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.