This is probably my last post in this blog, unless something truly important comes up. First of all, I am no longer formally authorized to write about psychiatry, because I don't do it anymore; I withdrew from my residency program and thus relieved myself of any and all responsibility.
Secondly, and most importantly, I realized that psychiatry is not an evil in itself, but only a symptom of the malady that the whole Western society seems to be suffering from. To criticize psychiatry without regard to our society's economy, politics, history or ecology is like treating depression without regard to a person's lifestyle, income, diet or love. Such treatment, and such critique, generates a lot of visible 'action' but is in fact pointless and doesn't help.
Besides, there are people who've said everything long ago and with such clarity that I can never hope to achieve. When's the last time you read Orwell's 1984? This book doesn't even mention psychiatry, but it contains everything that there is to understand about it. If you've read and understood this book, I really have nothing else to say to you; and if you haven't understood it, then no amount of my blogging is going to help you anyway.
And remember: Freedom is when you can say that two by two equals four, even if your Party (or your Doctor) claims otherwise. That's all there is to it, really.
Friday, March 27, 2009
Thursday, February 26, 2009
Myth 4. Psychiatric disorders are diseases of the brain.
It is very frequently told to psychiatric patients that the psychiatric disorders are diseases of the physical matter of the brain. It is in fact one of the cornerstone postulates of psychiatry, which allows it to maintain its position as a medical discipline. It takes root in the materialist philosophy which claims that consciousness is a direct product of matter and is therefore rigidly determined by it. No change in consciousness, it is said, can happen without being caused by the corresponding change in matter. Thus, it follows that the cause to any imaginable change or process in consciousness lies in the physical matter of the brain; by manipulating the brain with certain accuracy we can theoretically bring to life any state of consciousness.
It is important to realize, however, that this is no more than a philosophical concept. It may be a nice concept, but it has never been proved. Yes, there have been numerous cases in the history of psychiatry when some or other mental changes were achieved by manipulating the brain; many behavioral disturbances were successfully treated by biological means. One of the most famous examples of the latter is syphilis of the central nervous system, which can cause personality changes, psychosis or depression; a lot of such patients were cured by the newly discovered antibiotics, which reinforced the belief that one day we may find biological substrate of all psychological problems.
This was a generalization, and it still remains the object of rather abstract philosophical belief. We have not observed any physical brain changes in numerous well-shaped psychiatric syndromes, leave alone psychological states, despite years of frantic efforts to find them. Moreover, what we know about the brain physiology in relation to the content of thought, is rough and approximate. In a famous experiment a neurosurgeon caused a patient to hear music by inserting an electrode in a certain part of his brain. Impressed by this report, we tend to forget that, first, it was an accidental finding in this particular patient that would not necessarily work for all of us, and second, no matter where the surgeon would poke, he could not choose what music the patient was hearing. He would not have the faintest idea where to put his electrodes for the patient to suddenly say that two plus two equals eighteen instead of four, and where to move them so he says seventeen. This is not a technological problem; even theoretically couldn't we imagine, which of the brain parameters must be modified to achieve such an effect.
We may find out one day; but as of now to say that we have established and proved a direct causal connection between the brain matter and the consciousness is a grave exaggeration.
Actually, it is quite uncertain that such definite connection exists at all. Perhaps a famous computer analogy will be of use here. What we see on a computer screen depends to some extent on its hardware (processor, memory, monitor, and all kinds of colorful wires), but is not really determined by it. The hardware only provides the possibilities, the general scope of possible actions, but the actions themselves depend on the software as well. The software, on the other hand, is not something "material" in the usual sense of the word. We cannot take a snapshot, a picture, of the software. The code, of course, can be written down on a piece of paper, but in this form it will not work; for it to work, it must dynamically interact with the appropriate hardware in real time. No hardware by itself can determine, for example, what type of images appear on my screen - only whether or not the screen is capable of displaying images in general.
If the computer doesn't work properly, the problem may be either in the hardware, or in the software. Hardware problems must be dealt with by hardware means, whereas software problems by software means. By maintaining, essentially, that all problems are hardware-based, psychiatrists put themselves in an unenviable position of a person reaching for a screwdriver every time his keyboard language is wrong.
It is important to realize, however, that this is no more than a philosophical concept. It may be a nice concept, but it has never been proved. Yes, there have been numerous cases in the history of psychiatry when some or other mental changes were achieved by manipulating the brain; many behavioral disturbances were successfully treated by biological means. One of the most famous examples of the latter is syphilis of the central nervous system, which can cause personality changes, psychosis or depression; a lot of such patients were cured by the newly discovered antibiotics, which reinforced the belief that one day we may find biological substrate of all psychological problems.
This was a generalization, and it still remains the object of rather abstract philosophical belief. We have not observed any physical brain changes in numerous well-shaped psychiatric syndromes, leave alone psychological states, despite years of frantic efforts to find them. Moreover, what we know about the brain physiology in relation to the content of thought, is rough and approximate. In a famous experiment a neurosurgeon caused a patient to hear music by inserting an electrode in a certain part of his brain. Impressed by this report, we tend to forget that, first, it was an accidental finding in this particular patient that would not necessarily work for all of us, and second, no matter where the surgeon would poke, he could not choose what music the patient was hearing. He would not have the faintest idea where to put his electrodes for the patient to suddenly say that two plus two equals eighteen instead of four, and where to move them so he says seventeen. This is not a technological problem; even theoretically couldn't we imagine, which of the brain parameters must be modified to achieve such an effect.
We may find out one day; but as of now to say that we have established and proved a direct causal connection between the brain matter and the consciousness is a grave exaggeration.
Actually, it is quite uncertain that such definite connection exists at all. Perhaps a famous computer analogy will be of use here. What we see on a computer screen depends to some extent on its hardware (processor, memory, monitor, and all kinds of colorful wires), but is not really determined by it. The hardware only provides the possibilities, the general scope of possible actions, but the actions themselves depend on the software as well. The software, on the other hand, is not something "material" in the usual sense of the word. We cannot take a snapshot, a picture, of the software. The code, of course, can be written down on a piece of paper, but in this form it will not work; for it to work, it must dynamically interact with the appropriate hardware in real time. No hardware by itself can determine, for example, what type of images appear on my screen - only whether or not the screen is capable of displaying images in general.
If the computer doesn't work properly, the problem may be either in the hardware, or in the software. Hardware problems must be dealt with by hardware means, whereas software problems by software means. By maintaining, essentially, that all problems are hardware-based, psychiatrists put themselves in an unenviable position of a person reaching for a screwdriver every time his keyboard language is wrong.
Monday, December 1, 2008
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.
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.
Tuesday, November 25, 2008
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…
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…
Thursday, November 13, 2008
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.
Monday, November 10, 2008
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
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.
Wednesday, October 8, 2008
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.
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.
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