If Dr. K. Lynne Moritz were a haughtier sort, we could call her the queen in exile. Director of the St. Louis Psychoanalytic Institute for the past four years, she was one of its first graduates, back in the heady days before one had to apologize for Freud. Leaving pediatric medicine behind, she chose to concentrate on her patients psyches, which she defined, in secular terms, as their souls their essence, their identity, their consciousness and all it hid. Clues swirled in an ether of memories, dreams, imaginings and unconscious associations, and it was Moritzs job to hold the flashlight steady until her patients could see their way clear.
She found psychoanalysis deeply satisfying, but year after year she watched it grow more suspect as a wall rose, high and spiked, to divide the Institutes methods from the increasingly powerful, science-driven form of psychiatry practiced at the Washington University School of Medicine. Loyal to the analytic approach, Moritz stayed on at the Institute, a quiet, mushroom-beige International-style building on Forest Park Parkway, a block east of the bustling medical school. A block east, and a world apart. The people who fail with a biochemical approach eventually come here, she remarks, and the people we fail find their way there. Unfortunately, there has been a kind of tradition at Wash. U. to make that polarized.
She thinks, sometimes, about places such as Columbia-Presbyterian Medical Center in New York, where the psychoanalytic-training center is housed within Columbia's department of psychiatry and faculty have joint specialties in, say, psychoanalysis and neuroendocrinology, or epidemiology, or genetics. Wash. U.'s psychiatrists still bash Freud for sport at their grand-rounds lectures; they refer coolly, when necessary, to "those people at the Institute," but they rely on their own research-based, diagnosis-driven medical model.
To remain accredited, though, Wash. U. must at least acknowledge the most intense of the talk therapies. Moritz has supervised residents there, and Dr. Eric Nuetzel, the affable, bearlike, rosy-cheeked psychoanalyst who's replacing her as the Institute's director, has faculty standing at Wash. U. Their presence can be awkward: Nuetzel studied theater before attending med school (Moritz majored in English literature, aspiring to be a Shakespeare scholar) and both mine clinical insights from Chekhov, King Lear and the latest entries in the Sundance Film Festival. Wash. U. is not particularly hospitable to such fuzziness; at times, Nuetzel's lectures are nearly inaudible over the residents' cries of "Where's the proof?"
Passionate about teaching and genuinely interested in Wash. U.'s empirical research, Nuetzel weathers their criticism the way a boulder takes the waves. Moritz feels the skepticism a bit more keenly, but she doesn't buy it; for her, proof lies in her patients' lives. Still, she's convinced that St. Louis would be better served if Wash. U.'s esteemed psychiatrists and the Institute's esteemed psychoanalysts didn't run screaming from each other's company.
Dr. Eugene Rubin, professor of psychiatry and vice chair for education at Wash. U.'s medical school, admits there was some polarization back in the '80s, but says that it's over, and that it was inevitable. St. Louis had become the epicenter of an earthquake that shifted the entire field of psychiatry, knocking it off the psychoanalytic orientation that had dominated for decades. "Wash. U. succeeded in convincing the rest of the world that human behavior can be studied and understood with the same tools we use for the rest of medicine," says Rubin. "That battle has been won. But there's a lot we can still learn from the in-depth understanding --"
He doesn't finish the sentence "of psychoanalysis"; it's as though the very word hurts. "One of the difficulties of that model is that it makes major statements of fact but the statements are untestable," he continues. "Many of the things psychoanalysts have described make sense from a common-sense point of view, but they come to very strong conclusions that are not based on any data." One such conclusion is the "subconscious," imagined as vast catacombs where powerfully influential memories lie buried just out of reach and continue to haunt us. Wash. U. psychiatrists might conduct sleep studies, or study mechanisms of thought and perception, but they're not going to waste hours of therapy time digging for hypothetical, invisible causes of distress.
Moritz has spent four decades digging, and she trusts what she's seen. Besides, she says, the data are finally arriving. Studies indicate that our brains literally rewire themselves with successful talk therapy. High-tech scans show our brains lighting up with unconscious thoughts. Freud's notion of an instinctive id that speaks in our dreams and a rational ego that takes over during the day? The same scans show that, when we dream, the parts of our brains involved with emotion, memory and motivation light up, whereas the centers of logic and abstract thought stay dark as night itself. As for all that Freudian emphasis on our childhood and our parents, researchers now believe that the adult who's caring for a young child actually shapes and regulates, from the outside, the structure and neurochemistry of the child's maturing brain. A mother's touch can literally change her baby's mind.
It's an exciting time, with different disciplines taking different paths to the same conclusions, and Moritz is eager to integrate the new scientific findings at the Institute.
She's also eager to share those unprovable insights you can gain only by going deep, appointment after appointment, with one individual at a time. "We are a repository of information that is lost to the current health-care situation," she remarks. "But they are convinced we don't have anything to say."
Moritz grew up in the heyday of psychoanalysis -- but never heard the word. Born in LaGrande, Ore., she spent her free time swimming in the ice-cold Pacific, hiking, skiing, riding bikes and horses, sailing. "Everything was outdoors and action-oriented," she says. "It was the world as it was given to me, and I took it wholeheartedly."
Reminiscing, she first describes the "green, green Douglas firs and, looming over the horizon, Mount Hood, always snow-covered." Then she describes the wrench of losing her father, who went away to war when she was 3 and never came back. "My mother divorced him when I was 5," she explains. "She didn't want him back, but I did. I was Daddy's little girl -- my mom had my younger sister. And that early loss cast a shadow over my life."
Moritz's interest in medicine started soon after, when an adored family friend, the only physician in town, set her broken arm. Determined that she, too, would heal the sick, Moritz regularly embedded her tiny plastic stethoscope in the broom-bristle fur of the family's Scottish terrier. She nursed wounded bunnies, rescued kamikaze birds. "None of them seemed to survive," she admits, "but that only increased my consternation."
She grew up smart and responsible, with a wide, eager Mary Tyler Moore smile and a work ethic she still can't shake. As a freshman at Duke University, she fell in love with a Navy serviceman (in uniform, just like her daddy when he left). They married young and came together to St. Louis University for medical school in the late '60s. She still hadn't read Freud, but she remembers listening, fascinated, while her psychoanalytically trained professors drew meaning from their patients' lives like magicians pulling brilliant silk scarves from a black hat.
Moritz was set on physical healing, though; she wanted to save lives, ease pain, lay hands on swollen, inflamed skin and restore it to health. She had her first baby at the end of medical school and started a residency in pediatrics soon after but couldn't bear tending critically ill newborns while her own baby waited at home. She switched to psychiatry. And when her second baby was stillborn and the grief tore up her marriage, she sought treatment herself.
To her dismay, she was referred to Dr. James Anthony, then chair of child psychiatry at Washington University. (In the 1970s, psychoanalytic credentials were expected of a department chair; today they'd be a liability, and no Wash. U. chairholder would be caught dead practicing analysis.) Moritz had never met Anthony, knew only his formidable reputation. She walked in, gulped and called him sir, and he smiled the gentlest smile she'd ever seen. Then he listened to her, week after week, "in a way no one had ever listened before," she says. Emboldened, she followed his lead, moving "into very dark areas of myself that very much needed healing."
Back in Oregon, the pioneer ethic had ruled: "You pull yourself up by the bootstraps and forge ahead without ever wondering why certain things keep happening," Moritz says. Now, analysis was forcing her to take the time, see the patterns, admit that past hurts were still shaping her reactions to the world. As she did, the old anxiety drained away, and, along with it, the overpowering need "and a tendency toward depression that was tangled up with loss." Convinced that psychoanalysis could heal as surely as any scalpel, Moritz enrolled, in 1974, in the first class at the new St. Louis Psychoanalytic Institute.
Down the street at Wash. U., a revolution in psychiatry was beginning -- the same white-coat revolution that would eventually marginalize psychoanalysis. While Moritz pored over analytic texts, Harvard-trained research psychiatrist Eli Robins logged hours in Wash. U. labs, studying the brain, one cell at a time, and weighing each cell on tiny scales of his own devising. He pioneered studies in the biochemistry of depression, inveigling the coroner for slices of suicides' brains. He resurrected the ideas of a German psychiatrist named Emil Kraepelin, a contemporary of Freud's who refused to speculate about consciousness or "mind" and instead researched the physical brain, making systematic classifications of symptoms and tracing family histories of asylum patients. Kraepelin had nudged the field toward hard science, and Robins wanted to continue that push.
"Eli thought psychoanalysis was silly," remarks his widow, Lee N. Robins, who worked with him at Wash. U., studying family histories of psychiatric disorders, and is now emeritus professor of social sciences in psychiatry. "We were both psychoanalyzed, and we had to go ask our respective analysts if we could get married! The psychoanalytic point of view was that the most important things that happened to people were trauma in early childhood, and since there was just one treatment, diagnosis wasn't of great interest to them. Eli felt just the opposite."
It didn't help, note Wash. U. insiders, that Robins' Boston psychoanalyst, a pupil of Freud himself, misread the early atypical symptoms of multiple sclerosis as anxiety. It's said Robins' fury triggered a now-legendary series of studies emphasizing precise, standardized classification of psychiatric symptoms. Two like-minded colleagues, Dr. George Winokur and Dr. Samuel Guze, joined his quest, with Guze eventually succeeding Robins as department chair.
Brilliant, dispassionate and methodical, Guze had done a residency in internal medicine before his interest in psychosomatic disorders drew him into psychiatry. Affect, the messy emotions that drench individual therapy, was never his forte. When a Harvard psychiatrist guest-lectured about dream research and psychoanalysis, he jumped to his feet and yelled the Wash. U. question: "Where's the proof?" He would remain convinced until his death in July 2000 that "mental phenomena are based upon brain function. There isn't anything else there" (Dallas Morning News, July 21, 1999).
By 1980, the Wash. U. team had literally rewritten the profession's Diagnostic Standards Manual, dividing psychiatric disorders along two clean axes. The result neatly cleaved the major, biologically based mental illnesses from "social" and "personality" disorders. Insurers began to draw lines accordingly, stipulating what sorts of treatments, along what diagnostic axis, they would reimburse.
The medical model had won.
While Robins was weighing the brain, Moritz was girding herself to receive its secrets. "Your biggest worry is, are they going to lie down on the couch?" she admits, eyes twinkling. "Then you realize you don't have to be concerned about that. If somebody won't lie down, you're of course interested in why. But you can do analysis with people pacing defiantly, or with children, who won't lie down at all. A couch is simply a useful way to help people relax and turn inward, and it gets your own reactions out of the picture."
Her own couch was long and clean- lined, upholstered in a gray-and-cream windowpane plaid -- nothing like the curved-back, armless velvet chaise of popular imagination, accompanied by an aloof, goatee-stroking analyst whose own ego was unassailable. Americans grew angry at that mythical figure -- there were too many real-life analysts whose arrogance and vivid imaginations had ruined people's lives, and the culture as a whole had invested too much hope in Freud's shocking new mythos. "There was a kind of overselling of it," admits Moritz. "The expectations were far greater than what could be delivered." By the '80s, the country had lost interest in subterranean lusts and terrors -- why venture into dark dripping caverns where monsters lived if you could pop a pill or memorize new habits? Cast to the side, psychoanalysis began to revise itself into something humbler and warmer, open to multiple interpretations.
Moritz's own approach was instinctively warm, her reading of the dogma broader and more flexible than the original Freudians'. Still, she refused to throw out classical methods altogether. "Oral" and "anal" and "oedipal" stages were just one very useful way to diagram the complex evolution of a child's consciousness. And she was perfectly comfortable with the notion of penis envy -- not as the grounds of female sexuality (Freud was a little skewed by his own conditioning, she notes), but as an overall insight into the human condition. "It's something little girls have; it's something little boys have with their friends," Moritz says easily. "And little boys also have breast envy and pregnancy envy. We are all envious people, and what we don't have, we want."
She kept the basic schema, and she kept the tricks, too: the careful distance and reserve, the deliberate silences begging to be filled. "Psychoanalysis is always about the relationship, about a deeper and deeper knowing of each other," she says. "But for me there is a definite importance to not being known from the start in all your details. It gives the patient a chance to imagine you and relate to you the way they need you to be." The process, unprovable as id itself, is called "transference": It assumes that patients arrive with all the emotionally charged assumptions, desires and expectations of their past and project them onto the expressionless face of the analyst. "I've been Amazon sexual temptress, seductive mother, critical father -- patients go through a number of these as their treatment unfolds," she explains calmly. "Then, as it's no longer important, it's gradually given up, and they see you more and more realistically, as a struggling human just like them."
Her first patient was a woman in a baggy woolen shirt and pants who trembled with anxiety whenever her boss gave her an instruction. She'd been sexually abused by her grandfather, and now her husband was having affairs and flirting with their daughter in a way she was helpless even to acknowledge, let alone stop. The therapy lasted three years (a time frame most Wash. U. docs would find unconscionable), but the changes started within the first six months, as the woman realized the reasons for her own helplessness. "For most people, what happens is, their outside lives clear up and the symptoms come into your office," explains Moritz, adding that by the end of treatment the woman had divorced her husband, married someone healthier, become a stronger mother for her daughter and eased into what she continues to describe, in grateful Christmas cards, as a happy, regular life.
Hundreds more patients followed, each with his own Chinese box of memories and longings and fears. Moritz gained a kind of awe for the psyche's twists and turns, its ability to both protect and confound us. She guarded her patients' secrets fiercely, knowing all the while that this confessional seal was part of psychoanalysis' growing credibility problem. How could she do the kind of quantifiable, replicable research that science was demanding when her lab was the cobwebs inside her patients' minds?
Over the years, she watched with deep satisfaction as Wash. U. researchers exploded Freud's cruel speculations about cold, unreliable mothers who turned their children schizoid, pinpointed drugs to ease the torments of major mental illness without devastating side effects and traced genetic patterns of illnesses once blamed on warped character or early trauma. She also became active in the Eastern Missouri chapter of the American Psychiatric Association, working so closely with Wash. U. colleagues that the two sides grudgingly came to trust each other's good intentions. But they couldn't bridge the final abyss: the disagreement on how patients should be helped. The worldviews just didn't mesh. Wash. U. had created a standardized scientific vocabulary of classification; analysts treasured nuance and a fluid interplay between compartments. Wash. U. drew a straight line between mental illness and "problems of daily living" and focused on the former; analysts had seen "neuroticism" paralyze people and destroy their physical health as well. Wash. U. wanted to diagnose and relieve distressing symptoms; analysts wanted to share insight into their deepest causes.
When Moritz took over as director of the Institute in 1997, she placed unprecedented emphasis on research -- but psychoanalytic research was usually limited to comparisons of treatment outcomes or scrutiny of the therapy process itself. Patients weren't going to give up their confidentiality or jeopardize their own treatment to participate in a double-blind study, and, even if they did, the process would be so subjective and so variable that one couldn't generalize from it.
Wash. U. psychiatrists could generalize, by testing drugs, charting genetic traits and scanning brain mechanisms -- and that made the psychoanalysts look like high-priest wannabes, spoiled and self-indulgent and intellectually lazy. The image stung Moritz, who'd spent her entire life absorbing and clarifying and transforming other people's rage, agony, hatred, lust and muddle. "Nothing I have ever done is more fascinating, more completely absorbing, than this work," she says, leaning forward. "The trust that is involved is awesome. And the resiliency of people, even those who have been so scrunched down and constricted! I've seen spouses who've never had a moment of sexual pleasure in their lives; professionals who've sabotaged their own work for reasons they couldn't explain; people whose entire lives had to be rebuilt after a twist of fate destroyed everything. And, oh my God, the children. Grownups come to you with 40 years of issues, but children are right there in the beginning, and they take the analytic understanding and do handstands with it."
Friendless, the little girl spent every recess walking a perfect square around the school playground. At home, she went into tantrums if milk spilled or the schedule was broken, and she often begged her patient, loving, bewildered parents to kill her. Finally they brought her to Moritz.
Appointment after appointment, she let the child play.
"After my dying almost every day in fire, in rockets, in floods, she began more and more to focus on policemen and sirens and car smoke," recalls Moritz, "and she would put together, out of sheets of paper, massive highways that covered the floors of my room, everything perfectly done, Highway 40 with all its bridges. I went to her parents and said, 'Is there any chance that something happened on a highway to this child?' and they looked at each other and said, 'Oh my God. She was only 2; we didn't think she would remember.' She'd been in a car seat next to her dad, who was driving, and he had his first epileptic attack and jammed his foot on the gas, and the car went out of control. It was this idea that she had to be in charge of stopping the car, that she had to be the one who was making everything go right. And working this out made all the difference." Soon the child was playing kickball with the other kids, giggling uncontrollably. "It would have been all too easy to diagnose her with obsessive-compulsive disorder and give her drugs," concludes Moritz. "And drugs could have masked the symptoms for a long time."
Moritz has never opposed drugs; she gladly refers patients with biologically based illnesses such as schizophrenia to psychiatrists more skilled in the latest pharmacology, and as milder psychiatric meds have improved, she's become more willing to prescribe them for her own patients, especially early on, to lift a curtain of depression or anxiety long enough to reveal what's underneath. She's wary, though, after watching more and more psychiatrists try to solve existential angst with pharmaceutical stats. "We have run 3 million and eight people through these trials; all you have to do is increase the medication," she mimics in a pompous voice, "and when you get to the maximum of that one, you can change to a different family of drug, and for those who are 'resistant,' you can add an antipsychotic, you can add thyroid, you can add other drugs." Americans pay $10.4 billion a year for anti-depressants (a fivefold increase since 1993), yet depression, she remarks, is hardly ever a purely chemical problem. "People can be trapped in situations that undermine them and deplete their biochemistry. If you treat that symptomatically, you're not addressing the interrelationships of mind and brain and body. You can give them a false sense of happiness, perhaps, that covers over an inner emptiness and despair. But you haven't solved anything."
Moritz is one of those bright, poised and articulate women who, after confessing shyness, has to insist it's true. The surface makes a lie of any qualms -- her fingernails are perfect polished ovals, her hair curves softly on her cheek, her clothes are silk and wool, smoothly draped. Her ideas are polished, too, honed in that excess of perfectionism she's worked so hard to lose yet delivered so nicely that people miss their bite.
But in the spring of 1993, she surprised herself.
The phrase "managed care" was dangling in front of America like a horror-film string puppet, and the American Psychiatric Association had brought in the CEO of an insurance company to explain the facts of life to its legislative committee. "He said there were three important things about managed care: money, money and money," recalls Moritz, her mouth twisting. "He said they'd decided to decrease the number of psychiatrists by 50 percent and that those psychiatrists would treat only the sickest patients in hospital settings; talk therapy would be done by the least trained social workers."
She walked out furious, nerves zinging with a frustration she didn't need Freud to analyze. In France, psychoanalysis still reigned; in Holland, it was available even to prisoners. But U.S. psychiatric hospitals were folding as fast as nomads' tents, and managed care's new standard for a psychiatric session was eight minutes -- 12 for geriatric patients. "You can't even write down their meds in 12 minutes," she exclaims, "much less establish the kind of relationship they're hungering for!" As for children, they weren't likely to sit down, fold their hands and begin reciting their symptoms; you had to set aside lots of time, talk nonsense, listen for tangential clues and worm your way into their confidence. It was time well spent, because you could rescue them, restore them to a normal path before they got hopelessly lost.
But what managed-care company was going to reimburse you for building a tower of Legos?
Shyness now looked like a luxury, and she cast it aside. She became the president of the APA's Eastern Missouri branch in 1995, then the St. Louis Metropolitan Medical Society, and she started pushing through state bills to put mental illness on the same insurance footing as every other kind of illness. "There is a tract in the brain that uses dopamine as its neurotransmitter, and a disordered state in this tract becomes Parkinsonism," she testified at late-night hearings in Jefferson City. "An eighth of an inch away, there is another tract that uses dopamine, and a disordered state in that tract leads to schizophrenia. For those two illnesses to be covered differently makes absolutely no sense."
Three bills later, she's still working for full equity, and nobody's remarked on the irony that the strongest local champion of insurance rights is a psychoanalyst who long ago removed herself from all managed-care panels. "I don't think they know," she grins. "I just call myself a psychiatrist when I do this. I'm still fighting that CEO!"
One day a colleague at the Institute stormed in, his face mottled red. A child psychiatrist under his supervision was working in a managed-care setting, and a 6-year-old had just begun to haltingly describe sex abuse by her uncle, when a nurse banged on the door: It was time to move on to the next patient.
Another day, Moritz was lecturing to a group of physicians, and she described three problem patients: a suicidal alcoholic, a belligerent and litigious man who refuses to believe his diagnosis and a young woman harboring erotic delusions about her doctor. A man in the back of the room raised his hand and said, "I'm a primary-care physician, and I get paid $7 per patient per month. I wouldn't treat any one of them." His calculus made perfect sense. But, as Moritz warned fellow psychiatrists at a recent grand rounds at St. Louis University, "If they own you economically, they own you, and they can change us in that way. They can change what we think of as illness, what we think is treatable. They can change the essence of our profession."
It's easy for her to say this: The Institute is funded by patient fees, sliding-scale clinic fees, tuition fees from about 10 new candidates each round of admissions, and donations. Its 33 faculty members avoid managed-care reimbursements whenever possible: They don't want artificial constraints on their treatment time or methods; they don't want demands for confidential patient information; they don't want to spend 45 minutes on the phone requalifying their patients every week -- and managed care doesn't want them. Patients pay out-of-pocket for privacy and unfettered treatment, and the reimbursers apply their pressures elsewhere.
In today's system, the elitism Moritz once saw as a curse looks more like a blessing.
Moritz lights up when she talks about her students, many of whom came to the Institute seeking a humanity they can no longer find in managed-care psychiatry. The current poster child is Dr. Todd Dean, a gently intelligent young psychiatrist who wears a Mr. Chips-ish bow tie and listens carefully before he speaks. Dean did his residency at Wash. U. and stayed on to work there for another four-and-a-half years. In the beginning, he liked Wash. U.'s assertion that therapy shouldn't go on for years. "We saw tons of patients, and you did see bad symptoms get better really quickly, and that reassured me," he recalls. "It wasn't until the third year, when we started seeing people over longer periods of time, that I realized the quick fix often didn't last very long. That's when I began to think that the symptoms are not the problem. People spend years chasing their symptoms with meds, and no one ever asks why the symptoms are there in the first place."
One patient, chronically depressed, had run through every variety of anti-depressant. "Nothing seemed to be working," says Dean. "Then he told me his father had abandoned them when he was 13, he was made to work, his mom didn't date until he was 18 and then the first man she dated killed her. I went back to everyone who'd treated him, and no one knew that history. I asked him, 'Do you think this could have anything to do with how you're feeling?' and he said, 'No.'"
By then, Dean had come to dread the patients who informed him they had a chemical imbalance -- not because they didn't but because they'd neatly labeled their problems in a way a pill could fix. No longer convinced it could, he left Wash. U. to train at the Institute. It was the first time in decades that a Wash. U.-trained psychiatrist had crossed the moat.
The wall between Wash. U. and the Institute makes it hard for someone like Dean to find his place. But Moritz worries most about its effect on patients, who are forced to navigate the politicized, specialized and stormy waters of the entire profession before they even know what's wrong with them. Is their problem mainly biological, or mainly psychological? Did it start deep in their genes, or do they just not have enough serotonin to carry happy talk through the brain's tunnels? How do they figure out which worldview a particular psychiatrist holds, which language he or she speaks? Will they have to pick a bouquet of different practitioners to get the necessary meds and therapy, with nobody knowing the whole picture at any given time?
Moritz has heard her Wash. U. colleagues acknowledge the importance of a trusting therapeutic relationship -- as long as it doesn't go on too long -- but she's also heard them define the future of psychiatry as decoding the physical mechanisms of the brain. When they talk about trauma, they talk about the genes that predispose people to be abused and how much of personality is inherited ("more than 50 percent," notes Rubin). These are all subjects that can be studied. What Moritz hasn't heard much about is love and hate, unconscious motivations, buried pain, the accidents of life. By looking always for what can be scientifically proven, they confine themselves to the physical mechanisms of the brain and the generalities of genetics. In her mind, that's like trying to describe a beautiful spring day by listing the temperature, the humidity and the barometric pressure.
"What's missing is the human element," she says -- a patient's past, his quirks and motives and associations, the way he's learned to interpret his symptoms. Sure, those symptoms can be categorized, but there's a good chance they'll slosh into other diagnostic compartments or spill out of the container altogether. Wash. U.'s psychiatrists "talk about re-engineering the brain, and there are certainly genetically based illnesses for which that will be an amazing boon," adds Moritz. "But I can't imagine that you are ever going to do away with such things as abuse and neglect. We all know that early traumatic experiences can come back to haunt us, that we relive our worst nightmares over and over again. We believe it in literature and film and drama; we believe it in our own lives. We just disbelieve it when it means we're going to have to spend more money for health care.
"Even expensive medicines are cheaper than a physician's time," she adds. "Two people putting their heads together in a very intense way over a long period of time is expensive. But that is how the brain changes itself: permanent structural changes of the brain and permanent structural changes in one's life."
Stretched out luxuriously on a floral sofa that's never held a patient, Moritz chats with an ease her normal schedule doesn't allow. The air outside her New Orleans hotel room is thick with jazz and bourbon and steamy pleasure, but this afternoon she's caught by the cooler pleasures of the mind, anticipating the American Psychiatric Association conference. As secretary of the American Psychoanalytic Association, a delegate to the American Medical Association and a member of the Missouri State Medical Association's executive council, she arrived early, and now she's poring over an agenda that highlights all the new intersections between neuroscience, psychiatry and psychoanalysis. Even the workshop titles promise synthesis: "Mind Meets Brain"; "Neuroanatomy and Neurophysics of the Unconscious"; "A Neuroscience Perspective on Transference."
The halls already buzz with talk about Dr. Eric Kandel, who won a Nobel Prize last December for his patient work with the sea slug, species Aplysia. A very simple creature with very large cells, the slug allowed him to watch it "learn." What he saw, as the slug experienced the world, was that learning actually reconfigured its brain, triggering new expressions of the genes, forging stronger links between certain synapses. The lesson? The brain is truly plastic, and, with enough time and heat and focus, we can reshape it without depending on drugs. We can make new, permanent connections and pathways. We can change our habits, our associations, even our biochemical responses.
For Moritz and her analytic colleagues, that sea slug spelled vindication. Recent studies had shown that talk therapy could relieve symptoms as effectively as drugs, and that the drug effects were temporary. The anti-anxiety drug Paxil, for example, had given cowering rats the courage to seize the proffered bait of Cocoa Krispies -- but the minute the doses stopped, they cowered again. Now, Kandel's slugs would help the world understand that talk therapy could bring about permanent changes.
"There are billions of neurons in the brain, interconnected in infinitely complex ways," explains Moritz, "but our early upbringing makes certain patterns of response more likely than others. When babies are small, they put out all these little branches from their nerve cells -- it's called arborization, because they're making fuzzy trees. The branches can connect with other nerve cells, and the ones that are actually linked will stay, while the ones that are not linked to other neurons will recede. The more those links are cued off in the brain, the thicker they grow, and the stronger the connection that's forged."
If you cried as a babe and your mother immediately soothed and fed you, you formed an expectation that when you were distressed, your needs would be met. If your mother had ignored you instead, or spoken harshly to you, or slapped you upside the head, you would have formed a different expectation. And if the neglect were consistent, you would have begun to respond to the world not with a sense of trust and well-being but with anxiety, turning back upon yourself for what little comfort you could summon. Later in life, you'd find yourself reacting that way at the oddest times, without even understanding why.
"There are people who, out of their early experiences, get a kind of core idea of themselves as either bad and needing to be punished or as perennial victims of the world or as needing to be in a certain relationship to other people -- under their thumb, for instance -- to get their love," Moritz says slowly. "They grow up interpreting any ambiguous situation in a characteristic way, because they have a kind of expectation of what it means. And so they respond, physically and mentally and emotionally, in ways that are completely automatic and outside their awareness. Every time they go the same route, it becomes more of a rut." By drawing their attention -- repeatedly, in the intense framework of a therapy session -- to that route, a therapist can help erase the brain's rut, breaking up the old automatic patterns of association, deepening awareness of what caused them and clearing a path for new, healthier neuronal connections. Yes, it takes time, says Moritz, already defensive, and it should, because the brain responds better to gradual change, making more stable progress.
After her divorce, Moritz never remarried. "People combine themselves in marriage in different ways," she says tentatively. "I think, for us, what happened is, we kind of lost faith in each other. The loss of the baby was so disappointing and so hurtful -- it's, like, maybe you thought the two of you together, or that partner, could make the world be good, and when it didn't work out that way...." She raised the couple's two boys as a single parent, then, 12 years ago, fell in love with a steady, gentle engineer named John Georgiana. She feels no urgent need to make the relationship legal, yet she admits he's what sustains her through the political squabbles, the maddening social inequities and the unsettling empathy of her practice.
Three times a week, the couple stumbles into a fitness club at 5 a.m. and obeys a personal trainer. "I come out of there drenched with sweat," Moritz says, grinning, and slips her shoes off to demonstrate the walking lunges she dreads. "Did 'em this morning -- with weights. I would never work out this hard on my own." Nor would anyone dare psychoanalysis, risk the pain of reconstructing themselves memory by memory, if they didn't have a guide to ease their way. "People are frightened of psychoanalysis, you know," Moritz says abruptly. "We are afraid of our worst impulses -- afraid aggression will be unleashed or we will be ashamed of what we want." She remembers how her own heart thumped almost 40 years ago in Anthony's waiting room. What if she'd listened and fled? A more "medical" psychiatrist might have diagnosed her "depression associated with loss" as a biochemical imbalance foreshadowed in her genes. After starting her on anti-depressants, he might have suggested that she keep busy, think positive, eat well and get plenty of exercise. No need to remember how she'd resented her mother for divorcing her father or how she'd worried that anybody she loved would walk out on her. She would have won her way to a bland, resigned self-acceptance -- no guilt, no blame, just a life spent tinkering at her brain's surface. She might even feel better. But she'd never know why.
Instead, she devoted her life to that question. Does she ever wish she'd taken the crisp, medical approach? "Well, yeah," she retorts. "It seems so clean. It doesn't have anything to do with the messiness and horrors of the mind. It would be so nice to make a diagnosis by checklist and prescribe the proper med and see 'em again in a month for 15 minutes." The sarcasm drips right onto her coffee table. But a minute later, her voice softens: "The part of medicine I do think about sometimes is the laying-on of hands, the times when you know that concrete actions you have taken have dramatically helped. Yet in the end, psychoanalysis is the same -- people talk about 'the worried well,' but that is really not who we're dealing with. There is no pain like the pain of deep depression or being so ridden with anxiety you're afraid to leave your own home."
Her solution is to plumb the depths. Wash. U.'s not convinced it works. "Working hours a week with an individual patient, there is very little data that shows that that intensive, very costly therapy is effective," says Rubin. "Their response is, 'The patients will tell you how effective it is.' But how do you study that?" Impasse. Still, Rubin's convinced the old polarization has ended; he uses words such as "convergence" and talks about an emerging "sensitivity to the importance of time with patients" -- not hours and hours of psychoanalysis, perhaps, but the shorter, more efficient talk therapies. "Wash. U.'s medical model was overinterpreted, or misinterpreted, as purely biological. We're not only interested in drugs -- 'Pop a pill' is just bad medicine, and it's not what Eli Robins or Sam Guze taught the country. The medical model is a treatment approach."
Rubin predicts "a natural progression from the medical model to understanding the mechanisms of some of our illnesses at a very scientific level." He offers examples -- identifying the chemical hypocretin, which causes narcolepsy; targeting the abnormal accumulations of material in the brain of someone with Alzheimer's disease; finding the genetic underpinnings of abuse and other trauma. "We as a department may be again in the forefront," he adds with satisfaction, "in trying to push this approach."
Kandel, wizard of the sea slugs, applauds such biological research and urges psychoanalysts to involve themselves in its midst so they can both incorporate and shape the new discoveries. At the handful of medical centers where the disciplines are already integrated, it may just be possible.
Not in St. Louis.
There's middle ground at St. Louis University, which has always been more therapy-centered and even has a psychoanalyst chairing its psychiatry department. But the major research money, and the acknowledged research brilliance, is at Wash. U., and the deepest analytic expertise is at the Institute. For two decades, the two institutions have stood a block apart and barely spoken. Now, the analysts have outgrown their once-modern building, so they're scouting elsewhere for a bigger place. Somewhere in the county. Outside the shadow of the kingdom.