What if the Folly is in Us, Too?

Despite the enthusiasm of media reports, there’s not a hint that psychiatric patients have diseases, let alone treatable diseases—not a hint. That means that, since no biological abnormality has ever been found, there is nothing to treat, although there may be plenty to talk about. I’ll let you see the bad news (the good news?) right away—news that may come as a shock for those who want to believe that psychiatry is a bona fide scientific practice (a belief common in the public sphere, even though for many Mad in America readers it is old news).

It will surprise many people to know that the psychiatrists who prepared the DSM-5 have actually admitted that all psychiatric diagnoses are descriptive, that none are to be identified with a cause. Yet almost all of my psychiatric colleagues, especially those who work in a university setting, have not paid attention. More serious than that, they don’t seem to have paid attention to their own patients. The following quotation is a progress report on the DSM-5 planning process, which is an official publication of the American Psychiatric Association.

… the goal of validating these syndromes [i.e., psychiatric disorders] and discovering common etiologies has remained elusive … not one laboratory marker has been found to be specific in identifying any of the DSM-defined syndromes. Epidemiologic and clinical studies have shown extremely high rates of co-morbidities among the disorders, undermining the hypothesis that the syndromes represent distinct etiologies. Furthermore, epidemiologic studies have shown a high degree of short-term diagnostic instability for many disorders. With regard to treatment, lack of treatment specificity is the rule rather than the exception.

The efficacy of many psychotropic medications cuts across the DSM-defined categories. For example, the selective serotonin reuptake inhibitors (SSRIs) have been demonstrated to be efficacious in a wide variety of disorders, described in many different sections of DSM, including major depressive disorder … twin studies have also contradicted the DSM assumption that separate syndromes have a different underlying genetic basis …¹

Were they even more honest, the writers would go beyond an admission; they would shout out these conclusions from the rooftops: Hold your fire, colleagues. We don’t have the evidence we thought would show up. We’ve stumbled and have relied on opinions rather than evidence. It’s time to reboot, to rethink things, to go back to basics and use the scientific method to debunk a lot of what we’ve been saying.

Confessions like this are buried—as is the above passage—among many pages of speculative jargon, hopes, and predictions; a tiny glimmer of honesty in a book whose authors also restate all the old orthodoxies and politically correct pieties. It’s easy to miss such honest admissions. Undeterred by their own confession and equally unfazed by years of futile effort—I neither know nor do I ever expect to know of a single discovery—psychiatric scientists clamour for increased research funding. In homage to this madness, it says on the walls of the psychiatric hospital where I work, The Centre for Addiction and Mental Health in Toronto: “Research Transforms Lives.” I’m sorry to say that the Menninger Clinic where I trained uses the same slogan.

The obvious conclusion is that if there is nothing to treat, there’s nothing to say except to repeat that there is nothing to treat—although, as I’ve said, a doctor and her patient may well do some serious talking. I find the above fragment of honesty from the DSM-5 committee admirable, but those who wrote it have tarnished their honesty by going further, stating that these purely descriptive diagnoses are reliable and can be identified by many clinicians, a statement that falsely implies they are real diseases.

Not only are they wrong, they are ridiculous; any of us can, with a high degree of reliability, identify geniuses, fools, bankers, homebodies, Lotharios, derelicts, and athletes—categories that are also not diseases. What counts is validity, and without an objective marker, no valid disease can be pinned down. Just the same, biological psychiatrists are determined that a cause, an etiology of mad behavior can be discovered. These psychiatrists, often professors and researchers, ignore what they themselves know—that there are no objective data to study, no signs that would make a search for causes plausible. Psychiatrists are just plain peculiar, a tribe that is stubbornly ideological even though, because there are no objective things on which to do research, there is no way of applying the scientific method to their patients.

If, as the authors of the above quotation say, all treatments work for all psychiatric disorders, what in the world are we psychiatrists doing? Were it true that laxatives, insulin, cough medicine, antibiotics, and hydrocortisone cream all helped all medical patients, including those with diabetes, cancer, tuberculosis, and hyperthyroidism, all medical treatments would be suspect. But obviously they don’t work for all medical conditions. Contrast this with psychiatry in which drugs, psychoanalysis, every form of psychotherapy, and electric shock do ‘work’ in the treatment of every psychiatric disorder. And, I should add, acupuncture, herbs, astrology, homeopathy, chiropractic, eating seeds and nuts, yogic flying, and being reborn in Christ also work in the treatment of every psychiatric disorder—although a lot of psychiatrists haven’t noticed. But Robert Burton noticed. In his classic book, The Anatomy of Melancholy, published in 1621, Burton said, “1001 causes and 1001 cures.” The repetitive cry of “it works!” makes it obvious that these are placebo cures. This reminder may offend some people, but it is undeniably true.

Coming as it does from the pinnacle of psychiatric orthodoxy, the DSM-5 committee’s admission should have brought the psychiatric debate over diagnosis, diseases, and treatment to an end, but it hasn’t. Few of the psychiatrists I know have even read or noticed the passage I have quoted.

If we want the “truth,” especially when tackling a tricky subject like psychiatry, we have to be careful, because everyday language can lead us astray. Faced with living in a postmodern culture, we have to grit our teeth and admit that the truth—the final truth, the really real truth—is hard to nail down. We therefore need guidelines for what we are to believe, and there are only two:

• Custom, the day-to-day principles of proper behavior and proper taste: being “normal.”
• Science, understanding the physical properties of objects.

But be clear that science is pretty well useless for understanding the goal-directed properties of objects: that is to say, the actions, hopes, fears, and fantasies of people. Because the word has a nasty sting, I want to tell my colleagues that they are superstitious—that they’ve fallen into a trap. Even harder to swallow, if there are no truths and no beliefs that can be absolutely pinned down, the word superstition can be applied to any belief.

“Our fellow shrinks have fallen for a bunch of bullshit,” said a friend. “That non-existent abnormal biology, plus all those romantic words: empathy, trust, and so on.”

And he didn’t spare me. “I’m not into what you do either, Warme, that philosophical insight stuff. What we’ve got to do is to help people to be genuine, to get in touch with their true selves which Winnicott wrote about years ago. Authenticity is what it’s all about.”

Well, yes, we all want an answer, but why would my friend decide that “authenticity” is it? I guess it’s the fulfillment of his hopes, his romantic hopes? But my friend is like most people; he is determined that madness must be comprehensible, but it’s not. We know that social injustice, poverty, and persecution are important in some cases of madness, but they are important in your life and mine as well. And privileged people become psychiatric patients as well. We ought only to say that we don’t know why some people live the unconventional life led by the mad. I like the “unconventional” word because it fits the facts and makes no judgment. The determination to find a cause for madness only contributes to the idea that those people who live unconventional lives have a disease. Best to help all people, including the mad, as well as we can.

When living with fellow citizens who are odd, disturbing, and unconventional, all of us feel we ought to “do something.” We doctors, especially, want to do something: It’s what we’ve been trained to do. Faced with behavior different from our own or from our expectations, all of us feel that urge to “do something”—an act that is one of the beginnings of prejudice, a malignant virus that all of us have trouble shaking free of. Here is an example.

At dinner in a small hotel in Cambodia, in a mixture of sign language and gestures, I indicate to the waiter that I want a gin and tonic. Expecting me to follow up with my order for food, he continues to stand by my side. Thinking fast, I realize that, if I do order, the food will likely come with my gin and tonic. A typical Westerner, I want to linger over my drink before my food comes. Finally, I manage to persuade him to get my drink; he returns and puts it in front of me. But he lingers again, expecting that I will now order my dinner. I am irritated and wave him off, a small flick of the wrist which signifies that he should leave, should bugger off, should beat it; a contemptuous and dismissive signal, the memory of which makes me shudder. We are in his language culture, and I act as though we are in my language culture, and that mine has priority. Me, the big liberal, the world traveller, the sophisticate—as ready as anyone to judge difference as stupidity. The waiter’s face is impassive, but he knows exactly that he has been a witness to Western arrogance.

I want to say that my reaction is merely a “hint” of prejudice, merely the “seeds” of something bad, but it isn’t. It’s the real thing, leakage of an attitude that is full-fledged cultural prejudice, The Full Monty—full cousin to racism and the intolerance of difference that springs up when we have to deal with psychiatric patients, those citizens whose actions don’t fit with what’s usual in our culture.

Terrible questions come up when we think about this: if we call them psychiatric patients, have we taken the first step toward judging them, assigning them to a category lower than ours, suggesting that they are pathetic compared to you and me? And if we stop calling them patients, are we ready to treat them as full citizens, make them face the consequences of their behavior like everyone else, including being hauled before a court if they break the law?

Such awful questions make all of us want to “do something,” to solve the problem. Maybe science is the answer, we’re tempted to think. Because there are no scientific data to study, science can never be the answer. It’s hard to accept that there is no solution apart from the human decency that we already have ready at hand. Best to struggle with problems as they come up, case by case. No wishful thinking allowed, no thinking that we are the ones who have the answer.

Just about all of us think we have the answer, and that’s when trouble starts.