Melvin Sabshin addressed the meeting of members on December 19, 1997, at the fall meeting of The American. Here are adapted excerpts from his speech.
I am grateful for the invitation to make some remarks at this meeting of the American Psychoanalytic Association on the occasion of my retirement as Medical Director of the American Psychiatric Association. Perhaps more than many of you are aware, I have fought hard to maintain a close tie between psychiatry and psychoanalysis during a period when many forces coalesced to weaken those bonds.
I am pleased that the leaders of the American Psychoanalytic Association and the APA hold annual joint meetings. I am also pleased that prominent psychoanalysts have sought elected office in the APA. Formal representation of The American in the Assembly of the APA has been very helpful.
There have been many concerns in the context of remarkable recent changes in all health care, including psychiatry. The interaction of new economics and new research has had a revolutionary impact. I would like to focus on a few areas where I believe psychiatry and psychoanalysis can assist each other. At times the help will come more from psychiatry; at other times the help will come more from psychoanalysis.
The intersection of new economics and new research has enhanced the influence of neuroscience in psychiatry. From a clinical perspective, pharmacotherapy has been encouraged and psychotherapy has been inhibited. Managed care has evolved in the U.S. capitalistic system as a powerful regulatory force that demands quick solutions and seeks its own pragmatic form of evidence-based psychiatry. Theoretical models tend to be devalued, and instant utilitarianism often holds sway. There are many casualties and new threats under these circumstances.
Over the last decade, I have become concerned about the relative decline in psychological-mindedness among American psychiatrists. By psychological-mindedness I mean the capacity to perceive causal or meaningful psychological interactions, whether in terms of childhood experiences, predominant affect, defensive elaborations, structural characteristics, transference phenomena, or nuances of character. Knowledge and empathy about these phenomena had been relatively reduced in psychiatry by the emphasis on other types of apprpaches. Not much has been written about this change, but there is much informal discussion about it. Here, help from psychoanalysis to psychiatry could be particularly useful.
Psychoanalysts are psychobiological in theory, but in practice they epitomize psychological-mindedness. It is hard to become a psychoanalyst without the capacity. This is less true among psychiatrists. How can this be helpful in the relationship between psychiatry and psychoanalysis?
First, I believe that psychoanalysts should make efforts to continue to be active teachers in departments of psychiatry and residency
training programs. In a paper 14 years ago, I discussed a “new beginning” group of psychiatrists, including psychoanalysts and dynamically oriented psychiatrists, who I hoped would assume leadership roles. I now wish to place new emphasis on the importance of such teachers. I hope that these teachers do not assume a negative ideological stance against biological psychiatry and nosological developments. Rather, psychological-mindedness should be taught as a vital complement to other types of information. To be complementary shows an awareness of other approaches, or at least the reality of their importance. I have worked hard to see that this complementary approach is also reciprocally carried out by non-analysts. This is frequently a difficult struggle.
Second, the importance of psychological-mindedness in diagnosis and in treatment needs reinforcement. To be psychologically minded should help in making a reliable diagnosis rather than a mechanical diagnosis. To be psychologically minded helps in clinical management. There is much that can be done cooperatively by analysis and psychiatrists to facilitate this understanding.
I believe that psychoanalysts and psychiatrists need to work together to keep psychotherapy a highly valued activity among psychiatrists. There is much current activity in the APA aiming toward this goal, including the activities of the Commission on Psychotherapy, chaired by Drew Clemens.
I understand the significant differences between psychoanalysis and psychotherapies. However, an atrophy of psychotherapeutic skills and depreciation of psychotherapy by some psychiatrists would be closely correlated with depreciation of psychoanalysis itself. Analysts who present data about the effectiveness of psychotherapy need to know that data well and need to have a basic scientific knowledge of outcome research.
I am summarizing a great deal in that last sentence, including misunderstandings of many sorts. Outcome research needs much discussion. Nevertheless, I believe that psychiatrists should be helped to understand and to practice psychotherapy. This will, in turn, help support the practice of psychoanalysis.
For psychiatrists, the combination of pharmacology and psychotherapy is very important for the future of the field. Indeed, such a combination may be an important differentiation from non-medical therapists (who practice psychotherapy) and medical therapists (who practice pharmacotherapy).
If this use of combination therapy is to become valid over time, it is obviously important for psychiatrists to maintain competence in psychotherapy. While this type of combination is currently practiced (at least pragmatically), much more can be done to study and understand the nature of the combination. Medical psychoanalysts will be involved in this combination practice and should be interested in the subject from several vantage points. Rather than emphasize differences between those who prescribe and those practicing psychotherapy, psychoanalysts can contribute to understanding how medication, when used conjointly or sequentially, can affect capacity for psychotherapy.
Psychoanalysts might be interested in pharmacotherapy for still another reason. It is certainly possible to hypothesize that some patients may become analyzable after pharmacotherapy. Psychoanalysts should at least discuss this question in a culture where pharmacotherapy is common. The approach should be more than criticizing pharmacotherapy as an interfering parameter.
Much of the research in neuroscience and pharmacotherapy is pragmatic and empirical, but this is a time of great progress in understanding the brain. Freud's “Project” was a brilliant effort, but it was based on what we knew a century ago. Psychoanalysts need to be cognizant of the “Decade of the Brain” or the “New Millennium of the Brain.” We need to support workers who develop hypotheses about neuroscience and psychoanalytic theory and practice.
Again, I am emphasizing complementarity rather than confrontation. The practical way to achieve this goal deserves careful discussion, even in these days of difficulty in financing basic practice. In thinking about psychoanalytic theory and research, I am drawing attention to work that reflects the new understanding of brain function (such as memory, affect, dream formation, and defenses/adaptation) and using this information to supplement psychoanalytic theory.
One of the major developments in psychiatry that has caused rifts between some psychiatrists and analysts has involved DSM III and DSM IV.I shall never forget one prominent psychoanalyst's statement about the stultifying impact of DSM III. He said he would rather diagnose his patients as Raskolnikov, Hamlet, or Madame Bovary than use the dull language of the DSM. Psychiatry has needed to demonstrate that reliable diagnoses are possible, and DSM has increased understanding of this reliability. The vitalism implicit in the Madame Bovary concept has a profound impact on many potential critics. Psychoanalysts can help psychiatrists find an effective balance between the need to classify while maintaining what is unique in each of us. A number of psychoanalysts have made fundamental contributions to nosology, but many are still critical of the DSM.
One of the topics that has continued to interest me over the years has been the psychoanalytic concept of normality, and I've written extensively in this area. On several occasions I have had animated discussion with psychoanalysts on this subject. I am convinced that there is a need for further elaboration on the clinical implication of the “psychopathology of everyday life.” The boundaries between health and illness are important theoretically and practically. As Medical Director of the APA, I have been deeply involved in this question, often fending off criticism about the so-called “worried well.” The National Alliance for the Mentally Ill has been in the forefront of this issue, often criticizing psychiatry for advocating reimbursement for the treatment of the worried well. Future discussion of this topic would be useful, including an understanding of an implicit or explicit psychoanalytic epidemiology.
Related to the concept of normality is, of course, the further understanding of adaptation. Occasionally, the distinctions between defense and adaptation have been blurred. I believe that there may be additional reasons to clarify these differences. The psychobiology of adaptation processes should become one of the major topics for 21st-century psychiatry and psychoanalysis. Note my use of the word psychobiology. I do believe that many people avoid becoming ill because of the use of their adaptive capacities, not just their defenses. They adapt effectively to internal and external stresses. This needs further understanding from several viewpoints.
I am hopeful that the topics that I have enumerated (as well as many others) can be part of a continuing dialogue between psychiatrists and psychoanalysts. Indeed, I believe they should be topics at psychiatric and psychoanalytic seminars and meetings. I hope that they can be topics for continuing study at institutes and academic departments. I do not underestimate the difficulties in funding for such studies, but I know that the determination to carry on these investigations must precede the seeking of funds. Many do not agree. Cooperation between the American Psychoanalytic Association and the American Psychiatric Association is vital at the practical level. I am suggesting that theoretical work and scientific collaboration may also help in new beginnings.