By JULIA M. KLEIN
Is psychiatry mostly art, science, or hocus-pocus? The short answer: It depends on whom you ask, what condition you’re looking to treat — and what time frame you have in mind.
The debate two years ago over the DSM-5, the latest iteration of the manual guiding psychiatric diagnosis, treatment, and insurance reimbursement, suggested that our disease categories remain at least partly social constructions. They are, according to Irvin D. Yalom, “invented and arbitrary . . . a product of committee vote.” In his latest collection of tales from the couch, “Creatures of a Day,” Yalom argues that no manual can classify “the complexities and unpredictability of human thought and behavior.”
Jeffrey A. Lieberman, a former president of the American Psychiatric Association who chairs the psychiatry department at Columbia University College of Physicians and Surgeons, espouses a different view, lauding the DSM-5 as a victory for empiricism and psychiatric pluralism. “Shrinks,” his lucid popular history, is at once skeptical and triumphalist. It shows just how far psychiatry has come from its reliance on dungeon-like asylums, crude treatments such as frontal lobotomy and insulin coma therapy — and even psychoanalysis.
For Lieberman, talk therapy — especially scientifically-validated modalities such as Aaron Beck’s cognitive-behavioral therapy — retains a role: Psychiatry, he writes, must “embrace the mind and the brain simultaneously” and “touch upon fundamental questions about our identity, purpose, and potential.” But promising research at the frontiers of neuroscience, biological medicine, and genetics clearly excites him more.
Yalom, an emeritus professor of psychiatry at Stanford University, is more old-school: He cares about dreams, free association, and the therapeutic relationship. For him, psychiatry is an art and an existential inquiry more than a science. (One of his mentors was the existential psychologist Rollo May.) “Creatures of a Day” is a series of moving, if partly fictionalized, tales illuminating Yalom’s hand-crafted approach to treating grief, loss, regret and, above all, encroaching mortality.
Storytelling is, in fact, key to both books. It seems a stretch, though, to claim that “Shrinks” (which, like “Creatures,” uses composite characters and invented details) relates an “untold story.” Much of its account of psychiatry’s past — “with all its rogues and charlatans, its queasy treatments and ludicrous theories” — is familiar, if only from Hollywood images of the “snake pit” and the analyst’s couch.
“Shrinks” is organized, somewhat artificially, into three sections: “The Story of Diagnosis,” “The Story of Treatment,” and “Psychiatry Reborn.” Its introduction, about a schizophrenic patient whose parents kept her from doctors, telegraphs Lieberman’s passion: to destigmatize mental illness and help sufferers access effective treatments. “Her dramatic improvement,” he writes of this patient, “was a testament to the power of modern psychiatry.”
Yet, as recently as the 1970s, he notes, “the majority of psychiatric institutions were clouded by ideology and dubious science.” Lieberman critiques Wilhelm Reich’s discredited theory of “orgones” (supposedly a hidden form of energy), Franz Mesmer’s animal magnetism, Walter Freeman’s frontal lobotomies, Melanie Klein’s “sexual orientation conversion therapy,” and R.D. Laing’s “existential psychiatry.”
For Lieberman, Freud “stands in a class of his own, simultaneously psychiatry’s greatest hero and its most calamitous rogue.” His theories, says Lieberman, embody both “prescient insights” and “missteps, oversights, and outright howlers.” Lieberman regards psychoanalytic approaches to serious illnesses such as bipolar disorder and schizophrenia as particularly disastrous.
On the other hand, he admires Emil Kraepelin, who pioneered the modern classification of mental illness, and Robert Spitzer, who helped refine it with his oversight of the empirically-based DSM-III. Lieberman also celebrates the introduction of the first targeted psychoactive drugs (chlorpromazine for schizophrenia, imipramine for depression, and lithium for bipolar disorder) and looks forward to new advances in personalized psychiatric medicine. Quoting Winston Churchill, he declares psychiatry to have finally reached “the end of the beginning.”
Yalom’s stance is far more tentative. Still working in his 80s, he is a student of the human condition whose literary, as well as therapeutic, voice mixes wonder and humility. His book’s title (and its epigraph) is drawn from the Roman emperor Marcus Aurelius’s “Meditations”: “All of us are creatures of a day . . . Always reflect that soon you will be no one, and nowhere.”
Yalom’s part-time practice tends to draw older patients who often ask only for a session or two: an elderly man with writer’s block, a retired Russian ballerina lamenting a lost love, a doctor grieving his dead brother, a former CEO unable to adjust to a retirement home, two women wrestling with fatal illnesses.
Instead of grand theories, Yalom offers kindness, understanding, self-criticism, and occasional truisms. One patient recalls his smart advice to “give up the hope for a better past.” He tells another: “It’s always more painful to think of death when you sense you haven’t lived fully.”
He often works intuitively, improvising. “[I]f I can create a genuine and caring environment, my patients will find the help they need,” he writes, “often in marvelous ways I could never have predicted or even imagined.” It is unexpectedly poignant to eavesdrop on their modest epiphanies.