The more important question is: what has become of psychiatry?
We may be living in an age of conspiracy theorists, although I have never been one for faddish labels. But we do seem to be in an era of academic incompetence. We once had well educated people who could run laps around the laity, yet decades of publish-or-perish incentives and perfunctory academic practice have softened them to the point where the screwballs of the world are nipping at their intellectual heels.
And what of psychiatry? Surely it is at its lowest scientific and intellectual ebb. Never has a field run so hard back towards where it came from; soon we will be within sight of Galen. The discipline’s amnesia is breathtaking: the rediscovery of old, well-understood diseases; the inability to recall biomarkers it once identified; the erasure of its own technical vocabulary; forgetting basic facts about disease entities; forgetting half the mechanisms of action of its own drugs; forgetting large parts of its armamentarium; neglecting pathophysiological observations; an eccentric preoccupation with rating scales; and a bizarre penchant for the most abandoned faddishness.
I can only think that the backwards momentum is produced by the combined thrust of the fields forebears as they spin furiously in their graves.
The entire idea of critical psychiatry as something apart is born of the same wank. All scientific disciplines should be self critical and all scientists practising within it. If you look at the history of science it is only since it became so workmanlike that it has lost the ability to fully reflect.
I’m deeply intrigued by this comment, aligning as it does with my belief that there is a neglected corpus of psychiatric knowledge with invaluable clinical benefit... could you kindly direct me to literature on the forgotten biomarkers, armamentarium, diseases and pathophysiologies to which you refer?
It's really just a matter of going out and reading the old books. As you go, you'll find threads that will lead you down all sorts of rabbit holes.
Or set Google Scholar search before the year 1990 and make notes about keywords you find in the old literature and reuse them as new search terms.
Tom Ban’s book Psychopharmacology is a good book that straddles the early and middle period of modern psychopharmacology.
Besides that it is important to read all of the old French and German works: Falret, Esquirol, Pinel, Ritti, Baillarger, Kraepelin, Kahlbaum, Jaspers etc. English authors like Hammond and Conolly for example. There is also an interesting book in latin by Maximilian Locher that contains some rather modern descriptions of mania, melancholia and other psychoses along with their treatment.
I find Gallica is useful, sometimes it suggests books by other contemporaries. Just get AI to translate the text.
Case series are also excellent. Try to find old ones again using Google scholar. The old case series are interesting because they would often carry out the popular laboratory tests of their day. They weren't discouraged from performing biological tests the way we often are today because we believe there is nothing to be found.
Alec Coppen wrote an excellent paper in 1967 titled "The biochemistry of affective disorders", which is chock full of keywords you can use in new Google Scholar searches.
Another resource is to read the proceedings of conferences from yesteryear.
Bernard Carroll's lecture on the DST can be found on YouTube.
Tom Ban and Samuel Gershon founded an organisation called the International Network for the History of Psychopharmacology. Their website INHN is falling apart but it's still got many interviews with early pioneers in psychopharmacology.
Edward Shorter and David Healy’s books on the history of psychiatry are excellent and chocked full of forgotten ideas.
Ian Brockington also has a bunch of great books full of cases on puerperal psychoses and bipolar illness. He binds and publishes them himself and some of them are on his blog as free PDFs.
I'm currently reading the 5th edition of Karl Leonhard's Classification of Endogenous Psychosis.
Of course accessing this kind of information is not easy. I like to go to the state library. Although I will also not the existence of scihub and Anna's archive without in anyway recommending either.
Thank you for this. I agree that the debate about psychiatry and medications has become polarized in a way that is too reminiscent of our current political climate.
I think it's notable that there exists such a discussion as "Critical Psychiatry," but probably not "Critical Cardiology" or "Critical Nephrology." I think this is a reflection of not only the fact that mental illness and suffering is less well-located than other illness (although there are many poorly-understood medical illnesses) but also that psychiatry lends itself to reflection. I am critical of many aspects of psychiatric treatment, but I also think that we can't throw out the baby with the bathwater.
It reminds me of Heidi Schreck's play, "What the Constitution Means to Me." In it, Schreck examines all the failures of the U.S Constitution in terms of its treatment of women and people of color. At the end of the play, the audience members are asked to vote on whether to throw out the Constitution or not. When I attended, the vote was to keep it. I think that is the most common outcome.
Would I change many aspects of psychiatric training? Absolutely. Revamp the curriculum. Add books and talks by people who have been patients, have residents spend time as patients on a unit, change the paradigm, educate trainees about the risks and ethical challenges inherent in what they do. But still train them.
I think one of several problems is that some people have this flawed understanding of science. They think science must be neat, and messiness must be unscientific. It's either NEAT scientific explanations, or some sort of hopeless relativistic quagmire where "anything goes".
I was in a weird Facebook debate a while ago with an antipsychiatrist. Of the kind who has had really bad experiences as a psychiatric patient, so there's a basis for sympathy, but then, their view of science was so off. Basically what I described above. And they accused you of being unscientific for that reason. I said look, when it comes to madness/neurodivergence/mental disorders/dramatic problems of living, REALITY is messy. And when reality is messy, it's scientific to describe that messiness, unscientific to come up with a neat theory (whether that's simplistic biopsych or antipsychiatry) that fails to map on to reality. That's not the same thing as throwing your hands up and declare that anything goes.
I think I got through to SOME extent with this person, but I also suspect that this is a common view ...
I can sympathize with what you're saying, but what you're describing can end up becoming a thought-terminating cliché if its taken too far, which it often is. It can turn into a lazy retort, something like, 'Who really knows? It's all so messy.' We all do it, but neither 'messy' nor 'neat' really have much to do with anything. Of course, parsimony calls for simplicity, so it's easy to go too far and slip into the mindset of 'It's all just a big unexplainable mess.' The other problem is this kind of thinking is extremely popular, perhaps even more popular than reductionism. In fact, I think humans fall into one of two camps, those with a bias towards neat explainations and those with a bias towards messy ones. The trick I think is to focus on the evidence, which may point to simple or complex answer or anything in between.
I'm not sure where you think we disagree. You say we should focus on the evidence. I said the same thing. We shouldn't try to force reality, or force our observations, into a framework where it doesn't fit. We should strive to describe reality as it is.
Yes, I think we do agree. "Messy" is just very popular among people of my age group as an off handed way to dismiss any attempt at being precise. Reality is what it is. But maxims come and go. I've noticed Occam's razor is very popular with Gen X for some reason. Another classic is "correlation isn't causation. The point is each generation seems to favour a certain heuristic. For my generation that seems to be a post modernist sense of everything is messy and subjective. The problem is when a handy maxim becomes a thought terminating cliche. You know what I mean? I mean, are things really so terribly messy or is it just fashionable?
This was such a thoughtful piece. I take your point that critique can become corrosive when it aligns with those who want to delegitimize care altogether. At the same time, I wonder if your perspective is shaped in part by the (lovely but rarified) intellectual waters in which you swim.
Your pluralistic views and reflective stance make you especially attuned to the nuances psychiatry can embody, and to the delicate dialogue between psychiatry and its critics. But I suspect most practitioners aren’t overexposed to this kind of critique and nuance -- if anything, they’re woefully *under*exposed to these ideas (perhaps especially in psychology and psychotherapy, where I practice).
From that angle, one reason critique may have been so easily co-opted is that it hasn’t been sufficiently integrated *enough* into the mainstream of psychiatric and psychological practice. Too often, in the trenches, our fields present themselves in simplified, two-dimensional ways: disorders as unquestioned biological entities; DSM categories as settled truths; treatments validated by anecdote or practitioner conviction; patients consistently positioned as needing affirmation rather than also being supported in reflection, growth, and capacity-building; concomitant under-attention to the roles of context, social construction, normal human suffering, and the search for meaning.
When we present ourselves this cardboard-cutout way, it becomes easy for outsiders to dismiss us as incapable of self-correction or nuanced thought. Psychiatry and psychology are then vulnerable to corrosive critique not only because of bad-faith actors, but also because of the lack of visible, integrated critique within our own professions.
The challenge, as you suggest, may be to cultivate an “integrated critique”: one that resists corrosive debunking, pushes back against complacent reification, and instead tends to psychology and psychiatry’s fragile constructs with humility, care, and pragmatism.
I think this sense of disorientation within psychiatry is created to some degree by the prevalence of short course treatment. Due to the constraints of insurance, few psychiatrists see their patients for months or years. They seldom experience the long-term effects of medications they prescribe. Thus, they have no personal experience of the effectiveness for some and the deleterious effects on others.
If psychiatrists stayed with their patients for years rather than a few weeks, they would have a better personal experience of the effectiveness/ineffectiveness of psychiatric treatments. This would hopefully lead to a more balanced appreciation of the effectiveness of psychiatry.
Possible partial solution: Every prescription of a psychiatric med must be followed up at the three-month mark and the 12-month mark at no additional cost to the patient. The patient could even be given a modest payment for making these follow up visits. This would not only give patients a chance to give feedback, but it would give psychiatrists more hands-on experience and be an opportunity for large studies of medication effectiveness.
Yes, although, it would need to be much closer observation than this. Also, 12-months is not long enough to catch issues with certain medications, in particular the anticonvulsants, and probably not long enough to catch the metabolic and endocrine effects. Really we need family doctors who treat our entire family for a life time.
The more important question is: what has become of psychiatry?
We may be living in an age of conspiracy theorists, although I have never been one for faddish labels. But we do seem to be in an era of academic incompetence. We once had well educated people who could run laps around the laity, yet decades of publish-or-perish incentives and perfunctory academic practice have softened them to the point where the screwballs of the world are nipping at their intellectual heels.
And what of psychiatry? Surely it is at its lowest scientific and intellectual ebb. Never has a field run so hard back towards where it came from; soon we will be within sight of Galen. The discipline’s amnesia is breathtaking: the rediscovery of old, well-understood diseases; the inability to recall biomarkers it once identified; the erasure of its own technical vocabulary; forgetting basic facts about disease entities; forgetting half the mechanisms of action of its own drugs; forgetting large parts of its armamentarium; neglecting pathophysiological observations; an eccentric preoccupation with rating scales; and a bizarre penchant for the most abandoned faddishness.
I can only think that the backwards momentum is produced by the combined thrust of the fields forebears as they spin furiously in their graves.
The entire idea of critical psychiatry as something apart is born of the same wank. All scientific disciplines should be self critical and all scientists practising within it. If you look at the history of science it is only since it became so workmanlike that it has lost the ability to fully reflect.
I’m deeply intrigued by this comment, aligning as it does with my belief that there is a neglected corpus of psychiatric knowledge with invaluable clinical benefit... could you kindly direct me to literature on the forgotten biomarkers, armamentarium, diseases and pathophysiologies to which you refer?
It's really just a matter of going out and reading the old books. As you go, you'll find threads that will lead you down all sorts of rabbit holes.
Or set Google Scholar search before the year 1990 and make notes about keywords you find in the old literature and reuse them as new search terms.
Tom Ban’s book Psychopharmacology is a good book that straddles the early and middle period of modern psychopharmacology.
Besides that it is important to read all of the old French and German works: Falret, Esquirol, Pinel, Ritti, Baillarger, Kraepelin, Kahlbaum, Jaspers etc. English authors like Hammond and Conolly for example. There is also an interesting book in latin by Maximilian Locher that contains some rather modern descriptions of mania, melancholia and other psychoses along with their treatment.
I find Gallica is useful, sometimes it suggests books by other contemporaries. Just get AI to translate the text.
Case series are also excellent. Try to find old ones again using Google scholar. The old case series are interesting because they would often carry out the popular laboratory tests of their day. They weren't discouraged from performing biological tests the way we often are today because we believe there is nothing to be found.
Alec Coppen wrote an excellent paper in 1967 titled "The biochemistry of affective disorders", which is chock full of keywords you can use in new Google Scholar searches.
Another resource is to read the proceedings of conferences from yesteryear.
Bernard Carroll's lecture on the DST can be found on YouTube.
Tom Ban and Samuel Gershon founded an organisation called the International Network for the History of Psychopharmacology. Their website INHN is falling apart but it's still got many interviews with early pioneers in psychopharmacology.
Edward Shorter and David Healy’s books on the history of psychiatry are excellent and chocked full of forgotten ideas.
Ian Brockington also has a bunch of great books full of cases on puerperal psychoses and bipolar illness. He binds and publishes them himself and some of them are on his blog as free PDFs.
I'm currently reading the 5th edition of Karl Leonhard's Classification of Endogenous Psychosis.
Of course accessing this kind of information is not easy. I like to go to the state library. Although I will also not the existence of scihub and Anna's archive without in anyway recommending either.
Thank you for your detailed and thoughtful reply, and for pointing the way to such a wealth of fascinating by-ways in the history of psychiatry.
Thank you for this. I agree that the debate about psychiatry and medications has become polarized in a way that is too reminiscent of our current political climate.
I think it's notable that there exists such a discussion as "Critical Psychiatry," but probably not "Critical Cardiology" or "Critical Nephrology." I think this is a reflection of not only the fact that mental illness and suffering is less well-located than other illness (although there are many poorly-understood medical illnesses) but also that psychiatry lends itself to reflection. I am critical of many aspects of psychiatric treatment, but I also think that we can't throw out the baby with the bathwater.
It reminds me of Heidi Schreck's play, "What the Constitution Means to Me." In it, Schreck examines all the failures of the U.S Constitution in terms of its treatment of women and people of color. At the end of the play, the audience members are asked to vote on whether to throw out the Constitution or not. When I attended, the vote was to keep it. I think that is the most common outcome.
Would I change many aspects of psychiatric training? Absolutely. Revamp the curriculum. Add books and talks by people who have been patients, have residents spend time as patients on a unit, change the paradigm, educate trainees about the risks and ethical challenges inherent in what they do. But still train them.
I think one of several problems is that some people have this flawed understanding of science. They think science must be neat, and messiness must be unscientific. It's either NEAT scientific explanations, or some sort of hopeless relativistic quagmire where "anything goes".
I was in a weird Facebook debate a while ago with an antipsychiatrist. Of the kind who has had really bad experiences as a psychiatric patient, so there's a basis for sympathy, but then, their view of science was so off. Basically what I described above. And they accused you of being unscientific for that reason. I said look, when it comes to madness/neurodivergence/mental disorders/dramatic problems of living, REALITY is messy. And when reality is messy, it's scientific to describe that messiness, unscientific to come up with a neat theory (whether that's simplistic biopsych or antipsychiatry) that fails to map on to reality. That's not the same thing as throwing your hands up and declare that anything goes.
I think I got through to SOME extent with this person, but I also suspect that this is a common view ...
I share your observation and feel similarly.
I can sympathize with what you're saying, but what you're describing can end up becoming a thought-terminating cliché if its taken too far, which it often is. It can turn into a lazy retort, something like, 'Who really knows? It's all so messy.' We all do it, but neither 'messy' nor 'neat' really have much to do with anything. Of course, parsimony calls for simplicity, so it's easy to go too far and slip into the mindset of 'It's all just a big unexplainable mess.' The other problem is this kind of thinking is extremely popular, perhaps even more popular than reductionism. In fact, I think humans fall into one of two camps, those with a bias towards neat explainations and those with a bias towards messy ones. The trick I think is to focus on the evidence, which may point to simple or complex answer or anything in between.
I'm not sure where you think we disagree. You say we should focus on the evidence. I said the same thing. We shouldn't try to force reality, or force our observations, into a framework where it doesn't fit. We should strive to describe reality as it is.
Yes, I think we do agree. "Messy" is just very popular among people of my age group as an off handed way to dismiss any attempt at being precise. Reality is what it is. But maxims come and go. I've noticed Occam's razor is very popular with Gen X for some reason. Another classic is "correlation isn't causation. The point is each generation seems to favour a certain heuristic. For my generation that seems to be a post modernist sense of everything is messy and subjective. The problem is when a handy maxim becomes a thought terminating cliche. You know what I mean? I mean, are things really so terribly messy or is it just fashionable?
This was such a thoughtful piece. I take your point that critique can become corrosive when it aligns with those who want to delegitimize care altogether. At the same time, I wonder if your perspective is shaped in part by the (lovely but rarified) intellectual waters in which you swim.
Your pluralistic views and reflective stance make you especially attuned to the nuances psychiatry can embody, and to the delicate dialogue between psychiatry and its critics. But I suspect most practitioners aren’t overexposed to this kind of critique and nuance -- if anything, they’re woefully *under*exposed to these ideas (perhaps especially in psychology and psychotherapy, where I practice).
From that angle, one reason critique may have been so easily co-opted is that it hasn’t been sufficiently integrated *enough* into the mainstream of psychiatric and psychological practice. Too often, in the trenches, our fields present themselves in simplified, two-dimensional ways: disorders as unquestioned biological entities; DSM categories as settled truths; treatments validated by anecdote or practitioner conviction; patients consistently positioned as needing affirmation rather than also being supported in reflection, growth, and capacity-building; concomitant under-attention to the roles of context, social construction, normal human suffering, and the search for meaning.
When we present ourselves this cardboard-cutout way, it becomes easy for outsiders to dismiss us as incapable of self-correction or nuanced thought. Psychiatry and psychology are then vulnerable to corrosive critique not only because of bad-faith actors, but also because of the lack of visible, integrated critique within our own professions.
The challenge, as you suggest, may be to cultivate an “integrated critique”: one that resists corrosive debunking, pushes back against complacent reification, and instead tends to psychology and psychiatry’s fragile constructs with humility, care, and pragmatism.
I think this sense of disorientation within psychiatry is created to some degree by the prevalence of short course treatment. Due to the constraints of insurance, few psychiatrists see their patients for months or years. They seldom experience the long-term effects of medications they prescribe. Thus, they have no personal experience of the effectiveness for some and the deleterious effects on others.
If psychiatrists stayed with their patients for years rather than a few weeks, they would have a better personal experience of the effectiveness/ineffectiveness of psychiatric treatments. This would hopefully lead to a more balanced appreciation of the effectiveness of psychiatry.
Possible partial solution: Every prescription of a psychiatric med must be followed up at the three-month mark and the 12-month mark at no additional cost to the patient. The patient could even be given a modest payment for making these follow up visits. This would not only give patients a chance to give feedback, but it would give psychiatrists more hands-on experience and be an opportunity for large studies of medication effectiveness.
Yes, although, it would need to be much closer observation than this. Also, 12-months is not long enough to catch issues with certain medications, in particular the anticonvulsants, and probably not long enough to catch the metabolic and endocrine effects. Really we need family doctors who treat our entire family for a life time.