There's a psychiatrist who writes a blog that's older than Shrink Rap called 1boringoldman. It's a great blog, and Mickey, the blog owner, should have more appropriately named himself 1reallysmartoldman. I go to it sometimes, but it's more political than I like, it's often filled with graphs and numbers (more of a Roy thing), and .....I hesitate to admit this here because obviously that boring old man has better vision than I do....but the font is painfully small and the layout is hard to follow. It's archived by month/year, not subject, and sometimes I'm not sure I've expanded what I wanted to read. Oh, here at Shrink Rap, I change the font to large and we put the whole post, no matter how long, on the page so that no one has to search, though I am terrible about tagging topics. I know, psycritic says we need a new look, but there is something comforting to me about the familiar, even if it's noisy, and think about all the nonsense that travels through your brain, and then multiply that by 3, because there's three of us fooling with the sidebar, sticking on links and ducks, and books and bacon. I don't really understand why our sidebar offers "Shrink Rap with Bacon," but it does.
Rambling aside, in need of more coffee, I did love a post by Mickey the other day, so I thought I'd just steal it. If it troubles you, sir, I will take it down. With a link to the original post (if you're of a certain age, get your reading glasses): http://1boringoldman.com/index.php/2013/05/12/a-thought-3/http://1boringoldman.com/index.php/2013/05/12/a-thought-3/
Posted on Sunday 12 May 2013
There was a time – it was a long time ago, maybe 40 years ago – when I could think whatever I wanted to think. I could use a jillion models – be doctor medical model at 8AM, psychoanalytic at 9AM, cognitive behavioral before lunch, and throw in a little existentialism in the afternoon. It was like a toolbox filled with a lot of wonderful ways to think about the problems before me and my job was to bring whatever I could find to help until I found what really mattered – some shared way of understanding that my patient and I could use to make some headway. And in conferences we’d argue back and forth, the various different kinds of us, about what was right and wrong, which was all in fun because there wasn’t any right or wrong just different cameras on the same set, then we’d all go to the pub and be human together. It was an exciting time for me. I miss it – always have.
Then in the 1980s, that all changed. Because I was a psychiatrist, I was supposed to be a biologist. Well, I am a biologist, but that’s just a piece of what I am and what patients needed from me. And because I was a psychoanalyst, I was supposed to be … psychoanalytic, but that’s just a piece of what I am too and what patients needed from me. And so on and so on through the toolbox. And worse, I wasn’t supposed to meander from tool to tool until I found the one[s] that fit that patient on that day, I was supposed to have some consistent evidence-based position that could be validated by some third party to prove I wasn’t a charlatan or a I-don’t-know-what-but-it-was-a-bad-thing. I wasn’t up to it. I’d spent a long time refining my skills at doing it the other way which was some hard work, so I went off on my own and did what I’d learned to do until I retired. I’m so glad I did that.
Now it’s coming full circle. The psychologists are saying that the medical model psychiatrists are off the deep end. The biologists are at war with each other over which biology is the correct biology. The humanists are after the robots. The analysts have learned to be quiet, but you can bet they’re thinking their thoughts. I’m sure all the existentialists in France and elsewhere are off being existential together. I know a lot of very talented and competent mental health types who come from a wide variety of backgrounds but they are unified by a few simple things – a deeply ingrained practice ethic, a suitable awe for the marvelous and monstrous variability in human beings, a genuine curiosity, broad training and life experience, and humility. If they can’t help you, they’ll at least be able to help you find someone who can.
When I think back on things, the most helpful piece of my training in mental health was becoming a hard science Internist first. The reason is that I knew a secret my psychiatric colleagues didn’t know. The hard science medicine I left was no more precise and assured than the loosy-goosy psychiatry I went to. Sure there were more tests, more precise diagnoses, more drugs. But there was the wall of physical disease beyond which you couldn’t go. Once you found it, that was the end of the road. With mental illness, there’s no wall. Even with the worst cases of our most devastating illnesses, there’s still something that can be done, even if it is only a small thing. You may not find it, but it’s not because it’s not there.
So in one way, it makes me sad to read all these battles flying back and forth precipitated by the release of the DSM-5. On the other hand, it reminds me of those days long ago when we fought with each other to learn from each other. I’ve missed that more than I knew. And it makes me feel hopeful that what’s up ahead will be a toxic environment for the know-it-all psychiatric KOLs that have so contaminated our world [and detracted from the contributions of biologists with good sense], and their pharmaceutical marketing colleagues, and the opportunistic Managed Care types whose job it has been to keep us from doing ours. Right now, I hope right thinking psychiatrists of all flavors, psychologists of all flavors, social workers, counselors, etc. can brace themselves for a long-needed realignment that is consistent with our shared task. It won’t happen any time soon. We’ve been lost in the wilderness too long for that. But the wind blowing in the trees is at least encouraging to this old man…