Red Beard

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Stumbled across these two books on Amazon:

http://www.amazon.com/gp/product/1615990119/ref=s9_simh_gw_p14_i3?pf_rd_m=ATVPDKIKX0DER&pf_rd_s=center-2&pf_rd_r=0KNTED9E7004PAEJKW78&pf_rd_t=101&pf_rd_p=470938631&pf_rd_i=507846

http://www.amazon.com/gp/product/1932690409/ref=s9_simh_gw_p14_i1?pf_rd_m=ATVPDKIKX0DER&pf_rd_s=center-2&pf_rd_r=0KNTED9E7004PAEJKW78&pf_rd_t=101&pf_rd_p=470938631&pf_rd_i=507846

After checking out his wikipedia entry, his blog, and his youtube videos, I am intrigued.

It sounds like his fundamental message is:

1) If you examine psychiatry as a philosopher of science, especially biological psychiatry, you will find that there are zero valid theories on which to base any of the treatments being employed.

2) While mental health care is vital and deeply important to society, psychiatry is essentially stuck in the dark ages, a 'proto-science,' thanks to the squelching of dissent within psychiatric academia and the psychiatric publishing industry.

3) In order for psychiatry to survive, it must undergo a revolution in which we develop a fundamental, scientific theory of mind on which to base our investigation and treatment approach.

All that being said, I have yet to read his books (ordered them last night) but what I've read so far is resonating with me.

Curious what others think.

EDIT: Interview with the guy here: http://ezinearticles.com/?Interview-With-Niall-McLaren,-Author-of-Humanizing-Madness&id=973602
 

Doc Samson

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it must undergo a revolution in which we develop a fundamental, scientific theory of mind on which to base our investigation and treatment approach.
...and once we've done that, we can set about ending world hunger.

Why should psychiary be any different than any other areas of medicine? All of the practice of medicine is derived from an endless series of empiric experiments to see what works and what doesn't. Only in recent decades have been able to distill down the basic elements of exactly why things work - thus allowing us to have a fundamental scientific theory of anything. We can't all just stop our empiric trials in order to all philosopically opine on a theory of mind that we're going to base all our work on.
 

whopper

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I haven't read his books, but I have read the Amazon description given by it's editors.

Assailed from many directions, under constant attack for its reliance on "a drug for all problems" and increasingly unable to attract bright new trainees, the specialty is showing every sign of terminal decline. The reason is simple: modern psychiatry has no formal model of mental disorder to guide its daily practice, teaching and research. Unfortunately, the orthodox psychiatrists who control this most conservative profession are utterly antagonistic to criticism. Despite the evidence, they maintain a blind faith that "science will deliver the goods" by a biological examination of the brain. This book argues that their faith is entirely misplaced and is contributing to the destruction of an essential part of civilized life, the fair and equitable treatment of people with mental disorders. The author offers a rational model of mental disorder within the framework of a molecular resolution of the mind-body problem. Fully developed, this model will have revolutionary consequences for psychiatry--and the mentally-afflicted.
Assailed from many directions
Assailed, by who? The Church of you know who? Legitimate groups such as the FDA and the CDC don't seem to be assailing psychiatry.

under constant attack for its reliance on "a drug for all problems"
You've seen me write this for years on this board. Any psychiatrist worth his or her salt is not going to throw a pill at a problem. It's more complex than that. The biopsychosocial model is the standard that we should be basing our treatment.

Are there bad doctors that throw pills at problems? Yes--in every field of medicine. It's not a psychiatry thing. It's a bad medicine in general thing.

and increasingly unable to attract bright new trainees
Not in the last 2 years!

modern psychiatry has no formal model of mental disorder to guide its daily practice, teaching and research
No...the dopamine theory of psychosis, the catecholamine theory of depression, the serotonin theory of psychosis, etc.

There are plenty of formal theories to guide our practice, teaching and research.

the orthodox psychiatrists who control this most conservative profession are utterly antagonistic to criticism
I'm not exactly getting what the rationale is for label psychiatry as "this most conservative profession" and psychiatrists being "utterly antagonistic to criticism."

There may be several good points to the book, but it certainly is giving out some false data.

I'm getting an impression that this writer is similar to Breggin-in that most of the book is hokey bull, but there may be good points to it. In his book Toxic Psychiatry, I do think Breggin brought great points in that psychiatry needs to factor in that people need love and support. Medications aren't always the answer. Great, but the majority of his book proposes other things that are questionable at best.
 
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Red Beard, it's very good to hear that you're interested in Dr McLaren's work. I'm a 4th year medical student and I plan on going into psychiatry. I randomly found this author a couple years ago and been following him since. His insights are groundbreaking and his understanding of philosophy profound. Before I discuss his model and views more I'm going to address some of whopper's concerns. Any papers I reference are given as PMID. Just type that number in pubmed.org and you'll get the abstract.

"Assailed, by who? The Church of you know who? Legitimate groups such as the FDA and the CDC don't seem to be assailing psychiatry."

The criticism doesn't need to come from governmental agencies to be legitimate. Plus, they hardly criticize anything (search revolving door fda, pentagon etc.). "Ramin Mojtabai and Mark Olfson, two psychiatric epidemiologists found that the percentage of visits to psychiatrists that included psychotherapy dropped to 29 percent in 2004-5 from 44 percent in 1996-97. And the percentage of psychiatrists who provided psychotherapy at every patient visit decreased to 11 percent from 19 percent." (http://www.nytimes.com/2010/04/25/magazine/25Memoir-t.html). Also, the mean number of psychotropic meds prescribed in an office based psychiatry practice sample (n=13000) increased by 40.1% from 1.42 in 1996-1997 to 1.99 in 2005-2006 (PMID 20048220). The general public is increasingly seeing psychiatrists as pill pushers and the data indicates they're mostly right to think that.


"You've seen me write this for years on this board. Any psychiatrist worth his or her salt is not going to throw a pill at a problem. It's more complex than that. The biopsychosocial model is the standard that we should be basing our treatment. Are there bad doctors that throw pills at problems? Yes--in every field of medicine. It's not a psychiatry thing. It's a bad medicine in general thing."

Unfortunately, there are many psychiatrists that only throw pills at problems. The cold hard truth is that you make considerably more money if you only prescribe medications. Med checks are quick and well reimbursed. Just look at the therapy statistics. It's interesting that you mention the biopsychosocial model. In fact, Niall McLaren wrote a paper back in 1998 which staunchly criticized the philosophical stance of the BPS model (PMID 9565189; ATTACHED SEE BOTTOM). A good place to get a summary of his argument is at http://en.wikipedia.org/wiki/Biopsychosocial_model in the criticism section.


"Quote:
and increasingly unable to attract bright new trainees
Not in the last 2 years!"

Your statement is simply false. Family medicine's average step 1 score for US MD grads is 214; PM&R 214; then Psychiatry 216. The average US MD step 1 score was 225 for this year (2009).
Go to http://www.nrmp.org/data/chartingoutcomes2009v3.pdf. This is an incredibly useful link for all medical students.


"Quote:
modern psychiatry has no formal model of mental disorder to guide its daily practice, teaching and research
No...the dopamine theory of psychosis, the catecholamine theory of depression, the serotonin theory of psychosis, etc.
There are plenty of formal theories to guide our practice, teaching and research."

When the author refers to "formal model of mental disorder" he is referring to the fact that we have no unified model of mind to guide practice and research. He has in fact written his own model of mind, the Biocognitive Model, but more on that later. Additionally, the theories you listed above only can explain a portion of the picture. Drugs certainly can help, but without cognitive interventions the processes that lead to the need for drugs are not quelled.
As a side note, the serotonergic model of depression is grossly inadequate. Look up the drug tianeptine in the literature.

"Quote:
the orthodox psychiatrists who control this most conservative profession are utterly antagonistic to criticism
I'm not exactly getting what the rationale is for label psychiatry as "this most conservative profession" and psychiatrists being "utterly antagonistic to criticism."
There may be several good points to the book, but it certainly is giving out some false data.
I'm getting an impression that this writer is similar to Breggin-in that most of the book is hokey bull, but there may be good points to it. In his book Toxic Psychiatry, I do think Breggin brought great points in that psychiatry needs to factor in that people need love and support. Medications aren't always the answer. Great, but the majority of his book proposes other things that are questionable at best."

I believe he considers it conservative in the sense that it is resistant to change. He's had a lot of trouble getting published and the psychiatric establishment continually tells him not to rock the boat. He has outlined their practices in his 2009 paper "Science and the Psychiatric Publishing Industry." I can't find it on pubmed but the file is attached.

What's really great for med students is a lot of his work is in the medical literature (see wikipedia page for bibliography) and therefore free for us. The other major paper everyone should read is "Interactive Dualism as a Partial Solution...." (PMID 16459024; ATTACHED). This paper outlines the beginnings of his theory of mind and serves as a chapter in his book "Humanizing Madness." His work is often philosophically heavy so I'll try to explain as simply as possible.
Let's first have a discussion of monism and dualism. Monism contends that the mind and brain are one and fits very neatly within biological psychiatry. Thus within this realm the "chemical imbalance" is primary and the behavior secondary. The two biggest supposedly monist thinkers are Daniel Dennett (functionalism) and John Searle (biological naturalism). In an upcoming journal article Dr McLaren shows that while both of their models claim to be monist they use virtual machines to complete their explanations for their models. Unfortunately for Dennett and Searle virtual machines are in fact dualist in nature and therefore their models are dualist constructs. Dualism refers to the mind and body being two separate entities. Since the biological paradigm is rooted in monism, this is a major blow.
In the paper above (Natural Dualism....) he provides his explanation for consciousness in that consciousness is ineffectual. This has been well shown neurologically (see http://en.wikipedia.org/wiki/Neuroscience_of_free_will). Essentially, the vast majority of decisions we make everyday are made very quickly and are a byproduct of the rules we've acquired over the course of our lives. Some are virtually innate and others are most certainly learned. While we can modify these rules over time we often get ourselves into trouble via vicious feedback loops with our rules. For example, you are wary of others and think they're out to get you. When you run into a situation you are more likely to not give the person the benefit of the doubt. In turn they act maliciously back to you and this ratifies your initial inclination to be wary (note the ratification completes the vicious cycle thus promoting similar behavior in the future). As you can see this vicious cycle can be easily encountered in many other examples. The fact that we make the majority of decisions split second makes sense from an evolutionary perspective. There is a distinct advantage to reacting as quickly as possible when evolving. It is interesting that since consciousness is ineffectual "we're frightened because we run, we don't run because we're frightened." This is a very profound thought when you think about it. Therefore, he has hypothesized that the function of consciousness is the gateway to memory. Makes sense eh! So if consciousness is not typically a part of the decision making process what is. Essentially the human brain is probably much like a Turing machine (computer) and bases decisions on rules acquired over life.
The philosophical backing for his model is based on Natural Dualism as put forth by the philosopher David Chalmers. This provides a dualist explanation to the mind-body problem without invoking the supernatural.
There is much more to the model and I've literally only scratched the surface. I suggest after reading his papers in the literature you get his books "Humanizing Madness " (2007) and "Humanizing Psychiatry" (2009). He also has a new book which is being sent to the editor shortly so look out for that as well as a lecture tour in the US during the month of October 2010. I know he's going to be in New York and Boston but I don't know the other lecture locations. If you have any questions or comments about his work send him an email. I can almost guarantee he'll get back to you, he loves to hear from medical students who are interested in his work.

Below are some other good resources about the author and topics/persons he uses in the proof of his model
Blog- http://niallmclaren.com/
http://en.wikipedia.org/wiki/Niall_McLaren
http://en.wikipedia.org/wiki/Alexander_Luria
http://en.wikipedia.org/wiki/David_Chalmers
http://en.wikipedia.org/wiki/Alan_Turing
http://en.wikipedia.org/wiki/Noam_chomsky
http://en.wikipedia.org/wiki/Biopsychiatry_controversy (see reductionism section)
http://en.wikipedia.org/wiki/Biopsychosocial_model (see criticism section)

BE SURE TO SEE THE THREE ATTACHMENTS

Cheers
 

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whopper

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Your statement is simply false.
I don't see how it is false if the number of applicants is going up.
The average US MD step 1 score was 225 for this year (2009).
Look at the wording. Psychiatry is "increasingly" having problems attracting bright new trainees? The # of applicants is up. How is that false? How does the average step score disprove that?

The criticism doesn't need to come from governmental agencies to be legitimate.
You don't have to have government agencies, but you should listen to legitimate ones.

The problems as you mentioned, and as I mentioned, are not problems unique to psychiatry. They are problems with medicine in general. The same model you criticize in your post is a problem in all fields of medicine.

I haven't read the author's books. I am, however, criticizing the impression I got from the books based on the editor's comments. If someone wants to stick it to psychiatry for a problem that's happening in all fields, then I'll tell people that this is a medicine problem, not just a psychiatry problem. That's meant with the full intention that the problem should be fixed, not deflected away.

I believe he considers it conservative in the sense that it is resistant to change. He's had a lot of trouble getting published and the psychiatric establishment continually tells him not to rock the boat. He has outlined their practices in his 2009 paper "Science and the Psychiatric Publishing Industry." I can't find it on pubmed but here is the link http://www.ingentaconnect.com/conten...00001/art00004.
Hmm, well I'm not going to spring $48 to see the article. I will say that this guy having problems getting published is not proof positive of his accusations. Having problems being published can be due to a number of reasons including just writing a bad paper.

I've been published a few times. I never encountered any problems. The only times I worked on something for publication that wasn't published, I nixed it on my own because I didn't think the work was worthy of being published.

Now in this guy's defense, I hadn't read the paper. There are of course needs for improvement.

This guy may in fact be a guy I think is spot on if I actually spent the time to research him a bit more. I've criticized several aspects of psychiatry and needs for improvement. I did, however, disagree with aspects of how the publisher of his book presented the field of psychiatry.
 
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"I don't see how it is false if the number of applicants is going up.
Look at the wording. Psychiatry is "increasingly" having problems attracting bright new trainees? The # of applicants is up. How is that false? How does the average step score disprove that?"

Just because the number of applicants is up doesn't mean the quality of applicants is up.
You raise a number of valid points. It would be much better data if we had average step 1 scores over time. That would be a better measure. I wonder if we could find that data anywhere, it'd be very interesting. Of course it is true that the average step 1 score is most certainly an imperfect gauge of quality. However, step 1 scores do have some correlation and psychiatry is the third lowest.
Nonetheless, we could banter all day about what constitutes brightness and we'll never come to an answer. However, this is a much less important issue than the philosophical boat he's rocking.

"The problems as you mentioned, and as I mentioned, are not problems unique to psychiatry. They are problems with medicine in general. The same model you criticize in your post is a problem in all fields of medicine.
I haven't read the author's books. I am, however, criticizing the impression I got from the books based on the editor's comments. If someone wants to stick it to psychiatry for a problem that's happening in all fields, then I'll tell people that this is a medicine problem, not just a psychiatry problem. That's meant with the full intention that the problem should be fixed, not deflected away."


No, the model I criticize in my post is not the same model used in all fields of medicine. Psychiatry is unique namely because it pertains to the mind. You must remember that we are using model in the philosophical sense of the term. Thus, establishing whether the mind is a dualist or monist construct is of vital importance as this will influence the manner in which we treat patients.
As of right now almost all fields of medicine and science are based on reductionism. Meaning, to understand something you have to break it down and know the smaller parts. This has been the most successful scientific paradigm and has yielded miraculous results. That's why it's so hard to accept that reductionism doesn't work for the mind. Unfortunately, reductionism cannot explain the program (mind) that drives the machine. Here is a good paragraph about reductionism.
"Niall McLaren emphasizes in his books Humanizing Madness and Humanizing Psychiatry that the major problem with psychiatry is that it lacks a unified model of the mind and has become entrapped in a biological reductionist paradigm. The reasons for this biological shift are intuitive as reductionism has been very effective in other fields of science and medicine. However, despite reductionism's efficacy in explaining the smallest parts of the brain this does not explain the mind, which is where he contends the majority of psychopathology stems from. An example would be that every aspect of a computer can be understood scientifically down to the very last atom, however this does not reveal the program that drives this hardware. He also argues that the widespread acceptance of the reductionist paradigm leads to a lack of openness to self-criticism and therefore halts the very engine of scientific progress." http://en.wikipedia.org/wiki/Biopsychiatry_controversy


"Hmm, well I'm not going to spring $48 to see the article. I will say that this guy having problems getting published is not proof positive of his accusations. Having problems being published can be due to a number of reasons including just writing a bad paper.
I've been published a few times. I never encountered any problems. The only times I worked on something for publication that wasn't published, I nixed it on my own because I didn't think the work was worthy of being published.
Now in this guy's defense, I hadn't read the paper. There are of course needs for improvement.
This guy may in fact be a guy I think is spot on if I actually spent the time to research him a bit more. I've criticized several aspects of psychiatry and needs for improvement. I did, however, disagree with aspects of how the publisher of his book presented the field of psychiatry."

Luckily for you I attached three of his papers on my first post. You could also just go to google scholar and get it through your institution.
I'd be very interested to see what you think of his papers, I think you'll be pleasantly surprised.
 
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whopper

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You raise a number of valid points. It would be much better data if we had average step 1 scores over time.
So the USMLE score is the end all be all indicator of quality? Hmm, what about patient recividism in an inpatient unit? Patient satisfaction? # of days on a unit?

Like you said, we could argue on the problems with gauging quality, but the editor's comments said that a problem was there was an increasing problem with attracting bright new applicants. Applicants are up, and every PD I've talked to, and that's on the order of a handful tell me the quality is up because they have the opportunity to go through more applicants.

As for your 3 papers, I'll give them a looksie. I could be pleasantly surprised.

I will still, however, disagree with the presentation as given by the editor and publisher.

It could be that the good doctor doesn't even agree with the editor. Several authors I've known can't stand their editor/publisher and have accused them of misrepresenting them.

But in any case, I've said from the beginning that I haven't read much of the doctor's work. I'm criticizing the editor's comments. Reason why is because several anti-psychiatrists criticize psychiatry, not with the intention of fixing or reforming, but the purpose of destroying or profiting. The comments made about the doctor's book from his publisher take that tone. Don't believe me? I cut and paste the editor's description...

It says psychiatry is on the path of terminal decline (not true).
It's not attracting new applicants (applicants are up).
It's ruled by conservative group resistant to change that rely on "blind faith" and are contributing to the end of civilized life.

Wouldn't you admit these comments are a bit on the hyperbole side that's not constructive? If any journal were to contain an article with this type of rhetoric, the author would lose credibility in the community, and with good reason.

"Niall McLaren emphasizes in his books Humanizing Madness and Humanizing Psychiatry that the major problem with psychiatry is that it lacks a unified model of the mind and has become entrapped in a biological reductionist paradigm. The reasons for this biological shift are intuitive as reductionism has been very effective in other fields of science and medicine. However, despite reductionism's efficacy in explaining the smallest parts of the brain this does not explain the mind, which is where he contends the majority of psychopathology stems from. An example would be that every aspect of a computer can be understood scientifically down to the very last atom, however this does not reveal the program that drives this hardware. He also argues that the widespread acceptance of the reductionist paradigm leads to a lack of openness to self-criticism and therefore halts the very engine of scientific progress."
The above is something I accept as constructive. I took this from your previous post. This is an example of an argument I'm willing to start to take seriously. The publisher's comments...no I'm not.

I did write that I was getting an impression from the editor's comments that the writer is Breggin-like. I'm getting the impression from your posts that he is not (I have actually read much of Breggin's work.). That may be valid point you bring up, and again, I haven't read the author's work yet. But if you are right, then the publisher has certainly done the author an injustice with it's description of the author's books and opinions.
 
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Quote- "So the USMLE score is the end all be all indicator of quality?"
Whopper, that's not what I said at all. Remember this part of my post. "Of course it is true that the average step 1 score is most certainly an imperfect gauge of quality. However, step 1 scores do have some correlation...."
I'm completely not saying it is in any way "the end all be all indicator of quality." I'm not sure how you made that inference.

I can definitely guarantee that he's not making any money doing what he's doing. He published a paper actually, and it outlined exactly how much money he made and the breakdown of his outpatient psychiatric practice (SEE ATTACHED). Apparently rural psychiatry doesn't pay very well.

I can also guarantee you he is not anti-psychiatry in any way and the author has explicitly stated that fact. He is simply critical of the philosophical stance of his field. He honestly has laid out an excellent model of the mind and just wants it to have the chance to be read and critiqued. Notice, when he gets rejections from journals it's not because they refute his papers philosophically. They just give reasons like "it's not a good fit." And, based on their publishing guidelines the journals truly do have free reign upon what does or doesn't get published (Science and the Psychiatric Publishing Industry is a good paper on this; Previous attachment). This has really put him in a difficult situation and I think this is reflected in the tone of his writing, he's mad at how many hoops he has to jump through just to get the damn model critiqued.

His wikipedia page really is a great resource
http://en.wikipedia.org/wiki/Niall_McLaren
 

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Manicsleep

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The USMLE scores don't mean that much but here is a very small indicator. It was the only 2 that I could find.

USMLE step 1
2007: 210
2009: 216

USMLE Step 2
2007: 213
2009: 221

Another measure of increasing quality is the increasing competitiveness of medical school in general. MCAT scores have been going up and US graduates have been getting more and more competitive. Psychiatry has experienced an increase in applications from US grads.
 

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Stumbled across these two books on Amazon:

http://www.amazon.com/gp/product/1615990119/ref=s9_simh_gw_p14_i3?pf_rd_m=ATVPDKIKX0DER&pf_rd_s=center-2&pf_rd_r=0KNTED9E7004PAEJKW78&pf_rd_t=101&pf_rd_p=470938631&pf_rd_i=507846

http://www.amazon.com/gp/product/1932690409/ref=s9_simh_gw_p14_i1?pf_rd_m=ATVPDKIKX0DER&pf_rd_s=center-2&pf_rd_r=0KNTED9E7004PAEJKW78&pf_rd_t=101&pf_rd_p=470938631&pf_rd_i=507846

After checking out his wikipedia entry, his blog, and his youtube videos, I am intrigued.

It sounds like his fundamental message is:

1) If you examine psychiatry as a philosopher of science, especially biological psychiatry, you will find that there are zero valid theories on which to base any of the treatments being employed.

2) While mental health care is vital and deeply important to society, psychiatry is essentially stuck in the dark ages, a 'proto-science,' thanks to the squelching of dissent within psychiatric academia and the psychiatric publishing industry.

3) In order for psychiatry to survive, it must undergo a revolution in which we develop a fundamental, scientific theory of mind on which to base our investigation and treatment approach.

All that being said, I have yet to read his books (ordered them last night) but what I've read so far is resonating with me.

Curious what others think.

EDIT: Interview with the guy here: http://ezinearticles.com/?Interview-With-Niall-McLaren,-Author-of-Humanizing-Madness&id=973602
You could level those criticisms at almost all aspects of medicine and biomedical research. Seriously.

As a student of the philosophy of science who trained in a discipline that still takes that subject very seriously, I've been pretty appalled by my experiences with medicine and the very structure of biomedical research.

I confess I haven't read his works. I hope he acknowledges these limitations in all areas of the medical field.
 
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You could level those criticisms at almost all aspects of medicine and biomedical research. Seriously.
As a student of the philosophy of science who trained in a discipline that still takes that subject very seriously, I've been pretty appalled by my experiences with medicine and the very structure of biomedical research.
I confess I haven't read his works. I hope he acknowledges these limitations in all areas of the medical field.
Actually you can not level those criticisms at all aspect of medicine. Philosophically, psychiatry is distinct among the medical sciences namely because it deals with the mind. The medical sciences are largely based on reductionism and reductionism cannot provide all of the explanations needed to explain mental disorder. However, reductionism is great at explaining the other fields of medicine which is why it's hard for us to grasp that it won't deliver for psychiatry too. One of the problems is that monism (meaning the mind and body are one entity) is supported by the reductionist approach. Within monism disorders of the cognitive realm as perceived PRIMARY lesions in the brain. Unfortunately, just because we can associate mental disorder with lesions or chemical imbalances does NOT mean the chemical imbalances were PRIMARY. Just look at the field of epigenetics. I've ATTACHED a great paper on epigenetics which outlines how low parental interaction early in life decreases the expression of glucocorticoid receptors in the hypothalamus which are the receptors processing cortisol's negative feedback. Therefore, having a lower density of these receptors mean that these people's stress response is much more difficult to turn off as negative feedback is blunted.
The end result is that without a dualist model of mind mental life takes the backburner and we hunt and peck for biochemical lesions. Note that I am not saying that biochemical lesions are not important or do not exist, they are just not the answer to all of psychiatry's questions. It's just that we almost always look at these changes from the lesion-->mental state standpoint as opposed to the chronic mental state-->biochemical changes-->continued aberrant output.
I would contend that the mental state comes first in a good proportion of mental disorders, ESPECIALLY the anxiety disorders. It turns out anxiety disorders are grossly underrecognized in regular clinical practice. ATTACHED is a paper called "Comorbidity missed....". In this study they had two groups of 500 patients. One group got a regular interview, the other got a SCID (structured interview, takes 1/2 a day, catches nearly everything and is considered the gold standard). Of the 500 regular interviews only ~200 anxiety disorders were caught. However, in the SCID ~550 were caught. What is important to note is that the number of mood disorders were about the same between the two diagnostic arms (~350 each). Plus when you look at the data social and specific phobias have the highest rates of underdiagnosis (~200 had these two alone in the SCID group vs 20 in regular interview, that means ~180 pts, or about 1/3 of the 500 sample would have had their phobias missed in a regular psychiatric interview) and these most certainly have a significant mental component to their pathogenesis.
In closing, suppressing an output state (with meds) without fixing the cognitive processes that give rise to that mental state is an incomplete treatment paradigm for those whose biochemical aberrations are secondary.
In the other fields of medicine it does not matter if the mind is monist or dualist and that is why this criticism is very specific to psychiatry alone.

Lame, after writing this post apparently I have no more room for attachments so I'm listing links for the two papers I referenced. I was however able to get part of the table attached from the clinical vs SCID paper.
http://www.ncbi.nlm.nih.gov/pubmed/19960543
http://www.ncbi.nlm.nih.gov/pubmed/10360612
 

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whopper

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Whopper, that's not what I said at all. Remember this part of my post
Fair enough. To further debate on that point IMHO would not be constructive since IMHO it seems we both want to hear the voices of those that want to change our field for the better.

I read two of the guy's articles.

First, I do at least believe I see where he's coming from, though I suspect I may only have a superficial knowledge. More inspection and reading may reveal more to me that may change my opinion.

Second, I do think this guy takes on a much better tone than his publisher.

Third, I disagree with him. He calls psychiatry a pseudoscience based on the proposition that it does not have an accepted model of mental illness. The DSM gives guides on it's definitions, and even calls forth to clinicians to treat the disorders with an open mind that leaves a lot of leeway to the patient for benefits of doubt. It also clearly states it's limitations. In his opinion it seems that is not enough for a mental disorder. It appears he wants a disorder to be something on the order that is certifiable to the point where everything is 99% accurate or above. He did not use the word 99%, but reading his article as a whole, that's the impression I'm getting.

Several psychiatric disorders are to the degree where we are in a theoretical range more so than our other colleagues in the medical field. We for example can explain less about the definitive aspects of schizophrenia in what is going on in the brain than an oncologist can explain the definitive aspects of squamous cell carcinoma.

That said, despite the theoretical aspects of our field, if we take doctor's argument to it's literal form, several several medical fields are operating on pseudoscience. Diabetes decades ago could only be identified based on a cluster of symptoms because we yet did not have lab tests that were inexpensive and widespread enough to diagnose it. Those that studied diabetes to get it to the level where it is now, it seems by the doctor's definition would have been practicing pseudoscience decades ago. I think not. I think doctors who studied diabetes decades ago were scientists so long as they were using the scientific method, and they were pioneers that advanced the knowledge of that disorder to the degree it is today.

The doctor also puts forth that we have no theoretical models that are well formulated, lack theoretical basis, and have logical derived models with true predictive power. I do not agree.

Psychiatry is the only branch of medicine lacking
a well-formulated, theoretical basis and logically
derived models with true predictive power.
We do. Plenty need improvement, but say we're the only branch lacking a well-formulated theoretical basis and logically derived models with true predictive power is not true. Dementia, delirium for example are within an area where we have more detailed information on diagnosis and identification. Someone with depression due to hypothyroidism, that has high predictive power in treating it. Treating the thyroid disorder should treat the depression. Let's not, however, skirt the issue that several aspects of our field are not in this area.

For example, in predicting future violence, our own field has tests which 1-do have a theoretical basis, 2-use logically derived models, but 3-lack strong predictive power. While they lack strong predictive power, they are far better than not using them, and much better than random chance. Is that pseudoscience? I think not. Science involves formulating a theory, it needs a model, and that model needs to be tested in a manner that can be replicated So the tests are not 99% accurate. That is the process of science. With further study, better models, more testing, and more research, the tests will get better and better. The state of the art in this field has increased dramatically in the last 2 decades. It's gone on the order of being no better in comparison to a layman, to being better, but less than 50%, to being better than than that in the last 3 decades. That's pseudoscience? I think not. In fact it's possible with the use of fMRIs, it could start to have a very strong predictive power within the next decade.

I think the doctor does bring up good food for thought. I disagree with him, but I'm holding his comments to a higher degree than his publisher.

The good points he brings up, is that our field is in a position where there is a high room for debate with several things we do. This is something IMHO that can be missed, overlooked, and not taught in the medical curriculum because medical education focuses on overloading students with too much information, so students only focus on what's going to be on the test. Since the tests are usually completely multiple choice and not based on philosophical argument, these aspects of psychiatry's limitations will be ignored.

That is a point that should not be lost. I however, will not expect an overworked medical student to care (as a whole, I would however expect individuals who are outliers to take an interest), nor do I expect this to make a huge change in the way our field is practiced. I say this not as a defense of our field, but as a criticism.

I do think, practically speaking, that an ethics course on psychiatry should be given to psychiatric residents emphasizing the limitations of our field, and encouraging a mindset that just because we are doctors, we do not know as much as we sometimes think we do.

I am also wondering if there is something different about Australia than the US in the practice of psychiatry. Several eastern European countries, for example, were notorious in using psychiatry to shut up and control dissidents, so some intellectuals developed an antipsychiatry attitude there that has drifted over to the U.S. (Thomas Szasz). While some of the parallels in criticizing psychiatry in the US were justified (Wyatt v. Stickney), others were not.
 
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Fair enough. To further debate on that point IMHO would not be constructive since IMHO it seems we both want to hear the voices of those that want to change our field for the better.
I still haven't read this guy's stuff. I will try to today.
I completely agree, it totally derails from the point at hand. Just remember that he's a philosopher and writes his papers from a philosophical point of view. This makes some of his papers difficult reads (ie Interactive Dualism....) as the philosophy jargon can get pretty heady. I've found that it often takes me several reads to completely understand his argument in philosophical terms and I had to look up the terms he used often. Don't despair though, I have no philosophy training whatsoever and got through fine. It just requires a bit of study time and several reads. The nice part about his work is how dense it is. Every time I reread his books I learn knew parts of his model and theories that I may have glazed over in the previous read.

If you want to get to applications of his model I suggest reading http://en.wikipedia.org/wiki/Niall_McLaren -->section Humanizing Madness (2007)--> subsection Part III: Toward the Future of Psychiatry. This section requires no philosophical understanding and helps put his model in a real life context.
 
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First, I do at least believe I see where he's coming from, though I suspect I may only have a superficial knowledge. More inspection and reading may reveal more to me that may change my opinion.

Second, I do think this guy takes on a much better tone than his publisher.

Third, I disagree with him. He calls psychiatry a pseudoscience based on the proposition that it does not have an accepted model of mental illness.....
I agree that he does use some harsh words in his writing. I took a quick look at the wikipedia article for pseudoscience and I do see where you're coming from. Psychiatry most certainly does use the scientific method. However, a portion from the page reads
"Pseudoscience has been characterised by the use of vague, exaggerated or untestable claims, over-reliance on confirmation rather than refutation, lack of openness to testing by other experts, and a lack of progress in theory development.." These last two points are most certainly true (again see Publishing Industry paper). Psychiatry appears to be functioning in the realm of Kuhnian "normal science" as it is so resistant to even considering that the Biocognitive Model may be correct.
 

whopper

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Okay, here's my opinion as it stands now....

I disagree with him, but I think he makes good points. Real psychiatrists should be taking his comments seriously because, despite my disagreements, he clearly points out valid limitations in our own field.

It seems from his articles that he is not out to profit. If he were, he'd have far more sensationalism and clearly histrionic rhetoric in his articles. So, it may seem he actually is being intellectually honest in his criticisms.

I still believe, however, that he is wrong to call our field a pseudoscience. We have a lot of advancements we need to accomplish to get our field more out of the theoretical, but this does not make what we do pseudoscience. We are limited by the ethics of not being able to drill holes and attaching micro-osmotic-pumps into people's brains and use them as test subjects without regard with what it will do to the person. (Trust me, I know what I'm talking about on this because have done this on hundreds of rats, one rat at a time at the cost of several hours of time per rat). Another obstacle is we are dealing with disorders which may be largely intracellular in nature and based on problems with 2nd messenger systems.

So while the doctor can criticize us, one of the ways to get to what I think he'd consider better models is to start using humans as test subjects in horrid ways.

He could of course start suggesting what models we could use that would advance our field. He may have done so, but in his articles, I didn't see much on this area in his articles. If he has a better method, I'm opening to hearing it. Otherwise, at least for me, it doesn't change my impression of the state of psychiatry.

A guy could complain to a physician from 70 years ago about how pathetic the state of the science is with understanding diabetes. Fair enough, but I'd like to hear then what the guy wants to do to make the situation better instead of focusing on the complaint. I'm already aware of the problems, I'd like to hear solutions.

For a medical student, I do think the limitations of psychiatry need to be stressed, tempered with the information that several of the critics of psychiatry are also being a bit on the ridiculous in their criticisms. I don't think this guy is on the order of the ridiculous, but I do disagree with him.
 

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Note: please take the dripping sarcasm as generally playful, as that is the intended tone.

Philosophically, psychiatry is distinct among the medical sciences namely because it deals with the mind. The medical sciences are largely based on reductionism and reductionism cannot provide all of the explanations needed to explain mental disorder.
Just because my 2010 Honda Civic is a lot more complicated than my aunt's 1989 Honda Civic doesn't suddenly mean that the mechanics no longer try to fix it in a systematic way. (terrible analogy, but the best ones usually are).

Just because the mind is really complex doesn't make it different. It just means it's harder to figure out.

However, reductionism is great at explaining the other fields of medicine which is why it's hard for us to grasp that it won't deliver for psychiatry too. One of the problems is that monism (meaning the mind and body are one entity) is supported by the reductionist approach. Within monism disorders of the cognitive realm as perceived PRIMARY lesions in the brain.
No, disorders of the cognitive realm are perceived as primary lesions of brain FUNCTIONING, which is very different. Every time my computer screws up, I don't necessarily blame the CPU or the hard drive. I don't even blame Microsoft. But it could be either or both. And my computer is much simpler than a brain, in that the software doesn't necessarily mold the hardware over time, or vice versa.

Unfortunately, just because we can associate mental disorder with lesions or chemical imbalances does NOT mean the chemical imbalances were PRIMARY.
It doesn't mean they aren't, either. Sometimes they are, and sometimes they aren't. Most of us think they're multifactorial the vast majority of the time.

I've ATTACHED a great paper on epigenetics which outlines how low parental interaction early in life decreases the expression of glucocorticoid receptors in the hypothalamus which are the receptors processing cortisol's negative feedback. Therefore, having a lower density of these receptors mean that these people's stress response is much more difficult to turn off as negative feedback is blunted.
Yeah, the trauma folks have been doing great work like this for years. This argues AGAINST a dualist model, not for it. The paper says experience alters biology. ABSOLUTELY! Descartes was good at algebra, but he was a really really sloppy philosopher, and he's not really taken seriously anymore except at seminaries. You're not a Jesuit, are you?

The end result is that without a dualist model of mind mental life takes the backburner and we hunt and peck for biochemical lesions.
When an English Ph.D student writes her thesis on homosexual imagery in the works of H.P. Lovecraft, we don't fail her defense because she didn't talk about the harpoons in Moby Dick.

Just because we speculate about Jimmy's amygdala doesn't mean we forget his dad burned him with cigarettes after he threw his mother down the stairs.

Note that I am not saying that biochemical lesions are not important or do not exist, they are just not the answer to all of psychiatry's questions.
Okay, well when I find a psychiatrist who says that they are, I'll let you know. Straw man, straw man, straw man.

It's just that we almost always look at these changes from the lesion-->mental state standpoint as opposed to the chronic mental state-->biochemical changes-->continued aberrant output.
Not really. I mean, maybe Niall McLaren says we do, but right now I wouldn't trust the guy to tell me what to order at Wendy's, nevermind what psychiatrists really think about psychiatry.

I would contend that the mental state comes first in a good proportion of mental disorders, ESPECIALLY the anxiety disorders.
Do you also have a strong opinion about whether the chicken or the egg came first?

In closing, suppressing an output state (with meds) without fixing the cognitive processes that give rise to that mental state is an incomplete treatment paradigm for those whose biochemical aberrations are secondary.
Which is why every psychiatrist knows that "meds plus therapy" is the most common right answer. Maybe they're lazy regarding actually getting their patients into therapy, and maybe some patients don't like therapy, and maybe therapy is more expensive than a 4 dollar pill at Target pharmacy, and maybe a lot of people get incomplete treatment in all of medicine.

I think we disagree about what medications are supposed to do. Therapy is about learning. But so is just living your life. Most people learn everything they need to learn about living just from going about their day to day. If Ritalin helps the kid with ADHD learn at school what it feels like to not get yelled at for being out of his seat, if Zoloft helps the social phobic learn that when she talks to people they aren't going to laugh at her, these experiences are addressing the mental state, and the medications are helping to faciliate that. Are they doing so as well as combined therapy treatment? No. Are they even doing it as well as therapy alone? Sometimes yes, sometimes no.

We give people with broken legs crutches not so they can lean on them forever, but so they can stay more active, get through their days, and get stronger. And we give psychiatric medications with the same hopes, that by "suppressing the output state" of a gross, blunt concoction of diffuse, poorly targeted neural circuits, they might learn to "alter their mental state." No therapist has ever altered a patient's mental state. They just act as guides when guidance is needed.

Therapy is great, and plenty of the time we don't have drugs that address our patient's needs. But what we do and do not have at our disposal pharmacologically doesn't really inform a philosophical debate.

In the other fields of medicine it does not matter if the mind is monist or dualist and that is why this criticism is very specific to psychiatry alone.
Monist vs dualist was only an interesting debate when we were freshman in college avoiding studying chemistry at 4AM in our dorms. The mind is complex, and it doesn't exist separate circuits firing. Just because we are not smart enough to map this doesn't make it unmappable. If you're suggesting we keep a dualist model because it practically helps us focus on ways of helping our patients, okay. If you're suggesting we keep a dualist model because it's correct in some sort of cosmic sense, well, then I need to go watch the Big Lebowski again.
 
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Okay, here's my opinion as it stands now....
I disagree with him, but I think he makes good points. Real psychiatrists should be taking his comments seriously because, despite my disagreements, he clearly points out valid limitations in our own field.
It seems from his articles that he is not out to profit. If he were, he'd have far more sensationalism and clearly histrionic rhetoric in his articles. So, it may seem he actually is being intellectually honest in his criticisms.
I still believe, however, that he is wrong to call our field a pseudoscience. We have a lot of advancements we need to accomplish to get our field more out of the theoretical, but this does not make what we do pseudoscience. We are limited by the ethics of not being able to drill holes and attaching micro-osmotic-pumps into people's brains and use them as test subjects without regard with what it will do to the person. (Trust me, I know what I'm talking about on this because have done this on hundreds of rats, one rat at a time at the cost of several hours of time per rat). Another obstacle is we are dealing with disorders which may be largely intracellular in nature and based on problems with 2nd messenger systems.
So while the doctor can criticize us, one of the ways to get to what I think he'd consider better models is to start using humans as test subjects in horrid ways.
He could of course start suggesting what models we could use that would advance our field. He may have done so, but in his articles, I didn't see much on this area in his articles. If he has a better method, I'm opening to hearing it. Otherwise, at least for me, it doesn't change my impression of the state of psychiatry.
A guy could complain to a physician from 70 years ago about how pathetic the state of the science is with understanding diabetes. Fair enough, but I'd like to hear then what the guy wants to do to make the situation better instead of focusing on the complaint. I'm already aware of the problems, I'd like to hear solutions.
For a medical student, I do think the limitations of psychiatry need to be stressed, tempered with the information that several of the critics of psychiatry are also being a bit on the ridiculous in their criticisms. I don't think this guy is on the order of the ridiculous, but I do disagree with him.
He has outlined numerous implications for his model in his books. Unfortunately, you'll have to purchase those in order to see all of his applications and read his model (he also provides many case examples in his books). Again, I suggest you read http://en.wikipedia.org/wiki/Niall_McLaren -->section Humanizing Madness (2007)--> subsection Part III: Toward the Future of Psychiatry. This has some real life applications of his theories.
I have bolded a couple points you made that are not at all consistent with what the author advocates. His therapies and explanations are based on the cognitive realm and its mediation. He does not endorse "using humans as test subjects in horrible ways." How did you come to that inference?
He advocates talking to people as people, finding out WHY they do the things they do, and shaping their destructive personality rules and/or rectifying previous traumatic experiences, phobias, etc. As a side note he definitely prescribes medications, just at lower rates than other psychiatrists.
A perfect example of his approach deals with 4 patients I've had recently. They were all females diagnosed as bipolar. When I talked to them (us med students have time for hour interviews) they didn't meet the criteria for bipolar at all. I asked them how many nights is the most they ever stayed up. The average ran between 2-4 nights maximum. Then I asked them a simple question. WHY did you stay up for 4 days. All of them gave the same answer, they have recurrent nightmares (of trauma) that are so bad that they are scared to go to bed. Two of these patients said to me, "I've never been asked WHY I stayed up before." Of these 4 patients, only 1 had a current diagnosis of PTSD.
The cognitive realm is of vital importance, the output state is of much less importance than the reasons WHY the output state is realized. That is the approach the author advocates.
 

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I have bolded a couple points you made that are not at all consistent with what the author advocates. His therapies and explanations are based on the cognitive realm and its mediation. He does not endorse "using humans as test subjects in horrible ways." How did you come to that inference?
I think that Whopper was saying that the "pseudoscience" complaint is because ethics prevent us from the ideal of full human subject testing. He's not implying that Dr. McLaren supports that testing.
 
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Note: please take the dripping sarcasm as generally playful, as that is the intended tone.
Just because my 2010 Honda Civic is a lot more complicated than my aunt's 1989 Honda Civic doesn't suddenly mean that the mechanics no longer try to fix it in a systematic way. (terrible analogy, but the best ones usually are).
Just because the mind is really complex doesn't make it different. It just means it's harder to figure out.
That is not an accurate example. You would still use a reductionist approach to fix both cars.

No, disorders of the cognitive realm are perceived as primary lesions of brain FUNCTIONING, which is very different. Every time my computer screws up, I don't necessarily blame the CPU or the hard drive. I don't even blame Microsoft. But it could be either or both. And my computer is much simpler than a brain, in that the software doesn't necessarily mold the hardware over time, or vice versa. It doesn't mean they aren't, either. Sometimes they are, and sometimes they aren't. Most of us think they're multifactorial the vast majority of the time.
Yeah, the trauma folks have been doing great work like this for years. This argues AGAINST a dualist model, not for it. The paper says experience alters biology. ABSOLUTELY! Descartes was good at algebra, but he was a really really sloppy philosopher, and he's not really taken seriously anymore except at seminaries. You're not a Jesuit, are you?
This does NOT argue against a dualist model. I am not Jesuit, I'm actually an Atheist. Dualism does NOT necessarily imply the supernatural and in my previous posts I have reiterated the point that his dualist model DOES NOT INVOLVE SPIRITUALISM. Most previous dualist theories DO invoke spiritualism which is why dualism gets a bad rap. The two biggest monist thinkers, Daniel Dennett and John Searle, utilize "virtual machines" in their descriptions of the mind. A virtual machine plus hardware = two separate entities = dualism. Therefore their models are NOT monist and are in fact dualist.

If you're suggesting we keep a dualist model because it's correct in some sort of cosmic sense, well, then I need to go watch the Big Lebowski again.
I believe you are concerned because you're associating dualism with supernaturality, I have addressed this concern above.
 

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The two biggest monist thinkers, Daniel Dennett and John Searle, utilize "virtual machines" in their descriptions of the mind. A virtual machine plus hardware = two separate entities = dualism. Therefore their models are NOT monist and are in fact dualist.
Okay, now this just sounds like 90's anime. Psychiatry by manga! :)
 

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This thread seems to be going in a lot of different directions, but I'll address a few points.

Red Beard said:
It sounds like his fundamental message is:

1) If you examine psychiatry as a philosopher of science, especially biological psychiatry, you will find that there are zero valid theories on which to base any of the treatments being employed.
Agreed; however, lack of validity does not imply lack of utility. Although there is little evidence that most currently recognized mental disorders are separated by natural boundaries, many diagnostic categories retain utility by virtue of predicting outcome and treatment response.

I'm having a hard time figuring out where Dr. McLaren is coming from. He criticizes the biopsychosocial model and the biological psychiatry paradigm. I guess I have some reading to do.

whopper said:
No...the dopamine theory of psychosis, the catecholamine theory of depression, the serotonin theory of psychosis, etc.

There are plenty of formal theories to guide our practice, teaching and research.
This is where we may have some disagreement. These theories epitomize the reductionist tendencies of modern psychiatry and are horribly inadequate for explaining mental illness.

The pervasive use of psychiatric drugs is justified by the psychiatric community under the assumption that they function by helping to correct underlying biological abnormalities that produce particular symptoms. This view arose in the 1960s, around the time that it was discovered that neuroleptics antagonize dopamine receptors. The subsequent deduction that overactivity of dopamine neurotransmission was therefore responsible for psychosis is a non sequitur. An equally plausible alternative – that neuroleptics induce a state of neurologic suppression that reduces the impact of psychotic symptoms – was tossed out prematurely. In the second scenario, a possible therapeutic mechanism could be via the emotion flattening induced by neuroleptics, rather than treatment of the underlying disorder. I'm sure someone will argue that there is additional evidence supporting the dopamine hypothesis of schizophrenia, and I'm not arguing that dopamine does not have a significant role. However, the use of neuroleptics likely confounds a majority of the studies that demonstrate increased D2 receptor density/sensitivity, since D2 receptor upregulation is a consequence of D2 antagonists. Secondly, the relationship between dopamine and stress and arousal could be additional confounders, since an individual experiencing psychosis would likely experience significantly more stress than a healthy control.

The same goes for the monoamine hypothesis of depression. The idea that depression is due to deficiencies in 5-HT and NE is questionable at best, Machiavellian at worst. Advertising campaigns have been effective in persuading millions that mental disorders are caused by chemical imbalances, which can be corrected by drugs. Psychiatry needs to be more careful when considering the concept of cause and effect. My opinion is that abnormalities in neurotransmission can be better understood as correlations of psychological states than as causes of them.

cstruble said:
It is interesting that since consciousness is ineffectual "we're frightened because we run, we don't run because we're frightened." This is a very profound thought when you think about it. Therefore, he has hypothesized that the function of consciousness is the gateway to memory. Makes sense eh! So if consciousness is not typically a part of the decision making process what is. Essentially the human brain is probably much like a Turing machine (computer) and bases decisions on rules acquired over life.

The philosophical backing for his model is based on Natural Dualism as put forth by the philosopher David Chalmers. This provides a dualist explanation to the mind-body problem without invoking the supernatural.
These sentences seem contradictory to me. Dr. McLaren first argues that consciousness is ineffectual, and then goes on to argue that it is functional?

I should start by clarifying that I am firmly in the Chalmers camp when it comes to explaining the hard problem of consciousness, but I think Dennett and Searle bring some valuable ideas to the table. Also, Chalmers' philosophy is not dualist in the traditional sense. He has referred to his position as both a double-aspect ontology and as a naturalistic form of dualism. It has more in common with a monist view like physicalism, except that it encompasses phenomenal states, than with Cartesian dualism, in which the mind can affect the brain.

I agree that consciousness is ineffectual, in that the mind does not affect the brain as in Cartesian dualism, but I'm not sure I follow the first sentence. My understanding is that the emotional reaction of fear is a phenomenological correlate of a particular physiological state, but to say "we're frightened because we run, we don't run because we're frightened" is misleading, as the physiological correlate is much more complex than running…oversimplified perhaps? Running does not itself produce fear, much as the adrenaline surge that accompanies a frightening experience does not itself produce fear. Rather these are physiological accompaniments to the emotional reaction.

I also agree that consciousness is often bypassed in decision making; however, I'm not sure I agree that this leads to the conclusion that most decision making is analogous to the output of a Turing machine. I'm out of familiar territory here, but I'm inclined to appeal to the argument of Robert Penrose, that human consciousness – and perhaps unconscious mechanisms – are non-algorithmic, and thus are not capable of being modeled by a Turing machine.

An insightful post from a friend on another forum seems appropriate here:

"The picture of the unconscious being revealed by cognitive psychology/neuroscience is one of numerous semi-autonomous subsystems seamlessly integrated in their usual functioning, NOT in conflict with one another, and at no level guided by the pleasure principal or unifying sexual forces. The unconscious mind has experimentally demonstrated an ability to work with a wide array of content simultaneously in a way that is indistinguishable from working memory – which some psychological schools hold as synonymous with consciousness. Given the ostensible functional sufficiency of the unconscious mind to guide higher order behavior the mystery is shaping up to be why phenomenal consciousness exists at all."

As outlined in the quotation above, consciousness is not necessary to access memory and guide behavior. In the spirit of Chalmers, I argue that phenomenal consciousness, intentionality, the what it is like to be-ness of the mind, will never be accounted for by a functional explanation.
 
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Okay, now this just sounds like 90's anime. Psychiatry by manga! :)
Haha, Ghost in the Shell is an old favorite of mine. However, I can guarantee that is not one of the author's influences, haha.
That material is taken from his new paper, Monist Models...I'll let you all know when his "Monist Models...." paper is published. I have an advanced copy and it is scathing, but I really can't post that since it hasn't even been published.
 
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These sentences seem contradictory to me. Dr. McLaren first argues that consciousness is ineffectual, and then goes on to argue that it is functional?
He's NOT saying that consciousness has no utility, it is just not effectual in most decision making processes. It does have utility in that it provides the emotions and sensations involved in consolidating memory.
You've provided some very good points. You will certainly find his material stimulating. If you have any suggestions be sure to contact the author. He's very open to hearing other's viewpoints. I've forwarded this thread to him. It's likely we may be hearing from him over the next several days.
 
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cstruble said:
He's NOT saying that consciousness has no utility, it is just not effectual in most decision making processes. It does have utility in that it provides the emotions and sensations involved in consolidating memory.

You've provided some very good points. You will certainly find his material stimulating. If you have any suggestions be sure to contact the author. He's very open to hearing other's viewpoints. I've forwarded this thread to him. It's likely we may be hearing from him over the next several days.
Thanks. I enjoyed reading your posts as well, and I’ll look into some of the links you provided.

Regarding the utility of consciousness, I think a critical distinction needs to be made to have a meaningful discussion about consciousness, which is the distinction between psychological and phenomenological aspects of consciousness.

Phenomenal consciousness is the experience of mental content itself, experience qua experience, beingness (e.g. Thomas Nagel’s “there is something it is like to be a bat”). Chalmers states in his book, The Conscious Mind, “Phenomenal states, unlike psychological states, are not defined by the causal roles that they play. It follows that explaining how some causal role is played is not sufficient to explain consciousness. After we have explained the performance of a given function, the fact that consciousness accompanies the performance of the function (if indeed it does) remains quite unexplainable.” Although our understanding of the psychological mind is far from complete, psychology can be explained through third-person data. When someone says that the mind is complex, but is simply more difficult to figure out, they are referring to the psychological mind. Raw phenomenal consciousness, on the other hand, is characterized only by the way it feels, not by what it does, and thus is untouchable by third person data. This is what I mean when I say phenomenal consciousness has no functional explanation.

It's an entirely different problem when one equates complex psychological processes with inadequate reductionist biological explanations.

For anyone interested, here's an excellent article on the topic: Facing Up to the Problem of Consciousness.

Chalmers' philosophy has evolved in many respects since that time, but his formulation of the 'hard problem' and the distinction between what he calls the 'psychological' and 'phenomenal' aspects of consciousness haven't changed at all.
 
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Let me clarify...

Again, I suggest you read http://en.wikipedia.org/wiki/Niall_McLaren -->section Humanizing Madness (2007)--> subsection Part III: Toward the Future of Psychiatry. This has some real life applications of his theories.
I have bolded a couple points you made that are not at all consistent with what the author advocates. His therapies and explanations are based on the cognitive realm and its mediation. He does not endorse "using humans as test subjects in horrible ways." How did you come to that inference?
The comment by Notdeadyet is what I meant.

McLaren criticized our field for not having a more grounded scientific approach.

Fair, but a strong part of that reason is because of the level of invasiveness we can ethically accomplish. We have several theories that have not been better tested because to test them, we'd have to cut up people's brains to see what the medications are doing.

We have so many animal models because we can get several rats, cut up their brains, and see what happens. We can't do that with human subjects.

Again, I suggest you read http://en.wikipedia.org/wiki/Niall_McLaren -->section Humanizing Madness (2007)--> subsection Part III: Toward the Future of Psychiatry. This has some real life applications of his theories.
Fair enough, and I suspected that with his body of work, he may have given suggestions I have not yet read.

Altogether, given what I've read, and your mention of McLaren's work, I do think he's one of the better critics of psychiatry. I still disagree with him on some points, but I think he's worthy of consideration.

As for you Cstruble, I find your level of interest in this guy, and your level of debate quite impressive given that you haven't even started psychiatry residency yet.

He advocates talking to people as people, finding out WHY they do the things they do, and shaping their destructive personality rules and/or rectifying previous traumatic experiences, phobias, etc. As a side note he definitely prescribes medications, just at lower rates than other psychiatrists.
As is my philosophy in general, though I do have to admit I have engaged in high polypharmacy with a few patients. Those patients were very dangerous and psychotic, manic, and were treatment resistant even to Clozaril and lithium. I've actually gotten some patients completely off of psychiatric medications who were misdiagnosed as psychotic in a forensic institution and left to stew for years, and the patients did better when off of them. (The previous psychiatrists just labelled the troublesome patient as psychotic and left it at that--for years).

IMHO a good psychiatrist will try to understand the person's personality and will not reduce them to a set of symptoms to be treated.
 
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The cognitive realm is of vital importance, the output state is of much less importance than the reasons WHY the output state is realized. That is the approach the author advocates.
I don't understand why this is such a "revolutionary" position. Sure, modern psychiatry often glances over "the reasons WHY" out of convenience or lack of skill, but I'm pretty sure that good history-taking skills and psychotherapy are taught in every psychiatry residency in the US.
 
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My name is Niall McLaren, I am a psychiatrist of some 37years experience in some fairly tough parts of the world. In my spare time, I write critical analyses of the theories used in psychiatry. Without exception, they are not flattering to psychiatry but that is the result of the theories themselves, not of the criticism, which is absolutely stock standard philosophy of science, as applied to all other fields of science. The critiques are detailed and are all checked by reputable people before publication, but none of them are psychiatrists. Nobody has ever faulted the analysis. For example, one contributor to this debate says we have a biopsychosocial model to use as the basis for practice. No we don't. In 1998, I showed that it does not exist. Granted, there are a lot of people who are acting as though it exists but truth is not established by repetition of a falsehood. Our students and trainees are being actively misled into believing something which is patently false. That is just not acceptable practice.
For the record, my work is published but not in mainstream psychiatric journals.
I will be in the US in late September and early October to attend a conference in Syracuse, NY, and will launch my third book there. If anybody wants to hear more detail, I am still organising my trip and would be pleased to give talks to any medical school or resident program if I can fit it in. Please feel free to contact me but don't make the mistake of thinking I will just repeat the same dreary old stuff you have heard for years. My work is critical. Criticism of the status quo is the engine of scientific progress: No criticism, no progress. End of discussion.
Feel free to contact me, jockmclaren at gmail dot com.
 

whopper

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Good to hear from you.

Dr., I do agree with several of your assertions that our field does have limitations, and that we should criticize, but do so with the intent to improve.

Let's say for an example that I have a patient with bipolar disorder, I treat him with a mood stabilizer, and he's happy with it. He can afford it. When we talk during our interviews, he has no significant complaints outside what can happen to anyone (e.g. problems with the girlfriend, occasionally problems at work, none seem to be related to bipolar disorder.) He has good insight into his disorder, and understands to look for certain symptoms as a possible signal that his mania may restart (e.g. poor sleep).

How is that not using a biopsychosocial model? Bipolar disorder has pharmacological treatments that have been put reviewed and FDA approved, I regularly discuss the patient's social situations and we're both on the lookout to see how it affects his life, and we've also covered his own knowledge of his condition. There's data showing that multimodal interventions such as medications with psychotherapy are more effective than either alone.

Am I missing something? I've read some of your publications, but maybe I just missed your point.
 
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ClinPsycMasters

The skeptic in me asks whether it was a coincidence that Cstruble argued so enthusiastically in favor of Dr. McLaren's views in a number of posts, then told Dr. McLaren that such debate is taking place here, and now Dr. McLaren--supposedly it really is him--has come on the forum and is coming to States in a month or two, willing to give talks here and there and so forth. There has to be a better way ;)

Of course I do have a tendency to see patterns where non exist and even if this was merely an advertising gimmick, it would not detract from the doctor's arguments, needless to say.
 
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The skeptic in me asks whether it was a coincidence that Cstruble argued so enthusiastically in favor of Dr. McLaren's views in a number of posts, then told Dr. McLaren that such debate is taking place here, and now Dr. McLaren--supposedly it really is him--has come on the forum and is coming to States in a month or two, willing to give talks here and there and so forth. There has to be a better way ;)
Of course I do have a tendency to see patterns where non exist and even if this was merely an advertising gimmick, it would not detract from the doctor's arguments, needless to say.
No, you make an astute point. However, I wasn't the one who started the thread and I happened to find it the other day (plus it's been around for months). I was really excited to see that someone was inquiring about him. I know a lot about the author and his theories as I've read all his literature and his books. I actually became friends with him because I emailed him after reading Humanizing Madness. I agree though, the whole situation does look like it could be staged. Nonetheless, I can guarantee the person who posted is actually the author and not just another version of me.
It took me a second but I found a good way to prove it's him. Go to his website http://niallmclaren.com/ and read his introductory bio. At the end it gives his contact info which is the same as was posted.
 
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ClinPsycMasters

Okay, thank you for clarifying this.

I don't have any specific criticism of his arguments though I personally think that consciousness plays a bigger role than he and Dennett have suggested. In addition, Dr. McLaren is not the only one who has been critical of the psychoanalytic, behavioral, and biological models of human behavior, favoring a cognitive model instead. I haven't read his books and I'll try to get my hands on them when I go to the university this coming week as I am curious how evidence-based his views are. Is his emphasis on anxiety, for instance, merely speculative, based on personal philosophy (akin to some psychoanalytic views) and experience, or built on published research and quality studies?
 

whopper

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Of course I do have a tendency to see patterns where non exist and even if this was merely an advertising gimmick, it would not detract from the doctor's arguments, needless to say.
This is how a theory is established. No problem in theorizing. The problem starts when one starts making assumptions that the theory is true without enough evidence, or starts giving their theory enough credence without enough evidence.
 
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ClinPsycMasters

This is how a theory is established. No problem in theorizing. The problem starts when one starts making assumptions that the theory is true without enough evidence, or starts giving their theory enough credence without enough evidence.
Hmmm, reading my post over again I suppose my comment regarding seeing patterns where none exist, was essentially self-deprecating. It was noted right before I--more or less--accused the poster and professor of dishonesty and deception, so perhaps I was hoping to soften the blow.

Good catch Whopper. :)
 

masterofmonkeys

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Sorry it took me so long to get back to this thread. Real life called. Ok I lie. I was sitting on my couch in a cheeto fueled stupor. But still...

Actually you can not level those criticisms at all aspect of medicine.
I can, and I do. As do most of my compatriots in the fields of bioanthropology and exercise science

Philosophically, psychiatry is distinct among the medical sciences namely because it deals with the mind. The medical sciences are largely based on reductionism and reductionism cannot provide all of the explanations needed to explain mental disorder. However, reductionism is great at explaining the other fields of medicine which is why it's hard for us to grasp that it won't deliver for psychiatry too.
No actually reductionism is great at getting low p values but not much else. The human body is an immensely complicated, intertwined, and adaptive biological entity that is quite frankly underappreciated by medicine as a whole, and our understanding of all diseases suffers for it.

Reductionism gives us a picture of human biology that is abjectly impoverished. It's the difference between looking at the score for Beethoven's 5th versus actually hearing it played by the New York Philharmonic. The result being that we fail to understand the complex interactions of the various aspects of our biology.

The 'cholesterol hypothesis' of heart disease, diabetes, obesity, proximal degenerative joint disease, and spinal disease are just a few of the areas in which the pathetic inability of reductionism to offer a meaningful perspective of pathogenesis or avenues of treatment.

Heck, just listening to an MD opine about the 'genetics of obesity' or the ineffectiveness of diet and exercise has been known to result in my projectile vomit forming an ugly grey-green-yellow crysanthemum on the opposite wall. Don't get me started on MSK or psych.

I've always envied the physicists in their commitment to the GUT. The desire to understand how the various physical phenomena and laws fit together to form an overarching theory of how things work.

In medicine, reductionism and our lack of commitment to epistemology and proper honest to god theory formulation has left us incapable of forming cohesive descriptions of the body in health and disease.

One of the problems is that monism (meaning the mind and body are one entity) is supported by the reductionist approach. Within monism disorders of the cognitive realm as perceived PRIMARY lesions in the brain...
The end result is that without a dualist model of mind mental life takes the backburner and we hunt and peck for biochemical lesions. Note that I am not saying that biochemical lesions are not important or do not exist, they are just not the answer to all of psychiatry's questions. It's just that we almost always look at these changes from the lesion-->mental state standpoint as opposed to the chronic mental state-->biochemical changes-->continued aberrant output.
See I would argue is that the problem is that we do have a dualist mindset of the brain and mind, instead of a monist one. We treat thought as an epiphenomenon and essentially a nonbiological experience. Which is why our research has failed to even begin to attempt to address the issue of how, say....your mother dying and now you not having the purpose of 'primary caregiver' leads to a deep depression that expresses itself in biochemical and functional differences in brain structures. We've identified WHERE the pathology is, but we don't do such a great job of describing the WHY of the pathology. 'It's genetic' is self-evidently horseturds. Which may explain why no one is even attempting to explain the 'why'.

The status quo insists that only looking at the biochemicals is somehow more 'biological' than peering into psychodynamics and cognitive-behavioral issues. Which is hilarious because it ignores what is probably the most important 'biological' factor in the brain: namely biological adaptation and change, through all of its many, many, many mechanisms.

Another philosophical issue that dovetails into is the Western preoccupation with ahistoricity, which according to some schools of thought is essential to a well developed epistemology. Which I find hilarious because not only thought, life (at every level), and the very creation of our bodies, brains, and the world we live in today is fundamentally 'historical' in nature. I.e. What we are today is reflected in what we were in the past and the various vectors and forces that impact them, as well as the innate 'adaptive programming' that drives how these different factors will affect different individuals.

One could say in fact that the failure of much (not all) biological psychiatry research lies in the fact that it fails to take into account the most basic imperative of biology: to live is to change.

My counter to this is that the life of the mind, the thoughts we think, and our behaviors are fundamentally biological, and that all of those things impact the wetware of the brain, changing structure and function at the genetic, biochemical, functional, and structural levels, which in turn impacts all of the aforementioned things. As I have said a few trillion times, my interest in psychotherapy is so strong because of my undergrad and grad education in neurobiology. Anyone with the simplest understanding of the adaptive nature of the nervous system cannot possibly hope to explain psychiatric disease without invoking the effects of behavior, experience, and action and how they change neurons.

The failure of 'biological psychiatry' is that it attempts to take a snapshot of the brain at a single point in time, look for abnormalities, and then declare that those abnormalities are the 'cause' of symptoms that manifest as behavior, emotion, and thought patterns.

It's quite pathetic in all honesty and I would have been thrown out of grad school for using similar logic.

In closing, suppressing an output state (with meds) without fixing the cognitive processes that give rise to that mental state is an incomplete treatment paradigm for those whose biochemical aberrations are secondary.
In the other fields of medicine it does not matter if the mind is monist or dualist and that is why this criticism is very specific to psychiatry alone
Once again I must invoke the image of horseturds. 'Dualism' and a lack of historicity and contextuality hurts all aspects of medicine. And it is not only 'biological psychiatry' but most aspects of medicine that are rendered peurile by their inability to reflect in how behavior and action drive disease.

We've always thought of osteoarthritis as coming as a result of 'wear and tear' on joints. Which does explain the rates of osteoarthritis in hands of people who do a lot of work with them, and hips and knees of the obese. But doesn't explain the fact that athletes (including weightlifters) have LOWER rates of OA than the general population. And that in the latter, traumatic injury in the affected joint, or habitually poor movement patterns are responsible for most cases of OA.

So maybe it's not wear and tear, but joint loading, vascularization, nutrition, trophic activities, and the relative contribution of active and passive structures during movement...

Or type 2 diabetes research. No one has stopped to consider WHY brown people (of all shades and geographical origins) seem to have such 'higher risks' of it. Why do we fare so much more poorly than white people, even if we eat the same and weigh the same? Oh hey look at that! It wasn't around 100 years ago!!! that's so weird!!!!!! And why would such a 'bad' gene exist???? You mean that 'brown' people can put on mass easier at equivalent protein loads and with less trophic activity? Could it be that they have a more anabolically-shifted metabolic equilibrium? That they traditionally had less protein and less grain in their diets and so maybe have a hormonal profile that results in a more efficient use of available complex carbs and protein????

And I am going to shut up before I start talking about the patheticity of doctor-led exercise research or the cholesterol hypothesis of heart disease.

Suffice to say that before the NIH or NSF existed, experimental results were seen as a means toward developing more robust theory, rather than ends in and of themselves. And that very few scientific disciplines remain that train in the classical model of theory and philosophy based learning in which one is taught to take data and experimental findings and either incorporate them into existing theory or explain how they refute existing theory and thus how existing theory must change to reflect new findings.

Perhaps nothing better illustrates the sad state of biomedical science than the fact that one cannot build a career on their ability to synthesize available data into new theories, or that no A-journal is willing to publish commentary and theoretical (in the scientific sense) work as primary publications.

How the hell can science advance without the proper framework of dissent and debate?
 
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ClinPsycMasters

The 'cholesterol hypothesis' of heart disease, diabetes, obesity, proximal degenerative joint disease, and spinal disease are just a few of the areas in which the pathetic inability of reductionism to offer a meaningful perspective of pathogenesis or avenues of treatment.
Interesting stuff. Do you mind elaborating a bit?

Heck, just listening to an MD opine about the 'genetics of obesity' or the ineffectiveness of diet and exercise has been known to result in my projectile vomit....
Brilliant! Perhaps similar to: "no, no, it has nothing to do with your sister's suicide and your dad going bankrupt...your depression is a 'chemical imbalance.'"

say, your mother dying and now you not having the purpose of 'primary caregiver' leads to a deep depression that expresses itself in biochemical and functional differences in brain structures. We've identified WHERE the pathology is, but we don't do such a great job of describing the WHY of the pathology. 'It's genetic' is self-evidently horseturds. Which may explain why no one is even attempting to explain the 'why'.
Well, some types of depression can have a genetic component. Not all mental illnesses can be fully explained by adverse life events and "faulty" cognitions.

Also, as far as the WHY question, the answer is somewhat arbitrary. Let's pick up your example, imagining that one is dealing with a loss of a parent, but also of one's identity (as caregiver). Can we return this person's mother back to life? No. What can we do? We permit the person to grieve the loss, to feel some very intense and uncomfortable emotions. What then? We do talk therapy. Now that he has grieved, now that he has spent months/years submerged in depths of sea of emotions, I would, say, use some CBT to help the person re-examine his life in a rational manner, look at his current options, and get back to some of the activities that he once found rewarding. Or I might use interpersonal psychotherapy to help the person deal with loss and role changes. I may use psychodynamic psychotherapy if some intense patterns emerge that keep derailing the person. So we might re-examine a history of his past relationships, consider object relations, etc.

Do I believe that grief, that anxiety and depression have changed his brain over the years? Sure! In a limited number of mental illnesses, specially the ones that are usually subject of neuropsychiatric research, abnormal biological structures and/or processes are in fact conspicuous. In cases like above, it's hard to tell but it's there I am sure. Regardless, SSRI's might be helpful and I will ask a psychiatrist to examine the person.

I think there is pain and then there is unnecessary pain! Some suffering is inevitable and perhaps useful because depression is in fact adaptive in some cases. However, if someone is suffering greatly and/or for too long, or is too depressed to bother coming to a session, why not ask for meds?

You see, you can find causes of mental illness in biology and genetics, psychodynamics, sociology, economy, even spirituality, if you are so inclined. My view is mostly functional. In other words, I consider balancing short-term gains/losses with long-term ones, not to mention what I can change and what the patient can. I look at what social programs are available. Heck, I think it would be nice if psychiatrist and psychologists got involved in the politics and tried to do all they can so that more and better quality social programs become available to people. It is no big secret that the needy are significantly more likely to suffer from mental illness. From a humanistic point of view, I feel repulsed by so much inequality and gross injustice. However, at present, I need to be problem solving, remain idealistic but grounded enough to be helpful. I am against meds as first line treatment except in cases of an extremely dangerous and psychotic person. However, even psychosis can improve through therapy, having your basic needs met, and living a meaningful and fulfilling life. Antipsychotics are a crutch and nothing more. They do not "cure." They can be helpful at times, specially if the person is suffering greatly and there are no other treatments available or that it's essentially impossible to engage the patient in therapy at the time.

Another philosophical issue that dovetails into is the Western preoccupation with ahistoricity....
Explain please!

Or type 2 diabetes research. No one has stopped to consider WHY brown people (of all shades and geographical origins) seem to have such 'higher risks' of it. Why do we fare so much more poorly than white people, even if we eat the same and weigh the same? Oh hey look at that! It wasn't around 100 years ago!!! that's so weird!!!!!! And why would such a 'bad' gene exist???? You mean that 'brown' people can put on mass easier at equivalent protein loads and with less trophic activity? Could it be that they have a more anabolically-shifted metabolic equilibrium? That they traditionally had less protein and less grain in their diets and so maybe have a hormonal profile that results in a more efficient use of available complex carbs and protein????
Evolutionary explanation, right?

Suffice to say that before the NIH or NSF existed, experimental results were seen as a means toward developing more robust theory, rather than ends in and of themselves.
This is particularly interesting. Would you mind explaining more?
 
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Also, as far as the WHY question, the answer is somewhat arbitrary. Let's pick up your example, imagining that one is dealing with a loss of a parent, but also of one's identity (as caregiver). Can we return this person's mother back to life? No. What can we do? We permit the person to grieve the loss, to feel some very intense and uncomfortable emotions. What then? We do talk therapy. Now that he has grieved, now that he has spent months/years submerged in depths of sea of emotions, I would, say, use some CBT to help the person re-examine his life in a rational manner, look at his current options, and get back to some of the activities that he once found rewarding. Or I might use interpersonal psychotherapy to help the person deal with loss and role changes. I may use psychodynamic psychotherapy if some intense patterns emerge that keep derailing the person. So we might re-examine a history of his past relationships, consider object relations, etc.

. Antipsychotics are a crutch and nothing more. They do not "cure." They can be helpful at times, specially if the person is suffering greatly and there are no other treatments available or that it's essentially impossible to engage the patient in therapy at the time.
I think most doctors would agree that medicines should not be first line treatment except in cases of moderate to severe MDD, bipolar d/o, sz, delirium, panic disorder etc...... While therapy, particularly CBT, is effective for affective disorders I find that only the most highly functioning patients will benefit, think mild anxiety or dysthymia, and anyone with more severe symptoms will need additional help. And while we know that most medicines do not 'cure', perhaps with the exception of antibiotics and maybe the statins for infections and hyperlipidemia, respectively, many patients do need medicines or other treatment modalities(TMS or ECT) in order to engage in therapy. And we know antibiotics and statins have possible severe adverse side effects.

I do believe that therapy is effective, as I use it daily with many of my patients, but at the end of the day it has limitations. The empirical research studies have shown that even CBT has a high placebo response similarly to the SSRIs. Many extol the virtues of therapy but in reality, it isn't all that effective for patients with more than mild symptoms and lower cognitive functions. And we know therapy is not curative. My evidence is the 2-3 months waiting list at my office with patients referred by their PMDs, neurologists and non-MD therapists. This is similar in many offices nationwide.

It is easy to criticize psychiatry by many and this is fine as I think it is healthy. But because many mental health clinicians are not physicians, including med or pre health students, I think some of the comments can appear misguided and anecdoctal.
 
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masterofmonkeys

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I think most doctors would agree that medicines should not be first line treatment except in cases of moderate to severe MDD, bipolar d/o, sz, delirium, panic disorder etc...... While therapy, particularly CBT, is effective for affective disorders I find that only the most highly functioning patients will benefit, think mild anxiety or dysthymia, and anyone with more severe symptoms will need additional help. And while we know that most medicines do not 'cure', perhaps with the exception of antibiotics and maybe the statins for infections and hyperlipidemia, respectively, many patients do need medicines or other treatment modalities(TMS or ECT) in order to engage in therapy.

I do believe that therapy is effective, as I use it daily with many of my patients, but at the end of the day it has limitations. The empirical research studies have shown that even CBT has a high placebo response similarly to the SSRIs. Many extol the virtues of therapy but in reality, it isn't all that effective for patients with more than mild symptoms and higher cognitive functions. And we know therapy is not curative. My evidcence is the 2-3 months waiting list at my office with patients referred by their PMDs, neurologists and non-MD therapists. This is similar in many offices nationwide.
"Ask me for anything but time..."

Sometimes I think one of the problems we have in the tx of psychiatry is that we are expecting short outcome times...which if we accept the brain as the result of both long and short-term adaptive processes, makes absolutely no sense. The other thing we fail to do is address ALL of the issues involved. For any affective or anxiety disorder patient, it doesn't make sense NOT to address the psychodynamic, cognitive-behavioral issues, nutrition, and HPA axis. This is not a malfunctioning thyroid or a heart with a low EF, but something far more complex, and needs to be addressed as such.

I work in the domains of nutrition and exercise with a lot of people in order to combat their obesity, rehabilitate their nmsk issues, and, in some cases, make them look good. I am not going to take a 350lb person and get them down to 200 in 12 or 16 weeks. I'm not going to take someone with spinal and peripheral nerve damage and restore them to perfection inside a month. And I sure as hell am not going to take a 170lb scrawny white dude and put him on the Mr. Olympia stage in the final posedown in less than 6 months.

I'll take it one step further. My clients are not going to succeed with a single modality. If you train hard but ignore nutrition, you will fail. If you do the nutrition but don't train hard, you will fail. If you train hard, but not smart, you will fail. If you don't stretch, you will fail. If you don't sleep, you will fail. If you don't develop mindfulness and self-efficacy, you will fail.

You need to hit all the angles, and you need to give it time for your body to adapt, from the muscles themselves, to your vasculature, to your connective tissue, to your HPA axis, to your insulin sensitivity. These changes don't happen overnight.

In fact, one of the things you hear time and time again in the fitness biz is 'training age'. There is a big difference between a person who's been in the gym for 5 years and one who's just stepping in. Plenty of scientific evidence on that as well.

Pretty much all of that applies to your brain. CBT without psychodynamics (IMO) is a bad idea. Not paying attention to patient nutrition in terms of basic neural building blocks is a bad idea (5g n3fa for everyone. One of my standard prescriptions no matter why a patien presents). Not addressing the genetic load (if significant and/or present) with medications, is a bad idea. All of our studies address one or at best two moderators of mental health. Which is reductionistically pure, but also ******ed for a non reducible system.

I'm reminded of a bit from a Terry Pratchett novel in which beings from another plane of existence attempt to understand a masterpiece by reducing it to its component parts and then wonder what the power of this artwork is when it's made of boring old chemicals found in all sorts of mundane appliances and tools...
 
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"Ask me for anything but time..."

Sometimes I think one of the problems we have in the tx of psychiatry is that we are expecting short outcome times...QUOTE]

I think it is wonderful you are taking the nutrition approach in treating patients as obesity has been linked to overactive anti inflammatory response in addition to other endocrine abnormalities.

Generally for medication evaluations I ask that the patients must have had at least 6-9 months of therapy prior. More often than not patients come without a diagnosis and were referred because they continue to suffer or their symptoms have worsened. For TMS and ECT referals, the evaluation process is much more complex. Not that medications evaluation is ever easy.

Personally, psychiatry training certainly can always be improved but I think the the american psychological association and other licensing bodies need to limit who can be called therapists. Presently seems like anyone can be a therapist. And we know therapy has adverse side effect too.
 

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As someone with overlapping areas of interest, I'm interested (but not interested enough to buy an academic book right before starting medical school :p), less from what I've read here but more from the wiki article on Dr. McLaren, as to why he categorically rejected functionalism for a Chalmers-style property dualism. I like Chalmers alot, but I've never found he nor Dennett completely convincing for dualism or functionalism. I've leaned toward functionalism just because it seems simpler, but that's far from proof. I sort of wonder how seriously his critique is based on his philosophy of mind. If it is mainly, I would find it hard to believe, just because after studying philosophy of mind for years I find myself less than fully convinced, which is not a firm bedrock for criticism.

I also tend to agree that psychiatry MIGHT be special. I think it's less likely, but if his dualist view is right, than there are ways it might be different from other aspects of medicine (except, of course, where they overlap with psych). I don't think it is though. And moreover, while I am sure there is a great deal that is incorrect or incomplete in psych, I tend to see similar fundamental flaws in all areas of medicine, and similarly there are problems with the philosophy of science for much of medicine.

But in regards to philosophy of science, while theories are likely somewhat wrong, it seems that much of psychiatry is practically apt, within what is ethically available options. Theories and theories of treatments are tested and rejected. Through my work in research I've seen a really interesting theory be weakened but not at all removed, because of the complexity involved and other avenues remaining to test it. The theory makes sense in reductionist terms, although I could rewrite it in dualist terms and I think it would make sense then too, but the treatment trial did not have the hoped effects, so another medication is being tried with similar theoretical capabilities but different properties.

I'd be really interested in reading more though, even though I suspect I'll find his arguments based on faulty premises. I bet he does a better job arguing for it than wikipedia does summarizing it. He sounds like he'd be a really interesting person to talk to though.
 
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ClinPsycMasters

I think most doctors would agree that medicines should not be first line treatment except in cases of moderate to severe MDD, bipolar d/o, sz, delirium, panic disorder etc......
I mostly agree though I think as long as reality testing is mostly intact and patient is not planning to harm self or others, I would give therapy a chance. It is a good idea for the psychologist to work with psychiatrist so that medication and other biological treatments can be prescribed as necessary. I have always found psychosurgery to be dehumanizing, and I think ECT is not much different though I would certainly consider it as the very last option for a chronically suicidal patient who does not respond to any treatments--and that means actually trying more than a few types of talk therapy and meds.

While therapy, particularly CBT, is effective for affective disorders I find that only the most highly functioning patients will benefit, think mild anxiety or dysthymia, and anyone with more severe symptoms will need additional help.
Yes, I agree. I think more recent therapies, such as dialectical behavior therapy or acceptance and commitment therapy, may work better with lower functioning folks. Similarly, behavior therapy can be helpful specially if the patient does not have the intellectual capacity to engage in cognitive therapy. Psychodynamic psychotherapy is more appropriate for neurotic (as opposed to borderline or psychotic) patients so perhaps, along with strictly humanistic psychotherapy, it is well suited to high-functioning patients.

And while we know that most medicines do not 'cure', perhaps with the exception of antibiotics and maybe the statins for infections and hyperlipidemia, respectively, many patients do need medicines or other treatment modalities(TMS or ECT) in order to engage in therapy. And we know antibiotics and statins have possible severe adverse side effects.
Perhaps I shouldn't have used the word "cure" seeing how it implies that talk therapy does cure, which is open to debate. The reason I did use the word "cure" was in reaction to the prevalent "chemical imbalance" theory of mental illness and mental health.

I am humbled by the complexity of mental illness. Shockingly, all sorts of therapies seem to work, and that includes both med and talk therapy and even ECT. Why "shockingly"? Because often enough we have no coherent explanation as to why they work. Many of the medications were also accidentally discovered. Mechanism of effectiveness of talk therapies is also open to debate and far from clear. Is it all common factors and placebo? Is one better than the other in the long-term? These are empirical questions to some extent though there is no denying that the definition of mental illness/health has a philosophical component that is impossible to ignore.

Regardless, I think it's a good idea to consider the various ways diseases of the mind can be conceptualized and treated, so that we can be open to "chemical imbalance" theory and other biological views, but also behavioral, cognitive, psychodynamic, humanistic, existential, philosophical, cultural, sociological, economic, spiritual/religious...and postmodern understandings.

The very fact that all kinds of therapies seem to provide at least short-term benefit (though some can be more harmful than the rest) is not to say all are equal. However, such findings should make us hesitate a bit before pronouncing to the world that we know what causes what.

GW Bush had difficulty regaining credibility after his "mission accomplished" speech. Same goes with some political and religious leaders whose inspiring speeches and promises were unfounded. Presently, scientific approaches have considerable authority and credibility in our society. Psychiatry and psychology, claiming to be scientific, enjoy tremendous respect in the society too (though they have their detractors). Heck, making confessions and asking for guidance regarding all kinds of life problems used to involve a cleric not a MD or PhD. So things have definitely changed and territorial conflicts are to be expected. But making grand statements by transforming a shaky theory into fact, like the "chemical imbalance" theory, hurts psychiatry's credibility in the long-term--even if it provides a "rationale" for prescribing meds to patients who may refuse them otherwise.

It certainly is a difficult situation because in the current market-driven economy, people in all kinds of professions feel the need to "sell" their ideas, and that may translate into overstating what we know and what we can do for the patient. A psychologist I once met told me "everybody needs therapy." I obviously know why he said it but I don't approve regardless.

Look, there is a reason people don't trust car salesmen. And there is a reason psychiatry has its critics. As long as psychiatry, which is by the way significantly more powerful than psychology, stands behind dubious theories, we should expect to hear "pill pusher" and similar disparaging labels, over and over again. Big Pharma is here to stay so it's one's attitude towards treatments and the patient that ultimately matters the most. Trust is not easily gained once it's broken.

The best thing psychiatrists (and psychologists) can do is remain humble and tell it like it is. Accept the limitations of our professions. Stop telling the depressed patient, in the most confident manner, it's a "chemical imbalance." Long ago Freud said it was "penis envy." I'll simply say I don't know but we have some decent theories, and it could be your thinking or your behavior, or things that happened to you when you were younger, or the fact that you just went bankrupt...Or it could be some chemical imbalance involving your hormones or neurotransmitters or other processes/structures in your brain and your body. Or something like that. I'll say that a psychiatrist can examine you and decide if any medical treatments may be appropriate. I'll explain that there are different talk therapies, the advantages and disadvantages, and also talk about some realistic expectations.

I do believe that therapy is effective, as I use it daily with many of my patients, but at the end of the day it has limitations. The empirical research studies have shown that even CBT has a high placebo response similarly to the SSRIs.
Absolutely! I don't know the exact figures but CBT and other therapies seem to have significant placebo effect. Of course in the future we may find that the "placebo" (or "common factors") are more effective than the treatments that are currently available. This can be devastating for many who have vested interest in a particular sort of therapy, and it may lead to a paradigm shift in the field. So the focus may shift to compassion in therapist as opposed to reformulating CBT.

Many extol the virtues of therapy but in reality, it isn't all that effective for patients with more than mild symptoms and lower cognitive functions. And we know therapy is not curative. My evidence is the 2-3 months waiting list at my office with patients referred by their PMDs, neurologists and non-MD therapists. This is similar in many offices nationwide.
That's debatable.

It is easy to criticize psychiatry by many and this is fine as I think it is healthy. But because many mental health clinicians are not physicians, including med or pre health students, I think some of the comments can appear misguided and anecdoctal.
Well, I agree. Comments by people who are not familiar with the mental health field, and particularly psychiatry, is sometimes naive and other times just wrong. I remember someone criticizing Scientology and I asked him why and he said, "Tom Cruise, 'nough said." I do not defend Scientology, and in fact dislike some of the political tactics they have used, but if I'm to say it's not a "real" religion or it's ludicrous, I better have significant knowledge about what a "real religion" is and is not. I have read some intelligent and devastating critiques of Scientology, not as a religion but as an anti-psychiatry movement. So it's rather easy for me to spot knee-jerk and naive criticisms.

I should add that I have my masters in clinical psych and do assessments from time to time (and limited therapy) so my knowledge of psychiatry is limited. I do work with several psychiatrists too. So my opinions should be viewed in the context of my limited clinical experience and education in biology of mental illness.
 
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Ibid

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Neuroscientists will disagree, because they believe they can map the mind but the argument about the ontological separation of mind and body remains intractable and less relevant, while the mind is still considered a thing in itself.

The crux of the matter is not the squabble over dualism or not and its attendant implications. It is rather about meaning.

The mind is not something locked away in our skulls. Beliefs and values are not located inside ourselves, see Wittgenstein for an exploration of this idea. The work of Heidegger is instructive, although hard to grasp but the notion of reality itself not being a thing is central.

What this has to do with psychiatry from a practical perspective as Doc Sampson alluded to is that it implies that the responsibility for living with "psychotic experiences" shifts more squarely towards the people who experience them. A challenge that sadly is not taken up nearly enough.
 
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Okay, thank you for clarifying this.
I don't have any specific criticism of his arguments though I personally think that consciousness plays a bigger role than he and Dennett have suggested. In addition, Dr. McLaren is not the only one who has been critical of the psychoanalytic, behavioral, and biological models of human behavior, favoring a cognitive model instead. I haven't read his books and I'll try to get my hands on them when I go to the university this coming week as I am curious how evidence-based his views are. Is his emphasis on anxiety, for instance, merely speculative, based on personal philosophy (akin to some psychoanalytic views) and experience, or built on published research and quality studies?
He doesn't imply that consciousness has little role, just that it is ineffectual in most decisions we make day to day. He has postulated that one function of consciousness is that it's the gateway to memory. This makes sense too, the more sensory modalities involved the greater the chance of recall.
I'm really glad you brought up the anxiety bit. I had an attending say a couple months ago, "we need to move from evidence based medicine to wisdom based medicine." That's not to say that EBM has no utility, but a lot of the meta analyses are based on studies before the mid 2000s. Since preregistration for publication was not required before this point >20% of pharmaceutically funded studies were thrown in the garbage for not being significant. This then skews the data in favor of efficacy. I actually asked an attending who was previously in the pharmaceutical industry about the 20% figure. She said that sounded like a very low estimate based on what she's seen.
Anyway, he doesn't reference studies about anxiety in his book (at least in regard to preceding other psychopathology), but his observation is based on wisdom and years of practicing. He might not have referenced a study in his books but I found one a couple months ago that fits the bill perfectly. I actually posted it in an earlier post.

"ATTACHED is a paper called "Comorbidity missed....". In this study they had two groups of 500 patients. One group got a regular interview, the other got a SCID (structured interview, takes 1/2 a day, catches nearly everything and is considered the gold standard). Of the 500 regular interviews only ~200 anxiety disorders were caught. However, in the SCID ~550 were caught. What is important to note is that the number of mood disorders were about the same between the two diagnostic arms (~350 each). Plus when you look at the data social and specific phobias have the highest rates of underdiagnosis (~200 had these two alone in the SCID group vs 20 in regular interview, that means ~180 pts, or about 1/3 of the 500 sample would have had their phobias missed in a regular psychiatric interview) and these most certainly have a significant mental component to their pathogenesis."

So, in this outpatient sample about 200 of 500 had social phobia or specific phobia great enough to be diagnosed (but in a regular interview only ~20 would be diagnosed). I've also looked up the epidemiological data and social phobia precedes depression ~75% of the time and substance abuse ~85%. I'll try to find that paper and reference it later.
 
C

ClinPsycMasters

it implies that the responsibility for living with "psychotic experiences" shifts more squarely towards the people who experience them. A challenge that sadly is not taken up nearly enough.
How do you mean?
 
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Good to hear from you.

Dr., I do agree with several of your assertions that our field does have limitations, and that we should criticize, but do so with the intent to improve.
....
....
How is that not using a biopsychosocial model? Bipolar disorder has pharmacological treatments that have been put reviewed and FDA approved, I regularly discuss the patient's social situations and we're both on the lookout to see how it affects his life, and we've also covered his own knowledge of his condition. There's data showing that multimodal interventions such as medications with psychotherapy are more effective than either alone.

Am I missing something? I've read some of your publications, but maybe I just missed your point.
Hi, the most fundamental duty of a scientist is to criticise openly and honestly the prevailing models in his field. The simple fact remains that Engel never actually wrote his model. He called for an integrative model to counter what he saw as hegemonistic biomedicine but never completed his work. Also, it was not actually a model for psychiatry.

My feeling is that he couldn't because he was coming at it from his psychoanalytic background and that was itself non-scientific. So even if we look at a patient from the point of view of his biology, his psychology and his sociology, we are not using a genuine model to do so. I have expanded this point in my books but the mainstream in psychiatry chooses to ignore it. I don't know why they do, it would be an interesting sociological research thesis for somebody but it is exactly what Thomas Kuhn predicted. The orthodox establishment hangs on to a theory long after everybody else can see it is dead.

So yes, you are missing the point that a model is a deeper concept but what really counts is why your teachers bothered to make out the biopsychosocial model is a reality. Why don't you ask some of them? But be careful, it won't win you any friends. There will be another chapter on this bizarre episode in psychiatry's history in my next book, due out in October. I can't release it yet but it has already claimed one high-profile head. Good.
 
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The skeptic in me asks whether it was a coincidence that Cstruble argued so enthusiastically in favor of Dr. McLaren's views in a number of posts, then told Dr. McLaren that such debate is taking place here, and now Dr. McLaren--supposedly it really is him--has come on the forum and is coming to States in a month or two, willing to give talks here and there and so forth. There has to be a better way ;)

Of course I do have a tendency to see patterns where non exist and even if this was merely an advertising gimmick, it would not detract from the doctor's arguments, needless to say.
I'm afraid you are seeing a pattern where only chance exists. Why should I not follow a debate on my work? I find it very interesting but would be happier if people could actually read the material first. If it would help, I can ask the publisher to put it on Kindle. And yes, I am heading for a conference in Syracuse NY on October 8-9 where I will present a paper and lead a seminar, nothing unusual about that, then travel around talking to medical schools.
 

Ibid

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ClinPsychMasters

Thank you for your question. It rather cuts to the chase and lets me off the hook of further elucidating Heidiggers notion of the mind not being a thing in itself. The practical facts are to my mind several fold. (Franco Basaglia I think is the best proof that a new conceptualisation can lead to practical reform. Greater in my mind than Szasz, Laing and Foucault put together, just a shame most of his work has not been translated.)

One its allows for an authentic examination of the human condition that a paradigm grounded in a descriptive pathology will never allow.

Secondly it creates space where none or very little exists for the correct response to "psychosis" to be formulated by those who experience it to be developed by those same people with people who would seek to help them do so.

This is in stark contrast to the current situation where the hapless detained patient is brow beaten into taking covert action to hide the fact that they don't in fact take the medication they have been prescribed once they are discharged. No amount of "rationale" is ever going to convince a person who does not believe they have an underlying pathology to do so. This situation will be well recognised by seasoned practitioners who know that they are undertaking their own covert risk management plan and dressing it up as treatment. Hospitals are full of "well" people who just don't except the medical paradigm. Two quotations in evidence by two men who would have been influenced by Basaglia. Prof. Pierluigi Scapicchio, president of the Italian Psychiatric Association: "I think that coercion is very often a false problem.the need for coercion actually means that we have not chosen the right approach, or the words of Prof. Salvatore Merra, chairman of the largest mental health department in Rome, "The need for coercion is often the result of mental rigidity of the therapeutic staff that has not be able to offer to the patient a real alternative to the refused treatment"

See the article below as evidence of the dearth of skill when it comes to speaking simply to people about their experiences.

Engagement of patients with psychosis in the consultation: conversation analytic study
http://www.bmj.com/cgi/content/abstract/325/7373/1148?ijkey=e484d531e2004b9c3df583c2c6eadfd0cce18d29&keytype2=tf_ipsecsha

The other side of the coin is of course that people who have these experiences need to take the responsibility that comes with refusing to accept the dominant bio bio bio paradigm. Altered states of mind are "a dangerous gift". It is this responsibility for the dangerous element that especially young men either shirk or perhaps more correctly are not given the space to explore as they rail against those who refuse to communicate with them on their own terms. This to me is the crux of the matter and I think what you were asking about. It is the meat and drink of psychiatry in any case not the twiddling of medication as exists in the popular conception and even many practitioners.

Lastly the opportunity presented the philosophically minded to explore new ways of thinking about the mind is perhaps the most hopeful and even fun! Why should discussions always descend into the curative and preventative dichotomy. Might the coming into being of a healthy mind not be recreational or even aspirational, that would not even tax the neoliberal economic consensus that the medical paradigm fits into so well.
 
C

ClinPsycMasters

Thanks Ibid. I will respond to your post asap.

In the meantime, reading some of these critiques of psychiatry I was again considering how society influences who is seen as mentally ill. Imagine Hollywood (and most entertainment industries) disappearing from face of the Earth, getting replaced by a bunch of nuclear plants. Where are all those folks with cluster B traits going to go? Having a god-complex is not "functional" for a nuclear plant technician. Well, there is always politics to fall back on....:laugh:

In fact, most personality traits--and I have mentioned this elsewhere--can be functional in a particular setting/time and dysfunctional in another. Even a seemingly benign trait, like shyness, is perceived as more and more of an impediment these days in our individualistic culture--and a small step away from social phobia and Paxil. Gone are the days when shyness was seen as a feminine virtue. Women these days need to assert themselves in much more direct manner than it was the custom.

"Functional" definition of mental illness/health skirts some philosophical quicksands, but makes the dubious assumption that society and culture can be used as reference points. This sort of relativism and an ever-shifting frame of reference requires more extensive knowledge of sociology, anthropology, and social psychology. Yet, biological psychiatry continues to dominate the field, searching for causes and treatment of mental illness in the material of the brain. This forced marriage of disparate fields (e.g. biology and sociology) under the authority of medicine, does not give us any "better" definition of mental health than the strictly moral or philosophical ones.

Medical treatment seems to have two goals, to ameliorate patient's subjective distress and to improve function. Though seemingly compassionate toward patient and his suffering, psychiatry can be viewed from quite a different point of view too. From this perspective, psychiatry is a tool of social control in the hands of the elite. The powerful and wealthy worry that nationwide subjective distress and dysfunction (e.g. unemployment or work) can be channeled into a force, pushing for social change. Mass-medication, both in form of drugs but also talk therapy, can take the oomph out of the force.
 
C

ClinPsycMasters

ClinPsychMasters

Thank you for your question. It rather cuts to the chase and lets me off the hook of further elucidating Heidiggers notion of the mind not being a thing in itself.
Not quite. :D

Heidegger's work is very dense and I am not going to ask you to explain it to me. You mentioned that mind is a thing-in-itself while reality isn't. So reality is all appearances I suppose. Dare I ask a source for this so I can do more reading on my own? It's very difficult to try to imagine a being-in-itself because most beings are beings simply because of how we perceive them. To take ourselves out of the equation is necessary--for understanding this concept--yet feels impossible to do. This is like trying to fathom "what is it Like to Be a Bat?" (Nagel).

The practical facts are to my mind several fold. (Franco Basaglia I think is the best proof that a new conceptualisation can lead to practical reform. Greater in my mind than Szasz, Laing and Foucault put together, just a shame most of his work has not been translated.)
I am not familiar with him. Unfortunately, most of his works are in Italian. He seems to have been a major figure in deinstitutionalization movement in Italy.

One its allows for an authentic examination of the human condition that a paradigm grounded in a descriptive pathology will never allow.

Secondly it creates space where none or very little exists for the correct response to “psychosis” to be formulated by those who experience it to be developed by those same people with people who would seek to help them do so.

This is in stark contrast to the current situation where the hapless detained patient is brow beaten into taking covert action to hide the fact that they don’t in fact take the medication they have been prescribed once they are discharged. No amount of “rationale” is ever going to convince a person who does not believe they have an underlying pathology to do so. This situation will be well recognised by seasoned practitioners who know that they are undertaking their own covert risk management plan and dressing it up as treatment. Hospitals are full of “well” people who just don’t except the medical paradigm. Two quotations in evidence by two men who would have been influenced by Basaglia. Prof. Pierluigi Scapicchio, president of the Italian Psychiatric Association: “I think that coercion is very often a false problem.the need for coercion actually means that we have not chosen the right approach, or the words of Prof. Salvatore Merra, chairman of the largest mental health department in Rome, “The need for coercion is often the result of mental rigidity of the therapeutic staff that has not be able to offer to the patient a real alternative to the refused treatment”

See the article below as evidence of the dearth of skill when it comes to speaking simply to people about their experiences.

Engagement of patients with psychosis in the consultation: conversation analytic study
http://www.bmj.com/cgi/content/abstract/325/7373/1148?ijkey=e484d531e2004b9c3df583c2c6eadfd0cce18d29&keytype2=tf_ipsecsha
What a wonderful study! Maybe if we spent more money and resources doing these types of naturalistic studies (instead of millions spent on clinical trials) we'd be getting somewhere. I am not surprised that physicians in this study were not interested in helping patients make sense of their psychotic experiences. These kinds of psychotic fragmentation of patients' life narratives are labeled and ignored for the most parts. The patient is helpless in making sense of these painful gashes in her sense of self and often enough, the psychiatrist are instructed to skirt the issue and focus on functional issues and medication management.

The other side of the coin is of course that people who have these experiences need to take the responsibility that comes with refusing to accept the dominant bio bio bio paradigm. Altered states of mind are “a dangerous gift”. It is this responsibility for the dangerous element that especially young men either shirk or perhaps more correctly are not given the space to explore as they rail against those who refuse to communicate with them on their own terms. This to me is the crux of the matter and I think what you were asking about. It is the meat and drink of psychiatry in any case not the twiddling of medication as exists in the popular conception and even many practitioners.
This is interesting to say the least. Can we truly ask the person who is psychotic to take responsibility for their own actions? Even the neurotic can have moments when they are so overwhelmed with emotions that they lose contact with reality. Think of road rage. It happens more often with a borderline patient. And psychotics, well, can spend the majority of their days in a parallel universe, being chased down by swarms of FBI officers, devoured by voracious worm-like creatures from the inside, or fathering all the newborns in the world.

To hold psychotic patients responsible for their own actions is empowering but at the same time unsympathetic. If one believes--and this is someone I met--that people's blood has gone bad, and that he needs to drain out their blood and replace it with his own pure blood, he is not being irresponsible. In fact, he is no less than a superhero, sacrificing his own life to save the humanity! However, the physician's version of reality differs from the patient and he may drug the patient into oblivion for good reason: He is choosing the lesser of two evils, further destroying patient's sense of self instead of allowing the patient to destroy other people's physical bodies.

The patient's reality is destroyed so that the patient can embrace physician's reality. Unfortunately, the patient's sense of who he is may be tied to that other reality, so often enough he spends the rest of his life suspended between the two realities, on and off drugs, trying to piece the story of his life together. The physician is unable to give the patient the space to explore his beliefs because this can be too costly to the patient, physician, and the public.

Frequently the patient's hallucination and delusion have a basis in reality or in his subconscious (psychodynamics can be helpful to get to the root of them, though this field is another fantasy world itself ;)). The beanstalk reaches the clouds but is planted in Jack's garden, on this very Earth. Physicians do not have the resources to verify the details of patient's story. In addition, psychotic patients' thought content (as opposed to neurotics') is not analyzed, but is labeled "explosive" and put in a safe place. Hence, we do not know what part of the patient's story is true, nor are interested in tracing the fantasy to reality. This is not how we should be treating patients.

This, of course, is a generalization, and more a criticism of psychiatric industry as opposed to individual psychiatrists.

Lastly the opportunity presented the philosophically minded to explore new ways of thinking about the mind is perhaps the most hopeful and even fun! Why should discussions always descend into the curative and preventative dichotomy. Might the coming into being of a healthy mind not be recreational or even aspirational, that would not even tax the neoliberal economic consensus that the medical paradigm fits into so well.
 

Ibid

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I agree with your general train of thought.

*Imagine Hollywood (and most entertainment industries) disappearing from face of the Earth, getting replaced by a bunch of nuclear plants. Where are all those folks with cluster B traits going to go?

Yes, one may laugh but I believe you are not far from a very real truth. Is it not a coincidence that along with the program of deinstitutionalisation a commensurate rise in the number of people with personality disorders has appeared? The answer to that riddle might be that they used to be "the staff" they just have a new role! They used to hassle the patients, deprived of that bit of fun they now present to the staff who still have jobs.

Medical treatment seems to have two goals, to ameliorate patient's subjective distress and to improve function. Though seemingly compassionate toward patient and his suffering, psychiatry can be viewed from quite a different point of view too. From this perspective, psychiatry is a tool of social control in the hands of the elite. The powerful and wealthy worry that nationwide subjective distress and dysfunction (e.g. unemployment or work) can be channeled into a force, pushing for social change. Mass-medication, both in form of drugs but also talk therapy, can take the oomph out of the force.

Its not a surprise that all the focus on this forum is about personal services. The bigger question is perhaps not the goal of medical treatment but what are the goals of health services? The traditional Marxist analysis is the one you have posited with the the doctor in the role of capitalist tool returning useful workers to the factories. That analysis maybe correct, actually I think it is but one of its weaknesses is that it is not very rich when it comes to trying to understand what actually happens. Especially during the policy formulation that goes with constructing health services that are delivered to whole populations. To understand what really happens one of several types of structural analysis that considers the role of dominant groups and repressed groups need to be considered. (a whole host of threads needed here)

Essentially in my view health services should be measured by three metrics. Access, equity, and outcomes. Cost as you point out is a critical factor. Essentially the shape of services are defined by the way they are financed.

Taking three OECD systems
US - employment based
UK - pooled risk financed out of taxation
France Germany - Insurance based systems

Access
US - fail only 75% of population covered
UK -pass universal access to 100% via general practitioner
France - pass universal access through g.p. and some self referral to tertiary services

Equity
US - fail some people not able to gain access
UK - pass free at point of delivery based on clinical need
France - pass free at point of delivery
Outcomes
US - Fail UK - pass France pass People in France and the UK have greater life expectancy, and have fewer quality life years lost. I use that data because its hard to manipulate. It is what it is. Its published by the UN on the WHO site.

Cost per head of population, including those not covered, measured in PPP dollars (purchasing power parity dollars) wiki explains this well if not familiar. Before any one posits GDP comparisons they are no good for goods and services not traded across international frontiers.

US $3400
UK $1800
France $1900 (very bureaucratic which explains diff with UK)

I know which system I prefer. Of course Europe will never manage the same sort of general productivity figures the US achieves but I don't expect the French will be losing much sleep over that as they tuck into the foi gras and Beaujolais nouveau during their nine weeks holiday a year and the ros biff sunning themselves in the costa del sol won't be crying their eyes out either, although the Oboma care debate might afford some levity such that it impinges on the news.

I appear to gone off topic but the point is funding determines the shape of service and critically they way health services are rationed. In the UK that means that power resides in the department of health. The civil servants in the Doh recruit philosophy grads very heavily. Why? Because when you are delivering services to a population, questions of distributive justice and utilitarianism are central. Minority topics to doctors who its no surprise view the world through the prism of personal services. That's no criticism, its just the way it is. It's a game of divide and rule and the civil service always wins.

Of course you can leave the rationing to the market place but because there is always more demand than resource it is no wonder that portion of the population that gets left out is also the most vulnerable. All the above it goes with out saying, represents nothing more than my own opinion.

You might be interested in the work of Lord Layard at the London School of Economics. His goal of getting funding for new 10,000 CBT therapists in the UK is coming to fruition at the moment. The link to his lectures make very interesting reading even if one does not agree with it all.

http://cep.lse.ac.uk/events/lectures/layard/RL030303.pdf

http://cep.lse.ac.uk/textonly/research/mentalhealth/DEPRESSION_REPORT_LAYARD.pdf

Heidegger's work is very dense and I am not going to ask you to explain it to me. You mentioned that mind is a thing-in-itself while reality isn't. So reality is all appearances I suppose. Dare I ask a source for this so I can do more reading on my own? It's very difficult to try to imagine a being-in-itself because most beings are beings simply because of how we perceive them. To take ourselves out of the equation is necessary--for understanding this concept--yet feels impossible to do. This is like trying to fathom "what is it Like to Be a*Bat?" (Nagel).*

I don't think I could explain it to be honest. It is that the mind is not a thing and I think you are getting it as I do when you write that reality is appearance. Also as you write and I understand it is not accessible in the third person. The bat analogy is apposite. His work is all about "being". The original work is an option but this article puts it in a helpful context.

http://apt.rcpsych.org/cgi/content/full/10/5/361


http://www.bmj.com/cgi/eletters/325/7378/1433

Above if you can wade through it are some learned gentlemen not all of whom have grasped the nettle fully. The mind body split article is worth reading as it gives some clarification.

Can we truly ask the person who is psychotic to take responsibility for their own actions?

The critical point here is to separate the action and the consequences of it. The consequences the person must always remain responsible for. That is essential or they are robbed of humanity. For example calling some one a rude name or pushing them is something that a person may not be held responsible for but they could always feel bad about later and want to apologise for doing so. Obv this wont apply to psychopaths but that is not synonymous with psychosis although you could be forgiven thinking it was the majority opinion in some quarters.

To hold psychotic patients responsible for their own actions is empowering but at the same time unsympathetic

Again I should have clarified it is the consequences not so much the act itself which is critical. It high lights the essential cruelty of Szazs as he appears not to make this distinction. Most episodes are, in the jargon self limiting, and it is the aftermath of episodes of psychosis that the responsibility needs rebalancing more swiftly. It is in this space that all the trouble lies. Psychiatrists unwilling to hand over the responsibility and some patients wanting to take it but with out the attendant and much needed joint work that needs to be done but never is. I am not blaming people with psychosis, I am positing that because they are never given space they are never in the position to work with any one to formulate a different response other than one which fits with a biologically reductive paradigm.


The patient's reality is destroyed so that the patient can embrace physician's reality. Unfortunately, the patient's sense of who he is may be tied to that other reality, so often enough he spends the rest of his life suspended between the two realities, on and off drugs, trying to piece the story of his life together. The physician is unable to give the patient the space to explore his beliefs because this can be too costly to the patient, physician, and the public.*

Yes. You have said it better than me.

I agree. The real matter at hand is what is the correct response to "psychosis" and while the content is dismissed so to is the answer to this critical question. My point being it is the person with the experience who should be taking the lead here.

Frequently the patient's hallucination and delusion have a basis in reality or in his subconscious (psychodynamics can be helpful to get to the root of them, though this field is another fantasy . The beanstalk reaches the clouds but is planted in Jack's garden, on this very Earth. Physicians do not have the resources to verify the details of patient's story. In addition, psychotic patients' thought content (as opposed to neurotics') is not analyzed, but is labeled "explosive" and put in a safe place. Hence, we do not know what part of the patient's story is true, nor are interested in tracing the fantasy to reality. This is not how we should be treating patients.

Exactly, again the usual response is to ignore the content as unworthy of consideration and what the correct response should be is a question that never gets explored properly because the psychiatrist has his or her own ideas and it's a case of like it or lump it.

http://www.bmj.com/cgi/content/abstr...e2=tf_ipsecsha

What a wonderful study! Maybe if we spent more money and resources doing these types of naturalistic studies (instead of millions spent on clinical trials) we'd be getting somewhere. I am not surprised that physicians in this study were not interested in helping patients make sense of their psychotic experiences. These kinds of psychotic fragmentation of patients' life narratives are labeled and ignored for the most parts. The patient is helpless in making sense of these painful gashes in her sense of self and often enough, the psychiatrist are instructed to skirt the issue and focus on functional issues and medication management


Again exactly, far to much spent on fancy gizmos and toys for the boffins to play with at the expense of something that might actually be helpful right here right now, today, not in far off bio bio bio fantasy world.
 
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Mar 24, 2010
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Criticism of the status quo is the engine of scientific progress: No criticism, no progress. End of discussion.
Feel free to contact me, jockmclaren at gmail dot com.
Hi there-
I had the opportunity to read your website on my returned flight from a conference. And I wanted to address your criticism that modern psychiatrists are misguided in using the 'chemical imbalance' model to explain depression to their patients.

I'm quite sure this is no longer true. I've only noticed non MD therapists, primary care clinicians and other specialists citing this theory. They are well intentioned but predictably are not in our field and are misinformed. Similarly, I'm not familar with the latest in cardiology or plastic surgery.

A good review of the current theory was discussed in the PBS healthy mind series. Here is the link to the 27 minute clips with Eric Mandel and Jeffrey Borestein. For depression, the serotonin transporter, short L allete, area 25 and hippocampus volume reduction have more empirical evidence and are gaining traction by current practicing US psychiatrists. Couple of times I heard the 'chemical imbalance' comments by psychiatrists were done in good humor amongst colleagues. Particularly fascinating is the strong evidence that SSRI induce neurogenesis in the hippocampus which has shown to be reduced in people with depressive disorder. I must stress that nobody in psychiatry is discounting environmental stress in any psychiatry disorders as they do indeed induce neuroplasticity and direct physical CNS changes. Hence cognitive changes.

Not that low HIAA levels in CSF showed in multiple studies were flawed but the serotonin deficit model has proven too simplistic. Although increased serotonin can modulate the serotonin transporter receptor in area 25 and raphe nuclei and do play a role in response to treatment in depression.

http://www.wliw.org/productions/local/healthy-minds/neurogenesis-108/171/