I don’t avoid reading opinions strongly critical of psychiatry. They help sharpen my reasoning skills. It’s always possible they might alter my views in some way. And like most everyone, I consider myself openminded and receptive to criticism. However, after years of reading Thomas Szasz, Robert Whitaker, and the screeds of the less articulate, after perusing the leaflets and poster displays of the protesters at APA conferences, I’ve heard most of the arguments by now. I rarely engage with such harsh critics. As I’ve written elsewhere, there has to be a shared foundation, some agreed-upon axioms, for a dialog to take place. Otherwise it’s just a shouting match.
My own views are pretty stable at this point. I’m critical of many aspects of psychiatry: I blog about sloppy thinking in the field, the limitations of DSM nosology, the overuse of pharmaceuticals. I teach psychiatry residents to think psychologically and how to practice ethically. But unlike anti-psychiatrists, I don’t consider psychiatry a hoax or an evil injustice. If I did, I’d find another career. And while it isn’t hard to cite cases of psychiatric mismanagement, it’s a good deal easier to cite cases of psychiatric benefit. We help people far more than we harm them. Truth be told, I’m proud to be a psychiatrist. If I wasn’t, I’d do something else.
Philip Hickey PhD is a retired psychologist who blogs on behaviorism and mental health. His articles are reposted on Mad in America, a popular website created by Whitaker that is highly critical of psychiatry. Dr. Hickey wrote a lengthy critique of my December 12 post on whether psychiatric disorders are brain diseases. I considered replying in the comments section on MIA, but the anti-psychiatric echo chamber there assures it would fall on deaf ears. So instead I’ll follow up here.
In composing my last post I was more concerned about slamming luminaries in my field than worrying about how anti-psychiatrists might react. The piece, after all, is critical of language by prominent psychiatrists. Consequently, I granted that schizophrenia and several other named disorders look primarily biological in nature, even though this hasn’t been proven. Dr. Hickey agrees with me on first impressions, which was all I was claiming. However, he then goes to great lengths to refute this rather trivial bone I threw to the biological psychiatrists. I could now respond to each objection point by point — schizophrenia does affect a diverse array of mental functions, not merely the few in the DSM criteria; neuroanatomical changes go well beyond mere “brain shrinkage”. But why bother? I’m not here to argue for the biological foundations of schizophrenia. Indeed, doing so too well weakens the main point of my prior post. Note the insidious dynamic: confronted by someone so “anti” I’m called upon to be more “pro,” even though this serves neither of us.
I also predicted, without offering much in the way of argument, that a few severe psychiatric conditions will eventually be shown to have biological causes. Dr. Hickey vehemently disagrees, and holds that behaviorism and learning theory account for these conditions. That’s wildly implausible, but no matter. The truth is, no one really knows.
Dr. Hickey wanders into the weeds of DSM diagnosis and labeling, a topic I didn’t address at all, other than to use the common terms for psychiatric maladies. I don’t object to cautious circumlocutions like “feelings and behaviors currently lumped under the controversial label ‘schizophrenia’.” It just takes longer to write. Whether schizophrenia is one disease or many (or not a disease at all), whether the DSM criteria are valid or way off-base, whether some of the features called schizophrenia are actually iatrogenic — none of this matters for my argument. The point remains that the clinical presentation we call schizophrenia looks like biological dysfunction even though its etiology remains unknown.
Dr. Hickey took pains to explain in great detail the limitations of reductionist thinking, how new properties emerge at higher levels of organization, and how it is a category error to refer, say, to psychology at a molecular level. This is because I misspoke in trying to convey the reductionist viewpoint. I wrote that, in theory, “all psychopathology can be reduced to aberrant electrochemical events, i.e. brain disease.” That’s not true; a learned phobia is a ready counterexample. It’s particularly unfortunate that I made this mistake, as it confirms the worst fears of those who believe we psychiatrists are mired in primitive reductionism. Actually, Dr. Hickey and I agree here.
Now having said that, although some psychopathology arises solely psychologically, it’s also common for genetics or biochemistry to underlie aberrant psychological functioning. This is the case for the many known diseases such as brain tumors, neurosyphilis, and lead poisoning that were once wrongly thought to be purely psychological (or demonic). There is no reason to assume that all such discoveries are behind us. Rather than digging one’s heels into radical behaviorism, radical neurobiology, or radical something-else, isn’t it more honest simply to say we don’t know what the future will reveal?
I’ll end by noting that anti-psychiatrists object to any pathologizing of behavior as stigmatizing and dehumanizing. Unfortunately, it’s inevitable, and not just by psychiatrists. Paranoid psychosis — a behavioral description, not a diagnosis — may result from drugs, sleep deprivation, brain tumors, or extreme stress. Whatever the cause it’s still an unpleasant, dysfunctional state that differs markedly from the usual way human minds work. We can choose new, less stigmatizing names for such states, but we will never give up describing ourselves and others in value-laden terms. The conditions we call mental illnesses — and it’s interesting to ponder what exactly counts — are usually miserable for the sufferers, and arouse pity and fear in observers. It’s not realistic to imagine we’ll ever carefully tiptoe past naming such states.
I thank Dr. Hickey for his close reading of my article, and for calling it interesting and thought-provoking, probably the highest praise a psychiatrist can ever expect from such a critic. I note that he calls me a typical psychiatrist when he disagrees with me, atypical and rare when we agree. I would respectfully suggest that I’m not that rare. Most of the psychiatrists I know have no rigid orthodoxy, no ideological axe to grind. Most see only voluntary patients who come for relief of distress — and end up feeling relieved. All value psychotherapy whether or not they provide it themselves, and all add a healthy dose of common sense to their specialized training. Psychiatry has much to improve, but that will only happen when supporters and critics engage in dialog, not a shouting match.