Friday, May 31, 2013

Defending the lie

“It is the responsibility of intellectuals to speak the truth and to expose lies. This, at least, may seem enough of a truism to pass over without comment. Not so, however. For the modern intellectual, it is not at all obvious.”Noam Chomsky
I was writing a post about David Brooks’ latest opinionating, but that’s been preempted by a shocking piece I saw at Slate“Is Psychiatry Dishonest? (And if so, is it a noble lie?),” by Benjamin Nugent.

What’s shocking is, well, first, that Nugent would even ask the second question, and, next, that after he pretty much answers Yes to the first,* he leans toward Yes in response to the second. I hope I don’t even have to spell out why this is a terrible position. The idea of the “Noble Lie” is inherently authoritarian, contrary to every standard of epistemic and democratic ethics. When it comes to biopsychiatry specifically, the suggestion that there’s anything positive about the promotion of this scientifically invalid model is laughable. Nugent provides an autobiographical note, but fails utterly to address the extensive evidence of biopsychiatry’s real harms. In fact, I’m astonished that he could move so breezily from the first to the second question.

His concluding remarks left me nearly speechless:
It seems to me—and I am a novelist, not a mental health professional, and so have no dog in this fight, no drug company consulting gig, no claim on insurance payments to protect— that the DSM’s great purpose should be to curb the exuberance with which enterprising doctors and laymen invent, buy, and sell diagnoses for fun and profit. To be sure, this is a Kissingerian stance: Let’s prop up the dictator with the medals on his chest so long as he keeps the guerillas at bay. But if the DSM ceases to be the sourcebook doctors and patients use to determine the parameters of diagnoses, other sourcebooks will proliferate. Like those websites spreading the good news that Nabokov and Dickinson had Asperger’s.
In other words, we should support this brand of authoritarian pseudoscience, even though we know it’s dishonest, to prevent scientific anarchy (gasp).** It’s strange on so many levels: The DSM’s purpose in reality is precisely not to curb the invention and marketing of diagnoses, but to lend those invented and sold by drug companies and enterprising psychiatrists – and the project of biopsychiatry itself – a false air of scientific authority. Nugent just ignores this completely. Second, he isn’t even able to come up with a credible hypothetical threat – just a metaphor. Who are these diagnostic guerrillas and why should we fear them more than the politically and economically powerful corporate psychiatry we have now? (His one example makes his argument even more bizarre: the sites speculating that these famous people had Asperger’s are the outgrowth of biopsychiatry, not alternatives to it.)

But most important, even if we assumed – contrary to the facts - that there were no reasonable, humanistic, evidence-based alternatives, how could anyone possibly think that condoning and promoting dishonest, self-interested, profit-driven pseudoscience is a good idea? Over the past few years, I’ve been perplexed by people’s reluctance to examine the evidence about biopsychiatry. I’ve been surprised by their lack of outrage when they do recognize serious problems. But I never thought I’d see a writer basically acknowledge that biopsychiatry is and has long been a lie, placidly accept this fact, and then proceed to defend the lie. Kissingerian, indeed.

* There are several problems with Nugent’s attempt to answer the first question, beginning with his narrowed focus, typical of many recent articles, on the books by Greenberg and Frances (both apparently interested in saving psychiatry from itself) and his failure to cite the wave of articles and books over the past few years fundamentally challenging the model. Nugent, like so many others, doesn’t really seem to care very deeply about whether or not these diagnoses and this model are false, about whether psychiatry is dishonest. Even when he discusses probably the most obvious and obviously harmful example of corruption – Joseph Biederman - he breezes right past it with little evident concern.

** Nugent doesn’t appear to appreciate that he’s not actually sympathetic to Frances’ position here, because what he’s describing isn’t Frances’ position. I haven’t read his book, but it’s plain from Frances’ other public writings and statements that he believes that at the core of biopsychiatry is truth – he thinks that about 5% of the population (of the US or the entire world, I’m not sure) has a “real” mental “disorder.” He opposes “diagnostic expansion,” but this isn’t the same as an admission that biopsychiatry is based on a false model. But only if you recognize that it is can you talk about the benefits, drawbacks, and ethics of deception, as Nugent does.

(Frances is an interesting case. In this recent Al Jazeera interview, he seems to dodge the questions about the scientific basis for psychiatric diagnoses. He refers to them here and elsewhere as “constructs,” but leaves the implication hanging that the constructs capture a physical pathology, which is precisely the point in contention. It’s just impossible to tell how much of this is evasiveness and how much self-delusion.)

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