Vivak Datta, MD, is a second year psychiatry resident at the University of Washington, Seattle. He has a website called Medicine and Society, and on November 14, he published a lengthy article titled Science and Pseudoscience in Psychiatric Training: What Psychiatrists Don’t Learn and What Psychiatrists Should Learn. On November 20, the article was published on Mad in America.
Here are some quotes:
“…what is currently emphasized [in psychiatric training] is tantamount to pseudoscience.”
“As the DSM-5 debacle has shown, psychiatric diagnoses are not the product of nature but common consensus, a consensus that has been criticized for eroding the range of human behavior seen as normal.”
“In focusing on teaching psychiatric diagnosis à la DSM, psychiatrists are no longer familiar with the rich descriptions of morbid mental life described by Kraepelin, Jaspers, Bleuler, and Schneider, who attempted to feel their way into their patients’ experiences and catalog the heterogeneity of human suffering. In contrast, the DSM teaches psychiatrists there are prescriptive ways to suffer or become mentally ill throughout the globe. When the psychiatrist meets a patient who has the audacity to have not read the DSM and not present a constellation of symptoms described therein, the psychiatrist is at a loss, and the patient finds herself ‘not otherwise specified’.”
“Though psychiatrists routinely prescribe atypical antipsychotics, which cause metabolic syndrome, few psychiatrists are comfortable with treating hypertension, diabetes and dyslipidemia, and many of our patients are unable to access primary care. It is a shameful state of affairs that psychiatrists are not being trained to treat the very illnesses they cause in their patients and undermines the very basis of psychiatry as a medical specialty.”
“…cognitive psychology offers valuable explanatory frameworks that can be helpful in understanding depression, PTSD, and the formation of delusions and hallucinations.”
“Despite the rich social science contributions to psychiatry that are extremely relevant to clinical practice, most psychiatrists, especially in the United States, are completely unaware of the classic studies in our field.”
“…evidence-based mental health is openly disparaged, and when psychiatrists don’t get the results they want, they ignore them, suppress them, or denounce them. The suggestion that antipsychotics could worsen the course of psychosis was such an important one that you would think it would deserve considerable study, yet it has been largely forgotten. The finding that antipsychotics cause significant cerebral volume loss, rather than immediately being published, was analyzed again and again, until the reality of this finding could no longer be denied. When randomized controlled trials, the gold-standard investigation, showed that SSRIs were associated with suicidal ideation, the results were denounced invoking correlational studies showing a inverse relationship between adolescent suicides with SSRI prescriptions, despite these studies being methodologically inferior.”
I think most readers would agree that this material is not what one expects from a psychiatrist. In fact, it reads more like anti-psychiatry. And, indeed, it is clear that Dr. Datta has strong reservations about his chosen profession.
But it is always difficult to make radical changes from within, and there are several indications in the article that suggest that on the fundamental issues, Dr. Datta’s feet are squarely planted in psychiatric turf.
Here are some more quotes, interspersed with my comments.
“This emphasis on the DSM has …de-emphasized the construction of the medical and neurological differential for the psychiatric patient…”
This statement is somewhat obscure, but from the general context, I believe that Dr. Datta is calling for more emphasis on differentiating those problems of thinking, feeling, and/or behaving that are clearly caused by a medical/neurological pathology, and those that are not. In itself, this is a perfectly valid distinction that most of us on this side of the debate would endorse. However, on this side of the issue, we draw the logical conclusion: that problems of thinking, feeling, and/or behaving that are clearly not the outcome of physical pathology are not illnesses and are not the legitimate concern of psychiatrists or medical practitioners generally. We point out, with justification, that there are no logical/philosophical reasons why these kinds of problems should be considered illnesses, and we stress the empirical reality that psychiatric intervention in these areas has generally resulted in more harm than good.
But this is not where Dr. Datta appears to be going. Rather, he seems to be saying that those problems that are not the direct result of a medical pathology are as much the province of psychiatry as those that are. Here’s another quote:
“Yet most psychiatrists learn little about when to order EEGs, neuroimaging, viral, autoimmune, and paraneoplastic panels, heavy metal screens and other investigations that can help diagnose their patients’ maladies, and how to distinguish between these [problems that are due to a general medical condition or a toxic reaction] and primary psychiatric disorders.” [Emphasis added]
Note the phrase “primary psychiatric disorders,” which essentially means problems of thinking, feeling, and/or behaving that are not attributable to a biological pathology or ingestion of a substance. We don’t hear this expression much any more because in recent decades it has been one of psychiatry’s top priorities to promote the fiction that all problems of thinking, feeling, and/or behaving stem directly from biological pathology, particularly the much-touted chemical imbalances. But here is Dr. Datta, not only using the term, but clearly implying that these “primary psychiatric disorders”, although not strictly medical problems in any conventional sense of the term, are, nevertheless, the legitimate province of psychiatry.
Dr. Datta is certainly calling for reforms in psychiatry. But he is emphatically not calling for the fundamental reforms: that psychiatrists recognize that the great majority of the problems that they so unsuccessfully “treat” are not illnesses; and that they recognize that this spurious medicalization of non-medical problems is the primary reason for their poor outcomes.
Here’s another quote:
“Social science research explored why the prognosis of schizophrenia is better in developing countries, and the effects of political economy on mental health, and yet most psychiatrists are completely oblivious to the evidence for the causal role of macrosocial factors in major mental illness.”
Yes, most psychiatrists are indeed oblivious to the evidence that macrosocial forces can, and do, cause profound problems of thinking, feeling, and/or behaving, but Dr. Datta seems equally oblivious to the fact that these problems are not illnesses, and, emphatically, do not warrant medical intervention.
Here’s another quote:
“Psychiatrists risk being out of touch with the public if they do not have a full appreciation of the effects of social factors on the etiology and course of mental illness.”
But there’s no reference to the fact that psychiatrists risk being out of touch with reality if they cling to the spurious notion that every significant problem of thinking, feeling, and/or behaving is an illness.
The crucial dilemma for any would-be psychiatric reformer is this: one cannot reform psychiatry without debunking the concept of mental illness; but one cannot debunk the concept of mental illness without committing professional suicide. There is no middle ground. The medicalization of these problems was a wrong turning in human history, and the only way that psychiatry can correct this error is to acknowledge the reality, and back out. But this they will not do. In fact, their current response to these criticisms is to redouble their efforts in PR and spin, in an attempt to win support for a cause that on logical and moral grounds is long lost.
Dr. Datta wants psychiatrists to become more knowledgeable and skilled in the psychological and social areas. He wants psychiatrists to receive training in cognitive psychology, childhood development, the role of attachment, theories of personality, the role of social class, the importance of environment, the significance of life events, etc…
And who could argue with any of this?
But the fundamental question remains. Why should problems of thinking, feeling, and/or behaving that are not illnesses be the province of medically trained practitioners, even if they have had some additional training in these areas? Would this additional training somehow compensate for the fundamental fallacy at psychiatry’s very core? Would phrenology become valid if its adherents had received some training in the psychosocial area? Would the theory of the four bodily humours have been vindicated if its training programs had been laced with humanistic ideas and some insights on child development?
Dr. Datta wants to have his cake and eat it too. He wants to critique psychiatry, and his honesty and courage in this regard are to be commended. He wants psychiatry to change – to reform itself. But what he doesn’t recognize is that psychiatry is not reformable, any more than phrenology was reformable. Phrenology was simply wrong, and needed to be scrapped. Similarly, psychiatry’s medicalization of virtually all human problems, and its long-standing hegemony in the “treatment” of these problems is a non-reformable error. It is an error that has damaged and disempowered literally millions of people. And like phrenology, it simply needs to go away. Anything less than that is not reformation. It’s just repackaging.