On the Shoulders of Giants

All of us benefit from the generosity of mentors. Standing on the shoulders of giants is ultimately the only way we create the future. Most of the giants in my career – Irwin (Bob) Feinberg, Sydney Brenner, Herb Pardes are now dead and, in spite of their massive contributions, seem to be fading too quickly into the oblivion that will consume us all in this social media age.

Two others – Judy Rapoport and Edna Foa – both passed away last month. These two women lived in different scientific neighborhoods. Although their paths crossed a few times at scientific conferences – both were pioneers in obsessive compulsive disorder (OCD) – they were not friends. But both had an enormous influence on me, literally giants with shoulders on which I had the good fortune to stand. Before they too become distant memories, a few reflections.

Edna Foa was born in Haifa in 1937, more than a decade before the state of Israel. The Sabra spirit like her Israeli accent never left her. She was a pioneer and a fighter throughout a long career dedicated to treating people with anxiety disorders. When I first met her in 1980, she was a young psychology professor at Temple trying to convert the methods of her mentor, Joe Wolpe, into treatments for OCD and PTSD. Like her friend and colleague, Isaac Marks, Edna believed that the best treatment was overcoming avoidance, not by talking but by doing. She developed and optimized “prolonged exposure with response prevention” – doggedly helping people to immerse themselves in the things they most feared and keeping them from their washing, checking, or counting rituals until their anxiety had subsided. Or as Edna would say it, “You cannot think your way into a new way of acting; you must act your way into a new way of thinking.”

Through a series of rigorous clinical trials, Edna demonstrated the effectiveness and safety of this behavioral approach to anxiety. It was an approach that reflected Edna’s core – blunt, fearless, and confident. Frustrated by the low uptake of this treatment for both OCD and PTSD, she dedicated much of her career to teaching and scaling this treatment through courses and campaigns. While never opposed to medication, she rued the pharmaceutical marketing campaigns that led to adoption of SSRIs, treatments she considered inferior to a head-on behavioral approach. And always the Sabra, Edna maintained her connections to Israel even after a long career and raising a family in Philadelphia. When I spoke to her last, about 9 months ago, she was (at age 87) most of all dedicated to “stopping the insanity of this war in Gaza.”

Judy Rapoport provides a curious parallel narrative. Born in Manhattan in 1933, she attended the prestigious Walden School before Swarthmore and Harvard Medical School. Trained as a psychiatrist during the psychoanalytic era, Judy had the benefit of a fellowship at the Karolinska where her friend and collaborator, Marie Asberg, introduced her to a biological approach to mental illness. In the 1970’s, Judy joined the NIMH intramural program where she ultimately led the child psychiatry branch for over four decades.

I first met Judy in 1979 when I joined the NIMH as a clinical fellow at the recommendation of my mentor, Bob Feinberg, who had known her since high school. In those days, decades before Fitbits and Apple watches, Judy worked with an engineer to put actigraphy wristbands on kids with ADHD, providing the first objective measure of hyperactivity. She was the first to show that amphetamines improved attention in kids with and without ADHD. And the first to begin studying OCD in children, a syndrome then thought to be so rare that she advertised in women’s magazines to recruit her first research subjects. My career launched when she offered me the adults with OCD who were too old for her studies.

In contrast to Edna Foa’s behavioral approach, Judy’s research demonstrated the effectiveness of an early SSRI, clomipramine (marketed as Anafranil), as a safe and effective treatment for kids with OCD. Today it’s difficult to remember just how much this research, first published in the early 1980’s, challenged the prevailing paradigm. In those days, psychiatrists considered OCD a neurotic disorder to be treated by long-term psychoanalysis. The idea of giving children with OCD psychotropic drugs was heretical. When Judy’s 1989 book, The Boy Who Couldn’t Stop Washing, became a New York Times bestseller, she changed that paradigm forever.

For me, these two women were both colleagues and dear friends. To be honest, I found them difficult at times. They were “difficult” in the way that people who are right before their time often are – focused, tough, uncompromising. Looking back, I marvel at their success and their generosity. And I think their careers are instructive. That they saw the same clinical problem from different perspectives – one behavioral and one biological – captures the major rift in our approach to people with mental disorders. Of course, they were both correct. We need both a behavioral and a biological approach although our field remains split between psychology and psychiatry – much to the detriment of patients with OCD.

While I was personally close to both Edna and Judy, I don’t think they would have been friends. And yet they shared so much. Both had to overcome the psychoanalytic mafia who insisted that insight gained through years of talk therapy was the only legitimate treatment. Both had to succeed as women in a scientific culture where only men were taken seriously. And both decided early in their careers to dedicate themselves to mentoring the next generation leaving not only a series of outstanding papers but a legacy of talented leaders to carry on the work.

I like to use this Substack to highlight important trends in research or policy. But sometimes there are moments that deserve a call out. The deaths of these two outstanding clinical scientists last month offers a useful time to reflect on what matters. And to say thank you to two people who gave me and our field so much.