Is Psychiatry Like Acupuncture?

As I've discussed a few times here, this is the worst of times for antidepressants and other psychiatric medications; considering questionable efficacy and likely side effects, their popular esteem is at a low ebb. This makes them...a great deal like various alternative medicine treatments that remain highly popular and widely used (and paid for) despite the disdain of evidence-based medical critics.

In The Atlantic David H. Freedman discusses the persistent popularity of alternative medicine and its unlikely cohabitation with conventional research even at the Mayo Clinic and other hallowed institutions. He points out that while medicine made its reputation in the first half of the twentieth century with the significant (if not complete) conquest of infectious disease, its efforts to extend its domain to the kinds of chronic diseases that plague us today (diabetes, heart disease, cancer, Alzheimer's disease) have been frankly disappointing. What, exactly, has medicine done for us lately?

Psychotherapy and psychiatric medication have been targets of critical and cultural derision on the part of many for decades, yet millions of patients seem to derive some kind of healing experience from the pill or the couch, as the case (and the personal inclination) may be. The same could be said of the masses flocking to chiropractors, homeopaths, and, yes, acupuncturists in defiance of the conventional medical wisdom. We spend years in medical school learning about physiology, when practically speaking, healing arguably has more to do with constructing a healing ritual than with one's board scores. The "chemical imbalance," absurdly oversimplified though we hold it to be, may be like the acupuncturist's "lines of force," a necessary if fictional semantic scaffold on which to mount a clinical encounter. The shaman lives!

History of a Suicide

"I perceive I have not really understood any thing, not a single object, and
that no man ever can,
Nature here in sight of the sea taking advantage of me to dart upon me and
sting me,
Because I have dared to open my mouth to sing at all."

Walt Whitman


In puzzling over an unexpected suicide (and how many suicides are not, at some level, surprises?), we often ask empirical questions, as a detective might. How did this come about? Who or what is the primary culprit? But arguably the challenges suicide poses are chiefly existential and interpersonal, not factual. That is, the suicide, in rejecting life itself, dissents from values that we hold very dear.

And the question of "How could we not have known?" is more relational than epistemological. That is, suicide reminds us of the perturbing basic inscrutability of human relationships. If we do not know something so basic as whether someone is suicidal, what do we really know about them? That's why psychotherapeutic relationships can be the most intimate of all--not obviously in a physical sense, but in an existential one. The therapist often hears things that no one else in a person's life hears.

I just finished Jill Bialosky's History of a Suicide, which considers the suicide of her younger sister Kim some twenty years ago at the age of 21. It is a worthwhile and reflective addition to the suicide memoir shelf, but Bialosky is, like many, preoccupied with questions of causation. The problem is that completed suicide is complex and rare (relative to the numbers of the depressed); why would we expect suicide to be any more fathomable or predictable than other atypical behaviors, such as murder or sudden religious conversion? If we had the technology or insight to predict individual suicides, what other behaviors might we be able to foretell?

Bialosky seeks out a suicide specialist who tellingly conducts a "psychological autopsy," as if we can answer the dilemma of suicide using the tools of pathology. Unsurprisingly, a number of potential contributing factors come to light: a family history of mental illness and even suicide, a father who abandoned the family and ignored or rejected Kim, a depressed and withdrawn mother, an abusive boyfriend, and alcohol and drugs. This list is noteworthy for its obviousness and for the fact that every one of these things is objectionable in its own right even apart from any possible relation to suicide. The things we might do to reduce suicide risk--maintain family integrity, shore up communities, limit drug use, and increase awareness and treatment of depression--are things that we ought to be doing anyway. These influences ultimately tell us nothing, because we do not know which is necessary or sufficient.

The other thing that suicide teaches is how little we sometimes know of ourselves. It appears that a certain fraction of suicides, at least the final determination to act, are impulsive. If we could interview completed suicides after the fact, I suspect that a significant number would express surprise, if not dismay, that they actually went through with it.

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.

Who Needs Narrative?

Arguing for the psychological uses of narrative, Bill Benzon at The Valve distinguishes the "autobiographical self" (i.e. identity over time) from the "core self" (i.e. one's integrated psycho-physiological state at any given time). He claims that the "core self," influenced as it may be by intense situational and physical factors (he uses hunger and sexual desire as examples), not to mention its transient nature, threatens to disrupt the autobiographical self. He suggests that narrative (he specifically mentions "play-acting" and "storytelling") usefully provides an overarching frame within which to understand and evaluate our dispositions and behaviors over time.

The account leaves out a lot of course (for instance, it would seem that temperament straddles both kinds of self). And his case seems a bit extreme--as if even a starving man would look back on his life as having been little more than an ultimately unsuccessful quest for food--but there may be something to it. After all, someone in a deep depression may view much of his past "through a glass darkly" in a way that lightens considerably when the episode relents. And obviously the two selves affect each other reciprocally and continuously.

Staying with Benzon's schema, it would seem that psychological distress occurs in two varieties. Unhappiness is a malady of the autobiographical self, a dismayed sense that one's story has somehow gone awry through vicisitudes of sensibility or circumstance. One seeks in a therapist a kind of narrative catalyst that will open up unimagined possibilities, including the often profound possibility of actually being listened to and perhaps even understood. Dysfunction of the core self manifests as symptoms that may actively impede functioning. There is considerable overlap between the two, but arguably we resort to psychotropic medication inasmuch as symptoms appear to be beyond the power of narrative to reframe. But nothing is more frustrating than to try to treat unhappiness with meds or to tackle narrative-resistant symptoms with more narrative. Diagnostic confusions and controversies arise from the difficulty of distinguishing symptoms from unhappiness.

It occurs to me that like certain other phenomena such as religion and even music, narrative broadly considered (that is, interest in all stories whether contained in books, film, gossip, or hearsay) is hard to explain because it is very widespread but not truly universal. Some faculties, such as hunger and thirst, are obviously ubiquitous because their absence is not compatible with life. Others, such as basic senses or sexuality, are not imperative for individual life but are so typical of the species that their absence is uncontroversially deemed pathological.

Inasmuch as existence is necessarily temporal, some interest in narrative is presupposed, even if only speculation as to where the next meal will come from. But sophisticated narrative--that is, at least at the level of communal folk tales--has, like religion, been found to exist in virtually every human society. And yet just as there is a reliable minority of individuals who are irreligious, there are of course people here and there who are relatively free of the narrative bug, who may be more invested in other domains of experience (facts, ideas, bodily experience, etc.). If religion and narrative truly are central to (individual and species) human identity, then how is it that even a (non-pathological) small minority more or less escape their purview? Perhaps diversity itself is such a powerful evolutionary engine that it constantly throws out alternatives to the prevailing cultural trajectory, suggesting of course that those faculties we view as indispensable are actually contingent.

Human Experience

"(We) occupy landscapes of values--worlds made up not of quantum lattice structures, but of opportunities and obstacles, affordances and hindrances."

Alva Noe

The full 13.7 post is here and worth reading.

I think that this, the sensation of swimming in a sea of significance(s), whether noxious or gratifying, is a major reason I wound up a psychiatrist. It is no wonder that our species yields paranoids and creates deities to worship. We do not generally perceive the universe as what it would be without us--that is, a constellation of infinite facts--but rather as a shifting drama of desire and revulsion, of affirmation and repudiation.

You (Don't) Say It's Your Birthday

Happy birthday, Bob.


Alex Ross posted some favorite lines.


There is something about Dylan--the musician, the poet, the cryptic cultural figure-- that is gratuitously compelling. If grace were to exist, it would feel something like listening to Dylan, to that "thin wild mercury sound" of 45 years ago.


It seems miraculous that he is still alive, both literally and figuratively.


Favorite line? At random:


"Well, the comic book and me, just us, we caught the bus"

Postscript

One more thing. I ended a bit abruptly a month ago, yet I recently came across two links that encapsulate the blog's preoccupations so fittingly that I cannot resist tying this last speculative bow.

The Wittgenstein scholar Peter Hacker explains that philosophy, unlike science, does not add to our knowledge of reality; rather, it examines the conceptual schemas through which we consider reality. Formal science is extremely successful in the relatively narrow task of documenting external reality, and it brooks no competitors; but arguably everything we most care about exists outside of science's purview. I particularly liked his comment that science yields an aggregate of facts that can be transmitted from generation to generation as a kind of epistemological bolus, whereas philosophy--like the arts--must be perpetually recreated.

Hacker also assails the prevailing scientistic fetish for neuroscience, arguing that from the point of view of real human priorities, it is the unified human agent that counts, not his or her brain and its myriad parts. "My amygdala made me do it" is not so different from "My soul made me do it." The moral self must take ownership of its concepts and its actions, not hide from them by ascribing them to the brain. Neuroscience may increasingly give us the capability to tinker more viscerally with our own experience, but this is nothing but the means to an ever debatable end. Science is nothing but a method, and one which can never identify the life most worth living. The latter can only be arrived at biographically and culturally, through lived experience, dialogue, and contingency. Everything that is not a fact exists in the vast penumbra of narrative.

Andy Martin looks at the overlap of autism and philosophy, arguing that both phenomena (endeavors? conditions?) involve a basic inability, or perhaps unwillingness, to fathom seemingly transparent communications. He suggests a tension between a philosophy that seeks to eradicate or solve conceptual confusions and one that accepts their inevitability. The latter is what always drew me to philosophy and to literature, which to me constitute the infinite project of outlining and marveling at the fundamental riddles of (inter)subjective experience. Consciousness is interesting not despite, but precisely because, imperfect understanding cannot be avoided. A philosophy or a science that proposes to eliminate conundrums is oppressive and must be resisted; a refusal to fully understand or be understood is a kind of assertion of freedom.

However, philosophy should not be sheer mystification. Language is the most powerful tool ever devised, and as such it can never be totally under our control; to some degree it always has a life of its own. Its spontaneous complexity is luxuriant and life-giving, as I have said, but it is well-known that metaphors can become stifling vines threatening to choke off light and space. Philosophy is fundamentally a linguistic pruning operation, lopping off conceptual excresences that threaten our narrative well-being.

Philosophical, that is, moral and aesthetic truths can never be as unambiguous as scientific ones, but they achieve a certain pragmatic objectivity because, well, human beings are so constituted that we need certain standards that are not lightly or trivially modifiable. Where does psychology fit? Like medicine, psychology derives from science a sense of realistic empirical boundaries of what may be technically achieved, but its aims must arise through personal and cultural narrative philosophy.

And that really is all I have to say for now.