The couch, the clinic, and the scanner : stories from three revolutionary eras of the mind

Winner, 2023 Choice Outstanding Academic Title Over the past several decades, psychiatry has undergone radical changes. After its midcentury heyday, psychoanalysis gave way to a worldview guided by the Diagnostic and Statistical Manual , which precisely defined mental disorders and their treatments; more recently, this too has been displaced by a model inspired by neuroscience. Each of these three dominant models overturned the previous era's assumptions, methods, treatment options, and goals. Each has its own definitions of health and disease, its own concepts of the mind. And each has offered clinicians and patients new possibilities as well as pitfalls. The Couch, the Clinic, and the Scanner is an insightful first-person account of psychiatry's evolution. David Hellerstein—a psychiatrist who has practiced in New York City since the early 1980s, working with patients, doing research, and helping run clinics and hospitals—provides a window into how the profession has transformed. In vivid stories and essays, he explores the lived experience of psychiatric work and the daunting challenges of healing the mind amid ever-changing theoretical models. Recounting his intellectual, clinical, and personal adventures, Hellerstein finds unexpected poetry in hallways and waiting rooms; encounters with patients who are by turns baffling, frustrating, and inspiring; and the advances of science. Drawing on narrative-medicine approaches, The Couch, the Clinic, and the Scanner offers a perceptive and eloquent portrayal of the practice of psychiatry as it has struggled to define and redefine itself. "This book traces the history of psychiatry through three revolutionary eras--each exemplified by a different model of the mind--which Columbia psychiatrist David Hellerstein has seen over the course of his decades-long career. Each model was meant to organize the brain's unfathomable complexity in a simplified but compelling way. First, starting at the beginning of the 20th century, came the psychoanalytic model and the accompanying icon of the couch. Until the 1960s and '70s, Freudian psychoanalysts still ruled America; the mind could be liberated through free association, by regression, by interpretation of transference, and by patiently working through neurotic tangles. Then, In January of 1980, the Diagnostic and Statistical Manual, 3rd edition, the DSM-III, was published by the American Psychiatric Press. It was more than three and a half times the length of the DSM-II, with 83 more diagnoses--free of psychoanalytic ideas and seen by psychoanalysts at the time as a take-out menu of diagnoses and treatments. This era ushered in revolutionary new clinical treatments and medications. And then, in the early years of the 21st Century, Hellerstein's third decade of practice, yet another new dream began to emerge. We now find ourselves living in the era of the whole human genome, of "personalized," or what was soon renamed "precision," medicine, and the visualization of "task-based" brain center activations by a dazzling array of amazing neuroimaging techniques using MRI and PET scanning machines. Not only that, we are at the first stages of trying to tweak our brains' epigenetics and "retuning" aberrant brain circuits by direct current electricity, or profoundly disruptive drug infusions. We are now immersed in a neuroscience revolution in psychiatry. The sixteen stories that make up the book are autobiographical narratives, written from Hellerstein's perspective as a psychiatrist practicing in New York City from the early 1980s to the present day, a physician who spends his time working with patients, doing research, and helping to run clinics and hospitals. He witnessed firsthand these evolutions of the field: from the couch, to the clinic, to the brain scanner. Mindset documents Hellerstein's own internal battles as explorations of the self, full of wonder and angst and occasional surprising new understanding. And of course, Hellerstein's daily adventures center around the innumerable patients a doctor encounters every day, sometimes baffling and frustrating and often inspiring"-- Provided by publisher Table of Contents 6 Preface 8 Part I. The Couch, 1980–1994 20 1. The Work: Learning to Do Psychoanalytic Psychotherapy, 1980–1984 22 2. Tigers in the Night: A Therapist’s Own Therapy, 1981–1988 38 3. The Enchanted Garden: Psychoanalysis in the Psychiatry Marketplace, 1985 56 4. Dreams of the Insane Help Greatly in Their Cure: Demolition of the Psychoanalytic Mothership, 1994 68 Part II. The Clinic, 1985–2000 84 5. Treating the City: DSM Psychiatry in the Real World of the City Hospital, 1989 86 6. Reinventing the Egg: Translating the DSM Across Cultures and Languages, 1990–1994 102 7. The Red Box: Digging Deep Into the DSM, Late 1990s 117 8. Call: Testing the DSM Off Hours, 1998 127 9. Less with Less: Stripping the DSM to the Essentials or Beyond, 1998–2000 139 Part III. The Scanner, 1997–2023 162 10. Flights Into Health: Learned Safety and the New Neuropsychiatry, 2000–2007 164 11. Curing Families: Genes, Circuits, and the Frontiers of Treatment, 2005–2009 185 12. Off Label: Revisioning Drugs in the Age of Neuroscience, 1997–2023 199 13. Mind Wandering, Then and Now: New Views Over Three Eras, 2005–2023 213 14. Floating Brains and Magic Mushrooms: Ancient Psychedelics Test the Progress of Psychiatry, 2019 to Today 232 Afterword 252 References 254 Index 262