Wednesday, 28 March 2012

Psychiatry Redux

Will someone please remind me what psychiatrists are for? At one time I thought I knew the answer to this question but a lot of things have become less clear, since I stopped taking the blue pills.

My first psychiatrist impressed me hugely by summarising my life story in short, declarative sentences (about five of them) after a 45 minute consultation. Then, when I'd internalised the implications of this intellectual tour-de-force, I sank deeper into depression. I decided that suicide was the only sensible option and got as far as a wine bar, into which I descended to drink my last bottle of wine. Three bottles of wine later, I had lost the will to die and I went sheepishly home, never to return to work.

Psychiatrist number two operates out of the Priory, a loony bin for the well-insured. She changed my drugs, doubled the doses occasionally and advised me to find a therapist.

Shrink number three is an addiction specialist and has so far succeeded in trampling underfoot the miniscule sense of self worth that had survived the last few years of misery.

Presumably most psychiatrists embark on their careers with a sense of mission. Or perhaps I am being too generous. I really wonder, having suffered at the hands of the profession, whether its practitioners ever ask themselves what they are trying to achieve. Are they trying to minimize their patients' suffering? Are they trying to maximize their happiness? Are they trying to find a socially acceptable way of reintroducing mentally ill people to general society? Are they simply going to work and trying to get through the day without irretrievably fucking up their careers?

The three that I've been exposed to haven't, so far as I can tell, asked themselves this question. No. 1 was more interested in discussing his bond portfolio than my mental health. No.2's over-riding goal was to improve the IRR of The Priory's owner, my employer, RBS. No.3 is messianic in his conviction that substance abuse is the source of all evil, in which respect he is mistaken.

Over the years since I received the cathartic but fateful diagnosis of depression I have encountered dozens of general practitioners, psychiatrists, therapists and psychologists, only one of whom I admire. Only this one person can be said to have done me any good. I cannot help but wonder whether, if the profession of psychiatry were abolished, the quota of good in the world would increase or diminish.


Ron Tomlinson said...

torquatus said...

That's an interesting paper. Thanks for the link. While Szasz's argument that 'mental illness', as the term was used in 1960s America, to describe divorcees and communists as well as psychopaths and schizophrenics, is a socially constructed fiction is interesting, I think it is unhelpful, both to doctors and patients, to deny that the mind is as likely to break down as any other organ of the body.

Szasz explicitly distinguishes brain disease, which he says is the province of neurologists, and 'problems of living' which he says is the business of psychiatry. He seems to be a straightforward dualist, a position that is no longer tenable. His assertion that 'a person's belief...cannot be explained by a defect or disease of the nervous system' is just false. Certain beliefs, for instance a propensity to imbue moving objects with intentionality or a predisposition to develop religious beliefs clearly have an underlying neurological basis, which can be faulty or aberrant as surely as the insulin producing cells in the pancreas can).

Once you concede that the mind and the brain are one and the same entity - the philosophical position known as monism - which I think is undeniable, to attempt to practice psychiatry without reference to neurobiology is as absurd (and irresponsible) as practicing construction without reference to engineering.

Where I think Szasz is spot on is in his claim that the human condition, consisting as it does mainly in interactions with other humans, is inherently stressful. Many of the deeply unpleasant emotions that all humans experience: grief, shame, guilt and so on are clearly mental adaptations for human life. I cannot understand, however, why he can't see that some individuals express these traits at pathological levels (for instance an absence of empathy in psychopaths or 'malignant sadness', in Lewis Wolpert's excellent phrase, in the case of sufferers with depression).

A hypothesis that I suspect Szasz would find fascinating, as I do, is that depression itself should be regarded as an adaptation, an argument developed in Paul Keedwell's excellent book 'How Sadness Survived'. It is eminently plausible that depression is not an illness but a section of the distribution representing the human ability to experience joy.

Neither this perspective, however, nor Szasz's paper are directly relevant to my question 'what are psychiatrists for'? No-one denies that humans can experience both misery and joy and that witnesses can reliably report which of these and at what level they are experiencing at any given moment. If psychiatrists set out to minimise misery and maximise joy, rather than trying to 'cure' their patients, they might at least be worth their high-class hooker hourly rates.

Ron Tomlinson said...

Thanks for the Lewis Walpole phrase: I've ordered his book of the same title.

Can you recommend a defence of monism? My present understanding of the human mind is that it is a special kind of software which we don't yet understand, but which could in principle run on hardware other than the biological brain. (See Chapter 7 of 'The Beginning of Infinity'.)

FWIW: the present role of psychologists seems to be to paper over over the cracks in our society: for example, there's a moral problem with herding children together and requiring them to learn certain things. When a child refuses to cooperate, rather than face this problem, it has been found convenient to label him with a mental disorder.

The psychologist is there to provide pseudo-scientific authority for this process. I guess it was priests that used to do this sort of thing, though with a different-flavoured authority.

Talk therapy seems legitimate, though, provided it is voluntary. Everyone, from young to old, needs attention in order to thrive. (Otherwise one can't cope with that inherent stress of being human.)

Most people seem to get the attention they need from friends. The people who don't or can't are either (1) going off the rails, (2) solving their ongoing problems, (3) generating sufficient conscious attention from within. (The latter category are regarded as 'spiritual' people.)

Of course, if a therapist can't give this sort of attention but actually tries to enact some fashionable psychological theory or other, well, that isn't going to work. Psychiatrists prescribe drugs, don't they, well those might alleviate some of the physiological symptoms. This could be of temporary benefit while the underlying (non-medical) problems are being addressed.

torquatus said...

The best defence of monism that I've read is Daniel Dennett's 'Consciousness Explained'. Another book that I really like is Susan Blackmore's 'Conversations on Consciousness', in which she discusses the mind and the brain with about 20 scientists and philosophers working in the area. Most of these are monists, as indeed is almost everyone working in the field. All except Dennett, however, argue that he has emphatically not explained consciousness. I think personally that the software/hardware analogy for mind/brain is dangerous. We don't seem to understand brains well enough yet to claim that they are a substrate for running software. I don't think Deutsch defends this view particularly well.

I agree with you that both psychiatrists and psychologists often do abuse their authority to define as 'sick' states that are socially unacceptable but I don't think they do so knowingly. The psychiatrist prescribing Ritalin to a bored child presumably does so in the belief that he is helping the child overcome a debilitating condition. Much as Thomas More presumably believed he was saving souls when he burned apostates.

Drugs do seem to work, especially in severe depression, bipolar disorder and schizophrenia. Psychiatrists are the pushers and, if for no other reason, they are useful in this capacity.

Again I agree with you that talk therapy is in principle useful to patients. Unfortunately, in my experience, most practitioners seem to be both incompetent and under the influence of one or another school of voodoo medicine - psychoanalysis, Gestalt therapy, CBT or sticking pins in effigies of your parents. There's a lovely cartoon that I saw in one of Judith Harris's books showing the floor plan of a psychiatric hospital. It reads 'First floor: father's fault; Second floor: mother's fault'; Third floor: society's fault'.

You'll enjoy Wolpert's book and, if you suffer from depression, I think you'd get a lot from reading Keedwell's 'How Sadness Survived' too.

Ron Tomlinson said...

OK, I've started reading 'Malignant Sadness' (btw I've not experienced depression myself).

I like the way he won't accept low serotonin as an *explanation* of depression. Following David Deutsch I am a fan of good, hard-to-vary explanations. It seems reasonable to expect that some aliens get depressed too, but they're likely to have a different set of neurotransmitters to ours.

On page vii of the intro he thinks that exercise may help people to avoid depression because of the release of endorphins ('runners high'). My guess is that movement does indeed raise the spirits but not because of any high. It is that the coordinated movement of the body requires a different state of mind, one in which it's harder to think anxious thoughts.

My preliminary idea is that depression is getting stuck and then worrying about it, establishing a negative feedback cycle. If the monism is true perhaps this implies that the rate of neurogenesis lowers, for whatever reason, then a flurry of anxious thoughts depletes the brain of resources, causing neurogenesis to drop further, and so on.

torquatus said...

Who the heck are you? Don't feel obliged to answer that. I'm just curious. If you haven't done so already, check out the human connectome project. It's aim is to map the position of all the neurons in a typical human brain and all the trillions of connections among them. There's nothing in human experience that comes close in complexity terms. Your idea about depression might be right but I hope you don't take it as a criticism if I say that I doubt it. I am very happy to hear that you have never experienced depression. Long may that last. Oddly enough, I'm currently experiencing the longest period of depression-free life I can remember. It's weird, because, on paper, life is fucking shit but I just don't feel shit. It's mysterious. I hope you have more success than I have understanding it intellectually.

Ron Tomlinson said...

I'm a bloke from Bristol -- my name is Tom, I have two children, and I enjoy reading about science and philosophy.

My interest in the work of David Deutsch drew me to Alphatuosity: I've been searching around for thoughtful commentary on 'The Beginning of Infinity'.

Allow me to say that I think it would infuriate most to hear a non-depressed person opine about depression or anxiety.

However, you expressed only kindness. Also, you write beautifully :-)

I have some more ideas about depression which I believe may be important but I need to criticise them some more.

Relatedly, over the course of last weekend I consumed extract of Rhodiola rosea.

During the afternoon of the day after I stopped I experienced some self-hating and irrational thoughts. Thankfully they didn't trap me into some sort of cycle and I didn't identify completely with them.

Even so, it was an powerful experience. It is astonishing to recall the thoughts and the events that seemed to trigger them. (I say they were irrational but they were rooted in rationality. It was the emotional response that was way out of proportion.)

Since then I've found the same phenomenon mentioned in a story which may be interest:

torquatus said...

Well, Tom from Bristol, you have several things going for you: a fine first name, excellent taste in literature and an open (but not too open) mind about the usefulness of psychotropic drugs.

I don't think it's any more irritating hearing opinions about depression from someone's who has never experienced it than hearing opinions about pregnancy from a male gynaecologist. There are physiological correlates of depression (e.g. abnormal levels of certain neurotransmitters) that can be understood and manipulated perfectly well without reference to the mental states involved.

What's more, empathy allows us humans to partake of experiences and states with which we are not personally familiar. If you can 'feel' the suffering of a chimp locked in a laboratory cage, for example, then I don't see why you can't feel the suffering of a fellow human being locked in the mental cage of depression.

Thomas Nagel wrote a famous paper in the philosophy of mind entitled 'What is it like to be a bat?' He claims to show that reductionist approaches to resolving the mind-body problem are doomed to fail. This claim is controversial. I have a fiver each way on the outcome. He does show convincingly, however, that if you try to imagine what it is like to be a bat, what you are actually imagining is what it would be like if you were a bat. You simply cannot imagine what it is like for a bat to be a bat. I think the same is true for someone who has never experienced depression trying to imagine what the experience is like. You can perhaps imagine how you would feel if you were depressed but you, Tom from Bristol, cannot, however hard you try, imagine what it is like for me, Tom from Bradford-on-Avon to be depressed. Believe me, that's a good thing.

But that's enough about me. What do you think of 'The Beginning of Infinity'? I don't understand the physics. Just not clever enough, to my everlasting regret. But I do stand by my original comment that Deutsch's entire analysis of the potential of science is grounded in what I think should be termed the 'Puddle Fallacy', after Douglas Adams's brilliant metaphor of a small pool of water in thrall to the strong anthropic principle.

Ron Tomlinson said...

Sorry to read about your freezer. I find throwing stuff away to be increasingly problematic thanks to our new fortnightly rubbish collections.

This was my first-reading impression of BoI:

I love David Deutsch's worldview. It is deep, consistent and optimistic. He understands our most fundamental theories better than most because he has thought carefully and uncovered many connections between them.

Not sure what the Puddle Fallacy implies about the potential of science.

However this may be relevant: Deutsch argues that what we may know cannot be confined to a finite bubble. Check out the talk linked on the page below from 27:00 to 35:00