A Synapse Darkly: Psychiatry at a Critical Juncture

Just as our immune system protects us from outside, potentially harmful/pathogenic invaders, our defense mechanisms protect our minds from unacceptable assaults by reality. Yet in truth, reality is not “assaulting” us-it merely is. It is we who bring our own reactions, emotions, and stories (helpful or not) to interpret reality. In this spirit, I bring my own stories to bear on what I perceive as hazards to the field at the present time.

Defenses-darken not my vision, yet safeguard me from an overdose of reality . . .

An excellent cinematic example of our struggle to accept reality as it is, and relinquish unhelpful illusions, is the classic movie The Matrix. This movie had, and continues to have, mass appeal-and I contend it is not just because of the special effects. In The Matrix, the characters literally have to be painfully born again, and give up the comforting unreality of the Matrix for the reality of the world as it truly is, which in the movie had deteriorated into a barely recognizable landscape.

Psychiatry, and medicine as a whole, is currently at a critical juncture. In an eloquent graduation speech at Harvard Medical School, Dr Atul Gawande demonstrated his uncanny prescience and ability to view reality when he informed graduates that they would be facing a new type of medicine-a field in which they could no longer presume to be “cowboys” with the type of professional autonomy doctors had previously enjoyed.¹ Rather, they would need to see that they will be functioning as “pit crews”-each having his or her own more narrowly defined health care task to carry out, preferably as quickly as possible so as to get the patient/race car back on the track in record time. For at this point in time, we settle for nothing less than “fast, fast, fast relief.”²

I certainly cannot disagree with Dr Gawande that this is the way that medicine has and will continue to evolve. I would only point out a few key issues that I believe deserve further comment. First, even pit crews have a leader called the “crew chief.”³ This is the individual who must see the big picture, have the broadest knowledge, be able to function and make key decisions under pressure, and so forth. In other words, a successful pit crew does not consist of mere worker drones in isolation.

Second, I would return to the words of the great author Philip K. Dick, whose foresight at least rivaled Gawande’s: “The tendency in evolution is toward greater and greater specialization. . . . Continued complexity makes it impossible for us to know anything outside our own personal field-I can’t follow the work of the man sitting at the next desk over from me. Too much knowledge has piled up in each field. And there are too many fields.”⁴ What makes things particularly difficult for psychiatry is that it has been a field that attempts to address the most complex organ in the human body. Even within psychiatry, there are “too many fields,” and perhaps it is the case that we now have outstripped our current ability to effectively treat the growing number of human maladies we have cataloged as “mental illness.”

When I became an adult, I put an end to childish ways. For now we see through a glass, darkly.

-1 Corinthians 13:11-12

It would seem that the fluctuating boundaries of many mental disorders will continue to be debated until we devote sufficient time and attention to developing improved, scientifically valid and reliable methods of testing and effectively treating mental disease. Until this is accomplished, I believe it is incumbent on psychiatrists, as leaders in the mental health field, to help our patients and the general public distinguish the psychiatric fantasy from the psychiatric reality (Sidebar: to view click here). We need a full disclosure, so to speak, of what the current state of the clinical art and science has to offer-and how it may differ from various public misperceptions. Such a process may even help us clarify things for ourselves. We must be honest with ourselves first-and then, as night follows day, we cannot be false toward those we serve.

Striving for psychiatric reality

In practicing what we preach, we must keep our focus on the psychiatric realities. In this regard, what do we have to work with that we can count on? I submit that it is the lost art of the masters-the art and skill of the clinical interview and the detailed clinical narrative. From Kraepelin to Freud to Cleckley and many others-it was their rich clinical descriptions that helped us navigate the foreign terrain. But note well that they came across their insights by spending much time listening, observing, and questioning patients-a practice that has now been subordinated to 15-minute med checks, diagnostic coding, billing, etc.

In a related vein, I am concerned that we have imperiled ourselves to some extent by allowing our psychiatric “thought leaders” to be systematically eliminated. I have had personal conversations with many such thought leaders, immediately recognizable names in psychiatry, who have told me how it has become virtually impossible for them to secure time away from direct billing services to write, to think, and to carry out research. I stress this as important because in my own view, the most helpful insights into and advances in medicine have often come from those who are able to have one foot in the clinic and the other in research.

 Reality is that which, when you stop believing in it, doesn’t go away.

 -Philip K. Dick

Osler⁵ believed that one of the most important functions of a university was to “think.” By this he meant “that duty which the professional corps owes to enlarge the boundaries of human knowledge.” He believed it was this sort of activity that was critical to the advancement of medicine. I would humbly add that it is equally critical to the advancement of the branch of medicine known as psychiatry. Without any overlap between Gawande’s “cowboys” and “pit crews,” each will be searching about in his own narrowly defined compartment. The pit crew worker will see only the wheel or the fuel tank or whatever part he has been assigned to. He will have seconds to put the wheel back on, and then-another car will screech in for a pit stop. And so it will go-with a primary focus on speed and efficiency. Thinking about how to “enlarge the boundaries of human knowledge” is not an activity conducive to successful pit stops.

As far as the immediate realities of psychiatry are concerned, what is needed are diagnoses that (1) are practical and (2) help us target an illness, so that we can reduce suffering and incapacity in patients (R. Pies, MD, personal communication). In other words, if the diagnostic system does not help us reduce a patient’s suffering and incapacity, of what use is it?⁶ Finally, real progress in the field requires that we develop more reliable and effective treatments for psychiatric disorders. Only then will mental illness be seen as real as opposed to phantasm. Only then will mental illness be taken as the serious public health issue that it is. And only then will it be removed from places of punishment and returned to the healing attendance of the medical profession.

References:

References

1. Gawande A. Cowboys and pit crews. The New Yorker.May 26, 2011. http://www.newyorker.com/online/blogs/newsdesk/2011/05/atul-gawande-harvard-medical-school-commencement-address.html. Accessed November 17, 2011.
2. Chessick R. Psychoanalytic peregrination VI: “the effect on countertransference of the collapse of civilization.” J Am Acad Psychoanal Dyn Psychiatry. 2003;31:541-562.
3. Welcome to the crew chief club. http://crewchiefclub.com. Accessed November 17, 2011.
4. The Variable Man. From: The Collected Short Stories of Philip K. DIck. Vol 1. The Short Happy Life of the Brown Oxford. New York: Kensington Publishing Corp; 1987.
5. Osler W. A Way of Life and Selected Writings. New York: Dover Publications; 1958.
6. Pies R. Toward a concept of instrumental validity: implications for psychiatric diagnosis. Dialogues in Philosophy, Mental and Neuro Sciences. 2011;4(1):18-19. http://www.crossingdialogues.com/forthcoming_papers.htm. Accessed November 17, 2011.