A New Book From An Expert Psychotherapist

 

I first became aware of Mardi Horowitz’s work when I was researching adjustment disorders many years ago.  As an acute care psychiatrist that is one of the disorders that ends up on your unit that you must separate from severe mental illnesses and significant risks.  I wanted to do more than just make the diagnosis.  I also wanted to assist these folks with psychotherapy that might prove useful, even if I ended up discharging them the same day.  Dr. Horowitz has written extensively about that and many other topics.  I decided to buy his recent book Clinician Technique in Personalized Psychotherapy.  In the introduction he mentions watching decades of watching psychotherapy videotapes and trying to figure out what helped people change. 

In the forward by Roberta Isberg, MD – she mentions that therapists might see something in the book that they have been doing in practice for years.  That happened to me when I read the Chapter Confronting Dilemmas by Assertion of the Therapeutic Alliance.  In fact, I had mentioned this intervention just a few hours earlier in psychotherapy seminar that I coteach. In that seminar I discussed how making the therapeutic alliance explicit could be useful in resolving impasses.  Dr. Horowitz’s chapter uses a dyadic diagram of the therapeutic alliance (p. 103) that is good in that it delineates the roles of both the patient and the therapist and what the expected exchanges might be.  For example, the patient is disclosing and focused on problems while the therapist is intervening, supporting, and emphasizing adaptive changes by the patient. 

Dr.  Horowitz also presents a table of Common Dilemmas for a Psychotherapist.  He defines dilemmas as binaries where both poles are unlikely to be helpful.  A common example is encouraging further elaboration of a problem that the patient may find very problematic in terms of external relationships, the relationship with the therapist, or longstanding internalized patterns of thinking and behavior.  In the table he presents ten common dilemmas, the therapist’s intervention, and how it might be interpreted.  In the case of these dilemmas, he suggests clarifying the situation and trying to reach a middle ground:  “ The middle ground between the binaries of the dilemma may be reached if the therapists state the properties of the periodically experienced therapeutic alliance.” (p. 100).   

I thought I would present a frequent acute care dilemma as a vignette, but before doing that borrow another definition from Dr. Horowitz.  That is the idea that the vignettes are fictionalized composites of multiple therapeutic encounters.  In the case below it is hundreds of encounters:

Patient: “Are you the one holding me here?  Are you the one I have to talk to to get out of here?  I want to be released as soon as possible.”

MD: “I am the person who will make that decision….”

Patient: “Well what’s the hold up?  You can’t just keep me here.  There is no reason why I should be sitting in this hospital.”  

MD: “I will do what I can but I have to be able to make an independent assessment in order to do that….”

Patient: “Look – I don’t care about that.  You have no right to hold me here.  I want to go home right now and you are in my way.”

MD: “OK – this is the first time I am seeing you. None of the people who brought you to the hospital or admitted you to my unit have been in touch with me.  I have nothing to do with who is admitted to my unit and in fact have been told that I am supposed to discharge people as soon as possible.  But I can’t do that unless I am fairly certain that they will be safe….”

Patient: “So you’re just covering your ass doc?  Really?  You are just worried about getting sued?”

MD: “I am not worried about getting sued, but I do worry about not getting people the assessments and treatment they might need.  The way this is supposed to work is that you and I talk about what happened and try to determine if you have any problems that I can help you with. It is not me against you or you against me.  It is you and I working on an agreed upon set of problems.  Do you think we can do that?”

Patient: “I suppose…”

MD: “OK let’s give it a try.”

This is an example of a situation that many physicians find impossible to approach because their authority is questioned and the potential for escalation.  That escalation depends largely on the physician not taking the critical comments as a personal attack but rather as a process issue.  It requires the ability to remain neutral in addition to confronting the dilemma and establishing a middle ground to proceed on. This skill is critical in acute care psychiatry as well as in crisis outpatient situations.  And before I get too grandiose like all things in medicine there are no guarantees – only probabilities.  There are situations that will rapidly escalate out of control despite your best efforts – but in my experience they are rare.    

There are many other dilemmas facing therapists during assessments and in ongoing therapy.  More common examples arise from the situation where the patient is reluctant to disclose the details of certain events or has expectations of the therapist that are not consistent with the reality of the therapy situation.  The standard cinematic approach of reflecting the problem back to the patient (“well how do you feel about that?”) is generally not an optimal response and it is one that most people see as cliché these days.  Clarifying what is going on in the room and in the therapy is probably a better strategy.

I have written about the therapeutic alliance in several areas on this blog. Here is a post from 2012 and 2017.  I also posted diagrams of the therapeutic alliance in those posts and include my most recent modification below.  In the diagram I am using MD as the therapist since almost all the therapists I interact with are psychiatrists or psychiatric residents, but it also applies to non-physician therapists.

 

I use a tripartite diagram to highlight the problem space as being a specific focus of patient and therapist since it is the combined process of what is happening in the therapy rather than the isolated process of either person.  Some authors write about this as intersubjectivity (2) or the result of the interaction between two unique conscious states.  Most physicians are taught to observe and record findings from an objective third person position.  The exception is psychiatry where subjectivity has recognized value and the importance of the physician-patient relationship is emphasized.  

Intersubjectivity provides a more comprehensive look at what happens in the therapeutic alliance than seeing the interaction as orchestrated solely by an objective therapist.  The therapist and patient have complementary roles.  For example, empathy is a critical dimension of the therapeutic alliance and a critical skill for the therapist.  Empathy is also required on the part of the patient and its presence can be palpable to varying degrees.  Does the patient really understand what the therapist is trying to do?  Does the patient experience the therapist as a person who is trying to be helpful?  Intersubjectivity does not reduce the value of traditional concepts like transference and countertransference.  Both can exist in this intersubjective space.  It provides a more comprehensive framework for understanding.   

Intersubjectivity has developmental origins, is considered adaptive from an evolutionary perspective, and therefore most people have it to one degree or another. An exception might be autism where the absence of an intersubjective process has been considered as a deficit or a defense.  Along the same lines varying degrees of severe mental illness can impact it.   

In a therapy session, the process and content of the session are co-created rather than being dependent on the therapist.  As the therapy progresses the process may be more important than the content.  This is an obvious departure from criteria based diagnoses and highlights the social determinants of the problem. The underlying assumption of how the mind operates on an intersubjective basis is that the primary goal is to form object relations or real relationships and their internalized representations. That differs from some other assumptions of mind goals such as discharge for pleasure.  Like many technical terms used in therapy there is often confusion based on how they are used by different authors.  For example, when I have written about empathy on this blog I have used Sims very precise definition (par. 10). In the chapter I have referenced here, Stern suggests that intersubjectivity subsumes many dimensions including all the imprecise definitions of empathy, sympathy, and mind reading as ways to appreciate the subjective experience of another.  To further complicate matters, there are other descriptions of this phenomenon that are difficult to separate.  One is folk psychology which is defined as the intuitive way people understand and predict the behavior of others. Folk psychology (3) could be seen as the result of a long series of intersubjective encounters – the success of which will depend on both the quality of the interactions and the inherent properties of the subjects.

Before I get too far afield, I will add a brief comment about confusion over the objective and subjective in psychiatry. When physicians start out, the objective is highly valued.  What are the reproducible elements of diseases and treatments? Physicians leave medical school with a sense of medical science being like any other science until they start practicing and realize they are seeing hundreds of conditions that defy description and standard treatments.  In psychiatry there has been an historic move from an attempt at the highly objective approaches of the late 19^th century to the subjective wave of psychoanalytical dominance and back to the attempted objectivity of brain-based precision psychiatry.  That pendulum swing is more rhetoric than reality.  The reality is that in psychiatry we are privileged to work with the most complex organ in the body.  The brain has an obvious complex physical basis and an equally complex psychological basis.  Both must be understood as completely as possible.  That is difficult in that it takes a lot of time and effort – but that is the job.

On a practical note, what about the rest of the book and should you buy it?  I was pleasantly surprised to find what I have done for decades was recommended by an academic psychiatrist who is an expert in the field.  I am certain that most people who have been engaged in providing psychotherapy will find the same thing.  The overall advantage in this book is that it is an information dense text of 115 pages with additional pages for 84 references, an index, and a glossary.  It is set in what appears to be 10-point font and you can read it in one long sitting.  There is no elaboration on the history and technical details of schools of psychotherapy.  The chapters are matter-of-fact and straightforward. Every concept has a concise definition and definitions are added as needed as footnotes on the respective pages.  Since the author is a psychotherapy researcher there are some unique conceptualizations and jargon contained in the book.  There were well explained and not an impediment to understanding.  

The model of therapy described is described as an integrative cognitive-psychodynamic approach that consider both conscious and unconscious elements.  He takes the secret handshake elements out of psychotherapy by clearly stating what he is doing and providing many clinical examples.  When therapists are starting out especially in psychodynamic therapy – the goal of therapy is often not very clear.  It can seem like therapy hinges on definitive interpretations of unconscious wishes and the residuals of past interactions.  Even when a therapist gets to the point where they feel more competent to make those interpretations, they may be skeptical of their accuracy and concerned that they be trying to convince the patient to accept an inaccurate interpretation.  Dr. Horowitz is very clear that interpretations are not necessary for change and reviews several cognitive and behavioral interventions that can be useful. I counted about 39 of these interventions in the obvious places, but there are probably more.  In some spots it assumes that the reader has working knowledge of basic behavioral interventions (breathing techniques, relaxation, etc) for application in the early stages.   

This method of therapy – supportive interventions used initially and intermittently in association with more interpretive therapy is often not explicit in therapy texts, but I am convinced that it is the norm for people who learn psychodynamic therapy and apply it outside the context of psychoanalysis.  There are clearly times when people being seen strictly for therapy or psychiatric treatment are in crisis and need supportive interventions for stabilization or to assist them toward an intersubjective state consistent with more exploration and interpretation.

 The book benefits therapists at both ends of the training and practice spectrum.  If you are starting out – it is a good overview of the topics and skills that you need to provide psychotherapy.  If you have been working in the field for years or decades, it leads to reflection on what you have been doing, whether there is potential for improvement, and how what you are doing fits into the general scheme of things.

Either way Dr. Horowitz does not disappoint.     

 

George Dawson, MD, DFAPA

 

References:

1:  Horowitz MJ.  Clinician Technique in Personalized Psychotherapy.  American Psychiatric Publishing, Inc, Arlington, VA, 2025.

2:  Stern D.  Intersubjectivity.  In: Person ES, Cooper AM, Gabbard GO. The American Psychiatric Publishing Textbook of Psychoanalysis.  American Psychiatric Publishing, Inc, Arlington, VA, 2005, 77-92.

3:  Hutto, Daniel and Ian Ravenscroft, "Folk Psychology as a Theory", The Stanford Encyclopedia of Philosophy (Fall 2021 Edition), Edward N. Zalta (ed.), https://plato.stanford.edu/archives/fall2021/entries/folkpsych-theory

 

An MGH Case For Acute Care Psychiatrists

 

I have been a New England Journal of Medicine (NEJM) subscriber since I left medical school.  It was a recommended practice in my first year Biochemistry class by the distinguished professors in that class. We had very close contact with them in my medical school for two reasons – daily seminars where we discussed research papers in the applicable topics and their graduate students talking the same course.  It was one of the more intellectually stimulating courses in medical school.   

Over the subsequent 43 years of subscribing, I have noticed a couple of trends.  The most significant one is that psychiatry has been increasingly represented on the pages especially in the past 10-15 years. It is more likely that authors and discussants in the weekly case presentations will be psychiatrists.  You can also get updates on relevant psychiatric papers sent by email. If you scan the table of contents each week it is likely that 2 or 3 papers will be relevant to psychiatric practice – more if you are a neuropsychiatrist or medical psychiatrist.

That brings me to Case 22-2025 from the July 25, 2025 issue.  I will describe the case as briefly as possible due to copyright considerations and the fact you can read all the details in your medical library copy or access.  I want to focus on the diagnostic process and what it implies for both psychiatric diagnosis and treatment.  I also want to focus on the fact that there are acute care psychiatrists in intensely medical settings and they are very knowledgeable and take care of very tough problems that nobody else does.  That can get lost on an almost daily basis as you see provocative headlines and social media posts seeking attention by distorting what psychiatrists do and what they are capable of.

The patient is a 19-year-old woman admitted with episodic right arm and leg shaking and unusual behavior.  The symptoms developed over the 10 days prior to admission with episodic shaking and numbness of the right arm, and slowed speech. A week before admission she collapsed in public and full body shaking was observed.  In the emergency department she was noted to be drooling, confused, and had bitten her tongue.  She gradually became more alert.  In the MGH ED her exam was normal and the only remarkable lab finding was an elevated lactate.  CT and MRI of the brain were normal.  An EEG was normal.  On day 1 she had sudden onset of intense fear and dread followed by whole body shaking lasting 1-1 ½ minutes.  With the last episode she had a decreased oxygen saturation to 50%.  She was started on lorazepam and levetiracetam.  On day 2 she was started on lamotrigine. She was also seen by a psychiatrist and was noted to have extension and stiffening of the right arm, flexion and stiffening of the left arm, turning the head to the right and whole-body stiffening. The episode lasted a minute and she described feeling like “brain and mind were disconnected”. She denied hallucinations, suicidal ideation, and aggressive ideation but did not think that she could return to college.  She became more agitated, tried to run out of her room, and thought the staff were trying to kill her.  She became agitated and required physical restraint and IM olanzapine.

Additional history was remarkable for a grandfather with schizophrenia and past treatment for anxiety and depression – most recently with psychotherapy and no medication.  Following a recent discharge from another hospital and a 5-day admission she was taking levetiracetam, lamotrigine, melatonin, and folic acid. She was rehospitalized after she developed symptoms on the way home from that hospitalization.

This is a severe and acute problem that every acute care psychiatrist should be able to analyze and treat.  The patient exhibits seizure like activity, catatonia, and psychosis in the form of disorganized behavior rather than any descriptions of hallucinations or delusions.  The concern about hospital staff trying to kill her could be paranoia – but unless there is corroboration that it was present for some time – it can also be due to the significant cognitive problems of poor memory and inattentiveness. 

In the subsequent discussion and unfolding events – Judith A. Restrepo, MD – a C-L psychiatrist at MGH presents a refined approach to the problem as outlined in the graphic at the top of this post.  After describing the observed characteristics of the three syndromes on the left she looks at groups of disorders that may account for the syndromes and how common they are.  Since the emergency screening has already been done, she can rule out any associated with obvious abnormalities of brain imaging studies or lab tests.  She goes through each major category and states why a diagnosis is likely of not.  For example, in the Rare Disorders Where Psychotic Sx Are Typical she mentions acute intermittent porphyria and Creutzfeldt-Jakob disease and how they are unlikely due to the illness pattern, lack of GI sx, and a normal EEG. 

In that same category, Dr. Restrepo discusses autoimmune encephalitis as a possibility and eventually lands on that diagnosis.  In the subsequent evaluation (anti-NMDA receptor antibodies, CSF studies, abdominal ultrasound and CT) the diagnosis of anti-NMDA receptor encephalitis secondary to a malignant mixed germ cell tumor of the left ovary was noted.

The case report is useful to read in full because of the complicated post diagnostic course and description of what is known about the treatment of this condition.  I am going to focus on a couple of additional diagnostic issues and the implications for psychiatrists.

Pattern matching remains a critical aspect of all medical diagnoses and that includes psychiatry.  It is still a popular trope that psychiatric diagnosis is DSM centric and nothing could be farther from the truth. The real value of psychiatry is the training and direct observation and assessment of real problems. Reading a checklist of symptoms is essentially worthless without knowing those patterns.  The obvious examples from this case are psychosis, seizures, and catatonia and their many variations.  The wording in the case report is often stacked to cause an association to those patterns.

An obvious example is whole body shaking followed by hypoxemia and an elevated lactate level should lead to an association to generalized seizures and probably similar patients seen in the past with that condition.  Similarly, the features of catatonia should be obvious without referring to a catatonia rating scale and lead to associations to past catatonia patients diagnosed and treated. Superimposed on these diagnostic patterns should be a general pattern of how to approach very ill patients – in this case patients who have either serious psychiatric disorders or psychiatric syndromes secondary to serious medical and neurological conditions. How should a stuporous or comatose patient be examined (2)?   In this specific patient could the arm movements be decorticate or decerebrate posturing?   Could they be a movement disorder?  That should include a triage pattern of how that patient needs to be stabilized until the diagnosis is determined.

As an example – what should happen if this patient is described to you as an admitting psychiatrist?  Should they be admitted to a typical inpatient psychiatric unit?  All that I would need to hear is hypoxemia following seizure like activity and my answer would be no.  They need to be in a unit that has telemetry and critical care nursing and psychiatric units do not.

There are also patterns on the rule-in side.  Are there any features of this illness that match typical patterns of schizophrenia, bipolar disorder, or depression?  Are there any features that match acute intoxication with commonly used substances?  Is the patient medically stable enough to be treated on a psychiatric unit? 

How do we prepare acute care psychiatrists who are based in medical neuroscience?  Thomas Insel the former NIMH director had the idea of a rotating clinical neuroscience fellowship where neurology, psychiatry, and neurosurgery residents would do a 2 year fellowship before moving on their respective residencies.  That is a hard sell when you come out of it needing to do another 3 – 5 years of residency. 

I propose getting ready in medical school.  Most MS4 courses are electives and there is probably room to further modify the MS3 year.  In addition to basic general medicine and surgery I recommend the following electives: neurosurgery, neurology, endocrinology, infectious disease, renal medicine, cardiology, emergency medicine, and allergy and immunology.  Just rotating through is not enough given what I have said about the pattern matching requirement.  As many acute care cases and unusual presentations of psychiatric disorders associated with brain and medical illnesses need to be seen as possible.  Only that will get residents ready to make diagnoses like the one in this case. It helps to have an attitude and interest in treating the most severe problems in psychiatry. 

And once you are out – keep reading the journals including the NEJM.

 

George Dawson, MD, DFAPA

  

Supplementary 1:  Thought I would add a couple of supplementary comments here rather than adding them to the main post.

Psychiatry is not DSM centric:  Practically every critic of the field and by default these days every social media venue and many journals have lengthy debates about the DSM, what it does or not do, and how it affects the future of psychiatry.  The above post is a shining example of what I did in over 35 years of practice.  At no point in that 35 years did I pull the old DSM off the shelf and think: “Gee I wonder what the DSM will tell me to diagnose?”  Just today I was in a seminar where the question was: “What diagnosis should we use for psychotherapy?” and reminded that the primary use of the DSM and why it was invented – initially for statistical and census purposes and now for billing and coding.  In other words, today – you do not get paid if you don’t have a diagnostic code but that code is technically an ICD-10 code and not a DSM code.

Should that role lead to protracted debates in journals and social media.  I guess I will take the lead role is saying emphatically no.  You can take all the debates about the precision and validity of psychiatric diagnoses and watch it explode in this case report. We see real psychiatry in action.  A psychiatry where patterns of illness are recognized and critical in making a diagnosis of a life-threatening condition.

Pathology in a psychiatric case:  I did not mention that this case report contains a pathology report including photos of the gross pathology and microscopic pathology of the left ovarian mass and the malignant germ cell tumor. This is reminiscent of late 19^th/early 20^th century psychiatry looking for neuropathological autopsy correlates of severe mental illness and the famous psychiatrists involved. It was a more intellectually stimulating approach and there were results but not for the major psychiatric disorders leading to asylum care at the time namely bipolar disorder, schizophrenia, and depression/melancholia. Now that the pathology is more specific should psychiatrists be taught the pathology and the pathophysiology of these disorders?  Should they be aware of all paraneoplastic syndromes that cause psychiatric symptomatology.  Of course they should. It is more important than a DSM and unless the DSM is serious about including real patterns and pathology it will be much less relevant in the future.  We have reached a limit when it comes to parsing words about psychiatric diagnoses and need to get back to reality.    

References:   

1:  Restrepo JA, Mojtahed A, Morelli LW, Venna N, Turashvili G. Case 22-2025: A 19-Year-Old Woman with Seizure like Activity and Odd Behaviors. N Engl J Med. 2025 Jul 31;393(5):488-496. doi: 10.1056/NEJMcpc2412531. PMID: 40742263.

2:  Plum F, Posner JB.  The Diagnosis of Stupor and Coma.  FA Davis Company, Philadelphia, 1980.   

  

More on homelessness and violence as a public health problem...

 

This is further analysis of the homelessness and violence issue.  As I look back on the title of the White House Executive Disorder as a guy with an interest in rhetoric – I cannot help to notice those elements.  What does the title “Ending Crime and Disorder on America’s Streets” suggest?  First off – a definitive solution.  In other words, if you follow what is in this order that solves the problem – period.  Secondly, it suggests that there is crime and disorder that is widely agreed upon.  The problem is widespread.  Third and implicitly – that the problem was ignored until this administration came along to solve it.   Fourth as elaborated in the subsequent text – if you magically eliminate the problems of mental illness, substance use, and homelessness – the problem is solved.  Let’s look at the reality versus this rhetoric.

The definitive solution: Per my previous analysis this order conflates “crime and disorder” with homelessness, mental illness, and substance use.  It further conflates homelessness with mental illness and substance use.  None of the other features of homelessness noted by the OECD namely youth, the elderly, families, and immigrant status are mentioned. None of the features noted by the United States Interagency Council on Homelessness namely non-white minority status, homeless workers that cannot afford housing, and the fact that housing first options are effective is mentioned. The only solutions presented are law enforcement and forced mental health and substance use treatment.

Crime and Disorder are widely agreed upon:  Looking at the real crime rates in the top 100 cities by population in the US shows some interesting trends.  Some cities with very low crime rates (like New York City) are often held up as examples of crime being rampant in the US.  Other considerably smaller cities with much higher crime rates are never mentioned.  This selective attention from the news media and politicians illustrates that the rampant crime problem is pretty much what somebody decides to say it is - whether there are facts to back it up or not.  That is especially true because current violent crime rates using the same measure are down by 75% since 1993. Crime in cities is like crime in the homeless populations – it is localized and most people have no contact with it. Apart from occasional mass protests – I am not aware of any consistent widespread disorder in American cities that needs to be addressed.  I don’t think it is too much to consider that hyperbole.

The problem was ignored until this administration came along:  More hyperbole considering the obvious examples of lawlessness exhibited at the highest levels of government by this administration.  The January 6^th Insurrection was not as result of homelessness, mental illness, or substance use.  Neither was the pardon of all of those who were convicted.  The strong message in this executive order is that the homeless, mentally ill, and substance using populations are not above the law and need both the criminal laws and civil commitment laws enforced against them.  That is hypocritical considering the numerous incidents in this administration giving the strong message that certain people with many resources are above the law.  The message that nobody in the US is above the law falls apart under that scrutiny and this administration has no higher moral ground on enforcing the law than any other.  Further – it can be argued that consistent changes since 1993 have resulted in a major drop in violent crime in the US and stating otherwise is not historically accurate.  

The magic elimination of the problems: At this point – I hope that I have illustrated why the title of the executive order is grossly exaggerated.  On that basis alone eliminating the states problems of homelessness, mental illness and substance use would be expected to have no impact.  In the previous post, I also examine why the proposed solutions will not put a dent in a non-system of care that has been rationed for profit by the same politicians charged with improving it.  Massive cuts in health care spending and research by this administration can only make things much worse rather than better.  President Trump seems to think that if he orders something and does not provide resources people with either scramble to provide them for free or law enforcement will solve the problem by mass incarceration.

That is the rhetoric associated with the current executive order, but what is the reality.  Rhetoric flows both ways and for a long-time advocates for the mentally ill took the extreme that there was no violence risk or that it was not any greater than violence from people with no mental illnesses.  As an acute care psychiatrist, one of the commonest reasons people are admitted to acute care units is violent or aggressive behavior. I have assessed and treated thousands of those admissions and know the underlying causes, but have no good data on what it looks like in the community.  As can be imagined that real world data is difficult to come by because it involves access to information in a number of databases and a major effort to synthesize all of it.

That brings me to a recent study that I think was very well done and could probably not be done in the US (1).  The study was registry based and done in Denmark by a group of researchers with expertise in this problem. The study cohort was 1,786,433 Danish residents between the ages of 15-42 living in Denmark at some point during the ten year between January 1, 2001 and December 31, 2021.  The primary outcome was any violent offense leading to conviction as noted in the table below: 

 The authors used data on multiple registries in Denmark including the Danish Civil Registration System, the Central Criminal Register, the Danish Homeless Register, the Psychiatric Central research Register, the National Patient Register, National Register of Drug Abusers, and the National Register on Treatment with Heroin and Methadone.  The substance use registers were available only for a 10-year period and were used as a quality check on the other data.  This methodology is also why this kind of study cannot be done in the US. In the US all this data is siloed with respective insurers, managed care companies, pharmacy benefit managers, and pharmacies.  It is considered proprietary data that is typically out of the reach of most researchers.  The privatization of healthcare in the US has made this kind of research nearly impossible to do.  I consider this to be a conflict of interest because the same healthcare companies that profit from rationing healthcare control all the data needed to assess whether they are doing an adequate job.  

The main aggregation of data is illustrated in the first two tables.  During the study period a total of 55,624 experienced no homelessness and were convicted of their first violent offense or 55,624/1,771,879 = 3.13% of the sample.   1,460/14,555 = 0.08% of the sample experienced homelessness and were convicted of their first violent offense.  Without considering cultural or geographic factors that means if you were walking through Denmark about 3.2% of the non-homeless population over the time course of this study has first time violent offenses.  At the same time, 0.08% of the total population over this same period are violent first-time offenders who have also experienced homelessness (1,460/1,771,879).  In other words, all things being equal you are 38 times more likely to encounter a violent offender who has not been homeless than one who has.  That hardly seems like an argument for ending “crime and disorder” by ending homelessness.   

A Bayesian (based on prior probabilities) or cultural argument could be made that the first violent offense rate in the homeless is three times higher in that population than the general population and therefore caution should be used in homeless encampments. An extreme argument could be made that this is a reason for removing these camps.  But the fact is 90% of those people would not have violent offenses and there are certainly subcultures across any major city where the prevalence of violent crime is as high if not higher.  Is it rational policy to excise those neighborhoods from any city?  The heat map below is a graphic county by county representation of annual average violent crime rates.  The gray areas are unreported.  There are clearly high crime areas in the absence of significant homeless populations.  The heatmap below plots the number of reported offenses per 100,000 of population.  Data is from the FBI’s Uniform Crime Reporting (UCR) Program and violent crime is defined as four offenses: murder and nonnegligent manslaughter, forcible rape, robbery, and aggravated assault. 

The main data analysis in this project involves calculating incidence (defined as cases/10,000) and incidence rate ratios or IRR defined as the incidence in the homeless population/incidence in the non-homeless population.  The example below is from Supplementary Table 7a.  Association of homelessness and specific violent offences leading to conviction in men (10,623,486 person-years), 2001-2021. For the category “homicide and attempted homicide”.   

Raw Data	Incidence	Incidence Rate Ratio (IRR)
Homeless cohort: 36 cases/74,706 person-yrs x 10,000	4.8	4.8/0.4 = 12.2
Non-homeless cohort: 446 cases/11,144092 person-yrs x 10,000	0.4

 Calculating the IRRs across the board, the authors illustrate that the risk in the homeless cohort is generally many times greater for first violent offenses than in the non-homeless cohort. An additional substance use problem increases the IRRs further. Homelessness alone increased the risk of first violent offense by 5-6 times.  The degree of homelessness by the number of repeat contacts with homeless facilities increases the risk higher suggesting there is a duration factor (see supplementary table 4). In looking for explanation they consider that the best defense may be offense (violence perpetration explained as self-protection), adverse childhood experiences, the breakdown of social norms in homeless environments, and using drugs particularly methamphetamine as a coping strategy. 

There are also obvious environmental and ecological factors in homelessness that may be associated with violence.  Relative to any typical living environment there is limited privacy and security.  There are far fewer locked doors, security cameras, and alarm systems. Crowding is a problem that in general is associated with more conflict and violence.  Noise is an additional problem.  Poverty is a complicating factor that can make things worse if there are people getting retirement or disability checks at specified times or who are known to be carrying food or money. 

The neuropsychiatric and psychiatric disability aspects of homelessness were not explored to any degree in this paper.  Many homeless people come to the attention of law enforcement and end up in jail or transported to local emergency departments.  In both settings significant psychiatric disorders are noted and may or may not be treated. Severe psychiatric disorders can lead to many impairments associated with violence including delusional thoughts, impaired insight and judgement, and overt agitation and aggression. All of that behavior is worsened by alcohol and substance use which are also independent risk factors.   

The authors conclude for all the problems noted in their paper that homelessness is a significant public health problem that needs to be addressed.  They have made that assessment in a Scandinavian country with less income disparity and a more robust safety and medical network than the US.  In the US we have no definitive research – only a political statement in the form of an Executive Order that mischaracterizes the problem.  That Order also has clear parallels with previous action by the administration against immigrants because of their purportedly higher crimes rates, rates of mental illnesses, and substance use.  In that case it was shown that native born use citizens have higher rates of violent crimes, property crimes, and drug crimes than either legal immigrants or native born citizens (2).

The Executive Order in question has no scientific, rational, or moral basis.  Further – the party that supports it is long on a states’ rights approach that allows politicians to not provide needed medical and housing assistance to people in their own states.  At a national level – they have severely cut budgets that will result in the closure of hundreds of facilities (hospitals and substance use treatment facilities).  The idea that a public health problem can be addressed by removing resources and adding more law enforcement is pure fantasy - or politics. 

George Dawson, MD, DFAPA

References:

1:  Nilsson SF, Laursen TM, Andersen LH, Nordentoft M, Fazel S. Homelessness, psychiatric disorders, and violence in Denmark: a population-based cohort study. Lancet Public Health. 2024 Jun;9(6):e376-e385. doi: 10.1016/S2468-2667(24)00096-3. PMID: 38821684.

2:  Light MT, He J, Robey JP. Comparing crime rates between undocumented immigrants, legal immigrants, and native-born US citizens in Texas. Proc Natl Acad Sci U S A. 2020 Dec 22;117(51):32340-32347. doi: 10.1073/pnas.2014704117. Epub 2020 Dec 7. PMID: 33288713; PMCID: PMC7768760.

Graphics Credit:

Both graphics at the top of the post are from the Department of Justice Bureau of Justice Statistics dashboard at:  https://ncvs.bjs.ojp.gov/multi-year-trends/crimeType

The heatmap USA graphic was produced by me using the Datawrapper interface and FBI data. 

The Autocratic Approach to Homelessness

 

President Trump issued another poorly thought out Executive Order yesterday entitled ENDING CRIME AND DISORDER ON AMERICA’S STREETS. It contains many myths about homelessness as well as an unrealistic approach.  As a psychiatrist who focused on this issue in the population I treated for decades, I consider myself qualified to comment on this executive order and why it will fail.  Many of the central points have already been covered on this blog and I will connect to them when relevant.  Here is a section by section look.

“The overwhelming majority of these individuals are addicted to drugs, have a mental health condition, or both.  Nearly two-thirds of homeless individuals report having regularly used hard drugs like methamphetamines, cocaine, or opioids in their lifetimes”

There is the common conflation with homelessness and drug addiction and mental illness.  While these conditions are overrepresented in homeless populations – the idea that the overwhelming majority of the homeless are drug addicted or mentally ill is a myth per the government agency that directly monitors the problem (3). According to that agency the majority of the homeless do not have mental health or substance use problems and the majority of people with those problems are not homeless.

Further violent crime rates are about ¼ of what they were in 1993.  It follows if homelessness is higher in the context of dropping violent crime rates it is not likely a causative factor.

The order conflates mental illness with violent crime and suggests that it puts the public at risk for violent crime.  It suggests that the solution is to get them off the street and into institutions to protect the public.  Based on the lack of connection to crime that is a doubtful solution.  Further there has been a decades long initiative by federal and state governments to shut down long term bed capacity.  The US currently ranks 30 of 35 OECD countries in terms of psychiatric bed capacity.  That current minimalist bed capacity does not meet suggested standards to keep emergency department waits at an acceptable range and there is no evidence that the trend is changing.

The United States already uses jails as the largest psychiatric institutions.  Roughly 70,000 of the 350,000 incarcerated have a significant mental illness and receive various levels of inadequate care.  So where exactly are the “long-term institutional settings for humane treatment” supposed to come from? 

“seek, in appropriate cases, the reversal of Federal or State judicial precedents and the termination of consent decrees that impede the United States’ policy of encouraging civil commitment of individuals with mental illness who pose risks to themselves or the public or are living on the streets and cannot care for themselves in appropriate facilities for appropriate periods of time.”

I have written about civil commitment may times on this blog.  I have personally initiated and testified in hundreds if not thousands of civil commitment, guardianship, and conservatorship proceedings over a period of 35 years in the states of Wisconsin and Minnesota.  As far as I know there is no US policy to encourage commitment.  All civil commitment comes down to a county decision by a judge in that county.  Further – that commitment decision is affected by real world circumstances on the ground at the time including the financial state of the county, the number of commitments done per year, the ideological biases of the attorneys and judges, and the known outcomes of the court proceedings.  As an example of the latter, if a judge releases a patient from a hospital without commitment and that person kills or injures someone or themselves – it is less likely that court will take a similar risk in the future.

Inability to care for self is the third standard for commitment after danger to self (aggression directed at self as self-injurious behavior or suicidal behavior) and danger to others (outward directed violence and aggression).  It is the least likely standard to result in civil commitment and the most likely to result in a patient being discharged back into a homeless situation.

On a social media forum, a link was posted to me about 18 U.S. Code § 4248 Civil commitment of a sexually dangerous person. Although it was not explained it seemed to be a rebuttal to my statement that all commitments are local.  Sexually dangerous person is not a psychiatric diagnosis and it is not likely to be a significant factor in homelessness.  Additionally, the federal government does not track this diagnosis in terms of the total number of people incarcerated because of it. 

“provide assistance to State and local governments, through technical guidance, grants, or other legally available means, for the identification, adoption, and implementation of maximally flexible civil commitment, institutional treatment, and “step-down” treatment standards that allow for the appropriate commitment and treatment of individuals with mental illness who pose a danger to others or are living on the streets and cannot care for themselves.”    

This is an ironic statement considering the massive cuts to Medicaid and long history of federal cuts to any programs that fund long term care of the mentally ill.  Medicaid is a major funder of both health care for homeless populations and people with serious and persistent mental illness.  The idea that there will be funds available to massively convert the current rationed, stripped down services to a cornucopia of outpatient, inpatient, and residential services is more than a little unrealistic. 

A realistic goal would be to fund Assertive Community Treatment (ACT) and Forensic Assertive Community Treatment (FACT) teams across every county in the US. This approach to supportive treatment has been known since 1975 – but rarely encountered due to rationing at various levels.  The goal of this treatment is to support people with severe mental illnesses living housed and independently in the community and assisting them every step of the way with access to medical and psychiatric care.  There is no more humane approach. 

“Fighting Vagrancy on America’s Streets.  (a)  The Attorney General, the Secretary of Health and Human Services, the Secretary of Housing and Urban Development, and the Secretary of Transportation shall take immediate steps to assess their discretionary grant programs and determine whether priority for those grants may be given to grantees in States and municipalities that actively meet the below criteria, to the maximum extent permitted by law: (i) enforce prohibitions on open illicit drug use; (ii)  enforce prohibitions on urban camping and loitering; (iii)  enforce prohibitions on urban squatting”

Are there grants for enforcing existing laws?  With the draconian cuts already made by this administration exactly how much is available to enforce existing laws and would it be used with more effect in other areas. Trump has already cut $27 billion in funding for affordable housing and that has been estimated to affect 23 million households.  Homelessness assisted grants have been cut by $532 million or 12%.  These proposals have been described as “devastating” by housing advocates.  That is hardly a serious effort to address homelessness.

Instead, this appears to be an attempt to villainize the homeless and blame them for their predicament.  The wording in this section about monitoring unregistered sex offenders and suggesting that all arrested homeless are screened as sex offenders seems like the approach taken with undocumented immigrants.  Suggest a group of people are guilty until proven innocent and further suggest that law enforcement can make any problem go away.

“..ensure that discretionary grants issued by the Substance Abuse and Mental Health Services Administration for substance use disorder prevention, treatment, and recovery fund evidence-based programs and do not fund programs that fail to achieve adequate outcomes, including so-called “harm reduction” or “safe consumption” efforts that only facilitate illegal drug use and its attendant harm”

This is an overtly dangerous section of the order.  What is the administration calling “harm reduction”, “safe consumption”, and “illegal drug use”.  Would medications for opioid use disorder treatment (MOUD) fall under this category?  Would clinics prescribing methadone maintenance and buprenorphine maintenance be under even tighter scrutiny that they currently are? The wording suggests a level of accountability to an administration that clearly has none itself.     

This executive order is a good if not perfect example of an authoritarian approach to the problem.  Experts in the areas of homelessness, civil commitment, mental illness, and substance use have not been consulted.  Rather than expertise we see and overriding theme that law enforcement will be used to crackdown on the homeless. It suggests that there are systems of care that do not exist and cannot exist due to previous rationing and the more draconian measures from this administration.  In all of the rhetoric about the homeless problem in the US, the average American is led to be believe that this is a crisis unique to this country.  Real data (1) suggests otherwise.  The US has had a roughly 0.2% of the population homeless over the past 13 years and this is comparable to many OECD countries in Europe. Further – this is higher than the social democracies in Scandinavian countries and homelessness does correlate with economic disparity – another factor poorly addressed by this administration.

For all the above reasons – I don’t see any reason why this order will have much of an effect on the homelessness problem.  It probably will present many photo-ops of law enforcement disrupting homeless camps and arresting people.  The unfortunate outcome here is that there is ample opportunity for doing good across many problems – but apparently little interest in that.      

George Dawson, MD, DFAPA

 

References:

1:  OECD - Social Policy Division - Directorate of Employment, Labour and Social Affairs OECD Affordable Housing Database, 2023. – http://oe.cd/ahd

2:  ASAM Statement on Executive Order to Increase the Use of Involuntary Civil Commitment of Unhoused People with SUD.  https://downloads.asam.org/sitefinity-production-blobs/docs/default-source/advocacy/press-releases/asam-statement-exec-order-final_7-25-25.pdf

3:  United States Interagency Council on Homelessness.  Data and Trends.  (accessed 07/25/2025):  https://usich.gov/guidance-reports-data/data-trends

Metaphorical Brain Talk

 

There is a current paper written by Kenneth Kendler on metaphorical brain talk in psychiatry (1).  It is open access and I encourage people to read it.  I automatically read anything written by Kendler because he is probably my last remaining hero.  That is ironic given that he is only slightly older than me.  If you are not familiar with his work there is a Wiki page that will partially bring you up to speed.  I have referenced him many times on this blog.  His writing is consistently next level when it comes to psychiatric research and theory.  If you find yourself reading collections of “greatest papers in psychiatry” and don’t find his work there.  Throw that collection away and read Kendler.

In this paper he reviews the history of metaphorical brain talk (MBT) in psychiatry and what he sees as four implications for the field. He defines this as describing the altered brain function is psychiatric disturbances in a way that seems explanatory but have no explanatory power.  Examples would include the infamous chemical imbalance trope.  He reviews MBT across discrete periods in psychiatric history and gives examples in each one of these time frames.  Since this is an open access paper – I encourage any interested readers to look at all the examples.   I will touch on a few points that I find interesting.

He first reviews Asylum Psychiatry from 1790-1900.  Several authors wrote about conditions they observed in their patients using descriptive phrases like brain excitement, disordered nervous system, morbid action of vesicular neurine, peculiar and special force in the cerebral masses, excitement and vividness always emanate from one portion or spot of the brain, etc.  On the one hand the metaphors are obvious and consistent with Kendler’s characterization that they are biologically meaningless.  On the other the images are vague and the significant part of the metaphor is descriptive language of mental activity. 

In other writing Kendler has referred to this era is psychiatry as the era of protopsychiatrists. I have reviewed that history on this blog and agree that psychiatry as the profession we know today probably did not start until the 1920s in the US even though it was well established in Europe for a longer period.  The European version included physicians who were also described as neurologists, neuropathologists, psychiatrists, psychologists, and alienists.  If you read references to these physicians today – the descriptions are often interchangeable and research is required to clarify their qualifications and training. 

There was more going on during this period than meaningless metaphors.  Alois Alzheimer was a psychiatrist and neuropathologist (11).  Between 1891 and 1907, Alzheimer described several neurodegenerative diseases including vascular dementias and the disorder that would eventually come to be known as Alzheimer’s disease along with the clinical correlations of memory loss, inadequate self-care, and paranoia. Otto Binswanger (1852-1929) was a Swiss psychiatrist, neurologist, and neuropathologist who was also active at the time. In 1894, he described “encephalitis subcorticalis chronica progressive” while attempting to differentiate types of dementia from dementia caused by tertiary syphilis that was called general paresis of the insane or GPI at the time.  GPI was a very common reason for institutionalization at the time accounting for 20% of admission and 34% of the death in asylums in the 19th and early 20th century before the advent of antibiotics.  Both Alzheimer’s Disease and Binswanger’s Disease remain controversial entities to this day in terms of the definitive neuropathology and likely etiopathogenesis.  An important historical lesson is that these early psychiatric researchers did practice psychiatry while doing neuropathology and often had students who went on to have significant contributions to the field outside of neuroanatomy.  In the case of Alzheimer, Franz Nissl (1869-1919) became his longtime collaborator and head of the Psychiatric Clinic at the University of Heidelberg where Karl Jaspers (1883-1969) was his student.  Jaspers wrote his text General Psychopathology while working for Nissl.         

His next historical period is The First Biological Revolution in Psychiatry 1870s – 1880s.  Griesinger was a key figure and his central thesis that mental illnesses were brain diseases.  He also published an influential textbook and journal.  His students promoted neuropathological research through autopsies as the primary method of scientific inquiry during that period. Kendler concludes that this method of research was a dead end for classical psychiatric disorders – but there seems to be more going on in the field than that.  Several of these physicians over the next 50 years identified themselves not just as psychiatrists but also neurologists and neuropathologists. Otto Binswanger ((1852–1929) and Wilhelm Griesinger (1817-1868) were designated as neurologists and psychiatrists.  Freud (1856-1939) did 6 years of basic research in comparative neuroanatomy, published a monograph on aphasia (6) wherein he coined the term agnosia, and was a Privadozent in neuropathology.  All of that before he invented psychoanalysis.

 The Reaction to the Revolution 1880-1910 is described next with a critique by Kraepelin of excessive and speculative biological theories of psychiatric disorders.  The critique largely is focused on Meynert’s (1833-1891) work.  The critiques focus primarily on highly speculative hypotheses based on neuroanatomy. Meynert’s neuroanatomy work and that of his colleagues and students is still recognized today (2-4).  His poetic license may have been excessive, but the neuroanatomy was solid.

Metaphorical Brian Talk of the 20^th Century focuses initially in Adolf Meyer. Like the other psychiatrists discussed so far, Meyer had additional skills and was employed as a neuropathologist following his emigration to the United States from Switzerland. He famously said: “My entrance into psychiatry was through the autopsy room”(8).  Meyer had an indirect link to Meynert because his supervisor August Forel was one of Meynert’s students.  A quote is included from a 1907 paper in which Meyer suggests that early American psychiatrists:

“…pass at once to a one-sided consideration of the extra-psychological components of the situation, abandon the ground of controllable observation, translate what they see into a jargon of wholly uncontrollable brain-mythology, and all that with the conviction that this is the only admissible and scientific way.”

Meyer is credited with psychobiology model of psychiatry.  He saw the brain and mind as an evolved unitary and dynamic structure reacting to the environment.  As such it would not necessarily show typical disease related changes at the gross or microscopic levels and could only be studied if environmental and social variables were considered. 

Meyer’s psychobiology approach championed a detailed clinical approach to psychiatric disorders and avoidance of biological reductionism.  That would put Meyer along with Kraepelin squarely in the camp against not only MBT but also any theory suggesting that there was a direct biological explanation for mental behavior or psychiatric disorders. Both were trained as neuropathologists and Kraepelin worked with Alzheimer. That would seem to lend a measure of credibility to their concerns.  

Kendler ends that section with a quote from Jaspers that the neuroanatomy discovered by the neuropsychiatrists is one thing but it cannot possible be correlated with mental phenomenon.  He refers to this as “brain mythologies”.  Meyer’s and Karl Jasper’s approached have been credited by McHugh and Slavney in their comprehensive 4 perspective approach to mental disorders (7).

Kendler concludes that the metaphorical brain talk in psychiatry arises from several sources.  First, our identity as physicians dictates that like other specialists, we need an organ to focus on and that has been the brain. That relationship was impacted by neurology seeming to take over conditions with overt and definable brain pathology.  He concedes that there is overwhelming evidence that psychiatric disorders arise in the brain (in fact he is a world expert in this) but there are still no specific mechanisms.  MBT is one way to address that fact.  He defers to a historian that this may be status anxiety relative to other specialties with more definable pathology and in some cases mechanisms and MBT is a way to address that.  His own take on MBT is much more reasonable when he describes it as a wish that at some point we will get to the deeper understanding of the brain that we all seek.

Despite the historical digressions, Kendler comes to the same conclusion that I did decades ago.  We do not have to make things up in discussions with patients and we do not need to use metaphors devoid of biological reality.  That does not mean there is no room for real brain talk – the kind that occurs when you are discussing the effects of brain trauma, strokes, dementia, epilepsy, and endocrinopathies.  It does mean that you can flatly say for any diagnosis there is no known etiology but the research supports this treatment plan and beyond you can provide a discussion or references to the latest research.

The explanatory gap in psychiatry between the biological substrate and mental life or associated disorder is obviously there but it is present in every other organ system to one degree or another.  It is quite easy to pretend that basic medical conditions like asthma or diabetes have all been worked out with biologically precise mechanisms of action – but nothing could be farther from the truth.  Endophenotypes exist for both conditions, most people are symptomatic despite treatment, and death still occurs even in mild cases. There is a definite dynamic of idealizing medical conditions as completely knowable and treatable – when they are not.  In those cases, the explanatory gap is very basic between biology and wheezing or blood glucose. In the case of psychiatric disorders – many more symptoms and ordinary functions are across that gap.  The explanation is much harder and any symptoms are less clearly rooted in biology.  

I am less concerned about the effects of MBT and how it potentially affects understanding the mental life of our individual patients.  That is what psychiatrists are trained to do.  We are face-to-face with a person who we are supposed to help and, in that situation, it is doubtful that MBT will add much. 

There are a few other reasons that may have facilitated MBT in the historical contexts discussed. Rhetoric is a powerful and rarely discussed aspect of the scientific and medical literature.   The metaphor users were all active neuroscientists in their day.  As such they were likely competing for positions, labs, associations, recognition, and funding.  This is commonly how rhetoric occurs in research communities and scientific literature. 

 A related issue is personality and notoriety. It is rare to see much commentary about these issues with 19th and 20th century scientists.  Once a certain level of fame is reached, are you more likely to speculate and theorize?  Can some of those speculations take on the form of MBT?  One of the most criticized neuropsychiatrists in this paper was Meynert for suggesting overly elaborate mechanisms that had no basis in science.  On the other hand, Meynert is still renowned for some of his neuroanatomical findings (4).  Is it possible that a scientist with that level of accomplishment did not care about the difference between speculation and scientific findings?  Is it possible that his students and post docs encouraged him to speculate beyond his findings – just brainstorming? Is he just taking a chance that he might be correct in order get credit for an innovative finding?  I suppose a translation of his book might offer a few addition clues, but the reason I have these suggestions is that I have seen this happen in current times.  We might reassure ourselves that our publications are not suffering from metaphorical overreach but problems with irreproducible findings suggest otherwise.          

The state of neuroscience for much of the timeline of this paper could be a factor.  Not a lot was known about neurons or neuronal transmission.  Neuron theory and the term neuron did not happen until 1891. I have a slightly different take on the history of psychiatry in the US and how psychiatry and neurology split.  Until 1934, most psychiatrists were also practicing neurology. Many were self-designated as neuropsychiatrists.  The ABPN decided to require board exams in both neurology and psychiatry to practice both and at that time psychiatry began to grow disproportionately relative to neurology.  It is still possible to be doubled boarded in both. It is also possible to practice neuropsychiatry or medical psychiatry based on residency training and practice.  I have long promoted the idea that modern day psychiatrists should practice intellectually interesting psychiatry and for me that uses the DSM as a scope of practice specifier and knowing all the medicine and neurology necessary to care of those patients.  

Revisiting the main point of Kendler’s paper.  In his summary he states his major concern has been an impoverished conceptual foundation in the field based on a brain centric focus and metaphorical talk about it.  I agree with anything metaphorical and on this blog have numerous posts addressing the chemical imbalance and biomedical metaphors being paced upon us by our critics.  In many ways – I don’t think the clinical brain focus has been enough. Psychiatrists need to be able to rapidly recognize neurological and medical emergencies in addition to the medical and neurological causes of psychiatric syndromes. Psychiatrists need to be able to diagnose aphasias as well as they can diagnose thought disorders.  Those skills can all be traced back to late 19^th century and early 20^th century psychiatry. I also see that era as precipitating controversy, dialogue, and pendulum swinging so far in the other direction that at one point the medical internship was temporarily removed from residency programs.   

The reality is that we will see people referred to us or walking in off the street who have brain lesions and/or medical problems or not. They will generally have a psychiatric problem that has been assessed and treated by several other people that did not work. Our job is to do a thorough assessment of their physical and mental problem and come up with a plan – even when there is no known treatment.  That plan includes relationship building, helping them be more competent, and helping them make sense of their world. 

All the irrelevant metaphors can easily be ignored.

 

George Dawson, MD, DFAPA

 

 

1:  Kendler KS. A history of metaphorical brain talk in psychiatry. Mol Psychiatry. 2025 Aug;30(8):3774-3780. doi: 10.1038/s41380-025-03053-6. Epub 2025 May 13. PMID: 40360726; PMCID: PMC12240831.

2:  Liu AK, Chang RC, Pearce RK, Gentleman SM. Nucleus basalis of Meynert revisited: anatomy, history and differential involvement in Alzheimer's and Parkinson's disease. Acta Neuropathol. 2015 Apr;129(4):527-40. doi: 10.1007/s00401-015-1392-5. Epub 2015 Jan 30. PMID: 25633602; PMCID: PMC4366544.

3:  Meynert T, Putnam J (translated) (1872) The brain of mammals. In: Stricker S (ed) A Man. Histol. W. Wood & company, New York, pp 650–766

4:  Judaš M, Sedmak G, Pletikos M. Early history of subplate and interstitial neurons: from Theodor Meynert (1867) to the discovery of the subplate zone (1974). J Anat. 2010 Oct;217(4):344-67. doi: 10.1111/j.1469-7580.2010.01283.x. PMID: 20979585; PMCID: PMC2992413.

“The presence of neurons in the subcortical white matter of the human brain was first described and illustrated by Theodor Meynert in 1867, and additionally commented on in his subsequent publications (Meynert, 1867, 1872, 1884). Meynert illustrated these cells in both superior frontal (Fig. 1A) and primary visual (Fig. 1B) human cortex and pointed out that these are spindle-shaped (fusiform) neurons which are oriented vertically to the pial surface within the gyral crowns, but horizontally at the bottom of sulci. He also suggested that they have a special functional relationship to short corticocortical association fibres (fibrae arcuatae, or Meynert's U-fibres) and that these fusiform cells may therefore be regarded as intercalated cells of his Associations system of short corticocortical fibres (Meynert, 1872).”

5:  Cowan WM, Kandel ER.  A brief history of synapses and synaptic transmission. In:  Cowan WM, Sudhof TC, Stevens CF.  Synapses. The Johns Hopkins University Press, Baltimore, 2001. pp.  3-87.

6:  Freud S.  On aphasia: a critical study.  International Universities Press. New York, 1953.  Translation of 1891 German publication and introduction by E. Stengel.

7:  McHugh PR, Slavney PR: The Perspectives of Psychiatry, 2^nd ed. Baltimore, Johns Hopkins University Press, 1998

8:  Lamb S. Social Skills: Adolf Meyer's Revision of Clinical Skill for the New Psychiatry of the Twentieth Century. Med Hist. 2015 Jul;59(3):443-64. doi: 10.1017/mdh.2015.29. PMID: 26090738; PMCID: PMC4597240.

9:  Lamb S.  Pathologist of the Mind – Adolf Meyer and the Origins of American Psychiatry.  Johns Hopkins University Press,Baltimore, 2014. p. 255.

10:  Rutter M. Meyerian psychobiology, personality development, and the role of life experiences. Am J Psychiatry. 1986 Sep;143(9):1077-87. doi: 10.1176/ajp.143.9.1077. PMID: 3529992.

11:  Goedert M, Ghetti B. Alois Alzheimer: his life and times. Brain Pathol. 2007 Jan;17(1):57-62. doi: 10.1111/j.1750-3639.2007.00056.x. PMID: 17493039; PMCID: PMC8095522.

Photo Credit:  

I thank my colleague Eduardo Colon, MD for the surreal photo of the Foshay building in Minneapolis.