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.

Friday, November 6, 2015

Lieberman Speaks

Last night, I went to hear Jeffrey Lieberman (JL) speak about his book, Shrinks, at the William Alanson White Institute. He spoke on a panel, along with Andrew Gerber (AG), Medical Director and CEO of Austen Riggs, and Jack Drescher (JD), a training and supervising analyst at White (among many other impressive credentials). Each gave a brief talk in reference to the book, then they commented on each other's presentations, and then there was a Q&A. The moderator was Sue Kolod (SK), another training and supervising analyst at White.

A little background. The White Institute was founded in 1943 as an alternative to "mainstream orthodox Freudian psychoanalysis". It's known for its interpersonal point of view, and for an interdisciplinary approach. It was only very recently (like, last year) admitted to the American Psychoanalytic Association. I don't get all the politics involved. Frankly, I don't care. But I think the delay had to do with the less traditional approach, including differences in required frequency of analysis (3 times per week vs. 4 or 5), and other stuff I also don't get. In any case, I'm not affiliated with White.

The institute I am affiliated with, NYPSI, is more traditional. At least, that's its reputation. It's a lot more relaxed than it's given credit for, but it's not great at broadcasting that fact. Now, when Shrinks was published, NYPSI invited JL to speak. He declined. Well, no, actually he never responded. Even after several attempts by the chair of the program committee.

I had given up on seeing him address an analytic audience when I learned he'd be speaking at White. So I went. Maybe it was a good idea for me to go, maybe it wasn't. I took notes. I didn't get everything down. Sometimes I got most of a part down but missed a few points and interpolated. I'll try to indicate when that was the case.  I'm sure I got some things wrong, too. Unless otherwise indicated, I am quoting or paraphrasing the speaker being described. Here's what happened:

It was an oversold event, so they moved it to a larger location, a synagogue near White, with a moderately sized auditorium-not the main prayer space. Early in the event, someone asked the audience how many had read the book. Very few raised their hands. There was a pile of copies of Shrinks on a table in the back. By the end of the night, the pile of Shrinks had not shrunk very much.

SK introduced everyone. She said she had the idea of setting up this talk after reading Shrinks. She agreed with most of it, especially the parts about psychoanalysis' history of homophobia, rigidity, rituals, and a non-scientific approach. She had two goals. 1. To recognize that in his book, JL helps us to see how the general public sees us; and 2. To introduce JL to modern psychoanalysis, as it's practiced today, and hope to change his point of view.

Jeffrey Lieberman

JL spoke first. He said that even though we were in a synagogue, we had dispensation not to wear "yarmulkas or tallits" (skullcaps or prayer shawls). He was pleased to have 2 of his favorite colleagues as co-panelists.  He announced, "My analysis failed!" and said no more about it. I like to think that validated the hunch I mentioned back in my review of Shrinks:

Lieberman, (or maybe 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.

JL said that his concern about the stigma of mental illness is what prompted him to write the book. It's like the sign of Cain. or the Scarlet Letter. Or the gold star Jews were forced to wear in the holocaust. Why should mental illness be stigmatized? He asked, "Would you prefer to say you were missing a (something) because you threw your back out, or because you were depressed?" That, he said, is stigma.

He reminded us that there is no anti-cardiology movement. That the stigma of mental illness is woven into popular culture. That it is vestigial, and in contrast to the scientific research of the last 50 years, which demonstrates that mental illness is in the brain. Stigma denies the array of available treatments. He said something about the brain being more complex than the heart, and that it's taken a long time to understand how the brain works and gives rise to mental illness, and that we're just starting.

He pointed out the stigma that existed with AIDS early on, but then came the ACT UP movement which made sure there was money for research, and then came AZT, and now we manage AIDS like diabetes or hypertension.

He said that in the past, there was little treatment available for mental illness, but now things are different. He spoke about an anxious patient he had seen that day, who is now treated for his anxiety, and can't believe how different he feels.

He had a patient, Sarah, who suffered from (I didn't hear this but he must have said, "agoraphobia"). He had to see her in her home. But after initial introductions, followed by appropriate medication, she is doing well.

He said there are failures. He recalled a borderline patient, L, who he had seen as a resident, before there was DBT. His goal was just to keep her alive. She dropped out of treatment, and he didn't know what happened to her.

He said there is an indisputable difference between now and before the mid-20th century. Back then, the barrier to care was lack of treatment. The new barriers to care are: stigma, lack of awareness, and lack of access. He emphasized the need for early detection of mental illness via screening in primary care settings, schools, and the workplace. Like for TB. Also the need for coordination of community care in advanced disease. He mentioned that there is a 7 year delay in treatment for depression, and that women should be routinely screened pre and post-partum, and children routinely for LDs and ADHD (I think he said ADHD).

He claimed all this would reduce homelessness, jail populations, and violent episodes. He mentioned, among others, Adam Lanza (the Newtown, CT shooter), who had clear signs of mental illness for years and could have been treated. (Please see my post, Behind the Violence, for a more nuanced discussion of the matter). They were all shunned, no one reached out to them. We need to trade "don't ask don't tell" for "I am my brother's keeper".  We shun people who look weird or menacing, but we need to be proactive.

JL spoke about a piece he wrote following Robin Williams' suicide (BTW, did anyone else see the thing about Williams having Lewy Body Dementia?). He got a letter following its publication from a psych-nurse who turned out to be the borderline patient, L, now doing well, and grateful to JL for genuinely caring about, and not judging her.

He ended with, "End Stigma!"

Andrew Gerber

(I'm going to skim through this one) AG thinks JL is a great guy and a great chairman. He broke the book down into 3 parts:

1. What analysts need to hear-JL just wrote things we say to each other anyway, that analysis has a history of intolerance, of who's in and who's out. We need to think about how to test our ideas. We have a history of being anti-meds, of excluding non-MD's, of ethical violations. He mentioned the Central Fact-Gathering Committee of the American Psychoanalytic association which, back in the '50's (?) suppressed data about the limited success of analysis.

2. What we can teach JL-analysis is not the same today. White and Columbia are responsible for vast changes, there are >100 trials showing the effect of psychodynamic psychotherapy.

3. What can we do together? Teach each other about the mechanism of action in therapy, exposure/response prevention, modeling relationships, interest in the patient's narrative, EEG's, biomarkers, case studies. We need to tackle healthcare funding together.

Jack Drescher

JD noted that he is not a cheerleader for PSA (psychoanalysis). He has written extensively about, for example, homosexuality in analytic history. He is not opposed to the DSM (he was a member of the DSM-5 workgroup on sexual and gender identity disorders), or to ECT or meds. But he felt the book was an anti-PSA polemic. That you can't lay the low status of psychiatry at the foot of PSA. He noted the links between psychiatrists and big pharma. He had 4 main points (I wasn't really clear on what they were trying to accomplish but here goes):

1. How to tell a story-addressing a popular audience. There was early approbation of thorazine for relaxation, nausea in pregnancy, and hiccups. TD is not mentioned in Shrinks.

2. The limits of rationality-he was taught as a resident that patients will take their meds if you simply explain to them that they need to. There is a need to empathize with irrationality.

3. Attributing motives-JL accused PSA of folding everyone into its net, with no clear demarcation between normal and abnormal, but JD noted that if it was done, it wasn't malicious.

4. Again, PSA not responsible for the low status of psychiatry, and most people don't know anything about PSA, certainly not in its contemporary form. We don't look to the Schreber case to treat psychosis today. The stigma of mental illness may be transferred to the profession that treats it. The book doesn't improve things by taking pot shots at PSA.

Now the mutual comments:

JL: The idea of writing the book was to gain credibility by fessing up to the history of psychiatry. When I included the quote (p.200) that, "Freud's ideas, which dominated the history of psychiatry for much of the past century, are now vanishing like the last snows of winter, " I just meant that Freud is not as influential. The therapeutic relationship is always important when you talk to people.

JD: We argue among ourselves about ideology.

There was quite a bit more, including comments by AG, but I was distracted thinking about JL's "fessing up".

Then came the questions.

The first to speak was Leon Hoffman, who disclosed immediately that he had written a review of Shrinks in JAPA. He reiterated some of the things he had noted in the review, like the way JL's lack of ability to establish a rapport with patients' families (the two he describes in the book) doomed the treatments to failure. Hoffman said he was pleasantly surprised to hear that JL did value the therapeutic relationship, because that wasn't clear from the book. To which JL replied, "I'm not sure you read my book." Hoffman asked if JL thought psychiatrists should be trained in therapy at all. JL responded, "If that didn't come through in the book, then I failed."

There was another interesting exchange with a brave man whose name I didn't catch, he's a psychiatrist and analyst who treats mainly schizophrenia. He uses therapy and meds. He says his patients are mostly people whose mothers never gave up on them. And he has helped them extensively. He pointed out that stigma is decreased by understanding the meaning and significance of the illness, not by making it the same as diabetes. JL said, "All illness has meaning." The man replied, "Not the primary meaning." Then JL, with an incredulous look, said something to the effect that this would imply there's something different or exceptional about mental illness, as compared to other types of illness. And most of the audience went, "Yeeees."

I think this was when JL started yelling. Truly, he was yelling. He said, "Your opinion doesn't matter! Cases don't tell you anything! You need evidence!" He sounded really mad. He also said something like, "I'm sure you mean well, but..."

The guy started mentioning some of the evidence that's out there, and JL just talked over him. I heard someone near me use the phrase, "Used car salesman".

Once JL was done, JD said something about how the meaning might reduce the stigma for the patient, but not for everyone else.

There were a few more questions, with audience members starting to file out. One resident asked about how he can make a decision about where to direct his career with all this sectarianism. This elicited long responses from all three panelists, a kind of, let's take this opportunity to educate the young'uns.

I missed a lot of the Q&A because I was so disturbed by the "fess up" comment. So I did something atypical for me, and I got in line to ask a question. The gentleman in front of me had more of a comment, to the effect that JL is not helping the profession by dissing analysts.

I'm a little confused about the sequence of events, but I think JL said something here about the complete lack of evidence for PSA, except for a few little studies (with a hand wave), and how you can't expect to be reimbursed for something that has no evidence.

Then it was my turn, and I was the last questioner, which suited me fine because the room had cleared out a lot by then. I'm a pretty comfortable public speaker, so I was surprised to note how much my voice was shaking, until I realized it was rage, not stage-fright.

I told him I had read his book, that there's a lot more evidence for PSA than he's allowing for, and I paraphrased the passage where he states that if Willem Reich's patient were alive today, she would be diagnosed with an anxiety disorder and treated with an SRI and CBT, which made it sound easy. I pointed out that he was concerned about gaining credibility by fessing up to psychiatry's history, but the fessing up was selective, and that nowhere does he mention the difficulties with treatment, including things like metabolic effects of antipsychotics, or Paxil Study 329, and how does he mean to engender trust in the public by omitting those kinds of facts?

I know I was far less eloquent in my phrasing, and what I just wrote is not so great to begin with. I think he cut me off towards the end, because I never said anything about the severe limits of what we actually know about mental illness. He rolled his eyes and said, "Medications have side effects. Am I supposed to list every side effect in the book?" I have the impression he was still yelling something, but I could be wrong.

Some poor soul got up then and tried to talk about research by Jonathan Shedler, but he got steamrolled. I think JL said something about adding that to the next edition.

I was going to do a lot of editorializing, but this post is already really long, and in any case the facts speak for themselves.