Yes, I thought I was done with Jeffery Liebermans's, Shrinks: The Untold Story of Psychiatry, but it was not to be.
Clinical Psychiatry News asked me to write a shorter review than the one on my blog, from the angle of whether it would be a good book for a psychiatrist to recommend to patients.
So how could I resist? This one is much shorter, and less of a rant.
So please surf over there and check it out. It feels good to have my opinion expressed beyond these confines. I think the site is free but you may have to register. Also, the print version will be out in a few weeks.
Enjoy, and come back here to comment, if you like.
Showing posts with label Jeffrey Lieberman. Show all posts
Showing posts with label Jeffrey Lieberman. Show all posts
Tuesday, January 12, 2016
Wednesday, December 2, 2015
Summing Up 2015
Here we are at the end of the year. A lot has happened in the world of psychiatry in 2015.
Collaborative Care is alive and scoring a 0 on the PHQ-9. The Clozaril REMS deadline was extended. Tom Insel left NIMH for Google. Mandatory E-prescribing was postponed until this coming March. EHRs continue to disappoint. Meds long past patent have had their prices jacked up 5000%. The FDA is looking to appoint a new head, and Robert Califf, a cardiologist with strong ties to the pharmaceutical industry has been nominated (See NY Times and David Healy).
On the upside, Dinah at Shrink Rap came up with a brilliant way for people to access psychiatric care in Maryland. I hope this approach is replicated more broadly.
I was perusing my posts from this past year, and I made a list of some of the major topics, and their respective posts, both general and personal:
Maintenance of Certification
I studied for:
The Montillation of MOC
Percentages
And passed:
Done
There and Back Again
Framed
Signed, Sealed, Delivered
Switching the Labels
my board recertification exam.
And I was certified by the NBPAS, as well:
Another Board
The ABPN refused to make any significant changes to MOC, especially Part IV:
I Really Should be Studying, But...
An MOC Step?
Follow the Money
Although the Part IV Feedback modules are now optional.
And I developed my own Psychoanalytic PIP Module:
Fascinating
Here Goes Nothin'
A Monkey's Uncle
The best part about all of this is that I've written enough MOC posts that I now misspell "Maintenance" only about 5% of the time.
Affordable Care Act (ACA)
The ACA has kicked in:
Out of Network Benefits in NY
And pushed me over the edge into the realm of blog ads:
Adding Ads and the ACA
Psychoanalysis
I terminated my analysis:
Termination
Blessings
And wrote some other posts about psychoanalytic evidence and topics:
Analytic Evidence
AA Brill
The Blank Screen
Narcissism, Part I
Narcissism, Part 2
Jeffrey Lieberman
His book, Shrinks was published:
"Shrinks" Review: Introduction
Shrinks: The Untold Story of Jeffrey Lieberman's Oedipal Victory over Papa Freud
Shrinks Links, Etc.
And a torrent of posts followed, culminating in the one about his fiasco of a presentation at the White Institute:
Lieberman Speaks
Addyi
The FDA approved a drug that could hurt you but can't help you:
They Caved
That was immediately sold for $1Billion:
Addyi-dendum
And then the FDA and Valeant pawned off responsibility onto the doctors who prescribe it, and the pharmacies that fill the prescriptions:
Addyi REMS-A Shanda
Paxil 329
Finally, and perhaps most importantly, the restored version of Paxil Study 329 was published, with disturbing conclusions:
329
Do I have a favorite post from the year? Not really. The Lieberman posts, especially the reviews and the one about his talk at White took the most out of me. But in terms of content, I think the Analytic Evidence and 329 posts are the most important.
On to pastures greener.
Collaborative Care is alive and scoring a 0 on the PHQ-9. The Clozaril REMS deadline was extended. Tom Insel left NIMH for Google. Mandatory E-prescribing was postponed until this coming March. EHRs continue to disappoint. Meds long past patent have had their prices jacked up 5000%. The FDA is looking to appoint a new head, and Robert Califf, a cardiologist with strong ties to the pharmaceutical industry has been nominated (See NY Times and David Healy).
On the upside, Dinah at Shrink Rap came up with a brilliant way for people to access psychiatric care in Maryland. I hope this approach is replicated more broadly.
I was perusing my posts from this past year, and I made a list of some of the major topics, and their respective posts, both general and personal:
Maintenance of Certification
I studied for:
The Montillation of MOC
Percentages
And passed:
Done
There and Back Again
Framed
Signed, Sealed, Delivered
Switching the Labels
my board recertification exam.
And I was certified by the NBPAS, as well:
Another Board
The ABPN refused to make any significant changes to MOC, especially Part IV:
I Really Should be Studying, But...
An MOC Step?
Follow the Money
Although the Part IV Feedback modules are now optional.
And I developed my own Psychoanalytic PIP Module:
Fascinating
Here Goes Nothin'
A Monkey's Uncle
The best part about all of this is that I've written enough MOC posts that I now misspell "Maintenance" only about 5% of the time.
Affordable Care Act (ACA)
The ACA has kicked in:
Out of Network Benefits in NY
And pushed me over the edge into the realm of blog ads:
Adding Ads and the ACA
Psychoanalysis
I terminated my analysis:
Termination
Blessings
And wrote some other posts about psychoanalytic evidence and topics:
Analytic Evidence
AA Brill
The Blank Screen
Narcissism, Part I
Narcissism, Part 2
Jeffrey Lieberman
His book, Shrinks was published:
"Shrinks" Review: Introduction
Shrinks: The Untold Story of Jeffrey Lieberman's Oedipal Victory over Papa Freud
Shrinks Links, Etc.
And a torrent of posts followed, culminating in the one about his fiasco of a presentation at the White Institute:
Lieberman Speaks
Addyi
The FDA approved a drug that could hurt you but can't help you:
They Caved
That was immediately sold for $1Billion:
Addyi-dendum
And then the FDA and Valeant pawned off responsibility onto the doctors who prescribe it, and the pharmacies that fill the prescriptions:
Addyi REMS-A Shanda
Paxil 329
Finally, and perhaps most importantly, the restored version of Paxil Study 329 was published, with disturbing conclusions:
329
Do I have a favorite post from the year? Not really. The Lieberman posts, especially the reviews and the one about his talk at White took the most out of me. But in terms of content, I think the Analytic Evidence and 329 posts are the most important.
On to pastures greener.
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.
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.
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:
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.
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.
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.
Thursday, May 28, 2015
More on the Ritalin-Induced Psychosis Study
I'm following up on my last post, I Don't Know What to Think. A friend (not the same one who sent me the Levine piece) had access to one of the full articles, and forwarded it to me. This is the 1987:
Prediction of Relapse in Schizophrenia paper, from Arch Gen Psych. Having read it, what they were trying to do makes more sense to me, but it's still problematic.
The paper's introduction comments:
...A major deficiency in the clinical management of schizophrenia is the lack of proven methods for predicting the subsequent course of illness and identifying those patients who require neuroleptic maintenance to prevent relapse or, alternatively, those who would remain stable for substantial periods of time without drug treatment or while receiving substantially reduced dosages.
There were some previous studies suggesting that behavioral response to psychostimulants could be used as a predictor of relapse. They chose ritalin because it preferentially inhibits uptake of dopamine, and they were trying to find support for the dopamine hypothesis in schizophrenia.
The reason given for conducting the study is:
The application of a psychostimulant provocative test using methylphenidate with stable schizophrenic outpatients undergoing neuroleptic maintenance treatment is an attempt to study whether it may be feasible to exploit this phenomenon for clinical purposes.
That's it. Vague, but it kind of makes sense. It's like a glucose challenge test. You want to know if a specific patient will relapse if you take him off his meds. So you do the ritalin challenge test, and if he responds in a certain way, you know he needs to stay on his meds. And if he responds another way, you can take him off. And what are those "ways"? That's what the study is trying to find out.
They gave most of* the subjects a ritalin infusion, and a placebo infusion, 1 week apart, in random order, while they were still taking meds. They did this in a double blind fashion. They rated the subjects before and after infusions for behavioral, physiological, and physical states and changes.
Then they repeated this process several weeks after discontinuing meds.
This is what the ratings found:
You'll notice that while it was double blind, you can pretty much tell when the patient got ritalin.
Then they followed the patients for a year, or until they relapsed and needed meds again. And they looked at how response to ritalin infusion correlated with time to relapse. This is what they found:
Patients with greater behavioral and TD changes in response to ritalin, as well as patients with greater baseline TD, had significantly shorter times to relapse. Blink rate and pulse rate were not significantly correlated.
The paper does a bunch of additional analyses, with groups of symptoms rather than individual ones, to get more of what they wanted. But to me, the most interesting result is that patients with more baseline TD relapsed more quickly. That could be a useful piece of data, and it doesn't require a ritalin infusion.
There are technical problems with the study. It had very few subjects, there was a protocol change after the study had begun* (that's why some subjects only had infusions after discontinuing meds), and the paper was written before follow-up had been completed on all the subjects. Also, I can't quite figure out if they did an intent to treat analysis.
They also fudged a bit in the comments section:
...Specific biologic and clinical variables, including behavioral response to methylphenidate, presence of TD, blink-rate response to methylphenidate, and pulse rate response to methylphenidate, under specific pharmacologie conditions, are associated with outcome in terms of time to relapse following neuroleptic withdrawal.
In the results, blink rate and pulse rate are not so associated.
Here's the ethical problem. Participation in the study could not possibly have benefitted any of the subjects. It only had the potential to do harm. It's not like the authors were positing that a ritalin infusion might delay or prevent relapse.
So I'm skeptical about the consent process. We're not talking about healthy grad students who volunteer to stay awake for 3 days in exchange for $10 and meals. Did the subjects really understand that participation was completely altruistic? That the results could only benefit others, down the road, and maybe not even that?
I would have felt better about it if the idea had been addressed. They mention in the methods section that patients were evaluated for ability to give consent. But I think that somewhere, the authors should have written about the fact that the study was designed in a way that would not benefit the subjects. And that a shorter time to relapse after ritalin infusion might imply a different subgroup, one that might have had a longer time to relapse if they hadn't been given ritalin.
What do you think?
Prediction of Relapse in Schizophrenia paper, from Arch Gen Psych. Having read it, what they were trying to do makes more sense to me, but it's still problematic.
The paper's introduction comments:
...A major deficiency in the clinical management of schizophrenia is the lack of proven methods for predicting the subsequent course of illness and identifying those patients who require neuroleptic maintenance to prevent relapse or, alternatively, those who would remain stable for substantial periods of time without drug treatment or while receiving substantially reduced dosages.
There were some previous studies suggesting that behavioral response to psychostimulants could be used as a predictor of relapse. They chose ritalin because it preferentially inhibits uptake of dopamine, and they were trying to find support for the dopamine hypothesis in schizophrenia.
The reason given for conducting the study is:
The application of a psychostimulant provocative test using methylphenidate with stable schizophrenic outpatients undergoing neuroleptic maintenance treatment is an attempt to study whether it may be feasible to exploit this phenomenon for clinical purposes.
That's it. Vague, but it kind of makes sense. It's like a glucose challenge test. You want to know if a specific patient will relapse if you take him off his meds. So you do the ritalin challenge test, and if he responds in a certain way, you know he needs to stay on his meds. And if he responds another way, you can take him off. And what are those "ways"? That's what the study is trying to find out.
They gave most of* the subjects a ritalin infusion, and a placebo infusion, 1 week apart, in random order, while they were still taking meds. They did this in a double blind fashion. They rated the subjects before and after infusions for behavioral, physiological, and physical states and changes.
Then they repeated this process several weeks after discontinuing meds.
This is what the ratings found:
The white bars are before infusion, and the black bars are after.
You'll notice that while it was double blind, you can pretty much tell when the patient got ritalin.
Then they followed the patients for a year, or until they relapsed and needed meds again. And they looked at how response to ritalin infusion correlated with time to relapse. This is what they found:
Patients with greater behavioral and TD changes in response to ritalin, as well as patients with greater baseline TD, had significantly shorter times to relapse. Blink rate and pulse rate were not significantly correlated.
The paper does a bunch of additional analyses, with groups of symptoms rather than individual ones, to get more of what they wanted. But to me, the most interesting result is that patients with more baseline TD relapsed more quickly. That could be a useful piece of data, and it doesn't require a ritalin infusion.
There are technical problems with the study. It had very few subjects, there was a protocol change after the study had begun* (that's why some subjects only had infusions after discontinuing meds), and the paper was written before follow-up had been completed on all the subjects. Also, I can't quite figure out if they did an intent to treat analysis.
They also fudged a bit in the comments section:
...Specific biologic and clinical variables, including behavioral response to methylphenidate, presence of TD, blink-rate response to methylphenidate, and pulse rate response to methylphenidate, under specific pharmacologie conditions, are associated with outcome in terms of time to relapse following neuroleptic withdrawal.
In the results, blink rate and pulse rate are not so associated.
Here's the ethical problem. Participation in the study could not possibly have benefitted any of the subjects. It only had the potential to do harm. It's not like the authors were positing that a ritalin infusion might delay or prevent relapse.
So I'm skeptical about the consent process. We're not talking about healthy grad students who volunteer to stay awake for 3 days in exchange for $10 and meals. Did the subjects really understand that participation was completely altruistic? That the results could only benefit others, down the road, and maybe not even that?
I would have felt better about it if the idea had been addressed. They mention in the methods section that patients were evaluated for ability to give consent. But I think that somewhere, the authors should have written about the fact that the study was designed in a way that would not benefit the subjects. And that a shorter time to relapse after ritalin infusion might imply a different subgroup, one that might have had a longer time to relapse if they hadn't been given ritalin.
What do you think?
I Don't Know What to Think
A friend forwarded me this piece:
Leading American Psychiatrist Conducted Disturbing Experiments -- and Now He's Smearing Journo Who Uncovered It. (Bruce Levine/Alternet)
It's about experiments conducted by Jeffrey Lieberman. Here are the abstracts:
Arch Gen Psychiatry. 1987 Jul;44(7):597-603.
Prediction of relapse in schizophrenia.
Lieberman JA, Kane JM, Sarantakos S, Gadaleta D, Woerner M, Alvir J, Ramos-Lorenzi J.
Abstract
Despite the proven efficacy of neuroleptic drugs in the acute and maintenance pharmacotherapy of schizophrenia, practical methods for identifying patients who require neuroleptic treatment to prevent relapse are lacking. This study evaluated the use of a methylphenidate challenge test to predict the outcome in 34 stable outpatients with schizophrenia receiving neuroleptic treatment. Patients received two infusions, one of methylphenidate and one of placebo, in randomized order one week apart while receiving neuroleptic treatment and again three weeks after drug withdrawal. Behavioral, cardiovascular, and neurologic responses were evaluated before and after infusion under double-blind conditions. Patients were then followed up without medication for 52 weeks or until symptom recurrence. The results indicate that specific measures, including behavioral response to methylphenidate, presence of tardive dyskinesia, and, under specific pharmacologic conditions, tardive dyskinesia, blink-rate, and pulse-rate responses to methylphenidate, are associated with time and propensity to relapse following neuroleptic withdrawal. These measures may be potentially useful in the identification of candidates for neuroleptic withdrawal and/or dosage-reduction treatment strategies.
PMID: 2886110 [PubMed - indexed for MEDLINE]
Psychopharmacol Bull. 1990;26(2):224-30.
Behavioral response to methylphenidate and treatment outcome in first episode schizophrenia.
Jody D1, Lieberman JA, Geisler S, Szymanski S, Alvir JM.
Sandoz Pharmaceuticals, Sandoz Research Institute, East Hanover, NJ 07936-1951.
Abstract
In order to examine the relationship of behavioral response to psychostimulants and acute treatment response, we administered methylphenidate (0.5 mg/kg i.v.), an indirect dopamine (DA) agonist, to 38 patients who met Research Diagnostic Criteria (RDC) for definite or probable schizophrenia or schizoaffective disorder, were experiencing their first acute episode of psychosis, and had received less than 12 weeks or no prior lifetime neuroleptic exposure. Following baseline methylphenidate infusions, patients received a standardized regimen of acute neuroleptic treatment. Methylphenidate produced an increase in psychopathology reflected by a worsening of both positive and negative symptoms. Using a priori criteria, 61 percent of patients exhibited psychotic symptom activation, and 39 percent showed no change. Activation during methylphenidate infusion during the initial acute phase of illness was not correlated with time to achieve antipsychotic treatment response but was associated with side-effect vulnerability.
PMID: 2236460 [PubMed - indexed for MEDLINE]
Leading American Psychiatrist Conducted Disturbing Experiments -- and Now He's Smearing Journo Who Uncovered It. (Bruce Levine/Alternet)
It's about experiments conducted by Jeffrey Lieberman. Here are the abstracts:
Prediction of relapse in schizophrenia.
Lieberman JA, Kane JM, Sarantakos S, Gadaleta D, Woerner M, Alvir J, Ramos-Lorenzi J.
Abstract
Despite the proven efficacy of neuroleptic drugs in the acute and maintenance pharmacotherapy of schizophrenia, practical methods for identifying patients who require neuroleptic treatment to prevent relapse are lacking. This study evaluated the use of a methylphenidate challenge test to predict the outcome in 34 stable outpatients with schizophrenia receiving neuroleptic treatment. Patients received two infusions, one of methylphenidate and one of placebo, in randomized order one week apart while receiving neuroleptic treatment and again three weeks after drug withdrawal. Behavioral, cardiovascular, and neurologic responses were evaluated before and after infusion under double-blind conditions. Patients were then followed up without medication for 52 weeks or until symptom recurrence. The results indicate that specific measures, including behavioral response to methylphenidate, presence of tardive dyskinesia, and, under specific pharmacologic conditions, tardive dyskinesia, blink-rate, and pulse-rate responses to methylphenidate, are associated with time and propensity to relapse following neuroleptic withdrawal. These measures may be potentially useful in the identification of candidates for neuroleptic withdrawal and/or dosage-reduction treatment strategies.
PMID: 2886110 [PubMed - indexed for MEDLINE]
Psychopharmacol Bull. 1990;26(2):224-30.
Behavioral response to methylphenidate and treatment outcome in first episode schizophrenia.
Jody D1, Lieberman JA, Geisler S, Szymanski S, Alvir JM.
Sandoz Pharmaceuticals, Sandoz Research Institute, East Hanover, NJ 07936-1951.
Abstract
In order to examine the relationship of behavioral response to psychostimulants and acute treatment response, we administered methylphenidate (0.5 mg/kg i.v.), an indirect dopamine (DA) agonist, to 38 patients who met Research Diagnostic Criteria (RDC) for definite or probable schizophrenia or schizoaffective disorder, were experiencing their first acute episode of psychosis, and had received less than 12 weeks or no prior lifetime neuroleptic exposure. Following baseline methylphenidate infusions, patients received a standardized regimen of acute neuroleptic treatment. Methylphenidate produced an increase in psychopathology reflected by a worsening of both positive and negative symptoms. Using a priori criteria, 61 percent of patients exhibited psychotic symptom activation, and 39 percent showed no change. Activation during methylphenidate infusion during the initial acute phase of illness was not correlated with time to achieve antipsychotic treatment response but was associated with side-effect vulnerability.
PMID: 2236460 [PubMed - indexed for MEDLINE]
In the 1987 study, they were trying to figure out which patients with schizophrenia require maintenance treatment with neuroleptics to prevent relapse. So they took 34 stable outpatients who were on meds and gave them IV ritalin, so they might get psychotic. Then they kept them off meds for a year or until they got psychotic. They learned that certain responses to ritalin are associated with a tendency to relapse. I don't have access to the full article, so I don't know which responses.
How did using the ritalin help answer their question? They could have just taken them off their meds and followed them. Sure, that would have been uncontrolled. But how does trying to make stable patients unstable tell you which stable patients will relapse off meds? It only tells you which stable patients given ritalin will relapse off meds.
How did using the ritalin help answer their question? They could have just taken them off their meds and followed them. Sure, that would have been uncontrolled. But how does trying to make stable patients unstable tell you which stable patients will relapse off meds? It only tells you which stable patients given ritalin will relapse off meds.
In the 1990 study, they took 38 first break patients and gave them IV ritalin, which made 61% of them sicker. Then they looked at how these patients responded to antipsychotics.
Also back in 1987, Lieberman wrote a review of 36 studies that established the pscyhotogenic potency of ritalin. So the authors of the two studies above were aware that ritalin would likely make the patients psychotic.
According to the Levine piece,
On April 26, 2015, Jeffrey Lieberman, former president of the American Psychiatric Association, stirred up controversy by calling investigative journalist Robert Whitaker a “menace to society” on CBC radio because Whitaker, in his book Anatomy of an Epidemic, had challenged the long-term effectiveness of psychiatric medication...
In Whitaker’s Globe 1998 series in the segment “Testing Takes Human Toll,” he interviewed Lieberman about his and other psychotic symptom exacerbation and provocation experiments. Lieberman asserted, “To say that increasing a particular symptom—like hearing voices for a couple of hours in somebody who has been hearing voices for 10 years—is causing [suffering] rather seems like a stretch.”
I don't know what to think. I don't truly believe Lieberman is a monster. A jerk, maybe, but not a monster. But first break patients haven't been hearing voices for 10 years.
Maybe the idea was that they could learn a lot about who did and didn't need meds by causing a little bit of extra suffering, and that ultimately, that knowledge would help a lot of people. The same way it hurts to be vaccinated, but it's helpful.
Maybe the idea was that they could learn a lot about who did and didn't need meds by causing a little bit of extra suffering, and that ultimately, that knowledge would help a lot of people. The same way it hurts to be vaccinated, but it's helpful.
Maybe it was easy to get stuff like this by an IRB in the late 80's and early 90's.
Maybe the patients were able to give consent, and understood what was being done to them. To me, that, "Rather seems like a stretch." You're hearing voices that are frightening you? We'll just give you something to make those voices worse, and by doing so, we'll know exactly how to treat you.
Maybe it's the same kind of logic that comes up in Shrinks. We'll do a scan of your brain, and then we'll know exactly what's causing your mental illness.
Levine wants to blame the APA. He states, "Why would the American Psychiatric Association elect Lieberman president in 2012? Because psychiatry sees nothing wrong with these psychotic symptom exacerbation and provocation experiments."
Obviously, I don't agree with that opinion. And I also don't equate the APA with psychiatry.
There just seems to be so much stuff that comes up around this one guy.
I just don't know.
There just seems to be so much stuff that comes up around this one guy.
I just don't know.
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.
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.
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:
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.
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.
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
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.
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.
March 22, 2015
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.
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...
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:
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:
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.
...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.
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.
And unlike Lieberman, some people might be comfortable with a little ambiguity.
Reference:
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
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
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.
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.
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