For once, the conspiracy of the traffic lights was on my side and, despite having left late, I arrived at the APA headquarters at 1400 K Street in Washington on time. Gracious as always, Mel was waiting for me outside as I came to the front door. Undoubtedly Washington is a risky town in which to live or work, but here, perhaps more than anywhere else in the country, the status game is played out in arcane rites. Among these is the custom that a building's prestige is directly proportional to the complexity of its security system and that any system simpler than the CIA's or the Pentagon's is considered humiliating. Accommodating himself to my private-practice schedule, Mel had agreed to meet me on a Saturday and consequently was forced to wait outside in the hot April sun. We greeted each other; he pulled out his coded plastic card and pressed the right buttons; and we gained entrance.
Mel and I go back a long way, to the time when I was an intern at the Michael Reese Hospital in Chicago and he was Associate Director of the Department of Psychiatry under Roy Grinker. Mel is a psychoanalyst with whom I share essential values concerning the care and treatment of mentally disturbed human beings and an appreciation of the unique contributions of psychoanalysis to human knowledge in general and psychiatry in particular. But, as I am in private practice and Mel is an administrator, our perspectives differ sharply, and over the past decade and a half we have frequently found ourselves at odds over tactics and judgment calls.
We began our discussion by reviewing the paper Mel published in 1985 in the Journal of the American Psychoanalytic Association titled “Psychoanalysis and Psychiatry: Models for Potential Future Relations.” In that paper, Mel sketched three models: divorce, holding the line while resolving current conflicts to prevent destabilization, and a new beginning with closer ties. Although Mel clearly favors the third, he believes that over the past five years, the relationship has mainly followed the second model. He has not, however, given up hope for a new beginning.
In Mel's view, the years between 1945 and 1970 constituted the halcyon days of psychoanalysis and psychiatry in the United States. Adolf Meyer, who coined the term “psychobiology” and stimulated interest in the relationship between a person's life history and the symptoms of mental illness, created a receptive climate for psychoanalytic concepts of psychopathology. During this period, the psychoanalytic perspective also began to influence thought in many academic fields and attitudes toward a broad range of social issues. Concurrently, the professional roles for psychiatrists and psychoanalysts multiplied. But, to Mel, an unfortunate consequence of this expansion of psychoanalytic influence was what he terms a “structural demedicalization.” Ideologies—psychoanalytic, social and political—rather than scientific methodology, tended to dominate the debates; in psychoanalysis, the question of analyzability came to overshadow the classical medical triad of diagnosis, treatment and epidemiology.
Mel believes that psychoanalysts as a group did not appreciate their potential power and influence during those years of ascendancy. Few analysts, he says, gave thought to the public health policy implications of their evolving theory and practice. He wonders why organized psychoanalysis had no interest in epidemiology. Why were analysts not interested in identifying the populations in need of, and capable of, using their services?
During that brief historical period, Mel says, when psychoanalysts had an opportunity to influence the future delivery of psychiatric care, instead of exerting their power, they (with some justification) developed a “siege mentality.” Society's fascination with psychoanalysis has always been tempered with distaste and, at time, downright hostility. In response, Mel thinks, psychoanalysis became insular, attending primarily to its own development and not paying adequate attention to influencing the environment within which psychoanalysts practiced. Indeed, Mel believes, psychoanalysts who did attempt to influence the socioeconomic context in which psychoanalysis and psychiatry were practiced, were—and still are—viewed by many mainstream psychoanalysts as having somehow debased themselves by veering from the purity of psychoanalytic therapy, teaching and writing. It was my impression that, for Mel, this perception stings.
According to Mel, since 1970, there has been a progressive “remedicalization” of psychiatry. Interest in etiology has shifted from psychopathology to biochemistry, genetics, and the neurosciences; interest in treatment, from psychotherapy to psychopharmacology. This shift was both reflected in and fostered by DSM-III, which, while attempting to move toward objectification, developed an almost antitheoretical bias. To the extent that psychiatry has lost the human perspective and become dry, mechanical, and trivial, Mel sees the current problem as one of retaining and restoring what he calls “clinical vitality.” He hopes, however, that clinical vitality can be fostered without the reintroduction of a form of philosophical vitalism that places too much emphasis on the specificity and uniqueness of human behavior and resists classifying and grouping.
In his most optimistic moments, Mel hopes for a new synthesis of biological, psychological, and social perspectives. Metaphorically, he hopes for a new Meyer or Freud. He and I are both admirers of Freud's Project for a Scientific Psychology. Mel is excited by the prospect of integrating psychoanalysis
with the new developments in the neurosciences. He believes that such a marriage would once again stimulate interest in the person as a whole. A subject that intrigues him is the psychobiology of adaptation. How is it, for example, that some people with high “genetic loading” do not become ill?
A strong supporter of Jones, Mel is pessimistic about the long-term consequences of the decision to train nonmedical candidates in psychoanalysis. In Mel's view, the multiplicity of etiological factors that may produce similar symptom complexes makes diagnosis crucial; and, because some of those factors are biological, he believes the medical degree to be essential. He fears the development of a separate, nonmedical profession of psychoanalysis, which in time may join forces with those who downplay the importance of diagnosis and prescription of treatment—sometimes under the guise of discussing analyzability—while demanding equality of responsibility and privilege.
Mel knows that, as he phrases it, the tide of history is making it difficult for the solo private practitioner. We both worry that the humanistic values of medicine, psychiatry, and psychoanalysis may become lost—lost perhaps to the nonmedical professions—as a result of the increasing socioeconomic complexity of the physician's role. Mel is trying to help preserve the practice of psychoanalysis but is acutely aware of the intrinsic dangers of almost every move. Recently, for example, the AMA accepted “medical psychoanalysis” as a CPT code. This means that the AMA has formally recognized psychoanalysis as a distinct and reimbursable treatment; but, as Mel points out, separating psychoanalysis from other “medical psychotherapies” also leaves psychoanalysis vulnerable to discrimination.
After about two hours, I felt I had come to understand Mel's position. Trying to balance the interest of all groups of psychiatrists, and all groupings of patients in need of treatment, Mel is attempting to foster both the scientific and the humanistic trends of our profession while creating strategies for adapting to shifting socioeconomic currents. It is a difficult, if not impossible, task that Mel has assigned himself, and he knows that whatever he does, some will criticize him for not doing enough or not having done what they deem right.
On the way home, I was again struck by the changes along the K Street Corridor, as we call it here. When I moved to this area over 20 years ago, Washington was still pretty much a sleepy southern town. K Street is now a concrete and glass canyon. The formerly courteous drivers cut in front of you as furiously as anywhere else on the East coast, and strategically placed reinforced concrete “planters” protect our public buildings from car bombs. Am I, I thought, unrealistically and stubbornly trying to preserve an anachronistic model of practice I cherish, or is Mel too ready to accommodate to external forces of change?