Psychiatry's hubris

Is it fair to take a balanced, well researched critique of psychiatry, and use it as a springboard for polemics? It wouldn’t be the first time. This week, in reviewing Anne Harrington’s upcoming book, Mind Fixers: Psychiatry’s Troubled Search for the Biology of Mental Illness, psychiatric critic Gary Greenberg champions the measured points made by Harrington, then extends them into illogic and name-calling.

Harrington, a Harvard historian of science, chronicles psychiatry’s efforts over more than a century to account for psychiatric ills biologically. As her title says, it’s been a troubled search. Some practices, like lobotomy and ice-water hydrotherapy, are now seen as cruel and barbaric; once-popular “chemical imbalance” theories are now discredited. The smug assurance in recent decades that all psychiatry is neurobiological does indeed reflect hubris. It is said as though this were an empirically validated discovery. It is not.

Greenberg, writing in the April issue of the Atlantic magazine, has no quarrel with these observations, and indeed offers no substantive criticism of Harrington’s book. His main beef is that she is too nice. For Harrington is committed to restraint, noting that war between psychiatrists and anti-psychiatrists results in “tunnel vision, mutual recrimination, and stalemate.” She believes it should be possible to critique psychiatry, its past errors and even its current ones, without throwing the baby out with the bathwater.

Greenberg is a psychotherapist and author who has himself been profiled in the Atlantic. An outspoken critic of psychiatry’s Diagnostic and Statistical Manual (DSM), he doesn’t think much of us psychiatrists either:

It’s the universal paranoia of psychiatry that everybody who disagrees with them is pathological. You can’t disagree with a psychiatrist without getting a diagnosis.

This, of course, is untrue. I’ve never heard any psychiatrist diagnose Greenberg, or Thomas Szasz or Robert Whitaker for that matter. We’re all adults here, and we can disagree without calling each other names.

Meanwhile, back at the book review, Greenberg oddly cites the unknown mechanism of action of antidepressants as evidence they don’t work:

At last count, more than 12 percent of Americans ages 12 and older were taking antidepressants. The chemical-imbalance theory, like the revamped DSM, may fail as science, but as rhetoric it has turned out to be a wild success.

Greenberg apparently believes that 12 percent of Americans take antidepressants because their doctors falsely claimed they suffered a chemical imbalance. There is no evidence for this, and it’s highly unlikely. Much more likely is that these many patients sought symptomatic relief from depression or anxiety, and a prescriber believed an antidepressant would relieve their unwanted state of mind.

It doesn’t take knowledge of a drug’s mechanism of action to rationally prescribe it. The history of medicine abounds with empirical treatments, i.e., ones that worked although we didn’t know why. Aspirin is a good example: it was used effectively for generations before anyone had an inkling how it worked. Thoughtful psychiatrists embrace uncertainty and refrain from making unsupported claims about treatment. But absence of evidence is not evidence of absence. Psychiatric medication helps a great many people — admittedly not everyone, and not without cost — and there is no shame in prescribing it while admitting we don’t know why it works.

Greenberg later complains of an:

industry that touts its products’ power to cure biochemical imbalances that it no longer believes are the culprit. Plain bad faith is what’s on display, sometimes of outrageous proportion.

While I was an early critic of chemical-imbalance claims myself, I believe Greenberg’s argument is stale. Drug companies don’t push presumed mechanisms of action much anymore. The psychiatrists who still do are acting out of false pride in their scientific acumen, or perhaps to persuade hesitant patients to start treatment. These aren’t justifiable reasons, and psychiatrists shouldn’t act this way. But calling it bad faith is… bad faith. Greenberg also lumps drug companies, the American Psychiatric Association, and psychiatrists into an “industry.” As a solo practitioner with a largely psychotherapy practice, this is news to me.

The review ends with Greenberg quoting Harrington and then editorializing in a particularly dismissive way. Harrington ends her book by advising psychiatry:

“to overcome its persistent reductionist habits and commit to an ongoing dialogue with … the social sciences and even the humanities.”

Greenberg agrees with this advice, as do I. But he is pessimistic, and ends with his own diagnosis, that psychiatry’s hubris is incurable:

But no matter how evenhandedly she frames this laudable proposal, an industry that has refused to reckon with the full implications of its ambitions or the extent of its failures is unlikely to heed it.

Greenberg himself falls prey to the “tunnel vision, mutual recrimination, and stalemate” Harrington warns us about. Psychiatry is not an “industry”; the number of American psychiatrists (about 28,000 this year and dropping) pales in comparison to the number of clinical psychologists and other licensed mental health professionals. Drug manufacturing is certainly an industry, and we physicians must draw ethical lines around undue influence by these far more powerful and monied firms. Our APA should as well. The resulting picture is not of a psychiatric juggernaut, but of a largely disorganized profession asked to solve social ills while being eyed suspiciously. And while being battered by an under-regulated pharmaceutical industry, which also advertises directly to the public. The U.S. is nearly unique in the world regarding direct-to-consumer drug ads.

Is psychiatry hubristic? Certainly. Claiming to know things we don’t about neurobiology, claiming to hold authority over other mental health professionals like psychologists, claiming our time is worth more — yes, all of these reek of hubris. Many critics within psychiatry have pointed this out, and argue for more humility within our ranks. There are also valid critiques that as a group we are too quick with the prescription pad, and that we should conduct, or refer patients to, psychotherapy more than we do. There are many ways psychiatry can improve. But taking potshots at us doesn’t help, and dismissing us as incurable is the very definition of bad faith.

Finally, why would the Atlantic choose an outspoken critic to review a book about psychiatry? The publishers weren’t really expecting a balanced, measured review, were they?

2 comments to Psychiatry’s hubris

  • I was just reading Greenberg’s article when I saw your blog post. I love this line of yours: “The resulting picture is not of a psychiatric juggernaut, but of a largely disorganized profession asked to solve social ills while being eyed suspiciously.” This is definitely how I view our profession, and Greenberg calling psychiatry an “industry” is just showing us where his biases lie. Thank you for highlighting his bad faith and for calling out the Atlantic for choosing him to review this book.

  • Debbie

    Hi – I just found your blog. The first entry I read was “Ten Years of Blogging.” I hope you continue to blog. At the very least, I hope your archives remain accessible. I have a lot of catching up to do! Thank you so much!

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