Will Psychiatry Survive?

GUEST: Robert Michels, M.D.
VTR: 10/23/2006

I’m Richard Heffner, your host on THE OPEN MIND. And a good many decades have gone by since today’s distinguished guest first joined me at this table.

Then he was Professor and Chair of the Department of Psychiatry at the Cornell University Medical College as well as Psychiatrist-in-Chief at New York Hospital. Later he became Dean of the Medical College.

Now Walsh McDermott University Professor of Medicine, Dr. Robert Michels is University Professor of Psychiatry, Payne Whitney Clinic, New York-Presbyterian Hospital, Weill Cornell Medical College…as well as one of the nation’s most eminent practicing psychoanalysts.

Well, some years back, Dr. Michels joined me here for a program I titled “Psychoanalysis and Its Discontents”. Like most interested but not enormously knowledgeable laymen, I was, of course, aware that there is lots of trouble in Paradise…that perhaps modern psychoanalysis has even more than its fair share of discontents, and that Freud, the father figure, seems at times now quite besieged…though perhaps only as father figures eventually must be.

And now my favorite informant – my dear wife, a practicing psychotherapist herself, tells me that at medical education Grand Rounds recently, Dr. Michels—brilliantly as usual—addressed a series of quite intriguing questions: Will psychiatry survive? Why? Where? How? And I’ve asked him here to share his answers with us. But first, Bob, there’s another question, a kind of snippety one from me. Does anyone care as much anymore?

MICHELS: Well, two groups care. Psychiatrists care a lot, for obvious, but narrow reasons. More importantly, patients care. Psychiatry’s greatest group that care about its survival are the people who need and profit from its assistance. And we know that there are a huge number of people out there who need psychiatric help, who can profit from it, and many of whom who do profit from it.

When the World Health Organization looks at the major causes of disease, disability, morbidity—psychiatric illnesses are right on top. Three of the top 10 in the world. So I think psychiatry will survive because we have a constituency that won’t let us disappear.

HEFFNER: But you seemed in your address, which I had the pleasure of watching and reading in part, you seemed to be saying, “Well, for how long … maybe a hundred years or so.” Why would you even think in terms of…limits?

MICHELS: Well, I hope they’re limits. I hope …

HEFFNER: Why?

MICHELS: Well, the world is very dynamic. Psychiatry is really only two hundred years old. So if it survives for a hundred years that would be 50% longer than its current life span.

Psychiatry begins at the end of the 18th century with the medicalization of a group of people who were seen as strange by the rest of the citizens in the world. And that medicalization led to many things. One is it lead to their humane treatment. Previously, it wasn’t uncommon to see people that today we consider psychiatry patients, who’d be chained in institutions to keep them away from society.

It led to an attempt to study what was the nature of their problems, to describe them. It led to people talking to them instead of jeering at them or reviling them.

And it led to the development of more knowledge about the cause, the course and what factors might influence their disturbances. So it led to treatments. Within a 100 years those treatments were beginning to be…quite effective. We learned that some of them suffered from diseases we could cure.

At the turn of the century before this one…in nineteen hundred … a third of the patients in mental hospitals in this country suffered from the complications of infectious diseases. We largely cure those now so you don’t see them these days. We have some new infectious diseases. But we’ve pretty much cured the old ones that causes psychiatric problems.

We have remarkable new medications. We have great advances in talking therapy. Freud himself only began his work … oh, a 110 years ago or something like that. So that the medicalization led to investigation, knowledge, and the development of socially valuable interventions. That will continue, but as it continues, things become more specific and more narrow.

So there are changes in two ways. One is some patients don’t need psychiatrists because we have such good diagnostic methods and such good treatments, that they can be treated by a general practitioner. Just as a general practitioner today can treat diabetes and many forms of heart disease and arthritis without a specialist.

Other patients have problems that require dialogue, psychotherapy, a relationship with another person. And we don’t need physicians to provide that kind of treatment. They can provide it by non-physician mental health specialists. Psychologists, social workers, psychoanalysts who aren’t physicians. So the field in which psychiatry is essential may be come more specific.

We also have new interventions that may decrease the frequency of many psychiatric disorders. If we can diagnose them before they’re clinically apparent and intervene so they never emerge, we’d have a different world to live in. there are diseases which we can diagnose in utero and therefore in theory…prevent. So we’d expect in the dynamic field that an area of healthcare which may be large at one point in time … if it’s successful … will become smaller.

HEFFNER: Bob, you seemed to be talking about more than psychiatry. You seem to be talking about health generally in terms of the various means by which you feel we will deal with these problems.

MICHELS: Psychiatry is a big segment of healthcare. Everything I’ve said applies to psychiatric illnesses, psychiatric disturbances. Biologic treatments, psychologic treatments, genetic causes, experiential causes so that psychiatric disorders pretty much follow other types of medical disorders in their epidemiology, this distribution, their etiology, the way we do research on them and the treatments we develop for them.

Historically, for a variety of reasons, psychiatric disorders are complex. Fundamentally the brain is a much more difficult organ to study than the liver or the kidney or the heart. But we’re catching up.

HEFFNER: Are we talking about the brain, or are we talking about the mind?

MICHELS: We can’t talk about one without talking about the other. The brain is the organ of the mind, the mind is a way of talking about a series of functions of the brain. Our mind language and our brain language are different languages, but they’re talking about people and people’s experiences that involve … that can be understood in either language, or in either set of reference. So I would say everyone with a psychiatric problem has a brain problem.

I would also say everyone with a psychiatric problem has a mind problem. Whether we can best understand and intervene in this problem by thinking in brain terms or mind terms, is an empiric question and it’s a question that may change with knowledge or over the course of time. So there was a time when the only way we could help certain people was with mind language and we’ve learned that brain language gives us more effective ways of helping them.

But conversely, there are people that we’ve tried to help with brain language and we discover if we ignore the mind aspects of their problems we’re not as helpful to them.

HEFFNER: How has this changed…it’s so amazing to me to listen to you. It always is amazing for me to listen to you because you’re the future always in what you, what you talk about.

How is this going to impact upon what we call medical education?

MICHELS: Well, medical education itself is un … as you know, undergoing major changes. And where medicine is going is as murky, if you look into the distant future as where psychiatry is going. Much of what we’ve learned about the biology of the body has become highly specialized, arcane, and out of the daily kin of the typical physician.

So physicians are frequently in the position of doing the preliminary assessment and triage to decide what specialist is most effective at dealing with the problem that they’ve been able to outline.

Psychiatry is two things in medical education. One is it’s one of those specialties parallel to someone who’s an expert on kidney disease or liver disease. But the other thing it is, is psychiatrists are expert on one of the basic tools of all clinical medicine, which is talking to patients and much more difficult, listening to patients.

Psychiatrists are the people who teach medical students how to conduct an interview, how listen to what the patient says, how to listen to what the patient doesn’t say and find out about that and use that knowledge.

So psychiatry’s going to be central to medical education that involves the basic skill of meeting, finding out about, communicating with, establishing a relationship with and continuing to meet with a patient. And they’re also experts on a number of major disorders that affect our citizens. Those two roles are well fixed in medical education for at least the next few decades.

HEFFNER: Would you assume that the qualities that you looked for as Dean of the medical college—then—are the same qualities that you will look for in terms of this new world of medicine?

MICHELS: Qualities you mean in medical students?

HEFFNER: In medical students. In would-be medical students.

MICHELS: Yes, I think so. I think we’d want someone who is highly intelligent, organized, systematic who works well with others, who can work in this system of multiple people carrying on different functions but collaborating with each other, consulting with each other, referring to each other. That’s one set of skills.

And another set of skills is who can meet someone, who can make them comfortable, who can pay attention to them, who can receive what that person is saying to them and understand it, comprehend it and then who can provide them with knowledge and with advice that will help the patient do better. And both of those skills are vital, and we look for physicians who have both of them.

HEFFNER: And the impact of brain research, let me go back…not to that dichotomy, because you’ve straightened me out on that. The impact of what we now know…and are coming to know more about the brain and how it works. And how it can be changed, and how it can be put to your therapy uses. What’s the effect of that going to be upon the practice of medicine? Putting it in its most general terms.

MICHELS: I think it’s major effect is going to be on the area of medicine that deals with psychiatric and neurologic disorders rather than those general skills of meeting people and communicating with them and receiving their communication. Those general skills, at least for the foreseeable future have to do with mind understanding, rather than brain understanding.

But our knowledge about major psychiatric pathology like schizophrenia or bi-polar disease or obsessive compulsive disorder or our understanding of many of the biologic treatments used in psychiatry like the various pharmacologic interventions that we use and the various kinds of brain stimulation that are being experimented with now. Those all revolve around brain biology and brain understanding.

And our ability to identify the neuro-biologic substrate of psychiatric disorders and the genetic determinants that are one of the sets of factors that lead to those disorders…those revolved around brain biology and the way that the genes map the unfolding of the brain. Those skills should make it possible for us to make more precise diagnoses, to make diagnoses earlier in the course of psychiatric disorders and to intervene in a way which is … has fewer side affects and more direct value to the patient.

HEFFNER: You say “earlier”. How would that come about?

MICHELS: Well…

HEFFNER: Earlier.

MICHELS: …to give an example…we know that psychiatric disorders, the major ones, have a fairly strong amount of genetic determination. In the realm of 50%, 60% of the probability of developing schizophrenia or bi-polar disease reflects a genetic predisposition to it.

For the most part, not a genetic total cause. You can’t tell that somebody will or won’t get a disorder. But you can make a statistical statement about probabilities with a significant amount of value to that statement … prognostic value.

Genetic information is available, in theory, in utero. That means we can make statements in utero about the risks of developing a disorder, just as we routinely do now in medicine about the risks of developing Down Syndrome or Huntington’s Correa … we’ll be able to make similar statements about schizophrenia or bi-polar disease, or others.

HEFFNER: Will we?

MICHELS: Yes.

HEFFNER: You’ll say we’ll be able to, but will we use that ability?

MICHELS: Well, how will we use it to me is the more probable question.

HEFFNER: Okay.

MICHELS: Genetic screening is within the next decade plus. So that’s close on hand. The information we need about which genes determine which probabilities is also close on hand. That creates fascinating human problems.

There’s a sort of myth that we’ll be able to tell whether or not a fetus is normal. And of course the reality is no fetus is normal. Everyone has genes that they’d rather not have. Everyone has a few genes they’d rather not have. Sometimes the choices might be powerful like when there’s a very high probability of a fatal illness developing in the first year of life. Other times the choices might be very subtle … what if we do a screen and we say, “Look it’s almost certain that this person will develop Alzheimer’s disease at age 95”. Well, what do you do with that information?

Much of the time it will be in between. And there are going to be tough choices that people are going to have to make. I wrote an article a few years ago at the turn of the century when we were speculating about what various areas of psychiatry would be like a century in the future. And I said, “We won’t have that many major mental illnesses because we’ll have learned how to prevent them and how to treat them. But we’ll have an awful lot of people with and awful lot of anxiety, concern and anguish about the decisions they have to make because of our new information. And psychiatrists will spend more time counseling people about how to deal with this information than trying to intervene to treat the diseases that would result.”

HEFFNER: Your assumption is that given the presence of this ability to identify future disease, that we’re going to just plow ahead, whatever the social consequences.

MICHELS: That some of us will. And others won’t. And we’ll have …

HEFFNER: Explain that, please.

MICHELS: Well, I mean we haven’t used the word, but clearly one of the things I’m talking about is the possibility of the use of interrupted pregnancy or abortion, as one of the preventive measures when there’s a high probability of a very serious illness. That’s common now again with Down Syndrome. But there are segments of our population that won’t do that and feel it’s wrong to do that.

I don’t see any reason to think that the heterogeneity of our population will diminish in this regard, so I think we’ll see different patterns of approach. I also would suspect that as we have now, that people making either decision will be anguished because they’ve made a decision that they could have made otherwise. And it’s that kind of freedom that makes people concerned and want to talk about their decision and want to share their feelings with others and be helped with those feelings.

HEFFNER: And that’s why psychiatrists will always be with us.

MICHELS: And that’s why there will also be mind doctors as well as brain doctors.

HEFFNER: Are you…when you look forward, when you think in terms of the abilities we are developing to identify the likelihood, the statistical…not necessarily the personal, but then maybe in time, the individual likelihood…does this please you as a scientist?

MICHELS: Sure. First of all I think it’s inevitable, so I think whether it pleases us or not is probably not going to influence…the outcome. The history of our civilization as an inexorable march toward more and more knowledge, and if the knowledge would be seen as valuable by some people, you can be fairly confident we’re going to pursue it and acquire it.

HEFFNER: So you mean we have to bite that apple?

MICHELS: I think so. Literally. The metaphor comes from the original knowledge. I also think that it would be a—a better world in many ways if we had a different distribution of disease and suffering than we have now. I think we can improve the world by getting rid of some of our most—or reducing the frequency of some of our most dreadful diseases. And I also think…I would hate to live in a world where we knew how to do that, but shrank from it for some reason or other.

So it seems to me that if there are ways in which we can advance our knowledge in order to reduce suffering and reduce the incidence of illness and we don’t do that, we have a very, very…um…important problem to face that we’re not the kind of species we’d be proud to be.

This is really a current issue in national dialogue where there are many scientists, most scientists who feel there are avenues of research that would greatly enhance our understanding of disease and suffering that we’re not pursuing for ideologic reasons, probably of a minority of the population.

Do we want to live in a world where that goes on? And I think the answer we’ve seen in the last few years is there’s so many individual groups, states, nations that say we won’t accept that, I would predict that we, as a whole, will profit from the knowledge that’s gained even if some people in our community try to prevent us from gaining it.

HEFFNER: Yes, but then I’ll do the dirty thing I always do when you’re here because I know how well you can handle it. Aside from the ideological differences there…if you were asked…“But, Dr. Michels” what’s the down side of this “brave new world”…what would you say, what would you argue?

MICHELS: Sure there’s a downside. It’s not comfortable to know the future. It’s one of the oldest science fiction plots there is. And knowledge means ability to predict the future. So in varying ways, the more we learn about medicine, biology, psychiatry, any other area of medically related science…the more we’re able to make statements about what’s probably going to happen.

And…there was a…when I was born there was no way my parents could know whether I was a boy or a girl until they had a look. Today it’s routine for parents to know, early in gestation, whether they’re going to have a boy or a girl and we know there are countries in our world where people act on that information in ways we wish they didn’t act. But we can’t turn that back, we have the capacity.

We’re going to have that capacity with genome screening and we won’t be able to turn that back. Every bit of new knowledge leads to anguish and concern about the possible impact of that knowledge. But once again, our history as we absorb it and go on…and the world seems to be a richer, happier place even though there are anguishes we didn’t know we might have a hundred or two hundred years ago.

HEFFNER: I don’t know why, but I don’t thoroughly believe that you believe that. Now is there some…something I’m missing or something I’m reading into that? My own pessimism, perhaps? Your, your, your…your glorious optimism about the future…if we have the capacity to develop this knowledge…we’re going to do it.

But you, yourself, have said we have always been in a position where this brings great pain, too. Could it be that we are now entering a point where, in terms of the moral decisions that must be made we’re not going to be able to face it as easily?

MICHELS: I think that my optimism is related to having a very long term perspective. Short term, I’m not sure we’re going to be happier…we may be less happy. Frequently our knowledge has bought us short term great pain. But long term, we’re always better off. So if we can survive long enough, I think we’ll see the knowledge we’re developing now as something that opened up new possibilities and new pleasures for our civilization. However, the, the problem for our leaders and our citizens is to make sure we survive long enough (laughter) and we overcome the short term problems connected with it.

We will be able to reduce the painful side effects in time. But we have to cope with them during that time.

HEFFNER: And this is one of those things that you end up by saying, “This I believe.”

MICHELS: This I believe.

HEFFNER: So it’s faith. A faith based scientific observation?

MICHELS: All science is fundamentally based on faith in science.

HEFFNER: That’s interesting. On “faith in science.” You mean we’ve done it before and we can do it again?

MICHELS: And our history is for certainly the last four hundred years that over the long run our knowledge has helped up consistently again and again.

HEFFNER: So you want to keep biting that apple.

MICHELS: That’s…I want to turn it into applesauce and enjoy every taste.

HEFFNER: Bob, are there every moments when you feel otherwise? More than moments. Seriously.

MICHELS: I don’t think so. I think there are moments when I’m scared. And I’m aware of…that there are two sides to this. But again I think I’m much more confident for my great-great-grandchildren than for my children.

HEFFNER: I’m…I’m going to put this in stone, Bob. Hold you to it when we come back…maybe next year or maybe 10 years from now, or whenever, I say optimistically.

Dr. Michels thank you so much for joining me again today.

MICHELS: Thank you, Dick.

HEFFNER: And thanks, too, to you in the audience. I hope you join us again next time. For transcripts, please send $4.00 in check or money order to The Open Mind, P. O. Box 7977, FDR Station, New York, New York 10150.

Meanwhile, as another old friend used to say, “Good night and good luck.”

N.B. Every effort has been made to ensure the accuracy of this transcript. It may not, however, be a verbatim copy of the program.