Abstract
DEAR SIR,
Dr Koopowitz would have us believe that psychiatry would go forward if only we could all know more about neurology and its expensive tools.[1]
The 18-year-old patient in his article, after a few sessions, might start wearing low-cut dresses and bringing him gifts, thus arousing feelings in the psychiatrist. In his efforts to understand this practical and common problem (with all its potential for disaster), the psychiatrist might want to focus upon the patient's dysfunctional locus coeruleus, amygdala and noradrenaline levels. But, to do so rather misses the point, however distally relevant these concepts might be. The concept of transference, and the art of how sensitively to work with it, seem closer to the mark here, in order to protect this patient and doctor, and optimize her growth through her several predicaments. In the psychiatrist's search for leverage, psychodynamic concepts have the fulcrum arguably closer to the load. Let us hope that his training has been broad enough to let him know what is happening in the room, and how to deal with it.
The challenge for psychiatrists is not to adhere slavishly to any particular paradigm when endeavoring to understand a person. One approach is to use clinical observation to help infer the level of maximal, or primary, dysfunction. This might be at a molecular, neuronal, circuit, regional, or symbolic level. Then treatments can be pitched at the appropriate functional level, for maximal leverage.