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A Piece of My Mind: A Psychiatrist on the Couch

Richard Balon, MD

Wayne State University, Detroit, Michigan, USA

By Gordon Parker. Sydney, Australia: Pan Macmillan Australia; 2012; ISBN 978-1-742-61074-0; pp 340; $AU32.99 (paperback).

I confess that I like memoirs, biographies, and autobiographies because they frequently bring an interesting point of view, new information, or a more complex picture of a person, era, or topic. I usually look forward to reading those that we occasionally receive in the mail for review. However, I was a bit uneasy and hesitant when it came to A Piece of My Mind. A Psychiatrist on the Couch. It was sent by the author himself with a personal letter; maybe a bad sign of self-promotion? I procrastinated, but finally decided to open the book and give it a try. I started to read the introduction and became even more hesitant after reading the first few pages, asking myself what I was getting into and wondering about this guy, Gordon Parker (for those who don’t know, Gordon Parker is a well-known Australian psychiatrist, researcher in the area of depression, and founder of the Black Dog Institute). The book contains a lot of quotes attributed to others, and lots of suggestions that he is going to offend many. In all fairness, Dr. Parker defends these 2 features eloquently, paraphrasing Michel de Montaigne (“I quote others to better express myself”) and quoting Ricky Gervais (“If you’re not offending someone, you’re not doing anything”). Then the Introduction got a bit more interesting, with Dr. Parker quoting my favorite contrarian, the late Christopher Hitchens, and then stating that “serendipity or luck (though some create their own ‘luck’) have little to do with career trajectories and more to do with people’s innate (and often unexpressed and therefore unrealized) potential strengths” (p 9). I was becoming more interested and finally got into the full swing of reading this book.

The book consists of 3 parts; only Part I of this disjointed volume is autobiographical, covering everything from family roots to justification of the inclusion of the book’s other 2 parts. Dr. Parker describes his family, “gene pool,” schooling, and progress to becoming a psychiatrist in “chapters” with names illustrating what they are about (“Parental impact on psyche and career choice,” “Peaks and troughs of my school career,” “A university education,” “Brain waves and undines reprised,” “Showing up in the mother country,” “Welcome to psychiatry,” “An academic and administrative psychiatrist,” and “My research career as a paradigm chaser”). The author analyzes himself and certain aspects of his behavior. He reveals, among many other things, that he is a contrarian, stating, “the word ‘compromise’ is not one that sits comfortably with me and, when involved in negotiations where I detect someone is seeking to control me, my instinct is to play the man and not always the issue or the problem by itself” (p 57). He was—and still is—a multitalented man, having written a TV show as a young physician. He began publishing his observations quite early and developed into an astute observer and skillful physician. The description of his medical and psychiatric education reads a bit like the history of medicine and psychiatry of the last 50 years, with colorful illustrations. Those who dislike administration will appreciate Dr. Parker’s description of the administrative part of his career.

He also reflects on his personality throughout the book. When discussing being an administrator, he admits, “My personality has limited any lobbyist potential. My tendency to cut to the chase means that social proprieties such as a comment on the weather or even a ‘good morning’ are exemplars of inefficiency to me, although I do admire and appreciate such characteristics in others—up to a point, and as long as they get to the point before too long” (p 135). When describing the constant pressure to maintain a successful academic career, he quotes Irving Berlin who said, “The toughest thing about success is that you’ve got to keep on being a success” (p 138). When musing about what drives a researcher, he refers to an anonymous observer who said that “science, like sex, has a function, but it’s not why we do it” (p 139).

The last chapter of Part I—”My research career as a paradigm chaser”—gradually merges into Dr. Parker’s justification for the contents of the rest of the book. He discusses various aspects of his research endeavors: interpersonal relationships, seasonality research, alternative research. The latter includes a fascinating-but-true explanation of the adequacy of chiropractic and other alternative approaches, stating that “most regions of the world have a two-tier system of health practitioners. In third-world countries, people generally first attend a local ‘healer’ and only go to a western-trained healer if treatment fails. In western countries, the reverse phenomenon is more distinctive. If orthodox medicine fails, alternatives will be sought that have a level of credibility and where practitioners inspire hope” (p 149). The author later shares his observations on antidepressants—eg, aside from being an antidepressant, selective serotonin reuptake inhibitors have the capacity to mute “emotional dysregulation,” and appear to have mood stabilizing capacities in bipolar II disorder. He gradually comes to the same conclusion that other astute clinicians have, that no antidepressant therapy has universal relevance (p 157). He started to criticize various research conclusions and models and, as he claims, gradually got into a conflict with academic establishment outside of Australia with increasing rejection of his thought-provoking submissions… until he, as he writes, found out that all of his future submissions to some unnamed journals would be rejected. He admits that he failed at “being insufficiently astute to know exactly how and when to tackle certain targets” (p 169).

Then he comes to the principal reason for writing this book—Part II. This part contains Dr. Parker’s views on depression. The chapter titles are illustrative and reflective of Dr. Parker’s—and contemporary psychiatry’s—problems with the classification and management of depression (“Understanding ‘depression’,” “The cementing of the Unitarian model in the DSM-III And ICD-10 classifications,” “‘Major depression’: A mix of black and blue,” “Our alternate model for classifying melancholic depression,” “Our alternate model for classifying the non-melancholic depression,” and “Summary concerns about the classification and management of the depressive conditions”). Dr. Parker clearly sees that clinical depression is poorly defined and poorly managed (p 2), and that it is not a unitary condition. He (along with many others) strongly advocates the classification of melancholic and non-melancholic depression as 2 distinct conditions. He states that “pandemonium still reigns with psychiatry’s current non-specific and meaningless diagnostic groupings” (p 174), and arguably criticizes various thinkers left and right (mostly justifiably)—especially those who in his view have pushed the Unitarian dimensional view of depression (eg, Adolf Meyer and Hagop Akiskal). He cites Ned Shorter, a respected psychiatry historian, as describing Meyer as a “second-rate thinker and a verbose writer” who was never “able to disentangle schools that were absolutely incompatible, and ended up embracing whatever came along” (p 178). Dr. Parker’s take on the DSM-III’s problematic definition of depression is well taken and clearly more and more reflected in related discussions in psychiatric journals these days. He cites Shorter’s criticism of the DSM-III, which says it “was not really a scientific document but a political one, with decisions often made on advocacy and the need to be inclusive and avoid confrontation” (p 184). The entire section on depression is peppered with interesting personal and historical observations. Dr. Parker also reminds us of the serious limitations of trials that evaluate antidepressant drugs, and does not spare judgment of trials of other depression treatments either. He says that “the spotlight on antidepressant drugs being positioned as placebo therapies is somewhat unbalanced, when the same concerns hold (but are rarely considered) for CBT” (cognitive-behavioral therapy) (p 202). I loved his descriptions of observations made during his visit to Aaron Beck’s unit in the early 1980s, where he noted that all therapeutic group leaders were attractive, blonde females, age 25 to 35, who had distinctive cleavage. Beck supposedly responded to his observation by saying that “somehow CBT seems to work better that way” (p 230). A very important notion on Dr. Parker’s side is that “the formal literature regrettably minimizes the practical benefits of commonsense advice, counseling and simple problem-solving approach provided by an empathic professional for non-melancholic reactive depressive condition” (p 231). This is clearly not just a placebo effect! In the final pages of this section Dr. Parker also criticizes evidence-based medicine, quoting Kathryn Montgomery’s (book How Doctors Think) concerns about evidence-based medicine as “a tendency toward generalization without particularization… a reliance on generalization, one-size-fits-all rule-making, without the particularizing countermove required by clinical judgment” (p 239). This part of the book is a thought-provoking read that would be appreciated by any astute clinician.

Part III of this book focuses on being a clinical psychiatrist—a crucial issue of contemporary psychiatry. Interestingly, Dr. Parker advocates that he would choose a technically brilliant professional over a “caring” one, though he recognizes that most patients weigh a clinician’s style over their substance. He makes a sound argument for the importance of clinical judgment—yet he recognizes that clinical judgment is not celebrated, quoting Kathryn Montgomery as saying that “a celebration of clinical judgment is likely to be seen as ignorance or the dismissal of science.” He even muses about whether psychiatric judgment can be taught; it could be honed, but not always taught, and cites John Ellard’s The Music of Psychiatry (“Some have the music. Others can hear it. A small number are tone deaf forever”) (p 280). This part is provocative, intellectually stimulating, and important for any practicing clinician.

A reader may ask, what is the verdict on this book? It is an interesting read. The first part veers off at times, and for those uninterested in Dr. Parker’s life and defense of his “gadfly” style, could be skipped altogether. However, the second and third parts of this book—the real reasons for Dr. Parker’s writing of this text—address complicated issues, are written in an easy-to-read style, and are an interesting, significant, and stimulating read. It contains a lot of history of “psychiatric thinking of the last fifty years.” Readers may find the provocative style of the first part of the book a bit difficult to absorb, but it fits in with the rest of the book well, and makes it an enjoyable read.