Brooks on Psychiatrists As "Heroes of Uncertainty"

Well I suppose it is slightly better than the usual characterizations that we see in the New York Times, but David Brooks recent column on the "improvisation, knowledge and artistry" involved in psychiatry is little more than damning with faint praise.  His flaws include using the term "technical expertise" and comparing psychiatry to "physics and biology".  Psychiatry is certainly comparable to biology but not to physics.   And what is it about psychiatry that is unscientific?  The idea that psychiatry seeks to legitimize itself by appearing to be scientific is a popular antipsychiatry theme.  It is probably why many authors seek to equate psychiatry with the DSM.  The science of psychiatry is out there in many technical journals that are scarcely ever mentioned in the public commentary about psychiatry.  The idea that the science of psychiatry is collapsed into a modest (at best) diagnostic manual is a convenient way to deny that fact and portray psychiatrists as unscientific and perhaps not very much like physicians either.  

Brooks characterization of the DSM shows a continued lack of understanding of this manual by  every journalist who writes about it.  There is practically no psychiatrist I know of who considers it to be authoritative.  Very few psychiatrists  actually go about their diagnostic business by reading through DSM criteria.  That activity would be limited to novices and medical students.    It is well known that only a fraction of the diagnoses listed are ever used in clinical practice.  After familiarizing themselves with the major changes, few psychiatrists will every open it again.   Like most physicians, psychiatrists are looking for patterns of illness that are based more on their clinical experience than criteria listed in a manual.  The idea that this text has "an impressive aura of scientific authority" is certainly consistent with Brook's thesis, but that is not what a psychiatrist experiences when looking at it.  Despite all of the concern about the public impact - psychiatrists are the target audience here.  Psychiatrists are much more aware of the limitations of the approach than the media critics who write about it.  I guess a lay person might be impressed, but I never met a psychiatrist who was.  

Brooks is also confused about the nature of the DSM when he states that it contains "a vast body of technical knowledge that will allow her (your psychiatrist) to solve your problems".  That vast body of technical knowledge is firmly outside of the DSM and it is in the form of training and ongoing education of a psychiatrist.   That technical knowledge is contained in a vast literature, much of it written by psychiatrists.  It is the reason that ongoing training and education of physicians is a career long commitment.  In the general scope of things, the DSM would contribute a percentage point or two at most to that body of knowledge.

There is the associated question about whether physicians are scientists or not.  I have seen Kandel himself interviewed about this issue and he states quite definitely that they are not.  That is quite different from suggesting that physicians are unscientific.  There are certainly not many physicians who are performing scientific experiments and publishing papers.  I suppose that you have to do that to be a professional scientist.  On the other hand, physicians are certainly accountable for learning immense amounts of of scientific principles and data that can be applied in clinical situations and used in critical thinking about patients and teaching it to successive generations of physicians..  I teach Dr. Kandel's plasticity concept and how it applies to addictions in about 30 lectures a year.  Reducing scientific knowledge to "artistry" is really inconsistent with "technical expertise".  There really is no art in medicine.  The most technically competent doctors know the science, have seen more patterns of illness and can recognize those patterns.  They can apply that knowledge to patient care.  In complex medical (and psychiatric) care, a special plan can be designed for each individual patient and most aspects of that plan are rooted in science.

This essay strains under the weight of needing to place psychiatry outside of the scope of science and mainstream medicine.  My study of psychiatry finds it in neither of those locations.  There is a reason that psychiatrists need to go to medical school.  The cross section of basic science and clinical science that all physicians are exposed to is necessary to be a psychiatrist.  Using Brooks reasoning, I suppose he could say that this is just an effort to "legitimize" psychiatry by making it seem like it is on scientific par with the other fields of medicine.   When I am face to face with a severely ill patient who has liver disease, heart disease, diabetes, alcoholism and a refractory psychiatric disorder - the science involved is much more than a political exercise.   

Like every other branch of medicine, psychiatry is an amalgam of the clinical and basic sciences.  Biology especially neuroscience but also the anatomy and physiology of the human body is the central focus.  I will give Brooks partial credit when he writes about the DSM.  Unlike many of his colleagues at the NY Times - he does not refer to it as a "Bible".  When it comes to the issue of whether I am a scientist or not, I certainly realize that I am no Eric Kandel.   But I also know that I am not rolling the dice or taking a leap of faith.   I am  doctor seeing people, trying to understand their unique set of problems, and applying medical science to help them get better.

George Dawson, MD. DFAPA

David Brooks.  Heroes of Uncertainty.  NYTimes May 27, 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) 


Addendum:

I made this interesting discovery several years after the original post (on May 22, 2019). Dr. Gutting has a chapter on Michel Foucault in the Stanford Encyclopedia of Philosophy and this is very consistent with his flawed analysis of the DSM-5.  Link.