Robert P. Liberman on Electroconvulsive Therapy
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 Magazines 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?
Dr. Robert P. Liberman: Two of my previous episodes of treatment were
treated by psychiatrists who were proponents of traditional psychodynamic
psychotherapy [a treatment derived from psychoanalysis that focuses on
understanding the origins of feelings rather than directly trying to change
behavior or thinking patterns]. Despite the fact that I did not benefit
from their ministrations and even got worse, these psychiatrists never
suggested to me that I might improve with antidepressant medication. Its
like the adage, If you only have a hammer, then you only see nails.
Psychiatrists who are trained and experienced in only one type of treatmentwhether
it is pharmacology or psychotherapywill provide that one type of
treatment throughout their careers. If advocacy organizations, like the
National Alliance of the Mentally Ill (NAMI) or the Depression & Bipolar
Alliance, had existed when I first began having depressive episodes, I
probably would have been more assertive in asking for the best validated
treatments rather than submitting passively to whatever treatment the
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 didnt 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 couldnt continue. I called my psychiatrist
from the airport and said, Im running on empty. I feel as
though Ive fallen into a deep, black hole and cant 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 havent 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 havent responded to medications. Also,
ECT is much more rapidly effective. It didnt 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 supervisors reaction to your decision to try
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,
Ill go right to ECT from the start. Its 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
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 shouldnt publicize anything thats personal or related
to matters of health over a loudspeaker. Its 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, Ive 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 hes 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, its important to understand that one doesnt
go around with a sign reading bipolar II disorder hung around ones
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 Ive said.
The stigma of mental illness and its treatment is so great among psychiatristsboth
those in practice and those in trainingthat they prefer to pretend
that it doesnt 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; theyre still subscribing
to willpower, grit and determination, sometimes aided by a very weakly
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
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
didnt 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 wasprincipally 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 shouldnt they continue to provide treatment
the way theyve 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? Its complicated, Im uncomfortable talking with families!
Surgeons have to change, because if they dont improve their methods
they have more fatalities. They can lose their privileges in the hospital,
and their colleagues arent 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
dont 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 snails 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 dont
appear sufficient to provide good quality services.
RL: Fiscal constraints will always operate in psychiatry and medicinejust
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 careboth in medicine
and psychiatrywill 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 nations 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.
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