That’s one of my friend Russell Perry’s expressions. Russ is an old school mechanic, the kind who tries to actually fix cars rather than just swapping out expensive parts until the car runs. He’s got forearms like Popeye’s, and even though he’s 74 years old, he’s still at it full time. But he does spend part of each day telling stories to whoever happens to drop by, and sometimes those stories include a person telling another person something that should be obvious but nonetheless needs to be pointed out, like the fact that it’s not okay to drive with the oil light on. Which is what the expression is meant to convey, since, if you think about it (and I have), bear shit in buckwheat is not very hard to discern.

Anyway, a reader of a piece posted last night on the New Yorker’s elements blog has located the ursine excrement in the grain for me in an email. I’ll reproduce it in its entirety, save for his name, which I will change to Dr. Benway.  I will tell you that he’s a psychiatrist, although, like the bear shit, that is probably obvious.

 

Message: Your “damn book” tweet drew my attention. [I tweeted this morning about a mistake in the article, and about how I should have known better since the correct version was in my “own damn book.”] I read “The Psychiatric Drug Crisis”. Although you make a few valid points, you are obviously a polemicist and a gadfly, not a scientist. Until we are permitted to do biopsies on living brains (which I of course oppose), or come up with the equivalent, psychiatry will remain an art as well as a science.

Many discoveries in medicine (e.g. penicillin) were also made via serendipity. Anybody in my profession, which has plenty of flaws like any other, knows that true depression, on average, will remit in about 6 months. Antidepressants shorten that, as long as a proper diagnosis is made in the first place and a competent practitioner, by a necessary trial and error process, finds a medication that is at least reasonably effective and has a tolerable side-effect profile.

Rather than flacking your latest book on Twitter and elsewhere, I suggest you learn some science. You are obviously a gifted journalist, and any target is legitimate, but the article referred to above is deceptive, irresponsible, and self-serving. Any competent psychiatrist who is not wearing blinders knows that simplistic explanations of mental illness that are tied to neurotransmitters have been proven wrong. So what? That’s how science proceeds. We all know about the mind-brain debate. And incidentally, some of the most vocal and influential critics of prevailing models of mental illness and the practice of psychiatry have been psychiatrists themselves, like Thomas Szasz, R.D. Laing, and E. Fuller Torrey. At least they didn’t cobble their writings together based upon Cliff’s Notes or Psychiatry for Idiots.

Further, we know that mental illnesses can be misdiagnosed, overdiagnosed and even mislabeled. Again, that’s the way the world works. Physicians and scientists are human and the entire medical profession is currently under attack by persons much better qualified than you.

As to your comments about people being told that their condition is due to a chemical imbalance, would you rather they be told that they are crazy? Most of these “explanations”, even if ultimately proven wrong, are made in good faith, based upon what is hypothesized or “known” at the time.

Irresponsible, inaccurate (imipramine=Elavil)journalism like yours, as exemplified by the article in question, does a disservice. Just because a “chemical imbalance” may be an inadequate, or even false theory of mental illness, doesn’t mean that progress has not been made, and that, again, antidepressants work very well when judiciously utilized, but don’t work for everyone. That’s why treatment-resistant depression is a recognized entity.

In my opinion, psychiatrists have been their own worst PR people, and should be more proactive in informing the public about new developments, etc. Freudian theory and the dogmatism of its dwindling adherents have done tremendous damage to the public perception of psychiatry and a significant percentage of the population don’t know the difference between a psychiatrist, a psychologist, an analyst, a psychiatric social worker, a counselor and a therapist.

You would be doing the world a much greater service by presenting unbiased and constructive information instead of the poorly-targeted, deceptive, superficial and semi-informed work you bring out. BTW, I am aware of your personal experience with treatment. That experience is in and of itself a potential double-edged sword with respect to the objectivity of your views regarding psychopharmacology.

You have lost all credibility with me, and I certainly won’t be buying your “damn book”.

I really like this letter. It’s heartfelt, direct, and nicely written. He’s correct in many ways–surely that I am trying to sell books on Twitter and elsewhere, that I am a gadfly (although I’m not sure I am a polemicist) and not a scientist, that my article confused the names of two antidepressants, and that he probably isn’t going to be buying my damn book–although that’s a pity, because he might learn a thing or two from it. Plus he’s honest enough to admit how closed-minded he is.

But he does have a few things wrong. I never said progress hadn’t been made. I didn’t argue that psychiatry was the only medical specialty indebted to accident, and I didn’t cobble together my argument from Cliff;s Notes or Psychiatry for Idiots. I cobbled them together from two books that collectively took me more than five years to write, and which each run more than 400 pages with extensive bibiliographies. But that doesn’t matter, except for one thing: that accusation is, like the rest of the email, a nearly perfect example of one of the most common species of reactions to my work about psychiatry. Let’s call it the ad hominem gambit, in which the shortcomings of my character are somehow taken to invalidate what I am saying, and which reaches an apotheosis in this letter. I don’t think all these adjectives–self-serving, irresponsible, deceptive, superficial, polemical, ill-informed, dangerous, and personally experienced with treatment–have ever been gathered together in a critique of my stuff before. So my hat’s off to Dr.  Benway for his efficiency.

But go ahead and read my article and then try to find exactly what  Dr. Benway is saying is incorrect, other than that stupid error (now corrected) about the antidepressant names.  I think what my article says is fairly simple: the drug industry is giving up on making psychiatric drugs because mental disorders simply don’t respond to medication in the same way that many (but not all) physical disorders do. Or, to put it another way, the germ theory of disease, out of which the drug industry grew and which it adopted as its model, doesn’t work very well when it comes to psychological suffering. While once it was thought that neurotransmitter imbalances would play the same role as germs in understanding and treating mental illness, this has proven to be far too simplistic an approach, and the drug companies, having watched the wagon to which they hitched their hopes crash and burn, are unhitching themselves as fast as they can. And, I speculate, it’s possible that consumers, who have yet to fully understand that the neurotransmitter imbalance theory (NIT) works better as myth than as science, may not be far behind.

This last bit is, I think, where Dr Benway’s ire comes from. I think people tend to think of “myth” as a derogatory term; surely he does. But even if a myth is not the truth, it isn’t a lie. It’s a powerful way of knowing the world. The NIT has served its purpose. As he himself points out, it’s better than just calling people crazy. But does that mean it’s the best account of mental suffering? More to the point, when your myth relies for its power on a claim to scientific accuracy, and when science proves the myth inaccurate, is it a good idea to cling to the myth? And even more to the point, when the psychiatrists have abandoned the myth, is it a good idea to continue to pr0mulgate it among the laity?

That’s the point at which Dr Benway and I disagree about good and bad faith. Of course the myth originated in good faith. Contrary to Dr Benway’s belief about me, I havce studied those origins deeply. I’ve talked extensively with the scientists, at least the ones still alive, who originated it, and found them to be brilliant, engaging, compassionate people who really thought that the NIT was going to be the key to the mysteries of mental illness. (And many of these discoveries and theories were indebted to LSD, which really predisposes me to be sympathetic.)

But once the myth been discredited, once doctors are saying one thing to each other and another thing to the rest of us, then I think that is a definition of bad faith. And when simply saying it out loud, as I did in the New Yorker blog, inspires this kind of vituperation, I think what we are seeing is the attempt to divert attention from the fact that there is nothing with which to replace the myth. This is indeed disconcerting and worrisome to doctors and patients alike. It calls psychiatry’;s authority into question and leaves patients to wonder what will become of them. (Only corporations are well-equipped to respond to the end of the myth, which they are doing by abandoning it.)  And it leaves psychiatrists without a response other than the one their training prepares them for: diagnosing the messenger. But regardless of my character, the bear shit is definitely in the buckwheat, and it really does stink.

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