It’s that time of the month, and Dr. Lieberman has written another post, Change, Challenge and Opportunity: Psychiatry in Age of Reform and Enlightenment, on the APA’s website, Psychiatric News.
He tells us that these are changing times, and that he, for one, is choosing to see these changes as positive. He leads with a quote from Bob Dylan:
“The line it is drawn, The curse it is cast
The slow one now, Will later be fast
As the present now, Will later be past”
This is interesting, because, although I can’t speak for Mr. Dylan, I doubt if he would endorse the routine corruption of psychiatry by pharmaceutical money; the medicalization of every conceivable human problem; and the hijacking of the mental health system for the purpose of selling pharmaceutical products.
Also noteworthy is the fact that Mr. Dylan’s next three lines are:
“The order is rapidly fadin’
And the first one now will later be last
For the times they are a-changin’”
Mr. Dylan, of course, was writing during the social and political upheaval of the 60’s, and was predicting that many of the establishment’s cherished notions and practices were about to be overturned.
Today, I would suggest, the stanza could be applied to the undermining of psychiatric hegemony that happily is evident at every turn. “The first one now will later be last,” is surely pertinent to psychiatry’s fall from its position of undisputed leadership in the mental health field to its present ostracization and disgrace.
But Dr. Lieberman has told us previously that as far as he’s concerned, psychiatry has nothing to be defensive about. So I guess he just doesn’t see it.
Dr. Lieberman goes on to give us a brief account of psychiatry’s history: Philippe Pinel, Dorothea Dix, mental asylums, etc. Then he tells us:
“At their peak, public mental hospitals totaled 560,000 beds in over 300 facilities. But as this system grew, the burgeoning patient population in many hospitals led to appalling living conditions and poor care.”
I don’t think anyone would dispute that in many cases, living conditions were indeed appalling, and the standard of care was poor. Dr. Lieberman attributes these deficiencies to the “burgeoning patient population,” by which he presumably means over-crowding. But we need to remember that the decision to place the asylums under psychiatric leadership was driven by a desire to improve conditions and to improve the standard of care. Isn’t it reasonable to conclude that the psychiatrists who ran these facilities were doing a really dreadful job, and that the overcrowding was a direct result of chronically low discharge rates?
This conclusion is consistent with the kinds of “therapies” that psychiatrists conjured up (without the slightest supporting evidence) and routinely inflicted on the hapless individuals who were committed (often involuntarily) to their care. The kind of “treatments” that might have contributed to the “appalling living conditions and poor care” included:
- Insulin coma therapy
- Rotational therapy
- Hydrotherapy: submersion; mummifying in ice-cold towels, blasting with water from high-pressure hoses
- Surgical removal of teeth, tonsils, ovaries, and other organs
- Chemically-induced seizures, tried with caffeine and absinthe, before settling on metrazol
- Surgical sterilization
But, as always, Dr. Lieberman’s primary agenda is to deflect any criticism away from psychiatry. According to his lights, psychiatry is, and always has been, a profession of heroic, dedicated people who have selflessly devoted their considerable talents to the welfare of their “patients.” And people who say otherwise are cads and bounders.
Dr. Lieberman then mentions Sigmund Freud.
“The next pivotal point came with Sigmund Freud. His psychoanalytic theory and therapeutic methods provided an intellectually compelling conceptual framework for psychiatrists at a time when the field was lacking a scientific theory.”
Freud’s theories have been discussed and debated by abler writers than me, but I think there is widespread agreement that, however attractive or interesting these theories might otherwise be, they are entirely lacking in scientific validity. Dr. Freud simply made them up, which in science almost never works.
The fact that Freud’s theories and methods provided “an intellectually compelling conceptual framework for psychiatrists” says, in my opinion, a great deal about psychiatry’s lack of science.
Dr. Lieberman then discusses the pharmacological revolution of the 50’s, the deinstitutionalization policies, DSM-I and DSM-II, and the dramatic expansion of “diagnostic” categories that occurred with DSM-III.
He then assures us – and we’ve heard this before – that future DSM revisions:
“… will move beyond descriptive phenomenologic criteria to measures of pathophysiology and etiology and that they will involve laboratory tests to identify lesions and disturbances in specific anatomic structures, neural circuits, or chemical systems, as well as susceptibility genes—the kinds of tests that routinely inform the diagnosis of infection, cardiovascular disease, cancer, and most neurological disorders.”
Oh Happy Day. And then psychiatrists will be real doctors!
Next he tells us that there are two forces that have been “…unleashed that promise to pervasively alter psychiatry and mental health care over the next decade.” He assures us that we cannot underestimate their power, and the magnitude of the change they will bring. These forces are:
“The rising cost of health care and the increasing pace and momentum of scientific discovery.”
Many people, he tells us, have reacted to these forces with frustration and fear. And then, he changes the subject abruptly, and writes:
“In the past few decades, the focus has shifted more toward the brain and away from the mind. And changes in reimbursement systems today have rewarded hurriedly written prescriptions and encouraged psychotherapy to be provided by nonpsychiatrist therapists. Paperwork, insurance procedures, and government regulation have stretched physicians’ tolerance and limited the opportunities for meaningful interaction with patients. Research has only slowly yielded findings that have been translated to psychiatric practice and improved mental health care.”
So psychiatrists who limit their professional activities to 15-minute “med checks” and hurriedly written prescriptions are not to be blamed or censured in any way. They are the victims of changes in reimbursement systems! So, you see, there’s nothing they can do about it, poor souls. They’re trapped forever on the $200,000 per year (plus pharma handouts) treadmill, with no prospects of relief. Things are so bad for them, in fact, that it wouldn’t surprise me if they started contracting brain illnesses and had to start eating their own pills.
Paperwork, insurance procedures, and government regulations have limited the opportunities for meaningful interaction with patients. There it is again – psychiatrists as victims – wanting desperately to get to know their clients – wanting to provide real, honest, tangible help – not just “how are you sleeping and how are the bowels” – but, you know, person-to-person. But they can’t. Why? Paperwork, insurance procedures, and government regulations! Lambs.
Then there’s that curious admission about the lack of research support for psychiatric practice. This is true, of course, but it is in marked contrast to the assurance with which psychiatrists have been saying for decades, that depression and their various other “illnesses” are brain malfunctions, and even telling us that in many cases, the malfunctions were known and understood.
Dr. Lieberman concludes by telling us not to fear these “unleashed” forces, but rather embrace them, because they will ultimately “…improve the quality and status of our profession.” Note the word status – an acknowledgement, perhaps, that their reputation at present is drawing perilously close to that of street-corner drug pushers.
So there it is. Nothing new. Classic Dr. Lieberman spin. No acknowledgement of psychiatry’s errors or shortcomings. No apology for the corrupt relationship with pharma at the academic and practice levels. And, of course, no expression of any intention to change course. Just more repetition of the same tired old assertions, and an absolute refusal to engage in anything resembling critical self-scrutiny.
The question naturally arises as to why Dr. Lieberman writes these posts. Does he actually imagine that repeating these platitudinous assertions constitutes dialogue? A great many valid criticisms, conceptual and practical, have been leveled at psychiatry, and, in my view, it is a reasonable expectation that the President of the APA would welcome some honest in-depth discussion. But no: all we get is the same facile spin.
Psychiatry is not something good that just needs some minor corrections. Psychiatry is something fundamentally flawed and rotten – a wrong turning in human history.
[Thanks to S. Randolph Kretchmar on Twitter for the link to the Dr. Lieberman article.]