{"id":29758,"date":"2012-11-06T19:00:40","date_gmt":"2012-11-07T00:00:40","guid":{"rendered":"http:\/\/1boringoldman.com\/?p=29758"},"modified":"2012-11-07T00:58:03","modified_gmt":"2012-11-07T05:58:03","slug":"agendae","status":"publish","type":"post","link":"https:\/\/1boringoldman.com\/index.php\/2012\/11\/06\/agendae\/","title":{"rendered":"agendae&#8230;"},"content":{"rendered":"<div align=\"justify\">Reading through the available parts of Dr. Melvin Sabshin&#8217;s book, <a href=\"http:\/\/books.google.com\/books?id=fgCUrffGCfcC&#038;printsec=frontcover&#038;source=gbs_ge_summary_r&#038;cad=0#v=onepage&#038;q&#038;f=false\" target=\"_blank\"><u><strong><font color=\"#200020\">Changing American Psychiatry: A Personal Perspective<\/font><\/strong><\/u><\/a>, that had to do with his time at the APA was less engaging than the earlier part [<a href=\"http:\/\/1boringoldman.com\/index.php\/2012\/11\/04\/roots\/\"><u><strong><font color=\"#200020\">roots&hellip;<\/font><\/strong><\/u><\/a>]. The <strong><font color=\"#200020\">agenda<\/font><\/strong> was monotonous:<\/div>\n<div align=\"center\"><img loading=\"lazy\" decoding=\"async\" width=\"350\" vspace=\"7\" height=\"262\" border=\"0\" src=\"http:\/\/1boringoldman.com\/images\/sabshin-8.gif\" \/><\/div>\n<div align=\"justify\">The <strong><font color=\"#200020\">agenda<\/font><\/strong> of the book was to assert that the <strong><font color=\"#200020\">agenda<\/font><\/strong> of the DSM-III Revision was <u>not<\/u> simply driven by the economic problem of third party reimbursement, but represented a strong move on the part of the leaders in the profession to &quot;<strong><font color=\"#200020\">achieve a more evidence-based practice<\/font><\/strong>&quot; based on some other more lofty motive. But the rest of the available book focused on the economic problem of third party reimbursement, the impossibility of reconciling psychoanalytic treatments to an objective framework, and the uncooperativeness of the psychoanalysts of the time in the process. All of those things were true:<\/div>\n<div align=\"center\">&nbsp;<img loading=\"lazy\" decoding=\"async\" width=\"350\" vspace=\"7\" height=\"372\" border=\"0\" src=\"http:\/\/1boringoldman.com\/images\/sabshin-9.gif\" \/><\/div>\n<div align=\"justify\">I&#8217;m no help here. I always thought psychiatry and psychoanalysis were different things, agreeing with Freud. I started my analytic training during my psychiatry residency and paid for my own analysis out of pocket even though I had insurance that would&#8217;ve covered it, moonlighting as an ER doctor, putting in IUDs for Planned Parenthood, doing physicals on A&amp;D Units. So I guess I always thought that psychoanalysis and long psychotherapies were in the realm of choice [for both parties]. That was not the norm, but it was my norm, so I have little to say about that quagmire. I was actually looking to Dr. Sabshin&#8217;s book for help with other questions, a couple old and one new:<\/div>\n<ul>\n<li>\n<div align=\"justify\"><strong><font color=\"#200020\"><u>The Old Questions<\/u>:<\/font><\/strong><\/div>\n<div align=\"justify\"><sup><strong><br \/>        The Psychiatric <font color=\"#200020\">Diseases<\/font> were identified by Kraepelin a century ago and have remained essentially unchanged since that time, through many classifications [see <a href=\"http:\/\/1boringoldman.com\/index.php\/2012\/10\/24\/a-mere-catalogue\/\"><u><font color=\"#200020\">a mere catalogue?&hellip;<\/font><\/u><\/a>]. These Kraepelinian Illnesses were universally accepted as Diseases, probably biological in the minds of most. The borders with other people were distinct &#8211; both diagnostically and literally as most were in asylums back when, at least for some of the time. About that same time, Freud began to treat a different group of people who had symptoms and behaviors that he thought were generated by the mind and life. Over time, many other conditions were added to the mix by the psychologists, social workers, military psychiatrists, etc.&nbsp;This second group were generally thought to exist in people with an intact central nervous system. They were probably psychological and the borders with other [normal] people were indistinct. Except in crisis circumstances, they lived among us.<\/p>\n<p>                     Beside the questions of proof of treatment efficacy, the third party carriers were driven nuts by the indistinct borders of these latter conditions, and the psychoanalysts were of absolutely no help in defining these boundaries more crisply. So along came the DSM-III with its evidence-based medicine aiming to firm up the boundaries with its objective criteria. One Old Question was Why did they ablate the distinction between the Kraepelinian Psychiatric Diseases with definite borders and the second poorly delineated group? They all became  just Disorders. And in one glaring instance, they destroyed that distinction within a major diagnostic entity &#8211; Major Depressive Disorder. Melancholia and Depressive Neurosis ran together, becoming a subtyping issue implying a groundless and unjustifiable continuity.<\/p>\n<p>                    Another Old Question: While the DSM-III claimed to be non-etiologic, it was really something more than that &#8211; anti-psychologic is the only term I can think of. The Disorders known to be Brain Diseases are identified as such, but there was no place for psychological causation. So, why did all mental illness become not psychologic? Nobody thinks that all mental illness is non-psychological &#8211; not psychiatrists, psychologists, playwrights, social workers, neighbors, authors, psychoanalysts, physicians, mailmen, me, or you. Nobody&#8230;<\/strong><\/sup><\/div>\n<p>         <\/li>\n<li>\n<div align=\"justify\"><strong><font color=\"#200020\"><u>The New Question<\/u>:<\/font><\/strong><\/div>\n<div align=\"justify\"><sup><strong><br \/>       Well, my new question certainly isn&#8217;t Why did psychiatry become nothing but neuroscience and psychopharmacology? The answer to that one is kind of obvious. What other choice was there? And it&#8217;s not Did Melvin Sabshin, Robert Spitzer, and Allen Frances plan on their DSMs leading to the primacy of psychopharmacology, the union of PHARMA and academic psychiatry that resulted, and the debacle of the recent DSM-5 process? I think not, particularly in light of the reaction of Spitzer and Frances to the DSM-5 Task Force. But my question is How did things become so damned corrupt in psychiatry? so quickly? Was that inevitable? And I think that&#8217;s a pretty good question&#8230;<br \/>        <\/strong><\/sup><\/div>\n<p>    <\/li>\n<\/ul>\n<div align=\"justify\">What you&#8217;d expect at this point would be a summary of more of Dr. Sabshin&#8217;s book [<a href=\"http:\/\/books.google.com\/books?id=fgCUrffGCfcC&#038;printsec=frontcover&#038;source=gbs_ge_summary_r&#038;cad=0#v=onepage&#038;q&#038;f=false\" target=\"_blank\"><u><strong><font color=\"#200020\">Changing American Psychiatry: A Personal Perspective<\/font><\/strong><\/u><\/a>], but I can summarize it simply &#8211; the book should have been entitled <strong><font color=\"#200020\">Changing American Psychiatry: Psychoanalysis had to go!<\/font><\/strong>. It is all about the entrenched position of the psychoanalysts in that era, and their unwillingness to budge. Sabshin says it calmly and gracefully, but there&#8217;s little question what he went to the APA to do &#8211; and he did it. If I were not me reading this, I&#8217;d be wondering Why did psychoanalytically trained psychiatrists like Sabshin, Spitzer, and Frances shepherd the surgical expulsion of psychoanalysis from the APA&#8217;s psychiatry? But I am me, and I&#8217;m not worrying about that just now. Maybe I&#8217;ll write about it later, since I sort of know the answer. For the moment, I&#8217;ll simply say that the powerful <strong><font color=\"#200020\">agenda<\/font><\/strong> of the DSM-III was <strong><font color=\"#200020\">Psychoanalysis had to go!<\/font><\/strong>, not because of the trivial phrases in the DSM-II about defense mechanisms in the Neuroses but because the body psychoanalytic in psychiatry was entrenched, powerful, unwilling to adapt to the economic problems, and would&#8217;ve gone down with the ship if it came to that &#8211; again a topic for another day.&nbsp; Did Dr. Sabshin&#8217;s book sell me on his stated thesis?<\/div>\n<div align=\"center\"><img decoding=\"async\" vspace=\"7\" border=\"0\" src=\"http:\/\/1boringoldman.com\/images\/sabshin-10.gif\" \/><\/div>\n<div align=\"justify\">Not totally. I left the book feeling that <strong><font color=\"#200020\">the economic problem of third party reimbursement<\/font><\/strong> was the prime mover; that the powers in the APA felt strongly that <strong><font color=\"#200020\">Psychoanalysis had to go! <\/font><\/strong>was an absolutely essential ingredient to the solution; and that the more altruistic &quot;<strong><font color=\"#200020\">a profession eager to achieve a more evidence-based practice<\/font><\/strong>&quot; was a real force that came in third place, but that it was an amorphous goal with high hopes for the future but little clear direction. What happened was, for whatever it meant, quite an achievement:<\/div>\n<div align=\"center\"><img loading=\"lazy\" decoding=\"async\" width=\"350\" vspace=\"7\" height=\"295\" border=\"0\" src=\"http:\/\/1boringoldman.com\/images\/sabshin-6.gif\" \/><\/div>\n<div align=\"justify\">Like the arrival of <span class=\"st\">Vladimir Lenin at the Moscow Station, it was something of a bloodless coup at the time. The casualties came later [says 1boringoldman, eye witness]. As to my Old Questions, psychological causality, the basis of psychoanalysis, had to be expunged, accounting for some of the oddness of the DSM-III &#8211; leaving no reentry points for psychoanalysis like the messy Depressive Neurosis. I expect that some other oddnesses in the DSM-III were to keep the overall domain of psychiatry from shrinking, though I don&#8217;t know that for sure. It was, however, explicit in depression. And what about my New Question? <\/span>How did things become so damned corrupt in psychiatry? I think there are hints in Sabshin&#8217;s book.<\/div>\n<p align=\"justify\">The coming of the DSM-III created a void &#8211; actually several. First, it created an ideology void. Being non-psychological was hard work in a specialty that had been so psychological before. There was Aaron Beck, another recovering psychoanalyst who had developed Cognitive Behavior Therapy [AKA &quot;evidence based psychotherapy&quot;], but few others in the psychological realm. The psychopharmacology front was populated, but stalled after a brilliant surge in the 1950&#8217;s. But there was another void. Many of psychiatry&#8217;s best and brightest were the psychoanalysts, up and down the ranks, who drifted to their own worlds in the years that followed &#8211; a brain drain. So there was a fresh new milieu but it was relatively unpopulated, working on re-forming itself &#8211; looking for a direction. <em>Not psychoanalysis<\/em> just isn&#8217;t much of an identity.     <\/p>\n<p align=\"justify\">I think I might have happened on another force for later corruption in psychiatry in those days after the DSM-III reading Sabshin&#8217;s book. Once it was done, psychiatry needed something to organize its new non-psychological persona. People were eager to jump on band wagons a little too quickly, a bit uncritically. We were new to that much hard science and grasped at anything that looked good enthusiastically. As long as I&#8217;m using historical analogies, why not use one close to home? The <strong><font color=\"#200020\">Carpetbaggers<\/font><\/strong> flowed into prominence in the field and their misadventures were allowed by people who might have known better in a more mature scientific environment, might have raised red flags earlier. And, by the way, psychiatry was broke, so the pharmaceutical money looked real good. We grew us a crop of KOLs that were unlike the leaders of the past. Some of them made a great noise and lead us down a garden path. <\/p>\n<p align=\"justify\">Something else. I expect the people behind what I&#8217;m trying to talk about next would say it was the right thing and it had to be done, or that it was the only possible method, or some other rationalization for &quot;the ends justify the means.&quot; They might even be right about that. But it really was &quot;sneaky.&quot; The &quot;<strong><font color=\"#200020\">Psychoanalysis had to go!<\/font><\/strong>&quot; agenda wasn&#8217;t explicit, but was embedded in other language &#8211; scientific language, economic language, scapegoating. Scapegoats may always earn their fate at some level, but the simplification and polarization in the scapegoating process extracts a price. In this case, I suspect the price was a lot of latter-day &quot;sneakiness&quot; that has actually poisoned our waters.      <\/p>\n<div align=\"justify\">These are just my thoughts. Some of them brand new, even to me. Some are likely to get modified as they settle in. But thinking them has been a fine way to ignore the US Presidential election being decided today. I&#8217;m afraid that election has risen to consciousness now. I&#8217;ll reread this later and try to see where my own biographical lenses have gotten too prominent. It&#8217;s no fair commenting on the agendae of others without looking at your own &#8211; and that&#8217;s the hardest thing in the moment. Better done later&#8230;<\/div>\n<hr size=\"1\" \/>\n<div align=\"justify\"><strong><font color=\"#200020\">Postscript 12:30 PM<\/font><\/strong>:   <\/p>\n<ul><sup><strong>Well, it&#8217;s over. That&#8217;s all I have to say about the election. But while I was watching, I had a thought about these last several posts about the years around 1980 when I was young in psychiatry and way less aware of the future, or for that matter, the contemporary present, than I knew. One of my favorite authors [when I can tolerate his world] is Cormac McCarthy, author of the book made into the powerful film, &quot;<a target=\"_blank\" href=\"http:\/\/en.wikipedia.org\/wiki\/No_Country_for_Old_Men\"><u><font color=\"#200020\">No Country for Old Men<\/font><\/u><\/a>&quot; &#8211; a favorite movie [when I can tolerate watching it]. I don&#8217;t have the kind of dark disillusionment that pervades McCarthy&#8217;s work about much of anything, but I feel the sense of the title line, <font color=\"#200020\">No Country for Old Men<\/font>, in both the election and in the story of psychiatry. A long personal history can be a burden&#8230;<\/strong><\/sup><\/ul>\n<\/p><\/div>\n","protected":false},"excerpt":{"rendered":"<p>Reading through the available parts of Dr. Melvin Sabshin&#8217;s book, Changing American Psychiatry: A Personal Perspective, that had to do with his time at the APA was less engaging than the earlier part [roots&hellip;]. The agenda was monotonous: The agenda of the book was to assert that the agenda of the DSM-III Revision was not [&hellip;]<\/p>\n","protected":false},"author":2,"featured_media":0,"comment_status":"open","ping_status":"closed","sticky":false,"template":"","format":"standard","meta":{"_bbp_topic_count":0,"_bbp_reply_count":0,"_bbp_total_topic_count":0,"_bbp_total_reply_count":0,"_bbp_voice_count":0,"_bbp_anonymous_reply_count":0,"_bbp_forum_subforum_count":0,"footnotes":""},"categories":[2],"tags":[],"class_list":["post-29758","post","type-post","status-publish","format-standard","hentry","category-politics"],"_links":{"self":[{"href":"https:\/\/1boringoldman.com\/index.php\/wp-json\/wp\/v2\/posts\/29758","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/1boringoldman.com\/index.php\/wp-json\/wp\/v2\/posts"}],"about":[{"href":"https:\/\/1boringoldman.com\/index.php\/wp-json\/wp\/v2\/types\/post"}],"author":[{"embeddable":true,"href":"https:\/\/1boringoldman.com\/index.php\/wp-json\/wp\/v2\/users\/2"}],"replies":[{"embeddable":true,"href":"https:\/\/1boringoldman.com\/index.php\/wp-json\/wp\/v2\/comments?post=29758"}],"version-history":[{"count":52,"href":"https:\/\/1boringoldman.com\/index.php\/wp-json\/wp\/v2\/posts\/29758\/revisions"}],"predecessor-version":[{"id":42790,"href":"https:\/\/1boringoldman.com\/index.php\/wp-json\/wp\/v2\/posts\/29758\/revisions\/42790"}],"wp:attachment":[{"href":"https:\/\/1boringoldman.com\/index.php\/wp-json\/wp\/v2\/media?parent=29758"}],"wp:term":[{"taxonomy":"category","embeddable":true,"href":"https:\/\/1boringoldman.com\/index.php\/wp-json\/wp\/v2\/categories?post=29758"},{"taxonomy":"post_tag","embeddable":true,"href":"https:\/\/1boringoldman.com\/index.php\/wp-json\/wp\/v2\/tags?post=29758"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}