Sunday, 31 May 2015

Shrinks to Fit

Jeffrey Lieberman is gaining attention and opprobrium as he publicizes his new history of psychiatry "Shrinks". The book turns out to be a lively run through of the standard history-of-psychiatry over the last two centuries, though at first it's hard to know what to make of it. "Shrinks" initially reads as either the gentle reflections of a well intentioned psychiatric patrician, or a cynical attempt to skirt fascinating conceptual difficulties in the service of professional power. Which you pick depends on how much Machiavellian intent one imputes to its author.

Jeffrey Lieberman (very possibly the only psychiatrist 
alive who still wears a white coat).

In writing Shrinks, Lieberman does not just want to spin interesting yarns. There is an argument being made, and it explicitly invokes a narrative of progress. Psychiatry, according to Shrinks, has muddled through the Freudian intellectual backwaters of the 1950s and 60s; endured the clunking horrors of insulin coma and psychosurgery, and now it stands on the brink of a new scientific era. I might be missing something but this story strikes me as anything but "untold". It's a well worn and, I would argue, simplistic narrative which won't gain any traction among anyone even vaguely acquainted with the legitimacy crisis faced by psychiatry's classification system. You do not need to be one of Lieberman's "anti-movement" (I am not) to find passages like this a little too slick:
“For the first time in its long and notorious history, psychiatry can offer scientific, humane, and effective treatments to those suffering from mental illness. I became president of the American Psychiatric Association at a historic turning point in my profession. As I write this, psychiatry is finally taking its rightful place in the medical community after a long sojourn in the scientific wilderness.” (p.10)
That is not to say the book is not fascinating. For one thing Lieberman's prominence as a psychiatric researcher has given him front row seats for many of the major changes in psychiatry since the 1970s. He gives compelling accounts of the renegade neo-Kraepelinians gathering in St. Louis (far from the psychoanalytic powerhouse of New York) to assemble the "chinese menu" DSM-III which changed Lieberman's profession forever (entirely for the better by his account).

Lieberman also has some provocative personal perspectives on the broad debates concerning psychiatry, suggesting (on the basis of a conversation with E.F. Torrey) that R.D. Laing lost his argumentative lustre when his daughter started to suffer from a psychosis that was diagnosed as schizophrenia. Meanwhile, Thomas Szasz, "who I met several times [...] made it pretty clear he understood that schizophrenia qualified as a true brain disease, but he was never going to say so publicly" (p.113). He also peppers the book with clinical encounters, so we learn that Lieberman once gave ECT to the wife of a New York restaurant owner who was so happy with the results that he offered Lieberman free meals whenever he wanted.

We are also given to suspect that Lieberman harbours deep frustration with psychoanalytic dogmatism, and he concurs with Freud, who once muttered darkly to Jung that they were "bringing the plague to America". Lieberman writes like someone who endured a feeling of disconnection from his profession when he was starting out:
"If a trainee wanted to rise within the ranks of academic psychiatry or develop a successful practice, she had to demonstrate fealty to psychoanalytic theory. If not, she risked being banished to working in the public-hospital sector, which usually meant a state mental institution. If you were looking for an indoctrination method to foster a particular ideology within a profession, you probably couldn’t do much better than forcing all job applicants to undergo confessional psychotherapy with a therapist inquisitor already committed to the ideology.” (p.77)
However, he is no Freud-basher, calling the latter a “tragic visionary far ahead of his time" and suggesting that psychoanalysis remains the best way of understanding certain sorts of psychological problem (though this comes early in the book, and is soon buried by his aversion). Like Tom Burns in 2013's "Our Necessary Shadow" Lieberman has a story about helping a patient overcome an apparent conversion hysteria, lending weight to Freud and Breuer's early formulations of that fascinating disorder. He even mounts a rather good defence of Freud's approach to drawing empirical inferences from clinical data:
"Freud had no tangible evidence whatsoever of the existence of the unconscious or neurosis or any of his psychoanalytical ideas; he formulated his theory entirely from inferences derived from his patients’ behaviors. This may seem unscientific, though such methods are really no different from those used by astrophysicists positing the existence of dark matter, a hypothetical form of invisible matter scattered throughout the universe. As I write this, nobody has ever observed or even detected dark matter, but cosmologists realize that they can’t make sense of the movements and structure of the observable universe without invoking some mysterious, indiscernible stuff quietly influencing everything we can see." (p.43)
But Shrinks, like the proverbial psychoanalytic patient, might be most revealing where it least intends to be. This book is full of peculiar sentences whose brusqueness may reveal a studious irony or unfortunate lack of reflection:
“After watching shocked pigs become oblivious to the butcher’s knife, Cerletti decided that shooting 100 volts of electricity through a person’s skull was worth the obvious risks.” (p.167)
"While the publication of the DSM-III had been marked by tumult and controversy, the release of the DSM-IV was as routine and uneventful as the opening of a Starbucks." (p.271)
The breezy glibness on ECT, combined with the terribly unfortunate analogy between the DSM project and an oft-maligned international coffee chain, might have been calculated to provoke the dismay of the very people Lieberman seems keenest to convert. But then, perhaps it's just that Lieberman thinks he can best connect with a readership in modern corporate America. Just look at how he describes Freud's approach to leadership:

"If Freud was the CEO of the psychoanalytical movement, his management style was more like that of Steve Jobs than of Bill Gates." (p.54)

In a penultimate chapter on the creation of DSM-5, Lieberman sounds touchingly hurt by all the outrage the manual provoked (he puts it down largely to the Internet, and appears to lament the loss of a time psychiatry could go about its business in private), but puzzingly unwilling to acknowledge what was driving it. Detractors are either antipsychiatrists (Gary Greenberg) or purveyors of "epistemic hubris" (Thomas Insel). Only the DSM-5, for Lieberman, achieves the theoretical pluralism which must be psychiatry's future. Such pluralism is a noble goal for a discipline as wide ranging as psychiatry, but Lieberman is too sanguine about the ways that notorious "bible" (Lieberman favours "bible", a term I normally associate with critics) stifles rather than promotes it.

"Shrinks" is an entertaining read, and at least in some regards more nuanced than I expected. But Lieberman's unwillingness to wade into the conceptual confusions his specialty is still dealing with, combined with his true-believer optimism about its imminent brave new world (genetic tests for forms of psychosis; cognitive behavioural therapy apps), make for an all too smooth ride. This is a work of unabashed advocacy, even propaganda, and should be read as such.



After writing this, I found a wonderfully scathing review of the book by Rebecca Twersky-Kengmana, who draws out more of Lieberman's weird disdain for psychoanalysis. More than me she views Lieberman's position on it as a flat contradiction. Her post also includes some great Amazon reviews by people dismayed at the quality of Lieberman's historical scholarship:

Shrinks: The Untold Story of Jeffrey Lieberman's Oedipal Victory Over Papa Freud

Friday, 15 May 2015

Spare Me the Sanctimonious Bleating About Trigger Warnings

The New Republic is carrying an article by Jerry Coyne lamenting the rise of the trigger warning, and specifically the idea that college literature courses should consider applying them to the Western canon. Without much explanation, Coyne links trigger warnings to the "decline in free speech at American universities". It is not clear exactly what a trigger warning prevents one from saying.

He is particularly concerned about an article by Columbia University's Multicultural Awareness Advisory Board that had appeared in that college's paper. It described a student's distress after reading rape scenes in Metamorphosis (which had triggered memories of her own experience of sexual assault) and being dismissed by the teacher. Evidently unable to suppress his own sympathy, Coyne hedges about the specific case:

There is something gloriously stupid about this. Coyne seems to be trying to have it both ways: "I would have provided a trigger warning to this student, but I would never have been so crass as to say the words 'trigger warning'". This is a familiar reactionary tic, driven by the same pig headedness that detests political correctness for its requirement that people don't always spew the first offensive crap that jumps into their heads.

Having concluded that trigger warnings per se are not that bad a thing after all. Coyne could have stopped after four paragraphs, allowing us to agree that warning people about potential personal sensitivities is hardly an attack on the first amendment. Instead he spends the rest of the article talking about how much he hates them.

Coyne trenchantly enumerates all the great works of literature that no-one will be allowed to read anymore (probably) if trigger warning Fascism (and he does use the word Fascism) takes hold. The Bible sanctions rape; Huckleberry Finn is full of racism and Anne Frank's Diary contains antisemitism. Perhaps there's an argument in there somewhere, but Coyne lost sight of it long ago. His article becomes an ill tempered rant about other people's sensitivity, culminating in a weirdly defiant account of his trip to Auschwitz.

Should everyone go to Auschwitz? Perhaps. I should certainly go, but what about people whose parents died there? Or survivors who remember it just fine thankyou very much? Unlike Coyne (whose appetite for understanding the worst in people is laudatory), some people don't need a reminder that ordinary people are capable of brutal things.

"Life" as Coyne says "is triggering". Nobody denies as much, but what the trigger warning sensibility acknowledges is that it is not always triggering for everyone to the same degree. Some of us (Coyne is clearly one) can blithely ignore the warnings. Others can be grateful that they increasingly get a choice about whether to follow link that may lead them to get lumbered with flashbacks to their own sexual assault, accident or suicide attempt. 

These sorts of consideration can be managed entirely without any impact on freedom speech; the inclusion of a brief parenthetical "TW" next to links or items on a syllabus is all it takes. If that offends you (and being offended by trigger warnings themselves is infinitely more obtuse than being offended by violence, sexism or racism) then you can simply refer to the content in advance as Coyne helpfully suggests. It's easy. 

Thursday, 14 May 2015

Pushing Explanations

Clinicians of my temperament get worried about forcing our explanatory views on the people with whom we work. Whatever explanatory frameworks we may have encountered during our training (medical, cognitive, psychodynamic models), however helpful we may have found them, we have a basic reluctance about regarding them as the explanation, and are more comfortable drawing on the idiom an individual uses to explain their life. One way to accommodate this kind of reluctance is to adapt a form of explanatory pluralism, where multiple models are held in mind, sitting comfortably alongside one another.

This approach is useful because it not only allows us to think in terms of multiple philosophical models, but also leaves space for the language used naturally by individuals whose experiences we are trying to discuss.

Much of the time this approach is relatively trouble free. That is to say, most of the time there is no benefit in substantially disagreeing with a person about how they account for their experience (I am thinking of an individual I knew who heard voices and was perfectly clear there was nothing wrong; who was I to disagree?) .

However, despite my basic sympathy with explanatory pluralism (what I could call my conviction that, when it comes to talk of "mental illness" there is basically no fact of the matter) I realise that I can cook up some uncomfortable cases for myself, which make the approach less satisfactory. Sometimes simply going along with an individual's account of themselves won't be sufficient.

Here is one problem case:
A parent approaches you, the clinician. Their child is causing problems at school. These are not insubstantial problems. The child is disruptive and, on the face of it, unpleasant to teachers and making it difficult for the classroom learning to proceed. You do a school visit and discover things are just as bad as you were told. The teachers are at their wits end. The parent knows the nature of the problem and implores you to help by providing an official diagnosis: according to them the child has a disorder called ADHD and your help is needed. If you can test the child and affirm that yes, they do meet the criteria for ADHD, you can ensure necessary accommodations at school. The child is absolutely certain too, that they have ADHD. They feel like they are not in control of themselves, that they are not to blame for the trouble they are caught up in, that a "disorder" is the only possible explanation. 
You are uncomfortable. Yes the child meets the DSM criteria for ADHD, but you worry about this construal. You note that the child has recently had to deal with some life events which anyone would find emotionally disruptive (let's say a close relative recently died, or they moved school, or they are being bullied). You have a sense that if the family system was able to address this emotional disruption in some way (with help from a systemically inclined clinician for example), the "ADHD" might be substantially resolved. Further, you have worries about the use of the diagnosis ADHD. Sure you could oblige and diagnose, but you feel if you do that then the parent will be less inclined to view the child's problems in a way that might be helpful. In short, you feel it is incumbent upon you to try and discourage them from the explanatory framework (my child has a disorder) that they have adopted. This is not because you think they are straightforwardly wrong (you can see their point) but because you think their metaphor will encourage damaging courses of action like the prescription of avoidable stimulant drugs and the neglect of the child's emotional life. 
Here's another:
An individual you know lives in the community. They have suffered several episodes of disorganization and confusion before and these have tended to lead to dangerous and self destructive behaviour. At best the individual has had sustained periods of self-neglect. Now they are becoming disorganized again. You are worried about them. If they could be persuaded to allow themselves to be looked after (temporarily in a caring inpatient respite center you could refer them to) then they would be safe while they recovered. But although they are frightened they do not feel they need any extra care as there is nothing the matter. As far as they are concerned they are fine.
You disagree. You feel they are being overcome by some psychological change, that they are becoming unwell. You don't buy a "chemical imbalance" theory of their problems, but you can see they are not themselves, and the idea that they have succumbed to an illness would be a useful metaphor. You don't think they will always have this illness, nor be defined by this illness, but that characterisation seems a powerful way of accounting for the need they now have for extra care. 
What both of these stories have in common is a narrative brought to bear on them by the people whose lives they primarily concern. The acquiescent part of you wants to go along with these stories (they are the account that makes most sense to the person), but a concerned part of you does not. Let's not take away the easy way out; the optimistic proposal that you can always construct a joint understanding. In both these cases the person resists your interpretation, some degree of conflict is unavoidable. Even without saying the other person is "wrong", you are trying to give life to an explanatory framework which is at odds with their view of how their situation is functioning. In these cases, are you doing something beneficent or are you enacting a failure of mutual understanding? I would suggest the former. Helpful though it is to try and adopt language that "makes sense" to an individual, it won't always fit with our best image to how to help people.