Friday, May 9, 2014

APA Annual Conference 2014: The Future of Psychiatry

At 3:30 pm on Tuesday, May 6th, APA President Jeffrey Lieberman opened his talk on "The Future of Psychiatry" by asking how many people in his audience were not psychiatrists. Along with only two others, I raised my hand.

Lieberman then asked each of us what we were doing there. I said that I was a lawyer working with psychiatrists. He queried, "What side are you on?" I shrugged from the back of the room and smiled, and after a moment he asked, "Are you on the side of truth?" I answered, "Absolutely! And justice, and the American way."

He then suggested that someone in the crowd should probably take my picture, just in case....

Lieberman is a politician and a PR man, but his viewpoint is a little incoherent, and he just never quite wins.

After a brief, fairly competent lesson on the history of psychiatry (he omitted a few chapters, of course, like the key role psychs played in the holocaust and the highly embarrassing "satanic abuse/multiple personality disorder" craze in the 1990's), the President of the APA offered his key predictions for the future:

     1. Psychiatrists will work more and more for large organizations. They will not be hands-on, direct care clinicians as much as they are now. This is due to simple economics, i.e., no one wants to pay psychiatrists for direct care, because they're not worth what they charge. But ideally in the future they can become the elite advisors or "captains" of treatment teams, mostly removed from human patients.

     2. Breakthrough technologies from scientific research into the brain, and the position of psychiatrists as first implementers of these new technologies, will be the single source of value and power to command public resources for the profession, going forward. Modern culture has not caught up with the overriding significance of the brain, but when it does psychiatrists will be able to assert their role as the real experts on all of life.

Whether these prognostications seem glorious or darkly threatening, there is a major countervailing factor. BRAIN was one of two key words in Lieberman's dissertation. The other word was STIGMA.

Stigma is purportedly the basic reason why psychiatrists don't have the power they should, and why they can't get paid enough. People don't like to talk about mental illness or admit having it, and they don't want their friends to know if they're seeing a psychiatrist.

Ironically, psychiatrists themselves may stigmatize psychiatry as much as the lay public does. An interesting poster in the exhibition hall described a recent research study in Belgium which concluded, "It could be useful to explicitly start with anti-stigma campaigns during medical training in order to avoid a continuing decrease in the number of candidate psychiatrists." One of the authors of the study told me that as little as ten years ago, there were on average seventy candidate psychiatrists per year in Belgium; now there are only ten or fifteen. She said the trends are the same throughout Europe. It's just too socially embarrassing to be a psychiatrist.

So, on one hand Jeffrey Lieberman sees great and increasing power for the psychiatric elite as captains of a medical-industrial complex ruled by those who know the secrets of the brain. But on the other hand, he and the APA are now hiring crack PR firms to fight stigma, because after decades of public campaigning nothing has worked, and psychiatrists around the world can't even admit their profession to ordinary people in social circumstances.

With his forlorn hope that scientific miracles and arbitrary assertion of authority can save the psychs from the black stigma magic in the nick of time, there is an obvious schism between Jeffrey Lieberman and reality. Funny how that reminds one of a once-postulated "disease", schizophrenia.

There is no unity of view, or authority, in psychiatry. It's a profession falling apart.

As I left the hall after the President of the APA had given his speech on the future of psychiatry, I was approached by a doctor who asked me where I practice law. I told him Chicago, and he responded that he had family there, including six siblings who were all lawyers. He said that despite what Lieberman had implied earlier, as far as he was concerned I was welcome at the APA.