Jeffrey A. Lieberman -- Shrinks: The untold story of psychiatry
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Also see my reviews of the following:

- Gary Greenberg -- The book of woe

- Allan Horwitz and Jerome Wakefield -- The loss of sadness

Lieberman has a very sanguine view of the progress made by
psychiatry in the 2nd half of the 20th Century.  He has been, he
feels, part of that progress, so there is a bit of
self-congratulations scattered through this book.  Therefore, we
should be skeptical.  He has been (and perhaps still is) president
of the APA (American Psychiatric Association), which is the
organization that created, approved, and publishes the DSM
(Diagnostic and Statistical Manual of Mental Disorders), so he has a
vested interest and is likely to be defensive about criticism.  A
bit of skepticism is advisable.

That skepticism is especially justified given: (1) the abysmal
treatment of psychiatric patients during the first half of the 20th
Century; (2) the conflicting and changing definitions of psychiatric
aliments; (3) the unreliability of psychiatric diagnoses (and the
inability of psychiatrists to repeatedly diagnose patients
consistently; (4) the over prescription of powerful psychotropic
drugs, often without an understanding of the medical causes it is
hoped that those medications will treat (and it doesn't help that it
smells like there is a cosy, reciprocal relationship between
psychiatrists and the pharmaceutical industry); (5) the dominance of
Freudian psychoanalysis and of Freudian psychoanalytic theory for
many years and then the rejection of that movement as without
scientific basis and a lack of grounding in reality.

And, the most important tool in dealing with mental illness is a
book (various editions of the DSM) that describes symptoms without
trying or being able to tie them to underlying causes.  So, that now
many or most treatment attempts to deal with effects (or symptoms)
without understanding the cause of those visible effects.  It's as
if your medical doctor were to prescribe pills for hair loss without
knowing whether the cause of that hair loss is an external infection
or an internal chemical imbalance.

And, yet Lieberman struggles on, fighting what he believes is the
good fight to help save and boost confidence in the latest version
of that diagnostic manual: DSM-5.  He emphasizes (1) the success of
DSM III in guiding psychiatry toward a more evidenced base approach;
(2) the horrid conditions in psychiatric institutions before 1950
and how that has been improved dramatically; (3) the phenomenal
success of drug based treatment after the 1950's.

And, certainly there have been successes.  There have been
improvements.  Certainly many have been helped and saved by
psychiatric prescriptions and psychotropic medicines.  Certainly, it
is because of progress and improvements in psychiatry and
psychiatric treatment that some can lead normal lives who otherwise
could not, and that others can at least maintain instead of
descending into something far worse.  Lieberman gives a good account
of these improvements.

Of special interest to me in this book is Lieberman's account of the
very rough and contentious revision process that lead to DSM-5.
After reading Lieberman's account, it's hard for me not to believe
that Lieberman feels it was a success just because it's over and
just because DSM-5 was approved and accepted by the APA (the
American Psychiatric Association).  But, Lieberman says very little
about the quality of that (not so) final product or whether he
believes and has evidence that DSM-5 actually improves the help that
psychiatrists and therapists may be able to give to their clients.
It may even be that he feels that DSM-5 is good enough if only
because it maintains the evidence based approach that was begun in
earnest with the revision process that produced DSM-III.

I suspect that it would be a calamity if psychiatrists did not have
something like DSM-5 to justify some of their requests for
reimbursements from insurance companies.  Perhaps many people would
be denied the care they need if that basis were not there.  But, the
cynical among us might claim that psychiatric practitioners are best
off to use DSM-5 to justify insurance claims and, when treating and
talking with clients, to use their own best judgement.  Lieberman
himself suggests something similar when he says things like that we
need to learn more about and to use both biological psychiatry *and*
what he calls psychodynamic principles; both neuroscience and
attempts to listen to patients' accounts of their experiences,
emotions, and thoughts.  I take this to mean that neither
neuroscience nor talk therapy techniques alone seem to work very
well, so we'd best try both.  And, this kind of cynicism about the
DSM project is displayed blatantly in "The book of woe" by Gary
Greenberg, who seems to feel that the DSM is useful for getting
money from insurance companies, but should be ignored when a
therapist actually deals and talks with a client.

Even Lieberman seems to feel that the DSM is the best we've got and
that it is neither a botched attempt at biological psychiatry nor a
throwback to psychological theorizing that is not grounded on
evidence.  It's the best tool we currently have and we should use
it, perhaps with caution, perhaps with a bit of skepticism, until we
can produce something better.

By the way, Lieberman also says things that indicate that these
difficulties and limitations are a result of the inherent nature of
what we are attempting to deal with: a domain which is both brain
and mind, which calls for both neuroscience and talk therapy, and
which can be helped by both medication and counselling.  I suppose I
agree, but I and many others are wishing for more progress with this
kind of treatment.

08/01/2015

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