A Tragic Mistake

Written 03.04.08

Am I too naive to think that the principal aim of a hospital should be to help its patients? Well, apparently I am, because during the last two years that I have been working at one of the nation’s top psychiatric hospitals, I’ve seen very few examples that would back up this idea. The overwhelming majority of people and procedures employed by the psych hospital have very different objectives, ranging from maximizing the profit to minimizing the effort, and culminating in an all-consuming urge to cover one’s ass. Among the people who genuinely tried to struggle with the system and help the patients, during these two years some have been fired, and some have “gotten used to it”, but no one lasted long. As a matter of fact, I am fairly close to losing my job right now, after an argument with a charge nurse yesterday, during which she tried to din into me that the most important thing for her was not to lose her license. Not that I cared too much, because I had already given the termination notice anyway.

Too many people assume uncritically that if they go to a psychiatric hospital they will get help; even more believe that their children/parents/spouses will be helped if they send them there. This is what all the propaganda is about. But it is a lie. A mental hospital in this day and age is not an institution of help - it is an institution of confinement, much like a jail. It is a place in which kept are people who have not committed a crime but have nonetheless made their relatives or friends very uncomfortable with their being around. This point is so obvious that it doesn’t even need to be proved; just look at all the door locks and security guards in any mental hospital. If this institution was helpful, people would want to be there, and none of this would be needed.

Really, think about all the homeless people, all the battered spouses, all the terrified youngsters going through a psychotic episode, all the misunderstood children and suicidal adults longing for understanding or at least for a pacific place to curl up in the corner and sleep it over. Think about everyone who needs to get away from their environment for a while. If the proclamations of the psychiatric industry had some truth in them, if there really existed a place where they could relax and get help, those people would line up to get into this kind of institution! Obviously, a psychiatric hospital is not such a place, because most of the patients hate it there and struggle to break out. Until, of course, they lose their life drive and become dependent on the system.

Now, this is of course not to imply that the mental hospitals are completely worthless. There are people, and many, out there who are either morbidly stupid or completely out of their minds. They cannot survive in a demanding environment of a today’s city and therefore need to be confined and cared for. But to assume that the same mental hospital is a helpful place for all the able people just going through a difficult time, is a tragic mistake.

People who send their relatives to a psychiatric hospital never find out what actually happens there. Parents are told all kinds of stories about how helpful the place is and how much therapy their children receive. They don’t know that the therapy is heartless and superficial, or that the place is extremely boring and unfriendly. They never see their kids crying and begging a nurse for a breath of fresh air after being indoors for days and weeks, or being dragged to their room on the floor by uncaring strangers. They never observe their kids’ free spirit being broken into submission; if they did, they would not forgive themselves.

If there is only one thing to be remembered out of this whole journal, it is this. Please, don’t put your children and loved ones in a psychiatric hospital for help. Put them there because you want to confine them, get rid of them, forget about them! Put them there because you don’t care, or because you hate them - but not because you love them. Don’t fool yourself thinking that you are doing them good. Because nothing can be farther from the truth.

Mania and Depression

It surprises me that the official psychiatry makes a philosophical distinction between the states of mania and depression, while it is quite obvious to me that the two are one and the same. That is to say, the similarity between them is wide and profound, while the apparent difference is only a superficial nuance.

Let us consider a traffic light as an example. When it is red, it is very different from when it is green. But think about all the forces in background that are responsible for the traffic light operation. The power plant that provides electricity, the cables that conduct it, the engineering of the light bulb, the physics of light and the physiology of vision, as well as the philosophy of the city traffic and its regulation - all are absolutely the same in both states, and what is different is only the position of a small relay on the very surface of the process.

In exactly the same way, both mania and depression stem from one common background force, and the difference is only in the way a person reacts to it. When a big black cloud starts to cover the sky and nothing seems to matter anymore, some people succumb to it and halt all activity; others choose to run away from it in denial, putting on a tremendous buffoonery of omnipotence and invulnerability. Sooner or later they are exhausted and the cloud gets them.

That is why there is depression without mania, but there is never mania without depression. That is why the symptomatic treatment of both is bound to be inefficient. What we have to deal with is the black cloud. And to deal with our patients’, we first have to come to terms with our own…

Best quote from AMIA-2008

"It doesn't mean that our systems are bad, it is just that the combination of systems and practice doesn't work."

No comments.

Defying the Statistics

- What is the chance that you meet a dragon on the street?
- Fifty per cent.
- ???
- Well, either I meet him, or I don't!
A joke

Statistics plays a large part in psychiatry, as in the rest of medicine, because it helps clinicians to make decisions about what is likely to be beneficial or harmful to their patients. Most of the guidelines for physicians are based on the statistically significant conclusions from the clinical trials. The argument goes like this: It has been found that, say 70% of the patients with a certain diagnosis and a particular set of other characteristics (age, race, height, weight, etc.) get better on a medication. Therefore, if you have a patient Ivan Johnson who fits all these characteristics, his chance of benefiting from this medication is seventy per cent, which means he should take it.

Here at the American Medical Informatics Association conference I constantly witness conclusions like this being drawn. They have become basis of medical expert systems and much of medical informatics in general. Yet, I am going to show with one simple example, that this logic is erroneous. It is a case of scientific confusion between the probability of an event observed in many previous experiments, and the ability to correctly predict the result of one next experiment.

Let's not go as far as medical predictions. Let us take the simplest model of probability - a tossed coin. The probability of the heads is 50% - everybody knows that. Indeed, if we toss a coin a billion times, we will probably observe the heads in something very close to 50% of the cases. But that is all it means! You can't go any further in your conclusions! In your ability to predict what the coin will fall next, in your one-billion-and-first experiment, you are as helpless as you were when you'd thrown it for the first time. You simply don't know what it will be - all you can say is that it will be either one or the other.

It is not because the probability is 50% that you don't know. Take an experiment with the chance of outcome A being 90% and the outcome B being 10%. What is the probability of the outcome A in the next experiment? Nine out of ten, very well. But what outcome will the next experiment have? You can't ask this. You don't know. It will be either one or the other.

So what does this nuance mean for the system of psychiatry and health care in general? Not much, because the system operates on statistics, it deals with patients en masse, and therefore the results of multiple experiments correlate well with the predictions based on probability. But it means the world for an individual patient; for you and me.

Even if we forget for a minute that the experiments in which the probability is calculated were not actually done on you and me, but on some other people; even if we forget that the medical outcomes are not binary but multidimensional and unpredictable by their very nature - even then predicting an outcome for a particular patient will be impossible because of the effect I've just described. If 99.99% of the patients like you die in a month without an operation, it doesn't mean that you will also die in a month. The probability of it is high; whether it happens is not known.

I admit of course that with a chance like that you might want to strongly consider the operation; I would probably do the same. However, the majority of psychiatric statistics operates with numbers quite remote from the extremes. People talk about reducing risks from twenty-five to fifteen per cent, of improving the outcome in sixty per cent of the patients versus forty. For the hospital and the insurance company these numbers are big business; for you and me, they are simply meaningless.

Ads removed

I decided to remove the ads from this blog. Due to their contextual nature, they were mostly about promoting various psychiatrists' services, which created a sort of irony that I tolerated for a while. But then it's ridiculous after all.

Now I can proudly say that I have no financial interests whatsoever in discussing my views about psychiatry. :) If you like this blog, however, please donate a comment or two.

Psychiatry needs a user's manual

Psychiatry may be a nice tool, but only if you know how to use it, and whether it is the right tool for your tasks. Unfortunately, modern psychiatry is usually sold to the customers without a user's manual; the patients have to figure everything out by themselves.

As with any powerful tool, such approach is bound to be dangerous. Many a patient have suffered a great deal from psychiatric enterprise, only because they didn't know what to expect from it. Everybody knows how to behave if you're stopped by the police, but very few people seem to have any idea what they ought to do in a psychiatrist's office or a mental hospital.

Will the gene of schizophrenia help you?

So why am I not being too enthusiastic about psychiatric genetics? Why am I not excited by the prospect of uncovering the genetic basis of mental disorders, despite the proponents' claims that it should make diagnosis more reliable and eventually provide avenues for effective treatment?

Because these promises do not sound realistic to me. I have to admit that the question of psychiatric genetics is very interesting academically, and it is also readily funded by both drug companies seeking profit and the government seeking some kind of solution to the overwhelming quantities of mentally disturbed citizens. Still, I find it difficult to buy that genetic advances will benefit the real-world patients, and here is why.

First of all, the genetics of mental disorders is subtle and multifactorial. Therefore, even if some genetic predisposition could be statistically proven, in any concrete individual the environment plays a dominant role in determining whether the disorder will appear. In other words, regardless of whether a particular person possesses the wrong genes or not, his being sick or normal will largely depend on his life situation (which is exactly what we've known for a hundred years).

Let's take an example from oncology. There is a gene called BRCA1 that, if mutant, has been recognized as carrying much higher risk of breast cancer development. Now, in oncology the diagnosis can be made much more accurately than in psychiatry; the genetic association with BRCA1 gene is also simple and straightforward. Nonetheless, oncologists do not usually make predictions about any particular patient; even though the risk may be significantly increased, we still cannot say to the carrier or the mutant gene: "You will have breast cancer", or to the carrier of the normal gene: "You're cool, go home."

Whatever gene associations are found in mental disorders, they will not be enough to make predictions, because the environment plays a major role in the fate of any organism. Hence, we can only afford hunting for genes after we've done everything possible to fix the environment. Talking genetics when there are major problems in people's psychological well-being (look around!) is like cleaning the carburetor when the car's wheels are missing. It could help, but it's not the biggest concern right now.

The second reason why genetics is unlikely to benefit the patients is that psychiatry has a tendency of rushing things into practice as soon as they are discovered (if it can be profitable, of course). It is theoretically possible that genetic discoveries will lead to the creation of the effective treatment for psychiatric disorders, but most likely this simply won't have time to happen. What will happen much sooner is that some type of genetic analysis will be implemented, and people who are at risk will be recommended to take the medications preventively.

This will be catastrophic, because the drugs can make a healthy person sick; so there will be no way of disproving that they were really needed. This will reinforce the sense of scientific correctness, and promote further treatment and propaganda efforts, supported by the drug manufacturers. The tradition of giving drugs to healthy people, mandatory genetic testing of children and adults, and the arising legal battles will change the whole landscape of psychiatry into something entirely different from what we know today.

In the resulting confusion the original goal of the genetic research (to develop treatment) will be postponed, as scientists of the day will concentrate on getting out of the current crisis. And everything will repeat again - only the counter of the innocent victims of psychiatric help will advance by a few tens of millions... but who counts them?

Gene of Schizophrenia?

A recent advance in studying the genetics of schizophrenia is reported in this Nature article.

There are reasons why scientists keep looking vigorously for the genetic basis of psychiatric disorders despite decades of unsuccessful efforts. With such persistence it is likely that some kind of genetic association will finally be found, or at least claimed to be found. Given the computational complexity and sample sizes of the modern genetic studies, many years could pass before the results of any given study could be verified or disproved.

What worries me is that psychiatry has a tradition of trumpeting the first promising results of a new study and rushing them into practice before the results are verified. And the nature of the specialty is such that once something new is implemented, it confuses the picture so much that it becomes impossible to say if the new method was even helpful.

In practice, as soon as some believable hint is received that psychiatric disorders are genetic in nature, and some genetic testing procedures become available, it will make the case for preventive use of psychotropic drugs on people who are "at risk". This makes no scientific sense (I'll explain this point next time, otherwise I'll be late for my train), but this most definitely will be done.

When You See What You Like You Want It - Science Has Proved

"Strong cravings for alcohol can be sparked by the mere sight, smell and taste of a person’s favorite drink,"

- say scientists, who are about to publish their findings in Biological Psychiatry, a prestigious psychiatric journal, as reported by Science Daily article today.

This revolutionary scientific finding has opened our eyes on one of the most interesting aspects of human behavior: when we see something that we like, we start to want it. Turns out, alcoholics can abstain from drinking for a long time, but as soon as they see their favorite drink in an engaging environment (such as their neighborhood bar), their desire to consume the drink increases dramatically.

To discover this curious fact the scientists used the help of the rat behavioral model. They first trained the rats to drink alcohol in a special "bar cage". It isn't mentioned what types of drinks were served, which is one of the shortcomings of the study: after all, the rats' behavior would probably differ if they were offered vodka versus martini or beer (in which case domestic or imported could also make a difference). It was reasonably clear, however, that the rats enjoyed their drinking experience. Then the animals were put into a different cage, and deprived from alcohol. After a certain period of abstinence they were allowed to go back to the bar, and before the scientists knew it they were drinking again like there was no tomorrow.

“This effect is highly detrimental to humans who are trying to abstain from drinking,”

- says lead author Nadia Chaudhri, Ph. D., with the Ernest Gallo Clinic and Research Center at UCSF.

These humans, as her words imply, are hopelessly trapped inside the control centers of their essentially animal bodies that divert them from their chosen path and towards their favorite drink.

To help such unfortunate individuals, the scientists propose to broaden the context of the exposure-based therapies. The experiment has shown that when the drinks were no longer available even at the bar cage, the rats would gradually lose their interest to alcohol, and start to engage in other activities like mating and generally scratching around. Therefore, the alcoholics should, as part of their therapy, visit their favorite bars with the therapist, but - and here the ingenious scientific thought unveils itself - they shouldn't drink anything there.

"These contexts could be real, i.e., visiting bars or liquor stores, could be created using virtual reality techniques, or could simply be recreated by patients as they imagined visiting places that triggered their urges to drink,”

- says John H. Krystal, M.D., Editor of Biological Psychiatry and affiliated with both Yale University School of Medicine and the VA Connecticut Healthcare System.

It is easy to imagine how much this study can change the lives of alcoholics once its results are put into practice. And those of you who are not yet alcoholics (at least not the ones treated by psychiatrists) could also take a lot out of this study. If you know you want something, but shouldn't have it - you must never allow yourself to see it, smell it, or, perish the thought, taste it. Otherwise, your desire may increase. You've been warned!

Behavioral Therapy Doesn't Work Because People Are Not Stupid Enough

Behavioral therapy comes in many flavors, but they all more or less share the same outcome: either the therapy doesn't work, or it works but in such a way that it better didn't.

The reason for this is the basic error of assuming that people are stupid enough. I am not talking about the kind of stupidity that is the opposite of being a Nobel prize winner; but in order for behavioral therapy to work people must be so stupid as to not understand what is going on around them. Otherwise they quickly figure out the rules of the game, and refuse to participate if it gives them too much trouble.

Behavioral therapy is based on clever application of positive and negative stimuli in order to support or eliminate certain types of behavior. A textbook example: if the room is too cold (negative stimulus), the subject will set the thermostat up (desired behavior); thus, without any complicated analysis or dream interpretation business we have achieved the change in behavior, which is all we need after all (right?).

The problems start when we try to reproduce the situation in the real world. In the real world someone needs to go and set that thermostat down first, so as to create the negative stimulus. At this moment the subject, who is not stupid enough, says: "Wait a minute! Why are you doing this? Are you trying to manipulate me?" - and the whole ingenious plan goes down the drain.

Glance through any book on dog training, and then any behavioral therapy manual. You will notice a lot of similarities in approach; sometimes you will find it difficult to remember which book is which. But even being as stupid as a dog is still not enough! Anyone who attempted to train a dog knows that he will play along while he finds it funny; but at some point he will look at you suspiciously: "I thought we were playing, and turns out you're trying your silly methods on me?" From then on, if you persist in your attempts, you will only make the dog angry and put your relationship at risk.

To successfully train a dog, one must somehow convince him that being a good dog can be a lot of fun. You cannot explain it, or manipulate a dog into thinking so. The ability to convey the message is a matter of talent. All good trainers incorporate the principles of behavioral science in their work, but they do it "from within" - unobtrusively and naturally. Simply following a set of rules and methods does not work even with dogs, not to mention human beings.

Sometimes, however, the human beings are smart enough to realize that they have to go through therapy and follow the trainer's instructions. They will not get angry, but instead will play a double game, convincing everybody and themselves that they really don't see the person who enters the room and sets the thermostat down. They trick themselves into being genuinely surprised when the room becomes cold, and allow themselves to act upon the urge to get rid of the negative stimulus and reach the desired behavior. In so doing, they become persuaded that they really improve.

The situation thus grows worse than if there was no therapy at all. The patient now thinks that he is prepared for the life's misfortunes, but it is only an illusion; therefore his vulnerability actually increases. Besides, the long-term consequences of playing an idiot are not well-studied.

Drug Therapy: Does The Easiest Mean The Best?

From a conversation with a psychiatrist one typically gets the impression that the medications are the most powerful tool for treating mental disorders. Yes, you can try therapy, or lifestyle modifications, but if you are dealing with anything serious, the drug treatment is the only thing that has the real power to help.

At least partly, this conviction is based on the practical difficulty to use alternative treatments. For example, good psychotherapy exists but is hard to find and expensive; life style is possible to modify, but it requires significant time and energy invested into patient education and follow-up. Some patients cannot use these treatments even if they want to, because their mental disturbances result in the inability to understand and follow complex directions. The lifestyle modifications may be unattainable for economic or social reasons: someone whose entire family of nine lives in a one-bedroom apartment might want to modify his lifestyle, but be unable to do so.

A pill is certainly the easiest means of treatment, whether or not the most helpful. It can be used in any circumstances and by people of any economic, educational or social background. It is therefore true that medication therapy may be usable in cases when other types of treatment may not; however, any further implications about efficacy are much harder to prove.

Taking Medication Is Voluntary

Taking a psychiatric medication is a voluntary act. Unless you are brought to a psychiatric hospital by ambulance, or suspected of being a possible danger to yourself or others, or not obeying the directions of hospital personnel, or hallucinating, or not agreeing to take the drugs voluntarily for too long when the doctor deems it necessary, you cannot be given a medication against your will.

Don’t Talk About It! Do It!

(re-posted from my old blog, skpsycho.wordpress.com)

In response to the critique of the psychiatric medications, many people try to discredit the effectiveness of psychotherapy. In math this is called ex adverso, or proof by contradiction; when one is unable to prove his rightness, he tries instead to prove that his opponent is wrong. But in math this approach is used very carefully, and only with two mutually exclusive hypotheses. In psychiatry, as in politics, the presumed mutual exclusiveness of the poles is only an illusion, a classic “choice without choice”. If you’re asked to choose between a coffee from McDonalds and from Dunkin Donuts, then you’re screwed if what you really wanted was a good coffee, or a tea, or if, for that matter, you were not thirsty at all.

Notwithstanding the bias behind the statement, if someone says to me that psychotherapy doesn’t work, I will probably agree. Because the person saying so is most likely referring to the classic American understanding of psychotherapy: “talk therapy.” It is just what it says: two people talk about the problems of one of them. I carry no illusions about such therapy, in part for reasons that I have discussed elsewhere. In my opinion, the majority of people who benefit from talk therapy belong to one of the two categories: those whose problems are so insignificant that they can be helped by a sincere conversation with any intelligent being (and they should really go talk to their friends instead), and those who don’t want to change anything in their life and prefer to use the therapist as a kind of garbage can for their perpetually accumulating waste.

Fundamentally, all that the stereotypical talk therapy can do is generate new words. It allows the client to verbalize his feelings, give coherent definitions to his problems, and re-formulate his “wrong” principles in a different way. If the therapy is successful, the client can gain insight (which is learn to describe his internal happenings in words), reach new understanding (which is improve the wordings of his personal law-book of life) and, hopefully, achieve the improvement (which is also a word).

The whole system is based on a presumption that if you say the right words, the right doings will follow. But the universe doesn’t quite work this way. The acknowledgment of your sins by itself doesn’t cure those who suffer from them, nor does it teach you to live your life differently. To define and describe yourself as kind and balanced a person is not quite the same as to become one in reality; no more so then proclaiming yourself a violinist teaches you to play.

In fact, it works in exactly the opposite way. The more you talk, the less you’re able to do. Moreover, filling your head with the nicely-formulated verbal solutions to your problems discourages you from seeking the real, nonverbal solutions. Planning the future prevents you from perceiving the present. Conceptualizing your experiences spoils all the fun. Producing the more and more elaborate descriptions of your life leaves you no time to actually live it.

Good therapy, therefore, should be more like teaching, or coaching; the art being taught, the art of living. A good coach, does not talk much with his students; his role is to motivate them and gently correct their mistakes while they practise, practise, and practise. There’s no point in having conversations about the art of swimming; one simply needs to get into the water, and swim until he does it well. It may help to have a responsible adult nearby at first to save you if you lose control; but once you’re resuscitated, there’s no need to discuss it for too long - simply jump into the water and try again. The danger of talking about it too much is that eventually you may become completely convinced that you are capable of swimming. With this conviction under your belt you will proudly drown in the first real river on your way.

Don’t talk about it! Do it. Don’t verbalize your feelings; feel them. Don’t acknowledge that you’re bad; become good. Don’t apologize; start behaving differently. Don’t thank; accept. Don’t seek the correct definitions; definition is just a word.

If you don’t have a Zen master nearby as you’re reading this, take something heavy from your desk and, without saying what it is, hit yourself on your head.

Nine Reasons Why Psychiatrists Believe In Drugs

It is very tempting sometimes to blame the evil psychiatrists for everything, as if they were in some kind of conspiracy against the rest of us. It is obvious, however, that such a large and diverse group of people cannot maintain any conspiracy for long. Besides, many psychiatrists I've seen are very nice people.

Of course there are financial "incentives," but they would not mean much if the doctors did not really believe that their drugs work.

I've been trying to think of the reasons why they believe it. It looks like the practice of a typical psychiatrist is organized in such a way that the more medications he prescribes, the more convinced he becomes in their helpfulness - sometimes in spite of his own logic and common sense. It is a classic self-reinforcing loop, and drug prescription almost becomes a bad habit.

Once you start prescribing drugs, you are practically doomed to continue, unless something causes you to strongly suspect that something is not right, and make a forceful effort to break out of the vicious circle. (Incidentally, this is probably the moment when the financial incentives play a major role, as the sudden exacerbations of suspiciousness in a psychiatrist are soothed by the large doses of cash.)

So far I have though of nine mechanisms of the erroneous self-reinforcement that the psychiatrists fall prey to.

1. Placebo response.
2. Lack of control group.
3. "Could be worse" logic.
4. Selective memory.
5. Selective interpretation.
6. Short-term efficacy of drugs.
7. Long-term dependence on drugs.
8. Lying to psychiatrists.
9. Attributing success to drugs instead of doctors.

I will discuss each one in more detail in the following posts.

Psychiatry Critique and Antipsychiatry

I would like to make myself clear: I am not an antipsychiatrist.

The easiest way to change your point of view is by changing its sign to create the opposite. In this manner, religion is converted into atheism, love into hatred, promiscuity into puritanism, and psychiatry into antipsychiatry. Although the result is as far from the origin as possible, the similarity between the two points of view is still apparent.

An atheist spends as much time and effort as a preacher thinking about God, only trying to prove His non-existence instead of existence. An antipsychiatrist still limits his thinking to the arguments of psychiatry, only trying to prove them wrong. And all of these people remain rigidly faithful to their points of view.

I don't know if psychiatry - in general - is good or bad. I think that psychiatry could be used to help people. I think it could be one of the most humane and rewarding professions. This is why I had become a psychiatrist (I wouldn't like to practice in the United States today, but that's another story). I am fascinated by the works of Jung, Assagioli, Laing and others who took the art of psychiatry one step further, from simply "fixing" people to fit the social average, to helping them achieve self-realization and spiritual growth.

This said, I can't help noticing that today psychiatry in America is practiced in a very strange fashion. It is no longer art, but science. It is not uncommon to meet a psychiatrist who knows a lot about biology and chemistry but has no idea how to talk to people. (You wouldn't go to a concert where the musicians know all about the physics of sound and theory of composition, but cannot actually play, would you? What if they had shown you their certificates?)

People are being lied to or confused on every step of the way. Every first-time patient that I saw at the hospital was convinced that since he had signed in voluntarily, he may leave at any moment - which was of course not the case. People are distracted from solving their real-life problems by the unnecessary talks of genetics and chemical imbalance. People are told that the prognosis of schizophrenia is better with drug treatment, but it is not proven. People are told that what matters is the symptoms, and not the cause of their depression, but it is ridiculous. They are told that modern drugs are safer than the older ones, but it is a lie. They are told that the drugs are scientifically proven to work, but it is a mystification.

At the same time, most of the doctors are very nice people, and they really believe that what they do is good. I don't know how that happens, but I see that for some reason many professionals have adopted rather simplistic and superficial views of human nature, reducing it to mere behavior, and refusing to understand its depths. I have seen psychiatrists making a diagnosis of schizophrenia and prescribing a drug to the patients complaining of hearing voices, without even so much as asking what those voices were saying. They are simply not interested - and with good reason: the drug that they prescribe will still be the same.

I am not even going to mention here the enormous financial pressures that psychiatry now has to endure. It is a subject for a long discussion.

To sum it all up: psychiatry in general is not good or bad per se, but at this point of its development in America it seems to be hurting more people than it helps, while proclaiming the opposite. Thus, although psychiatry may be helpful to some people, in dealing with it a healthy degree of skepticism and common sense needs to be maintained.

History of Hysteria

There is a little exhibition in the library today, and one of the images is the famous linotype depicting Charcot's lecture on hysteria. This picture almost requires no comments.

You could accuse me of imagining things, as in the famous anecdote. A psychiatrist shows some pictures to the patient, of simple geometric figures, and asks to interpret them. About a triangle the patient says: "It is a tent where they are having sex," and about a square: "It is a dark room where they are having sex". After a while the patient looks suspiciously at the doctor and asks: "Doctor, but where have you got such nasty pictures from?"

Risking to look like this patient, I nonetheless dare ask: Could you deny that this image of Charcot and colleagues treating a young hysteric woman is profoundly sexual? And sexual not in a natural way, but in a way that masks the natural urges behind the facade of scientific interest. Just think of all these bearded men scratching their chins and going: "Um... Hmm... This is a truly remarkable case! Very exotic and stimulating!", as they think about their future practice, in which they will be now scientifically approved to spend hours talking to young ladies about all the intricate details of their sexual lives.

In a society where sexuality was suppressed, and hard to practice especially by the men of education and social status, the discoveries of Charcot, and his student Freud, provided a very nice avenue for the sublimation of sexual desires - a process that Freud himself attributed to his hysteric patients. It created a way to practice "intellectual sex" - by talking about it - which was safer, and to some people more enjoyable, than the natural one. The diagnosis of hysteria, once coined, was destined to prosper.

From this does NOT follow that since the reality of hysteria is questioned, hence the modern biological views are more correct. Of course not. The binary logic "hysteria versus genetics," or "neurosis versus psychosis" is artificial and arbitrary. The defeat of the one does not mean the victory of the other; instead each one needs to be proved or disproved separately.

In fact, the two points of view are rather alike than different. The modern views are a continuation of the general direction of understanding the human issues by way of framing them into medical diagnoses. First there was hysteria, then schizophrenia, then depression, then homosexuality, then PTSD and so on. I am not saying with affirmation that each of the diagnoses was artificially invented - I don't know. The fact is, however, that each of them kept, and continues to keep, many influential people busy and satisfied.

Software Problems

When your text processor displays the wrong font size, you don't typically reach for a screwdriver to look for a problem in the hardware of your computer. The software is not directly caused by the hardware, although there is certainly a relationship between them. This relationship, however, is of a remote, abstract, and dynamic nature.

Psychiatrists deal with even less clear objects than computer scientists do. Yet they usually disregard the abstractness of the connection between the brain and the mind, and treat it in a straightforward fashion.

Take the neurotransmitters idea as an example. Saying that a mental disease is caused by too much neurotransmitter is like saying that your incorrect font size is caused by too much electricity. While true in some sense, it has little practical significance. Neurotransmitters are too simple molecules to be anything more than local electrochemical signals. And it is not the amount of signals that is the problem, but their dynamic distribution patterns. Simply modifying the level of a neurotransmitter in the brain makes as much sense as plugging a computer to 220 volts outlet instead of 110 and hoping for the best.

An Excellent Piece Of Writing

I have found this as a comment to this article on the alternet.org portal. There was no link to the comment itself, and it was buried under the pile of other comments, so I decided to re-post it here in its entirety. It is really an excellent piece of writing.

Quote:

Human progress is not a given consequence of new technology.

Posted by: Coleman on Jun 18, 2008 8:29 AM

Fifty years ago social scientists were writing utopian pamphlets wondering what ordinary folks were going to do with all their free time. The buzzword of the day was "automation." With modern machines, it took fewer and fewer people to reproduce the conditions necessary for the current standard of living. For example only a very small percentage of the population is engaged in agriculture, yet industrialized nations consistently yield food surpluses.

However, as we all know, the surpluses in agriculture, like every other commodity, are scandalously squandered while many go hungry. At every point in our system there is waste, from the excess restaurant food scraped off plates into the trash, to the most high-tech industrial processes which are - again, scandalously - devoted to producing the latest electronic trifles. This very act of wasting may be inherent in our notion of the "good life". And even if you don't agree with that, it's certainly central to the functioning of capitalism.

People who don't like work, or school, or cops, or the job options of their ghetto, people who are bored, people who don't identify with chauvinistic sexuality, people who are bad at performing their correct social roles are, by definition, a problem. They're a contradiction. They know, deep down, that nearly everything our society celebrates and champions - cutthroat competition, narrow and artificial standards of beauty, "efficiency" (the most Orwellian of popular terms) - are bankrupt notions emptied of their meaning.

However, as the aspiring social worker pointed out above, even with the best intentions (like becoming a social worker!), it is increasingly difficult to escape. The age-old social injunction to "get with the program," has always been delivered by parents, schools, judicial authorities, etc. Now, all of these entities have the option to medicate their subjects and abort the self-reflection and growth that comes with the individual negotiating her place in the world. It proves to be far cheaper, but like most cost-cutting, it might be fatally short-sighted.

The great irony is that a largely drugged populace may prove to be devoid of the dynamism and struggle that enabled the progressive aspects of capitalism in the first place. The bourgeoisie myth of the free, rebellious, maverick individual who flees his home and makes his own way seems is not only a relic of another time, but in the advanced capitalist nations is physically impossible. There is nowhere unthreatened by the great Sameness of our dumbed-down discourse, of our distracted and alienated corporate culture. There is nowhere to flee where you won't be trespassing.

Which is not to say that we shouldn't have anti-psychotic drugs or automation. Clearly we want these things, to some extent. And it is also not the case that we shouldn't have universal symbols for "get food here" or "get computers here", which is the benevolent aspect of easily recognized brands. The question is, as always, who is in control? Is their claim to rule legitimate? And why do they need to put so many people in jail? And why do they need to put so many people on drugs? And why are our schools like prisons, too? And why, if my job is unnecessary to life on earth, indeed, if my job is wasteful and thus detrimental to life on earth, why, then, do I work so hard?

Prozac As Good As Placebo

In a PLoS Medicine article, a British professor Irving Kirsch and his colleagues have reported that the antidepressant drugs like Prozac are not more efficient then placebo in the treatment of depression.

The authors have gained access to, and analyzed the data from the unpublished trials of these medications.

Even before that, according to the most optimistic data from the published studies, the drug and placebo response rates were around 50% and 40% respectively. Now when the unpublished studies are taken into account, it turns out (perhaps not surprisingly) that the drug-placebo difference is almost non-existent.

A Guardian article comments on this more extensively, and describes some drug producers's reaction to these findings.

To Become Or Not To Become

Martin says I must become a psychiatrist precisely because I understand so much about how the enterprise really works - so I could help many people. This makes a lot of sense, but to me it's still not very convincing. It is a bit like recommending someone who understands everything about politics to go ahead and become a politician. A layman has the luxury to be optimistic; when you know the organization well enough, you may also know that it cannot be changed.

What Is Good For America...

American psychiatry is a product of the American culture. No one here claims that it is perfect; instead, everybody is ready to recognize its weaknesses and give convincing explanation as to why things are as they are.

The problems start when the American psychiatry is being exported to, and aggressively promoted in different cultures. There, its cultural bias becomes apparent, and creates all sorts of misunderstandings.

No Test Required

Another interesting point that Mr. Jeff Griffin makes in the interview I mentioned yesterday is that psychiatrists do not have to use any objective medical tests in order to make a diagnosis or prescribe a medication.

Some tests have been developed, and are even used in clinic and in research. All these tests consist of questions and answers. They are not, strictly speaking, objective. What they provide is a quantative scale. The result of such a test is usually a number, that the researchers can compare with other numbers received from other research. Yet, this number still depends on the subject's ability to understand the question, willingness to answer it truthfully, as well as the interviewer's manner of gathering the information.

So, these tests are subjective, if convenient for comparative measuring. Yet, even they are not required in clinical practice. A subjective judgment of a psychiatrist alone is still enough to detain someone in a psychiatric hospital, label him with a diagnosis and give him medications agains his will. Strange as it is, this is the law.

Nine Million Time-Bombs

In a television interview Jeff Griffin, the Executive Director for the Western U.S. of the Citizens Commission on Human Rights, talks about some of the problems that our society faces in connection with the expanding power of the psychiatric industry.

This interview shares the common problem of nearly all critics of psychiatry: the extreme persuasion and bitterness. They lash out the abuses of psychiatry, and call it all kinds of bad names. It is perhaps not surprising. Anyone who spent some time uncovering psychiatry's dark secrets would probably become bitter in the process; but while their words may be correct, their very tone of voice and style of speech stand in the way of accepting their arguments. The listener can't help thinking that maybe all this is just another political game.

Nevertheless, Mr. Griffin, who has been fighting psychiatry for many years, mentions some extremely important points in this interview. One of them is the 9 million children who currently take one or more psychotropic medication.

He calls them "9 million time-bombs" and explains that in nearly every single case of school shooting or other mass-murders made by children one or another psychiatric drug was involved. The interview was apparently filmed before the Virginia Tech; I happened to watch the news on the day when it happened, and the reporters mentioned several times that the guy had been taking psychiatric drugs, although this information was not mentioned again in the subsequent media coverage.

We have never before given so much drugs to children as during the last decade; the drugs that are capable of causing restlessness and homicidal ideas, particularly in the withdrawal period. We have yet to find out what these kids will be like when they grow up. With the economic crisis that the US and its health-care system is facing, many of the people taking one or more psychotropic drugs will be forced to go into withdrawal. Jeff Griffin is right to be concerned.

Financial Side of Children's Bipolar Disorder

In a New York Times article it is reported that several world-famous Harvard psychiatrists have failed to disclose the bigger part of their income received from pharmaceutical companies for the last 7 years.

The research activity of these psychiatrists during this time has influenced the public and professional opinion on the problem of bipolar disorder in children and adolescents, as well as the patterns of drug prescription to the younger patients. Largely as a result of their studies it is now an accepted norm to prescribe atypical antipsychotic medications to children, for the treatment of bipolar disorder. It turns out that those studies were de facto funded by the pharmaceutical companies that produce the drugs in question.

The concept of pediatric bipolar disorder is controversial in itself, because a lot of symptoms that allow for this diagnosis (mood swings, rebellious behavior, sadness, appetite loss, problems in communication with peers, et cetera) may just as well be regarded as normal stages of child or teenager's development.

The credibility of the Harvard psychiatrists's research is questioned, but it is too late: the idea that children can be diagnosed with bipolar disorder and given antipsychotics has spread around the world. It will take years, and many thousands of children, to revert this trend.

Craft Addicts

A recent article describes a psychiatrist who've discovered yet another new psychiatric disorder: pathological computer gaming.

He maintains that playing computer games feels more shameful to adults who suffer from this problem than if they were watching porn, because porn is a socially accepted pastime for adults, while gaming is "for kids".

The inception of pathological computer gaming is an evidence of the continuing expansion of the list of mental disorders, and the desire of any psychiatrist to find a nice "niche" for his services. The doctor talks about singular cases of people who are distressed because they spend 15 hours a day at their computers playing games, and who forget to shower and use the toilet in the process.

His ideas, however, may be applied too loosely (as it happened with many other psychiatric ideas), and we may eventually start treating people who spend a lot of time in front of their computers simply because this is "wrong", without regard to whether they have a problem with it, or actually like it.

We also must not forget that a significant part of the "addiction" to computers, like any other addiction, lies in the inability of the society to provide a person with anything more meaningful to do. The alternative for a pathological gamer would be to immerse himself into the battles with colleagues and bosses in the office, instead of the battles with orks and goblins on the unknown planets. Exactly why is one better than the other?

Depression Meds

There was a guy at a party the other day, who worked for a pharmaceutical company. He said: "Imagine that! They try to sue our company claiming that one of its medications for depression causes suicides. I mean, how stupid is that? They are already depressive, we try to help them, and then they sue us!"

A very nice interpretation, I thought. He had a PhD, and he didn't have a clue. I wonder, do at least the CEOs of the pharmaceutical companies know what they are doing?

First Post

Today I am starting my new blog, which I am determined to update daily. In this blog I will share my thoughts and observations related to the way psychiatry is practised in the United States.

The contents of this blog do not necessarily represent the author's opinion.