Shrinks

Introduction

What's Wrong with Elena?

A few years ago, a well-known celebrity—let's call him Mr. Conway—reluctantly brought his twenty-two-year-old daughter to see me. Elena had taken a leave of absence from Yale, Mr. Conway explained, because of issues surrounding a mysterious drop in her grades. Mrs. Conway nodded assent and added that Elena's slacking off stemmed from "a lack of motivation and low self-confidence."

In response to their daughter's perceived troubles, the Conways had hired a parade of motivational experts, life coaches, and tutors. Despite this pricey coterie of handlers, her behavior failed to improve. In fact, one tutor even volunteered (rather hesitantly, given Mr. Conway's celebrity) that "something is wrong with Elena." The Conways dismissed the tutor's concern as an excuse for his own incompetence and continued to look for ways to help their daughter "snap out of her funk."

They turned to naturopathic agents and meditation, and when those didn't help, they shelled out more money for hypnosis and acupuncture. In fact, they had done everything possible to avoid seeing a psychiatrist until "the incident."

While traveling uptown on the New York subway to meet her mother for lunch, Elena was accosted by a balding middle-aged man in a grimy leather jacket who coaxed her off the subway car. Without informing her mother, Elena abandoned the lunch appointment and accompanied the man to his seedy basement apartment on the Lower East Side. The man was in the kitchen preparing something alcoholic for her to drink when Elena finally answered a call from her frantic mother on her cell phone.

When Mrs. Conway learned where Elena was, she speed-dialed the police, who swooped in and carted her back to her parents. Elena didn't protest her mother's abrupt intervention; in fact, Elena didn't seem fazed by the incident at all.

As the Conways narrated these events in my Manhattan office, it was apparent that they loved their daughter and were genuinely concerned for her welfare. Having two sons of my own, I could easily empathize with their distress over the possible fate that could have befallen their daughter. Despite their concern, they made plain their doubts about the need for my services. After he sat down, the first thing Mr. Conway said was, "I gotta tell you, I really don't think she needs a shrink."

The profession to which I have dedicated my life remains the most distrusted, feared, and denigrated of all medical specialties. There is no anti-cardiology movement calling for the elimination of heart doctors. There is no anti-oncology movement protesting cancer treatment. But there is a large and vocal anti-psychiatry movement demanding that psychiatrists be downsized, reined in, or extirpated. As chairman of the psychiatry department at Columbia University, chief psychiatrist at the New York Presbyterian Hospital–Columbia University Medical Center, and past president of the American Psychiatric Association, I receive emails each week expressing pointed criticisms like these:

"Your bogus diagnoses exist merely to enrich Big Pharma."

"You take perfectly normal behaviors and call them illnesses to justify your existence."

"There is no such thing as mental disorders, only diverse mentalities."

"You quacks don't know what the hell you're doing. But you should know this: Your drugs destroy people's brains."

Such skeptics don't look to psychiatry to help solve mental health problems… they claim psychiatry is the mental health problem. All around the world, people have an abiding suspicion of "shrinks"—the most common epithet for the self-important charlatans believed to populate my profession.

I ignored the Conways' skepticism and began Elena's evaluation by taking her history, soliciting biographical and medical details from her parents. Elena, I learned, was the oldest and brightest of the Conways' four children and the one who seemed to hold the greatest potential. Everything in her life had been going great, her parents confided wistfully—until her sophomore year at Yale.

Open, gregarious, and popular during her freshman year, over a span of a few months Elena gradually stopped discussing her sorority life and romantic interests with her friends and parents. She adopted a strict vegetarian diet and became obsessed with the Kabbalah, believing its secret symbology would lead her to cosmic knowledge. Her attendance in class became erratic, and her grades dipped sharply.

At first, her parents were not worried by these changes. "You need to give kids space to find themselves," offered Mrs. Conway. "I sure marched to my own drummer when I was her age," agreed Mr. Conway. But Elena's parents finally became concerned after a phone call from Yale's student health services.

Elena had accused girls in her sorority of taunting her and stealing a gold bracelet. But when questioned by university administrators, Elena's sorority sisters denied any bullying—and they insisted they never saw the bracelet. They had noticed, on the other hand, that Elena's behavior had become increasingly strange. One of Elena's professors had even expressed concern over Elena's response to an exam question. When asked to explain James Joyce's stream of consciousness technique, Elena wrote that Joyce's literary style was "a code with a special message to selected readers with wisdom implanted in their minds by the spiritual forces of the universe."

After that, the Conways requested a leave from school for Elena and enlisted private coaches and applied new age remedies until a friend recommended a popular Manhattan psychotherapist. This social worker was well known for promoting a decidedly nonmedical model of mental illness, pronouncing psychological issues as "mental roadblocks." As treatment, she favored a form of confrontational talk therapy of her own invention. She diagnosed Elena as suffering from a "self-esteem disorder" and began a series of expensive twice-weekly therapy sessions to help her remove her roadblocks.

After an entire year's worth of confrontational therapy produced no improvements, the Conways next turned to a holistic healer. He prescribed a purgative regimen, vegetarian diet, and meditative exercises, but despite his most creative efforts, Elena remained emotionally detached and mentally scattered.

Then the incident of the sleazy stranger's aborted abduction happened, forcing the Conways to confront the disconcerting fact that their daughter seemed oblivious to the dangers of going home with lecherous strangers. At this point their exasperated family physician implored them, "For Christ's sake, take her to a real doctor!" and they came to me.

Completing the interview with Elena's parents, I requested the opportunity to speak with their daughter privately. They left my office, and I was alone with Elena. She was tall, slender, and pale, with long blond hair that was tangled and unwashed. Earlier, as I was speaking with her parents, she had exhibited a demeanor of nonchalant distraction, like an idle cat. Now, as I addressed her directly, her gaze shifted randomly, as if she considered the lights in the ceiling to be more interesting than her interviewer.

Rather than feeling slighted, I felt genuine concern. I was familiar with this vacant and desultory gaze, which one colleague calls "fragmented attention." It suggested that Elena was attending to stimuli inside her mind rather than those unfolding in the room around her. Still contemplating Elena's distracted demeanor, I asked how she was feeling. She pointed to a photo on my desk of my wife and children. "I know those people," she replied, in a soft monotone like the whir of a ceiling fan. As I started to ask how she could know them, she interrupted. "I need to leave. I'm late for my appointment."

I smiled encouragingly. "This is your appointment, Elena. I'm Dr. Lieberman and your parents arranged this meeting to see if there is anything I might be able to do for you."

"Nothing's wrong with me," she replied in her flat, hushed voice. "I feel fine except my sisters keep making fun of me and messing with my artwork."

As I asked her about school and why she had left, she abruptly announced that she was no longer interested in school—she was on a quest to save the world by discovering the secret source of divine power. She believed God had placed angels in her parents' bodies to guide her on this sacred mission.

"Your secretary knows about it, too," Elena added.

"Why do you think that?"

"The way she smiled at me when I came in. It was a sign."

Such delusions, which psychiatrists classify as both "narcissistic" (relating incidental external events to one's self) and "grandiose" (imbuing mundane activities with transcendent purpose), are known as Schneiderian symptoms, after the German psychiatrist Kurt Schneider, who first described them in the 1940s as characteristic symptoms of psychosis. This initial constellation of behaviors and history strongly suggested a diagnosis of schizophrenia, the most severe and perilous of mental illnesses, and the illness I have studied for three decades.

I dreaded having to inform the Conways of this news, but at the same time I was shocked and saddened that this once lively girl may have been suffering with a highly treatable illness for three years while being repeatedly exposed to a series of useless remedies. Worse, by avoiding genuine psychiatric treatment, her parents had placed her at risk to very real dangers: First, her impaired judgment could have led her to make disastrous decisions. Second, we now know that if schizophrenia is left untreated it gradually induces irreversible brain damage, like the engine of a car driven without an oil change.

I invited Elena's parents back in. "So what's the verdict?" Mrs. Conway asked glibly, drumming her fingers on the chair. I told them I could not be completely sure until I had performed more tests, but it appeared likely their daughter had schizophrenia, a brain disorder affecting about 1 in 100 people that usually manifests in late adolescence or early adulthood. The bad news was that the illness was severe, recurrent, and incurable. The good news was that with the right treatment and sustained care there was an excellent chance she could recover and lead a relatively normal life, and even return to college. I knew the next part would be tricky: I looked Mr. and Mrs. Conway in the eyes and urged them to hospitalize their daughter immediately.

Mrs. Conway cried out in protest and disbelief. Her husband shook his head defiantly and fumed, "She doesn't need to be locked up in a hospital, for God's sake. She just needs to buckle down and get her act together!" I persisted, explaining that Elena needed continuous supervision and prompt treatment to safely restore her to sanity and avoid further hazards like the subway incident. Eventually they relented and agreed to admit her to the psychiatric unit of New York Presbyterian Hospital–Columbia University Medical Center.

I personally oversaw Elena's care. I ordered blood tests as well as EEG, MRI, and neuropsychological assessments to rule out other causes of her condition, then prescribed risperidone, a very effective antipsychotic medication with only a modest potential for side effects. Meanwhile, in socialization groups, therapists helped her with her social skills. Cognitive therapy enhanced her attention and concentration. Guided instruction in the basic tasks of daily living aided her hygiene and appearance. After three weeks of medication and intensive care, cosmic symbols faded from her attention and Elena's natural personality started to shine through: She was cheerful and intelligent, with a playful sense of humor. She expressed embarrassment over her recent behavior and the strong desire to return to college and her friends in New Haven.

Her dramatic improvement was a testament to the power of modern psychiatry, and I couldn't wait to see Elena reunited with her parents. The Conways were delighted to get their daughter back, and I even saw Mr. Conway smile for the first time once he took in her transformation.

But when our treatment team met with the Conways to discuss Elena's discharge plan and the need for continuous outpatient care, they remained unconvinced that Elena's dramatic improvements were due to the medical treatment she had just received. Sure enough, a few weeks later I heard from the outpatient clinic that Elena had stopped showing up. I contacted the Conways and implored them to continue Elena's medical care, insisting that without it she was certain to relapse. While they thanked me for my help, they claimed they knew what was best for their daughter and would arrange for her treatment.

The truth is, if this had happened in the 1970s when I was in medical school and treating my very first patients, I might have sympathized with—or even shared—the Conways' aversion to psychiatrists. Back then, the majority of psychiatric institutions were clouded by ideology and dubious science, mired in a pseudomedical landscape where devotees of Sigmund Freud clung to every position of power. But the Conways were seeking treatment for their daughter in the twenty-first century.

For the first time in its long and notorious history, psychiatry can offer scientific, humane, and effective treatments to those suffering from mental illness. I became president of the American Psychiatric Association at a historic turning point in my profession. As I write this, psychiatry is finally taking its rightful place in the medical community after a long sojourn in the scientific wilderness. Buoyed by new research, new technologies, and new insights, psychiatry does not merely have the capacity to raise itself from the shadows but the obligation to stand up and show the world its revivifying light.

According to the National Institute of Mental Health, one in four persons will suffer from mental illness, and you are more likely to need services from psychiatry than from any other medical specialty. Yet far too many people—like the Conways—consciously avoid the very treatments now proven to relieve symptoms. Don't get me wrong; I would be the first to admit that psychiatry has earned much of its pervasive stigma. There's good reason that so many people will do everything they can to avoid seeing a psychiatrist. I believe that the only way psychiatrists can demonstrate just how far we have hoisted ourselves from the murk is to first own up to our long history of missteps and share the uncensored story of how we overcame our dubious past.

That's one reason I wrote this book: to provide an honest chronicle of psychiatry with all its rogues and charlatans, its queasy treatments and ludicrous theories. Until quite recently, authentic scientific triumphs were rare and bona fide psychiatric heroes rarer still. The history of sibling specialties like cardiology, infectious disease, and oncology are mostly narratives of steady progress punctuated by major leaps forward, while psychiatry's story consists mostly of false starts, extended periods of stagnation, and two steps forward and one step back.

But the full story of psychiatry is not just a dark comedy of fanciful gaffes. It is also a detective tale, propelled by three profound questions that have vexed and beckoned each successive generation of psychiatrists: What is mental illness? Where does it come from? And, most pressing for any discipline devoted to the Hippocratic oath, how can we treat mental illness?

From the start of the nineteenth century until the start of the twenty-first, each new wave of psychiatric sleuths unearthed new clues—and mistakenly chased shiny red herrings—ending up with radically different conclusions about the basic nature of mental illness, drawing psychiatry into a ceaseless pendulum swing between two seemingly antithetical perspectives on mental illness: the belief that mental illness lies entirely within the mind, and the belief that it lies entirely within the brain. Regrettably, no other medical specialty has endured such extreme volatility in its fundamental assumptions, and this volatility helped forge psychiatry's reputation as the black sheep of the medical family, scorned by other physicians and patients alike. But despite its many false leads and dead ends, the detective story of psychiatry has a gratifying finale in which its impenetrable mysteries have begun to be elucidated.

Over the course of this book, you'll learn about a handful of renegades and visionaries who bravely challenged the prevailing convictions of their time in order to elevate their embattled profession. These heroes declared that psychiatrists were not doomed to be shrinks but destined to be a unique class of physicians.

As a result of their pioneering triumphs, psychiatrists now understand that the successful treatment of mental illness requires us to embrace the mind and brain simultaneously. Psychiatry is like no other medical specialty; it transcends a mere medicine of the body to touch upon fundamental questions about our identity, purpose, and potential. It is grounded upon a wholly unique doctor-patient relationship: The psychiatrist often becomes privy to patients' private worlds and innermost thoughts—their most secret shames and most cherished dreams. The intimacy of this relationship places grave responsibility for the patient's welfare on the psychiatrist, a responsibility that psychiatrists have often failed to live up to—but no longer. 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.

Let me share with you exactly what it took to get here…