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European Association of Psychoanalysis |
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European Association of Psychoanalysis |
NEWS
Psychiatry´s Valid but Dishonest Reconsiderations
Much of the newest wave of psychiatric self-criticism is salutary and headed in the right direction; the problem is the field's unwillingness to credit the psychiatrist who paved the way
Over half a century ago psychiatrist Dr. Thomas Szasz shocked the world of
psychiatry with his then, and still, electric book The Myth of Mental Illness.
Since that time, he has been unmasking the invalidity of psychiatric practice
and its raison d´etre the diagnosing and treatment of mental illnesses. His
reasoning through scores of major works and over one thousand articles,
reviews and letters has been based on a simple but profoundly true insight
mental
illness and mental health and their derivative concepts are metaphors, since
the mind is not an organ.
From that insight the entire mental health establishment has been
intellectually reeling while occupationally profiting for the same 5 decades.
Psychiatrically-based rhetoric has used schizophrenia as the prototype mental
illness
because it represents in the lay public´s minds the most bizarre and
inexplicable behavior of the "mentally ill," and most important, some people
labeled
"schizophrenic" may have genuine brain disease. This constitutes a tiny
percentage of those labeled "mentally ill," a population which psychiatry has
recently alleged has grown to over a majority of the general population. Let
there be no confusion about this claim of the discovery of brain disease,
however. If persons called schizophrenic - again, a tiny percentage of those
labeled
"mentally ill" -- are discovered to have a lesion that correlates perfectly
with their behavior, or clearly causes their behavior, a mental illness has
not been discovered. A new brain disease has been discovered.
Szaszian critics of psychiatric theory and practice tend to find the
prototype mental illness to be in the "problems in living" category, first
extensively discussed by Szasz. This would comprise the vast majority of the
over 300
mental illnesses named in the current Diagnostic and Statistical Manual
(DSM-IV-R) of the American Psychiatric Association (APA).
The National Institute of Mental Health, the primary sponsor of this finding
-- that over 55% of the American population as suffering from some mental
illness over a lifetime -- produced its conclusion, according to a June 7, 2005
article in The New York Times titled "Most Will Be Mentally Ill at Some
Point," at a time conducive to complementing its efforts to promote lucrative
screening and treatment for mental illness among all ages. The study involved
non-medical interviews conducted by non-physician personnel. What constitutes
"mental illness" is that which is approved by the Board of Trustees of the
American Psychiatric Association for the latest version of the Diagnostic and
Statistical Manual (DSM), now set for revision by 2010.
Politics and Psychiatry
Studies such as these can lead to changes in the manual which varies often
according to politics of the profession. In 1973, pursuant to protests by the
gay community and others, homosexuality was removed as a mental disorder, but
self-diagnosed involuntary homosexuality, called "ego-dystonic"
homosexuality, remained until it, too, was removed. There were no scientific
studies which
adumbrated the change; only unfriendly sociological phenomena. Thus,
homosexuality exited as a disease the same way it came in. Homosexuality was
classified as a disease for political reasons. It was declassified as a disease
for
political reasons, too. No other real disease has ceased being a disease.
Its prevalence and incidence may have diminished, consider tuberculosis and
small pox, for example. But even if smallpox were wiped off the face of the
earth, small pox would still remain a disease, not subject to political winds
and
changes.
Studies such as the recent surveys are the non-scientific Rosetta stone of
the mental health community. There is no limit to the percentage of the
population which can be said to be "mentally ill," since as a metaphor, there is
no
way to confirm or disconfirm diagnoses (or the number of people who are
mentally ill). Moreover, there is no limit to the variety of behaviors which can
be successfully labeled as "mental illness" since there is no measurable
criterion which eliminates such labeling or name-calling.
As one example from an inexhaustible list, a couple of years ago, a major
story was titled in The Washington Post "Psychiatry Ponders Whether Extreme Bias
Can Be a [Mental] Illness" (December 10, 2005). Some prominent psychiatrists
such as Dr. Gary Belkin, deputy in chief of psychiatry at New York´s
Bellevue Hospital, were arguing for the APA to include extreme racism in the
DSM´s
list of mental disorders - and thus were inadvertently conceding that
psychiatrists falsely medicalize anti-social behavior as mental disorders.
Belkin
revealingly put forth this argument:
"Psychiatrists who are uneasy with including something like this [extreme
racism] in the Diagnostic and Statistical Manual need to get used to the fact
that the whole manual reflects social context...That is true of depression on
down. Pathological bias is no more or less scientific than major depression."
Serious psychiatrists intuitively recoil from the worst fatuities of their
field, of course. Several establishment mental health professionals have
publicly disassociated themselves from the claims of such widespread incidence
of
mental illness and the limitless extending of its diagnosis. According to the
same article on racial prejudice´s being an illness, the APA´s director of
research, Darrel A. Regier, asks, "Are you pathologizing all of life?" Still,
he supports research into the matter.
Regarding the claim of over 55% of Americans' suffering from mental illness,
psychiatrist Dr. Paul McHugh, the well-respected former chief of psychiatry
at Johns Hopkins, incredulously and famously stated, "Fifty percent of
Americans mentally impaired - are you kidding me?"
McHugh is one of the more skeptical psychiatrists, whose writing reveals
significant agreement with Szasz and yet who, one may assume due to
sociologically approved distaste for Szasz among mental health professionals,
refuses to
give him credit for his original skepticism and critiques of psychiatry.
One finds in McHugh´s impressive, if not original, treatise, in the
well-respected intellectual magazine Commentary ("How Psychiatry Lost Its Way,"
December, 1999) many criticisms of psychiatry that were first made by Szasz,
including the following:
1. We are witnessing a proliferation of new, nonorganic, bogus psychiatric
disorders;
2. Psychiatry utilizes reliability of psychiatric disorders (testing to see if diagnosticians agree on what psychiatric disease patients suffer from) instead of focusing on the gold standard: the validity of psychiatric diagnosis, or in other words whether it measures what it claims to measure.
3. In psychiatry, as opposed to somatic medicine, the symptom is the
disease, rather than a sign for the disease;
4. There is collusion between some pharmaceutical companies and some
psychiatric diagnosticians;
5. The problematic DSM approach of "using experts and descriptive criteria
in identifying psychiatric diseases has encouraged a productive industry," Dr.
McHugh observes. For comparable arguments, see Dr. Szasz's well-known
article, "Diagnoses are Not Diseases" in The Lancet (1991);
6. There is a profound consequence of self-fulfilling prophesy in the public
positing of new psychiatric disorders;
7. Positing "biological markers" for psychiatric disorders is unreliable and
invalid; Szasz has argued exhaustively for decades that there are no
pathological or physiological measures that are specific to mental illnesses.
8. The changing of behaviors by psychotropic drugs ("Everyone is more
attentive when on Ritalin...") affects anyone who takes them and cannot be
validly
used as indicative of psychiatric disorders;
9. And finally, there is the one point for which Dr. McHugh does give Szasz
credit: "exercises in mental cosmetics should be offensive to anyone who
values the richness of human psychological diversity."
From discussions long ago with McHugh we know the personal distaste he has
for Szasz, but this should not prevent McHugh or his psychiatric brethren from
citing the lineage of these important and compelling points. There are still
profound differences between Szasz and his psychiatric critics, including the
critical component of free will claimed by Dr. Szasz in literally all
alleged psychiatric disorders from "drug addiction" to "anorexia nervosa," but
their differences are narrowing, and McHugh should have acknowledged that.
These points serve as continuing topoi for new skeptics in psychiatry. One
can find the objections to the overdiagnosis and overmedicating of children and
to a lesser extent women and people in general in book after book now. All
of these criticisms are intellectually and academically indebted to Szasz´s
work.
The Latest Establishment Criticism in Psychiatry
The new self-skepticism in psychiatry has reached its current zenith with
the publication of the work The Loss of Sadness: How psychiatry transformed
normal sorrow into depressive disorder by Allan V. Horwitz and Jerome C.
Wakefield. The authors are not physicians, but are professors of Sociology and
Social Work respectively. This work combines the new in-house skepticism of
psychiatric diagnosis - this time focusing on depressive disorder -- with the
ethically suspect ignoring of Szaszian ideational and evidentiary lineage. The
books main contention is that normal sadness has been "medicalized" or
"pathologized" into "depressive disorder" due to the ignoring of the normalcy of
sadness in many contexts as well as the lack of use of exclusionary criteria,
the
proper use of which eliminate most instances of normal, situational
depression's being falsely diagnosed as disordered depression. In addition the
arbitrariness of DSM´s duration criteria and its lack of confronting its own
criteria of intensity and length of time of suffering add to the misdiagnoses.
The book is potentially quite significant to the practice of psychiatry,
because limiting diagnoses of disordered depression, often cited as resulting in
the invalidating of up to 20% of psychiatric diagnoses, would put quite a
crimp into the patient numbers, prescription numbers and 3rd party coverage. The
consequences of acceding to their recommendations are not addressed by
Horwitz and Wakefield.
Establishment Support for Self-criticism
The Loss of Sadness revealingly includes the support of Dr. Robert Spitzer,
the longtime overseer of the D. He wrote the book´s Foreword and stated
therein that the book is "relentless in its logic," and it "forces one to
confront
basic issues that cut to the heart of psychiatry." He calls the book a
"brilliant tour de force." In return, the book´s authors are extremely
flattering
to Spitzer, citing his "prodigious research efforts" for DSM-III and
complimenting his "accomplishments" and his "greatest achievement," "the
sheparding of
the creation of an entirely new psychiatric clinical diagnostic
classification system" which, the authors claim, ensured reliability in the
manual.
At the same time, the book virtually ignores Szasz´s contributions to the
criticism of psychiatry which led to Horwitz and Wakefield´s. (It should be
noted that in an earlier Horwitz book, Creating Mental Illness, there is again
the lack of relevant and academically required footnoting of Szasz´s voluminous
works -- Horwitz references him on a couple of pages essentially to say that
Szasz calls mental illness a "myth" but ignores him on many points on which
Szasz has declaimed over the years. He also notes that Szasz is a
libertarian). In addition regarding the only 2 citings of Szasz, one is simply
historically inaccurate: the citing of his support of the "antipsychiatry"
movement
which, in fact, he opposes. The other grotesquely oversimplifies and minimizes
Szasz´s extraordinary, unique and comprehensive corpus by saying in 11 words
only that he argues that "there are no mental disorders because disorders
require physical lesions." This leads them to the unsurpassable non sequitur
that Szasz (and others) "preclude the prospect of effectively critiquing
overexpansive psychiatric definitions of disorder."
"The Loss of Sadness" cribs many of the Szaszian insights that others in the
mental health fields also have, but the list in this work is striking, and
the many omissions of Szasz in the text and particularly in the endnotes are
deeply disturbing. Here are some of those correct but "borrowed" ideas:
1. Normal, understandable suffering should not be rhetorically diseased
2. Normal sadness is too often falsely medicalized
3. Coercive counseling and forced counseling are neither ethical nor
effective
4. One of the dangers of misleading diagnosis in psychiatry is that the
symptom doesn't point to the illness but is the illness
5. The popularization of the notion of non-medical, non-psychiatric
"problems-in-living" concept is pointed out in contradistinction to mental
disorders
6. The frequent observation that just because drugs change behavior doesn't
mean that a disease is being cured
7. Deficiencies or changes in brain chemistry could be the result rather
than the cause of depression.
The current retrenchment of psychiatry unembarrassingly takes much from
pre-eminent critic Szasz, but there remain unbridgeable differences. Much that
remains insufficiently examined that Szasz would argue deserves intense scrutiny
includes the psychological, social and economic outrage of creating
dependency, wherein people lose their autonomy and must be drugged and cared for.
The longstanding and ongoing use of Thomas Szasz's criticisms of psychiatry
without sufficient -- and sometimes without any -- attribution is, of course,
indefensible. The motive may be resentment toward Szasz or it may be
complicated, such as the desire to affect psychiatric history to falsely imply
that
psychiatric theory adapts through internal processes of
thesis-antithesis-synthesis.
Irrespective of the expropriation of Thomas Szasz´s insights over the past
half-century, there remain some unbridgeable gaps. Szasz differs from
psychiatry and conventional wisdom in the totality of his argument: that there
is and
can be no such thing as a mental disease or an empirically verifiable mental
disorder. In additionSzasz´s arguments that people must be held responsible
for all of their behavior -- particularly criminal behavior -- is
undercovered. Reflexes, palsy and behavior emanating from authentic neurological
diseases
may not be chosen, but all purposive behavior is, he argues. Drugs may
affect mood, but that does not mean that they are curing a disease. The metaphor
of "mental illness" is an all-purpose explanation, as Szasz has repeatedly
cautioned, which purports to explain everything, but in fact explains and
clarifies nothing.
Much of the newest wave of psychiatric self-criticism is salutary and headed
in the right direction; the problem is the field's unwillingness to credit
the psychiatrist who paved the way.
Richard E. Vatz and Jeffrey Schaler*
From USA Today Magazine (March, 2008)
*Richard E. Vatz is associate psychology editor of USA Today Magazine and is
professor of rhetoric and communication at Towson University.
rvatz@towson.edu
Jeffrey A. Schaler, a psychologist, is a professor of justice, law and society at American University´s School of Public Affairs, Executive Editor of Current Psychology, and edited Szasz Under Fire: The Psychiatric Abolitionist Faces His Critics (Open Court, 2003, Chicago). schaler@american.edu
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