This episode of Rationally Speaking features Dr. Jerome Wakefield, psychiatrist, PhD in philosophy, and author of "The Loss of Sadness: How Psychiatry Transformed Normal Sorrow into Depressive Disorder." Julia, Massimo and Jerome talk about the arbitrariness of the DSM and the controversies around the boundaries of various mental disorders, including depression and sexual fetishes.
Jerome's pick: Bertrand Russells's Autobiography
OMG, I can't WAIT to hear this.
ReplyDeleteThe line between Genius and insanity is as nature is, infinitely immeasurable. Attempting to define it scientifically is a mental disorder. =
ReplyDeleteVery interesting conversation but I was disappointed that Julia's very fruitful approach was sidestepped and just ignored, IMO.
ReplyDeleteI really think that much of this whole debate stems from some kind of duality-style thinking about our minds and could be resolved if we just thought of mental illnesses as a subset of physical illnesses. (Today I say this 9gag post: http://9gag.com/gag/a5dXoAq)
A lot is lost because diagnosis is confounded with treatment. It seems to me that what Dr. Wakefield is against is the over-treatment of what he sees as "normal human experience". Maybe he's got a fair point but that's an empirical question: Which is the best course of action given a situation?
For example, no one would deny that having a cold is bad, common and a normal response of being infected with a rhinovirus, but the fact is that the best "treatment" is just and rest and wait. The same could be said of mild depression caused by the lost of a love one. It's bad, it's common, it's a normal response of a loss and in most cases the best "treatment" is time and social support.
I fully agree with him that we don't understand mental illness, but maybe the problem is not on the epidemiologists side but on the popular conception side of things. As he said, you don't have to be a sociopath to have a mental disorder and it very may well be that there are lots of "benign" mental disorders that, just as Wakefield's benign tumour, doesn't deserve much attention.
Maybe it's just a matter of accepting that mental disorders are as common as physical disorders and in most cases they are benign, don't require much intervention and are self-limited.
@ Massimo
ReplyDeleteA large part of the problem with psychiatry can be directly linked with the materialistic paradigm. Jerry Wakefield basically implied this when he argued that psychiatrists are trained to believe that all mental disorders are ultimately brain disorders and can be treated with drug therapy. He also argued that psychotherapy (a field which you have repeatedly denigrated on this blog) does just as well (if not better) than drug therapy. (You will recall that, in another thread, I furnished you with documentation that a placebo is almost as effective as depression/anxiety medication.)
I enjoyed this podcast, but I was disappointed that it didn't seem to take a definite position on the question of whether psychiatric diagnosis is science or pseudoscience. Although Wakefield did suggest that harm should be the criterion that distinguishes mental illness from normal “undesirable” mental states or experiences, because the issue of what a mental disorder is was not quite answered, I was left doubting that we should be satisfied with consideration of harm as an adequate justification for the wholesale conceptualization of what are called mental disorders primarily in medical terms, e.g. “symptoms,” “illness”, “depression”, “disorder” etc., particularly when there is quite clearly a non-negligible quantity of culturally-specific, non-medical subjectivity applied to the identification and classification of such disorders.
ReplyDeleteI know you only had an hour to discuss this huge topic, and I am certain that Wakefield has more to say about psychiatry, but I think I can safely posit that the harm criterion is not sufficient to ensure reliable avoidance of the very harmful psychiatric misnomers and errors that Wakefield himself has identified, or to justify why it is that psychiatrists, who are not conceptual analysts as Wakefield said, should be primarily in charge of making the very consequential judgments that they are permitted to make.
There is a lot more fruitful controversy here to be investigated. I hope you look into it on another show with a view to finding a more satisfactory resolution of these issues, which arise out of the still questionable ontological, or epistemological, status of mental illness qua an illness (or disorder). The criticisms leveled by Thomas Szasz and Foucault, whose names Wakefield chirped, would be a good place to start, though not necessarily to finish. It is not clear that their arguments have been debunked, though they are often assuredly brushed off as having staked out too extreme positions.
Thank you for your podcast.
@Alastair,
ReplyDeleteI think you've got it backwards. The problem is that we don't yet have an adequate understanding of the neurology of not just mental disorders but mind itself, and until we do, psychotherapy is proto- or pseudo-scientific, and we are stuck with "treatment" based on a lot of bad metaphors.
But I'm guessing that in addition to a debate on dualism, you and I also differ on what we consider to be the greater harm in misguided therapy. I'm guessing from your placebo reference that you are more concerned about psychotropic drugs, and I am more concerned about the talk therapy industry which I feel probably does more harm than good. My father was a psychiatrist and my mother and step mother were psychologists, so I have a little bit of an insider's view. Oddly, talk therapy would jump to the conclusion that my experience actually disqualifies me from having an opinion, because one supposedly can't possibly think clearly about one's own life without a trained mediator (at the rate of $200/50 mins).
I liked the podcast, but I'll admit, I was hoping for more psychotherapy bashing. I don't blame psychology for being in its infancy, I blame it for not admitting how much it is in its infancy and all the people making money off unsubstantiated theories (often with the collusion of the state). I think Wakefield underestimates how much religious and sexual dogma is being foisted on us by psychotherapists.
As a screenwriter, I have firsthand knowledge of exactly how much these bad metaphors dictate the culture. The very notion of what a "story" is depends on our concepts of self, health and morality.
@ OneDayMore
Delete> My father was a psychiatrist and my mother and step mother were psychologists, so I have a little bit of an insider's view. <
I obtained my insider's view by reading "Toxic Psychiatry" by Peter Beggins - a practicing psychiatrist who exposes the abuses of the psychiatric profession.
> But I'm guessing that in addition to a debate on dualism, you and I also differ on what we consider to be the greater harm in misguided therapy. <
Agreed.
> I'm guessing from your placebo reference that you are more concerned about psychotropic drugs, and I am more concerned about the talk therapy industry which I feel probably does more harm than good. <
Yes, I am more concerned about psychotropic drugs (amongst other things). Whatever shortcomings pscyhotherapy has, it pales in comparison with biopsychiatry.
The problem in this asylum we live in is not the patients, or we ourselves, but rather it is Nurse Ratched and her belief that her judgements and methods can fix us. Fortunately those same powers that be have found me good enough to drive the bus. If you ever need a ride after the shock treatment, climb aboard, its free! =
ReplyDeleteHow should 'Tea Party' syndrome be listed in a Diagnostic and Statistical Manual of Mental Disorders?
ReplyDeleteCase study: http://en.wikipedia.org/wiki/Steve_Stockman
My reaction listening to this podcast was, if people are suffering and that suffering can be categorized and treated, what difference does it make whether it's "normal" suffering or not? I know someone who suffered terribly when his marriage fell apart. The technicality of whether or not he had a disorder didn't matter. He was suffering and treatment helped him through it. I have to say that I'm relieved the doctor he visited didn't turn him away because his agony was just the normal agony of someone whose life had fallen apart.
ReplyDeleteYour thoughts mirror mine on this issue perfectly.
DeleteIf there is distress and detriment of functioning, it doesn't much matter whether that distress and impairment in functioning is statistically prevalent or not.
What I perceive to be fatally flawed about mental health diagnosis is the reference to what is "normal" as a standard for health. This would be ludicrous in any other field of health- if it should be the case that it is normal to have cancer at age 20, are we then going to say that it is no longer pathological?
The cultural relativism of mental health disorders seems another strike against it; cancer is cancer in Greece, Japan, France, etc. etc. So too it should be for mental health conditions. Autism is autism in all places, depression is depression in all places. Narcissistic personality disorder is NPD in all places.
This confused thinking results out of trying to determine health ideals from statistical norms.
Lewis Thomas characterized his own profession, medicine, as being the "youngest science" (http://www.amazon.com/The-Youngest-Science-Medicine-Watcher-Foundation/dp/0140243275). If Steven Novella has to work so hard to get science-based medicine across, we should be patient with psychiatric practice. No-one is getting hospitalized for "moral insanity" or having their genitals clipped for "excess masturbation." The efficacy of cognitive-behavioural therapy has been established far in advance of any neurobiological research. Reasonable and humane solutions to mental distress can start now without waiting for salvation by neurobiology. The effectiveness of regular physical exercise in treating minor depression should also make us cautious about the promises pharmacology holds. Regular and responsible qualitative data collection -- including systematic reviews of case reports and evidence of outcomes -- might provide a comprehensive improvement of psychiatric services sooner than hoping for a single bullet from the pharmacy. Finding ways for people to live more satisfying lives is a rational approach that includes the research sciences but can't be reduced to any one of them. Big ups to feloniousmonk94's statement. But even schizophrenia as a condition is not experienced universally. Some cultures find ways to reabsorb schizophrenic youths after their episodes instead of having them sent off into a permanent outsider social status or entanglement in the institutions. The problem of mental health can't be limited to the contents and operation of minds in isolation.
ReplyDelete