Psychiatry and the Long View: Paul Summergrad, MD

Conversations in Critical Psychiatry

Conversations in Critical Psychiatry is an interview series that explores critical and philosophical perspectives in psychiatry and engages with prominent commentators within and outside the profession who have made meaningful criticisms of the status quo.

Awais Aftab, MD

Paul Summergrad, MD, is the Dr Frances S. Arkin professor and chairman of the department of psychiatry, professor of psychiatry and medicine at Tufts University School of Medicine, and psychiatrist-in-chief at Tufts Medical Center. Dr Summergrad served as the 141st president of the American Psychiatric Association from 2014 to 2015. He is also a past president of the American Association of Chairs of Departments of Psychiatry and is Secretary for Finances of the World Psychiatric Association and a member of the WPA executive committee. Dr Summergrad’s research focuses on mood disorders, medical-psychiatric comorbidity, and health system design. He received the Distinguished Faculty Award from Tufts University School of Medicine in 2015 and the Leadership award of the American Association of Chairs of Departments of Psychiatry in 2018. He was elected to the Honorary Fellowship of the Royal College of Psychiatrists, their highest honor, in 2020. He is the lead editor of the Textbook of Medical Psychiatry (2020, American Psychiatric Association Publishing).

Paul Summergrad, MD

In many ways, Dr Summergrad exemplifies the best of psychiatric leadership. He has a charismatic and warm persona, an in-depth knowledge of psychiatry’s history, an appreciation of its pluralistic roots in medicine as well as psychoanalysis, and a preference for taking the long view of psychiatry’s development as a field. I was pleased to be able to speak to Dr Summergrad about his intellectual development, his views on psychiatry’s identity, and the challenges facing the medical model and psychiatric classification.

Aftab: Perhaps we can begin with the trajectory of your intellectual and philosophical understanding of psychiatry, particularly how you have navigated the psychoanalytic as well as neuroscientific aspects of psychiatry over the course of your career?

Summergrad: I have been thinking a lot about this, and I do not know that I can separate any of this from certain cardinal experiences of my life. So, I think we will have to take a little detour into my life story and how I entered medicine and psychiatry.

I am a child of the 60s in the sense that I was in college during the 60s. That was an extremely disruptive time in American history for a variety of reasons, and it became a disruptive time in my own life as well. I had been interested in psychiatry well before that, probably since I was 14 or 15 years old. For some reason, I was just pulled towards psychiatry. Maybe it was because I read Civilizations and its Discontents in high school, or because I had also worked at a camp run by a Jewish social welfare organization. There was a cohort of kids at the camp who had emotional and social difficulties. As part of that experience, we learned a bit about how to work with kids who had emotional difficulties, and that also reinforced my interest in psychiatry.

I started college in 1967. Looking back on it, I doubt that I was clinically depressed, but it was definitely an emotionally turbulent period of my life. I was significantly thrown off both by where I was living as well as by my living circumstances. I hated Buffalo and its winters. Going outside in the winter there seemed like crossing Siberia to a New York City native. I was not really prepared for it. And I was a freshmen male living in gender segregated rental housing off campus. During that year, I took a course on the Dhammapada, which as you know is one of the foundational texts of Buddhism. I was very much drawn to that course, as well as to another course on Chinese history, but otherwise I felt very disconnected from school. Like probably a lot of other college students at that time, I started smoking cannabis. In the spring of that year, I took LSD—I am certainly not advocating for the casual use of psychedelics or cannabis here—and I had a profoundly religious experience. It was as if I had been dropped into Nirvana, perfection, holiness, oneness. It was a deeply mystical experience, and it also changed my thinking about the self. It made me think a lot about neurobiology and consciousness, because if a tiny dose of a drug like this could change one’s perception so profoundly, what did that mean regarding how we understand the mind-brain relationship, and relevant to psychiatry, the etiology of mental illness?

Partly as a result of that, I then went on to study Zen Buddhism and considered training as a Buddhist monk. I ended up spending a couple of years doing very intensive Zen Buddhist meditation at a training center in Rochester, New York. There was no drug use of any kind and a fairly ascetic lifestyle. Towards the end of that period, I spent a year in a self-imposed isolation, in a liminal state, because I really felt that I needed to cut out the external messages of the dominant culture to discover what I really wanted to be and do. At the end of this period, I had a couple of important dreams and one of the dreams was extraordinarily powerful, a great dream in the Jungian sense, which basically resolved my dilemma. I woke up and my crisis was over. I knew exactly what I wanted to do and how to integrate the various strands of my life. I knew I wanted to go to medical school and to likely become a psychiatrist.

In medical school it turned out that I really liked medicine, and I ended up training in internal medicine for 3 years before I trained in psychiatry. The medical training left a deep influence. I was impacted by being in a medical setting where neuropsychiatric conditions were among the most common admitting diagnoses. When I was an intern, probably a third of the admissions to the medical service were due to altered mental status. I realized that in practically every rotation, the only thing I really cared about was the neuropsychiatric consequences of the medical conditions I was studying. So, I really could no longer resist the siren song of psychiatry, but I was impacted by my medical training, such that for me, the boundary between medicine and psychiatry has always been very porous.

Aftab: What sort of notion of psychiatry did you have at that time, and how was it influenced by your earlier mystical and meditative experiences?

Summergrad: My sense of psychiatry was in part tied to depth psychology and psychoanalysis. Given my Jewish background, and given Freud’s own cultural Jewish identification, there was a pull towards psychoanalysis from a cultural standpoint, but there was also a pull towards it as being somehow central to psychiatry. Depth psychology provided me with a way to merge my experiences with dreams, meditation, and psychedelics with my interests in medicine and science.

I went on to undertake psychoanalytic training at the Boston Psychoanalytic Society and Institute. Despite my psychoanalytic training, I thought psychiatry had to be profoundly anchored in medicine, and by medicine I am broadly including here internal medicine, neurology, as well as the neurosciences. For my residency I went to the most medically oriented psychiatric program in the United States, which was Massachusetts General Hospital. Tom Hackett, MD, was the chief there when I was a trainee. His view was that if psychiatry was not anchored in medicine, it was kind of homeless, from a clinical as well as operational standpoint, and I agree with that. I think it is unfortunate that a lot of the time as psychiatrists we end up giving away our connection to the rest of medicine and neurology. The other side of it is the risk that we may justify our existence as physicians by overvaluing what seemed to me to be a narrower biological psychiatry. I think if we were more secure in our relationship with medicine, we might not see quite this tension within the profession.

Aftab: How did you reconcile psychoanalysis and neuroscience in your mind?

Summergrad: Early in his career, prior to the development of psychoanalysis, Freud wrote a book called The Project for a Scientific Psychology, which was officially published in 1950, well after his death. I felt that my interests in neurobiology and psychology came together in The Project for a Scientific Psychology and to some degree The Interpretation of Dreams which mirrors, especially in its critical seventh, metapsychological chapter, The Project. Freud was really struggling with how to place his interest in depth psychology in the context of the burgeoning neurobiology of the late 19th century. The late 19th century was a fertile period: the neuron doctrine was being established. Ramón y Cajal, MD, produced his first drawings of neurons around that time. Freud attempts in The Project to use what he understood as the accepted neurobiological model and tried talk about how this whole apparatus works to generate mental states. I thought that he engaged with that issue in that book in a much more profound way than psychoanalysis has subsequently. Freud was severely limited by the neuroscience of his times, but he was convinced that a scientific explanation of psychological phenomena in terms of neurobiological phenomena was possible. He basically thought of psychologic states in parallel to the physiology of the brain that, while separate, they were “dependent concomitants,”¹ and I think this central idea provides a potential means of reconciliation.

Aftab: In the mid-20th century, the psychiatrist Erwin Stengel, MD, was commissioned by the World Health Organization to review existing psychiatric classifications. He noted in his 1959 report²:

Recently, the attitude of many psychiatrists towards the conventional type of classification has become one of ambivalence, if not of cynicism… classifications based on the Kraepelinian system have continued to be used in some form or other all over the world. Many psychiatrists have done so under protest and expressing their disbelief in the working hypotheses underlying that system.

This description strikes me as quite applicable to our own times. The controversy surrounding the development of DSM-5 and the on-going search for alternative classification frameworks reveals just how deep the dissatisfaction is. What are your thoughts on why attitudes towards classification continue to be ambivalent in the psychiatric community, and what do you see as the path forward?

Summergrad: The dynamic as described by Stengel does seem to exist. I think that we tend to get into a lot of unnecessary battles around classification, regarding how we classify and what we classify, as if these were not constructs imposed on real conditions. It is not that psychiatric disorders are not real. They are terribly real. All you need to do is take care of someone who is experiencing a severe episode of mania or catatonia, to know that they are profoundly and powerfully real. I tend to see psychiatric classification as more of a tentative and open-ended iterative process, subject to revision by evolving data and models of disorders. . This is a difficult task, as you know, we are dealing with things at multiple levels of observation. Take Research Domain Criteria (RDoC), for example. Even if you are going to use RDoC to do a research study, you still need to select and study a group of patients using some form of clinical categorization, whether it is something broad as mood disorders, or specific symptoms such as anhedonia, etc. There was recognition in the 1960s and 1970s, by the group of psychiatrists at Washington University in St. Louis as well as Robert Spitzer, MD, and colleagues that there needed to be some operational criteria to ensure reliability of observations. This recognition emerged in the context of many studies which had showed the poor reliability of various diagnoses at the time, such as the differences between the diagnoses of bipolar disorder vs schizophrenia in the United Kingdom and the United States.³

I think the development of our current nosologies in the 1970s was an understandable reaction against a lack of scientific rigor, at least around reliability. It starts becoming a problem when the operational constructs become reified as real, as valid. This will be relevant to our discussion regarding the medical model as well, because mental disorders are profoundly personal and intimate, and they affect one’s deepest sense of who one is. A psychiatric diagnosis can be heard as somebody saying that it is as if your intrinsic being is somehow medically defective or genetically defective; it is not just that your body is diseased, but that you are diseased, with the implication that you may be unchangeable.

Tensions emerge from well-reasoned and well-intentioned attempts to get closer to the truth about the causes, etiologies, and the treatments of disorders. I think that to a great extent, our diagnostic systems, whether it is DSM or ICD, have been helpful with regards to clinical practice and research, in allowing us to do systematized studies, because after all, we want to know whether the interventions are actually going to help somebody or not. We want to know with some degree of medical certainty whether we can recommend electroconvulsive therapy for the treatment of catatonia or for certain kinds of major depression, or whether we can or cannot recommend antidepressants for individuals who have bipolar depression. We cannot do that, we cannot really tell whether we are going to help patients or hurt them, unless we utilize reliable categories. These practical considerations are one of our primary obligations.

Again, I think that we struggle with this in part because the problem is so difficult, philosophically and intellectually, because it relates to the very things that we experience as the most intimate parts of ourselves, and also because we do not fully understand how the brain and the mind interrelate and interact. In fact, setting these difficulties aside, even if you look at general medicine, things are bit more clear-cut, but a large number of patients who present to general medical clinics have medically unexplained symptoms or they remain undiagnosed in terms of etiology. So, things are not always straightforward in rest of medicine either.

Aftab: The impression I get from your description of classification is that we need to take it a little less seriously. That we need enough that we can do our practical and scientific work with some structure and reliability, but it becomes problematic when we start to ascribe metaphysical importance to these operational constructs.

Summergrad: Yes, that is right. When we reify these categories, we almost make them unchangeable objects. In order to begin to approximate validity, we need to be able to formulate hypotheses and then test them, and the only way we can do so is if we begin with some reliable way of describing the phenomena. Our diagnostic categories and our rating scales have a lot of limitations. We are relying on self-report, communications, physician observations. So, we always have to approach them with some degree of humility.

Aftab: Going back to your personal experience, when you were 18 years old and in that phase of emotional and existential turmoil, someone could very well have suggested that you were suffering from clinical depression and that you needed to see a psychiatrist. How do you think you would have reacted to that?

Summergrad: In fact, I did get that message. That I was clinically depressed, and that I just needed to see a psychiatrist and be on the right antidepressant, and all of this would go away. I strongly rejected that message. The very last thing I was going to do at that time was to go see a psychiatrist. So, I understand where some of this resistance against the so-called medical model comes from.

If you had taken me at age 18 or 19, and had tried to look at my experiences at that time through the lens of a diagnostic or medical model, I would have agreed with the critics that the medical model was not the best frame for this. But if I had had to drop out of school because of intrusive obsessional thoughts or compulsions that may be quite different, and the medical model is in my view an appropriate frame of inquiry. Or perhaps I just do not have an accurate view of my 18-year-old self. I think that one critique of the medical model, as it is understood by many, is driven by a concern that we are judging individuals, pushing them away, not listening to their experience, and distancing ourselves from them by labeling them. We always have an obligation to listen and to be prepared to revise our thinking,

Aftab: The medical model in psychiatry is facing considerable opposition from many prominent critics. How to best understand the medical model is a complex issue, something we briefly touched on in your interview for Current Psychiatry,⁴ and in this series I have talked about the medical model in detail with Dr Huda.⁵ A question I would like to ask you is about the limits of the medical model. The concern around medicalization reflects a growing anxiety that more and more of our lives are being viewed through the medical gaze. It is perhaps to be expected that as medical practitioners we tend to focus on the ways in which the medical model can improve lives, but at what point does medicine say to itself, “Maybe we are not the best professionals to address this. Maybe this is a situation where we should let our colleagues in psychology and social work take the lead. Maybe this is a situation where the medical understanding of a condition should not dominate over or should not exclude a more psychological, social, or existential understanding of the phenomenon”? How can medicine be more reflective over its own limits and boundaries?

Summergrad: Everything depends on what we mean by the medical model. To me, in its most basic form, the medical model is a hypothesis-generating method, the roots of which can be traced back to Thomas Sydenham, MD, among others. The basic idea is that there are signs and symptoms that assort together more likely than would be expected by chance, and we recognize them as syndromes. If we properly define what the syndrome is, we can begin to then investigate what causes it and how to treat it. This is an incredibly fertile thread that runs through all of medicine. This is the sort of thinking that serves as the foundation for Robert Koch, MD’s postulates or Rudolf Virchow, MD’s pathological studies. It is a syndromic model, which leads to a hypothesis, which leads to investigation, and then the results of these investigations may force us to redefine our syndromes or redefine our hypothesis, so it is an iterative process as well. In this iterative process, diagnoses can be lumped together, or they may be split further, or rearranged in other unique ways. The syndromes are intended to have parsimonious explanations, to achieve as Einstein said at Oxford in 1933, “the supreme goal of all theory is to make the irreducible basic elements as simple and as few as possible.”⁶

When individuals use the term medical model in psychiatry, I think what they mean is that psychiatrists are ascribing a medical cause to an individual’s experience or feelings. So when we, as psychiatrists, ascribe a medical cause to the feelings and experiences, we are referring to some ineluctable and unchangeable element about the individual, with the implication that their very essence is dysfunctional or pathological. That is, in my view, a mistaken understanding.

Do I believe that some of the experiences in the realm of psychic suffering are better understood as existential rather than medical? Absolutely, I do. I do not believe that every form of mental suffering or emotional suffering is a mental disorder, but do I believe that there are mental disorders which are best understood through the syndromic lens. DSM is a variant of this syndromic model, and it is a very useful tool to categorize mental disorders, a tool that also provides us with ways to validate our constructs, with validators such as course of illness, family history, genetics, biology, and a variety of other things that have been well-described by Ken Kendler, MD, among others. These validators help us put some guardrails around what we are postulating through the syndromic lens.

Aftab: I think the thing that concerns or worries many critics is that when something is viewed through that syndromic lens it tends to crowd out other ways of understanding it.

Summergrad: It is an important worry, but it is not a necessary consequence of the syndromic view. Do all human experiences fall within the realm of medicine or psychiatry? I do not think they do, or that they should. I think that would be a mistake. In other words, there is definitely a risk that our diagnostic concepts can be over-extended and that everyday life can be medicalized. That is something we have to guard against.

I do think we have both an obligation to say, this is our best evidence of what is effective for this kind of entity, and an obligation to recognize that not all emotional or mental states are best understood through this syndromic medical model. Neither the profession nor the general public is well-served by medicalizing ordinary human experience. It also does not mean that psychotherapy cannot be beneficial for developmental or existential concerns. It can be. Freud viewed the goal of psychoanalysis as converting neurotic “misery” into “common unhappiness.”⁷ The challenge we face is not to convert human unhappiness, what my Buddhist teachers would call, in the Pali Canon, Dukkha, into a psychiatric illness.

Aftab: I really liked something you said in your presidential address to the APA⁸:

My bias is to look at the long, far view, if for no other reason than change is hard, complex, and always takes longer than we expect. We tend to look for instant transformation, analysis, and understanding, which is not always forthcoming, reliable, or desirable. This is especially true at times of great upheaval and uncertainty, which we are certainly experiencing in the sciences related to psychiatry, and more broadly in technology and culture.

It seems to me that the discourse in psychiatry has tended to fluctuate between extremes of enthusiasm and disillusionment, with this cycle repeating every 30 to 50 years. Do you think adopting the long view can help us avoid getting trapped in this cycle?

Summergrad: Part of the reason why I think the long view is useful is that it allows you to see the changes that have actually happened. If we are too close to the events in question, it is hard to know whether meaningful or long-lasting change has taken place or not. I think if you take the long-view, the comfort that exists in contemporary culture with regards to talking about mental illness, the protections that exist within law, the reimbursement of care from insurance companies for psychiatric conditions (imperfect as it is), and the increased awareness regarding human rights in psychiatric care, all of those things to me represent advances in the course of history, but you cannot see them if you are too close to them. There is this story of Henry Kissinger, PhD, meeting with Zhou Enlai, the great Chinese prime minister, during the opening to China in the early 1970s. The story goes that they were making small talk before the visit and Kissinger asked Zhou, “What do you think of the impact of the French Revolution?” Zhou paused, and replied, “Too soon to tell.” I think that captures well my own sentiments.

Aftab: Speaking of the long view, in a 2013 editorial for World Psychiatry, on the 100th anniversary of Karl Jaspers, MD’s General Psychopathology; Mario Maj, MD, PhD, commented on the analogies between Jaspers’ historical context and our own. He wrote⁹:

The most striking analogy is that nowadays, exactly like one century ago, the enthusiasm brought about by a period of exceptional progress of research in neurosciences is being followed by some disillusionment, due to the limited relevance of that progress to the elucidation of the pathophysiology of mental disorders.

Your thoughts on this?

Summergrad: I do think that eventually we will learn a lot more about the organization and the functioning of the brain: how it works, not just at the genetic or the cellular level but also at the circuitry level, such that we would begin to link the activity of the brain circuits with certain states of mind. We can already do that to some degree already, but we will be able to do it better, with more precision and explanatory power.

That is not to say that everything can be or should be explained by neurobiology. You know, again, one of the implications of my psychedelic experience for me has been that it is hard to think about these issues with our current limited understanding of the mind-body problem.

A difference between where we are now and where we were a hundred years ago is that the late 19th century, early 20th century was kind of the end of that neuroscience period. Alois Alzheimer, MD, was born in 1864 and died in 1915. Emil Kraepelin, MD, was born in 1856, the same year as Freud. The neuropathological work that the generation of Alzheimer and Kraepelin were doing peaked in the late 19th century and early 20th century in terms of its effects on psychiatry. The discovery of plaques and tangles in dementia, or the work arounds tertiary syphilis, for example. Neuroscience obviously continued on in the next decades, but its impact on psychiatry was very limited. In contrast, I think we are in a period now where the current wave of neuroscientific research is still offering more and more fertile hypotheses and lines of inquiry. For example, all the research going on around immunological and inflammatory processes in psychiatric disorders. It may turn out to be right or wrong, we do not know, but my timeframe to think about these things is more like 50 years, not 10 or 20 years.

Aftab: Any message for psychiatric trainees and early career psychiatrists?

Summergrad: First of all, I think we are in a fabulous time for psychiatry. The number of US medical school graduates going into psychiatry has nearly doubled over the last 7 years. No other major specialty has seen such a large growth of new recruits. The field has enormous flexibility, richness, and breadth of interests. The stigma around mental disorders is going down and there is greater public discussion about mental health. One only has to look at the discussions related to mental health around the COVID-19 pandemic. This emphasis on mental health is really quite unprecedented.

We never know how our lives and careers are going to work out for us as individuals. If somebody had told me when I was a first-year resident in psychiatry at Harvard that I would become the president of the American Psychiatric Association, I would have laughed. I expect that our trainees will accomplish even greater things. Not only psychiatry trainees should have confidence in the field and in themselves, but their mentors should also have confidence in them. There is a great episode of The West Wing that I quoted in my presidential address.⁸

President Bartlet is played by Martin Sheen and his communications aide, Sam Seaborn by Rob Lowe. They are playing chess while at the same time Bartlet is navigating a complex China-Taiwan diplomatic crisis. Sam is amazed and asks him how he does it. Bartlet answers, “You have a lot of help. You listen to everybody and then you call the play. [Rises to his feet] Sam, you’re gonna run for President one day. Don’t be scared. You can do it. I believe in you. [Looks at the board] That’s checkmate.”

So, that is kind of what I am saying to you, and to trainees who are younger than you: I believe in you, and I think that you can do amazing things. Not that I know about anybody’s individual future, but I can see that our trainees and younger psychiatrists such as yourself are going to have an impact on the field and the world around them. And that is a great thing, and you should feel confident that you have the ability to make a difference, and to do that in a way that is respectful of others, even those who are critical of the field.

Aftab: Thank you!

The opinions expressed in the interviews are those of the participants and do not necessarily reflect the opinions of Psychiatric Times^TM.

Dr Aftab is a psychiatrist in Cleveland, Ohio, and clinical assistant professor of Psychiatry at Case Western Reserve University. He is a member of the executive council of Association for the Advancement of Philosophy and Psychiatry and has been actively involved in initiatives to educate psychiatrists and trainees on the intersection of philosophy and psychiatry. He is also a member of the Psychiatric Times^TM Advisory Board. He can be reached at awaisaftab@gmail.com or on twitter @awaisaftab.

Dr Aftab and Dr Summergrad have no relevant financial disclosures or conflicts of interest.

References

1. Freud S. The Unconscious. In: The Standard Edition of the Complete Psychological Works of Sigmund Freud. Hogarth Press; 1915. Volume 14:159-204.

2. Stengel E. Classification of mental disorders. Bull World Health Organ.1959;21(4-5):601-63.

3. Kendell RE, Cooper JE, Gourlay AJ, et al. Diagnostic criteria of American and British psychiatrists. Arch Gen Psychiatry. 1971;25(2):123-130.

4. Aftab A, Summergrad P. Paul Summergrad, MD, on the state of psychiatry. Current Psychiatry. 2021;20(1):30-3.

5. Aftab A. The Medical Model in Theory and Practice: Ahmed Samei Huda. Psychiatric Times. September 4, 2020. Accessed May 18, 2021.

6. Einstein A. On the Method of Theoretical Physics. The Herbert Spencer Lecture, delivered at Oxford, 10 June 1933. Clarendon Press; 1933.

7. Breuer J, Freud S. Studies in Hysteria. Trans. Nicola Luckhurst. Penguin Classics, 2004.

8. Summergrad P. The Long View. Am J Psychiatry. 2015;172(8):714-716.

9. Maj M. Mental disorders as "brain diseases" and Jaspers' legacy. World Psychiatry. 2013;12(1):1-3.