HOORAY! VETO!

In a week when Minnesota has become the 12th state to recognize same-sex marriage and biopsychiatry has finally started to receive its comeuppance, Will Potter reports that

Tennessee Governor Bill Haslam has vetoed a bill that would punish whistleblowers who expose animal welfare, environmental, and workers’ rights abuses on factory farms and slaughterhouses. It’s a huge victory for Tennesseans, but it also has national significance. The tables have turned on Big Ag, and corporate front groups are desperately trying to pick up the pieces of the worst PR blunder in the industry’s history.

(And may Andy Holt’s statement be preserved for history.)

Haslam received thousands of calls and emails, and Potter’s online petition against ag-gag laws has gathered over 100,000 signatures.

Next up: North Carolina’s SB 648, the “Commerce Protection Act.”

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.

Today offers alternative perspective on AGW from the Heartland Institute

Before they attended to the real news - about Prince Harry - Today did a short piece this morning on catastrophic global warming. To offer a contrary perspective, they showed part of an interview with denialist Jay Lehr, introduced by something along the lines of “But not all scientists agree.” Way to cover science, NBC.

Long Time Gone

Truth vigilantes, they aren't

And the New York Times continues its proud tradition of uninvestigative journalism.*

Patients and parents concerned about mental illness have every right to be confused.

Stop referring to people experiencing psychological distress or exhibiting behaviors labeled abnormal or disruptive as “patients.”

The head of the federal agency that finances mental health research has just declared that the most important diagnostic manual for psychiatric diseases lacks scientific validity and needs to be bolstered by a new classification system based on biology, not just psychiatric opinion. The hitch is that such a biology-based system will not be available for a decade or more.

No, the hitch is that it won’t be available. The evidence compiled over the past 50 years leads to no other reasonable conclusion. There is a better possibility that Saddam Hussein’s WMDs are going to turn up. You should question Insel about why he holds such unwavering faith in the biopsychiatric model in the face of several decades of evidence that does not support it.

Dr. Thomas Insel, director of the National Institute of Mental Health, posted his critique of the manual in a “Director’s Blog”on April 29 and expanded on his reasoning in a recent interview with The New York Times. He was critiquing a forthcoming revision of the American Psychiatric Association ’s Diagnostic and Statistical Manual of Mental Disorders, the first major reissue since 1994. Although there have been controversies over particular changes in diagnostic descriptions, he said, the new revision involves “mostly modest alterations” from its predecessor.

This is important. It points to the fact that the problem goes deeper than this edition of the DSM.

The psychiatric association’s diagnoses are mostly based on a professional consensus about what clusters of symptoms are associated with a disease, like depression, and not on any objective laboratory measure, like blood counts or other biological markers. The mental health institute says scientists have not produced the data needed to design a system based on biomarkers or cognitive measures.

This isn’t something the institute “says.” It’s not a matter of opinion – it’s a claim of fact. It’s your job to investigate the truth of that fact claim, not simply to repeat it and then repeat contrary statements and spin. If you were to do so, you would find a hint in David Kupfer’s admission. You would find that he was compelled to make this admission at long last because the reality is that they don’t have the scientific evidence to support their diagnoses. The diagnoses lack scientific validity. The model is not supported by science. That’s quite a shortcoming.

You would also find that all of the hedging spin you typically, lazily repeat does not accord with the truth. The diagnoses aren’t “mostly” based on consensus. They’re not approximations, imperfect, or inexact. The problem isn’t diagnostic inflation or abuse, and it isn’t “overmedication.” It isn’t a lack of training in “proper” diagnosis. The core problem isn’t the medicalizing or misdiagnosing of the “normal.” The problem is that the diagnoses lack scientific validity. The model is not supported by science.

To fill the gap, the agency started a program two years ago to finance research in biology, genetics, neuroscience, cognitive science and other disciplines with the ultimate goal of helping scientists define disorders by their causes, rather than their symptoms.

There is no gap. There is a set of invalid diagnoses based on a false model.

The underlying problem is that research on mental disorders and treatment has stalled in the face of the incredible complexity of the brain.

It hasn’t stalled. Or slowed. Or stagnated. Scientifically, biopsychiatry has been a failure from the start.

That is why major pharmaceutical companies have scaled back their programs to develop new psychiatric drugs; they cannot find new biological targets to shoot for.

There are no old biological targets. There are no biological targets. There are decades of propaganda convincing people that there are biological targets, but there aren’t in fact biological targets.

And that is why President Obama has started a long-term brain research initiative to develop new tools and techniques to study how billions of brain cells and neural circuits interact; the findings could lead to better ways to diagnose and treat psychiatric illnesses, though probably not for many years.

There are better ways to understand and address psychological distress right now. Of course, it isn’t difficult to improve upon a false model. And stop referring to “psychiatric illnesses” and “symptoms” when the whole purpose of your editorial statement is to respond to the growing recognition that there is no scientific evidence of psychiatric illnesses.

Meanwhile, the diagnostic manual remains the best tool to guide clinicians on how to diagnose disorders and treat patients. Consensus among mental health professionals will have to suffice until we can augment it with something better.

Bullshit. Your job is not to prop up biopsychiatry or the pharmaceutical industry. It’s to find and report the truth. It’s bad enough that you’re stragglers in uncovering this epic medical and human rights scandal. The least you could do at this point is grow some semblance of a journalistic spine.

*OK, I actually think it’s a good and worthwhile paper in many ways. But I’m angry at the moment.

UK clinical psychologists call for abandonment of biopsychiatry

“I believe there is nothing more important that a professional body can do than speak the truth about the evidence – and that is what this statement does.” – Lucy Johnstone

Tomorrow,

the UK Division of Clinical Psychology, a sub-division of the British Psychological Society, will issue a Position Statement…which calls for the end of the unevidenced biomedical model implied by psychiatric diagnosis.

There are two articles about this positive development in the Observer, neither of which, unfortunately, is very good and both of which irresponsibly mislead in both their headlines and actual content. Lucy Johnstone’s post at Mad in America (MIA will make the text of the position statement available tomorrow morning) is a better introduction.

The basic position of the DCP parallels my own:

The main difference – and of course it is a crucial one – between the position of these eminent psychiatrists [those who’ve recently publicly acknowledged the lack of validity of psychiatry’s diagnoses] and the DCP is that the former are determined to pursue the biomedical model at all costs. Indeed, NIMH has…announced the intention of launching a 10-year programme to pin down, once and for all, the elusive biomarkers that have evaded researchers so far. The project starts from the remarkably unscientific position of assuming what needs to be proved: in their words that ‘mental disorders are biological disorders.’ Flawed as this enterprise is, it will allow traditionalists to continue to claim that ‘We’re getting there – honestly!’ In the meantime, the overwhelming amount of evidence for psychosocial causal factors is once again relegated to a back seat.

We’re in a moment of extraordinary opportunity. It won’t help to listen to the self-serving claims that abandoning a false, unscientific, and harmful model is dangerous and that there is no alternative. There has long existed an alternative in the form of a radical humanist (or post-humanist) reality-based psychology/psychiatry. While the movement claims no absolute consensus or single direction, there’s a rich tradition of thought and practice to draw from (including but of course not limited to Fromm) that can point the way toward a revolutionary transformation of our understanding of and approach to psychological well-being. It’s an exciting time.

Habeas Porpoise? Really?

Oh, who am I kidding? Of course I love it.

Arie Trouwborst, Richard Caddell, and Ed Couzens, whose article about the orca Morgan in Transnational Environmental Law I mentioned previously, have a follow-up post at the Cambridge journals blog.

The Amsterdam District Court reviewed the previous decision, yet after consideration upheld the finding that Morgan’s transfer was legitimate. We consider this verdict to be demonstrably legally flawed. The Court based its determination primarily on a surprising appraisal of the ASCOBANS text, finding that a removal of an orca for rehabilitation purposes did not constitute “intentional taking” (such taking being precluded under the treaty). Moreover, the Court considered that enduring captivity was justified by the need to conduct research pursuant to obligations under ASCOBANS. This is deeply perplexing, since ASCOBANS does not consider permanent captivity for research (or any other) purposes acceptable. The judgment remains highly unsatisfactory in the light of these and other treaty obligations, while the Court seemingly ignored evidence that the facility to which the orca had been transferred does not engage in substantive research into cetacean ecology.

It must have been difficult for people to keep a straight face while arguing that Morgan’s captivity at Loro Parque was about research. It’s very obviously a theme park in which animals are exploited for human entertainment.

Democracy and more democracy (US style)

Yesterday, former US-backed dictator Efraín Ríos Montt was convicted of genocide in Guatemala.



Corey Robin reminds us that Ríos Montt found a strong ally and supporter in Ronald Reagan, who didn’t hesitate to praise him as “a man of great personal integrity . . . totally dedicated to democracy.”

In continuing democratic developments, FAIR has a piece criticizing Paul Richter’s Los Angeles Times article about The Bolivian government and several others expelling USAID from their countries. I’ve been talking about how shamelessly the corporate-mainstream media spins news about Latin America, and particularly those movements and governments that oppose US imperialism (here’s more). I expected to find, and did find, that reports of Evo Morales’ announcement of the expulsion follow this pattern:

They repeat the same phrases and tropes. They present the story as “Morales accused the US government of imperialistic and antidemocratic interference; US officials vehemently denied the allegations and talked about how wonderful their motives and actions are in the country,” and leave it at that. They give little voice to Bolivians. They present little or no historical or contemporary context. They undertake no independent investigation of the actions of USAID in the region.* They imply that the expulsion was an impulsive reaction to John Kerry’s calling Latin America “our backyard”…

But Richter’s piece – “USAID develops a Bad Reputation Among Some Foreign Leaders” - is another story. The article reads like planted PR spin from the State Department or the CIA, like Office of Public Diplomacy-type propaganda that isn’t even trying to disguise itself as a news report. (And it’s indicative of the sorry state of affairs in US journalism that these can be so indistinguishable.)

Richter “reports”:

USAID "threatens our sovereignty and stability," the eight-nation Bolivarian Alliance of the Americas fumed in June in a resolution that accused the United States of political interference, conspiracy and "looting our natural resources."

The problem is USAID doesn't just try to boost economies, healthcare and education in poor countries. It also spends about $2.8 billion a year teaching campaign skills to political groups, encouraging independent media, organizing fair elections and funding other grass-roots activities intended to promote democracy and human rights.

Some foreign leaders view those American efforts as thinly veiled attempts to weaken the status quo or even engineer a change of governments.

"A lot of governments are nervous about this growth in civic participation they're seeing," said Thomas Carothers, vice president at the nonpartisan Carnegie Endowment for International Peace. "When it's connected to foreign governments, it's even more unsettling — maybe subversive."

Their anxieties were intensified by George W. Bush's aggressive advocacy of a "freedom agenda," which called for democratic transformation in the Arab world, and President Obama's support for the 2011 "Arab Spring" revolts that toppled or challenged leaders in the Middle East and North Africa.

Sure, Richter. They hate our promotion of democracy.

* And when they do, they fail to pursue even the information the agency provides them:

In a 2010 Freedom of Information Act request, The Associated Press asked USAID for descriptions of the Bolivian recipients of grant money. The response did not go into detail but did include such items as $10.5 million for "democracy-building" awarded to Chemonics International in 2006 "to support improved governance in a changing political environment."

A related USAID brochure said components of the three-year "Strengthening Democratic Institutions" program included "teaching basic citizenship principles and skills" in all of Bolivia's nine states, including the lowlands opposition stronghold of Santa Cruz.

Here’s a bit more detail.

Atheists might appreciate this analogy

Of Insel’s recent actions:

Some people have likened this to a ‘revolution’….

Rather I think that this ought to be seen as a Reformation, as in Protestant….

We have an old, hegemonic institution, once revered but increasingly regarded as sclerotic – the DSM system / Catholic Church. This institution is, in theory, the one true embodiment of an idea – biological psychiatry / Christianity. But along comes a critic who believe in the idea, perhaps more fervently than ever, but want to reform the institution that they believe has failed its mission – Thomas Insel / Martin Luther.

Quite.

I don’t think Neurocritic realizes just how appropriate that analogy is.

criminal tendencies

Eduardo Galeano has a new book out – Children of the Days: A Calendar of Human History.



It features an entry for each day of the year. Here’s the one for February 15:

More Stolen Children

‘Marxism is the worst form of mental illness’, ruled Colonel Antonio Vallejo Nájera, psychiatrist supreme in Generalissimo Francisco Franco’s Spain.

He had studied Republican mothers in prison and proven that they harbored ‘criminal tendencies’.

To defend the purity of the Iberian race, threatened by Marxist degeneration and maternal delinquency, thousands of newborns and infants, children of Republican parents, were kidnapped and plopped into the arms of families devoted to the cross and sword.

Who were those children? Who are they, so many years later?

No one knows.

Franco’s dictatorship falsified the records to cover its tracks and ordered everyone to forget: it stole the children and it stole their memory.

Fine, so it’s not valid. It’s still useful!

What good is a psychiatric label?

As I’ve been reporting, biopsychiatry’s proponents have in recent days publicly admitted that their diagnoses lack validity. It’s not a new realization on their part. As one blogger describes:

The reaction to the 1970s crisis of American psychiatry was to use claims about the ‘reliability’ of diagnosis to strengthen the profession’s ‘scientificity’ in appearance but not reality.

What they’ve done, in effect, is play the game of using the alleged reliability of their diagnoses to imply or suggest validity,* and they’ve been remarkably successful at it for several decades. But this pretense has faced growing challenges, leading to the public admissions of the past couple of weeks.

The champions of biopsychiatry certainly recognize the significance of any public recognition of the validity problem - if they didn’t, they wouldn’t have spent decades trying to hide it. Now, however, they’re attempting to argue that a lack of validity isn’t really a fatal flaw for a psychiatric diagnosis. A recent New York Times article – “Psychiatry’s Guide Is Out of Touch With Science, Experts Say” – quotes NIMH head Thomas Insel stating that, while his agency will abandon these categories as invalid,** “his motivation was not to disparage the D.S.M. as a clinical tool.” In the interview, he calls the DSM “the best tool now available for clinicians treating patients” and says it “should not be tossed out.”

While they faithfully hold to their assumption that their bold “new” biopsychiatric research program will produce useful diagnoses, these people know that they have none to offer at present. So they’re left to assert that what exists must be useful. Michael First, also quoted in the article, claims that while NIMH’s RDoC “is clearly the way of the future,” it “can’t do what the D.S.M. does. The D.S.M. is what clinicians use. Patients will always come into offices with symptoms.” This comports well with the APA’s spin - as David Kupfer put it (quoted in my earlier post): “DSM, at its core, is a guidebook to help clinicians describe and diagnose the behaviors and symptoms of their patients. It provides clinicians with a common language to deliver the best patient care possible.”

So these are the arguments used to support the continued reliance on the DSM: people continue to experience psychological problems, it’s what physicians use in understanding these problems, it’s reliable, and there’s no available alternative. Added to these is a very real concern about the denial of legitimacy and care to people who aren’t officially diagnosed using these categories. Despite its fundamental lack of validity, then, it’s claimed that the DSM remains a useful clinical tool.

The first of these arguments is correct: it is overwhelmingly used in psychiatric diagnosis. The claims about reliability and nonexistent alternatives are not accurate, and rest on a series of problematic assumptions. For the sake of argument, though, let’s assume that all of these claims are sound, and evaluate the basic case for continuing to recognize the DSM “diagnoses.”

Obviously, the fact that physicians use a tool doesn’t make it clinically useful. Nor does the fact that it serves the function of matching people to drugs or other interventions. The distinction between usefulness to pharmaceutical corporations, psychiatrists or psychologists, the criminal justice system, and so on and usefulness to people experiencing problems has to be maintained. The system is not the client.

The third argument is the most astonishing. What they seem to be saying is that since people continue to experience psychological distress or exhibit behaviors deemed undesirable (I’m not playing along with their “patient” and “symptom” language), and the DSM provides a reliable means of classifying these experiences or behaviors, that makes it a useful clinical tool. How would his work, precisely?

The purpose of a clinical diagnosis, as I understand it, is to identify a real condition so as to facilitate effective treatment. But a diagnosis that isn’t valid, that doesn’t identify a real condition, is just a gratuitous label. How is that useful as a clinical tool? It’s interesting how often the DSM is described as psychiatry’s “Bible,” because a similar set of diagnostic classifications could be derived from the literal Bible. A reliable diagnosis of Bipolar, for example, could be replaced by a reliable diagnosis of Demonic Possession. I can’t imagine that anyone reasonable would contend that this would be a clinically useful diagnosis for the person so labeled. The same could be said about reliable diagnoses based on different chakra imbalances or what have you.

It seems plainly that the “clinical” function of the diagnostic labels is to prop up belief in the biological model and promote the drugs. What we’re talking about in psychiatry is a simulacrum of medical diagnosis. We can see this if we imagine what prescribing the drugs would look like if everyone knew and understood that the diagnoses were invalid. Many other interventions can happen without labels, but psychopharmacology pretty much requires them.***

The last argument - that we should be concerned about people not receiving needed help or respect if these diagnoses are scrapped - is an important one, if irrelevant to the question of their usefulness as clinical tools. The system is set up around invalid diagnoses. But the response to that fact isn’t to retain those labels in order to preserve the system but to abandon them - and the larger obsession with medical models - and create a system in which people can receive help and respect without having to adopt a pseudoclinical label. (Not least because the diagnoses don’t contribute to effective interventions and their actual effect is to stigmatize and delegitimize people’s experiences and their sociopolitical concerns.) That system would look very different.

* I like Marcia Angell’s simple description of the difference between reliability and validity:

The DSM-III was almost certainly more ‘reliable’ than the earlier versions, but reliability is not the same thing as validity. Reliability…is used to mean consistency; validity refers to correctness or soundness. If nearly all physicians agreed that freckles were a sign of cancer, the diagnosis would be ‘reliable’, but not valid.

** One Boring Old Man sums up Insel’s likely motive:

Dr. Insel hears a great sucking sound over at the APA offices and he’s trying to get out of its way before it sucks him down with it. His NIMH was a major partner with the APA in the DSM-5 conferences and planning. His RDoC was born in that failure as a way to keep the dream alive when the APA failed.

The Times piece notes another consideration: “[Insel] added that he hoped researchers would also participate in projects funded through the Obama administration’s new brain initiative.”

*** This isn’t to imply a one-to-one matching of diagnosis to drug. It works much more profitably as organized now: around the notion that one drug can treat multiple disparate disorders and a single disorder might respond to several different drugs.

The Butcher of Bariloche

The Butcher of Bariloche

The perfect escape
this Fitzroya gothic village
old friends meet
for days of mythic forgetting
in the steeled bliss
of Priebke’s delicatessen

“America happens to be my client”

The short documentary Doctors of the Dark Side does a better job of documenting the history of health care professionals involved in torture since 9/11 than of examining their mentality, but one featured quotation does stand out. It’s from a 2009 NPR interview with Dr./Capt. Bryce Lefever, Joint Special Forces Psychologist in Afghanistan and majority member of the American Psychological Association’s PENS Task Force, which approved members’ participation in interrogations.*

America happens to be my client. America is- and Americans are who I care about. I have no fondness for the enemy, and I don’t feel like I need to take care of their mental health needs. Producing some pain just seems to be - you know, at first you blush – something that would be wrong, because we ‘do no harm’. But if it does the most good for the most people it’s, it’s entirely ethical. And to do otherwise would be unethical.

* This was later overturned by the organization:

The APA’s response to the NIMH announcement: a Spin-to-English translation

Statement by David Kupfer, MD

Chair of DSM-5 Task Force Discusses Future of Mental Health Research

The promise of the science of mental disorders is great.

Hey – look over here, to the wondrous FUTURE! SCIENCE! Pay no attention to the present exposure of our diagnoses and model as a sham!

In the future, we hope to be able to identify disorders using biological and genetic markers that provide precise diagnoses that can be delivered with complete reliability and validity. Yet this promise, which we have anticipated since the 1970s, remains disappointingly distant.

OK, we admit it. Our diagnoses are invalid. Our model is false. Oops.

But still…the FUTURE!

We’ve been telling patients for several decades that we are waiting for biomarkers. We’re still waiting.

We haven’t actually been telling people this at all. We and our friends at the pharmaceutical corporations have been leading people to believe for decades that our diagnoses reflected brain disorders for which we had scientific evidence. The chemical imbalance myth? Ours. And we’ve grown rich and powerful in the process. Where would we be if we’d been open all along about how unscientific our diagnoses are?

In the absence of such major discoveries, it is clinical experience and evidence, as well as growing empirical research, that have advanced our understanding of disorders such as autism spectrum disorder, bipolar disorder, and schizophrenia.

Please continue to ignore that the biomarkers we’ve encouraged you to believe in for the past several decades don’t exist. You know that clinical experience you reject when anti-vaccination activists try to use it? Well, that’s what we’ve got. Oh, and some other empirical research we don’t have to tell you about. But it’s growing. And by growing, we mean unreplicated.

This progress will soon be recognized in the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5).

What progress, you ask? The progress we just mentioned. Isn’t that enough?

The new manual, due for release later this month, represents the strongest system currently available for classifying disorders. It reflects the progress that we have made in several important areas.

• A revised chapter organization signals how disorders may relate to each other based on underlying vulnerabilities or symptom characteristics.
• Disorders are framed in the context of age, gender, and cultural expectations, in addition to being organized along a valuable developmental lifespan within each chapter.
• Key disorders were combined or reorganized because the relationships among categories clearly placed them along a single continuum, such as substance use disorder and autism spectrum disorder.
• A new section introduces emerging measures, models and cultural guidance to assist clinicians in their evaluation of patients. For the first time, self-assessment tools are included to directly engage patients in their diagnosis and care.DSM, at its core, is a guidebook to help clinicians describe and diagnose the behaviors and symptoms of their patients. It provides clinicians with a common language to deliver the best patient care possible. And through content such as the new Section III, the next manual also aims to encourage future directions in research.

None of this addresses the basic invalidity of our diagnoses in any way, but it is a lot of words. And our references to disorders and clinicians sound sciencey, don’t they?

Efforts like the National Institute of Mental Health’s Research Domain Criteria (RDoC) are vital to the continued progress of our collective understanding of mental disorders.

If we keep saying things like “continued progress,” will you keep believing us?

But they cannot serve us in the here and now, and they cannot supplant DSM-5.

DSM-5 is the best currently available invalid, pseudoscientific manual. I think we can all agree that we need an invalid, pseudoscientific manual, and ours can’t be beat.

RDoC is a complementary endeavor to move us forward, and its results may someday culminate in the genetic and neuroscience breakthroughs that will revolutionize our field.

You know – those breakthroughs you all thought happened decades ago and formed the basis of our model.

In the meantime, should we merely hand patients another promissory note that something may happen sometime? Every day, we are dealing with impairment or tangible suffering, and we must respond. Our patients deserve no less.

Look, we need you to keep believing this isn’t quackery. Our profession’s status, millions in grant funding and proceeds from our book, and billions in drug sales depend on it. Please continue to believe that there’s no alternative to our pseudoscience.

“Decades of negative results”: the failure of psychiatric genetics

My post the other day discussed how admissions from prominent proponents of biopsychiatry that should be devastating to the enterprise are framed such that they not only avoid directly challenging the brain-disease model but continue to prop it up. This is accomplished through hedging about the invalidity of the model by making or repeating unsupported claims that it’s merely a partial or simplified but still real and important aspect of a more complex reality and by diverting people’s attention with (also unfounded) suggestions that, whatever its scientific shortcomings, the model has been individually or culturally beneficial.

The final element in this spinning of biopsychiatric failure is the repeated presentation of fantastical futuristic scenarios in which new lines of research will provide scientific grounding to the model and vindicate it. This is almost always combined with the implication that recent discoveries have demonstrated this potential to rebuild biopsychiatry on a new, but vaguely related, biological foundation.

What strikes me most about these projections is, for one, their childlike enthusiasm and overconfidence. Here’s a portion of one such dream I quoted yesterday:

“I hope I'll be able to give a patient with possible bipolar a proper clinical assessment,” Craddock says. “I'll do a blood test and look for genetic risks and send them into a brain scanner and ask them to think of something mildly unhappy to exercise their emotional system.” The results could be used to trace the underlying cause — such as a problematic chemical signal in the brain. “I'll then be able to provide lifestyle advice and treatment.” He pauses. “Actually it won't be me, because I will have retired by then.”

The possibilities, and even probabilities, claimed for genetic psychiatry seem to know no bounds. And the sense of tangible promise is heightened by its presentation as cutting-edge area of research where exciting discoveries are now being made, awaiting only the technological and intellectual capacity to convert them into powerful to clinical therapies.

But peel back the rhetorical façade and we find that psychiatric genetic research isn’t new at all. It’s been ongoing for decades, and its record is as dismal and disappointing as that of biopsychiatry itself. (This shouldn’t be surprising when we understand the fundamental flaws in the brain-disorder model itself: people are looking for genetic causes of constructs for which there’s no evidence of a real biological basis in the first place.)

So the very lines of research proclaimed as biopsychiatry’s best new hope are really just part of the same sorry history of disappointed expectations. And this isn’t news, either. A recent book chapter by Jay Joseph and Carl Ratner* (full text available here) tells this story of failure. They describe a 2012 meta-analysis by Neil Risch et al.:

Risch and colleagues concluded that ‘few if any of the genes identified in candidate gene association studies of psychiatric disorders have withstood the test of replication’. They further concluded:

Despite progress in risk gene identification for several complex diseases, few disorders have proven as resistant to robust gene finding as psychiatric illnesses. The slow rate of progress in psychiatry and behavioral sciences partly reflects a still-evolving classification system, absence of valid pathognomonic diagnostic markers, and lack of well-defined etiologic pathways. Although these disorders have long been assumed to result from some combination of genetic vulnerability and environmental exposure, direct evidence from a specific example has not been forthcoming.

Thus the fields of behavioral genetics and psychiatric genetics are rapidly approaching a period of crisis and reexamination. In the words of a leading group of psychiatric genetics investigators, writing in 2012 about the decades-long failure to uncover any genes that cause schizophrenia (the most studied psychiatric disorder), these negative results ‘suggest…that many traditional ideas about the genetic basis of SCZ [schizophrenia] may be incorrect’.

Joseph and Ratner note that “[T]hree genetically oriented Nobel Prize-winning researchers and their colleagues, in a 2010 Science ‘Policy Forum’ article, recognized the ‘frustrating lack of progress in understanding the genetics of mental disorders'.”

It’s fascinating: the fields that are supposed to rescue biopsychiatry are themselves in full crisis. But, as in biopsychiatry more generally, people have failed to recognize or appreciate the scientific significance of the “decades of negative results” in psychiatric genetics. This failure to discover genetic factors is interpreted, based on assumptions drawn from earlier kinship studies, as the problem of “missing hereditability.” Joseph and Ratner’s goal in their chapter is “to suggest that the misreading of previous kinship studies of families, twins, and adoptees has led the scientific community to the premature conclusion that genes for psychiatric disorders and psychological trait variation must exist.” They argue for dropping the assumptions about missing hereditability based on these kinship studies, arguing that the reasonable interpretation of the failure of decades of research in psychiatric genetics is nonexistent hereditability.

It’s not the purpose of their chapter, but it’s worth noting that Joseph and Ratner – like Erich Fromm, but unlike biopsychiatry’s enthusiasts like the one quoted above** – think about the social and political significance of our approaches to human problems, “not only scientific and social issues that form the assumptions that guide this work but also the scientific and social consequences of this work.” They appreciate that, as I argued in my earlier post, the continuing emphasis on genetic psychiatry serves socially to buttress the notion “that these disorders have biochemical causes, and that psychology has biochemical causes,” and vice versa. They’re also attuned to the fact that “[g]enetic-determinist ideas divert society’s attention from these environmental conditions and shift blame onto people’s brains and bodies.” Their hope is that “research into these issues will support the rejection of the genetic paradigm of psychiatric disorders and will give grounds for an alternative paradigm that emphasizes the role of familial, social, cultural, and political influences.”

* Joseph, J., and Ratner, C. 2013. “The Fruitless Search for Genes in Psychiatry and Psychology: Time to Reexamine a Paradigm.” In S. Krimsky and J. Gruber (Eds.), Genetic Explanations: Sense and Nonsense (pp. 94-106). Cambridge, MA: Harvard University Press.

** It’s interesting how profoundly politically naïve and unthinking these futuristic biopsychiatrists appear. It’s almost as though they’ve never given a moment’s thought to the human implications of their model, either as current practice or as a future clinical possibility. It’s adjustment psychiatry carried to its antihumanistic extreme.