0 P O V RANT

WHAT THE ELITE

WONTTALK ABOUT
THE STIGMA ABOUT MENTAL-HEALTH CONDITIONS REMAINS RAMPANT, EVEN AMONG THOSE WHO HAVE
ACCESS TO WORLD-CLASS CARE.JEFFREY LIEBERMAN, M.D., ARGUES THAT IF WE UNDERSTAND THE BREAK
THROUGHS OF 21ST-CENTURY PSYCHIATRY, THE BARRIER TO SEEKING TREATMENT WILL FALL.

FO U R DECADES AGO, when Shortly after I became chair of psy angry gestures. W hen I remained silent
my cousin needed treatm ent for chiatry at C olum bia University, I was and observed her, she talked to h er
her asked to consult on a 66-year-old woman selfm ore accurately, she talked to
away from the m ost promi named Dr. Kim* She had been admitted nonexistent people. Because I could not
and well-estaffished psyo to our hospital with a severe skin infec engage her in conversation, I decided
facililies o ft :ime, fearinpihey tion that seemed to have gone untreated to speak w ith her family. The next day,
migM: only ifjH :e things worse for for a long time. This was puzzling: Dr. her husband and adult son and daugh
her. Today, I M>uldnt h e itate to Kim was both educated and affluent. She ter reluctantly came to my office. After
send her to the psychiatric depart had graduated from medical school and, much cajoling, they revealed that shortly
m ent o f any major medical cen- as the wife of a prom inent industrialist, after Dr. Kim graduated from medical
; someofil who haHvorked she had access to the best health care. school, she had developed symptoms of
: front lines o f clinical care, I quickly discovered why a psychia schizophrenia.
en firsthand the sweepin trist had been called to see a patient with Her family was ashamed of her con
ISTOCKPHOTO

*ress th a t as transform ed a skin infection. W hen I tried to ask Dr. dition. Despite their wealth and resources,
liatry; s not everyone Kim how she was feeling, she began to neither Dr. Kims parents nor her hus
^ e f i t from it. shout incoherently and make bizarre, band sought any kind of treatm ent for
* Name has been changed.

Adapted from the book Shrinks by Jeffrey A. Lieberman. MD with Ogi Ogas. Copyright (cl 2015 by Jeffrey Lieberman Reprinted with permission of Little. Brown and Company. All rights reserved. M ay/Ju ne 2015 P sych olog y Today 39
 NEW RANT
WORKBOOK
N e w York Times
her illness; instead, they decided to do
Bestselling A uthors o f whatever they could to prevent anyone DESPITE HER
The W hole-B rain C h ild & from discovering her diagnosis. They sec
tioned off her living quarters in a wing
WEALTH,
N o -D ra m a D iscipline of their spacious home and kept her iso RESOURCES,
lated whenever they had guests. Despite
her having received a medical degree,
ANDMEDICAL
practicing medicine was completely out DEGREE,THE
of the question. Until she developed the
skin rash, Dr. Kim rarely left the prop
PATIENTS
erty. Her family tried over-the-counter CONDITION WAS
r the^ ^
remedies, hoping for relief. But when
the rash becam e infected and rapidly
HIDDEN FOR
WHOLE-BRAIN ^ began to spread, they were frightened 3 0 YEARS
CHILD and called in the family doctor. W hen
L WORKBOOK he saw her torso dotted with abscesses,
he implored the family to take her to the
hospital, where she was diagnosed with
a severe staph infection.
I repeated back to them what they A few short generations ago, the
DANIEL 3 SIEGEL. M had told methat for the past 30-some greatest obstacles to the treatm ent of
TINA PAYNE BRYSON. years, they had conspired to keep their mental illness were the lack of effective
wife and mother shut off from the world therapies, unreliable diagnostic criteria,
to avoid public em barrassm ent. They and an ossified theory of the basic nature
unabashedly nodded their heads in uni of the conditions. Today, the single great
son. I told them that their decision to est hindrance to treatm ent is not any
withhold treatm ent was both cruel and gap in scientific knowledge or short
im m oralthough, tragically, not ille coming in medical capability, but social
gal and I urged them to let us transfer stigma. This stigma, unfortunately, has
her to the psychiatric unit when she had been sustained by the legacy of psychia
A u n iq u e , in te ra c tiv e a p p ro a c h been medically cleared so that she could try s historic failures and its enduring
th a t allow s readers n o t o n ly to be treated. They refused. reputationno longer justifiedas the
th in k m o re d e e p ly a b o u t h o w stepchild of medicine.
They informed me that even if Dr.
th e ideas fit th e ir o w n p are n tin g
Kim could be successfully treated, at Though we live in a time of unprec
a p p ro a c h , b u t also d e v e lo p
this point the resulting changes would edented tolerance of different races, reli
cu s to m iz e d a n d p ractical w ays
to im p le m e n t.
be too disruptive to their lives and their gions, and sexual orientations, mental ill
position in the community. They would nessesinvoluntary medical conditions
have to explain the reason why she sud that affect one out of four people are
20% OFF & denly began to appear in public after such still regarded as a mark of shame, a scarlet

Free Shipping a long absence and who knows what

she herself might say or how she would
behave in such circumstances? The Kims
perceived the stigma of mental illness as
so oppressive that they would have this
once intelligent, otherw ise physically
healthy woman remain untreated and
8 0 0 8 4 4 -8 2 6 0
-
incapacitated, her brain irreversibly
deteriorating, rather than face the social
Use C ode: child consequences o f acknow ledging her
mental illness.
letter C for crazy.
I encounter this shame and sensitiv
ity nearly every day. Many of the patients
seen by o u r faculty opt to pay out o f
pocket rather than use health insurance,
for fear o f th eir treatm ent becom ing
known. Other patients choose not to visit
our doctors at the Columbia Psychiatry
Clinic, preferring a private medical office
without any signs indicating the specialty
practiced inside.

*sr mbs*

Actress Glenn Close, who has a sister and nephew who both suffer mental illness, helped found
the nonprofit Bring Change to Mind. Here, she speaks about the organization Fountain House.
A FEW YEARS AGO, I gave a talk about
mental illness at a luncheon in Manhat
tan to raise funds for psychiatric research.
Afterward, I circulated among the attend
eessmart, successful, and outgoing peo
ple who had all been personally invited
to the event by a w om an Ill call her
Sarahwho was a prom inent socialite
whose schizophrenic son had committed
suicide. They chatted over poached salm
on and Chablis, openly praising Sarahs
selfless efforts to raise awarenessthough
none of them adm itted any direct expe
rience w ith m ental illness themselves.
Instead, m ental illness was treated like
the genocide in Sudan: an issue deserv
ing public attention, but one distant and
removed from the patrons own lives.
Several days later, I received a call.
One of the attendees, an editor at a pub
lishing company, asked if I could help
her. It seemed that she had lost interest
in her job, had trouble sleeping, and fre
quently become emotional, even tearful.
Was she having a midlife crisis? I agreed
to see her and eventually diagnosed her
as suffering from depression. But before
she made the appointm ent w ith me, she
insisted I keep it completely confiden
tialadding, Please dont tell Sarah!
In the next few weeks, I received
more calls from Sarahs invitees seeking
help. Over time, fully half o f the people
who attended this event reached out to
me, and none w anted Sarah to know
about their problems.
Its finally tim e to end this stigma.
And, now, theres good reason to think
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we can. One key reason for this psychiat
ric renaissance is my professions adop
tion of a pluralistic view of mental illness.
C o n tem p o rary psychiatry em braces
neuroscience, psychopharm acology, is ra A new
and genetics but also wields psycho
therapy to understand a patients unique IOURNEY
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problems and history.
But the hardest part for so many
peoplelike the Kimsis simply believ D is c o v e r S a n ta M o n ic a s first
ing that a psychiatrist can actually help. e atin g d is o rd e rs c e n te r to o ffe r a
In the media, psychiatrists are still por u nique array o f treatm ent program s
trayed as shrinks spouting psychobabble. fo r a d u lts a n d a d o le s c e n ts :
And although in the past, psychiatry
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director he wanted to switch to neurology. sies and Calens DNA revealed that they
1 promptly arranged to meet with share a rare genetic variant, resulting in
him. He told me he was fascinated by extra copies of the gene that produces
the daunting complexities of mental an enzyme that metabolizes the amino
illnesses but disappointed by the clini acid glycine, which has been implicated
cal practice of psychiatry. We still base in psychotic disorders. This meant that
diagnoses on symptoms and assess the Jessie and Calen were deficient in gly
effectiveness of treatments by observing cine because their bodies overproduced
the patient rather than relying on labora the enzyme that metabolizes it. When
tory measures, he lamented. I want to Levy gave them supplemental glycine,
feel that I have some real sense ofwhy my their symptoms markedly improved.
patients are sick and what our treatments It was like watching a patients fever
are doing in their brains to help them. decline after giving him aspirin. When
How could I argue? Ahmeds con they stopped taking the supplemental
cerns were common and valid. But I glycine, their symptoms worsened.
explained that even though we were still Using a genetic test on this mother
bridging the gap between psychological and son pair to identify a specific drug
constructs and neurobiological mecha that could ameliorate their mental ill
nisms, it was entirely possible to embrace ness was one of the first applications
both, as many world-class researchers of personalized medicine in psychiatry.
have done. The most exciting psychiatric This technology holds the promise of
research in the 21st century is linked to revolutionizing the diagnosis and treat
neuroscience, and all the leaders in our ment of mental illness.
field now have some kind of biological or In light of these advances, Ahmeds
neurological training. At the same time, generation would be the one to finally
there is still steady progress in psycho close the gap between psychodynamic
therapy. Cognitive-behavioral therapy, constructs and biological mechanisms
one of the most effective forms of psy and given his own abilities and passions,
chotherapy for depression, has recently he could lead the way. Ahmed is now
been adapted by psychodynamic pioneer conducting an innovative project on
Aaron Beck to treat the negative symp the pathophysiology of psychotic disor
toms of patients with schizophrenia. ders. Ironically, despite maintaining his
Another promising area of research focus on neuroscience research, he has
is genetics. It is virtually certain that no shown himself to be a most empathic
single gene alone is responsible for any and skilled psychotherapist. To my mind,
particular mental illness, but through he personifies the 21st-century psychia
genetic techniques we are starting to trist. No longer an alienist, shrink, pill-
understand how certain patterns or pusher, or reductionist neuroscientist, he
networks of genes confer levels of risk. has become a compassionate and plural
These genetic signatures will lead to istic psychiatric physician.
more precise diagnosis of patients, as
well as earlier identification of those JEFFREY LIEBERMAN,
Shrinks
vulnerable to severe mental illness. The
M.D., former president of
Actress Glenn Closes family pro U ntold theAmerican Psychiatric
vided one of the first examples of the Story Association, is the Law
of
application of genetics in psychiatry. In Psychiatry rence C. Kolb professor
2011, her sister Jessie and nephew Calen, and the chair of psychia
both havinga mental illness, volunteered try atColumbia. Heisthe
Jeffrey
for a study led by Deborah Levy, a psy Lieberman, MO author of Shrinks: The
with O gj Ogas
chologist at Harvard. An analysis ofjes-
Untold Story of Psychiatry.
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