Saturday, February 9, 2013

Moralizing About Psychiatry and the Limits of Philosophy


This article came to my attention this week from the New York Times blogs.  The author identifies himself as a philosophy professor and scholar who is an expert in French philosophy.  He presents some viewpoints of Foucault and others to criticize the DSM and of course the clinical method in psychiatry.  I will be the first to admit his initial argument is confusing at best and is based on Foucault’s observation: “What we call psychiatric practice is a certain moral tactic….covered over by the myths of positivism.”  Indeed, what psychiatry represents as the “liberation of the mad” (from mental illness) is in fact a “gigantic moral imprisonment.”  In the next sentence the author  acknowledges: "Foucault may well be letting his rhetoric outstrip the truth, but his essential point requires serious consideration."

From my viewpoint whenever an author’s rhetoric outstrips the truth it means that at the bare minimum any observer should be skeptical of the biases involved and these appear to be the common themes that we see from antipsychiatrists.  It does not take the author very long to develop that angle:

“Psychiatric practice does seem to be based on implicit moral assumptions in addition to explicit empirical considerations, and efforts to treat mental illness can be  society’s way of controlling what it views as immoral or otherwise undesirable behavior.”

He gives examples of the previous treatment of homosexuality and women and uses this as a platform for suggesting “….there’s no guarantee that even today psychiatry is free of similarly dubious judgments.”  With no credit given to Spitzer’s role in both the DSM and eliminating homosexuality as a mental illness back in the 1970’s (where is the rest of America on that issue even today?) he latches on to the bereavement exclusion as the latest example of how psychiatrists are trying to dictate how people live and how various nonphysicians are better equipped to decide about whether the bereavement exclusion should be left in place.  Like every other commentator he waxes rhetorical himself using the well worn descriptor “medicalization” and suggesting part of the motivation for these changes is pressure from the pharmaceutical industry.  I recently posted a response to a less well written criticism from the Washington Post that addresses these issues and I would encourage anyone interested in finding out what is really going on to take a look at that post.

The question here is what have Professors Foucault and Gutting missed in their critiques about psychiatry?  It turns out they have missed a lot. The first obvious flaw is the misinterpretation about the role of psychiatric diagnosis and a diagnostic manual for psychiatrists.  The DSM (or any technical diagnostic manual) does not represent a blueprint for living and there is no psychiatrist who has ever made that claim.  This error is promulgated in the media by referring to the DSM as a "bible".  In fact, it is not a bible or blueprint for living.  Psychiatrists more than anyone realize that they are addressing a small spectrum of human behavior with the goal of alleviating suffering and restoring function.  The second flaw is that changing a diagnostic criteria in a DSM has any meaning with regard to treatment and diagnosis.  In the case of bereavement that ignores the fact that only a tiny fraction of patients with complicated bereavement or depression ever come to the attention of a psychiatrist.  Grief is a normal human reaction and everybody knows it.  Taken to an absurd level – if organized psychiatry said that everyone with grief needed to take an antidepressant for the simple fact that “we have special knowledge about how people should live”  we would have no credibility at all.  People everywhere know that grief is common and expected and severe mental illnesses are not.  At that level psychiatry is an extension of the common man’s psychology.  The third flaw has to do with impairment.  A diagnosis can be made only with an impairment dimension.  From DSM-IV:

“In DSM-IV, each of the mental disorders is conceptualized as a clinically significant behavioral or psychological syndrome that occurs in an individual and that is associated with present distress (e.g., a painful symptom) or disability (i.e. impairment in one or more areas of functioning) or with significantly increased risk of suffering, death, pain, disability or an important loss of freedom.  In addition, this syndrome or pattern must not be merely an expectable and culturally sanctioned response to a particular event, for example, the death of a loved one.” – DSM-IV

The critics never acknowledge that like all physicians, a psychiatrist’s role is to treat illness and alleviate suffering.  Further, the clinical method in psychiatry is the only specialty training that emphasizes clinical neutrality and recognizing emotional and intellectual biases that impact the physician patient relationship and offers ways to resolve them.  That is hardly a model for forcing value judgments about preferred mental states on people who other physicians are frequently unable to treat because of their own value judgments.

The author also erroneously concludes that it is dangerous to make psychiatrists “privileged judges of what syndromes should be labeled mental illnesses” based on the fact that “they have no special knowledge about how people should live”.   Since psychiatrists do not make that claim, and since various groups including governments and religious institutions have been making these judgments for centuries with very poor results, I would suggest that psychiatry has had some problems – but the progress here is undeniable.  That makes psychiatrists experts in their own field in their own field and the purveyor of their own diagnostic methods and not a claim that people should live in a particular way.  DSM-IV takes pains to point out that it is classification system for syndromes and NOT people.  The DSM is not designed for an untrained person to look at and make a diagnosis or get guidance for living.  It is designed to be a common language for psychiatrists who have all had standardized training.

I would also like to suggest that the same philosophical criteria be seriously applied by philosophers to the pressing problems within the health care system.  The DSM is not even a gnat on that landscape.  We have had nearly 30 years of active discrimination by governments and insurance companies against persons with mental illness.  While much criticism has been heaped on the bereavement exclusion criteria, people with addictions and serious mental illnesses are routinely denied potentially lifesaving interventions.  This discrimination has been well documented and it has fallen disproportionately on the mentally ill.  Jails and prison have become de facto mental hospitals.  People are being treated with addicting drugs on a large scale to the point that many consider opiate use and deaths from overdose to be an epidemic.  Governments save money and pharmaceutical companies and the managed care cartel prosper.  Contrary to the author’s suggestion that “psychiatrists are more than ready to think that just about everyone needs their services” psychiatrists are rare and access is strictly controlled by managed care companies and the government.  Even if a person sees a psychiatrist, their medications, access to psychotherapy, and access to hospital treatment are all dictated by a business entity rather than their doctor.

It would seem that philosophers could find something to critique in that glaringly bleak health care landscape other than a trivial change in the diagnostic manual of a vanishing medical specialty.   If not, I would be very skeptical  of their arguments.

George Dawson, MD, DFAPA

Gary Gutting.  Depression and the Limits of Psychiatry.  New YorkTimes February 6, 2012.

Fulford KWM, Thornton T, Graham G.  Oxford Textbook of Philosophy and Psychiatry.  Oxford University Press, Oxford, 2006: 17.

"Some of the main models advanced by antipsychiatrists, mainly in the 1960s and 1970s, can be summarized thus:
1.  The psychological model...
2.  The labeling model...
3.  Hidden meaning models...
4.  Unconscious mind models...
5.  Political control models..." <-Foucault is located here. (p. 17)

Shorter E.  A History of Psychiatry.  John Wiley & Sons, New York, 1997: 302.   

"By the early 1990, DSM-III, or the revised version that appeared in 1987 (DSM-III-R), had been translated into over 20 languages. French psychiatry residents, initially taken with antipsychiatry and the doctrines of Jacques Lacan and Michel Foucault, began memorizing the 4 criteria (and 18 possible symptoms) 6 of which must be present for anxiety disorder." (Shorter: p 302) 


10 comments:

  1. I understand your point, however; the health care system in many countries has come to a point where there is a pill for every ill. Few psychiatrists are doing talk therapy; schools are desperate to have the children medicated with ritalin, and guess what? many psychiatrists and psychologists fall for it; doing some serious parapraxis!! Out of many psychiatrists I've met (I'm a psychologist) only 2 would actually bother to know the patient, talk to them and really analyze if medication is needed. The rest mostly look for their check lists, ask for the symptoms and prescribe the latest pharmafia pill.

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  2. Thank you for your input. We clearly know different groups of psychiatrists. As an example, in my career I have never seen a person initially for less than 60-90 minutes and I have done hour long psychotherapy on both an inpatient and outpatient basis. That has been true of the groups I have worked with and I have worked with outstanding psychiatrists. I would not see your observations as the typical standard of practice. One the other hand, many health care systems diagnose depression and anxiety without the input of a psychiatrist or a psychologist. They do it strictly with a checklist like the PHQ-9 and the explicit assumption is that anyone above the cutoff score will be treated with an antidepressant medication. It is actually their “quality” marker. The medications are prescribed by primary care prescriber. The contention of the blog post is that psychiatrists are inherently wicked because of their “implicit moral assumptions” (the implication being that they are control agents for the state and whatever group is out of favor). In fact, the” implicit moral assumptions” here that are dangerous to people have nothing to do with psychiatry. They have to do with businesses making money, governments thinking that they are saving money by turning mental health care over to managed care companies, and the conflicts of interest created by insurance companies getting favorable treatment by politicians. So you can continue to blame psychiatrists for the problem and I am sure there are many caught in this managed care paradigm as “prescribers.” But anyone functioning this way is basically a proxy for the government and managed cartel discriminating against anyone with a mental illness. I have never met a psychiatrist who wanted to practice according to the current government and managed care driven model. Claiming that this is the practice of psychiatry is a distortion that prevents the real problems from ever being confronted – hence my response to the original post.

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  3. "I have never met a psychiatrist who wanted to practice according to the current government"

    You must have led a sheltered life. Are you employed by the state?

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  4. @Anonymous - not only do I not work for the state, but they have rejected my applications to serve on state committees and they (so far) have not disclosed information on depression monitoring that I have requested. I think that many of the reasons for that have to do with what I have posted here and in other forums. As a former officer of my district branch I have been able to talk with many psychiatrists and I can guarantee you that nobody wants an insurance company dictating the care that their patients gets.

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  5. The aphilosophical circular reasoning of this post reminds me of Christian apologetics. Which, of course, is what most academics today are - liars for Orthodoxy.

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    1. I always thought there was surprisingly little difference between philosophy and rhetoric at times. I guess this post confirms it. I will take "aphilosophical" as a compliment.

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  6. Are you one of these people who thinks social class / ethnic / cultural differences don't exist, and that everyone is living in a mansion / married to a model / driving a Ferrari? The whole idea that behavior can be considered outside its social context belongs in the mono-cultural 1950s. Countries whose citizens experience higher socio-economic inequalities display higher levels of mental distress. Unfortunately, because Americans live in denial of socio-economic differentials, psychiatry tries to solve problems that are really matters of economic policy (with little success, as you admit).

    The example of Spitzer erasing homosexuality from his list of diagnostic criteria is a poor one, if you are trying to make a case that psychiatry is politically impartial. During the 'uptight' 50s, homosexuality was considered a 'mental illness' - during the 'slacker' 70s it became 'normal'. What more evidence is needed that psychiatry follows cultural/political fashion? Really, the whole thing is a pseudo-scientific form of social control, increasingly meaningless as western culture becomes more diverse and pluralistic.

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  7. It is quite amazing what people can imagine about psychiatrists and in this case their life style. If you knew about how psychiatrists are controlled and actually reimbursed you would know that a Ferrari/Mansion lifestyle is out of the question. I drive a soccer mom van.

    The idea that psychiatrists ignore social causes of distress is common rhetoric by anyone who has not actually read the psychiatric literature. Pick up a copy of Paykel's "Handbook of Affective Disorders" and read the chapters on early environment, social stress, and life events. Look up the literature on childhood adversity and you will find that psychiatrists and psychiatric literature is prominent:

    http://www.ncbi.nlm.nih.gov/sites/myncbi/collections/public/1HMwP7DXBVoUxyYtZiIcYb/

    Read the literature form Bowlby and Spitz on the results of early childhood deprivation from the 1940s. Read the early literature on bereavement written by psychiatrists. Read two decades of neuroendocrinology research beginning in the 1980s that studies the effects of social attachment. Anyone who says that psychiatrists are not interested in or take account of social etiologies of mental disorders is either not paying attention or has some other agenda.

    In the case of Spitzer, his decision antedated any "normalization" of homosexuality by society by decades. It was not a reaction to political trends in the 1970s. Your anti-psychiatry thesis of social control makes no sense in an era where health care companies run all access to health care, especially psychiatric care for at least the last 30 years and have clearly restricted access to psychiatric care at a much higher rate than other services.. Where have you been?

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  8. Hello Dr. Dawson -

    It’s a bit late to be commenting here but I came to your article after reading Professor Gutting’s and wanted to elucidate a few points. Psychiatric practice and the discourse surrounding psychiatry could be very positively enhanced by an understanding of the philosophy of psychiatry Gutting discusses here. His task was not easy; it’s almost a joke to represent the workings of a field in such a short format, and the critical study he alludes to normally takes place within the academic web of terminology, references, sources, etc - all of which make a newspaper-format adaptation a challenge.

    I think Professor Gutting manages a very good overview of the prevailing academic position on the philosophy of psychiatry, but I do have some background in critical theory and can understand how his piece could be interpreted as unfounded aggression. In reality, Gutting does not seek to make statements of blame about the health care system or order of psychologists. He is not trying to defame psychiatry as a field in general. He instead examines an important tension that necessarily exists within the field: i.e., that though ‘depression’ and other mood ‘disorders’ have obvious and very ‘real’ manifestations (physical and otherwise), they are phenomena that are socially conceived of. What we today conceive of as ‘depression’ is a historically-bound phenomenon. The professionals we consider points of authority on psychiatric phenomena are just as human as their patients — that is to say, they are equally implicated within the system of meaning upon which our society is based. They are part of the apparatus (in which we all participate) that defines ‘normal’ and ‘abnormal’, or even ‘depression’ and ‘happiness’.

    After writing the paragraph above I am even more impressed by Gutting’s work. It’s difficult to explain this theory from the ground up. Please let me know if I can clarify any points — what I’ve come up with so far is a very loose survey only

    In the following, I will address one of your concerns with Gutting’s work:

    “ The question here is what have Professors Foucault and Gutting missed in their critiques about psychiatry?  It turns out they have missed a lot. The first obvious flaw is the misinterpretation about the role of psychiatric diagnosis and a diagnostic manual for psychiatrists.  The DSM (or any technical diagnostic manual) does not represent a blueprint for living and there is no psychiatrist who has ever made that claim.  This error is promulgated in the media by referring to the DSM as a "bible".  In fact, it is not a bible or blueprint for living.”

    Gutting does not claim that psychiatrists are intentionally trying to force on society a standard for living. Of course, psychiatry and psychiatrists cannot be represented in a single book or by a third party. His main point in this regard was that psychiatry in general (and therefore certain psychiatrists and the DSM) functions within a discourse of power in our society. Psychiatry is conceived of as a source of true knowledge. It is bigger and more powerful than it’s patients. It categorizes its subjects and defines what is ‘wrong’ with them. In doing so, it also defines the normal and abnormal. The DSM is thus not explicitly considered a blueprint for living in the way you imagined; however, it is definitely a blueprint for living in a more implicit sense. This notion has very pertinent implications.

    There is much more to be said on the subject but this is not the right forum for a proper treatment of the ideas at play. I hope to hear your comments on the subject.
    
Regards.

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    1. Thank you for your detailed comments.

      I have no doubt that Prof. Gutting has more nuanced work and that I may benefit from reading more extensively about this theory. On the other hand he is very explicit in this New York Times piece. That is fairly obvious from his statement that psychiatrists think everyone needs their services and the usual "psychiatrists as tools of the pharmaceutical industry" and "medicalization" rhetoric. He briefly acknowledges that psychiatrists may have something to contribute in the area of treating severe mental disorders, but fails to understand that is the core problem when psychiatrists see a severe depression that began as bereavement (see my post on this blog with the circa 1980 quote from Paykel's text). The point here as I have repeated many times is that psychiatrists are not going to see everyone with bereavement. They are only going to see a small fraction of people with depression. They are going to see only people with severe disabling depressions that started out as bereavement. Psychiatrists are trained to treat only the most severe conditions or what Gutting refers to as "humanly devastating." Those are the people that we want to see. We are not viewing bereavement as a set of symptoms and in fact don't view anything as a set of symptoms. He was probably caught up in the "read the DSM and make a diagnosis reverie" that occurred prior to the release.

      Your argument about the DSM being a blueprint for living in the "implicit sense" seems inaccurate to me. The first problem that I would see philosophically (and I am obviously not a philosopher) would be proof that the DSM functions that way. You agree with me that it does not exist that way explicitly. What are the philosophical arguments that it is an implicit blueprint for living?

      The philosophers in my reference at the end of the post take a clear view of Foucault’s work as an antipsychiatry philosophy rooted in the industrial revolution. Gutting doesn't hesitate to use the old "If all you have is a hammer, everything looks like a nail" to indict psychiatry based on his displeasure with a change in a technical manual that he clearly does not understand and that applies to a low percentage of people treated by psychiatrists. That adage seems more appropriately applied to Foucault.
      I am interested in the arguments about the implicit function of the DSM and hope that there are more than I have read in the papers.

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