psychiatry

[Adam Blatner]

Reflections on Trends in Psychiatry

    The field of psychiatry is a very mixed bag, with a fair number of colleagues whose 
approach I am proud of, and, alas, many to whom I would not refer patients.

1.   About psychiatrists presenting at the APA conference:
             For a while, Dean Elefthery hosted symposia--- I was a co-faculty at the 1976 
one, as well as Lew Yablonsky and some others; then Neville Murray did it around 1980---  
including folks like Adaline Starr, etc., and me. Other conferences I missed around that 
time. But in 1985, after Neville died, I took over this workshop and presented psychodrama 
to an average of 25 professionals, 2/3 psychiatrists, at a paid course at the annual 
American Psychiatric Association conference. It was received well enough so that I was 
invited back and we gave this class each year for about 9 years. Then it shifted more 
towards biology and the courses stopped. Some of these 1985-1994 classes were co-taught by 
folks such as David Swink, Eva Leveton, etc.
      I stopped being active in the APA around 2001 and began to move into 
semi-retirement.

AH: Maybe Amy Konkle, MD in Indianapolis could get it going again. I believe she is a CP. 
It would help to bring the new docs up to date.
     AB  responding also to changes not only in psychiatry, but also in the financing of 
care. The idea of longer-term in-patient care was more prevalent through the early 1990s. 
Indeed, there was an expansion of such services in the 1980s, which ended up backfiring! 
There were regulatory issues mixed with entrepreneurial capitalism. By the mid-1990s, the 
trend was accelerating towards very short-term hospitalization and follow up with day 
treatment, group work, etc., but there wasn't as much funding so this follow-up wasn't 
always, well, followed up.

    Responding to requests for certain medical tests---the problem is that there is little 
evidence that such tests are meaningful, leading to doing anything different for the 
patients. The claims for orthomolecular psychiatry are, along with literally other 
alternative medicine health care claims, un-substantiated. The research just doesn't 
support that this approach does much more than homeopathy. (I know, some folks believe in 
that, too!)
      So, while there are indeed problems with the influence of the pharmacology industry 
and other semi-corrupt practices, this does not mean that the entire enterprise is 
meaningless. There will need to be a continuous process of finding the proper balance.
        Many psychiatrists are quick to admit the limits of knowledge. The problem is that 
when people are desperate and in great psychic pain, are incredibly self-destructive, 
families and social networks and the patients themselves--- it depends--- often seek help 
even when the experts don't have perfect tools for diagnosis and treatment---because they 
aren't known yet!
As for the status of psychodrama---well, it is important that we not feel too entitled. 
Many other therapies also have blossomed and faded, lacking sufficient empirical evidence 
to justify their use. Some were very time-intensive, costly, and many were under-developed 
regarding any research that determined the proper indications and contra-indications.
       Even psychodrama was problematic through the 1970s, with many then (and still 
today, alas) doing the process with little training. Nor was the field fully mature then, 
nor is it today. There are still new frontiers.
      A number of modifications of technique have been introduced by Kate Hudgins and 
others regarding working with people who are trying to heal their traumas. Many still 
don't know or use these approaches.
         So the field continues to evolve.

   More, since the 1970s some of the more recent developments have arisen to compete with 
psychodrama (and other more popular approaches), so what's more in now is, for example, 
the Dialectical Behavior Therapy of Marsha Linehan (which is skill building and has a few 
areas in common with role training); and of course, the better research-documented 
Cognitive Behavior Therapy. More, many therapists are integrating elements from many 
sources.

   So, Georgia, when was it that you worked in a psych hospital where the "old doctors" 
admired psychodrama, my use of John Mosher's Healing Circle, and my attempts to help the 
clients create therapeutic communities?
When did the new, just out of residency "baby docs" come on board? You said, "In a short 
time, I was threated with firing if I didn't stop psychodrama, and forget therapeutic 
communities." It could be that the key power wasn't the baby docs but the flip that 
happened in the 80s as business managers came to really determine what would be done, and 
medical directors became puppet figureheads rather than leaders. These collaborated with 
the trend towards evidence based medicine in way not that dissimilar to the trend towards 
testing in another institution---public schools. The underlying theme was 
"accountability," and many approaches and professionals couldn't make the cut.

well, that's enough for now. Warmly, Adam Blatner