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News Gram™ January 2006

January 2006 ~ Volume 12, No. 6

The last decade has witnessed a sea change in the way psychiatrists ply their trade. For nearly a hundred years, psychiatrists played out the stereotype of the pensive, serious, nearly silent, usually male figure whose couch was the instrument of his profession. Sometimes, he practiced in a hospital; at other times, in a clinic, but mostly in his office. He favored tweed suits, subdued ties and starched shirts. From his mouth fell such words as  “conflict”, “super-ego”, “neurosis”, “unconscious” and “phallic stage”. On a rare occasion, he would prescribe a medication for one of his patients. Treatment often extended for four years or longer.

Throughout this long period, psychiatrists differed with one another about ways to relieve their patients of the problems that visited them. While most alienists (as they were called in the 19th century) preferred the “talking cure”, many others were disdainful and believed the best way to help someone was through medicine, electroconvulsive therapy, insulin coma therapy or frontal lobotomy. In emergency situations, the latter was apparently administered in emergency rooms via an instrument resembling an ice pick that entered the brain via the super-orbital ridge, just above the eye. For many years, the patient’s consent was not required; the doctor had only to make the decision and then proceed.

Psychiatrists who adhered to the idea of unconscious processes governing our behavior and who preferred the couch were commonly referred to as “dynamic” in their orientation. By this term they were referring to the psychic forces that underlie all that people do and which became apparent in the course of psychoanalytic treatment. Those who preferred to use what were called “somatic therapies” were referred to as organic psychiatrists, as was the kind of psychiatry to which they were drawn.

The tension between the two groups has persisted to the present day. Now, however, the stage on which this intellectual battle is being fought has changed dramatically. For most of the 20th century, the dynamic psychiatrists held sway. Psychiatric training programs based their pedagogical efforts on teaching residents the theory that explained aberrant behaviors. Yes, of course it was reasonable to use medications but these agents were simply to relieve anxiety or assist someone in sleeping through the night. The real work concentrated on unconscious conflicts, repressed sexual strivings, phobic anxiety and the like. The goal of psychiatric treatment, at one level or another, was for  the  patient to gain a deeper understanding of himself – his motivations, conflicts and ideals – in order for him to feel able to run his own life.

On the other hand, organic psychiatrists had little interest in the meaning of a person’s problems. They sought mostly to relieve a patient of the awful sense of depression he might experience or the shakiness that accompanied anxiety or the sense that the fluorescent lights were talking to him. To the dynamic psychiatrist, such a belief was a heresy. It seemed impossible to conceive of a patient whose problems resolved without understanding the underlying conflict, trauma or deficiency. Simply eliminating symptoms was inadequate to the task of returning someone to his maximum level of functioning.

As things have evolved, organic psychiatry has moved to the top of the heap. It now reigns supreme and the branch of dynamic psychiatry has sprouted few leaves. The idea of meaning seems to have left psychiatry in favor of medications that relieve depression, anxiety, obsessions and compulsions, hallucinations and delusions, panic and yes, stress. These problems are a tall order and American psychiatry seeks to cure each of these conditions without worrying about the symbolic significance of their symptoms or the underlying significance for a person’s value system. Instead of worrying about someone’s deepest strivings, organic way of thinking favors regarding these conditions as syndromes, dysfunctional or disease states that can be ameliorated through the judicious use of specific medications.

All of which has brought about a significant change in the relationship between the pharmaceutical industry and psychiatry. Many people think Big Pharma, as it is often called, has an uncomfortably close relationship with medicine and with psychiatry. They are unhappy with the way such companies influence training programs, continuing medical and psychiatric education and treatment protocols for various disorders. Physicians like to think of themselves as independent-minded, free of undue influence and not subject to commercial interests of any sort. In fact, though, there are many within psychiatry and the rest of medicine who think quite the opposite. They are uncomfortable with the way drug companies are extending their influence. How all this will play out is still unclear.

It is not unusual for non-medical and non-scientific forces to exert themselves within the realms of science, medicine, and, in this case, psychiatry. In recent years, though, there is little doubt that such influence has increased at a remarkable rate. Perhaps it is time for physicians to take a closer look at why they are doing what they do in their practices. Perhaps, they also need to look inside themselves, something psychiatrists used to be comfortable with and now are strangers to such a process.

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