Saturday, 7 November 2015

The Hickey-Lieberman Test

Phil Hickey has an interesting post over at his blog about what happened when Jeff Lieberman was asked if psychiatry over-medicated people:

Absolutely.  I had an experience with my own son.  I have two sons.  My older son was going to nursery school, and they said he’s not paying attention and were concerned.  ‘You should have him tested.’  We had him tested.  The neuropsychologist said, ‘Well there’s some kind of, you know, information processing problems, you should see a pediatric psychiatrist.’  I said, “Well, I am a psychiatrist, but I’ll take him to see a pediatric psychiatrist.’  We took him to see a pediatric psychiatrist, spent twenty minutes with him, and he started, you know, writing a prescription for Ritalin.  I said, ‘Why?’ and he said ‘Well, he’s got ADHD.’   I said, ‘I don’t think so.’
So, long story short, he ended up graduating from University of Pennsylvania, law school at Columbia, he’s in a top law firm.  So, yes, it happens, and part of that is social pressure.

There is something very telling about this story. I think one intuitively sides with Lieberman's sense that ADHD is an unnecessary label under the circumstances. But how can one avoid such undesirable clinical encounters? It's tempting to prescribe a healthy dose of "common sense", but this is a questionably useful. I am sure the paediatric psychiatrist in the story felt they were applying common sense in their work by applying a DSM diagnosis, so invoking it only leads to a conflict between two people's notions of what is meant by that rough and ready notion.

I want to propose we use Hickey's report of Lieberman's anecdote to formulate a test for ourselves as mental health professionals. I call this the "Hickey Lieberman test" to recognise the role of Jeff Lieberman in articulating the problem, and Phil Hickey in transcribing Lieberman's story. The Hickey-Lieberman test should be applied in any situation in which a psychiatric or mental health intervention (be it diagnosis, prescription, therapeutic plan, change in living circumstance, or really any substantive change) is being considered. It consists of four questions the intervening clinician(s) should ask themselves before taking action.

The Hickey Lieberman Test: 
1.How would I react if this intervention was to be applied to me, or to someone I cared about?
2. What would be the basis of that reaction?
3. If I would react negatively to this intervention, can I nonetheless justify it in terms of converging lines of evidence that it is an appropriate course of action?
4. If the answer to 3 is no, what would I change about this intervention to make it more reasonable for the person toward whom it is directed? 

The Hickey-Lieberman test is hardly water tight. If you agree with my reservations about "common-sense" then you will notice that this proposal also contains a great deal of subjectivity. However, a formal test does demand at least a moment's thought. When people act in ways they think are concordant with "common-sense", they may often be rationalising after the fact rather than thinking in advance. Much like the "reasonable person" test applied in legal settings, the Hickey-Lieberman test draws on the notion of a shared agreement about what it means to behave sensibly, which isbetter than nothing. 

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