An excerpt from the second edition of Dr. Joel Paris’ excellent book, made available to me by the author.
It’s excellent. Enjoy.
DG
Introduction
Mental illness is, and always has been a mystery. In spite of active research, we may have to wait many decades for answers to important questions. Yet the fact that mental illness is enigmatic is precisely why I chose psychiatry as a career, and why I still love it. Sixty years later, I can say that becoming a psychiatrist was one of the best decisions I ever made, and I have little interest in retirement.
Over time, my perspective on psychiatry has changed, in the direction of greater skepticism. As a student, I did not understand why I needed to be taught the history of medicine. Once ideas go out of date, why bother to learn them? Yet as I grew older, I became more interested in the history of my specialty, and came to realize that progress is not linear. Impeded by false beliefs, medical science can go off on serious tangents. Understanding past mistakes can help us to be appropriately skeptical about current theories and practices–some of which may be remembered as dangerous errors.
I have always been the type of person who questions everything. When I was young, this attitude got me into trouble. I asked tough questions that threatened the certainty of my teachers. Since I did not accept received wisdoms, they saw me as a rebellious young man. Now, in old age, I have been called a curmudgeon for saying many of the same things. While psychiatrists do a lot of good, it remains important to criticize contemporary practice, with its susceptibility to fads and its penchant for fallacies. That is the passion that drives this book.
My title is a deliberate paraphrase of a classic volume by Martin Gardner (1951), “Fads and Fallacies in the Name of Science”. Fads are ideas and practices based on temporary bursts of enthusiasm, while fallacies reflect cognitive errors or wishful thinking. When we think of fads, bizarre ideas come to mind, and Gardner’s book focused on some of the strangest and most pseudoscientific theories of the time. But fads in psychiatry have not only occurred on the fringe, but in the very mainstream of theory and practice. Some of the trendiest theoretical paradigms turn out to be unsupported by data. In diagnosis, currently faddish approaches to classification lack a secure base in etiology, and many are unlikely to last. In treatment, both psychopharmacology and psychotherapy have embraced interventions that have a weak base in evidence and that have made unjustified claims for their efficacy. These errors run the risk of doing harm to patients.
Should we be surprised or discouraged that psychiatry does not yet understand mental illness? No. The brain is the most complicated structure in the known universe. Neuroscience has not solved these problems fast enough to be applied to practice. We are often told that answers lie just around the corner, but that is where they tend to stay. The most important questions remain unanswered.
Given that psychiatrists still have so much to learn, they need to remain humble. For example, the current rage to reduce everything about mental illness at a molecular or a neuronal level is an over-simplistic and hubristic idea. I am not criticizing basic research. But for clinical application, biological processes behind disorders can only be understood in the context of interactions with psychological adversities and sociocultural stressors, i.e., within a biopsychosocial model (Engel, 1980). While multifactorial models can be intimidatingly complex, they explain why research on the origins of mental illness and their treatment is so difficult.
Ironically, the main source of psychiatric fads is that its practitioners want to help patients. Human nature being what it is, clinicians are uncomfortable with doubt and seek certainty. They have trouble maintaining a cautious stance in the face of scientific ignorance. Practitioners don’t want to wait a hundred years for answers, and are tempted to believe they know enough to practice in the present. Yet that is the main reason why psychiatry has been infected by fads and fallacies. This book will document how and why this happens.
Why I Have Written This Book
I began my career as a clinician and an educator. In spite of my contrarian temperament, I largely accepted the point of view of my teachers. Yet with time, I came to realize that the older generation was wrong about many things. Quite a few relied on clinical judgment to support theories and were barely familiar with empirical data. I gradually became committed to a scientific and empirical perspective, and, with the help of colleagues, trained myself to become a researcher. I became a passionate convert to evidence-based medicine. I no longer take clinical experience, including my own, for granted. In spite of the current fad for “lived experience”, I am not prepared to accept ideas that fail to be supported by quantitative data.
For this reason, I have taken care in this book to ensure that its conclusions are consistent with the scientific literature, and will refer the reader either to relevant studies, comprehensive reviews, or metanalyses. But since the subject is so vast (psychiatry as a whole), I have had to be selective about references.
This book will also draw on my 50 years of work as a consultant. While one cannot base practice on clinical experience, it can be used to illustrate points that confirmed by data. Since 1972, I have run a hospital clinic that sees hundreds of patients every year referred from primary care. I also worked in a university health service for 25 years and saw thousands of troubled students. In 2001 and 2007, I founded two specialty clinics for the treatment of personality disorders. Over the last two decades I have conducted many thousands of consultations on patients with these problems. While the patients I treat myself are highly symptomatic, like many of my colleagues, I now spend more time than on consultations to primary care providers.
In total, I estimate that I have seen at least 30,000 patients over the last 50 years. When my students ask me how I reach conclusions fairly rapidly, I tell them that things get easier after the first 30,000 cases. Yet even the most extensive experience does not make you right. You could be making the same mistakes thousands of times. That is why I strongly support evidence-based psychiatry.
If you want to practice scientific medicine, you have to give up on certainty and embrace doubt. In the first ten years of my career, I aimed for radical change. With experience, I learned that while I could help many or most patients, psychiatry lacks the tools to achieve consistent and stable remissions of serious mental disorders. The field is only beginning a very long journey. Once I recognized that my specialty has a thin knowledge base, I went into research to do my part in broadening it.
My second career in research started rather late, in my mid-40’s. For that reason, I could not reach the same level as those who began earlier. Moreover, I am only one soldier in a vast army. Yet I benefited from more clinical experience that some of my research colleagues, tied to labs and desks, lacked. Being an active clinician also helped me to ask more relevant questions. In turn, conducting research affected my practice. The doubt that characterizes the scientific culture is the best antidote to fads. I brought its worldview back to my clinical work and my teaching.
The clinical trenches are far from the ivory tower of academia. While I aim to practice, as much as possible, in an evidence-based way, some of the most crucial questions cannot yet be answered by empirical data. Thus, when I treat patients, I keep in mind what I can and cannot do. And while I teach students to follow the research literature, I advise them to remain cautious about generalizing from just one or a few published studies. Unfortunately, not all my colleagues share this perspective. Some jump on bandwagons and pretend to have an unjustified certainty. Most simply follow the crowd, and join in a consensus, however uncertain, that is shared by their colleagues.
Psychiatric Fads—Then and Now
When I was young, two major theoretical models shaped psychiatry, and both became sources of orthodoxy. One was the psychoanalytic model. I began training in the late 1960’s, towards the end of the heyday of psychoanalysis in North America. At many universities, including my own, analysts were the leaders of academic psychiatry. Trainees revered them, mainly because they were eloquent and seemed to have an answer for everything. Some may have been a bit arrogant, but students tend to be attracted to confidence and certainty. As teachers, analysts could provide plausible (or not so plausible) explanations for symptoms of all kinds. They also insisted, without evidence, that their treatment method was highly effective. When it didn’t work, that would only happen because therapy was not long enough, or wasn’t conducted with sufficient skill.
The psychoanalytic fad was never as powerful in Europe. It had a good deal of influence in the UK, but never dominated psychiatry there. Disinterest in research ultimately proved to be the downfall of these ideas. Neither the theory nor the method could stand up to empirical scrutiny. Today, while the analytic movement remains alive, it plays a rather marginal role in psychiatry, both in North America and in Europe. I have written two books about its decline (Paris, 2005, 2019).
While psychoanalysis was a fad, one cannot say that it was only a fad. Many of its concepts and methods have been incorporated into other forms of psychotherapy that have since undergone clinical testing, and that have been shown to be effective. Even cognitive behavioral therapy (CBT) was founded by an analyst (Aaron Beck), and one can see a few surviving elements of his previous training in the method. But the key issue concerns the length of treatment, which leads to therapy being expensive and unavailable to most patients. As I will show in this book, research supports brief courses of both psychodynamic psychotherapy and CBT, but does not support seeing patients regularly for years on end.
This having been said, psychoanalysis has a legacy. My training promoted an ability to listen empathically to patients and to understand what they might be thinking and feeling. (This is also a skill that cannot be entirely turned off, even in private life.)
Following the move away from psychoanalysis, modern psychiatry returned to its medical roots. Even in my student days, biological psychiatry had become an alternative way of looking at psychopathology. But it had not yet become an orthodoxy, and did not yet take psychopharmacology to an extreme, as it does now. While drugs are often effective (and occasionally miraculous), clinicians who only treat symptoms with medications tend to lose interest in people and their life histories. Yet research show that in disorders such as depression and anxiety, the effects of psychological treatment are more durable (Cuijpers et al, 2020). That is why I expect and hope that psychotherapy, much of which is well supported by research, will make a comeback.
The 1960’s was the golden age of psychopharmacology. The dramatic success of drug treatment for severe mental disorders gave biological psychiatry an enormous boost. Healy (2002) described the medical management of psychosis as one of the most inspiring moments in human history. I entirely agree. I visited a large mental hospital as an undergraduate student, and saw what psychotic patients were like before drugs were available to control their symptoms. Only a few years later, psychiatrists had effective treatments for most of the psychoses and severe mood disorders. I saw patients being discharged and maintained in the community after years of serious illness. This was indeed a time of miracles.
Biological psychiatrists may be less colorful than psychoanalysts, but they have kept psychiatry within the scientific mainstream. Instead of tradition and authority, they rely on research studies and clinical trials. Gradually, neuroscience became the dominant force in psychiatry, even if clinicians did not understand why the drugs they prescribe are effective. Unfortunately, the neuroscience community has taken a narrowly biological approach, claiming that mental disorders are “nothing but” brain disorders. That mantra is both true and untrue. There can be no mind without brain. But psychiatry needs to study mind at its own level, not as something that can be reduced to neural connections. Moreover, neuroscience need not ignore (or pay lip service to) the powerful effects of psychological and social forces, which interact with biological factors, and which can also shape the structure and function of the brain.
In this way, biological psychiatry, when associated with an almost total dependence on drug treatment, can be as dogmatic as psychoanalysis ever was. Its ideas are based on a core of truth that has been stretched to the point of faddishness. Drugs are useful tools, but rarely cure severe mental disorders, many of which tend to remain chronic. Psychiatrists, rushing to gain the respect of their medical colleagues, embraced an ideology that is triumphant for now, but covers vast ignorance with a gloss of science.
Thus, in spite of the progress of recent decades, neuroscience is still in its infancy. Brain research has not even begun to explain how psychological symptoms develop. It should eventually do better. But it will never be possible to reduce all mental phenomena and symptoms to a cellular level, or to neural networks. Unless psychiatry embraces a broader model, it will suffer from a cripplingly narrow perspective.
Fads in Contemporary Psychiatry
I wish I could say that psychiatry has outgrown the fads and fallacies of my youth. But it has not. This book will focus on three areas that remain problematic.
The first is the diagnostic system used by psychiatrists. The Diagnostic and Statistical Manual of Mental Disorders (DSM) is now in its fifth edition, and although developed by American psychiatrists, it is used is most places in the world. I will examine this system and outline its limitations. The latest revision, the DSM-5-Text Revision (DSM-5-TR; American Psychiatric Association, 2022) is a tool that works best for the most severe illnesses, but is much less useful for the common disorders that are most prevalent in practice. I will also examine several of the alternatives to DSM, including the International Classification of Diseases, now in its eleventh edition (ICD-11, World Health Organization, 2018). Some of these alternatives are based on quantitative dimensions rather than qualitative categories. But none of these has been shown to provide a solution to a lack of precision in categorization. They are still limited by absence of etiologically based models, and the lack of data describing the endophenotypes that lie behind clinical disorders. This book will conclude that while DSM-5 is problematic, we currently lack the knowledge to replace it with something radically different or better.
This second focus of the book will be a critical view of the currently popular view that neuroscience, by itself, can provide the answers to all the dilemmas of psychiatry. Clinicians have often been promised breakthroughs, each of which have been touted as being “just around the corner”. But since the corner is where solutions remain, these promises remain unfulfilled.
In some ways, the more we learn, the more we realize how difficult will be the task of understanding mind and brain. The brain is an incredibly complex system with about 85 billion neurons and trillions of connections between them. Reading the 20,000 or so genes on the genome, and using genome-wide association studies (GWAS), has not yet been of much help. As we will see, this research shows that every phenotype is rooted in small effects from hundreds or thousands of interacting alleles. We can add up these correlations to produce a “polygenic risk score”, but that measure only accounts for a small part of the outcome (Tam et al, 2019).
Progress in biological research continues to be more relevant to basic science than to clinical needs. Unfortunately, the National Institute of Mental Health (NIMH) in the US mainly funds studies of neuroscience, and provides little support to research that examines issues of direct clinical relevance. Perhaps research funders believe in making long-term investments at the expense of current needs. But this fallacy is based on hope, not facts, and is a disservice to the millions who suffer from mental illness. We have the tools to help many or most of our patients, but suffer from serious under-funding and lack of human resources to make our efforts count for more.
This book will argue that we need to avoid reductionism and adhere to a biopsychosocial model that acknowledges the complexity of the interactions that carry the risk for mental disorders. The bias in favor of neuroscience has greatly affected clinical practice. Psychiatrists these days may only spend fifteen minutes with each patient, just enough time to check on symptoms and to write a prescription. And when medication fails to help, the result is often more medication, i.e., polypharmacy.
The third, closely related, issue concerns the marginalization of psychotherapy in the practice of psychiatry. Only a minority of psychiatrists are seriously committed to making talking therapy part of their clinical activities, and that field is now dominated by clinical psychologists. This would not be a problem if psychological treatment were properly insured and readily available, but it is not. In the USA, psychotherapy remains expensive, with most insurance covering only a few sessions. The result is that patients with common mental disorders (anxiety and depression) routinely receive medication without access to evidence-based forms of psychological treatment. In the UK, a serious effort has been made to make psychotherapy for these problems available in the National Health Service (Clark et al, 2018). But this welcome initiative only scratches the surface of the problem, especially for patients with severe and disabling mental disorders.
The Antipsychiatry Movement
A book like this, focusing on how psychiatrists can go wrong, might suggest to readers that its author supports what has been called “antipsychiatry”. That is most definitely not the case. I am a mainstream thinker and practitioner who is only asking my colleagues to slow down and exercise more scientific caution.
The antipsychiatry movement goes back at least to the 1960’s. It was always political. A right-winger and radical libertarian like Thomas Szasz (1961) could claim that mental illness was a myth, and that nobody should ever be treated involuntarily. This point of view could only be maintained by someone who was safely protected by academia, and who never spent time working in hospital emergency rooms or wards. But it appealed to those who felt threatened by the idea that any of us can lose our minds, and that we may have to be looked after against our will.
On the left wing of politics, Ronald Laing (1967) took a similar view, romanticizing mental illness as an exciting journey into the boundaries of the mind. Laing, unlike Szasz, did treat seriously ill patients, but had little success doing so. Instead of providing medication to psychotic patients, Laing offered psychotherapy, pretending to be their guru on a “trip”. His personal life was marked by alcoholism and abandonment of his many children, several of whom ended up dying young (Burston, 1998).
The opposition of antipsychiatrists to psychopharmacology is a marker for the irrationality of their opposition. In recent years, the American journalist Robert Whitaker (2002) has claimed to be a spokesman for the supposedly oppressed mentally ill. The British psychologist Richard Bentall (2009), who emphasizes trauma as a cause of psychosis, has played a similar role.
A few other sticks have been used to beat psychiatry. One that shows up often is a so-called “experiment” reported 50 years ago by Rosenhan (1973) and published in the journal Science. Rosenhan described sending 8 volunteers to mental hospitals who were instructed to pretend to be psychotic, resulting in their admission. Needless to say, anyone can obtain admission to a hospital, whether medical or psychiatric, by faking the symptoms of an illness. But the truth of this story is even darker. Careful investigation by a journalist (Cahallan, 2019) showed that the entire study was a fraud. Rosenhan seems to be the only person who pretended to be ill, and the other participants were figments of his imagination. This story shows how fraudulent research with sensational results can make it to the pages of the most respected scientific journals. And it has been told and retold in books and the media ever since.
My reaction to antipsychiatrists is that they seem not only to hate the idea of mental illness, but are prepared to undermine the treatment of people who suffer from them. Fortunately, these critics have had little influence on the practice of psychiatry. Antipsychiatrists prefer to stand on the sidelines, and to add the mentally ill to the long list of oppressed sufferers who require the service of social justice warriors.
Antidotes to Fads
Faddish clinical practices derive from overly simplistic theories. Given our lack of knowledge about the causes and potential cure of mental illness, it is not surprising that clinicians have often failed to adopt practices based on evidence-based medicine. Contemporary views about the etiology of mental disorders have favored the idea that mental symptoms are due to a “chemical imbalance” or aberrant neural circuits. These theories could turn out to be at least partly correct, but are currently unsupported by good evidence. Even so, many practitioners, and quite a few patients, believe these ideas to be scientific truth. The result is that treatment aims to correct putative imbalances with a “cocktail” of drugs. Many patients are being given prescriptions they do not need.
The enterprise of science encourages debate and doubt, which are the best correctives for faddish ideas. In the basic sciences, even the most powerful paradigms decline when the weight of evidence fails to support them, but change is slower in medicine. Sick people can be desperate, and physicians may seek desperate remedies. I have great sympathy for front-line clinicians who deal with highly distressed clients. But that is why psychiatry, which deals with poorly understood illnesses that cause profound suffering, is so susceptible to faddish ideas. A scientific worldview implies a commitment to test all theories before accepting them, and to subject all treatments to clinical trials. Practitioners can practice virtues such as patience, humility, and caution.
The antidote to fads consists of thinking scientifically and conducting evidence-based practice (Evidence-Based Medicine Working Group, 1992). This influential concept, developed by the British physician Archie Cochrane, in whose name guidelines to treatment are still being published, is a principle to which we all pay lip service. But clinicians have preconceptions that make them see the world in a way that confirms their point of view. These confirmation biases (Kahnemann, 2011) lie at the heart of fallacious thinking in clinical work. Close attention to the scientific literature helps keep biases in check, and it also leads to a more cautious and conservative way of working with patients. Adopting an evidence-based perspective helps us to be comfortable with uncertainty, makes us less likely to harm patients, and more likely to help them.
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