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.

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 passé, 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.

A Mad Tea Party

Okay, back to other matters. I've quoted before from Michael E. Staub's Madness Is Civilization, (Chicago, 2011). Staub also tells how it became known in 1967 that

... a military psychiatrist named Lloyd H. Cotter had conducted behavioral experiments on patients diagnosed with schizophrenia at the Bien Hoa mental hospital in South Vietnam. Cotter’s stated goal was to help these patients, but it was impossible for critics not to read in Cotter’s report an utter disregard for the terror and suffering he must have brought them. In brief, Cotter had become enamored with “operant conditioning,” a technique devised by psychologist B. F. Skinner that suggested that “positive” and “negative” reinforcements could encourage individuals to give up behaviors deemed undesirable. Cotter had also read how psychiatrist O. Ivar Lovaas had withheld food from autistic children to promote a reduction in their antisocial behavior, and decided he would starve his own “difficult-to-activate patients.” Some patients held out for five days without food before they succumbed to Cotter, but the doctor was in the end able to announce that every single patient had finally “volunteered for work.” Yet this was not all. Cotter further administered to recalcitrant patients unmodified electroconvulsive treatments (a technique already illegal in the United States because it meant patients did not receive anesthetics or muscle relaxants and therefore ran a risk of fractured bones and compression injuries of the spine). Undeterred by the frank chance that he might injure his patients, Cotter announced that he’d given “several thousands” of these shock treatments, and that “our objective of motivating them to work was achieved.” And what kind of work exactly were these patients asked to do? It was growing crops for a deployment of Green Berets stationed nearby [124-5].

As I understand it, operant conditioning as B. F. Skinner developed it stressed rewards rather than punishments: "negative reinforcement" was seen as ineffective. But regardless of what Skinner thought, Cotter seems to have been more interested in negative reinforcement. What he was doing really sounds more like human experimentation, of the kind the Nazis were notorious for, than anything therapeutic.

Perhaps you'll argue that Cotter was a lone kook, a mad scientist doing his dirty work in the Vietnamese jungle far from responsible scrutiny, and that he therefore shouldn't be seen as representative of psychiatry in the 1960s. That argument won't work, though, because Cotter published his report not in Soldier of Fortune or Spanking Tales but in the American Journal of Psychiatry, a peer-reviewed professional publication -- which means that his colleagues read the article and concluded that it was a serious contribution to scientific knowledge in the field. According to Staub it was "radical therapists" who were appalled by it, not mainstream psychiatrists.

Staub then discusses another controversial issue from the same period:

In late 1967 another case sparked indignation, this time involving three doctors at Harvard Medical School who had suggested that social and economic factors alone could not explain the violent rioting in Detroit that summer – riots that left forty-three dead, more than a thousand injured, and resulted in over seven thousand arrests. In an oft-cited essay, “Role of Brain Disease in Riots and Urban Violence,” which appeared in the Journal of the American Medical Association, psychiatrist Frank Ervin and neurosurgeons Vernon Mark and William Sweet argued that while it was “well known” that poverty, unemployment, slum housing, and inadequate education underlie the nation’s urban riots,” the “obviousness of these causes may have blinded us to the more subtle role of other factors, including brain dysfunctions in the rioters who engaged in arson, sniping, and physical assault.” There was a strong need for clinical studies to be conducted “of the individuals committing the violence” to determine whether “brain dysfunction related to a focal lesion lays a significant role in the violent and assaultive behavior” of black ghetto dwellers. There was additionally a need, the doctors added, to develop “reliable early-warning tests” to detect and screen for potentially violent offenders. This last research agenda received major grants of more than $600,000 from the National Institute of Mental Health and the Justice Department’s Law Enforcement Assistance Administration, monies designed expressly to study “the incidence of violent disorders in a state penitentiary for men; estimate their prevalence in a non-incarcerated population; and improve, develop and test the usefulness of electrophysical disorders in routine examinations.” There had also to be established diagnostic detection centers that could help to prevent violent outbreaks. The first such center “for the study and reduction of violence” opened at UCLA in 1972 (and received more than a million dollars in state moneys from California governor Ronald Reagan in 1973) [125-6].

(The Journal of the American Medical Association is also peer-reviewed, by the way.)

Staub doesn't mention the vogue for psychosurgery in the same period, nor the role American psychiatrists played in developing new forms of torture, but they had the same intent: to treat dissent and resistance as symptoms of brain dysfunction, and to control subjects' behavior. No psychiatric professional seems to have thought of applying the same concepts and remedies to the practitioners of state violence, not even to the police who attacked Civil Rights demonstrators with clubs, firehoses, and attack dogs, let alone to Ronald Reagan.

It's a safe bet, though, that they would have considered the possibility of brain dysfunction in the demonstrators themselves. Armchair psychoanalysis of white student dissidents was a popular pastime in those days. Commentators like "Sidney Hook, George Kennan, Jacques Barzun, Irving Kristol, Nathan Glazer, and H. Stuart Hughes each offered his own unflattering diagnosis of young radicals’ mental states, identifying all sorts of possible analytic explanations for student radicalism" (168), despite "hundreds of empirical research summaries – most finding student radicals to be well adjusted" (235, note 11)" that indicated otherwise. None of those pundits was qualified to diagnose anyone's mental health, of course.

Later in Madness Is Civilization, Staub briefly mentions Marge Piercy's 1976 novel Woman on the Edge of Time. That story, you may remember, shuttles in time between the 1970s present and a utopian twenty-second century future. The protagonist, Connie, is in a mental hospital and has been drafted for an experiment involving the implantation of electrodes into patients' brains to enable control of their behavior by the doctors. Staub remarks that "in the evil 1970s, however, psychiatrists are sinister figures and the main character is involuntarily committed and diagnosed paranoid schizophrenic" (176). Given the evidence Staub himself has collected, it seems fair to say that many mainstream psychiatrists have been "sinister figures."

Which isn't to say that they all were, only to point out why many people in that period came to distrust the profession. Your psychiatrist might genuinely be trying to help you, or he* might be trying to advance his career, with you as a guinea pig. And even if he did want to help you, he might have no idea how to do so. A lot of empirical research also showed that psychiatric treatment was less effective than placebos or no treatment at all. Remember too that homosexuality was still officially a disease until 1973, and not until this century did the psychiatric profession reject attempts to change sexual orientation as the quackery they were.

Nor am I denying that there are people who are distressed and disabled by what goes on in their minds, or that they shouldn't be helped. It appears that changes in medication have helped some of them, though I retain some skepticism about that since the profession also touted its successes in the days of the talking cure, electroconvulsive therapy, and psychosurgery. I wonder what mainstream practices of today will have to be forgotten another generation down the line.
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*I'm not using "he" generically; in those days most doctors and psychiatrists were male.

Father Knows Best

I just finished reading Michael E. Staub's Madness Is Civilization: When the Diagnosis Was Social, 1948-1980 (Chicago, 2011), which is an interesting account of the clash between the medical model of mental illness and the "social diagnosis" model in the United States during the decades right after World War II.

It just occurred to me that there's a parallel with the essentialist / social constructionist debates going on here, though Staub doesn't refer to that terminology. At times Staub seems to believe that the antipsychiatry movement of the Fifties and Sixties, exemplified by R. D. Laing and Thomas Szasz, held that there was no such thing as mental illness, though he also shows and seems to recognize that this is, at best, only partially true. There has been a lot of confusion about that question, though, as shown by a declaration Staub quotes from the Icarus Project, a "mad pride" collective: "Are we delusional and dysfunctional, or is it the culture we live in?" (192) As Staub documents throughout the book, this is a familiar idea: it weaves back and forth between denying that the concepts of madness and sanity/normality have any meaning at all, and declaring that I'm not sick, you are! -- which seems to concede the reality of "mental illness", but tosses it back and forth like a hot potato.

That's why I've always been ambivalent about this idea. I've read a fair amount of literature which holds that in an insane society, it's sane to be insane. (That's the premise of Doris Lessing's 1971 novel Briefing for a Descent Into Hell, for example, though it's also a theme in much of her fiction.) I'm inclined to think that sanity and normality may be relative to the situation, like Darwinian fitness: a trait that's adaptive in one environment may be maladaptive in another. But it also seemed to me that if the "mad" are really, as some have suggested (the questions are often more rhetorical than serious), gifted and superior beings, they should be able to function more successfully in an "insane" society than those of us who are putatively normal. Or maybe not: the real problem is that sanity and insanity are not very well-defined concepts, and even professionals are far too quick to label others as insane or mad or crazy -- not a whole lot better than laypeople. (As Staub also shows, "schizophrenia" is an ill-defined, hard-to-diagnose condition to this day, despite the ongoing claims that it's a medical, biological illness with a genetic base. I've long suspected that it will ultimately be defined circularly, as whatever condition responds well to a given treatment, and other conditions that don't, but which would have been confidently labeled schizoid in the past, will be defined as something else.)

Anyway, there's a lot of useful information in Madness Is Civilization, with a whole chapter largely devoted to the feminist revolt against the psychiatric/psychoanalytic establishment.

With disarming candor the psychoanalyst Theodore Reik – who had been trained by Sigmund Freud and who founded the National Psychological Association for Psychoanalysis in New York – repeatedly revealed that his female patients were unwilling to accept his insights into their states of mind. “When you listen to me a long time without saying anything, I often have the impression that what I say is silly woman’s stuff and without value,” one patient told Reik. “It is as if you do not consider it worth your while to speak to me.” Reik recollected how another female patient responded more sharply to his interpretations: “Goddam, I don’t know why I am here. Fuck yourself!” And a third female patient had this exchange with Reik: “When I told a patient in her forties that she had wanted to be a boy like her brother, she began to curse and abuse me, saying ‘Fuck you!’ and ‘Go to hell!’ and other unladylike expressions.” But these challenges to his authority did not cause Reik to doubt his own judgment. At no point did Reik allow for the possibility that outbursts from female patients reflected the legitimacy of their frustrations with him. (It was left to radical feminist Shulamith Firestone to point out that Reik’s commentaries read “like a Freudian jokebook.”) Yet by the early 1970s even the densest of analysts and other MDs could see that an extraordinary number of women were increasingly uncomfortable with their treatment.

Women in therapy were reportedly becoming so uncooperative that a proposal in 1971 sought to introduce a new diagnostic phenomenon. Called “the angry woman syndrome,” it described patients who took “fiendish delight in deriding their husbands” and who exhibited a “baleful disregard to decency.” These women were superficially well adjusted and successful in their lives, but they nonetheless “strike out blindly, frightened by any threat to their not being the sole center of attention.” In short, their behavior revealed patterns that “at times border on psychotic with paranoid and aggressive overtones.” In 1972 there was a second proposal for another new category of client called “the intractable female patient.” These were women who initially presented “exactly the kind of patient with whom the young resident in particular hopes to work.” But looks could be deceiving. In reality these women were supreme manipulators who used their feminine wiles to turn psychotherapy “into a quagmire from which escape is ever more difficult.” The psychiatric solution for the intractable female patient was for therapists to “set a firm discharge date reasonably early” and to insist that the husband “assume a posture of strength and resolution – especially toward his wife.” This was because the intractable female patient most desired to be dominated by men, the essay concluded, and though she might repeatedly test the resolve of men to dominate her, “she really hopes that she will not win” [144-45].

Here are some good examples of what I wrote earlier. Women who were angry at being confined by the narrow strictures of 1950s American femininity were not just labeled as sick, they were borderline psychotic. And you know it had to be true, because this was a scientific medical diagnosis, by the intellectual heirs of the Enlightenment and its values! Only an irrationalist would reject the authority of these men of science! In much the same way as today's evolutionary psychologists are embarrassed by and try to dissociate themselves from the racist and sexist eugenics of the earlier twentieth century, today's scientific psychiatrists probably prefer to forget this period in their field. The question for the layperson, though, remains what it was sixty years ago: how am I to tell whether today's practitioner really has a sound basis for his or her diagnosis -- or will it look just as embarrassing a few decades from now as "the intractable woman"? It's like asking a theist why I should believe in his or her god, but not in someone else's.

I'm not rejecting the medical model of mental illness out of hand, you understand. It may well be useful in some cases. But the burden of proof lies on the person who advocates the medical model, and a sharp, informed skepticism toward such a person's claims is not just appropriate, it's obligatory.