"Evidence based" psychotherapy

When a mental health clinic, online referral service, or private practice offers “evidence based” psychotherapy, that certainly sounds like a selling point.  It suggests solid science supports the therapy offered — and that competing services lack this support.  But what does this phrase really mean?

“Evidence based medicine” first appeared in the medical literature in 1991.  It cast doubt on physicians’ clinical intuition and anecdotal experience, reminding them that science should guide medical practice.  (The term was new, the warning was not.)  Acceptable scientific evidence included clinical epidemiology, bench research, published case reports, and so on.  However, the randomized controlled trial (RCT) soon emerged as the gold standard, the best evidence that a treatment works.

In a RCT, subjects who all suffer the same disease are randomly assigned either to the treatment under study, or to a control group.  The latter receives an inactive placebo, or sometimes an active comparison treatment.  Ideally, RCTs are “double blind”: neither the subjects nor those rating them know who is in which group.  This minimizes psychological effects such as confirmation bias, where both researchers and subjects tend to rate more improvement where they expect to see it.  If the treatment group then fares better on average, this is taken as strong evidence of treatment efficacy.

RCTs are powerful tools — with limitations.  Best for studying a single treatment applied to a single disease, the method becomes impractical when studying patients with multiple or ill-defined conditions, or when assessing treatments with nuanced variations.  It can be hard to find a suitable placebo or comparison treatment, and sometimes it proves impossible to create double-blind conditions.  For a variety of reasons, there is still an important role for evidence aside from RCTs.

In the field of psychotherapy, the paradigm in the first half of the 20th century was psychoanalysis and its offshoots.  Its prominence was largely due to intellectual elegance and compelling case reports, not RCTs.  But by mid-century, critics began questioning the broad claims of psychoanalysis.  New medications and psychotherapies were introduced.  And in 1980, psychiatry’s Diagnostic and Statistical Manual was revised.  It would thereafter define mental disorders not narratively, but by symptom criteria.  With the right set of symptoms, a patient would “meet criteria” for one or more diagnoses.

Drug developers and the newer schools of therapy, especially cognitive behavioral therapy (CBT) and short-term structured therapies, were eager to prove they could reduce these symptoms and, by definition, relieve psychiatric disorders.  Many RCTs were done, and indeed these studies showed, on average, that symptoms were reduced.  This led to FDA approval for the medications, and to “evidence based” claims for the therapies.

Yes, CBT and other symptom-focused therapy is “evidence based.”  But that’s only part of the story.  Left unsaid is that a great deal of scientific evidence finds traditional, psychoanalytically based therapy effective as well.  This includes group studies using standardized measures — even RCTs — as well as patient satisfaction surveys, a myriad of case reports, and other lines of evidence.  Although there are fewer RCTs of analytic therapy than CBT, often the amount of improvement (the statistical “effect size”) is greater in the former.

“Evidence based” also glosses over why people seek therapy.  Many hope to decrease concrete symptoms: to feel less anxious, to have a brighter mood, to sleep more soundly.  Here the evidence supporting CBT and similar treatments is very solid.  But others are motivated by vague complaints that arise only in the context of close relationships.  Or by a lack of meaning in life.   Or by unwitting self-sabotage.  Not uncommonly, they really can’t say what is wrong.  No RCTs exist for such problems, as there is no diagnostic group to randomize, no concrete symptoms to treat.

It reflects a fundamental misunderstanding — or false advertising — to promote “evidence based psychotherapy” for these sufferers.  There is no such evidence, if by that we mean RCTs.  Yet if evidence is more broadly construed, as it was in the original conception of “evidence based medicine,” it is psychoanalytic therapy, not CBT, that is supported by far more evidence.

“Evidence based therapy” has quickly become an empty phrase that slights the competition.  The evidence is real, but its relevance often is not.  This false narrative has misled insurers, government agencies, and many patients into believing certain approaches to psychotherapy are inherently superior when they are not.

Cognitive, highly structured, symptom-focused therapies certainly help many people.  Psychoanalytic therapies, and other therapies that rely on depth and relatedness, do as well.  The best choice for an individual depends on factors unique to that person, starting with his or her presenting complaints and preferences.  It may or may not be relevant that a particular therapeutic approach works against specific symptoms as tested in RCTs.  “Evidence based” is mostly sales-talk, not a blanket scientific endorsement.  All mainstream psychotherapy is evidence-based.

Image by Gerd Altmann from Pixabay

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?

Dynamic therapy as 'Alternative medicine'

“Complementary and alternative medicine” (CAM) is a category that includes all the methods of physical or mental healing that do not fall under the umbrella of western medicine. Examples include comprehensive healing traditions from other cultures, such as Chinese or Ayurvedic (Indian) medicine; herbal remedies; and a wide variety of mind-body treatments, such as meditation and yoga. CAM treatments are popular everywhere, including here in the U.S. But they are considered unproven by western medicine, usually because they haven’t shown statistically significant treatment effects, as compared to placebo, in randomized controlled trials (RCTs).

Advocates of CAM argue that RCTs are the wrong tool to assess such treatments. Western medicine is founded on diagnosing a disease, then applying one or more treatments known to fight that disease. Individual differences among patients who share a given disease are considered error variance that can’t be accounted for. These differences are averaged out in subject groups, which is why large subject groups lend more statistical power to RCTs than do small subject groups. Thus, antidepressant drugs and cognitive behavioral therapy (CBT) are accepted as legitimate in western medicine because research subjects with diagnosed major depressive disorder improve — on average — with these treatments to a greater degree than similar patients in control groups. Differences between responders and non-responders in a given group are usually unstudied and unknown, and in any case irrelevant to the finding that the treatment is “effective.”

A common feature of CAM is that individual differences are highlighted, not thrown away as noise. Chinese and Ayurvedic medicine describe subtle balances of tendencies or energies within the individual, and seek to restore health by correcting imbalances. Similar principles are purportedly at work in chiropractic, western herbalism, tai chi, and so forth. It remains an empirical — but often hard to test — question whether these CAM practices actually have a healing effect.

Psychodynamic psychotherapy (and for purposes of this discussion, psychoanalysis) is not considered CAM because it does not fall outside the umbrella of western medicine. Dynamic principles are taught to psychiatry residents (i.e., physicians), health insurers pay for treatment, and non-psychiatric physicians have few qualms about referring their patients for such therapy.

However, this is changing. The term “evidence based treatment” is increasingly used to differentiate psychiatric interventions that fit the standard RCT paradigm. These include FDA-approved medications and other somatic treatments such as electroconvulsive therapy (ECT) and transcranial magnetic stimulation (TMS). They also include CBT in its various forms. Notably, dynamic therapy and psychoanalysis are not included, despite a sizable literature showing efficacy. “Evidence based treatment” is thus a misleading term, a kind of sales pitch for certain types of treatment. But it’s an effective sales pitch. It is becoming “common knowledge” that some psychotherapy is “evidence based” and some is not. There are only small, fledgling efforts thus far to counter this misperception.

Dynamic therapy is thus veering from mainstream legitimacy to something approaching CAM. It’s no coincidence that it also shares important commonalities with CAM: a focus on individual differences, subtle energies (unconscious impulses and feelings in this case), a “balancing” paradigm within the individual, and a rejection of one-size-fits-all treatment.

On the one hand, it is small comfort that psychodynamics now joins company with implausible healing arts such as reiki and homeopathy. It feels unfair to discount our careful theories, myriad case reports, our documented successes. We’re not some crackpot cult positing invisible entities and forces, like chakras, kundalini, and chi. Except that, in the eyes of many these days, we are. It can all be a bit depressing.

On the other hand, sometimes CAM eventually gains legitimacy even in the eyes of western medicine. Acupuncture and probiotics are arguably two such examples. Perhaps the pendulum will swing back when more sophisticated research methods show unique advantages for dynamic treatments. Or more simply, when “evidence based” isn’t accepted blindly.

In the meantime, given the unfortunate delegitimization of dynamic treatment, practitioners may be well served to embrace its undeniable and laudable kinship with CAM. “Precision medicine,” a buzzword these days, rightly applies not only to genetic testing and personalized pharmacology, but also to individualized psychological treatment. Focusing on the person and not the disease need not be the sole province of eastern healing philosophies. Attention to subtlety and nuance need not be relegated to mystical, esoteric practices. In all these areas, the dynamic tradition has been there and done that.

Ten years of blogging

This month marks a decade of blogging on “Reidbord’s Reflections.” This is the 130th post. My posting frequency dropped precipitously over the years, from 20 posts in the first two months to one every couple of months now. I imagine I share with most bloggers a limited set of rehearsed topics, things I always wanted to write about. Once these were exhausted, new ideas came more slowly, often spurred by news articles.  Lately I’ve been more inclined to write about current events and news items, less about psychiatry.  I find people’s minds and ideas engaging.  As for the practice of psychiatry — tweaking this med or that, arguing over nuances of psychotherapy technique, weighing ethical goods like beneficence and autonomy — well, my interest waxes and wanes.  Psychiatry doesn’t change quickly, and as a result I feel little time pressure to write about anything particularly psychiatric.

I don’t track my readership here, but I crosspost to a blog on Psychology Today’s website, and they keep records. Far and away, my most read post there is “Countertransference, an overview” with nearly 400,000 views.  It’s fairly well written in my humble opinion, but not especially so.  I can’t account for its outsized popularity.  Other favorites of mine, never mind their popularity, include the two-part posts on placebos and psychiatric disability; my ethics piece on Pharma and doctors; my post on charging patients for missed sessions (with a record 130+ comments); “Antidepressants are just a crutch“; my sailing analogy; whether therapists should accept gifts; and my one attempt at fiction.  Actually, there are more, but I’ll stop there at ten.

Also, I was surprised to learn that my “Brief History of Psychiatry,” a page deep in the website for my practice — not in my blog — is quite popular.  It’s often found by folks searching for… a brief history of psychiatry.  As it happens, roughly 50% more people search this phrase and go directly to that page on my site, than search for psychiatric services and go to my landing page.

I somewhat regret naming my blog after myself.  If I’d known I’d be at it ten years later, I might have thought harder about a better name.  I envy the creative titles of some psychiatry blogs: Shrink Rap, Thought Broadcast, The Alienist, 1 Boring Old Man, The Last Psychiatrist.  Sadly, however, none of these are active anymore.  Dinah Miller shut down Shrink Rap in August, Mickey Nardo (“1 Boring Old Man“) died nearly two years ago, The Alienist stopped posting in 2015, the anonymous Last Psychiatrist went silent in 2014, Thought Broadcast in 2013.  Psych Practice and Psycritic haven’t posted for over half a year, either.  It’s nice to see George Dawson still posting long, thoughtful, frequent pieces on Real Psychiatry, even if I sometimes disagree with his conclusions.  There are, of course, other psychiatry blogs I’m less (or not) familiar with.

I was pleased that a content aggregator called Feedspot ranked “Reidbord’s Reflections” number six out of the “top 50” psychiatry blogs and websites.  I don’t know how they decided this, but I thank them nonetheless.  I even added their badge to my blog several months ago.  I didn’t pay them or anything.

The future of this blog? With the demise of Shrink Rap, a longtime favorite, it crossed my mind to shut down too.   I realized early on that the 1000-word cerebral essay isn’t ideal for blogging.  It’s not my style to post quickly and often, nor to repost cute cartoons and jokes from other sites.  By only occasionally posting anymore, I imagine that long ago I lost the regular readers I once had.  (I miss the dialog we sometimes had in the comments in the early years.)  I’ve thought about turning some of this writing into a book.  Or maybe try more seriously to publish op-eds in old-fashioned newspapers.

On the other hand, I’d feel bad to kill this creature I created.  On balance, I figure I’ll keep posting here as ideas occur to me. I enjoy writing (and crossword puzzles, and other wordplay).  As long as it’s fun there’s no reason to stop.  And you’re more than welcome to keep reading — and commenting, and even tossing me a writing-topic suggestion now and then.  It’s good to have you along.

The photo is an iPhone calendar from 2008.

We are one

E pluribus unum strikes the pluribus lately as a threat, not a promise — more like assimilation by the Borg than a patriotic ideal.  Instead of striving for the common good, we’ve split into factions, each defined largely by its enemy.  Feminism fights patriarchy, Black Lives Matter fights police brutality, the 99% fight the 1%.  Elsewhere on the political spectrum, midwesterners fight coastal elites, populists fight the “deep state,” white supremacists fight immigration.  There’s an awful lot of fighting going on, and a lot of circling the wagons, i.e., huddling together with the like-minded, or at least the like-identified.

“Identity politics” was coined in 1977 by the black feminists of the Combahee River Collective, but the term no longer carries its original meaning.  Identity politics was a starting point, a catalyst for political activity.  To the Collective it was not an end in itself.  Cultural critic Kimberly Foster writes:

Their ideology began with self, but it was not self-obsessed. Ultimately, they knew their work would benefit everyone…. An identity politics that is not principally concerned with dismantling all forms of inequality quickly devolves into a never-ending game of oneupmanship where self-satisfaction is all that’s won.

For both the Left and Right, identity politics is now a substitute, not a catalyst, for benefiting everyone.  Identity has become a credential for oneself and a prejudicial discrediting of others — the very definition of argumentum ad hominem.

This degraded sense of “identity politics” reflects a much older human propensity: tribalism.  Tribalism stands opposed to universalism, inclusive regard for humanity as a whole.  The two exist in dynamic tension, with universalism arguably gaining ground over time.  To paraphrase Martin Luther King, the arc of history is long, but it bends toward expansion of our “tribe”: from families to villages to nations, and eventually to supranational coalitions like the European Union and United Nations.  Looking ahead, the science-fiction world of Star Trek envisions a utopian Federation of humans joined by like-minded aliens.  As generations come and go, we slowly find common cause with those less and less like ourselves.  Yet tribalism never goes away.  There is always an enemy: a Communist or terrorist menace in real life, the Borg in our imagined future.  It’s hard to conceive of group cohesion, Oneness, without an Otherness.

Plus, the long arc isn’t smooth.  As with King’s moral universe bending toward justice, there are backlashes.  We’re currently experiencing one: a worldwide, presumably temporary regression to smaller tribes.  Brexit is an obvious example.  Here in America, our enemies these days are not extraterrestrials or even Communists, they’re our neighbors with politics opposed to our own.  And while animosity between Left and Right is as heated as ever, we also battle enemies even closer at hand: progressives fight with liberals, traditional conservatives with Trumpists, different schools of feminism with each other.  We’re in a freefall of “splitting” instead of “lumping”.  Why this backlash?

Apparently it’s fear.  Life in western-style democracies today must feel precarious indeed: in a frenzy we defend ourselves against all who aren’t explicitly in our camp.  Fearful self-preservation compels us to hunker down, circle the wagons, and make rough, seemingly vital distinctions between friend and foe.  Honoring the humanity of one’s adversary becomes a precious luxury, quickly jettisoned when survival is at stake.  Conversely, huddling with the like-identified answers the rhetorical challenge: “You and what army?”  There’s strength in numbers.

Living in a small camp under siege, or perceiving life that way, means always scanning for possible attack.  It can culminate in paranoia.  Unfortunately, there is no compelling way to refute paranoia.  Rational argument cannot convince a paranoid person to let down his guard.  Paranoia subsides as safety and trust are (re-)established; it’s an incremental process that takes time.  Trust must be earned, which is why betrayal is so devastating and reconciliation so slow.

It’s bad enough to live among myriad warring camps.  Even worse, the ammunition used in these wars are often competing claims of victimization, a tricky dynamic that in turn leads to whataboutism and charges of false equivalence and fake news.  Intersectionality, a term coined in 1989 by law professor Kimberlé Crenshaw, attempts to account for multiple simultaneous forms of oppression.  It was first applied in concrete and pragmatic fashion to the intersection of misogyny and racial oppression in the lives of black women.  However, despite Crenshaw’s disclaimer, intersectionality lately connotes a tally of personal identities, i.e. group memberships, whereby one can claim oppression.  As commonly used, intersectionality demands finer and finer screens for tribal membership.

In an insightful opinion piece, philosopher Kwame Anthony Appiah notes that intersectionality so construed precludes anyone from speaking on behalf of a tribe, no matter how narrowly defined:

If Joe had grown up in Northern Ireland as a gay white Catholic man, his experiences might be rather different from those of his gay white Protestant male friends there.

It only takes a moment to realize there is no end to this divvying up.  Identifying with a particular tribe can multiply political power, but ultimately tribes are an illusion: a strategic foregrounding of certain shared attributes while backgrounding all the others.  Barack Obama is “black” here in the U.S. but “white” when he visits Africa; it depends on whether his half-blackness or half-whiteness is in the minority and thus in the foreground.  Irish and Italians were considered non-white when many immigrated here over a century ago.  Jews are white or non-white (and oppressor or oppressed) depending on the point of the identification.  Clarence Thomas and Ben Carson are plainly in the African American camp, except when their political views argue otherwise.

Owing to the miscibility of group identification, it is always erroneous to claim to speak for a tribe, regardless of how narrowly defined it is.  I can’t speak for all Americans or all physicians — or even for all San Francisco psychiatrists who write blogs.  Likewise, no one can speak for “the disabled,” “real, God-fearing Americans,” or an identified sexual minority.  While it’s often useful to clarify one’s viewpoint by noting that it stems from experience as a manual laborer or transgender person or Hawaiian, it doesn’t imply — can never imply — a like-minded army marching behind one’s words.

We speak for ourselves alone.  Each of us is only one, no more and no less.  This prospect may sound like a lonely and desperate “Every man for himself!”  Paradoxically, however, it may pivot us back to the long arc of history.  It may gently ease our social paranoia and allow universalism to gain ground once again.

Recognizing the uniqueness of the individual and the arbitrariness of group identification complicates tribalism.  If there is no simple dividing line between friend and foe, if there is no clear-cut tribe or camp with members in lockstep, we may again permit ourselves to see humanity in our adversaries.  If we’re lucky, the role of Otherness will be played by impersonal challenges such as climate change and resource limitation, not by other people.  As we rejoin the long arc of history, identity politics will be our on-ramp to helping all in need, not just those who look, vote, or pray like us.  Inevitably — but sooner is better than later — we will again identify with expanded tribes such as nations, the human race, or all living creatures.  Like the stamp of e pluribus unum on our coins, “we are one” will mean honoring both our individuality and commonality.  We will share kinship with a great many, not a small camp.

What counts as a medical issue?

It has become a sign of legitimacy to call a personal problem “medical.”  This aims to distinguish the problem from those of morality or character.  It implies both that the problem is serious, and that it is unbidden and largely out of the suffer’s control.  Unfortunately, it isn’t clear what exactly qualifies as “medical,” so this label serves more as a rhetorical device than a scientific finding.

Alcoholism is the paradigm and perhaps least controversial example.  Through the 19th Century, alcoholism was variously declared a disease, or a matter of will and character.  The disease model gained prominence in the 1930s and 40s with the “powerlessness” identified in the 12 Steps of Alcoholics Anonymous, as well as researcher E.M. Jellinek’s descriptions of progressive stages and subtypes of alcoholism.  The American Medical Association declared alcoholism an illness in 1956 and has endorsed the disease model ever since, partly as a strategy to ensure insurance reimbursement for treatment.

The model expanded to include other abused substances with the formation of Narcotics Anonymous in the 1950s, and as a result of widespread recreational drug use in the late 1960s and early 1970s.  The specialty of addiction medicine was first established in 1973 in California.  The American Society of Addiction Medicine now states: “Addiction is a primary, chronic disease of brain reward, motivation, memory and related circuitry.”  Proponents of the disease model of addiction cite many documented brain changes and a plausible neuropathology, as well as the presence of genetic risk factors, cognitive and emotional changes, impaired executive functioning, and disability and premature death.  The model purportedly destigmatizes addicts — they are no longer “bad” or “weak” people — thereby making it more acceptable for them to seek treatment.

Nonetheless, the disease model of addiction remains controversial.  In addition to the existence of alternative models, the disease model itself has been criticized.  Some believe it removes personal choice and responsibility, and actually contributes to the problem of addiction.  Others cite surveys of American physicians who consider alcoholism more a social or psychological problem — even a “human weakness” — than a disease.  Critics note that about 75% of those who recover from alcohol dependence do so without seeking any kind of help, and that the most popular and recommended treatment, Alcoholics Anonymous, is a fellowship and spiritual path, not a medical treatment.

Behavioral addictions to gambling, sexpornography, the internet, video games, and food are described in language that explicitly parallels addiction to alcohol and drugs.  The same brain pathways are implicated.  Accordingly, these problems are called medical as well.

Addiction is not the only domain that has been declared, often somewhat stridently, as medical.   Depression has been deemed a medical issue for several decades now, using much the same rationale.  The push to frame all psychiatry as neurobiology is a larger matter.  But here, too, documented brain changes, genetics, and characteristic signs and symptoms underlie a rhetoric that may, or may not, decrease stigma and facilitate treatment.  Moreover, a number of other behaviors and traits, formerly considered bad habits or personality quirks, are now reified as discrete psychiatric disorders (not the same as diseases, but close): shyness is now social anxiety disorder, misbehaving kids have oppositional defiant disorder, and so forth.  What are the risks in subsuming more and more of human experience into nosological categories?

One risk is that medicalizing problems may hide political or other bias.  The most shocking historical examples include drapetomania in the U.S. and the misuse of psychiatry in the former Soviet Union.  Yet even well-meaning efforts to highlight a social problem, give it gravitas, and impart a clinical, impersonal air to one’s opinions can result in this sort of over-reach.  Examples include the “politics is part of pediatrics” antiwar stance of famed physician-author Benjamin Spock, and Physicians for Social Responsibility, a group that opposes nuclear arms from a medical perspective.  Most recently, some mental health professionals have published impassioned statements characterizing President Trump’s behavior in medical/psychiatric terms.  Such statements have no medical purpose: they neither clarify Mr. Trump’s behavior (which is well known to all), nor change it.  Their effect, if any, is solely on electoral politics.  Medical language can thus amount to little more than grandstanding.

A related risk of medicalization is that it may lurch toward absurdity.  Suicide, that profoundly personal matter studied by poets and philosophers as well as scientists, also may be deemed a disease.  This confuses disease with symptom — as if “headache disease,” for example, were touted as a new diagnostic entity.  No doubt there will soon be measurable brain findings that distinguish suicidal people from non-suicidal people; no doubt such findings, too, will soon distinguish the state of having a headache from the state of not having one.  In this nascent era of functional brain imaging, is it sufficient to see something “light up in the brain” to call it a medical problem?

Doing mental arithmetic is detectable by fMRI.  Is math a medical issue?

A plainly medical disease such as diabetes results from nature and nurture, genetics and environment.  What makes it medical are not its causes.  The effect of diabetes on the human body, the fact that it historically has been treated by physicians, and to a lesser degree the nature of its treatment make it medical.  Addiction also appears to result from genetics and environment, to have consistent effects on the human body, and for a few decades at least, has been treated by physicians.  Its treatment, though, is mostly non-medical in the usual sense of the term, i.e., not pharmacological or surgical.  There are strong behavioral and psychological aspects to addiction, and often sociocultural ones as well.  It is thus not surprising that its status as medical remains, to some, a matter of debate.  However, by the time we get to war, nuclear arms, a heretofore unimagined presidency, or suicide, we are talking about matters that have no consistent findings in the human body, are not historically treated by physicians, and respond almost exclusively to non-medical solutions.  The phrase “medical issue” can’t stretch to cover this territory, no matter how fervently physicians would like to weigh in.

In the future, more and more brain function will be open to scrutiny.  As our brains mediate all human behavior, advancements in functional imaging and similar technology may tempt us to declare any and all products of the human mind “medical issues.”  Problems such as prejudice, racism, violence — or, from other viewpoints, liberalism, collectivism, and the like — may be claimed as the physician’s to treat.  It will be hard to resist this temptation; doctors like to fix things.  But the cost of succumbing is to reduce medicine to threadbare rhetoric, weakening our moral status as healers of the human body.

Graphic courtesy of Pixabay, CC0 license.


“60 Minutes” ran a segment last Sunday on electroconvulsive therapy (ECT), better known as shock treatment.  Kitty Dukakis was interviewed as a long-time recipient and advocate of ECT for her severe depression.  The piece was almost entirely positive, save for brief mention of memory loss as an unfortunate side-effect.  This was soon left behind by video of a treated, newly smiling patient declaring no such problem: new technologies are in development, e.g., magnetic shock therapy or MST, that promise to mitigate this issue.  ECT was presented as an under appreciated miracle treatment — and miracle treatments, unfortunately, always make me worry.

In addition to reassuring the public — ECT isn’t painful and doesn’t feel punitive anymore, in contrast to its fictional depiction 43 years ago in “One Flew Over the Cuckoo’s Nest” — the segment also admonished psychiatrists who don’t use ECT often enough.  According to “60 Minutes,” severely depressed patients are languishing for years on ineffective antidepressants, imprisoned by their doctors’ outdated prejudices and unfounded fears.

Like so much in the news these days, this report oversimplified to make a rhetorical point.  The reality is rather different.  I can only recall two patients in my decades-long practice who possibly would have benefitted from ECT.  (I’m not trained to administer it, so they would have been referred to a colleague.)  All the other depressed folks I’ve seen, hundreds of them, improved on psychotherapy, standard antidepressant medicine, or both.  Or they had longstanding personality issues that made them depressed — a vexing problem to be sure, but not one ECT can fix.  The great majority were eventually helped by more benign and far less expensive treatment than ECT.

This is not surprising considering that most depression is of modest severity.  And the modest severity of most depression is itself not surprising.  In an effort to capture as many cases as possible, the DSM-5 diagnostic criteria for major depressive disorder includes chronically unhappy people who are still able to work or attend school, people with no psychomotor slowing, and people who have never given suicide a serious thought.  While severe melancholic depression looks and acts very much like a disease worthy of a medical intervention under general anesthesia, i.e., ECT, most of what we call depression these days does not.  A great many people hobble along, not really enjoying life but not being severely impaired either.  Suggesting ECT for this group is irresponsible.

The perceptions and history of ECT remain roadblocks as well.  Even voluntary ECT is the epitome of paternalistic medicine: a powerful, technological treatment done to a passive patient.  And while most ECT is now voluntary and requested, historically it wasn’t.  Some ECT in the U.S. is still court-ordered today.  This again follows from its use in the most severely depressed patients, who may exhibit nihilistic delusions, or are so impaired they can’t participate in their own treatment.  Even if it is highly effective and without better alternatives, restraining someone in order to administer anesthesia and an electric shock that causes a grand mal seizure is a tough notion for the public to accept.

Feel-good pieces on television are no match for the discomfort most of the public feels about shock treatment.  I would not hesitate to recommend it for severely depressed, non-functional patients, especially those with classic melancholic depression who have failed full trials of standard antidepressant medication.  Also, ECT may be a good first choice when depression is accompanied by mood-congruent delusions.  But these are unusual conditions where the established efficacy of ECT outweighs its attendant memory loss, cost, and apprehension.  Realistically, we ought to think of ECT as we do life-saving surgery: an essential option when needed, but hardly something to be popularized or welcomed lightly.