My early psychiatric development took place in the epoch between AF (after Freud) and BP (before Prozac). This was an interesting time. Freud demystified psychiatric illness taking it from the realm of the spiritual and brought it to the phantasmagorical. He created hope that mental illness could be understood through careful introspective exploration. However, his followers really developed a new secular religion. Psychoanalytic theory was based upon fantasized assumptions that when repeated enough were taken as gospel. Any challenge to the theories was viewed with distain and analysts repeatedly resisted efforts to do controlled research into the efficacy of the treatment.
As a secular religion it relied heavily upon the faith of the followers to make investment in often four to five time per week therapy sessions. Patients were instructed to pour out their inner thoughts and much like believers going to confessional hoped for absolutions of their traumas from the fatherly analyst. Patients went with the hope that their symptoms would be resolved but the analysts’ goal was insight and not symptom reduction. When new medications came out that reduced symptoms, they scoffed at this “superficial” treatment. They argued, rightfully, that patients’ symptoms returned after discontinuation of medications. Yet they failed to demonstrate that their analytic treatment even reduced symptoms at all and were not some spontaneous symptom reduction that would occur with years of treatment.
The analyst’s theories and beliefs were very compelling and powerful. With intensive treatment they could enter a patient’s mind and cure its defects as no medication could do. Faith it its efficacy lead to even the Catholic church sending its impaired priests to analytically oriented programs at the Institute of Living. It wasn’t until I had been in practice long enough to see that patients who had years of analysis were not cured. I got to see a fair number who had treatment by some of the best analysts and their symptoms were coming back. When I treated them successfully with some modern medications, they confessed that their symptoms never really remitted with therapy but that they had learned to live with them.
This wouldn’t be so bad an outcome, learning to live with one’s symptoms. However, these were some of the least ill patients. Analysts correctly chose to work with the least ill, realizing that analytic therapy often made patients with severe mental illness worse. The shame was the abandonment of the chronically mentally ill and relegation to state hospitals. But as these state hospitals continued to close at an accelerated rate, these chronically mentally ill patients were faced with a community system that didn’t know how to handle or treat them.
My first rotation in psychiatry was in 1980 when the DSMIII first came out. This was the most significant break that psychiatry made with its analytic past. In categorizing disorders it removed all the analytical fantasy based assumptions and replaced it with symptom categories. This allowed for testing of various treatments to see their efficacy against specific symptoms. This was true not only for medications but also various therapies. The analysts refused to participate in these efficacy trials despite being offered Federal grant money.
When Prozac came out there was great excitement for finding better and safer medications. The next epoch of AP (after Prozac) was characterized by a focus on rapid discovery of newer and better medications. Unfortunately, these new medications had new side effects, like metabolic problems. One set of side effects was replaced by another set. Still the effect was improved acceptance of the medication. Still there was not a cure. Gradual improvement, but complete remissions were not frequent enough.
We are now at a new juncture in psychiatry. This is a richer and more broad minded epoch. We are recognizing that therapy is still vital to treatment but we have new evidence-based therapies, cognitive behavioral, dialect behavioral, exposure therapy, cognitive remediation, among others. These are more practical problem solving types of therapies. They work in conjunction with medications. We are learning the importance of lifestyle changes. Prevention strategies of drug and alcohol avoidance, healthy diet and exercise regimes all may prevent initial presentations or relapse. These strategies invite the patient to become a participant in his or her own recovery. Active participation in one’s treatment also involves self-advocacy.
What does self-advocacy mean? I see it having many facets. This ranges from being more effective in communicating with one’s provider about symptoms, medication side effects and functional difficulties to advocating for breaking down stigma barriers. Connecticut has been at the forefront in the efforts to reduce stigma. We were one of the first states to have true parity in mental health insurance coverage. People like Karen Kangas put themselves in the public arena showing that individuals with mental illness could be effectively treated and be exceedingly productive members of society. They are role models showing that mental illness should be treated like any other illness.
I wrote Psychiatry in Techno Colors partly to destigmatize and demystify what a psychiatrist does in diagnosing and choosing treatments. I describe some of the traumas and conflicts that I had in my psychiatric training and how I came to reconcile the differences between what I was taught with what my patients were telling me. I try to explain symptoms in a language that may facilitate a patient or family members communication with a prescriber. We now have a broad array of treatments both medications and therapies. We are beginning to learn some of the genetics and triggers to illness. We recognize the benefits of healthy diet and lifestyle to emotional as well as physical well being. The goals of treatment now are remission of symptoms not just symptom reduction and prevention of relapses that impede recovery of function. The future looks bright. We still need families and patients to continue to advocate for stigma reduction and prevent the taking away of hard fought parity laws and ADA protections.
