Clash of the psychiatric titans
Some 30 years later, the Snow-Leavis debate was recapitulated in psychiatry. This was a clash of psychiatric titans carried out in the pages of the American Journal of Psychiatry in 1990. Arguing from the corner of science was one of the most eminent biological psychiatrists of the time—Gerald Klerman, MD. Klerman had been a psychiatric expert retained by Osheroff and spoke with experience of the case as well as with his recognized authority in American psychiatry. Representing the corner of traditional psychiatry, and thus psychoanalytically informed psychiatry, was Alan Stone, MD, whose undisputed authority in both law and psychiatry provided the balanced matchup for Klerman.
Klerman’s opening salvo was powerful to the point of authoritarian: he proclaimed that there should be a legally recognized “right to effective treatment.” He invoked the scientific powers made famous by Archie Cochrane, stressing the centrality of the randomized controlled trial (RCT) and that “the issue is not psychotherapy versus biological therapy but, rather, opinion versus evidence.”10 In fact, Klerman seemed prepared to annihilate all forms of treatment that had not been supported by an RCT. Leveling his psychiatric authority down on all “lesser” forms of knowledge, he warned: “practitioners and institutions who continue to rely on forms of treatment with limited efficacy will be on the defensive and at possible jeopardy for legal action.”6
Stone’s response was as powerful as Klerman’s but differed in style. Stone began by refuting Klerman’s notions about the law. It was Stone’s opinion that Klerman should have limited himself to stating that using exclusively psychoanalytic treatment for Osheroff was not clinically acceptable—a point with which Stone agreed. However, Stone was very concerned about Klerman’s threat to dictate a “universal rule set by one school of psychiatry for the others.” He went on to point out that the Osheroff case was more complex than “the pills worked.”5
Stone questioned the very nature and reliability of efficacy research in psychiatry and followed with a suggestion that there may have been more to Osheroff’s improvement than mere medications. Stone warned that Klerman’s edicts would “repudiate the traditional commitment of both the law and psychiatry to diversity” and could become “detrimental, even to the aspirations of ‘scientific psychiatry.’” Stone revealed his motivating intent as freedom—in particular, the freedom to consider both science and the humanities, which seems to be necessary for psychiatry to avoid a scientific dictatorship.
2. Shapiro SJ. The “Hart-Dworkin” Debate: A Short Guide for the Perplexed. February 2, 2007. U of Michigan Public Law Working Paper No. 77. http://dx.doi.org/10.2139/ssrn.968657. Accessed January 24, 2013.
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5. Robertson M. Power and knowledge in psychiatry and the troubling case of Dr Osheroff. Australas Psychiatry. 2005;13:343-350.
6. Klerman GL. The psychiatric patient’s right to effective treatment: implications of Osheroff v Chestnut Lodge. Am J Psychiatry. 1990;147:409-418.
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8. Snow CP. The Two Cultures: And a Second Look. New York: Cambridge University Press; 1963.
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11. Klerman GL. The Osheroff debate: finale. Am J Psychiatry. 1991;148:387-390.
12. Borrell-Carrió F, Suchman AL, Epstein RM. The biopsychosocial model 25 years later: principles, practice, and scientific inquiry. Ann Fam Med. 2004;2:576-582.
13. Freud S. The future chances of psychoanalytic therapy. Selected Papers on Hysteria and Other Psychoneuroses. http://www.bartleby.com/280. Accessed January 24, 2013.
14. Perry JC, Bond M. Change in defense mechanisms during long-term dynamic psychotherapy and five-year outcome. Am J Psychiatry. 2012;169:916-925.
15. Gerber AJ, Kocsis JH, Milrod BL, et al. A quality-based review of randomized controlled trials of psychodynamic psychotherapy. Am J Psychiatry. 2011;168:19-28.
16. Gabbard GO. Long-Term Psychodynamic Psychotherapy: A Basic Text. 2nd ed. Arlington, VA: American Psychiatric Publishing, Inc; 2010.
17. Shedler J. The efficacy of psychodynamic psychotherapy. Am Psychol. 2010;65:98-109.
18. Douglas CJ. Studying the efficacy of psychodynamic psychotherapy. Am J Psychiatry. 2011;168:649-650.
19. Vaillant G. Lifting the field’s “repression” of defenses. Am J Psychiatry. 2012;169:885-887.
20. Dennett DC. Facing Backwards on the Problem of Consciousness. November 10, 1995. http://ase.tufts.edu/cogstud/papers/chalmers.htm. Accessed January 24, 2013.
References1. National Endowment for the Humanities. National Foundation on the Arts and the Humanities Act of 1965 (P.L. 89-209). http://www.neh.gov/about/history/national-foundation-arts-and-humanities-act-1965-pl-89-209. Accessed January 24, 2013.