A. Because it's lost its way. In 1960, when I first went into it, the specialty felt very coherent. But psychiatry, at the time, was being held together by psychoanalysis.

Over the years, psychoanalysis became "the god that failed." At the same time that many psychiatrists became disillusioned with psychoanalysis, they failed to pick up on its humanistic implications, the idea that people, on a one-to-one basis, could help each other. Finally, there's been the unwitting success of medication, which enabled psychiatrists to empty the mental hospitals without really caring for patients.

Q. Has psychiatry "lost its way" partly because of the economics of mental health financing?

A. Oh, absolutely. The states no longer take responsibility for the mentally ill. There's a constant call for
privatizing the care of these people, which is impossible. No one will ever be able to make any money off of this kind of business. It's silly. These people have severe handicaps. Even if they're walking around the streets on Thorazine or whatever, they're still very impaired people.

When I began my training, I couldn't have anticipated the emptying of the mental hospitals and seeing people on the streets. But these are the most disenfranchised of the disenfranchised, and almost no one speaks up for their interests. My own institution, Massachusetts Mental Health Center, which is located on a very prime piece of medical real estate, is constantly threatened with closure.

Q. Why did psychoanalysis become "the god that failed"?

A. I think people became disillusioned with psychoanalysis, because it was, ultimately, a strange way of caring for people. There was this tendency in the psychoanalytic world to imply that everything was psychodynamic.

In my own training, I saw things that seemed cruel and that I believe, partly, led to the downfall of psychoanalysis. Very strange, for instance, was this business of distancing oneself from patients in order to obtain what was thought of as a crucial objectivity. Even stranger was the idea of blaming mothers for what happened to their kids. Or worse, blaming the patients themselves.

This notion that everything was psychodynamic, I think, led to poor patient care. During my years of training, I was told, for instance, to control psychosis with psychoanalysis, which couldn't work.

I was told that I shouldn't give anyone medication, because it would muck up transference. I mean, I was dealing with catatonic schizophrenia people who were really, really crazy.

Then came the revolution of psychopharmacology, and suddenly the pendulum swung the other way. Psychotherapy was down the drain, including the more useful parts, like humanistic psychology and an understanding of the unconscious.

At the same time the field was declining, there have been tremendous breakthroughs in the brain sciences. I want to say to medical educators, "We've finally got what Freud always wanted, the chance to make a psychology based on brain science."

Q. How would you reorganize medical training so that you'd attract better and more students to your speciality?

A. I'd tell them that they have a chance to work on one of the last great medical frontiers, which psychiatry could be. This is a field where they'll have license to talk about psychology and physiology and philosophy, all together. Where else can you do that?

I'd make the courses exciting. There was a professor named Fred Barnes at Brown University who's always said it is astonishing the way psychiatrists had managed to mess up the field and make it unexciting. In his psychiatry courses, he had actors come in and act out these little dramas for medical students. The students got hooked, emotionally, by what they saw. The rest was easy.

Q. Let's return to the clinical part of your work. Considering the state of mental health care, if you were an ordinary citizen with run-of-the-mill health insurance and a teenager showing schizophrenic symptoms, where would you go for help?

A. I would be at a loss. It's devastating. The families watch their kids founder because, in most cases, there's no place for them to go.

I've got a brain-damaged son. He's 40 now, and we've managed well. Part of the reason is that we found good outside help. Ian lives in a group home. He supports himself completely. And he's a happy man. He comes to see my younger children, 6-year-old twins, and he's very involved with them.

Of course, I would have liked a different scenario for Ian, but I feel ennobled by this boy. Every time I see him, I feel better. And this is a feeling that I believe should be engendered in psychiatrists as they care for their patients. I still have patients that I saw in the beginning of my career. With the seriously ill patients, on the whole, they don't stop being mentally ill, but they can do well. They can do better because a doctor cares for them. And you can be clever with the medications, restrained about their use. Probably the most important thing you can do is to give them a sense of human place with you.

Q. The recent film "A Beautiful Mind" has brought issues of mental illness into the public consciousness. As a therapist, have you found it a useful tool?

A. I suspect a lot of people have taken to this movie because it appears in some ways to simplify, even romanticize, mental illness. I know, for instance, someone whose own personal history is very troubled. She's just rhapsodic about it. She thinks of herself as miraculously cured, and she's not.

Most people don't like the reality of mental illness. You can't just say, as some do, that being straightforward with patients will get them well. They don't get well easily, and sometimes they don't at all. What psychiatrists and the patients' families need to do is be straightforward, not abandon the person, not get impatient, not feel like we're a failure if we don't cure them. We're dealing with chronic long-term disability, and nobody likes it. You don't want to have it. And you don't want a family member to have it. But it happens.

bridges4kids does not necessarily agree with the content or subject matter of all articles nor do we endorse any specific argument. Direct any comments on articles to deb@bridges4kids.org.