Monday, May 13, 2013

Allen Frances angered by biopsychiatry’s fall; calls those who disagree crazy

I appreciated many of Allen Frances’ criticisms of the DSM-5, and linked here and elsewhere to some of his articles about it. Over time, though, I became more wary. What became increasingly clear was that he wanted to confine his criticism to the new DSM (and, admirably, the one he chaired as well); he continues to be desperately attached to the biopsychiatric model. This is understandable given that his life’s work has been based in this model and his sense of identity and purpose must be bound up with it. But I saw that it was leading him to some arrogant and callous views that I couldn’t in good conscience link to.

In his thinking, a problem is either a brain disorder or nothing. Psychiatric labels have to have biological meaning, so if Binge Eating Disorder isn’t a “real” brain disorder people who would be diagnosed with it must just be gluttons. Either illness or a character flaw. Either “patient” or “worried well.” This is not only false but is precisely the sort of perspective with which critics of biopsychiatry are commonly charged: that if we state that psychiatric diagnoses are scientifically invalid we’re denying the reality of people’s suffering. But I haven’t heard a critic of the brain-disease-drug model – and certainly not anyone from the survivors movement – say anything like this. We recognize distress and suffering and the need for help without any need to identify them with a broken brain. The false choice of disorder or nothing Frances presents is the product of biopsychiatry, not of its critics.

Now that biopsychiatry is imploding, Frances is lashing out at its critics in a post at HuffPo called – I’m not joking – “The Inmates Seem to Have Taken Over the Asylum.”
Mental health practitioners and patients are being poorly served by the organizations most entrusted to represent their interests. We have entered a truly remarkable silly season of interacting absurdities committed by the American Psychiatric Association, the National Institute of Mental Health, and the British Psychological Society. May, it turns out, is the cruelest month for mental health.

It started with DSM-5 offering its untested new diagnoses that will mislabel millions of the worried well as mentally ill -- turning our current diagnostic inflation into hyperinflation and distracting attention and resources away from the people who really need help.

Then the NIMH recklessly renounced all syndromal DSM diagnosis as invalid.
This is the point at which he should stop and think. Was it reckless because it was false, or reckless for some other reason? To stop supporting diagnoses that lack scientific validity isn’t reckless. Nor is stating this truth publicly. Quite the contrary: it’s terribly reckless to base interventions in the lives of people experiencing psychological distress on pseudoscience.

You can’t insinuate that the new DSM categories are scientifically invalid while implying that previous ones were mostly or all valid. Frances doesn’t even try to establish the scientific validity of psychiatric diagnoses – which, of course, he can’t. He simply implies a core validity through the use of terms like “diagnostic inflation.”
But NIMH has nothing to offer now in its place except an oversold and undeliverable promise of some future strictly biological model of mental illness that will take decades to deliver -- assuming it can ever be delivered at all.
It can’t be delivered. But of course a biological model of “mental illness” is what Frances’ profession has for decades led people to believe it was delivering, and what their pharma partners have quite literally sold, so this criticism is pretty rich coming from him.
Now the British Psychological Society has produced its own brand of extremist posturing, offering its own quixotic paradigm shift away from the notions that the brain has much to do with mental illness
That’s incorrect.
or that schizophrenia and bipolar disorder are useful constructs.
They’re not useful constructs. More to the point, they’re not scientifically supported constructs. Most people would see that as a serious problem.
Instead mental health problems should be framed primarily in psychological and social terms.

This is all Alice Through The Looking Glass foolishness. The NIMH biological reductionism finds its absurd reflection in the British Psychological Society pscho-social reductionism. Responsible leaders of powerful organizations should know better than to suggest that complicated mental illnesses can ever be reduced to simple and reductionistic answers.
This part is just bizarre. He’s accusing the NIMH of biological reductionism! But the problem with biopsychiatry isn’t that it’s reductionist. It’s that it’s false. That’s an important distinction.

And it’s odd to claim that understanding psychological distress in psychosocial terms is simple and reductionistic. Talking about how our psychology is shaped by our social context and experiences is not only the opposite of reductionistic but is as undeniable as any claim about humans can be. There have been and continue to be reductionistic psychosocial models, and many will be wrong or so incomplete as to be useless, but it shows how far down the biopsychiatric hole we’ve fallen that a psychiatrist could assert in all seriousness that a program of research and care founded in the recognition of the social causes of psychological distress is extremist and a silly dream.
We need a model of mental illness that attends to the biological, to the psychological, and to the social.
That “attends to” is doing a lot of evasive work here. But the full BPS statement is now available; anyone who reads it can see that this is precisely what it advocates (minus the “mental illness” language).
We need leaders who address the current unmet needs of patients -- who are not so enchanted with utopian grand designs for the distant future that they lose interest in the urgent problems of the present.
Every criticism Frances is making of Insel applies to all of biopsychiatry. Again, the claim that a socially oriented psychology is some “utopian grand design” is just laughable. (And stop calling people “patients”!)
DSM-5, the NIMH, and the BPS have all gone far wrong and all for the very same reason -- each has prematurely promised a grandiose paradigm shift when none is remotely possible. Paradigm shifts emerge from new scientific findings -- not from bloviating statements, however well intended.
The chair of the DSM-IV accusing others of grandiosity is a bit much. In any case, this bloviating evades the fundamental issue. Scientific findings do not support the biopsychiatric model. These people have gotten by for a long time with this game. Biopsychiatry’s existence as a “paradigm” and its use of medical language lend it an aura of scientific credibility which is doesn’t possess in reality. Nothing about the availability or quality of alternatives will alter the fact that the diagnoses and the model itself are scientifically unsound.
Patients and practitioners are the collateral damage of this ridiculous controversy. Patients who need help may well lose faith in a mental health establishment that seems so confused and is so confusing.
They should have lost faith in biopsychiatry long ago. For the love of Kraepelin, the model is false. To the extent that the model continues to hold sway in the “establishment” – and I hope the clinical psychologists’ statement is just an important stage in its collapse – it will continue to produce harmful pseudoscience.
It is past time to have just one thing in mind in preparing diagnostic manuals or statements about mental illness that will be widely disseminated. Will this help or hurt our patients' access to quality care?
That is an important question (stop referring to people as patients!). It’s not separable from the scientific question. If a manual or statement or intervention is based on pseudoscience, it’s very likely to hurt people.
So my plea to the American Psychiatric Association, to the National Institute of Mental Health, and to the British Psychological Society -- spare us your empty promises of premature paradigm shifts and instead help us take better care of our patients.
My plea to Allen Frances – acknowledge that, while there are many compassionate, well-meaning people in your profession, good intentions are perverted by the irrational insistence on a failed “paradigm.” The problem goes far deeper than the new DSM. You would do well for people and for your profession if you joined the British clinical psychologists in abandoning it.

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