From the PresidentPsychiatric Newsby Jeffrey Lieberman, M.D.July 17, 2013The integrity of our profession and the science of psychiatry are being questioned—again by articles in the media. Two recent missives, which I found particularly disturbing, are by the noted columnist David Brooks ["Heroes of Uncertainty," New York Times, May 28] who calls psychiatry a “semi-science,” and by Leonard Sax, a British psychologist [Wall Street Journal, June 26], who accused DSM-5 of having “broadened the definition of mental illness to absurdity.” Although the most recent media criticisms have been focused on the process and finished product of DSM-5, such invective is really nothing new. But it may be time to respond in a new way.
I recently wrote an article for the Scientific American blog that explores how stigma and antipsychiatry sentiments fuel prejudice against our field and our patients. But I think it’s also important to note how the unwillingness of the public and pundits to accept psychiatry as a scientific discipline and full-fledged medical specialty perpetuates the false dualism of the mind and the brain — attempting to transport psychiatry back to the Cartesian philosophy of the 17th century. It also undermines the progress that has been made to deconstruct the almost unfathomable complexity of the brain into its constituent neurobiological mechanisms that mediate emotion, perception, and cognition.
The intellectual thrust of psychiatry, throughout its entire history, has been to understand the maladies of the mind in terms of the brain. Prior to the 18th century, mental illness was considered a spiritual or moral affliction. When enlightenment thinking inspired the view of mental illnesses as medical conditions, psychiatrists proceeded to examine the brain but found no visible pathology. Even Freud, a neurologist, appreciated the need to invoke the brain to understand behavior and psychopathology. His “Project for a Scientific Psychology” anticipated a neurobiological explanation for mental processes and unconscious psychic phenomena. However, the science of his day was inadequate for the audacity of his vision, and he was required to resort to clinical and metaphysical conceptions of mental mechanisms. It has only been in the last half century that we have been able to even envision the possibility of achieving Freud’s dream.
Many critics take issue with the fact that our disorders do not manifest in lesions or biologic abnormalities. But numerous nonpsychiatric conditions are clinically diagnosed without observable pathology or laboratory tests [such as migraine headaches, irritable bowel syndrome, etc.]. Interestingly, our critics do not cast aspersions on PTSD, which also has no physical diagnostic stigmata—because that would be politically incorrect.
The maturation of psychiatry has been limited largely by technology. Just as Galileo could not confirm heliocentrism until the telescope was developed, and Pasteur required the light microscope to identify microorganisms, psychiatry could not begin to gain traction on the functions of the brain until the emergence of psychopharmacology, modern neuroimaging methods, and molecular genetics. These technologies, combined with rigorous scientific methodology, have enabled psychiatrists, psychologists, and neuroscientists to begin to integrate the mind and the brain.
The dependence of medical progress on enabling technologies was made very clear recently with the announcement of President Obama’s Brain Activity Map Project. The sheer magnitude and complexity of the brain, with its 100 billion cells, 30 trillion synaptic connections, myriad interwoven neural circuits, and vast mosaic of gene expression, requires a great leap forward in technology and instrumentation to help us further elucidate its relationship to mental functions and behavior. This big science project, along with the Human Connectome Project, is intended to address this need, just as the Human Genome Project did previously.
Our understanding of the relationship between the brain and mental disorders may have been slow to develop, but recent advances in research have shown us that they are biological in nature and caused by genetics and environmental factors. Patients are not responsible for their mental illness, and psychiatrists are doing their best to recognize and treat mental disorders and help patients as best we can within the limits of our knowledge. For this noble mission, we have nothing to be defensive about.
So one way to understand Dr. Lieberman’s [and many other contemporary psychiatrists] is to define psychiatry in terms of conditions that fit his biomedical model, and there are many that do just that. I have no problem with that solution. When I am thinking in a biomedical way about conditions like Melancholia, Manic-Depressive Illness, Classic Schizophrenia, ADHD, Alzheimer’s, etc., I am a bona fide psychiatrist. When I am thinking about people with illnesses that arise from development, experience, culture, other sources – I am being something other than a psychiatrist. I could live with that [and have]. I guess such conditions wouldn’t be called mental disorders.
DSM-III [Introduction p. 7]: "The major justification for the generally atheoretical approach taken in DSM-III with regard to etiology is that the inclusion of etiological theories would be an obstacle to the use of the manual by clinicians of varying theoretical orientations, since it would not be possible to present all reasonable etiologic theories for each disorder"…
"Because DSM-III is generally atheoretical with regard to etiology, it attempts to describe comprehensively what the manifestations of the mental disorder are, and only rarely attempts to account for how the disturbances come about, unless the mechanism is included in the definition of the disorder. This approach can be said to be ‘descriptive’ in that the definitions of the disorders generally consist of descriptions of the clinical features of the disorders"…
Dr, Lieberman is implicitly denying the painful truth that the things he’s saying in this article are at the root of a massive over-medication of the populace; a gross mistreatment of many patients who have troubled lives they don’t know how to sort out in spite of their perfectly normal constitutions; an obvious set of biases shaped by managed care, guild loyalty, and the pharmaceutical industry; and an indefensible scientific generalization based on limited evidence and conjecture. Psychiatry right now has a lot to be defensive about – a whole lot. Scientists are supposed to be rigorously honest, not wildly speculative. And the phrase "recent advances in" should be retired from the psychiatric lexicon forever.
“Psychiatry right now has a lot to be defensive about”
This couldn’t be more true.
The root of the problem is not too difficult to see.
Psychology’s primary belief, I guess the ‘philosophy’ of Psychology is that “Logic can be performed with words”.
The philosophy, the underpinning of science, is that “Logic can not be performed with words, logic can only be performed with numbers”.
This of course is the whole reason that science came to be, and the specific explanation of how science was different from every process of producing knowledge that came before it, like philosophy and religion.
In science, an observation can only be performed by reducing the physical word to mathematics. This is done by using a standardized instrument, like scale for weight, volume, distance, etc. Examples are scales, calipers, graduated cylinders, and MRI Voxel imaging, QEEG, and Position Emission Tomography.
Psychology, with it’s belief that logic can be performed with words, tries to arbitrarily convert words directly to numbers (such as though using subjective rating scales, like the Hamilton Depression rating scale).
The difference between a measurement made with a standardized instrument, and subjective symptom rating scales, is that the former can be reproduced by another observer the same way every time. The subjective symptom rating scales, when enough observations have been completed, will not exceed pure chance as predicted by statistical analysis.
This is because subjective observations are not scientific, in other words can not be reproduced because words are not numbers. The patients and the physician make two separate observations, and yet another observer makes a 3rd, all 3 are different.
So in short, no matter how far Astronomy advances, it won’t make Astrology any more ‘scientific’ then it started. If we mix the two together, it becomes harder to tell it’s not science, but it’s still not science.
Personally, I think psychiatry went over a cliff the day they started giving patients physical treatments. That opened the door for drug companies and medical devices manufactures to prey on the subjective nature of the profession, and many initial patients had no human rights to decline forced treatments back then.
For Lieberman to say “The maturation of psychiatry has been limited largely by technology” as an explanation for the extreme lack of progress followed by the sudden declaration by the DSM that all Neurological illnesses are now also ‘psychiatric’ is outright offensive.
I think it is simple too. I think too many who rule psychiatry are beyond the label of “narcissists” gone wild, I think the pure antisocial element is pervasive and extensive. People who do what is profit focused and just strokes ego and power is detrimental. The fact that Lieberman is so quick and brusk, in my interpretation at least, to attack and dismiss ANYcriticism of psychiatry he and his ilk promote is what the antisocial does.
I guess we either continue to tolerate and minimize this agenda by the APA, or, at least rethink what we as professionals who genuinely care will do to refute the agenda of a select few will do to corrupt and ruin the lives of the many who want to do that is right and responsible.
Think about it.
…after a time, I took some comfort in noting that those retorts were, themselves, Freudian remarks about my unconscious biases or my narcissistic attachments to my beliefs – things in my mind…
chuckle
The trick is to transcend the Cartesian mind/body duality while denying that humans are mammals and particularly social animals whose mental development requires responses and relationships with other mind/bodies during a long childhood, so that no mind/body is an island unto itself; and the majority of the contents of each mind/body is culturally generated. That’s like laying claim to all the property in a game of Monopoly and telling the other players that they can’t have any money, hence play the game, because they are philosophically unsophisticated and don’t understand economics.
Honestly, I don’t think Lieberman is much more close to the truth of most of the “mental illnesses” in the DSM than the stupid disciples of Freud.
Personally, knowing that psychiatrists have been giving mood stabilizers and anti-psychotics to infants is one of the most outrageous things I’ve ever heard. I cannot trust a discipline that would do this and do it on the basis of a parent’s complaints. Knowing that Lieberman is behind this makes me despise him. Reading his smug propaganda just confirms for me that he is a snake and a charlatan.
After reading a paper on the history of the concept of “autism” which described the early history of the study of child psychology, I wondered what the world would look like if psychoactive drugs had been developed during the reign of Freud and the theories had remained— a bio-freudian approach. So, I made a joke ad for the Sigmund-Lieberman Pharmaceutical company which people here will get, I think, even it isn’t doesn’t make you laugh. It’s at wileywitch dot com, second post down if you’re interested.
The really funny part about Lieberman’s article, to a neurologist, is the attempt to buttress psychiatric diagnoses by analogy to migraine and irritable bowel syndrome, two of the most psychological of the physical ailments. There is a biological basis to migraine (and I assume, IBS) but it is very much a “whole person” illness, affected by moods and sensitivities and ideas as much as any of the normal-range psychiatric syndromes.
http://debunkingdenialism.com/2013/08/07/some-common-anti-psychiatry-archetypes/
Which ‘anti-psychiatry’ archetype are you?
I am not a medical professional nor do I play on tv, therefore I have no skin in the game either way (psychological vs biological), except that I would like better treatment options. However, what does disturb me is the disingenuous of those who wish to promote the biological/medical/Rx model. A new article titled Exploring New Therapeutic Areas in the Treatment of Depression on Psychiatric Times begins with the sentence “We have recently become aware of the limitations of existing antidepressant medication.” Even though I am thankful that new research is being done, I was dumbfounded by the use of the term “recently” and posted a comment there regarding this. My comment was not rude yet it was challenging and somewhat morose, so I do not hold it against them that they decided to delete it.
Regardless, I would take their camp much more seriously if they were being honest about the issues within their model, and if they were working harder to address them. If they believe they have the most accurate model then why would they spend all their energy promoting and defending the facade that exists today instead of questioning items like the “limitations of existing antidepressant medications” at the time professionals such as you surface them (and well before it dawns on laypeople). In addition, they could work on improving their model by listening to their patients instead of drug reps yet they choose not to until these issues can’t be ignored any longer. So this leaves me with the impression that they are not scientists at all, yet just a group of highly educated, highly paid people defending their turf with their patients being the collateral damage.
I realize I have added nothing new to the discussion, yet please just accept this as a layperson finally realizing how much of a facade there really is in modern psychiatry. Thank you (I think) for giving me a glimpse of what goes on behind the curtain.
“Psychiatrists continue to look for the twisted molecule behind every twisted thought.”
Quote by Dr Thomas Szasz in his book ‘Insanity – the idea and its consequences’
Best book on psychiatry ever written.
Arby: Don’t sell yourself short. Nice comment.
When Steve Jobs introduced iPhone, people went wild because they it perceived as an advancement in phones. The talks from Lieberman are akin to Elop of Nokia (probably no one has even heard of him) stomping his foot, claiming his Lumia phones with Microsoft OS are just as good as other phones, demanding clients should buy their phones just because they just are better. Maybe more stomping the ground will help.
I’m not in academy, but it already starts to irritate to read things such as “Advancements in ..” and “Emerging new ..”, etc.
What is the process for electing an APA president?
I’m guessing “proprietary”.
“When Steve Jobs introduced iPhone, people went wild because they it perceived as an advancement in phones. The talks from Lieberman are akin to Elop of Nokia (probably no one has even heard of him) stomping his foot, claiming his Lumia phones with Microsoft OS are just as good as other phones, demanding clients should buy their phones just because they just are better. Maybe more stomping the ground will help.”-Hermes
Commodification of objects and ideas of great value will also lead to alternate routing via appropriate tech and would upset the whole market by devaluation:
http://boingboing.net/2013/04/18/how-is-a-12-phone-possible.html
FYI
Viewing a problem space from outside the space often elucidates
the dynamics of forces operating within the problem space. I found
a book that provides this kind of insight for mental illness.
Pharmaceutical Reason
Knowledge and Value in Global Psychiatry
ANDREW LAKOFF
Cambridge University Press
2005
from page 3-4 of the introduction
“First, to what extent is scientific knowledge about mental disorder universally
valid? One quality attributed to the natural sciences is the independence
of their established facts from local contexts: a given chemical element
or a chromosome is the same ‘‘thing’’ whether studied in San Francisco
or Sa˜o Paulo. Work in the social studies of science has shown that such
universality is a tenuous achievement: the solidification of a fact requires
the ongoing stabilization of the network of actors and techniques through
which the fact is produced.3 Psychiatry is a field that has not achieved such
stabilization. Perhaps, as Ian Hacking argues, this instability is inherent to
the human sciences because the classifications scientists use to study humans
interact with and transform the very objects they are studying.4 Recent
developments in the life sciences such as genomics promise the achievement
of universal validity. Whether they can do so remains uncertain. As we will
see, given the heterogeneity of its epistemic forms, the Argentine mundo-psi
(psy-world) is an apt site for studying the challenges faced by a ‘‘global’’
technique such as genomics in assimilating mental disorder.
Secondly, the interaction raised the question of the salient aspect of the
human that is at stake in expertise about mental disorder. This encounter
between biotechnology research and psychoanalytic self-identity in a marginal
hospital in Buenos Aires was exemplary of a broader contemporary
conflict over where to locate mental illness: is it in the psyche or in the
organism? Can it be recognized and treated through purely technical
means, or must one account for the particular life trajectory of the subject?
To ask about the site of disorder is to ask about ways of knowing – and
working on – the human. The early life history in which a subject is formed;
the social surroundings in which a person sustains relationships; the neurochemical fluctuations that alter an organism’s behavior: all of these
name possible sources of disorder and possible targets of intervention.
Such controversies over models of the human are significant beyond the
narrow confines of debates among experts. The psy-sciences are key sites in
which selves are constituted as beings of a certain kind, where individuals
come to understand the sources of their actions and adopt techniques for
transforming themselves.5 The analysis of current transformations in
expert knowledge about human behavior, then, is also a way of studying
what kind of humans we are becoming. Such a study is not a matter of
seeking to discover the truths about ourselves – whether through cathartic
self-exploration or genomic technology – but rather involves an analysis of
the historically situated process in which experts come to recognize
humans as beings of a certain kind.”
from chapter 6 the segmented phenotype p 176
“Thus the development and application of genomic knowledge does not necessarily lead to a biological determinism. In this case, an apparatus for
defining and treating illness incorporates biological knowledge into its
inventions. Pharmacogenomics technologizes – functionally simplifies –
the strategic logic I have called pharmaceutical reason. That is, it is a
device that links chemical intervention to diagnostic representation
according to the norm of disease specificity. The incorporation of this
logic into psychiatry – as we have seen in the case of DSM – reconfigures
the role of expertise. The task of the expert is not to interpret signs of
psychic distress in terms of a trajectory of subject formation; nor is it to
point to the deleterious effects of the social milieu on the ties that bind
self to collective. Rather, the psychiatrist’s role is limited, if still ambitious:
to manage the neurochemical imbalance that disrupts normal
behavior. Not surprisingly, such a transformation occasions resistance
among recalcitrant experts, as we have seen in the mundo-psi of Buenos
Aires.
The hunt for bipolar patients in Argentina was a small episode in the
larger story of the ‘‘informationalization’’ of life at the turn of the twentyfirst
century, at the intersection of the burgeoning life sciences industry, a
changing politics of health provision, and rising ethical anxiety in both
secular and religious circles. Given the marginal status of psychiatry within
medicine, and the peripheral position of Argentina in global circuits of
knowledge and commerce, the case raised a number of distinctive issues:
could knowledge of the psyche be assimilated into the new molecular
sciences? What would such an effort mean for the politics of mental health?
And what new position would the process imply for the subject of psychic
distress?”
chapter 1 has been published as:
Diagnostic Liquidity: Mental Illness and the Global Trade in DNA
Author(s): Andrew Lakoff Source: Theory and Society, Vol. 34, No. 1
(Feb., 2005), pp. 63-92
“What is the process for electing an APA president?”
What crony/hack/agenda pusher is due for leader next.
Like how the Republicans work, and politics in general as well.
The APA has an election page,
http://www.psych.org/network/board-of-trustees/apa-national-elections
From the guidelines and such it seems any ‘campaigning’ person can be ‘nominated’ for a particular position. APA members are then expected to vote.
There was a complaint from the 2010 elections,
http://psychnews.psychiatryonline.org/newsarticle.aspx?articleid=1032212
Apparently there was no information at all provided to voters about the candidates running.
So i guess unless you’re particularly fluent with Google and have good investigative skills, there’s no way to tell who the candidates are associated with or what they plan to do.
I’ll bet the number of votes in total is very small — effectively, cronies electing cronies.
Ha! http://www.psych.org/network/board-of-trustees/apa-national-elections has a link to 2013 results. Looks like only about 5,000 psychiatrists voted. Paul Summergrad, M.D. is the new president-elect with 3,304 (62.1%) of the vote.
And there it is, a minority antisocial group keeping the agenda well defined and secure. This is why I write about it, folks. The USA redefined. I will post about it on Sunday, not just limited to psychiatry though.
Along those lines, Jamzo, concepts believed to be true and/or normal in the Western, Educated, Industrial, Rich, and Democratic (WEIRD) societies are the exception, rather than the rule in this world and in human history.
Finally (I feel like I’ve been holding my breath for this realization since 1984), Western anthropologists, the social sciences, and the humanities in WEIRD cultures are starting to catch on. Of course, a lot of sciences more scientific than psychiatry is blinkered by such assumptions as well.
Were leaders in the fields of psychiatric research and clinical research to just catch on to the fact that they think and work from a position of privilege that includes significant bias in favor of white, middle-class, male, educated behavior. and that they appear to be labeling anything contrary to the needs of Harvard and Yale schools of business management and 9 to 5 jobs, it would be a breath of fresh air.
http://www.psmag.com/magazines/pacific-standard-cover-story/joe-henrich-weird-ultimatum-game-shaking-up-psychology-economics-53135/
Conceivably, one could affect the APA elections with a good mailing list to like-minded members who are pledged to vote.
I guess you’d have to find out the candidates first.
Umm, what person who is responsible and appropriate would be a member of an organization that the APA has devolved into these past 15 years?
Besides, the APA has some committee or board that is geared to making sure the candidates, if at least the most influential to nearly guarantee being elected, keep it rigged to sell the message of “the status quo, we need pharma monies”.
What I have been saying for years, who belongs to the APA who has a soul?
No one I respect overall. Because if a member has morals and a conscience with patients, being clueless and ignorant of the usual mechanics to the organization does not give one a free pass to being absolved of accountability. No, if you belong to an organization that supports and practices irresponsibly and without regard to honest and appropriate patient care, then you are guilty of association.
Besides, the APA now stands for the Antisocial Psychiatric Association to me. With the leadership they keep, who needs Attila the Hun as a spokesman!? Yeah, I know, rude and crass. Works for me in attacking the APA of late. Being kind and polite, forget it!
I am warming to you Joel… you may not like Szasz but at least he did raise the issues.. his book ‘Insanity’ is a must read even if you disagree…