Shrinks: The Untold Story of Psychiatry - 386

shrinks

Jeffrey A. Lieberman, MD, is a Professor and Chairman of Psychiatry at the Columbia University College of Physicians and Surgeons and Director of the New York State Psychiatric Institute. He is a well-recognized researcher and writer in the areas of schizophrenia and psychiatry broadly. He has also served as a past president of the American Psychiatric Association in 2013-2014.

This book presents a wide-lens synopsis of psychiatry and its development as a medical profession over the last century. Although it is largely concerned with the U.S. focused history of psychiatry, Leiberman paints this historical account through prominent personalities, discoveries and developments in treatments for mental illnesses, controversies around the definition and diagnoses of mental disorders, idiosyncratic causal theories, the rise and fall of psychoanalysis in clinical psychiatry, and the recent developments in molecular biology and genetics proclaiming the age of biological psychiatry. This history is well contextualized within social changes, like growth of asylums and impact of great wars, and the political imperatives like the economics of community care and a diagnostic bible to save the profession and secure treatment funding.

Psychiatry has long been in search of valid diagnostic constructs underpinned by distinct aetio-pathogenesis to establish itself as a scientific medical discipline. This journey, as the author traces, has taken many twists and turns through the mysticism of Mesmer’s animal magnetism theory, Reich’s Orgone hypothesis, Benjamin Rush’s disruption to blood circulation conjecture, Freud’s revealing insights in to the unconscious, and the modern day scientific breakthroughs in neuroscience, neuroimaging, genetics, and molecular biology.

The book chronicles many undeterred spirited personalities who, with passion and dedication, sometimes misguided, put their faith in malaria parasites, rotational chair, bilious pills, orgone accumulators, insulin shocks, ice picks, electricity, tranquilizers, and reclining chairs to treat mental disorders. Then came in 1950s the chemical revolution of chlorpromazine, imipramine, and lithium. Thus, psychiatry was changed forever; we may still not understand, but we could treat mental illness.

The book also provides an interesting overview on the changing persona of the ‘physician of the mind’ in public imagination from the mesmerist, to the asylum bounded Alienist, the aloof and quiet psychoanalyst, the Hollywood inspired Shrink, the armed forces neuropsychiatrist, to finally the modern day pluralistic Psychiatrist. However, readers may notice the disparaging tone of the author describing the earlier iterations, changing to more positive view of the modern day ‘scientific’ psychiatrist.

This rather contemptuous tenor of the psychiatry’s development in the first   half of last century is most evident when the author gives an account of rise and fall of psychoanalysis in the American psychiatry. The influence of author’s training in the heydays of psychoanalysis, which transformed the initial allure of the theory of mind to his desperate disenchantment from the prophetic aetiological speculations, is apparent across the book. Sadly, despite his passion for evidence, Lieberman emphasized the much-disputed analytic concepts of ‘schizophrenogenic mother’ and ‘double-bind hypothesis’ of schizophrenia, as his contention to discredit psychoanalysis.

He appeared to have taken some pleasure in selectively quoting the excesses of psychoanalytic heydays. On p199, immediately after having mentioned the meteoric rise and shameful downfall of Nathan Klein’s psychopharmacological successes, he quotes from the Time magazine, “The ivory-tower critics (mainly psychoanalysts) argue that the red-brick pragmatists – state hospitals – are not getting to the patients’ ‘underlying psychopathology’ and so there can be no cure. These doctors want to know whether he withdrew from the world because of unconscious conflict over incestuous urges or stealing from his brother’s piggy bank at the age of five. In the world of red-bricks, this is like arguing about the number of angels on the point of a pin.” This, at times sounding personal, rancour exhibited under the guise of providing an ‘untold’ account of the psychiatry’s history is, in my view, a major shortcoming of this book.

However, he is at his best when championing the origin of biological psychiatry from the ashes of psychoanalytic psychiatry. The book vividly describes the coming together of the forces for change between 1950 and 1970s, with passionate diplomacy of Robert Spitzer, daring aspirations of Feighner and his group, public humiliation of psychiatry in the ‘On Being Sane in Insane Places’ experiment, armed forces involvement with psychiatry during WW II, antipsychiatry movement of Szasz, Laing, and Goffman, disorder of homosexuality, untenable economics of the burgeoning asylums, and ultimately discovery of chlorpromazine, imipramine, and lithium.

Not many would recall today that the journey of diagnostic psychiatry started in 1941 when the US army convened a committee, headed by William Meninger, to develop a consistent system to evaluate recruits in the WW II. A new classification system was produced in 1943 as a 28-page War Department technical bulletin called as Medical 203. It described about 60 disorders; it was the first diagnostic system that classified every known form of mental illness. It will be an interesting read for many to learn the political drama and conceptual shifts in psychiatry from Medical 203 to DSM 5. The author’s personal involvement in the development of DSM 5 gives a certain glorified tint to this controversial achievement of our profession.

There is a whole chapter dedicated to the story of Post Traumatic Stress Disorder, with its various iterations from “irritable and exhausted soldier’s heart”, Shell Shock, Combat Neurosis, Battle Fatigue, Combat Exhaustion, Post-Vietnam Syndrome, to its current diagnostic form. This highlights psychiatry’s important contribution in advocating for identification and treatment of this disabling condition even in the face of public scepticism and organizational resistance.

Along with the advances in naming and treating mental disorders, came the new wave of brain-focused psychiatrists who were not contend by restricting themselves to the therapy rooms. They spent hours in the labs, working on simple organisms to understand one synapse at a time. The book presents inspiring portraits of the pioneers of biological psychiatry like John Cade and Eric Kandel; but, regrettably, downplays egregious cautionary tales of psychopharmacological excesses in Nathan Klein.

Although scathing of psychoanalysis, Lieberman finds reassurance in the changing approach to mind from understanding meanings to modifying behaviours. He acclaims the contributions made by Beck (Cognitive Behavioural Therapy), Weissman and Klerman (Inter-personal Therapy), and Linehan (Dialectical Behavioural Therapy) heralding a new future for psychotherapy.

Despite all the recent advances in our knowledge in diagnosing and treating mental illness, most community epidemiological studies indicate that only a small proportion of people seek treatment for mental illness, only about half of those respond to treatment, and a smaller proportion comply with the recommended treatment. For all the enthusiasm about psychiatry’s recent scientific achievements, the fact remains that only a fraction of people with mental illness achieves full remission of their illness and psychiatric disorders remain very high on the burden of disease order. Why this discrepancy1,2?

In the introduction, Lieberman illustrates his optimism about recent developments in biological psychiatry by presenting the case of ‘Elena.’ He shares his excitement in the success of modern day psychiatry in effectively treating symptoms of schizophrenia within three weeks of treatment. However, he fails to notice that she stopped the treatment and her parents did not share the psychiatrist’s conviction about the diagnosis or the marvel of current day’s treatment. I think therein lies another shortcoming of this book. It tries to persuade the reader in trusting psychiatry’s recent achievements by mocking the steps along the process of reaching our current state of scientific understanding.

The knowledge gathered over a century of psychoanalytic work informs us that to understand and treat mental illness is more than a chemical process. To explore the personal meaning of symptoms, illness, and recovery for the person is an important part of therapeutic process3, and perhaps as the case of Elena illustrates, sometimes a key element to ensure alliance and compliance.

Most readers will agree with Lieberman that it is an exciting age for psychiatry with the opportunities to integrate exciting developments in sciences to understand causes and better ways to treat mental disorders. However, the enthusiasm requires caution; we are known to underestimate the subjective bias in celebrating our knowledge and accomplishments. This takes me back to psychoanalysis and its contribution. Lieberman’s overly authoritative prophesying about the new dawn in our understanding and success in treating mental illness is ironically like the claims made by many others in the past, whom, with the wisdom of hindsight, he describes as charlatans and frauds.

This book will be of interest to anyone who wants to learn about the milestones in psychiatry’s professional development. It is a worthwhile effort in synthesizing important figures and the trajectory of psychiatry’s development as a scientific discipline. It concludes with making a compassionate appeal to address social stigma about mental illness by highlighting the possibility of fulfilling and accomplished lives despite severe mental illness in the examples of Elyn Saks, Kay Jamison, and Andrew Solomon. It is my opinion that Kandel’s pluralistic psychiatry4 is better placed than Lieberman’s biological version to achieve this goal.

Reference:

  1. Anthony F Jorm (2014) Why hasn’t the mental health of Australians improved? The need for a national prevention strategy. Australian & New Zealand Journal of Psychiatry 48:795 – 801
  2.  Mojtabai, Ramin et al.(2015)  Trends in psychological distress, depressive episodes and mental health treatment-seeking in the United States: 2001–201.2   Journal of Affective Disorders 174: 556 – 561
  3. Metzl JM, Riba M. (2003) Understanding the symbolic value of medications: a brief review. Prim Psychiatry, 10:45-48
  4. Kandel ER. Psychiatry, Psychoanalysis and the New Biology of Mind. Washington DC: American Psychiatric Publishing; 2005