Sep 17 2013

More On Mental Illness Denial and How Not to Argue

I recently came across a critique of a prior post of mine on the DSM-V – Mental Illness vs Normal Behavior. The critique is by Philip Hickey, a retired PhD psychologist, on his blog Behaviorism and Mental Health – An alternative perspective on mental disorders.

Hickey disagrees with my defense of psychiatry, which he seems to equate with an extreme “medicalization” approach to life problems. In his response, however, he does not actually address my position, as I very carefully laid it out. Instead he attacks a series of straw men – characters in a narrative that he apparently already has well established in his mind. This narrative creates a very thick filter distorting his view of my position.

Hickey summarizes his position early on:

Now, for me, this is fairly obviously true and is borne out by the facts.  Psychiatrists who talk in terms of “diagnoses” and “chemical imbalances” etc., do in fact ignore causal factors such as abuse, poverty, and social deprivation.  They call their clients “patients” and they routinely tell these “patients” that they have “an illness just like diabetes” and that the pills will fix their brain chemistry.

He states as a fact that psychiatrists ignore “abuse, poverty, and social deprivation.” That is his premise, and he will not be dissuaded from his premise regardless of what I write. He dismisses my characterization of what is typical of psychiatry in favor of his own, but his distortions of my position (even right after quoting paragraphs from my post clearly stating what that position is) do not fill me with confidence in his perception.

I acknowledge it is difficult to provide solid evidence for what psychiatrists “typically” believe. In general when I talk about the standard within a profession, I am talking about the standard as established by official publications, academics, and published standards, not the average private practitioner “in the field.” Hickey, however, seems to prefer the “in the field” approach.

I have had much direct contact with psychiatrists, as a student and then as a colleague, and I am basing my impressions on that exposure. Also, however, reading articles written by psychiatrists is probably the best indication of what the profession generally believes. I never – ever – encounter Hickey’s extreme straw man, that all mental disorders are caused by underlying brain dysfunction and chemical imbalances, ignoring environmental factors. Hickey consistently confuses “sometimes” with “always” in this regard – even when I explicitly state the sometimes.

For example, he states of my position:

Dr. Novella delineates the two extreme responses to his essential question:

– those who consider human problems to be part of the normal spectrum

– those who medicalize all human problems

Dr. Novella then expresses the opinion that the best approach is something “in the middle:”  “…before you can recognize the abnormal you have to recognize the full spectrum of what is normal.”  He goes on: “…we need to recognize the full spectrum of human nature, accept less common and atypical forms of human mood, thought, and behavior, and also recognize the relative roles of biology, situation, and culture (and their interactions) in forming a person’s mental state.”  Now this is all fairly good stuff.  It certainly is a far cry from standard psychiatry, and you might actually be wondering if Dr. Novella is a closet “denier.”

I disagree with his assumption that the position I described in “a far cry” from standard psychiatry. My position is partly the result of my education at the hands of psychiatrists. Notice how he also confuses the nuanced and scientific position that I describe with the “denier” position. Hickey continues by quoting another paragraph from me:

“On the other hand, the brain is an organ, it is biology, and it can malfunction biologically just like any other organ. Further, even a biologically healthy brain can be pushed beyond tolerance limits resulting in an unhealthy mental state. We can reasonably define “unhealthy” in this context (probably a more appropriate word than “abnormal”) as follows – a mental state that is significantly outside the range of most people, may represent the relative lack of a cognitive ability that most people have, and results in definable harm. That last bit is critical – it has to be harmful.”

At this point my position should be very clear – I carefully define “mental disorders” and explain that they are caused by the full spectrum of influences from biology to social and environmental. Further, I explain that definitions are complicated and unavoidably subjective when dealing with something as horrifically complex as human behavior. This does not preclude a working definition of “disorder” that allows clinicians to identify, discuss, and treat problems of mood, thought, and behavior.

Hickey neither acknowledges nor addresses my actual position, even after directly quoting it. Instead he takes one piece of it, (quoting from myself again) “On the other hand, the brain is an organ, it is biology, and it can malfunction biologically just like any other organ,” and creates a straw man out of that. He writes:

Dr. Novella goes on to acknowledge that “there is an unavoidable amount of subjectivity in the above definition,” giving the impression that he is a reasonable person willing to concede that the “deniers” might have some validity in their corner.  But he evades the core issue – or at least what for me is the core issue – that although brain malfunction can and does cause problem behavior, problem behavior can and does occur in the absence of any brain malfunction.

The fallacy that Dr. Novella has fallen into is:  A has been noted to cause B.  Therefore every instance of B must have been caused by A.  A lightning strike can damage your TV.  But it would be unwarranted to assume that a lightning strike was the culprit every time your TV malfunctioned.

Hickey is comfortable concluding (assuming, really) that I am just giving the impression of being reasonable, rather than actually being reasonable. I am not evading the core issue – I spell it out explicitly. Hickey just ignores my explanation to erect a blatant straw man.

I never wrote or implied that all mental disorders are caused by brain malfunction. In fact he wrote that right after quoting me as saying:

“Further, even a biologically healthy brain can be pushed beyond tolerance limits resulting in an unhealthy mental state.”

I don’t see how this can be misinterpreted. I state directly that a biological healthy brain can be pushed into an unhealthy mental state by extreme circumstances. Yet, Hickey characterizes my position right after quoting me as being the opposite. He flays this straw man for a few more paragraphs, then tries to do it further by critiquing my characterization of ADHD as a deficit of attention:

(summarizing my position) Brains and parts of brains malfunction.  Parts of brains are dedicated to paying attention.  If a child isn’t paying attention, there must be something wrong with those parts of his brain.

But the reality is more complicated.  Children (and adults) are always paying attention to something.  The point about ADHD is not that the child is inattentive, but rather that he is not paying attention to the things that he needs to attend to.  Everyone knows that playing is easier than studying.  Doing what we like is easier than working.  A child will generally not pay attention to the latter items unless he has been actively trained to do so.  Absent this training, he does whatever he likes and consequently attracts a “diagnosis” of ADHD.

Yes – the reality, and my position, are more complicated that your straw man. Notice what he does here. I am clearly stating that mental disorders generally are caused by some combination of biological and environmental factors. He distorts this position into saying that my position is the extreme version of the “brain illness theory of the so-called mental illnesses.”

He then states that the reality is more complex, and then states an extreme non-biological theory of mental disorders. To be fair, he does also state:

“Nobody is denying that brain problems can cause behavioral problems.”

But I disagree. There are those who do deny that brain problems can cause behavioral problems. I have had many a debate with those who take that position. I will, however, take Hickey at his word that he is not such a person. He acknowledges that brain disorders that cause behavioral problems exist (I would add mood and thought disorders also) but does not seem to want to label such brain-caused behavioral problems as mental illness, and rejects the “disease model” of such brain problems.

In his one example, however (responding to my position on ADHD) he takes a position that is not supported by evidence and seems to be an extreme environmental position. He is saying explicitly that ADHD results not from a brain disorder (a decrease in activity in that part of the brain which allows us to pay attention, what is called “executive function”) but rather an absence of training – i.e. bad parenting.

This position flies in the face of decades of research which clearly show that ADHD is a genetic disorder characterized by hypofunctioning of the frontal lobes leading to a relative deficit of executive function. This part of the brain serves as a “resource allocator” – allocating brain resources to various tasks. Relative lack of this function results in a reduced ability to pay attention to the things we should be paying attention to.

(It’s difficult to provide a single reference to reflect all this research, but here is a JAMA summary.)

Now, before my position is distorted further, there are of course environmental influences on ADHD, and there is a role for psychological and behavioral interventions. But ADHD happens to be a dominantly biological disorder (that’s just the way the research turned out). Psychiatrists did not assume biology. In fact the “bad parenting” hypothesis was their assumption until the research proved otherwise. It would take a separate article delving into this one issue to do it justice – perhaps a follow up.

Hickey gives an indication of his opinion of such research, however, writing:

But let’s be clear.  Training causes changes in brains.  This is self-evident.  So there are differences between the brain of a disciplined, well-behaved child and an inattentive, self-indulged, misbehaved child.

This is a convenient way to dismiss all neuroscience providing evidence for specific mental disorders having an underlying biological basis. Hickey is falsely accusing those who acknowledge that biology sometimes plays a role in mental disorders of being hyperreductionist – pointing to brain changes and assuming they are the cause, rather than the result or just a marker, of the behavior in question. He writes:

If I were to kick you on the knee, and you asked why I had done this, would you accept it if I replied –”brain chemistry”?  That’s the essence of the brain malfunction theory of mental illness.

No, that is the essence of Hickey’s ridiculous straw man, not any serious position taken by any professional. Researchers do not assume that brain changes are the cause, rather than the result, of the correlating behavior. Neuroscientists speak of “neuroanatomical correlates” and recognize that correlation does not equal causation (although sometimes it can be due to causation).

Hickey further explains his position toward the end of his post:

The deniers’ point, however, (or at least this denier’s point) is that mental illness is an archaic, pre-scientific concept with no explanatory value, exactly analogous to phlogiston or witchcraft.

Wait – but I thought that brain disorders can cause behavior problems? Wouldn’t such a case that Hickey acknowledges exists be considered a “mental illness?” I’m trying to be fair, but such comments certainly sound like mental illness denial to me.

Conclusion

Hickey provides an excellent example of how not to argue or respond to a contrary position. He attacks a series of straw men, even immediately after quoting my position as being very different than the one he attacks.

He accuses me and psychiatrists generally of ignoring psychological factors, assuming all mental symptoms are caused by brain disease, assuming cause and effect from brain correlations, and taking a hyperreductionist approach to brain science. None of this is true – and he provides the quotes that betray his own distortions.

Rather, Hickey is taking an extreme anti-biology position. He pays lip service to the notion that brain disorders do exist and can cause “behavior problems,” which is vastly understating the reality, but then later contradicts that position by calling the very notion of mental illness pseudoscience.

If there is a reasonable position to be made against the concept of mental illness, I have yet to hear it. So far I have only encountered the level of argument similar to or worse than Hickey’s unfair and confused article. I am open to any reasonable argument to be made against my current position. That would require, however, engaging with my actual position, not a distorted cartoon of my position.

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