Welcome to my blog, a place to explore and learn about the experience of running a psychiatric practice. I post about things that I find useful to know or think about. So, enjoy, and let me know what you think.

Thursday, May 21, 2015

Because I Couldn't Resist

I just read an interview with Jeffrey Lieberman in the May edition of Psychiatric Times, and I couldn't stop myself from writing about the nonsense he spouts.

For example, he's asked why mental illness and psychiatry are still stigmatized, and he replies:

Originally no one understood what the causes of mental illnesses were. It was thought that mental illness was due to some supernatural phenomena, demon possession, being cursed by the gods, or so forth. 
Beginning in the 19th century, there were efforts to try to understand the neurologic basis of the illness. But the tools and technology of the time were inadequate. 
Then Freud came along. As compelling and intuitively interesting as his theories were, they did not explain why somebody was schizophrenic, manic-depressive, or depressed; or had OCD or panic disorder; or was autistic or demented. 
It was not until the latter part of the 20th century that psychiatry began to radically change, and we started to acquire a scientific foundation. But, even though things have changed dramatically in recent decades, old attitudes still prevail and mental illness is still considered different from other types of medical illnesses and psychiatry is considered a step-child of medicine. 

I'm not sure how to think about what he says. Does Lieberman believe we now understand what causes schizophrenia, etc., just because we have brain imaging? Does he not believe it but want to imply it, and that's why he answered cagily? He mentions a "scientific foundation". What does he understand science to be?

The notion of "sciencey-ness" certainly exists-machines that whir and light up and produce pretty pictures of the brain, lab equipment with bubbling liquids, numbers and percentages thrown into paragraphs for good measure, Latinate terms bandied about. 

Those are all "sciencey".

But science, real science, is how a toddler figures out that holding onto a helium balloon does not prevent him from falling on his butt. 

I think "sciencey-ness", not science, is what Lieberman is referring to, and I'm very concerned that he doesn't know the difference between the two. 

He claims, "We do have effective treatments...as effective as treatments in any other field of medicine." But, he says, people don't get these treatments because of shame or stigma or poor government policy. 

Does he really believe that if only everyone had access to psychiatric medications and CBT, suffering from mental illness would all but cease?

To put it bluntly, is he lying, deluded, or stupid?

And I know I don't need to worry about retribution for writing that, since he'll never read it. I can't seem to get him to engage in any exchange, no matter how provoking I am. But maybe this one will get through, somehow.

The other topic that came up in this interview that is greatly concerning is Lieberman's understanding of suffering. He states:

When we talk about mental illness, we're not talking about the "worried well" or problems in living. We're talking about what might be considered to be brain disorders, which include traditional mental illnesses, addictions, and intellectual disabilities...The number of people affected by mental illness is enormous, and the costs of neglecting their treatment is staggering. 

Now, I'm not trying to minimize the misery of people with schizophrenia or bipolar disorder or depression, or their difficulties obtaining care outside the penal system. But in a room filled with 100 random people, on average, one will have schizophrenia. How many will have "problems in living"? Troubles with work, or family, or romantic partners. Debilitating troubles. Troubles that cause pain to themselves and those around them. And why doesn't their suffering matter?

Wednesday, May 13, 2015

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

I finally finished reading Shrinks, and I submitted a 1 star review to Amazon, with the heading, "Painful to read, misleading, and with no insight into its own deficits. Don't buy it! Don't borrow it! Don't read it!" The following is not what I wrote on Amazon, but it's related.

I've given a lot of thought to how I want to write this full review (see my partial review here). Shrinks is an excruciating rant-sneering, caustic, and just so wrong in so many ways. It was tempting to just shred it point by invalid point. But the truth is, there's something pathetic about the lengths to which Lieberman goes to "prove" that his version is the only true psychiatry.

So I decided to focus on my real concern-the impact this book may have on a lay audience. This is where I think it's downright dangerous. Lieberman writes about present day psychiatry as though it's already achieved all the goals it aspires to. He speaks as though current brain imaging has already explained the etiology of all mental illness, and as though DSM has classified every possible psychiatric disorder: 

...the book precisely defines every known mental illness. It is these detailed definitions that empower the DSM's unparalleled medical influence over society.

He writes about the wonderful breakthroughs that Thorazine, lithium, and imipramine represented-and I agree that these drugs were godsends to many people, but he includes virtually no information about the problems that these and other meds can cause, or about the fact that they don't always work. To hear him tell it, biomarkers are already in widespread use and predictive of treatment response in many psychiatric illnesses. And most of all, his version of psychiatry is, wait for it, SCIENTIFIC.

As I read Shrinks, I tried very hard to imagine what it would be like if I were a reasonably intelligent adult with no particular knowledge of psychiatry, but who was interested in learning about the field. (Okay, cue the jokes about my being reasonably unintelligent and questionably adult)

It's an unrealistic thought exercise, but I imagine I might think I'm reading a book by someone who is an expert in his field, chair of psychiatry at a prestigious hospital, former president of the APA, so he must know what he's talking about. I'm pretty sure I wouldn't be familiar with the immensely varied modes of thinking that exist in psychiatry. I suspect I'd assume psychopharmacology and psychoanalysis are areas that all psychiatrists are trained in. And since Dr. Lieberman is a psychiatrist, psychoanalysis must be part of his field, so if he's claiming there's no validity to it, he must be telling the embarrassing but necessary truth. And if he claims drugs and CBT are effective and "scientific", he must be right about that, too. 

I hope I would pick up on the painfully disparaging tone, and the fact that sneering does not constitute evidence, but I'm not sure I would. 

At some point, I realized I didn't need to speculate about what a layperson would think of the book, I could, instead, read reviews on Amazon. And it turns out that, for the most part, it got good reviews from people outside the field, and bad reviews from people who know something about psychiatry, or its history. Here are some examples, both good and bad:

April 12, 2015
Shrinks by Dr. Jeffrey Lieberman is a fantastic read and a real eye opener for those of us who know next to nothing about psychiatry...The bottom line is that Shrinks brings to light many myths about psychiatry, but it also points out its historic shortcomings. More importantly it presents mental illness not as something to be ashamed of or for which there is no cure, but rather as a medical condition just like any other which can and should be addressed with proper treatment. Thankfully the advances in neuroscience and psychiatry, reviewed by Dr. Liberman in his book, have enhanced the understanding of the causes of mental illness and vastly improved the methods of its treatment.

April 1, 2015
...In his book, Dr. Lieberman clearly offered his experience as a scientist and physician and the history of psychiatry...The best parts of the book describe the rise and fall of theories championed by Freud and how they stymied real science and the description of the motivation behind some of organized psychiatry's most barbaric practices...
Dr. Lieberman explains so well the past failures, the research being presently done and the future of psychiatry. What an honest book...
Lieberman tells this story with remarkable clarity, complete honesty about his own viewpoint, and unusual humility for someone in the field. The human mind, whether it functions well or ill, is poorly understood, but recent progress in both understanding and treatment is significant...but most importantly, there is help.. the right help and the exciting future with DNA exploration...
This top psychiatrist says his field of medicine has recently turned a corner and he shows how it is offering real help to those with anxiety, eating disorders, phobias, obsessions, PTSD, bi-polar disorder, etc. And for people facing brain issues like Parkinsons, autism, Alzheimers, etc, scientists are getting oh so close.

March 28, 2015
I'm biased. I am a historian of psychiatry. Really. I have a PhD from the University of Michigan, served on the faculty of the University of Chicago, and wrote a book on the history of psychotherapy. ...So arrogant as this may sound, I know what I'm talking about. This book is compendium of errors -- at least from a historian's perspective. It fails to consider virtually all of the scholarship produced over the past fifty years on the subject, cites virtually no primary sources, and simply recycles common stories -- many of which have long since been discredited....this book does an extraordinary disservice to those who have been producing exceptional scholarship in the field for decades. What's more, it reveals how easy it is for a well-respected (and deservedly so) physician to publish nonsense about a subject about which he knows little and has probably read even less....You might not agree with me. But I can promise you this: I did my homework. That's not something Dr. Lieberman can say. What's more, I didn't pay someone to write my book for me.

To read this book, you would think that everyone who was treated with psychotropic drugs was miraculously cured and anyone who was not sunk into misery or worse. There is no mention of the millions of prescriptions written to treat questionable disorders for children as young as two, or of the terrible side effects of the some of the powerful medications that Dr. Lieberman evidently eagerly dispenses to virtually every patient who walks into his office. You would further conclude that no one was ever helped by psychoanalysis, nor for that matter any other form of therapy than his. This is a book filled with half truths, omissions, distortions, and propaganda. The "untold story of psychiatry" indeed.

In my earlier review, I wrote that I was willing to buy into the historical information included in the book. I stand corrected.

The basic outline of the book is this: first we had "alienists", who oversaw the care of the mentally ill in institutions, even though there was nothing much to be done for these patients. Then Freud came along and treated the "worried well" with what we now know is a bogus treatment designed by Jews and for Jews (not clear to me why Lieberman emphasizes that particular point, but he seems to feel it's important). Beginning in WWII, a taxonomy of mental illness was finally! developed, by an analyst, no less, and this ultimately led to the DSM-III, the savior of psychiatry. Then meds came along, and brain imaging, and CBT, and more recently, genetic markers. And today, psychiatry can proudly state that it understands the etiology of mental illnesses, and has the tools to successfully treat them. 

The book's argument reminds me of people who understand evolutionary process to mean that living beings have maintained a progressive course over eons just to reach the pinnacle of existence that is humanity. 

Lieberman never explains why the things he sneers at are unscientific. He just states it as fact. He has no understanding or knowledge of, nor does he make any reference to, psychoanalysis as it has been practiced and understood for the last 30 or so years. His bio on the Columbia site indicates that he is a, "Physician and scientist," so it's hard to understand why he doesn't even attempt to give a factual basis to his assertions. 

And he seems completely unaware of his own internal contradictions. He criticizes psychoanalysis for blaming family members for a patient's illness, such as the idea of the "refrigerator mother" in autism, or the "schizophrenogenic mother". 

But then he goes on to describe several of his cases, in which his recommended treatment failed because of the patients' families, who he criticized. 

I told them quite bluntly that their decision to withhold treatment was both cruel and immoral-though tragically, not illegal...

Lieberman seems to think that only his recommendations matter, and once he's made them, there's no need to establish a rapport with a patient's family, in order to help the patient. They should just do what he says because he's right. 

He has no clue about the limitations of the DSM, which he refers to repeatedly as "The Bible of Psychiatry". He's convinced that everything in the DSM is "scientific", despite his own descriptions of how many of the decisions about its content were made-often as compromises and to reassure the public and get proper insurance reimbursement.

He thinks that knowing there's an amygdala-hippocampus-prefrontal cortex loop in PTSD explains why people get PTSD. He claims that some people have genetic differences that predispose them to PTSD, and that's why some get it and some don't.
He proudly describes two traumatic experiences of his own-his apartment was invaded and he was robbed at gunpoint when he was in medical school, and 12 years later, he accidentally dropped an air conditioner out of his 15th floor apartment window. No one was hurt in either incident, but he was not traumatized by the former (the robbery), and had some PTSD symptoms following the latter (the air conditioner). Obviously, he can't claim his genetic predisposition changed in the intervening 12 years. Instead, he comes up with a long-winded story about how he had the illusion of control when being robbed, but not when dropping the air conditioner and that created a different amygdala loop. It never occurs to him to ask WHY he had the illusion of control in one situation but not the other. He has no sense that the two events had different meanings for him. And it certainly doesn't occur to him that HE was the aggressor in the incident that gave him PTSD symptoms.

Meaning, for Lieberman, is meaningless. All that matters are symptoms and getting the diagnosis right.

I'm trying not to harp on this part, but another truly dangerous aspect to the book is the way Lieberman disses any type of talk therapy that isn't CBT. Especially psychoanalysis. Here's some of the language he uses:

Gradually, physicians came to recognize that focusing on unobservable processes shrouded within a nebulous "Mind" did not produce lasting change...

...Sigmund Schlomo Freud stands in a class of his own, simultaneously psychiatry's greatest hero and its most calamitous rogue. (Incidentally, Freud's accurate birth name was, "Sigismund", not "Sigmund")

Freud ended up leading psychiatry into an intellectual desert for more than half a century...

As a psychiatrist who lived through many of the worst excesses of the psychoanalytic theocracy, I regard Freud's fateful decision (to discourage scientific questioning) with sadness and regret.

(On the move of many early analysts to American due to WWII): These psychiatric refugees would soon change the fundamental nature of mental health care in the United States, but not necessarily for the better. They brought with them the dogmatic and faith-based approach to psychiatry that Freud had espoused, discouraging inquiry and experimentation. Eventually,...psychoanalysis would become a plague upon American medicine, infecting every institution of psychiatry with its dogmatic and antiscientific mind-set...
...By 1940, American psychoanalysis had become a unique phenomenon in the annals of medicine: a scientifically ungrounded theory, adapted for the specific needs of a minority ethnic group (Jews).

Knowing that the path to influence ran through medical schools and teaching hospitals, psychoanalysts began targeting universities.

Had it been able to lie upon its own therapeutic couch, the psychoanalytic movement would have been diagnosed with all the classic symptoms of mania: extravagant behaviors, grandiose beliefs, and irrational faith in its world-changing powers.

Talk about projection!

Psychoanalysts  and psychoanalysis are compared to or described as:

omen-divining wizards

the primeval sorcery of the jungle witch doctor

the circus Big Top

a mangled map of mental illness

the psychoanalytic hegemony

The Oracle of Delphi

I get a definite sense of a man with no tolerance for ambiguity or ambivalence. 
He writes about his college experimentation with recreational drugs, which involved his researching which drug would be the best for him, before going on to try it. This is clearly not a guy who dropped acid because someone offered him some at a party. 
He idolizes Robert Spitzer for creating the DSM-III. He relates an anecdote in which a teenage Spitzer, at summer camp, was confused about his feelings towards girls, so he made charts of those feelings and kept them on his bunk wall. This is viewed, in the book, as a demonstration of Spitzer's great promise as a researcher, not as an indication of a highly intellectualized defense.

Lieberman also dislikes the notion that mental illness exists on a spectrum, that there is no clear defining line between sickness and health, and he feels this was one of Freud's great mistakes:

It was no longer acceptable to divide human behavior into normal and pathological, since virtually all human behavior reflected some form of neurotic conflict, and while conflict was innate to everyone, like fingerprints and belly buttons, no two conflicts looked exactly alike...the psychoanalysts set out to convince the public that we were all walking wounded, normal neurotics, functioning psychotics...

No wonder the DSM-III had such great appeal for these men. When Lieberman writes about the standing ovation Spitzer got when the DSM-III was approved, it feels like a conquest, like he has vanquished the evil empire established by Freud, the community from which he was excluded for his "scientific" beliefs, and the sun is finally beginning to shine on psychiatry. 

The title of this post was intended to be provocative, but there really is an Oedipal victory feel to the book. As you can tell from the quotes above, there's a lot of disparaging comparison of psychoanalysis to magic or religion, along with some comments that flirt with antisemitism, but then he keeps calling the DSM the "Bible of Psychiatry". Apparently, his is the better religion.

Lieberman, (or maye it's Ogas) writes with particular vehemence about the period when most psychiatrists did analytic training. It made me wonder if he was rejected from a training program at one point, or if he was in an analysis that he quit because he found it intolerable. I have absolutely no basis for these thoughts- they're just conjecture. But here's the description:

Think about that for a minute. The only way to become a psychiatrist-a bona fide medical professional-was to share your life's history, innermost feelings, fears, and aspirations, your nightly dreams and daily fantasies, with someone who would use this deeply intimate material to determine how devoted you were to Freudian principles. Imagine if the only way you could become a theoretical physicist was to confess an unwavering and unquestioning dedication to the theory of relativity or the precepts of quantum mechanics, or if the only way you could become an economist was to reveal whether Karl Marx appeared as an angel (or devil) in your dreams. 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.

Nowhere does he indicate that he has even considered the possibility that understanding ones own limitations can make one a better clinician. He doesn't even seem to get that if one is caring for patients, it might be helpful to know what it's like to be a patient. And forget the idea that an analysis is intended to be helpful. He seems to view it as nothing but a threat. The analyst as, "therapist-inquisitor".

Reading the paragraph above, it really is hard to believe Lieberman's claim that he likes psychoanalysis. 

The final concern I have has to do with Lieberman's inability to imagine that other people may not think the same way he does. Here's a quote:

...a psychoanalytic diagnosis of Abigail Abercrombie might account for her spells of anxiety by connecting them to the way she reacted to her parents' strict Lutheran upbringing, combined with her decision to leave home at an early age to work rather than marry. A Kraepelinian diagnosis would characterize Abbey as suffering from an anxiety disorder based upon her symptoms of intense fear and discomfort accompanied by heart palpitations, sweating, and dizziness, symptoms that occurred together in regular episodes.

Lieberman obviously believes that the analytic approach is wrong, and the Kraepelinian approach is right. But leaving aside the issue of which is correct (and why can't there be some of both?) I feel like he's assuming everyone prefers to have his internal
experience described by symptoms and their duration. There's no sense that some people might prefer his way, but others might prefer to have their experiences of anxiety considered in the context of a fuller narrative of who they are, with some continuity to how they got to be this way. Some might even find it offensive to be reduced to a bunch of symptoms and a diagnosis code. 

And unlike Lieberman, some people might be comfortable with a little ambiguity. 

J Am Psychoanal Assoc. 2015 Apr 24. pii: 0003065115585169. [Epub ahead of print]
The Psychiatrist, Circa 2015: "From Shrink to Pill-Pusher".
Hoffman L. PMID: 2591090

Monday, May 4, 2015


I really thought I was on an extended hiatus from being irked by the American Board of Psychiatry and Neurology. I was all set to wait until I get the bill for the annual fee to be pissed again, but they got to me sooner.

I haven't yet received my new board certificate. When I got my board scores, the package included a certificate shipping form that I could fax to them if I wanted to change my shipping address. It also had a box you could check if you were willing to waive the required signature. I wanted to do this in case no one was home when it was delivered, but the form was incomprehensible, because it wasn't clear if you had to change your address to check that box, or if you should include your current address or leave it blank because you don't have a change of address. I figured anything I did would only make it worse, so I didn't bother with it.

That was bad enough. Today, I get a letter from Jim Henry, Inc, informing me that my certificate is being prepared, and will be mailed to me on June 30, 2015. It also offered me, "A choice of quality frames as described in the enclosed brochure... Just indicate your choice of frame...and return it to us with your remittance no later than May 19, 2015. If no order is received from you by this date, your certificate only will be sent to you unframed at NO CHARGE." (boldface and caps are theirs, not mine).

I am so done with these people. The frames range in price from $70 to $600, with additional costs for special finishes. I already have a framed certificate. The ABPN sent it to me the first time around. It has a little rectangular piece in the lower left hand corner with the expiration date, and that's all that needs to be replaced. But they're sending an entirely new certificate with no expiration date which will need to be framed.

If I bother.

Do I have to speculate about whether the ABPN gets kickbacks on the frames? Honestly, the brochure looks like something from a company that does high school yearbooks. And if you checked out the link to their site, you may have noticed the "pharmaceutical" tab at the top. It links to this page, with the image:

Thousands of dollars in direct payment, board review, and lost patient hours already spent, and now they want me to pay for a crappy frame. Boy they must be broke. How fitting that medical associations and the pharmaceutical industry are grouped together.

In the words of someone very wise, "Sheesh!"

Monday, April 27, 2015

Let There Be Light

One of the things I heard about a couple months ago, in the session I described in Gene Kelly at the Waldorf , and have been meaning to write about, is a 1 hour film by John Huston called, Let There Be Light. Huston went into a psychiatric hospital following World War II, and filmed the treatment of a group of veterans with PTSD.

This took place at an interesting time in the history of psychiatry, when analytic precepts were an accepted and assumed part of psychiatric treatment. 

The servicemen were admitted to Mason General Hospital for an 8-10 week stay. They had individual therapy, group therapy, occupational activities, sports, music and other recreational activities, and training for reintegration into civilian life.

I found the 58 minute film very moving. The men they spotlighted all did well, despite having started out extremely debilitated. One man had repetitive head-shaking, another had developed a severe stutter, another had amnesia, another couldn't walk, still another was suicidal. 

They all completed the program and were shown at a graduation ceremony at the end, walking, talking, and smiling. 

The man who couldn't walk was shown rounding the bases at top speed at a baseball game shortly before the graduation. 

I was powerfully struck, and rendered tearful, by how young they all were. And yet, this is after the war, and even though some of them are maybe 19 or 20, none of them looks like a boy, the way they probably did when they entered the service. These were all men who had been through some terrible experiences. 

I was also struck by how articulate and thoughtful they were, despite some obvious differences in socioeconomic, educational, and intellectual backgrounds. 

It's interesting to watch a film made pre-privacy concerns. The men are told to ignore the camera, that they're simply having their progress tracked. At least one full name is used. The men seem to take it as a given that they have no say in what the military chooses to do. 

I wondered about the effect of the camera. In the scenes with individual therapy, the soldiers tend to avert their eyes from where the camera is positioned.

The psychiatrists, all male, of course, are interesting. They speak like something out of a 1940s movie, and at first I thought they were a bit callous, but after watching for a while, I could see the kindness coming through.

There was one doctor, in particular, who seemed to be the hypnosis expert. He was remarkably skilled. He conducted an amytal interview with the young man who couldn't walk, and after determining that the paralysis started after the soldier heard that his mother was ill, he proceeded to get him to talk about his mother, who was a difficult, angry, critical woman. He was then able to stand the man up and have him walk across the room.

He also used an amytal interview to cure another soldier of his stutter, which rendered him practically speechless. It started when he was talking to his buddies on their boat, saying something about the port side, and he got stuck on the "s" sound. During the amytal interview, the soldier is overcome by the realization that his speech has returned to normal. He then goes on to relate that the "s" sound reminded him of the sound of a, "German 88 high explosive shell coming in." His speech returned to normal after the interview.

This doctor treated a different man suffering from amnesia with hypnosis. I got the impression that it was the doctor's assured tone that made the young man believe he could remember. He got the man to speak about how terrified he was when the shells were coming in, and how he just wanted to forget everything. Then the doctor told him he didn't need to forget, because it was all over, and he could let himself remember. This was effective.

The narration is quite fascinating, at least from my analytic perspective. We are told that the paralyzed man's symptom had been treated, but that his neurosis will require time and therapy.

We hear that the amytal interview is, "Like hypnosis, a shortcut to the unconscious mind. It brings to the surface the emotional conflict that's the cause of the symptoms. And it removes through suggestion those symptoms that impede the patient's recovery."

And also, that, "Modern psychiatry makes no sharp division between the mind and the body."

At the beginning of the film, when we first see the individual interviews, the men make comments like:

I was the first scout. My buddy was second scout, but he got ahead of me, and I couldn't get back to him.

I was just hoping I would die.

I was told I was gonna die, so I thought I was dead.

I'm jumpy. I used to have fun, but now I don't like to do nothing no more.

I never was nervous before. I was a solid man.

The diagnosis given is, "Anxiety Reaction, Severe," and in group therapy, the men refer to themselves as "psycho-neurotics".

In an early group therapy session, they're asked, "Do you feel changed? Not the same boy as when you went away?" They're told that the purpose of therapy is to get them out of their feeling of isolation, to show them that they're like other people. That they will use a core of treatment methods, to help them develop knowledge of themselves. That underneath, "I can't," you usually find, "I won't." That a stutter or inability to speak reflects an underlying anger and resentment. That their sense of personal safety, or lack thereof, stems from their childhood sense of safety, and that, in turn, from their parents' senses of safety. They are encouraged to talk about childhood experiences, and they do.

I thought the last two examples smacked of "wild analysis", of jumping very rapidly to conclusions about the patient without a lot of data. But the soldiers seemed to be helped by it.

A later group therapy session is much different. They openly discuss their concerns about reintegrating into civilian life. They worry the public will think they're crazy. That the hospitalization will be perceived as shameful. That there needs to be an education program for the public. The psychiatrist asks, "Would you make it a point to tell your employer that you're a psychoneurotic?"

One man points out that there are plenty of wealthy civilians on Park Avenue who are more nervous than they are, and who rely on pills to help them cope. He's proud of what they've accomplished, and the doctor comments that they have nothing to hide or be ashamed of, that they've learned a great deal.

Another man, the one who couldn't walk, says, "We just wanna show people we can be as good as anyone else. They just have to give us a chance."

I don't know what they long-term outcome of this treatment was, or if there was even follow-up done. I suspect not all the men were able to maintain the progress they had made, once they left the hospital setting. I also don't know how extensive the program was. But it was so moving to see how much genuine care and effort the military put into helping these men, in the best ways they knew how at the time.

Friday, April 24, 2015

MOC Survey Results

I've now closed my MOC survey on SurveyMonkey, so let's talk about the responses. There were 11, which is nowhere near as pathetic as previous surveys I've conducted. To those of you who responded, you have my thanks.

To those who didn't, there will always be opportunities down the line, so you didn't miss out too much.

As a reminder, this was a one question survey, and that question is:

Would you be willing to openly boycott the ABPN and refuse to pay the annual C-MOC fee until the Part IV requirement is removed and an effort is made to demonstrate the usefulness of a 10 year exam?

And now, the big reveal:

Most of the people who responded to my survey would be willing to boycott. Since I limited myself to one question, I don't know why the person who wouldn't be willing to boycott feels that way. Or for that matter, why the other 10 feel the way they do.

It might have been interesting to get that information, but my sense is that the shorter the survey, the more likely people are to respond.

What now? I don't know. If the survey is representative of the greater population of C-MOC psychiatrists, then it would be worth trying to organize something. But there's obviously no way to know if it is.

To be honest, I'm a little sad thinking about it. I feel like I don't have the motivation or energy (or time) to push for something organized and bigger, but maybe I would if I thought more people would join me. And I'm guessing that's the way a lot of us feel.

So maybe we stage our own little, individual protests by not paying the annual fee, but we're not formally together as a group, so maybe it doesn't have that much impact. Or maybe money talks regardless of whether the same amount is being withheld by one large collective, or by individuals.

It still feels kind of isolated.

What would you do with this?

Sunday, April 19, 2015

"Shrinks" Review-Introduction

Jeffery Lieberman's, Shrinks: The Untold Story of Psychiatry, has been in the air lately.  There was a piece in the NY Times that claimed Lieberman claims there is no evidence for the effectiveness of psychoanalysis, and in response to that, I wrote a post about some of the supposedly non-existent evidence (Analytic Evidence).

In a series of tweets in reference to my post, @1boringyoungman asked if any groups had commented on "Shrinks". For my own unconscious, narcissistic reasons (more evidence), I read this as something like, Has Dr. Lieberman commented on my post?, to which I responded, "Not to my knowledge."

In turn, @MichaelBDonner tweeted, "Hard to comment without seeming defensive. He doesn't like psychoanalysis." To which @Drjlieberman eventually replied, "Not true."

MBD: What's not true? You do like psychoanalysis?

JAL: Yes.

MBD: You like psychoanalysis. Good to know. Didn't come across to me. I stand corrected. My apologies.

After this exchange, I decided I wanted to read the book. But I didn't want to buy it, because I didn't feel like contributing to Lieberman's income. I tried the NY Public Library, but there were like 30 holds ahead of me (also my card has apparently expired and I have to go to a branch to renew it, which I'm too lazy to do because I don't know where I put the card, since I usually just use their app to check out books).

So I bought it. The $14.99 Kindle version, as opposed to the $21.17 hardcover version.

My plan was to read it in its entirety and then write a review, but I'm finding it hard to get through. It's engaging enough as a read, I'll give it that. But the tone is quite disparaging. I'm trying to keep an open mind while I read it. Maybe he has some valid points to make. Research in psychoanalysis is notoriously complicated and controversial, since it's innately a non-manualized treatment, and it goes on for such a long time, and it's so dependent on the particular dyad, and much of the research doesn't correspond with the kind of controlled studies we're used to seeing for drugs or short-term, manualized treatments. So maybe I can learn something.

But the tone is kind of like, "This is what those silly, misguided shrinks think, but of course, we know better, wink, wink." The thing is, thus far, and I'm about a quarter of the way through, he hasn't explained what's wrong with what those silly, misguided shrinks think, or why we know better. He just states it as fact.

But along with prescient insights, Freud's theories were also full of missteps, oversights, and outright howlers. We shake our heads now at his conviction that young boys want to marry their mothers and kill their fathers, while a girl's natural sexual development drives her to want a penis of her own. As Justice Louis Brandeis so aptly declared, "Sunlight is the best disinfectant," and it seems likely that many of Freud's less credible conjectures would have been scrubbed away by the punctilious process of scientific inquiry if they had been treated as testable hypotheses rather than papal edicts.

The next paragraph goes on to describe the way Freud would megalomaniacally discredit anyone who didn't agree with him, which is true, to the best of my knowledge, but doesn't it sidestep the question of why oedipal theory constitutes a misstep, oversight, or howler? Are readers just supposed to accept that this is so, without an explanation of what's wrong with it? Papal edict, indeed.

The only "evidence" Dr. Lieberman has supplied for why analysis is no good is in descriptions of incidents like Wilhelm Reich's Orgone Accumulator. Somehow, this ridiculous idea of Reich's discredits all of psychoanalysis.

Another problem. The book describes the history of psychoanalysis. I'm not a historian. In fact, I'm kind of the opposite of a historian. If it didn't happen in 1492 or 1776, I don't know anything about it. So I'm willing to assume that this history is accurate. But Lieberman treats the history as though that's all there is to know about analysis. It's analogous to saying, "I've studied the history of Bellevue Hospital, so I know everything there is to know about the care of psychiatric inpatients."

Sure, it's fun to read about what a jerk Freud was, and who he kicked out of his circle when, but that doesn't tell you anything about the practice of psychoanalysis.

Lieberman makes a point of describing the way he cured a patient of his conversion disorder with an Amytal interview. Nice work, Dr. L, but do you think that means you conducted an analysis with the patient? Or do you think that means analysis is useless, since conversion disorders were what Freud initially treated, and they may respond to medication? And does that, in turn, imply that you think today's analysands all sought out psychoanalysis as a treatment for their conversion disorders? Or that conversion disorders are all that can be or should be or are treated by an analysis?

To me it seems like the book is intended to escort the lay reader into the sacred halls of neuropsychiatry and biomarkers, to convince the unwary reader that any psychiatric treatment that doesn't involve medication, or lasts longer than 30 sessions, is bogus. And that the true psychiatry, the kind that Lieberman practices, is scientifically valid and effective. Just like the rest of medicine. That's his agenda, I get it, but I think he's misleading.

And speaking of misleading. I saw the following image in the April 17th edition of Psychiatric News:

There's Dr. Lieberman in his white coat, like all psychiatrists wear, getting ready to lead a discussion on May 18th at the APA meeting, on psychiatry's past, present, and future. And there's his book, Shrinks: The Untold Story of Psychiatry, by Jeffrey A. Lieberman, MD.

That's funny, because the book cover on Amazon, and the one on my Kindle, looks like this:

Same title, same author, but look! Who's Ogi Ogas? I googled him, and it turns out he's not a Dr. Seuss character. He's a computational neuroscientist, science book author, and game show contestant. Dr. Ogas won half a million dollars in 2006 on Who Wants to be a Millionaire.

He co-authored, A Billion Wicked Thoughts: What the World's Largest Experiment Reveals about Human Desire, which was published in 2011. One description stated:

The researchers wrote a computer program to capture sexual queries in publicly listed catalogs of Web searches. They later categorized the searches and did some number crunching. They estimate that their research reflects the online behavior of 100 million people.

Does any of this disqualify Ogi Ogas as a co-author or whatever he was of Shrinks? No, of course not. But why did JL chose him? Surely there must have been someone better suited.

And finally, the hubris. Lieberman offers a comment about the misguided patient who sought out Wilhelm Reich's care:

You use the word, "confidently", you throw in a couple of science-y sounding brain structures, you mention medication by its class, and CBT, the acceptable therapy, and what do you get? Optimistic, normal, symptoms controlled.

That was easy!

And this pretty much says it all:

I really hope the book starts to redeem itself at some point, and I'm not just out $14.99.

Wednesday, April 15, 2015

Follow the Money: A One Question Survey

Check out the update on MOC, recently sent out by the ABPN. In particular:




Okay so wudda we got?

You have to attest to your CME, SA, and PIP activities, and pay a fee annually.

And you only need 1 PIP unit.

Also the PIP requirement has been modified.

Finally, the board MAY waive SA requirements.

To me, it sounds like the ABPN is getting desperate. They want you to pay the annual fee, so they make noises about modifications to requirements. But if you pay the fee anyway, why should they make any changes?

And judging by the financial state of the ABIM, I'm guessing the ABPN is not doing so great money-wise. Plus they're obviously worried about losing diplomates to the NBPAS.

I think doctors as a group are a pretty suck-it-up bunch. We're so used to hard work that if you tell us we need to do something for "patient care" or for "regulatory requirements", we just do it. (See my post, The Culture of Medicine and the Art of K'vetching).

But this seems like a good jumping off point for negotiations. They want us to invest $175/year in them, with the promise of a meaningful exam in 10 years. Okay. What are they going to do for us? How about they remove the Part IV requirements, as a sign of good faith, and while they're at it, lay out a plan for how they're going to demonstrate that taking an exam every 10 years improves patient care. And once they've done that, then, maybe, we'll start paying them.

Seriously, what if everyone who goes into the C-MOC program joins together and refuses to pay a dime until they hold up their end of the bargain. Because it is a bargain. It's just a financial deal. They shouldn't get to make money AND screw us over.

So here's my one question survey. Is anyone up for this fight? Let's follow the money and see where it leads:

Create your own user feedback survey