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Psychiatry and Society
by Keith Russell Ablow, M.D.
March 1996

A Timid Ear

The healing power of psychiatry depends on the ability of its practitioners to listen for the truth, despite the camouflage of psychological defenses or social mores. Freud's genius was largely the independence of his ear, which allowed him to hear the music of the unconscious mind in a world not yet attuned to it. His gift to modern medicine, like most scientific breakthroughs, required a break with tradition, a stubborn persistence of instinct and intuition over orthodoxy.

We have lost our commitment to receive psychological data that depart from social and scientific convention. We seem so enamored of our new neuropharmacologic respectability that we balk at exploring any out-of-the-ordinary routes to healing that patients tell us relieve their suffering.

Dozens of my patients, for example, have insisted they feel a lasting sense of calm and self-possession after cutting themselves and bleeding. Given that inflicting surface lacerations represents no threat to their lives, they wonder at the insistence of inpatient and outpatient clinicians that they simply must stop.

Is this directive, after all, a scientific one or a moral one? And why haven't we looked in depth at whether periodically cutting oneself -- being cut--could aid in the treatment of affective illnesses? Are we worried whether psychiatry's scientific image can withstand a study in which one group of depressed or borderline individuals is treated with Prozac, and another with a kind of bloodletting?

Even more patients state that the use of laxatives calm them. Might laxatives be an effective treatment for psychological distress? Are we too worried about being laughed at to propose the possibility and rigorously investigate it?

Likewise, psychiatric inpatients, particularly those suffering psychotic illnesses, seem to live for their next cigarette break. Perhaps tobacco--or one of its components--acts as a potent antipsychotic or mood stabilizer. Should schizophrenics who don't smoke be encouraged to start? Can we still ask such a question? Or do politics stand in the way?

Many alcohol-dependent patients I treat insist that without the drug they would have been moved to suicide, that the addiction was a necessary evil during periods of their lives that would otherwise have been utterly unbearable. Is it wise to attempt to detox all  alcoholics? Are there some cases of severe psychiatric illness in which alcohol is the best available treatment?

Studies of patients who sleep with their therapists consistently find that a great majority of these patients consider the experience harmful. But I have yet to see a study that details the thoughts of the minority of patients who considered the interaction helpful. Are there specific situations in which patient-therapist sex is healing? Do we dare raise the possibility?

No. We do not. We have become intellectually timid. We prefer our debates be framed by the synapse, where an Internet of neurotransmitters leaves us as disconnected from the emotional experiences of patients as browsers on a worldwide web of humanity. If we hadn't long ago discovered the power of denial or transference (or even ECT), 1 believe we would miss it now. Our view is getting too narrow to see very much.

Strangely, managed care may be the friend to ingenuity we need. Where the power of intellectual curiosity and the desire to heal has failed to motivate us, the profit motive might succeed. Maybe I'll pitch U.S. Healthcare or Harvard Community Health Plan on the bloodletting idea. It's certainly cheap enough.