Tuesday, November 6, 2012

Psychiatry, Psychology, and Philosophy

6/11/2012 3:31PM

One of the more puzzling features of the mental health profession is the refusal to engage in a rigourous analysis of their own assumptions. It is as if they ignore the warning of Bertrand Russell when he advised that one of the first goals in philosophy is to recognise that a problem exists. Psychiatry is wedded to an excessively reductionist view of behavior , it is as if they have never encountered the concept of emergent properties let alone realised that a bottom up approach to understanding a complex system is almost always doomed to fail when there are many variables in play. The brain is the penultimate complex system. (Perhaps, given we don't know what brains do it may turn out that the processes are very simple, like a series of reiterations of very simple processes.) The psychologists catch and grab and whatever therapy comes along until it is eventually seen to be just another therapy offering little more than the placebo effect. Carl Rogers may deserve more credit than he is given today. Paradoxically the placebo effect may be the principle benefit in many therapeutic interventions but of course neither psychiatrists or psychologists would admit that because that would constitute a problem for them. No-one likes having the foundations of their concepts challenged. It is painful and could demand a complete re-appraisal of a conceptual structure. Hard work.

Therapy is typically conducted in the therapist's office which has specific environmental contingencies that can have profound implications for behavior modification. For most people the therapist is an authority figure, someone to be revered and someone who is going to provide a solution to their problems. Therapists can only facilitate change they cannot enforce it. What needs to be realised here is that the mere presence of the therapist is potentially a placebo effect. In itself that can be a very good thing but therapists can then fall into the trap of asserting it was the specific therapeutic intervention that did the trick when they may not be true at all. There is no easy way to distinguish these causal factors and perhaps that isn't even necessary. What is necessary though is for the therapist to appreciate that any given therapeutic intervention is not an isolated causal agent, that many causal agents are in play and can be very important in therapeutic interventions. Psychiatrists, moreso than psychologists, can be guilty of focusing too much on the therapeutic strategy and so fail to realise that their presence, how they conduct themselves as a person interacting with another person, can have profound implications for treatment.

The therapist as an authority figure will alter the nature of self-reports and this alteration will very much depend on the patient's therapeutic aims. If they think they need more treatment they will overstate their problems. On the other hand they may be the type of person who wishes to please the authority figure and so be inclined to assert that the therapy is working and they are feeling better. Self reports, like surveys, are riddled with problematic claims yet the therapist is in a bind here because of confidentiality issues. It is nigh impossible to get "inside the head" of the patient which is why when a depth psychoanalytic approach is undertaken it takes many months and even then confounding contingencies still make this exercise highly problematic. Indeed the ongoing therapeutic intervention creates a behavioral context that can be vastly different from the context in which the patient needs to alter their behavior: in the world at large.

Wherever possible the self-reports of the individual should be analysed with reference to the reports of others about the behavior of the patient. The parents or lovers, employers, the children of the patient, even close friends or other health professionals providing treatment for the patient can provide important appraisals. What needs to be appreciated is that behavior is contextualised, the behavior the patient in the therapist's office is not necessarily a good indicator of the behavior of the patient where it really matters: in the world at large.

Yet the phrase: "in the world at large" betrays another dangerous assumption. We behave differently in different situations, our verbal behavior is typically modified for the audience we are addressing, how we behave at work can be very different to how we behave at home, when the boys get together they are not going to behave the same way as when the gals are around. There are some who argue we should be "true to ourselves", as if there is some hidden core that constitutes are our real being. Be true to yourself? How? What is that self I must be true towards? I still like Jung's idea of individuation but I think that many people misinterpret this as an individual finally becoming what they were meant to be whereas I interpret as an individual realising, either slowly or abruptly, that their behavior has been heavily determined by their culture and the cognitive dissonance that comes with that causes a movement towards new behaviors that reduce that distress. That is why Jung wrote: "When a man knows more than others he becomes lonely." If you wish to kick against the prevailing pricks in your culture it is inevitable the pricks will stab you and attempt to bring you into line. Failing that the pricks will alienate you. This is a really difficult challenge, there are no simple answers here and certainly no absolute answers here. All of us are compromising our behavior in relation to our beliefs. Which is far better than creating rationalisations. We should at least be honest about the contradictions within ourselves and recognise that these are not moral failings but an inevitable result of living with others. That might explain why some people in their latter years retreat from society. Perhaps they value integrity and honesty too much.

Let's be clear here: no matter what society exists there will always be individuals within that society who will demonstrate maladaptive behaviors. That is a statistical inevitability. There is no utopian psychology or psychiatry. Satori is just a dream(David Bowie). Adaptive behavior cannot be understood without reference to the environment in which that behavior occurs. There are those who assert modern culture is breeding mental illness but fail to realise that any culture will create mal adaptive behaviors. What is truly remarkable about human beings is the tremendous adaptability of our species. Only a few hundred years ago literacy was the exception, most people were put to work before reaching their teen years. Now it is not uncommon for human beings to undergo training for productive contributions to society that can take up to 25 years of their life.

One of the more successful areas of behavior modification, if not the most successful, is in relation to phobias. How does this success arise? The patient is exposed to the stressor in varying degrees, a strategy of desensitization that slowly increases the patient's exposure to the painful stimulus until the patient has adapted their response to the stimulus. This is very important: drugs do not help, talking the fear down does not help, what helps is direct behavioral intervention to the relevant stimulus so the patient learns to adjust their own behavior. All the drugs on the shelf, all the cognitive behavioral therapy under the sun, has little efficacy here. What works is addressing specific behavioral responses and modifying those. This should be instructive but it seems to me that in most other areas of mental health we labour under the illusion that we can think our way to better behavior or drug ourselves into better behavior.

Psychiatry has moved towards the reductionist explanations and done so in the belief that this represents a scientific approach to understanding behavior. Sadly it was only in the late 1950s that ideas like chaos theory and mathematical explorations of complex systems indicated that the explanation of the behavior of a complex system is not reducible to its individual constituents. This raises some profound questions about the nature of causation in the natural world, a topic I am still exploring and probably will be til I'm dead because it is fascinating and I am insatiably curious. Psychiatry has presented so many simplistic ideas about behavior that it has exhausted its claims in this matter because these have so often been found wanting. If psychiatry had kept thinking about the limits of the reductionist enterprise, or more correctly recognise that the reductionist paradigm does not mean all phenomena are ultimately explicable in relation to the individual elements within those phenomena, psychiatry may not have then assailed us with simplistic claims like "chemical imbalance", or the dopamine or glutamate hypotheses of schizophrenia, or that ADHD is because of DAT alleles. Seeking to appear scientific psychiatry has revealed its philosophical naivety.

Psychology has generated so many theories of personality that it should have long ago recognised it was engaging in the wrong level of analysis. It too much labours under the false assumption that we have some hidden core to us, that the psychologically healthy person is one who is relatively free of cognitive dissonance and that a healthy soul is an honest soul. It seeks too often to change the whole of the person rather than the specific behaviors of the person. That is why psychologists are so often guilty of writing self help books on how to be a better person, as if being a better person is predicated on some moral absolutes that stand above our culture, as if there is some specific human nature and if we can just find that within ourselves we shall individuate towards happiness and all things sugar and spice.

Psychiatry and psychology face fundamental constraints in attempts to reduce mal adaptive behaviors. The challenge is beyond these two disciplines but our emphasis on these disciplines reveals the widespread belief that behavior is ultimately a function of the individual and that the environment only plays a minor role. The challenges for the mental health profession go beyond the treatment of individuals but mental health professionals are expected to resolve mal-adaptive behaviors by only modifying the individual rather than the environment, particularly the cultural aspects of the environment within which that individual must function. In this regard we could do well to revisit the themes explored by Jung, Fromm, and other authors. The present challenge though is to recognise that not only have psychiatry and psychology laboured under misconceptions about human behavior but that our whole culture still labours under many such misconceptions. We have a lot of hard work to do and it is not going to be finished in my lifetime. It will never be finished, it will always be an ongoing enterprise because the numbers of variables impacting on human behavior are and always will be for all practical purposes infinite. That is not cause for despair it is a recognition that in most areas of human endeavour we are always reaching towards the goal but never quite grasping it. There is no final solution.


Ivana Fulli MD said...

Thanks for those thoughts.

I also found food for thought in the differenciation between mental illness and mental illhealth used by Dr Luke Beardon, a British psychologist who works for aspies.

John said...

That is a very useful differentiation Ivana. I would add to that behavioral disorders. Thanks.

You would have more insight to this than myself - I often get the impression that psychiatry and psychology tend to be in opposition. The result, as so often happens in human behavior and especially in politics, is that the opposing parties become too focused on the problems of their protagonists rather than concentrating on the problems in their thinking.

Ivana Fulli MD said...

My view is that nowadays, psychologists and neuroscientists are inundating the internet and Journals with garbage quality studies and it is a pity since some of them are very clever and very innovative but their work is lost in an ocean of publications using 19 undergrads to work on a senseless project...

On the other hand, psychiatrists' research is suffering from Bad Pharma money talking too loud...Unless they are epidemiologists. I, for one, believe epidemiology might give us many answers-and i ma not an epidemiologist by training and far too old to become one.

To go back to the subject of your post, to my poor psychiatrist - but educated by clients mind - overgeneralization and oversimplification are the two main morals sins -or for an intellectual and scientist like yourself, heuristic bias- of neurosciences and clinical researches in psychiatry and psychology.

You are right, one should treat every individual people and neither a disease elected by a DSM or ICD committee nor symptoms like Dr Bentall et Dr Moncrieff asked for recently.

I am sorry to write it because the man is not stupid and very energetic and hard working but Pr David Bentall is a culprit of the same sins -only in a mirror way – when he proposes (with Dr Moncrieff, a psychiatrist) to treat symptoms and not mental illnesses...

They should have said you should treat the person!

Do you want an example: On the topic of exercise effect in depression in a recent neuroskeptic blog, Mr Petrossa, an aspie, told the neuroskeptic's audience that he likes to take his pills and to sit on a bench looking at the sea.

Everyone in the healing trade should respect Mr Petrossa ‘s views on pills and exercise.

(Often in my experience aspies get relaxation from looking at the sea and I ask those persons to get a postcard from their favorite beach to have in their pocket to look at it or even touch it before melting down in stressful situations.

But I also know, in person, a young male British aspie who was a university drop out living in isolation on benefits -to the point of spending 3 days without going out of his flat who changed his life by deciding to do a walk every day and latter working a lot on his physical fitness. He is now a successful university student, almost friend with other students as he put it to me although they are much younger than himself and he is autistic.

It is why antipsychiatrists are as dangerous as psychiatrists lacking morals for clients and society because they are ideologues and politicians of sort with oversimplification and overgeneralization as a tool.

Ivana Fulli MD said...

Addendum: Dr Bentall also wrote a very unbalanced paper against ECT

without taking into account that some people say ECT saved their life and that the alternative in some cases is a very heavy drug regimen and forced hospitalization:

“I would happily die rather than have ECT again.” (Woman, Yorkshire.)
 and “If I had not received ECT I would be dead by now.” (Woman, Staffordshire.) from http://www.mind.org.uk/help/medical_and_alternative_care/making_sense_of_ect

And that same Dr Bentall wants for the psychologists the right to prescribe drugs that might be even more damaging to clients due to metabolic syndrome, brain shrinking, tardive dyskinesia, deadly hyperthermia and the likes.
But he wants to do his politics along with Dr Breggin against Dr David Healy an Irish psychiatrist...

It is why, in my opinion, psychologists should not be allowed to prescribe drugs unless they get a MD first - This because:

1) too many drugs are already prescribed instead of talking and knowing better the client
2) those drugs are not curative of the brain and are poison to every cell in your body like any really potent drugs
3)you cannot be a doctor and ignore that you have to adapt the dosage and choice of treatments to the client even in internal medicine with a real disease complete with lab test.

To be clearer, if Dr bentall was a clinical psychologist in oncology, nobody will trust him to prescribe cancer treatment drug regimen because those drugs have side-effects and he is not an MD.

There is not difference in psychiatry.

Thank you John for that clever post and your kind support when I have difficulties to speak my mind on other blogs.

John said...


The publish or perish phenomenon is resulting is a parade of piddling proclamations that perpetuate the pretension that inferential statistics is an appropriate method of analysis for the complexities of human behavior. The "controlling for variables" is so simplistic because it presumes the independence of the variables but this is not always true when it comes to understanding behavior. It can even be true in many cases that the variables undergo an exponential cascade if not explosion because the interaction of the variables creates new variables; which to my knowledge are not "controlled for" if only because we cannot know all the relevant initial variables let alone their potential interactions. So the fundamental method of mathematical analysis is in itself wrong. That's why experienced therapists often learn to trust their experience to guide patient treatment and like yourself become increasingly cynical of all research claims.

Diedre McCloskey, an economist, has written a penetrating article on this. See:

She cites the work of Jack Cohen, a statistician who in the 60's wrote a paper to the effect that the results of various psychological studies were statistically impossible to justify.

But most people don't think this issue through, they are trained to use inferential statistics and accept it as given that this is a valid means of analysis. McCloskey's paper deals with biomedicine at large where the same problem is present but it is much more severe when it comes to understanding behavior.

Unfortunately even the anti-psychiatric crowd don't grasp this essential point. They know something is wrong with our approach to understanding behavior and then blame the psychiatrists. Additionally what they do not understand is that the psychiatrists are fundamentally constrained in their treatment options and this has a good deal to do with the demands of modern society which requires that psychiatrists get people better yesterday when the reading of the relevant literature indicates that patients who have experienced sustained stress undergo cerebral structural changes(eg. receptor density changes, amine fluctuations) that can take several months to normalise.

For the record, I think the anti-psychiatric crowd is far more dangerous than the dangers they purport to be protecting patients from.

That is why the drugs can be so valuable because the drugs can very quickly prompt the CNS back towards a state more appropriate for instantiating behavior change. The drugs are dangerous but most medical interventions are. My original intent in writing up this post was to write about the potential conflict between drugs and psychotherapy but my thinking moved in a different direction. With luck I may write up my original line of thinking in the next few days.

It is not surprising you have difficulty conveying your point of view. You are kicking against the pricks, an old phrase which refers to how oxen was prevented from kicking backwards against the farmer by a series of wooden pricks placed on the harness that would pierce their hind legs when they attempted to kick back. I have known a number of people like yourself and they encounter the same opposition, often becoming very frustrated at the tribal nature of modern thinking about behavior modification.

Ivana fulli MD said...

As long as I get clients who benefit from my help and friends like yourself, I feel OK.

But what you described is one of the reason I stopped doing research in pharmacology when as a psychiatrist registrar I had a nice start with a paper published in "Psychological medecine" that i didn't conceive but worked for in oxford (England)and another one I conceived in The lancet on female hormones and the mood!

you really are clever and full of experience and good sense john!

I have to go back now on working for my case against the French medical board and will be silent for some times but I will read your blog regularly.

baz said...

Hello John and Ivana
Thank you both for your insights into the current world of psychiatry and human behavour. It has been a long time now since i have felt inspired but the ongoing dialogue between you two reminded me of the letters between Freud and Jung (the early letters when they were on the same page :))
I am a social worker and i could not agree more with what you have said and in particular the relationship between the person and their environment. This traditionally has been the home for social work the "person and environment fit" and understanding the social and politcal constructs that impact upon behaviour.
An excellent book By S. Millar, B Duncan and M Hubble " Escape from Babel" also touches on some of what you covered. It is a meta analysis of many of the pyschotherapies endeavouring to discover those factors which actually make a difference in a persons life when they attend therapy.They discovered that the most important factor is that you respect the clients veiw of whats happening and their thoughts about solutions (go figure?) This is an approach that social work has been using for years under various names but primarily under the term "Strengths approach" Believing in the clients ability can instill a certain confidence and help them identify factors withiinin themselves that can solve issues. The second factor included the therapeutic relationship which you refer to. One aspect of this relationship includes Rogers oldie but a goodie "unconditional positvie regard". It apparently didn't matter what technique the therapist used as long as the relationhsp was "right" and that both the client and the therapist believed in the particular therapeutic approach. Thirdly success for the clients was determined by how much hope a client had and if this was nutured by the therapist and lastly almost any model would do as long as it provided structure and novelty...

Others have also explored the common factors of successful therapeutic interventions.

Asay and Lambert (1999) get deeply into a meta-analysis in this area and conclude that technique ranks a dismal 4th (equal with placebo effects) when measuring the effects of therapy. “Extratherapeutic factors” like lifestyle changes and social support comes first (40%), relationship with the therapist is 2nd (30%), and technique accounts for only 15% of change

Enough of my babblings ,just wanted to say thanks and for giving me a bit of hope..

"I cannot forget what one of my patients once said when i asked him ,"What do you believe was the reason that i could succeed to cure you after all these years of misery ?" He answered ." i became sick because i had lost all hope. And you gave me hope" Alfred Adler