Jeffrey Lieberman is angry with the New York Times. The eminent psychiatrist (until recently president of American psychiatry’s professional body the APA) last week fired off an astonishing broadside against the newspaper, accusing it of “journalistic opportunism” and perpetuating stigma. Lieberman went so far as to suggest that the paper has got it in for psychiatry in general, but his wrath was specifically in response to an op-ed by anthropologist T.M. Luhrmann.
Lurhmann is part of a growing group of mental health academics who view the categories of psychiatry (schizophrenia, bipolar, depression) as dubious. She was promoting a report released last November by the British Psychological Society “Understanding Psychosis“, which argues that “professionals should not insist that people agree with the view that experiences are symptoms of an illness”. Some of its contributors have personal experience. One of them, Dr. Eleanor Longden has spoken movingly of how unhelpful it was for her to be told she had schizophrenia. Such categories are a little shaky; defined by behavioural observations rather than a clear cut test. This means they can sometimes be applied to people who might have been better off not thinking of themselves as having a disorder.
So what’s Lieberman’s beef? He claims the report fails to take psychiatry’s subject matter sufficiently seriously, and that giving patients a choice about whether they view their problems as an illness is “preposterous”. Such “phenomenologic relativism”, Lieberman argues, could give patients “licence to doubt” they have a disorder, leading to unnecessary termination of helpful treatments. For Lieberman, critiques like Luhrmann’s are “useless and confusing at best and destructive at worst”.
Who is right? In fact both these writers are caught in a debate that psychiatry cannot seem to effectively resolve. We need to acknowledge the truth on both sides in order to move forward.
Critics have long argued correctly that psychiatry cannot afford to take its constructs too seriously. There is much evidence that psychiatry’s system of labelling is not performing as well as the profession would like. When the DSM 5 was in the final stages of preparation, it quickly became clear that many of the disorders it describes were not possible to apply reliably enough.
And this is only part of the problem. I could create criteria for reliably identifying any “disorder” I cared to cook up, but that would not make it real. Diagnoses need to be “valid” too, meaning they should refer to a discrete entity “out there” in reality. Psychiatrists know this, and work is ongoing on a new classification system, the RDoC, which it is hoped will define psychiatric problems in terms of disrupted neural circuitry rather than problematic behaviour.
Lieberman mentions the RDoC (an “aspirational goal for how diagnoses may be defined in…the distant future”) but still says the DSM is still “the gold standard of what needs to be used”. This looks a little like having one’s cake and eating it. If the DSM were really a “gold standard”, why go to all the bother of replacing it? The truth is that the DSM is at best an approximation of reality. The question of how good an approximation is where the controversy lies.
Nonetheless, it is a mistake to allow, as the BPS’s report does, that none of the problems treated by psychiatrists could be illnesses in the straightforward sense of the word. Luhrmann points out that human experiences lie on a continuum (psychoanalyst Donald Winnicott once said “we are poor indeed if we are only sane”), but this is also true for many physical illnesses.
British Journalist Clare Allan’s response to the BPS report suggested that psychosis may be a “rational response” to abuse. This reasoning implies psychosis could be something people choose, when it in fact often overwhelms them in dramatic and frightening ways. Many people want to be rid of the terror of psychosis as soon as they can, and despite problematic side effects, drugs remain the most dramatic treatment (albeit a treatment people should be allowed to refuse). We do have a choice about whether we label these phenomena “illnesses”, but it won’t always make much difference.
Psychiatry has been lumbered with this debate for almost as long as it has existed. Doctors like Lieberman are getting tired. “Psychiatry has the dubious distinction of being the only medical specialty with an anti-movement” he complains. The profession also has the dubious distinction of policing the boundary between deviance and illness, and this makes it a field we should never stop examining for signs of mission creep. However, in maintaining this critical perspective we should also not lose sight of the fact that when our minds come apart, it can be as powerful and debilitating as any illness.