One of many differences between "shut up and calculate" in physics and "shut up and treat" in psychiatry, is that (I assume) you can get the calculations reliably right in physics even if you don't do any particular interpretations. In psychiatry, on the other hand, there's no evidence-based treatment that works for every patient with a specific diagnosis or particular symptoms. "Evidence-based" just means that a given treatment gives some measurable improvement to most people with a diagnosis, but it's still gonna be ineffective for lots. And if you refuse to theorize and interpret, all you can do is shrug and continue with your trial-and-error.
I've published and talked a lot about reality doubts. If you don't know what's real or not and this is extremely distressing, you get antipsychotics, and then you should try to "reality-test" as a complement. Whether the meds change your perception of reality to a more stable one or not must be due to brain stuff that a philosopher like me isn't equipped to figure out. But a philosopher CAN tell you at least ONE reason why reality-testing works for some people and not at all for others - every philosophers knows that you gotta take a lot for granted to even begin to prove more specific things about the reality we share. If you doubt too much or if your doubts go too deep, there's nothing you can use as a starting point for your "testing". Also, it's possible that once you have, so to speak, EXPERIENCED the kind of deep doubt that philosophers from Saint Augustine through Descartes to Wittgenstein has treated as intellectual puzzles, the MEMORY of that experience is enough to prevent you from comfortably taking reality for granted again, even if you're on meds that effectively prevents new such experiences from occurring.
Recognizing that someone suffers from this philosophical problem of knowledge and doubt can at least be a starting point for discussing how to handle it. But if you refuse to touch philosophical questions with a ten-foot pole, you're left with "uh okay, this is the evidence-based treatment but unfortunately it didn't work for you ... we'll try other things then, I'm sure we'll find something that works down the line". Or, as one psychiatrist told me when I lectured on these things, "but those are just SICK doubts. They're SUPPOSED to go away when you're on medication and you're well again."
(Btw, I'm fine not having a medical diagnosis beyond "probably somewhere on the schizo-spectrum". But I wouldn't be where I am today without all the philosophical interpretations!)
One counter argument is the need to meet patients where they are. Many don't want to have a philosophical discussion about the meaning of their illness (though some do), often they just want to be well enough to get on with their lives.
Similarly, just as clinicians work with patients who hold views completely at odds with modern medicine (fans of homeopathy, natural remedies, reiki, etc), we need to respect our patients interpretation of what their illness means. Especially if this disagrees with our own model of illness/diagnosis.
In these situations a bit of agnosticism can be helpful.
"When we leave patients to their own devices to come up with a narrative of what they are going through, we leave them at the mercy of folk biomedical narratives and folk resistance to such narratives." Psychiatry is hard. Comments here and elsewhere make it clear that it is currently impossible to agree on a cohesive narrative. And in the absence of such a narrative, folk narratives and resistance to them extend into healthcare law in harmful ways. Thirty years ago there were no obstacles to moving my father with Alzheimer's disease from home into a locked care facility--it was a family decision with no interference from the law, judges, or civil rights attorneys. My older brother recited the letters of our father's name one-by-one and our dad, perhaps unwittingly, slowly signed himself into the facility. Our mother moved into a separate assisted living section and visited her husband almost every day. My brother and I visited both of our parents nearly every weekend. Today, as a caregiver, I would find it exceedingly difficult to force my daughter with schizophrenia into a care facility even if she were homeless and living under a bridge. Furthermore, when we completed our estate planning, my wife and I learned we are prohibited from assigning to one another the authority to make medical decisions about psychiatry hospitalization (i.e., my wife cannot put me in a psychiatric hospital and I cannot put her in one). I think the reason for these differences is due to a distrust of psychiatry arising from a tragic history of missteps mostly due to ignorance rather than deliberate malpractice and the lack of a persuasive and consistent narrative. However, I mostly attribute that lack of a narrative to no-fault ignorance about psychiatric illness rather than to willful incompetence.
But as previously stated on this blog (I think in one of the interviews Awais has done with other people), the choice shouldn't be between coercion and abandonment.
I'm not arguing that coercive care should be completely dismantled (I don't argue for the opposite either), I'm just arguing that we must NOT assume that because madpeople are so freaking mad it's inevitable that we have to choose between coercion and abandonment pretty much all the time. But what kind of treatment options exist, and whether staff treat you with compassion and respect or not, and obvs things like affordability too, makes a big difference to the extent people voluntarily seek out treatment or just flee it. People can even "lack insight" and still voluntarily see a clinician because they still want to talk to someone sympathetic about their distress (as psychiatrist Rosa Ritunnano has written about with "Harry", for instance). And on the flipside, if you meet clinicians who are dismissive, condescending, don't listen to you, you might very well flee mental health care even IF you have "insight".
Clinicians are actually taught not to listen to their patients. I recently listened to a podcast interview with Christine Forner. After working as a clinician for 7 years, and having some patients with DID, she took some courses. At school, what she had learned from listening to her patients, was denied by her teachers. She says:
“I was being told I should never learn about DID, that I should stay away from that. . . I wanted to specialize in the dissociative disorders . . . I had people who were fairly aggressive telling me that what I was doing wasn’t okay, or that there’s no point in studying DID—saying this in front of a whole classroom—touting this authority that they know what they’re talking about, though they hadn’t worked with [people with DID.]
This is terrible, and I've met psychiatrists who have espoused the same views in conferences. My guess would also be that this is a much bigger problem for some diagnoses and patient groups than others. But trust me that it's not the case that all clinicians are taught this, or think like this. I say this as someone with experience from several different sides here:
- I was, myself, a psychiatric patient for decades
- As a scholar, I've collaborated with psychiatrists who also do research and publish
- And finally, I teach psychiatrists and psychiatric nurses in the ethics and philosophy of psychiatry.
Thank you so much Sofia for your kind reply. I get so desperate sometimes as I encounter over and over the inability of professionals to cope with patients like myself. I think you’re right that “this is a much bigger problem for some diagnoses and patient groups than others,” and among the diagnoses that are most confounding are surely the dissociative disorders. Since almost everyone who has C-PTSD has some degree of dissociation, this is surely not acceptable. But perhaps there are more people than I know about being taught about dissociation now. I hope so!
And psychosis disorders in general - there's this view among clinicians that people like that are just crazy, no use listening to us or try to understand us, the only thing to do is try to medicate the craziness away.
But there are lots of clinicians who don't think like that as well. I mean, we're both here at Awais Aftab's blog, and he sure doesn't ... :-)
The biomedical model cannot account for the reality that expectancies about the pills, outweigh the actual impact of the pill. People who thought they got an SSRI, but actually got a placebo, showed more improvement than those who thought they got a placebo, but actually received an SSRI.
There are many things to take into account in situations such as this, eg, whether expectancy is measured prior to intervention or whether we are looking at the people who are making a guess as to what they got (in which case their guesses are influenced by whether they have substantially improved or not… if you have improved, you are more likely to think that you got the medication even if you got the placebo)
In any case, the issue of efficacy of SSRIs relative to expectancy has little to do with the “biomedical” model. I’m fairly confident psychotherapy doesn’t fare that better when it comes to comparisons with expectancy since psychotherapy-placebo average difference is similar to the AD-placebo difference.
You seem to be saying that the state and history of psychiatry/psychology is a disaster, as far as curing mental disorders or having a coherent and correct model of the meaning of various disorders. Am I misinterpreting? Maybe I’m projecting my own views.
The crazy thing is, there is actually a coherent model of mental disorders which is biomedical as well as psychological as well as sociocultural as well as narrative/story. It simply states that what you experience when you are young shapes your brain and body in ways that set you up for either health or illness as an adult. (Of course, what happens to you as an adult matters too and so does genetics and epigenetic.)
This is so obvious that we hardly need science to show it to us. It’s always been understood, if only vaguely, that we are shaped this way by our families and the larger environment in which we are raised. We all know that who we are is due to a complex interaction of genes and experience, nature/nurture.
The only question is: why is this model resisted? Why does psychology not embrace it?
Can you answer this question for me? I have my theories about why it’s resisted, but maybe you have some different ideas.
One of many differences between "shut up and calculate" in physics and "shut up and treat" in psychiatry, is that (I assume) you can get the calculations reliably right in physics even if you don't do any particular interpretations. In psychiatry, on the other hand, there's no evidence-based treatment that works for every patient with a specific diagnosis or particular symptoms. "Evidence-based" just means that a given treatment gives some measurable improvement to most people with a diagnosis, but it's still gonna be ineffective for lots. And if you refuse to theorize and interpret, all you can do is shrug and continue with your trial-and-error.
I've published and talked a lot about reality doubts. If you don't know what's real or not and this is extremely distressing, you get antipsychotics, and then you should try to "reality-test" as a complement. Whether the meds change your perception of reality to a more stable one or not must be due to brain stuff that a philosopher like me isn't equipped to figure out. But a philosopher CAN tell you at least ONE reason why reality-testing works for some people and not at all for others - every philosophers knows that you gotta take a lot for granted to even begin to prove more specific things about the reality we share. If you doubt too much or if your doubts go too deep, there's nothing you can use as a starting point for your "testing". Also, it's possible that once you have, so to speak, EXPERIENCED the kind of deep doubt that philosophers from Saint Augustine through Descartes to Wittgenstein has treated as intellectual puzzles, the MEMORY of that experience is enough to prevent you from comfortably taking reality for granted again, even if you're on meds that effectively prevents new such experiences from occurring.
Recognizing that someone suffers from this philosophical problem of knowledge and doubt can at least be a starting point for discussing how to handle it. But if you refuse to touch philosophical questions with a ten-foot pole, you're left with "uh okay, this is the evidence-based treatment but unfortunately it didn't work for you ... we'll try other things then, I'm sure we'll find something that works down the line". Or, as one psychiatrist told me when I lectured on these things, "but those are just SICK doubts. They're SUPPOSED to go away when you're on medication and you're well again."
(Btw, I'm fine not having a medical diagnosis beyond "probably somewhere on the schizo-spectrum". But I wouldn't be where I am today without all the philosophical interpretations!)
Thought-provoking piece!
One counter argument is the need to meet patients where they are. Many don't want to have a philosophical discussion about the meaning of their illness (though some do), often they just want to be well enough to get on with their lives.
Similarly, just as clinicians work with patients who hold views completely at odds with modern medicine (fans of homeopathy, natural remedies, reiki, etc), we need to respect our patients interpretation of what their illness means. Especially if this disagrees with our own model of illness/diagnosis.
In these situations a bit of agnosticism can be helpful.
"When we leave patients to their own devices to come up with a narrative of what they are going through, we leave them at the mercy of folk biomedical narratives and folk resistance to such narratives." Psychiatry is hard. Comments here and elsewhere make it clear that it is currently impossible to agree on a cohesive narrative. And in the absence of such a narrative, folk narratives and resistance to them extend into healthcare law in harmful ways. Thirty years ago there were no obstacles to moving my father with Alzheimer's disease from home into a locked care facility--it was a family decision with no interference from the law, judges, or civil rights attorneys. My older brother recited the letters of our father's name one-by-one and our dad, perhaps unwittingly, slowly signed himself into the facility. Our mother moved into a separate assisted living section and visited her husband almost every day. My brother and I visited both of our parents nearly every weekend. Today, as a caregiver, I would find it exceedingly difficult to force my daughter with schizophrenia into a care facility even if she were homeless and living under a bridge. Furthermore, when we completed our estate planning, my wife and I learned we are prohibited from assigning to one another the authority to make medical decisions about psychiatry hospitalization (i.e., my wife cannot put me in a psychiatric hospital and I cannot put her in one). I think the reason for these differences is due to a distrust of psychiatry arising from a tragic history of missteps mostly due to ignorance rather than deliberate malpractice and the lack of a persuasive and consistent narrative. However, I mostly attribute that lack of a narrative to no-fault ignorance about psychiatric illness rather than to willful incompetence.
But as previously stated on this blog (I think in one of the interviews Awais has done with other people), the choice shouldn't be between coercion and abandonment.
I'm not arguing that coercive care should be completely dismantled (I don't argue for the opposite either), I'm just arguing that we must NOT assume that because madpeople are so freaking mad it's inevitable that we have to choose between coercion and abandonment pretty much all the time. But what kind of treatment options exist, and whether staff treat you with compassion and respect or not, and obvs things like affordability too, makes a big difference to the extent people voluntarily seek out treatment or just flee it. People can even "lack insight" and still voluntarily see a clinician because they still want to talk to someone sympathetic about their distress (as psychiatrist Rosa Ritunnano has written about with "Harry", for instance). And on the flipside, if you meet clinicians who are dismissive, condescending, don't listen to you, you might very well flee mental health care even IF you have "insight".
Clinicians are actually taught not to listen to their patients. I recently listened to a podcast interview with Christine Forner. After working as a clinician for 7 years, and having some patients with DID, she took some courses. At school, what she had learned from listening to her patients, was denied by her teachers. She says:
“I was being told I should never learn about DID, that I should stay away from that. . . I wanted to specialize in the dissociative disorders . . . I had people who were fairly aggressive telling me that what I was doing wasn’t okay, or that there’s no point in studying DID—saying this in front of a whole classroom—touting this authority that they know what they’re talking about, though they hadn’t worked with [people with DID.]
This is terrible, and I've met psychiatrists who have espoused the same views in conferences. My guess would also be that this is a much bigger problem for some diagnoses and patient groups than others. But trust me that it's not the case that all clinicians are taught this, or think like this. I say this as someone with experience from several different sides here:
- I was, myself, a psychiatric patient for decades
- As a scholar, I've collaborated with psychiatrists who also do research and publish
- And finally, I teach psychiatrists and psychiatric nurses in the ethics and philosophy of psychiatry.
Thank you so much Sofia for your kind reply. I get so desperate sometimes as I encounter over and over the inability of professionals to cope with patients like myself. I think you’re right that “this is a much bigger problem for some diagnoses and patient groups than others,” and among the diagnoses that are most confounding are surely the dissociative disorders. Since almost everyone who has C-PTSD has some degree of dissociation, this is surely not acceptable. But perhaps there are more people than I know about being taught about dissociation now. I hope so!
And psychosis disorders in general - there's this view among clinicians that people like that are just crazy, no use listening to us or try to understand us, the only thing to do is try to medicate the craziness away.
But there are lots of clinicians who don't think like that as well. I mean, we're both here at Awais Aftab's blog, and he sure doesn't ... :-)
The biomedical model cannot account for the reality that expectancies about the pills, outweigh the actual impact of the pill. People who thought they got an SSRI, but actually got a placebo, showed more improvement than those who thought they got a placebo, but actually received an SSRI.
There are many things to take into account in situations such as this, eg, whether expectancy is measured prior to intervention or whether we are looking at the people who are making a guess as to what they got (in which case their guesses are influenced by whether they have substantially improved or not… if you have improved, you are more likely to think that you got the medication even if you got the placebo)
In any case, the issue of efficacy of SSRIs relative to expectancy has little to do with the “biomedical” model. I’m fairly confident psychotherapy doesn’t fare that better when it comes to comparisons with expectancy since psychotherapy-placebo average difference is similar to the AD-placebo difference.
You seem to be saying that the state and history of psychiatry/psychology is a disaster, as far as curing mental disorders or having a coherent and correct model of the meaning of various disorders. Am I misinterpreting? Maybe I’m projecting my own views.
The crazy thing is, there is actually a coherent model of mental disorders which is biomedical as well as psychological as well as sociocultural as well as narrative/story. It simply states that what you experience when you are young shapes your brain and body in ways that set you up for either health or illness as an adult. (Of course, what happens to you as an adult matters too and so does genetics and epigenetic.)
This is so obvious that we hardly need science to show it to us. It’s always been understood, if only vaguely, that we are shaped this way by our families and the larger environment in which we are raised. We all know that who we are is due to a complex interaction of genes and experience, nature/nurture.
The only question is: why is this model resisted? Why does psychology not embrace it?
Can you answer this question for me? I have my theories about why it’s resisted, but maybe you have some different ideas.