Commencement Addresses for Psychiatrists, #2: Now

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PSYCHIATRIC VIEWS ON THE DAILY NEWS

Almost 50 years since I completed my residency education, what does the psychiatry I portrayed in my mock 1975 commencement address, posted yesterday, look like now? So, once again, let’s pretend that I am giving an updated speech.

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Welcome graduates, colleagues, and loved ones to our psychiatric resident class graduation. This is a special nostalgic opportunity for me. Like many of us senior psychiatrists do—and there is even a group called Senior Psychiatrists—reviewing the past helps to not only understand our patients, but to put our personal and professional lives in perspective. What are some of the things that have changed in psychiatry?

Almost 50 years ago, I used Bob Dylan’s 1964 song “The Times They Are A-Changin” as a framing device, and will do so again today. Not only is he still alive and singing, but he received a Nobel Prize for literature, confirming the value of the meaning of the words of his songs.

Back in my residency time, psychiatry was certainly changing in profound ways, especially with the rapidly increased use of medications. Now, however, it seems like the pendulum has swung too far in the biological direction that Freud predicted.

Psychiatry is now often known as being bio-bio-bio, with its extensive use of medication being criticized by various critics. Even so, with a lack of new medications over the last decade or 2, we see a beginning resurgence in the research and original promise of the psychedelics for depression, anxiety, posttraumatic stress disorder, and even a sense of cosmic connection, from micro doses to new formulations.

For another focus in 1975, not only has homosexuality been completely removed from the DSM classifications, but gay marriage has been legalized. On the other hand, we psychiatrists should not be surprised that there is a political backlash occurring, with over 500 anti-LGBTQ+ bills on the table in the country.

The biggest target is the trans population. Thinking back to it, I never heard the term trans or transgender in residency. I finally learned about it in the late 1990s, when I was asked to be medical director of the Midwest center for processing their transition. There, I learned of the mistake of using a psychoanalytic analysis and a sort of conversion-oriented treatment. Now, the appropriate care is an educational and physical process, but transphobia has even resulted in politicians playing doctors in limiting the treatment we can legally provide. Moreover, the transgender identity is still in our DSM 5 with “gender dysphoria,” harkening back to one of the stages in the homosexuality DSM changes. In my opinion, anything directly transgender should eventually also be removed completely from DSM, though transgender identity may need to still be a general medical diagnosis because, in contrast to homosexuality, insurance coverage is needed for the desired physical changes.

Psychiatric leadership is poised to help the mental health of the LGBTQ+ community. The new President of the American Psychiatric Association is openly gay and married, and presented one of his goals to be the addressing of sexual and gender discrimination. It is Pride month right now.

There is another gender social issue that has just made a drastic change back in time to my residency. Soon after I started to approve many pregnant women for abortions, Roe v Wade was passed in 1973, only to be struck down by the Supreme Court this year. Abortions went from a constitutional right for women to being unconstitutional.

Unfortunately, from undue social causes, general psychological distress and suicidality has been increasing over the last decade or more, and especially so during the pandemic. Not only that, but what I call the social psychopathologies—the isms, antis, climate deniers, and social phobias—have generally been increasing. Social psychiatry and social psychiatrists should be poised to connect positive relationships from the therapeutic dyad to the societal tribes.

The increasing business control of medicine that started with for-profit managed care after Nixon’s landmark law makes this even more challenging. Besides, this business intrusion has been associated with the epidemic of burnout in health professionals. Now add artificial intelligence, for better or worse.

If only we could rely on luck to make things better. Of course, there was no internet 50 years ago, but I understand that on TikTok recently, there is a craze called #LuckyGirlSyndrome with hundreds of millions of views. Now we know the power of confirmation bias to believe in such luck, but it is realistic hope with appropriate action that is necessary to reduce burnout and increase freedom of thought.

Such hope led to what is here now to document and discuss all that psychiatry is becoming. That is Psychiatric Times, the journalistic town hall of psychiatric ideas, founded in 1985 and seemingly thriving.

Dr Moffic is an award-winning psychiatrist who has specialized in the cultural and ethical aspects of psychiatry. A prolific writer and speaker, he received the one-time designation of Hero of Public Psychiatry from the Assembly of the American Psychiatric Association in 2002. He is an advocate for mental health issues related to climate instability, burnout, Islamophobia, and anti-Semitism for a better world. He serves on the Editorial Board of Psychiatric Times.