On December 21, 2014, Vivek Datta, MD, published an article on Mad in America. It’s titled Psychiatry and the Problem of the Medical Model –Part 1. The same article appeared the day before on Dr. Datta’s own website.
Dr. Datta begins by stating unambiguously:
“Psychiatry is a branch of medicine. As such, psychiatrists apply the medical model to problems of emotion, thought, behavior, human relations, and living.”
He describes this approach as a “narrow gaze” and expresses the belief that it has brought psychiatry “under severe criticism” both from within and without.
Here are some quotes from Dr. Datta’s article, interspersed with my comments:
“Many critics of psychiatry engage in ‘splitting’. They see psychiatry as an ‘all bad’ object, mired by pseudoscience, pathologizing all of mental life, peddling quack treatments, often under coercion or control. So-called ‘real medicine’ is idealized as the product of scientific advancement, with diagnoses and treatment precise, its diseases and treatments not influenced by sociopolitical, or economic fancy, and its practitioners portrayed as healers rather than agents of social control. Psychiatry aspires to be like the rest of medicine. Given that the problems that beleaguer psychiatry in particular, are true of medicine in general, it is a mistake to criticize psychiatry alone, and not locate it within a medical-industrial complex in need of dire reform.”
Note the immediate attempt to marginalize, even caricature, the opposition. Many critics, we are told, see psychiatry as “…pathologizing all of mental life…,” the phrase “all of mental life” embraces every conceivable thought or feeling, including maternal love, sexual attraction, post-prandial satisfaction, feelings of success, etc… I have never encountered anyone on this side of the debate who alleges that psychiatry pathologizes these kinds of feelings. What we do assert, correctly, is that psychiatry pathologizes all significant problems of thinking, feeling, and/or behaving, a fact that is clearly evident in the definition of a mental disorder in successive revisions of the DSM, and in psychiatry’s routine use of drugs and electric shocks to “correct” these problems.
Similarly, the notion that we “idealize” general medicine is unfounded. I suspect that, as a group, we critics of psychiatry are fairly widely distributed with regards to our stance towards general medicine. There may be some who idealize it, but most of us, I think, regard it fairly realistically as something which, although by no means perfect, does have a very good understanding of the illnesses that it treats, and treats them, for the most part, successfully. When we fall seriously ill, we are glad that it’s there. We do indeed see its practitioners as “healers rather than agents of social control,” and, I suggest, these views are grounded in reality.
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“Many critics of psychiatry object to the use of the term ‘mental illness’. These critics argue either that because the mind is a metaphor, it cannot be diseased (and thus conflate disease with illness), or wrongly believe the term implies such problems are biomedical in origin and warrant medical intervention. Illness is the subjective experience of being unwell, does not imply the existence of underlying disease, and labeling problems as illness never has led the majority of people to seek medical consultation…Even with the creeping medicalization of everyday life and professionalization of helping, it is still the case that the majority of those who may identify as ill, ‘mental’ or otherwise, do not seek medical attention. Thus it is incorrect to state that ‘illness’ implies medicalization when it is a subjective experience that may or may not correspond with disease. Many of the individuals I see endure immense suffering and understandably see themselves as sick. I think it would be incredibly invalidating of me to say they are not ‘ill’ though they do not have disease.”
So those of us who object to the term “mental illness” are wrong. We are either confusing the terms “illness” and “disease”, or we are under the mistaken impression that the term “illness” implies a biological pathology which warrants medical intervention.
Well, there is indeed confusion here, but I suggest that most of it lies in Dr. Datta’s contentions. To illustrate this, let’s imagine a conversation between Dr. Datta and myself:
I: The term “illness” entails biological pathology.
Dr. Datta: No it doesn’t. You’re wrong.
I: Yes it does.
Dr. Datta: No it doesn’t.
Well, it doesn’t take much insight to see that this would go nowhere. The point being that Dr. Datta’s contention – that we critics of psychiatry are “wrong” in believing that the term illness implies physical pathology – is simply an abrogation of an authority to which he has no legitimate claim: that is, the authority to legislate on the meaning of words.
The meaning of words is dictated, not by Dr. Datta or by psychiatrists, but by common usage, but psychiatrists simply will not let go of the notion that because they, deceptively and self-servingly, equate distress with illness, we should all follow suit, and that we are to be condemned as confused and wrong if we refuse to do so.
Like almost every word in the English language, the word “illness” has a core meaning, plus a variety of informal or acquired meanings, most of which bear some real or figurative resemblance to the former. The core meaning of “illness” is physical/organic pathology. This can be illustrated clearly by examining some of the informal meanings.
During the month of October in the US, one will frequently hear people say that they are sick of TV election ads. If one were to press this matter, and ask: “Do you mean that you’re really sick?”, one would almost certainly receive the reply: “No. Of course not. I mean I’m disgusted!” The point being that “sick” (meaning-disgusted) is an entirely different thing from really sick (meaning organic pathology). Let’s take another example. A parent whose child is undergoing emergency surgery might say “I’m sick with worry!”, but if asked “Do you mean that you’re really sick?”, would generally reply along the same lines as the disgusted TV viewer described above.
I think that anyone remotely familiar with the English language could produce literally hundreds of similar examples. The essential point being that in general usage, the words “illness” and “ill” refer to organic pathology, but are routinely used more loosely to mean a variety of unpleasant states or to convey disapproval.
Ironically, perhaps the strongest evidence for this – if evidence is needed for something so self-evident – comes from psychiatry itself. It was psychiatry who coined the phrase: “a-real-illness-just-like-diabetes”. Psychiatrists have been using this expression for decades, as in “depression is a real illness just like diabetes,” or “ADHD is a real illness just like diabetes,” etc… There has been some curtailment of this in recent years because it has been exposed as deception by critics of psychiatry, but the phrase is by no means defunct.
But the point is this: in describing problems like depression and inattention as “real illnesses just like diabetes,” psychiatry is in fact acknowledging that the word “illness” entails biological pathology. What’s clearly being stated here is that depression or ADHD or OCD, or whatever, is not an illness-in-some-vague-airy-fairy-metaphorical sense of the term, but in the real biological pathology sense. That’s the significance of the phrase “just like diabetes”. And that is 100% in accord with generally accepted usage. The only group of people that I know of, or that I’ve ever even heard about, who insist otherwise are psychiatrists, and then only when it suits their purposes.
But, even if we allow psychiatry the professional prerogative of developing their own specialized language, and even if, in the exercise of that prerogative, they decide that the term “illness” means nothing more than the subjective experience of distress, then there’s still a problem – because we will now have two quite different meanings for the word illness. There will be illness per general usage, meaning biological pathology, and illness per psychiatry, meaning the subjective feeling of being distressed.
If psychiatrists insist on using the term illness in this special sense, and if they want to avoid confusion, then they need to take specific clarificatory action. Every time they assert that depression, say, is an illness, they would need to add the rider – “but we don’t mean illness in the usual sense of organic pathology; we just mean the subjective feeling of distress.”
This is particularly important because when psychiatrists assert that depression is an illness, the vast majority of people who hear this believe that they are referring to a specific, scientifically established brain pathology. And furthermore, this is precisely the message that the vast majority of psychiatrists – including psychiatric leaders – have been promoting unambiguously for decades.
Any psychiatrist who wants to undertake the mission to clear up this long-standing and blatant deception needs to scream the truth from the rooftops: that depression is not a brain pathology, rather than obfuscate the matter further by asserting that depression is an illness in the special psychiatric sense of a subjective feeling of distress.
And the problem is exacerbated because psychiatrists skip from one meaning to the other to suit the exigencies of the moment. To justify their drug-pushing, they go with the brain pathology meaning, but when challenged, they fall back on the subjective-feeling-of-distress meaning. The logical fallacy here is self-evident, and surely needs to be labored no more.
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“Thus it is incorrect to state that ‘illness’ implies medicalization when it is a subjective experience that may or may not correspond with disease.”
From his use of the word “thus” in this sentence, it is clear that Dr. Datta is under the impression that he has proven his case, when in fact, all he has done is arbitrarily, or, I suggest, even arrogantly, attempted to impose a use of words that conflicts with general usage. When psychiatrists assert that depression, say, is an illness, they are medicalizing this feeling. They are saying that depression is a medical matter, requiring medical attention. And that is precisely the intention. That is the very justification for their existence as a profession, and in practical terms, is the justification for their pushing of drugs and electric shock.
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“Many of the individuals I see endure immense suffering and understandably see themselves as sick. I think it would be incredibly invalidating of me to say they are not ‘ill’ though they do not have disease.”
Let’s examine the “…understandably see themselves as sick…” phrase.
I am old enough to remember a time when nobody, except perhaps a very few biological psychiatrists, saw depression as an illness. The vast majority of people saw depression for what it is: a negative feeling brought on by loss, negative circumstances, and/or negative life events. It was seen as an integral part of the human condition – something that needed to be resolved either by seeking the solace of family and friends, by making changes in one’s circumstances, or by just putting one foot in front of the other until the feeling passed.
Then along came pharma-psychiatry with its billions of dollars a year advertizing budget, and research psychiatrists who were willing to sell their integrity for money – and today the spurious notion that depression is an illness has entered the cultural mainstream and is widely accepted. Dr. Datta’s hypothetical client understandably thinks he/she is sick (and thereby powerless to help him/herself) because that is the lie that pharma/psychiatry has been promoting by every means possible for the past forty years.
But watch where Dr. Datta goes with this:
“I think it would be incredibly invalidating of me to say they are not ‘ill’ though they do not have disease.”
To which I can only say: No, Dr. Datta, it would be an act of honesty and integrity. Comfort bought at the price of honesty is almost always a poor bargain, as any victim of psychiatry can attest.
In 2010, Daniel Carlat, MD, talking to NPR, acknowledged that he had often told the illness falsehood to clients. But at least he admitted that it was a convenient fiction which clients found “reassuring”, and which helped keep his sessions to 15-20 minutes. But Dr. Datta would have us believe that he lies to his clients for their own good – to avoid “invalidating” them. Wouldn’t it be more validating to tell the truth?
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In the rest of the article, Dr. Datta contends that psychiatry is no worse than general medicine.
“Psychiatry has rightly been criticized for the ever-expanding definition of mental illness, with the boundaries between mental health and mental illness (arbitrary as they are) becoming increasingly blurred. However this is true of medicine as well, where asthma is now diagnosed in children with minor wheezing and breathlessness, and diabetes expanded with a lower threshold of glucose level needed for the diagnosis. There is now even ‘pre-diabetes,’ a harbinger state of full-blown disease recognized as a condition.”
It is indeed the case that psychiatry’s definition of “mental illness” has been expanding. But Dr. Datta is overlooking the fact that it is the equating of distress with illness (which he himself promotes) that underpins and drives this expansion. As long as psychiatry clings to the idea that any distressing problem of thinking, feeling, and/or behaving is an illness (which they unambiguously assert in DSM’s III, IV, and 5) then there is literally no limit to the expansionist possibilities. So on the one hand Dr. Datta is decrying psychiatry’s “diagnostic” expansion, while simultaneously supporting the spurious ideology that drives this expansion.
Dr. Datta’s contention that general medicine is also engaged in diagnostic expansion may indeed be true, but is not relevant to the central issue. Almost all organic pathology starts small, and then, either resolves itself, or gets bigger. It is obvious that the dividing lines between wheeziness and asthma or elevated blood sugar levels and diabetes are arbitrary. It is equally obvious that physicians will disagree as to the point where medical intervention is warranted, and that these disagreements will be reflected in changes to treatment guidelines. But in all cases there is organic pathology. An “early cancer” is still a cancer!
This is a far cry from psychiatry’s core contention that distress is an illness.
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“Take the example of hypertension. This is a risk factor rather than a disease, but it is ‘objectively’ measured and thus the point at which blood pressure is considered hypertension in need of treatment should be uniform based on the scientific evidence. Yet if you live in the US and had uncomplicated hypertension, you would be treated when your blood pressure is above 150/90mmHg. In the UK, you would be treated if your blood pressure is above 160/100mmHg. What constitutes hypertension in need of treatment cannot then be based on science alone. It is constrained by interpretation, an act which itself is constrained by the surrounding social, political, and economic space.”
Let’s look at the facts. The heart is a pump. It pumps blood through the various vessels, and it does this by generating pressure in the blood stream. A fit, healthy adult will have a resting blood pressure somewhere in the region of 100/70. Generally speaking the pressure will be higher after exertion, lower after rest, and will vary for other reasons.
Chronic high blood pressure is a clear indication of organic pathology. It may be that the heart is pumping too hard or that the vessels are partially clogged and the heart has to work harder to get the blood to go round. It is also the case that high blood pressure causes damage to other organs, especially organs that contain small fragile vessels, as these can be damaged by the excess pressure.
In all of this, the precise cut-off point at which physicians believe intervention is warranted will inevitably be a moving target, and in the current debate is irrelevant.
There is simply no logical parallel between cardiologists disagreeing over the precise point at which treatment for high blood pressure should begin, and psychiatry arbitrarily asserting that distress equals illness and therefore warrants psychiatric intervention.
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“Diagnostic tests in the majority of cases were never meant to ‘make’ a diagnosis but to support a diagnosis, which is made from carefully listening to the history of the illness and through physical examination. As medical practice has become more litigious and we have become more reliant on tests to make diagnoses, doctors spend less time listening to their patients, and no longer trust their clinical skills. I went into psychiatry because of the focus on subjectivity, narrative, meaning and relationships. Because these are no longer valued in medicine, they are also less valued in psychiatry.”
This, I suggest, is a self-serving rationalization. Subjectivity, narrative, meaning, and relationships are far less important in the treatment of real illness, than in helping people deal with personal problems. A person who is prone to skin cancers, for instance, goes to a dermatologist, not for solace, understanding, or “meaning,” but rather for early identification and removal of tumors. It may be that in the course of this treatment, the dermatologist will touch upon issues of meaning and relationships, but these are, at best, incidental to the main endeavor.
When a person seeks professional help for profound sadness, however, issues of meaning and relationships are central. That psychiatry should ignore these kinds of considerations is not at all on a par with any similar developments in general medical specialties.
Note particularly the last sentence in the above quote:
“Because these are no longer valued in medicine, they are also less valued in psychiatry.”
So psychiatry devalued personal and relationship issues because general medicine had done the same! I suggest that this is simply not true. Psychiatrists abandoned and devalued personal and relationship issues because the invention of “diagnoses” and the pushing of drugs and electric shocks enhanced their prestige and increased their income. It was a tawdry, venal, and self-serving move which no amount of post hoc rationalizing can excuse.
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On December 16, 2014, I critiqued an earlier article by Dr. Datta. Some of the comments generated by my earlier article took me to task for this on the grounds that many of Dr. Datta’s criticisms of psychiatry were valid. And of course, they were. But my point was, and continues to be, that psychiatry is not something good that needs some minor critiquing and correcting. Rather, psychiatry is something fundamentally flawed and rotten. The problem with psychiatry is not that it has gone too far in the invention of diagnoses or the pushing of drugs. The problem with psychiatry is its core assumption: that distress equals illness. This is the self-serving flaw from which all of psychiatry’s ills flow. And this flaw is irremediable, because once it’s acknowledged, then psychiatry’s reason for existing is gone. Critiquing psychiatry’s worst excesses, while clinging tenaciously to its core fallacy, is, I suggest, a strategy whose purpose is to neutralize the opposition while leaving psychiatry essentially unchanged.