Who Needs Psychiatrists?

I have seen a medicine
That's able to breathe life into a stone,
Quicken a rock, and make you dance canary
With spritely fire and motion, whose simple touch
Is powerful to araise King Pippen, nay,
To give great Charlemain a pen in's hand
And write to her a love-line.

All's Well that Ends Well


The criticisms of contemporary psychiatry are coming fast and furious now, and not just from the fringe any more. Cheryl Fuller at Jung at Heart refers to a review by Marcia Angell of three recent anti-psychiatry volumes (of which I have read Daniel Carlat's Unhinged and Robert Whitaker's Anatomy of an Epidemic, but not Irving Kirsch's The Emperor's New Drugs). And while it's not specifically about psychiatry, an American Scholar article by Harriet Washington documents the discouraging corruption of medical research and publishing by so-called Big Pharma.

The mounting charges are of the most serious kind, and warrant a full-on response from the profession (which this blog post does not aspire to be). To very briefly summarize, the basic effectiveness of antidepressant drugs (and to greater or lesser extents, all psychiatric medications) is increasingly dubious as the integrity of research purportedly showing their efficacy is called into question. Critics maintain that for decades (antidepressants came into general use in the 1960's), thousands of psychiatrists (and of course other physicians as well) and millions of patients have prescribed and taken non-therapeutic compounds based on an underestimation of the placebo effect.

As for neurobiology, critics point out, correctly, that there is no evidence for any specific "chemical imbalance" that antidepressants allegedly alleviate. However, this is not the crux of the issue, for other central nervous system agents (e.g. anticonvulsants and anesthetics) have mechanisms of action that remain somewhat mysterious. And depression is in fact correlated with specific neurobiological states, but only because every psychological state--falling in love, undergoing religious conversion--can only be based in the brain. The question is not whether any given psychological phenomenon has a biological correlate (of course it does); the question is whether said phenomenon is best understood and potentially modified in chemical as opposed to other (psychological, interpersonal, social) terms.

It is one thing to claim that antidepressants are overblown and oversold; it is quite another, of course, to claim that they are useless or even pernicious. For instance, Robert Whitaker's arguments can lead only to the conclusion that antidepressant drugs should be expunged from the earth, and that psychiatrists are either unwitting or cynical quacks for prescribing them. And of course, as psychologists and social workers have taken over much of the psychotherapy territory that used to belong to psychiatry, the profession's identity has been ever more given over to psychopharmacology. After all, Freud didn't think psychoanalysts needed to be physicians, and there is no evidence that psychiatrists make better therapists than those with other degrees, so absent real results from biological treatment, why does psychiatry exist, exactly, beyond a function as a research program?

As someone who has, regrettably, long recognized the limitations of existing drugs but who still prescribes them, what do I believe? And can what I believe be remotely legitimate inasmuch as my current livelihood (by no means opulent in doctorate-level terms, but reasonable) depends on these medications having a role? Intellectual honesty demands that if one has a pressing self-interest in believing something, one should subject that belief to fierce and insistent criticism. There is no sin greater than tendentiousness.

This discussion derives from the valorization of the randomized, placebo-controlled trial as the ultimate arbiter of medical outcome, very much at the expense of individual clinical judgment. After all, many hold that clinical judgment is subjective and idiosyncratic, and therefore open to bias and not to be trusted. If all that needs to be known about medications can be inferred from statistical trials, than anyone (such as Whitaker, a journalist) can know more about them than a physician. Indeed, on this view only the non-physician can accurately appraise medical treatments because his view is not warped by self-interest. And yet there is considerable question as to whether patients (or "patients") in rigidly controlled research studies are truly representative of real-world clinical encounters.

What, then, do I believe? I believe, with the Buddhists, that life is suffering (but not only that); the long history of humanity is one of untold miseries of anxiety and depression that were either merely endured (there being no other choice) or compensated for by relationships, religion, art, or alcohol. Like the agonies of even routine childbirth or the ravages of even typical old age, mental disorders have always been part of the human condition; only relatively recently have we tried to modify them. One can make an argument that all of these things should, again, be merely endured, but I don't think history has a rewind button. Yet the expectations regarding mood and anxiety have exceeded all bounds, as has the expectation that one has some right to reach ninety with sound mind and body.

I believe that existing drugs do not counteract specific or discrete physiological processes, but (like psychotherapy) are nonspecific mental balms. SSRI's and benzodiazepines are to mental distress as NSAID's and opiates are to physical distress, that is, they are often disappointing and attended by sometimes dismaying side effects, but millions of patients have found them of some use. I believe that in a modest way they reduce suffering, by no means always or even often, but on average. I believe this on the basis not of research studies, but of my clinical experience and that of many others. And the day I stop believing that is the day I will stop prescribing.

Mad Scientists at Work

"I have neither the scholar's melancholy, which is emulation; nor the musician's, which is fantastical; nor the courtier's, which is proud; nor the soldier's, which is ambitious; nor the lawyer's, which is politic; nor the lady's, which is nice; nor the lover's, which is all these: but it is a melancholy of mine own, compounded of many simples, extracted from many objects, and indeed the sundry contemplation of my travels, in which my often rumination wraps me in a most humorous sadness."

Jacques, As You Like It

Most psychiatrists can't go a week without hearing the "guinea pig" comment from a patient alarmed by the all-too apparent imprecision of the enterprise. Problem is, it would be bad enough if treatment were up in the air; the reality is that diagnosis itself is often in flux. Two links--Mitchell Newmark, M.D. at Shrink Rap and Joe Westermeyer, M.D. in the green journal--illustrate nicely the yawning gulf between theory and practice when it comes to the art of the shrink.

Patients (and insurance companies) often crave DSM-type diagnosis for the sake of clarity, but such categories often do not usefully guide treatment. Both psychotherapeutic and biological interventions, strangely, can be both more general and more idiosyncratic than by-the-book diagnoses would suggest. After all, many of the most basic psychotherapeutic stances--Rogerian acceptance and cognitive reframing just to name two--apply across numerous diagnoses. The same may be true of medications--"antidepressants" are used to treat not only depression, but multiple anxiety disorders as well as eating disorders.

In this sense, two seemingly contradictory propositions may be said to be true: every case of depression is alike, and no two cases of depression are alike. The former may as well be the case when it comes to biological treatment, or rather, it is merely the case that depression exists on a spectrum of severity which dictates the aggressiveness (but not the basic type) of intervention. But it is just as true that when it comes to the fine-tuned approach to the patient (including, but not limited to, formal psychotherapy), myriad developmental and personal variables guide treatment far more than DSM diagnosis. Another way of putting this is that despite decades of attempts to make the DSM more specific, individuals within a category (whether schizophrenia or borderline personality disorder) are still more different than they are similar.

I think of evaluation and treatment as situated among three axes: severity, symptoms, and idiosyncratic history. The most basic question is: how impaired is the individual, and what extremity of intervention is called for? The first issue, whether evaluation or treatment is required at all, has already been answered, by the patient or someone close to him/her, by the time the clinician is on the scene. The second issue is whether biological intervention is likely to be helpful. In select cases, the third issue is whether inpatient or residential treatment is indicated.

Individuals are driven to treatment by symptoms, and once it is decided, if it is decided, that biological intervention is appropriate, it is shaped by symptoms more than by diagnoses. Yes, there are a few major categories helpfully kept in mind--primary psychotic disorder, depression/anxiety, bipolarity, substance abuse, and ADHD (or other cognitive impairments)--but those suffice for general formulation so far as biological treatment is concerned. When it comes to general and psychotherapeutic approaches, the unique idiosyncrasy of the patient is the chief guide of treatment.

As Dr. Newmark points out in his post, psychiatry remains profoundly different from the rest of medicine, where diagnosis is everything, in this respect. If a patient presents with chest pain, it is supremely important to know whether it is due to a heart attack, aortic dissection, bronchitis, pulmonary embolus, gastroesophageal reflux, or costochondritis, because each of these calls for clearly distinct treatments. Psychiatry is not like that. Deciding whether a person's diagnosis is depression, bipolar disorder, or schizophrenia will suggest moderate differences in treatment, but the latter will derive more from specific symptoms and personal background. This goes to show that psychiatry remains far more art (or "art") than science. The research-powers that be have yet to persuade the practitioner otherwise.

Why This Psychiatrist Isn't Practicing Psychotherapy

In expectation of their forthcoming book, the Shrink Rap folks did a post soliciting inquiries about psychiatry. Predictably, among them was: why aren't more psychiatrists doing psychotherapy? There are a number of ways to answer this, the simplest and least sophisticated being: shrinks are increasingly co-opted by Big Pharma and choose big bucks over introspection and integrity. That happens, of course, but it isn't the whole story.

Another way of looking at it is just the division of labor. People tend to get better at what they spend a lot of time doing. In recent decades huge numbers of psychologists and social workers entered the therapy arena, and not only do they often do therapy as well as a psychiatrist could--often they do it better. Why don't internists offer physical therapy, or detailed nutritional counseling? Because there are specialists who offer those services. Yes, they do offer them somewhat cheaper than an internist could or would offer them, but the more important point is that those specialists get really good at what they do.

To assume that psychiatry without formal psychotherapy (of the explicitly defined, 50-minute variety) is nothing more than pill-pushing is a warped and shrunken view of the medical role. The medical dimension of psychiatric practice has its own healing frame and ritual, the management of which calls for nuanced understanding of human nature and diagnosis; that is, psychiatry should offer a unique professionalism. Psychiatry without psychotherapy should not be confined to the peddling of antidepressants any more than internal medicine without physical therapy or nutritional counseling should be defined by the peddling of muscle relaxants or oral hypoglycemics.

As Freud himself believed, an M.D. after one's name does not endow one with unique therapy skills. As a psychologist reminded me years ago, people tend to do what they are trained to do. And as a commenter responded to a previous post on this topic (I can't seem to find it, so I paraphrase), people tend to practice what they believe. That is somewhat limiting (there are a lot of things I believe in more than in psychiatry, but it is necessary to pay the bills), but more or less true. I practiced ECT for years, but I don't "believe in" ECT more than in therapy. There is also, crucially, the matter of personal fit.

There are a lot of good therapists out there, and there are a lot of primary care physicians able to offer an SSRI (for better or worse) for transient or mild conditions. But people seem to have a hard time finding intelligent psychiatrists to offer, if nothing else, prognosis and understanding if typical treatments don't seem to work. One can have and apply a knowledge of the history, sociology, and philosophy of mental disorder without feeling the need to provide formal psychotherapy. I have done the latter in the past, and perhaps I will do it again, but for the time being it is more interesting in the abstract than in actuality.

America's Most Wanted (Doctors)

The dogs may bark, but the caravan moves on. Just when I had carried my graduate school application to the mailbox (do they still accept paper?)--I heard the market for Wallace Stevens studies is strong--I see that, according to an update in Psychiatric Times, I may not want to give up my day job quite yet.

It is striking that as many critics deride the profession and its tools, its real-world prospects grow apace. Indeed, the treatment of children, now most controversial, is precisely where the best jobs are. Why I wonder? Pharmaceutical behemoths stoking demand? Post-imperial, recessionary American malaise? Perhaps it is also related to the increasing pressure on primary care doctors, who just can't handle the huddled masses of the unhappy.

Knowing and Being Known

"There is nothing so practical as a good theory."

Kurt Lewin (?)

I can't resist commenting on Daphne Merkin's New York Times article on her (mis)adventures in therapy, not specifically because of its implications for her or for psychoanalysis, but because of general issues it brings to mind regarding diagnosis and levels of understanding.

On a human level the piece intrigues mainly with its idiosyncratic portraits of Merkin's successive therapists; taking full advantage of the writer's prerogative, she turns the tables by pigeonholing them (this one is dowdy, this one seedy, this one aloof, etc.) just as they would aspire to pigeonhole her. However, the surprising yet perhaps telling thing is that she doesn't actually document them pigeonholing her, that is, there is almost no discussion of diagnosis beyond the vaguest of terms: anxiety, depression, neurosis.

It is not my role her to speculate on Daphne Merkin, who is a brilliant writer. But any decent clinician is going to have one diagnosis come to mind when she discusses having poor boundaries, chaotic relationships, one therapist who comments on her difficulties with navigating emotional proximity, and at least one episode of severe regression when given free rein to explore her childhood issues. And yet there is no discussion of diagnosis or its extension, prognosis; that is, what pattern exists here and how might it unfold over time?

Merkin seems surprised herself at how little overall clinical effect her perpetual "life in therapy" has had, not least because while some of her therapists were clueless and unhelpful, others were deeply empathic and understanding. Indeed, she felt very understood by and very attached to at least a couple of them, and yet nothing seemed to change for her overall, at least in the way she was hoping for. What is going on here?

This question also came to mind when I read Cheryl Fuller's most recent post on obesity which, while making no explicit reference, followed and seemed an implicit response to my most recent post here. Her eloquent post, decrying allegedly simplistic overgeneralizations, was a plea for deep understanding of the individual experience of obesity. It brought to mind what I see as a tension between empathy and theory (or diagnosis) as ways of knowing that have different but complementary purposes.

Empathy is, of course, a fine-grained attunement to an individual's emotional state and history, an engagement with a truly unique sensibillity and life trajectory. This is obviously a form of knowledge, and may be likened to other forms of perception that are sui generis: a singular Picasso, or a sunset whose precise configuation of color and shadow will never be precisely repeated anywhere or at any time. Human beings have a powerful need to understand and to be understood in this way, which is the way of love, friendship, ethics, and aesthetics. It is what most people think of as the ends (i.e. the goals) of human life.

However, the whole point of theory and diagnosis is to overlook endless idiosyncratic differences and to identify how entities and processes may be alike, not how they differ. This kind of classification has three purposes: it enables us potentially to know how phenomena may develop over time, how we may go about modifying them, and on a more abstract level, how "it all fits together." The former two aims are those of science, while the latter aim belongs to spirituality. These things are necessary because a universe of irreducible uniqueness is also a universe of chaos (and also a universe without language, which also intrinsically glides over differences; a language could do full justice to individuality only if it had as many words as there are entities).

A good theory (or diagnosis in medicine) should either either lead to effective interventions or to a recognition of the necessary limits of treatment, i.e. prognosis. A theory that aids in neither altering nor predicting outcomes is useless. But there are different levels of explanation with corresponding different levels of treatment. For instance, we lack an ultimate theory of obesity, that is, an explanation of who gets fat and why, but we have a more proximate theory: obese people become obese because more energy is absorbed through their stomachs than their bodies expend as energy. Therefore one can intervene at that level of explanation through bariatric surgery (the ethical and cultural considerations of which I'm not touching here).

To come back around to Daphne Merkin's quandary: as presented in her article at least, the diagnostic/theoretical system has failed her on multiple levels. For while psychoanalysis has never been accused of neglecting theory, and the practices she describes imply a theory, this is never made explicit to her. While there may be passing and perceptive interpretations, no therapist ever comes out and says what may be wrong with her.

There is also a problem with prognosis. If I see someone who has seen a dozen other doctors over decades without success, then there are three possibilities (listed in ascending probability): the diagnosis is wrong, the diagnosis is right but not every possible treatment has been tried, or the condition is untreatable. Merkins's therapists never seem to consider that the diagnosis may be one that is not amenable to classical analysis. Or even if they consider this option but reject it, they are undeterred by the failure of a dozen of their colleagues in the past. Why? Perhaps because in psychoanalysis idiosyncrasy plays such a primary role that there are as many different treatments as there are individual therapists. The last option is that her therapists know that the treatment will not work in any conventional sense but view it as a kind of palliative care. This seems to be Merkin's own take on it; by the end she is not hopeful of any real progress, but life in therapy seems at least slightly less intolerable than life without.

So medicine and psychiatry need both levels of understanding: the empathic and the theoretical. If the latter unopposed is crude and callous, the former unopposed is static and ineffectual. Theory enables us to manipulate the world (including our own bodies) to our own ends, while empathy enables us to decide what those ends will be. When it comes to psychiatry, as I have written here in the past, flaws in treatment are far less grievous to the profession than flaws in diagnostic understanding. As perpetual debates over psychoanalysis and the DSM-5 demonstrate, our map of the human psyche still has wide swaths of empty space, offering limited guidance to those lost on the way. Our minds so often rush to treatment options (how do we get there from here?) that we often skip a crucial orientation step (where are we exactly?). Psychiatry will be waiting for its GPS for a long time. When we finally get it, let's not become overly dependent on it...

Whatever You Say, Doctor

"The brain that is innately fearful and angry has been selected for by evolution."

Allan Hobson

"My holy of holies is the human body, health, intelligence, talent, inspiration, love and absolute freedom--freedom from violence and falsehood, no matter how the last two manifest themselves."

Chekhov

Two years ago tomorrow appeared the first post of this peculiar A. P. blog; 361 posts later, it still seems as good a rationale as any. Happily, I have little more to say about the activity of blogging itself--it is an intellectual hobby, full stop.

I am forever casting about for serviceable metaphors for what it is that psychiatrists do. Well, psychiatrists are doctors--what do they do? Arguably they have a dual role, one scientific/technological and the other dramatic/emotional. Taking the latter first, the clinical encounter is a carefully scripted and staged act of caring which grounds the endeavor in the aim of healing rather than, say, exploitation. And yet it cannot be only drama; medicine functions legitimately only if there is real technical know-how beyond the layman's scope that doctors are privy to. The two act in concert to produce a clinical outcome.

It is the technical basis that Daniel Carlat has, to some scandal, questioned in his recent book Unhinged. If the science of medicine comprises diagnosis and treatment, both come under intense scrutiny in that volume. As the "debate" over DSM-V has grown into the kind of ad hominem free-for-all that would seem typical of the U. S. Congress, psychiatric diagnosis is considered by many to be as much hearsay as real science. And as alleged technical breakthroughs like vagus nerve stimulation and transcranial magnetic stimulation have turned out to be relative duds, some of psychiatry's most powerful somatic treatments remain at the level of mid-20th century technology. Carlat concludes that psychiatrists should no longer have to be physicians by training--the implication is that our technology, such as it is, does not justify it.

Undeterred, Henry Nasrallah, M.D. extols the "futurology of psychiatry," laying out the technical revolution that is just around the corner--we have been hearing that for 25 years, but this time it's apparently for real. I think of a sonorous voice from my childhood: "Gentlemen, we can rebuild him; we have the technology." But while other physicians are replacing knees and stenting coronary arteries, psychiatrists are...prescribing Valium. But Lee Majors looking mellow for an hour wouldn't have made for much of a show--even in the 1970's.

Granting the profession's shortcomings yet decrying the infighting and self-doubt, Ronald Pies advocates the "prescriptive bond" as the essence of the medical mission of psychiatry (one that, presumably, could not be performed by psychologists with prescribing privileges). Basically, he is writing about the drama of the white coat, that is, a seemingly trivial prescription has the history and authority of several millenia of medical tradition behind it. The caduceus. The Aura of the Doctor. And yet what good is that if the prescription is for sugar pills, or for something that may do more harm than good?

I think of the psychiatrist as a weird hybrid of the philosopher, the priest, the legislator, and the pharmacist. All of these must grapple with inherently ambiguous and contentious issues corresponding to crucial human needs. All must deal with the man on the street, whose opinions on these matters often exceed all in intensity if not in wisdom. But what ensues when the community loses faith in the shaman is...debates like these. Everyone feels he knows best about his body and what to put into it, about right and wrong, about God, about what policies to enact. And yet society sees fit to appoint "experts" for these roles not really befitting the title of "expert." Psychiatrists should not be glorified druggists, but those with enough perspective and wisdom to usefully frame human suffering. In that sense, pace the futurologists, there will be "nothing new under the sun."

Medicine and Metaphor

It seems as if the honey of common summer

Might be enough, as if the golden combs

Were part of a sustenance itself enough,

As if hell, so modified, had disappeared,

As if pain, no longer satanic mimicry,

Could be borne, as if we were sure to find our way.

Wallace Stevens, from "Esthetique du Mal"

To judge from the vituperative comments section of his blog, Daniel Carlat, M.D. is now apparently the Most Hated Psychiatrist in America, having offended fellow shrinks and patients alike by being honest. In his recent book, Unhinged, he bravely and forthrightly discusses the obvious, i.e., that we don't know nearly as much about the brain and about psychotropic medications as we would like, and that psychiatrists don't do psychotherapy nearly as much as they used to.

Until we have a full neurophysiological and philosophical understanding of consciousness, we will lack a complete understanding of psychotropic drugs, whether marijuana or Thorazine. Deal with it. We don't even have a full grasp of sleep, which is one of the most basic behaviors in the animal kingdom. Do we fully fathom how anesthetics work? And yet we submit to them, and to trust people to cut into our bodies while doing so. Can someone tell me exactly how the experience of pain works, and therefore how Tylenol is effective?

Indeed, one of the commenters on Carlat's blog likens psychotropics to aspirin, and I think that is an apt comparison. In all of medicine, psychiatric conditions are most similar to pain syndromes, and psychiatrists are most similar to pain management specialists. In both cases we have an imperfect account of underlying pathophysiology, but the resulting distress is clear, so we do our best to alleviate it. The DSM is a bit of a red herring; in their everyday work most psychiatrists treat symptoms.

There are of course legitimate philosophical debates about the proper place of pain in life, and no doubt we have become less tolerant of both physical and psychic distress in contemporary times, but the whole enterprise of medicine is predicated on the supposition that suffering is not inherently redemptive (it is a shame that Nietzsche lives on in the public imagination mainly with "What does not kill me makes me stronger," which is plainly wrong, or at least very selectively true). If patients come to a psychiatrist looking for a one-time fix or an indisputable explanation, they will likely be disappointed. But I would suggest that they're looking for someone who will understand and validate their suffering and offer some relief.

Any decent doctor should know that pharmacology and other technological interventions have their limitations and drawbacks--insight and behavior change should be attempted first, just as they should before, say, considering bariatric surgery for obesity. The psychiatrist's message should amount to: "I see that you are hurting. You're not alone and you're not a freak; I have seen a lot of people with similar problems. It's not your fault. I can't completely explain where your pain comes from, but I know of some things that could help."

Unless they are of the tiny minority subject to involuntary commitment, folks are free to avoid psychotropic drugs just as they may choose to steer clear of analgesics, but they shouldn't condemn those who find them helpful. The problem, as I've written here many times, is not that mental illness doesn't exist or that psychotropic drugs don't work even for symptoms (they unequivocally do, although not as completely or as often as we would like); the problem is that psychiatry has been far too confident and grandiose in its claims of diagnostic specificity and treatment efficacy.

People see psychiatrists who declare that their Major Depression is as clear and unambiguous as appendicitis might be, and that Prozac will definitely be the solution. But the majority of patients we see present with symptoms more like chronic back pain than like appendicitis. In a perfect world we would have a full understanding of back pain, such that it could be eliminated directly (or--gasp--tolerated) rather than treated with clumsy analgesic regimens. But that is a heroic ideal, not the world we live in. We need more realistic expectations, which is what Dr. Carlat has tried to supply in his blog and his book. As someone once said (oh right, Buddha), life is suffering, and since the dawn of civilization human beings have fermented, distilled, and smoked whatever they could get their hands on in an effort to tinker with flawed consciousness, and psychiatry, like pain management, is an attempt to undertake this in a way that is, yes, civilized.

The Heart of the Matter

"It's hard to make that change

When life and love

Turn strange

And old."

Neil Young

Hats off to Dr. Rob at Musings of a Distractible Mind, who muses (of course) on suffering and the ends of medicine. Every now and then it is good to look up toward the remote (and ultimately inaccessible) peak at whose base one labors. To switch metaphors, each morning we march out upon the beach, brooms at the ready, braced to sweep back the tide. Physicians should know their Sisyphus. Heroic? Not usually. Futile? One hopes not. For some it seems to be the worst possible profession, except (a la Churchill) for all of the others.

Robert Pinsky and the Muse of Psychiatry

Robert Pinsky's fascinating "Essay on Psychiatrists," which surely must be by far the longest published poem in the history of the world that is devoted to shrinks, once inspired me to write a much less felicitous essay of my own. I was surprised to discover today that, well, both "essays"--one a must-read, the other not so much--are fully available online.

This is Pinsky's conclusion (section 21. 21!):

Essaying to distinguish these men and women,
Who try to give medicine for misery,
From the rest of us, I find I have failed

To discover what essential statement could be made
About psychiatrists that would not apply
To all human beings, or what statement

About all human beings would not apply
Equally to psychiatrists. They, too,
Consult psychiatrists. They try tentatively

To understand, to find healing speech. They work
For truth and for money. They are contingent...
They talk and talk...they are, in the words

Of a lute-player I met once who despised them,
"Into machines"...all true of all, so that it seems
That "psychiatrist" is a synonym for "human being."

Even in their prosperity which is perhaps
Like their contingency merely more vivid than that
Of lutanists, opticians, poets--all into

Truth, into music, into yearning, suffering,
Into elegant machines and luxuries, with caroling
And kisses, with soft rich cloth and polished

Substances, with cash, tennis and fine electronics,
Liberty of lush and reverend places--goods
And money in their contingency and spiritual

Grace evoke the way we are all psychiatrists
All fumbling at so many millions of miles
Per minute and so many dollars per hour

Through the exploding or collapsing spaces
Between stars, saying what we can.

This was published in 1975, but not so much has changed, really. One can't expect him to get everything right...Even lutanists had the temerity to despise us? What would guitarists do, crush us like bugs? What "prosperity?" Okay, maybe more prosperous than contemptuous lutanists and snarky poets, but opticians may be a close call...Not really into caroling (is anyone?)...

One of my observations back then was the back-handed compliment at the heart of the poem. Message: psychiatrists are just like the rest of us, no worse, no better. Therefore don't hate them, but why pay to see them really? I've got kids to feed...

Auf Wiedersehen to Academia

A few days ago a friend and former colleague sent me news that a paper that we had begun at least three years ago (what is that in "blog years?") had finally appeared in the print world. He wrote it, I merely advised and proofread. But while I've been physically removed from the university for two years now, it occurred to me that only now, with the paper trail complete, was the academic experience complete, with closure as the cliche goes. As my first peer-reviewed article appeared in 2000, this nicely rounded the experiment up at a decade.

When I was a senior resident in the late 90's, the department chairman at the time, Allen Frances, M.D. (he of DSM-IV notoriety) rounded a few of us up to discuss our career prospects. At that point I had developed a strong interest in the history and sociology of psychiatry, and told him so. He nodded vaguely, as I recall, and said something about that being a worthwhile "hobby" (his word) to pursue alongside my real career of clinical work and, perhaps, more respectable (and funded) research.

At the time I privately took some offense, for the philosophical dimensions of psychiatry were a primary passion of mine; all of the mainstream trappings of the profession were necessary evils. The clinical experience has always been crucial, but its props (the diagnostic categories, the meds, etc.) I have always taken with some grains of salt. When I entered an academic position at a different institution, it was understood that the "props" (to include inpatient work and ECT) would earn my keep and justify my salary, but the deeper motivation for me was the intense and hard to define strangeness of the psychiatric endeavor itself.

So began a rather parallel career. On a theoretical (not, I hope, a personal) level I fumbled my way toward hysteria as the route to the pervasive but often acknowledged role of narrative and value(s) in clinical work, and I found, in poetry and short fiction, promising windows upon this state of things. In my mainstream work I tried to do good, broadly speaking, for people (ranging from administrators to patients) who want what they contingently want and upon whom thoughtfulness, unfortunately, is all too often wasted. But as I never really felt at home in the psychoanalytic community--it has always seemed a bit hieratic, a bit hothouse to me--a niche wasn't easy to find. I always felt that literature had more to teach psychiatry than vice versa.

Unless one counts a few paid trips to conferences (granted, Emily Dickinson in Hawaii is hard to beat), I was never funded a cent for publications or presentations over those years. My clinical work paid the way, so in that sense Allen Frances was right, my humanistic leanings were a kind of professional hobby in a way. I was an amateur, although hopefully in the best sense of the term. This was probably as it should be; why should taxpayers pay for an academic physician to indulge in esoteric speculations perhaps of no use to anyone (and surely not of measurable use) when he could be doing the "real work" of seeing patients?

I confess I never greatly enjoyed teaching medical students or psychiatric residents, at least not in the classroom setting and not the kind of mainstream stuff (the "descriptions and prescriptions") that they most wanted to know (I don't fault them, as they were responding to a professional and economic system with its own incentives). I mention this somewhat sheepishly, because teaching is one of those things--perhaps like growing your own vegetables or volunteering in soup kitchens--that is considered universally praiseworthy. But I most enjoy those activities that are done for their own sake, and for that reason the best learning takes place outside of a classroom. There were the occasional exceptions, the thoughtful ones; good teachers speak to a group of 30 for the sake of the 5 or so who truly care, or in the hope of increasing that 5 to 10. I'm just not wired that way; an autodidact by nature, I have found my best teachers in libraries, bookstores, and the "book of nature" for the most part.

The reason I finally left academia was the realization that, in medicine at least, tenure means nothing in the absence of separate funding. I was awarded tenure and...nothing changed; I still had to maintain a busy clinical practice to earn a few precious hours per week that I might devote to thinking and writing. But the kind of topics I care about are to medicine what, say, poetry is to the publishing world--it doesn't make any money for anyone. So it occurred to me that I didn't really need the academy; I could do clinical work anywhere to finance my parallel interests in literature and psychiatry. Clinical work--the fact of suffering--is the existential engine, but the narrative mode is the way I prefer to steer.

So the Ars Psychiatrica blog was the unfinished business of my academic career, the things left over that needed saying that I hadn't gotten around to sending to refereed journals. It was nice to publish in three seconds rather than three years, although many, many posts could have benefited from stringent peer review. I have always admired writers who, instead of whining about people not buying their stuff, arrange to have a day job that will earn them a living (T. S. Eliot at the bank, Wallace Stevens at the insurance company). I do get tired of contemporary journalists and writers complaining about the Internet threatening their livelihood. Why don't they do what the rest of us have to do, learn a trade that they can get paid for? I'd love to get paid for keeping a blog, but it isn't going to happen.

It Depends

"To generalize is to be an idiot; to particularize is alone distinction of merit."

William Blake

A New York Times article reminds us of the distinction between complicated and complex, and our tendency to mistake the latter for the former. Complicated is a list of 10,000 instructions that must be followed to the letter; complex is a system so intricate that one can only hope to guide and shape its overall outline, not master or control its every detail.

David Barash shows how science neglects individuality in favor of generalizations.

Consciousness and its myriad maladies are instances of complex particularity. Psychiatry is therefore hubristic and diagnosis is stupid, but human beings have a need for these things.

Think Again

In the throwaway journal Current Psychiatry, editor Henry Nasrallah, M.D. offers what he calls a "psychiatric manifesto," a professional apologia of a kind, which is an interesting if typical example of the perennially insecure status of the discipline.

Here is an alternative "manifesto:"

1. Psychiatry deals with diverse impairments of mood, behavior, motivation, cognition, relatedness, self-understanding, impulse control and personal integration; that is, it deals with disorders of the self. While other areas of medicine deal with generic aspects of biological functioning, psychiatry specifically concerns itself with obstructions to self-determined individuality, in other words, selfhood.

2. Self-determined individuality has an essentially narrative aspect; the self comprises self-fulfilling stories which coincide or clash with the self-fulfilling stories of other persons. That is why third-party corroboration ("collateral information") is so often crucial to psychiatric assessment, and why psychiatry is irreducibly linguistic and why it has so little to say about an unconscious patient.

3. All mental phenomena derive from brain phenomena, so in principle all subjective experience may be influenced by neurophysiological means. However, as noted above, neurology deals with the generic aspects of brain functioning (its infrastructure as it were), whereas psychiatry deals with the idiosyncratic story that the brain, impinged upon by surrounding stories, endeavors to tell about itself. Mental disorders therefore entail an unstable and not precisely definable mixture of voluntariness and involuntariness.

4. While brain phenomena underlie all mental phenomena, the current very limited state of neuroscientific insight is such that practicing psychiatrists are not neuroscientists any more than, say, taxi drivers are auto mechanics. For the routine practice of contemporary psychiatry, the vast majority of neuroscience per se is irrelevant. This may change in the future, but despite freqent promises over the past twenty years that this will change any day now, it hasn't yet.

5. Because it aspires to authority over potentially controversial and debatable aspects of human conduct, such as matters of human behavior, identity, and relatedness, psychiatry has an inherently political and contentious dimension. Psychiatric nosology is an ongoing global process of consensual negotiation in which psychiatrists, while experts of a kind, are also mere participants.

6. Increasing knowledge of brain science and technology will no more solve disputes over psychiatric diagnosis than, say, the Internet has solved political problems. Debates over, say, psychotherapy versus medication arise to some degree from contrasting sensibilities and climates of opinion and are not therefore altogether resolvable by evidence-based analyses.

7. For the above reasons, while the stigma of mental disorders is very often damaging and regrettable, it is naive to think that such ailments will ever be as simple or as straightforward as many medical problems. This is so because any diagnosis constitutes not merely description, but also a moral claim, and in psychiatry's case, an unavoidably equivocal one.

8. While psychiatry as a discipline is probably no more flawed than any other large human institution dealing with complex phenomena, it is unhelpful to view critics of psychiatry as necessarily "ignorant" or "self-interested." The controversy has to do not with any exceptional benightedness of the discipline or its detractors, but rather is inseparable from the nature of the undertaking. Psychiatry attracts critics for the same reason that, on larger scales, the federal government or the Catholic Church do: all relate to powerful and yet deeply ambiguous human needs and vulnerabilities.

Psychiatry in a Slump

A brief commentary by Henry A. Nasrallah, M.D. in the, with all due respect, throwaway journal Current Psychiatry strikes a chord. Entitled "Is Psychiatry in a Recession?", the piece examines the field's setbacks, with respect both to publicity and to substance, in recent years.

Psychiatry may have suffered more than other disciplines from the medical and cultural backlash against the marketing tactics, the profitability, and the faulty products of pharmaceutical companies. The uniquely malleable nature of psychiatric diagnosis has invited therapeutic creep (or perhaps therapeutic rush is more like it), whereby antidepressants and antipsychotics are used for an increasingly broad array of mental ailments. And psychiatrists, perhaps owing to their perennially modest stature and income among medical specialists, have arguably shown an unseemly eagernesss to ally themselves with drug companies.

We constantly hear about breathtaking advances in neuroscience, but as yet none of these have led to major consensus, either philosophically or scientifically, with respect to the nature and boundaries of mental disorders. So as the field looks forward to (perhaps braces for would be more apt) the DSM-V within a few years, there seems to be no more agreement than ever about such fundamental entities as ADHD or bipolar disorder. For those invested in psychiatry becoming a twin of neurology, this is bad news; for those drawn to psychiatry precisely because of its ambiguous and eclectic nature, this may be strangely reassuring.

As Nasrallah mentions in general terms, on a practical level psychiatry has met with disappointment over the past decade. The SSRI's, once seen as the vanguard of future generations of increasingly effective and well-tolerated antidepressants, have stalled out, plagued by concerns over sexual and suicidal side effects (yes, an odd pairing) and limited efficacy. Atypical antipsychotics, while arguably better tolerated in a subjective sense than older drugs, have their own major problems of expense and metabolic side effects. Once seemingly cutting edge treatments such as vagus nerve stimulation and transcranial magnetic stimulation, while still potentially helpful for individual patients, have not transformed the treatment of depression as once hoped. It speaks volumes that the single most effective treatment for acute depression remains electroconvulsive therapy, which is 70 years old.

This concern over morale in psychiatry speaks to the unique cultural valence of the field. It's hard to imagine nephrologists, for instance, fretting over the status of their discipline (kidney failure is kidney failure, period). The best antidote for abstract debates is to remain focused on patients, to realize that beneath academic considerations of the socially constructed nature of social anxiety or whatever, there really is a vast pool of suffering and psychopathology out there. Like the ocean, it is exhaustively documented, yet arguably our ignorance of it still dwarfs our knowledge. It may seem like I refer to it as a good thing; it's not--if it ever dried up, I could finally justify going back to graduate school.

Psychiatry on Life Support

Wait, this was in 1962, in an interesting snippet from Aldous Huxley's Island, his final novel featuring, in compensation perhaps for Brave New World, a utopia. A young nurse from said paradise is complaining about a lecture from a visiting Western psychiatrist (one long paragraph in original; sorry):

"What was it about?"
"About the way they treat people with neurotic symptoms. We just couldn't believe our ears. They never attack on all the fronts; they only attack on about half of one front. So far as they're concerned, the physical fronts don't exist. Except for a mouth and an anus, their patient doesn't have a body. He isn't an organism, he wasn't born with a constitution or a temperament. All he has is the two ends of a digestive tube, a family and a psyche. But what sort of psyche? Obviously not the whole mind, not the mind as it really is. How could it be that when they take no account of a person's anatomy, or biochemistry or physiology? Mind abstracted from body--that's the only front they attack on. And not even on the whole of that front. The man with the cigar kept talking about the unconscious. But the only unconscious they ever pay attention to is the negative unconscious, the garbage that people have tried to get rid of by burying it in the basement. Not a single word about the positive unconscious. No attempt to help the patient to open himself up to the life force or the Buddha Nature. And no attempt even to teach him to be a little more conscious in his everyday life. You know: 'Here and now, boys.' 'Attention.'" She gave an imitation of the mynah birds. "These people just leave the unfortunate neurotic to wallow in his old bad habits of never being all there in present time. The whole thing is just pure idiocy! No, the man with the cigar didn't even have that excuse; he was as clever as clever can be. So it's not idiocy. It must be something voluntary, something self-induced--like getting drunk or talking yourself into believing some piece of foolishness because it happens to be in the Scriptures. And then look at their idea of what's normal. Believe it or not, a normal human being is one who can have an orgasm and is adjusted to his society." Once again the little nurse held her head between her hands. "It's unimaginable! No question about what you do with your orgasms. No question about the quality of your feelings and thoughts and perceptions. And then what about the society you're supposed to be adjusted to? Is it a mad society or a sane one? And even if it's pretty sane, is it right that anybody should be completely adjusted to it?"

The perennial critique of psychiatry is all there: the narrow reductionism (psychoanalytic at that time), the inattention to questions of value as pertaining to the well-lived life or the good society.


How will psychiatrists retrain when the utopia comes?

Shrinkage

What are you changing?

What do you think you're changing?

You can't change things, we're all stuck in our ways

It's like trying to clean the ocean

What do you think you can drain it?

Well it was poison and dry long before you came

But you can wake up younger under the knife

And you can wake up sounder if you get analyzed

And I better wake up

There but for the grace of God, go I

Jenny Lewis

Okay, let's try this again. I'm reminded of the performing violinist who, puzzled but pleased by repeated calls of "Encore!" from the audience, obligingly played his piece several times over. Finally he heard a hectoring voice cry, "Encore! You're going to sit there and play it until you get it right!" (I've decided to institute an annual joke here at the blog; that was it for 2009).

So my musings yesterday about the blog title brought to mind one of several oddities about being a psychiatrist (and by psychiatrist I always mean a therapist of any kind). (Sometimes people ask if I mind the designation "shrink." I really don't, and it isn't offensive, but as a word I've always found it to be somehow stale and antiquated, very 1970's, sort of like groovy, although I'm not in fact sure when the word arose.)

Many are fascinated by what drives a person to pursue psychiatry, or by implication, what sorts of people are drawn to field, but fewer reflect on how the active practice of psychiatry, or the sustained adoption of the role, could change a person (for better or worse). I will defer that deeper issue, but merely observe that, compared to other professions, that of psychiatrist has the potential, in terms of social perception at least, to hijack the identity.

Perhaps this is because the presence of a psychiatrist tends to make the layperson self-conscious. I would imagine that apart from celebrities of any sort, this is true of only a small number of occupations: priests or ministers mainly, but also perhaps police officers, judges, and teachers also (and tellingly, psychiatry could be said to comprise elements of all those roles).

I can think of plenty of other occupations that would provoke greater admiration or even interest, but not necessarily more self-consciousness. Not long ago I read a blog post by an English professor who complained that everyone she met suddenly seemed apologetic about their grammar or knowledge of books. But I don't think that if I were a plumber (talk about a road not taken!), people I met would feel self-conscious about their pipes. Psychiatrists, preachers, law enforcement types, and teachers foster transferences (of the psychological, religious, legal, and academic kinds, respectively) wherever they go.

After I got married some years ago I was surprised by how many women asked my wife what it was like to be married to a psychiatrist. Can you imagine asking anyone what it is like to be wed to a teacher or an engineer? No, because they're assumed to be regular folks. No, this was like asking what it was like to be mated with a giant millipede, or perhaps a demented taxidermist. The answer is presumed to be titillating, but likely not pretty. No, my wife always answers (with, I never fail to note, something less than delectation in her voice) that it's pretty much like being married to any other man (as if that weren't the lily that couldn't be gilded in the first place).

Impossible Profession

I mean impossible in the good sense, of course. Time is limited tonight, so I enthusiastically recommend a fine brief commentary I came across today on the strange, agnostic difficulty of psychiatry. Written by Rachel Dew, M.D. in the American Journal of Psychiatry, it is by a psychiatrist and intended primarily for other psychiatrists, and it conveys nicely the mind-boggling nature of the undertaking.

The piece speaks for itself, but no blogger can resist a few comments. When Dr. Dew claims psychiatry as "the hardest specialty," I assume she means "hard" in a moral and not a simplistically cognitive way. For the very reason that so much ambiguity does still prevail in psychiatry, there is not nearly as much of the kind of mental calisthenics--the grand connect-the-dots-game involving obscure diseases, symptoms, and physical and lab findings--pertaining to much of the rest of medicine.

If much of medicine is, cognitively and sometimes physically, a kind of triathlon, perhaps with elaborate obstacle courses thrown in, then psychiatry might be more akin to...meditation. Obviously aspiring to mindfulness, psychiatry at its best tries to slow things down, to notice things otherwise unnoticed, to accept an emptiness at the heart of things without giving in to despair. It attends to suffering, knowing that pain often cannot be eliminated but that pain need not be shrouded in affliction.

Psychiatry is not just that, obviously. There are a number of things we do know, even if only in a pragmatic and not a metaphysical or in a purely scientific way. No triathlon perhaps, but one can meditate while walking.

In addition to the inherent difficulty here, there is the added complication that, these days especially, many patients show up to psychiatry looking for a triathlon (to watch, that is). Increasingly, practicing psychiatry is like offering a meditation class in which people keep showing up, asking "Where does the race start?" Well, I don't know, but tell me what you're looking for.

How Much is a Psychiatrist Worth?

As I've thought about some of psychiatry's recent pharmaceutical research scandals, the broader role of money in medicine has naturally come to mind. After all, there is no way to be totally free of conflicts of interest. Any physician in private practice, or any physician who gets credit of any kind for sustaining a volume of clinical work (such as in academia, where physicians often are salaried but must accrue billings to justify that salary from year to year) has an interest in providing services that may conflict with doing what is medically and ethically justified.

The old joke goes that if you walk into a barbershop and ask if you need a haircut, chances are the answer is going to be yes. But we hold physicians to a higher standard than barbers; even when a surgeon or a psychotherapist could use the business, if a procedure is not indicated in a certain case they are obviously expected to honestly say so, despite their own pecuniary interest. Needless to say it doesn't always play out that way.

According to a list I randomly looked up, the average psychiatrist income in this country is $134,000 (I don't know how specifically reliable that particular survey is, but all the figures are on par with other surveys I have seen various places in the past). In terms of all specialties psychiatry is at the low end, but it is comparable with the other office-based, non-procedural specialties. As this list notes, many physicians put in well more than 40 hours per week, including night and weekend hours.

Perhaps it is puritanical of me, but even apart from the general corruption of psychiatry's already fragile knowledge base that I've already written about, I have also been bothered by the sheer tackiness of psychiatrists augmenting their income in a big way essentially by auctioning off their degree-related expertise to the highest bidder (that is, by giving highly lucrative "educational" talks or obtaining drug company research funding that is more about funding than about research).

Obviously physicians should be and will be paid well in the overall scheme of things. It is a demanding and stressful profession requiring prolonged (7-12 years depending on specialty, usually 8 or 9 for psychiatry) education and training beyond an undergraduate degree. And nowadays medical students often graduate with over $100,000 in student loan debt.

A medical degree is earned through a great deal of hard work, but it is also a privilege granted by society for the general health and welfare, not for the enrichment of individuals. Physicians obviously live comfortably, but the great majority of them are not CEO's-with-three-homes-and-a-yacht kind of rich (maybe a nice home, a superfluity of books, a menagerie of high-maintenance pets, and a canoe).

Some people seem to think it's obscene for a baseball player or a rock star to make many millions of dollars, but in a capitalist society one can hardly object. If one is providing entertainment or any other discretionary product, then one deserves whatever income one can pry out of the market. But short of high-end psychoanalysis and cosmetic procedures, health care is not a discretionary product, unless life itself is discretionary.

Some of the high-profile academic psychiatrists who have generated the recent opprobrium (detailed in the link in my post two days ago) earned seven figures over several years from drug companies, above and beyond their already hefty clinical and academic reimbursements. In a field that, due to the potentially devastating effects of mental illness, frequently serves the most socioeconomically dispossessed members of society, that strikes me as being unseemly. For individuals making six figures to have fancy meals bought for them by drug companies soliciting their services seems to me to be in equally poor taste.

Any opinions out there--do psychiatrists and other physicians make too much money, too little, or just right?

Psychiatry and its Problems

Prince: I see a good amendment of life in thee, from praying to purse-taking.

Falstaff: Why Hal, 'tis my vocation. 'Tis no sin for a man to labour in his vocation.

A couple years ago I saw a great New Yorker cartoon featuring a deeply dorky-looking fellow wearing a t-shirt emblazoned with the motto "I love my problems." That may have nothing to do with this post--I just thought I'd mention it.

No, this post is about the strange relations between psychiatry and the world's oldest profession. Forgive me, I repeat myself. Or so one might think from the most concise yet complete review I have yet found of psychiatry's troubling ties to the pharmaceutical industry, by Marcia Angell (former editor of the New England Journal of Medicine) in the current New York Review of Books.

As her article notes, the ties between big pharma and medicine are now deep, far deeper than patients suspect (reaching depths compared to which the recent decision to stop giving pens and other trinkets to doctors is nothing short of laughable). To my mind, the most profound issue is the corrupting bias of published research involving effectiveness of medication, as this endangers the knowledge base resorted to even by physicians who willfully bypass all other interactions with drug companies. In that sense there is no escaping the distortion.

The great hazard here for physicians is nihilism regarding published research, mirroring the nihilism one sees in others regarding the general news media. If reporting is demonstrably biased in significant numbers of cases, how can one believe anything? Barack Obama may well be indistinguishable from Osama bin Laden, and all antidepressants may be no better than placebo--who is one to believe in this crazy world? It takes care and attention to separate the trash from what is real--care and attention not likely to be in evidence at a boozy pharma-funded Continuing Medical Education program. I'll pay for my own wine, thank you.

Who's Afraid of the DSM?

An unhappy people in a happy world --

Read, rabbi, the phases of this difference

An unhappy people in an unhappy world

Here are too many mirrors for misery

A happy people in an unhappy world --

It cannot be. There's nothing there to roll

On the expressive tongue, the finding fang.

A happy people in a happy world --

Buffo! A ball, an opera, a bar.

Wallace Stevens

I'm sure we'll be hearing a lot about psychiatry's Diagnostic and Statistical Manual in coming years, with the fifth edition due out around 2011. For some of us, diagnostic issues, like politics did around 2006, is about to get a lot more interesting. The New York Times has an article today on how things are coming along (without a single bone of contention, rest assured).

There are some misunderstandings about the infamous tome. As is widely noted, the number of official "mental disorders" has increased significantly with every edition of the book, to nearly 300 today. But many of these are minute variations of the same basic problems. For instance, Alcohol Abuse is a distinct diagnosis from Alcohol Dependence, but both are just degrees of severity of the same addiction.

As I've written here recently, the DSM often does not directly dictate a great deal about how a psychiatrist goes about treating a specific patient, whether with medication or psychotherapy. This is true because the treatments we have are geared to very broad symptom domains that often span several (technically) distinct diagnoses. This is why psychiatrists tend to think very holistically; this can look like sloppiness, and it can progress that far, but in itself this approach is often merely realistic.

For instance, in terms of the general clinical approach it is far more important to figure out whether a patient has, basically, an anxiety problem or a substance abuse problem (or if both, which is the driving process) than to decide which of several anxiety disorders is present or which substance is being abused. The latter details are not meaningless, but they matter less for treatment than does the broader paradigm for the purposes of available treatments.

A good example of this is Binge-eating Disorder (involving gorging on food without the compensatory purging characteristic of bulimia), which has not previously been an official diagnosis but is being considered for the next DSM. If a psychiatrist under the current system learns that this behavioral symptom is present, then he will attend to it and use customary medications and/or psychotherapy to work on it, regardless of whether it is in itself an official diagnosis. After all, the majority of patients with Binge-eating Disorder will have accompanying anxiety or mood syndromes that are "coded" diagnoses; this kind of "comorbidity" is what makes diagnosis so slippery to begin with.

But psychiatrists are very much affected indirectly by the way in which the DSM drives insurance reimbursement, future psychiatric research, and general cultural understandings of mental illness. Like any massive institution, psychiatry is like a great ship that can be steered in a new direction only a little bit at a time and with massive effort; a new DSM is a significant nudge on the wheel. In the short term, a new edition likely won't change much about what transpires in psychiatrists' offices, but the long term differences will matter. As the NYT article notes, the elimination of homosexuality as a diagnosis decades ago certainly did matter.

The linked article states that the most recent DSM edition was in 2000, but this was a relatively trivial edit of the last major revision in 1994. In the latter year I was a third-year medical student making up my mind what area of medicine to pursue; I now realize that the buzz over that new edition was, while not a deciding factor obviously, nonetheless part of my interest in a field that never fails to be strange, surprising, and contested.

While psychiatry will always have a political element--in the widest sense of negotiated human values and the idea of the good life--there are in fact real human brains amid all the cultural buzz. Brains have real attributes, which one hopes we are getting slightly better at identifying and modifying. So one hopes the next DSM will represent at least a modicum of progress and not just another turn of the wheel...for the sake of a turn of the wheel.

Where Liberals Lurk

And if you gaze for long into the abyss, the abyss gazes also into you.

Nietzsche

I got to thinking about political dispositions in the mental health professions when I read a recent post by D. G. Myers in A Commonplace Blog. He tries to account for the great preponderance of political liberals in academia, particularly in humanities and social science departments, which is well-documented and has apparently been the case for a long time. I'm not sure I quite agree with his claims, but they are worth reading here (plus a couple of comments from yours truly).

Another group that is predominantly liberal-leaning is mental health professionals. I have remarked about this before and am quite sure that I have seen surveys supporting it, but with limited time and database access I am unable at the moment to summon citations (I welcome suggestions by anyone who knows of any, even if they don't support my supposition). I am not saying that this professional political bias is obviously either good or bad (and certainly not that a liberal therapist is better than a conservative one), but I'm curious as to why it may be. I am not aware of this kind of trend in health care professionals in general (if anything, physicians are popularly associated with more conservate viewpoints on average, although I don't have data for that either--after all, this is a hobby, not a job).

In thinking about this I was reminded for some reason of Jonathan Haidt's work on morality and political worldviews (links to which can be found here). Haidt, a psychologist who has also written extensively on happiness, has argued that both liberals and conservatives place high value on moral and ethical considerations, but that they tend to appeal to different sources of moral significance.

Briefly, Haidt maintains that moral considerations can be divided into five domains, which he describes as: harm/care, fairness/reciprocity, ingroup/loyalty, authority/respect, and purity/sanctity (and he postulates evolutionary roots for each of these). In general meaning these terms are fairly self-explanatory. His central point is that modern ethical thought in the West (which has been the foundation of liberal politics) has focused, disproportionately perhaps, on the first two domains, which pertain to issues of individual autonomy, the well-being of the self, and particularly justice.

According to Haidt, conservative thought does not disregard the domains of harm/care and fairness/reciprocity, but it tends to give equal weight to the other three domains, which relate to the need for collective restraint and clear boundaries of appropriate behavior. For example, political dissent even in tense wartime conditions, which is a basic value of liberalism, is suspect from a conservative point of view due to appeals to loyalty and respect. Liberals and conservatives often cannot agree on a particular issue not because one group is more ethical or even more clear-thinking than the other, but because their moral foundations are different. As a psychologist Haidt is just trying to explain, not to justify; I don't know if he is right, but the categories make intuitive sense to me.

So why would mental health professionals lean toward the harm/care and fairness/reciprocity domains? A possibility that comes to mind is that we tend, on average, to work with people who have been socially marginalized as a result not only of direct illness effects but also of often very powerful social stigma. Autonomy and self-determination are precisely what they struggle with; too little self and not too much (in the true sense of the term) is the issue.

We keep seeing the David half of countless David and Goliath confrontations, so perhaps it is natural for us to be critical of prevailing trends and to stick up for the little guy. Somewhere I read once that the mad are the absolute poor, for they have lost even their minds. And as Myers points out with respect to academia, once a political slant gains ground in a subculture, it often grows more marked with time as members tend to recruit more of their own into the discipline.

Of course, most liberal therapist-types are liberal well before they become therapists. And with respect to the five moral domains, we still have a lot to learn about how people, through whatever vagaries of biology and culture, develop the "courage of their convictions." And these five factors presumably interact with five other factors, those commonly used for psychological profiles (OCEAN: opennness (vs. conventionality); conscientiousness (vs. laxity); extraversion (vs. introversion); agreeability (vs. contentiousness); neuroticism (vs. lack thereof)).

For instance, I have always had a strong aversion to violence, whether toward animals or human beings. What seemed squeamish or even weak to a 13-year-old has become an attribute that I do not apologize for (although I would be a really pathetic Marine). And I have long had a regard for authority that is not, so to speak, excessive. So presumably both psychological and moral factors account for what I do for a living.