Journeying through the history of psychiatry with Jeffrey A Lieberman is not unlike being led by Voltaire’s indomitable optimist, Professor Pangloss, through the seven years’ war and the Lisbon earthquake.
Psychiatry’s past may have been blinded by mesmerists and fast-talking snake-oil sellers. There may have been brutal incarceration of the “mad”, terror, torture by insulin coma, surgery and electricity, and too many Freudian years of rooting around in buried familial sites. But all is now for the best in the best of all possible worlds. The asylums have closed. Chemistry is in. Psychiatry has at last fully joined its fellows in medical departments and attained a sound scientific footing. Psychiatrists can hold their heads high. Evidence-based diagnoses and effective treatments rule, alongside brain and genetic research. You could say there’s never been a better time to qualify for the hundreds of disorders the bestselling DSM (Diagnostic and Statistical Manual of Mental Disorders) describes and get your insurance provider to foot the bill for the latest pharmaceuticals, plus the current chat of choice – cognitive behavioural therapy.
I’d really like to go the distance with Lieberman. He’s a breezy, charming, and genial guide to a field fraught with difficulties. He comes with a host of expert “testimonials”, from Kay Redfield Jamison to Andrew Solomon, and has had 30 years of experience of working with “schizophrenics” and other patients. He is at the pinnacle of his profession – a former president of the American Psychiatric Association, chair of psychiatry at Columbia University, and a member of the committee that oversaw the making of DSM-5 after controversy erupted at its secretive procedures and architects of earlier editions Robert Spitzer and Allen Frances engaged in open criticism. He is, in other words, an insider, with the kind of experience most professional historians cannot claim.
What the book’s author blurb doesn’t note is that, like so many top US psychiatrists, Lieberman has received research grants, honoraria and fees from most of the main pharmaceutical companies. It may thus not be surprising if his take on progress, particularly where the success of the pharmaceutical model of treatment is concerned, is upbeat, and his history inevitably selective. Indeed, this is the first history I’ve read that occasionally sounds like a corporate report, one set to attract new recruits and investors to a burgeoning field that has numbered Nobel winner Eric Kandel for his brilliant work on memory in sea slugs, and Sigmund Freud, though only in his American guise. Lieberman thinks of Freud as the dictatorial, if brilliant, Steve Jobs of his profession, as opposed to the more open Bill Gates.
But then, though the book doesn’t specify, this is quintessentially a story of American psychiatry. The French father of psychiatry, Philippe Pinel, who liberated the mad from their chains, gets a brief look in. So does the late 19th-century German Emil Kraepelin, the important psychiatric observer and classifier who first noted the existence of cyclic illness (what we now call bipolar disorder). No Brit, apart from RD Laing, appears, and indeed the untold story of British or French, let alone Argentinian or Chinese psychiatry, would have a rather different trajectory.
Lieberman’s Freud wears the face American psychiatry gave him. Cool, silent, aloof, this Freud is wholly incorporated into a medical training system that thinks in terms of disease models. Freud, himself a therapeutic pessimist, championed lay analysts, was talkative, preferred cases to systematisation, thought symptoms were less important than underlying conflicts and never considered homosexuality an illness.
Nor is Lieberman’s story an “untold” one. It traces a known movement from asylum to private practice, and from talk to drugs. The pendulum swings between periods when observations and explanations located in mind dominate to those when the focus is on brain structure and chemistry have also been covered more fully elsewhere.
But where Lieberman features as a player, his book has all the interest of a tale of insider knowledge. In one of his best sections, he recounts the battle that ended the status of homosexuality as a mental illness in the US and coincided with the assault from anti-psychiatrists to topple the Freudian-influenced edifice of American practice. He is also good on the takeover of the DSM-III taskforce by Robert Spitzer and its transformation from a slim, vaguely Freudian manual to one ordered around symptom-clusters based on “data” gathered from groups of psychiatrists.
Yet it’s difficult to share Lieberman’s triumphalist certainties. No medical specialisation outside American psychiatry counts it a success to have vastly grown the number of those who suffer from its burgeoning classifications; to have promulgated the taking of regular medication by everyone, including toddlers suffering from a new DSM category of illness that in the past might have been termed “rambunctious childhood”; or to have boosted mood-altering pill-popping to an extent street pushers would consider a bonanza.
The head of America’s National Institute for Mental Heath (NIMH), holder of the world’s largest mental-health research budget, Tom Insel, repudiated DSM-5 on the grounds that even psychiatry’s most supposedly stable diagnoses – schizophrenia and bipolar disorder – contain clusters of symptoms that may stem from any number of biochemical causes, and no one really knows if treatments will work or why. New research, not based on diagnostic classifications in which data masquerades as evidence, but on brain circuitry and genetics, is called for.
Perhaps we haven’t quite arrived at the best of all possible worlds. Pace Pangloss.
Lisa Appignanesi is the author of Mad, Bad and Sad: A History of Women and the Mind Doctors (Virago). Shrinks is published by Virago, £20. To buy for £16, click here
