Fiction vs. Lies

I was going to post this as a reply to a comment left by Barney Carroll, but then I realized–hey, it’s my blog. i can make a new post if I want. The original comment is here

It’s the one that isn’t about my being a “self-serving pompous self-promoter,” which is pretty hard to argue against when you’re out on the hustings trying to sell your book. So bravo to that guy for his perspicacity.

The one I’m talking about is the one from my frenemy Barney Carroll. Too bad you weren’t at at my book event last night, Barney. You woulda thought I was channeling you, telling people that diagnostic uncertainty is the norm in medicine. My example was about two radiologists differing over whether an MRI revealed a stroke, a diagnosis that could only be confirmed by the neurologist doing the clinical exam. But I could have used any other, including some of the examples you cite. My point was to say that psychiatry, far from being a laggard or misfit, might be a harbinger of the time when the magic bullet model of disease—one pathogen, one diagnosis, one treatment—has run its course, and we no longer have the unreasonable expectation that the bacteriological paradigm has left us with.

Here I think we agree. Where we disagree, near as I can make out, and where I become tiresome to you is in what we can and should make of this fact. In your view, if I understand you, the uncertain nature of medical diagnosis should just be accepted as the way things are. We should recognize we will always be stuck with probability rather than dead certainty, and we (or should I say I?) should stop slinging arrows at psychiatry for failing to live up to a standard that is so ignorant of the way disease really works, and that the rest of medicine doesn’t live up to either. (I also think this is your gripe with RdoC, that for all its apparent sophistication, it’s still a reductively materialistic view of things. ) And then we should get on with the business of making a nosology (and using it) based on how the world really works rather than the way we wish it would work.

I don’t disagree with you about this either. But where we part ways, I believe, is over my sense that we can’t just say that the paradigm is irrational, doesn’t work, etc., and then leave it at that. Because for now, regardless of how realistic it is, the bacteriological model, as I have said elsewhere, has become a myth, meaning a story that controls the way we understand the world. In this case, it is the myth that gives medicine its power. I’m not sure you understand me when I say this, but when I talk about psychiatric diagnosis as being fictive, this is how I mean it—not that it is a lie or a fraud, but that it is also not a fact. Bayesian analysis, which I do not pretend to understand except at the broadest conceptual level, seems to me to be a way of trying to negotiate this middle ground between outright falsehood and bedrock truth by focusing on probabilities. My interest is elsewhere—in the way the myth functions epistemologically and, ultimately, how it can shape our sense of ourselves.

When I talk about this, I think you hear me suggesting that because psychiatry can’t point to biological findings, etc., that it is a failure and maybe even a scandal. I also think you believe that when I make this criticism, it is based on my feeling that until and unless psychiatry can find that elusive schizococcus or depressenza, it is doomed to fail. But I don’t believe these things. I’m not the one imposing that standard. It is psychiatrists, who have repeatedly announced that they need to be “real doctors” treating “real diseases” in order to succeed, and that those real diseases will only be real when they are biologically based. My book, and my previous book, trace the history of this idea, locate it in mainstream psychiatry, and capture it in the words of eminent psychiatrists from Kraepelin to Spitzer.

Much as some nosologists have been careful to temper expectations regarding the ontology of psychiatric illness, or even, as you and Allen Frances do, to reject outright the notion that validity comes only with biology, I don’t think you can deny that this is the myth on which psychiatry bases much of its authority, and that at least in some quarters, psychiatrists have done their best to exploit it. The DSM-III had many purposes, but one of them was rhetorical: to solidify psychiatry’s then-shaky hold on public confidence. It did this in part by leaving wide open the implication that these categories were the categories of mental disorder that exist in nature, i.e., the brain. I don’t mean that as an accusation of conspiracy, just an acknowledgment of the way that power works in a society and a culture that no profession in particular has built or owns a monopoly on, but which some professions benefit from more than others.

It’;s also the myth on which all of medicine is based, but the difference between most other specialties and psychiatry is that they all have a few slam-dunks, the pneumococcus and influenza and other findings that live up to the demands of the myth. That doesn’t necessarily make them better, but it does strengthen their claim to the ethos. More to the point, they are less likely to get into trouble when people point out the cases in which they don’t have that claim to validity; the head gastroenterologist or endocrinologist cannot make the claim that Insel made last week that their nosology has no validity. And so they are less likely to have to try to have it both ways, to claim that they have “real diseases” and then to back away from that claim when someone points out that they really don’t.

Here;’s my favorite example of this phenomenon, one that I did not put in my book. I attended a talk given by David Kupfer. He gave what I think you would say was a reasonable if superficial account of the problematic relationship between diagnosis and biology, and of the inescapably probabilistic nature of diagnostic categories, and framed this as a discussion of why the DSM had to be a living document. In the Q&A, I asked him how he thought psychiatrists like him should deal with the predictable public response to what he was saying—that it implied that psychiatric diagnosis was provisional, always subject to change, and, for the moment, not validated by the kind of biological findings we (the public) expect from doctors. His response was, “I didn’t say it was provisional.” But in fact, he had said exactly that; I have the tape. The difference was that I was asking him to account for what this meant for public confidence. That is a scary topic for some psychiatrists, so suddenly Kupfer was back on the side of the positivists.

That’s what I mean by trying to have it both ways. I do understand why it is discomfiting, annoying, and perhaps inexplicable to you that I would continue to make this point, and to object to the difference between the way doctors talk to each other about this and the way they talk to the rest of us. (Allen Frances would add destructive to that list.) I really can’t offer a defense except to say that I think there is room in the world for people like you to try to counsel quiet acceptance of the dissonance between our expectations  and the reality of medical nosology, and for people like me to counsel skepticism when that dissonance seems to favor one group over another.

As to why I would pick on psychiatry, the answer is that I think the mind is different from other functions of the human, and that we are changed in part by what we come to believe about ourselves. for better or worse, and without their asking for this role, psychiatrists are among those who have
more to say than others about our self-understanding. People feel this. That’s why it’s so easy to get them to hate psychiatry. I’m sorry if I seem to you that I am stoking that rage. Mostly, I am trying to understand it, locate it in the history of the self, and possibly educate it.
One last thing: the point I was making originally was only that I believe it is incumbent on psychiatry to make its domain clearer (and probably smaller). I did not mean to suggest that the only way to do that is via biologically based validity. I meant to say that this is how psychiatry, implicitly or explicitly, claims to be doing it. That’s not an entirely unreasonable claim. If only we could identify brain pathologies, and say that the mental illness caused by them are psychiatry’s proper targets and everything else is not, we could stop yelling at each other. But so far no one has been able to find those markers. So in the meantime, to me anyway, the question is how to do it. And the deeper question is, who is going to do it?

3 Responses to “Fiction vs. Lies”

  1. Dr_Tad says:

    Hi Gary

    OK, and maybe I should write a proper review of Book of Woe following on from this comment, but I think this blog post encompasses exactly the part of your argument that doesn’t convince me, even though I thoroughly enjoyed the book and learned a lot of new stuff from it — a perfect reading choice for the week before the APA meeting.

    You quote Peter Sedgwick’s insights in this book and the last, but I think what’s frustrating is that you fall short of accepting his full argument against positivism — that all health and illness, physical and mental, is a social construction — because your critique of society (c.f. psychiatry) is either purposely held back or undercooked compared with his. Of course Sedgwick was a libertarian Marxist engaged in active revolutionary politics at the time he wrote most of the essays that would later form the backbone of Psychopolitics, and this comes across in his explicit aim to not merely reflect on but actively politicise the contradictions of mental healthcare as part of a project not only for “more and better psychiatry” but a different kind of society. His theory was not just critical at the level of ideas but intended as part of a praxis of social transformation.

    This limitation means, I think, that you correctly point to the historical evidence that psychiatry (and medicine more generally) remain fixated by simplistic biological reductionism that took shape in the second half of the 19th century, but you cannot really explain why this is — and therefore there is not much basis for an argument about how (or if) that organising myth might be challenged beyond having debates like this one with Dr Carroll. So you develop a powerful critique of psychiatry’s contradictions in its fumbling attempts to deal with the richness of human social experience, but you miss how an immanent critique of psychiatry might tell us a lot more about social contradictions themselves. The latter approach can, in my view, provide a way of looking at mental health and illness in genuinely scientific terms — shorn of all the positivist detritus that psychiatry tangles itself up in.


  2. Sarah Harper says:

    I think that part of the reason why psychiatry is so obsessed, compared to the rest of medicine, with proving itself as based on real legitimate unquestionable biological fact, is because they make more arrogant claims upon their patients’ lives than any other branch of medicine. What I mean is this: say you have someone suffering from cancer or a traumatic injury, who is faced with a drug or procedure that may cure them, but that also may not work and/or has serious side effects. The doctor will usually see the patient as capable of informed consent about whether or not to do the treatment, and will walk them through their options without trying to manipulate them in one direction. Even in the case of life-threatening illnesses, patients in this situation can often choose to refuse the treatment and opt for hospice/palliative care. Psychiatrists, on the other hand, because of the prejudice that people with “disordered thinking” are incapable of making choices about their own lives, regularly violate the rights of their patients. Psychiatrists can and do:

    *lock people up based on their opinion about whether the person may commit suicide in the near future
    *use their opinion about a patient’s “stability” to determine the length of a patient’s hospital stay, regardless of the patient’s wishes
    * force people to take drugs with serious side effects and questionable effectiveness as a condition of remaining in their homes
    * physically force people to undergo injections of tranquilizers in order to control their behavior in the short term

    Someone who is claiming the right to trump patient consent based on their medical opinions is going to be very concerned with proving to the outside world that those opinions are iron-clad. They are used to operating within a power structure that expects them to act in loco parentis for their patients. Acknowledging their discipline’s fallibility would not necessarily end the practice of prescribing psychiatric drugs, but it would dismantle that power structure. Like many oppressor groups that feel their privileges over others are being taken away from them, they are reacting with incoherent panic.

  3. gary says:

    Sarah–Thanks for saying all that so cogently and succinctly. Power may be the last great taboo subject, and its workings are hard to reveal without sounding like a paranoid nut, but you succeed.

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