Kenneth Gilbert, MD

Maybe I have heightened interest in blindness as a conversion symptom because I can sympathize with it. Sudden blindness happened to me during a diagnostic attempt to figure out the precise location of my brain bleed, and it left me with permanent right hemianopsia. I know that terrible moment: everything seems to be working fine—and then it is not.

Here is what being treated for sudden blindness was like for me, an experience that many patients with conversion symptoms might share. For 24 hours little flashlights appear as if by magic. Whoever is shining them seems to think that perhaps this time the result will be different than when the last individual shined a light in your eye. Everyone from the nursing aid to the senior neurologist sternly directs you to tell them how many fingers they are holding up. This continues long past the point when you are more than convinced that you cannot see fingers at all. Eventually they give up on finger counting and leave you to settle into the world that you can no longer see.

By the next day your newly discovered blindness is condensed down in their minds to an incidental mention in the morning report. Should you recover from the stroke, as I did, and be assertive enough to get a full copy of your hospital record, you may find that on the morning of the fateful event, the clinical statement is “patient complaining that he cannot see on the right side.” 

 is such a convenient word for the clinician, whose procedure has just rendered the patient with half a field of vision for the rest of his life. 

 suggests that it is really a small thing that the annoying patient is making into some big deal.

So I know the routine of the probing flashlights, and the insistent fingers, and the report that you are complaining. It makes me feel connected with the folks brought to the emergency department (ED) with sudden-onset blindness. Of course, possibilities such as stroke, or tumor, or multiple sclerosis must be ruled out, and flashlights have their role in the diagnostic. But when all those mechanical reasons for malfunction have been ruled out, we sometimes hear that there is no cause found, so it must be conversion disorder.

Conversion disorder is a diagnosis of elimination: when nothing can be identified by scan or blood work, the ED physician concludes that this is a rare case of conversion disorder. The DSM-5 named these experiences 

, which was meant to be less pejorative (not to mention less sexist) than the previous term 

 is from the Greek word for uterus). The word “conversion” is used to convey the sense that forbidden emotional conflicts are being converted to physical symptoms. This comes directly from Freudian explanations about how things work in the mind, and to my knowledge it is the only scrap of Freudian orthodoxy that remains in current psychiatric nomenclature. To me, the fact that DSM-5 is still using language derived from Freud suggests that there is little new thinking about how the brain produces the experience of blindness or, in other cases, paralysis, anesthesia, or seizures.

In a remarkable German study, researchers reported on a unique clinical situation, in which conversion disorder produced blindness in only 2 quarters of the visual field. The researchers were able to detect differences in the electrophysiological indices of visual processing, meaning that there were amplitude differences between the area of visual cortex where vision was occurring and the area of visual cortex where vision was not occurring. Psychodynamic therapy for this patient continued for a year and a half, augmented by a technique in which “a facilitator uses descriptive language intended to psychologically benefit mental imagery, often involving several or all senses, in the mind of the listener.”

The report specified that a great deal of effort went into helping the woman develop her own language to express feelings in a biographical framework. All of this therapy proceeded on the Freudian assumption that physical symptoms were expressions of emotion, but rather than experiencing forbidden emotions, the woman may simply have lacked the words to articulate and identify her own feelings. The woman regained her full field of vision, but the transition from being blind to experiencing full vision involved a period when she could see swirls, and then later periods when she could see clearly for brief periods of time. 

 reported that having achieved full visual field, a re-measurement of the electrophysiological indices found them to be equivalent in all 4 quadrants.

The article contains a graphic of the physiologic measurements of the evoked potential of the cortex response to the non-seeing eye area compared, to the same measurement normal vision area of the eye. There is a clear difference between the 2 traces, with the seeing portion of the eye producing a potential that is about double that which is measured from the non-seeing area. The publisher has not given permission to reproduce this remarkable figure, but 

it may be found online here (see figure 2).

This Schoenfield paper is amazing in several dimensions. Being able to measure electrophysiological activation deep in the visual cortex with such precision is a remarkable technological feat. Identifying a study participant who had blindness in just 2 of her 4 visual field quadrants was a statistical improbability. Even more remarkable (to this American practitioner) was the availability and funding of such high-quality multimodal therapy for a full year and a half.

Current medical education on conversion disorders suggests that the symptoms develop instantly and then resolve quickly, as soon as it is revealed to the patient that there is no medical justification for their symptom. The German article suggests otherwise, as this woman’s vision deteriorated in spite of good ophthalmologic care over a period of 4 years, and it recovered in gradual steps over a period of 18 months.

This study carries forward our understanding of the process and electrophysiological correlates of conversion blindness, but it does not offer any answers to questions such as: What is the body-mind alliance that institutes these changes? Why in this case was the symptom blindness and not muscle weakness or gastro-intestinal disturbance or migraines? Why opposite quadrants and not whole field vision? Even without giving answers to those questions, we are brought to consider that if the body-mind alliance is strong enough to cause this undesired change to happen, why would it not be strong enough in other circumstances to cause desired changes to happen?

Our training in allopathic skills does not carry us to any clear view, and so we tend to ignore the evidence. The body-mind alliance is there, in plain sight, waiting for us to recognize it and for us to use it as a healing tool.

is a community psychiatrist contracting telepsychiatry services to small community mental health centers in the rural area of his state. The author reports no conflicts of interest concerning the subject matter of this article.

1. Schoenfeld MA, Hassa T, Hopf J-M, et al. Neural correlates of hysterical blindness. 

Articles

A case in Germany overturns old ideas about conversion disorders. 

Hidden in Plain Sight

His explanation was clear enough. I was just unable to process what he said. The young man was there for a follow-up outpatient visit, his third since he had been discharged from a 30-day residential substance abuse program. His original ticket to the program had been a short detoxification stay in hospital after an opiate overdose. The overdose had been a close call. The fast action of the paramedic administering naloxone was the only thing that kept him alive.

He was the youngest son of faculty members at a private high school and appeared to have been raised well, in a liberal sort of non-pressured way. Not particularly motivated by his own hopes, he had a bachelor’s degree in fine arts and steady job as a waiter at an east-Asian restaurant. The restaurant’s owner, a motherly figure, gathered the staff together after the restaurant closed for the night and insist that they sit together at the biggest table and consume remarkable portions of the best food as she urged: “Have some more! Have some more!”

This event was perhaps the only socially engaged moment of his week. He lived with a person who he referred to as his girlfriend, but neither of them seemed committed to the relationship. I had noted, but not made much of, the seeming emptiness of his life in prior visits. Even with that caveat, during the prior follow-up visits, I had been able to check all the boxes that represented the agency’s aspirations for his success. He had reported neither cravings nor any sense of missing opiate drugs.

He now described to me his most recent overdose and the experience of coming to consciousness in the ambulance as he was being transported to the hospital emergency department. This time the hospital did not even bother to admit him or notify us that he had overdosed again. Both he and his girlfriend were (to use his term) messing with fentanyl. He was amused at the amazement in my voice when I asked why. “There was nothing good at the movies,” he replied. Yes, they knew that fentanyl was deadly. Still, that risk was part of the fun for them. Not quite as definitive as Russian Roulette, but certainly life-endangering. So, for a second time, his life had been saved by naloxone, which ambulances had only started carrying 10 years ago.

That moment of dumbfounded amazement was my introduction to the opioid crisis, which seems to have only gained momentum since that time. Opioid overdose deaths rose steadily from that date to 2018 when we saw a “

significant decrease … to 46,802 deaths

 Most prognosticators are suggesting that the death rate will rise again as the result of COVID-19, with its emotional stress and enforced lack of productive activity. The medical establishment’s journals and editorials have bemoaned the overly casual prescribing of pain medications as the initiating cause of this great disaster. A regiment of state attorneys general have joined in suits against big pharmaceutical companies for promoting use of high-potency opioids and have impressed juries with their arguments. The accepted story line is that individuals with addiction are being victimized by the availability of opioids in the country.

In my opinion, the media, as well as much of the institutional health effort, has described the opioid epidemic as if it is outside of the larger picture of what some are calling 

. In the year 2018, deaths from heroine (15,000), methamphetamine (13,000), cocaine (15,000), 

 are rising right along deaths due to opioids.

Perhaps it is only a partial truth, but is it possible that individuals who die of these causes do not feel that their own lives are worth protecting? The authorities that society has charged with understanding this rolling disaster are self-motivated and curious individuals who have achieved much in their lives. Is it possible, then, that the existential experience that one’s own life is not worth protecting is so distant from researchers’ experiences that they simply do not or cannot have the imagination to explore this possibility.

 reports: “Emergency department patients who survive an opioid overdose are 100 times more likely to die of an unintentional overdose and 18 times more like to die of suicide within a year than patients who visit the emergency department for other reasons.”

 In addition, “of the 21,080 who were revived from an opiate overdose by ER visit, 368 died within a year of an unintentional overdose,” and another 29 died of what was judged to be an intentional opioid overdose. Other research quotes similar sequences for those revived from sedatives and hypnotics. The conclusion offered is: “patients who survive an opioid overdose, whether unintentional or intentional, should be carefully evaluated for substance use disorders and suicide risk …[and ]… receive appropriate referrals for follow-up substance use and mental health care.”

The previously mentioned study (and many like it) do not explore the possibility that there might be something other than the standard explanation of substance use disorder. Is it not possible to ask whether these individuals are trapped in a world that provides no sense of meaning or engagement for them? Without a sense of meaning or engagement, they might have no reason to protect their own lives and, like the young man who initiated me to this world of despair, would be as happy messing with fentanyl as they would be to go to a good movie in the evening. Spending more money on drug rehabilitation will not move the needle on the death rate for such individuals.

In this conversation I find the pastoral care literature much more relevant than the psychiatric literature. That literature carries the concept of an 

. Orienting systems, or how we think about ourselves, are a specific theme of these Mind-Body Alliance columns. Orienting systems are defined as: “Embedded beliefs and values, perhaps outside of one’s awareness but enacted in one’s practices, especially under stress.”

 The idea of orienting systems is more specifically defined by the psychologist Kenneth Pargament, PhD. I first learned of his work when he presented the Oskar Pfister Award Lecture at the 2009 American Psychiatric Association Annual Meeting.

 His work recognizes that the orienting systems of each individual can be very different. Some are deliberate beliefs that have been taught in formal religious education, but most of them have been informally taught in the school of experience or absorbed by imitation of parents. No matter how a person has assembled their orienting system, Pargament says it must meet 4 criteria

1. Must be complex enough to bear the weight of suffering.

2. Must integrate one’s values and beliefs with one’s actual practice.

3. Must be a flexible enough spiritual basis to cope with stress.

4. Must incorporate beliefs of the goodness of life or goodness of God that foster self-compassion and compassion for others.

The idea that healing from addiction involves spiritual practice is not a new idea. Alcoholics Anonymous (AA)’s

 of makes repeated references to spirituality. In an appendix written shortly after the first edition emerged in 1939, spirituality was explained in this way

Quite often friends of the newcomer are aware of the difference long before he is himself. He finally realizes that he has undergone a profound alteration in his reaction to life; that such a change could hardly have been brought about by himself alone. What often takes pace in a few months could seldom have been accomplished by years of self-discipline. With few exceptions our members find that they have tapped an unsuspected inner resource which they presently identify with their own conception of a Power greater than themselves.

The AA movement continues to be the most effective and most accessible program for alcoholism. Modifications of this format are now widely used for other addictions as well. With the concept of orienting system as our lens, my reading of 

 concludes that the conscious intent of the program was to support individuals in replacing an experience of vacuity with a strong sense of self. I hasten to say not an inflated sense of self, but a self that acknowledges and claims its own scars and wounds. To reflect back to Pargament, a self that is complex enough to bear the weight of suffering, and still claim that life itself is good. Traditional religions, whatever their shortcomings, did convey this sort of orienting system to their adherents. The liberal tradition, wishing to free itself from the baggage of a supernatural lawgiver, appears to me to have not figured out how to sustain the function of incorporating individuals into a functional orienting system.

With some 64,000 individuals dying annually from self-administered recreational drugs in the United States, perhaps the solution lies outside the narrow understanding of medical addiction management, with its focus on dopamine reward systems. Is it possible with our national concern for separation of church and state to work through government funded programs to work on the issue of vacuous lives? Or are we locked into rules that will require us to continue to spend money on things we consider totally secular to deal with a problem that is at base a question of meaning?

This set of columns is titled “Body Mind Alliance: How We Think About Ourselves.” Up to this point I have been referring to how our patients think about themselves. We can, of course, flip the lens and inquire as to how we think about ourselves. What is the orienting system upon which we ourselves rely? Is it not true that we are almost always blind to our own orienting systems and too easily assume that our patients think about themselves in more or less the same way that we think about ourselves? And how is it that we can manage to catch sight of our own orienting system since it is so fully integral to ourselves? Would I have ended up with an understanding of my own orienting system if I had followed the advice of my residency faculty and gone into analysis as my co-residents did? Do we not often lose track of the fact that how we think about ourselves is intensely individual? The parallel to that statement is that how our patients think about themselves is intensely individual and beyond our control or prescription pens. To the degree that we assume the normative nature of our own orienting systems when we talk about deaths of despair, we will altogether miss the main conversation.

is a community psychiatrist contracting telepschiatry services to small community mental health centers in the rural area of his state. The author reports no conflicts of interest concerning the subject matter of this article.

The opinions expressed in this article are those of the author and do not necessarily reflect the opinions of 

What do you think? Do you have an orienting system? Is the field’s approach to treating addiction

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1. National Institute on Drug Abuse. Overdose Death Rates. March 10, 2020. Accessed November 24, 2020. 

https://www.drugabuse.gov/drug-topics/trends-statistics/overdose-death-rates

2. National Institute of on Alcohol Abuse and Alcoholism. Alcohol Facts and Statistics. Updated October 2020. Accessed November 5, 2020. 

https://www.niaaa.nih.gov/publications/brochures-and-fact-sheets/alcohol-facts-and-statistics

3. National Institute of Mental Health. Suicide. Accessed November 5, 2020. 

https://www.nimh.nih.gov/health/statistics/suicide.shtml

4. D’Arrigo T. Risk of suicide, unintentional death soar after nonfatal overdose. 

 Journal of Psychiatry. 2009;167(2)226:232. Accessed December 15, 2020. https://ajp.psychiatryonline.org/doi/pdf/10.1176/appi.ajp.2009.167.2.226

7. Pargament K. Spirituality: a pathway to posttraumatic growth or decline? In: eds Calhoun L, Tedeschi R. 

Handbook of Post Traumatic Growth: Research and Practice

Drug use is not only a consequence of addiction. It can also be a response to a deeper, existential problem. 

Dying Without a Dream

Placebo: a harmless pill, medicine, or procedure prescribed more for the psychological benefit to the patient than for any physiological effect.

Nocebo: a detrimental health effect produced by psychological or psychosomatic factors, such as negative expectations of treatment or prognosis.

The mom said very little as I interviewed her teen-aged son, but her active eyes let me know that she took in everything that had been said. By the end of the assessment I was clear that this set of complaints did not line up with any usual diagnosis and was processing my list of medical illness that can masquerade as psychiatric issues. I needed lab work to take the next step but as is often the case in this rural part of the country I anticipated that the family would not have insurance to cover it. (Details of this case have been changed in respect of personal privacy, but the situation as described represents the clinical challenge.)

I handed the mom my lab requests and had started to explain where I thought the work could be done at least cost. She folded over the lab order and placed it thoughtfully in her purse, and then mentioned to me that they appreciated my effort but the family was going to pursue “natural” therapy to see if that might be useful. She named the product they would use. I pivoted into my “we will support whatever modality you decide to use” comment, and things were left in suspension as they left without making a follow up appointment.

That evening I did a quick web search to discover just what she had been talking about when she said “natural” therapy. My web search revealed that she was referring to an apparatus operating with a name that is printed out to look very much like the logo of a recognizable nation-wide laboratory service. The apparatus consists of 2 metallic handgrip bars that vibrate slightly and a set of blue lights that dance in various patterns in front of the person. While holding onto the brass handgrips, electronic sensors are said to detect something called energy signatures, and the online explanation reports that it detects 40,000 medical abnormalities. The product website includes a small disclaimer that the product “does not diagnose, cure, prevent or treat disease.” It further notes that those with a medical condition or concern should consult an appropriate health care professional. These statements are obviously meant to protect the company from any sort of legal liability. The problem, of course, is that the individuals who are making use of this product see the ream of “data,” not the disclaimer nestled on the bottom on the homepage.

I later got in touch with the family and asked for a copy of these results. The data print out covered more than 10 pages of supposed indicators, and I specifically noticed that the printout did not include the small disclaimer that was on the website.

I strongly suspected that there was a treatable cause for this young man’s symptoms, and doubted that it should be thought of as a psychiatric syndrome. I thought that he needed something much more substantial than a read out of the “energy signatures” of his body.

At the same time, you can see the attraction to the family of the “natural” evaluation. On the one and the patient’s family has Dr Gilbert, who looks worried, says he does not really know what is going on, and orders about $400 worth of lab work during the very first appointment. On the other hand, the family has the confidence of a local unlicensed practitioner/purveyor of this product who comfortably assures the family that he can quickly and inexpensively determine the problem and recommend a set of “natural” remedies to address it. After 4 or maybe 5 treatments, or perhaps a recommended course of supplements that he will be glad to sell them at a special discount price, all will be well. His fee is a lot less than $400.

I think I can say that this fancy apparatus offers a high-tech method to create a placebo effect. Harvard researcher Ted Kaptchuk 

 and makes the point that “the placebo effect is more than positive thinking—believing a treatment or procedure will work. It’s about creating a stronger connection between the brain and body and how they work together.” He continues, placebos “have been shown to be most effective for conditions like pain management, stress-related insomnia, and cancer treatment side effects like fatigue and nausea.”

 Other researchers have shown that, properly used, placebo is not only as effective as opiates for some categories of pain, but apparently involves the same brain receptors as opiates do. Having used appropriate mind-body methods for alleviating pain, the subsequent administration of naloxone resulted in pain return just as it does when pain has been managed by opiates.

I want to be respectful of the placebo benefit, although the phrase can imply a worthless remedy, sold by a shyster. Of course, I need to stay centered in my own training and tradition as an allopathic physician. That training appropriately emphasizes the role of the scientific method to prove that something works. At the same time, I am humble enough to know there are other healing traditions that make other assumptions about causes of illness. Science is very important in my tradition, but science does not yet explain everything, and given the millions of visits that are made annually to non-allopathic healers in the United States, we have to conclude that they provide relief that is valued even if we do not understand how that happens.

There are several healing traditions that appear to rely on what allopathic medicine calls placebo:

—American Metaphysical Health Movement: Phineas P. Quimby (1802 to 1865) invented this approach to illness that is now carried on in a movement. It persists today in groups such as Christian Science, Unity, and Divine Science, all of which continue to serve a large following.

 At the time of its inception, this treatment option may well have gotten overall better results than the standard medical options of the day.

— Indigenous medicine: Notwithstanding the role that herbal preparations may play, virtually all indigenous medicine applies spiritual insights to their healing capacity through ritual and often community support.

: With no disrespect to its practitioners who have explained its theory of body energy to me, I hold that Reiki is a placebo strategy.

: chiropractic practitioners in my experience apply placebo in addition to physical manipulation and (generally excellent ) history-taking.

 Since there are thousands of chiropractic visits annually in the United States, we must acknowledge their healing benefit. Practitioners of allopathic medicine are quick to point out that there are a few individuals who are permanently paralyzed every year from an 

 Allopaths cannot be too smug in this observation, however, since by comparison, the favored allopathic treatment for headache (nonsteroidal anti-inflammatory drugs) account for about 7500 deaths per year in the United States.

Somewhere in this conversation, we have to recognize that traditional, organized religious practice brings many of the benefits we attribute to mind-body therapies. A 10-year study of individuals who stated that religion was very important in their lives had one-tenth the frequency of depression compared with those who said religion was of no importance in their lives.

 A 16-year study involving almost 150,000 women revealed that those who attended religious services more than once per week experienced 33% lower all-cause mortality compared with women who had never attended religious services.

 Religion has been providing guided imagery, as well as therapeutic suggestion, meditation, and some forms of hypnosis for as long as we can track back through recorded history. Of course, there are many problems with a psychiatrist promoting specific religions to patients, but we certainly should support our patients’ proposals to make use of their own religion as a healing modality.

Challenged to participate in multi-modal care

Let me return to my teenaged patient being assessed with flashing blue lights and vibrating grip bars. The conversation about how to proceed presented obvious challenges. I attempted to respect the potential placebo effect, but at the same time perform my medical duties in an ethical way. There was yet another layer of complexity to the conversation, because this family belongs to a religious community that selectively uses allopathic medication, but does not enroll in individual health insurance programs. If there is an expensive diagnostic course, paying for it will involve communicating the whole process to the bishops of the community, who will have to agree that the costs of assessment and treatment will be borne by the community as a whole. My experience in the past is that the bishops of a particular community can be both very wise and very unpredictable. Getting them involved in an illness with vaguely defined symptoms would be a challenge, yet once involved I had found community support to be unwavering and I have to respect the research that points out that those for whom religion is very important have substantially better long-term outcomes than those who report no active religious involvement in their lives.

The clinical challenge is to proceed in a way that is respectful of the family’s experience of the mysterious electronic apparatus, but also allows the family to recognize this is not the most productive route for their son’s illness. As of this writing the family has dispatched their son to a residential program which purports to be based on “natural” healing. But they have left me with a very specific internal dialogue about the role of allopathic physicians in a multi-modal health care world. I will expand on that dialogue in the next column with an exploration of how Cognitive Behavior Therapy is part of the conversation of how we think about ourselves.

The opinions expressed in the interviews are those of the participants and do not necessarily reflect the opinions of Psychiatric Times.

1. The power of the placebo effect: treating yourself with your mind is possible, but there is more to the placebo effect than positive thinking. Harvard Health Publishing. Accessed August 15, 2020. 

https://www.health.harvard.edu/mental-health/the-power-of-the-placebo-effect

2. Colloca L. How do placebo effects and patient-clinician relationships influence behaviors and clinical outcomes? 

. Southern Methodist University Press; 1987.

4. Kaptchuk TJ. Placebo studies and ritual theory: a comparative analysis of Navajo, acupuncture and biomedical healing. 

5. Reiki(“RAY-kee”): “A Japanese form of energy healing believed to have originated in the late-19th century. Reiki centers on the manipulation of ki, the Japanese version of chi. Rei translates to God’s Wisdom or the “Higher Power" and Ki to “life force energy.” Reiki is the “spiritually guided life force energy.” Reiki is based on the belief that when spiritual energy is channeled through a reiki practitioner, the patient's spirit is healed, which in turn heals the physical body.” Medical Definition of Reiki. MedicineNet. 

https://www.medicinenet.com/script/main/art.asp?articlekey=31106

“A health profession concerned with the diagnosis, treatment and prevention of mechanical disorders of the musculoskeletal system, and the effects of these disorders on the function of the nervous system and general health. There is an emphasis on manual treatments including spinal adjustment and other joint and soft-tissue manipulation.”

Definition of Chiropractic. World Federation of Chiropractic. 

https://www.wfc.org/website/index.php?option=com_content&view=article&id=90&Itemid=110

7. Perrine J. The Dangers of Neck Adjustment. 

 April 16, 2007. Accessed September 15, 2020. 9/15/2020. 

https://www.self.com/story/chiropractors-causing-strokes

 M, et al. Religiosity and major depression in adults at high risk. 

9.Li S, Stampfer M, Williams D, et al. Association of religious service attendance with mortality among women. 

A psychiatrist steeped in the scientific method considers the healing power of the placebo effect.

Acknowledging the Place of Placebo

I passed the boards in 1985. That means I am grandfathered into a system that required you to pass the boards once and then never made you take them again. To those who chafe under 

Maintenance of Certification requirements

, that may seem idyllic. But let me tell you, I am intensely aware of all that I have had to learn since residency.

Think for a moment about what residency was like in the early 1980s. Is it possible to imagine a psychiatric residency that existed before Prozac was invented? Along with my fellow trainees, I had no idea what a computerized tomography (CT) scan or magnetic resonance imaging (MRI) might be. Our residency director had to fight hard to incorporate the radical approach to therapy called cognitive behavioral therapy (CBT). As trainees, we were certainly expected to have read all 182 pages of the DSM-II (the DSM 5 comes to 816 pages without the glossary and tables in the back), and I recall I was the only member of the residency group who was not in psychoanalysis. Consider those facts for a moment, and you will have some idea of how psychiatry has changed since I entered the field and how much I have had to learn.

As a psychiatric grandfather, I am the product of sweeping advances, as well as some therapeutic catastrophes, that have happened over the lifetime of my generation. I was already in practice when posttraumatic stress disorder (PTSD) was rarely considered a psychiatric diagnosis, except in cases of military combat. Medical marijuana was considered an anarchist’s fantasy. The idea of multi-generational 

 was a common topic of academic study, and the services and institutions that had been established to treat the victims of that trauma collapsed under the weight of multiple lawsuits. I was only in mid-career when the American Psychiatric Association (APA) figured out that being gay was not a mental illness. The flowering of so-called second-generation antipsychotics started with risperidone, and I can remember when $7 a tablet seemed utterly beyond comprehension and forever out of reach of my patients on Medicaid. For four-fifths of my years as a psychiatrist, I was paid at 60% of the rate that primary care doctors received, because the idea of parity was considered impossibly idealistic. Even the insurance offered by the APA to its own members did not cover psychiatric services at parity, and when I wrote to the insurance manager to point that out, I was told that it was just impossible to imagine such a policy.

I learned some things about psychiatry almost as soon as I could walk. I have very clear childhood memories of walking past the units for disturbed males at Kalamazoo State Hospital. These 3-story buildings had open porches facing the road and behind each porch were dozens of mostly naked men groaning and shouting. I was 3 years old, holding on tightly to my mother’s hand as we walked to visit my grandmother who was, thankfully, usually on the quiet women’s unit. It was years before her life was changed by the miracle of Stellazine, but she never left the state hospital.

In parallel with sea changes within the discipline of psychiatry, my own life has been blessed with a career that spanned many different settings. In all these settings, I've been a front-line clinician, always loving the challenge of seeing patients myself but never interested in academic psychiatry or administration. Shortly out of residency, I served on the staff of a state hospital and briefly as medical director, and later as an international graduate trainee in the British Health System. I lived in a village in West Africa and organized a health program for all the villages in the district. I have been employed as a contract psychiatrist in a state prison system (see the columns “Working on the Inside” from that segment of my life) and been self-employed in solo office practice, specializing in trauma—ie the folks who other psychiatrists refused to see because they would not deal with self-injury. I have worked as an inpatient psychiatrist who was on call every third night and expected to make rounds 7 days a week. I carried a practice of several hundred adults with intellectual disabilities living in 16 bed community housing settings—about two-thirds of whom carried a second diagnosis of psychiatric disorder. For several years I managed dual diagnosis clients in a major substance abuse program. I was a contract psychiatrist for a residential program that housed persons with serious mental illness, folks who 3 generations previously would have been confined to the chronic ward of the state hospital where my grandmother had lived. These opportunities have been woven into my life, almost always alongside at least 1 contract as the psychiatrist for a community mental health agency.

I retired once when I was 55. It might be more accurate to say I was driven out by the heavy-handed ways that managed care constrained pharmacy costs. My retirement did not last, and I returned to work, even though I had had a brain bleed at age 64 and was still having visual hallucinations. I retired again when I was 70, but again I have been drawn back into psychiatry. I continue to work today, albeit mostly via telepsychiatry connections. The technology allows me to work despite the fact that the brain bleed left me with right hemianopsia, so I am not able to drive a car to the clinics where I work.

I am a person who is always curious, and for some reason a 

 article, reporting work done by the Harvard researcher Ted Kaptchuk, led me to reflect on all the ways that body and mind are linked.

 As psychiatrists, we often send our patients to practitioners of CBT, which is the disciplined evocation of mind-body connections. Our training prepares us to think in terms of the allopathic principles of scientific intervention and the mechanics of the brain. The stated purpose of our professional organization is to promote “scientific psychiatry” and it is eager to claim allopathic parity with the other “scientific” branches of medicine, such as cancer surgery or procedural radiology. Perhaps because of that interest in being recognized as fully allopathic, in our day-to-day work we mostly ignore all the ways we know mind and body are linked.

I am proposing to organize a series of columns that tracks the mind-body relationship. This reflection for me started with Ted Kaptchuk’s research on placebo effect.

 I have extended it in my own mind to think about how it is relevant in the way we conceptualize what is going on when thousands of people knowingly ingest fentanyl and similarly dangerous substances as part of their recreational choices. I believe we can also appropriate work of some cardiologists, who have begun to explore the implications of mind-body linkages.

As a way to begin the reflection, please consider with me the problem of high placebo rates in recent drug trials.

 Notwithstanding legitimate concerns that among paid trial participants, there may be some who were convincingly claiming illness as a ticket to get into the program, placebo rates of30 to 40%

seem striking. Drug companies value these studies because they certify that their medication is worth hundreds of dollars a month, as opposed to self-healing, which would presumably cost the patient nothing. Among those who are considered by researchers to be “placebo responders,” there many who are really improved. They experienced good or great benefit from the treatment. The drug trial protocol will dismiss this placebo effect as a problem to overcome. Of course, the drug company wants to draw our focus to the benefit beyond the placebo effect, because they want to prove the effectiveness of their product in order to make a profit There would be no profit in proving that placebo effect works.

If we as a community of outpatient psychiatrists want to know how to get people who are disabled back on their feet and well again, should we not be very interested in something that works 50% of the time at a price the patient can afford? From my perspective that question holds a lot of interest. I hope you will join me in coming months as I pursue this and similar reflections on how we think about ourselves.

1. Greenberg, G. What if the Placebo Effect Isn't a Trick? 

. Nov 7, 2018: Page 50. Accessed 10/1/2020.

2. The Power of the Placebo Effect: Treating Yourself With Your Mind Is Possible, but There Is More to the Placebo Effect Than Positive Thinking. 

. May, 2017. Updated August 9, 2019. Accessed September 25, 2020.

3. Sonawalla SB, Rosenbaum JF. Placebo response in depression. Dialogues 

A Psychiatrist Looks Back on His Career and Considers the Role of the Placebo Effect in Treatment.




Kenneth Gilbert, MD

Articles

Hidden in Plain Sight

Dying Without a Dream

Acknowledging the Place of Placebo

Reflections on How We Think About Ourselves