An Honest Psychiatrist… (1boringoldman blog)

erasing history…

Posted on Thursday 13 March 2014

You can’t really erase history, even though we all try. For one thing, it doesn’t go away. It just sits there in the background having an effect even if it has been selectively removed from consciousness. Freud made the analogy of The Mystic Writing Pad [when I was a kid, it was called the Magic Slate]. You wrote on cellophane with a stylus, When you lifted the cellophane, the writing disappeared, but it left traces in the wax below. Freud was using the metaphor to describe memory traces in the Unconscious. It was a good analogy. As a psychotherapist, one learns that it’s not like in the movies – some cave full of repressed memories. But rather, the mind just skips over or goes around unpleasant or traumatic previous experience, almost without noticing. While the gain is comfort, the loss is in not learning the important lessons that experience has to teach – so history repeats. And in eliminating chapters from the story, the book-of-you makes much less sense, because we are our stories, our narrative. What else could we be?

Right now, psychiatry seems to be attempting to erase a piece of its own history – a recent piece at that. We’ve had a couple of decades where many academic psychiatrists have been in an unholy alliance with the pharmaceutical industry, one that allowed industry to control our scientific literature, our continuing medical education, and, indeed, the whole direction of our specialty. The profits from that alliance have become the stuff of Wall Street legend – blockbusters! The ramifications of those years are everywhere around us – in our diagnostic manual, our relationships with patients and other mental health specialties, our place in the third party payment hierarchy, in the eyes of the public. As those years are finally drawing to a close, they seem to be becoming the elephant in the room that nobody’s talking about.

    • Example: Right now, the AllTrials campaign is going great guns.  Boehringer IngelheimGlaxoSmithKlineRocheSanofiViiV HealthcarePfizer, and now Johnson & Johnson are putting systems in place to allow access to their Clinical Trial data. I’ve been involved with some of the early results of that, and though it’s not a completely easy process, it’s definitely moving in the right direction towards “good enough.” But nobody’s saying why they’re doing it. They’re giving us access because they’re good guys. Nobody talks about the stream of ghost written jury-rigged decepticons that flooded our literature for a decade or more, barely disguised drug industry commercials. Nobody talks about the legal settlements that are rapidly escalating to the point where they are going to really start hurting, or the growing clamor for criminal prosecutions. They’re just being generous.
    • Example: Right now, Tom Insel is renovating the NIMH. The DSM-anything is out. The RDoC is in, when it gets around to existing. NIMH Clinical Trials have been changed. We’re on a new tack to find new drug targets. The reason the DSM-5 is out? It’s because medications and neuroscience findings don’t map onto the clinical categories. Little is mentioned about the lackey-ing around with drug trials and neuroimaging/genetics/etc. work the NIMH has funded to study and cavort with the industry’s drug output. Nothing is said about the APA/NIMH series of symposia in the lead up to the DSM-5. Not much mentioned that the Research Agenda for the DSM-V essentially laid out the RDoC agenda which came into being as it became apparent that the grand plans for the DSM-5 were going up in smoke. And there’s absolutely no comment about the fact that nothing [not even patients] map well to the DSM because it has been so distorted by outside forces.
    • Example: Dr. Lieberman [APA President] and now Dr. Summergrad [APA President Elect] can’t talk enough about something called Collaborative Psychiatry – meaning psychiatrists should work in practices with general physicians. But they don’t mention that psychiatry so bought into the psychiatrists-as-medication-prescribers model and now there are no more new meds to prescribe that they’re trying to find some kind of new identity for psychiatrists to fit into.


We did this already in 1980 – abandoned our history, whether by intent or not. One would’ve thought that the only historical figure that ever mattered was Emil Kraepelin. The psychoanalysts, Adolf Meyers, Harry Stack Sullivan, Karl Jaspers, social psychiatrists, family theorists, psychotherapists [other that CBTers] – the pantheon of psychiatrists who had contributed to our understanding of mental illness were largely forgotten and rarely mentioned in any positive way. And of interest, since the 1980s we haven’t produced any “greats” – only KOLs with a limited shelf-life.

Without our history, there is no “psychiatry.” And the current silence, particularly about our recent history, will not serve us well. Without a thorough review of the DSMs and their glitches and mistakes, who can say if Dr. Insel’s flight from clinical diagnosis into neural circuitry is a reasonable idea? And without a long look at these years of pharmaco-mania, who knows if the NIMH spending on a frantic search for new drug targets is a sound idea as opposed to some balance in the psycho· and social· arenas? And how about some new blood instead of the same old NIMH awardees getting the grants. Their history is pretty dismal. Much of what’s happening in psychiatry is a reaction to the recent past and where it has brought us. It’s the height of folly to know that’s true, and yet to talk as if that very past is off limits for serious or frank discussion, particularly the dark side…



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