Shrinks

SHRINKS: THE UNTOLD STORY OF PSYCHIATRY
By Jeffrey A. Lieberman with Ogi Ogas

The practice of psychiatry has always been both an art and a science. But while the science of psychiatry has recently been showing signs of progress, the art has been falling out of favour.

Traditional psychotherapy in particular has lost a lot of its cachet, to the point where this new history of psychiatry can speak dismissively of Freud leading the profession into “an intellectual desert for more than a half century.” The dark ages of early modern asylums were replaced by the only slightly less dark ages of universal neuroses and Oedipal fantasies. But we have now arrived at a new dispensation.

Today the diagnosis and treatment of mental illness is a more technical affair, due mainly to the breakthroughs that have been made in neuroscience, brain imaging, our understanding of the role of genetics, and the development of an entire industry of psychopharmaceuticals. In Jeffrey Lieberman’s view it’s an optimistic story of medical progress.

Having said that, perhaps the first thing to note about Shrinks is that it does not present the “untold story of psychiatry.” As a former president of the American Psychiatric Association, with a list of other credentials as long as your arm, Lieberman is about as official a mouthpiece for the profession as you could imagine. There is nothing here that is, or ever was, hidden or secret.

This is a bit disappointing, as psychiatry has not been a stranger to secrecy and controversy. The main reason for this is that in addition to being an art and a science, psychiatry is also a business.

The flashpoint for much public squabbling in recent years has been the Diagnostic and Statistical Manual of Mental Disorders, or DSM, commonly referred to as the Bible of Psychiatry.

According to Lieberman the DSM “might just be the most influential book written in the past century.” It is used as a manual by mental health professionals and affects the lives of tens of millions of people who are diagnosed on the basis of its criteria. In addition, it shapes the funding of health care, directs research and mental health programs, and has significant impact in fields like education, workers’ compensation, and the criminal justice system.

It is also a work done on Lieberman’s watch, as its latest iteration, DSM 5, was completed and published in 2013 during his term as president of the APA. Like any parent, he is both proud and protective of his baby, and he makes its publication the capstone of his story, seeing it as marking “the triumph of plurality,” and its broad acceptance by the psychiatric profession as an answer to its many critics.

This is the official line, and it papers over what were major critiques both of the new DSM and the way it came about. Perhaps the most outspoken critic was Gary Greenberg, whose own recent account of the making of DSM 5, The Book of Woe, is worth considering as a counter-narrative to Lieberman’s.

For Greenberg, the current state of mental health classification is dangerously detached from reality as well as overly politicized. And compounding these problems are the economic drivers: the fact that “medicine is a service industry, that diseases are market opportunities, and that a book of them [the DSM] is worth its weight in gold.” His summation of this golden book is worth quoting in full:

we all know that the DSM is at its best a clumsy and imperfect field guide to our foibles and at its worst a compendium of expert opinions masquerading as scientific truths, a book whose credibility surpasses its integrity, whose usefulness is primarily commercial, and whose most ardent defenders are reduced to arguing that it should be taken less seriously even as all of us – clinicians, researchers, and copyright holders alike – cash in on the fact that it is not.

Lieberman isn’t blind to these complaints. Indeed some of them are briefly registered. But what he presents is very much the authorized version of the story of psychiatry, one that leaves us with a sense of satisfaction at the “progress and proliferation of auspicious developments in our society’s understanding of mental illness and psychiatry.” He understands that there are still “the specters of . . . suspicion and scorn,” but one gets the sense that he sees these views as merely misinformed.

Some scepticism, however, is justified. It’s not just that psychiatry still has a long way to go. It has to face up to doubts about where it is.

Notes:
Review first published online December 14, 2015.