I awoke here in Portland (where it is of course raining, and where I will be conversing with Will Hall at 730 at Powell’s) to a chunky, satisfying LA Review of Books review of Book of Woe by Andrew Scull. The book is paired with Hippocrates Cried, written by neuropsychiatrist Michael Taylor.

It is a relief for once for Book of Woe not to be reviewed along with Saving Normal, which for all its other virtues, doesn’t present critics (or readers) with what is strangest about the DSM-5 backlash: the way that even ardent defenders of psychiatry are despairing about descriptive psychiatry, and deeply worried about the professional empire erected upon it. An astute reading my BOW and SN together will yield the bromance, maybe even the rivalry between Allen Frances and me, and will have two easily detectable sides to pit against one another: his, which defends psychiatric diagnosis by viewing the DSM-5 as an outlier, and mine, which argues that the DSM-5’s weaknesses are only the latest instance of a problem that underlies the whole DSm project.

But by putting together my book with Taylor’s, a jeremiad by a mainstream psychiatrist who agrees with me nearly entirely about what’s wrong with DSM, Scull hits on the way that the DSM-5 debacle has made for strange, to say the least, bedfellows. Or to put it in a way that will no doubt reinforce Scull’s notion that I am narcissistic and preening, the way that writing this book has ended up putting me in bed with the most unexpected paramours, and I take that as a sort of compliment.

By the way, I think Scull is trying to be droll when he suggests that Taylor and I both suffer from Narcissistic Personality Disorder and thus points out one of the least appreciated uses of the DSM: as a dictionary of insult. (And as the guy who once called DAvid Brooks’s book the love child of Kilgore Trout and Malcolm Gladwell, I can hardly complain when someone takes a cheap shot. ) But what is interesting about his comment, and about the review that ensues once he gets the name-calling out of the way is the way it captures this strange bedfellows phenomenon. I don’t know Michael Taylor, although I am pretty sure that he’s the same guy who coauthored the proposal to put melancholia into the DSM-5, which I report about in BOW. But the fact is that Andrew Scull thinks that we are cut from the same cloth, and at least in one sense I have to agree.

Of course, that’s not the psychopathological sense. I don’t know about Taylor (or Scull for that matter) but it would be ridiculous to deny I’m self-regarding. I am a writer, for crying out loud. On the other hand, it’s not just self-regard. Like a therapist’s, a writer’s self-regard is (or should be) countered by unremitting doubt, which is in turn nurtured by a continuous infusion of self-directed misanthropy. I suppose a good writer is someone whose self-regard edges out his self-loathing  often enough to allow whatever talent he has, and whatever message, to emerge in words. And even Scull has to admit that my “constant need to inject [myself] into the story” doesn’t stop the book from being a “serious indictment.” (He is probably correct that my “self-consciously populist” approach “distracts the reader from the seriousness of the underlying issues,” but that’s probably a question of who the reader is. To an intellectual like Scull who is very familiar with this history and has taken it seriously enough to devote much of his career to, I’m sure it’s really annoying. To a lay reader who has only the vague idea that there’s something wrong with this whole business, the fact that I set out to entertain might actually be helpful in informing his or her antipathy.)

But the sense in which I think Scull’s observation about the likeness between Taylor and me (and, as he points out late in the essay, between Thomas Insel of the National Institute of Mental Health and me) is valuable is the way it highlights the direness of psychiatry’s predicament. In Scull’s words:

We’re stuck. Descriptive psychiatry is a shambles, as both Taylor and Greenberg’s books help to show, and as the events of this month (May 2013) have made even more dramatically obvious. But, at present, it has no plausible rival.

When a man who believes, as Taylor does, that psychiatry is poised to provide the answers we need, if only it would abandon the remnant of the Freudian shibboleths, agrees with a man like me, who believes that the total eradication of at least one of those shibboleths–thgat mental suffering is not the same as physical–then you know you’re down the rabbit hole.

Of course, this is where Taylor and I (at least according to Scull) part ways. Indeed, it the cracker-eating that leads all my odd bedfellows to give me the heave-ho–or, in the case of Allen Frances, to come to regret they ever took a tumble with me in the first place. I want to take the fact that psychiatry is in a shambles seriously enough to wonder whether we can do more than just plod along with a system that no one likes, all the while waiting for it to be replaced by a system–brain-based diagnosis–that I’m guessing only the drug companies will like. (Not that this matters right now, because brain-based diagnosis, its ontological problems aside, is a long long way off.)

So the question for everyone is what to do, now that the curtain is being drawn back. Taylor (and Tom Insel) thinks we should put pedal to metal on the brain research. Frances thinks we should let psychiatry limp along on its admittedly flawed foundation and in the meantime to keep quiet about those flaws, so that people can continue to benefit from it.  I think we should just get honest. As Scull points out, I do propose a solution, what he, quoting from Book of Woe, calls a thought experiment.

What would happen if [psychiatrists] told you that they don’t know what illness (if any) is causing your anxiety or depression, or agitation, and then, if they thought it was warranted, told you that there are drugs that might help (although they don’t really know why or at what cost to your brain, or whether you will be able to stop taking them if you want to; nor can they guarantee that you (or your child) won’t become obese or diabetic, or die early), and offer you a prescription [for these substances

Seems simple and straightforward enough, right? But there is a problem with this proposal, at least Scull thinks so:

Psychiatry’s status is precarious enough as it is. One can only guess to what depths it might sink in such a transparent world.

Perhaps on reflection both doctors and patients would prefer to cling to their illusions. But it seems they may not be able to do so for much longer. And then what?

Scull earlier talks about psychiatry as a con game (a point I make in the book, although he doesn’t cite it, by quoting from Melville’s The Confidence-Man). Confidence underlies the effectiveness of all healing, mental and otherwise. But it generally doesn’t survive the unmasking of its specious basis, any more than the Wizard’s authority in Oz could survive Toto’s indiscretion. Does that mean that psychiatry can’t survive? The Wizard masterfully turned his unmasking into a triumphal exit, leaving while he was still loved. But that means he left when the people were still duped. And this is what I can’t figure out about people who worry as Scull does about the future of psychiatry once the con game is up: do they have this little confidence in people, in our ability to use our trust judiciously? What exactly are they worried about?

 

 

 

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