PARDES PSYCHOANALYSIS AND DYNAMIC PSYCHIATRY
The American Academy of Psychoanalysis and Dynamic Psychiatry Herbert Pardes I appreciate this opportunity to reflect on psychoanalysis and dynamic psychiatry in today’s mental health care environment.* Psychoanalysis and dynamic psychiatry were important parts of my training and practice. They have contributed to my understanding human behavior throughout my career. I completed psychoanalytic training in 1970 at New York Psychoanalytic Institute, adding psychoanalysis to my psychotherapy and pharmacotherapy practice. While my career veered away from private practice, I have run clinics, hospital units, adolescent units, military outpatient departments, and enjoyed an academic career. I found practice interesting and fulfilling. Human behavior fascinated me early. I had the unique experience of growing up in Catskills resort hotels. My father owned the Greenwood Hotel in Lakewood, New Jersey where I lived during the winter. He co-managed Catskills hotels where I spent summers. Watching customers was fascinating. Mr. Weissman, learning there was special apple strudel dessert, would request cherry strudel. When Mr. Felstein arrived, he re-wiped all his silver, glasses, and dishes. Mrs. Millberg (200 pounds), sitting across from Mr. Millberg (125 pounds), finished her meal and started his. I wanted to laugh. After a period of interruption from hotel work, I returned as a waiter. One night a woman entered first as the dining room opened. My waiter colleague and I watched her approach a table and state loudly, “Where is my waiter; I want hot tea.” I said, “If she is on my station, I’ll never work in a dining room again.” She was and my career as a waiter ended. Years watching countless people with amusing and intriguing behavior made me want to understand them. These experiences drew *Presidential Address given at the American Academy of Psychoanalysis and Dynamic Psychiatry’s 57th Annual Meeting, May 18, 2013, San Francisco, CA. Herbert Pardes, M.D., Executive Vice Chairman of the Board of Trustees. NewYorkPresbyterian Hospital. Psychodynamic Psychiatry, 42(2) 307–318, 2014 © 2014 The American Academy of Psychoanalysis and Dynamic Psychiatry
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me to Psychiatry. My initial interest had been Internal Medicine. But in outpatient medicine I saw patients with huge charts and multiple clinic visits whose psychiatric problems complicated the picture. I enjoyed figuring those out and treating them. Whether I had an early desire to understand people, or whether it came from specialty training in Psychiatry and Psychoanalysis, psychodynamics played an important role in my professional life and has been helpful throughout. In the 1960s, I did a psychiatric residency and research fellowship. Psychoanalysis was the heart of Psychiatry. Most new psychiatry chairs were psychoanalysts. Colleagues sought psychoanalytic training intending to practice psychodynamic therapy. The world, however, changed. Over the next 43 years I moved toward leadership in academic medicine, national health and mental health policy, and administration in government and the private sector. It became acknowledged that psychoanalysis and dynamic psychotherapy could not solve all psychiatric problems. Biology, brain neuroscience, and genetics assumed (Pardes, 1986b) more intellectual importance in Psychiatry. As a career, Psychiatry became less popular. The choice of Psychiatry among graduating medical students fell from a high of 10% of students in the ‘60s to a low of some 2% by the end of the ‘70s (Pardes, 1978). At the same time Psychiatry underwent a paradigm shift. Profound changes occurred in the organization and financing of psychiatric services. Care and treatment of psychiatric illness, long a State responsibility and taking place predominately in remote State institutions, began migrating to populated communities (Ozarin & Sharfstein, 1978) with financial responsibility shifting from states to the federal government. This move was supported by President John F. Kennedy, whose “1963 Mental Retardation Facilities and Community Mental Health Centers Construction Act” marked the first substantial federal effort to finance services for seriously mentally ill. The Act’s goal was 1,500 Community Mental Health Centers (CMHCs) nationwide, each responsible for providing mental health care to a catchment area averaging 200,000 people. This totaled 300 million people, the nation’s projected population at program completion (Sharfstein, 1979). CMHC services were supported by NIMH grants. The Act, however, was truncated by Congress before being fully realized. Over time a concern grew that the sickest people were not receiving services, and that mental health was inadequately supported by the states and the federal government. In 1977, Jimmy and Rosalynn Carter developed a Presidential Commission on Mental Health. It strengthened support of psychiatric re-
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search, epidemiology, and treatment. Its major product was the Mental Health Systems Act, designed to provide more care for underserved populations: children, minorities, elderly, the chronically mentally ill, and psychiatric patients in general health care settings (Grob, 2005). That law, passed in the fall of 1980, was nullified when Reagan took office in 1981. The Reagan Administration reversed direction again, giving more control to states through block grants which reassigned federal money designated for programs like CMHCs to states for use in substance abuse and psychiatric disorders (Ray & Finley, 1994). The National Institute of Mental Health and the Federal government’s role in mental health care generally was dramatically reduced. Although swings in mental health care policy in the late 1970s and 1980s seriously affected care delivery, research affecting what Psychiatry could potentially do for people blossomed. Neuroscience generated exciting insights into brain function. Roger Sperry won the Nobel Prize for discovering that the left and right brain hemispheres had different functions (Nobelprize.org, 2013a), Lou Sokoloff won the Lasker Award for work in PET scanning (The Lasker Foundation, 1981), and Eric Kandel won the Lasker Award for neuroscience and its relationship to mental health (The Lasker Foundation, 1983). Kandel, along with Greengard and Carlsson, later won the Nobel Prize in 2000 for their work on the molecular basis of memory (Nobelprize.org, 2013b). Nancy Wexler won a Lasker award for discovering the gene which causes Huntington’s disease, a neuropsychiatric illness (The Lasker Foundation, 1993). Citizen advocacy groups—for example, the National Alliance on Mental Illness (NAMI) and the Brain and Behavior Research Foundation (BBRF)—grew in the 1970s and 1980s (Pardes, 1986a) and advocated with support of national leaders, among them, Senators Ted Kennedy, Paul Wellstone and Pete Domenici, Mrs. Carter, and mental health professionals. This generated a movement successful in increasing support for psychiatric research (McCarty, 2013) and eventually nudged the country toward parity for mental health care reimbursement. Simultaneously, Federal government withdrawal from direct financing and oversight of mental health clinical services and delegation of mental healthcare to states caused 50 state clinical programs to go in scattered directions. Today we see both good and bad news. The good news: • Increased research money, although tempered recently by NIMH cuts (NIMH, 2013). • Increasing number and use of diverse treatments (World Health Oranization, 2003).
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• Some decline in stigma (Sartorius, 2007). • Greater numbers of mental health professionals to give care (Scheffler & Kirby, 2003). • Recognition by the World Health Organization (WHO) of the enormous effect of psychiatric illness (World Health Organization, 2004). • Realization that many people with psychiatric illness improved (Anthony, 1993). Negative developments: • Reduction of mental health facilities with inadequate services to replace them (Torrey, Fuller, Geller, Jacobs, & Rogasta, 2012). • Decline in depth of psychological discovery and psychiatric care. A tendency to treat superficially, using medication with the goal of symptom relief only, with avoidance of efforts to understand patients more fully by careful interview and assessment. • Spread of groups attacking Psychiatry. Detractors include Scientologists, groups criticizing the use of psychiatric medications in children, and critics of psychotherapy and psychoanalysis. • Care and treatment of the seriously mentally ill has also deteriorated. • Jails filled with patients often housed in inhumane settings (Perez, Leifman, & Estrada, 2003). • Emergency rooms overflowing with psychiatric patients. • Few settings to which psychiatric patients can be sent. • Weakening advocacy for mental health. • Economic stressors causing reduced availability of services and less ability of patients to afford mental healthcare. • Increase in military suicide and posttraumatic stress disorder (PTSD) and increased suicide among civilians (Bryan, Jennings, Jobes, & Bradley, 2010). • Tendency to overestimate the role of psychiatrically ill individuals in incidents of public violence. • Fewer Congressional advocacy leaders for mental healthcare, partly because of competing demands on the country’s resources. Political changes have brought legislators concerned exclusively with economic cuts rather than with programs. This situation is unlike the appealing life many trained in the 1960s and 1970s expected to have—using psychotherapy, psychoanalysis,
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and pharmacotherapy to help psychiatrically ill individuals and their families. The field of mental health had seemed full of possibilities. At that time, clinicians focused on psychodynamic psychotherapy were mainstream. Today, a new chapter in Psychiatry relates to the main theme of this conference—the future role of psychodynamics and psychoanalysis. How do these treatment modalities fit into psychiatric health care? Some say they have little role. They argue, for example, that psychodynamic psychotherapy and psychoanalysis take too long and are too expensive except for a small fraction of the population. We could make a different case: • The prevalence of psychiatric illnesses recognized by the World Health Organization is impressive. Worldwide depression and other mental and substance abuse illness contribute heavily to human suffering and impose an economic toll as well. • Patients with comorbidity, that is, psychiatric problems accompanied by a non-psychiatric medical problem or substance abuse, generate enormous costs (Saravay & Iava, 1994). • There is increased interest in coordinating and integrating mental health and general health care. A mental health service embedded in a general healthcare setting often lowers cost and improves quality of care (Katon et al., 2012). • Some suggest medical care has limitations. At this point, even used together all our mental health interventions accomplish less than is optimal in psychiatric illness care (Luhrman, 2013). In the 2012 winter editon of Psychodynamic Psychiatry there are excellent articles by Drs. Richard Friedman (Friedman, 2012) and Michael Robbins (Robbins, 2012). Dr. Friedman states most patients who suffer severe and chronic or recurrent mental illness “require psychodynamically informed assessment, crisis intervention and treatment that may vary in length and include brief psychotherapy and intermittent treatment over lengthy periods of time.” Dr. Robbins describes 11 years of psychoanalytic treatment with a paranoid schizophrenic woman with an unexpected follow-up 20 years later initiated by the patient (Sara). At follow-up, Dr. Robbins described Sara: an “impressive mature woman with a solid sense of self.” She described a satisfying marriage, master’s degree in creative writing, a career as a novelist, and raising a disturbed adolescent son she had adopted with her husband to “constructive and mature manhood.” Over
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20 years after treatment with Dr. Robbins concluded, she reported no further psychotherapy or medications. Dr. Robbins notes the rarity of reports of an entire course of treatment, Few people receive 11 years of psychoanalytic psychotherapy, of course. We could question whether the greater depth to which psychodynamically oriented mental health professionals go in treating mental illness is valued at a time when quick “med checks” and avoidance of in-depth assessment and treatment of the patient hold sway. As Dr. Friedman commented, reimbursement authorities might react cynically to such lengthy, expensive treatment as Dr. Robbins’s patient received. At a Mental Health Symposium (April, 2013) held by our Health Policy Center at New York Presbyterian Hospital, Professor Elyn Saks from University of Southern California (USC) stated frankly that she has been schizophrenic for 30 years. Early in life she had been told she had a poor prognosis and would never live independently. She had childhood problems, countless episodes of psychotic and bizarre behavior, multiple hospitalizations, and one drug rehabilitation experience. Despite all this, she finished first in her Vanderbilt University class with straight As and went on to Oxford and Yale Law School. Her life has been a mix of unbelievable accomplishments and unfortunate downward spirals. Once she found herself bizarrely singing on the roof of Yale Law School. At times Elyn went four to five times a week for treatment. She bears similarities to Dr. Robbins’ patient, Sara. She endured months of hospitalization (Saks, 2007), yet functioned well enough to receive a Ph.D. in psychoanalytic science and learned psychoanalysis. Elyn credits the combination of psychodynamically oriented psychotherapy and medications with helping her accept her mental illness and advance her life. She married in her 40s and today conducts a professional effort to de-stigmatize mental illness and educate people about how appropriately to care for patients with psychiatric illnesses. She is conducting a study on 20 high-functioning individuals in California with serious psychiatric illness to understand better this phenomenon she experienced of illness and success. It is unfortunate that our briefer psychiatric treatments do not help all patients. It is unlikely public resources will be spent on extended psychotherapy or psychoanalysis. But one consideration is whether psychodynamically trained professionals can instruct and coach nonpsychiatric care providers and paraprofessionals in general health or psychiatric healthcare settings in psychodynamically based techniques to improve patients’ care. Might we improve care by widening the population of psychodynamically informed therapists? Innovative examples of care exist. For example, in New York’s Westchester County a program trains patients who themselves have been
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treated for psychiatric problems to provide peer support for new patients (Agency for Healthcare Research and Quality, 2013). Others are working to enhance range and volume of care or to make quality psychiatric care more efficient. Dr. Jürgen Unützer in Washington State developed an integrated population approach to mental health care for adults (Unützer et al., 2012). Efforts exist in Massachusetts to make child psychiatric consultation rapidly available to families (Connor et al., 2006). So, do psychodynamically oriented mental health providers have a role in today’s mental health care? In an Editor’s Introduction in the Spring 2013 edition of Psychodynamic Psychiatry, Dr. Elizabeth Auchincloss optimistically writes, “the age of polarization of psychiatry is coming to a close” (2013). She observes that biological psychiatry may have reached a plateau in its offering of new treatments. She states “. . . basic scientists in the field of cognitive neuroscience are rediscovering basic principles behind psychodynamic psychiatry.” She writes that all psychiatric residents should have strong supervised experiences of psychodynamic psychotherapy. She notes that psychodynamic psychiatry “is the most intense encounter ever invented for clinical purposes” and continues that only in psychodynamic psychotherapy do residents get first-hand knowledge of the psychodynamic model of the mind and that it is the most complex model of human psychological functioning for clinical purposes. All psychiatrists, Dr. Auchincloss asserts, are most effective if they truly understand human motivation. In his Psychodynamic Psychiatry case report Dr. Robbins acknowledges a question regarding how important verbal content is in providing effective psychiatric care. Sara had told him she benefitted more from his unwavering patience and caring rather than specific things he said. Does content count? People learn many things by processes which retrospectively they cannot recall although they were learned with substantial guidance. The child’s experience learning to walk, talk, become socialized, and think are examples of this. Sara said “she transformed the things he tried to teach her about her mind from an alien threatening presence she wanted to destroy to a third party in her mind and eventually to a valued part of herself.” Dr. Robbins writes that he felt he became part of her, more than just a set of specific memories. Sara showed remarkable improvement. Some could argue that this is one patient, one anecdote. But, a longstanding core principle in psychiatry considers biological, social, and psychological factors together. Optimal treatment for many is a combination of pharmacotherapy to address symptoms with psychological therapies that build personal functioning.
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Gerry Klerman, a professor of Psychiatry first at Yale, later at Cornell, wrote an article entitled “Better But Not Well” (Klerman, 1977), describing limits to the value medications offer and suggesting those limitations support the need for complementary psychotherapy. Many positive studies demonstrate psychotherapy’s effectiveness. For instance, there is strong evidence for the effectiveness of cognitive behavioral psychotherapy (Butler, Chapman, Forman, & Beck, 2006). Aaron Beck, the intellectual leader for this treatment, received the Lasker Award in 2006 for this seminal work (The Lasker Foundation, 2006). Other data show value in behavior therapy. There have been attempts with some success showing psychodynamic psychotherapy’s value (Shedler, 2010). Many clinicians report seeing dramatic changes in patients treated with psychodynamic psychotherapy and are convinced of the therapeutic benefit and mental healthcare gains. Today I am rarely involved in clinical practice, but attention to individual psychology helps me in many executive roles. In every organization and institution there are instances of sibling rivalry, narcissistic behavior, depression, and poor work performance secondary to a variety of different kinds of psychopathology. Knowledge of personality styles and group process facilitates accomplishment of goals in every kind of organization. Mental health is searching for answers. It attracts public attention— most recently from controversies about the latest version of the Diagnostic and Statistical Manual or DSM (Halter, Rolin-Kenny, & Dzurec, 2013), possible overdosing of children with Attention Deficit Disorder (Stubbe, 2000), school violence (Brener, Simon, Krug, & Lowry, 1999), veterans’ posttraumatic stress disorder (Mayo, MacGregor, Dougherty, & Galameau, 2013), and recent increases in suicide rates. The Mental Health Conference convened by President Obama on June 3, 2013 to launch a new program, the Brain Initiative, demonstrates how important public health issues, mental health and illness are (Normann, 2013). Mental health has global significance. These issues and events of public interest call attention to mental health and illness. For practitioners of psychodynamic psychiatry, one question remains, how to contribute most effectively? Have you ideas, principles, theory that can help? Do you have clinical experience to strengthen treatment or supervision of the care of people with psychiatric problems? It was harder 100 years ago. The need was not recognized. Today, the numbers who need mental health service in the United States but receive no care has grown dramatically, 4.3 million in 1997, 7.2 million in 2010 (Roll, Kennedy, Tran, & Howell, 2013). There is great need. People with psychoanalytic and psychodynamic expertise can bring benefit to the practice of mental health care.
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I hope this Academy and the broad mental health community recognize that efforts to enhance integration between care for mental health and physical health are necessary. We need to work and improve our understanding of psychiatric illness. We need to explore every avenue for the welfare of the many suffering people with mental disorders, their families, and their communities.
References Agency for Healthcare Research and Quality. (2013). Care coordination, peer support, and discretionary fund improve quality of life and reduce costs for adults with serious mental illness—AHRQ innovations exchange. Retrieved from http://www. innovations.ahrq.gov/content.aspx?id=3387. Anthony, W. (1993). Recovery from mental illness: The guiding vision of the mental health service system in the 1990s. Psychiatric Rehabilitation Journal, 16(4), 1123. Auchincloss, E. (2013). Introduction: Teaching psychodynamic psychiatry to psychiatry residents. Psychodynamic Psychiatry, 41(1), 3-11. Brener, N. D., Simon, T. R., Krug, E. G., & Lowry, R. (1999). Recent trends in violence-related behaviors among high school students in the United States. JAMA, 282(5), 440-446. Bryan, C. J., Jennings, K. W., Jobes, D. A., & Bradley, J. C. (2010). Understanding and preventing military suicide. Archives of Suicide Research, 16(2), 95-110. Butler, A., Chapman, J., Forman, E., & Beck, A. (2006). The empirical status of cognitive-behavioral therapy: A review of meta-analyses. Clinical Psychology Review, 26(1), 17-31. Connor, D. F., McLaughlin, T. J., Jeffers-Terry, M., O’Brien, W. H., Stille, C. J., Young, L. M., & Antonelli, R. C. (2006). Targeted child psychiatric services: A new model of pediatric primary clinician–child psychiatry collaborative care. Clinical Pediatrics, 45(5), 423-434. Friedman, R. (2012). Editor’s introduction: The official journal of the American Academy of Psychoanalysis and Dynamic Psychiatry. Psychodynamic Psychiatry, 40(4), 543-547. Grob, G. (2005). Public policy and mental illnesses: Jimmy Carter’s presidential commission on mental health. The Milbank Quarterly, 83(3), 425-456. Halter, M., Rolin-Kenny, D., & Dzurec, L. (2013). An overview of the DSM-5: Changes, controversy, and implications for psychiatric nursing. Journal of Psychosocial Nursing and Mental Health Services, 51(4), 30-39. Katon, W., Russo, J., Lin, E. H., Schmittdiel, J., Ciechanowski, P., Ludman, E., Peterson, D., et al. (2012). Cost-effectiveness of a multicondition collaborative care intervention: A randomized controlled trial. Archives of General Psychiatry, 69, 506-514. Klerman, G. (1977). Better but not well: Social and ethical issues in the deinstitutionalization of the mentally ill. Schizophrenia Bulletin, 3(4), 617-631.
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Lasker Foundation, The. (1981). The Albert Lasker Clinical Medical Research Award 1981. Retrieved from http://www.laskerfoundation.org/awards/1981_c_description.htm. Lasker Foundation, The. (1983). The Albert Lasker Basic Medical Research Award 1983. Retrieved from http://www.laskerfoundation.org/awards/1983_b_ description_p.htm. Lasker Foundation, The. (1993). The Albert Lasker Public Service Award 1993. Retrieved from http://www.laskerfoundation.org/awards/1993_p_description.htm Lasker Foundation, The. (2006). The Albert Lasker Clinical Medical Research Award 2006. Retrieved from http://www.laskerfoundation.org/awards/2006clinical. htm. Luhrman, T. (26 Sept., 2013). Beyond the brain. Wilson Quarterly. Retrieved from http://wilsonquarterly.com/essays/beyond-brain. Mayo, J., MacGregor, A., Dougherty, A., & Galameau, M. (2013). Role of occupation on new-onset post-traumatic stress disorder and depression among deployed military personnel. Military Medicine, 178(9), 945-950. McCarty, D. (2013). Parity: An ongoing challenge and research opportunity. The American Journal of Psychiatry, 170, 140-142. National Institute of Mental Health. (2013). NIMH budget. Retrieved from http:// www.nimh.nih.gov. Nobelprize.org. (2013a). The Nobel Prize in physiology or medicine 1981. Nobel Media AB. Retrieved from http://www.nobelprize.org/nobel_prizes/medicine/laureates/1981/. Nobelprize.org. (2013b). The Nobel Prize in physiology or medicine 2000. Nobel Media AB. Retrieved from http://www.nobelprize.org/nobel_prizes/medicine/laureates/2000/. Normann, R. (2013). Building on the brain initiative. Journal of Neuroengineering, 10(4), 1-2. Ozarin, L., & Sharfstein, S. (1978). The aftermaths of deinstitutionalization: Problems and solutions. Psychiatric Quarterly, 50, 128-132. Pardes, H. (1978). Why are fewer students entering psychiatry? Bulletin Area II American Psychiatric Association, 20, 55-57. Pardes, H. (1986a). Advocacy for the mentally ill. In J. H. Marks (Ed.), Advocacy in health care (pp. 103-111). Clifton, NJ: Humana Press. Pardes, H. (1986b). Neuroscience and psychiatry: Marriage or co-existence? The American Journal of Psychiatry, 143, 1205-1212. Perez, A., Leifman, S., & Estrada, A. (2003). Reversing the criminalization of mental illness. Crime and Delinquency, 49, 62-78. Ray, C., & Finley, J. (1994). Did CMHCs fail or succeed? Analysis of the expectations and outcomes of the community mental health movement. Administration and Policy in Mental Health and Mental Health Services Research, 21, 283-293. Robbins, M. (2012). The successful psychoanalytic therapy of a schizophrenic woman. Psychodynamic Psychiatry, 40(4), 575-608. Roll, J. M., Kennedy, J., Tran, M., & Howell, D. (2013). Disparities in unmet need for mental health services in the United States. Psychiatric Services, 64, 83-87. Saks, E. (2007). The center cannot hold: My journey through madness. New York: Hyperion.
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Saravay, S., & Iava, M. (1994). Psychiatric comorbidity and length of stay in the general hospital: A critical review of outcome studies. Psychosomatics, 35(3), 233-252. Sartorius, N. (2007). Stigma and mental health. The Lancet, 370(9590), 810-811. Scheffler, R. M., & Kirby, P. B. (2003). The occupational transformation of the mental health system. Health Affairs, 22(5), 177-188. Sharfstein, S. (1979). Community mental health centers: Returning to basics. American Journal of Psychiatry, 136, 1077-1079. Shedler, J. (2010). The efficacy of psychodynamic psychotherapy. American Psychologist, 65(2), 98-109. Stubbe, D. (2000). Attention-deficit/hyperactivity disorder overview: Historical perspective, current controversies, and future directions. Child and Adolescent Psychiatric Clinics of North America, 9(3), 469-479. Torrey, E. F., Fuller, D. A., Geller, J., Jacobs, C., & Rogasta, K. (2012). No room at the inn: Trends and consequences of closing public psychiatric hospital. Washington, DC: Treatment Advocacy Center. Unützer, J., Chan, Y., Hafer, E., Knaster, J., Shields, A., Powers, D., & Veith, R. (2012). Quality improvement with pay-for-performance incentives in integrated behavioral health care. American Journal of Public Health, 102(6), e41-e45. World Health Organization. (2003). The mental health context. Geneva, Switzerland: World Health Organization. Available at http://www.who.int/mental_ health/resources/en/context.PDF. World Health Organization. (2004). Promoting mental health: Concepts, emerging evidence, practice (summary report). Geneva, Switzerland: World Health Organization. Available at http://www.who.int/mental_health/evidence/en/promoting_mhh.pdf.
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The American Academy of Psychoanalysis and Dynamic Psychiatry Herbert Pardes I appreciate this opportunity to reflect on psychoanalysis and dynamic psychiatry in today’s mental health care environment.* Psychoanalysis and dynamic psychiatry were important parts of my training and practice. They have contributed to my understanding human behavior throughout my career. I completed psychoanalytic training in 1970 at New York Psychoanalytic Institute, adding psychoanalysis to my psychotherapy and pharmacotherapy practice. While my career veered away from private practice, I have run clinics, hospital units, adolescent units, military outpatient departments, and enjoyed an academic career. I found practice interesting and fulfilling. Human behavior fascinated me early. I had the unique experience of growing up in Catskills resort hotels. My father owned the Greenwood Hotel in Lakewood, New Jersey where I lived during the winter. He co-managed Catskills hotels where I spent summers. Watching customers was fascinating. Mr. Weissman, learning there was special apple strudel dessert, would request cherry strudel. When Mr. Felstein arrived, he re-wiped all his silver, glasses, and dishes. Mrs. Millberg (200 pounds), sitting across from Mr. Millberg (125 pounds), finished her meal and started his. I wanted to laugh. After a period of interruption from hotel work, I returned as a waiter. One night a woman entered first as the dining room opened. My waiter colleague and I watched her approach a table and state loudly, “Where is my waiter; I want hot tea.” I said, “If she is on my station, I’ll never work in a dining room again.” She was and my career as a waiter ended. Years watching countless people with amusing and intriguing behavior made me want to understand them. These experiences drew *Presidential Address given at the American Academy of Psychoanalysis and Dynamic Psychiatry’s 57th Annual Meeting, May 18, 2013, San Francisco, CA. Herbert Pardes, M.D., Executive Vice Chairman of the Board of Trustees. NewYorkPresbyterian Hospital. Psychodynamic Psychiatry, 42(2) 307–318, 2014 © 2014 The American Academy of Psychoanalysis and Dynamic Psychiatry
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me to Psychiatry. My initial interest had been Internal Medicine. But in outpatient medicine I saw patients with huge charts and multiple clinic visits whose psychiatric problems complicated the picture. I enjoyed figuring those out and treating them. Whether I had an early desire to understand people, or whether it came from specialty training in Psychiatry and Psychoanalysis, psychodynamics played an important role in my professional life and has been helpful throughout. In the 1960s, I did a psychiatric residency and research fellowship. Psychoanalysis was the heart of Psychiatry. Most new psychiatry chairs were psychoanalysts. Colleagues sought psychoanalytic training intending to practice psychodynamic therapy. The world, however, changed. Over the next 43 years I moved toward leadership in academic medicine, national health and mental health policy, and administration in government and the private sector. It became acknowledged that psychoanalysis and dynamic psychotherapy could not solve all psychiatric problems. Biology, brain neuroscience, and genetics assumed (Pardes, 1986b) more intellectual importance in Psychiatry. As a career, Psychiatry became less popular. The choice of Psychiatry among graduating medical students fell from a high of 10% of students in the ‘60s to a low of some 2% by the end of the ‘70s (Pardes, 1978). At the same time Psychiatry underwent a paradigm shift. Profound changes occurred in the organization and financing of psychiatric services. Care and treatment of psychiatric illness, long a State responsibility and taking place predominately in remote State institutions, began migrating to populated communities (Ozarin & Sharfstein, 1978) with financial responsibility shifting from states to the federal government. This move was supported by President John F. Kennedy, whose “1963 Mental Retardation Facilities and Community Mental Health Centers Construction Act” marked the first substantial federal effort to finance services for seriously mentally ill. The Act’s goal was 1,500 Community Mental Health Centers (CMHCs) nationwide, each responsible for providing mental health care to a catchment area averaging 200,000 people. This totaled 300 million people, the nation’s projected population at program completion (Sharfstein, 1979). CMHC services were supported by NIMH grants. The Act, however, was truncated by Congress before being fully realized. Over time a concern grew that the sickest people were not receiving services, and that mental health was inadequately supported by the states and the federal government. In 1977, Jimmy and Rosalynn Carter developed a Presidential Commission on Mental Health. It strengthened support of psychiatric re-
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search, epidemiology, and treatment. Its major product was the Mental Health Systems Act, designed to provide more care for underserved populations: children, minorities, elderly, the chronically mentally ill, and psychiatric patients in general health care settings (Grob, 2005). That law, passed in the fall of 1980, was nullified when Reagan took office in 1981. The Reagan Administration reversed direction again, giving more control to states through block grants which reassigned federal money designated for programs like CMHCs to states for use in substance abuse and psychiatric disorders (Ray & Finley, 1994). The National Institute of Mental Health and the Federal government’s role in mental health care generally was dramatically reduced. Although swings in mental health care policy in the late 1970s and 1980s seriously affected care delivery, research affecting what Psychiatry could potentially do for people blossomed. Neuroscience generated exciting insights into brain function. Roger Sperry won the Nobel Prize for discovering that the left and right brain hemispheres had different functions (Nobelprize.org, 2013a), Lou Sokoloff won the Lasker Award for work in PET scanning (The Lasker Foundation, 1981), and Eric Kandel won the Lasker Award for neuroscience and its relationship to mental health (The Lasker Foundation, 1983). Kandel, along with Greengard and Carlsson, later won the Nobel Prize in 2000 for their work on the molecular basis of memory (Nobelprize.org, 2013b). Nancy Wexler won a Lasker award for discovering the gene which causes Huntington’s disease, a neuropsychiatric illness (The Lasker Foundation, 1993). Citizen advocacy groups—for example, the National Alliance on Mental Illness (NAMI) and the Brain and Behavior Research Foundation (BBRF)—grew in the 1970s and 1980s (Pardes, 1986a) and advocated with support of national leaders, among them, Senators Ted Kennedy, Paul Wellstone and Pete Domenici, Mrs. Carter, and mental health professionals. This generated a movement successful in increasing support for psychiatric research (McCarty, 2013) and eventually nudged the country toward parity for mental health care reimbursement. Simultaneously, Federal government withdrawal from direct financing and oversight of mental health clinical services and delegation of mental healthcare to states caused 50 state clinical programs to go in scattered directions. Today we see both good and bad news. The good news: • Increased research money, although tempered recently by NIMH cuts (NIMH, 2013). • Increasing number and use of diverse treatments (World Health Oranization, 2003).
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• Some decline in stigma (Sartorius, 2007). • Greater numbers of mental health professionals to give care (Scheffler & Kirby, 2003). • Recognition by the World Health Organization (WHO) of the enormous effect of psychiatric illness (World Health Organization, 2004). • Realization that many people with psychiatric illness improved (Anthony, 1993). Negative developments: • Reduction of mental health facilities with inadequate services to replace them (Torrey, Fuller, Geller, Jacobs, & Rogasta, 2012). • Decline in depth of psychological discovery and psychiatric care. A tendency to treat superficially, using medication with the goal of symptom relief only, with avoidance of efforts to understand patients more fully by careful interview and assessment. • Spread of groups attacking Psychiatry. Detractors include Scientologists, groups criticizing the use of psychiatric medications in children, and critics of psychotherapy and psychoanalysis. • Care and treatment of the seriously mentally ill has also deteriorated. • Jails filled with patients often housed in inhumane settings (Perez, Leifman, & Estrada, 2003). • Emergency rooms overflowing with psychiatric patients. • Few settings to which psychiatric patients can be sent. • Weakening advocacy for mental health. • Economic stressors causing reduced availability of services and less ability of patients to afford mental healthcare. • Increase in military suicide and posttraumatic stress disorder (PTSD) and increased suicide among civilians (Bryan, Jennings, Jobes, & Bradley, 2010). • Tendency to overestimate the role of psychiatrically ill individuals in incidents of public violence. • Fewer Congressional advocacy leaders for mental healthcare, partly because of competing demands on the country’s resources. Political changes have brought legislators concerned exclusively with economic cuts rather than with programs. This situation is unlike the appealing life many trained in the 1960s and 1970s expected to have—using psychotherapy, psychoanalysis,
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and pharmacotherapy to help psychiatrically ill individuals and their families. The field of mental health had seemed full of possibilities. At that time, clinicians focused on psychodynamic psychotherapy were mainstream. Today, a new chapter in Psychiatry relates to the main theme of this conference—the future role of psychodynamics and psychoanalysis. How do these treatment modalities fit into psychiatric health care? Some say they have little role. They argue, for example, that psychodynamic psychotherapy and psychoanalysis take too long and are too expensive except for a small fraction of the population. We could make a different case: • The prevalence of psychiatric illnesses recognized by the World Health Organization is impressive. Worldwide depression and other mental and substance abuse illness contribute heavily to human suffering and impose an economic toll as well. • Patients with comorbidity, that is, psychiatric problems accompanied by a non-psychiatric medical problem or substance abuse, generate enormous costs (Saravay & Iava, 1994). • There is increased interest in coordinating and integrating mental health and general health care. A mental health service embedded in a general healthcare setting often lowers cost and improves quality of care (Katon et al., 2012). • Some suggest medical care has limitations. At this point, even used together all our mental health interventions accomplish less than is optimal in psychiatric illness care (Luhrman, 2013). In the 2012 winter editon of Psychodynamic Psychiatry there are excellent articles by Drs. Richard Friedman (Friedman, 2012) and Michael Robbins (Robbins, 2012). Dr. Friedman states most patients who suffer severe and chronic or recurrent mental illness “require psychodynamically informed assessment, crisis intervention and treatment that may vary in length and include brief psychotherapy and intermittent treatment over lengthy periods of time.” Dr. Robbins describes 11 years of psychoanalytic treatment with a paranoid schizophrenic woman with an unexpected follow-up 20 years later initiated by the patient (Sara). At follow-up, Dr. Robbins described Sara: an “impressive mature woman with a solid sense of self.” She described a satisfying marriage, master’s degree in creative writing, a career as a novelist, and raising a disturbed adolescent son she had adopted with her husband to “constructive and mature manhood.” Over
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20 years after treatment with Dr. Robbins concluded, she reported no further psychotherapy or medications. Dr. Robbins notes the rarity of reports of an entire course of treatment, Few people receive 11 years of psychoanalytic psychotherapy, of course. We could question whether the greater depth to which psychodynamically oriented mental health professionals go in treating mental illness is valued at a time when quick “med checks” and avoidance of in-depth assessment and treatment of the patient hold sway. As Dr. Friedman commented, reimbursement authorities might react cynically to such lengthy, expensive treatment as Dr. Robbins’s patient received. At a Mental Health Symposium (April, 2013) held by our Health Policy Center at New York Presbyterian Hospital, Professor Elyn Saks from University of Southern California (USC) stated frankly that she has been schizophrenic for 30 years. Early in life she had been told she had a poor prognosis and would never live independently. She had childhood problems, countless episodes of psychotic and bizarre behavior, multiple hospitalizations, and one drug rehabilitation experience. Despite all this, she finished first in her Vanderbilt University class with straight As and went on to Oxford and Yale Law School. Her life has been a mix of unbelievable accomplishments and unfortunate downward spirals. Once she found herself bizarrely singing on the roof of Yale Law School. At times Elyn went four to five times a week for treatment. She bears similarities to Dr. Robbins’ patient, Sara. She endured months of hospitalization (Saks, 2007), yet functioned well enough to receive a Ph.D. in psychoanalytic science and learned psychoanalysis. Elyn credits the combination of psychodynamically oriented psychotherapy and medications with helping her accept her mental illness and advance her life. She married in her 40s and today conducts a professional effort to de-stigmatize mental illness and educate people about how appropriately to care for patients with psychiatric illnesses. She is conducting a study on 20 high-functioning individuals in California with serious psychiatric illness to understand better this phenomenon she experienced of illness and success. It is unfortunate that our briefer psychiatric treatments do not help all patients. It is unlikely public resources will be spent on extended psychotherapy or psychoanalysis. But one consideration is whether psychodynamically trained professionals can instruct and coach nonpsychiatric care providers and paraprofessionals in general health or psychiatric healthcare settings in psychodynamically based techniques to improve patients’ care. Might we improve care by widening the population of psychodynamically informed therapists? Innovative examples of care exist. For example, in New York’s Westchester County a program trains patients who themselves have been
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treated for psychiatric problems to provide peer support for new patients (Agency for Healthcare Research and Quality, 2013). Others are working to enhance range and volume of care or to make quality psychiatric care more efficient. Dr. Jürgen Unützer in Washington State developed an integrated population approach to mental health care for adults (Unützer et al., 2012). Efforts exist in Massachusetts to make child psychiatric consultation rapidly available to families (Connor et al., 2006). So, do psychodynamically oriented mental health providers have a role in today’s mental health care? In an Editor’s Introduction in the Spring 2013 edition of Psychodynamic Psychiatry, Dr. Elizabeth Auchincloss optimistically writes, “the age of polarization of psychiatry is coming to a close” (2013). She observes that biological psychiatry may have reached a plateau in its offering of new treatments. She states “. . . basic scientists in the field of cognitive neuroscience are rediscovering basic principles behind psychodynamic psychiatry.” She writes that all psychiatric residents should have strong supervised experiences of psychodynamic psychotherapy. She notes that psychodynamic psychiatry “is the most intense encounter ever invented for clinical purposes” and continues that only in psychodynamic psychotherapy do residents get first-hand knowledge of the psychodynamic model of the mind and that it is the most complex model of human psychological functioning for clinical purposes. All psychiatrists, Dr. Auchincloss asserts, are most effective if they truly understand human motivation. In his Psychodynamic Psychiatry case report Dr. Robbins acknowledges a question regarding how important verbal content is in providing effective psychiatric care. Sara had told him she benefitted more from his unwavering patience and caring rather than specific things he said. Does content count? People learn many things by processes which retrospectively they cannot recall although they were learned with substantial guidance. The child’s experience learning to walk, talk, become socialized, and think are examples of this. Sara said “she transformed the things he tried to teach her about her mind from an alien threatening presence she wanted to destroy to a third party in her mind and eventually to a valued part of herself.” Dr. Robbins writes that he felt he became part of her, more than just a set of specific memories. Sara showed remarkable improvement. Some could argue that this is one patient, one anecdote. But, a longstanding core principle in psychiatry considers biological, social, and psychological factors together. Optimal treatment for many is a combination of pharmacotherapy to address symptoms with psychological therapies that build personal functioning.
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Gerry Klerman, a professor of Psychiatry first at Yale, later at Cornell, wrote an article entitled “Better But Not Well” (Klerman, 1977), describing limits to the value medications offer and suggesting those limitations support the need for complementary psychotherapy. Many positive studies demonstrate psychotherapy’s effectiveness. For instance, there is strong evidence for the effectiveness of cognitive behavioral psychotherapy (Butler, Chapman, Forman, & Beck, 2006). Aaron Beck, the intellectual leader for this treatment, received the Lasker Award in 2006 for this seminal work (The Lasker Foundation, 2006). Other data show value in behavior therapy. There have been attempts with some success showing psychodynamic psychotherapy’s value (Shedler, 2010). Many clinicians report seeing dramatic changes in patients treated with psychodynamic psychotherapy and are convinced of the therapeutic benefit and mental healthcare gains. Today I am rarely involved in clinical practice, but attention to individual psychology helps me in many executive roles. In every organization and institution there are instances of sibling rivalry, narcissistic behavior, depression, and poor work performance secondary to a variety of different kinds of psychopathology. Knowledge of personality styles and group process facilitates accomplishment of goals in every kind of organization. Mental health is searching for answers. It attracts public attention— most recently from controversies about the latest version of the Diagnostic and Statistical Manual or DSM (Halter, Rolin-Kenny, & Dzurec, 2013), possible overdosing of children with Attention Deficit Disorder (Stubbe, 2000), school violence (Brener, Simon, Krug, & Lowry, 1999), veterans’ posttraumatic stress disorder (Mayo, MacGregor, Dougherty, & Galameau, 2013), and recent increases in suicide rates. The Mental Health Conference convened by President Obama on June 3, 2013 to launch a new program, the Brain Initiative, demonstrates how important public health issues, mental health and illness are (Normann, 2013). Mental health has global significance. These issues and events of public interest call attention to mental health and illness. For practitioners of psychodynamic psychiatry, one question remains, how to contribute most effectively? Have you ideas, principles, theory that can help? Do you have clinical experience to strengthen treatment or supervision of the care of people with psychiatric problems? It was harder 100 years ago. The need was not recognized. Today, the numbers who need mental health service in the United States but receive no care has grown dramatically, 4.3 million in 1997, 7.2 million in 2010 (Roll, Kennedy, Tran, & Howell, 2013). There is great need. People with psychoanalytic and psychodynamic expertise can bring benefit to the practice of mental health care.
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I hope this Academy and the broad mental health community recognize that efforts to enhance integration between care for mental health and physical health are necessary. We need to work and improve our understanding of psychiatric illness. We need to explore every avenue for the welfare of the many suffering people with mental disorders, their families, and their communities.
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