Thanks for writing candidly about the subject of prescribing psychoactive medicine. It is interesting to learn how your thoughts have evolved from the beginning of your career to your more nuanced and informed views of today. When and how to relieve suffering is a difficult question, and the example of grief is a good way to illustrate that dilemma. It is courageous, and important to write on MIA that there exists some people for which anti-psychotics can be beneficial. But it is counter-productive to do so without insisting at the same time on their excessive use, their long-term damaging effects, and the recognition that the MIA audience is full of people that have been harmed by them or seen harm caused by them to other people. Your use of the word “enjoys” sounded odd to me. There are many interesting dialogues in the comments of your text, but I am afraid the ambiguity about the meaning of the word “enjoy” in your title and conclusion unnecessarily closed some doors. Words can hurt, and some unfruitful suffering might have been avoided by choosing a word that does open a path to so many misinterpretations in this context. Looking towards reading you again, I did enjoy reading all of your posts 🙂
Thanks for writing candidly about the subject of prescribing psychoactive medicine. It is interesting to learn how your thoughts have evolved from the beginning of your career to your more nuanced and informed views of today.
When and how to relieve suffering is a difficult question, and the example of grief is a good way to illustrate that dilemma.
It is courageous, and important to write on MIA that there exists some people for which anti-psychotics can be beneficial. But it is counter-productive to do so without insisting at the same time on their excessive use, their long-term damaging effects, and the recognition that the MIA audience is full of people that have been harmed by them or seen harm caused by them to other people.
Your use of the word “enjoys” sounded odd to me. There are many interesting dialogues in the comments of your text, but I am afraid the ambiguity about the meaning of the word “enjoy” in your title and conclusion unnecessarily closed some doors. Words can hurt, and some unfruitful suffering might have been avoided by choosing a word that does open a path to so many misinterpretations in this context.
Looking towards reading you again, I did enjoy reading all of your posts 🙂
Thanks for a great post as usual.
It seems important to always be able to consider any mental aspect under both the mind and the body perspective, as well as the social dimension. It is refreshing to read from somebody like you (or many others on MIA) who can hold those different perspectives without dismissing any of them.
Thanks for this very informative article.
A lot of heritability talk is based on simple causality reasoning (and the assumption that genetics and environment contributions are overall independent/additive) that seems useless in discussing outcomes as complex as psychiatric disorders.
I like the following thought experiment: let say in XVIII century america, an anonymous “black” newborn and an anonymous “white” newborn are discovered the same day at the door of the main house of a traditional plantation. One baby become a slave, the other become a plantation owner. Is that outcome a result of the genes determining their skin color, or is it the result of an environment that discriminates based on skin color? Would anyone suggest we dismiss the differences in the environment they got confronted with based on the fact those environmental differences were “elicited” by their genes?
Thanks for reminding us that there is nothing new or revolutionary in that study, and that it does not in any mean that genes for psychiatric disorders have been found.
But I diverge on why exactly the research article, and the nytimes report are misleading. I don’t think the findings of that specific research are a false positive. It is only the presentation that is mostly marketing talk for “continue to give us money because the research on genes is important”. But the real evidence collected is serious and is in fact matching MIA regular claims (that the role of genes in psychiatric disorders is at least orders of magnitude smaller than common beliefs).
When people claim to have “likely discovered the tip of the iceberg” (in their own words), it means they have only evidence for superficial conclusions. They basically confirmed they did not get evidence of a true “iceberg” (whether they still *believe* something is hidden underneath is less relevant that the admission they have no evidence for it).
That research actually confirms that the most significant and relevant genes ever found “confer only a small risk of psychiatric disease” (in their own words). I think that is a good study to use to support MIA claims.
While the authors are overall competent, they show their lack of understanding of statistical and mathematical meanings in promoting a very small p-value in the abstract out of context, while avoiding to mention the estimated range for the individual risk factors associated with that p-value.
I am glad research tools are so advanced that we can measure the statistical significance (at the population level) of risk factors that are themselves pretty insignificant, but it is wrong or stupid to only emphasize out-of-context the positive part of the result (that supports getting more grant money), without looking at the overall conclusion of that otherwise interesting genetic research. Since it would be surprising for any gene (or combination) to be absolutely mathematically neutral on any human characteristic (in a thought experiment where all other things are equal), finding statistical significance in the population is completely irrelevant if you don’t put a lower bound on the “effect sizes” that are in play.
Excellent article. I agree with you the medical foundations of psychiatry are not well established, and many common assumptions don’t stand serious scrutiny.
Following your reasoning (which I totally share), there is still one immediate open question remaining once we have rejected the medical validity of ICD or DSM: what kind of (likely non-medical) criteria, or classifications could be used today to determine or prioritize who is entitled to public help and resources, and to account for how those resources (be it counseling, social work, hospital or other respite centers) are used.
I wish we would live in a world of such prosperity that just asking would be a sufficient criteria to obtain help, but in our real world, managing scarcity of resources (human or otherwise) is a reality, and that requires guidelines and criteria to do it fairly. And removing any kind of public role in providing help to people in difficult situations does not seem a viable option to me either.
Thanks for writing here. I have been very impressed by the clarity and soundness of previous articles I have read from you, and next on my list is reading your “The missing gene” book.
You say: “researchers frequently claim that the environmental factors contributing to the development of psychiatric disorders are unknown, or are not well understood.”. If you mostly disagree with that claim, and had to name one book (for a general audience) that is a good reference for valuable knowledge about environmental factors in psychiatric disorders, which one would that be?
Oops, my last sentence was meant to credit “Jonathan, Jeffrey and Brett”.
Excellent article. The words that were indeed worth putting in bold face when talking about Kirsch (a guy who should get a medal) is the ‘dirty little secret’. What is it in the current organization of medical research and practice that make secrets, and distorting the truth (at least by omission) a common, acceptable and widespread practice?
After Kirsch’s book, I am surprised by the absence of self-reflection by the concerned actors of the type:
– “how can be avoid repeating those major shortcomings in the future, and become better at our mission of researching and communicating?”
One of the key tenet of science is to always be ready to revise previous assumptions when reality calls them into question. While the ‘dirty little secret’ is finally coming to light (I am optimistic about that, even if most clinical practitioners still need to get the word), self-improvement and reform of the organization of scientific institutions, individual researchers, companies and journalists that made possible this major blunder does not seem to be on the general radar (as opposed to blame-shifting).
At least, that required self-reflection is on Jonathan, Leo and Brett’s radar. Keep up the good work, guys!
Thanks for coming to write on this website. I wholly agree with the goal of abolishing the current system of diagnosis (especially in clinical practice), as too few doctors understand or care about the difference between reliability and validity, the side-effects of labeling are ignored, and circular explanations about pseudo-etiology are embarrassing (kudos for your writing wit in pointing that circularity).
I hope that quest will be focused on moving away from the focus on explanations and root cause assumptions to move towards solutions and problem-solving.
When there is no obvious way to establish etiology with confidence, the best is to acknowledge we don’t know (that explanations are too complex with too many factors for us to pretend to understand what happened, let alone to assign blame in a narrow fashion). It is better to focus on changing ourselves, and familial and societal dynamics rather than retrospectively explain how we got there (there is a difference between life narratives focusing on “objective” descriptions, and dubious explanatory “subjective” narratives).
I do think that the need for explanations is often by itself a significant source of suffering and conflict, even when the explanations err on the side of psycho-social assumptions (traumatized is itself a label and could become an unhelpful lifelong diagnosis). Accepting that we cannot adequately explain the past or present is a first step in focusing our energy on improving the future.
Whether problems are biological or psycho-social, we should focus on overcoming them. There is no reason to think that biology is harder to overcome than psycho-social problems, or that even when biology is likely a significant factor, drugs or other “biological” interventions are the only way to alter biological dynamics.
Great wisdom. I understand the “try, but not too hard” as a requirement to value and focus at the same time on:
– acceptance (at least of past and present),
– and hope and drive to improve things.
The other important dilemma you mention is how to keep our mood and emotions attuned to the social context we are in, while neither letting a bad context disable us, nor letting a good-enough context make us complacent. Too much “positive thinking” sounds like a encouragement to dissociate our mood from our situation (not a good idea in general).
And I like the option of temporarily surrendering to unpleasant or unusual states (while keeping everybody physically safe).
Thanks for writing!
Thanks for promoting hope as a cornerstone of human life. After reading your beautiful text, I tried to reformulate/mix it through my own mind and language (I hope I did not stray too far from what you meant):
It is good practice to not promise more that we can deliver. But hope is what bridges on one side the lack of any guarantee, a possible history of setbacks, and on the other side the need to always continue to try to move forward anyway (at our own pace), and to choose to promote life. We should be cautious when doing promises, but we should hope in a unbounded way.
There are a few laws of nature that are firmly established, but for the biggest part, our future cannot be predicted, and when confronted with the mystery of what will be, when no science can provide a firm answer, promoting unbounded hope and reasonable optimism should be a moral imperative.
Hope is the feeling that no matter what we are confronted with, our mind can still be OK.
For me, two of the (many) big flaws about the DSM are:
– using discrete categories,
– trying to define a clear boundary between normal and ill.
I think those two flaws were a significant factor in having most people believing the syndromes were valid diseases (making DSM extremely toxic). A multi-dimensional classification based on trying to define non-pathological personality traits (with the understanding that some extreme combinations are pathological but without defining any specific threeshold) might have been a better first step in trying to establish a common language among psychiatrists.
On a related subject, what do you think about the NIMH RDoC (Research Domain Criteria) project?
Hi Lucinda. Thanks for bringing your story here. It is always good to hear from somebody doing well (after chronic depression in the past). It is also good to hear on this site from people whose wellness currently includes some medications, even if you make it clear that wellness neither starts nor ends with them.
You seem to be able to embrace two views at the same time without contradictions (that’s a good thing): a view of wellness and mental diversity (or dangerous mental gifts) familiar to readers of this website, as well as a success story of psychiatric care (which is a rarer story here).
I hope you will tell us more about your views about the strengths and weaknesses of current mental health care in America, seen from your experience, and how it relates or contrasts to the experiences of others like Tom Wootton or Corinna West or Laura Delano or other bloggers here with first-hand experience of psychiatric care.
Thanks for exposing the deep flaws of how that research was conducted. The people responsible for Dan Markinson care failed him in the most horrible way.
There is one sad perspective under which one could argue that Dan Markinson enrollment in a clinical trial was not the main factor in his death: the treatment that Dan Markinson received does not look very different from treatment as usual. Ignoring family warnings, and continuing the same treatment despite worsening of symptoms is sadly too often the norm under standard care.
It is shocking to see that a patient enrolled in a clinical trial was not better protected or monitored that people in standard care. At the same time, one cannot escape the feeling that Dan Markinson story also represents the typical tragedies and substandard care occurring under treatment as usual outside of clinical trials.
Either way, it is critical to make this case as widely known as possible. Thanks for you work doing that!
Being aware of the historical shifts in psychiatry history should definitely make everybody humble. I like your perspective, and your narration of historical context.
On a lighter note, is your post title one of those mind tricks where nobody is supposed to notice the duplication of the word “to to” (maybe “we want to see” only one “to”?)?
To comment on the meaning of the title, I wonder if previous knowledge, and previous perceptions are not possibly more important than our will (or our conflict of interests) in having different people interpret the same reality differently. I will admit my perception bias: I think the metaphor of the elephant and the blindmen has more validity to explain those perception differences than explanations based on “emotional” or “want” biases (even if I am also a big fan of Kahneman).
Thanks for posting.
You point to a fundamental dilemma between the urgency of the issues, and the fact that making progress on these issues requires time and patience.
Even if I often advocate building bridges, it is obvious that trying to build bridges with Torrey, Lieberman, Nemeroff or Kenney would be a waste of time.
But I don’t see an opposition between being more forceful and building bridges with other people, on the contrary those bridges are what will bring force to your ideas.
The bridges have to be built with people who care more about outcomes than about their pet business/ideology. That is the “silent majority”. Especially when trying to educate about the mind, you will only have credibility with that audience if you master the art of constructive and creative dialogue.
Preaching to the choir with force will not advance any cause if the pews are empty.
Thanks Laura. Those are powerful words, and a powerful testimony that will contribute to offering real options, and a real voluntary choice to people finding themselves in similar circumstances from now on.
It’s hard to add anything other than my appreciation to the thoughtful and inspiring comments and dialogue already made here.
John, I really like that principle. Being able to engage in a good-faith transforming conversation with people close in goals or beliefs seems both a good strategy.
It might also be a test of credibility: that approach seems easier than curing people from emotional distress, so when reaching for the latter, it is important to convince ourselves and others we can do the former.
Thanks for telling all those stories you discovered in your journey. They are so many simple false myths about homelessness and homeless people, it is important and enlightening to discover the complexity and some real name and stories behind the label.
Thanks a lot for coming to the madinamerica website, for what will hopefully be a fruitful conversation. I take your message as a call to focus on recovery, and living meaningful lives, without assuming the illness part of mental conditions has to be chronic or permanent.
I really appreciate your introductory question: “What would be possible if Mental Health Conditions were viewed as gifts that require effective management and responsible use?” I think that question is at the core of most discussions here.
Maybe the answer starts with recognizing that diagnoses like depression or bipolar have very little predictive power, and are agglomerate labels for very diverse situations (in causes, dynamics, characteristics and response to treatments) whose commonality is only a set of non-specific symptoms. Even if we recognize some usefulness to the diagnosis of bipolar disorder, I have never seen any science justifying the lifelong prognosis generally given by doctors for that disorder to individual patients. That prognosis can become a powerful self-fulfilling prophecy, but then we might as well assume that the resulting lifelong handicap is a iatrogenic condition (resulting from bad science and the nocebo effect of prognosis) rather than a valid medical prognosis.
You said: “Largely missing in the public discourse is the recognition that many people successfully manage their mental health issues.”. I like that. But in your view, is there any difference between “successfully managing mental health issues”, and no longer having a disorder? If language defines our world, do you make any difference between: “As a person who successfully lives with bipolar disorder […]” and “As a person who used to have bipolar disorder in her past, but no longer has the disorder”.
In any case, thanks for your work and your thoughts!
Great post. You cover a lot of ground on the major issues that are causing harm in mental health care. Such good summaries are a important part of contributing to improve the system
I’d like to comment on minor aspects of your views:
– First a language issue: while I feel close in spirit and understanding to the post-psychiatry community, “post” comes from “postmodernism”, which encompasses an eclectic set of views (many of those I find very interesting, but there is also a lot of B.S. going on under the cover of postmodernism). In many circles (especially scientific circles), the mere mention of postmodernism is usually associated with being anti-science or pseudoscience (that is an unfortunate oversimplification, but the association is unlikely to disappear any time soon). When promoting a focus on social factors, it is ironic (and a little self-defeating) for a group to choose a language term that might restrict its social influence.
The second point is that the issue of billing probably deserves more emphasis. Whether ICD or DSM, both are individual medical perspectives that basically don’t provide an answer to the many situations of persistent social stressors that are not caused by a specific individual dysfunction. Social workers should be able to bill their services for “overwhelming stress due to the influence of persistent external factors or relationship problems that a person cannot be expected to control or avoid without help”.
If financial resources are only available to address individual problems, then all familial or social problems will be explained in terms of individual dysfunction, and things will not get better, *even* if we remove biology out of the equation. Many families can testify that individual psychotherapy can often make things much worse: if all problems are seen as individual, then inevitably each participant of a conflict will put the blame on the personality of the others, which can only worsen the initial conflict (eventually making things bad enough that biopsychiatrists will be the last resort for the survivors).
I really enjoyed reading your post. It seems you got an incredibly wide range of different experiences, and I hope you will share in more details those stories on this website in the future.
I took a quick look at the introduction of your book on domestic violence offenders. It is such a tough subject, it takes courage for trying to be a mediator of change in that area, and you certainly seem to have brought valuable perspective there. The previous perspectives I had read about were the feminist perspective and the Duluth model, and the significantly different work from Steven Stosny. The dialogue with the persons in those difficult conflicts is likely to bring new perspectives about the human mind, that have implications for all of us (and for any conflict situation).
Hi Sandra, thanks for that great post. I commend you for answering Torrey rigid beliefs about schizophrenia with a problem-solving attitude. One major criteria to determine that a discourse is grounded in science is the focus on problem-solving rather than unverifiable explanations. So on scientific grounds, you are definitely more convincing than Torrey (and on many other grounds too).
Torrey seems to misunderstand the monist concept, and implies that associating some behavioral or thinking deficit with some brain anatomy is sufficient by itself to identify a disease process that is purely “biological” in its etiology or in its solutions (that would still be very crippled thinking, even if the associations were robust). Torrey seems to be half-dualist/half-monist (a confused mode of thinking).
It is understandable for families or patients to miss the implications of the common saying: “mental illness is a biologically-based brain disease, not a character flaw”. But people like Torrey should tell us whether, in their opinion, character flaws, or character virtues, or any learning or thinking are independent of any cellular-level activity or organization of the brain. Does the process of developing a character flaw happen without brain involvement?
Linking brain activity with thinking or behavior does not mean any of those has been explained or solved, it only confirms than spirit emerges from matter, and that matter maps the spirit (a monist perspective). By itself, that linking does not tell anything about etiology or what to do about the situation. By Torrey’s logic, showing differences between the brains of a pianist and a non-musician would be sufficient to make piano teaching and learning a purely bio-medical matter.
Great post. You have the grace of rising above what would be a sterile controversy about the ownership of the word recovery, while promoting effectively the concepts, relationships and interactions that are making life (and the word recovery) more meaningful.
Kudos!! This was a great talk! I was very impressed by the feat of having the same person talk inside and outside of APA. It seems a brilliant and very effective way to have innovative ideas discussed in the mainstream without risking being phagocytized by the system.
I also like to thank the conference organizers that made your talk possible.
When reading Thomas Insel, I usually feel there is some common sense in a lot of his views, but there is always often leaps of logic where I need to pinch myself, like the following:
“There are no drugs to target the main symptoms of autism such as social deficits and language disorder, Insel said. Those deficits often respond well to intensive behavioural treatments, which suggests there’s potential for a pharmacological approach.”
Thank you for your posts. They seem to provide a very concrete, practical and effective framework to raise healthy kids. While acknowledging the vast differences between adults and kids, I wonder whether it is possible to derive a few fundamental rules about learning mechanisms that could apply to any age.
In particular, I would be interesting by your take on the “highway patrol approach to discipline”, which might not only tell us something about raising kids, but also something about promoting cooperation in adults (by thinking about the ideal cop). Those parental principles are described at the following link:
Is it a good idea when thinking of parenting style to evaluate discipline in the light of how similar rule enforcement would be done between adults (and maybe even reciprocally)?
Great article. Thank you for pointing at the trends in the thinking of some mainstream academics.
About the FDA: “safe and effective” is actually the criteria for over-the-counter, so prescription drugs never fit that criteria. The criteria for FDA-approved prescription drugs would sound more like: “the drug provides benefits for a specific symptom for a majority of the target group, and the observed side-effects are deemed worth those benefits, even if that positive trade-off is not true for all individuals of the group”.
Part of the reason people end up on harmful polypharmacy is that even doctors are thinking “safe and effective” (and “my ass is covered by the FDA”), rather than thinking in terms of both taking a risk and evaluating a trade-off. If the decision is framed in terms of taking a risk and evaluating a trade-off, then it makes sense to involve the patient in the decision, and it makes sense to plan for the possibility that the drug might be counter-productive, and to consider other ways, or abandon the drug after trying it unsuccessfully.
You rightly point on how Friedman is saying things late and not in a very bright manner, but you are too mild:
– Friedman criticism about antipsychotics is based on his claim that a SSRI or a combination of two SSRIs are the right solution for “modern life” (I guess we have to wait ten or twenty more years of experience, before publishing on the danger of SSRIs).
– According to Friedman, antipsychotics are safe and effective without qualifiers for people diagnosed with bipolar or schizophrenia (even pharma papers don’t push the deception that far: the numbers-needed-to-treat, and effect-size they claim are very modest, pharma knows that contrary to academics, they are sometimes held liable for exaggerating too much).
I mostly agree with your assessment of America, you can see my answer above to Stephen, clarifying my questions (which I meant as genuine questions, not as disguised suggestions).
Stephen, I agree with Bruce (and with you too) much more that my comment wording might show, or that you might speculate.
If I am allowed a little humor, I would say that on a text that praises the anti-authoritarians, toeing the line of the author without questioning would have been a self-contradictory attitude.
But humor aside, my questions were meant to be serious. FWIW I am not happy with the current oppressive state of society, but asking whether in the big picture we are currently regressing or progressing, and whether there are better role-models (in past history or other areas of the world) for inspiration is a pretty mild question.
The ability and will to cooperate has an influence on power structures. The corporate world knows when to work together on their power, while competing for customers. Asking ourselves whether there might be some internal factors contributing to the fragmentation of the opposition is uncomfortable, but IMHO a useful question.
Interesting proposition. I agree with many of your main points: the unwarranted pathologization of legitimate behavior, the need for society to improve the ways in which each of us can negotiate social influence with more fairness, and the obvious fact that power structures have a tremendous influence on distress.
All that being said and agreed, I also think there is a possibility of occasionally overreaching by focusing too much on the political context, and external powers, for factors where it is secondary. I don’t think that corporate power can be the scapegoat for every individual or family ill; for instance you mention social isolation: isolation is more likely to be solved by education and emphasis about social skills, valuing other people (including temporary opponents), and how to reconcile tolerance, respect and assertiveness.
While being a psychologist helps bring credibility to the critique of the psychology field, there would be an irony from choosing to be or stay a psychologist (rather than a teacher, politician or journalist), and wanting to explain distress only at the level of the big societal power struggles, while never mentioning the existence of self-destructive states or dysfunction at the individual or familial level (that are not caused or maintained by the influence of a larger power structure).
It might also be appropriate to warn that sometimes abusive local or familial power can be maintained under the cover of an anti-authoritarian stance (by somebody undermining any other authority except his own).
There is two questions I have:
– when looking at the evolution and direction of power structures, do you see any significant period since the start of history having lived in a society that is less repressive (economically or otherwise), more open to anti-authoritarian stance, having more freedom of expression than America today?
– When you put 100 anti-authoritarian people in a room, do you end up with the most cooperative crowd you can imagine, or with typical power struggles?
The world of health insurance, or disability insurance is a market where recovery and quality research of outcomes could be lucrative. From a free-market perspective, since our society chose to harness the financial power of pharma companies for research purposes, it might as well throw another devil in the mix (hoping it might provide some checks and balance).
The ethical question would be: under what conditions should a respite center or an open-dialogue team accept some funding from a disability insurance company?
Unfortunately, Lieberman is just embracing an idea that is mainstream and currently accepted as fact by a part of American culture: that the common good arises out of the fair competition between greedy and selfish instincts, and that as long as competition is fair (i.e. not biased by government), then greed, selfishness and lucre should be encouraged (aka Ayn-Rand-101).
There is certainly some irony in proposing greed as an indirect cure for mental illness (rather than as a DSM diagnosis), but I do believe Lieberman is honest, and authentic with himself when making that proposal.
Open Dialogue is a treatment that could justify itself even if it was a money-loosing proposition. But there should be no shame in pointing that in addition to the human values it conveys and to its scientific credentials, it seems a big potential money-saver in the long-term, especially since we might not be able to afford keeping those pharma companies on the welfare rolls of medicare/medicaid/government-assistance indefinitely.
Some aspects of this discussion might be linked with one of the important thesis of Bob Fancher (or the starting point of postpsychiatry): that no school of psychiatric research can pretend to be purely scientific and culturally-neutral, any research about mind/behavior operates within a set of axiomatic cultural values, and the best that can be done is to be aware of those cultural assumptions.
Keep up the good work, Michael :-). I like your way of asking the question: “If madness isn’t what psychiatry says it is, then what is it?”.
Even on MIA, it would probably be hard to find two persons in full agreement regarding the answer to that question, but that’s consistent with you saying “madness is complicated”. In any case, since a consensus answer won’t happen any time soon, we are left with a more pressing question: what are we doing about it? And to answer that one, I’ll just hope I end up in your hands rather than in the hands of standard clinical practice if I get mad in the future.
Thanks for the great reporting.
“There is on average, only three weeks between the time when a young person first experiences psychotic symptoms and meets with a team”. Your previous reporting seems to mention days rather than weeks before intervention, is three weeks considered a short-time compared to the rest of the world?
I like that Open Dialogue seems to rely strongly on creating a cooperative mode of operation between the minds of each person present (without creating a hierarchy between treatment team and others). As in many areas, practice and training might be more important than assimilating guidelines, protocols and case histories, and I can understand that there is no “manual”. On the other hand, I hope there would not be a reluctance to describe what it is in more details in (a) book(s), and I was wondering if there was already an example of such a book?
Thanks for sharing your story. It seems similar in many ways to the pattern followed by several members of my family (except they are still buying the drug model hook, line and sinker in spite of having their health, mood and functioning becoming worse on them). The only reason I did not follow that same drugged path was due to a very lucky combination of circumstances.
Also, thanks for the excellent work on following-up on the “Elizabeth Wurtzel” story.
Happy 10th Anniversary to all contributors of the Icarus project! Congratulations on all the excellent work!
I agree that it is hard to communicate, debate and get things done without having a consensus on the meaning of words.
But reaching that dictionary/glossary consensus is by itself extremely hard. Defining the meaning of words is by definition a mostly circular reasoning exercise. Not counting that everybody gets defensive about their own pre-existing definitions (and since most people associate emotional value to words, language is not neutral, which I think was one of the point made by Corinna here).
If you were to have every participant of MIA create from memory a dictionary of the terms commonly used, you would get a number of partly irreconcilable dictionaries (both in meanings, and also with different emotional value attached to words). To understand each other, we have to always make an effort from context to be aware of the possible personal variations in our language.
For instance, the word “disease” has a completely different definition for different MIA participants.
I am totally with you on the fact that language is important. I appreciate the language of the distress model, it has a way to convey the fact that recovery is possible. That language helps counter the common practice of diagnosing a permanent disease which is both unscientific and dangerous, as well as the common practice of assuming genetic causality.
That said, for even more accuracy, it might be better to oppose the “distress model” to the “permanent disease model” rather than to the “disease model” (by itself “disease” can be temporary as in flu, cold, chicken pox).
Another thing: it would be extremely counter-productive to alienate similarly-minded people just because of language issues. Promoting the use of some vocabulary like “madness vs mental illness” or “distress vs disease” makes sense because of the historical unsound use of those terms, but most truths can be expressed in different languages, and vocabulary should never be a show-stopper when evaluating an idea.
On your last question, I would be a bit ambivalent depending on where the money is supposed to come from, but right now, under my personal circumstances, I would choose a 20% chance for 10000$.
That said, I see the original gold medal question as unrelated to risk-taking, you were proposed a choice between two propositions:
– no: I go with a small chance of legitimately winning a gold medal, that would represent the fact I was able to fairly out-compete everybody in a game involving talent, sacrifice, commitment, risk-taking and determination.
– yes: I trade ~50 years of my average life expectancy, to get a gold medal that allows me to pretend to have been the best, while perfectly knowing myself I cheated to get it, might not have won it in a fair game, but obtained it through bribery in a Faustian bargain.
Answering no shows a sense of fairness and integrity (in addition to an appreciation for life). I am not sure what anyone can prove by answering yes.
I personally interpreted your “no” answer as proof of virtue and intelligence. I am not sure which one you are ambivalent about.
Looking at the 1998 Boston-Globe paper from Robert Whitaker gives some sense of the long struggle that led to this website. It is interesting that in that paper, Dr. Torrey was Robert Whitaker’s chosen ally in denouncing the corruption of science by pharma.
I am sorry if part of my comment sounded like criticizing the olympic spirit or olympians in general. That was not at all my intention, I do respect them completely, and the last part of my comment was meant to be limited to discussing the result of the poll: “would you take a pill, win a medal, die one year later?”.
Are you ambivalent about having chosen to answer no to that question?
Thanks for your great work, and for sharing it here. I haven’t read your book yet (but did order it).
I am very convinced by everything you say, and your model seems powerful when applying it to at least some “mad” people I have befriended.
You associate delusions with a loosening of cognitive structures (during some crisis). I would say it is important to distinguish unstable breaks with reality (corresponding to a loose structure with no self-consistency over time), from very stable delusions (possibly lifelong) that form an extremely logic/rational/self-reinforcing perception of reality (and that can develop in a rational non-traumatic way) with hardly any more contradictions that “consensus reality” (I love that expression).
For instance, some paranoid people are often very logical/rational/intelligent, and have developed a dog-eat-dog model of their environment that is hard to disprove without the possibility of mind-reading (any act of good-will is seen as being a conscious and purposeful malevolent grooming-manipulative act), and don’t have significant dilemmas about their place in it.
Great story Corinna. Thanks for sharing.
I was impressed by the testimony from Kayla Harrison, she seems like a excellent role-model: authentic, resilient, caring, humble and strong.
“If you could take a pill to guarantee you would get a gold medal, but it also guaranteed that you would die a year later, would you do it?”. 80% said yes. Should we boycott 80% of the olympics? That is really scary! Talk about a culture of death (no wonder doping is a big problem in many high-level competitions)! Thanks for being part of the 20% that are still sane, and pointing at other members of this group.
I agree with Anonymous that SSRIs are irrelevant in determining responsibility for a case like James Holmes. But I don’t think the goal of Dr. Healy was to minimize individual legal responsibility.
When a camel’s back breaks after adding a straw, only fools will mostly focus on the straw while being completely blind to the 800 pounds of metal the camel was already carrying.
That does not mean that as a matter of public policy, SSRIs role in violence is not a legitimate topic (like spreading straws on a overloaded camel caravan).
SSRIs don’t cause individual violent acts, but David Healy is asking a legitimate question: do they load the dice (or the camel)? Could they have a real statistical effect on society’s violence.
David Healy might be provocative in suggesting that spreading SSRIs might increase violence in society. But his stance is helping restoring balance against the common psychiatry bias: when somebody gets better, psychiatrists thank the drug and congratulate themselves on saving the world, when somebody gets worse, they express their sorrow at the worsening of the natural course of the mental illness and congratulate themselves on the fact it would have been even worse without drugs.
To oppose that predominant bias, and force people to think twice, you sometimes have to be provocative, and make suggestive (rather than scientific) associations. The context is what make the provocative discourse legitimate.
Individual responsibility is tantamount to the world health. Good public policies, and collective thinking/discourse are equally important.
I agree biomedical psychiatry is unfortunately still the dominant force. I can agree it is still very close to its maximum peak even if I do believe the signs it is “past that peak”.
Great work for everybody that made that center possible. I am glad to see such solutions supported by SAMSHA. I think it proves the biomedical/genetic/lifelong-illness model is already past its peak (even if still dominant in clinical practice).
John McManamy is an excellent independent journalist reporting on the trends of psychiatry, in May 2009 he was already reporting on the “Sea Change” that was occurring at the APA meeting, with psychiatry moving away from biological psychiatry:
From his 2009 report: “At a brief pause in the proceedings, I ask the psychiatrist next to me what is going on, and he confirms my impressions. In essence, the bloom has gone off biological psychiatry, which translates into sending patients out the door with just a prescription. We’re seeing the pendulum swing back toward an earlier era when psychiatrists used to spend time working with their patients to find solutions to their personal problems.”
The recovery movement might have to also adjust, to ensure that the retreating tide from biological psychiatry:
– happens faster (the trend is good, but very slow),
– does not lead to equally hurtful new psychiatry trends.
A very inspiring post. The beliefs, expectations and theories we have about our mind are very powerful placebos or nocebos (i.e. cures or poisons) for mental issues, whether we take a pill or not. I don’t remember seeing that fundamental principle expressed as well and as convincingly, with all the cultural implications, than in your various posts. I look forward for your webinar.
The expectations and explanations we have about ourselves are shaped by our culture and the expectations and explanations (whether optimist or pessimist) that significant people have for us. Not just our parents, but also very importantly members of the mental health professions (whether through therapy, or mainstream books, or journal columns).
Mental health professionals are quick to recognize the major influence of parents on mental struggles (unfortunately maybe too systematically), but they rarely take responsibility in any outcome for their own influence, even if the struggles appeared in adulthood long after parents have stopped being the most significant influence, and even for people that have considered for years the mental health profession as the most significant source of authority for life issues.
I consider any mental health professional or organization that gives a “lifelong” mental illness prognosis as dangerous and partly responsible for that outcome if it becomes true.
Lots of good historical information in your blog. Thanks!
There is an interesting ambiguity in your introduction about describing Keris Myrick as a peer/survivor. Survivor is often a short-hand for “psychiatric survivor” (i.e. recovering in spite of psychiatric intervention), whereas she describes her relationship with her psychiatrist as one significant component of her recovery. I was wondering if the ambiguity is from her own message, or in how others perceive her.
One thing I particularly like about Keris Myrick talking about her story is that she clearly put forward and foremost the fundamental goal of well-being and recovery and life fulfillment. Explanations of mental illness, diagnosis issues, management and treatment issues are subordinated to that goal, those aspects don’t matter by themselves.
I can relate to most experiences you are describing, and the longing for a radical transformation, but my current thinking is the following:
– A transformation can be popular or radical, but not both.
– A transformation can be radical or fast, but not both.
– A transformation can be fast or popular, but not both.
Having a radical proposal is quite popular, but the reality is that most radical proposals floating in the world are different and incompatible on fundamental levels. The quasi status-quo, or slow evolving of society does not result from radicalism being unpopular, it results from the absence of significant commonality in any large enough group of radicals.
The only credible transformations that can be fast and popular are those that are significantly driven by technological or scientific breakthrough, or that are totalitarian in nature (democracy is slow and messy when applied to large groups).
Those principles applies even to a group of moderate size like MIA, and on issues as narrow as psychiatry. Everybody at MIA agrees that psychiatry should be radically transformed, but when you get into the details of what people want as a replacement, beyond a few consensus points, diversity is the key word (and diversity is good).
So my thought is that either embracing diversity or embracing large coalitions implies moderation (at least of pace, not necessarily of long-term goals) rather than radicalism. And radicalism is better suited for experiments at a small scale in communities of like-minded people (like-minded always corresponds to small communities, it does not scale in democratic environments).
Great news for everybody. Congratulations to Keris! And an important step for NAMI.
Thanks for all the information about the role of Gibbons in the controversy about suicide and antidepressants.
I agree Gibbons is influencing many people with his bad (or possibly fraudulent) science, and that is sad. Being of a optimistic nature, I think it is equally important to point that Gibbons is not necessarily representative of any majority in the medical field:
– Gibbons advice/vote did not sway the FDA. Eventually the FDA did a useful thing, decided on the black-box warning, and maintained it. In spite of all its flaws, we would probably be much worse off without the FDA (and equivalent foreign institutions).
– In the funny (or sad) back and forth between Pies and Jonathan Leo about chemical imbalance, Dr Ron Pies said something that seems very true and quite significant:
“[Leaving aside] the dubious notion that there is a ‘psychiatric community’-I see it more as a balkanized collection of competing fiefdoms!-“.
So for most purposes, the “psychiatric community” does not exists, which makes it clear there is no conspiracy or general delusion affecting all psychiatrists.
– The following blog provides a powerful argument about why clinical trial data is generally irrelevant to reach a conclusion (either way) about SSRI and suicide:
I will add that if being suicidal were considered a distinctive “diagnosis” category, it is one for which nobody could recommend any science-based drug treatment, because suicidal people are specifically excluded from any drug trials (that looks to me as if we were excluding diabetic people from tests about diabetic drugs, that would make the testing safe and useless).
– Delusions often feed on either the absence or the weaknesses of competing thought/beliefs systems. I can see how MIA contributes to the emergence or promotion of new proposals for the treatment of madness, but I hope “MIA-approved” approaches are internally subjected to the same level of scrutiny than competing approaches. In many ways, right now, MIA is already one of the competing fiefdom in the psychiatry field (I hope it grows while maintaining high internal standards, rather than any specific direction).
Thanks for pointing interesting bits. While I usually oppose bashing any psychiatrist, I find it interesting when one of them does it at Psychiatric Times.
Rone Pies says:
“In the past 30 years, I don’t believe I have ever heard a knowledgeable, well-trained psychiatrist make such a preposterous claim, except perhaps to mock it. On the other hand, the “chemical imbalance” trope has been tossed around a great deal by opponents of psychiatry, who mendaciously attribute the phrase to psychiatrists themselves.”
I am not sure in what alternate dimension Dr. Pies has lived in the last 30 years: making an association between “chemical imbalance” and ignorant, untrained psychiatrists is a double-edged sword, and the second edge is wide and powerful.
Thanks for the pointer to Jonah Lehrer article. There is a refreshing contrast on how well-documented and researched this article is (about “the decline effect”), and the cautiousness in its conclusion “This suggests that the decline effect is actually a decline of illusion.”.
I am not a statistician, but I still have enough training and credentials in mathematics to question how one aspect of the significance of results is presented in many research papers I read:
– too many research papers put forefront in summary/abstract the “P” factor that justify their research result (often very low), like if it was a marketing argument, while hiding well the effect-size or numbers-needed-to-treat.
– in justifying their result, most writers don’t seem aware that the “P” factor is only meaningful when making the assumption that there is no noise and no bias in the data collection process itself, and no errors in the methodology (good methodology with P=0.1, and good effect-size is much more credible than poor standards with P=0.001 and small effect-size). Maybe one day, somebody will propose to systematically use some extra statistical balancing measure, that would give a numerical assessment of the upper bound of unknown potential noise or bias that would still make P<0.05 (the current base value of P is irrelevant to measure that "robustness" to bias/noise). Maybe then the "decline effect" can be nipped in the bud, as some illusions might be detected more early.
I loved the article. Thanks for making me discovery Williams James: “Faith in a fact can help create the fact.”.
I have been a fan of Skeptic magazine for years, and the only thing that has occasionally bothered me about that literature is that self-fulfilling prophecies, placebos, beliefs and faith have always been dismissed as anomalies that should be indiscriminately removed from the face of the earth, rather than identified for what they are.
What is dangerous is the inability to distinguish between faith and science, between beliefs and knowledge, between assumptions and the laws of nature (and thanks for Skeptic for helping making those distinctions). But faith that is acknowledged as faith can be a force for good (for optimism, mental health, and motivation, and to change the world for the better in any area related to the human mind).
I am glad you got to publish in Skeptic an article debunking the fact that faith is all bad or incompatible with critical thinking.
“From several classic studies, we know that moderately depressed people are, in a sense, more critically thinking than are non-depressed people.”. Isn’t your article showing that this is likely just a self-fulfilling prophecy, resulting from the irrational belief that “critical thinking is not compatible with faith”. Once debunked, critical thinking becomes compatible with reasonable optimism, and reasonable happiness.
Great expose about the nocebo effect of the chemical imbalance hypothesis.
I think a very similar argumentation would also apply to various other unproven claims about diagnosis/prognosis and treatment, if the chemical imbalance theory was replaced by epigenetics, neuronal dynamics, post-trauma determinism, the idea of schizophrenogenic mothers, some astrology practices, or oedipus complex.
You focused on what patients believe and are telling you. You mention your own view, but I would curious to know more about what you are answering your patients when they present themselves with those beliefs.
On a different point, I don’t think the democrats versus republicans influence on research corresponds to a biological versus social model. The difference between republicans and democrats is about what kind of society and family culture lead to mental suffering, and which lead to mental health (republicans do believe “healthy” families, church and communities impact the individual character and health, even if they are averse to use any word that starts with “social” to describe those contexts, in the same way democrats believe about virtue and individual character but are often averse to use any word that start with “moral” to talk about those beliefs). In any case, I don’t see biology-obsession as a politically partisan issue.
Dear Dr. Datta, thanks for this thoughtful contribution. You emphasize that mental illness definition, and the level of mental health are defined as much (or even more) by our social structure than by the mental health professions. That case needs to be repeatedly made, in the convincing way you just did, as it is not obvious to everybody.
That said, while emphasizing the multi-factorial causes of mental illness is part of the job of psychiatrists, it is also their job and their responsibility to use the time and resources given to them to improve individual mental health in the current specific context. We live in the society we have, not the one we wish we have, and some mental conditions need urgent care (without waiting for society to change). So it is psychiatry responsibility to find how to lower the death count from mental illness not just in the future society of the XXII century, but also in the present society, next week, next month and next year, focusing mainly on the individual and its immediate family and friends. Even within those very restrictive conditions, it is hard for me to believe that psychiatry has reached a plateau, and is already doing the very best that can theoretically be achieved, and that nothing better can be done without changing the core structures of society (I know you are taking an interest in what psychiatric practices are actually making people’s mental health worse, that research field is vast, barely explored, and would lead to immediate benefits in today’s context. In addition identifying counter-productive treatments might also be a good intermediate step for discovering new positive treatments).
Thanks for your contribution, and I look forward to more of them.
Hi Michael, this is an interesting view, and I agree with a lot of what you said, but I can neither embrace the premise nor the conclusion on several grounds:
– cognition, worldview, perception, emotions, language are all inter-dependent. While emotions affect everything, including our worldview perception, our cognition, our language, our behavior, our volition, the same can be said for cognition, worldview, perception and language. Each aspect of the human brain influences the regulation of our emotions, as well as all other aspects. In my opinion, focusing on emotions as the most important feature of our brains is kind of arbitrary, because no model of human beings based on a chain of causality with a specific root-cause will be universal. I think any high-level conceptual model of the human being has to look more like a complex imbrication of feedback loops (or a complex ecosystem, or a self-organizing network).
– different individuals are not just different on the expression of emotions, but on their internal intensity. Some people are more analytical, some people are more emotional. What you say might be relatively true for some people, but might not make sense for others, unless you redefine the term “emotions” from a different way that the one present in dictionaries.
– we know that too few emotions, as well as high-expressed emotions are a driver of low mental health and suffering in families. Maintaining a balance between the different features of our mind seems the most healthy way of interacting with ourselves and others. Paying too little or too much attention to emotions is dangerous.
– I am afraid I don’t understand what you mean by “emotional truths”. I agree that emotions are the main driver for many things, including both delusional obsessions and the quest for truth-seeking, I agree on its central role in creativity or motivation, but talking about “emotional truths” as being the main truth is playing with words in a way that seems to me an attack on either language or reality.
One sentence triggered my attention: “I marvel at the process through which, as a society, we collectively decide that one drug is a problem and another is a life enhancing treatment.”.
Chemistry and chemistry research is working at a certain scale of time. Culture and collective assumptions about chemistry are evolving at a different scale of time, and in a way that might match in complexity the dynamics of the brain network.
In the same way human higher-level reasoning trumps the power of an individual neuron (but evolves much more slowly, and is much less reactive), I do believe that eventually collective intelligence trumps and transcend the finding of any individual or group of individual.
In any case, thanks for helping move collective intelligence ahead!
Thanks for being part of those scientists that are constantly trying to distinguish what we know and what we assume, and trying to increase the former. Your word carries the credibility of the scientist that has no agenda, apart from following the evidence wherever it leads to.
I would be interested to hear more from you about the psychotherapy component that you mentioned. Are there any “mind models” in individual psychology/psychotherapy that you find more useful or more well-founded (or more likely to pass the test of time)? There are many models of personality or mind or psychotherapy: big-five model, the DSM-IV personality disorders, the DSM-5 dimensional-based personality model, CBT, logotherapy, schema-therapy, RFT, psychoanalysis,…. Do you have a few “favorites” inside or outside that list?
In the same line, are there any psychiatry/psychological books you frequently recommend to patients?
Thanks Dan Fischer for bringing the focus on the cruel abuses at the JRC. There are degrees in inhumane treatment, and the JRC treatment is the only current one (that I know of) that no doctor or judge would ever think to apply to terrorists or criminal (it is scary that it is deemed OK for severely disabled kids). It seems even more inhumane than any seclusion, forced drugging, or forced ECT under anesthesia (and probably than waterboarding). Speaking for myself, if I ever turn out to be out-of-control in my life, while I would prefer not to be forced-drugged, between two bad solutions, I would prefer forced drugging over the extreme methods of the JRC (the JRC claim of using aversive therapy does not reflect reality, I can think of some mild aversive therapy like spanking, which while misguided and abusive, would not deserve the label of torture).
The JRC stuff sounds like evil science-fiction: wearing a electric backpack 24/24 which is used to remotely send you extremely electrical shocks (not just for dangerous behavior, but even for harmless child-like behavior), sometimes hundreds times a day, and doing that for years (and often increasing the voltage over the years). It seems like somebody decided to do for real the experience that Stanley Milgram only simulated, the actor-victim is replaced by a disabled kid, the electrical shocks are real, and the only reason the shocks are not made deadly is to be able to continue applying them for many years.
While the JRC treats some kids born with major biological brain defects (due to birth accidents or other well-identified causes), it is important to note that some of the kids are put there because after years under 6 to 12 powerful drugs, they became much worse (while they were probably not initially that bad before the drugs). The JRC provides one more reason to be cautious about drugs: they can turn problematic kids into kids that are so crazy and hopeless that some parents and some judges are then OK’ing torture on them.