The British Psychological Society
Division of Clinical Psychology
This report of the British Psychological Society mirrors a widespread reaction against a purely biomedical explanation for psychosis, for Schizophrenia. They propose the alternative possibility that it can be an adaptation to childhood trauma and abuse. They advocate access to psychotherapy for these patients and suggest using neuroleptic medications only when helpful or requested, not as a steady diet. "Many people find that ‘antipsychotic’ medication helps to make the experiences less frequent, intense or distressing. However, there is no evidence that it corrects an underlying biological abnormality. Recent evidence also suggests that it carries significant risks, particularly if taken long term." This report comes from the UK where offering talk therapy to psychotic patients is apparently mandated, but not really available. Something like that.
New York Times
January 18, 2015
Tanya Luhrman is an Anthropologist at Stanford. Among her books, Of Two Minds is a study of the transformation within psychiatry in the 1980s. In this New York Times piece, she reports favorably on the British Psychological Society’s report above, saying: "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. One outcome of this rethinking could be that talk therapy will regain some of the importance it lost when the new diagnostic system was young. And we know how to do talk therapy. That doesn’t rule out medication: while there may be problems with the long-term use of antipsychotics, many people find them useful when their symptoms are severe…"
New York Times
January 27, 2015
Luhrman had mentioned that the NIMH had abandoned the DSM-5 and instituted their RDoC Project. Paul Summergrad, current APA President, offered a short clarifying reply to her NYT piece: "Ms. Luhrmann notes approvingly that the National Institute of Mental Health, in beginning a program called Research Domain Criteria, determined that existing psychiatric diagnoses ‘were neither particularly useful nor accurate for understanding the brain, and would no longer be used to guide research.’ However, she does not mention a joint statement by the institute’s director, Dr. Tom Insel, and the former president of the American Psychiatric Association, Dr. Jeffrey Lieberman, which explained: ‘All medical disciplines advance through research progress in characterizing diseases and disorders. DSM-5 and RDoC [Research Domain Criteria] represent complementary, not competing, frameworks for this goal.’ Precisely."
February 18, 2015
In the Medscape article, Jeffrey Lieberman, immediate past President of the American Psychiatric Association, comes out of the gate with:
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. Specifically, Dr Luhrmann was prompted to write this by a report that came from the British Psychological Society, which is a professional organization in the United Kingdom. This report, titled Understanding Psychosis and Schizophrenia, suggested that hearing voices and having feelings of paranoia were common experiences; that they commonly occur in the course of everyday life, particularly in the context of trauma, abuse, or deprivation, and that they shouldn’t be considered symptoms of mental illness and attached to diagnoses because that is only one way of viewing them. Viewing diagnoses as normative mental phenomena has relative advantages and disadvantages. This strikes me as preposterous. It is, at best, phenomenologic relativism, and at worst, simply conflating symptoms with a disorder or a disease… 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…
It is not my intent in this blog to defend or oppose the position of the British Psychological Society or Luhrman’s piece. Standards of proof transcend the opinions of any of us. It is, however, my intent to ask, "Who does Jeffrey Lieberman think he is?" "What gives him the right to lambast people who disagree with him with a string of contemptuous invectives like this?" "Does he not realize that if these critics overstate their case, it is at least partly in response to his kind of rigid self-righteousness?" And Tanya Luhrman didn’t write this because of the British report. It’s part of her long held opinion, one that runs as a thread throughout her academic career. But my central point is that Lieberman’s disdainful language and dismissive tone is way out of line no matter what she thinks – conduct unbecoming…
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. After making this point, which essentially equates symptoms with illness, the author says that this is consistent with the view taken by the National Institute of Mental Health [NIMH] Director Tom Insel…
We all know that antipsychotic drugs block dopamine. Neither how that affects psychosis nor whether dopamine is directly involved in the cause of psychosis is any more known now than it was when I first learned about it in the 1970s. Is he missing the point on purpose? To use one of his medical analogies, narcotics are a vital ingredient in treating kidney stones. If you’ve had one, you know what I mean. But kidney stones have nothing to do with opioid receptors. And as for Tom Insel’s blog about the NIMH abandoning the DSM in the run up to the release of the DSM-5, Luhrman’s article is clear that the position of the British Psychological Society is not the same as that of the NIMH. And I expect the joint statement later issued by Lieberman and Insel came after a few rather steamy phone calls with a rant that rivals this one.
Why would such a report be printed in a widely respected publication such as the New York Times? What other medical specialty would be asked to endure an anthropologist opining on the scientific validity of its diagnoses? None, except psychiatry. Psychiatry has the dubious distinction of being the only medical specialty with an anti-movement. There is an anti-psychiatry movement. You have never heard of an anti-cardiology movement, an anti-dermatology movement, or an anti-orthopedics movement. What would give an anthropologist license to comment on something that is so disciplined, bound in evidence, and scientifically anchored? 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.
Besides his apparent misunderstanding of the functions of media, this is a low point. There is, indeed, an antipsychiatry movement, but this isn’t it. That movement is suffused with the same kind of contempt and disdain as his own comments here. If he doesn’t know the difference, I’ll be glad to send him the links that will make the differences immediately apparent. And as for his having to "endure" criticism by an Anthropologist, what does he think Anthropology actually is? Is my discipline is longer than your discipline really an argument he wants to make in an enlightened world? And are his amateur commentary on the motives of the New York Times evidence-based or simply a defensive screed? My vote is clear.
Among her publications are "Understanding the American Evangelical Relationship With God," "Case Studies in Culture and Schizophrenia," "Other Minds: Essays on the Way Mind Understanding Affects Mental Experience," "Of Two Minds: The Growing Disorder in American Psychiatry," and "Persuasions of the Witch’s Craft: Ritual Magic in Modem Culture." This hearkens back to the days when psychiatry had only fanciful theories about the mind and what caused mental illness in people, and also, unfortunately, when it tried to implement ineffective or, at times, harmful and even barbaric treatments. 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.
After thirty-five years of hearing dismissive phrases like "fanciful theories about the mind" about things that have been important to my own and many others understanding of mental illness and mental life, I am probably not the person to rationally even comment on this part, so I’ll pass. But I am a psychiatrist who actually uses the treatments he mentions in that last sentence and keeps up with the science involved. Both the British Psychological Society and Tanya Luhrman recognize the place of medications in treating psychosis, but imply that the medications have been over-used, which they have. They lobby for a place for "talk therapy" in the treatment of psychotic people, which I agree with no matter what one thinks about causality. And while I might generally differ with their contentions about etiology, theirs is a hypothesis to be proven just like any other, not something to mock.
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.
One of the rules about making a diagnosis, particularly in psychiatry, is therapeutic intent – a diagnosis is something you do for a patient, not to them. But Dr. Lieberman should be aware that the temptation in the minds of many readers of this piece with his level of self importance and entitlement is to see him as the object of diagnosis rather than an expert in diagnosis. And equally, one might legitimately ask why Medscape would publish his embarrassing rant.
My own dog in this hunt has to do with an acquired pet peeve. I wrankle when people personify psychiatry as in "psychiatry thinks …" as if psychiatry is a unity all of one mind. I have the same reaction to "psychoanalysis thinks …" for that matter. Because what comes next is usually something I don’t think. But I try to keep my mouth shut because I can see why people do that. He purports to speak for all of us. But I sure don’t think all that Dr. Lieberman says in this piece. And I don’t think what the British Psychological Society or Tanya Luhrman think either, though their general recommendation of more judicious use of medication and access to "talk therapy" have always been part of my own thinking about these patients. Since I don’t know what causes psychosis, I would justify both recommendations on other grounds. There is little question in my mind that the neuroleptic medication can prevent relapse, and in a significant number of cases, that’s an important dilemma added into the mix.
When I arrived on the scene in psychiatry forty years ago, the psychoanalysts were entrenched in the seats of power much as the bio-psychiatrists are now. Some spoke from an arrogant position similar to that taken by Dr. Lieberman here. Even as an immigrating rookie from another specialty, I could sort of smell where that was headed. So it was back then that I learned about what happens when a paradigm flows way beyond its defensible boundaries. And like now, there was money involved – billing medical insurance for long but often optional psychotherapies. A sense of rightness clouded their vision and they missed many opportunities to become right-sized, attacking or becoming defensive when they should’ve been listening and adapting. Sounds familiar. Things were lost in the process.
That epoch is too much a part of my own history for me to feel great comfort in extrapolating it into the present with any certainty, but for what it’s worth, it feels like it’s a pertinent analogy – a time to clean up our side of the street rather than point across the road. I have doubts that Dr. Lieberman is going to be any help at all in that enterprise…
Addendum: An earlier version:
by Jeffrey A. Lieberman
May 20, 2013
by Judy Stone
May 24, 2013
"Conclusion: So many symptoms are now being medicalized, even absurdly, grief. It makes me wonder if there a DSM 5 diagnosis for someone who is self-serving, can’t accept criticism, and believes critics are prejudiced bigots? I was very disappointed to see Dr. Lieberman’s shallow, self-serving and evidence-free diatribe appear in Scientific American as a guest opinion. He failed to reveal important conflicts of interest. He made serious claims for which he presented no evidence. He has made thinly veiled personal attacks on his critics, without offering anything substantive to counter rationally…"