Thank you so much for this. This idea has been floating around for me for a while that psychiatry (maybe a relative of Malcom’s “Psychoanalysis the impossible profession”) at the very core is a dynamic multidisciplinary multidimensional field of uncertainty that weaves the physical experience of biology, physiology, neuro anatomy, inflammatory processes, neurotransmitters, receptors, networks, electricity, plasticity, cellular functioning into more abstract territories— developmental frameworks, our rudimentary understanding of consciousness, inter subjective theory, affect and the complex interactions of environment on subject. Psychiatry is a Sisyphean task at best to expand broadly and deeply enough to integrate philosophy, art, cultural and political forces, biology, technology, chemistry, physiology and anatomy (to name a few). And to make an interpretation, we cling arrogantly and stubbornly to theories and practices that make us feel legitimate because it is too humiliating to admit that we are looking through a pinhole. And have no idea actually how to understand the complexities of brains in bodies with strands of genes stretching back through time and environments that exert pressures and shape how we experience reality. Being a psychiatrist is, to me, the most profoundly complex practice. We walk in the dark, we do not know what we do not know, and we are confronted with the fundamental struggles of grief, neurosis, relationally, despair, suffering, and how a medication can shift the kaleidoscopic experience of being a human on earth. Godspeed to all who enter this path. I am forever slightly embarrassed by our field and continually drawn to the expansiveness it requires. For me, it is the intellectual sustenance of needing to know more. But never actually knowing the answer. Humility, a sense of humor, and a profound belief that everyone deserves to be actively and attentively listened to and attuned to are what make it possible to do this. Without connection, what the hell are we doing? Great interview.
David, I accept your critique. I weighed whether to keep the metaphorical pairing, mindful of Ronald Pies's compelling analysis (https://www.psychiatrictimes.com/view/debunking-two-chemical-imbalance-myths-again). I also had little doubt I'd be challenged — though not, I confess, by the very first comment posted on Awais's blog mere moments after the interview appeared. :)
I'm fine with that.
I don't dispute Pies's framing. What I dispute are the inferences that you and others draw from it, which strike me as implausible: namely, that a majority, or even a significant plurality, of psychiatrists have not embraced the metaphor. I think they have. Not that there's anything wrong with that. Cardiologists know there's no such thing as "good" and "bad" cholesterol. Oncologists know — I imagine, at least — that one cannot wage a "war on cancer." Indeed, William James, more than a century ago, introduced MEOW (Moral Equivalent of War), or so I think. But I could be mistaken. Pies may well be right about the commercial origins of "chemical imbalance," but being right about that strikes me as more scholastic than illuminating.
I suspect if we had a chance to speak, we'd enjoy the exchange. Have a great weekend. And buy the book and let me know what you think.
This book will be, among other things, the latest in an increasingly long line of data points that add to the idea that psychiatry, as a whole, is a naked emperor. Much as I have resisted this, especially the broadsides from the 'critical psychiatry' corners, I wonder how psychiatry and psychiatrists can better present ourselves as doing more than providing a series of metaphors to explain what we're doing. We have to balance humility with being able to say we are effective in helping people in spite of our limited understandings. Our PR stinks.
I'm also a little surprised that Dr. Bresch hasn't heard much about chemical imbalances. True that it's not invoked in scholarly articles, but it sure caught on for a couple of decades; thankfully it's subsiding. PCPs ate it up, too. How many patients did I have who wanted "the test for the chemical imbalance"? That led to fruitful discussions, but initially a lot of corrective education about the meaninglessness of that term, appealing though it was for the public and some pharmacy.
Richard, I do not believe psychiatry is a naked emperor. And I think one would be hard-pressed to come away with that inference after reading When Healing Harms (admittedly, a shameless plug).
As William James observed more than a century ago, in a not dissimilar context, medicine is not a finished science. It never will be. Psychiatry as practiced today helps many people—myself among them. But it also fails too many. Not because its practitioners are malign or indifferent, but because the brain is neither a pump nor a filter, like the heart or kidneys. Disturbances of mood, thought, and behavior are extraordinarily difficult things to explain, much less treat.
And there is a historical irony here. Whenever psychiatry (I’m being anachronistic) finds a mechanism that explains such disturbances—think of the spirochete in syphilis or niacin deficiency in pellagra—its patients tend to pass to other specialties. Or, better still, cease to be patients at all.
That is a good outcome, not a bad one. The measure of psychiatry’s success should not be whether it can defend its historical turf. It should be whether it can relieve suffering while remaining honest about what it knows, what it does not know, and the difference between the two.
I didn't think that you thought psychiatry was naked. I sure don't. I do think there is an unfortunately wide perception that too much of what we do is trial-and-error, as if random. We know it's not like that, but I can see how it can appear that way. It is more complicated and time-consuming to explain how the brain works (to the extent that we can) compared with those other organs. I can see how much of the public - especially those whom psychiatry has not helped a lot - can wonder how we can say we're just as expert on brain stuff as cardiologists and nephrologists are about heart and kidney stuff. [and just for the record, I've never understood kidneys]. Take a look at madinamerica.com for a bracing look at how some view psychiatry.
And you may consider your shameless plug successful:). I'd just finished my residency when that case was surfacing. Shocking then, too.
Bob Whitaker read the manuscript, liked it, and wrote a blurb:
“A compelling exploration of all aspects of this story, legal and personal... an in-depth biography of nephrologist Ray Osheroff, telling of how his life was upended by depression and his subsequent legal battles with Chestnut Lodge.”
Robert Whitaker
George Polk Award winner; author of Madness in America and Anatomy of an Epidemic
Yes, I had seen that. He's done some very good work, though his criticism of the field sometimes, in my view, overshadows things. I'm sure that's not the case for your book; this blurb seems quite balanced. Coincidentally, both Awais and I have written or otherwise contributed to his madinamerica site.
I ordered the book some time ago, as soon as I found out about it. I’m excited to read it.
My understanding has been that shifting the ‘standard of care’ was an explicit aim of biological psychiatrists of the 1980s, not a purely psychotherapy vs. pharmacology argument. Not so sure this was a good thing, and the biological standard of care promoted in 1980s and 90s may not hold up well in the light of history. I’d argue it already doesn’t. There is undoubtedly a distinction between legal standard of care and good care. Sometimes they overlap, sometimes they clash. Perhaps Chestnut Lodge was failing at both by the 1980s.
Also, if you receive glowing reviews at work but are completely sundered from your children and can’t maintain an intimate relationship this is usually not a great sign where personality problems are concerned.
Eric, I think you are likely to appreciate this video clip from the Osheroff hearing from one of the expert witnesses for the Lodge: https://www.youtube.com/watch?v=KFxu64cdI7c
This is a marvelous discussion and I heartily approve of its focus and approach but in that spirit I can’t let the offhand comment about “chemical imbalance”, pass. Where in hell did you get that from? I expect a remark like that on Tictoc but not from an erudite scholar. What text or research promotes this absurd idea? I have been practicing psychiatry for twenty five years. I hold three board certifications in areas central to current neuroscience. Never once have I come across this formulation in any scientific text or paper. To me it’s a sort of joke.
This isn’t a charitable reading IMO. Various varieties of monoamine hypotheses were respectable ideas in psychiatry. “Chemical imbalance” as a term is a popular characterization, too vague, wielded by pharma advertising, but it was used by many in the psychiatric community for public communication and was based on monoaminergic thinking.
I dare you to show me one recognized text or peer-reviewed paper that coins this phrase. It is ridiculous. In any event, we are so past a strictly monoamine paradigm that to paraphrase essentially anti-psychiatry or Cosmo-level sources and represent that as "psychiatric thinking", is unjust. Furthermore to say that monamines have some role in the mechanism of psychiatric drugs, is a LONG way from implying that patients with mental illness have " a chemical imbalance". No one at the green or purple journals is that stupid.
We are also way past a strictly psychoanalytic paradigm, doesn’t mean we can’t talk about it in a historical context. Psychiatry gave us the monoamine hypothesis (and related biochemical cousins like the dopamine hypothesis) and the field colloquialized them as chemical imbalances, and just because we have moved beyond them doesn’t mean they weren’t once a thing. I’m not saying we should attack psychiatry using the “chemical imbalance” rhetoric as psychiatric critics are doing — and I myself have gone on record and challenged that sort of rhetoric — but that’s not what is happening here in this interview.
I have never seen any researcher in psychiatry characterize the monoamine hypotheses as "a chemical imbalance". It was never part of our history, sorry. Psychiatry has lots to feel ashamed about. "Chemical imbalance" did not come from our field, and it is not something we should have to argue. On the contrary, psychoanalytic perspectives are most definitely part of psychiatric history especially in the USA.
To quote you "psychiatry has unearned confidence in both its theories of mind and its theories of brain". You also wrote that as mechanisms are discovered their diseases exit our field. Your examples weren't accurate, at least not in the way you meant them. Syphilitic insanity no longer was a problem for psychiatrists because with antibiotics, people no longer experienced syphilitic insanity. The same with pellagra. In contrast, we do care for patients with NMDA receptor antibody encephalitis (for example), whose pathophysiology is well known, but is very hard to treat or prevent.
Psychiatry has chosen its domains, and this has not been constant in time. The best example of this is sleep medicine. The pioneers of sleep medicine were psychiatrists, but the lack of connection between sleep medicine and the psychanalytic framework and psychotherapy service that was prevalent at the time, plus the growth of obesity that made breathing disorders so much more prevalent, led to psychiatry bowing out of the field to a certain extent. Psychiatry's abstaining from sleep medicine is particularly ironic since the discovery of the pathophysiology of narcolepsy is one of the most consequential discoveries in behavioral medicine since the discovery of antidepressants. And one of the few.
I would argue that my field may have had unearned confidence in the past (though judging from Sylus Weir Mitchell's famous 1894 critique, not for too long), but it has a huge research base and a solid foundation for what it "knows". That isn't very much. Unfortunately I have to answer for past sins when I answer patient's concerns. The internet and social media have made this problem very difficult to handle and has had some unintended consequences for public health. I am not alone: there is overlap with the anti-vax movement. So I want to be very precise about what we psychiatrists "claim". Like all scientific knowledge it is imperfect and liable to alteration as we learn more. I can tell you that the public representation of what psychiatry "claims", for example as represented by RFK, is not at all what we psychiatrists actually think or even publicly state or represent to our patients. And unfortunately, we are not monolithic so some psychiatrists may state things that are extremely misleading, this was evident in the expert testimony at the Lindsay Clancy trial, which did my profession no good, and it was especially disappointing and misleading in my view.
I read this reference you found and while The Psychiatric Times is quite the rag, this is a lovely essay. I am surprised he even managed to find the examples he did of the term "chemical imbalance" spouted by some experts, of course they lose their precise meaning out of context. But you can see we have struggled mightily for a long time now with this. Unfortunately the vocabulary of psychiatry and certain other factors like the DSM, a huge money-maker for the APA, have made psychiatry seem deceptively accessible to the laymen in a way nephrology (for example) or proctology (for another example), never would be.
But you are wrong: we have NOT embraced the metaphor, not psychiatrists. I can't speak for everyone else involved in the mental health mechanism.
I appreciate the spirited debate here, and I'm eagerly looking forward to reading "When Healing Harms." I'd like to offer a totally non-scientific and unverifiable observation that the chemical imbalance idea had its own short-lived placebo-like affect, at least in my experience, and perhaps it's worth not disregarding it over semantics, politics, etc. All I know is that my mother died at peace believing that the (never proven, of course) imbalance in her brain chemistry that "caused" her forty years of manic-depressive disease was "scientific evidence" proving that her madness wasn't her fault. This was the thinking that allowed her to live with herself, and if this isn't a form of healing, wrong as it may be from a biological/social/genetic perspective, and ethically wrong in the same way as the harms done by physicians who withheld a diagnosis of cancer from their early 20th c. dying patients, then I'm not sure there's much hope for psychiatry.
If you'd like to see video testimony from the expert witnesses in Osheroff v. Chestnut Lodge, visit my companion website: https://rayosheroff.org/people/. Just click the image of the person whose testimony you'd like to see, and a window will open.
Thank you so much for this. This idea has been floating around for me for a while that psychiatry (maybe a relative of Malcom’s “Psychoanalysis the impossible profession”) at the very core is a dynamic multidisciplinary multidimensional field of uncertainty that weaves the physical experience of biology, physiology, neuro anatomy, inflammatory processes, neurotransmitters, receptors, networks, electricity, plasticity, cellular functioning into more abstract territories— developmental frameworks, our rudimentary understanding of consciousness, inter subjective theory, affect and the complex interactions of environment on subject. Psychiatry is a Sisyphean task at best to expand broadly and deeply enough to integrate philosophy, art, cultural and political forces, biology, technology, chemistry, physiology and anatomy (to name a few). And to make an interpretation, we cling arrogantly and stubbornly to theories and practices that make us feel legitimate because it is too humiliating to admit that we are looking through a pinhole. And have no idea actually how to understand the complexities of brains in bodies with strands of genes stretching back through time and environments that exert pressures and shape how we experience reality. Being a psychiatrist is, to me, the most profoundly complex practice. We walk in the dark, we do not know what we do not know, and we are confronted with the fundamental struggles of grief, neurosis, relationally, despair, suffering, and how a medication can shift the kaleidoscopic experience of being a human on earth. Godspeed to all who enter this path. I am forever slightly embarrassed by our field and continually drawn to the expansiveness it requires. For me, it is the intellectual sustenance of needing to know more. But never actually knowing the answer. Humility, a sense of humor, and a profound belief that everyone deserves to be actively and attentively listened to and attuned to are what make it possible to do this. Without connection, what the hell are we doing? Great interview.
David, I accept your critique. I weighed whether to keep the metaphorical pairing, mindful of Ronald Pies's compelling analysis (https://www.psychiatrictimes.com/view/debunking-two-chemical-imbalance-myths-again). I also had little doubt I'd be challenged — though not, I confess, by the very first comment posted on Awais's blog mere moments after the interview appeared. :)
I'm fine with that.
I don't dispute Pies's framing. What I dispute are the inferences that you and others draw from it, which strike me as implausible: namely, that a majority, or even a significant plurality, of psychiatrists have not embraced the metaphor. I think they have. Not that there's anything wrong with that. Cardiologists know there's no such thing as "good" and "bad" cholesterol. Oncologists know — I imagine, at least — that one cannot wage a "war on cancer." Indeed, William James, more than a century ago, introduced MEOW (Moral Equivalent of War), or so I think. But I could be mistaken. Pies may well be right about the commercial origins of "chemical imbalance," but being right about that strikes me as more scholastic than illuminating.
I suspect if we had a chance to speak, we'd enjoy the exchange. Have a great weekend. And buy the book and let me know what you think.
This book will be, among other things, the latest in an increasingly long line of data points that add to the idea that psychiatry, as a whole, is a naked emperor. Much as I have resisted this, especially the broadsides from the 'critical psychiatry' corners, I wonder how psychiatry and psychiatrists can better present ourselves as doing more than providing a series of metaphors to explain what we're doing. We have to balance humility with being able to say we are effective in helping people in spite of our limited understandings. Our PR stinks.
I'm also a little surprised that Dr. Bresch hasn't heard much about chemical imbalances. True that it's not invoked in scholarly articles, but it sure caught on for a couple of decades; thankfully it's subsiding. PCPs ate it up, too. How many patients did I have who wanted "the test for the chemical imbalance"? That led to fruitful discussions, but initially a lot of corrective education about the meaninglessness of that term, appealing though it was for the public and some pharmacy.
Richard, I do not believe psychiatry is a naked emperor. And I think one would be hard-pressed to come away with that inference after reading When Healing Harms (admittedly, a shameless plug).
As William James observed more than a century ago, in a not dissimilar context, medicine is not a finished science. It never will be. Psychiatry as practiced today helps many people—myself among them. But it also fails too many. Not because its practitioners are malign or indifferent, but because the brain is neither a pump nor a filter, like the heart or kidneys. Disturbances of mood, thought, and behavior are extraordinarily difficult things to explain, much less treat.
And there is a historical irony here. Whenever psychiatry (I’m being anachronistic) finds a mechanism that explains such disturbances—think of the spirochete in syphilis or niacin deficiency in pellagra—its patients tend to pass to other specialties. Or, better still, cease to be patients at all.
That is a good outcome, not a bad one. The measure of psychiatry’s success should not be whether it can defend its historical turf. It should be whether it can relieve suffering while remaining honest about what it knows, what it does not know, and the difference between the two.
I didn't think that you thought psychiatry was naked. I sure don't. I do think there is an unfortunately wide perception that too much of what we do is trial-and-error, as if random. We know it's not like that, but I can see how it can appear that way. It is more complicated and time-consuming to explain how the brain works (to the extent that we can) compared with those other organs. I can see how much of the public - especially those whom psychiatry has not helped a lot - can wonder how we can say we're just as expert on brain stuff as cardiologists and nephrologists are about heart and kidney stuff. [and just for the record, I've never understood kidneys]. Take a look at madinamerica.com for a bracing look at how some view psychiatry.
And you may consider your shameless plug successful:). I'd just finished my residency when that case was surfacing. Shocking then, too.
Bob Whitaker read the manuscript, liked it, and wrote a blurb:
“A compelling exploration of all aspects of this story, legal and personal... an in-depth biography of nephrologist Ray Osheroff, telling of how his life was upended by depression and his subsequent legal battles with Chestnut Lodge.”
Robert Whitaker
George Polk Award winner; author of Madness in America and Anatomy of an Epidemic
Yes, I had seen that. He's done some very good work, though his criticism of the field sometimes, in my view, overshadows things. I'm sure that's not the case for your book; this blurb seems quite balanced. Coincidentally, both Awais and I have written or otherwise contributed to his madinamerica site.
I ordered the book some time ago, as soon as I found out about it. I’m excited to read it.
My understanding has been that shifting the ‘standard of care’ was an explicit aim of biological psychiatrists of the 1980s, not a purely psychotherapy vs. pharmacology argument. Not so sure this was a good thing, and the biological standard of care promoted in 1980s and 90s may not hold up well in the light of history. I’d argue it already doesn’t. There is undoubtedly a distinction between legal standard of care and good care. Sometimes they overlap, sometimes they clash. Perhaps Chestnut Lodge was failing at both by the 1980s.
Also, if you receive glowing reviews at work but are completely sundered from your children and can’t maintain an intimate relationship this is usually not a great sign where personality problems are concerned.
Eric, I think you are likely to appreciate this video clip from the Osheroff hearing from one of the expert witnesses for the Lodge: https://www.youtube.com/watch?v=KFxu64cdI7c
This is a marvelous discussion and I heartily approve of its focus and approach but in that spirit I can’t let the offhand comment about “chemical imbalance”, pass. Where in hell did you get that from? I expect a remark like that on Tictoc but not from an erudite scholar. What text or research promotes this absurd idea? I have been practicing psychiatry for twenty five years. I hold three board certifications in areas central to current neuroscience. Never once have I come across this formulation in any scientific text or paper. To me it’s a sort of joke.
This isn’t a charitable reading IMO. Various varieties of monoamine hypotheses were respectable ideas in psychiatry. “Chemical imbalance” as a term is a popular characterization, too vague, wielded by pharma advertising, but it was used by many in the psychiatric community for public communication and was based on monoaminergic thinking.
I dare you to show me one recognized text or peer-reviewed paper that coins this phrase. It is ridiculous. In any event, we are so past a strictly monoamine paradigm that to paraphrase essentially anti-psychiatry or Cosmo-level sources and represent that as "psychiatric thinking", is unjust. Furthermore to say that monamines have some role in the mechanism of psychiatric drugs, is a LONG way from implying that patients with mental illness have " a chemical imbalance". No one at the green or purple journals is that stupid.
We are also way past a strictly psychoanalytic paradigm, doesn’t mean we can’t talk about it in a historical context. Psychiatry gave us the monoamine hypothesis (and related biochemical cousins like the dopamine hypothesis) and the field colloquialized them as chemical imbalances, and just because we have moved beyond them doesn’t mean they weren’t once a thing. I’m not saying we should attack psychiatry using the “chemical imbalance” rhetoric as psychiatric critics are doing — and I myself have gone on record and challenged that sort of rhetoric — but that’s not what is happening here in this interview.
I have never seen any researcher in psychiatry characterize the monoamine hypotheses as "a chemical imbalance". It was never part of our history, sorry. Psychiatry has lots to feel ashamed about. "Chemical imbalance" did not come from our field, and it is not something we should have to argue. On the contrary, psychoanalytic perspectives are most definitely part of psychiatric history especially in the USA.
To quote you "psychiatry has unearned confidence in both its theories of mind and its theories of brain". You also wrote that as mechanisms are discovered their diseases exit our field. Your examples weren't accurate, at least not in the way you meant them. Syphilitic insanity no longer was a problem for psychiatrists because with antibiotics, people no longer experienced syphilitic insanity. The same with pellagra. In contrast, we do care for patients with NMDA receptor antibody encephalitis (for example), whose pathophysiology is well known, but is very hard to treat or prevent.
Psychiatry has chosen its domains, and this has not been constant in time. The best example of this is sleep medicine. The pioneers of sleep medicine were psychiatrists, but the lack of connection between sleep medicine and the psychanalytic framework and psychotherapy service that was prevalent at the time, plus the growth of obesity that made breathing disorders so much more prevalent, led to psychiatry bowing out of the field to a certain extent. Psychiatry's abstaining from sleep medicine is particularly ironic since the discovery of the pathophysiology of narcolepsy is one of the most consequential discoveries in behavioral medicine since the discovery of antidepressants. And one of the few.
I would argue that my field may have had unearned confidence in the past (though judging from Sylus Weir Mitchell's famous 1894 critique, not for too long), but it has a huge research base and a solid foundation for what it "knows". That isn't very much. Unfortunately I have to answer for past sins when I answer patient's concerns. The internet and social media have made this problem very difficult to handle and has had some unintended consequences for public health. I am not alone: there is overlap with the anti-vax movement. So I want to be very precise about what we psychiatrists "claim". Like all scientific knowledge it is imperfect and liable to alteration as we learn more. I can tell you that the public representation of what psychiatry "claims", for example as represented by RFK, is not at all what we psychiatrists actually think or even publicly state or represent to our patients. And unfortunately, we are not monolithic so some psychiatrists may state things that are extremely misleading, this was evident in the expert testimony at the Lindsay Clancy trial, which did my profession no good, and it was especially disappointing and misleading in my view.
I read this reference you found and while The Psychiatric Times is quite the rag, this is a lovely essay. I am surprised he even managed to find the examples he did of the term "chemical imbalance" spouted by some experts, of course they lose their precise meaning out of context. But you can see we have struggled mightily for a long time now with this. Unfortunately the vocabulary of psychiatry and certain other factors like the DSM, a huge money-maker for the APA, have made psychiatry seem deceptively accessible to the laymen in a way nephrology (for example) or proctology (for another example), never would be.
But you are wrong: we have NOT embraced the metaphor, not psychiatrists. I can't speak for everyone else involved in the mental health mechanism.
I appreciate the spirited debate here, and I'm eagerly looking forward to reading "When Healing Harms." I'd like to offer a totally non-scientific and unverifiable observation that the chemical imbalance idea had its own short-lived placebo-like affect, at least in my experience, and perhaps it's worth not disregarding it over semantics, politics, etc. All I know is that my mother died at peace believing that the (never proven, of course) imbalance in her brain chemistry that "caused" her forty years of manic-depressive disease was "scientific evidence" proving that her madness wasn't her fault. This was the thinking that allowed her to live with herself, and if this isn't a form of healing, wrong as it may be from a biological/social/genetic perspective, and ethically wrong in the same way as the harms done by physicians who withheld a diagnosis of cancer from their early 20th c. dying patients, then I'm not sure there's much hope for psychiatry.
What a lovely comment. Thank you!
If you'd like to see video testimony from the expert witnesses in Osheroff v. Chestnut Lodge, visit my companion website: https://rayosheroff.org/people/. Just click the image of the person whose testimony you'd like to see, and a window will open.
"Psychiatry has given us both the Oedipus...What it has not given us, not yet, are mechanisms that correlate ..."
Is not primary maternal attachment and rivalry with father resolved by a same sex co-identifying chum friend during latency period... a mechanism?