Psychiatric Medications: Promise or Peril? (Part 1)

About twenty years ago, Robert Nozick published a brilliant paper, “Socratic Puzzles,” intended to address the apparent paradox of Socrates’s avowal of ignorance:

Socrates claims he does not know the answers to the questions he puts, and that if he is superior in wisdom this lies only in the fact that, unlike others, he is aware that he does not know. Yet he does have doctrines he recurs to…and he shows great confidence in these judgments. …Is this supremely confident Socrates merely being ironic when he elsewhere denies that he knows? How are we to understand what Gregory Vlastos terms ‘Socrates’ central paradox’, his profession of ignorance? (“Socratic Puzzles,” in Socratic Puzzles, p. 145).

I won’t try to summarize Nozick’s (to my mind successful) resolution of the Socratic paradox. I’ll just cut to the chase regarding its payoff:

Inquiry arises because of puzzlement, John Dewey said. People who are quite confident of the truth of their very extensive views are unlikely to engage in probing inquiry about these matters. The first step for Socrates, then, must be to show these others that they need to think about these matters, that is, to show them that what they already are thinking (or unthinkingly assuming) is quite definitely wrong. (“Socratic Puzzles,” p. 153).

And more:

Socrates has doctrines but what he teaches is not a doctrine but a method of inquiry….He teaches the method of inquiry by involving others in it, by exhibiting it. Their job is to catch on, and to go on. (“Socratic Puzzles,” p. 154)

And yet more:

Socrates shows something more: the kind of person that such sustained inquiry produces. It is not his method alone that teaches us but rather that method (and those doctrines it has led him to) as embodied in Socrates. (“Socratic Puzzles,” p. 154).

That’s a long preface to a discussion about psychiatry, but it seems to me the best entree into a discussion of the Felician Institute event that I organized this past Saturday, “Psychiatric Medications: Promise or Peril?” The upshot, ironically enough, was a collective but highly instructive profession of ignorance by the four presenters invited to address the symposium. Whatever their “doctrinal” disagreements, all four presenters agreed–in some way, at some level—with this proposition (my words, not theirs):

Despite the ubiquity of the use of psychiatric medications in the United States (and perhaps the First World generally), we really have no clear idea what we are doing when we use them, with what consequences, or with what rationale. What’s clear is that we’re widely overusing them with highly problematic consequences.

They may not have put it that way (though I think one or two did), but I think all four were committed to the claim. When you consider what’s at stake—the mental health not just of the present but of future generations, of children,  the elderly, and everyone in between—that’s a fairly sobering thought.

The “profession of ignorance” involved here was not the helpless or hapless “I don’t know” of the unprepared student or the ignorant layperson coming to the issue for the first time. It was a profession of ignorance by people in one way or another professionally involved in the field of mental health—as a science reporter and activist (Robert Whitaker), as a psychiatrist in private practice (Ray Raad), as a counseling psychologist and professor of counseling (Peter Economou), and as a philosopher of psychiatry and patient (Christian Perring). And the audience they were addressing was also, to large degree, professionally involved in mental health, consisting in large part of students from Felician’s Master’s Program in Counseling Psychology. It was a Socratic profession of ignorance—a profession of ignorance of the sort possible to people with deep knowledge of a subject, and something important to say about it.

I’m very pressed for time, given the end of the semester, but what I’d like to do over the next few days is to summarize what the presenters did say, and perhaps invite some further discussion both from the panelists and audience to add to or correct what I’ve missed. Obviously, any reader of the blog is invited to comment as well.

A summary of the event is perhaps in order:  The event began with a remarkably personal and candid introduction by Dr. Anne Prisco, our College president, on the dilemmas she’s faced as a mother, confronting the issue of whether or not to medicate one of her sons for what might have been (but might not have been) a case of ADHD. She decided not to: better that he should underperform, her reasoning went, than that he should become dependent on stimulants. That deep skepticism about the use of psychiatric medications set the agenda and tone of the rest of the conversation (with some significant provisos and caveats offered by Ray Raad, the only psychiatrist on the panel, and probably the only psychiatrist in the room).

The first of the two panels featured a 45-minute talk by Robert Whitaker, and centered on the thesis of Whitaker’s controversial (and prize-winning) 2010 book, Anatomy of an Epidemic, which is highly critical of the use of psychiatric medications. Whitaker’s talk was followed by a 25 minute commentary by Ray Raad, a psychiatrist in private practice in New York City. Raad agreed in a very general way with Whitaker’s argument, but disputed many of the specifics, with interesting (and still debatable) implications for Whitaker’s thesis. What followed was a relatively brief but very interesting discussion. I can’t quite remember the details anymore, so perhaps other participants can fill them in when I manage to write up a summary of the panel itself.

The second of the two panels featured two thirty minute presentations. The first, by Peter Economou, sketched a “middle of the road” approach to psychiatric or psychological treatment, combining cognitive-behavioral therapy with the judicious use of medications. Peter’s was perhaps the most skeptical, theoretically eclectic, and overtly Socratic of the four presentations: he actually just came out and said, “The truth is, we know what works in this or that context, but ultimately, we have no idea why it works or what we’re doing.” Christian Perring came at the issue by considering the “epistemic difficulties” presented by consumers of mental health services in confronting the conflicting claims of “psychiatric expertise.” The talk was tellingly and instructively inconclusive: considering the nature of the epistemic difficulties, it’s not entirely clear what potential patients should do, or what “informed consent” means under such conditions of uncertainty. We had a nice (meaning: contentious) hour-long discussion after that, which I’ll try to reconstruct at some point if I can.

After that, of course, we had a reception in which participants self-medicated with the widely-used psychotropic substance known as “alcohol.” (The event was fueled by self-medication via that other widely-used psychotropic substance, “caffeine.”)

More to come, as I manage to get to it.

(Thanks to George Abaunza for the NPR link on medicating the elderly.)

Postscript, December 10, 2014: An interesting article in today’s New York Times, about the use of ketamine (“Special K”), a hallucinogen, for depression.

Reminder: “Psychiatric Medications: Promise or Peril?” Fall 2014 Felician Symposium

Here’s a reminder, for those of you in the New York/New Jersey Metro Area, of our upcoming symposium, “Psychiatric Medication: Promise or Peril? An Interdisciplinary Discussion.” The symposium is the third annual one sponsored by the Felician Institute for Ethics and Public Affairs, and is co-sponsored by the Felician College Department of Psychology, and Felician’s Graduate Program in Counseling Psychology. It takes place Saturday, December 6 between 1 and 5 pm in the Castleview Room on the Rutherford, New Jersey campus of Felician College. The Castleview Room is located on the second floor of the Student Union Center on the Rutherford campus. (The GPS address is 223 Montross Ave., Rutherford, NJ, 07070.)

The topic is timely enough as it is, but has been made particularly so by recent coverage of the issue in The New York Times, among other places. Check out this article on psychiatric drug use in children, as well as these follow-up letters on the same article. This review of Yochi Dreazen’s The Invisible Front discusses the use of psychiatric drugs for PTSD in returning veterans. Also worth checking out is Alan Schwarz’s controversial series on ADHD in The New York Times, which you can find by scrolling backward on his dedicated page at their website. Likewise worth checking out (and more supportive of the use of medications) are guest posts at the Times by Richard Friedman of Weill Cornell Medical College.

I’ve only scratched the surface of the popular literature on psychiatry, but I’ve found the work of Peter Breggin, Gary Greenberg, and Peter Kramer illuminating in addressing the important background issues. (For whatever it’s worth, despite his reputation among libertarians, I have generally not found the work of Thomas Szasz particularly helpful. And despite her reputation among mainstream readers, I have very mixed feelings about the work of Kay Redfield Jamison.)

Here’s the line-up of presenters at the Felician event:

Raymond Raad replaces Cheryl Kennedy of Rutgers New Jersey Medical School, who unexpectedly had to cancel. I’m very grateful to Ray (who lurks on PoT) for doing the event on such short notice.

Whitaker’s work features prominently in a much-discussed two-part review by Marcia Angell in The New York Review of Books; for another view of Whitaker’s work, check out this highly critical review by E. Fuller Torrey, along with Whitaker’s response.

If you’re interested in issues at the intersection of philosophy, psychiatry, and psychology, and don’t know Christian Perring’s Metapsychology Online Reviews, you probably need to head there ASAP (see link above). [Added later: Perring is the author of the entry for “Mental Illness” for the Stanford Encyclopedia of Philosophy, the  main reference work in the field.]

Peter Economou not only has the distinction of having founded a Counseling and Wellness Center in New Jersey (see link above), but of being on the New Jersey State Board of Psychological Examiners (aka “the licensing board”)–and of being my academic advisor in the counseling program at Felician.

Hope to see some of you at the symposium.

PS., More grist for the mill: Though much of it is behind a paywall, I just happened to notice this piece by Mitchell Feinberg, “On the Moral Use of ‘Smart Drugs,'” in The Objective Standard. Perhaps readers who subscribe to TOS can tell us what Feinberg says. Meanwhile, neurophilosopher Patricia Churchland weighs in on the controversy in her recent book, Touching a Nerve: The Self as Brain:

To the degree that I am optimistic, it is because there are scientific discoveries that obviously and unequivocally have been used to make life better–such as polio and smallpox vaccines; such as Prozac and lithium; such as hand washing by surgeons and the use of local anesthetics by dentists….(p. 23)

It does seem generally true that as we come to understand that a particular problem, such as PMS or extreme shyness, has a biological basis, we find relief–relief that our own bad character is not, after all, the cause and relief because causality presents a possible chance for change. If we are lucky and current science has moved along to understand some of the causal details, interventions to ameliorate may emerge. Even if a medical intervention is not available, sometimes just knowing the biological nature of the condition permits us to work around, or work with, what cannot be fixed. For some problems, such as bipolar disorder and chronic depression, medical progress has been greater than for other problems, such as schizophrenia and the various forms of dementia. As more is unraveled about the complex details of these conditions, effective interventions will likely be found. The slow dawning of deep ideas about the brain and the causes of neurological dysfunction has lifted us from the cruel labeling of demonic posesssion or witchery. (p. 31)

I take it that Churchland takes her neurophilosophical eliminativism about mind to prescribe support for the pro-medication (“promise”) side of the debate? If she doesn’t intend that, it’s not clear to me what she is saying. (Of course, it’s not clear to me how eliminativists can have intentions, either, but never mind.)

Postscript 2, November 30, 2014: Some excellent posts on psychiatric medications, care of Scott Alexander at Slate Star Codex: SSRI’s, More Than You Ever Wanted to Know, and Such Crazy Feelings About Crazymeds.

Philosophy, Psychiatry, Psychology: Some Resources and Announcements

I have no way of knowing where the readers of this blog live, but I know that some of you have an interest in issues at the intersection of philosophy, psychiatry and psychology. So, in one way or another, this post is for you.

(1) On Saturday, December 6 (1-5 pm), the Felician Institute for Ethics and Public Affairs will be holding its third annual fall symposium in the Castle View Room of Felician’s Rutherford, New Jersey campus (located on the second floor of the Student Union Building).* This year’s topic is “Psychiatric Medications: Promise or Peril? An Interdisciplinary Discussion.” The symposium will feature four speakers:

Whitaker’s work featured prominently in a much-discussed two-part review by Marcia Angell in The New York Review of Books; for another view of Whitaker’s work, check out this highly critical review by E. Fuller Torrey, along with Whitaker’s response.

I’ll be moderating one session; the other will be moderated by Ruvanee Vilhauer, Professor of Psychology at Felician and until recently, chair of the Psychology Department here. It should be an exciting afternoon, so if you’re in the area and interested, I hope you’ll consider attending. Thanks to Jacob Lindenthal of Rutgers New Jersey Medical School (NJMS) for his advice in putting the event together. Thanks also to Dr. Lindenthal for putting together the Mini-Med School event that I attended this past spring at NJMS, and which, in part, provided the inspiration for the Felician event.

The event is free and open to the public. Refreshments will be provided.

P.S. The papers from the 2012 symposium, on Robert Talisse’s Democracy and Moral Conflict, were just published in Reason Papers and Essays in Philosophy. The papers from last year’s symposium, on Christine Vitrano’s The Nature of Value of Happiness, will be published in Reason Papers in 2015.

(2) Other metro-area conference announcements:

  • On Sunday, November 2, the Northeast Counties Association of Psychologists will be presenting a lecture by Kenneth Frank, “Practicing Psychotherapy Integration: Can Neuroscience Help?” at the Cresskill Senior Center in Cresskill, New Jersey. Details here. I’ll be there along with a few PoT people (so to speak), so if you’re in the area, stop by (though there’s a fee). Thanks to Peter Economou for the suggestion.
  • The Association for the Advancement of Philosophy and Psychiatry has been around since 1989, but for some reason I just managed to notice its existence (obviously a case of narcissistic personality disorder), but it’s jam-packed with valuable resources. Their last conference was in New York; their next conference has yet to be announced. Christian Perring heads the New York-area chapter (small world!).

(3) On a related note, as a fledgling counseling student, I was recently obliged to buy my personal copy of DSM-5, the Fifth Edition of the Diagnostic and Statistical Manual of Mental Disorders. Meanwhile, to make sense of it, I’ve been making my way through Gary Greenberg’s The Book of Woe: The DSM and the Unmaking of Psychiatry. I’ve only gotten about 80 or 90 pages into Greenberg’s book (it’s about 400 pages long), but it’s a great read so far.  Greenberg is a psychologist with an anti-psychiatry ax to grind; he’s also a great writer and a clear thinker who knows how and when to raise the relevant philosophical issues. The book raises some important questions not just about psychiatry per se, but about the logic of classification and the axiology of health and disease. I recently read and enjoyed Greenberg’s Manufacturing Depression: The Secret History of a Modern Disease, but I happen to like Book of Woe better. Highly recommended, for whatever that’s worth.

*The location was changed on October 22, 2014. It had previously been scheduled for a location on the Lodi campus.