Tag: psychiatry

Psychoanalysis 2.0

Posted on by Herbert Harris

by Herbert Harris

I began my psychiatric training in 1990, the year that marked the start of a program called the “Decade of the Brain.” This was a well-funded, high-profile initiative to promote neuroscience research, and it succeeded spectacularly. New imaging techniques, molecular insights, and psychopharmacological discoveries transformed psychiatry into a vibrant biomedical science. The program brought thousands of careers, including my own, into the neurosciences.

Despite its progress, the Decade of the Brain also widened an existing rift. This was the large gap between the psychoanalytic tradition and the biological sciences. The divide wasn’t new. Freud started with neurology but shifted to psychoanalysis when the brain sciences of his time couldn’t fully explain the complexities of the mind. For the first half of the 20th century, psychoanalysis was the main way to understand mental illness. Then, in the 1950s, new psychiatric drugs appeared: chlorpromazine for psychosis, lithium for mood disorders, and antidepressants for depression. For the first time, it seemed possible to treat mental illness by directly targeting the brain, rather than long-term therapy or institutional care.

By the time I was a resident, these diverging traditions had opened into a chasm. On one side was biological psychiatry, focused on neurotransmitters, neuroimaging, and cognitive-behavioral treatments, with outcomes that could be measured and tested. On the other side were psychoanalysis and its branches: attachment theory, object relations, and the investigation of unconscious conflicts through language, narrative, and symbolism. They had become separate languages, spoken within distinct professional communities, each wary of the other. There were occasional efforts at rapprochement, but little sustainable progress. By the end of the Decade of the Brain, reconciliation seemed almost impossible. I was fortunate to be in a training program that had a research track, allowing me to work in a lab, but I also had mentors who were distinguished analysts. It was like being in two different residencies.

Both have proven valuable over the years, but I never expected them to converge. However, today, circumstances appear to be shifting. A merging of neurobiology, computational neuroscience, and neuroimaging has created a new paradigm: active inference. For the first time, we can start to identify strong links between analytic models of the mind and biological models of the brain. Read more »

Monday, December 10, 2012

There Was No Couch: On Mental Illness and Creativity

Posted on by Jalees Rehman

by Jalees Rehman

Siemens_konvulsator_III_(ECT_machine)The psychiatrist held the door open for me and my first thought as I entered the room was “Where is the couch?”. Instead of the expected leather couch, I saw a patient lying down on a flat operation table surrounded by monitors, devices, electrodes, and a team of physicians and nurses. The psychiatrist had asked me if I wanted to join him during an “ECT” for a patient with severe depression. It was the first day of my psychiatry rotation at the VA (Veterans Affairs Medical Center) in San Diego, and as a German medical student I was not yet used to the acronymophilia of American physicians. I nodded without admitting that I had no clue what “ECT” stood for, hoping that it would become apparent once I sat down with the psychiatrist and the depressed patient.

I had big expectations for this clinical rotation. German medical schools allow students to perform their clinical rotations during their final year at academic medical centers overseas, and I had been fortunate enough to arrange for a psychiatry rotation in San Diego. The University of California (UCSD) and the VA in San Diego were known for their excellent psychiatry program and there was the added bonus of living in San Diego. Prior to this rotation in 1995, most of my exposure to psychiatry had taken the form of medical school lectures, theoretical textbook knowledge and rather limited exposure to actual psychiatric patients. This may have been part of the reason why I had a rather naïve and romanticized view of psychiatry. I thought that the mental anguish of psychiatric patients would foster their creativity and that they were somehow plunging from one existentialist crisis into another. I was hoping to engage in some witty repartee with the creative patients and that I would learn from their philosophical insights about the actual meaning of life. I imagined that interactions with psychiatric patients would be similar to those that I had seen in Woody Allen’s movies: a neurotic, but intelligent artist or author would be sitting on a leather couch and sharing his dreams and anxieties with his psychiatrist.

I quietly stood in a corner of the ECT room, eavesdropping on the conversations between the psychiatrist, the patient and the other physicians in the room. I gradually began to understand that that “ECT” stood for “Electroconvulsive Therapy”. The patient had severe depression and had failed to respond to multiple antidepressant medications. He would now receive ECT, what was commonly known as electroshock therapy, a measure that was reserved for only very severe cases of refractory mental illness. After the patient was sedated, the psychiatrist initiated the electrical charge that induced a small seizure in the patient. I watched the arms and legs of the patients jerk and shake. Instead of participating in a Woody-Allen-style discussion with a patient, I had ended up in a scene reminiscent of “One Flew Over the Cuckoo's Nest”, a silent witness to a method that I thought was both antiquated and barbaric. The ECT procedure did not take very long, and we left the room to let the sedation wear off and give the patient some time to rest and recover. As I walked away from the room, I realized that my ridiculously glamorized image of mental illness was already beginning to fall apart on the first day of my rotation.

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