Tuesday, July 16, 2013

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.