If RWH hasn't already learned this: mental illness is what the mental health profession says it is; if - (falsely) so-called mental illness isn't in the DSM, there will be no insurance coverage/reimbursement for it; once a professional socilety puts such a compendium out, it becomes a "bible" for a religion known for sacrificing dissidents; with increasing competiton for healthcare dollars, the more potential patients, the merrier; BS + ICD-10 = DSM 5.
"If RWH hasn't already learned this: mental illness is what the mental health profession says it is; if - (falsely) so-called mental illness isn't in the DSM, there will be no insurance coverage/reimbursement for it; once a professional socilety puts such a compendium out, it becomes a "bible" for a religion known for sacrificing dissidents; with increasing competiton for healthcare dollars, the more potential patients, the merrier; BS + ICD-10 = DSM 5."
1. Of course, I don't disagree with Kirk Skeptic taking the DSM to task. In fact, I'd like to hear more from Kirk Skeptic on the DSM, because he's a psychiatrist and my hope is it'd be beneficial to others.
2. However, for better or for worse, keep in mind what Kirk Skeptic says is colored by the fact that he's a Thomas Szasz devotee (e.g. see Kirk Skeptic's own blog posts here, see what Kirk Skeptic has said about Szasz elsewhere on Triablogue here).
3. Other physicians and scholars have said the following about Szasz:
a. British psychiatrist Theodore Dalyrmple has said: "Thomas Szasz, a brilliant but dogmatic polemicist (as well as a professor of psychiatry), overcame this problem by denying that psychiatric disorder existed. According to Szasz, bizarre, distressing, or harmful behavior was either the result of an objectively observable pathology - hypothyroidism, say, or hypoglycemia, Cushing’s syndrome, or a brain tumor - or the patient was wholly responsible for it and suffered from nothing but a moral defect."
b. Likewise I've posted some comments on Szasz by Dr. David Martyn Lloyd-Jones.
Szasz's critics have responded along several lines.
[a] Some do not take issue with his underlying understanding of the illness concept but disagree with his claim that it is not applicable to mental phenomena. Mental illnesses, according to these critics, have been (or will soon be) reducible to neurological or neurochemical dysfunction. They argue that advances in neuroscience give us reason for thinking that the prospect for finding the neurological or neurochemical correlates for at least some of our mental illnesses categories is high (Bentall 2004, 307).
[b] Other critics have argued instead in the other direction and attacked Szasz’s construal of physical illness. Szasz’s arguments have been taken, by some, to imply that physical illness itself is a deeply evaluated category reflective of value-judgments in much the same way mental illness is meant to on Szasz’s account (Fulford 2004; Kendell 2004).
[c] Still others have aimed to preserve Szasz’s primary claim that the overarching category of ‘mental illness’ will prove to be a non-natural interactive-kind, reflective of our values and practices, while simultaneously maintaining that “particular kinds of mental illnesses may yet constitute valid scientific kinds” (Pickard 2009, 88).
I agree with much of Szasz without being a devotee; also I'm not a psychiatrist but am boarded in family medicine. Since generalists prscribe most of the psychotropics dispensed in the US, we're not without experience and perspective in mental health treatment.
The metaphoric problem remains, however, because mental healthcare provders insist on using physical language (eg disease) without relying on physical means of diagnosing such by identifying lesions; eg the diagnosis of hepatitis c is objective in that one needs the presence of a specific antibody, and one can measure viral loads and response to treatment without worrying about cultural influence or observer bias. MH practitioners can't identifu etiologies or truly objectify their diagnoses in the same way an internist can; this is not to say that mh patients aren't truly suffering, but a suffering spirit or is not the same thing as an infected liver and language should rflect that difference. As belivers in total depravity, the idea of emotional consequences of hard-wired or acquired sin should come as no surprise.
Szasz is not the last word, but neither are those sources cited by RWH; perhaps he could identify the presuppositions his sources hold in order to explain why they believe in mental illness?
"I agree with much of Szasz without being a devotee"
Well, based on what you've said in the past and present, what if we just say you strongly support several of Szasz's key ideas? Such as his idea that mental illness is "myth" and "metaphor" rather than "real" (which you reiterate below in this very comment).
Not to mention your original comment in this thread seems to reflect Szasz's idea that the state via psychiatric professionals and organizations (e.g. the APA) uses "mental illness" as a means to control people in society.
I should say (as I've said in the past) I actually agree with a lot of Szasz. But I think he goes too far in certain respects. However, that's a debate I don't have time to delve into at the moment. Hence my referencing other resources above.
"also I'm not a psychiatrist but am boarded in family medicine."
Thanks for the clarification. I have a great amount of respect for family physicians and PCPs in general. I wish PCPs were better appreciated and valued than, say, proceduralists, who often seem to be overvalued. But thankfully God knows and thankfully your patients know.
"Since generalists prscribe most of the psychotropics dispensed in the US, we're not without experience and perspective in mental health treatment."
I never called into question your experience, and I never would.
That said, I would think a psychiatrist would be more experienced in dealing with mental illness. Of course, I realize you don't believe "mental illness" is real, hence not sure if you believe psychiatry is a legitimate medical field or specialty in the first place. Or perhaps you believe psychiatry can be if it adopts Szasz's criticisms.
"The metaphoric problem remains, however, because mental healthcare provders insist on using physical language (eg disease) without relying on physical means of diagnosing such by identifying lesions; eg the diagnosis of hepatitis c is objective in that one needs the presence of a specific antibody, and one can measure viral loads and response to treatment without worrying about cultural influence or observer bias. MH practitioners can't identifu etiologies or truly objectify their diagnoses in the same way an internist can; this is not to say that mh patients aren't truly suffering, but a suffering spirit or is not the same thing as an infected liver and language should rflect that difference."
There's much to agree with here, and much to disagree with. The human mind is highly complex. But my only point for the time being is this seems to strongly echo Szasz's core ideas about mental illness, for better or for worse.
"As belivers in total depravity, the idea of emotional consequences of hard-wired or acquired sin should come as no surprise."
Sure, I suppose, it's "no surprise" there can be "emotional consequences of hard-wired or acquired sin." However, we'd need to further unpack the phrase.
Moreover, isn't the question as raised by Szasz more about whether that is all it is? That mental illness isn't "real"?
"Szasz is not the last word, but neither are those sources cited by RWH, perhaps he could identify the presuppositions his sources hold in order to explain why they believe in mental illness?"
Not sure why one needs to "identify the presuppositions." Not that "presuppositions" aren't important, and indeed everyone has their own presuppositions, but that seems a roundabout way to approach all this. For example, why do we need to "identify" Martyn Lloyd-Jones' "presuppositions" in all this? Wouldn't it be better to simply read Martyn Lloyd-Jones' criticisms of Szasz, and see if you agree or disagree with his criticisms? That seems more straightforward and to the point.
I've reread your posts, but first a clarification: my statement about genralists prescribing psychotropics was not a resonse to an imagined slight, but rather pointing out that, despite not being boarded in psychiatry, we are not mere armchair observers.
Dr LJ' concern re: Szasz's moralizing of mental illness is valid, but one can hardly deny that there is a moral component to those who are labelled as mentally ill and respond to stiutations sinfully, or suffger what was once attributed to the consequences of a guilty conscience because they were in fact guilty (Szasz used the example of Lady Macbeth). Psychiatry's disease model of mental illness results in exculpatory language; ie one speaks of "relapses of alcoholism" for drunken binges or various Axis II terms for brats; whereas Szasz may have overmoralized, psychiatry has (wittingly or no) unmoralized its patients' suffering. Think what you will of Limbaugh, but he was spot on when he said "words mean things." Just as Szasz could be said to be dated, so could LJ, who was not even a physician but a surgeon (the British medical education system is such that physicians and surgeons get different degrees, with the former addressed as "Dr" and the latter as "Mr"); what would he have thought of gender dysphoria?
Presuppositions matter in this discussion because of the tendency of the psychiatric side to assume the false moral high ground of science and attribute an antiscientific bias to its critics. Also, if one believes in materialism one will make distinction made between brain and mind and deny the existence of the soul, thereby making mental illness no different to physical illness and psychiatry no different to neurology. The theist in general - and the Christian particularly - will distinguish between brain and mind, believe in the existence of the soul, and realize that physical language and methodology will be severely limited in dealing with what becomes a spiritual matter. What strikes me about Szasz is that he saw this clearly and, despite his atheism, saw himself and his colleagues as secular clergy clergy rather than physicians dispensing counsel to voluntarily-associating patients rather than physicians practicing scientific medicine - hence his general support for Chrisitan counseling. He never denied that mental patients suffer, but rather insisted in statig that they had no disease and hence should not be treated as such; this is hardly denying any reality to suffering.
As for unpacking "emotional consequences of hard-wired or acquired sin," Szasz' example of Lady Macbeth is perfect. Today she would be counseled about her excessive guilt, medicated for obsessive-compulsive disorder (all that handwashing), and perhaps even court-ordered to have ECT due to her refractory suicidality. The fact that she wqas guilty of real sin would not occur to her psychiatrists, and thus no discussion of repentance and need for salvation would ensue. She might even be told of the the importance of "moving on" with her life. Psychiatry has no concept of sin and is at best moralistically and therapeutically deistic; ie if believe in an "higher power" keeps you from being a public nuisance or threat, go for it. The consistent Christian knows better, and might see psychiatric practice akin to medicating a patient complaining of stabbing lumbago while ignoring the dagger in his back.
"I've reread your posts, but first a clarification: my statement about genralists prescribing psychotropics was not a resonse to an imagined slight, but rather pointing out that, despite not being boarded in psychiatry, we are not mere armchair observers."
Again, I never claimed otherwise. Nevertheless, again, a family physician's knowledge and experience on the topic of mental illness and related isn't necessarily equivalent to a psychiatrist's knowledge and experience on mental illness and related.
"Dr LJ' concern re: Szasz's moralizing of mental illness is valid, but one can hardly deny that there is a moral component to those who are labelled as mentally ill and respond to stiutations sinfully, or suffger what was once attributed to the consequences of a guilty conscience because they were in fact guilty (Szasz used the example of Lady Macbeth)."
The issue isn't whether "there is a moral component to those who are labelled as mentally ill" in some cases, which I've already granted is certainly possible, but whether every case of "mental illness" is predominantly due to personal sin and guilt.
"Psychiatry's disease model of mental illness results in exculpatory language; ie one speaks of "relapses of alcoholism" for drunken binges or various Axis II terms for brats; whereas Szasz may have overmoralized, psychiatry has (wittingly or no) unmoralized its patients' suffering."
No doubt that's true with many secular psychiatrists. But faithful Christian psychiatrists don't necessarily adopt the language and methods of secular psychiatry. And to the degree that we can even say there's a single model, it's not as if Christian psychiatrists can't challenge secular psychiatry.
"Just as Szasz could be said to be dated, so could LJ, who was not even a physician but a surgeon (the British medical education system is such that physicians and surgeons get different degrees, with the former addressed as "Dr" and the latter as "Mr"); what would he have thought of gender dysphoria?"
What makes you think Lloyd-Jones was a surgeon rather than a physician? Do you have evidence Lloyd-Jones was a surgeon? If so, I'd be interested to know. However, at least from what I've read, Lloyd-Jones was (among other things) a member of the Royal College of Physicians (as opposed to Royal College of Surgeons) as well as Chief Clinical Assistant to Sir Thomas Horder, who was the Royal Physician to the King.
Besides, Lloyd-Jones wasn't the only critic of Szasz I cited.
By the way, I'm well aware of the Mr designation for surgeons in the UK and other Commonwealth nations. But in my experience it's not a hard and fast rule (e.g. I've met UK and other Commonwealth surgeons who have introduced themselves as Dr rather than Mr).
"Presuppositions matter in this discussion because of the tendency of the psychiatric side to assume the false moral high ground of science and attribute an antiscientific bias to its critics."
I'd say that's true of many secular scientists (e.g. militant atheists). It's not something distinct to psychiatry as a field.
"Also, if one believes in materialism one will make distinction made between brain and mind and deny the existence of the soul,"
I think some materialists or physicalists might disagree with your statement (e.g. David Chalmers).
"thereby making mental illness no different to physical illness and psychiatry no different to neurology."
I don't see how this logically follows from your former statement. You certainly don't provide any connecting argument between the former and the latter.
"The theist in general - and the Christian particularly - will distinguish between brain and mind, believe in the existence of the soul, and realize that physical language and methodology will be severely limited in dealing with what becomes a spiritual matter. What strikes me about Szasz is that he saw this clearly and, despite his atheism, saw himself and his colleagues as secular clergy clergy rather than physicians dispensing counsel to voluntarily-associating patients rather than physicians practicing scientific medicine - hence his general support for Chrisitan counseling."
I guess you're just attempting to summarize Szasz's beliefs here (e.g. his belief that psychiatrists are more akin to "secular clergy" than "physicians practicing scientific medicine").
"He never denied that mental patients suffer, but rather insisted in statig that they had no disease and hence should not be treated as such; this is hardly denying any reality to suffering."
You're tilting at windmills since I never denied the reality of suffering.
"As for unpacking "emotional consequences of hard-wired or acquired sin," Szasz' example of Lady Macbeth is perfect. Today she would be counseled about her excessive guilt, medicated for obsessive-compulsive disorder (all that handwashing), and perhaps even court-ordered to have ECT due to her refractory suicidality."
Again, a character like Lady Macbeth may be a helpful stand-in for some people who suffer mental illnesses, but again she's hardly a stand-in for all people who suffer mental illnesses.
"The fact that she wqas guilty of real sin would not occur to her psychiatrists, and thus no discussion of repentance and need for salvation would ensue."
Again, I don't have any problem saying some people with mental illness are actually suffering mental illness because of their sin, but how is that necessarily true of all people who suffer mental illness?
"Psychiatry has no concept of sin and is at best moralistically and therapeutically deistic; ie if believe in an "higher power" keeps you from being a public nuisance or threat, go for it. The consistent Christian knows better, and might see psychiatric practice akin to medicating a patient complaining of stabbing lumbago while ignoring the dagger in his back."
That's not true of faithful Christian psychiatrists (e.g. Richard Winter).
There's still some tapdancing here, as psychiatrists (secular or faithful) have not demonstrated a lesion - this is a requirement for calling something a disease in our current understanding a la Virchow. How does one demonstrate a lesion (a physical entity) on a mind, unless one equates mind with brain? Otherwise one must have a mechanism to objectify the metaphysical. This is also why suffering from a mental/emotional/spiritual problem is not the same as suffering from a physical ailment like hepatitis. That not all mental issues stem from moral lapses is not so much the issue as is none of those who have purely psychiatric diagnoses have identifiable physical lesions (a tautology to be sure); a relapse of cancer or malaria is in no wise comparable with a relapse of alcoholism and is nought but mixing metaphors. Show me the lesion and we can then put Szasz' - and others' - works in the same pile as treatises on phlogiston and aether; until then, those who insist upon claiming mental illnesses to be bona fide diseases must shoulder the burden of proof - which they have not.
As for my commenting about Szasz not denying suffering, ISTM that is the attitude I get from his critics,as if denying that someone has a disease is in some way belittling them or delegitimizing their suffering.
"There's still some tapdancing here, as psychiatrists (secular or faithful) have not demonstrated a lesion - this is a requirement for calling something a disease in our current understanding a la Virchow. How does one demonstrate a lesion (a physical entity) on a mind, unless one equates mind with brain? Otherwise one must have a mechanism to objectify the metaphysical. This is also why suffering from a mental/emotional/spiritual problem is not the same as suffering from a physical ailment like hepatitis. That not all mental issues stem from moral lapses is not so much the issue as is none of those who have purely psychiatric diagnoses have identifiable physical lesions (a tautology to be sure); a relapse of cancer or malaria is in no wise comparable with a relapse of alcoholism and is nought but mixing metaphors. Show me the lesion and we can then put Szasz' - and others' - works in the same pile as treatises on phlogiston and aether; until then, those who insist upon claiming mental illnesses to be bona fide diseases must shoulder the burden of proof - which they have not."
1. Virchow lived in the 19th century and died around the turn of the 20th century. Although he made many significant contributions to medical science (e.g. his cell theory including the oft-quoted bit about every cell coming from other cells; his opposition to humoralism), he likewise held beliefs about disease causality which today would largely be considered mistaken (e.g. he strongly opposed Pasteur's germ theory of disease; he opposed antiseptic techniques such as handwashing; his belief that cancers "spread like a liquid"). In any case, judging by modern standards, Virchow held both correct and incorrect beliefs about disease. Hence I wouldn't necessarily take Virchow's understanding of disease as the last word or even an authoritative word in light of modern medicine; it'd depend on the specific details of what you're saying about Virchow's understanding of disease.
2. If you contend the brain is physical, while the mind is non-physical, then by definition you're ruling out the possibility of a "lesion" or other "physical entity." Hence it's a bit unfair to say "show me the lesion" when by definition you're precluding its possibility in the first place, in advance.
Related, you're assuming disease must mean physical disease. But that's a point in contention.
3. Or at the very least, we cannot test for non-physical things in the same way we can test for physical things. However, just because we cannot test for the non-physical doesn't mean the non-physical doesn't exist. Take a normal person like you or me. I cannot directly test that you're conscious or that you have a consciousness. A brain CT or MRI won't reveal your consciousness. But this doesn't mean your consciousness doesn't exist.
4. What's more, we can infer your consciousness from effects. Indeed, science routinely infers causes from effects, even when no known instrument could test for the cause. Inference to the best explanation is a tried and true basis for scientific investigation. Particularly in the historical sciences such as cosmology, geology, paleontology, forensic science, and so on. Several intelligent design theories likewise rely on inference to the best explanation. Would you say these scientists are all mistaken each time they make an inference to the best explanation from effects instead of "showing a lesion" (as it were) i.e. deductively demonstrating a necessary cause? If so, then that's not rational.
5. You've claimed sin is the primary (or perhaps sole) cause of suffering in mental illness. Yet, we cannot always "show a lesion" or "physical entity" when it comes to sin either. (Obviously we know this is true because we're Christians, but non-Christians wouldn't necessarily agree.) As such, judging by your own lights, it'd seem sin is therefore not necessarily a better explanatory cause for someone's suffering than "mental illness." At best, they're on equal explanatory grounds with one another.
6. You've suggested as a family physician that you've prescribed psychotropics (e.g. you said "Since generalists prscribe [sic] most of the psychotropics dispensed in the US, we're not without experience and perspective in mental health treatment"). If you have prescribed psychotropics, then what I don't understand is why prescribe psychotropics if you don't believe mental illness is real? Or if you don't think these medications are efficacious to some degree?
7. You're implying if there is no "physical lesion" or "physical entity," then there is no disease. This in turn implies the absence of evidence is therefore evidence of absence. But why should one accept this premise? It seems illogical to argue because we do not know the cause or etiology of x, therefore x doesn't exist. For example, although we have theories, we don't know the specific etiology of migraines. Yet does this mean migraines don't exist? Of course not.
We could say similar things about certain pains which the patient says he or she feels but which don't seem to have a physical cause as far as our best tests can detect (e.g. no C fibers firing).
8. At the same time, it's possible to say x causes y, but x doesn't necessarily always cause y. Mutations in the BRCA1 and BRCA2 genes could be said to cause breast cancer, but BRCA mutations don't necessarily always cause breast cancer.
9. Szasz shoulders a burden of proof inasmuch as he's not arguing for an agnostic position on mental illness, but rather he's positively arguing mental illness does not exist or is a myth or metaphor.
PS: my confusion re: LJ stemmed from my reading of his practicing at a "surgery," which i learned is a term for any dr's office; mea culpa. As for Dr Winter, I favorably cited his work on my blog but still see his difficulty regarding the disease metaphor; this is no minor point .
"PS: my confusion re: LJ stemmed from my reading of his practicing at a "surgery," which i learned is a term for any dr's office; mea culpa. As for Dr Winter, I favorably cited his work on my blog but still see his difficulty regarding the disease metaphor; this is no minor point ."
No problem at all. That's understandable.
Please see my reply above regarding "the disease metaphor."
Regardless of when Virchow lived, his paradigm is still in operation; ie the concept of the lesion. Our classification system is based upon it; no lesion, no disease, and there is a practical logic to medical taxonomy. This does not mean no reality; there are syndromes and associations, but diseases require lesions. As phyicians we still address and treat symptoms, so it is no contradiciton to prescribe psychotropics for symptom relief.
The rub comes when we believe that our psychotropics are addressing *the problem,* as if suffering the slings and arrows is nought but a function of neurochemistry rather than overwhelming mental anguish +/- sinful responses thereto. With no understanding of how prolonged exposure to these medications may change brain hard-wiring and hence behaviors and emotional responses, to not address the spiritual side of mental issues is to act as a reductionistic materialist and in a sense deny Scripture.
I nowhere claimed that sin was either the sole or primary etiology of mental issues; rather it is an important etiology the existence of which is denied by psychiatry, which can only think in terms of vague spirituality. They deny the existence of the soul in practice, so it is they not I who have the problem of absence of evidence = evidence of absence.
Your point #7 disregards medical taxonomy; a group of symptoms and findings might not be a disease, but that doesn't say its not real. We should not feel free to use words (and hence ideas) idiosyncratically, thereby introducing confusion. Our classification system exists for the reason of clarity, and hence can't just mean what it means to you today.
Historical sciences are similar to the above problem in that they are allowed to mask sheer speculation as established fact, making entire dioramas of alleged paleological life or pontificating about the age of the earth and beginnings of mankind from the scantiest of evidence and with methodology that would get them defenestrated at the laboratories and lecture halls of real science.
Your points 2-4 remind me of Chinese medicine's doctrines of chi (life force), meridians, and even organs that have no anatomic locus (eg "triple warmer"). None of this is physically demonstrable, but acupuncture analgesia is successfully used in even veterinary surgery; does this mean it's not real? By your logic, because I reject vitalistic doctrines like chi and the existence of the triple warmer, I must reject acupuncture despite evidence of its efficacy. I could posit that, while the model is bunk, there is something going on that I don't understand but which is reproducible and works across cultural and even species boundaries (ie objective). Thus I can acknowledge the reality of mental anguish without resorting to a model not fitted to it (eg physical model of disease), and not confuse medicine with sage and empathetic counsel (this excludes the sort of panering and enabling seen in treating gender dysphoria, labelling mutilative surgery and unphysiologic hormone treatments as "medically necessary"). Primum non nocere.
And thank you for your informative response as well.
"Regardless of when Virchow lived, his paradigm is still in operation; ie the concept of the lesion. Our classification system is based upon it; no lesion, no disease, and there is a practical logic to medical taxonomy. This does not mean no reality; there are syndromes and associations, but diseases require lesions."
1. You ascribe the "no lesion, no disease" concept to Virchow. But (at least from what I can tell) it seems to me it's more like Szasz's interpretation of Virchow.
2. Regardless, I'm not sure why we need to focus so heavily on Virchow's conception of disease while failing to include modern concepts and theories. I'm not suggesting there's anything wrong with looking to the past, but it's obvious medicine has come a long way since Virchow. I think we can appreciate both Virchow (where he was right) as well as modern understandings of disease. It's not either/or but both/and.
3. As for "no lesion, no disease," that's the very point in contention. Just because Szasz says so doesn't necessarily make it so. There's considerable debate over this, but it seems to me you're attempting to imply there's a consensus behind "no lesion, no disease" (e.g. such as by saying "Our classification system..."). As if most of the medical community agrees with Szasz. But from what I've seen there's no general consensus.
"As phyicians we still address and treat symptoms, so it is no contradiciton to prescribe psychotropics for symptom relief."
That's a fair point.
"The rub comes when we believe that our psychotropics are addressing *the problem,* as if suffering the slings and arrows is nought but a function of neurochemistry rather than overwhelming mental anguish +/- sinful responses thereto. With no understanding of how prolonged exposure to these medications may change brain hard-wiring and hence behaviors and emotional responses, to not address the spiritual side of mental issues is to act as a reductionistic materialist and in a sense deny Scripture."
Again, I don't deny sin may be the fundamental issue in some or many cases of mental illness. Again, I don't deny that there's a moral element to some or many cases of mental illness. But I don't see how this is necessarily true in most or all cases of mental illness.
"I nowhere claimed that sin was either the sole or primary etiology of mental issues; rather it is an important etiology the existence of which is denied by psychiatry, which can only think in terms of vague spirituality. They deny the existence of the soul in practice, so it is they not I who have the problem of absence of evidence = evidence of absence."
Well, Szasz claims so-called mental illness must either be due to a physical lesion (e.g. brain tumor) or to personal moral deficiency. Isn't that your belief as well?
"Your point #7 disregards medical taxonomy; a group of symptoms and findings might not be a disease, but that doesn't say its not real. We should not feel free to use words (and hence ideas) idiosyncratically, thereby introducing confusion. Our classification system exists for the reason of clarity, and hence can't just mean what it means to you today."
1. I'm not quite sure why you're attempting to paint what I said as idiosyncratic. What I said disagrees with your idea of "no lesion, no disease," but that's not an idiosyncratic position to take.
2. Besides, even if it were idiosyncratic, why would this be a problem? The idea of "no lesion, no disease" is arguably idiosyncratic. When Szasz first wrote his Myth of Mental Illness much of what he said was idiosyncratic. What's important isn't whether a concept (such as the definition of disease) is idiosyncratic, but whether it's true or false.
"Historical sciences are similar to the above problem in that they are allowed to mask sheer speculation as established fact, making entire dioramas of alleged paleological life or pontificating about the age of the earth and beginnings of mankind from the scantiest of evidence and with methodology that would get them defenestrated at the laboratories and lecture halls of real science."
1. If you're alluding to neo-Darwinism or OEC, and suggesting because some or many people in a field subscribe to these positions, in order to discredit inference to the best explanation, I'm afraid it doesn't work. That's because my point isn't about the fields themselves (they're just examples), but rather about the use of inference to the best explanation. In other words, a paleontologist or cosmologist need not subscribe to neo-Darwinism or OEC and yet still use inference to the best explanation in his or her field.
2. In other words, my main point was science routinely infers causes from effects, even when they cannot directly detect the cause. Likewise, if (arguendo) mental illness is real, it's theoretically possible to infer a cause of mental illness exists from the effects of mental illness even if we cannot directly detect the cause itself.
"Your points 2-4 remind me of Chinese medicine's doctrines of chi (life force), meridians, and even organs that have no anatomic locus (eg "triple warmer"). None of this is physically demonstrable, but acupuncture analgesia is successfully used in even veterinary surgery; does this mean it's not real? By your logic, because I reject vitalistic doctrines like chi and the existence of the triple warmer, I must reject acupuncture despite evidence of its efficacy. I could posit that, while the model is bunk, there is something going on that I don't understand but which is reproducible and works across cultural and even species boundaries (ie objective). Thus I can acknowledge the reality of mental anguish without resorting to a model not fitted to it (eg physical model of disease), and not confuse medicine with sage and empathetic counsel (this excludes the sort of panering and enabling seen in treating gender dysphoria, labelling mutilative surgery and unphysiologic hormone treatments as "medically necessary"). Primum non nocere."
1. I'm not sure how you got vitalism, the Chinese idea of chi, and so on from what I wrote. I don't see how these are analogous to established sciences like cosmology, geology, paleontology, forensics, etc., which was what I explicitly gave as examples. I'm afraid most of this seems like a non sequitur.
2. It's possible there are "lesions," but these lesions are currently indetectable by our instruments (e.g. perhaps these "lesions" exist at a level which we can't measure). This doesn't overturn the "no lesion, no disease" idea, but it does undermine it. Hence my point that the absence of evidence is not necessarily evidence of absence.
3. It's possible mental illness exists but is not reducible to physical lesions in the brain. For example, a computer can run multiple computer programs at the same time. This includes running a less than optimally performing computer program. Say a computer program with some bugs, but not enough bugs to keep it from running, just keep it from running optimally. Likewise, if we accept (arguendo) the computational theory of mind (or something like it), then it's possible the mind can "run" several mental faculties or processes at the same time, including "running" faculties or processes with "bugs" in them. If something like this is occurring with the human mind, then no physical lesion needs to be present for there to be a buggy mental faculty or process present.
4. I'd add, according to interactionist dualism, the brain may affect the mind, and the mind may affect the brain. Sometimes we can directly detect the effects, but many times we cannot, because only the brain may be detectable directly. Thus, even though we can't always directly detect the effects of the mind and/or can only directly detect the effects of the brain, it doesn't necessarily rule out mental illnesses as real.
If RWH hasn't already learned this: mental illness is what the mental health profession says it is; if - (falsely) so-called mental illness isn't in the DSM, there will be no insurance coverage/reimbursement for it; once a professional socilety puts such a compendium out, it becomes a "bible" for a religion known for sacrificing dissidents; with increasing competiton for healthcare dollars, the more potential patients, the merrier; BS + ICD-10 = DSM 5.
ReplyDeleteKirk Skeptic:
Delete"If RWH hasn't already learned this: mental illness is what the mental health profession says it is; if - (falsely) so-called mental illness isn't in the DSM, there will be no insurance coverage/reimbursement for it; once a professional socilety puts such a compendium out, it becomes a "bible" for a religion known for sacrificing dissidents; with increasing competiton for healthcare dollars, the more potential patients, the merrier; BS + ICD-10 = DSM 5."
1. Of course, I don't disagree with Kirk Skeptic taking the DSM to task. In fact, I'd like to hear more from Kirk Skeptic on the DSM, because he's a psychiatrist and my hope is it'd be beneficial to others.
2. However, for better or for worse, keep in mind what Kirk Skeptic says is colored by the fact that he's a Thomas Szasz devotee (e.g. see Kirk Skeptic's own blog posts here, see what Kirk Skeptic has said about Szasz elsewhere on Triablogue here).
3. Other physicians and scholars have said the following about Szasz:
a. British psychiatrist Theodore Dalyrmple has said: "Thomas Szasz, a brilliant but dogmatic polemicist (as well as a professor of psychiatry), overcame this problem by denying that psychiatric disorder existed. According to Szasz, bizarre, distressing, or harmful behavior was either the result of an objectively observable pathology - hypothyroidism, say, or hypoglycemia, Cushing’s syndrome, or a brain tumor - or the patient was wholly responsible for it and suffered from nothing but a moral defect."
b. Likewise I've posted some comments on Szasz by Dr. David Martyn Lloyd-Jones.
c. According to the Internet Encyclopedia of Philosophy:
Szasz's critics have responded along several lines.
[a] Some do not take issue with his underlying understanding of the illness concept but disagree with his claim that it is not applicable to mental phenomena. Mental illnesses, according to these critics, have been (or will soon be) reducible to neurological or neurochemical dysfunction. They argue that advances in neuroscience give us reason for thinking that the prospect for finding the neurological or neurochemical correlates for at least some of our mental illnesses categories is high (Bentall 2004, 307).
[b] Other critics have argued instead in the other direction and attacked Szasz’s construal of physical illness. Szasz’s arguments have been taken, by some, to imply that physical illness itself is a deeply evaluated category reflective of value-judgments in much the same way mental illness is meant to on Szasz’s account (Fulford 2004; Kendell 2004).
[c] Still others have aimed to preserve Szasz’s primary claim that the overarching category of ‘mental illness’ will prove to be a non-natural interactive-kind, reflective of our values and practices, while simultaneously maintaining that “particular kinds of mental illnesses may yet constitute valid scientific kinds” (Pickard 2009, 88).
I agree with much of Szasz without being a devotee; also I'm not a psychiatrist but am boarded in family medicine. Since generalists prscribe most of the psychotropics dispensed in the US, we're not without experience and perspective in mental health treatment.
DeleteThe metaphoric problem remains, however, because mental healthcare provders insist on using physical language (eg disease) without relying on physical means of diagnosing such by identifying lesions; eg the diagnosis of hepatitis c is objective in that one needs the presence of a specific antibody, and one can measure viral loads and response to treatment without worrying about cultural influence or observer bias. MH practitioners can't identifu etiologies or truly objectify their diagnoses in the same way an internist can; this is not to say that mh patients aren't truly suffering, but a suffering spirit or is not the same thing as an infected liver and language should rflect that difference. As belivers in total depravity, the idea of emotional consequences of hard-wired or acquired sin should come as no surprise.
Szasz is not the last word, but neither are those sources cited by RWH; perhaps he could identify the presuppositions his sources hold in order to explain why they believe in mental illness?
Kirk Skeptic
Delete"I agree with much of Szasz without being a devotee"
Well, based on what you've said in the past and present, what if we just say you strongly support several of Szasz's key ideas? Such as his idea that mental illness is "myth" and "metaphor" rather than "real" (which you reiterate below in this very comment).
Not to mention your original comment in this thread seems to reflect Szasz's idea that the state via psychiatric professionals and organizations (e.g. the APA) uses "mental illness" as a means to control people in society.
I should say (as I've said in the past) I actually agree with a lot of Szasz. But I think he goes too far in certain respects. However, that's a debate I don't have time to delve into at the moment. Hence my referencing other resources above.
"also I'm not a psychiatrist but am boarded in family medicine."
Thanks for the clarification. I have a great amount of respect for family physicians and PCPs in general. I wish PCPs were better appreciated and valued than, say, proceduralists, who often seem to be overvalued. But thankfully God knows and thankfully your patients know.
"Since generalists prscribe most of the psychotropics dispensed in the US, we're not without experience and perspective in mental health treatment."
I never called into question your experience, and I never would.
That said, I would think a psychiatrist would be more experienced in dealing with mental illness. Of course, I realize you don't believe "mental illness" is real, hence not sure if you believe psychiatry is a legitimate medical field or specialty in the first place. Or perhaps you believe psychiatry can be if it adopts Szasz's criticisms.
"The metaphoric problem remains, however, because mental healthcare provders insist on using physical language (eg disease) without relying on physical means of diagnosing such by identifying lesions; eg the diagnosis of hepatitis c is objective in that one needs the presence of a specific antibody, and one can measure viral loads and response to treatment without worrying about cultural influence or observer bias. MH practitioners can't identifu etiologies or truly objectify their diagnoses in the same way an internist can; this is not to say that mh patients aren't truly suffering, but a suffering spirit or is not the same thing as an infected liver and language should rflect that difference."
There's much to agree with here, and much to disagree with. The human mind is highly complex. But my only point for the time being is this seems to strongly echo Szasz's core ideas about mental illness, for better or for worse.
"As belivers in total depravity, the idea of emotional consequences of hard-wired or acquired sin should come as no surprise."
Sure, I suppose, it's "no surprise" there can be "emotional consequences of hard-wired or acquired sin." However, we'd need to further unpack the phrase.
Moreover, isn't the question as raised by Szasz more about whether that is all it is? That mental illness isn't "real"?
"Szasz is not the last word, but neither are those sources cited by RWH, perhaps he could identify the presuppositions his sources hold in order to explain why they believe in mental illness?"
Not sure why one needs to "identify the presuppositions." Not that "presuppositions" aren't important, and indeed everyone has their own presuppositions, but that seems a roundabout way to approach all this. For example, why do we need to "identify" Martyn Lloyd-Jones' "presuppositions" in all this? Wouldn't it be better to simply read Martyn Lloyd-Jones' criticisms of Szasz, and see if you agree or disagree with his criticisms? That seems more straightforward and to the point.
I've reread your posts, but first a clarification: my statement about genralists prescribing psychotropics was not a resonse to an imagined slight, but rather pointing out that, despite not being boarded in psychiatry, we are not mere armchair observers.
DeleteDr LJ' concern re: Szasz's moralizing of mental illness is valid, but one can hardly deny that there is a moral component to those who are labelled as mentally ill and respond to stiutations sinfully, or suffger what was once attributed to the consequences of a guilty conscience because they were in fact guilty (Szasz used the example of Lady Macbeth). Psychiatry's disease model of mental illness results in exculpatory language; ie one speaks of "relapses of alcoholism" for drunken binges or various Axis II terms for brats; whereas Szasz may have overmoralized, psychiatry has (wittingly or no) unmoralized its patients' suffering. Think what you will of Limbaugh, but he was spot on when he said "words mean things." Just as Szasz could be said to be dated, so could LJ, who was not even a physician but a surgeon (the British medical education system is such that physicians and surgeons get different degrees, with the former addressed as "Dr" and the latter as "Mr"); what would he have thought of gender dysphoria?
Presuppositions matter in this discussion because of the tendency of the psychiatric side to assume the false moral high ground of science and attribute an antiscientific bias to its critics. Also, if one believes in materialism one will make distinction made between brain and mind and deny the existence of the soul, thereby making mental illness no different to physical illness and psychiatry no different to neurology. The theist in general - and the Christian particularly - will distinguish between brain and mind, believe in the existence of the soul, and realize that physical language and methodology will be severely limited in dealing with what becomes a spiritual matter. What strikes me about Szasz is that he saw this clearly and, despite his atheism, saw himself and his colleagues as secular clergy clergy rather than physicians dispensing counsel to voluntarily-associating patients rather than physicians practicing scientific medicine - hence his general support for Chrisitan counseling. He never denied that mental patients suffer, but rather insisted in statig that they had no disease and hence should not be treated as such; this is hardly denying any reality to suffering.
As for unpacking "emotional consequences of hard-wired or acquired sin," Szasz' example of Lady Macbeth is perfect. Today she would be counseled about her excessive guilt, medicated for obsessive-compulsive disorder (all that handwashing), and perhaps even court-ordered to have ECT due to her refractory suicidality. The fact that she wqas guilty of real sin would not occur to her psychiatrists, and thus no discussion of repentance and need for salvation would ensue. She might even be told of the the importance of "moving on" with her life. Psychiatry has no concept of sin and is at best moralistically and therapeutically deistic; ie if believe in an "higher power" keeps you from being a public nuisance or threat, go for it. The consistent Christian knows better, and might see psychiatric practice akin to medicating a patient complaining of stabbing lumbago while ignoring the dagger in his back.
Kirk Skeptic
Delete"I've reread your posts, but first a clarification: my statement about genralists prescribing psychotropics was not a resonse to an imagined slight, but rather pointing out that, despite not being boarded in psychiatry, we are not mere armchair observers."
Again, I never claimed otherwise. Nevertheless, again, a family physician's knowledge and experience on the topic of mental illness and related isn't necessarily equivalent to a psychiatrist's knowledge and experience on mental illness and related.
"Dr LJ' concern re: Szasz's moralizing of mental illness is valid, but one can hardly deny that there is a moral component to those who are labelled as mentally ill and respond to stiutations sinfully, or suffger what was once attributed to the consequences of a guilty conscience because they were in fact guilty (Szasz used the example of Lady Macbeth)."
The issue isn't whether "there is a moral component to those who are labelled as mentally ill" in some cases, which I've already granted is certainly possible, but whether every case of "mental illness" is predominantly due to personal sin and guilt.
"Psychiatry's disease model of mental illness results in exculpatory language; ie one speaks of "relapses of alcoholism" for drunken binges or various Axis II terms for brats; whereas Szasz may have overmoralized, psychiatry has (wittingly or no) unmoralized its patients' suffering."
No doubt that's true with many secular psychiatrists. But faithful Christian psychiatrists don't necessarily adopt the language and methods of secular psychiatry. And to the degree that we can even say there's a single model, it's not as if Christian psychiatrists can't challenge secular psychiatry.
"Just as Szasz could be said to be dated, so could LJ, who was not even a physician but a surgeon (the British medical education system is such that physicians and surgeons get different degrees, with the former addressed as "Dr" and the latter as "Mr"); what would he have thought of gender dysphoria?"
What makes you think Lloyd-Jones was a surgeon rather than a physician? Do you have evidence Lloyd-Jones was a surgeon? If so, I'd be interested to know. However, at least from what I've read, Lloyd-Jones was (among other things) a member of the Royal College of Physicians (as opposed to Royal College of Surgeons) as well as Chief Clinical Assistant to Sir Thomas Horder, who was the Royal Physician to the King.
Besides, Lloyd-Jones wasn't the only critic of Szasz I cited.
By the way, I'm well aware of the Mr designation for surgeons in the UK and other Commonwealth nations. But in my experience it's not a hard and fast rule (e.g. I've met UK and other Commonwealth surgeons who have introduced themselves as Dr rather than Mr).
"Presuppositions matter in this discussion because of the tendency of the psychiatric side to assume the false moral high ground of science and attribute an antiscientific bias to its critics."
DeleteI'd say that's true of many secular scientists (e.g. militant atheists). It's not something distinct to psychiatry as a field.
"Also, if one believes in materialism one will make distinction made between brain and mind and deny the existence of the soul,"
I think some materialists or physicalists might disagree with your statement (e.g. David Chalmers).
"thereby making mental illness no different to physical illness and psychiatry no different to neurology."
I don't see how this logically follows from your former statement. You certainly don't provide any connecting argument between the former and the latter.
"The theist in general - and the Christian particularly - will distinguish between brain and mind, believe in the existence of the soul, and realize that physical language and methodology will be severely limited in dealing with what becomes a spiritual matter. What strikes me about Szasz is that he saw this clearly and, despite his atheism, saw himself and his colleagues as secular clergy clergy rather than physicians dispensing counsel to voluntarily-associating patients rather than physicians practicing scientific medicine - hence his general support for Chrisitan counseling."
I guess you're just attempting to summarize Szasz's beliefs here (e.g. his belief that psychiatrists are more akin to "secular clergy" than "physicians practicing scientific medicine").
"He never denied that mental patients suffer, but rather insisted in statig that they had no disease and hence should not be treated as such; this is hardly denying any reality to suffering."
You're tilting at windmills since I never denied the reality of suffering.
"As for unpacking "emotional consequences of hard-wired or acquired sin," Szasz' example of Lady Macbeth is perfect. Today she would be counseled about her excessive guilt, medicated for obsessive-compulsive disorder (all that handwashing), and perhaps even court-ordered to have ECT due to her refractory suicidality."
Again, a character like Lady Macbeth may be a helpful stand-in for some people who suffer mental illnesses, but again she's hardly a stand-in for all people who suffer mental illnesses.
"The fact that she wqas guilty of real sin would not occur to her psychiatrists, and thus no discussion of repentance and need for salvation would ensue."
Again, I don't have any problem saying some people with mental illness are actually suffering mental illness because of their sin, but how is that necessarily true of all people who suffer mental illness?
"Psychiatry has no concept of sin and is at best moralistically and therapeutically deistic; ie if believe in an "higher power" keeps you from being a public nuisance or threat, go for it. The consistent Christian knows better, and might see psychiatric practice akin to medicating a patient complaining of stabbing lumbago while ignoring the dagger in his back."
That's not true of faithful Christian psychiatrists (e.g. Richard Winter).
There's still some tapdancing here, as psychiatrists (secular or faithful) have not demonstrated a lesion - this is a requirement for calling something a disease in our current understanding a la Virchow. How does one demonstrate a lesion (a physical entity) on a mind, unless one equates mind with brain? Otherwise one must have a mechanism to objectify the metaphysical. This is also why suffering from a mental/emotional/spiritual problem is not the same as suffering from a physical ailment like hepatitis. That not all mental issues stem from moral lapses is not so much the issue as is none of those who have purely psychiatric diagnoses have identifiable physical lesions (a tautology to be sure); a relapse of cancer or malaria is in no wise comparable with a relapse of alcoholism and is nought but mixing metaphors. Show me the lesion and we can then put Szasz' - and others' - works in the same pile as treatises on phlogiston and aether; until then, those who insist upon claiming mental illnesses to be bona fide diseases must shoulder the burden of proof - which they have not.
DeleteAs for my commenting about Szasz not denying suffering, ISTM that is the attitude I get from his critics,as if denying that someone has a disease is in some way belittling them or delegitimizing their suffering.
Kirk Skeptic
Delete"There's still some tapdancing here, as psychiatrists (secular or faithful) have not demonstrated a lesion - this is a requirement for calling something a disease in our current understanding a la Virchow. How does one demonstrate a lesion (a physical entity) on a mind, unless one equates mind with brain? Otherwise one must have a mechanism to objectify the metaphysical. This is also why suffering from a mental/emotional/spiritual problem is not the same as suffering from a physical ailment like hepatitis. That not all mental issues stem from moral lapses is not so much the issue as is none of those who have purely psychiatric diagnoses have identifiable physical lesions (a tautology to be sure); a relapse of cancer or malaria is in no wise comparable with a relapse of alcoholism and is nought but mixing metaphors. Show me the lesion and we can then put Szasz' - and others' - works in the same pile as treatises on phlogiston and aether; until then, those who insist upon claiming mental illnesses to be bona fide diseases must shoulder the burden of proof - which they have not."
1. Virchow lived in the 19th century and died around the turn of the 20th century. Although he made many significant contributions to medical science (e.g. his cell theory including the oft-quoted bit about every cell coming from other cells; his opposition to humoralism), he likewise held beliefs about disease causality which today would largely be considered mistaken (e.g. he strongly opposed Pasteur's germ theory of disease; he opposed antiseptic techniques such as handwashing; his belief that cancers "spread like a liquid"). In any case, judging by modern standards, Virchow held both correct and incorrect beliefs about disease. Hence I wouldn't necessarily take Virchow's understanding of disease as the last word or even an authoritative word in light of modern medicine; it'd depend on the specific details of what you're saying about Virchow's understanding of disease.
2. If you contend the brain is physical, while the mind is non-physical, then by definition you're ruling out the possibility of a "lesion" or other "physical entity." Hence it's a bit unfair to say "show me the lesion" when by definition you're precluding its possibility in the first place, in advance.
Related, you're assuming disease must mean physical disease. But that's a point in contention.
3. Or at the very least, we cannot test for non-physical things in the same way we can test for physical things. However, just because we cannot test for the non-physical doesn't mean the non-physical doesn't exist. Take a normal person like you or me. I cannot directly test that you're conscious or that you have a consciousness. A brain CT or MRI won't reveal your consciousness. But this doesn't mean your consciousness doesn't exist.
4. What's more, we can infer your consciousness from effects. Indeed, science routinely infers causes from effects, even when no known instrument could test for the cause. Inference to the best explanation is a tried and true basis for scientific investigation. Particularly in the historical sciences such as cosmology, geology, paleontology, forensic science, and so on. Several intelligent design theories likewise rely on inference to the best explanation. Would you say these scientists are all mistaken each time they make an inference to the best explanation from effects instead of "showing a lesion" (as it were) i.e. deductively demonstrating a necessary cause? If so, then that's not rational.
5. You've claimed sin is the primary (or perhaps sole) cause of suffering in mental illness. Yet, we cannot always "show a lesion" or "physical entity" when it comes to sin either. (Obviously we know this is true because we're Christians, but non-Christians wouldn't necessarily agree.) As such, judging by your own lights, it'd seem sin is therefore not necessarily a better explanatory cause for someone's suffering than "mental illness." At best, they're on equal explanatory grounds with one another.
Delete6. You've suggested as a family physician that you've prescribed psychotropics (e.g. you said "Since generalists prscribe [sic] most of the psychotropics dispensed in the US, we're not without experience and perspective in mental health treatment"). If you have prescribed psychotropics, then what I don't understand is why prescribe psychotropics if you don't believe mental illness is real? Or if you don't think these medications are efficacious to some degree?
7. You're implying if there is no "physical lesion" or "physical entity," then there is no disease. This in turn implies the absence of evidence is therefore evidence of absence. But why should one accept this premise? It seems illogical to argue because we do not know the cause or etiology of x, therefore x doesn't exist. For example, although we have theories, we don't know the specific etiology of migraines. Yet does this mean migraines don't exist? Of course not.
We could say similar things about certain pains which the patient says he or she feels but which don't seem to have a physical cause as far as our best tests can detect (e.g. no C fibers firing).
8. At the same time, it's possible to say x causes y, but x doesn't necessarily always cause y. Mutations in the BRCA1 and BRCA2 genes could be said to cause breast cancer, but BRCA mutations don't necessarily always cause breast cancer.
9. Szasz shoulders a burden of proof inasmuch as he's not arguing for an agnostic position on mental illness, but rather he's positively arguing mental illness does not exist or is a myth or metaphor.
PS: my confusion re: LJ stemmed from my reading of his practicing at a "surgery," which i learned is a term for any dr's office; mea culpa. As for Dr Winter, I favorably cited his work on my blog but still see his difficulty regarding the disease metaphor; this is no minor point .
ReplyDeleteKirk Skeptic
Delete"PS: my confusion re: LJ stemmed from my reading of his practicing at a "surgery," which i learned is a term for any dr's office; mea culpa. As for Dr Winter, I favorably cited his work on my blog but still see his difficulty regarding the disease metaphor; this is no minor point ."
No problem at all. That's understandable.
Please see my reply above regarding "the disease metaphor."
Thanks for your reply & understanding.
DeleteRegardless of when Virchow lived, his paradigm is still in operation; ie the concept of the lesion. Our classification system is based upon it; no lesion, no disease, and there is a practical logic to medical taxonomy. This does not mean no reality; there are syndromes and associations, but diseases require lesions. As phyicians we still address and treat symptoms, so it is no contradiciton to prescribe psychotropics for symptom relief.
The rub comes when we believe that our psychotropics are addressing *the problem,* as if suffering the slings and arrows is nought but a function of neurochemistry rather than overwhelming mental anguish +/- sinful responses thereto. With no understanding of how prolonged exposure to these medications may change brain hard-wiring and hence behaviors and emotional responses, to not address the spiritual side of mental issues is to act as a reductionistic materialist and in a sense deny Scripture.
I nowhere claimed that sin was either the sole or primary etiology of mental issues; rather it is an important etiology the existence of which is denied by psychiatry, which can only think in terms of vague spirituality. They deny the existence of the soul in practice, so it is they not I who have the problem of absence of evidence = evidence of absence.
Your point #7 disregards medical taxonomy; a group of symptoms and findings might not be a disease, but that doesn't say its not real. We should not feel free to use words (and hence ideas) idiosyncratically, thereby introducing confusion. Our classification system exists for the reason of clarity, and hence can't just mean what it means to you today.
Historical sciences are similar to the above problem in that they are allowed to mask sheer speculation as established fact, making entire dioramas of alleged paleological life or pontificating about the age of the earth and beginnings of mankind from the scantiest of evidence and with methodology that would get them defenestrated at the laboratories and lecture halls of real science.
Your points 2-4 remind me of Chinese medicine's doctrines of chi (life force), meridians, and even organs that have no anatomic locus (eg "triple warmer"). None of this is physically demonstrable, but acupuncture analgesia is successfully used in even veterinary surgery; does this mean it's not real? By your logic, because I reject vitalistic doctrines like chi and the existence of the triple warmer, I must reject acupuncture despite evidence of its efficacy. I could posit that, while the model is bunk, there is something going on that I don't understand but which is reproducible and works across cultural and even species boundaries (ie objective). Thus I can acknowledge the reality of mental anguish without resorting to a model not fitted to it (eg physical model of disease), and not confuse medicine with sage and empathetic counsel (this excludes the sort of panering and enabling seen in treating gender dysphoria, labelling mutilative surgery and unphysiologic hormone treatments as "medically necessary"). Primum non nocere.
Kirk Skeptic
Delete"Thanks for your reply & understanding."
And thank you for your informative response as well.
"Regardless of when Virchow lived, his paradigm is still in operation; ie the concept of the lesion. Our classification system is based upon it; no lesion, no disease, and there is a practical logic to medical taxonomy. This does not mean no reality; there are syndromes and associations, but diseases require lesions."
1. You ascribe the "no lesion, no disease" concept to Virchow. But (at least from what I can tell) it seems to me it's more like Szasz's interpretation of Virchow.
2. Regardless, I'm not sure why we need to focus so heavily on Virchow's conception of disease while failing to include modern concepts and theories. I'm not suggesting there's anything wrong with looking to the past, but it's obvious medicine has come a long way since Virchow. I think we can appreciate both Virchow (where he was right) as well as modern understandings of disease. It's not either/or but both/and.
3. As for "no lesion, no disease," that's the very point in contention. Just because Szasz says so doesn't necessarily make it so. There's considerable debate over this, but it seems to me you're attempting to imply there's a consensus behind "no lesion, no disease" (e.g. such as by saying "Our classification system..."). As if most of the medical community agrees with Szasz. But from what I've seen there's no general consensus.
"As phyicians we still address and treat symptoms, so it is no contradiciton to prescribe psychotropics for symptom relief."
That's a fair point.
"The rub comes when we believe that our psychotropics are addressing *the problem,* as if suffering the slings and arrows is nought but a function of neurochemistry rather than overwhelming mental anguish +/- sinful responses thereto. With no understanding of how prolonged exposure to these medications may change brain hard-wiring and hence behaviors and emotional responses, to not address the spiritual side of mental issues is to act as a reductionistic materialist and in a sense deny Scripture."
Again, I don't deny sin may be the fundamental issue in some or many cases of mental illness. Again, I don't deny that there's a moral element to some or many cases of mental illness. But I don't see how this is necessarily true in most or all cases of mental illness.
"I nowhere claimed that sin was either the sole or primary etiology of mental issues; rather it is an important etiology the existence of which is denied by psychiatry, which can only think in terms of vague spirituality. They deny the existence of the soul in practice, so it is they not I who have the problem of absence of evidence = evidence of absence."
Well, Szasz claims so-called mental illness must either be due to a physical lesion (e.g. brain tumor) or to personal moral deficiency. Isn't that your belief as well?
"Your point #7 disregards medical taxonomy; a group of symptoms and findings might not be a disease, but that doesn't say its not real. We should not feel free to use words (and hence ideas) idiosyncratically, thereby introducing confusion. Our classification system exists for the reason of clarity, and hence can't just mean what it means to you today."
Delete1. I'm not quite sure why you're attempting to paint what I said as idiosyncratic. What I said disagrees with your idea of "no lesion, no disease," but that's not an idiosyncratic position to take.
2. Besides, even if it were idiosyncratic, why would this be a problem? The idea of "no lesion, no disease" is arguably idiosyncratic. When Szasz first wrote his Myth of Mental Illness much of what he said was idiosyncratic. What's important isn't whether a concept (such as the definition of disease) is idiosyncratic, but whether it's true or false.
"Historical sciences are similar to the above problem in that they are allowed to mask sheer speculation as established fact, making entire dioramas of alleged paleological life or pontificating about the age of the earth and beginnings of mankind from the scantiest of evidence and with methodology that would get them defenestrated at the laboratories and lecture halls of real science."
1. If you're alluding to neo-Darwinism or OEC, and suggesting because some or many people in a field subscribe to these positions, in order to discredit inference to the best explanation, I'm afraid it doesn't work. That's because my point isn't about the fields themselves (they're just examples), but rather about the use of inference to the best explanation. In other words, a paleontologist or cosmologist need not subscribe to neo-Darwinism or OEC and yet still use inference to the best explanation in his or her field.
2. In other words, my main point was science routinely infers causes from effects, even when they cannot directly detect the cause. Likewise, if (arguendo) mental illness is real, it's theoretically possible to infer a cause of mental illness exists from the effects of mental illness even if we cannot directly detect the cause itself.
"Your points 2-4 remind me of Chinese medicine's doctrines of chi (life force), meridians, and even organs that have no anatomic locus (eg "triple warmer"). None of this is physically demonstrable, but acupuncture analgesia is successfully used in even veterinary surgery; does this mean it's not real? By your logic, because I reject vitalistic doctrines like chi and the existence of the triple warmer, I must reject acupuncture despite evidence of its efficacy. I could posit that, while the model is bunk, there is something going on that I don't understand but which is reproducible and works across cultural and even species boundaries (ie objective). Thus I can acknowledge the reality of mental anguish without resorting to a model not fitted to it (eg physical model of disease), and not confuse medicine with sage and empathetic counsel (this excludes the sort of panering and enabling seen in treating gender dysphoria, labelling mutilative surgery and unphysiologic hormone treatments as "medically necessary"). Primum non nocere."
Delete1. I'm not sure how you got vitalism, the Chinese idea of chi, and so on from what I wrote. I don't see how these are analogous to established sciences like cosmology, geology, paleontology, forensics, etc., which was what I explicitly gave as examples. I'm afraid most of this seems like a non sequitur.
2. It's possible there are "lesions," but these lesions are currently indetectable by our instruments (e.g. perhaps these "lesions" exist at a level which we can't measure). This doesn't overturn the "no lesion, no disease" idea, but it does undermine it. Hence my point that the absence of evidence is not necessarily evidence of absence.
3. It's possible mental illness exists but is not reducible to physical lesions in the brain. For example, a computer can run multiple computer programs at the same time. This includes running a less than optimally performing computer program. Say a computer program with some bugs, but not enough bugs to keep it from running, just keep it from running optimally. Likewise, if we accept (arguendo) the computational theory of mind (or something like it), then it's possible the mind can "run" several mental faculties or processes at the same time, including "running" faculties or processes with "bugs" in them. If something like this is occurring with the human mind, then no physical lesion needs to be present for there to be a buggy mental faculty or process present.
4. I'd add, according to interactionist dualism, the brain may affect the mind, and the mind may affect the brain. Sometimes we can directly detect the effects, but many times we cannot, because only the brain may be detectable directly. Thus, even though we can't always directly detect the effects of the mind and/or can only directly detect the effects of the brain, it doesn't necessarily rule out mental illnesses as real.