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

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