditional group that had been in psychiatry’s sphere – the large cohort of patients whose mental suffering was neither biologic nor medication responsive. They were presumably passed on.

There was a flaw. It only works so long as there is a robust leading edge in drug development without which the alliance of psychiatry and the pharmaceutical industry collapses as patents lapse and the whole conduit of support implodes. Speaking of conduits, the system was rife for corruption and did not disappoint in that arena. Corruption in psychiatry will, in fact, become the stuff of legend for many years to come [speaking of library sections]. So I say that the coming crisis in psychiatry is not the problem of the current flattening of new drug development. That was and has always been inevitable. If not now, it was bound to happen sooner or later. The current crisis is the consequence of the solution to the last one – the one that came to a head in the 1970s and was badly resolved in the 1980s. A Faustian contract inevitably reaches the day for payments due.