The rat motif continues. First, with this post at the New Yorker’s elements blog, called The Rats of NIMH, because who could resist?

Then with Allen Frances’s response, which came soon after the blog was posted.

As usual, I find your take irresponsibly Szaszian. Any dummy can point out the limitations of psychiatric dx- I have been doing it for 30 yrs. But it takes a callous indifference to pt welfare not to balance this in every single piece with a statement of its value for those who really need it. Donna really pegged you- ‘a plague rat who climbed on to the ship’. Please try to be a responsible trustee of pt welfare, not just a clever cheap shot artist. I fear for your immortal soul. You can be better than this.

[Donna is Frances’s wife, Donna Manning. To be fair to me for a second, I did report her comment in my book.]

I’m guessing that Frances is being a little facetious when he says he fears for my immortal soul; he has often accused me of believing in such a thing, and offered the counsel that my belief reflects an unbecoming naivete,so I think he’s trying to get double mileage out of that tweak. But I am sure he thinks I can be better than this. He may even wish that I was, given the extent to which he participated in my book.

More to the point, he is surely not being facetious when he says that it is irresponsible (and juvenile, he has said elsewhere) of me not to point out the value of psychiatric diagnosis whenever I point out its flaws. He’s absolutely right that I don’t do that. That may indeed be because I am a “clever cheap shot artist” with no regard for the public welfare. But on the other hand, a virtue that has to be reiterated at every turn is awfully fragile, and after a while, it just begins to sound like protesting too much.

But shorn of the condescension, I suppose it’s a fair criticism.  Psychiatry, maybe more than other specialties, relies on confidence to be effective. Mental health treatments, drug and otherwise, hinge on the placebo effect, and there’s no question that this DSM-5 episode is undermining that confidence and thus may vitiate effectiveness.  Perhaps I am a rat for saying this out loud. But I have to say even if that’s true, then I don’t think I’m the only plague rat on the ship, or  the squeakiest.

I’ve been having a pretty good time on book tour. I’ve been able to share a stage with a couple of friends–Mitch McCabe in DC, and last night in Cambridge, Errol Morris, who, as Mitch filmed, graciously did not upstage me. My mother was there. So were a bunch of friends, old and new. Ben Nugent, the guy who figured out that Allen Frances and I had a bromance going, showed up. So I had fun.

I’m not sure the audience, which was overflow, did. Or at least a segment of the audience. That’s because they are disappointed that I am not an antipsychiatrist. That is to say, they feel that I don’t go far enough in my critique. I don’t say all psychiatrists are avaricious sociopaths, or that all psychiatric drugs are poison for all people, or that psychiatry is a criminal conspiracy to turn us all into Shrink McNuggets. I just think that their diagnostic system stinks, and in this many psychiatrists, including the head of the National Institute of Mental Health, agree with me. I’m not sure what we should do about that, which is the source of another complaint I’ve been hearing–that I don’t offer a solution. I have to say I don’t understand that. HOw did it get to be my job to reimagine psychiatric diagnosis? Why isn’t it enough to show what is wrong with it and how it got to be that way? Do we need happy endings that badly?

Anyway, the fact that I am getting thrashed by the antipsychiatrists will probably not persuade Allen Frances that I am not one of them. I don’t care all that much what Frances thinks of me, but as his bromantic partner I do care about how he feels, and sometimes it would appear that he might regret having gotten in so deep with me. He says not, but I’m not so sure.

I’ll let you be the judge. He sent me his review of my book. He promised not to publicize it, but he didn’t say I couldn’t. So here it is.

Thanks for ‘book of woe’. Here is my review of your ‘unmaking of psychiatry’. This is just between us and donna- I won’t ever do an unmaking of the unmaking of psychiatry

Reportage A+  Thorough, well organized, entertaining, accurate, lively. You missed your calling.

Writing style B+ The book is a good fast read- you are constitutionally incapable of ever writing a dull sentence or an uninteresting paragraph. But you were right to worry that this doesn’t sparkle as much as your usual.

Originality C: I marveled at how much I learned  from all your previous books and articles . This one seemed pretty much to skim the surface- it doesn’t take any great genius to trumpet the limitations of psychiatric dx. I know- I have been doing it for 30 yrs. .

Moral compass D: Too many conspiracy theory pot shots and wise guy cracks that disregard the possible harm inflicted on patients- which is mentioned only in 1 quick inconclusively reflective paragraph at the end. Unlike the creator of Liebowitz you go really easy on yourself after bombing Caseno. The human element of patient suffering and need is remarkably missing and you totally lack a plan B. You do scorched earth- I don’t.
I know your narrow focus on unmaking psychiatry is just the scorpion being a scorpion, but this is why Plato decided that comedians and poets were dangerous to the Republic.
I certainly have no regrets re time spent with you- both because on a personal level you are so much fun and because it is possible that your portrait of psychiatry might have been even more fun house distorted without our dialogues.
But I can’t answer positively to the one utilitarian question that matters so much more to me than it does to you- does this book make the world a better place for patients to find peace and hapiness?
Of course, your counter argument could easily be that with APA and NIMH as its friends, psychiatry doesn’t need enemies. You would be right- the self inflicted harm and harm to patients inflicted by APA and by the recent bone-headed NIMH announcement are orders of magnitude worse than you at your worst. Not much consolation though. You call it a noble lie when I  defend psychiatry so as to encourage those who very much need it not to lose trust- I call it adult responsibility.

So maybe it’s not a bromance after all. Maybe it’s an Oedipal thing.

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?

I couldn’t resist that title, but the only rat I’ll write about here is me. Actually, Nasir Ghaemi didn’t call me a rat in his psychology today blog. He called me an “extremist psychologist.” I think I’d rather be a rat.’

Not that I mind the extremist part. But I am not a psychologist. I never claimed to be a psychologist. The psychologists own that word, and insist that only people licensed as psychologists can call themselves psychologists. Which is fine by me. I wouldn’t join a club that would have me as a member unless I needed to in order to make a living or get laid or something like that. This whole guild thing makes me a little nuts.

I’ll explain. Back in the 1990s, when I was getting my Ph.D. in psychology, the American Psychological Association, as if to prove that the American Psychiatric Association was not the only APA that could be power hungry, took over the licensure apparatus in as many states as possible. They created a model statute and regulatory scheme that required people who did not get their degree from an APA-approved program, which mine was not, to plead their case to the state, submitting course syllabi and other arcana for their review. I could have gone through that whole painful (and expensive; everyone I knew who succeeded did so only after lawyering up)  process, but I already had a license-=-as a Professional Counselor–and a full practice, so I figured, why bother. And I didn’t.

As to the extremist part. To my great surprise, neither Laura Miller nor Ben Nugent nor Dwight Garner seems to think so. One way or another they all make reference to my middle course. Miller goes out of her way to tell Scientologists that I am not on their side, and Nugent finds enough nuance in my argument to tease out the antipsychiatry from the propsychiatry strand. Actually, I don’t totally agree with this; my book is less dialectical than I would have wanted, but mostly because the APA (the psychiatrist one) didn’t do a very good job of creating narrative tension for me. Which is the biggest reason I was glad when Tom Insel called them out.

So I think Ghaemi is wrong to tag me as an antipsychiatrist; on the other hand, he;s a psychiatrist, so he is bound to diagnose what unsettles him. And I know he’s wrong to say that I believe “that no psychiatric condition can ever be a biological disease.” Of course I know that the brain can malfunction as surely as the liver can, without any prompting, for no particular reason other than that the body is a time bomb that will explode at some point or other, eventually lethally. Some of the mental disorder out there is undoubtedly as “medical” as the kidney disorder or the bacteriological disorder out there. But despite decades of effort, psychiatry has yet to tell us which mental disorder that is, and therefore which properly falls under its aegis. In the absence of limits the profession, largely through the DSM, has expanded to encompass all of it–an expansion that serves its interests in unsavory ways. When psychiatry can tell me what mental disorder is really a brain disease, and when it finally figures out the distinction between necessary and sufficient conditions, then maybe I will stop ratting it out.

David Kupfer, chair of the DSM-5 task force, shot back at Tom Insel, head of NIMH today with a statement that even by the standards Kupfer has set over the last five years is immensely obfuscating.

The promise of the science of mental disorders is great. In the future, we hope to be able to identify disorders using biological and genetic markers that provide precise diagnoses that can be delivered with complete reliability and validity. Yet this promise, which we have anticipated since the 1970s, remains disappointingly distant. We’ve been telling patients for several decades that we are waiting for biomarkers. We’re still waiting. In the absence of such major discoveries, it is clinical experience and evidence, as well as growing empirical research, that have advanced our understanding of disorders such as autism spectrum disorder, bipolar disorder, and schizophrenia.

Where to start? How about with that “we’re still waiting”? You’re still waiting? How about all the people whom you have diagnosed with what you insist are real illneesses (even if you acknowledge that they aren’t) caused by biochemical imblances (which you know don’t exist) and treated by drugs (whose mechanisms you don’t understand). They’re still waiting for your knowledge to catch up with your claims, and the idea that your clinical experience and empirical research somehow add up to more than a stopgap measure that is increasingly problematic, that has spawned a drugging of the population that is going to look to future historians like the lead contamination of the Roman water supply does to us–this idea is really beginning to wear thin.

But that;’s not the best part. The best part comes here–after the obligatory defense of DSM-5 as “the strongest system available,” leaving out the part about how it’s pretty much the only system available.

RDoC is a complementary endeavor to move us forward, and its results may someday culminate in the genetic and neuroscience breakthroughs that will revolutionize our field. In the meantime, should we merely hand patients another promissory note that something may happen sometime? Every day, we are dealing with impairment or tangible suffering, and we must respond. Our patients deserve no less.

RDoC is the NIMH initiative, harebrained in its own way, to find the neurocircuitry of psychopathology and develop a diagnostic system based on it. NIMH has a long time frame for RDoC, ten yeaqrs or so. But they’re not issuing any promissory notes, except maybe to congress to whom they are promising research results in return for appropriations. The people being asked to take psychiatry on faith are the patients, and the people soliciting the credit are psychiatrists, especially the psychiatrists of the APA. We still,they are saying,  after 150 years, don’t know what a mental illness is, we gave up a long time ago on trying to figure it out, we can’t agree on how to identify the mental illnesses that we think might exist, we just spent $25 million to make a diagnostic manual that, by our own measure, is worse than the last one, and we can’t even articulate a decent defense of it that doesn’t sound like saying we know it’s a mutt but it’s our mutt and it protects our house and if it Biedermans on the floor or Nemeroffs on the carpet or once in a while Abilifies the neighbor’s cats, well, that’s just the cost of having us around, and so you should just trust us, and by the way if you don’t, then you either don’t care about the mentally ill or you are just an antipsychiatrist following Tom Cruise because he’s so cute.

I mean, if the DSM-5 ain’t a promissory note, then I don’t know what is. and like many promises issued by confidence men, it’s not worth the paper it’s printed on.