Saturday, September 18, 2021

Comments by Bob Fancher, PhD

Showing 94 of 94 comments.

  • You may well be right, Stanley. I would rephrase your analysis as saying that the heritability quotient abstracts too far to be meaningful. Would that be apt?

    What gives me pause is your particular example of bipolar. In classic bipolar, we generally only see that develop in adulthood–the idea that kids can be bipolar was largely the work of Joseph Biederman, right, who has been pretty well disgraced? So I’m not sure how the feedback loop you offer would apply to early childhood.

  • Stanley–

    The heritability quotients I quoted are h(squared) numbers, which measure the proportion of variance within a population that can be accounted for by additive genetic variance. By definition, this does not include COV (G,E). COV (G,E) would be a source of confounds, in the context of this discussion.

    The h (squared) heritability quotient also does not include nonadditive genetic factors or epigenetic factors. That means the number probably underestimates heritability.

    No one in behavioral genetics would ever claim that a heritability quotient is predictive for an individual. I think of these numbers as the scouting party’s finding out whether there’s a reason to send out an exploratory team: we will really only understand what is and isn’t inherited from a fine-grained exploration, including molecular biologists and others, but we need to know whether to bother. Your perplexity at how we could measure the relative contributions of genes vs environment is well-taken; but remember that these measures are taken at the population level, not the level of individual development, and all we have to do is count the instances within the population. Thus, the issue is not so much how complex the phenomenon is, as that we set a clear definition as to what will count as an instance of it within the body of research.

    There are all sorts of things that we can’t tease out at the individual level, but looking at the level of the population enables us to get at the issues. For instance, in an individual’s case, we would have a hard time discerning the relative roles of income, marital satisfaction, professional success, and the like in his general state of mind. But looking at population numbers enables us to begin to see what sorts of roles those factors generally play.

    It is certainly true that for individuals, gene/environment interaction is most important in phenotypic development, especially where heritability quotients are low to moderate. Note, though, that “environment” includes everything from the amniotic sac and the mother’s health during pregnancy to childhood illness to nutrition to family SES, etc., and positive as well as negative factors–not just, or mainly ACEs.

    I had not read the SEP article until you referenced it, and honestly it surprised me. I haven’t kept up with the intra-disciplinary fights of philosophers in years, but I was under the impression that Lewontin et al had long since been surpassed. They certainly have in the broader community of scientists who study heritability. I don’t know what to say about that particular portrayal of the fights within philosophy–except to underline the article’s point that it is very odd to find philosophers of biology arguing against heritability calculations.

    I know that I don’t need to say this to you, but since people seem to be having such a hard time getting my point, let me reiterate nonetheless: my point is that we know quite well that genetics plays a strong role in development, that the ACEs literature neither addresses nor contradicts this knowledge, and genetic confounds increase the difficulty of knowing what proportion of the correlation between ACEs and mental ilness reflection a causal relation vs a spurious correlation because of confounding factors.

    And let me reiterate that I did not lead with the genetic material, since that was not my main point. I led with the more fundamental issue, that according to the ACEs literature itself, only a small minority of people who suffer ACEs develop mental illness, and mental illness often develops in the absence of ACEs.

  • Surely you would not have trouble with the notion that one’s genetically-mediated temperament may dispose one to irritability, poor impulse control, sensation-seeking, and the like, would you? And surely you would not have trouble with the idea that within a family culture, under various sorts of stresses, those genetically-mediated traits might incline one toward intemperate behaviors? No one of any repute, to my knowledge, has ever said that one is genetically determined to abuse children. But it seems unreasonable to insist that genetically-mediated traits cannot be among the significant risk factors involved in the emergence of conditions difficult for or harmful to kids.

  • I certainly agree that not everything is relative, that there are truths, and that we need to know and work with them. But I also believe that we can only distinguish truths from pleasing myths on the basis of evidence and rigorous inquiry. My point is that the evidence does not support a wide variety of pleasing therapeutic practices, and the ACEs literature doesn’t change that.

    When you teach people that their adverse experiences have a significance that, in fact, the evidence does not support, you teach them modes of self-understanding, and of understanding events and other people, that are unlikely to be true. Truth, not relativity, is precisely the issue.

  • Richard, when you ask, “Why should we downplay . . . ” or “why should we deny our patients . . . ” you are begging the question–assuming as true what’s under debate. If we knew it to be the case that the “obvious connections” were in fact real connections, your formulations would be correct. But we do not know that what’s obvious is correct. Indeed, we know quite well from cognitive neuroscience that humans’ inveterate pattern-making is quite routinely powerful, convincing, and wrong. The obvious connections we see are often mythical.

    Similarly, we do not know that what you refer to as “transformation” or “profound discovery” are in fact either of those things. People can have emotionally powerful experiences, interpreted to them or by them in certain ways which change how they live, while misunderstanding the source of the emotion, and shaping the emotion into satisfying but false narratives.

    I am not saying that adverse experiences do not have bad effects. I am not saying that people do not need to talk through bad experiences with a sympathetic listener. I am not saying that we do not need to make to make sense of our lives. But I am saying that the ACEs literature cannot be correctly interpreted as vindicating therapeutic practices and mythologies that fell into disrepute precisely because they are often destructive and generally poorly evidenced, despite being emotionally pleasing to patients and therapists.

  • While I remarked in passing that we know schizophrenia to be about 80% heritable, I didn’t understand myself to be making any “bold claim.” I’m just reporting the very-widely-accepted state-of-the-art in research.

    The purpose of my post is specifically to address the notion that the ACEs literature rehabilitates a certain idea–call it “p,” for brevity’s sake. “p” has fallen into disrepute. To say that ACEs does not rehab “p,” it is certainly not necessary for me to rehash the arguments that have put “p” in disfavor.

    It’s also not my job, in pointing out that the ACE’s literature doesn’t challenge the behavior genetics literature, to repeat all the reasons that the behavior genetics literature is reliable. It’s simply to point out that ACEs isn’t even about behavior genetics, and it is not inconsistent with it. Which is to say, again, that the ACEs literature does not rehab “p.”

    I’m sorry that I’m not available for the particular debate you seem to want to have. But I’m just not.

  • Stanley–

    I certainly believe that at this point in the history of our knowledge, we should be looking at all three “legs” of the “biopsychosocial” stool.

    As for “education,” I’m not sure what you’re referring to–are you talking about educational institutions, or how a kid gets taught about the world? It’s not my job here to address education policy–though I did work in that field, and publish in it, for awhile. But I certainly think that one way or another, kids need to learn things specific to their particular temperaments and interests, as well as the general things we all need to know, and it would be nice if everyone had people in their lives attentive enough to personalize that learning for them.

    The question of one’s appearance and how it’s received in the environment is usually referred to as a “gene-environment interaction.” It may sometimes be the case that the sort of example you give confounds parsing the respective roles of genes and ACEs. If the child’s physiognomy were a function of the same genetic factors that dispose toward mental illness, we would not know to what extent the prejudice effected the outcome, versus how likely the outcome would have been anyway.

    A genetic confound is a genetic factor that is involved in both of the phenomena in a correlation. It can be fairly indirect–e.g., a parent and child may share the genes that mediate depression, and the action of those genes in the father may lead to mistreatment of the child, or even to social circumstances that cause the child problem. An ACE that was due to such factors–again, perhaps bullying at school, if the family were very poor in a wealthy district, or if the dad had disgraced the family–would confound our understanding of the what role the bullying played in the genetically-mediated depression the child suffered in later life.

  • I’d really rather address the topic I set out to address, not some more wide-ranging set of issues. On the latter, I’m only willing to reiterate the “mission statement” of my blog here says: I want us to know the difference between what we know and what we don’t, and to try to know more, while helping patients without claiming more for our beliefs than is warranted.

    In this particular case, I think we should almost never tell, or encourage a patient to believe (or believe ourselves) that his or her early childhood experiences explain his or her distress. To tell someone that seems to me an intellectually unsound, unjustified position to take.

    My personal wishes are surely beside the point. If we are going to hold our opponents to high standards of proof, we must hold ourselves to the same ones. What we might personally want to believe is no more relevant to what’s right for us to say than the personal wishes of the head of the DSM committee are relevant to what it is right for him to say.

    I would say that you seem to be misreading Sapolsky or misunderstanding the behavioral genetics literature, and certainly attributing to me something I never implied nor believe. Hardly one denies that the “nature/nurture” dichotomy is wrong. The behavioral genetics literature is all about parsing the respective contributions of genes and environment. Certainly nothing I said involves “genetic determinism.”

    As for wanting a better world, with less oppression–well, of course we should want that, because it would be better. That does not depend on any link to mental illness.

    And BTW–all caps is generally considered shouting on the internet. There’s really no need to shout at me.

  • My point was very clear, Richard:
    1. A certain proposition which was once widely believed has fallen into scientific disrepute.
    2. Some people think the ACE research has rehabilitated that proposition.
    3. A correct reading of the ACE research shows that it does not say nearly so much as that.
    4. Therefore, it does not rehabilitate the old notion.

    Which part is not clear?

  • I resisted the results of behavioral genetics for many years, and finally realized I was simply being obdurate, looking for reasons to disbelieve rather than considering the issue disinterestedly. Certainly behavioral genetics, like all inquiry, is limited by human finitude and where we happen to be at a given point in the history of science, and subject to further development; but it is a serious science, conscientiously pursued by excellent minds, not notably corrupted by corporate money. If anything, BG studies probably underestimate the influence of heritability, for at least two reasons: (1) we know that, depending on the specific geographical region, the actual father is not the father of record in 5% to 20% of cases, and (2) it may be the case that more is inherited than is captured by the simple calculations of what identicals, 1st, and 2nd degree relatives have in common. I am not adept enough on current research into epigenesis, and the ways that germ lines are being discovered to contain a great deal more than the simple picture that obtained before the Human Genome project and ENCODE, to be sure about the latter point. But I’m sure about the first point.

  • People think of psychiatry as medical because psychiatrists are physicians, with MD after their names, who are required to have medical licenses to practice. At different points in history, in different parts of the country,in different med schools, in different offices, on different days, psychiatrists do different things. It is the social tasks taken on, and the institutions within which those tasks are taken on, that define the field–not the regimens currently in fashion.

    In my reply to Stanley Holmes, I was making a particular point about ethics and values, and the sad state of how knowledge gets partitioned within mental health care. I’m not under the illusion that the divisions within the mental health industries will ever go away (at least not for many generations), so I have no particular policy recommendations on that score.

  • You understand me correctly, Stanley. If it were up to me, I’d scrap the whole set of mental health industries currently in place. The division between psychiatrists, psychologists, and social workers–not to mention pastoral counselors and lay therapists–the division between clinical psychologists and other (more scientifically sound) areas of psychology, the distance all of them keep from the other social sciences and parts of the humanities–those are all artifacts of historical accient, not at all appropriate divisions relative to the subject matter. I’d have an interdisciplinary system. And I would certainly not continue the pretense that values and ethics are irrelevant to wellbeing, including the issues that bring people into our consulting rooms.

  • Until recently, for most of the twentieth century psychiatry departments have been dominated by psychoanalysts. So no, it would’nt be true that prescribing makes people see psychiatry as medical. Before that, a variety of “biopsychosocial” methods were used. People see psychiatry as medical because it is practiced by physicians.

  • I couldn’t agree more, Stanley. A lot of what the positive psychology research finds–including, for instance, being embedded in a community of meaningful relationships–has to happen for its own sake. Yep, good people with rich relationships (and some other things) tend to be happy–but “Oh, I’ll go be good and get some relationships” sort of thing gets the cart before the horse.

    Thanks, as always, for your supportive comments.

  • You wrote: “Can the medical model change, Bob? Is there change happening beyond the madding crowd, and our headline focused attention? Do we usually only recognize change in hindsight?”

    No doubt it can, and will–and as your reference to “hindsight” suggests, we can’t know in advance exactly how.

    I expect the mental health community to be responsive, slowly and with much protest, to complaints that its clientele is ill-treated. But I don’t expect the mental health community to put itself out of business, and the history of how these industries established themselves suggests that something resembling the medical model will remain at their foundation. I don’t like that, but that’s my best analysis.

  • The Lakoff reference makes an interesting point. Jonathan Haidt has done a lot of research from which he makes an argument for “disgust” as a fundamental moral emotion, which would need to be taken into account in thinking about this.

    Your post, though, doesn’t explain what I’m trying to explain: why our culture embraces the medical model. We’ve expanded its reach into everyday life, and people willingly seek out mental health diagnoses and treatments. We don’t usually willingly brand ourselves negatively. I’m trying to explain why the mental health industries have grown, and become part of conventional wisdom.

  • I’m reluctant to engage in any further discussion of the issues raised in this most unpleasant and uncalled for exchange. Things have been imputed to me that I did not say, that are not implied by anything I did say, and that I do not believe—some of them very ugly. I do not care to engage in further conversation of that sort—and won’t.

    For the sake of clarity, however, and so that this particular exchange is more likely to be remembered correctly in the future, I’d like to state a few things plainly:

    1. I believe there are such things as mental illnesses. It would be very strange if, in fact, there were no such illnesses: things break, systems go awry. But I do not believe, in most cases, we know how to identify them with any precision, and in no case do we understand fully their etiology.

    2. I do not believe that mental illness equals brain disease. I do not know how to be any clearer about this than I have been. Some mental illnesses are likely to be best understood in neurological terms; some are likely to be better understood in psychological terms.

    3. Brain science is, and will remain, central to understanding human life, including how minds work—as cognitive neuroscience is already establishing.

    4. Whether an illness turns out to be best understood in neurological or psychological (or other) terms has nothing to do with its severity or duration. Presumably a fair number of mental illnesses will be analogous to sunburns, flu, or food poisoning.

    5. Whether or not one has an illness has nothing whatsoever to do with one’s value as a person. To be ill is not to be inferior.

    6. Whether one’s illness is incapacitating is an empirical issue, not a conceptual one, and must be determined by what capacities a person shows or fails to show. Certainly some of the greatest contributors to all cultures have been persons who, every reasonable consideration would suggest, most likely suffered mental illness. It is only reasonable to assume that countless millions of people who suffer similar challenges contribute brilliantly and ably, if less visibly, than these culturally prominent people.

    7. But as I have said many times, I do not think most suffering should be understood in terms of the medical model. One should always assume that the person’s basic human capacities are functioning correctly unless driven to a different conclusion.

    Please note that, in fact, I never said anything about any individual’s problems.

    That should cover the relevant concerns, so I won’t have anything else to say on these issues in this thread. Thanks.

  • My point is much simpler: “normal response to abnormal circumstances” does not imply “not a disease or disorder.”

    All diseases and disorders have causes; these disorders or diseases are not only the normal but in many cases the necessary “responses” to prevailing conditions. I used concussion as an obvious example.

    And if we can’t agree that a concussion is a disorder, then, to my mind, the language has lost its meaning.

  • This strikes me as hopelessly sophistic reasoning.

    Concussions are set of brain dysfunctions caused by a blow.

    Brains have functions. A trauma causes a set of dysfunctions, malfunctions–whatever way you want to name it: the brain simply is not working correctly. We call that set of brain-gone-wrong events a concussion.

    By your argument, one might as well say that cancer is not dysfunctional, since cancer doesn’t have a function.

  • You wrote: “We need to admit that these categories are not scientifically meaningful, DISCARD this crappy terminology, and start over with a method of “drawing the line” (as you put it) that allows a sufficient measure of scientific verifiability. Otherwise, I don’t think any science can really happen.”

    Ah–got it. I would agree with that. Thanks for clarifying.

  • I’m not quite sure what point you’re making about my post, Steve. I’m sure I didn’t say anything about physiology, or make the claims you’re attributing to me. I also don’t know exactly what you’re referring to as my “faith in science.” My claim is that the medical model isn’t going away, and my argument consists in explaining why. My argument is sociological and historical. I’m reluctant to set out on a different discussion–how physiological explanations factor into the medical model, for instance, or whether psychiatry has irretrievably contaminated the scientific study of mental distress.

    However, there is reason to believe you’re wrong when you write, “There is no fixing that without wiping the slate clean and starting over, and genuinely asking the question, ‘Could SOME of these phenomena that we observe be caused by physiological events, and if so, which ones, and how do we objectively tell them apart?’ and then actually test out this hypothesis against real physical evidence.” There are, in fact, very serious scientists doing serious work on precisely that question. I cited one example, Kevin Mitchell, in a reply to an earlier comment.

  • I wouldn’t disagree that psychiatric diagnosis codifies and reifies attribution errors. I believe most psychiatric diagnosis “legitimizes” a host of errors, including attribution errors.

    But Adam–sweet Jesus, when you claim that a concussion isn’t dysfunction, I believe you’ve been run over by your train of thought!

  • Well, judging a hypothesis is not only part of science, but a central part of science. Every grant-making committee, every investigator deciding whether to undertake an inquiry, judges the quality of the hypothesis to be studied.

    No one in science suggests “speculating” on the truth or falsity of hypotheses. What makes science science is studying whether or not a hypothesis is true. What makes a hypothesis good or bad is its likelihood to lead to significant findings.

    If, for instance, someone proposed to study the hypothesis, “Hearing voices is a function of microscopic green onions growing in the inner ear,” that would be a bad hypothesis, because it is implausible and would be a waste of time and money and other resources to study. If, though, someone proposed to study, “Hearing voices is due to malformations in neurological connections between certain parts of the brain,” that would be a good hypothesis, because it is plausible, within the range of currently conceivable methods, and would lead to significant findings, whether or not it turned out to be true.

    You can find the characteristics of a good hypothesis here:

    As for how science works–which is not quite as you say–this is a nice recent piece:

    And BTW, Moniz won the Nobel Prize “for Physiology or Medicine.” I don’t think anyone considered him a physiologist. And since the development of non-Euclidean geometries in the nineteenth century, the status of the Pythagorean Therorem has, in fact, changed.

  • Stanley, you mght find interesting a series of posts I wrote for a different site a couple of years back, on “secular pastoral care,” how mental health care might appropriate some of the realities of experience over which religion has traditionally exercised stewardship, that mental health types tend to pretend aren’t real. It starts with “Someone to Talk To”
    and goes through “‘Boundaries’ as Moral Ideals.”

  • The difference between me and the people who talk of “worried well” is mainly that those people tend to be dismissive of the suffering of those who are not severely mentally ill. There’s something condescending, to my ear, about the “worried well” language.

    For most suffering, I think the question of “well or ill” is unilluminating. Knowing that someone does not suffer a major mental illness doesn’t tell us much about what’s the problem for him or her, and parsing his or her problems in medical terms isn’t going to shed light on anything. That’s part of the point of my series of posts on “The Idea of Depression”–medicalizing most suffering makes us less smart about it, not more able to help with it.

    As for “drawing the line”–no, at present I don’t think we can, in any fine-grained way. Some things are pretty obvious, but that’s on the far side of the lines that need to be drawn.

    Not knowing where, most of the time, to draw the line is one big reason that I think it wise to refrain from assimilating suffering into the medical model wherever possible. I believe, and practice, that one should always assume that a person’s basic mental equipment is working correctly unless forced to another conclusion.

    Eventually I think we’ll know how to draw the line, or some lines in some cases. But that will require a great deal more science than we currently possess.

    As an example of the kind of science that will probably eventually help with this, you mght have a look at Kevin Mitchell’s blog, “Wiring the Brain.” I don’t agree with his aversion to psychological explanations, but I greatly admire his work. The URL:

    Thanks, as always, for your thoughtful comments.

  • Have a look at the movie “A Beautiful Mind”–which, in fact, underplays the severity of Nash’s illness and overstates his recovery. If you don’t agree his mind was “broken,” there will be no convincing you, and there’s no point discussing it further.

  • Biological psychiatrists would surely agree with you, which is why they have tried so assiduously to root everyone else out of the seats of power within psychiatry for the last thirty years or so. The chair of the DSM-5 committee, who seems intent on turning psychiatry into clinical neuroscience, would also agree with you. Historically, though, you’re simply incorrect. The great majority of developers and practitioners of the medical model have not reduced suffering to biology, and the medical model does not presuppose or imply reductive biological explanations.

  • Thanks for the thoughtful reply.

    But when you write, “It does not follow, however, that concussion is a dysfunctional response to being hit over the head with a baseball bat. Or that concussion itself is a dysfunction,” surely you are not serious. No one could plausibly deny that a concussion is dysfunctional.

    You’ve raised a host of issues, some of which inhere in the medical model and some of which don’t. On the issue of blame, for instance: Social psychologists have long-since shown that we all tend to explain our own behavior in terms of our circumstances and the behavior of others in terms of their personalities, traits, or character. This is not a function of psychiatry or the medical model, but a basic fact of how our minds work.

    I certainly agree that the causes of suffering must be understood in order to assess it, and to relieve or come to terms with it. Which sorts of suffering are due to what circumstances, and whether that suffering is likely to be permanent or passing, and whether we have some responsibility for it, and whether it disqualifies us for fit company, and how to deal with it–these are empirical questions, and the answers will differ for different sorts and occasions of suffering. To try to resolve them at the conceptual level is a mistake, no matter which set of concepts we use.

  • I don’t know of advocates of the medical model who believe what you claim about the “disease model.” For instance, diseases, disorders, illnesses have causes, and no one I know would deny that life events can be among the causes. It is also not true that the medical model presupposes or asserts permanence, or that treatment must be of the sorts you mention.

    As for what you’re calling the “distress model”–well, I’m talking about the history and cultural influence of an idea, and the idea I’m talking about is historically and culturally pervasive. Your distress model is not.

    I would point out that “normal response to abnormal events” does not establish what you seem to want. For instance, the normal response to being hit in the head with a baseball bat is a concussion, which is surely a disorder. The normal response to abnormal events may, indeed, be a disorder, disease or illness.

    I’m sorry you don’t like my language, but I’m reasonably sure it is historically and culturally accurate.

  • I agree completely, David, that suffering is part of the human condition–and that analyzing most of it through the medical lens distorts.

    Stay tuned for the next installment. In saying that the medical model is the faith of the secular age, I hope to saying something more interesting, and helpful, than simply analogizing the mental health industries to religion. We’ll see if I can pull that off!

  • There have been many alternative explanations offered, as I said. Certainly a variety of schools of thought have developed sociopolitical explanations–Marxist, feminist, postmodern, etc.. However, none of those have been able to find an institutional home, hence have fallen to the wayside.

    I would add that sociopolitical explanations are unlikely ever to find a dominant place within mainstream mental health care. More or less by definition, these approaches call for reforming society. Also almost by definition, the mainstream–to be economically viable and to achieve legal protections (licensure)–supports and serves, rather than threatens, the status quo. Society is not likely to institutionalize care that demands that society change.

  • The medical model is not the same as the biological model. Both of the alternatives you mentioned were, in fact, developed within the medical model. Personality disorders, for instance–which were for decades the main diagnoses–are presumed to involve one or both of those ideas. The medical model is simply the idea that one’s problems reflect “malfunctioning” psychological faculties, so that the remedy for one’s problems is to be found in healing, restoring, or compensating for this malfunction.

  • Well, now, that’s just not true, as any working scientist–or
    any graduate student in the sciences who is designing a thesis project–knows. Hypotheses can be plausible or not, ripe for study or not, coherent with known principles or not, etc.

    And at the hypothesis stage, one simply cannot know whether an idea is true or false. That’s what makes it a hypothesis.

  • I do, in fact, think that the medical model is sometimes applicable, for axiomatic and empirical reasons.

    It’s simply axiomatic that things break, and complex systems have more breaking points than simple systems. Minds are certainly complex systems, with many breaking points. Ergo, they break.

    Empirically, it certainly seems to be the case that sometimes the “machinery” is awry. In my personal and professional experience, I have certainly known many occasions when this was the most plausible and parsimonious explanation.

    The problem with the medical model is not that it is always wrong, but that it is made to do work, and used as the basis of authority and life-guidance, that it lacks the epistemic credentials to do–and that it often does that work for which it is unqualified very badly.

    ‘Hope that makes my meaning clear.


  • Yes, it will be a mess.

    David’s advice sounds right to me–and that level of reform is beyond my expertise, anyway, so I’m glad he weighed in.

    The dimension of the “mess” that falls within my bailiwick, that gets almost no attention, is that we have effectively already lost a generation of talk therapists, as talk therapy–in its misguided efforts to compete with meds and to earn insurance reimbursements–has moved toward mechanistic (“manualized”) treatments of “disease entities” or disorders. As best I can tell, therapists are not currently being taught to listen and respond, to follow the unstated threads of client concern, to help clients face what they fear and work through the particular trials that beset them, to help chart the distinct contours of unique lives. Learning to follow predefined programs of mood manipulation is not the same as learning to respond to, and help with, the particularities of individuals’ lives.

    So part of the mess will be that, when it all collapses, we may not even have in place talk therapists who know how to do it differently.

  • Richard, I doubt we disagree on much about what’s wrong with current care, or what we’d like to see happen.

    But it IS illogical to assert “a” and “not-a” at the same time, and “fraud” is a legally defined action, not a matter of personal preference.

    Yes, I am trying to make the point that the majority of talk therapists have bought into the medical model and become part of the problem. We have, in fact, seen psychologists and other talk therapists change what counts as science, and what counts as good care, in order to fit into the overriding medical paradigm. That’s going to get worse, not better, with more money available to those who buy in. I wish it weren’t so–but we both know which hand fills up first when you wish in one and . . .

    Put simply: You dance with the devil, the devil always leads. Talk therapy has decided to dance with the devil, and finances are a gigantic reason.

  • I’m not quite sure, “Anonymous,” what point you’re making. If you’re disagreeing with my saying that the trend is in favor of psychiatric orthodoxy, I’d point out that people routinely describe themselves these days as “struggling with depression,” “ADD,” “bipolar,” “OCD,” “suffering an anxiety disorder,” “PTSD,” “Aspie,” etc, in ways, and with a frequency, that they didn’t twenty years or so ago. They routinely refer to each other with DSM terms–“narcissistic,” “bipolar,” “borderline,” and so forth. Parents actively seek diagnoses for their children. I have seen a drastic increase in people (mostly wrongly) reporting to me their self-diagnoses, and (again, mostly wrongly) describing their significant others in diagnostic terms, in the twenty-seven years I’ve been practicing.

    And the Wellstone Domenici Act did not pass because politicians bravely stood up against the wishes of their constituents.

    There’s simply little evidence that the public is up in arms against psychiatric orthodoxy, or ready to repudiate insurance or public funding of the mental health industries. This is indepedent of the issue of drugs versus talk therapy.

    If you were agreeing with me, thank you.

  • I would point out that everyone who makes a living providing mental health care is working “for profit.”

    Being a “not-for-profit organization” refers to a tax status, and how the proceeds of one’s work can and can’t be distributed. But even NFPs have to run in the black, and their clinicians want to be paid.

    Whether you work for an Evil Corporation or a welfare agency or run a private practice, you depend on making money to survive. Generally, getting that money from a medical care underwriter means you’re going to come to understand yourself to be doing medical work.

    I would also point out that villainizing the pharmaceutical companies and psychiatrists, while giving a pass to the trade organizations of the talk therapy professions, is less than astute. The American Psychological Association and the National Association of Social Workers, for instance, engage in significant lobbying and PR to make sure that their constituents get their piece of the medical pie. They’re as much a part of the problem as the usual suspects.

  • “I am questioning your point that we have no right to speak or complain if we are forced under the current system to use the DSM to get care for needy clients.”

    I don’t think you’ve understood my point; maybe I didn’t make it plainly enough:

    1. You can speak or complain all you want, but the fact remains that when one claims medical benefits for non-medical conditions, one is speaking incoherently. One should not be surprised to find others unpersuaded. It’s simply illogical to claim medical benefits for nonmedical conditions.

    2. It’s also fraud.

    3. Most people cannot live with the cognitive dissonance and moral queasiness of knowingly misrepresenting their work for money. Most people come to believe they say.

    4. To the extent that the mental health industries depend upon, or avail themseves of, third party payments for their material sustenance and prosperity, they will understand themselves to be doing medical work. Some folks will, as you say, “hold their noses” but the overwhelming trend has been to accept the medical model, in order to protect the sense of speaking coherently and being good.

    It’s not a question of the right to protest and criticize but of making sense and living with what one says and does. Most people can’t and won’t do as you recommend, since most people cannot maintain a sense of incoherence and a recognition of misrepresenting themselves for money.

  • This reply seems to me beside the point. at best.

    It doesn’t matter whether we use insurance or single payer or a national health system: To see suffering as qualified for third party-paid medical care, no matter what the third party, we have to see suffering as a medical issue. People will still have to qualify for medical care–that is, receive a medical diagnosis. In the US, mental health care, by law, requires a diagnosis for insurance reimbursement. I believe the same is true for mental health care under publicly-financed mental health care, e.g., VA, MedicAid, and MediCare. Going to a national health system would not suddenly make the DSM go away; it would simply mean it’s applied by government, rather than insurance company, administrators.

    Going to a publicly-financed health system would make the problem I’m talking about worse, not better. We’d see more pressure, not less, to conform care to preconceived, cost-saving treatments correlated with even-more-strictly enforced diagnostic criteria.

    And just FYI, I’m all in favor of a single payer or national health care system. That’s just irrelevant to the point I’m making. A single payer or national health care system won’t undermine the medical model. How could it? It would just change how the medical model gets funded.

  • I’m with you, David. Perversely, rising insurance coverage has made it harder for those of us who “opt out” to make a living–I work a whole lot harder to make less money than I did a dozen years ago, and it’s not because I’ve become less able as a therapist, but (at least partly) because now I have to compete with people’s co-pays, not with what other therapists actually charge.

    Personally, I think medical insurance makes sense, because medicine involves a lot of overhead. (Yeah, I know, we use way too much medical care in this country–but still, even appropriate care takes a lot of overhead.) Except for the issues of the poor and disabled, though, I think we of the mental health industries ought to live or die by the market. If people don’t want what we sell, or we don’t want to provide it for what they’re willing to pay, we should go out of business. But that’s not how it has developed.

  • Maybe so, but the fact is that it’s getting far more funding due to the laws I cited. Taxpayers so far don’t seem inclined to disbelieve the mythology of the mental health industries. Quite the contrary–use of mental health services continues to rise, and people’s understanding themselves in DSM terms increases exponentially. It’s now part of conventional wisdom to think in DSM terms.

  • Jonathan–

    Not only is Sharpe’s willingness to entertain a utilitarian justification morally wrong, it is factually ill-based. Though psychiatrists constantly claim that the biological psychiatry ideology decreases stigma, that’s untrue.

    A major study, funded by NIMH and published in the American Journal of Psychiatry, found that acceptance of the “neurobiological illness” idea increases stigma.

    As “psychcentral” summarizes, “. . . the results show that although believing in neurobiological causes for these disorders increased support for professional treatment, it did nothing to alleviate stigma. The results show that, in fact, the effect increased community rejection of the person described in the vignettes.”

    You can find the published study here:

    Excuse me, please, for a moment of, “I told ’em so.” In “Cultures of Healing” I predicted exactly this.

  • I’m pretty sure that’s mistaken on all counts. If memory serves, in Freud’s account, in psychosis the ego has been defeated by the id, and primary process thinking has overpowered secondary process. So far as I know, Freud never thought that his theory of mind failed to encompass psychosis–and while he certainly didn’t try to put psychotics on the couch, I don’t think he was hostile to the widespread use of psychoanalytic principles in asylums. Your rationale for the American psychiatrist’s refusal to allow non-MDs to train in ther institutes does not match anything I’ve ever read on the controversy.

  • David–

    I don’t know what Marian’s reasoning would be.

    I don’t know how one can see Freud as an originator of biological psychiatry, though I’d be open to seeing that argument. He justified his account of the unconscious in terms of the legitimacy of giving a “purely psychological” account, against those who would see people’s difficulties as organic. And as I said before, he argued against the idea that psychoanalysts needed to be physicians–many of his inner circle, like Otto Rank and Anna Freud, were not, and he was livid with the American Psychoanaltyic Association for refusing to train non-physicians or accredit non-MD-admitting institutes.

    Historically, in this country the biological psychiatrists have been opponents of the psychoanalysts and vice-versa–in the thread in which you made your original comment, I was talking about how all forms of depression got conflated into Depression; that development in the DSM was vehemently opposed by the psychoanalysts within the American Psychiatric Association, and a major loss for them.

    Your teacher may have been making a different point: that many people who would simply have been seen as malingerers before Freud can be understood as suffering unconscious conflicts beyond their control, hence in need of professional care.

    Freud and his followers certainly vastly expanded the field of psychopathology–e.g., “The Psychopathology of Everyday Life”–though he neither thought psychopathology to be necessarily organic nor of medical provenance. It’s certainly true that psychoanalysis was crucial in the development of psychiatry–psychiatrists used it to become economically viable and culturally influential, for one thing, since it offered ways of understanding the distress of people who were fully functional, capable of paying for therapy, not in need of custodial care.

    But it true neither that Freud originated the concept of mental illness, nor that he supported biological psychiatry in anything resembling the form we know it. ‘Hope that helps.

  • Let me speak to your question at some length–but I’ll tell you up front that my final recommendation is, Show this film to anyone and everyone you can. It’s truly astounding.

    Now, to back up.

    I’ve known Lucy Winer and Karen Eaton for over twenty years, and Lucy talked with me often and long when she was undertaking the personal pilgrimage that led to the film. (When she turned fifty, she was taken with a need to look into having been hopsitalized in her teens, to try to gain access to her records and to make sense of what that experience had been for her.) So I knew about the film before it was a film, and I’ve known of its development through the years.

    I visited Karen in New York in May–Lucy was away, screening the film somewhere–and Karen gave me a copy of the piece.

    I didn’t rush home to watch it. I had some trepidation. As Lucy will tell you, I don’t lie to my friends–though I hope I’m generally polite and diplomatic–and I had some concerns about whether I was going to be happy with the outcome. Like you, I was puzzled that NAMI and others within the psychiatric mainstream seemed to embrace the movie. If I hated the movie, or felt that Lucy and Karen had somehow drunk the Koolaid, I was not looking forward to having to communicate with them about it.

    Finally, two weeks ago I scheduled a Sunday morning to watch “Kings Park.” It blew me away. If this is not the best film Lucy’s ever done, it’s right at the top.

    Lucy’s one of the smartest people I’ve ever met. One way her absolute brilliance shows–or doesn’t show–itself is her ability to say things by not saying them, to make her points by juxtaposing material that–if the viewer is paying attention–makes those points clear to those willing to see them without tipping her hand to, or infuriating, those who are too blind to see.

    In “Kings Park,” Lucy is trying to make sense of her own experience, and that effort leads her to broader issues. She never pretends to expertise she does not have, nor does she jump on any bandwagons. She addresses the complexity of questions about care for severe distress directly and concretely–and very personally. And with her characristic style of speaking by what she does not directly say, letting the material and its manner of presentation speak for itself.

    I think this is brilliant, moving work.

    Hope that helps.

    Bob Fancher

  • Sara–

    The most bizarre development in clinical care during my lifetime has been the utter perversion of what counts as science within clinical psychology and related fields. We’re now educating a generation of clinicians who have a completely false understanding of the many roles many different scientific efforts have played in understanding (and treating) distress, who possess an idiosyncratic notion of science and its uses.

    That we consider clinical studies to be science at all is rather peculiar. They’re more like engineering than science–they’re product development, quality assurance, technical testing. They don’t tell us much of anything about psychology. If you haven’t looked at my post on “Therapy Works. So what . . . ?” you might find it useful.

    The 2005 APA report I reference in my post above is worth looking at. It’s a very political document, but you will discover there that may estimable scientists and clinicians within psychology are unhappy with what’s being done under the rubric of “evidence based” care. The bibliography will point you toward some very fine critiques and studies.You might get a lead to someone with whom you’d enjoy studying.

  • Ron–

    I re-read your original post, as well as this new one, this morning. Your thinking is very sound, and your story quite moving.

    As you know, I originally decided to study how minds work via philosophy rather than psychology because I did not intend to become a clinician, and psychology’s institutionalized refusal to criticize–even be aware of–its own assumptions put me off. Years later, when I decided to become a clinician after all, I went back to school for that training. In subsequent decades, the intellectual weakness of clinical psychology has become far worse. That fact is utterly shocking to me, since the same period of time has been one of stunning advance in other fields of psychology, and especially in interdisciplinary efforts to understand minds. I really think studying clinical psychology is second only to studying psychiatry as a sure way to become stupid about life.

    When people ask my advice about becoming a therapist, after trying to dissuade them–since the field is changing so drastically–I advise that they study social work to learn something of the context of distress and to get their union card–I mean, license–and then study something else to learn how minds, and life, work. Anthropolgy, sociology, social psychology, cognitive neuroscience, philosophy, even literature or business–something that studies life.

    Hang in there, buddy. Here’s hoping you’ll have the luck needed to find some satisfaction.

  • “By accepting psychiatry’s “terms of engagement”, or the insurance companies’, talk therapy has already lost before it even leaves the starting line.”

    But that’s exactly what has happened–which is my point.

    If the Affordable Care Act stands, and receives funding, this will get worse: everyone will have access to insurance-funded mental health care, which will give the insurance companies a powerful incentive to enforce “evidence based” standards for talk therapy (and to promote medication treatment because it’s cheaper), which will make the financial survival of therapists who aren’t willing to comply next to impossible.

  • There seems to be some confusion among the correspondents in this thread as to what I was arguing in my original post.

    Historically “the medical model” does not mean biological psychology, but that the distress that brings patients in for help is the result or manifestation of a deficit, disorder, or malfunction. Historically, the medical model treated psychopathology as “functional illness,” as distinct from organic illness. The role of biolgy in psychopathology has always been up for debate.

    By “medical model,” I mean only what the term has meant historically: that the patient’s/client’s distress is the result of a defect, a deviation from correct function.

  • I have no doubt that “CBT could be effective for certain people.” But I think “effective” is an inadequate criterion. For instance, the most effective way to cure warts around the fingernail would be amputation of the finger at the first joint–but no on recommends it. I believe CBT has a variety of effects that we should not countenance, whether or not it reduces people’s distress.

  • I agree with you completely that locating “the problem” “inside” the individual is a travesty. One of the many reasons I despise CBT is precisely that: The fundamental message of CBT is, “Everything is fine, if you’d just learn to think straight.”

  • In the U.S., insurance reimbursement is required by law to be linked to a diagnosis–this was part of the “deal” for insurance parity during the Clinton administration.

    I agree with you, and despair, about the impossibility of individuals changing the direction of the tide. Actually, I’m less sanguine than you, in that I don’t think the various new organizations are likely to accomplish a great deal beyond shoring up their respective members. There’s just too much money, and too much prestige,behind the status quo–the American Psychological Association,no less than the psychiatry and pharmaceutical interests. I’m pretty sure none of the new organizations have the money or clout to overturn existing law.

    So I think the only hope available to individuals in need of help is to find individual providers of care who, for their own reasons, have opted out of the status quo.

  • I think compassionate, attentive care to anyone, including someone in the throes of psychosis, is helpful, out of simple humanity. Now, you probably wouldn’t want to do any rigorously structured, programmatic therapy, and certainly nothing designed to impart “skills.” But you can be present, and attuned emotionally even if the words don’t make a lot of literal sense. How can that not help?

    The lore on “meds plus therapy” is surely strong. I suspect the impetus for clinicians to believe it is mostly,”Whew–we can stop fighting and divvy up the pie!” In the U.S., the talk therapy professions are so thoroughly in the thrall of psychiatrists that anything that lets them claim crumbs from the table feels like manna from Heaven. And psychiatrists have so little training in how life works that they have little or nothing to say to patients, so they’re happy enough to let the talk therapists have them. The “meds plus talk” canard gives everyone a fig leaf.

    But you’re certainly correct that the ideological explanations make no sense: a broken brain, one suffering a chemical or other malfunction, isn’t likely to think productively, hence isn’t likely to be all that available for talk therapy. It’s a bit like prescribing a good jog for a sprained ankle, isn’t it?

    Empirically, though, it does seem to be the case that by some measures–though the measures are debatable–some people do better with the combination. That would suggest that the ideology is wrong. As with most things, we don’t know why it woud work. Generally, I think, meds provide one or another sort of sedation or stimulation, and it’s surely conceivable that for some people, under some conditions, being calmed a bit or goosed up a bit could be of use. I do know that with some patients for whom antidepressants seemed to provide a “floor” so they didn’t fear going into their worst lows, they seemed to have more courage to look at issues that they’d seemed to shy away from. That’s just my anecdotal observation, though.

    I only have anecdotal and speculative thoughts on how people who can’t get enough talk therapy cope. Some, I am sure, seek other care under the guise of physical maladies–just having someone taking care of them offers some comfort. I suspect a lot of “fringe” or “alternative” healers make their living off troubled souls whose mental health benefits didn’t do the trick. Drgus and alcohol provide something resembling solace for some souls, of course. Religious ardor can genuinely help some folks–I am sure that many strict religions provide for their adherents a way of organizing and understanding their troubled inner lives, and rituals for finding something like relief, over and over.

    Thanks for your thoughtful comments.

  • I’ve been thinking about your post for a few days. Your last paragraph points in the right direction, but has the trajectory wrong. It isn’t that “psychiatry allows this nonsense to stand”–it’s that psychiatry insists on this nonsense to serve its own purposes. But you’re right, that those purposes are in large part to justify medication.

    I don’t think psychiatry’s parsing of depression–in either sense of the word–was correct before DSM-III, and DSM-II corrupted a previously-correct analysis. Indeed, under the sway of psychoanalytic hegemony, depression was always considered to be a sign of a personality disorder. That was never well-evidenced, and seems to me manifestly wrong. But at least before DSM-III, the phenomenological difference between what I’ve called little-d depression and what I’ve called melancholia was admitted, even if the psychiatrists’ explanations of little-d depression leaned too heavily on psychoanalytic beliefs.

    I would point out–and will write more about this in the future–that prior to the 1990s, DSM and its way of defining depression did not occupy the place in our culture it has come to occupy. Psychologists and social workers, and the vast number of mental health workers trained in other ways, generally did not give it much authority. Psychiatry did not have control over the mental health market–in the late 1970s, psychiatry provided only about 30% of mental health care. Outside of psychiatry, there were all sorts of ways of understanding little-d depression that were better than psychiatry’s efforts, I think.

  • That’s really not correct, David, in at least two ways. First, concepts of mental illness long predate Freud. There’s a huge literature on this–David Grob’s “The Mad among Us” is good, and George Drinka’s out-of-print “The Birth of Neurosis” is worth getting from a library. I have a chapter on the history of care, and how physicians captured the market and defined the field, in “Health and Suffering in America.” Second, Freud generally opposed medicalizing mental health care. The American Psychoanalytic Association was almost kicked out of the International Psychoanalytic Association over this issue. Freud wrote a little book, “The Question of Lay Analysis,” arguing that talk therapists are more like “secular pastoral workers” than physicians.

  • Thanks for the Breivik example–perfect.

    Yes, I do think one could do an accurate catalog of mental illnesses, or of the sorts of problems that tend to beset us even when they do not rise to the level of “disorder.”I don’t think it’s a great thing that these problems came within the purview of medicine–in my book “Health and Suffering in America,” I argue that it was a matter of historical accident that doctors captured the market. We are currently seeing psychiatry consolidate its hold over mental distress–I’m going to write more in a future post about how psychology and social work lost (or sold out) their bids to create alternate understandings of mental distress. But I certainly believe that matters of mind (including problems of mind) exhibit enough regularity to be investigated and cataloged meaningfully. Thanks for that very good question.

  • I think both your points are very good: If you have to be “screened” for “depression,” you don’t suffer anything resembling melancholia–the traditional, pre-DSM-III definition of depression. And sad to say, we become increasingly a culture in which pain and suffering do not count, in which they are not attended and cared for, except insofar as they get medical imprimatur. I find both facts most distressing.

    Thanks for the comments.

  • I certainly do think “do no harm” applies to words–misguided words can be as destructive as most anything.

    Since theories of mind affect how we think about our selves–and how we live–I think we need to be extremely careful to avoid theories that are most likely (or known to be) false, and do our best to base our theories on careful thinking. Where we have to believe in excess of evidence, we need to be mindful of the ethical implications of our chosen beliefs: a true idea simply has to be accomodated, but adopting an optional idea is a choice, and hence subject to moral evaluation.

    I certainly hope popularity does not entail becoming defunct–we would surely hope that true theories would become popular!

    Thanks for the good words and thoughtful comments.

  • Thanks, especially for ther link to Mickey Nardo.

    As you’ll see when I post next, I think the issue isn’t just skills to deal with a slump–though that’s certainly a problem–but a much deeper, broader issue: the ability to understand, and learn from, our difficulties.

  • Thanks for the note, Bill. I’d say the VA docs were right about the “combative” thing! I’ll look forward to hearing your story about the VA when I get back to Portland.

  • Thanks, Steve.

    I would point out, though, that the disclaimer in the intro of DSM is making a bit different point than the one I’m making here. While DSM is, at least nominally, agnostic on the causes of disorders, it does say that the various items on its checklists constitute the disorders. I’m questioning the wisdom of that, specifically on depression. But as I said in a reply to someone else, DSM isn’t my main topic here. All sorts of people who don’t like DSM do this thing I’m questioning–lump too much of experience into a postulated underlying thing called “depression.”

    As you correctly discern, I am trying to say that, aside from one’s theory of causation, the habit of seeing disparate things as manifestations of “depression” may not be helpful.

  • Thanks for your comment and your good words, Stanley.

    The practice I’m drawing attention to in this post is illustrated by, but not limited to, the DSM. The habit of attributing multiple mental states, behaviors, physical changes, and the like to an underlying “depression” is common even among many folks who don’t like the DSM.

    As you correctly note, I am concerned with how our naming things changes how we think about them–and thus how we analyze ourselves and others, and what avenues of action are opened or closed by those ways of seeing.

    The changes in how we see things often have less to do with scientific, or other, discoveries, than we’d like to believe. I’m raising the question here of whether this habit of attributing all sorts of things to an underlying thing we call “depression” may not lead us to see our difficulties more crudely, and with fewer options, than we should.

  • Thanks for coming back to this, David.

    We need both episteme and techne, but we need to know the difference. Therapists exert an influence, and claim an authority, that we really don’t deserve, when we use the fact that clients come to feel better to claim knowledge about how life works and how people ought how to think, feel, and act.

    My concerns with this issue are many–I written about them in my book, “health and Suffering in America.” For one thing, I believe that we generally foist off on clients our own values, hidden under definitions of “health.” Generally, when a mental health type calls something “healthy,” he has next to no evidence that health has anything to do with it. He or she is saying, “This is how I think it would be good for you to live.” I think mental health types often exert a bad ethical influence in this way. I’ll write more about this in future blog posts.

    But if I smuggle in my values, while helping you feel better, and claim simply to be doing what’s “scientifically valid,” you probably adopt those values while thinking you’re simply conforming to something scientists’ have discovered about the world.

    I am also appalled at how many things even the most self-righteously “evidence based” therapists teach their clients that are radically at odds with much better science found outside the clinical psych fields. Cognitive behavior therapy, for instance, is simply flat wrong in much of what it says about cogniition and emotion. By claiming to be “scientifically validated,” and adducing clinical trials as if they were strong science, CBT’ers convince clients to believe things about minds and emotions that simply do not stand even the most rudimentary comparison to the genuine scientific–“episteme”–record. CBT is at least as bad as psychoanalysis in foisting off preposterous beliefs on its clients. But adducing clinical trials as if they were good science obscures this fact.

    Finally, for now, I am deeply disturbed that under the influence of “evidence based” practice, what clients are allowed to talk about, and how they’re supposed to think about the things they talk about, is drastically circumscribed. Most things that bother most clients have not been, and cannot be, submitted to clinical trials. And the fact that taking a certain attitude toward the things you talk about makes you feel better quicker is not strong evidence that you really ought to be taking that stance. Feeling better is not evidence of truth–often, far from it. I’ll write more on that over time, too.

    ‘Hope that helps. And I do appreciate your thinking more about my post.

  • Can we feel better under the sway of false beliefs? Without a doubt.

    Take, for just one instance, the fact that every therapist who has worked for long has helped people by using ideas that he or she later realizes were wrong. He or she later helps people using different ideas. Q.E.D.

  • Yes.

    All I mean by this phrase is “accurate information about reality.” Education aims to help us understand how the world works. Mental health professionals claim to know a great deal about how the world works–they claim to know things they would not know without their specialized educations. Whenever we tell someone that a particular idea is true, we are making a claim about how the world works.

  • Thanks, Buzz.

    I first taught in college a bit over thirty-five years ago, and I’ve been shocked at the changing standards of teaching. I think our “be happy” culture does promote grade inflation, and making students feel good about themself at the expense of demanding rigor. I know the teachers who did the most to help mature my mind also did the most to make me feel bad about myself, in the early going of working with them, because they revealed my ignorance and fuzzy thinking and deflated my naive self-confidence. But you’re certainly right that the best teachers know how to use a “spoonful of sugar.”

  • Jeff–

    Thanks for the thoughtful, substantial comment.

    I’m not trying to debate the evidence-based versus not issue in this post. I’m making a different point: Even with the best outcome studies, therapists are selling a product, not teaching their clients how the world works.

    We have to evaluate products–and their salesforces–differently than we evaluate the discoveries of scientists. Therapists are generally less than accurate in their self-understanding, and less than honest in their pitches to clients, because they pretend to have and convey knowledge when, even if you grant that outcome studies are accurate and probative, what they’re selling just isn’t that.