ROBERT MICHELS
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they sedate people who are psychotic, but they don't work as sedatives in
people who aren't psychotic. They are "normalizing," anti-psychotics
rather than general depressants. We have drugs that aren't really stimulants,
although they stimulate people who are depressed and make them feel
more normal. We have other drugs that have minimal effect on normal
people but quiet manic patients and seem, therefore, to have a rather spe–
cific anti-manic, but not sedating activity. More recently we have developed
drugs that have specific effects on obsessive-compulsive disease, on specif–
ic aspects of schizophrenic syndromes. So the modern psychiatrist has
therapeutic choices. Should I give a patient psychoanalytic therapy, or one
of these various medications which might help their disease, or only pro–
vide them with humane care?
We also have a number of people who, intrigued by the potential of
psychoanalysis and psychoanalytic therapy but troubled by its relative fail–
ure in treating the major severe mental illnesses, have developed
psychotherapies which are psychoanalytically flavored but not really psy–
choanalytic. Some are not designed to deal wi th the totali ty of the person
as psychoanalysis is, but rather to treat specific disorders, such as major
depressive disorder, panic disorder, or obsessive-compulsive disorder. Such
treatments may be more effective for these specific disorders than psycho–
analytic psychotherapy is. As a result, a contemporary psychiatrist who has
seen a patient has a more complex set of choices to make: should the
patient be analyzed or get psychoanalytic psychotherapy, should he/ she
receive one of the four or five different kinds of medication now available,
or should we prescribe one of the psychotherapies which isn't analytic, but
which borrows from analytic ideas and is designed to treat a patient's spe–
cific disorder. This also means that it is much more important to be specific
in that ini tial assessment and to determine the diagnosis. In 1955 the treat–
ments for mania and schizophrenia were identical. There was no need to
worry about the precise diagnosis, because it didn't make any difference.
In 1997 the treatments are entirely different. We become extremely
concerned about the precision of differential diagnoses. Similarly some of
our psychotherapies today are quite specific. The diagnostic and appraisal
process has become more complicated than it used to be.
So what do you do in 1997? You meet patients, find out what's both–
ering them, ask them about their problems, get all the history you can
about the problems they've had before, find out which problems have been
in their family, not only because families are important to people, but
because we have a much more sophisticated appreciation of the way in
which some psychiatric problems run in families and therefore we can
make a more accurate diagnosis if we know what problems their fathers ,
mothers, aunts, and uncles had. You determine whether they have a major
