Has there ever been a medical specialty as beleaguered as psychiatry? Since the profession’s founding in 1844, the doctors of the soul have had to contend with suspicions that they do not know what mental illness is, what type their patients might have, or what they should do about it—in other words, that they are doctors who do not practice real medicine. Some of the worry comes from the psychiatrists themselves, such as Pliny Earle, who in 1886 complained that “in the present state of our knowledge, no classification of insanity can be erected upon a pathological basis.” In 1917, psychiatrist Thomas Salmon lamented that the classification of diseases was still “chaotic”—a “condition of affairs [that] discredits the science of psychiatry and reflects unfavorably upon our association,” and that left the profession unable to meet “the scientific demands of the present day.” In 1973, the American Psychiatric Association voted to declare that homosexuality was no longer a mental illness, a determination that, however just, couldn’t possibly be construed as scientific. And for the six years leading up to the 2013 release of the fifth edition of its diagnostic manual, the DSM-5, the APA debated loudly and in public such questions as whether Asperger’s disorder were a distinct mental illness and if people still upset two weeks after the death of a loved one could be diagnosed with major depression. (The official conclusions, respectively: no and yes.)
To the diagnostic chaos was added the spectacle of treatments. Psychiatrists superintended horrifyingly squalid asylums; used insulin and electricity to send patients into comas and convulsions; inoculated them with tuberculin and malaria in the hope that fever would cook the mental illness out of them; jammed ice picks into their brains to sever their frontal lobes; placed them in orgone boxes to bathe in the orgasmic energy of the universe; psychoanalyzed them interminably; primal-screamed them and rebirthed them and nursed their inner children; and subjected them to medications of unknown mechanism and unanticipated side effects, most recently the antidepressant drugs that we love to hate and hate to love and that, either way, are a daily staple for 11 percent of adults in America.
It’s not just diagnostic uncertainty or therapeutic disasters that cast suspicion on the profession. It’s also the bred-in-the-bone American conviction that no one should tell us who we are. For that is what psychiatrists (and the rest of us in the mental-health professions) do, no matter whether we want to or not. To say you know what mental health and illness are is to say you know how life should go, and what we should do when it goes otherwise. You’d better know what to do when you’ve made a grievous error in those weighty matters, or at the very least, how to ask for forgiveness. And you’d better hope that, apologies offered, you can give the public a reason to believe that at long last you know what you are doing.
This is the unenviable task that Jeffrey Lieberman, past president of the APA, chairman of psychiatry at Columbia University’s medical school, chief of psychiatry at its hospital, and director of the New York State Psychiatric Institute, has taken on in his book Shrinks: The Untold Story of Psychiatry. “Psychiatry has earned its stigma,” he writes at the outset, and its practitioners must “own up to our long history of mistakes.” Otherwise it will remain “the black sheep of the medical family, scorned by physicians and patients alike.”
In Lieberman’s history, most of the profession’s travails can be traced to the mischief caused by one man: the Viennese neurologist who, on arriving for his first (and only) visit to America, said, “They don’t realize that we are bringing them the plague.” That at any rate is what, according to legend, Sigmund Freud said to Carl Jung as their ship pulled into New York harbor in 1909. Lieberman agrees wholeheartedly that Freud unleashed a plague. The pathogen was not, Lieberman says, the self-doubt and pessimism for which Freud is justly famous, but his autocratic approach to his patients and his insistence that his disciples remain in lockstep. Worst of all, says Lieberman, Freud “blurred the boundary between mental illness and mental health” by maintaining that conflict among the various agencies of the mind, set off by early childhood experience, was unavoidable.
In the early twentieth century, according to Lieberman, the members of the APA weren’t interested in Freud. American psychoanalysts, however, were interested in the APA. The analysts’ campaign for recognition eventually succeeded. Lieberman argues that this was largely because psychoanalysis offered psychiatrists “a way out of the asylum” and into cushy private practices ministering to the well-heeled “worried well.” Having convinced doctors (and patients) that we were all at least a little neurotic, Freud had opened the way to travesties like the pathologizing of homosexuality and endless and ineffective stays on the analytical couch.
For three decades or so, the “psychoanalytic hegemony” persisted without much challenge. By 1960, Lieberman says, “almost every major psychiatry position in the country was occupied by a psychoanalyst.” The Freudian lingo had entered the American vernacular, and with it the idea of universal neurosis and need for treatment. In the late 1940s, Harry Truman created the National Institute of Mental Health, an agency that, “in the psychoanalytic spirit of social activism,” advocated trying to improve society in order to eradicate mental illness. Psychiatrists “didn’t just want to save your soul,” Lieberman writes. “They wanted to save the world.”
Lieberman thinks this ambition was pure hubris, especially when coupled with Freud’s unscientific notions about the psyche, and that it was only a matter of time before psychiatry got its comeuppance. The troubles began in 1961, when the renegade psychiatrist Thomas Szasz argued, in The Myth of Mental Illness, that he and his colleagues weren’t treating medical illnesses but merely “problems in living.” The book was a best seller and gave birth to an “organized activist movement” that Lieberman calls “anti-psychiatry,” which includes the Church of Scientology and is dedicated to the destruction of the profession. (I was surprised to see Lieberman count me among these activists. While I have written a number of books and articles critical of psychiatry, I have never called for its elimination, nor denied the reality of mental illness, nor participated in any of the activities of the groups he identifies.) Antipsychiatrists, bolstered by academics like Erving Goffman and rogues like R. D. Laing, helped to convince the American public that mental illness was only deviance labeled as disease by powerful psychiatrists.
About a decade after Szasz dropped his bomb, and as if to prove his point, a Stanford psychology professor, David Rosenhan, sent eight people to emergency rooms around the country to complain that they were hearing the words thud, empty, and hollow. All but one were diagnosed with schizophrenia (the eighth was diagnosed as manic-depressive) and, despite acting normally once they got admitted, were hospitalized for as long as fifty-two days. When the respected journal Science ran Rosenhan’s version of the story under the title “On Being Sane in Insane Places,” it touched off a sensation. The homosexuality debacle, highly publicized, followed shortly after. “Our profession has been brought to the edge of extinction,” the APA declared in a frantic missive to its membership. The problem was not inherent in the attempt to medicalize psychic suffering, the organization decided, but in the means psychiatrists had used to do so. Psychoanalysis, with its “fundamentally incorrect understanding of mental illness,” had led psychiatry to the brink. To save it, psychiatrists had to toss Freud off the cliff.
Aided by a new generation of practitioners disenchanted with Freudian orthodoxy, the APA doubled down on its claim of practicing real medicine by bypassing the question of what caused mental illness in favor of looking only at the way it showed up in people’s behavior. Grouping symptoms into categories, it developed a diagnostic manual, the DSM-III, in which depression, for instance, defined under the Freudian regime as “an excessive reaction . . . due to an internal conflict or to an identifiable event,” became a disorder characterized by the presence of at least five of nine criteria, ranging from sad mood to insomnia to indecisiveness. While some psychiatrists grumbled that “clerks rather than experts can make this kind of classification,” most were ready to sign on to the new, more scientific diagnostic paradigm. The DSM-III extended “a lifeline to the entire field, a chance to restore psychiatry’s battered reputation,” says Lieberman, and it went on to become “one of the most influential books written in the past century.”
This triumph accompanied another: the ascent of neuroscience and the discovery of psychiatric drugs. As Lieberman acknowledges, these developments occurred in the opposite order: The drugs were discovered accidentally, mostly in the 1950s and ’60s, and neuroscientists have been trying since then to figure out how they work. But the upshot, at least in Lieberman’s view, is an unmitigated success. Armed with drugs that “targeted the symptoms of mental illness in a kind of lock-and-key relationship,” psychiatrists have become “empathic prescribers of medications targeting specific illnesses.”
Not that all the answers lie in biology, Lieberman cautions, and attention to the brain won’t “replace the psychodynamic element that is inherent to existential disease.” But psychodynamics are not what they were in the Freudian era. The slippery unconscious has been replaced by schemata, the rules that guide cognition and feeling like computer algorithms, and interminable psychoanalysis has been replaced by short-term therapies aimed at reprogramming our cognitive software. Psychiatry has finally “matured from a psychoanalytic cult of shrinks into a scientific medicine of the brain.”
I may be critical of psychiatry, but as a clinician, I would be thrilled if the portrait Lieberman paints of the mental health field bore a closer resemblance to reality. If a scientific medicine of the brain were truly available, I’d be glad to avail myself of it. At the very least, I’d be relieved not to worry that every time I sent a patient to a psychiatrist, she might return with a fistful of prescriptions, little idea of how the drugs work (for no one really knows) or what side effects she may suffer, and no guarantee that she will get better. Lieberman’s apologetics suffer from his cheerleading, from a tendency to gloss over history that would perhaps suggest a less sanguine conclusion than his.
The most ironic, if not the most important, elision occurs in his account of the psychoanalytic takeover of American psychiatry, on which he pins so much of the blame for his profession’s ordeals. In fact, psychoanalysts did not storm the gates of the APA. Rather, what happened was that, starting in the mid-1920s, the New York Psychoanalytic Society, seeking legitimacy, campaigned to limit the practice of psychoanalysis to medical doctors—a move that Freud, who had trained and sanctioned many nonphysician analysts, bitterly opposed. Medical education, he said, “burdens [an analyst] with too much . . . of which he can never make use.” Subject to the “temptation to flirt with endocrinology and the autonomic nervous system,” doctors would turn psychoanalysis into a “specialized branch of medicine”—one that offered quick cures rather than Freud’s infamous promise to transmute “neurotic misery into common unhappiness.” It is at least arguable that the disasters Lieberman narrates are the result not of psychoanalysts taking over the APA but of doctors (primarily psychiatrists) appropriating psychoanalysis. As Freud would have been the first to point out, we should not be surprised when a past in which mental suffering is medicalized leads to a present in which psychiatrists face scorn for failing to cure that which they have called a disease.
But it’s not just the distant past that Lieberman leaves unrecounted. He minimizes or entirely overlooks such unsavory recent chapters as the widespread diagnosis, against the criteria of the DSM, of bipolar disorder in the very young and their subsequent treatment with powerful (and untested in children) antipsychotic drugs—an episode that occasioned Senate hearings and front-page exposés. He never acknowledges that the “serotonin imbalance” that antidepressants supposedly rectify does not exist—or if it does, it has yet to be discovered—and his lock-and-key image belies the much less certain clinical reality, in which antidepressants are routinely prescribed for anxiety disorders, antipsychotics for mood disorders, and anti-anxiety drugs for a wide range of complaints—and all on a trial-and-error basis. He fails to mention that no new psychiatric medications have been discovered in the past quarter century, or that none of the newer ones have proved more effective than the drugs discovered in the 1950s (although some of them do have fewer side effects). And he vastly overestimates the current state of neuroscience, which is only beginning to unravel the mysteries of how the billions of neurons and trillions of connections among them turn into consciousness.
Perhaps most glaringly, he speeds by the rift that opened when, on the eve of the DSM-5’s release, NIMH director Tom Insel publicly repudiated it—not, as Lieberman implies, out of some wish to impose the agency’s biological orientation on psychiatric diagnosis, but rather because neuroscientific discoveries have made it clear that even the most stable DSM diagnoses, like schizophrenia and bipolar disorder, are collections of symptoms that may stem from any number of biochemical causes, and are not discrete diseases. Nor, despite his claim to have quickly achieved a rapprochement with Insel, does he address his underlying point: that, as Insel once told me, “whatever we’ve been doing for five decades, it ain’t working. . . .We don’t know which treatments are working for which people. Maybe we just need to rethink this whole approach.”
That’s not what Lieberman has done in Shrinks. Psychiatry, in his view, isn’t in need of rethinking, or at least it hasn’t been since it dumped its Freudian baggage. What it needs now is only better public relations. His book is an attempt to let the world know that the bad old days are over, that the profession has transcended its past and entered a “pluralistic” era in which doctors use “the latest techniques of neuroscience and the latest psychodynamic theories of mental function.” This anodyne summary discounts the possibility that we will never know how brain produces mind, that indeed the two realms are incommensurable, and it overlooks the continued unsatisfactory performance of even these latest techniques. Lieberman wants us to think that the story of psychiatry’s progress is one we have never heard, but it’s not nearly so untold as he would have us believe. It’s the story that every defender of tradition likes to tell, the one in which we are on a march, led by quiet heroes like him, from the slime to the light, a parade whose leaders we disregard or overthrow only at risk of losing our way entirely.
This is perhaps how Lieberman differs most from Freud, who insisted that the past cannot be escaped but merely reckoned with, and only by a mind which is itself a product of that history. Lieberman wants to acknowledge yesterday’s errors, but he doesn’t want to understand how they shape us. Instead, he takes us on a whirlwind tour and then directs our gaze to a future in which the long-promised golden age can’t help but come to pass. For Freud, the past is prologue. For Lieberman, it is merely backdrop.
Gary Greenberg is a psychotherapist, a contributing editor of Harper’s Magazine, and the author of The Book of Woe: The DSM and the Unmaking of Psychiatry (Blue Rider, 2013).