On Psychiatric Meds and Forgetting the Person
In Shrinks: The Untold Story of Psychiatry, Jeffrey A. Lieberman, Lawrence C. Kolb Professor and chair of psychiatry at Columbia University College of Physicians and Surgeons and former president of the American Psychiatric Association, states that “psychiatry’s dramatic transformation from a profession of shrinks to a profession of pill-pushers came through sheer serendipity” (p. 172). In this note, I will highlight some of the problems with this volume.
Unfortunately, the book does not promote the need for practicing psychiatrists and trainees to incorporate psychodynamic psychiatry into their education and practice. At its core, a psychodynamic approach mandates, as Glen Gabbard puts it, that the psychiatrist “look at each individual as a person with highly individual, even idiosyncratic features.” But, he adds, “[t]his 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.” It seems this has happened with Lieberman’s account.
Lieberman’s estimation of psychopharmacology as the Holy Grail of psychiatric treatment is evident in the laudatory tone with which he describes the historical arc of the profession of psychiatry: “the mind-boggling effectiveness of psychiatric drugs began to transform the fundamental nature of psychiatry and elevate its professional status. The black sheep of medicine could rejoin the flock because it finally had medicine” (p. 189). Thus he tracks the movement of psychiatry’s status as “stepchild of medicine” to the “triumph of pluralism”: DSM-5.
Except for a section titled “Toward a Pluralistic Psychiatry” (pp. 284–291), the volume strikes me as unidimensional. Lieberman evinces a seeming lack of appreciation for the complexities of both mental life and therapeutic interventions. For example, at the end of his introduction, he states: “The modern psychiatrist now possesses the tools to lead any person out of a maze of mental chaos into a place of clarity, care, and recovery.” In light of Lieberman’s rendering, it’s a wonder so many people still suffer. And what suffering Lieberman does discuss he attributes to the stigma of mental illness, rather than addressing the well-known limitations and side-effects of psychotropic medications.
Lieberman’s perspective – that pills are the main, if not the only therapeutic means in a psychiatrist’s armamentarium – is illustrated by two cases, Elena, a young woman with schizophrenia and a chronically psychotic woman, Mrs. Kim.
In both cases, the families refused psychotropic medications. It was striking to me that there was no discussion about how to address psychodynamic issues, family interactions, and cultural barriers involved. Instead, the cases read as if the patients were simply discharged because medications were refused.
Lieberman does not examine why some patients with severe mental illness continue their use of antipsychotics and others do not. For example, Lieberman’s friend Elyn Saks, whose symptoms are described in the book (pp. 178–179), has written that she considers herself to be a patient “with psychosis who has benefited enormously from psychoanalytic treatment, four or five times a week for over three decades” (Saks and Evans 2011, p. 59). Kay Redfield Jamison (1992), to whom Lieberman also refers to as a “dear friend” (p. 311), has also written about the value of psychotherapy in the treatment of bipolar illness.
Despite this, the value of psychotherapy is virtually effaced in Lieberman’s description of their treatments. In fact, his clinical descriptions of these four cases (Saks, Jamison, Elena, and Mrs. Kim) lend themselves to a testable hypothesis: Do psychotic patients do better when their treatment with psychotropic medications is accompanied with psychotherapy, or not? And if they do, should the psychotherapy be provided by the prescribing psychiatrist or by another mental health professional?
Jeffrey Lieberman is a distinguished leader in the field of psychiatry. It would have been a real contribution to the field had this volume engaged in self-reflection, rather than displaying an authoritarian approach that does a disservice to the field.
For an extensive essay about this book, visit http://apa.sagepub.com/content/63/3/565.full.pdf+html