Coda Intersection Of 20thcentury Forces Leading To A 21stcentury Synthesis

There were periods during the 20th century (e.g., the Freudian era) when psychiatrists interested in the deep dynamics of the mind isolated themselves from a progressive understanding of the brain. More recently, with the neuroscience revolution and the striking molecular successes of biological psychiatry, the converse problem has emerged in some quarters—an excessive separation of psychiatric thinking from any coherent attempt to conceptualize the nature of the mind. Now that our mind inquiries can be supported by an impressive neuroscientific armamentarium, there is promise for ever more impressive docking of brain/mind issues.

Because of such advances, and only because of them, creative psychological approaches, such as those advanced by Freud, can now be tempered with neuroscience, allowing many neglected ideas to be tested rigorously for the first time. For instance, there are many neuroscientific ways to conceptualize repression, transference, projections, repetition compulsions, and various defense mechanisms. With the advent of modern brain imaging and psychopharmacology, revitalized depth psychological theories may point us toward subtle mind issues that can finally begin to be empirically resolved.

However, in cultivating diagnostic precision, we must avoid creating new disorders out of marginal differences. We must avoid constructing Kafkaesque nightmare documents similar to the Malleus Maleficarum that informed inquisitors of the Dark Ages, in great detail, how to identify and find witches. Without diagnostics that are linked to clear and measurable biological underpinnings, the classic tensions between the splitters and lumpers are bound to remain. There are no easy resolutions of the dilemmas such disparate views generate. With the one hand we must aspire to create a diagnostic precision that may be unattainable, and with the other we must help support the humanistic and deeply experienced affective needs of individuals in ways that are often beyond our reach. Only through a creative tension between such perspectives can a balanced synthesis emerge.

In the final accounting, we must invest in variants of the "Meyerian synthesis" by accepting the multidimensional psychobiological nature of individual therapeutic relationships. There is no substitute for the human touch. Psychological existence, of both doctor and patient, is built upon substantive emotional interactions. The life stories of individual patients should not be forsaken, even when managed care insists that simple medications should suffice. The individuality of each person is reflected within his or her unique life encounters, diverse dispositions, and vulnerabilities. Idiosyncratic individuality must continue to be cherished. Indeed, through an increasing understanding of genetic diversity, there may be personalized psychiatric medicines in the future. We may also be better able to identify individuals who can get by on lower doses of psychoactive agent than others, thereby minimizing side effects.

To achieve this, patients should be better educated so they can become more active participants in the evaluation of their holistic treatment plans. Indeed, if new and gentle neuropeptide-based therapies do eventually emerge, we may find that they do not operate well without appropriately supportive social contexts. Such issues will be difficult to analyze empirically, but we should remain open to the likelihood that there will eventually be medicines that facilitate opportunities for people to master the emotional subtleties of their lives. In addition, optimal therapeutic effects may only emerge when patients are encouraged, as in the ancient Greek "ritual purifications," to move their bodies in emotional ways, aided by dance, music, and the other bodily passions and arts.

As we increasingly recognize the actual emotional systems that evolution has built into the mammalian brain, we will better conceptualize the psychobiological nature of mental order as well as disorders. Our emerging knowledge about the biological sources of human nature, along with our traditional human tools to listen and to empathize, may eventually help us to regulate the passions of the mind with a precision that presently seems barely imaginable. Hopefully that will be achieved in the most humanistic way possible.

Acknowledgement

I thank Mortimer Ostow and Jaanus Harro for constructive comments on this chapter. This historical summary also owes a debt to Paul McHugh's state of the field presentation entitled "Beyond DSM IV: From Appearances to Essences" at the 2001 Annual Meeting of the American Psychiatric Association, themes that are also elaborated in his book with Phillip Slavney (McHugh and Slavney, 1998).

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