BOOK REVIEWS
Book Reviews
Shrinks: The Untold
Story of Psychiatry
by Jeffrey A. Lieberman, M.D., with
Ogi Ogas; New York, Little, Brown
and Company, 2015
The victors get to write the
history books.
In his new book, Shrinks,
Dr. Lieberman shares his view
of the victorious legacy of a
cohort of courageous biologi-
cal psychiatrists whom he be-
lieves rescued psychiatry from
superstition and chicanery to
be a fully respectable medical
specialty, battling with cultish
psychoanalysts and fighting off the barbaric antipsychia-
trists. Dr. Lieberman’s introduction culminates in this as-
sertion: “The modern psychiatrist now possesses the tools to
lead any person out of a maze of mental chaos into a place of
clarity, care, and recovery. The world needs a compassionate
and scientific psychiatry and I’m here to tell you, with little
public fanfare, that such a psychiatry has arrived at last.”
Dr. Lieberman tells us that the reason for the biological
psychiatrists’ success is clearheaded, scientific research, but
for better or worse, that isn’t the story this book tells. This
book isn’t a review of all the data that support (or question)
biological psychiatry. It doesn’t even include Lieberman’s
own massive CATIE study (which, in my opinion, does
both). This book is the much more enjoyable—and I think
much more honest—story of the people striving for victory
and the strategies they used to achieve it. For example, he
tells us the fascinating, political backstory of how Spitzer
maneuvered around the diagnosis of homosexuality, rather
than citing studies about the validity, or lack of validity, of
homosexuality as a diagnosis, or the effectiveness, or lack of
effectiveness, of sexual orientation change therapy. I don’t
know if an honest, data-driven book justifying today’s bi-
ological psychiatry could be written (especially if it had to
focus on long-term quality-of-life outcomes and include
study dropouts in the analysis).
This book instead thoughtfully takes us on a personal
journey of biological psychiatrists and how they strategically
wrested psychiatric diagnosis, psychiatric research funding,
academic training programs, and therapeutics away from their
archrivals, the psychoanalysts. I admired the emotional and
the intellectual integrity of this book: Dr. Lieberman describes
Psychiatric Services 66:11, November 2015
his own deep emotional ambivalence toward Sigmund Freud,
whose book The Interpretation of Dreams drew Lieberman
into psychiatry in the first place (as it did me) but whose
egotism and intolerance damaged psychoanalysis so badly that
the biological psychiatrists determined that it needed to be de-
stroyed for psychiatry to progress scientifically, thus launching
their version of a cold war against an evil empire.
Lieberman talks openly about how emotionally disturb-
ing delivering electroconvulsive therapy (ECT) can be, ad-
vising “You must keep reminding yourself that extensive
research and data supports the therapeutic effects of ECT.”
He also describes how early medications appealed more to
cost-cutting administrators than to the psychiatrists working
in the hospitals at the time, the alienists; how one of his
heroes, Dr. Kandel, who was looking for the neurological
basis for the ego, id, and superego, ended up studying nerve
cells in sea slugs; how psychiatric genetics have a “recurring
and deeply frustrating patter” of producing “fool’s gold”; and
how Dr. Nathan S. Kline, a “flamboyant pioneer of psycho-
pharmacology,” was banned from doing drug research be-
cause “he hadn’t bothered to get the proper informed consent
from the patients to whom he was administering experi-
mental psychoactive compounds.”
This emotional and intellectual openness makes his sto-
ries a compelling read, yet I am puzzled that nothing seems
to give Lieberman pause or a shred of self-doubt. To seri-
ously consider doubts would be to give the antipsychiatrists
ammunition. Perhaps the ends justify the means.
What gives me pause is how few stories he includes of
actually leading “any person out of a maze of mental chaos
into a place of clarity, care, and recovery.” His opening story
is illustrative: Elena is a young woman whose life is falling
apart due to worsening psychosis. She and her family have
spent a couple years diligently pursuing a variety of appar-
ently ineffective interventions before her family reluctantly
brings her to see Dr. Lieberman because their family doctor
said, “For Christ’s sake, take her to a real doctor!” After
witnessing her display Schneiderian symptoms, he diagnoses
schizophrenia, hospitalizes Elena for three weeks, and gives
her risperidone, which helps a lot. A few weeks after discharge,
she and her family dropped out of outpatient treatment, and
their search for help continued elsewhere. How is that a tri-
umphant story? Something important seems to be missing
before victory can confidently be claimed.
Dr. Lieberman himself points us in a crucial direction
when he asserts that “the world needs a compassionate and
scientific psychiatry,” but readers will not learn in this book
how to be more compassionate with patients—for example,
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BOOK REVIEWS
by working alongside a peer advocate or by implementing
trauma-informed care in a hospital ward or by working with
motivational interviewing or WRAP plans.
Lieberman says that he admires and emulates his fellow
faculty member Siddhartha Mukherjee’s book The Emperor of
All Maladies, which tracks the scientific advancements in the
treatment of cancer. I admire Elisabeth Kübler-Ross’ book On
Death and Dying because of the massive enhancements
in compassion it brought to the staff, patients, and families
struggling with cancer. I just wish more scientific oncologists
would integrate the compassion of hospice into their work
before deciding that their patients are “totally hopeless.”
Psychiatry can integrate both compassion and science.
Dr. Gabor Maté was given up by his mother as an infant in
Hungary to survive the holocaust. In his recent book In the
Realm of Hungry Ghosts he draws deeply upon his own
personal struggles and addictive behaviors in order to em-
pathize with his patients, who include people with severe
mental illnesses, substance use disorders, HIV, life on the
streets, incarceration, and residents of a Housing First pro-
gram in Vancouver. Maté includes long chapters about his
understanding of the biological impacts of prolonged child-
hood trauma and of prolonged severe drug addiction, as well
as chapters about his struggles to build compassionate, heal-
ing relationships with his patients. He melds the two as he
makes strong recommendations about working with a chal-
lenging patient population. He succeeds in sustaining himself
and his relationships with his patients—a therapeutic alliance
that nurtures and heals both parties. Yet the difference in
the tone of the two books is striking. In the Realm of Hungry
Ghosts never approaches the triumphant, self-satisfied tone
of Shrinks. Then again, Shrinks never describes working
with patients like Maté’s.
In a late chapter of the book, Lieberman describes Vietnam
veterans and posttraumatic stress disorder (PTSD). Here he
talks about his own traumatic reactions, how peer support
rap sessions are often more helpful than psychiatrists, and
the importance of people’s reactions to their situations in
determining their symptoms and outcomes. These veterans
evoked compassion that ultimately profoundly affected both
their DSM diagnosis and their treatment. Maybe more com-
passionate exposure—for example, to people who were se-
verely abused and traumatized as children, foster care children,
homeless people, prison inmates, people whose children were
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removed, gang members, and battered women—could affect
their DSM diagnoses and their treatment. His chapter on
DSM-5 describes it as “The Triumph of Pluralism,” and he
praises the DSM-5 developers for keeping an open mind.
Today’s public psychiatrists would certainly welcome an
inclusion of entries on, for example, developmental trauma
disorder; attachment disorders; damaged pleasure centers
from prolonged substance abuse; trust, hypervigilance, and
aggressive disorders from prolonged incarceration; learned
helplessness; rape victims; battered women; people broken-
hearted from having their children removed; and immigrant
disorientation. With such clarification, we’d no longer have to
wedge diagnoses into depression, bipolar disorder, PTSD, and
borderline categories and give the patients poorly targeted
treatments. These aren’t “worried well” people. These are the
pervasive conditions in today’s community mental health
centers and public hospitals.
Lieberman’s final chapter that “reflects upon the work
that still lies ahead” includes a story about his success in
competing for a talented psychiatry resident and talking him
out of switching to neurology by convincing him of modern
psychiatry’s scientific basis and effectiveness. I would advise
that resident that if he really wants to become “a compas-
sionate and pluralistic psychiatric physician” and work ef-
fectively in public psychiatry, he should go beyond what
Dr. Lieberman and this book can teach him. For starters, he
could spend time with the Project for Psychiatric Outreach to
the Homeless, Fountain House, a transitional-age youth as-
sertive community treatment team, and a battered women’s
shelter. Otherwise, he’s at risk of becoming another tragic
hero, like Dr. Lieberman, proud of his accomplishments yet
frustrated that his patients, their families, and society don’t
properly appreciate the treatments that psychiatry provides.
Lieberman explains quite well how the DSM, research,
academia, and medications were all molded into weapons
of war against the psychoanalysts. We don’t have to live in
the shadow of that war forever. It’s time to reform these
tools collaboratively with our patients, their families, and
our communities into peaceful tools for recovery. To do that
we’ll need leaders who have moved on from old battles.
Mark Ragins, M.D.
Dr. Ragins is the medical director of the MHALA Village in Long Beach,
California.
Psychiatric Services 2015; 66:e1–e2; doi: 10.1176/appi.ps.661104
Psychiatric Services 66:11, November 2015