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October 3, 2005 This is in response to a letter from James Gambrell regarding my essay about the "Psychiatric Game." He raises some interesting points which need to be addressed. He has given his permission to publish his letter and provide his name. He is also invited to reply to my response and it would be published here if he does so. His comments are in black type and my responses are in red type.
JG: Dr. Dolhenty, First let me tell you that I love your site. I'm a big fan of Mortimer Adler for one, and your mini-courses and other materials are all very well written and highly informative. JD: Thank you. I appreciate your kind words. JG: However, I'm also an aspiring Clinical Psychologist, so I'm curious about the nature and extent of your objections to psychotherapy. I think you have overstated the situation quite a bit in your article The Psychiatric Game. For example, your quote:
JD: That, indeed, is what I have said. JG: One of the fundamental tenets I have been taught as a student is that a mental disorder is only a "disorder" if it fulfills some important criteria:
Now, this second requirement can be superseded by the courts obviously, but I don't think anyone really complains about being "sentenced to counseling" as opposed to prison or something. So I don't find that psychiatry or psychology is unappreciative as to the whether the activities are harmless to the people involved. Far from it, psychiatrists have been known to assist clients with suicide, and famously have treated clients involved in criminal activities. JD: Let's stop for a moment. I have to question your use of the term "mental disorder" since I don't accept that term anymore, as usually defined, than I accept the terms "mental disease" or "mental illness." If by "mental" we mean "mind," then I have to reject the use since, in my opinion, the "mind" cannot suffer from any such phenomenon. If, however, the term "mental" refers to the "brain," then I have no objection. In this case, however, we are talking about a "physical" organ and, therefore, a "physical" disorder, disease, or illness. If we are talking about a "mental" disorder in the sense of a "brain" problem, then it doesn't matter if it is "recognized" or not by the client (patient) or by friends or family, or even by the courts. It would be "objectively" a disease or illness as diagnosed by an appropriate medical practitioner. There would be medical procedures by which it could be determined whether or not a person was suffering from a physical disorder and any diagnosis could be, usually, agreed upon by competent physicians and a common resolution suggested to the patient. (This is generally the case -- I admit physicians may disagree over minor issues in any diagnosis or treatment, but they are resolved by "objective" means.) JG: Your assertion that psychiatry and clinical psychology is in the business of passing moral judgment is quite the OPPOSITE of what most practicing psychologists actually engage in. The dominant form of therapy in America today is based on Carl Roger's client-centered therapy, the main tenant of which is unconditional, non-judgmental positive regard. This positive regard is often all that is needed to improve the lives of suffering people. JD: I am not that concerned with the "passing of moral judgment" per se. If the problem is truly one of a "brain" disorder (chemical, hormonal, or otherwise), then "moral judgment" is not a factor here, anymore than passing moral judgment on someone who is suffering from diabetes or lung cancer. We certainly do not say someone is "bad" or "wrong" or "disreputable" or "immoral" just because that person has a brain tumor or arthritis. What I was referring to was the matter of certain behaviors which have come to be defined as "mental" illnesses or diseases. These usually refer to a society's "moral" judgment about the behaviors and have nothing to do with a true physical disease or illness. Many behaviors which are deemed by a society to be "unacceptable" are commonly considered to be a matter of psychiatric or psychological concern, and, therefore, "mental illnesses." I am challenging that notion. JG: As you rightly point out, psychiatry is beset by a multitude of dubious forms of therapy:
And the apparent problem with this:
The first two statements in this last quote are quite accurate, the scientific evidence for most therapies is weak and correlational at best. JD: Thank you for recognizing that. However, I might point out that the scientific evidence for most psychological therapies (with the exception of a very few) is not "weak," but "nil." That is, the "treatments" just don't percolate. They don't "cure." They don't even "help." Sad to say, many of them may even contribute to more serious problems. JG: The last statement however, is dead wrong, unless you are going to a religious therapist like one of those guys who are supposed to "cure" homosexuality. Psychiatry is indeed the modern secular replacement for the old confessional booth, or a one-on-one talk with your pastor, but as I have mentioned, it is non-judgmental, and vastly more tolerant. If you ask me, it's a big improvement, except for the fact that it costs a lot more. JD: Sorry, I have to disagree with you here. I stand by my statement. Psychiatry and clinical psychology did transfer carte-blanche many of their judgments from the Western religious realm to their "supposed" secular kingdom. A quick comment and a couple of examples should suffice, although there are many more. First, modern psychiatry did consider homosexuality to be a "mental" disorder or disease and subject to "cure." And I think it is plain to see that it derived its initial judgment about homosexuality from the influence, indeed dominance, of Judeo-Christian theology upon Western culture (the ancient Greeks and Romans had no such views about such sexual behavior). The Diagnostic and Statistical Manual of Mental Disorders, published by the American Psychiatric Association, is the handbook used most often in diagnosing mental disorders in the United States and internationally. It classified homosexuality as a "mental" disorder or disease until 1973. In that year, a decision was made by VOTE to remove homosexuality from the diagnostic manual. In a sense, this was the biggest immediate cure in human history! Overnight, millions went from "diseased" or "ill" to "cured" or "healthy." Has the American Medical Association ever done that with any "physical" disease? Second, in the latter part of the 19th century and well into the 20th century, psychiatrists (often at that time called "alienists") were diagnosing and treating so-called "masturbatory insanity." This "perversion" was clearly derived from Judeo-Christian sources. The psychiatrists promoted many "cures" for this "mental disorder" which were what we would call today "irrational" and, in some cases, prescriptions of torture. Magazines of the time ran advertisements for devices to "cure" both boys and girls of this "solitary" practice. And people were put in "mental" institutions after being caught "playing" with themselves. (I know personally of just such a case -- over 20 years incarcerated -- the uncle of a friend of mine found masturbating behind his family's barn.) So my point is that many of the so-called "deviant" behaviors categorized by psychiatrists as "mental" disorders or diseases are simply behaviors which have been condemned by religious beliefs and transferred over to psychiatry or behavioral psychology without criticism. Granted, this is not that big a problem today since many of these behaviors have been seen to be harmless and "normal" or whatever. Still, there are some advances to be made. JG: Your article and other books on the subject often give very contradictory reactions to psychiatry in my opinion. Typically, three objections to psychiatry are leveled. On the one hand, psychiatry is derided for being non-scientific, non-replicable, subjective, etc. At the same time it is derided for pigeonholing people into labels and categorical illnesses with no regard for whether the person is actually happy with themselves or not. Isn't it obvious that these two statements are incompatible? If you can go to five different psychiatrists and get diagnosed with five different "illnesses" because psychiatry is unscientific, how are you being pigeonholed and labeled? JD: Psychiatry as traditionally practiced (exceptions will be noted at the end of this discussion) has been unscientific and subjective. There is little doubt about that, I think, at this time. The major psychiatric therapy, Freudian psychoanalysis, has yet to produce a genuine "cure" based on scientific standards. And psychiatrists have categorized or labeled individuals and are still doing so without any objective reference supporting the diagnosis, except for mere "opinion." The issue of "happiness" has nothing to do with the matter. "Happiness" in the psychiatric or psychological sense means simply "contentment." It has nothing to do with the state of one's actual objective situation. I am sure that William Sutton was very "happy" robbing banks because, after all, that's "where the money is." A subjective state of "contentment" is hardly a good criterion for determining whether one is psychologically sound or whether one's behavior is moral or acceptable or rational. Or, worse, whether one has a genuine "brain" disease or illness, a physical ailment which can be treated by "physical" (material, chemical) means. JG: The labeling phenomenon is really created by the economics of drug companies and health insurance companies. These companies need labels for things so they can try to control costs and spell out benefits. Labeling is just an unfortunate fact that serves to over-simplify things for business purposes. JD: And scientists and medical practitioners are to cave in to corporate conveniences? I think not! Drug companies and insurance companies are not to determine what constitutes a disease and what does not. Period. I'm willing to submit that little matter to a vote of ordinary people. While I'm willing to leave a lot of things for the free-market to decide and for private businesses to support and provide, decisions about scientific truths and procedures are not something I'm willing to allow the private economic sector to have the final say about. JG: [Quoting me]
Of course Psychiatric causal hypotheses for things like homosexuality are post hoc and dubious, neurobiologists are still trying to figure out exactly what glial cells (90% of the brain) are for! In most cases, the causes of mental illnesses are simply biological. Beyond that, they will probably never be understood. As with most social problems, the focus is on how to cure/help them, not figure out what the cause was. JD: This particular matter is still a matter of argument. I don't pretend to have the solution to the so-called "homosexual problem." If, indeed, it is a problem at all. It wasn't for many civilizations of the past. It isn't for some today. Whether genes are the causal factor in producing homosexuals or something else is, I, frankly, don't care. I don't see it as a "psychiatric" or "psychological" problem per se, and if someone is having a problem with homosexuality (either pro or con), then I think he or she should address it and discuss it with someone (and, maybe, even with a clinical psychologist!) and get the problem behind them. The "problem," however, is not a "mental" one, either way. JG: The third objection, articulated in books like The Myth of Mental Illness goes like this: Psychiatry offers a big cradle of excuses for people who lack self-control and responsibility for themselves. It gets hundreds of criminals off the hook by way of supposed "diseases" and encourages more criminals to break laws and then plead insanity. This accusation is usually leveled by people who have no personal experience with the mentally ill. JD: First, Dr. Szasz, who is the author of the book you cite above, is a renowned psychiatrist and has lots of experience with the so-called "mentally" ill. He makes the distinction, which I support, between a true physical disorder which appears to be a "mental" problem and a problem which is the result of a lack of self-control and responsibility. When a real physical disease is present, it needs to be treated with the appropriate material means. When it's a matter of irresponsiblity, that's another matter and it won't be treated with a material means. The matter of "insanity" is a legal situation and not a psychiatric one. It is a matter for lawyers and judges, not for scientists and medical practitioners. The definition of "insanity" has varied from time to time, from culture to culture, and has never had a genuine "objective" reference. The "M'Naghten Rule" (1843), which seems to govern the question of insanity in American courtrooms is absolutely ridiculous, in my opinion. And I can't change that. All I can say is that it needs to be thrown out and updated with the latest scientific information we have (fat chance!). JG: The response to this objection is obvious, most criminals ARE mentally handicapped or mentally ill, otherwise they wouldn't be committing low-benefit, high-risk crimes in this country of legitimate opportunity. This applies doubly so to the criminals dumb enough to get caught. The average IQ of the prison population is 91, and that of death row inmates is even lower. They also tend to suffer from a unbalanced deficiency in verbal ability. Engaging in illegal activity (in the US) is about as objective a sign of mental handicap as one could ask for. JD: How do you know that most criminals are, in fact, "mentally" handicapped (whatever that means) or "mentally" ill (which I don't accept at the outset)? Recently we have seen many real criminals convicted and sentenced to long terms in prison who are, by any definition, not in either of those categories. Think ENRON. Think WORLDCOM. Think Martha Stewart (although that, in my opinion, was a travesty of "justice"). Then think of Bill Clinton, lying under oath, committing perjury, and that is a crime. There are, to be sure, "dumb criminals." There are also smart ones who get away with their crimes forever. There are hundreds of murders never solved. The recently convicted BTK killer was loose for years without being caught. I suspect he was not that "dumb." I have to disagree with you that engaging in illegal activity is a sign of "mental" handicap, necessarily. There is good evidence that most people at one time or another engage in an illegal activity (be as small or as uninteresting as it may be). Are all these people "mentally" handicapped? In that case, the majority of Americans, I submit, may be "mentally" handicapped and, if that is true, then you may have to modify your definition of "handicapped." Maybe a "handicap" is really "normal." JG: The fact is crime is largely a product of environment (relative poverty/boredom) and biology (mental problems), not personal choice. That is why cities suffering from rampant poverty have rampant crime (New Orleans, Chicago). Eliminating crime is not easy, but it is straightforward. Eliminate poverty, increase the value of a person's life and they won't risk it as quickly. They'll also be too busy playing video games. JD: Sorry to say, this is the old "sophistic," "relativistic," and now "modern liberal" argument regarding human behavior. It is a myth of mythical proportions (pardon my pun!) that poverty or boredom or any other specific environmental situation "causes" crime or immorality. There is no evidence that poverty per se "causes" criminal behavior. There is no evidence that boredom per se "causes" criminal behavior. These and other simplistic explanations have, for the most part, been put now into the social science garbage dumpster. Some of the wealthiest cities in the United States have the most crime. Some of the poorer sections of the country have the least. There are rural parts of the U.S., where the residents live way below the poverty level, which experience virtually no crime at all. On the other hand, Los Angeles, California, and Las Vegas, Nevada, two of the richest cities in the world, are criminal cesspools. As was New Orleans before it was drowned. JG: So what if we eliminate poverty for the most part? What happens to the criminal population? Well, now that all the mentally healthy kids are thinking about college and Halo II, we are left with jails full of the mentally handicapped. That is why mental illness pleas are on the rise, it is a good sign. A sign that our healthy citizens are more likely to NOT be in court. JD: Well, I suspect we will never eliminate poverty from the human scene. The poor will always be amongst us, as the Bible says. I have studied over six thousand years of human history during the past fifty-plus years and there never was a period where the poor-population was not present. It seems we are "condemned" to have the rich and the poor and, maybe, the middle class. If I knew a way to make everyone wealthy, without devolving them into rank irresponsibility, I would promote that program. Unfortunately, I don't have the solution. Living responsibly demands morality. And morality requires responsibility. And free will. And choice. And thought. And rationality. And...well, some other things, I suppose. Like courage, fortitude, temperance, prudence, and so on. JG: In conclusion, I agree with many of your observations about the "game" psychiatrists play. It is indeed a game. However, classical liberals like yourself tend to judge psychotherapy and other social remedies on the wrong criteria. You point out that treatments often don't work, have no guarantee of working, or can even make things worse. So why do people keep paying? The same reason people gamble, it works out quite well for some people. That laundry list of treatments, meant to make psychotherapy seem laughable, actually reflects the increasing power of therapy. If every therapy has a some chance of helping a person, then each new therapy invented that a therapist can add to their repertoire increases the chances they can help a person. The improvement of a single person's life is all the justification a therapist really needs. JD: Yes, I think most of this thing is a "game." Unfortunately, and to the detriment of the individual. I don't know what you mean by the "wrong criteria." Why do people keep paying? Well, why do people keep investing in "get rich quick" schemes? Why do people keep undergoing agonizing cosmetic surgery to "stay young." Why do people do anything at all? It's because they seek what they perceive to be the "good" for them, regardless of whether it's "really" good for them. That's part of the Human Condition and always has been from time remembered. It is true that people seek "therapy." They always have. That is, to put it frankly, the power of propaganda and the obsessive search for immortality. Regardless, many a modern therapist is simply selling "snake oil" to the populace and raking in the bucks to boot. That I find reprehensible. Now, this is not to say that psychiatry and clinical psychology, properly practiced on a scientific basis is to be ignored or dismissed. I am a strong advocate of orthomolecular psychiatry (which is based on a physical paradigm) and of cognitive behavior therapy and its relative, "reality therapy." There are many areas of behavior where a clinical practitioner may be of help to all of us, such as overcoming phobias, personality defects, and common relationship problems. And, of course, psychiatry which is based within the biological-chemical paradigm is to be applauded.
The first book I recommend is Cognitive Therapy of Depression, by Aaron T. Beck, et al, which offers, in my opinion, the best presentation of so-called "Cognitive Therapy" of behavior. Cognitive therapy is an active, directive, time limited and structured procedure based on the assumption that affect and behavior are largely determined by the way we structure our world. (This is what most of us Classical Realists believe, I think.) The thesis is that depression arises from a "cognitive triad" of errors and from the idiosyncratic way one infers, recollects, and generalizes.
Sounds a lot like Classical Liberalism to me. Best regards, Jonathan Dolhenty, Ph.D.
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