By MATTHEW HUTSON
In May, protesters plan to demonstrate outside the annual meeting of the American Psychiatric Association (APA) — as they’ve done for the past 47 years. They’ll hold signs saying things like “The mental illness industry is a danger to society” and “Don’t mess with my brain.” Half of all Americans will experience mental illness at some point — nearly a fifth in any one year. And yet many will never seek treatment, based in part on a fear or misunderstanding of psychiatry. As a result, people will suffer, sometimes die, and occasionally take others with them. At the APA, it’s the protesters who appear to be the larger danger to society.
Perhaps I’m biased, since without psychiatry I might not be alive. As a teenager my depression nearly got the upper hand before I was saved by drugs — a one-two punch of tricyclic antidepressants and tryptamine psychedelics — and I continue to find better living through chemistry. But I confront a nagging question: Which is the real me, the more content one on drugs or the less content one off them? Such existential queries — whether a disease is inherent or a treatment artificial — haunt me daily as my meds rise and fall in my bloodstream.
But I’ve learned that those questions are not particularly helpful. What matters is not “Which is the real me?” but rather “Which me do I prefer?” Modern psychiatry cuts through philosophy and offers tools for improving one’s daily functioning. If you want to be a certain way, it can help you get there. No blaming and no handwringing.
Yet the profession inspires fears that aren’t completely baseless. Not long ago, psychiatrists weren’t much different from the barber-surgeons of Medieval Europe who relied on leeches and spoke of humors. For the first half of the 20th century, shrinks — a.k.a. headshrinkers, for their purported likeness to witch doctors — gave their patients malaria for psychosis, induced hypoglycemic comas for schizophrenia and scrambled brain matter via lobotomies for everything under the sun. And these were the effective treatments. “The fact that the Nobel committee [honored] malaria cures and lobotomies underscores the desperation for any form of treatment for mental illness,” Jeffrey Lieberman writes in his new book, “Shrinks.”
Lieberman isn’t another muckraker trolling the profession: He’s the chair of psychiatry at Columbia University and a former president of the APA. He may be raking up some old muck, but for good cause: “The only way psychiatrists can demonstrate just how we have hoisted ourselves from the murk,” he writes, “is to first own up to our long history of missteps.” And he (with help from Ogi Ogas) tells this history in engaging and authoritative detail.
Many people reject psychiatry on the grounds that diagnosis is hogwash, at best subjective guesswork and at worst the pathologizing of healthy behavior. In 1961, the psychiatrist Thomas Szasz vandalized his profession from the inside with his still-in-print book “The Myth of Mental Illness,” wherein he alleged that psychiatry is a pseudo-science, the troubled don’t need to be “cured” so much as taught responsibility for their actions, and dangerous behavior can be categorized as eccentricity. (He later joined forces with Scientology.)
The same year, the sociologist Erving Goffman published “Asylums,” arguing that psychiatric diagnosis was just a tool of societal control. In 1973, the journal Science published a study called “On Being Sane in Insane Places,” in which healthy volunteers arrived at several mental hospitals to see whether they’d be needlessly admitted, and many were, raising a public outcry that the profession didn’t know what it was doing. (Never mind that the impostors had falsely complained on arrival of hearing voices.) All these arguments resonate today. It doesn’t help that homosexuality was once a diagnosable condition, as was “drapetomania,” the desire of a slave to seek freedom.
The problem of diagnosis is now less daunting, thanks to the Diagnostic and Statistical Manual of Mental Disorders. “The DSM might just be the most influential book written in the past century,” Lieberman writes, possibly without exaggeration. The document shapes mental health care, the insurance industry, scientific research, pharmaceutical investment, workers’ compensation, criminal law, parenting, schooling and the military. It guides our very definitions of sickness and illness, so central to our views of ourselves and humanity. The third edition, in particular, was revolutionary when it was released in 1980, for it ignored the causes of illness, using hard data to focus solely on observable symptoms. Mother issues became irrelevant, and doctors could now agree on what they saw.
Per the claim that doctors see all behavior as illness, the way a man with a hammer sees everything as a nail, Lieberman writes, “Perhaps the strongest piece of evidence that psychiatry is not trying to pathologize ordinary behaviors can be found in the changing number of diagnoses”: The current DSM has 265, down from the previous version’s 297.
People also fear psychiatric treatments, calling them useless or worse. In addition to brain-scramblers, the 20th century saw fraudulent attempts to rid the body of energies called “orgones,” a profession overrun with devout Freudians and fears that Ritalin was damaging children’s brains. (Possibly, but I’ve taken it most of my life and can still write a sentence.) But we now have safe, targeted medications for many mental illnesses, evidence-based psychotherapies such as cognitive behavioral therapy, and new technologies such as transcranial magnetic stimulation and deep brain stimulation. And so with research-backed theories and methods, psychiatry now more closely resembles a science — no longer, as Lieberman puts it, “the unwanted stepchild of medicine.”
Other complaints levied against the field focus on money. Pharmaceutical companies, for instance, spend billions of dollars lobbying government agencies, advertising to consumers and buying influence with doctors. Lieberman stays away from all this, perhaps because the truth is messier than he would like or perhaps because the influence-peddling detracts little from psychiatry’s net benefit.
But belief in psychiatry’s impotence, malevolence or shadiness is not all that keeps people away. Shame and accusation will always attach to diseases of the mind. Robin Williams drew ire along with sympathy when he killed himself. “Today the single greatest hindrance to treatment is not any gap in scientific knowledge or shortcoming in medical capability,” Lieberman writes, “but the social stigma.”
That stigma may hit hardest those soldiers suffering from PTSD: Among soldiers fighting in Iraq and Afghanistan, fewer have died in battle than from suicide. Attributing our thoughts and behaviors to the meat in our heads may make scientific sense, but reducing personal frailties to biological afflictions goes against strong intuitions and norms that place free will at the center of the person. It’s hard not to blame people — oneself included — for their imperfections.
One of the most important frontiers for psychiatry may not be on the couch but in the community. Mental health professionals, Lieberman writes, need to engage with people in schools, businesses and primary-care offices. To convince them that mental illness is a medical condition like any other — nothing to be ashamed of — and, further, that it can be treated.
Some of the APA picketers may have valid grievances from their personal pasts. But whether you believe in orgones, Oedipus or the Operating Thetans of Scientology, you would probably benefit from a chat with your friendly neighborhood shrink.