Criticizing Psychiatry Without Throwing the Baby Out with the Bathwater

So, I read this article in The Atlantic called “The Real Problems with Psychiatry” and…I’m torn. The article is an interview with this guy Gary Greenberg, a therapist who has previously written a book called Manufacturing Depression: The Secret History of a Modern Disease and has now followed that up with The Book of Woe: The Making of the DSM-5 and the Unmaking of Psychiatry.

Now, to be clear, I haven’t read either of these books. I might, just to see the full depth of his arguments. But I decided to read the interview anyway and assume that he accurately represented his own claims in it.

Parts of the interview, I think, are really on point. Greenberg discusses the history of the DSM (the manual used to diagnose mental disorders) as a way for psychiatry as a discipline to establish credibility alongside other types of medicine. He criticizes the DSM on the grounds that the mental diagnoses that we currently have may not necessary be the best way to conceptualize mental illness, and he thinks that once we gain a better understanding of the brain we will find that they have little to do with the physical reality of mental illness:

Research on the brain is still in its infancy. Do you think we will ever know enough about the brain to prove that certain psychiatric diagnoses have a direct biological cause?

I’d be willing to bet everything that whenever it happens, whatever we find out about the brain and mental suffering is not going to map, at all, onto the DSM categories. Let’s say we can elucidate the entire structure of a given kind of mental suffering. We’re not going to be able to say, “here’s Major Depressive Disorder, and here’s what it looks like in the brain.” If there’s any success, it will involve a whole remapping of the terrain of mental disorders. And psychiatry may very likely take very small findings and trump them up into something they aren’t. But the most honest outcome would be to go back to the old days and just look at symptoms. They might get good at elucidating the circuitry of fear or anxiety or these kinds of things.

I don’t know if he’s right. But I suspect that he might be.

He also makes a great point about the fact that we often assume that anyone who acts against social norms, for instance by committing a terrible crime, must necessarily be mentally ill:

It’s our characteristic way of chalking up what we think is “evil” to what we think of as mental disease. Our gut reaction is always “that was really sick. Those guys in Boston — they were really sick.” But how do we know? Unless you decide in advance that anybody who does anything heinous is sick. This society is very wary of using the term “evil.” But I firmly believe there is such a thing as evil. It’s circular — thinking that anybody who commits suicide is depressed; anybody who goes into a school with a loaded gun and shoots people must have a mental illness.

Greenberg also discusses how mental diagnoses have historically been used to perpetuate injustice, such as the infamous “disorder” of “drapetomania,” which was thought to cause slaves to try to escape their masters, and the fact that homosexuality was once considered a mental illness (and other types of sexual/gender variance still are).

He also talks a lot about how the DSM and its categories are tied in with all sorts of things: scientific research and mental healthcare coverage, for instance:

To get an indication from the FDA, a drug company has to tie its drug to a DSM disorder. You can’t just develop a drug for anxiety. You have to develop the drug for Generalized Anxiety Disorder or Major Depressive Disorder. You can’t just ask for special services for a student who is awkward. You have to get special services for a student with autism. In court, mental illnesses come from the DSM. If you want insurance to pay for your therapy, you have to be diagnosed with a mental illness.

The point about needing a DSM diagnosis in order to receive insurance coverage is really important and cannot be overstated (in fact, I wish he’d given it more than a sentence, but again, he did write books). As someone who plans to eventually practice therapy without necessarily having to formerly diagnose all of my clients, this matters to me a lot, because it may mean that I might have to choose between diagnosing and working only with clients who can afford therapy without insurance coverage (which, at at least $100 per weekly session, would really not be many).

But sometimes Greenberg makes a good point while also making a terrible point:

One of the overlooked ways is that diagnoses can change people’s lives for the better. Asperger’s Syndrome is probably the most successful psychiatric disorder ever in this respect. It created a community. It gave people whose primary symptom was isolation a way to belong and provided resources to those who were diagnosed. It can also have bad effects. A depression diagnosis gives people an identity formed around having a disease that we know doesn’t exist, and how that can divert resources from where they might be needed.

First of all, we don’t “know” that depression “doesn’t exist.” We know–or, more accurately, some of us suspect–that the diagnosis we call “major depression” might not map on very accurately to what’s actually going on in the brains of people who are diagnosed with it. What we call “major depression” is a large cluster of possible symptoms, and since you only have to have some of them in order to be diagnosed, two people with the exact same diagnosis could have almost completely different symptomology. Further, because depression can vary like a spectrum in its severity, the cut-off point for what’s clinical depression and what’s not can be rather arbitrary. It’s not like with other types of illnesses, where either you have a tumor or you don’t, either you have a pathogen in your bloodstream or you don’t.

Second, Greenberg doesn’t seem to extend his analysis of the effects of the Asperger’s diagnosis onto other disorders. There is absolutely a community of people who have (had) depression, eating disorders, anxiety, and so on. Those communities are absolutely valuable. My life would be demonstrably worse without these communities. They haven’t “diverted resources” from anything other than me wallowing in self-pity because I feel like I’m the only person going through these things–which is how I used to feel.

Right after that:

What are the dangers of over-diagnosing a population? Are false positives worse than false negatives?

I believe that false positives, people who are diagnosed because there’s a diagnosis for them and they show up in a doctor’s office, is a much bigger problem. It changes people’s identities, it encourages the use of drugs whose side effects and long-term effects are unknown, and main effects are poorly understood.

Greenberg is correct that false positives are a problem and that diagnosing someone with a mental illness that they do not have can be very harmful. However, his dismissiveness of the problem of false negatives–people who do have mental illnesses but never get diagnosis or treatment–is stunning coming from someone who is a practicing therapist. Untreated mental illnesses are nothing to mess around with. They can lead to death, by suicide or (in the case of eating disorders) otherwise. Even if things never get to that point, they can ruin friendships, relationships, marriages, careers, lives. While I get that Greenberg has an agenda to push here, some acknowledgment of that fact would’ve been very much warranted.

In short, Greenberg seems to make the logical leap that many critics of psychiatry and the DSM do; that is, because there is much to criticize about them and because it’s unclear how valid the DSM diagnoses are, therefore depression is “a disease that we know doesn’t exist” and antidepressants are harmful (that’s a whole other topic, though).

Antidepressants may very well be harmful. Diagnostic labels may also very well be harmful, for some people. But I think the stronger evidence is that untreated mental suffering is harmful, and sometimes therapy just isn’t enough and cannot work quickly enough–for instance, for someone who is severely depressed to the point that they can’t possibly use any of the insights they may gain in therapy, or to the point that they are about to commit suicide.

I hope that one day we’ll have all the answers we need to minimize both false negatives and false positives. But for now, we don’t, and I worry that attitudes like Greenberg’s may prevent people from getting the help they urgently need, as much as they may simultaneously promote vital criticism and analysis of psychiatry and the DSM.

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Note: I didn’t fact-check everything Greenberg said in the interview because I’m hoping that The Atlantic employs fact-checkers. But if you have counter-evidence for anything in that article, even parts I didn’t quote here, please let me know.

The Pressing Issue of Sham Gay Marriages

This, sadly, is not an April Fools’ joke. (Gotcha with that last one, though, right??)

Sue Everhart, chairwoman of the Georgia Republican Party, on same-sex marriage:

You may be as straight as an arrow, and you may have a friend that is as straight as an arrow. Say you had a great job with the government where you had this wonderful health plan. I mean, what would prohibit you from saying that you’re gay, and y’all get married and still live as separate, but you get all the benefits? I just see so much abuse in this it’s unreal. I believe a husband and a wife should be a man and a woman, the benefits should be for a man and a woman. There is no way that this is about equality. To me, it’s all about a free ride.

Sometimes people just come so close to the source of the problem but then still manage to veer off into complete idiocy.

Of course there would be same-sex couples who’d get married just for the benefits if same-sex marriage were legal where they live. There are already straight couples who do that. Hasn’t Everhart ever seen The Proposal? (Ignoring the part where they totally unrealistically fall in love, that is, because romcom.) And couldn’t gay men and lesbians just marry each other for the benefits, too?

Perhaps Everhart lives in a fantasy land in which people are only friends with others of the same gender, meaning that legalized same-sex marriage would indeed make it easier for people to shack up just for the benefits. But that’s not really how friendship works, especially since the need for healthcare and green cards goes beyond gender.

The truth that Everhart came so close to but still managed to completely miss is that federal benefits for married couples are fundamentally unfair. Why should having a certain type of relationship entitle you to special prizes? And don’t give me that crap about promoting procreation; we already heard it last week in the Supreme Court arguments. First of all, we give married couples those benefits even when no procreation is reasonably going to happen, and second, if you really believe that what this world most desperately needs are additional humans, I feel sad for you.

Everhart clearly thinks that marrying “for the benefits” is the wrong reason to get married. But what’s the right reason? Because one of you got pregnant and abortion is wrong? Because you need someone to provide for you (or take care of your household)? Because your families want to exchange property? Because you “truly” love each other and not just “as friends,” whatever that means?

Assuming that getting married “for the benefits” is Bad, well, that’s the problem when the government chooses to incentivize certain kinds of human relationships with material benefits, and when health care is only available to those who are given insurance by their employer, who can afford to buy insurance or pay for healthcare out of pocket, or who can marry someone to get on their insurance plan. Why should you only have that “wonderful health plan” of which Everhart speaks if you happen to have the right employer or be married to the right person? None of these things should be tied to marriage. But if they’re going to be, it’s only fair that same-sex couples have access to them, too.

Cultural phenomena like marriage are constantly changing in meaning and purpose. It used to be that most marriages were essentially “for the benefits”–for the husband’s family to get a dowry and carry on their family name, for the wife’s family to get the bride price, for the wife to have financial support, for the husband to have a housewife and a source of sexual gratification, for both families to receive social advantages of some sort, and so on. So, either Everhart should condemn all forms of marriage-for-benefits, or she should acknowledge that it only bothers her when the gays do it.

Conveniently, she basically did just that: “Lord, I’m going to get in trouble over this, but it is not natural for two women or two men to be married. If it was natural, they would have the equipment to have a sexual relationship.”

All I can say to that is that I truly feel sorry for Everhart if she really thinks that P-in-V is the only way to have sex.

Limbaugh Really Should Educate Himself About Birth Control

Up until this week, those of us with a shred of optimism and/or naivete could have pretended that the difference between liberals’ and conservatives’ perspectives on birth control were due to something as benign as “differing beliefs.”

However, now that Rush Limbaugh has run his mouth on the subject, I think we can all agree that much of the conservative opposition to birth control is due not to differing beliefs that are equally legitimate and should be respected, but to simple, stupid ignorance.

The following is probably common knowledge now, but I’ll rehash it anyway:

  • Sandra Fluke, a 31-year-old Georgetown University law student, was proposed by the Democrats as a witness in the upcoming Congressional hearings on birth control. Her history of feminist activism and her previous employment with a nonprofit that advocated for victims of domestic violence made her an appropriate witness for their side.
  • Representative Darrell Issa (R-CA), the chairman of the House Committee on Oversight and Government Reform, turned her down because, he claimed, her name had been submitted too late.
  • The resulting panel of witnesses for the Congressional hearings turned out to consist of absolutely no women whatsoever, which is really funny in that not-actually-funny-way because hormonal birth control of the sort whose mandated insurance coverage was being debated is only used by women/people with female reproductive systems.
  • A week later, she testified for House Democrats, mentioning that birth control would cost her $3,000 over three years. Lest anyone misinterpret her argument as being solely about those slutty women’s desire to have tons and tons of sex, she also mentioned her friend with polycystic ovary syndrome who developed a cyst because she was denied coverage for birth control pills (which would’ve helped because they would’ve reinstated a regular menstrual cycle).

A few days later, Rush Limbaugh decided to insert his expert opinion into the discourse surrounding mandated insurance coverage of birth control. His expert opinion?

What does it say about the college coed Susan Fluke [sic], who goes before a congressional committee and essentially says that she must be paid to have sex? What does that make her? It makes her a slut, right? It makes her a prostitute. She wants to be paid to have sex.

The next day, he clarified his views:

So, Ms. Fluke and the rest of you feminazis, here’s the deal. If we are going to pay for your contraceptives, and thus pay for you to have sex, we want something for it, and I’ll tell you what it is. We want you to post the videos online so we can all watch.

And the next day (allow me to shamelessly quote Wikipedia):

The following day Limbaugh said that Fluke had boyfriends “lined up around the block.”[18] He went on to say that if his daughter had testified that “she’s having so much sex she can’t pay for it and wants a new welfare program to pay for it,” he’d be “embarrassed” and “disconnect the phone,” “go into hiding,” and “hope the media didn’t find me.”[19]

I’m not going to waste anyone’s time by explaining how misogynistic Limbaugh’s comments were, especially since plenty of excellent writers have done so already. However, it continually shocks me how he gets away with saying things that are not only offensive and inflammatory, but simply inaccurate.

First of all, a primer for anyone who’s still confused: except for barrier-based forms of birth control (i.e. condoms and diaphragms), the amount of birth control that one needs does not depend on how much sex one is having. Hormonal birth control works by preventing ovulation, and in order for it to work, it has to be taken regularly and continually. For instance, you take the Pill every day, or you apply a new patch every week, or you get a new NuvaRing each month, or you get a new Depo-Provera shot every three months. You stick to this schedule whether you’re having sex once a week or once a day or ten times a day. You stick to it if you’re having sex only with your husband, and you stick to it if you’re having sex with several fuck buddies, and you stick to it if you’re a prostitute and have sex with dozens of different people every day.

Same goes for IUDs, which last for years.

Therefore, when Limbaugh says that those who support mandated insurance coverage of birth control are “having so much sex [they] can’t pay for it,” he’s not merely being an asshole. He’s also simply wrong.

And for the record, he didn’t even get her name right. It’s Sandra, not Susan. One word of advice for you, Limbaugh: if you’re going to call someone a slut and a prostitute, at least use their correct name. But I guess we should give him credit for knowing which letter it starts with.

I don’t care what your views are on mandated insurance coverage of birth control. I don’t care what your views are on how much or what kind of sex women should be allowed to have (as much as they want and whichever kind they want, in my opinion). Because whatever your views are on these things, you have to agree that these questions should not be getting answered by people who have absolutely no understanding of how these things actually work.

For instance, Limbaugh completely ignored the part of Fluke’s testimony in which she described the problem faced by her friend with polycystic ovary syndrome. This friend’s predicament has nothing to do with sex. Absolutely nothing. For all we know, she’s a virgin.

After all, polycystic ovary syndrome isn’t caused by anything that involves sex. The current medical opinion is that it’s probably caused by genetics.

Unlike some feminists, I don’t think that men should be excluded from debates about women’s health. But men (and women) who show little or no understanding about women’s health should absolutely be excluded from these debates.

You wouldn’t let a doctor who believes that babies come from storks deliver your baby. You wouldn’t let a mechanic who doesn’t know how an engine works work on your car. And you shouldn’t let politicians and commentators who think that you need more birth control if you have more sex decide whether or not birth control will be covered by your insurance.

And, for the record, I also don’t think that Congressional hearings on birth control should look like this: