Sunday, May 19, 2013

A Most Influential Professor

On the first day of Abnormal Psychology class, The Professor sat on stage, just him with his cane, no notes or Powerpoint. His jowls hung low, giving him a bulldog look. Instead of appearing mean, however, he seemed almost bored, in a wizened sort of way. The Professor began by asking the class to come up with all of the different names that exist in our culture for someone who is "crazy." Students got into it, enthusiastically shouting out dozens of nouns, ranging from the clinical (psychotic, delusional) to the pejorative (nutso, wacko). A graduate assistant wrote all of the words down on a chalkboard while The Professor continued to sit, expressionless. There were almost 50 words on the board by the time people started running out of ideas. "What is the purpose of all these words," The Professor asked us, before answering himself that they are labels, used by those who were "well" or "normal," to define those who were "not normal."

He proceeded to launch into an explanation of his background. "I am an insight-oriented object-relations psychodynamic psychotherapist," he began, and while I had no idea what that actually meant, I was impressed by his certainty. Mental illnesses, he explained, are nothing like physical illnesses. Psychiatric labels are cultural inventions, a "word game" that cannot be separated from the time and the place in which those words originated. "I do not believe in biological reductionism or determinism," he continued, speaking in composed paragraphs to students who were used to hearing bullet points. He lamented how biological treatments have taken over much of mental health, and he told us that we would spend little class time covering conditions like depression, anxiety, or schizophrenia. Instead, he focused on conditions for which there were no medications (at least at the time): Conversion and other somatoform disorders, dissociation, addictions, eating disorders, and of course, personality disorders.

Over the course of the semester, The Professor repeatedly emphasized to us that human traits are on a continuum, even though the DSM tried to fit everything into discrete categories. He used his own dimensional scale to rate each patient on various traits such as impulsivity, neuroticism, and even adaptive regression in the service of the ego. He staged live demonstrations in front of the class in which he interviewed actors trained to portray patients with various psychopathologies; the auditorium was so crowded on those days that I'm convinced he could have sold tickets.

The Professor told us many stories, colorful and memorable. He mesmerized us with tales of 18th century mass hysteria. He lectured authoritatively on the superego lacunae present in those with narcissistic and antisocial personalities, and I could not help but visualize Swiss cheese. He recounted many of his own experiences with patients, especially those with histrionic and borderline personalities, whom he described as very "kiss kiss bang bang." Though I missed the James Bond reference (there was no Google back then), that description still strikes me as particularly apt.

Of course, The Professor was far from infallible. Humility and self-doubt were not part of his repertoire. He was prone to broad generalizations, delivered matter-of-factly: Bulemics were histrionic and attention-seeking, while anorexics had more severe super-egos and conflict with their mothers. Women who were sexually abused as children became obese as an unconscious defense against further advances. People who suffered severe enough abuse could develop multiple personalities as a way of coping. The Professor, after the first day of class, never stooped to acknowledge any other perspectives besides those which he knew to be true.

A friend of mine, who took Abnormal Psychology with a different professor, hated the class because his professor treated the DSM diagnoses as if they were naturally-occurring phenomena like planets or animal species. Looking back on my journey through psychiatry, this was often the perspective of the teachers I had from medical school onward. Therefore, I'm especially glad I had The Professor so early on. He was not a big name at the university, as a clinical psychologist in a department filled with researchers and "cognitive neuroscientists." Yet he has influenced me more than anyone else with regard to how I think about psychopathology and psychiatric diagnosis. In particular, the dimensional system just made sense. The DSM-5 even incorporates some dimensional scales to rate symptom severity, though I was disappointed when the APA Trustees voted down efforts to add a dimensional element to personality disorders in DSM-5.

I also learned from The Professor the importance of recognizing the limits of our knowledge and perhaps why psychoanalysis had fallen out of favor, even though those were not lessons he was explicitly trying to teach.