Robert P. Liberman, M.D. is one of the fathers of the rehabilitation movement in psychiatry. For the past 25 years he has directed the UCLA Center for Research on Treatment and Rehabilitation of Psychosis, where he studies skills training and other treatments for individuals with severe mental illnesses like schizophrenia. Diagnosed with bipolar II illness himself, he has been a tireless advocate for the greater availability of information and worked to improve access to the most effective treatments for patients and families. In Part I of this interview, found in the Donny Osmond issue of ABILITY Magazine, Dr. Liberman discussed the reasons mental health care often fails to meet the needs of patients with severe mental illness and their families, and what changes are needed. Dr. Liberman also discussed some of his own experiences with depressive episodes.
ABILITY Magazine’s editor-in-chief, Chet Cooper, and health editor, Gillian Friedman, M.D., continue the interview with Dr. Liberman at his office on the campus of UCLA.
Dr. Gillian Friedman: What treatments were offered to you as you began seeking help early in your illness?
Chet Cooper: Looking back, do you think another approach might have helped you come out of your depressions more quickly?
RL: Yes, I know I would have benefited from earlier identification and treatment of my depressions when I was younger. Unfortunately, general physicians even now are not trained to diagnose depression nor to treat it effectively, despite the fact the vast majority of persons with mood disorders are seen only by primary care doctors. I would also have benefited considerably if the psychiatrists with whom I consulted had offered me better education about the nature of my disorder, the spectrum of available treatments, how to recognize the early warning signs of relapse and the importance of family involvement and support. Good physicians are not only competent in a technical sense, but they must also be good teachers and able to collaborate with their patients so that treatment is a joint undertaking.
GF: At their worst, how bad did your depressive episodes get?
RL: The worst depression was the last one. Recurrent depressions often worsen over time. I had gone eight years without a depression when one recurred in 1994. I had just spent a feverish period coordinating the work of more than fifty scientist-clinicians from UCLA to complete an application to the National Institute of Mental Health (NIMH) for renewal of our mental health research center grant. In academia people tend to work in their own labs rather than in large groups, so getting a number of researchers together for a large proposal can be quite a task. We finally met the deadline and sent our four hundred page document to Washington, DC. Given the switch from a lengthy period of high energy and productivity, it was understandable that within a few days of submitting the grant application I fell into another depression.
GF: How did you react?
RL: I returned to the psychiatrist who had helped me with my previous depression and he wisely prescribed the same medication that had been effective in the past. Unfortunately, it didn’t work this time. We tried a variety of other medication combinations, but nothing worked very well. Still, I continued to fulfill my daily responsibilities in teaching, research and seeing patients. Nevertheless, my depression got worse and reached a crisis level three months later when I returned from a lecture tour in Europe.
During that trip, I pushed myself and hid my depression, but at great personal cost. I remember coming back from this hectic 3-week trip, landing at LAX, and feeling that I just couldn’t continue. I called my psychiatrist from the airport and said, “I’m running on empty. I feel as though I’ve fallen into a deep, black hole and can’t climb out.” I had lost all of my interests, pleasures, effervescence and confidence. Recognizing my desperation, my psychiatrist arranged to see me in two days and requested I bring my wife to help in decision-making.
GF: What happened at that session?
RL: I was fortunate to have a psychiatrist who is very smart and invites the participation of his patients and relatives in planning treatment. He said to us, “We have a couple of alternatives. One is to continue some other drug treatments that we haven’t yet tried, and the other is electroconvulsive therapy (ECT, or “shock therapy”). As a psychiatrist, I knew that ECT was the very best treatment for depressions, especially severe ones that haven’t responded to medications. Also, ECT is much more rapidly effective. It didn’t take much time for me to decide. I said, “I want ECT.” That was a wonderful decision, given the rapid improvement that ensued.
CC: What was your supervisor’s reaction to your decision to try ECT?
RL: I told my supervisor at UCLA that I had been depressed and was proceeding with ECT. He was very supportive and encouraged me to take as much time off as I needed to recover. Fortunately he was trained in England where ECT is commonly used for depression and is respected as the most effective treatment for mood disorders. English psychiatrists and laypeople do not share the stigma that ECT often engenders in the US. If ECT is good enough for Queen Elizabeth and luminaries in British scientific, literary and artistic circles, then it should be good enough for anyone.
GF: How long did it take for ECT to bring you out of your depression?
RL: It was remarkably and mercifully fast. Within three ECT treatments, I was feeling optimistic and on track again. I even led a team of colleagues to Washington, DC where we were successful in passing a stringent review of our grant application. After six treatments I felt like my normal self and regained my zest for life. I continued for a total of twelve ECT treatments, which is the standard number for serious depressions. To maintain its benefits, I take an antidepressant and a mood stabilizer, and I have been completely well now for over eight years. If I ever get depressed again, I’ll go right to ECT from the start. It’s a fabulous treatment. Thousands of individuals with depression in our country are dysfunctional and unnecessarily in pain because of the under-use of ECT. It would help to educate the public and professionals on the realities of ECT if more articles like one recently published in the Los Angeles Times would reach the media.
CC: How does ECT work?
RL: Nobody knows for sure. Obviously it stimulates the neuronal circuits in the brain that are responsible for regulating our moods. There are a lot of theories about the specific mechanisms in the brain that are normalized by ECT, including changes in the way neurotransmitters and their receptors, the so-called chemical messengers, function. However, no one has really nailed down the actual events in the brain that are responsible for reversing depression, either with ECT or antidepressant medications. One way to think about ECT or medications is that they operate like jump-starting or charging the battery of a car to get it moving again.
CC: Have you been reluctant to describe your experiences with ECT and medications to the public or to your colleagues?
RL: One shouldn’t publicize anything that’s personal or related to matters of health over a loudspeaker. It’s important to think before you speak and ask yourself, “What good will it do for me to tell others about my mood disorder and the treatments that have helped me to recover?” For example, I’ve told educational groups of patients who are reluctant to take medications about my own positive experiences with medications, since this has been shown to overcome their resistances and to improve their adherence to their prescribed treatment. Recently I was evaluating a young man who was having a very hard time accepting his bipolar disorder and the need to take medications for the rest of his life. My disclosure of my own favorable experiences to him made an immediate impact, and he’s now determined to participate actively in his treatment and gain control over his illness.
For the same reason, I was eager to talk to you and have my story presented in ABILITY Magazine, because it is another opportunity to reach a larger audience that needs educating about mood disorders, the most common of all mental or brain disorders and some of the most disabling diseases known to mankind. There will continue to be stigma about mental illness unless psychiatrists and other mental health professionals talk openly, positively and matter-of-factly about the treatments available and how they restore people to productive, satisfying, full and happy lives.
CC: How do other psychiatrists and mental health professionals react to your openness in disclosing your bipolar II disorder and your history of recurrent depressions?
RL: First of all, it’s important to understand that one doesn’t go around with a sign reading bipolar II disorder hung around one’s neck. Self-disclosure is important when it can be helpful to others, especially patients and their family members, but also for professional peers who carry stigma toward the very disorders they are paid to treat. Having said that, I have gotten very positive comments from colleagues who have attended my lectures where I have talked judiciously about my illness and recovery. In particular, peers in psychiatry who have hidden the successful treatment of their own disorders often engage me in lively discussions about whether revealing their personal stories could reduce the tension in their professional milieus and relationships. I am often told, with good reason, that it is much easier for me to talk publicly about my mood disorder because my career is protected by academic freedom, the security of tenure and a highly productive professional life. While this statement is very likely correct, mental health professionals who avoid being role models lose the opportunity to reinforce the benefits of treatment and recovery in restoring a normal and happy quality of life.
GF: How do your medical students and psychiatric residents respond when you discuss your bipolar II illness?
RL: When I have disclosed my recovery from a lifelong mood disorder to patients, as a means of motivating them to accept treatment even if it involves indefinite use of medications, residents (doctors in training to be psychiatrists) appear to ignore or not hear what I’ve said. The stigma of mental illness and its treatment is so great among psychiatrists—both those in practice and those in training—that they prefer to pretend that it doesn’t affect physicians, only their patients. It is not until I sit down with a resident or colleague and open a discussion about the usefulness of self-disclosure in helping our patients that I finally break through the stigma barrier. One recent survey of psychiatric residents discovered that, while most of them who were receiving psychotherapy had disclosed this to their peers and supervisors, very few who were taking psychiatric medications revealed this aspect of their treatment. These young psychiatrists still were endorsing the dichotomy between mind and body, a distinction that was abolished by modern science since the death of Descartes more than three hundred years ago. Psychiatrists as well as laypeople hate to think that their mental, behavioral and functional status is related biologically to their brains; they’re still subscribing to willpower, grit and determination, sometimes aided by a very weakly effective psychotherapy.
CC: As an internationally renowned psychiatrist who, at the same time, is a person who has received treatment for a mood disorder and recovered, have you ever talked with representatives of groups who view themselves as having been abused or harmed by psychiatry, called “survivors of psychiatry?”
RL: I had an interesting experience once. I was a speaker at a statewide conference in Illinois concerning treatment and rehabilitation of people with serious mental illnesses. One of the other psychiatrists invited to talk was a big protagonist for recovery from schizophrenia and other mental illnesses without any treatment other than self-help and social support from other consumers or survivors.
GF: Do these folks believe that you can simply “Just Say No” to schizophrenia and it will go away?
RL: In a matter of speaking, yes. Some of them believe that mental illness is a myth foisted upon citizens who are different, unique, special or behave in bizarre ways simply because they are following their own path in life. Others believe that mental illnesses are real disorders, but that medications, ECT and other services offered by professionals are more harmful than helpful. There is some hypocrisy in many of these proponents of “survival from psychiatry.” For example, the psychiatrist who shared the podium with me at that conference in Illinois told the audience of mental health professionals that he worked part-time in a mental health clinic and did give medications to some of his patients. He also described his own aversive experience with psychiatric treatment of what he claimed was schizophrenia (but was much more likely a brief, reactive psychosis or some less severe and transient disorder) and how he was able to cure himself by faith, self-help and support from other consumers and survivors. Once he concluded, I described my very positive experiences with psychiatric treatment for my mood disorder, including the benefits I obtained from a hospitalization, medications and ECT. I forcefully indicted people who smugly opposed and stereotyped mental care in pejorative ways, pointing out how such negativism serves only to stack stigma ever higher against the hundreds of thousands of persons with mental disorders and, consequently, poisons their need and interest in effective treatments. He was taken aback, his mouth was agape and he was speechless. After regaining his composure, he leaned toward me and whispered, “I didn’t know you had a mental disorder and got treatment.” In effect, I took the wind out of his sails and exposed his pompous posturing for what it was—principally a means for developing a career as a spokesperson for the survivor movement.
GF: Is the national residency review committee considering the importance of more exposure to the rehabilitation model in psychiatric training for the new generation of psychiatrists?
RL: There is some lip-service movement. When residency requirements and board certification requirements change, that means psychiatric education will change. But even more important is when the payment contingencies change. As long as marriage and family therapists, psychologists, social workers and psychiatrists get paid whether or not they use the techniques that have been shown to be more effective through various kinds of research, why should they change? Why shouldn’t they continue to provide treatment the way they’ve always done it? “Give them medication. Why do I have to do anything more than that? Why do I have to invite the family in? It’s complicated, I’m uncomfortable talking with families!” Surgeons have to change, because if they don’t improve their methods they have more fatalities. They can lose their privileges in the hospital, and their colleagues aren’t going to refer people to them if they continue to do traditional prostate biopsies instead of sonograms and skinny needle biopsies. There is general acceptance of better techniques based on the research that is published. But the payment contingencies don’t seem to change in psychiatry. You are paid by patients, insurance companies, Medicare or public mental health programs no matter what your treatment might be because the standards of quality have not yet incorporated evidence-based, validated treatments. Until fiscal contingencies force psychiatry to develop and accept standards for effective, quality care similar to those that have impacted other medical specialties, progress in our field will proceed at a snail’s pace.
GF: Do you believe the financial constraints in psychiatry contribute to the lack of progress in the adoption of evidence-based services? Managed care and public psychiatry are areas where available funds don’t appear sufficient to provide good quality services.
RL: Fiscal constraints will always operate in psychiatry and medicine—just as they do in all areas of civic life, business and government. In fact, the United States is blessed with far more psychiatrists per capita than any other country in the world, let alone other mental health professionals. The point is not lack of funds, but rather how those funds are allocated, for what problems, with what techniques, by whom, when and where. Lack of funds is a reality for those of us who are captives of outdated systems of care, methods of treatment, and modes of training and continuing education. The only way for us to free ourselves is a major reform of our entire healthcare system. This will require reorganizing and redeploying personnel which is anathema to the American way of making decisions. With professional organizations, insurance companies, government-supported systems of care, labor unions and other interest groups pressuring and lobbying legislators to maintain the status quo or shift funds from one sector to another, little or no progress will occur. The system of care—both in medicine and psychiatry—will have to reach crisis proportions and implode before true reform and reorganization can bring a better level of care to the vast majority of our nation’s population. The economic tail always wags the clinical dog. Whether the payments and reimbursements for mental health services can be made contingent upon evidence-based, efficiently organized and valuable treatment priorities is very much up in the air. We should never underestimate the resistance of self-interested individuals, groups and systems of care to change how and what they practice.