I had planned to announce that this October's Psychiatric Annals, guest edited by Russell Gardner Jr., MD, highlights the growing identity crisis of psychiatry. Then I realized I was writing on the anniversary of 9/11, the day the world changed for America — or, as Leonard Cohen sings, “the day they wounded New York.”
This realization is amplified exponentially by the realization recently presented to us by Hurricane Katrina, that despite national wealth, mind-boggling technology, and government that is on a historic spending spree, we are always vulnerable to forces beyond our comprehension. Buddhist wisdom tells us there is no security (a Swiss bank account won't prevent the onset of a lethal cancer); life is transient and unpredictable. Living fully in the moment, unattached to anything, but offering compassion and loving kindness to all living beings is an answer to the uncertainty and pain that characterizes life. Making our life meaningful and engaged moment by moment assumes great cogency in the face of recent events.
What about psychiatry? What is it? Where is it going? In my early days in psychiatry, I was satisfied that it was the branch of medicine that had the relationship of mind and body — a person's life story and physiology, as well as pain as its focus. It seems that things have gotten more complicated. Is there an over-arching principle that describes the trajectory of this field that we have dedicated our professional lives to practicing? This month's issue, articulating the concept of “The Social Brain,” exemplifies the crisis of identity forming like a massive cloud bank over the Sangre de Christo and Jemez mountains here in Santa Fe most afternoons this time of year.
When I entered this field, thirsty for knowledge, psychoanalysis was psychiatry in terms of a comprehensive theory, despite a major absence of empirical evidence and outcome data to support it. It seemed to me that it disconnected the mind from medicine, as wonderfully described in Descartes' Error by Dimascio. Then came the psychopharmacologic revolution, with clinical outcome studies (mostly short-term), followed by the flowering of neuroscience, molecular biology, functional neuroimaging, and genetics, all showing critical relevance for mind–body–psychosocial disorders. More recently, the behaviorists and cognitive psychologists working with the neuroimagers have shown us that learning affects brain structure and function while having the capacity to lead to lasting therapeutic benefit.
While science is flourishing and promising amazing advances in the future, economics formerly applied to selling soap or automobiles is crushing psychiatry into a smaller and smaller corner. Many psychiatrists are being pressured into critical assessments that should address the whole person or the social brain into a fragmented superficial assessment, leaving time for a barely adequate triage and offering of medications as a quick bandage to try to stem total breakdown, suicide, or mayhem. Time to establish a therapeutic relationship, try to understand the patient as a person, and make even brief psychotherapeutic interventions is being consigned to a scrapheap named “cost inefficient” and replaced with checklists. In all of medicine, patient–doctor relationships are being pulled apart by cost-effective medicine championing the “silver bullet” aimed at the chief complaint. The psychiatrist increasingly is pressured to practice substandard psychiatry and medicine (the psychiatrist is, after all, a physician, you may recall). What overarching theory that describes the trajectory of the field driven by these forces do we have?
I wonder if it will rain today? Or will the lush cloud bank slowly dissolve, revealing the magnificent blue sky above it, until another day?