Mood Swings

A psychiatrist surveys the mind and the wider world

Existential Psychopharmacology: A Tribute to Dr Jacob Katzow

How a mensch lived and practiced

After finishing my psychiatric training, when I began work in my home city of Washington DC in the late 1990s, Dr Frederick Goodwin, who had accepted the task of mentoring me, told me I should get to know some of the practicing psychiatrists in the area. “Begin with Jack Katzow,” he said. “He’s very experienced.” Not only would Jack turn out be an experienced colleague and fellow clinician/researcher, he became a kind fatherly friend for two decades.

Jack’s office was in Washington Circle, across the street from George Washington University Hospital, where I worked. Often, I’d cross the street and visit with him, sitting next to that fireplace in his cozy office. Jack had been sitting there since the late 1960s, when he opened what he told me was the first psychopharmacology practice in the city. In an era when federal health insurance paid for unlimited psychoanalysis, and one could make a living psychoanalyzing a dozen patients for an hour daily, Jack decided to use medications to treat the diseases of the mind in hundreds of patients at a time.

He was trained in psychoanalytic psychiatry with the best of them, a graduate of the premier residence of that era, Harvard’s Massachusetts Mental Health Center program. He was a protégé of Gerald Klerman, a leading Harvard psychiatrist who would later be Jimmy Carter’s top mental health aide (they regularly met in Georgetown for lunch during this period) and a driving force behind DSM-III, the 1980 massive change in psychiatric diagnosis. The profession caught up with Jack about 20 years later when, influenced by Klerman among others, psychopharmacology replaced psychoanalysis as the main treatment given. By the 1990s, when I arrived, Jack was a senior figure in DC psychiatry: he had treated some prominent figures in the city, had his own local public radio talk show about psychiatry, had taught residents at GWU, had maintained almost three decades of continuous private practice in the same location. Twice my age, he treated me like an equal from the start, and we eventually published a half dozen scientific papers together (mostly on the bipolar spectrum concept, its diagnosis, and potential medication treatments).

His method was natural to him, but also a reflection of his unique amalgam of his psychoanalytic training and his pharmacological approach. He would sit down with patients and just talk to them; they’d talk about whatever they wanted, for about 20-30 minutes, and in the course of the session, he’d make judgments about symptoms and medications, and, after they left, he would jot down a few lines for his chart. I’ve reviewed many of those notes for papers we published: they were clear and told you what you needed to know about symptoms and improvement and drugs. What wasn’t recorded, and what few psychiatrists other than Jack now do, was the half hour of getting to know the person behind the patient. Jack always began with his patients as human beings, and would find out what he needed to know about their illnesses by and by. Doctors today hand out drugs for symptoms, and hardly know their patients. This is our psychopharmacology today. What Jack did was more profound, much more humanistic, and also more scientific. He knew what he was doing when he gave pills for diseases, and when he didn’t.

He was, in my experience, the best exemplar I’ve seen of the practicing psychiatric clinician, as one who seeks to help, but also is always acutely aware of the many ways he can harm. He set an excellent example; if I ever needed psychiatric help, despite all the experts I know, I would have turned to him first.

Jack was practicing, as I look back on it now, a kind of existential psychopharmacology. He was with his patients, human being to human being—that’s the existential part. But he also was evaluating his patients for diseases, and knew how to treat them correctly, if found, with drugs—that’s the psychopharmacology part. Too many people who profess an attachment to humanistic attitudes, or even identify themselves as existentially-oriented, refuse to accept the reality of disease, and view all biological talk as bad biological talk. Diseases parade in front of these self-proclaimed humanists, and they see nothing. They think they see clearly only because they refuse to change their focus beyond one line of sight.

In contrast, as is well known, many biological reductionists just treat every symptom with a drug and never get to know the human beings whose brain they are manipulating, and even damaging, with a reckless psychopharmacology.

You can’t be humanistic if you aren’t scientific and biological too. You can’t be scientific and biological unless you are also humanistic. Science and humanism need each other. Existential and biological approaches in psychiatry are not opposites; they can’t validly happened without each other. Very few psychiatrists, or opiners on psychiatry, manage to be both existential and biological. Jack Katzow did so, existentially, without much overt conceptualization of what he was doing.

My sense is that he hit upon his unique practice from a mix of his training at Mass. Mental in a very existentially-oriented psychoanalytic program. Its leader, Elvin Semrad, about whom I’ve written before, gave generations of his student that stamp. His message was that the psychiatrist’s job was to acknowledge, bear, and put in perspective suffering. Acknowledging and bearing is the existential work, and putting in perspective was something he interpreted psychoanalytically, which may be sometimes valid. But sometimes, when a disease is present, the valid perspective needed is the biological one. Jack knew that Semrad’s approach was only half the story. (He had personally studied with Semrad somewhat in residency, and Jack was closely mentored by Klerman, as mentioned, whose closest mentor was Semrad). His own personal inclinations were in line with Semrad’s existential approach; it came naturally to Jack to just talk to patients like human beings, rather than enforcing a psychoanalytic paradigm on what they said.

But he also had a natural antipathy to existential extremism, to the attitude that medical models of disease just didn’t apply to any mental illness. He knew that diseases existed in psychiatry and that some drugs were very effective, and he followed the scientific literature to understand the true nature of diseases and the real effects of drugs. He came to the conclusion, as I did, that a broadly-defined bipolar spectrum is a disease process that is not well-appreciated by psychiatric clinicians, and, when it is recognized, it is typically mistreated with the wrong drugs (antidepressants in particular), which often worsens the disease even further. He and I felt that some new anticonvulsants and neuroleptics, along with lithium, could be correctly managed to improve the disease.

Biological existentialism, existential psychopharmacology – we need some kind of phrase like this to get the idea across. This is what Jack Katzow practiced, I think, and this is what I’m trying to teach.

As Jack got older, unlike most people, he did not remain set in his ways. He was always asking questions about everything, new drugs, new diagnostic ideas; he was always seeking new knowledge. He was extremely curious; his mind didn’t stop; he talked a lot and seriously looked into you to see if he could add to his store of knowledge. He was almost feverish in his wish to know more and more. He read the journals, and attended the conferences, and took his medical task seriously. He was fully committed to his profession, embodying Osler’s warning about medicine being a jealous mistress.

This freedom of mind isn’t minor: so many medical clinicians run in place for half a century; they practice medicine as a repetitive task, with nothing new learned or done since their youth. They are not curious, open-minded, inquisitive, aware. This is the average psychiatric clinician. Jack was the opposite.

Most of our conversations were about medicine and psychiatry and drugs and diagnoses—even in our last meeting, when we walked around the mall in Tysons Corner, and sat for a coffee. I kept asking about him, how he felt, his feelings; he wanted to talk about this drug and that, and this symptom and that. Maybe it was denial; maybe not. He had always been this way; he wasn’t going to change.

It is said that to learn how to live and to learn how to die are one and the same thing. Jack managed his illness matter-of-factly, calmly, with concern to lighten the burden for his friends and family—just as he lived.

At psychiatric conferences, he’d walk around and when we would sit with other colleagues, often younger than him, he’d ask them volleys of questions too. He wanted to know where they worked, what they did, what they thought. He would say what he thought about diagnosis (the bipolar spectrum was his favorite notion) and medications (he always tried new things and often had a good sense what they did before the clinical trials were finished). Those who met him always came away with the awareness that they were meeting a master clinician.

He wasn’t a politician; he didn’t try to get on committees or make it to the podium at conferences. He was content to sit in the audience, and see if he could learn something more. He was an astute observer. Once, in a DC restaurant, where I was going to give a talk, the pharmaceutical company representatives who arranged the talk asked Jack to introduce me. He stood up and alluded to my prior work in the city, and our work on the bipolar spectrum and new medications for it, and then he turned the microphone to me. After I had finished, he took me aside and said: Nassir, you know, you came alive up there. When you’re talking to people one on one, you’re a bit shy and nervous; but when you get a microphone, and talk to a group, you become outgoing and funny and impressive. What a personality change!

He said it clinically, not judgmentally: This is the way you are. Isn’t that interesting? Everything was interesting to Jack.

He was always trying to help me improve in my talks or books. He was the sympathetic observer in the audience who could tell me what I said that was unclear, or how I might better express an idea for clinicians. Once, after I had sent him a mood disorders handbook I wrote, carefully hand-dedicated to him, he sent it back with pages and pages of marginal corrections of typography and nuances of content. He always tried to make me better. I think he did this with everyone.

I could say more: about how he ran into me in the airport listening to music, and asked who I was listening to, and didn’t recognize the Cure; about the sad jingle he wrote about New Year’s Day (you can find it on YouTube); about how kind he was to my small children; about how he and his wife Fran threw a gracious and bittersweet going-away party for my wife and I when we moved away from DC; about how he always asked about my personal life and about the constant solicitude he had for my personal happiness.

Sometimes he talked about music; sometimes he gave advice about child-rearing (don’t waste your time with housework, he said; pay someone else to do it, and spend your time with your children); sometimes he talked politics (usually Middle Eastern). He’d sometimes allude to Yiddish phrases or jokes (he highly recommended The Joys of Yiddish, which I bought), sometimes reminisced about his California youth.

Jack was a multidimensional man—and if success means getting what you want and being satisfied with it, then he was successful.

Jack wasn’t much of an email user; I have no paper trail of our friendship. He would call on my cellphone, usually with an astute clinical question. Then we’d arrange to talk later at night, usually for an hour or so. Jack was a talker; he lived life in words and with persons. He had trouble writing, and didn’t ever transition to the computer era. He was so humane that he needed human contact. There wasn’t enough of it, in retrospect, between us in his later years. I’m glad that I made it a few times to visit him in his Cleveland Park neighborhood, in his home, at the local bagel place. That’s the way I would like to remember him, in our closest, most personal, simplest interactions.

Jack’s mind outlived his body. He would have and could have kept going, doing what he did, working, helping others, happily enjoying his friends and family, learning more and more. But his body didn’t cooperate and give us the extra years we would have wanted. It is our loss, not just his.

There’s a single word for this kind of man; it’s a good Yiddish word that has the many layers of meaning needed to acknowledge his special humanity: Jack was a mensch. If you look it up in the Joys of Yiddish, you’ll find these comments by Leo Rosten: “It is hard to convey the special sense of respect, dignity, approbation, that can be conveyed by calling someone a real mensch. As a child, I often heard it said: The finest thing you can say about a man is that he is a mensch!

…To be a mensch has nothing to do with success, wealth, status. A judge can be a zhlub; a millionare can be a momzer; a professor can be a schlemiel, a doctor a klutz, a lawyer a bulvon. The key to being a real mensch is character, rectitude, dignity, a sense of what is right… “

So I should end by just saying Jack was a mensch, a real mensch. I think he would have appreciated that, despite being a bit embarrassed, and not wanted more. But I’d like to say a bit more, maybe because I don’t appreciate the Yiddish meaning well enough still. To me Jack was a kind good, fatherly friend, and exemplary as a compassionate, humane, scientific physician. The world can never have enough people like him, and those of us who got to know him well and were enriched by his companionship can only be thankful for those experiences, remember them with fondness, and try to live our lives well enough that others may also think of us half as well as we think of him.

 

 

 

 

Nassir Ghaemi, M.D., M.P.H.,

is Professor of Psychiatry at Tufts University School of Medicine, and Director of the Mood Disorders Program at Tufts Medical Center in Boston. more...

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