Today I read Psychiatric News, the newspaper of the American Psychiatric Association, and I was drawn to an article about the new APA President, Jeffrey Lieberman, because the front page teaser announced that “he is ‘mad as hell’”.What, I wondered, is he so mad about?
In the article, which reports on Dr. Lieberman’s address at the opening session of the annual APA meeting in May, we learn that he is angry not only about “stigma associated with mental illness” but also “the lack of respect toward psychiatry as a medical specialty”.
“I suppose there might have been a time when psychiatry wasn’t as scientifically based as it should have been”, he said, “But that was then and this is now.” He goes on to bemoan the pharmaceutical industry’s abandonment of the field and the critiques of the DSM by “self-styled critics and the anti-psychiatry movement.”But Dr. Lieberman finds hope for the profession. He states, “The emergence of psychopharmacology, neuroimaging, molecular genetics and biology, and the disciplines of neuroscience and cognitive psychology have launched us into the mainstream of medicine.”
Dr. Lieberman, I am also angry. The reference to the 1976 movie “Network” is, oddly, something I often think about when I am writing these blogs. It is the feeling that drives me to stay up late at night writing. My recollection is that the famous rant in that movie was in part directed at an industry that pursued profit above all else. Dr. Lieberman may label me a self-styled critic or an anti-psychiatrist – whatever those terms might mean – but I remain resolute in my belief that we can not move forward until we acknowledge the role psychiatrists, including leading academic psychiatrists, have played in distorting the evidence base that we so proudly promote.
“The emergence of psychopharmacology, neuroimaging, molecular genetics and biology, and the disciplines of neuroscience and cognitive psychology have launched us into the mainstream of medicine.”
Ironically, on the very next page, there is a story about Patrick Bracken’s talk about psychiatry’s need to develop a new paradigm. This talk was based upon the article, “Psychiatry Beyond the Current Paradigm” written by Dr. Bracken and colleagues and published in the British Journal of Psychiatry. Dr. Bracken is critical of the field’s focus on what he calls a technological paradigm. He states, “Psychiatry faced three great quests over the past 30 years – the quest for valid classification systems, the quest for biological and psychological causal pathways in mental illness, and the quest for technological treatments used independently of context – and all are falling apart in front of our eyes.” Despite all of our advances in research, “What matters is the quality of the relationship between the patient and the therapist, whether the patient feels respected, and whether the encounter is meaningful.” In the article, Bracken and colleagues point out that rather than using our aspirations towards a technological paradigm to garner the respect of our medical colleagues, we can use our profound understanding that treatments are context dependent to lead the way in medicine.
After reading these articles, I went to one of my favorite bloggers, 1boringoldman, who coincidentally had just written about the Bracken article. Dr. Mickey Nardo, a retired psychiatrist and the author of that blog, is such an articulate and wise man that I am hesitant to paraphrase but here goes. He wrote about the arc of his career – how he veered from the intended pursuit of basic science towards the practice of internal medicine to psychiatry – a field that he thought had the hope of combining humanism with science in a way that could be of great help to others. Having read his posts for some time, I have no doubt that he achieved this goal. He was more wistful than jubilant as he realized that what was being described as the future of psychiatry in the Bracken article was the career he had started about 40 years ago.
It is a central conceit of modern medicine that our intellect will allow us to rise above conflicts of interest and allow us to use our scientific principles to see the fundamental truths. Giving talks for drug companies, serving on advisory boards of pharmaceutical companies, earning a considerable share of our incomes from these companies, we tell ourselves, will not taint us as long as we are true to science. Dr. Nardo, Dr. Marcia Angel, another of my heroes, and so many others have demonstrated by their diligent investigation, that this is not true. Are the current leaders of my field really this naive?
I spend a lot of my time talking to people who see things in their world that others do not see. Such views are often considered mad. I guess my experience – seeing something that seems so obvious to me and yet is ignored by others – is classified as anger rather than madness because I am clearly far from alone in recognizing it but, at the same time, I do not understand why it is not more obvious to all.