04/7/17

Souless Psychiatry

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A psychiatric resident at Stanford University School of Medicine wrote an essay on the crisis with psychiatry that appeared in a Scientific American blog. The author said the field was in decline as fewer medical students sought to specialize in psychiatry. He stated psychiatry was looked down upon by nearly every segment of society; and patients avoided treatment because of the stigma related to the field. His solution was to change the name of the field—call it something else.

The crisis, in his view, stems largely from a misunderstanding of what psychiatry is. He said it was “the medical field where doctors incorporate neuroscience and medical research to treat patients with diagnosable mental disorders.” But his friends seem to think he interprets dreams and administers Rorschach tests. Administering Rorschach tests and interpreting dreams are activities associated with psychoanalytic practice that dominated psychiatry up until the 1970s. While “mental health” has made great strides raising awareness (i.e., May is now National Mental Health Awareness Month), “psychiatry has been left behind as its anachronistic forebear.” So he asked, “Would renaming the field help?”

The word psychiatry evokes thoughts of dated medical practices, like Freudian analysis and ice-pick lobotomies. Its sordid history turns away patients, providers, and the public from the progress of mental health care today.

He acknowledged where relabeling could be seen as a Band-Aid. A mere name change ignores the root causes of the problem, which from his perspective is the stigma attached to psychiatry and mental illness. However, citing studies of name changes within the U.S. and other countries, he suggested these language shifts helped psychiatry sound more reputable. He imagined most people would rather have a mental health disorder than a psychiatric disorder, “even if it were the same thing.”

“Mental Health Care” would be a simpler name for the field instead of psychiatry. Psychiatrists would then become “mental health physicians.” Medical centers could create departments of mental health, combining specialties such as internal medicine, psychiatry, psychology and social work. “By uniting these fractured disciplines under one roof, clinicians could provide more comprehensive care to patients without the stigma associated with aging terminology.” Mental health units were said by the author to be far less frightening than psychiatric wards.

In conclusion, he noted how the term psychiatry meant: “healing of the psyche,” drawn from the Greek goddess of the soul—Psyche. “It’s a romantic notion, but we don’t treat patients’ souls. We treat diagnosable diseases of the brain. Perhaps it’s time to rename the field.”

In reading this essay, I was reminded of what psychiatrist Jeffrey Lieberman wrote in his book, Shrinks about psychiatry. He commented that in the 1970s, “the majority of psychiatric institutions were clouded by ideology and dubious science,” mired in a pseudomedical Freudian landscape. But now in the twenty-first century, psychiatry offered scientific, humane and effective treatments. “Psychiatry is finally taking its rightful place in the medical community after a long sojourn in the scientific wilderness.” You can read about the fallacies of “Freudian analysis and ice pick lobotomies” in Shrinks, but you won’t hear the complete and unvarnished truth about psychiatry.

Robert Whitaker astutely commented that Shrinks is more of a story of how psychiatry sees itself as an institution, than it is an accurate history of psychiatry. And I see the same approach here. I wonder if the Stanford psychiatric resident who wrote “Maybe We Should Call Psychiatry Something Else” is simply rehashing the received view of psychiatric history.

If you want a truly unvarnished look at psychiatry, read Whitaker: Mad in America, Anatomy of an Epidemic, and Psychiatry Under the Influence. You can read more about Lieberman and Shrinks on this website. Do a search for “Lieberman.”

The term “psychiatry” was originally coined by Johann Reil—a German physician—in 1808. And it does literally mean the medical treatment of the soul. Another German physician, Johann Heinroth was the first person to hold a chair of psychiatry. He also staked out working with the mentally ill as medical territory. Since there was little or no knowledge within the medical tradition to equip doctors to deal with mental disturbances, he proposed the creation of a new branch of medicine—psychiatry.

In his 1818 Textbook of Mental Disturbances, Heinroth said: “Since we are speaking of medical art and science, we should think that nobody but a doctor should have a right to make mental disturbance the object of his studies and treatment.” In The Myth of Psychotherapy, Thomas Szasz said of this time:

The birth of psychiatry occurs when the study of the human soul is transferred from religion to medicine, when the “cure of souls” becomes the “treatment of mental diseases,” and, most importantly, when the repression of the heretic-madman ceases to be within the jurisdiction of the priest and becomes the province of the psychiatrist.

There have been some radical shifts in how psychiatrists function since the early 1800s. Initially they were administrators of large institutions for the insane. Under Freud’s influence, psychiatrists began to consult with individuals living in society rather than working solely with those within institutions. Then in 1909, Freud was invited to give a series of lectures on psychoanalysis by Stanley Hall, the president of Clark University.

The cover photo for “Maybe We Should Call Psychiatry Something Else” shows seven men from the time of that conference, but only identified Sigmund Freud and Carl Jung. At the time, Jung was still friendly with Freud. The photo credit said the others were “pioneers in psychiatry,” but that is not entirely accurate. The photo shows Sigmund Freud and Carl Jung on either side of Stanley Hall in the front row. In the back row from left to right are Abraham Brill, Ernest Jones and Sandor Ferenczi.

Stanley Hall was a well-known American psychologist in addition to the then president of Clark University. He had an interest in Freud’s psychoanalytic theories and invited him to be part of a “galaxy of intellectual talent” to celebrate the twentieth anniversary of the founding of Clark University. Jung and Ferenczi were invited as the leading European disciples of Freud. Ernest Jones, another protégé of Freud, was then in Toronto Canada, building a private psychoanalytic practice and teaching at the University of Toronto. Jones would later become a biographer of Freud. Brill was the first psychoanalyst to practice in the U.S. and the first translator of Freud into English. In 1911 he founded the New York Psychoanalytic Society.

So these individuals are better seen as pioneers of Freudian psychoanalytic practice —the approach dismissed by the author of  “Maybe We Should Call Psychiatry Something Else” as a dated medical practice, which he placed alongside ice pick lobotomies.

By the 1940s, psychoanalytic theory had not only taken over American psychiatry, it had become part of our cultural psyche. Alfred Hitchcock’s 1945 film, Spellbound is an example of how influential psychoanalytic thinking was. The opening credits of the film announce that it wanted to highlight the virtues of psychoanalysis in banishing mental illness and restoring reason. Look for the Freud look-a-like character as Ingrid Bergman’s psychoanalyst and mentor.

Psychoanalytic thought dominated the field until the 1970s when the birth of biological psychiatry was ushered in by Robert Spitzer and his reformulation of psychiatric diagnosis. After Spitzer was appointed to do the revisions for the 3rd edition of the DSM in 1974, he was able to appoint whomever he wanted to the committees. He made himself the chair of all 25 committees and appointed individuals who he referred to as the “young mavericks” psychiatry. In other words, they weren’t interested in Freudian analysis. Spitzer said: “The feeling was that the same techniques that were useful in medicine, which is you describe something, you do laboratory studies; that those same kind of studies were appropriate for psychiatry.” Except it didn’t happen because in the 1970s, there just wasn’t a lot of psychiatric research. So the decisions of the committees were based on the expertise of the committee members.

David Chaffer was part of the process back then. He said committee members would gather together into a small room. Spitzer would sit with a mid 1970s “portable” computer and raise a provocative question. “And people would shout out their opinions from all sides of the room. And whoever shouted loudest tended to be heard. My own impression was … it was more like a tobacco auction than a sort of conference.” So much for using the same techniques as those used in medicine. Listen to the NPR story, “The Man Behind Psychiatry’s Diagnostic Manual” for the above information on Spitzer and the DSM.

But the real driving force behind the revisions made by Spitzer and others was because a “psychopharmacological revolution” couldn’t begin with the diagnostic process that existed before Spitzer and the DSM-III. Allen Frances, the chair of the next revision, the DSM-IV, acknowledged as much in his comments before the American College of Neuropsychopharmacology in 2000. Frances said the DSM-III was an innovative system that focused on descriptive diagnosis and provided explicit diagnostic criteria. “In many ways this aided, and was aided by, the knowledge derived from psychopharmacology. . . . The diagnostic system and psychopharmacology will continue to mature with one another.”

The psychopharmacological revolution required that there be a method of more systematic and reliable psychiatric diagnosis. This provided the major impetus for the development of the structured assessments and the research diagnostic criteria that were the immediate forerunners of DSM-III. In turn, the availability of well-defined psychiatric diagnoses stimulated the development of specific treatments and increasingly sophisticated psychopharmacological studies.

In the Foreword to his book, The Anatomy of an Epidemic, Robert Whitaker explained how he first wandered into the “minefield” of psychiatry by writing in the mid 1990s about research practices such as rapidly tapering schizophrenic patients off of their antipsychotic medications and then giving them a drug to exacerbate their symptoms. This “research” was done in the name of studying the biology of psychosis. Jeffery Lieberman took part in some of those studies, using methylphenidate (Ritalin, Concerta) to deliberately provoke psychotic symptoms in schizophrenic patients. Read “Psychiatry, Diagnose Thyself! Part 2” for more information on Whitaker’s articles and Lieberman. Incidentally, the series of articles Whitaker co-wrote for the Boston Globe was a finalist for the Pulitzer Prize for Public Service. Whitaker said in the Foreword to Anatomy of an Epidemic:

I began this long intellectual journey as a believer in the conventional wisdom. I believed that psychiatric researchers were discovering drugs that helped “balance” brain chemistry. These medications were like “insulin for diabetes.” I believed that to be true because that is what I had been told by psychiatrists while writing for newspapers. But then I tumbled upon the Harvard study and the WHO findings, and that set me off on an intellectual quest that ultimately grew into this book, The Anatomy of an Epidemic.

Maybe there is a stigma against psychiatry for more than just the past use of ice pick lobotomies or insulin comas or ice baths or the electroshock treatment shown in One Flew Over the Cuckoo’s Nest. But simply changing the name of what we now call psychiatry will not change the opposition against a medical specialty that no longer treats patients’ souls. And perhaps that is really why the field is in decline.

08/12/15

A Censored Story of Psychiatry, Part 1

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© alexskopje | 123rf.com

Doctor Jeffrey Lieberman, the Chair of Psychiatry at the Columbia University College of Physicians and Surgeons and a former president of the American Psychiatric Association (APA), recently wrote a book, Shrinks. It purports to tell the true story of how psychiatry grew from a pseudoscience into “a science-driven profession that saves lives.” But for me, it reads more like a piece of APA propaganda. What follows is an illustration of why I believe Shrinks is not a credible historical account of the history of psychiatry.

In his Introduction, Dr. Lieberman wrote: “As I write this, psychiatry is finally taking its rightful place in the medical community after a long sojourn in the scientific wilderness.” He added that psychiatry has earned much of its “pervasive stigma.”

There’s good reason that so many people will do everything they can to avoid seeing a psychiatrist. I believe that the only way psychiatrists can demonstrate just how far we have hoisted ourselves from the murk is to first own up to our long history of missteps and share the uncensored story of how we overcame our dubious past.

He said that modern psychiatrist now possesses the tools (medications?) to lead anyone “out of a maze of mental chaos into a place of clarity, care and recovery.” He said he is fortunate to be living through the time in history when psychiatry matured from “a psychoanalytic cult of shrinks into a scientific medicine of the brain.” But in concluding his book, he said he was under no illusion that “the specters of psychiatry’s past have vanished,” or that psychiatry has “freed itself from suspicion and scorn.” Notice the implication that any current suspicion or scorn of psychiatry is illegitimate, as its missteps are in the past.

Lieberman is aware that others disagree with his sense how psychiatry has become “a scientific medicine of the brain.” Again in his Introduction, he said: “The profession to which I have dedicated my life remains the most distrusted, feared, and denigrated of all medical specialties.” He then quoted from some of the rude and abusive emails he’s received. His comment was that such skeptics don’t look to psychiatry to help solve mental health problems. Rather, they see psychiatry itself as a mental health problem. While not explicitly using the term at this point, Lieberman does seem to be referring to what he calls the “antipsychiatry” movement.

This is a term that has been applied to individuals critical of some aspect psychiatry, or even psychiatry as an institution, since the 1960s. And Lieberman touched on and dismissed many of the historically big names tied to “antipsychiatry”: Thomas Szasz, R.D. Laing, and David Rosenhan. Here, I want to look at Lieberman’s portrayal of Rosenhan and give you an alternate perspective to his to illustrate why I see Shrinks as APA propaganda.

In an aside, Lieberman seems to have neglected to mention Dr. E. F. Torrey’s 1974 contribution to the antipsychiatry movement, The Death of Psychiatry. Torrey maintained that most of the so-called mentally ill are suffering from problems in social adaptation, not from diseases of the mind. He would later become affiliated with The Stanley Medical Research Institute (SMRI), where he is now an Associate Director. SMRI has spent over $550 million researching “brain diseases” like schizophrenia and bipolar disorder since it began in 1989. It seems Torrey changed his tune. Perhaps that’s why his antipsychiatry work wasn’t mentioned. Lieberman also cited Torrey as providing anecdotal evidence (no references or footnotes) that both Laing and Szasz eventually believed that schizophrenia was a brain disease, but would not sat so publically.

In chapter three of Shrinks, Lieberman described the impact of the classic 1973 study done by David Rosenhan, “Being Sane in Insane Places.” Another copy of the article is available here on a link from Harvard University. Lieberman gave an inaccurate and unfair gloss of Rosenhan as “a little-known Stanford-trained lawyer who had recently obtained a psychology degree but lacked any clinical experience.” As a matter of fact, David Rosenhan had a BA in mathematics from Yeshiva College (1951), an MA in economics (1953) and a PhD in psychology (1958), from Columbia University—the same academic institution to which Lieberman would become affiliated in his own professional career.

In addition, Rosenhan was a psychologist for the Counseling Center at the Stevens Institute of technology from 1954 to 1956; a lecturer at Hunter College and the director of research in the Department of Psychiatry at City Hospital at Elmhurst from 1958 to 1960. He was an assistant professor for the Departments of Psychology and Sociology at Haverford College from 1960 to 1962; a lecturer for the Department of Psychology and Psychiatry at the University of Pennsylvania from 1961 to 1964; a lecturer for the Department of Psychology at Princeton University from 1964 to 1968; a professor in the Department of Psychology and Education at Swarthmore College from 1968 to 1970; and a visiting professor in the Department of Psychology at Stanford University from 1970-1971. He was a professor of law and psychiatry at Stanford from 1971. The above biographical information on David Rosenhan was taken from a February 16, 2012 article from the Stanford Law School News announcing his death at 82 years old.

This information was readily available to anyone interested enough in David Rosenhan to do a simple online search. It certainly doesn’t agree with Lieberman’s dismissal of Rosenhan’s credibility. Here’s what David Rosenhan did in his study. He had eight “pseudopatients” (individuals with no history of serious psychiatric disorders) seek admission to 12 different psychiatric hospitals. They complained of hearing voices say “empty,” “hollow,” and “thump.” They were all admitted to the various hospitals. The eight pseudopatients consisted of a psychology graduate student in his 20s, three psychologists, a pediatrician, a psychiatrist, a painter and a housewife. Rosenhan was one of the three psychologists. Three pseudopatients were women and five were men.

Once admitted to the hospital, they stopped simulating any symptoms of abnormality and waited to see how long it took before they were released. Their length of stay at the hospitals ranged from 7 to 52 days, with an average of 19 days. None of the pseudopatients were indentified as such by hospital staff members. However, it was quite common for the patients to uncover the pseudopatients. Other patients in the hospitals were reported as saying things such as: “You’re not crazy. You’re a journalist, or a professor [referring to the continual notetaking]. You’re checking up on the hospital.” Rosenhan commented: “The fact that the patients often recognized normality when staff did not raises important questions.”

Lieberman said that claim was debatable, “since many nurses did record that the pseudopatients were behaving normally.” Actually, Lieberman’s comment is itself debateable. If nursing staff recognized the pseudopatients as normal, why was the average length of stay 19 days? If nursing staff recorded impressions that particular pseudopatients were behaving normally, it seems their observations were ignored or failed to result in speedy identification and release. Seven of the eight were admitted with diagnoses of schizophrenia and their discharge diagnoses were schizophrenia “in remission.”

What Rosenhan actually said was that the pseudopatients were to secure their own release from the hospital by convincing staff that they were sane. The psychological stressors associated with hospitalization were considerable and as a result, the pseudopatients were motivated to be discharged “almost immediately after being admitted.”

They were, therefore, motivated not only to behave sanely, but to be paragons of cooperation. That their behavior was in no way disruptive is confirmed by nursing reports, which have been obtained on most of the patients. These reports uniformly indicate that the patients were “friendly,” “cooperative,” and “exhibited no abnormal indications.”

Rosenhan’s study and its opening question, “If sanity and insanity exist, how shall we know them?” remains today a powerful question of the legitimacy of psychiatric diagnosis. He noted how most mental health professionals would insist they are sympathetic toward the mentally ill. But it is more likely that “an exquisite ambivalence” characterizes their relationships with psychiatric patients. The mentally ill, said Rosenhan, are society’s current lepers. Negative attitudes are the natural offspring of the labels patients wear.

A psychiatric label has a life and influence of its own. Once the impression has been formed that the patient is schizophrenic, the expectation is that he will continue to be szhizophrenic. When a sufficient amount of time has passed, during which the patient has done nothing bizarre, he is considered to be in remission and available for discharge. But the label endures beyond discharge. . . . Such labels, conferred by mental health professionals, are as influential on the patients as they are on his relatives and friends, and it should not surprise anyone that the diagnosis acts on all of them as a self-fulfilling prophecy.

Psychiatry had a guild interest at the time for revising psychiatric diagnosis. Citing an article by M. Wilson in their book, Psychiatry Under the Influence, Whitaker and Cosgrove noted where APA leaders felt psychiatry was under siege and worried that it could be headed for extinction.

Psychiatry in the 1970s faced a crisis of legitimacy and Rosenhan was one of its opponents who intensified the crisis.  Although the publication of the DSM-III would become an answer to that crisis, Rosenhan’s study threatened to discredit psychiatry before that makeover could be accomplished—to recast psychiatry as “a science-driven profession that saves lives.” The censored history of psychiatry presented by Lieberman attempts to present “an extreme makeover” of a profession that may still be more “pseudo” than science. Whitaker and Cosgrove’s comment seems to hit the mark:

Remaking psychiatric diagnoses could be part of a larger effort by psychiatry to put forth a new image, which metaphorically speaking, would emphasize that psychiatrists were doctors, and that they treat real ‘diseases.’

05/28/14

If God Spoke to You, Would You Tell Your Psychiatrist?

As a young Christian, I remember being anxious as an agency treatment team meeting approached. A young woman I counseled reported strange things began happening to her soon after she started to read a Bible. Although her experiences seemed to have a spiritual aspect, they were also borderline delusional. And I had suggested that she read her Bible.

The thought crossed my mind to not say anything at the treatment team meeting. But I reported the woman’s experiences and my suggestion that she read her Bible. I said I did not think she was becoming psychotic, gave my opinion why, and held my breath. After a slight pause, the psychiatrist said to let him know if her condition deteriorated. The woman continued to read the Bible; the strange experiences stopped; and she eventually went to YWAM (Youth With a Mission) for a short time.

Beginning with Sigmund Freud, psychiatrists have been less religious than the general population; and sometimes even anti-religious. Freud himself was a life-long atheist and critic of religion. He said religion was a “universal obsessional neurosis.”

In 1928 Freud published a short paper entitled: “A Religious Experience.” There he psychoanalyzed an American physician who had attempted to convert him. The American doctor wrote of a time when he himself questioned whether or not God existed, and heard an internal voice say: “ I should consider the step I was about to take.” This was a religious turning point for the doctor. He said knew then that Jesus was his only hope; and that the Bible was God’s Word.

Freud wrote that he was glad the experience enabled the man to retain his faith, but that God had never allowed him to hear an inner voice. He commented that if God did not hurry, it would not be Freud’s fault if he remained “an infidel Jew.”

The American doctor wrote back that being a Jew was not an obstacle to true faith. Prayers were being “earnestly addressed” that Freud be granted faith to believe. He begged Freud to give thought to the matter of life and death. After describing this exchange in his paper, Freud said: “I am still awaiting the outcome of this intercession.”

Freud then gave an “obvious” analytical explanation of the doctor’s religious experience. “All of this is so simple and straightforward that we cannot but ask ourselves whether by understanding this case we have thrown any light at all on the psychology of conversion in general.”

By the 1970s, internal changes began in psychiatry that largely threw over the influence of psychoanalysis on the field. Research studies began to demonstrate that religion has many psychological benefits. But psychiatrists continued to be less religious than other physicians.

In 2007, a study published in the journal Psychiatric Services found that psychiatrists were less religious than other physicians. Psychiatrists were less likely to believe in God than other physicians (65% versus 77%). And they were less likely to say they looked to God for strength, support and guidance (36% versus 49%).  See the original study here.

Not all psychiatrists, even those who don’t believe in God, would view an individual who said God spoke to them as delusional or psychotic. But there is a risk that what the person sees as a purely religious experience will be interpreted as a symptom of schizophrenia or a delusional disorder.

So should Christians who believe that God actually spoke to them tell their psychiatrist of that experience?