Shrinks to Fit

Jeffrey Lieberman is gaining attention and opprobrium as he publicizes his new history of psychiatry "Shrinks". The book turns out to be a lively run through of the standard history-of-psychiatry over the last two centuries, though at first it's hard to know what to make of it. "Shrinks" initially reads as either the gentle reflections of a well intentioned psychiatric patrician, or a cynical attempt to skirt fascinating conceptual difficulties in the service of professional power. Which you pick depends on how much Machiavellian intent one imputes to its author.

Jeffrey Lieberman (very possibly the only psychiatrist 

alive who still wears a white coat).

In writing Shrinks, Lieberman does not just want to spin interesting yarns. There is an argument being made, and it explicitly invokes a narrative of progress. Psychiatry, according to Shrinks, has muddled through the Freudian intellectual backwaters of the 1950s and 60s; endured the clunking horrors of insulin coma and psychosurgery, and now it stands on the brink of a new scientific era. I might be missing something but this story strikes me as anything but "untold". It's a well worn and, I would argue, simplistic narrative which won't gain any traction among anyone even vaguely acquainted with the legitimacy crisis faced by psychiatry's classification system. You do not need to be one of Lieberman's "anti-movement" (I am not) to find passages like this a little too slick:

“For the first time in its long and notorious history, psychiatry can offer scientific, humane, and effective treatments to those suffering from mental illness. I became president of the American Psychiatric Association at a historic turning point in my profession. As I write this, psychiatry is finally taking its rightful place in the medical community after a long sojourn in the scientific wilderness.” (p.10)

That is not to say the book is not fascinating. For one thing Lieberman's prominence as a psychiatric researcher has given him front row seats for many of the major changes in psychiatry since the 1970s. He gives compelling accounts of the renegade neo-Kraepelinians gathering in St. Louis (far from the psychoanalytic powerhouse of New York) to assemble the "chinese menu" DSM-III which changed Lieberman's profession forever (entirely for the better by his account).

Lieberman also has some provocative personal perspectives on the broad debates concerning psychiatry, suggesting (on the basis of a conversation with E.F. Torrey) that R.D. Laing lost his argumentative lustre when his daughter started to suffer from a psychosis that was diagnosed as schizophrenia. Meanwhile, Thomas Szasz, "who I met several times [...] made it pretty clear he understood that schizophrenia qualified as a true brain disease, but he was never going to say so publicly" (p.113). He also peppers the book with clinical encounters, so we learn that Lieberman once gave ECT to the wife of a New York restaurant owner who was so happy with the results that he offered Lieberman free meals whenever he wanted.

We are also given to suspect that Lieberman harbours deep frustration with psychoanalytic dogmatism, and he concurs with Freud, who once muttered darkly to Jung that they were "bringing the plague to America". Lieberman writes like someone who endured a feeling of disconnection from his profession when he was starting out:

"If a trainee wanted to rise within the ranks of academic psychiatry or develop a successful practice, she had to demonstrate fealty to psychoanalytic theory. If not, she risked being banished to working in the public-hospital sector, which usually meant a state mental institution. If you were looking for an indoctrination method to foster a particular ideology within a profession, you probably couldn’t do much better than forcing all job applicants to undergo confessional psychotherapy with a therapist inquisitor already committed to the ideology.” (p.77)

However, he is no Freud-basher, calling the latter a “tragic visionary far ahead of his time" and suggesting that psychoanalysis remains the best way of understanding certain sorts of psychological problem (though this comes early in the book, and is soon buried by his aversion). Like Tom Burns in 2013's "Our Necessary Shadow" Lieberman has a story about helping a patient overcome an apparent conversion hysteria, lending weight to Freud and Breuer's early formulations of that fascinating disorder. He even mounts a rather good defence of Freud's approach to drawing empirical inferences from clinical data:

"Freud had no tangible evidence whatsoever of the existence of the unconscious or neurosis or any of his psychoanalytical ideas; he formulated his theory entirely from inferences derived from his patients’ behaviors. This may seem unscientific, though such methods are really no different from those used by astrophysicists positing the existence of dark matter, a hypothetical form of invisible matter scattered throughout the universe. As I write this, nobody has ever observed or even detected dark matter, but cosmologists realize that they can’t make sense of the movements and structure of the observable universe without invoking some mysterious, indiscernible stuff quietly influencing everything we can see." (p.43)

But Shrinks, like the proverbial psychoanalytic patient, might be most revealing where it least intends to be. This book is full of peculiar sentences whose brusqueness may reveal a studious irony or unfortunate lack of reflection:

“After watching shocked pigs become oblivious to the butcher’s knife, Cerletti decided that shooting 100 volts of electricity through a person’s skull was worth the obvious risks.” (p.167)

"While the publication of the DSM-III had been marked by tumult and controversy, the release of the DSM-IV was as routine and uneventful as the opening of a Starbucks." (p.271)

The breezy glibness on ECT, combined with the terribly unfortunate analogy between the DSM project and an oft-maligned international coffee chain, might have been calculated to provoke the dismay of the very people Lieberman seems keenest to convert. But then, perhaps it's just that Lieberman thinks he can best connect with a readership in modern corporate America. Just look at how he describes Freud's approach to leadership:

"If Freud was the CEO of the psychoanalytical movement, his management style was more like that of Steve Jobs than of Bill Gates." (p.54)

Baffling!

In a penultimate chapter on the creation of DSM-5, Lieberman sounds touchingly hurt by all the outrage the manual provoked (he puts it down largely to the Internet, and appears to lament the loss of a time psychiatry could go about its business in private), but puzzingly unwilling to acknowledge what was driving it. Detractors are either antipsychiatrists (Gary Greenberg) or purveyors of "epistemic hubris" (Thomas Insel). Only the DSM-5, for Lieberman, achieves the theoretical pluralism which must be psychiatry's future. Such pluralism is a noble goal for a discipline as wide ranging as psychiatry, but Lieberman is too sanguine about the ways that notorious "bible" (Lieberman favours "bible", a term I normally associate with critics) stifles rather than promotes it.

"Shrinks" is an entertaining read, and at least in some regards more nuanced than I expected. But Lieberman's unwillingness to wade into the conceptual confusions his specialty is still dealing with, combined with his true-believer optimism about its imminent brave new world (genetic tests for forms of psychosis; cognitive behavioural therapy apps), make for an all too smooth ride. This is a work of unabashed advocacy, even propaganda, and should be read as such.

-------------------------------------------------------

Postscript:

After writing this, I found a wonderfully scathing review of the book by Rebecca Twersky-Kengmana, who draws out more of Lieberman's weird disdain for psychoanalysis. More than me she views Lieberman's position on it as a flat contradiction. Her post also includes some great Amazon reviews by people dismayed at the quality of Lieberman's historical scholarship:

Shrinks: The Untold Story of Jeffrey Lieberman's Oedipal Victory Over Papa Freud

Spare Me the Sanctimonious Bleating About Trigger Warnings

The New Republic is carrying an article by Jerry Coyne lamenting the rise of the trigger warning, and specifically the idea that college literature courses should consider applying them to the Western canon. Without much explanation, Coyne links trigger warnings to the "decline in free speech at American universities". It is not clear exactly what a trigger warning prevents one from saying.

He is particularly concerned about an article by Columbia University's Multicultural Awareness Advisory Board that had appeared in that college's paper. It described a student's distress after reading rape scenes in Metamorphosis (which had triggered memories of her own experience of sexual assault) and being dismissed by the teacher. Evidently unable to suppress his own sympathy, Coyne hedges about the specific case:

There is something gloriously stupid about this. Coyne seems to be trying to have it both ways: "I would have provided a trigger warning to this student, but I would never have been so crass as to say the words 'trigger warning'". This is a familiar reactionary tic, driven by the same pig headedness that detests political correctness for its requirement that people don't always spew the first offensive crap that jumps into their heads.

Having concluded that trigger warnings per se are not that bad a thing after all. Coyne could have stopped after four paragraphs, allowing us to agree that warning people about potential personal sensitivities is hardly an attack on the first amendment. Instead he spends the rest of the article talking about how much he hates them.

Coyne trenchantly enumerates all the great works of literature that no-one will be allowed to read anymore (probably) if trigger warning Fascism (and he does use the word Fascism) takes hold. The Bible sanctions rape; Huckleberry Finn is full of racism and Anne Frank's Diary contains antisemitism. Perhaps there's an argument in there somewhere, but Coyne lost sight of it long ago. His article becomes an ill tempered rant about other people's sensitivity, culminating in a weirdly defiant account of his trip to Auschwitz.

Should everyone go to Auschwitz? Perhaps. I should certainly go, but what about people whose parents died there? Or survivors who remember it just fine thankyou very much? Unlike Coyne (whose appetite for understanding the worst in people is laudatory), some people don't need a reminder that ordinary people are capable of brutal things.

"Life" as Coyne says "is triggering". Nobody denies as much, but what the trigger warning sensibility acknowledges is that it is not always triggering for everyone to the same degree. Some of us (Coyne is clearly one) can blithely ignore the warnings. Others can be grateful that they increasingly get a choice about whether to follow link that may lead them to get lumbered with flashbacks to their own sexual assault, accident or suicide attempt. 

These sorts of consideration can be managed entirely without any impact on freedom speech; the inclusion of a brief parenthetical "TW" next to links or items on a syllabus is all it takes. If that offends you (and being offended by trigger warnings themselves is infinitely more obtuse than being offended by violence, sexism or racism) then you can simply refer to the content in advance as Coyne helpfully suggests. It's easy. 

Pushing Explanations

Clinicians of my temperament get worried about forcing our explanatory views on the people with whom we work. Whatever explanatory frameworks we may have encountered during our training (medical, cognitive, psychodynamic models), however helpful we may have found them, we have a basic reluctance about regarding them as the explanation, and are more comfortable drawing on the idiom an individual uses to explain their life. One way to accommodate this kind of reluctance is to adapt a form of explanatory pluralism, where multiple models are held in mind, sitting comfortably alongside one another.

This approach is useful because it not only allows us to think in terms of multiple philosophical models, but also leaves space for the language used naturally by individuals whose experiences we are trying to discuss.

Much of the time this approach is relatively trouble free. That is to say, most of the time there is no benefit in substantially disagreeing with a person about how they account for their experience (I am thinking of an individual I knew who heard voices and was perfectly clear there was nothing wrong; who was I to disagree?) .

However, despite my basic sympathy with explanatory pluralism (what I could call my conviction that, when it comes to talk of "mental illness" there is basically no fact of the matter) I realise that I can cook up some uncomfortable cases for myself, which make the approach less satisfactory. Sometimes simply going along with an individual's account of themselves won't be sufficient.

Here is one problem case:

A parent approaches you, the clinician. Their child is causing problems at school. These are not insubstantial problems. The child is disruptive and, on the face of it, unpleasant to teachers and making it difficult for the classroom learning to proceed. You do a school visit and discover things are just as bad as you were told. The teachers are at their wits end. The parent knows the nature of the problem and implores you to help by providing an official diagnosis: according to them the child has a disorder called ADHD and your help is needed. If you can test the child and affirm that yes, they do meet the criteria for ADHD, you can ensure necessary accommodations at school. The child is absolutely certain too, that they have ADHD. They feel like they are not in control of themselves, that they are not to blame for the trouble they are caught up in, that a "disorder" is the only possible explanation. 

You are uncomfortable. Yes the child meets the DSM criteria for ADHD, but you worry about this construal. You note that the child has recently had to deal with some life events which anyone would find emotionally disruptive (let's say a close relative recently died, or they moved school, or they are being bullied). You have a sense that if the family system was able to address this emotional disruption in some way (with help from a systemically inclined clinician for example), the "ADHD" might be substantially resolved. Further, you have worries about the use of the diagnosis ADHD. Sure you could oblige and diagnose, but you feel if you do that then the parent will be less inclined to view the child's problems in a way that might be helpful. In short, you feel it is incumbent upon you to try and discourage them from the explanatory framework (my child has a disorder) that they have adopted. This is not because you think they are straightforwardly wrong (you can see their point) but because you think their metaphor will encourage damaging courses of action like the prescription of avoidable stimulant drugs and the neglect of the child's emotional life. 

Here's another:

An individual you know lives in the community. They have suffered several episodes of disorganization and confusion before and these have tended to lead to dangerous and self destructive behaviour. At best the individual has had sustained periods of self-neglect. Now they are becoming disorganized again. You are worried about them. If they could be persuaded to allow themselves to be looked after (temporarily in a caring inpatient respite center you could refer them to) then they would be safe while they recovered. But although they are frightened they do not feel they need any extra care as there is nothing the matter. As far as they are concerned they are fine.

You disagree. You feel they are being overcome by some psychological change, that they are becoming unwell. You don't buy a "chemical imbalance" theory of their problems, but you can see they are not themselves, and the idea that they have succumbed to an illness would be a useful metaphor. You don't think they will always have this illness, nor be defined by this illness, but that characterisation seems a powerful way of accounting for the need they now have for extra care. 

What both of these stories have in common is a narrative brought to bear on them by the people whose lives they primarily concern. The acquiescent part of you wants to go along with these stories (they are the account that makes most sense to the person), but a concerned part of you does not. Let's not take away the easy way out; the optimistic proposal that you can always construct a joint understanding. In both these cases the person resists your interpretation, some degree of conflict is unavoidable. Even without saying the other person is "wrong", you are trying to give life to an explanatory framework which is at odds with their view of how their situation is functioning. In these cases, are you doing something beneficent or are you enacting a failure of mutual understanding? I would suggest the former. Helpful though it is to try and adopt language that "makes sense" to an individual, it won't always fit with our best image to how to help people.

New BPS Guidelines on Diagnostic Language are a Move Against Pluralism

(A commenter on this blog-see below- has pointed out that I did not include reference to the scope and purposes of the document I am writing about. To try and address their concerns I have edited the post, striking out some sentences and inserting a few new ones in blue.)

Something incomprehensible and unpleasant happens to a person. It behooves them to make sense of it. Into this vacuum of understanding steps language: an attempt to give form to an experience in a way that allows them to live with it.

The BPS's Division of Clinical Psychology has released new guidelines on the use of language in official documents which pertain to such circumstances.

Consisting of three principles (guiding on language to avoid and language to adopt)  It is a clear statement that illness-talk and disorder-talk are out:

Such guidance is on a clear continuum with other efforts to discard the language of disorder, and concerns the organisation has raised about the DSM, a manual which can itself be viewed as a hyper-regulatory set of guidelines about how to talk. 

I am all for questioning the language of the DSM. Naming people "disordered" or "ill" is often experienced by them as an insulting effacement of subjectivity. What is more, once illness-language gets into the pool of possible interpretations it seems to hand power to the only people with sufficient expertise to deal with illnesses, the healthcare professionals (who of course stand to gain from their status as knowers).

But there is calling into question and there is discouraging ruling out. The problem with an official language (the DSM is a dictionary rather than the "bible" it is often claimed to be) is that it sets up a seemingly "correct" and an "incorrect" way of talking. In some cases this is necessary (the much scorned "political correctness" is an appropriate effort to rule out ways of talking which offend minority groups in society), but there is always a trade off. The downside of being "PC" is that it can make people less considerate about their linguistic choices, while leaving them feeling righteous nonetheless. Think of the character Gareth in The Office, bemoaning the fact that his dad says "darkies, instead of coloureds"

This is one way in which the new BPS guidelines look to me like a misstep. Moving from "mental illness" to "mental distress" is superficial in itself. Language surely interacts with habits of thought, but a guideline like this just replaces one jargon with another.

The Turn Against Pluralism:

If this were my only complaint then I would lump it. We should be careful about language, and sometimes guidelines are the only way to do that. But the language of mental health is different from the language of race. There are racial terms so bound up with hate that officially discarding them is the only sensible choice. The same is not true of "illness", "OCD" and "Anxiety Disorder". 

We don't yet have the definitive account of who is and and who is not ill (defining illness turns out to be a dreadful philosophical tangle) so for all practical purposes there is no fact of the matter. One way of dealing with this uncertainty is to adopt a form of pluralism which allows for multiple frameworks for understanding. 

Some people see themselves as ill, others don't. Some people think of themselves as ill because they feel themselves to be ill. While not unproblematic, pluralism puts a person's experience at centre stage, affirming their chosen framework as a way to make sense of them. This is a principle I thought I saw affirmed in the "Understanding Psychosis" document released last November:

Plenty of first person accounts attest to the value of "illness-talk" (some of them in Understanding Psychosis itself), but the BPS has just discounted those experiences in a stroke. The approach adopted in the new guidelines is a solution that DSM-detractors have been descrying for decades. Rather than expand the repertoire of explanatory terms, this document shrinks it. Some language is good, some bad; some frameworks more correct than others. This works for people who are served by the new official language (those for whom "mental distress" is personal preference), but it alienates anyone who falls outside the charmed circle. Given how strongly the BPS has opposed the regulating languages of official psychiatry, I am astonished they have chosen this route. 

Election 2015: Those Pathetically Vague Mental Health Pledges in Full

I'm working on a longer post about the manifesto pledges that have been made on mental health. Manifestos are supposed to help people decide which party to vote for on the basis of concrete promises for which they could later be held to account. As I read through the different parties' mental health pledges I noticed that many of them were so vague as to amount to no promise at all. In this post I bring you the crappest and most hopeless mental health election pledges of 2015.

Conservative:

How's this for conjuring an empty promise out of thin air and giving it the veneer of credibility despite the total absence of any concrete objective? The Tories seem to suggest that there are not already therapists in "every part of the country", but this seems like a hard claim to defend. Do they mean in every town, in every borough, in every post code? Exactly which parts of the country have no therapists, and when can this promise be judged to have been fulfilled? The Tories here acknowledge that there could be more therapists, but without saying what they are committing themselves to precisely zero action on changing the status quo. Crafty!

Green

Perhaps because they have the least to lose (no-one anticipates a Green led government after May, sorry!) the Greens actually have the most concrete list of promises on offer. However, this one stood out. Which party is not going to "invest in dementia services", and in what sense will the Greens' offerings be different than anyone else's in terms of "support"?

Labour:

Let's get this clear, you're going to "encourage" social and emotional skills. How will you "encourage" them exactly? Billboards? A daily radio broadcast? This is a sentence comprised almost entirely of rather zeitgeisty hot-air with "mindfulness"crowbarred in as a very tokenistic buzzword.

Liberal Democrat:

The Liberal Democrats are going to get kudos for developing probably the most detailed plans on mental health (though it's a close race between them and the Greens), but this bullet point struck me as a little weird. First there is this idea of a "clear approach" which, in the absence of detail is actually anything but. Second, there is the notion of the well being equivalent of the "Five a Day" campaign. I have no idea what it is that one should do to improve mental resilience that is "the equivalent" of eating five pieces of fruit or veg. The Liberal Democrats clearly don't either. 

Another strikingly vague promise from the Lib Dems here. I can't argue with the sentiment , but neither can I tell you what it really means

UKIP:

UKIP win the competition for the greatest number of half arsed bullshit empty pledges.

What would the mental health world do without UKIP? In these two promises they affirm that people should be directed to mental health professionals "when appropriate" (begging the more interesting question of when UKIP feel it actually is appropriate) and that there is "often a link" between addiction and mental illness. Excuse me while I completely reconfigure everything I thought I knew about psychiatry! Why offer a specific policy formulation when you can have the half-baked wittering of some bloke in a pub?

Here's another half arsed thought:

Gee...thanks guys. UKIP seem to have heard of stigma but, unclear exactly what it means, they offer some vague handwaving around the issue, assuming apparently that it mainly has to do with not having a job. Feeble.

Book Review: A Prescription For Psychiatry

This month I have a review of Peter Kinderman's "A Prescription for Psychiatry" in the BJP. This post is a more extended version of the text published there.

      "Is the problem you're allergic

       To a well familiar name?
       Do you have a problem with this one
       If the results are the same?"

           -The White Stripes:

Girl You Have No Faith in Medicine

Battle-fatigued psychiatrists could be forgiven for wanting to steer clear of what looks like another attack on their profession. More waggish readers may wonder about responding with their own “formulation for clinical psychology”, and then there is the combative note. Does not the title seem to indicate a barely concealed desire to give psychiatrists a taste of their "own medicine"?

However, such aversion would be a tremendous shame, for while there is some familiar ground trodden here, there is also much that is new, positive, and well worth some serious thought. There is also an idea that is more audacious and direct than usually be found in books about psychiatry.

The book is made up of nine chapters, the first three of which occupy just over half the space. In this first half, more than in the second, there is a focus on criticism. The “disease model”, the use of diagnosis, and the role of medication are all subjected to scrutiny. Some of this ground is wearyingly familiar. On the subject of illness as opposed to “psychosocial problem”, we must ask whether Kinderman is giving full due to all the available evidence. The roles of trauma and of life events in schizophrenia are offered to raise our credence that this problem is best considered a psychological reaction. A major alternative theory, that some manifestations of this behavioural presentation may best be considered a developmental disorder, (after all, not everyone who meets the DSM criteria will have been abused or suffered other traumas) is not even mentioned, let alone appraised.

On diagnosis: It is quite right that psychiatry should face the shameful aspects of its history. The tremendous psychic damage wrought by pathologising homosexuality for decades, and the odious debacle of draetopmania are not to be lightly dismissed. However, given the intentions of the present book, Kinderman might have done more to explain why these despicable examples have a substantive bearing on the question of modern diagnostic practice in general. The DSM is a problematic and contested document, but while we should feel queasy about its politics and many of its categories (“Oppositional Defiant Disorder” gets a justified grilling), even the most sceptical clinician cannot shy away from asking whether we can as easily dissolve those two major categories “Schizophrenia” and “Bipolar Disorder”.

A superficially appealing argument raised here is that "abnormal psychology" is an unreasonable field of study; after all, we don't speak of "abnormal physics". There is an important idea here with which I find myself aligned. Using the word "abnormal" is indeed a needlessly unpleasant way of speaking about people, but the physics analogy doesn't fly. All physical phenomena are subject to the same basic laws (as far as we know), but that hasn't prevented the fruitful subdivision of their study into solid state physics, condensed matter physics, and so forth. When people have experiences of psychological distress, these tend to manifest in a propensity toward particular states of mind. Is it really so unreasonable to study these states in their specificity, cautiously categorising them until some better framework is offered?

Kinderman favours a dimensional approach to mental distress, and a recent international survey of psychiatric attitudes (Reed et al, 2011) suggest that close to half of psychiatrists could feel the same way. A more significant question is whether this is really inconsistent with a system of classification; unless mental health problems could somehow be incorporated on the same single dimension (as opposed to a psychotic spectrum, an affective spectrum etc.), there is no reason it should be.

The book is, in my relatively ill-informed view, sensibly skeptical on medication, suggesting (via Joanna Moncrieff) the adoption of a “drug centred” model, with prescription based on anticipated effects of a compound rather than the anticipated imbalances caused by a disease. Such caution seems laudatory, though there is an interesting debate about how to judge the risks and benefits of specific medications, and Kinderman prefers to leave this in the hands of others.

Those readers who get beyond the first half will find themselves on more interesting territory. Books that criticise psychiatry are common enough, but a considered and viable set of suggestions for improvement of the mental health system is much harder to come by. A number of the issues Kinderman raises are very important, and the book is good on linking its own position to the debates that are taking place within the profession of psychiatry itself. What is more, many of the suggestions made in the last six chapters are not dependent on his having won over the reader in the first three. Alzheimer’s is a brain disease, but that shouldn't rule out the provision of psychosocially oriented residential care for sufferers. Down’s Syndrome is a genetic disorder, but it would be extremely myopic not to provide care and support of an imaginative and holistic nature for this population.

Thus, regardless of his audience’s prior commitments on the nature of mental health problems, Kinderman is going to find much more agreement on the broad thrust of chapters 4 to 9. Many of these questions go well beyond a simple question of which profession is dominant and which intervention is the “correct” one. He is quite right to advocate a holistic approach to wellbeing, and his proposal for comfortable, decent residential care (“a place of safety”) over psychiatric hospital wards should be a public health priority. These latter can be traumatising and chaotic (not to mention expensive) places, and the “medical” context can place unnecessary limits on the nature of the care that is provided. Under Kinderman’s model, a new generation of local authority funded homes would provide safe, calm places for “respite” rather than “cure”. A suggestion that mental health nurses be renamed “psychosocial therapists” (on the grounds that “nurse” is overly medical) seems, to my mind, unnecessary given that the verb to nurse has thoroughly humanistic connotations.

Hanging over all this is the audacious idea referred to above. In "Our Necessary Shadow", Tom Burns doubted psychiatry would even exist without Schizophrenia and Bipolar Disorder. Kinderman's most radical conclusion pushes that logic to it's ultimate conclusion. In a chapter on promoting health, he suggests that psychiatrists add little value to mental health beyond a general medical consulting role. In his breathless (and well thought out) penultimate chapter he even insinuates that we could save considerable expenditure if our mental health system did without them altogether.

While it has often occurred to me that other professionals could perform many of the legal and leadership roles currently undertaken by psychiatrists, to argue they are entirely redundant relies on the acceptance of a conclusion that Kinderman has already taken for granted. Namely, that the field currently denoted by those two headline diagnoses is one devoid of anything resembling an illness or disorder. I am considerably more agnostic than Kinderman on this score, so while I have to credit him for such an invigorating interrogation of the “value added” of psychiatrists, I don’t think the argument has been won. Further, even if you do accept such a premise, the expertise required to distinguish "organic" psychiatric presentations from "functional" ones (yes this is something like a dualism, but it's really just a loose way of talking: think of the distinction between a drug induced psychosis and a psychosis whose causal factors are more diffuse) is not something psychologists are trained to develop.

This is a rip-roaring book; readable and broadly constructive. Like the broader debate of which it is a part, it succeeds where it is most surprising and lets down where it is most predictable. 

23 Contentions

Keeping an argumentative blog has the strange effect of "placing" you within the broader debates your writings touch. In the context of discussion, supporting or denying any claim raises questions about which other related claims you also might also endorse or contest. This gets tricky. In virtue of a position I have taken, other parties to a debate have often assumed they know my views on similar but different points. Frustratingly it can be mistakenly suggested that a claim I support entails another which I do not. Of course for my part I've frequently made precisely the same mistake in return. This experience has made me wonder what general statements about mental health I do feel broadly committed to. In turning over this question over the last months I have collected a rag-bag list of claims and suggestions that I think I would stand by, but which don't necessarily warrant more developed blog-posts in their own right. The only thing uniting them thematically is that writing this blog has brought me into contact with all the issues here at various times. Some of my contentions will seem trivial and others more challenging depending on your starting point, but I have included them for three reasons. The first is that many of them go too often unsaid, which is a shame. The second is that some of them may trigger interesting discussion with people who don't agree about them. The third is that I am curious to see which of them will stand the test of time and which I might end up being persuaded to abandon.

1. Individual case studies are significantly less informative than large scale controlled trials when it comes to determining the efficacy of a treatment. That said, the label "anecdote" can seem to be needlessly dismissive of people's experience.
2. Case studies and testimonials are extremely valuable in virtue of their potential to improve services and highlight malpractice. However, they also have much value in their own right.
3. Empirical research in psychology and psychiatry has historically been deployed toward both progressive emancipatory political ends and restrictive conservative political ends, but generally facts are a powerful corrective to bias, bigotry and oppression. 
4. Given the ways in which mental function is rooted in brain function, it would be extraordinary if a moderate amount of what we call "psychological distress" was not determined principally by biological factors.
5. An apparent thematic similarity between early life experiences (i.e. being bullied) and later symptoms (i.e. being paranoid) can easily mislead us into overestimating the extent of any causal link.
6. Childhood Sexual Abuse would be just as abhorrent if it played no role at all in psychosis.
7. Whatever the disadvantages of psychiatric diagnosis, it has validated the experiences of millions of people who have felt themselves to be suffering from serious illnesses.
8. Whatever the advantages of psychiatric diagnosis, it has saddled millions of people with labels they find inaccurate and invalidating.
9. The DSM project has almost certainly led to a huge rise in the diagnosis of certain mental disorders that is probably not commensurate with a change in anything other than diagnostic practices around those categories.
10. "Personality Disorder" is no way to talk about people.
11. There is no satisfactory way of cleanly distinguishing "mental disorder" from "mental health". This does not in itself invalidate these categories or render talk about them nonsensical.
12. The fact that gay people were "cured overnight" by the removal of homosexuality from the DSM does not provide a good analogy for other DSM diagnoses. If the DSM were scrapped, people currently diagnosed with many of its disorders would continue to suffer from their experiences. This would be in virtue of facts about those experiences that have little to do with how they are described.
13. That being said, the way we choose to describe people's experiences has real and substantial impact on the people who have them. People's lives can be improved dramatically by changing the way their experiences are constructed.
14. The statement " schizophrenia exists" may capture reality in important ways, but it cannot be regarded as straightforwardly true.
15. It can be overly general and dismissive to make statements of the form "Schizophrenia does not exist", even though the considerations that often motivate such statements are rooted in fact.
16. The claim that CBTp is not effective does not amount to a claim that people with psychosis should not be offered psychosocial support. It is claim about the relative efficacy of a specific treatment.
17. To promote CBTp is to privilege, over other approaches, a particular technical and hierarchical way of talking to people. In virtue of this it is more in line with a "medical model" than many of its advocates generally emphasise.
18. The provision, by health services, of CBTp stands to benefit the profession of clinical psychology in ways that are analogous to (though different in scale from) gains that have accrued to psychiatry through the provision of drug treatments.
19. It seems to be the case that different parties in the broad conversation about mental health want for it to be true that mental health problems are "mainly biological" or "mainly environmental". This is a decidedly strange fact and should stimulate our curiosity.
20. In the broad conversation about mental health, we all show a tendency to align into loose (but real) groups. Once in these groups we are more forgiving of the rhetorical excesses, rudeness and inaccuracy perpetuated by those with whom we are aligned.
21. On balance, "antipsychiatry" and "critical" psychiatry and psychology have been extremely valuable contributions to the discussion on mental health.
22. Sometimes asking questions can be an effective rhetorical strategy for avoiding the existence of people's efforts to provide answers whose implications we would benefit from talking about.
23. Mental disorders would not need to be geographically or temporally invariant to be considered real in a meaningful sense.