Credo Quia Absurdum Est

 I'm glad I read Mad Science before I read Allen Frances's Saving Normal, because it gave me a grounding against which to read Frances's rather biased presentation.  His survey of the overuse of psychotropic drugs, for example, puts all the blame on Big Pharma for pushing all those medications and on the public for demanding them.  He admits that psychiatrists should have stood their ground against the hordes of Better Living Through Chemistry, but it wasn't their fault.  Nobody could have foreseen the diagnostic inflation that misused the Diagnostic and Stastical Manual III and IV, even though diagnostic inflation had historically been a problem in medicine and psychiatry, and the overuse of drugs was no novelty either.

But some things would have made me skeptical anyway.  Try this excerpt from Frances's discussion of diagnostic fads, past and present.  He calls Demonic Possession a fad, though he admits it's thousands of years old and never really went away, but he has a theme to sustain in this chapter, okay?

The belief in demonic control is universal across cultures and enduring through time because it makes so much sense to most people; it taps into something basic in human psychology and explains a large part of human experience in a simple and plausible way.  The battle against demons appeals to the theological mind; cures most of the system that ails us; ministers to the soul; and binds the tribe.  Demons are a completely logical, if prescientific, way of understanding the changes caused by psychiatric and medical illness (and also by drugs, dreams, and trance states).  It appears silly only to us children of the Enlightenment who believe in biological causes of strange behavior.  But there is one unavoidable problem with this otherwise useful diagnostic category -- it has provided a wonderful excuse for the persecution, torture, and murder of the mentally ill.  The very most inhumane treatment could easily be justified on the spurious grounds that it was part of a holy fight against the devil [119].

The "theological mind" is actually the rational mind, bearing "Garbage In, Garbage Out" in mind: logic is only as valid as the premises it begins from.  The demonology of the late Middle Ages was highly rationalist, as the historian Hugh Trevor Roper wrote in The European Witch Craze of the Sixteen and Seventeenth Centuries, "The sixteenth-century clergy and lawyers were rationalists. They believed in a rational, Aristotelean universe, and from the detailed identity of witches’ confessions they logically deduced their objective truth."

The same applies to modern science, including outliers like psychiatry.  Notice Frances's proud claim to be a child "of the Enlightenment who believe[s] in biological causes of strange behavior."  Earlier in Saving Normal he devoted a chapter to a glib, simplistic, and misleadingly linear history of approaches to understanding and treating madness, which he depicted as a brave march toward the recognition of biological causes of strange behavior -- even though he admitted at the beginning of the book that "Billions of research dollars have failed to produce convincing evidence that any mental disorder is a discrete disease entity with a unitary cause" (19).  There is, in other words, no scientific evidence that mental disorder does have biological causes, but Allen Frances has true faith and won't be led astray by the absence of evidence.

The concluding two sentences are completely wrong.  First, there's no inherent reason why belief in demon possession should lead to cruel treatment of the victim, particularly in Christendom.  Jesus was a pre-eminent exorcist, and the gospels teach that Christians will be empowered to follow his example: they contain a fair amount of advice for driving out demons.  Jesus freed people from demonic possession not by beating or torturing them, but expelled them by divine power: he ordered them to leave, and they had to obey.  Occasionally he encountered resistance, as when the demons would counter that they knew his true identity ("I know who you are: the Holy One of God!"), which should have given them power over him, but it didn't even faze Jesus; he ordered them out, and they obeyed.  One powerful argument against the claims of Christianity, especially modern Christianity, is that its practitioners can't drive out demons with the power Jesus promised them.

Second, modern psychiatry has its own history of inhumane treatment of the mad.  In addition to the interventions I mentioned and criticized in previous posts, proponents of Assertive Community Treatment endorsed coercion against patients on the ground that they were "Obviously … not … a group of fragile, broken-spirited persons but rather … tough, formidable adversaries who were 'pros' and who had successfully contended with many different staffs on various wards in defending their title of 'chronic schizophrenic'" (quoted in Mad Science, 99-100).  Even the comparatively mild use of psychotropic drugs, prescribed to patients with abandon whether they needed them or not, has a serious downside: some of those drugs' adverse effects include anxiety and suicidal ideation; they may bring on diabetes and other serious physical conditions, and patients on such medications have a significantly lower life expectancy than other people.  All this despite the fact that these drugs are not much (if any) more effective as treatment than placebos.  I'd say that punitive, abusive attitudes toward the mentally ill aren't a result of theology or a rejection of the Enlightenment, but of the practitioner's temperament.

There are some problems, then, at the core of Allen Frances's apologia for modern psychiatry.  Like any apologist, the need to defend his faith leads him to distort the facts in predictable directions.  That's too bad: his intentions are good, but good intentions aren't enough.

Doing the Same Thing Over and Over Again and Expecting Different Results

Something I forgot to put into yesterday's post -- what the hell, it was long enough already, so I'll just say it here.

It goes along with Allen Frances's attack on people who criticize the illness model of mental disturbance: he implies that those critics are not only out of touch with the hard realities of the world, but that they don't care about the suffering of the mad and the people who love them.  Psychiatrists -- real psychiatrists, not the fake "armchair theorists" -- may not be perfect, but they are at least determined to help those poor people, and they'll go on helping them.

Leave aside the fact that, as I pointed out, his villains are not armchair theorists but actual psychiatrists, psychoanalysts, psychologists, and mental health social workers.  My other difference with Dr. Frances is that it's open to serious question how much orthodox psychiatrists do help their patients.  Think of the days when homosexuality was officially classified as an illness, treatable by the talking cure (probably the least harmful of the options), but also by institutionalization, electroshock and other aversion "therapy", hormone treatments of the kind that were imposed on Alan Turing.  Remember that even after homosexuals were no longer officially sick, professionals were still allowed to "treat" us for real and imagined pathology for another thirty years, long after it was known that such therapy didn't work.  Then think of the other orthodox treatments I mentioned in previous posts, such as the Army psychiatrist who forced Vietnamese schizophrenics to work in the hospital gardens by denying them food and submitting them to electroshock, or the Wisconsin doctors who "treated" a violent patient by tormenting her psychologically and then using a cattle prod on her.  Think of the long acceptability of lobotomy and other psychosurgery as "treatment."

But my objection goes beyond these horror stories, important though they are as a reminder of what was considered acceptable by mainstream, scientific, evidence-based psychiatry.  The real problem is that the mental health professions have a surprisingly poor record when it comes to cures, or even improvement, of their patients.  In Mad Science Stuart Kirk, Tomi Gomory, and David Cohen quote a 2001 article in the journal Psychiatric Services which claimed that Assertive Community Treatment was a successful approach because "compared with other treatments under controlled conditions, such as brokered case management or clinical case management, assertive community treatment results in a greater reduction in psychiatric hospitalization and a higher level of housing stability" (103).  As Kirk, Gomory and Cohen point out,

The clinical effectiveness of any treatment is usually measured in symptom reduction, reduced disability, better functioning, or improvements in behavior, self-or other-rated.  What is noteworthy about the quote above is that keeping people out of a hospital or in a community residence is used as the markers of success.  It might come as a surprise then that an award-winning “treatment” program made few claims that it improved patients’ clinical condition.  In fact, Philips et al. admit that “[t]he effects of assertive treatment on quality of life, symptoms, and social functioning are similar to those produced by these other treatments” (p. 771, emphasis added).  In other words, ACT does not reduce the mad behavior or improve the functioning of the severely mentally ill any more than any other approach.  Decades earlier, the ACT inventors admitted: “a change in the site of treatment [from the hospital to the community] says nothing about whether the patient’s clinical status or functioning has improved.  Some would argue that only the place of a person’s suffering has changed” (Test & Stein, 1978, p. 360) [103].

As for the ballyhooed revolution in treatment represented by psychoactive drugs:

The three studies [CATIE, STAR*D, STEP-BD], reportedly costing taxpayers over $100 million, … showed unambiguously that drugs do not make most people considered psychiatrically impaired significantly better for any sustained period of time. Since the studies appeared, mainstream popular and professional reactions suggest that the demonstration has been absorbed, digested, and recycled like every such negative finding over the past sixty years: it appears to have made only a tiny dent in the myth of psychiatric progress [220].

Placebos turn out to be nearly as effective as those very fancy and expensive drugs, whose adverse effects often make it impossible for patients to continue taking them, even if they worked:

But even if we stick to the placebo effect as traditionally defined in drug trials (the measurable therapeutic changes induced by pharmacologically inactive or inert substances), we may consider the conclusion reached by psychologists Seymour Fisher and Roger Greenberg.  After one of the most insightful, restrained, and evidence-informed reviews in the entire literature on antipsychotics, stimulants, antidepressants, and anxiolytics, these two authors stated, “that when proper controls are introduced [in research studies] the differences in therapeutic power between the active drugs and placebos largely recede” (1997, p.382).  It is sobering for anyone to reflect that merely introducing “proper controls” in scientific research would doom the modern psychopharmacologic enterprise [232].

And in any case, "… Big Pharma has signaled its withdrawal from psychiatric drugs since most lucrative patents from the 1990s are expiring or have expired" (317).

This doesn't mean that mental health professionals never do their patients any good: the subject here is their overall track record.  Here's where I regard Stuart, Gomory and Cohen with the same skepticism I direct at Allen Frances.  "People who are distressed or misbehaving can be helped without inferring some, as yet undiscovered, neurological defects," they write (321), but I'm not clear on how those distressed people can be helped.  I hope they can, but mostly the help seems to boil down to the ancient Hippocratic injunction, First, do no harm.  Even that has been often beyond the power of the mental health professions.  To say that isn't to deny that people suffer, or make other people suffer: of course they do.  But to admit that doesn't license any and all clinical interventions on the ground that we've got to do something.  Not doing something upsets many people, but sometimes nothing is the best you can do.

But This Diagnosis Is Just Right!

I've begun reading Saving Normal: An Insider's Revolt Against Out-of-Control Psychiatric Diagnosis, DSM-5, Big Pharma, and the Medicalization of Ordinary Life (Morrow, 2013), by Allen Frances.  Frances, now retired from his profession, was chairman of the American Psychiatric Association task force that produced the fourth edition of the Diagnostic and Statistical Manual, or DSM-IV, so his "revolt" is noteworthy.  Saving Normal appeared on the library shelf at almost the same time as Mad Science, so I picked it up even though I didn't know at the time who Frances was.

Frances confirms some key claims of Mad Science, for example that

Billions of research dollars have failed to produce convincing evidence that any mental disorder is a discrete disease entity with a unitary cause.  Dozens of different candidate genes have been "found," but in follow-up studies each turned out to be fool's gold.  Mental disorders are too heterogeneous in presentation and in causality to be considered single diseases; instead each of our currently defined diseases will eventually turn out to be many different diseases [19].

But this admission occurs in the context of a bad argument:

Some radical critics of psychiatry have seized on its definitional ambiguities to argue that the profession should not exist at all.  They take the difficulty in finding a clear definition of mental disorder as evidence that the concept has no useful meaning -- if mental disorders are not anatomically defined medical diseases, they must be "myths," and there is no real need to bother diagnosing them ... "Saving normal" is taken by them to its logical extreme -- the extremely illogical position that everyone is normal.

Frances equivocates here, between "mental illness" and "mental disorder," though it may be that the vagueness of the term "mental disorder" is part of its usefulness.  That might not be a problem if psychiatrists hadn't long claimed, and continue to claim, that mental disorders are anatomically defined medical diseases, despite the absence of evidence for that claim.  Notice that in the first passage I quoted, Frances claims that "each of our currently defined disorders will eventually turn out to be many different diseases"; there's no evidence for that one either.

(Incidentally, Frances doesn't seem to consider the useful distinction between "normal" and "normative" in his discussion.  What is "normative" -- accepted by a society as the proper way to behave -- is not necessarily "normal" in the sense of widespread or prevalent.  Confusion between those senses of the word "norm" often leads to problems in disagreements about society and its values.)

Now, as I wrote yesterday, it doesn't follow that because "mental disorders" are not (as far as we know) anatomically defined medical diseases, that people don't suffer from them, or that they shouldn't be helped to feel better.  Frances doesn't cite or any quote specific offenders who declare that there is no real need to bother diagnosing them.  The logical question would be more along the lines of: if these problems are not diseases, is "diagnosis" the right word for trying to make sense of them, even to classify them?  The very word "diagnose" begs the question by implying that we are dealing with diseases, that a medical metaphor is a good way to make sense of them.  The authors of Mad Science wrote, for example:

A fidgety boy or an adult who thinks the devil is out to kill him does not need to be labeled as suffering from a brain disease called Hyperactivity Disorder or Delusional Disorder. They are more usefully and honestly called … a fidgety boy and a person with incredible, scary beliefs. People who are distressed or misbehaving can be helped without inferring some, as yet undiscovered, neurological defects [321-322].

To say that mental illness is a "myth" doesn't mean that people aren't suffering: it means that the word "mental illness" imposes a conception of what is wrong with such people that attempts to make sense of it, without regard to whether it's accurate.  (Analogously, Robert Wilken's The Myth of Christian Beginnings didn't deny that Christianity began at some point in time: it discussed a myth about those beginnings.)  As Thomas Szasz (presumably one of the "radicals" Frances is attacking), wrote in 1960:

While I have argued that mental illnesses do not exist, I obviously did not imply that the social and psychological occurrences to which this label is currently being attached also do not exist.  Like the personal and social troubles which people had in the Middle Ages, they are real enough.  It is the labels we give them that concerns us and, having labelled them, what we do about them.

"Mental illness" is an analogy whose structure posits that minds can be ill just as bodies can be ill.  Maybe psychiatrists would have a stronger case if they stopped claiming that mental illnesses have a physical basis, and take advantage of the fact that the mind is inaccessible to direct measurement and diagnosis.  But to do so would undermine their efforts to establish psychiatry as a science.  "Disorder" is not much better, because it's used in medicine to refer to physical ailments and is probably borrowed by analogy for mental ones: again, it assumes what needs to be proved.

Frances goes on to declare:

This shibboleth can be believed only by armchair theorists with no real life experience in having, living with, or treating mental illness.  However difficult to define, psychiatric disorder is an all-too-painful reality for those who suffer from it and for those who care about them [18].

As already noted, those "radical critics" don't deny that people diagnosed with "mental illness" really are suffering, so that part is a straw man.  Thomas Szasz, probably the most prominent of the radical critics, was not an "armchair theorist with no real life experience": he was a psychiatrist by training, with years of clinical experience.  R. D. Laing, another radical theorist unnamed by Frances, also was a psychiatrist with clinical experience in dealing with "mentally distressed people."   Some laypeople probably misunderstood these men's theories, but the same can be said of laypeople who garble mainstream psychiatric theory and practice.  Frances's dismissal of them as "armchair theorists" is profoundly and disturbingly dishonest.

Frances goes on to offer an analogy between psychiatric diagnosis and umpiring in baseball.  He imagines three thought-umpires with "competing opinions on how well we can ever apprehend reality":

Umpire One: "There are balls and there are strikes and I call them as they are."

Umpire Two: "There are balls and there are strikes and I call them as I see them."

Umpire Three: "There are no balls and there are no strikes until I call them."

Umpire One believes that mental disorders are real "diseases"; Umpire Three that they are fanciful "myths"; Umpire Two that they are something in between -- useful constructs that provide no more (but no less) than a best current guess on how to sort psychiatric distress [19].

This, of course, is the ever-popular The-Truth-Lies-Somewhere-In-Between move, and as usual, the middle of the road just happens to be where Allen Frances is standing.  As I've already argued, Umpire Three is a straw man.  Umpire One is the mainstream of contemporary psychiatry.  But the position of Umpire Two, as Frances explicates it, doesn't help his argument; I'd say that it actually undermines it.

Balls and strikes are constructs, as he says: they can be defined by objective, clearly defined criteria (which is more than can be said for Frances's "mental disorders").  They did not exist, however, until human beings created and defined them.  Those definitions can and do change, not to achieve a better approximation of reality, but "in an attempt to control the balance of power between pitchers and hitters."  In principle, they could be completely abolished and replaced with a different classification for pitches that batters don't intercept.  This is not the lesson Frances wants us to take away from his analogy.

Now consider a couple of cases.  Stuart, Gomory and Cohen pointed out in Mad Science that "many women were identified and sorted into an early category of 'witches,' but that sorting did nothing to establish the validity of the idea of witches" (174).  Indeed, credentialed professionals wrote diagnostic manuals to enable reliable diagnoses of witches.  Later radical critics -- mostly,  no doubt, armchair theorists with no real life experience in having, living with, or dealing with witches -- denied that there was any such thing as witchcraft, and therefore no real witches.  Some revisionists argued that there were real witches, but they were good people, unjustly vilified and persecuted by the patriarchal church.  Others, moderates like Umpire Two, argued that there were witches, but they had been misdiagnosed: they were really mentally ill, not worshipers of Satan.  It was less often argued that their accusers were delusional, but given the quality of the evidence available, armchair diagnosis at a remove of centuries ought to be attempted with more humility and caution than most of its practitioners have displayed.

Next, consider the case of homosexuality.  Kirk, Gomory and Cohen argue in Mad Science that the removal of homosexuality from DSM in 1973 constituted part of the crisis of legitimacy in psychiatry that led to the 1980 DSM-III.  How could homosexuality go from disease to health virtually overnight?  In fact, it didn't quite happen that way.  First, the status of homosexuality had been disputed in the mental health professions for many years, as exemplified by Sigmund Freud's statement that "it cannot be classified as an illness" in a 1936 letter to an American mother.  Second, though homosexuality itself was depathologized, the APA continued to classify distress over being gay as an illness eligible for treatment, and didn't condemn change therapy for another thirty years.  Third, the opponents of the change were correct that it was largely motivated by "politics"; but the original classification had been no less political, based on social prejudice rather than scientific evidence.  The trouble was that this was true for most psychiatric diagnoses, which is why Robert Spitzer set out to revise the DSM to provide a scientific patina of reliability for diagnosis in the future.

So: there were those who saw homosexuality as an obvious dread disorder; there were those, no doubt armchair theorists with no real life experience in having, living with, or dealing with homosexuality, who denied that there was any such thing as a homosexual; then there are those in the middle, who only wanted to help those poor souls struggling with same-sex desires.  Many gay people do feel distress about being gay, and it can be argued that this is due to social pressure from an antigay environment.  But how does a clinician decide?  How do those tasked with defining diagnoses of "mental disorders" tell?

Ironically, the current trend, championed by psychologists and the main stream of the American gay movement, is to insist that homosexuality is a biologically based condition; it may even be physically inscribed in the brain.  If Simon LeVay's research had been available to the APA in 1973, maybe homosexuality could have remained in the DSM -- though that was the opposite of LeVay's intention  in doing his work.  Despite this, I haven't heard of any attempts in the APA to reinstate homosexuality as a diagnosis, no doubt for political reasons.  The status of homosexuality (which isn't listed in Frances's index; I don't know if he'll discuss this ancient history in the pages to come) is a stumbling block for the whole question of psychiatric diagnosis.

I'm going to continue reading Saving Normal, to see what else I can learn from Frances's perspective, but I'll be reading critically, with appropriate skepticism.  He may be engaged in a revolt against some practices of his profession, but he's still a very protective insider.