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One patient, chronically depressed, had run through every variety of anti-depressant. "Nothing seemed to be working," says Dean. "Then he told me his father had abandoned them when he was 13, he was made to work, his mom didn't date until he was 18 and then the first man she dated killed her. I went back to everyone who'd treated him, and no one knew that history. I asked him, 'Do you think this could have anything to do with how you're feeling?' and he said, 'No.'"
By then, Dean had come to dread the patients who informed him they had a chemical imbalance -- not because they didn't but because they'd neatly labeled their problems in a way a pill could fix. No longer convinced it could, he left Wash. U. to train at the Institute. It was the first time in decades that a Wash. U.-trained psychiatrist had crossed the moat.
The wall between Wash. U. and the Institute makes it hard for someone like Dean to find his place. But Moritz worries most about its effect on patients, who are forced to navigate the politicized, specialized and stormy waters of the entire profession before they even know what's wrong with them. Is their problem mainly biological, or mainly psychological? Did it start deep in their genes, or do they just not have enough serotonin to carry happy talk through the brain's tunnels? How do they figure out which worldview a particular psychiatrist holds, which language he or she speaks? Will they have to pick a bouquet of different practitioners to get the necessary meds and therapy, with nobody knowing the whole picture at any given time?
Moritz has heard her Wash. U. colleagues acknowledge the importance of a trusting therapeutic relationship -- as long as it doesn't go on too long -- but she's also heard them define the future of psychiatry as decoding the physical mechanisms of the brain. When they talk about trauma, they talk about the genes that predispose people to be abused and how much of personality is inherited ("more than 50 percent," notes Rubin). These are all subjects that can be studied. What Moritz hasn't heard much about is love and hate, unconscious motivations, buried pain, the accidents of life. By looking always for what can be scientifically proven, they confine themselves to the physical mechanisms of the brain and the generalities of genetics. In her mind, that's like trying to describe a beautiful spring day by listing the temperature, the humidity and the barometric pressure.
"What's missing is the human element," she says -- a patient's past, his quirks and motives and associations, the way he's learned to interpret his symptoms. Sure, those symptoms can be categorized, but there's a good chance they'll slosh into other diagnostic compartments or spill out of the container altogether. Wash. U.'s psychiatrists "talk about re-engineering the brain, and there are certainly genetically based illnesses for which that will be an amazing boon," adds Moritz. "But I can't imagine that you are ever going to do away with such things as abuse and neglect. We all know that early traumatic experiences can come back to haunt us, that we relive our worst nightmares over and over again. We believe it in literature and film and drama; we believe it in our own lives. We just disbelieve it when it means we're going to have to spend more money for health care.
"Even expensive medicines are cheaper than a physician's time," she adds. "Two people putting their heads together in a very intense way over a long period of time is expensive. But that is how the brain changes itself: permanent structural changes of the brain and permanent structural changes in one's life."
Stretched out luxuriously on a floral sofa that's never held a patient, Moritz chats with an ease her normal schedule doesn't allow. The air outside her New Orleans hotel room is thick with jazz and bourbon and steamy pleasure, but this afternoon she's caught by the cooler pleasures of the mind, anticipating the American Psychiatric Association conference. As secretary of the American Psychoanalytic Association, a delegate to the American Medical Association and a member of the Missouri State Medical Association's executive council, she arrived early, and now she's poring over an agenda that highlights all the new intersections between neuroscience, psychiatry and psychoanalysis. Even the workshop titles promise synthesis: "Mind Meets Brain"; "Neuroanatomy and Neurophysics of the Unconscious"; "A Neuroscience Perspective on Transference."
The halls already buzz with talk about Dr. Eric Kandel, who won a Nobel Prize last December for his patient work with the sea slug, species Aplysia. A very simple creature with very large cells, the slug allowed him to watch it "learn." What he saw, as the slug experienced the world, was that learning actually reconfigured its brain, triggering new expressions of the genes, forging stronger links between certain synapses. The lesson? The brain is truly plastic, and, with enough time and heat and focus, we can reshape it without depending on drugs. We can make new, permanent connections and pathways. We can change our habits, our associations, even our biochemical responses.
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