Friday, February 13, 2015

Psychiatry Today

Jeffrey Lieberman’s new book, Shrinks: The Untold Story of Psychiatry has not yet been published. It’s expected in a month or so.

Still, Gary Greenberg has reviewed it for Bookforum. His review and Lieberman’s book are serious efforts to tell the story of psychiatry. All things considered, especially the theme of this blog, we are duty-bound to address some of the issues both men raise.

Happily, Greenberg offers, in a single paragraph an overview of what has from its inception been a slightly dubious profession.

Right or wrong, he offers a good piece of writing:

Psychiatrists superintended horrifyingly squalid asylums; used insulin and electricity to send patients into comas and convulsions; inoculated them with tuberculin and malaria in the hope that fever would cook the mental illness out of them; jammed ice picks into their brains to sever their frontal lobes; placed them in orgone boxes to bathe in the orgasmic energy of the universe; psychoanalyzed them interminably; primal-screamed them and rebirthed them and nursed their inner children; and subjected them to medications of unknown mechanism and unanticipated side effects, most recently the antidepressant drugs that we love to hate and hate to love and that, either way, are a daily staple for 11 percent of adults in America.

Next, Greenberg exposes what he considers psychiatry’s primal flaw:

To say you know what mental health and illness are is to say you know how life should go, and what we should do when it goes otherwise. You’d better know what to do when you’ve made a grievous error in those weighty matters, or at the very least, how to ask for forgiveness. And you’d better hope that, apologies offered, you can give the public a reason to believe that at long last you know what you are doing.

I think Greenberg is correct to say that psychiatrists often pretend that they know how life should go. The best of them, however, know that they do not know.

At best, they know how life should not go, but knowing how life should not go is not the same as knowing how it should go.

Being a medical discipline, psychiatry has most often focused its attention on what happens when things go wrong, when people cannot function. It has tended to leave people to their own devices in figuring out how life should go.

When psychiatry went wrong, why did it go wrong? Lieberman blames the famed Viennese neurologist, Sigmund Freud.

Greenberg summarizes:

In Lieberman’s history, most of the profession’s travails can be traced to the mischief caused by one man: the Viennese neurologist who, on arriving for his first (and only) visit to America, said, “They don’t realize that we are bringing them the plague.” That at any rate is what, according to legend, Sigmund Freud said to Carl Jung as their ship pulled into New York harbor in 1909. Lieberman agrees wholeheartedly that Freud unleashed a plague. The pathogen was not, Lieberman says, the self-doubt and pessimism for which Freud is justly famous, but his autocratic approach to his patients and his insistence that his disciples remain in lockstep. Worst of all, says Lieberman, Freud “blurred the boundary between mental illness and mental health” by maintaining that conflict among the various agencies of the mind, set off by early childhood experience, was unavoidable.

Freud broke down the wall between mental health and mental illness, thus making everyone a potential patient. Psychiatrists rushed into psychoanalytic training, the better to leave the asylums and to open up private offices.

In Greenberg’s words:

Having convinced doctors (and patients) that we were all at least a little neurotic, Freud had opened the way to travesties like the pathologizing of homosexuality and endless and ineffective stays on the analytical couch.

As you might or might not know it, but Lieberman’s view has much in common with my own. See my book, The Last Psychoanalyst.

The dialectic feels a little too neat, but Lieberman continues to say that psychoanalysis provoked a reaction, the anti-psychiatry movement.

In many ways anti-psychiatry insisted that severe mental illness was merely a manifestation of social oppression. Voices that had been repressed by the authorities screamed out through neurotic and psychotic symptoms.

But, psychiatry had surely gone too far in pathologizing normal human experience. It led to the following study by a Stanford psychologist:

… Stanford psychology professor, David Rosenhan, sent eight people to emergency rooms around the country to complain that they were hearing the words thud, empty, and hollow. All but one were diagnosed with schizophrenia (the eighth was diagnosed as manic-depressive) and, despite acting normally once they got admitted, were hospitalized for as long as fifty-two days. When the respected journal Science ran Rosenhan’s version of the story under the title “On Being Sane in Insane Places,” it touched off a sensation.

The anti-psychiatry notwithstanding, mental illness did exist. The more severe versions, the psychoses, are now considered to be brain diseases, and anti-psychiatrists managed to persuade some psychiatric patients to stop taking their medication, often with disastrous results.

Lieberman believes that, once rid of Freud, psychiatry got its footing and moved forward with cognitive neuroscience and new psychiatric drugs.

Greenberg writes:

This triumph accompanied another: the ascent of neuroscience and the discovery of psychiatric drugs. As Lieberman acknowledges, these developments occurred in the opposite order: The drugs were discovered accidentally, mostly in the 1950s and ’60s, and neuroscientists have been trying since then to figure out how they work. But the upshot, at least in Lieberman’s view, is an unmitigated success. Armed with drugs that “targeted the symptoms of mental illness in a kind of lock-and-key relationship,” psychiatrists have become “empathic prescribers of medications targeting specific illnesses.”

Lieberman understands that there’s more to life than biology. Greenberg explains:

Not that all the answers lie in biology, Lieberman cautions, and attention to the brain won’t “replace the psychodynamic element that is inherent to existential disease.” But psychodynamics are not what they were in the Freudian era. The slippery unconscious has been replaced by schemata, the rules that guide cognition and feeling like computer algorithms, and interminable psychoanalysis has been replaced by short-term therapies aimed at reprogramming our cognitive software. Psychiatry has finally “matured from a psychoanalytic cult of shrinks into a scientific medicine of the brain.”

As with all science, advances in psychiatry deserve to be greeted with some skepticism.

For his part, Greenberg takes exception to Lieberman’s triumphalist view of today’s psychiatry:

He minimizes or entirely overlooks such unsavory recent chapters as the widespread diagnosis, against the criteria of the DSM, of bipolar disorder in the very young and their subsequent treatment with powerful (and untested in children) antipsychotic drugs—an episode that occasioned Senate hearings and front-page exposés. He never acknowledges that the “serotonin imbalance” that antidepressants supposedly rectify does not exist—or if it does, it has yet to be discovered—and his lock-and-key image belies the much less certain clinical reality, in which antidepressants are routinely prescribed for anxiety disorders, antipsychotics for mood disorders, and anti-anxiety drugs for a wide range of complaints—and all on a trial-and-error basis. He fails to mention that no new psychiatric medications have been discovered in the past quarter century, or that none of the newer ones have proved more effective than the drugs discovered in the 1950s (although some of them do have fewer side effects). And he vastly overestimates the current state of neuroscience, which is only beginning to unravel the mysteries of how the billions of neurons and trillions of connections among them turn into consciousness.

Psychiatry did well to jettison Freudian thinking. It has perhaps been overly optimistic in its embrace of biochemistry, but still, it is moving in a better direction.


Unknown said...

Psychology is supposedly a science but much of it is horribly subjective. The horrifying abuse of Psychiatry by the Soviet Union where they classified enemies of the state as insane is just a glaring example of the subjective nature of Psychology.
Homosexuality has for thousands of years been considered abnormal even above and beyond religious issues due to the strange deviant behaviors such as sado masochism and peadophilia associated with homosexuals. When the DSM added homosexuality as a mental illness it was well understood why as at the time it was illegal in most places. However, a simple coup d'etat of the APA by homosexuals allowed them to unilaterally change "science" and cultural norms based simply on those in charge of the organization's personal preference for deviancy. The incredible cowardice of rank and file members with doctoral degrees convinces me that the future for this profession is derision and scorn along the lines of Astrology and Phrenology which were once accepted sciences with powerful backers and general acceptance. Trust takes years, decades or even centuries to cultivate and can be lost in less than five minutes when people no longer believe your veracity.

Ares Olympus said...

re: At best, they know how life should not go, but knowing how life should not go is not the same as knowing how it should go.

It's a good general assertion. And at one level, we all want humility in our experts, but we also crave their certainty and will to take a stand on one path over another path.

I've been watching the TV series House on NetFlix and the whole story is that he's a jerk, but in the end he's always right, so people put up with his outrageous behavior because he finds answers that no one else can.

And on TV we always know there's a cause for illness, and almost always there's a treatment, if the cause can be found fast enough. And because House doesn't see people but puzzles, he's happy to find the cause, even if its too late to save the patient. Because for him, its one more datapoint that might help him solve the next case.

And maybe that shows the predicament. If you're objective, and only looking at "data", then your conscience is only triggered because you failed to correctly interpret the data. But if you're looking at a "whole person", then you're suddenly faced by endless unknowns, and every person is an individual, and what you learn from one individual may have absolutely nothing to do with any other case you'll face again. So if nothing else, "data" wins because you can spend 1% as much time with 100 times the confidence.

Of course the "cost" of that approach is you may always be treating symptoms and missing the primary cause.

So I'd say if the goal is "productive people", then its best to treat the symptoms, and if the goal is "maturity and wholeness", then we have to see things differently, and find long slow relationships that get people towards their goals.

But again, "wholeness" is something that is hard to quantify, so who wants to spend a lifetime "helping people" while admitting everything you do might be crap?