Saturday, July 13, 2013

Appealing to Authority

The cartoon above isn't completely off the mark, but it sets up a dubious binary.  Sure, just sitting on your couch and speculating probably won't produce meaningful criticism or dissent.  But it might: it depends on who's sitting on the couch and speculating.  The corporate media are well-known for choosing experts and critics by inexplicable criteria, and of setting up supposed antagonists who basically agree with each other in hopes of getting a mediagenic squabble out of them.

But it's the other pole of the binary that I find interesting.  The cartoonist seems to take for granted that a three-year-study funded by the National Institute of Health and conducted by a doctor will automatically deserve respect, if not fawning obeisance.  This is Science we're talking about here, people!

I don't think that three-year studies published in peer-reviewed journals automatically deserve respect. Scientists and their work, like anyone else, must earn respect.  It's even part of the mythology of Science that scientific work should be approached skeptically and critically, that scientists look at their own and other scientists' work with the aim of tearing it apart, and if it survives this trial by ordeal, it can be anointed as True Knowledge until someone comes along with new knowledge or a better theory and consigns it to the dustbin of history.  Just in principle, then, the fact that a study lasted three years should cut no ice.

It should be remembered that quite a lot of appalling garbage has passed peer review.  Scientific racism, for example, or studies purporting to prove that homosexuality can be cured.  I've mentioned before research, published in peer-reviewed journals, that involved coercing schizophrenic patients to work in the hospital garden by depriving them of food for up to five days, and if that failed, by electroconvulsive "treatment"; that "study" appears to have gone on for some time, maybe even for three years or more.  It's perfectly legitimate to criticize it while sitting on one's couch.

The study I just mentioned was conducted in Vietnam during the US invasion, but such coercive methods were routinely used in the US at the time, and afterwards.  In Mad Science, Stuart A. Kirk, Tomi Gomory and David Cohen discuss research conducted by a founder of the very influential Assertive Community Treatment approach to psychiatric treatment:
Leonard Stein, after replacing Arnold Ludwig as the director of research and education at Mendota State Hospital, coauthored a study with “provocative therapy” advocate Brandsma, entitled “The Use of Punishment as a Treatment Modality: A Case Report” (Brandsma & Stein, 1973). The study examined the value of using involuntary electric shock to reduce the “unprovoked” assaultive behavior of a “retarded, adult, organically damaged” (p. 30) twenty-four-year-old woman. This publication appeared during the time that TCL/ACT community research was already well on its way … and was apparently part of a line of research focused on force and violence as treatment, begun earlier at Mendota State. Ludwig, Marx, Hill, and Browning (1969) had previously published a single-case study on a paranoid schizophrenic patient, entitled “The Control of Violent Behavior through Faradic Shock.” The authors justified this study by its “uniqueness,” because “this procedure was administered against the express will of the patient” (p. 624, emphasis added). They used an electric cattle prod as the “aversive conditioning agent,” because it was “an excellent device for providing a potent, noxious stimulus … capable of producing a faradic shock spike of approximately 1400 volts at 0.5 milliamperes, the resulting pain lasting … as long as the current was permitted to flow” (p. 627) [100-101].
In order to "obtain a 'baseline' measure (a requirement of single-subject design research) of this patient’s assaultive behavior, she was baited and ridiculed so she would respond aggressively (101). Kirk, Gomory and Cohen quote the researchers' account:
The patient was required to sit in an armchair throughout .… During the base rate week the staff quickly developed a consistent provocative approach in order to ensure a high frequency of behavior from the patient … This consistently involved: 1) ignoring the patient in conversation; 2) refusing to give the patient candy or snacks when others were eating them; 3) denying all requests, for example, during the session if she asked if she would be able to go for a walk that afternoon, she was immediately told, “No you can’t.”; 4) refusing to accept her apologies or believe her promises of good behavior; 5) The … female sitting next to her often leading the provocation; 6) using provocative labels for her behavior, i.e., “animalistic, low grade”; 7) discussing family related frustrations, i.e., her mother’s refusal to write or visit, how her dead grandmother would be displeased with her present behavior if she were alive. It should be noticed that throughout the program the patient was kept in a seclusion room at all times except when involved in a baseline or treatment session. (Brandsma & Stein, 1973, pp. 32-33)
This is, I admit, a somewhat extreme case in terms of the methods used, and so easy to disapprove and discredit.  It should be remembered, however, that the study was not fringe science but was published in a mainstream, peer-reviewed journal.  For now my point in citing it is that it can be completely appropriate to dismiss and attack credentialed work when it's blatantly inhumane; no amount of authority can justify the kind of mistreatment these doctors write about so cheerfully.

So let's look at a case that is less obviously troubling: the development of the third edition of the American Psychiatric Association's Diagnostic and Statistical Manual, a process which took six years, from 1974 to publication in 1980.  Kirk, Gomory and Cohen show that a major concern of the psychiatrists who produced DSM-III was to produce reliability in the diagnosis of mental illness, so that different clinicians could agree on the specific mental disorders troubling their patients. They didn't succeed even in doing this, but focusing on reliability enabled them to dodge the question of diagnostic validity -- that is, whether the feelings and behaviors they observed in their patients actually constituted discrete mental illnesses.  To this day, two revisions of the DSM later, that goal has not been achieved.
DSM offers behavioral diagnostic criteria as if they confirm the existence of a valid disorder, when the criteria merely describe what is claimed a priori to be an illness. Descriptive diagnosis is a tautology that distracts observers from recognizing that DSM offers no indicators that establish the validity of any psychiatric illness, although they may typically point to distresses, worries, or misbehaviors [166].
But the detailed, proliferating classifications of DSM-III were highly successful in their way: the book became a best-seller, almost univerally used by psychiatrists, other mental health professionals including social workers, drug companies, and insurance companies.  It facilitated the vastly increased use of psychoactive drugs as medications (despite their questionable effectiveness), and the coverage of such medication under insurance plans by giving nameable disorders to write on billing statements and claims.  But actual diseases -- that is, detectable disorders of the brain manifesting themselves as "mental illness" -- have not been found:
We repeat: no distinct biological determinism has been demonstrated in any mental disorder. For decades this was occasionally acknowledged, but discreetly, deep in textbooks and professional articles, rarely by experts in popular discourse. According to a survey of a probability sample of the US population, conducted by the American Psychiatric Association (2005), 75 percent of people believe that mental disorders result from “chemical imbalances.” But, already, chemical imbalances are pass√©, at least according to the director of the NIMH [251-2].
The speculative physiological basis for mental illness changes continually.  "Chemical imbalances" have fallen by the wayside, and neurobiology is currently a hot topic.  Brain imaging makes pretty pictures that make "wonderful marketing copy" (268):
One reason for the focus on neurobiology in the absence of definitive findings may be the extent to which descriptions of biomedical facts over the last two decades have become tied to technological advances that dazzle observers with their appealing pictures of brain function. Finding that the brains of different people seem to function differently has provided endless fascination for those who see in these differences confirmation that biology “explains” everything disordered in humans. That taxi drivers or musicians show different brain activity on certain spatial or musical tasks than other people seems merely interesting. That depressed people occasionally show different brain functioning than other people, however, “proves” that they’re diseased. This logic is erroneous, because subtle physiological difference might arise from experience or learning; it might be a consequence, not a cause, of the person’s problem diagnosed as a psychiatric disorder. And such difference does not mean “disease” unless the meaning of disease is – as we have been suggesting – distorted beyond recognition [267].
So, just because a credentialed professional publishes the results of years of research in a peer-reviewed journal, his or her work shouldn't automatically be granted authority.  The work might be valid, but it might not, and again the question arises of how a layperson can distinguish valid from invalid science.

One caveat: when I wrote about this problem a couple of years ago, one reader wrote to insist that mental illness is real, that people really do suffer, and their suffering is important.  I'm not denying that human suffering is real and important, but I am saying that "mental illness" may not be a good way of thinking about it, let alone helping those who suffer.  It is, at any rate, not the only way to think about it, or to take it seriously.  I'm going to bring this post to a close, but I'll have more to say on this subject soon.