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Are Psychiatrists the Sick Ones?

May 29, 2013

To New York Times columnist and cultural and political commentator David Brooks, psychiatrists are not heroes of science but “heroes of uncertainty.” Such is the title of his May 27, 2013 Op-Ed piece. 

Brooks takes the compilers of the DSM-5 and contemporary psychiatry to task for presenting their field as scientific. At the same time, he praises psychiatrists for their artistry, calling them “daring adapters, perpetually adjusting in ways more imaginative than scientific rigor.”

Brooks is not the first to point out the often-vast differences between the philosophy of a social institution and the philosophy and practice of the actual people who work in a given field. (It’s commonplace to read about teachers who teach in the face of the mandate of the institution of education to raise test scores, for example. And caring doctors who listen to their patients. ) But he does it well—so well, in fact, that readers might rush to make an appointment with a psychiatrist.

According to Brooks, the behavioral sciences—of which psychiatry is one—is not really a science, and so it shouldn’t pretend to be one. But it does pretend—these days, with a vengeance. It’s an obsession. Brooks calls it “Physics Envy.”

“If the authors of the psychiatry manual want to invent a new disease, they should put Physics Envy in their handbook. The desire to be more like the hard sciences has distorted economics, education, political science, psychiatry and other behavioral fields. It’s led practitioners to claim more knowledge than they can possibly have. It’s devalued a certain sort of hybrid mentality that is better suited to these realms, the mentality that has one foot in the world of science and one in the liberal arts, that involves bringing multiple vantage points to human behavior.”

On this we agree. My mentor, the late philosopher and social therapist Fred Newman, and I wrote a whole book on the subject (Unscientific Psychology: A Cultural-Performatory Understanding of Human Life).  In his social therapy practice and writings as a philosopher and a playwright, Newman took the psychology (that is, the pretend science) out of helping people and understanding human life. He tried to help people embrace the uncertainty of living, to themselves be “heroes of uncertainty.”

I liked Brooks’ column. I thought he did a good job in showing the institutional bias of psychiatry and its Physics Envy. But he didn’t go far enough for my taste.

He still holds fast to a disease model: “It’s more important to know what sort of person has a disease than to know what sort of disease a person has.” In doing so, I think he’ll lose the argument every time. (Do you want an artist treating your disease?) More than that, though, he’s reinforcing the belief that there’s something wrong with how we’re feeling and that the doctor knows how to fix it.

One of my favorite philosophers is Ludwig Wittgenstein—a brilliant, eccentric and, by his own account, tormented man. No doubt he would have been diagnosed with a mental disorder were he alive today. In his writings, he showed how trying to create an objective science of the subjective gives us “mental cramps,” causing great confusion and pain. He said, “We can fight, hope and even believe without believing scientifically.”

Fred Newman is another of my favorite philosophers. Following Wittgenstein, he created an approach to helping people in emotional pain with a subjective science of the subjective. In his book, Let’s Develop! A Guide to Continuous Personal Growth, he said, “Therapy should be a culturally transforming experience, teaching us a new, and developmental, way of seeing and creating a new life.”

If psychiatry heeded Wittgenstein and Newman, they might well be cured of Physics Envy.

 

 

 

 

 

 

Posted in Critical psychiatry, Culture, DSM-5, Human Development, Philosophy, Psychotherapy, Social Therapy, Wittgenstein.

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By loisholzman – May 29, 2013

NIMH Wants to “Fail Better” than the DSM-5 Did

May 6, 2013

I wonder why no major media outlet is covering this story—the National Institute of Mental Health (NIMH) announced on April 29, 2013 that it won’t be using the Diagnostic and Statistical Manual of Mental Disorders (DSM) anymore. (The story is all over the blogosphere, which is how I found out about it.)

But don’t put this into the category of “Good News” just yet.

Yes, the rejection by NIMH “delivers a kill shot to DSM-5,” in the words of  blogger Hank Campbell. What killed it is its lack of validity—something tens of thousands of professionals and consumers have pointed out in petitions, books, articles, TV and radio interviews, forums and blogs over the past eighteen months. Most of the protest surrounding the DSM-5 attributes its invalidity to its mischaracterization of mental distress as brain disease and its medicalized study and treatment. The sloppy data collection and field trials, not to mention psychiatry’s collusion with pharmaceutical companies, have also been widely exposed. Some, like myself, locate all the above in the broader political-philosophical issues of “What are emotions?” and “Why diagnosis?” (Search my blog for DSM-5.)

But for the NIMH, the DSM-5’s invalidity stems from the fact that, unlike the rest of medicine, it is symptom-based. So, far from killing the DSM-5 because it’s too tied to the medical model and the medical industries, NIMH is abandoning it because it finds it to be bad medicine. (I do agree with that.)

According to NIMH director Thomas Insel, MD, in “Transforming Diagnosis” (his NIMH blog entry announcing the change),

“Unlike our definitions of ischemic heart disease, lymphoma, or AIDS, the DSM diagnoses are based on a consensus about clusters of clinical symptoms, not any objective laboratory measure. In the rest of medicine, this would be equivalent to creating diagnostic systems based on the nature of chest pain or the quality of fever. Indeed, symptom-based diagnosis, once common in other areas of medicine, has been largely replaced in the past half century as we have understood that symptoms alone rarely indicate the best choice of treatment.”

As NIMH sees it, diagnosis in mental health “must not be constrained by the current DSM categories” but rather needs to include the biology along with the symptoms. The government agency is launching its own work to map “the cognitive, circuit, and genetic aspects of mental disorders.”

So the break with the DSM-5 actually takes us even further down the biological path. And it’s based in more assumptions than even the abyssmal DSM-5. I liked how one blogger put it in the post, “Paradigms lost: NIMH, McGorry & DSM-5’s failure”:

“Such assumptions [about biology, the brain and mental helath/illness] are little more than speculative, yet they are presented as conclusive. They serve to close off avenues of research that fall outside their boundaries rather than open them up. They point to the imperviousness of the dominant biological paradigm to evidence that contradicts it. In the words of Samuel Beckett, “Try again. Fail again. Fail better.” 

The blogger goes on—and I think he points to some of the reason these scientists and bureaucrats continue to “fail better”:

Because psychiatry, like the rest of medicine, is deeply imbued with scientific positivism (that real science is free of social values) and methodological individualism (that social processes are merely the aggregate outcome of individual behaviours), it cannot fully grasp that all health and illness — mental and physical — is both socially embedded and socially constructed. Therefore it cannot critically reflect on its own social nature, its own ideologies and practices that are inextricably bound up with wider social conflicts in their historical contexts…A new paradigm that doesn’t simply repeat those flaws cannot be built from above, not by DSM committees nor NIMH directors. It can only be built through the struggles of patients and clinicians for a mental health system driven by quite different social priorities. (my emphasis)

I couldn’t agree more.

Posted in Critical psychiatry, DSM-5, Human Development, Politics, Psychology.

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By loisholzman – May 7, 2013

Radically Accepting Poverty

May 2, 2013

“Radically accepting the poverty of one’s own life and community while simultaneously depersonalizing it makes possible a certain kind of growth/development – especially if one is simultaneously involved in activities that engage the underdevelopment that accompanies poverty.”

Lenora B. Fulani

Lenora B. Fulani

So says Dr. Lenora Fulani in her just-released, ”Helping the Poor to Grow A Special Report on Solving the Poverty Crisis in America.” Lenora is a developmental psychologist, grassroots educator, political activist and co-founder (with Fred Newman) of the All Stars Project. She didn’t just say these words at the Annual Meeting of the American Educational Research Association (AERA). She showed its power.

This happened last Sunday at an invited Presidential Session, “Education, Poverty, and Development: Breakthroughs in Addressing the Subjectivity of Poverty,” I organized and chaired at the AERA Annual Meeting in San Francisco. Lenora gave a version of her paper and then interviewed three young people who participate in the San Francisco Bay Area All Stars. (The All Stars Project also operates in NYC, Newark NJ, Chicago and Atlanta.) They spoke openly and intimately with the audience about their lives, touching upon ways that being poor narrowed their identities, limited their hopes, and made them feel they didn’t belong to the broader society. When asked how it felt to be in the Hilton Hotel addressing a ballroom full of professionals, they said, “Great.” “It’s a relief.” “We need to speak about poverty.” “We need to grow.”

The Speakers

The Speakers

Professors A. J. Franklin of the Boston College Lynch School of Education and David Grusky, director of the Stanford University Center on Poverty and Inequality, added passionate and important commentary. They highlighted some of the characteristics that make the All Stars uniquely successful. The organization brings development back into the education equation. It’s been a pioneer in using performance—on stage and off stage—to help young people from poor communities to develop. It’s also 100% independently funded. Professors Franklin and Grusky urged that we follow in the footsteps of Fulani and the All Stars: buck the orthodoxy, reject the established wisdom on who young people are, how to help them, and how to fund projects—and help our kids to grow.

Many in the audience cried. I believe everyone in that room grew right then. We were having a new kind of conversation together. And people grow from that.

 

 

 

 

 

 

 

 

Posted in Community Organizing, Culture, Education, Human Development, Learning Environments, Outside of School, Performance Movement, Play, Politics, Youth Development.

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By loisholzman – May 2, 2013

Join the Social Therapeutics Conversation

April 23, 2013

A few years ago while doing some teaching in Brazil, I was interviewed (in English) for Internet radio on where social therapeutics comes from and where it’s going. The interview was rich and far-reaching, as I recall—radical therapy,  social constructionism, politics, philosophy, culture, community….

This interview is the topic of the April monthly free webinar series of the East Side Institute.

You can listen to the interview here

And since it’s more fun and intriguing to learn in group conversation, you can sign up for a live web chat taking place on Friday, April 26, 12 p.m. EDT, Institute faculty member Jan Wootten will be leading the conversation. Join the chat room here.

You can always send me comments here too.

Posted in Community Organizing, Culture, Human Development, Philosophy, Politics, Postmodern Marxism, Psychology, Psychotherapy, Social Therapeutics, Social Therapy.

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By loisholzman – April 23, 2013

Avoiding the Social in Social Anxiety

April 9, 2013

Joseph LeDoux’s opinion piece in The New York Times, “For the Anxious, Avoidance Can Have an Upside,”  is an interesting essay that—like so many reports of neuroscience research in the mass media—miseducates the public.

Here’s the formula, as I see it. Take a phenomenon of human social life—in this case, social anxiety and responses to trauma and stress. Present some pre-neuroscience results of lab experiments on animals and generalize these results to human beings. Then present current research that shows where and how the brain accounts for the behaviors in question and again generalize—this time not from animal to human, but from brain to living being-in-the-world.

The topic is social anxiety and the types of avoidance people and rats exhibit in the face of perceived danger. There’s what’s called active avoidance and passive coping, as when rats who receive an electric shock paired with a sound will then freeze whenever they hear the sound again, or when people “with social anxiety problems” avoid social situations. Then there’s what’s called proactive avoidance and active coping, as when the sound is turned off when the rat makes any kind of movement at all and gradually learns (through the use of what psychology calls negative reinforcement) that the sound is not a threat, or when people develop strategies, like breathing or relaxation techniques, that make being in social situations tolerable. In the case of both rats and people, it’s better to be active and take control of what’s stressing you out.

At this point you may be thinking, as I was, “Huh?”This is common sense” (folk psychology, if you will). Not to mention that conditioning has the topic of the first chapters of Psych 101 texts for the past 75 years.

Apparently, what makes the rat experiment and its generalization to humans worthy of being recycled is research showing that different parts of the brain do different things and that “the active coping response, proactive avoidance…requires that the information processed in the input region be redirected to a different output controller in the amygdala, one that engages goal-directed actions.” All this, apparently, to justify this conclusion:

“When avoidance prevents one from dealing with life, it is maladaptive. But when avoidance is proactive and part of active coping and agency, it helps the person control the accelerator, brakes, and the track switches. It is a useful adaptive activity.”

I might not have stopped to share my thoughts on this essay (or even to give it any thought) if it were not about avoidance. Because what struck me as a peculiar irony of the essay was the author’s apparent unawareness of his own avoidance—an avoidance of the social in the scientific path he was taking to social anxiety.

I’m all for learning everything we can about how our brains work and discovering/creating the value this new learning can have. But to use brain research as somehow explanatory of the incredible complexity of human life, to reduce the pain of social anxiety a particular person experiences to internal information processing pathways is silly, dangerously so. It’s silly and dangerous in the way that reductionistic science has always been. In the way that psychology has for a century avoided the fundamental socialness of human life by going inward instead of outward, and by distorting who we are in order to explain us—instead of embracing who we are in order that we might be empowered to go beyond who we are.

As a step in this direction, we could locate what the experts are calling social anxiety in the broader culture and the way people live their lives, ask ourselves how it came to be that people can be afraid to talk to one another, that loneliness can be someone’s life companion, that we are seduced by the knowers of the world even though they’ve failed us time and time again, that it’s become harder and harder for more and more people to see and seize upon possibilities for creativity and growthful transformation of their lives, and that trying to avoid uncertainty in an uncertain world makes us crazy. Let’s continue studying the brain—by not relating to it as if it doesn’t reside in the social world we’ve created.

 

Posted in Critical psychiatry, Human Development, Philosophy, Psychology, Psychotherapy.

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14 comments

By loisholzman – April 10, 2013

Knowing Keeps Us Dumb

April 4, 2013

There’s no shortage of pithy quotations from revered wise women and men, from centuries past to this morning’s media, about how creativity, imagination, discovery and invention are essential for nations and their people to thrive. There’s also no shortage of op-eds, books, blogs and radio and TV talk about how America’s major institutions are stifling creativity, imagination, discovery and invention. Why the disconnect?

To get a glimpse of the muddle we’re in, let’s look at two of those pithy quotes from the wise. Commenting on his trade, the great artist Pablo Picasso said, “Every child is an artist. The problem is how to remain an artist once we grow up.” And the brilliant theoretical physicist Albert Einstein advised, “We cannot solve our problems with the same thinking we used when we created them.”

Both Picasso and Einstein are pointing to the same trap we’re in—once we know how to do something, we become less willing and able to do new things. We get stuck doing what we know how to do. Imagination reigns supreme when we’re little—when we don’t yet know that we’re supposed to know. We take risks. We learn how to paint, draw, sing, dance, talk, even think, because we “paint” “draw” “sing” “dance” “talk” and even “think” without knowing how! Before we know, we do. We play, we perform, we pretend our way to growth, learning and knowledge. This is the fundamental developmental activity of the human species.

To remain an artist as an adult, then, we can’t let all the knowledge we’ve accumulated about art, color, perspective, how things are supposed to look, etc. take over, or suppress our imagination and stop us from doing things with paint and pencil that we’ve never done before. And it’s the same with thinking. By the time we’re adults, most of us know how to think, and for a big portion of our lives, that way works pretty well. But not always. And when it doesn’t, we need to let go of “I know what to do” and generate new ways of thinking about the situation. “I know” only keeps us dumb.

 

Posted in Creativity, Human Development.

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By loisholzman – April 5, 2013

Vygotsky—Closing the Cognition-Emotion Gap

March 17, 2013

Lev Vygotsky was a brilliant psychologist who lived and worked in the first decades of the Soviet Union. His writings and teachings—he began very young (when only 19) and died very young (when only 38)—have been inspiring and teaching psychologists and educators for many decades. His understanding of human learning and development, of how important play is to development, and of what language is, were revolutionary during his time.

Vygotsky’s approach was cultural. To him, human beings create who we are—on the species level and the person level—by creating culture, adapting to the culture we create, re-creating it, adapting to the re-creation, and so on.

Vygotsky’s approach was social. To him, what we do we do with others—like learning to speak by having “conversations” with our mothers, brothers, sisters and fathers, long before we know the language— and that’s how we become the unique person each of us is.

Vygotsky’s approach was developmental. To him, what we need to be looking at is not merely who people are now, but also—and at the same time—who they are becoming. Because if we only relate to who we are and what we can do today, we’ll never learn to do new things.

Vygotsky’s approach was monistic and wholistic. To him, human intellect and human emotion are a unified process, not two separate and distinct human systems that compete with each other. To separate them and focus only on the intellectual, he said, creates “a one-sided view of the human personality.”

Sadly, despite interest in his work all around the world by academics and cursory reference to him in education courses, Vygotsky’s ideas are still rarely implemented on a mass scale—so entrenched are the cognitive, behavioral and individualistic biases that characterize the psychological and educational institutions of our day.

As someone who, for decades, has been “Vygotskian-izing” how education, psychology and psychotherapy are done, I’ve experienced its power and humanity in many different contexts and countries. If you want to learn more and help spread the word, here’s a few places to start:

 Mind in Society (a short introduction to Vygotsky’s own writing)

Lev Vygotsky (a documentary film about his life and current implementations of his ideas)

Mind, Culture and Activity on Vimeo (lectures and interviews with Vygotskian scholars)

Lev Vygotsky: Revolutionary Scientist (Fred Newman’s and my understanding of Vygotsky’s ideas and importance)

Vygotsky at Work and Play (my book showing some of what the Vygotskian-izing of psychotherapy and education looks like)

Posted in Activity Theory, Creativity, Education, Human Development, Psychology, Psychotherapy, Vygotsky.

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By loisholzman – March 17, 2013

Is Emotion Nothing More Than a Form of Cognition?

March 1, 2013

Here’s some promo for the latest products from the Psychotherapy Networker, a popular online resource for therapists—

“Learn how working with emotions can transform your practice”

“Gain the understanding, insight, and know-how to engage authentically with clients as emotions emerge”

“Working with emotions can be tough for both clients and therapists. This series is designed both to deepen your understanding of emotions and to strengthen your ability to work with them effectively. The focus is on providing you with practical insights that you can put to work right away.”

Really? Sounds like something from The Onion to me.

Aren’t emotions the stuff of psychotherapy? Is this an admission of a blatant omission in the therapist’s toolbox? What have therapists been doing all these years?

I know—they’ve been relating to emotional pain with cognitive and behavioral therapies. This unfortunate irony is only highlighted by the “revelation” of the Psychotherapy Networker (and several other organizations). I hadn’t realized that emotions had been so absent from psychotherapy training and literature that therapists have to be told to work with emotions and shown how.

What’s happening that emotions are hailed as the new frontier in psychotherapy? And what does it reveal about the depth of the cognitive bias of psychotherapy, psychology, and our overall culture?

At least in part, the surge of interest in emotion is coming from discoveries in neuroscience—which, even from reading just the popular press, seem to be made each day (and which are fascinating). But what are others doing with these discoveries?  Quoting the Psychotherapy Networker again, “Neuroscientists have recently established that emotion is the prime organizing force shaping how we cope with challenges…emotion is anything but primitive and unpredictable. It’s a complex, exquisitely efficient information-processing system, designed to organize behavior rapidly in the interests of survival.”

Sounds just like a typical descriptions of cognition, doesn’t it?

For sure, Western culture has not been kind to emotion. It’s been ignored, demeaned and outcast as inferior to cognition, the enemy of rationality, characteristically female (and so unworthy of attention) for centuries. Even though feminist psychologists and philosophers have exposed the male biases of accepted conceptions of being human, the overall cultural environment of psychology and psychotherapy hasn’t changed much. Theoretically and institutionally, it remains paradigmatically male and cognitively overdetermined. I fear that legitimizing emotion because of findings in neuroscience—and distorting the enormous historical and cultural complexity of human emotionality to fit a cognitive, information-processing model will only makes it worse.

If you know of therapists who work with some kind of social-cultural understanding of human emotion, sing their praises! I do.

 

 

Posted in Psychology, Psychotherapy, Social Therapy.

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12 comments

By loisholzman – March 2, 2013

If Creations are not a Possession

February 25, 2013

Last month I wrote and turned in to the publisher the Introduction to the Classic Edition for  Lev Vygotsky: Revolutionary Scientist, which Fred Newman and I wrote twenty years ago. I’m happy that the book is in producction and will be released in the early fall of this year. There’s just little things remaining for me to do, like deciding whether to keep the original Epigraph or choose a new one.

 

The Ocean at Sunset

The Ocean at Sunset, Montauk, 2/25/13

I spent today in Montauk, a village at the end of Long Island, 120 miles from New York City. It’s pretty much my favorite place, surrounded by ocean and bay, and filled with beaches, clifffs and woods to hike in. Before I left the house for an ocean walk with a friend and my dog Reggie, I looked at the Epigraph Newman and I had chosen. On the walk I fell in love with the quote again and decided it was definitely staying.

It’s a quote from Merleau-Ponty, the French phenomenological (and, according to some, existential) philosopher. (It might have come from his book, Sense and Non-Sense. I can’t remember the source, so if you know, please tell me.)   I’ve only read a little of his writing and it’s pretty fascinating and far reaching. I’d like to do a more serious study of him someday.

Here’s the quote:

If no painting comes to be the painting,

if no work is ever absolutely completed and done with,

still

each creation changes,

alters,

enlightens,

deepens,

confirms,

exalts,

recreates,

or creates in advance

all the others.

 

If creations are not a possession,

it is not only that,

like all things,

they pass away;

it is also that

they have almost their whole life before them.

Actually, that’s not the exact quote. Merleau-Ponty wrote it as prose, like so—

If no painting comes to be the painting, if no work is ever absolutely completed and done with, still each creation changes, alters, enlightens, deepens, confirms, exalts, recreates, or creates in advance all the others. If creations are not a possession, it is not only that, like all things, they pass away; it is also that they have almost their whole life before them.

I took the libery of setting it down poetically, to make visible how I hear his words.

 

Posted in Creativity, Philosophy.

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4 comments

By loisholzman – February 26, 2013

Danger: Psychiatrists as Moralists

February 7, 2013

I just read an Opinionator piece in The New York Times on “Depression and the Limits of Psychiatry.” The author is Gary Gutting, is a professor of philosophy at the University of Notre Dame. He tells us he’s been teaching a graduate seminar on Michel Foucault’s work and proceeds to discuss depression, psychiatric diagnosis and the DSM in light of Foucault’s unpacking of the history of madness and psychiatric practice.

It’s thoughtful piece. From Foucault’s perspective that psychiatric science is moral judgement in disguise, Gutting takes a look at the definition of depression in the soon-to-be released DSM-5— in which the exception for bereavement has been eliminated—and shows the faulty logic in concluding that bereavement and depression are the same. No empirical evidence can determine what is normal when it comes to suffering the loss of a loved one, let alone conclude that this kind of suffering is no different in kind from any other. It’s a value judgement presented by psychiatry as science.

Gutting goes on to raise the question of whether psychiatrists should be the moralists of the 21st century. He answers, “No.” After all, psychiatrists are physicians. They’ve been trained in a model—medicine—that wasn’t designed to judge moral issues. For me, this was the most interesting part of the essay.

“…psychiatrists as such have no special knowledge about how people should live. They can, from their clinical experience, give us crucial information about the likely psychological consequences of living in various ways (for sexual pleasure, for one’s children, for a political cause). But they have no special insight into what sorts of consequences make for a good human life. It is, therefore, dangerous to make them privileged judges of what syndromes should be labeled ‘mental illnesses.’

This is especially so because, like most professionals, psychiatrists are more than ready to think that just about everyone needs their services.  (As the psychologist Abraham Maslow said, “If all you have is a hammer, everything looks like a nail”). Another factor is the pressure the pharmaceutical industry puts on psychiatrists to expand the use of psychotropic drugs. The result has been the often criticized “medicalization” of what had previously been accepted as normal behavior-for example, shyness, little boys unable to sit still in school, and milder forms of anxiety.”

I agree with Gutting that those with a broader view—from humanistic psychology, medical ethics and the philosophy of psychiatry, as well as people who have experienced severe bereavement and their families and friends—are necessary voices, arguably ones with far more expertise on the matter than psychiatrists. They have more than a hammer, so they can see more than nails.

Posted in Critical psychiatry, DSM-5, Philosophy.

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17 comments

By loisholzman – February 7, 2013