On February 18, Jeffrey Lieberman, MD, Professor of Psychiatry at Columbia University, published a video lecture (with transcript) on Medscape.
The article is titled What Does the New York Times Have Against Psychiatry?, but in his opening paragraph, Dr. Lieberman points out that the piece could be titled “Psychiatry Suffers Another Indignity.”
The background to this is an article by Tanya Luhrmann, PhD, an anthropologist at Stanford University, which appeared a month earlier (Jan 17, 2015) in the New York Times. This article was titled Redefining Mental Illness, and developed some of the themes in the British Psychological Society’s earlier paper Understanding Psychosis and Schizophrenia.
Here are some quotes from Dr. Lieberman’s article, interspersed with my comments:
“The article about mental illness was an incredibly unscholarly, misinformed, confused—at worst, unhelpful, and at best, destructive—commentary that will add to the confusion about the diagnosis of mental illness, enhance the stigma, and may lead some patients to doubt the veracity of the diagnoses that they have been given and the treatments that they are receiving.”
I have read Dr. Luhrmann’s article, and can only say that I disagree with Dr. Lieberman’s somewhat petulant assessment. In fact, my only quibble with Dr. Luhrmann’s paper is that it leans too far in the pro-psychiatry direction and, by implication, endorses the validity of the concept of mental illness.
But note in particular Dr. Lieberman’s concern:
“… may lead some patients to doubt the veracity of the diagnoses that they have been given and the treatments that they are receiving.”
And there it is, bold and clear: how dare this anthropologist encourage psychiatric “patients” to doubt the pronouncements and prescriptions of their psychiatrists! How dare she sow such seeds of discord!
As I’ve said many times, psychiatry is not very open to criticism. Dr. Lieberman’s condemnation is the more notable in that Dr. Luhrmann’s article isn’t particularly anti-psychiatry. Here are some quotes:
“The implications are that social experience plays a significant role in who becomes mentally ill, when they fall ill and how their illness unfolds. We should view illness as caused not only by brain deficits but also by abuse, deprivation and inequality, which alter the way brains behave. Illness thus requires social interventions, not just pharmacological ones.”
“The World Health Organization estimates that one in four people will have an episode of mental illness in their lifetime.”
“When the United Nations sets its new Sustainable Development Goals this spring, it should include mental illness, along with diseases like AIDS and malaria, as scourges to be combated. There is much we still do not know about mental illness, and much we can do to improve its care. But we know enough to do something, and to accept that knowing more and doing more should be a fundamental commitment.”
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Dr. Lieberman then expounds on the distinction between a symptom and a diagnosis, and tells us:
“It’s a constellation of symptoms occurring in a specific pattern and conforming to an observed and potentially validated condition that defines a diagnosis.”
Well there are two responses that could be made. Firstly, the pattern of symptoms in psychiatric “diagnosis” is anything but specific. Apart from the vagueness and inherent subjectivity of the individual items, the polythetic feature (three out of five, four out of six, etc.) renders the term “specific” quite meaningless. Secondly, note the term “potentially validated” – an acknowledgement that psychiatric diagnoses aren’t validated yet, but perhaps will be validated, any decade now.
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Dr. Lieberman assures us that there are “rigorous principles” that govern the process of creating or changing a psychiatric diagnosis. In fact, changes to the DSM are ultimately decided by voting, which is not particularly rigorous, and, given that 69% of DSM-5 task force members had ties to pharma money, may even be corrupt.
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Dr. Lieberman takes Dr. Luhrmann to task for her assertion “that there is no strict dividing line between mental illness and normality.” He writes:
“Viewing it this way is, in a way, challenging the veracity of diagnoses and giving people who have symptoms of a mental disorder, license to doubt that they may have an illness and need treatment.”
In fact, as is obvious to anyone who has ever even glanced through any copy of the DSM since DSM-III, there is no strict dividing line between psychiatry’s so-called illnesses and normality. But, according to Dr. Lieberman, we should not view the matter this way. We should, perhaps, wear blinkers, and deny this obvious truth. Why? Well, he gives us two reasons:
- Because it represents a challenge to the veracity of diagnoses! Good Heavens! Here we are again, questioning the dogmatic pronouncements of psychiatrists. How dare we! Will this indignity never end?
- Because it gives psychiatry’s clients “license to doubt that they may have an illness and need treatment.” License to doubt! License means permission. So Dr. Lieberman apparently is saying that psychiatry’s clients have no business questioning the pronouncements of their psychiatrists or the “treatment” that these practitioners prescribe. He criticizes Dr. Luhrmann, and presumably the BPS, for giving these individuals permission to question the validity and efficacy of their so-called treatment. Perhaps somebody at Columbia would take the good doctor aside and remind him that here in America, people – even psychiatric “patients” – don’t need permission to question anything. It’s a constitutional right!
Quite apart from the ethics of this matter, Dr. Lieberman’s position stands in stark contrast to that of general medicine, where patients are actively encouraged to participate in the process, ask questions, seek second opinions, and – yes – even challenge the accuracy and effectiveness of the interventions.
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“Next, the article addresses the fact that there is no evidence that antipsychotic drugs correct any biologic abnormality, which also is inaccurate. Antipsychotic drugs work through the antagonism or the blocking of dopamine. They may have other downstream and upstream effects with a neural pathway, but the link between dopamine activity and psychotic symptoms is indisputable.”
In fact, there is no evidence that neuroleptic drugs correct any biological abnormality. Dr. Lieberman asserts that this is inaccurate, but cites no references in support of this contention. He writes in very simplistic terms, about the blocking of dopamine and the link between dopamine activity and the psychotic symptoms. But he neglects to point out that the latter link is tenuous indeed, and that the great majority of people “diagnosed with schizophrenia” have dopamine production levels in the normal range. I have discussed this matter in detail elsewhere.
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At this point in the narrative, Dr. Lieberman takes Dr. Luhrmann to task because she draws some parallels between the BPS’s paper and the famous Thomas Insel blog post of April 29, 2013. In that post, Dr. Insel, Director of the NIMH, had critiqued the DSM.
“While DSM has been described as a ‘Bible’ for the field, it is, at best, a dictionary, creating a set of labels and defining each.”
” The weakness [of DSM] is its lack of validity.”
In this post, Dr. Insel went on to say that NIMH would no longer fund research based on the existing DSM categories, but instead would focus on basic brain research and would follow the findings as they emerged, even if they did not endorse the ontological status of the various DSM entries.
Dr. Luhrmann discussed Dr. Insel’s post, and in my view, accurately reflected its contents. In addition, there are parallels between Dr. Insel’s statement and the BPS report. Dr. Luhrmann was accurate in drawing these parallels:
“Moreover, the perspective is surprisingly consonant — in some ways — with the new approach by our own National Institute of Mental Health, which funds much of the research on mental illness in this country. For decades, American psychiatric science took diagnosis to be fundamental. These categories — depression, schizophrenia, post-traumatic stress disorder — were assumed to represent biologically distinct diseases, and the goal of the research was to figure out the biology of the disease.
That didn’t pan out. In 2013, the institute’s director, Thomas R. Insel, announced that psychiatric science had failed to find unique biological mechanisms associated with specific diagnoses. What genetic underpinnings or neural circuits they had identified were mostly common across diagnostic groups. Diagnoses were neither particularly useful nor accurate for understanding the brain, and would no longer be used to guide research.”
This is a very fair summary of Dr. Insel’s post. Here are some quotes from the latter:
“But it is critical to realize that we cannot succeed if we use DSM categories as the ‘gold standard.'”
“That is why NIMH will be re-orienting its research away from DSM categories.”
“We are committed to new and better treatments, but we feel this will only happen by developing a more precise diagnostic system.”
But, as becomes clear in his next paragraph, Dr. Lieberman’s complaint stems, not from Dr. Insel’s original post, but rather from an NIMH press release dated about two weeks later (May 13), and published jointly by Dr. Lieberman and Dr. Insel.
“But in a letter that Dr Insel and I (as then president-elect of the American Psychiatric Association) jointly released in 2013, we both stated that although our RDoCs [research domain criteria] may represent our aspirational goal for how diagnoses may be defined in the future, that was in the distant future, and for the present, the clinical diagnoses that have been used and continue to be refined through the iterative DSM process are the gold standard of what needs to be used. Absent these, which is basically the same set diagnoses reflected in the ICD [International Classification of Diseases]-10, there would be no way for consistency in communication and treatment to occur across populations and within the healthcare community.”
This is the famous Dr. Insel reconciliation article, and has been characterized by some as a retraction of his earlier position. In fact, a careful reading of the text makes it clear that it is in no sense a retraction. In particular, Dr. Lieberman’s statement that both he and Dr. Insel stated that “the clinical diagnoses that have been used and continue to be refined through the iterative DSM process are the gold standard of what needs to be used” is, quite simply, false.
What is written in the May 13 press release is:
“…the DSM is the key resource for delivering the best available care.” [Emphasis added]
and
“The diagnostic categories represented in the DSM-IV and the International Classification of Diseases-10 (ICD-10, containing virtually identical disorder codes) remain the contemporary consensus standard for how mental disorders are diagnosed and treated.” [Emphasis added]
Note the wording: “…the best available care,” and “the contemporary consensus standard.” There is nothing in either statement to suggest that Dr. Insel considers present psychiatric treatment to be “the gold standard of what needs to be used.” In fact, in his original post, which incidentally, he has never retracted, he wrote: “…symptoms alone rarely indicate the best choice of treatment”, and “…it is critical to realize that we cannot succeed if we use DSM categories as the ‘gold standard.’ [Emphasis added] The term “best available care”, could actually describe care that was of very poor quality.
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Dr. Lieberman’s contention, quoted above, that in the absence of psychiatric diagnoses, “there would be no way for consistency in communication and treatment” is also false, and is critical to the entire debate. A simple statement of the presenting problem, developed jointly through client/practitioner dialogue, with such detail as is considered pertinent, is vastly more informative, and therapeutically useful, than a “diagnosis.” The latter inevitably distorts the reality, and is of benefit only to the psychiatrist, for whom it provides spurious justification for medical involvement in matters that are not medical in nature. It provides no benefit to the client, and in fact is a major contributor to the stigma attached to being a recipient of mental health services.
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“To equate the thesis of the report from the British Psychological Society with the RDoCs initiative of the NIMH seems to me quite a stretch and completely implausible.”
In fact, Dr. Luhrmann didn’t equate the BPS’s report with Dr. Insel’s statement, but merely pointed out the obvious fact that there are some interesting parallels, notably a shared disenchantment with the DSM’s taxonomy.
But what appears to have upset Dr. Lieberman is not so much the realities of the issues, as the fact that an outsider (Dr. Luhrmann) has dared to challenge psychiatry.
“What other medical specialty would be asked to endure an anthropologist opining on the scientific validity of its diagnoses?”
“What would give an anthropologist license to comment on something that is so disciplined, bound in evidence, and scientifically anchored?”
There’s that word “license” again. How dare she! Dr. Lieberman’s reference to “something that is so disciplined, bound in evidence, and scientifically anchored” is presumably intended to be a reference to psychiatry, though I can think of no evidence to support this contention.
Incidentally, here are some quotes from the Wikipedia entry for Tanya Luhrmann:
“Her third book, and the most widely acclaimed, explored the contradictions and tensions between two models of psychiatry, the psychodynamic (psychoanalytic) and the biomedical, through the ethnographic study of the training of American psychiatry residents during the health care transition of the early 1990s. Of Two Minds (2000) received several awards, including the Victor Turner Prize for Ethnographic Writing and the Boyer Prize for Psychological Anthropology (2001).”
“Other projects she is working on include a NIMH-funded study of how life on the streets (chronically or periodically homeless) contributes to the experience and morbidity of schizophrenia.”
“Tanya Luhrmann was a faculty member in Anthropology at the University of California, San Diego, from 1989 to 2000. From 2000 to 2007, she was Max Palevsky Professor in the Department of Comparative Human Development at the University of Chicago, where she was also a director of the program in clinical ethnography. Since Spring 2007, she has been a professor of Anthropology at Stanford University.”
“She was elected a fellow of the American Academy of Arts and Sciences in 2003, president of the Society for Psychological Anthropology for 2008. She has received numerous awards for scholarship, including the American Anthropology Association’s President’s award for 2004 and a 2007 Guggenheim award. In 2006, Luhrmann delivered the Lewis Henry Morgan Lecture at the University of Rochester, considered by many to be the most important annual lecture series in the field of anthropology.”
I leave it to readers to decide whether Dr. Luhrmann is competent to comment on the scientific validity of psychiatric diagnosis, a facile sorting activity posing about as much intellectual challenge as paint-by-numbers.
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Dr. Lieberman concedes, with great grace, that in former times “…psychiatry had only fanciful theories about the mind” and “…tried to implement ineffective or, at times, harmful and even barbaric treatments.” But he assures us:
“Thankfully, we are well past that. We now have scientifically developed and proven efficacious treatments that are safe and are changing and, in many cases, saving lives”,
information that I will pass on to the many people who write to me every month cataloging the truly dreadful experiences and outcomes that they have had at the hands of psychiatry. I’m sure that they will be comforted.
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Dr. Lieberman now turns his attention to the New York Times.
“I can’t imagine how the New York Times editors would think that providing a platform for this would be useful. Maybe they want to be edgy. They want to be provocative and they think this is going to be somewhat controversial and attract readers. It may be interesting reading, but frankly, I think it’s irresponsible.”
Notice, he doesn’t even consider the possibility that questioning or critiquing of psychiatry might be warranted. It is also clear that Dr. Lieberman takes this entire matter very personally.
“Finally, when I read the article, disappointed and annoyed as I was, I tried to write a serious, responsible, and constructive letter to the editor, which I submitted within 24 hours. Seventy-two hours have elapsed since the article’s publication. I haven’t heard from the Times about their interest in publishing my response, so I assume they won’t publish it. The name that I publish under is my own. My credential is the Chairman of Psychiatry, Columbia University College of Physicians and Surgeons, one of the leading departments of psychiatry in the country, past president of the American Psychiatric Association, and author of the forthcoming book for the lay public called Shrinks: The Untold Story of Psychiatry.
Assuming that my letter was not completely uninformed or incoherent, I would think that there would have been reason to accept it, given my credentials and the fact that I made a reasonable point. Let’s see if they print it. If they don’t, that adds further to my dismay over what I consider to be journalistically irresponsible behavior by this once-respected newspaper.”
So a “once-respected newspaper” loses its respectability if it doesn’t publish a letter from Dr. Lieberman. The fact is that the New York Times has already published a con letter from a Harvard professor, a pro letter from a Yale professor, and a somewhere-down-the-middle letter from APA President Paul Summergrad, MD.
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Dr. Lieberman expresses the opinion that Dr. Luhrmann “needs to be more thoughtful.” Debate, he assures us, is to be encouraged, “…but this is not debate.”
“This [Dr. Luhrmann’s article] is non–peer-reviewed opinion, which is wholly uninformed and misguided. It is useless and confusing at best and destructive at worst.”
which reminds me of a couplet by one of my favorite poets:
“O wad some Power the giftie gie us
To see oursels as ithers see us!”
Robert Burns (1759–1796)