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chapter six Cease-fire Ending the Psychiatric Civil War In Beirut during the 1970s, Christians and Muslims tore their nation apart in a bloody civil war. There was a boundary that could not be crossed, except at the risk of one’s life-the Green Line; on one side lived Christians,on the other Muslims.For more than a decade, violence ruled. A Psychiatric Civil War The world of 1970s psychiatry was not dissimilar, with physical violence replaced by verbal conflict. On one side of the grand divide stood the psychoanalysts, the Old Guard, with their own informal politburo of leaders; on the other stood the Young Turks, the biological renegades, an “invisible college,” scheming and plotting to take over the profession.What was at stake was not only our understanding of mental illness but, to put it frankly, power (Foucault was partly right here). For decades, one could not be a chairman (women were rarely chairs) of a department of psychiatry without being a psychoanalyst. Patronage of academic jobs, control over training the younger generation, access to university resources and government funds-all these were in the hands of the psychoanalytic profession. In the bi- ological laboratories of the National Institute of Mental Health of the 1950s, some government-salaried psychiatrists began to challenge psychoanalytic dogmas and dared to study the brain in relation to mental illness. This group, headed by Seymour Kety, thereafter expanded its reach when Kety and a group of his disciples obtained jobs on the Harvard faculty and at Massachusetts General Hospital (MGH). The way was paved for them because Stanley Cobb, the former chair at MGH, while supportive of the psychoanalytic approach, also believed in the importance of biological methods. Kety’s arrival in Boston coincided with a gradual disaffection of younger residents with traditional psychoanalytic teaching, as observed at that time in the premier psychiatric residency in the nation, the Massachusetts Mental Health Center (“Mass Mental”). Mass Mental had been headed for decades by Elvin Semrad, a charismatic teacher who had imbued hundreds of residents with his skepticism for diagnosis, biology, and pharmacology and with an overriding belief in the importance of the human doctor-patient relationship (augmented with psychoanalytic concepts). It is ironic that the leaders of the biological Young Turks came mostly from Semrad’s later Mass Mental students (most prominently Gerald Klerman) or across town at MGH from Kety’s new students (most prominently Eli Robins).1 At first, the major centers of psychiatric training and practice (like Washington, New York, Los Angeles, and Chicago) remained firmly in psychoanalytic hands. (To this day,those large cities have notable cadres of practicing psychoanalysts,unlike most other small or medium-sized American cities). Like Mao’s communist revolution in 1940s China, the biological rebels would have to start in the countryside and gradually surround the cities. Perhaps the most important node in the rebellion was St. Louis, where Eli Robins went after his training at MGH to become psychiatry chairman at Washington University. He linked up with a like thinker, Samuel Guze, and trained a cadre of biologically oriented leaders that would remain prominent for decades to come. The Washington University school also produced the first new empirical research on diagnostic criteria, returning to Emil Kraepelin’s basic notions augmented by genetic, course, and treatment studies. Robins and Guze published a classic paper, “The Reliability and Validity of Diagnostic Criteria for Schizophrenia” (Robins and Guze 1970), that might be compared , if readers will forgive the continuing analogies, with a Communist Manifesto for the biological revolution. It remains to this day the core of our conception of psychiatric nosology, of what make a diagnosis valid. In that paper, Robins and Guze argued that because no single gold standard exists to validate clinical diagnoses in psychiatry (brain pathology cannot provide the “right” answers for clini70 The Rise of the Biopsychosocial Model cians), we must validate psychiatric diagnoses using multiple independent lines of evidence. They defined these four categories as symptoms (phenomenology), genetics (family history), course of illness (age of onset, number of episodes, etc.), and treatment response (or laboratory tests if available). (This is a somewhat altered version of their original paper, updated to its current usage.) With these tools, they went about demonstrating that definitions of mental illnesses could be established and tested. This diagnostic research proceeded below the radar screen of mainstream psychiatry , as psychoanalysts went about their business in the 1960s and 1970s, more or less oblivious...


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