1 Boring Old Man

In on history ₁ …  I was musing about my own early look at psychiatry when I arrived from internal medicine. I think I read those dusty old books trying to understand how it had become so different from the medicine I’d known. They placed the origins of modern psychiatry in the days of the French Revolution when Philippe Pinel removed the chains from the patients in the Asylum and introduced Moral Treatment, the subject of numerous heroic paintings and seen as an application of the values of the Enlightenment. Treatment in that case referred not so much to the current use of the word as in treating disease, but rather to how the patients were treated as people – with kindness [as in the same kind as the rest of us]. Over the 19th century, the Asylums with physicians called Alienists and separated from prisons grew. It was within these large Asylums that Emil Kraepelin and Eugen Bleuler developed their classifications, and later where treatments like those of António Egas Moniz [lobotomy], Ugo Cerletti [ECT], and Manfred Sakel [insulin coma] were developed. But even Moral Treatment and the concept of mental illness became shrouded in controversy. French philosopher Michel Foucault saw it as a shift from a physical to a mental oppression [The History of Insanity] while American psychiatrist Thomas Szasz saw the psychiatrist as an agent of the state masquerading as a physician [The Myth of Mental Illness]. Then in the 1950s, pharmacotherapy came into the picture in a big way – penicillin for Neurosyphilis, the neuroleptic antipsychotics for Schizophrenia, lithium salts for Mania, the tricyclics for Depression – and the overcrowded and expensive Asylums finally began to empty. Like the Civil Rights initiatives of the time, it had a Movement [the Community Mental Health Movement] and an Act [the Community Mental Health Act of 1963] which funded the effort to provide services and support for the deinstitutionalized patients released from Asylum life – a funding that was quickly evaporating at the time I arrived.

So I’d voluntarily chosen a profession where reform turned to oppression, where the solution to the last problem would become the next problem, where c·o·n·t·r·o·v·e·r·s·y surrounded every issue, where Therapeutic Zeal and Therapeutic Nihilism were in a constant dance, and where the best you could hope for was ambiguity with precious islands of clarity. I took solace from and was amused by the fact that those dilemmas mirrored the characteristics of mental illness itself to a tee. Like the generations before me, I found my place in the swirl.  But just about the time I had understood and adapted to the myriads of ways psychiatry was different from the medicine I’d come from, the announcement came over the loudspeaker that declared that psychiatry was to be medicalized and that the part of psychiatry I’d been drawn to was on the wrong side of the pendulum. It was a short while until I realized that whatever was happening was much bigger than I was and retreated from the flow of psychiatry’s history. I think I was luckier than most in that my medical identity preceded psychiatry altogether and wasn’t so tangled up in the things as it was with many of my colleagues on both sides of the big changes.

Another way psychiatry was different was how much it was involveded in other estates – matters legal, social change, government programs, sources of funding, other professions like psychology and social work, etc. I had gotten used to that too, but I didn’t notice what a huge role insurance carriers [Managed Care], the pharmaceutical industry, and the powerful and directive American Psychiatric Association were playing in shaping the psychiatry of the time. I’m ashamed to say that I viewed a lot of what was passing for the new scientific, evidence-based credo as trivial. I had done hard time in hard science, and I didn’t really see drug trials as scientific research – something more like product testing, much ado about small differences. I wasn’t very attentive and there was plenty else to focus on. So something of a scientific snobbery had a role in my not seeing how much industry was pulling the strings. I just wasn’t looking.

I tried to be gracefully swept aside, but there was one particular thing that really did stick in my craw all along. The way I thought about it was even odd. Psychiatry had come to view its history as being in the future. The past wasn’t rushing anywhere, it was receding. I first thought about it when I later came into contact with residents or more recent graduates. It wasn’t just that they didn’t know the early history like Philippe Pinel, or even about Freud and his colleagues. It was other things. They didn’t know about the epidemics of war neurosis in the two world wars and the principles of preventive psychiatry and crisis intervention that grew from those years. I mentioned Erich Lindemann’s studies of grief and pathological grief and met blank stares. I was once talking about an attachment disorder and was asked, "attachment to  what?" They knew what CBT was, but not how it came to be. There were innumerable examples over the years that followed my leaving academia, including their not knowing about the psychiatrists in the last post and about the Therapeutic Zeal [they did know about Emil Kraepelin]. Yet they knew an amazing amount about the current research and what was projected up ahead. The other place I noticed the same future orientation was in referred patients, some of whom seemed to long for the next breakthrough almost as much as their former doctors. Their real treatment was in the undiscovered future. It was as if there had been no useful past save for Kraepelin and the neoKraepelinians – and little in the way of a felt historical continuity. I wondered if that were generally true or just in my corner of the world [I suspected the former].