When critics reveal that science doesn’t show what biological psychiatrists claim it does, we get a bit unhappy. As well we should. We don’t like being misled. We don’t like being put at risk on the basis of misinformation.
But weak science and exaggerated reports of discovery aren’t the special province of biological psychiatrists. We don’t really understand much about the suffering that brings people into care. None of the science underlying mental health care could withstand the sort of scrutiny biological psychiatry is beginning to endure.
As one example, consider “attachment theory”—the idea that mental health depends on infants “becoming attached” to reliable caretakers. Countless therapists believe, and teach their patients, attachment theory. They devise innumerable interventions on the assumption that they can improve attachment. A huge research industry studies attachment, and claims a variety of important discoveries.
But outside the realm of its own believers, that science generally isn’t all that highly respected. The Harvard psychologist Jerome Kagan showed long ago that some research methods of attachment theorists simply don’t prove what they claim. Behavioral geneticists have shown fairly well that many correlations attachment theorists attribute to attachment actually have mainly to do with genes, not parent/child interactions. No one denies that kids need good care, and neglected kids suffer for it. But it’s far from clear that “attachment” is the issue.
We don’t hear an incensed outcry against attachment theorists, though. Criticisms of attachment theory—Steven Pinker had some unflattering things to say about it in The Blank Slate—don’t get any traction.
As another example, consider the fact that few cognitive neuroscientists would agree with CBT’s account of how minds work. A consensus in the field holds, in effect, that the “distortions” that CBT theorists claim cause pathology are basic to how normal minds work. Nobel Prize-winner Daniel Kahnemann’s new book, Thinking, Fast and Slow, offers an exhaustive account of the research that led to such alarming accounts of how minds normally work.
That we’re not seeing an outcry against CBT is especially odd, since this work on fundamental irrationality has gotten an enormous amount of attention in the last twenty years—think of the bestselling books Predictably Irrational, Nudge, Sway, How Doctors Think, and the seemingly interminable outpouring of similar works.
One more example. We all hear, all the time, that CBT is “scientifically validated.” I’ll be looking at that claim over time—there’s much less to it than meets the eye. For now consider this: CBT research almost never looks at the side effects of treatment. We do not even know what kind of effects, beyond manipulation of moods, CBT has on how people live. Completely ignoring the unintended consequences of one’s work would be considered bad science in any other realm of health care.
We get up in arms about the side effects of medications, but we don’t seem to care that CBT doesn’t study its side effects at all.
What’s my point? That we should stop criticizing biological psychiatry, since the rest of us do no better scientifically? That we should all go out of business because our scientific basis is much weaker than we claim?
Neither. My point is that we need to study the beliefs that we like as critically we study the ones we don’t. We don’t have to pipe down about the sins and shortcomings of biological psychiatrists—so long as we’re willing to be equally relentless in self-examination.
In truth, we don’t understand much about the suffering that brings people into care. We lack an adequate science of suffering. But when people need help, they need it, and we have to do what we can.
We need to cast our nets wide for any form of reliable knowledge. That may come from sciences outside the clinical realm—sociology or social psychology, for instance. It may come from at least some of the humanities disciplines—philosophy or history, certainly. Some astute observers of the human condition have cast their wisdom into literature. Even a few journalists have noticed important things about how life works.
We learn, and use, rigorous methods of logical and evidentiary analysis and use them when we listen to our clients and parse what they’re saying. We need to know the difference between what we’re hearing and what we’re making of it. We need to know when what we’re hearing really doesn’t hang together. Many of those methods are better learned in the disciplines of communications, rhetoric, and logic than in psychiatry or psychology.
We can think through the severe limitations the conditions of care impose on what we can know about particular patients or clients, so that we’re less likely to offer things no one knows, or could possibly know, in the clinical setting. Philosophers are probably better than anyone else at analyzing what can and can’t be known under various conditions.
We can do all this from a position of humility, not authority. We can be honest with patients and clients rather than passing on our interpretations, instructions, and advice as if they were deliverances of Truth.
Recognizing the weak knowledge base of mental health care doesn’t have to be the occasion for despair. We can distinguish better from worse thinking even where we lack strong conclusions. We can distinguish the more likely from the improbable, the rash from the judicious, even when we’re not sure how a line of inquiry will play out.
As this blog goes forward, I will invite you to share with me the effort to do just that. I invite you to join me in the effort to think about care with care—to think carefully.