Archive for July, 2010

Dworkin: The Rise of the Caring Industry

Ronald W. Dworkin – Frank Henry Sommer Professor of Law and Philosophy at New York University and Jeremy Bentham Professor of Law and Philosophy at University College London – has a piece entitled “The Rise of the Caring Industry” in the June 2010 issue of Policy Review.  The essay can be accessed online here.  The author of the 2006 book Artificial Happiness: The Dark Side of the New Happy Class considers how the growth of the helping professions (particularly those concerned with mental health) represents not simply an institutional change, but a shift in ethos.  As he puts it:

In this way the caring industry exercises a double fascination — on the one hand as a sounding board for lonely, unhappy individuals, and on the other as emblematic of a new ethos of civilization. The age of caring is a more skeptical age, but also a more tolerant one, expressing a distrust of authority and an antipathy to old enthusiasms that wavers between laughter and disgust. It would be wrong to say that people today deny the world; they simply prefer to ignore it, presenting a blank wall of indifference to how people live and what they believe. They prefer meeting their psychological needs through a therapy session rather than through a community of blood brothers.

The topic has been of particular interest to observers in the United States, and, over the past fifteen years, a number of scholars and writers have written on the subject, including Ellen Herman (The Romance of American Psychology: Political Culture in the Age of Experts, 1995), Eva Moskowitz (In Therapy We Trust: America’s Obsession with Self-Fulfillment, 2001) and Barbara Ehrenreich (Bright-Sided: How the Relentless Promotion of Positive Thinking Has Undermined America, 2009).

New Issue of International Journal of Mental Health

The latest issue of the International Journal of Mental Health is dedicated to Mental Health in a Time of Economic Contraction. One article is specifically dedicated to the recent history of this problem.

Economic Contraction and Mental Health. A Review of the Evidence, 1990-2009 by Sidra J. Goldman-Mellor, Katherine B. Saxton, Ralph C. Catalano (School of Public Health, University of California, Berkeley). The abstract reads:

Background: Theory and empirical evidence suggest that economic contraction predicts increased incidence of psychological disorder. The extent to which this relation can be causally attributed to the economic experiences of individuals remains uncertain. Methods: We critically examine literature concerning the impact of economic contraction, measured at the individual or ecological level, on four mental health outcomes (depression, suicide, substance abuse, and antisocial behavior) from the past two decades. Studies at the individual level use job loss, transition to inadequate employment, or welfare as the independent variable. Studies at the ecological level primarily use the unemployment rate. Results: In the studies that best establish causality, research indicates a moderate but significant adverse effect of job loss on individual depression symptoms, but the net population effect remains speculative. For suicide and antisocial behavior, individual- and ecological-level studies converge to suggest a moderate positive association with economic contraction. Although some research on substance abuse suggests procyclical effects, the majority indicate that job loss significantly increases the risk of heavy drinking and symptoms of alcohol abuse. For all outcomes, various characteristics of the population or the specific economic exposure studied can modify the overall association. Conclusions: The studies reviewed suggest that adverse economic transitions predict increased mental health problems, particularly depression, suicide, and substance abuse. The strength of the association, particularly when measuring the response of populations to contracting economies remains unclear.

Review – Ethan Watters. Crazy Like Us: The Globalization of the American Psyche. New York: Free Press, 2010.

This book aims to demonstrate how, regrettably, over the last twenty years or so, typically American conceptions of mental illness have been exported successfully to the rest of the world. According to Watters, the often enthusiastic international reception of DSM-III and IV with its standardized descriptions of typical American forms of mental anguish, has homogenized human suffering all over the world. Psychiatry appears to be following the example of McDonald’s, which successfully homogenized (and worsened) the daily diet of humankind.

Watters presents his argument with four case studies. The first one focuses on the tragic death of an emaciated 14-year old woman in Hong Kong, who fainted and fell to her death in broad daylight in 1994. When journalists wanted to report on the case, they quickly found out, using Google, about the symptoms and causes of anorexia nervosa. Soon after, awareness campaigns and prevention programs were organized based on Western insights—and lo and behold, the number of young women in Hong Kong suffering from anorexia nervosa increased dramatically. By way of contrast, Watters describes the research and ideas of Dr. Sing Lee, who had studied a small number of women patients who had deliberately starved themselves. Interestingly, they did not display the symptoms of anorexia nervosa. They did not have a morbid fear of becoming overweight, did not have body image issues, and did not starve themselves to look thin and attractive. It appeared that Dr. Lee had found a rare form of mental illness which might be unique to Asia, and which resembled anorexia nervosa, but was a distinct disease entity. Unfortunately, he was not able to cure this condition with the aid of traditional Chinese medicine and other approaches based on local culture. His only patient with this condition died of starvation.

The second case focuses on the effort to relieve the trauma of the inhabitants of Sri Lanka after the tsunami. The descriptions of NGOs falling over each other and investing significant resources in turf wars are familiar by now. The conclusion that construction materials were needed more urgently than trauma counsellors can come as no surprise. Nevertheless, Watters judges the influence of these counsellors to be relatively benign—ending his chapter with the bemused smiles of young children drawing and painting, not having the faintest idea of what the art therapist who gave the material to them was up to. The third case study focuses on the way an individual with schizophrenia was maintained by his family in Zanzibar. The narrative is moving but because it only involves one individual, it is hard to make any generalizations.

The last study deals with the mega-marketing of depression in Japan. It details the successful efforts of GlaxoSmithKline, the producers of Paxil, to introduce new conceptions of sadness and depression to Japan. Previously, Japanese psychiatry and popular thinking only acknowledged a rare and very severe form of depression, which required institutionalization. Medical anthropologists and open-minded psychiatrists were feted in exclusive holiday resorts and received generous honoraria for their willingness to share their insights with CEOs and marketing experts. A smart marketing campaign then presented new images of depression—after all, experience in the Western world had demonstrated that marketing disease leads to much higher sales that marketing specific cures. The image of depression that was presented to the Japanese public was left deliberately vague, but it was one that could affect almost everyone, in particular the young, the smart, the aspiring, and the successful. Ask-your-doctor commercials appeared everywhere, de-stigmatizing depression and encouraging individuals to take charge of their own condition by requesting prescriptions. At the same time (around the year 2000), as we now know, the evidence in favour of Paxil (and many other SSRIs) remained flimsy, incomplete, and inconclusive. Undesirable side-effects (including, possibly, akathisia, violent behaviour and increased risk of suicide) had been deliberately swept under the carpet. Nevertheless, marketing campaigns do not let questionable science stand in the way of good sales figures.

Of course, it should be emphasized that the pharmaceutical industry is very interested in Japan, because it is a wealthy country. This contrasts with its complete lack of interest in many developing nations, which are often deprived of much-needed medications. The chapter on the mega-marketing of SSRIs in Sri Lanka, for example, would be remarkably brief.

There is much to commend about Watters’ book. It is a page-turner which hardly ever fails to engage its reader. It is significant that recent developments in the history of psychiatry are discussed—after all, we know an awful lot about the asylum by now, but not much about what happened after the 1960s. Studies focusing on the post-World War II world are still relatively rare, even though significant developments in psychiatry and mental health care have taken place over the last sixty years (deinstitutionalization and the development of psychopharmacology, to mention only two). Also appealing is Watters’ discussion of the “rest of the world.” Thus far, most historians of psychiatry have focused on psychiatry in the Western world. Over the past twenty years, colonial psychiatry has received ample scholarly attention, but studies on this topic have often focused on the activities of Western psychiatrists in far-away places (articulating theories in which “race” took the place of “class”). Unfortunately, the reactions, ideas, initiatives, and theories of the original inhabitants of these far-away places are rarely taken into account.  This is exactly what Watters does—although he presents Western (or, more accurately, American) psychiatry as decisively hegemonic. As a consequence, psychiatrists, other mental health care workers, and media types concerned about mental illness in the rest of the world appear almost exclusively reactive. The flow of ideas, however pernicious in its effect, moves from the United States to the rest of the world—and, strangely enough, the rest of the world enthusiastically embraces it, discarding much more refined and interesting indigenous approaches (even though they do not actually work in the examples given in the book—and many more examples of traditional healing methods in the developing world could be mentioned that are inhumane and cruel). The four case studies are sufficiently diverse to compare and contrast responses to mental illness and Western psychiatry.

Nevertheless, a feeling remains that the story fits together too well. Criticizing American initiatives has been a favourite activity of academics for some time now—Watters’ analysis therefore has a familiar feel.  Nevertheless, one could imagine countless scenarios in which psychiatrists and other mental health care workers in the non-Western world maintain a more level-headed approach to the patients they see (in all fairness, Watters’ ire is mostly reserved for uncritical media types and pharmaceutical corporations, rather than for physicians). After all, many American mental health care practitioners often view picking a DSM-diagnosis as a bureaucratic exercise after which the real treatment can begin. The importance of DSM in many developing countries appears to be somewhat overstated.

If the influence of American psychiatric ideas could be diminished, psychiatric anthropologists would be able to conduct more interesting research projects. At least that appears to be Watters’ opinion. His interest in the rest of the world is laudable. Nevertheless, he completely overlooks the fact that in most developing countries, there are hardly any psychiatrists and access to psychotropic drugs is very difficult. As a consequence, many individuals do not receive the care they need and suffer unnecessarily. If Watters’ caution were widely heeded, this situation would likely only worsen.

Lastly, why should we be particularly concerned about the disappearance of various culturally-specific forms of mental suffering? Watters compares the disappearance of exotic forms of mental illness (often described as culture-bound syndromes) to the increasing extinction of plant and animal species, which is impoverishing the bio-sphere. The metaphor of disappearing species is not altogether convincing—who would, after all, advocate preserving the current diversity in suffering? Because Watters often appears to be critical of American psychiatry, his descriptions of reactions to mental illness in the rest of the world are often empathic, generous, and positive, while American approaches only appear in a negative light. Seen that way, the pervasive influence of American psychiatric thinking is easily regarded as pernicious—in particular if it is a poor fit with the experiential world of non-American patients. The often cruel and pointless treatment methods that are still widespread in the non-Western world do not find a place within this book.

Hans Pols, University of Sydney

Review – Noga Arikha. Passions and Tempers: A History of the Humours (Harper Collins 2007)

Passions and Tempers is a real treat. Noga Arikha has written a lucid book that provides a concise history of humours and how they evolved from Hippocrates in the 5th century B.C. to the mid 20th century A.D. Arikha sought neither to revise nor to add new evidence on the history of humoural medicine, so her book might be received with a slight sense of disappointment from a specialist, expecting a dry account of a seemingly bygone medical method. However, for the lay reader, and even for an informed reader, the book provides an excellent introduction to humours, and a thesis that jabs right at the heart of the history of medicine, or more specifically, the inability of doctors to part with their theories.

The book is divided into seven chapters; each chapter tells the story of a new era of understanding, or the evolution of humours in medicine: from the earliest beginning in ancient Egypt and Greece, to the transmission of humoural theories in the Muslim world, to physicians in Europe during the Middle Ages and the early modern era. The four humours, or fluids that were hidden in the human body, explained much about health or disease. The human body required a balance of blood, choler (yellow bile), melancholer (black bile), and phlegm to remain healthy. These fluids should not be confused with the visible secretions of the body, such as blood, puss, blood clots or mucous; instead, they were invisible within the bloodstream, thus their influence on body and mind could only be determined by a study of the symptoms. Although no physician had ever seen these humours with his own eyes, the diagnosis of an imbalance in humours sent physicians, throughout the ages, to prescribe medicines and treatments that were to restore some form of balance. These remedies were sometimes bitter, cold, hot, sweet or even involved sending a patient to a different location.

Each humour corresponded to a combination of basic qualities: hot, cold, wet or dry, which in turn were related to the four elements: air, fire, earth and water; and, the seasons of the year: spring, summer, fall and winter. In fact, each humour had a matching color, and even a time of day, when its influence on the body was thought to be stronger. Humours were so ingrained in medical theory that they also had corresponding temperaments: sanguine, choleric, melancholic and the phlegmatic personalities.

As one era gave way to another, new meanings were attached to this basic division of the human body; whereas melancholia might have been related to demonic possession in one period, it turned into a clinical disease in another. Yet another disease of the melancholer was hypochondria, or an excess of black bile in the body. Today, hypochondria is associated with a morbid fear of diseases, a form of melancholy; however, in the 16th century it meant something completely different: Duke Francesco Sforza, whose liver stopped producing yellow bile and produced black bile instead, was diagnosed with dropsy, or swelling of organs due to an excess of liquids, which eventually killed him in 1466. Today, as Arikha pointed out from the known medical data, doctors might have diagnosed the duke with hepatic cirrhosis, which is, as the name suggests, a disease of the liver, but is not a type of hypochondria.

I found the digressions in the book entertaining, but some readers might find that Arikha spent too much effort on explaining historical events that had little or no influence on physicians and their understanding of humours. For example, she devoted a subchapter to Galileo’s cosmology without explaining how it had affected humoural medicine, if at all. This digression, however, should not be discounted as merely a fanciful description of an unrelated theory. Instead, it helps the reader to identify one of the underlying themes of the book, which revolves around the seen and unseen elements of medicine and the struggle between secular and religious methods of healing. In an attempt to describe the human body, secular physicians resorted to humoural medicine as opposed to religious methods of healing in an attempt to trace god’s or the gods’ will. Physicians could rely on humours to diagnose maladies, which led to their prognoses. As a result, physicians had no need to rely on miracles to heal. They also stressed the need to rely on observation, just like Galileo had suggested, but with their reliance on humoural medicine they fell into the same pitfalls as priests because they entered the realm of the unobservable, and delved into theories that they could not test or even see.

The most interesting chapter of the book was reserved for last. In it Arikha examines the influence of humoural medicine on us, our lives, and more importantly, on our doctors. She demonstrates that despite the medical revolutions of the modern era, old ideas died very hard, and sometimes were revived, or kept an existence in the background. Thus, she illustrates how modern day medicine explains addiction in a surprisingly similar tone to how the mechanics of love-melancholy was depicted in the 17th century.  In fact, the old theories of olden days still exist today in common parlance as one can still speak of melancholic or sanguine personalities.

After reading the book, I could not escape from the thought that perhaps doctors are still influenced by the four humours when they impress on the public ideas that I, like the rest of us, should exercise more, eat less red meat and watch my cholesterol. And so, I decided to check my humoural personality on the book’s webpage at Perhaps the reader would discover, as did I, that he has a healthy dose of blood and phlegm, but a lack of black and yellow bile, making me a bit too passive and prone to contemplation and thought rather than action. Now, I can only speculate on the remedies my doctors would have me take to restore the balance to my body. Would they really have me exercise, swallow bitter pills and eat less dairy products?

Jonathan Lewy, Hebrew University of Jerusalem

APA condemns psychologist implicated in torture

In an unprecedented move, the American Psychological Association is taking steps to sanction one of its members, psychologist James Mitchell, in response to his role as a consultant to the CIA on its techniques of “enhanced interrogation” and a participant in the 2002 CIA interrogation of detainee Abu Zubaydah. The APA has been deeply divided over the ethical issues surrounding the participation of psychologists in interrogation for several years.

Here is the story:

By ANDREW WELSH-HUGGINS, Associated Press Writer – Sat Jul 10, 2010

Psychologists in the United States have been warned by their professional group not to take part in torturing detainees in U.S. custody.

Now the American Psychological Association has taken the unprecedented step of supporting an attempt to strip the license of a psychologist accused of overseeing the torture of a CIA detainee.

The APA has told a Texas licensing board in a letter mailed July 1 that the allegations against Dr. James Mitchell represent “patently unethical” actions inconsistent with the organization’s ethics guidelines.

If any psychologist who was a member of the APA were found to have committed the acts alleged against Mitchell, “he or she would be expelled from the APA membership,” according to the letter, a copy of which was obtained by The Associated Press. APA spokeswoman Rhea Farberman confirmed its contents.

The letter is the first of its kind in the board’s history, Farberman said.

“The allegations put forward in the complaint and those that are on the public record about Dr. Mitchell are simply so serious, and if true, such a gross violation of his professional ethics, that we felt it necessary to act,” Farberman said.

Mitchell is a retired Air Force psychologist who participated in the 2002 CIA interrogation of detainee Abu Zubaydah, according to a 2008 Senate armed Services Committee report on the treatment of detainees in U.S. custody. Mitchell is not a member of the American Psychological Association.

Interrogators in Thailand subjected Zubaydah to severe cold, food and sleep deprivation, confinement in a narrow box and, with Mitchell participating, a simulated form of drowning known as waterboarding, according to the complaint filed with the Texas State Board of Examiners of Psychologists.

“Regardless of what legal categories these techniques fall within, one conclusion is clear: a psychologist who helps inflict such cruel and shocking abuse on a defenseless human being would appear to have violated basic standards of conduct of the profession,” according to the complaint by Northwestern University law professor Joseph Margulies and filed on behalf of a Texas psychologist.

“Obviously, I’m not free to discuss any work I may have done for the CIA,” Mitchell told the AP. He called the complaint libelous and said it is “riddled throughout with fabricated details, lies, distortions and inaccuracies.”

Sherry Lee, the Texas board director, said complaints are shielded under Texas law and she could not comment.

The APA is monitoring similar filings in Ohio and New York made Wednesday against psychologists who oversaw detainee interrogations at Guantanamo Bay, but has no plans to back those efforts.

The accusations against Mitchell are “at a level of seriousness and credibility that we think is different than any other allegations against other psychologists that we know of,” Farberman said.

The San Francisco-based Center for Justice & Accountability filed a complaint against Dr. John Leso with the New York Office of the Professions, alleging professional misconduct. Leso led a behavioral science consultation team at Guantanamo in 2002 and 2003.

The complaint said Leso developed abusive interrogation techniques based on Army survival methods. Those methods, “Survive Evade Rescue and Escape” or SERE, teach soldiers how to withstand physical and psychological abuse they might face if captured by the enemy, according to the complaint against Leso.

In a second complaint, Harvard University’s International Human Rights Clinic alleges that retired Army Col. Larry James observed abusive interrogations and didn’t do anything to stop them.

The complaint says James, dean of professional psychology at Wright State University in Dayton, oversaw abuse at Guantanamo Bay in Cuba in 2003, 2007 and 2008 when he served with the base’s Behavioral Science Consultation Team.

The complaint against Leso says he is stationed at Fort Rucker, Ala. He could not be immediately reached. Messages were left Wednesday and Friday with the fort’s public affairs office. James has declined to comment. The Ohio board declined to pursue a similar complaint filed against James in 2008.

Boards in California, Louisiana and New York have rejected similar complaints in the past. But new sources of information, such as the 2008 Senate Armed Services Committee report, provide details that make the new complaints stronger, said Kathy Roberts, staff attorney with the Center for Justice & Accountability.

In 2008 the APA voted to ban its members from taking part in interrogations at the prison at Guantanamo Bay, Cuba, and other military detention sites where it believes international law is being violated.

The APA has also condemned the use of sexual humiliation, allegations of which are included in both the James and Leso complaints.

As a result, the Harvard clinic expects the APA to follow suit with those complaints, said Deborah Popowski, of the clinic.

Steven Reisner, a New York psychologist who brought the complaint against Leso, urged the APA to support an investigation, saying the case was similar to the Mitchell complaint.

Zubaydah was arrested in Pakistan in March 2002 on suspicion of being a top al-Qaida official. He was the first detainee subjected to Bush administration-approved harsh interrogation techniques, which included waterboarding, slamming the suspect into walls and prolonged period of nudity.

Zubaydah later told a military tribunal he suffered physical and mental torture and nearly died four times. Zubaydah claimed that after many months of such treatment, authorities concluded he was not the No. 3 person in al-Qaida as they had long believed.

New Issue of Medical History

The third issue of the Medical History for 2010 has been released online. Included in this issue is an article by Jesper Vaczy Kragh on Shock Therapy in Danish Psychiatry. The conclusion reads:

By the time the new plans for psychiatry were put into effect in the 1950s, Cardiazol shock therapy had been phased out. In most state hospitals it had been replaced by ECT in the late 1940s and early 1950s. ECT proved safer to use and, unlike Cardiazol therapy, it did not produce the same intense feelings of dread in patients. But before the late 1950s, Cardiazol shock therapy had, none the less, played a significant role in the development of Danish psychiatry. Although it was no magic bullet for schizophrenia, it did have beneficial results for other groups of patients, who would otherwise lead miserable lives in mental institutions. Furthermore, psychiatrists reported good results with patients who were suicidal, in a dangerous manic phase, or who suffered from postpartum psychosis. However, patient records of the state mental hospitals show that physicians found Cardiazol shock therapy useful for other purposes. In Vordingborg hospital the patients’ fear of Cardiazol therapy was sometimes exploited in order to control their behaviour. In general, patients who were characterized as destructive, hot-tempered, noisy, and aggressive often became candidates for shock treatment. This treatment was not used exclusively on these patients, however, and inmates who posed no problem for the hospital staff were also treated with Cardiazol. In sum, Danish psychiatrists found the treatment useful in dealing with very different types of disorders, and Cardiazol therapy was used on a wide scale to treat almost every diagnostic category. Side effects of the treatment such as vertebral fractures and death were perceived as inevitable. In addition, the press did not focus on this aspect but portrayed shock therapy as highly successful. A similar view was presented by psychiatrists, for whom Cardiazol shock therapy became an important tool in efforts to enhance the status of psychiatry and increase the funding of mental hospitals. Together with other somatic treatments of the 1930s and 1940s, Cardiazol therapy was successfully employed in campaigns for grants and for recognition of the psychiatric profession in Denmark.
The resolve to change the public image of psychiatry was not only restricted to Denmark; similar efforts were made by psychiatrists in several European countries and in the United States. As Pressman notes, somatic treatments were useful to American psychiatrists, “who were waging an ideological campaign to convince the public, the general medical community, and themselves that psychiatry did indeed have medical treatments, deployable in medical settings, that functioned according to medically understandable precepts”. Likewise, Cardiazol therapy and other somatic treatments were adopted in Germany, Switzerland, and Britain, where psychiatrists valued the therapies as a means of transforming psychiatry.
The Danish case, however, shows some differences when compared to that of other countries. In Denmark, Cardiazol therapy and ICT were used in every mental hospital and department, and there were no psychiatrists who opposed the wide use of these treatments. A similar spread of the two therapies cannot be found in many other countries, where Cardiazol therapy and ICT were criticized by internationally recognized psychiatrists. In Britain, for instance, Edward Mapother and Aubrey Lewis disapproved of somatic therapies; in France, Henri Baruk implored his colleagues to forsake Cardiazol shock therapy; and in Switzerland, Max Müller discarded the treatment because of the patients’ agonized fears of dying. In the United States, Philip Polatin and co-workers reported that vertebral fractures occurred in 43 per cent of patients, and these statistics were so compelling that a number of American hospitals abandoned Cardiazol. In the UK, the treatment’s reputation was also tarnished by published articles on the fractures it often produced, and it was discontinued in some British hospitals as a result. In Denmark, reports about side effects were published, but they did not affect the use of the therapy in any significant way.
Considering these diverse responses, it is possible that the use of Cardiazol therapy in Danish mental hospitals was in some respect different from the practice in other European countries. Yet it is difficult to draw conclusions regarding this, and an in-depth comparative analysis is beyond the reach of this article. In order to get a broader picture of the general use of Cardiazol shock therapy in Europe or worldwide, more studies of medical records and other primary sources are required. So far, studies of case notes have not been common in the historiography of somatic treatments, and Cardiazol shock therapy especially is in need of further historical scrutiny.
To read the whole article, click here.

Rescheduled Conference: “Brain and Self. Psychiatric Nosology: Definition, History and Validity”

This is the rescheduling of the cancelled April 2010 conference in Copenhagen on Brain and Self.

The field of psychiatry is again undergoing a major re-examination of its classification system. The two major nosologic systems – DSM and ICD – are both currently undergoing revisions. This conference – to be held November 14-16, 2010 in Copenhagen under the sponsorship of the University of Copenhagen (Danish National Research Foundation’s Center for Subjectivity Research; Psychiatric Center Hvidovre; PhD School, Faculty of Health Sciences) – will examine the conceptual and philosophical bases for psychiatric diagnoses. The conference is organized into 5 sessions:

i) The Basics – The Definition of Psychiatric Illness and Rules for Classification,
ii) The Historical Development of Modern Psychiatric Diagnoses,
iii) Concepts of Validity in Psychology and Psychiatry,
iv) Application to Major Depression and Schizophrenia and
v) The Way(s) Forward.

Speakers include leading figures in the philosophy of psychiatry, vice-chair persons of the Task Force on DSM-IV and DSM-V and psychiatrists who have made important recent contributions to the philosophy-psychiatry dialogue (see program below). The meeting will emphasize dialogue with each presentation being followed first by formal comments from another of the contributors and then by open discussion.

The conference will take place in November 2010. For more information, click here.

%d bloggers like this: