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.

Monday, June 15, 2015

Shrinks Links, Etc.

I haven't posted anything in a few days. I've been busier than usual, lately, but mostly, having forced myself to read all of Jeffrey Lieberman's, Shrinks, and then to write an extensive review of it, I find I'm all blogged out, and I have nothing to say right now. I'm waiting for another topic to bubble up and inspire me.

In the meantime, I've noticed that the reviews of Shrinks keep piling up. So I thought I'd post some links, along with brief comments.

First, there's this piece, by Natalie Angier, in the NY Times, published on March 26, 2015. She seems to agree wholeheartedly with Lieberman's perspective, with about the same level of scrutiny of the facts.

There's a review by Leon Hoffman, MD, to be published in the Journal of the American Psychoanalytic Association. Hoffman points out Lieberman's descriptions of what are, in fact, his own clinical failures and blaming of the families of patients. He makes reference to Lieberman's antisemitic tendencies, comments on Lieberman's limited understanding of the complexities of the human condition, and questions one of Lieberman's most prominent excuses for the book, that it will help reduce the stigma of mental illness.

There are my reviews: Shrinks Review-Introduction; and Shrinks: The Untold Story of Jeffrey Lieberman's Oedipal Victory Over Papa Freud. Feel free to read them, if you haven't already.

There's another review by Robert Freedman, MD, in the May 2015 American Journal of Psychiatry. Freedman is all gung ho about the book, and sees Lieberman's brush with PTSD symptoms as evidence that he's tough and up for the fight to champion psychiatry.

As it happens, a colleague and I wrote a letter to the editor about this review, but it was rejected. Since it's not going to be published by the AJP, I guess I can include it here:

In his review of Shrinks: The Untold Story of Psychiatry (1), by Jeffrey Lieberman, Robert Freedman seems unaware of the irony of his statement about, "...the place Psychiatry has earned in society by helping patients and families, one at a time." Freedman writes about a young woman with schizophrenia, described in Shrinks, whose treatment failed because her family refused Lieberman's recommendations.

Freedman neglects to note, or notice, that it was Lieberman who failed to establish a sufficiently powerful therapeutic bond with both the patient and the family, to consider the individual psychologies of all of them, and to take into account the forces emanating from the family’s social milieu. Any mental health professional who treats patients every day would recognize that without this bond and effort at understanding the patient and family, treatment is doomed to fail, no matter how great the power of the medication or the authority of the physician. 

Indeed, Glen Gabbard (2) has recently commented: 

“The core of psychodynamic psychiatry is to look at each individual as a person with highly individual, even idiosyncratic features. This core principle of good psychiatric practice, and even good medical practice, may be obscured by our progress in so many areas of ‘hard science’ in our field.”

Lieberman’s patient was one of two mentioned in Shrinks whose treatment failed because of his inability to establish a rapport with family members who disagreed with him. Of the second patient, Lieberman states, "I told them quite bluntly that their decision to withhold treatment was both cruel and immoral though tragically, not illegal..." Freedman lauds Lieberman as, "...unshaken by any criticism that he confronts from the same 'rogues' who derailed the treatment...” by preventing the young, psychotic woman from continuing her psychotropic medications. In fact, it was Lieberman, himself, who derailed her treatment by alienating her family. It is puzzling why Freedman does not address Lieberman’s obvious failure as a physician and a clinician.

Unfortunately, Freedman’s review reinforces the valorization of the deleterious trend in contemporary psychiatry which prioritizes the biomedical model and devalues the biopsychosocial model, as first explicated by George Engel.

The rejection email we got from Robert Freedman referred to the letter as, "sprightly," but it stated that, unfortunately, there was only room for one review of Shrinks. That seems to miss the point that the letter was a review of the review. Whatever. So it goes.

Another review is from The Guardian, written by Lisa Appignanesi. She notes Lieberman's ties to the pharmaceutical industry, and therefore questions his enthusiasm about meds. She writes:

Yet it’s difficult to share Lieberman’s triumphalist certainties. No medical specialisation outside American psychiatry counts it a success to have vastly grown the number of those who suffer from its burgeoning classifications; to have promulgated the taking of regular medication by everyone, including toddlers suffering from a new DSM category of illness that in the past might have been termed “rambunctious childhood”; or to have boosted mood-altering pill-popping to an extent street pushers would consider a bonanza.

The final review is by Richard C. Friedman, MD, in Psychodynamic Psychiatry. This is an extensive review, fairly evenhanded, in fact, a bit too generous to Lieberman, in my opinion. But I'll quote the Conclusion:

On the front and back cover of Shrinks is a vacant, red couch—Lieberman’s symbol of…what? Incompetence? Sexual seductiveness? The cover seems to express his view that American psychiatry was falsely led by an empty couch, the equivalent of an empty suit. Possibly the vibrant red color suggests that Lieberman is criticizing psychoanalysis for a sybaritic quality. Or, perhaps, red was chosen simply as a marketing device, a tempting lure enticing potential customers to buy the book. And what of the word “shrinks”? Lieberman might have simply been deconstructing the use of the term in mass culture, but I don’t think so. Rather, I believe that he joins with those who use “shrink” as a term of devaluation. In doing so, he seems to take the role of Gulliver amidst the psychoanalytic Lilliputians. Shrinks is written in a popular style for a lay audience. It has academic ambitions, but dispenses with academic conventions. There are no references documenting the assertions and conclusions and no footnotes; there is simply a list—surprisingly brief—of “sources and additional reading” at the end. In expressing opinion without evidence Lieberman responds precisely like the “psychoanalysts” about whom he speaks with contempt. Finally, I must confess that I was taken aback by Lieberman’s reference to Freud as a “rogue,” “Psychiatry’s greatest hero and its most calamitous rogue” (p. 39). The dead are forever silent but I cannot help but wonder what Freud would have thought of Lieberman. I imagine he had to deal with many Liebermans in his time.

Finally, I'd like to go on record as acknowledging how much energy I've devoted to Jeffrey Lieberman, a man I've never met. There is something about him that invites this kind of response. Something infuriating. Something to think about.