Reviewed by Victoria
I read two reviews of this book before starting to write my own: the first from a UK newspaper that said the book was a fun and engaging trot through the history of psychiatry that stood in danger of sounding like a recruitment drive for the profession, such was its partisan triumphalism and side-stepping of psychiatry’s continued lack of properly reliable solutions; the second was from a US newspaper that hailed the book as a vital setting-straight of a record ruined by that damned Freud and his talking cure, a cure that helped no one and was torture to all who had to undergo it. There was half a sentence on the end that admitted the drugs don’t always work. I’m not sure if this is a national divide in perspective (it may be – the Americans with whom I’ve talked about therapy have been wholly against it), and if it is, then my bet is it’s caused at least in part by the cruel realities of American medical insurance. But for me the most interesting part of the great debate around mental illness is the virulence of the conflict between those who vote for the brain and those who vote for the mind as the key point of intervention. It’s almost as if there’s an awful lot unconsciously at stake in how we understand our most essential source of being-in-the-world.
But let’s talk about Lieberman first, who does indeed write a very jaunty and fun guide to the basic history of psychiatry, earning brownie points in the early sections for his ready apologies for the sins of his profession. This is a very American-centric view of psychiatric history, but then the author was former president of the American Psychiatric Association; understandable but it makes for a partial history in places. Psychiatry began in America with the ‘alienists’, or those who were nominally in charge of the pretty horrible asylums into which the terminally mad were shoehorned. No one was having a good time in them, thanks to overcrowded and inhumane conditions and the violently aggressive, shouty and filthy people who would never get well. For these reasons, Lieberman argues, any method that might bring some relief to the sufferers was embraced, be it inducing malaria in the schizophrenics for a ‘fever cure’, knocking them out cold for a ‘coma cure’ or drilling into their skulls for a frontal lobotomy.
During the 1930s, as World War Two neared and persecution of the Jews steadily increased, a whole tribe of psychoanalysts crossed the Atlantic in search of safety, bringing the Freudian talking cure with them. And now, it caught on in a big way, though, Lieberman argues, mostly with the ‘worried well’. Lieberman starts out perfectly fair towards Freud, admitting that many of his theories remain the best we have and use about behaviour, but pointing out that Freud’s big mistake was to have an over-controlling management style and to resist any insubordination, which is to say, ideas that came from other people. This is definitely true. However, things get perplexing in the sections of the book that deal with the mid-20th century. Psychoanalysts got a bit too big for their boots in America and decided they could treat schizophrenia, manic-depression and homosexuality, states that Freud completely ruled out as open to psychoanalytic intervention, and in the case of homosexuality, not an illness at all. But they are still called the ‘Freudian psychoanalysts’ by Lieberman and blamed for holding science back. There’s a lot of notable hostility here, which strikes me as a tad unfair, when psychiatrists were still inserting ice picks under people’s eyelids as a good, cheap cure, and psychoanalysts were essentially holding down the fort.
Anyway, things did finally perk up with the extremely lucky discovery of effective drugs for the ‘flagship’ illnesses of schizophrenia, anxiety and depression. In each case the story of the discovery is fascinating and sort of alarming – the scientists concerned all followed ‘hunches’ with absolutely no reason to do so other than inner conviction. Not quite the data-based dream that this book upholds as the essence of psychiatry but never mind. The spirit of a new scientific approach to mental illness was taking hold, and the DSM, the American bible of mental illness, created new ways of defining various disorders – by symptom and duration of illness rather than the previous wishy-washy descriptions. And then, psychiatry was coming along in leaps and bounds as PET scans and fMRI technology allowed insight into the brain’s workings, and genetics suggested another way of understanding why some people got ill. Liebermann’s enthusiasm for these new developments and his love of psychiatry really shine through these sections and you can’t help feeling a little inspired, even though it does make him rather partisan.
Not a hint in any of this section that the anti-anxiety meds wear off, only a third of depressives will benefit from the drugs, and that lithium has terrible side effects when taken long-term for schizophrenia or other manic states. And not much said about the fact that both brain scans and genetics are fascinating areas of research that are still in their infancy and have produced few usable insights. Lieberman’s enthusiasm carries him to the point of claiming that it’s brain imaging that gave us a solution to trauma by showing how memory functions differently in traumatic circumstances. This spoiled an otherwise excellent section for me, as therapist Bessel van der Kolk was working with the difference between trauma memory and ordinary ‘narrative’ memory in patients back in the 1980s. And finally, whilst we may indeed have these incredible scientific resources being developed in our research hospitals, how many ordinary people benefit from them? How many non-rich people reap the rewards of the top level of research?
The last two chapters of the book were extremely important ones, I felt. In the penultimate chapter, Lieberman argues for a pluralistic approach to mental illness – one that combines science with talk therapy to get the best results and avoid professional hubris. And in the final chapter he argues powerfully and persuasively that the real problem remaining around mental illness is the stigma. Despite modern technology’s hard evidence that mental illness is an illness, it still provokes the reactions of contempt, fear and shame in the populace at large. Stigma dissolves, he argues, when we have a medical understanding of illness and a medical cure. Which I found a very interesting insight as I hadn’t thought of it that way before. And it brings me back to the original conflict between those who would treat the brain and those who would soothe the mind. If we must insist on mental health problems as being all about illness, in order if nothing else to shut up the judgers and the doubters, then we forgo the essential developmental benefits that therapy has to offer. Because minds don’t just need to be fixed, they very much need to grow and develop, particularly in a life that holds constant and often cruel challenges.
Victoria is one of the editors of Shiny New Books.
Jeffrey A. Lieberman with Ogi Ogas, Shrinks; The Untold Story of Psychiatry (Weidenfeld & Nicholson, 2016). 978-1780227016, 352 pp., paperback.
BUY Shrinks from the Book Depository.