Sunday, 9 November 2014

A Response to Wessely: Why We Don't Need More Psychiatry.

Welcome back to The Philosophy of Psychiatry magazine. In this article, I will investigate a recent post titled, "The Real Crisis in Psychiatry is that There Isn't Enough of It" by Simon Wessely, a Professor of Psychological Medicine at King's College London. 

Before I begin unpacking Wessely's article, please consider reading Wesseley's full article here. 

Back at it.

Wessely opens his treatise with:

"Psychiatry is apparently in crisis – again. On the one hand, psychiatrists are agents of social control, carrying out society’s bidding to ensure that the socially deviant are kept locked up out of sight and mind. And, despite having little idea of what causes the disorders they claim to treat (which some critics claim don’t exist), they remain set on medicalising more and more aspects of human existence. More still, psychiatry is a pawn of the pharmaceutical industry, peddling drugs that either don’t work or make you worse."

On the first claim, that psychiatry is apparently in a crisis again, I must agree. Psychiatry is in a crisis, so the word 'apparently' can be dropped from his opening line. But, psychiatry is not in a crisis because of the reasons he then cites quite cheekily, I might add. The criticisms against psychiatry are not a joke, as his tone suggests. While it is true that psychiatry has been accused of such things as being the 'agents social control', that highly qualified academics argue the validity of many psychiatric diagnoses, and that psychiatry has been accused of having a less than ethical relationship with pharmaceutical interests, such criticisms have all been mounted against psychiatry for very good reason. 
On the first count of social control, I can point to the MK Ultra 'study' performed in the 1960s by Dr. Cameron. When it comes to questioning the validity of psychiatric diagnoses, all I have to do it point to the happenings of December 1973, when psychiatry - after a rather long meditation on the matter - had decided to remove homosexuality from the DSM, effectively 'curing' millions of gay people. Or, one could point to The Rosenhan Experiment, an experiment that effectively 'un-pantsed' any credulity psychiatry could ever claim to have with respect to diagnostic validity. And finally, when it comes to the unhealthy relationship with pharmaceutical interests, all one must do is point to the ongoing litigation mounted against pharmaceutical interests and subsequent undoing of the 'monoamine hypothesis' for the explanation of depression. Or that psychiatric drugs make up half of the top ten largest pharmaceutical settlements for misrepresentation. These are just brief examples of why anyone would decide to criticize psychiatry. 

So ample justification is awarded for there to be serious criticism of psychiatry. And it's not to be taken lightly. 

Wessely then states: 

"The thing is, none of these claims are either new, or radical. Look up “psychiatry in crisis” on Google. And then stand well back. Since I started my psychiatry training in 1984, not a year has passed without a clutch of articles, papers and opinion pieces discussing this “crisis”. A random selection of articles shows that we have been in crisis because of recruitment (1982), lack of political clout (1984) and public image (1985). In 1997 The Lancet published an article on perceived biological bias. A few years later in the British Journal of Psychiatry it was for not being biological enough … You get the picture."

Again, I agree with Wessely's opening sentence; however, the way in which he attempts to use this claim is unclear. Although he claims that these criticisms of psychiatry are not 'new or radical', I am tempted to wonder why he would even bother to insinuate that they could be. Again, given the ongoing problems and shifting epistemic belief shifting in favour of that psychiatry is not exactly veracious or 'scientific', it is not surprising that there would be significant criticisms mounted at it. The only explanation I could find for Wessely's use of language is to think he is attempting to say that criticizing psychiatry is a mundane act and unoriginal, as if any criticisms against psychiatry shouldn't be taken seriously just because they are so well rehearsed. I tend to think that while he may be correct in stating that the criticisms mounted at psychiatry are not radical and I do think it is because they are becoming the belief of the consensus. But again, Wessely is unclear so I will not endanger my retort by erecting a Straw Man fallacy by assuming the intention or argument of the author, I will instead leave this section open for interpretation. 

Wessely then concludes his opening with: 

"The launch of another revision of the Diagnostic and Statistical Manual (DSM-5), the American handbook for classification, precipitated an outpouring and claims of a “deep” and “recurring” crisis, while a letter in World Psychiatry this year at least concluded that there was still hope for us."
Again, there is not much to disagree with here. The DSM-5 did cause a massive outpouring of criticisms mounted against psychiatry that continues to validate the historical the criticisms that there is questionable validity behind its diagnoses, and that the DSM has become a vehicle to make prescription of psychiatric drugs easier. 

So far, so good. Considering the opening I have only minimal dissent with Wessely's article. 

Wessely goes on to argue: 

"Yes, psychiatrists do detain patients (as do social workers, and indeed psychologists). In May 2014, 11,965 people were detained in hospitals under the Mental Health Act. However, in the same month, 963,769 people were in contact with secondary mental health services. In other words only 1.2% of those being managed by psychiatric services were detained.
Any humane society has a duty to try and look after its citizens when, as a result of a mental disorder, they pose a serious risk to themselves or others. And if this is the case, then it is better that it is sanctioned by law and implemented by health professionals, rather than by vigilantism and mobs. True, we don’t have the balance right yet, but not in the way the “crisis” lobby would have you believe. Take jail, for example, there are far too many people in prison with serious mental illness – not too few."

This is where the rails and Wessely's wheels lose contact.

I am less concerned with the first paragraph as I am with the second. The first paragraph attempts to state that 'sectioning' people is not just the work of a psychiatrist but that psychologists and social workers do this also. This is an attempt to state that psychiatry ought not be demonized because they are not the only ones detaining people. But what Wessely fails to mention is that this practice is highly equivocal in any case, not dependant on who does it. The argument that just because psychiatrists are not the only ones who do this does not imply it is uncontroversial. Nor does it discharge the fact that psychiatry does most of it.

Now for the second paragraph:

I can't disagree with the claim that a human society has a duty to try and look after its citizens in any case. But where Wessely loses credibility in this claim is where he draws the conclusion that the so-called mentally disordered are taken care of by health professionals than by vigilantism and mobs. Of course I agree that people with so-called mental disorders should be helped, perhaps even by health professionals, but I'm not sure if it is because the alternative is to save them from vigilantism and mobs. I have to disregard Wesseley's argument in this case as hyperbolic and illogical. Furthermore, in many jurisdictions (including the one in which I am a senior policy advisor for a Ministry of Health) there has been a move away from psychiatric services in favour of a more comprehensive model of care. So when Wessely says, "health professionals" I hope he means 'psychologists, social workers, dieticians, personal trainers, mindfulness coaches, peer advocates and spiritual leaders', not just psychiatrists. But given the title of the article, "The real crisis in psychiatry is that there is not enough of it" does not lend to this conclusion.On the final account, that there are too many people imprisoned with so-called mental illnesses, I concur, but I can't decide which form of imprisonment is 'better', that of prison in the truest sense or sectioning in psychiatric wards, a close relative of the former.

Here is where Wessely starts to talk about treatments:

"Treatments are certainly far from perfect. But no more than in the rest of medicine; a recent review showed that treatments used by psychiatrists, both physical and psychological, compare well to treatments in routine use in other branches of medicine."

This is a seemingly simple paragraph mired in incredibly complex philosophical problems, not to mention problems in data reporting and the problem of where psychiatric clinical data comes from and who conducts it
For one, treatments being far from perfect is a vast understatement. This is because the notions of 'perfect' and 'treatment' are highly ambiguous and subject to endless interpretation. So Wessely's use of the word 'perfect', I argue, is a red herring. A reasonable person would not expect a treatment to be 'perfect' if they knew the problems underlying the task of defining perfection. But a lot of people might not detect this philosophical problem and gloss over it as if we ought to expect medical interventions to be any version of what any person considers 'perfect'. So on the first account, the argument from 'perfection' is rendered flaccid. I think, but cannot assume, that Wessely might have intended to  use the term 'effective' in the place of 'perfect'. Perhaps he used perfect instead of 'effective' as the notion of 'perfection' may draw less criticism as it is difficult to state that psychiatric treatments are in fact 'treatments' in terms of effectively treating the cause of the alleged psychopathology. Again, I cannot assume what message is intended here. 
On the second account, the attempt to defend psychiatry by levelling psychiatric treatments by stating they 'compare well' to other branches of medicine is an impossible claim to establish. This is because there is no way to know if this statement is true. No one will ever know if ECT for the treatment of depression compares well to taking an antibiotic for strep throat. The two situations are completely different and ought not be compared. Furthermore, I could easily dispatch this argument stating, "because other branches of medicine are argued as imperfect does not give license to argue that psychiatry should argue that its acceptable to be imperfect." But again, this argument fails to demonstrate what 'perfect' consists of and how we ought to define it. 

Notably, the defence that psychiatry compares well to other branches of medicine is a dangerous and disingenuous claim to make given that it attempts to justify treatments and diagnoses based on the validity and efficacy of treatments in other branches of medicine. In effect this claim is stating that because oncology makes errors, we ought to be able to also - so give psychiatry a break! Yeah, but no. As stated previously, there is sufficient cause to criticize psychiatry based on the veracity of its claims and the 'perfectness' of its treatments. After all, given 60+ years of psychiatric interventions using antidepressants, depression - according to the WHO - will be the number one cause of disability by 2020. "Far from perfect" and "compare well to other branches of medicine" fail to convince me given this simple example. 

The appeal for psychiatry as being no different than other branches of medicine as an apology is also highly unconvincing. Consider oncology, a medical speciality that is also far from 'perfect'. Would you agree that oncology is the same as psychiatry? Would an oncologist get away with the same kind of claims defending its practice? I sincerely hope not. With oncology there has not been a never-ending expansion of nosology and diagnoses (unless based on a confirmed physiological phenomena) nor has there been an increase in the incidence or prevalence of cancer based on its diagnoses, only 'imperfect' cancer treatments that extend lives. Arguably, the diagnostic expansion and ever-increasing demographic of persons thought to be 'mentally disordered' and subsequent claims for efficacy of treatments is a magic trick only psychiatry has been able to master. 
I digress.

Wessely then claims:

"There remain doubts and uncertainties about the causes of many of the disorders we see. But this is not because we are ignorant, lazy or complacent; it is because psychiatric disorders, such as major depression, arise out of a complex set of circumstances – starting from your genetic inheritance, early upbringing, the relationships you make and the physical and psychological traumas and adversities to which you are exposed to in adult life. The issues with which we grapple are rarely simple or straightforward."

I feel sorry for Wessely after reading this paragraph. I for one do not think that psychiatrists are 'lazy, ignorant, or complacent'. Instead, I think that they fail to consider many incredibly complex philosophical problems that underlie the way in which psychiatry currently operates. Because of this lack of philosophical introspection, when psychiatry is criticized, the result is the tendency to either resort to ad hominem (or to play the 'hurt feelings card', which seems to be the flavour of Wessely's defence in this case) or defend the philosophical problems underlying psychiatry by widening the goal-posts on the arguments that defend its practices. Wessely's paragraph demonstrates this nicely. No one can argue that psychiatry can be wrong about the cause or aetiology of a so-called mental disorder given this paragraph. This is because it is effectively stating that 'everything' in a non-specific order is the cause of the problem is impossible to argue against. So what a task psychiatry has been awarded to solve with these insurmountable problems!' 
I feel sorry for them, I guess this card trick worked. 

But wait. If the message now from psychiatry is to say that 'we aren't sure', then how can it also come to the conclusions it has drawn about its so-called mental disorders? How can they defend diagnosing and prescribing drugs or other treatments if they simply do not know? Yet another act of wizardry from psychiatry. Unlike psychiatric practice you'd be hard pressed to find an oncologist who would diagnose a brain tumour without sufficient evidence. You'd also be very hard pressed to find an oncologist who would order treatment on a brain tumour without sufficient evidence. Perhaps you could find an oncologist who has made these errors, but you'd have to look long and hard. With psychiatry, you do not need to look long and hard as diagnosis and treatment in psychiatry warrant no such evidence of validation for diagnosis. And if you could find an oncologist who did such a thing, you might also find his lawyer standing at his side defending them in a case of medical malpractice, something that is less often seen for misdiagnosis and unjustified treatment in psychiatry. This is because it might be easier to prove misdiagnosis in oncology than it in psychiatry. But I may be wrong, as this case demonstrates what ought to happen with psychiatry if they want to be considered one-in-the-same as another medical speciality. See the case here.   (I have yet to understands a way in which he can prove he was misdiagnosed in this legal case...) 

"Not for us the simplicities of some other parts of medicine. Here is a cancer – take it out. There is a bug – kill it. In psychiatry, the ability to tolerate uncertainty is an essential skill. Because we have to negotiate fuzzy boundaries – between eccentricity and autism, between sadness and clinical depression, between hearing voices and schizophrenia – and there will always be boundary disputes."No disagreement here except for the questioning of and the unrelenting psychiatric need to establish boundaries. But I'll leave that philosophical problem for another day.
"Far from backing away from such debates, my experience of psychiatry is that we relish them. We are not the only branch of medicine that argues about classification – so do tumour biologists – but the difference is that the issues that we face in classification are more readily understood by the general public."

Agreed. It is not difficult to find a psychiatrist to argue with about the ills of psychiatry. But it is not unremarkable that people understand the language inherent to psychiatry. After all, in the United States people are constantly being bombarded with direct-to-consumer advertising about 'asking your doctor' about the next pill aimed at the treatment of depression. (I realize direct-to-consumer drug ads are prohibited in the UK). And I'm not convinced that psychiatric classification is 'more readily understood by the general public.' If psychiatrists can't truly understand what is and is not a certain psychiatric construct given the "complex set of circumstances" underlying any given psychiatric disorder, then how can it be assumed that a layperson can understand it? 

I'll leave it to the psychiatrists to provoke and answer that question...

"If there is a little bit of crisis, like argument and discussion it keeps us on our toes, alert to new developments, and is an antidote to complacency."Agreed. It must be exhausting being a psychiatrist, especially one who attempts to defend against the ongoing criticisms that are not 'new or radical'. 

And for the Wessely's conclusion:

"I recently took over as president of the Royal College of Psychiatrists. Since then I have had numerous interactions with patients and carers – and also a large post bag. Most of the patients and carers that I have met have been particularly grateful to mental health services; there are criticisms, but nearly all speak warmly of the psychiatrists and mental health teams that they meet. Not all letters I’ve received have been complimentary, but the main themes have not been about our services, but the lack of them."

Excellent, a sincere congratulations. 

"A frequent complaint is how long it has taken for parents to get skilled mental health assessments for troubled children. Another is how stretched services are, or how many patients don’t receive enough support to assist them staying on vital medication, without which relapse is all-too common and all-too ghastly. Others lament the lack of specialized services, at present especially in child psychiatry and addictions."I have not much to say about this paragraph except that the notion of giving children psychotropic medications. For one, psychiatry still has no idea when a drug is working and when it is not working. At best, they venture a guess and take credit for positive outcomes while usually ignoring the problems in diagnostic validity and concepts supporting efficacy of treatment when they do not work. The tendency in psychiatry is to tinker. If the unwanted behaviours or emotional suffering doesn't subside with one combination of or amount of medication, they change the medications, give them more or add more kinds, which implies 'cocktailing'. When and if the behaviour or emotional suffering subsides, they then give credit to the medications they prescribed. If not, they keep on trying various combinations. This process can be quite damaging to the patient, especially because psychiatric drugs are notable for their potentially highly troublesome side-effects. In terms of offering a conception of 'inexact science' or 'imperfect', this kind of guesswork is a 'troubled (poster) child.' Interestingly, psychiatry has tried to answer to this by devising blood tests to diagnose depression. What they failed to consider in devising these tests is that all one has to do to invalidate a diagnosis of depression based on a blood test is to say: "I'm not depressed." So it is inconclusive why a 'troubled child' as Wessely describes, should be treated with psychiatric drugs or why anyone (adult or otherwise) should be enticed to stay on drugs once started. To suggest this is the ethical way to go about things will require much more evidence and argumentation. 

But on the account of children requiring psychiatry, I can find some form of clarity on this matter by making a simple comparison. I do find it interesting how my 5-year-old child demonstrates panic at bedtime about a monster living under his bed. He believes that there is in fact a monster under his bed and fails to be convinced otherwise. Psychiatrists call this 'delusion' because there is no monster under his bed and that he cannot be convinced otherwise. Generally, we find this fear perfectly acceptable for a child of his age. However, if a 40-year-old man did the same, psychiatry would likely diagnose as 'psychotic' or 'delusional' and prescribe antipsychotic medication(s). What I find problematic from this comparison is the that psychiatry has now decided to claim that children are also vulnerable to the same psychiatric diagnostic constructs as adults and have started to prescribe them medications, as if there are no issues with adult psychiatry and that drugs for children are safe and a good idea. But I guess it is an all or nothing wager emanating from psychiatry: if you agree with biological reductionism, then what happens in one brain at one age must be able to happen in another brain at another age...
The continuing reduction in the number of beds available for crisis care is another repetitive theme: patients in severe distress been driven hundreds of miles in a desperate search for care and sanctuary.

Yes, this is a problem and not isolated to your jurisdiction. Agreed on this account, but this does not mean we ought to increase the amount of psychiatrists, but rather that we ought to help people. 

The reality of hard-pressed services struggling to cope with increasing demand and shrinking resources mocks the charge of our critics that we are engaged in a vast conspiracy to force more and more aspects of normality into needing these services.

 It is not that psychiatry's critics are suggesting directly that psychiatry is conspiring to "force more and more aspects of normality into needing these services." People who are in emotional distress will access psychiatric services if they want to.  Conversely, critics are suggesting that psychiatry has widened the goal posts to the point of arbitrariness of its diagnoses and this has resulted in many more people thinking they require psychiatric services. The result of this is a population thinking it has a psychiatrically defined mental disorder, when in fact their situation could as easily be argued 'normal'. Furthermore, it may even be that widening the goal posts on diagnosis might result in the exhaustion of psychiatric services. But lets be honest: the issue at hand here is that the entire system is a 'mugs game'. If a person arrives at a psychiatrists office in distress, it is impossible for the psychiatrist to say, "no, your self-reported symptoms don't count, go away." A psychiatrist can rarely justify doing such a thing, and it's not because they are conspiring to boost profit through clandestinely use psychiatric language to play some kind of Jedi mind trick on people. Instead it's because to decide that someone has a so-called mental disorder requires a clinical judgment alone, and by widening the scope of diagnosis, this results in a situation where it is very difficult to escape it. Once the language is in place to diagnose something, there is a temptation to use it and to think it is meaningful. So with the increase in diagnoses and proliferation of psychiatric language, the result is a kind of 'a person's 'right to having a psychiatric diagnosis'. If I have symptom 'x' and 'y' then I have psychiatric disorder 'a', and whether or not I get this diagnosis is dependant on the clinician, who will disagree with the next clinician, who will then disagree with the next clinician. So is it not best to just to go by the book, the DSM or ICD? No, because the interpretation of it cannot be standardized in clinical practice. Furthermore, it is a medico-legal problem for a psychiatrist not to diagnose with every patient for the risk that this patient might cause harm to themselves or another. Best to err on the side of caution, which is currently argued to be to diagnose and to treat...

The real crisis in psychiatry is that there isn’t enough of it.

And for the finale - I understand the final sentence not to mean what the author intends to say, 'that there isn't enough psychiatry', but instead that that 'there isn't enough crisis in psychiatry'. In either case, the latter will be realized, as the trend has been that the more psychiatry society is given, the more crisis seems to follow it. In conclusion, this response is not intended to polemicize Wessely's article so much as it is intends to show that in each instance there is significant philosophical unpacking needing to be done. 

The message I want to communicate is hat we ought not to award a psychiatrists opinion a prima facie credulity simply because the information comes from a psychiatrist. Just about everything Wessely stated in his article is open for debate and is vulnerable to opposing views.  This is the precise problem with psychiatry- that it leaves itself open for equivocation and doesn't cover up it's philosophical inconsistencies. 

As shown in his article, Wessely's kind of argumentation should be just be considered an opinion, as is also admittedly the case with my retort. But I do argue that such a treatise from a psychiatrist - "that there isn't enough psychiatry"-  is a potentially uneven claim and that his argument is not well justified. It is not that we need more psychiatry, it is that we need better explanations offering solid justifications as to why we go to psychiatry to solve the problems we task it with in the first place.