Last week, thanks to a tweet from Ginger Breggin, I came across an article by Jeffrey Lieberman entitled Psychiatry: Nothing to Be Defensive About. Dr. Lieberman is president of the APA, and has gone on record more than once as saying that all these dreadful criticisms of psychiatry are very unfair, and that psychiatrists are good guys who have the high moral ground.
Well, he’s back, and his current article is about on a par with previous efforts.
“The integrity of our profession and the science of psychiatry are being questioned—again by articles in the media.”
He mentions two articles that he finds “particularly disturbing.” The first, Heroes of Uncertainty, by David Brooks, refers to psychiatry as a “semi-science;” and the second, ‘Unspecified Mental Disorder’? That’s Crazy, by Leonard Sax, accused DSM-5 of having “broadened the definition of mental illness to absurdity.”
Dr. Lieberman tells us that “…such invective is really nothing new. But it may be time to respond in a new way.” This is classic Dr. Lieberman spin. First of all, describing psychiatry as a “semi-science,” and accusing DSM-5 of broadening the definition of mental illness “to absurdity” doesn’t even come close to the meaning of the word “invective.” Merriam-Webster defines invective as: an abusive expression or speech; insulting or abusive language; vituperation.
What Dr. Lieberman is doing is attacking his critics rather than responding to the criticisms. This is a tactic he has used throughout this debate.
As for it being time to respond in a new way, this is particularly noteworthy, because in his June 18 article What It Means to Be President, he told us that he was going to respond to psychiatry’s critics by rededicating himself to his Distinguished Fellow’s pledge. Presumably, he’s now done this and he now has a new response.
In his next paragraph, Dr. Lieberman mentions his May 20 article in Scientific American that explored “…how stigma and antipsychiatry sentiments fuel prejudice against our field and our patients.” Here again, we have classic Dr. Lieberman spin. One of the principal anti-psychiatry sentiments being expressed at the present time is that psychiatry’s medicalization of human problems is a major contributor to stigma. And those of us on this side of the debate have marshaled compelling arguments and evidence for our position. Dr. Lieberman’s response, however, is simple denial. “We’re the good guys – you’re the bad guys.” I guess this is his idea of a new response.
Then it gets really interesting:
“But I think it’s also important to note how the unwillingness of the public and pundits to accept psychiatry as a scientific discipline and full-fledged medical specialty perpetuates the false dualism of the mind and the brain—attempting to transport psychiatry back to the Cartesian philosophy of the 17th century.”
So the pundits and the public are unwilling to accept psychiatry as a scientific discipline and full-fledged medical specialty. The word “unwilling” in this context has a willful, malicious connotation. The fact is that many of us don’t accept psychiatry as a scientific discipline or as a full-fledged medical specialty. This is because it is neither of these things. The term “unwilling” casts us as a bunch of ill-willed curmudgeons who begrudge the ever-virtuous psychiatry its rightful place at the table. It would make more sense for Dr. Lieberman to address some of the cogent and well-articulated objections that have been leveled against his profession, rather than continue in this kind of vein.
And what’s the outcome of this grudging unwillingness on our part? We are perpetrating the “false dualism of the mind and the brain,” and “attempting to transport psychiatry back to the Cartesian philosophy of the 17th century.”
Rene Descartes’ notion of mind and body as two distinct and separate entities, is one of the most discredited theories in the history of science. Aligning psychiatry’s critics with this theory is a subtle form of defamation. It’s a bit like calling people flat-earthers. It’s classic Dr. Lieberman stuff.
But there’s a serious issue tucked in there that needs to be unraveled.
Psychiatry’s general position for the past three or four decades is that the “diagnoses” listed in DSM are illnesses of the brain, and that the various behaviors and emotions listed in the criteria sets are caused by these illnesses. On this side of the debate, we disagree, and we point to two general sets of arguments in support of our position. Firstly, that apart from a very few diagnoses (e.g. Alzheimer’s dementia), the existence of the putative illnesses/malfunctions has never been proven. Secondly, there is a great deal of evidence, formal and informal, to support the notion that these behaviors arise as a result of other, more holistic, factors.
The psychiatric assumption is based primarily on the fact that the brain is involved causally in everything we do, from the simplest eyeblink, to solving differential equations. Without brain input, the heart won’t beat, sensory input will not be interpreted, muscles will not contract, etc… Without brain activity, there can be no thinking, no hoping, no wishing, no feeling, no laughter, no sadness. We know relatively little about the precise relationship between specific human activity and specific brain activity. But there’s no doubt that the relationships exist, and knowledge of the field is expanding.
This general concept is widely accepted today. Also accepted is the notion that damage or malfunction to the brain can and does have a deleterious effect on function – including behavior and emotion. Where psychiatry and its critics part company, however, is the contention that all counterproductive or otherwise sub-optimal behaviors/feelings necessarily arise from brain malfunction.
Driver intoxication can and does cause erratic driving, but not all erratic driving stems from intoxication. Fear, in certain circumstances, might cause a person to run very fast, but not all fast running is caused by fear.
Certain head injuries cause people to be grumpy and irascible, but not all grumpiness is caused by head injuries. A person can become grumpy and irascible through learning, even though his brain is perfectly OK.
Computer analogies can sometimes be helpful. If someone hacked into your computer and arranged for it to say rude and offensive things to you every time you boot up, it would be rash to conclude that there is something wrong with the computer. Similarly, if a person does something rude and offensive or even violent, it is similarly rash to conclude – on the basis of no other evidence – that there is something wrong with the person’s brain. Computers can be programmed. People can learn. We can acquire positive, functional habits, or we can acquire negative, counter-productive habits. Which kinds of habits we acquire depends on our circumstances, history, relationships, aspirations, etc., etc… The general process by which we acquire positive habits (e.g. respect for others) is the same as the general process by which we acquire negative habits (e.g. disregard for others). The presence of negative habits in no way establishes the presence of neuropathology. But this is the core assumption of modern bio-psychiatry – an assumption that they have elevated to the status of dogma.
A complication in this regard arises from the fact that the judgment that a habit is positive or negative is inherently subjective, and will vary from context to context. The habit of killing other people without compunction might be a very positive habit in warfare, but very negative in peacetime. Habits of persistent suspicion might be positive in a context of extreme competition for vital resources, but very negative in more normal times.
In his fourth paragraph, Dr. Lieberman states:
“Many critics take issue with the fact that our disorders do not manifest in lesions or biologic abnormalities. But numerous nonpsychiatric conditions are clinically diagnosed without observable pathology or laboratory tests (such as migraine headaches, irritable bowel syndrome, etc.). Interestingly, our critics do not cast aspersions on PTSD, which also has no physical diagnostic stigmata—because that would be politically incorrect.”
The migraine headaches and irritable bowel syndrome reference has been bounced around quite a bit lately. Certainly there are some conditions treated by general medicine in which a precise biological abnormality has not yet been identified. But they are the exception rather than the rule. In psychiatry, they are the rule rather than the exception. Pretending that this doesn’t matter is more Dr. Lieberman spin.
The final sentence in this paragraph is noteworthy. Psychiatry’s critics, he tells us, “…do not cast aspersions on PTSD, which also has no physical diagnostic stigmata – because that would be politically incorrect.”
The notion of casting aspersions at a diagnosis, even a spurious, destructive diagnosis, suggests a rather individualized use of the English language, but let’s assume that he meant to say something like: …do not question the validity or usefulness of PTSD… because that would be politically incorrect.
I, for one, have stated several times on this website that the condition known as PTSD is not an illness, and that giving victims of this spurious diagnosis neuroleptics, SSRI’s, and benzodiazepines, which happens routinely in the VA, is not helpful. The notion that I would be dissuaded from this stance by considerations of political correctness is simply false.
Other critics of psychiatry have made similar statements. Peter Breggin, MD, for instance, is on record as condemning the use of antidepressants to “treat” PTSD, which he describes as “…the normal human reaction of soldiers who have been exposed to combat.”
Richard Bentall, PhD, after discussing PTSD, states very plainly:
“…these findings do not imply that post-traumatic stress can be adequately understood as a disorder of the brain. It is better thought of as a psychological reaction to adverse events that manifests itself at the biological level, as changes in brain structure.” (Madness Explained, p 160) (As an analogy, Dr. Bentall mentions the brain changes that occur in London taxi drivers as they memorize London’s streets. A change in brain structure or function does not necessarily entail an illness.)
Herb Kutchins, MSW, PhD, and Stuart Kirk, DSW, state:
“PTSD has become the label for identifying the impact of adverse events on ordinary people. This means that normal responses to catastrophic events often have been interpreted as mental disorders. Moreover, people must demonstrate how ‘sick’ they are in order to get help; that is, assistance is offered to victims only after they demonstrate how mentally ill they have become. DSM is the vehicle for establishing this sickness. The diagnostic process makes it harder for victims to overcome problems they have not created and are trying to resolve.” (Making Us Crazy, p. 125) (Emphasis added)
Ethan Watters, in his book Crazy Like Us, strongly condemns the widespread exporting to other countries of the western concept of PTSD, which he likens to “…a broken spring in a clockwork brain.” (p. 120)
Philip Thomas, MD, a British psychiatrist, in his article What is Critical Psychiatry, states:
“The diagnosis of PTSD has less to do with science and natural categories than it has to do with internal political struggles to salve a nation’s conscience after a terrible conflict.”
It took me about 15 minutes to track down these criticisms of the concept of PTSD, in the light of which it’s difficult to interpret Dr. Lieberman’s contention that his critics “…do not cast aspersions on PTSD…” as anything other than more spurious nonsense.
Dr. Lieberman goes on to tell us that the “…maturation of psychiatry has in the past been limited by technology.” But now they have psychopharmacology, modern neuroimaging, and molecular genetics, which they are combining with – and this is good, coming from the lead researcher on the CAFE study – rigorous scientific methodology.
Nor is this confluence of technology and science some vision for the future. Dr. Lieberman assures us it’s already here, and that it has enabled psychiatrists to begin to integrate the mind and the brain!
I think what he means by this (and one can never be quite sure with Dr. Lieberman) is that they have made progress towards finding the biological underpinnings of their various “diagnoses.” To which I can only respond that they must be keeping them under tight wraps – unless, of course, he means the various theories that psychiatry has espoused over the years that have been subsequently discredited, even by Thomas Insel, MD, Director of NIMH (Transforming Diagnosis).
Dr. Lieberman’s next paragraph is worth quoting in full.
“The dependence of medical progress on enabling technologies was made very clear recently with the announcement of President Obama’s Brain Activity Map Project. The sheer magnitude and complexity of the brain, with its 100 billion cells, 30 trillion synaptic connections, myriad interwoven neural circuits, and vast mosaic of gene expression, requires a great leap forward in technology and instrumentation to help us further elucidate its relationship to mental functions and behavior. This big science project, along with the Human Connectome Project, is intended to address this need, just as the Human Genome Project did previously.”
So, he tells us, the brain is a very complex organ. This is a little difficult to square with the standard psychiatric practice of bashing it with neurotoxic chemicals and enough electricity to cause seizures. But let that go – every great endeavor requires sacrifice, and we can’t expect psychiatrists to sacrifice themselves!
With President Obama’s brain project, psychiatrists are going to know so much more about the link between neuronal activity and overt behavior. So when that happy day arrives, psychiatry will be able to say to their clients that depression (or schizophrenia or ADHD, etc.) is an illness just like diabetes, and that the client needs to take the pills for life. But hang on! Aren’t they saying that already?
Which takes us to the final paragraph of Dr. Lieberman’s article. Again, I must quote in full because no paraphrase of mine can do justice.
“Our understanding of the relationship between the brain and mental disorders may have been slow to develop, but recent advances in research have shown us that they are biological in nature and caused by genetics and environmental factors. Patients are not responsible for their mental illness, and psychiatrists are doing their best to recognize and treat mental disorders and help patients as best we can within the limits of our knowledge. For this noble mission, we have nothing to be defensive about.”
Firstly, note the new-found humility – psychiatry’s understanding of the relationship between the brain and mental disorders may have been slow to develop. You might be thinking: better late than never. But no. The humility evaporates like ground mist on a summer’s morning. “Recent advances have shown us that they are biological in nature and caused by genetics and environmental factors.” This is a repetition of the classic psychiatric error – biological activity equals biological illness – which I’ve discussed earlier. Wouldn’t you think that an eminent psychiatrist like Dr. Lieberman would know that all human activity is biological-in-nature-and-caused-by-genetic-and-environmental-factors? The contention is not that the behaviors embraced by the APA’s so-called diagnoses are not biologically based. The point is that they are not illnesses. The fact that – like all human activity – they stem from biological processes is irrelevant.
And finally, the plaintive whine:
- We’re doing our best
- We help as best we can within the limits of our knowledge (more fake humility)
- Our mission is noble
- We have nothing to be defensive about
Dr. Lieberman began this article by telling us that it was time to respond to psychiatry’s critics “…in a new way.” But frankly, it looks like classic Dr. Lieberman to me.
- Our critics are cads and bounders.
- They’re prejudiced against us.
- They stigmatize our “patients.”
- They want to take us back to the dark ages.
- Biological activity equals biological illness.
- Just you wait until till we get the brain mapped, then you’ll all be sorry!
- We are really good guys doing the best we can.
What we don’t see, of course, is also classic Dr. Lieberman
- No proof that their “diagnoses” are in fact biological illnesses
- No acknowledgement of past and present wrongs in client care
- No acknowledgement of psychiatry’s past and present wrongs with respect to corrupt relationships with pharma
- No apology
And remember, dear readers, Dr. Lieberman is not a regular run-of-the-mill psychiatrist. Dr. Lieberman is the President of the APA – arguably the most prestigious psychiatrist in the world! Wouldn’t you think he could do better than this?