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Transhumanist Therapy IV: The Current Crisis in Psychiatry

Although largely ignored by the mass media and traditional intellectuals, a major drama began in 2013 when Tom Insel, director of the National Institute of Mental Health, posted a blog attacking the American Psychiatric Association for the self-serving stupidity of the fifth edition of its Diagnostic and Statistical Manual

NIMH was supporting a new research initiative, based on a growing body of research studies using gene sequencing and brain scans, seeking purely biological means for diagnosing psychiatric disorders and dismissing the APA’s catalog of symptoms as imprecise and biased.  However this debate works out, the consequences could be vast.  For example, people who lack biological markers of brain disorders might no longer be called “mentally ill,” potentially liberating unethical entrepreneurs to launch new psychotherapeutic fads to exploit all the sufferers who had been abandoned by the medical profession.

Insel’s blog links to a few of the studies on the genetics of mental disorders, for example raising very severe questions about whether old diagnostic distinctions like that between depression and schizophrenia are real.  The history of the Diagnostic and Statistical Manual was rocky anyway, as I note in a chapter on ethics to be published soon in a collection about computer-enabled ubiquitous healthcare:

Originally heavily influenced by Psychoanalysis, the American Psychiatric Association developed its Diagnostic and Statistical Manual (DSM) in 1952, but a 1980 revision reduced this influence while asserting a disease conception of mental deviance.  The most visible area of dispute was whether to count homosexuality as a disorder or an example of human diversity, and branding it psychiatric tended to disparage homosexuals and devalue their contributions to society.  More generally, psychiatric orthodoxy contradicts the frequent observation of anthropologists that standards of normality vary across cultures, even such that qualities judged normal or even praiseworthy in our society are condemned in other societies.  Modern society is very different from the hunter-gatherer form of life in which humanity originally evolved, and thus the culture within which psychiatrists frame their diagnoses may itself be pathological.  At the extreme, psychiatry is used as a tool of social oppression by the elite, and in modern society the information technologies can serve like the whips or shackles of oppressors.

Indeed, much can be learned by gazing backward, especially at the period of emergence of mental hospitals.  Decades ago, I was at a government data archive scanning through microfilms of the original 1860 US census records, seeking the data for one of the Shaker religious communes, when by accident I stumbled across something else, the records of a large insane asylum.  I was astounded to see that the census enumerator had listed the supposed cause of insanity for each inmate. 

Fortunately, I had access to the extensive libraries of Harvard University, so I was able to find a copy of the 1860 instructions to census takers, which today anybody may download from the website of the US Census Bureau, and read:

“In all cases of insane persons, you will write in the space where you enter the word ‘Insane,’ the cause of such insanity; and you will in every case inquire into the cause or origin thereof, and write the word - as intemperance, spiritualism, grief, affliction, heredity, misfortune, &c.  As nearly every case of insanity may be traced to some known cause, it is earnestly desired that you will not fail to make your return in this respect as perfect as possible.”

Perhaps distracted by the Civil War, or lacking the information technology that played such a role in tabulating the 1900 census, the published volumes of the 1860 census fail to report much of the data collected on many subjects, but other sources are available.  As early as 1833, the annual reports of the State Lunatic Asylum at Worcester, Massachusetts, listed such causes for the madness of its inmates, and page 278 of the 1860 American Almanac summarized:

“Supposed cause of insanity of some of those admitted since the opening of the Hospital: - ill health, 651; intemperance, 472; domestic affliction, 383; epilepsy, 115; puerperal, 141; jealousy, 40; masturbation, 260; hard labor, 79; religious excitement, 289; Millerism 10; spiritualism, 35; fear of poverty, 39.” 

The institution in Augusta, Maine, reported on page 267: “Supposed causes of insanity of those admitted during the year, ill health, 28; intemperance, 5; puerperal, 4; domestic trouble, 11; religious excitement, 11; business and loss of property, 2; masturbation, 5; spiritualism, 3; other causes, 24; not assigned, 30.” 

The 1848 History, Description and Statistics of the Bloomingdale Asylum for the Insane by leading alienist (psychiatrist) Pliny Earle reported a similar diversity of causes.

Several motivations energized the construction of large mental hospitals in the middle of the nineteenth century, and no simple story tells it all.  Some alienists believe that madness was an innate characteristic of inferior people, while others more optimistically believed it was caused by unusual life stresses and thus temporary.  All the alienists of both persuasions sought respectability and income, so they were forced to compromise, giving at least lip service to a standard theory:  Life events can put extreme stress on people’s nervous systems; some people have naturally weak nervous systems, so less stress is required to drive them into insanity.  Asylums, as the name implied, should be low-stress environments where people’s nervous systems may heal, restoring the sufferers to sanity.  This theory is reasonable but not popular today, except perhaps in terms like post traumatic stress disorder and nervous breakdown.

Early statistical studies of outcome suggested that indeed many patients regained sanity during relatively brief asylum stays, but the statistics quickly eroded as asylums became custodial institutions, and the nervous breakdown theory lost favor.  In its 1880 report, the Cleveland, Ohio, asylum reported only five categories of inmate: 3 suffering from innate imbecility (severe metal retardation), 5 from dipsomania (alcoholism), 6 from paresis (syphilis), 210 from melancholia (depression), and 369 from mania (schizophrenia).  The fact that today we might use a term like manic-depressive (bipolar) does not mean that the word mania meant in 1880 what it means today.  But then, why should we believe that today’s use of depression and schizophrenia is any more objective, if the National Institute of Mental Health doubts their legitimacy?

Perhaps social psychology, the non-medical field most relevant to psychotherapy, has made great discoveries since Sigmund Freud vanished from the scene.  However, scanning journals in recent decades fails to reveal discoveries, while many of the studies seem to couch ordinary folk psychology in technical terms, and to simulate progress by renaming concepts every few years.  The most recent evidence on this point was published August 28, 2015, by the prestigious journal Science, where the Open Science Collaboration reported that only 25% of the studies in the main psychology journal of the field, Journal of Personality and Social Psychology, could be verified through careful replication. 

One wonders what fraction of that 25% actually reported something novel, rather than platitudes.  Gloom in social psychology has been apparent since William H. Sewell published “Some Reflections on the Golden Age of Interdisciplinary Social Psychology” in the 1989 issue of Annual Review of Sociology, acknowledging that few if any theoretical advances or empirical discoveries had been achieved since the Golden Age of 1940-1965.  In the 2008 pages of the main sociological journal of the field, Social Psychology Quarterly, James S. House contemplated Sewell’s judgment and could not proclaim progress in the two decades since he had written.

It should be no secret that within the community sympathetic to the NIMH approach are many knowledgeable people who harbor doubts about the potential success of gene sequencing and brain scans to diagnose more than a very small fraction of mental disorders, let alone the possibility of developing effective treatments.  Some of the NIMH-cited research concerns rare single nucleotide polymorphisms (“snips”), and some snips may really cause specific problems.  But more often many genes interact, perhaps also affected by day-to day changes in the intrauterine environment where the structure of the brain largely consolidates, and by those infamous villains of science called random factors.  The voxels that are the pixels of computerized brain scans may contain as many as 100,000 neurons, so we are able to study only very gross structures.  Increasing the resolution much more would require more powerful microwaves that first cause convulsions then fry the brain.

It is too early to commit to pathological pessimism, but optimism can be pathological as well, an insight encoded in the logical if possibly incorrect bipolar concept, manic-depressive.  But as an intellectual exercise, and to prepare ourselves for the future to come, we can consider a sequence of five related scenarios.

1. The NIMH vision is fulfilled, as many different mental disorders are rigorously diagnosed, and some fraction of them prove amenable to treatment, while others must at best be coped with.  It may be that the problematic success rate of many current treatments is simply that the cases are poorly diagnosed.  Good diagnoses would improve the success rate simply by avoiding giving treatments unsuited for the disorder suffered by the particular patient.  In some fraction of cases, better diagnosis might not help current patients but improve prevention.  This would probably raise the difficult ethical issue of aborting a fetus if genetic testing showed it carried high-risk genes, but perhaps in some cases environmental chemical causes might be discovered and then avoided.

2. If the NIMH vision is fulfilled, significant numbers of people suffering mental or emotional problems would be shown not to have brain disorders.  This might trigger a wave of innovations, many doing more harm than good, to develop a range of new non-medical approaches.  Yes, cognitive behavioral therapy and some other talking cures may be of value for relatively minor and well-defined problems, but at the present time we lack good candidates for major new methods.  Privately, many of my colleagues wonder why psychology has not vanished from the scene, now that we have cognitive science, just as phrenology gave way to psychology earlier in history.  Yet we cannot with confidence say what the future will bring.

3. The collapse of psychotherapy and psychology could clear space for a renewed appreciation of social commitment solutions.  Traditionally, these were couched in religious terms, such as the Process mentioned in the earlier blogs of this series, but that need not be the case.  People who have incurable but modest disabilities often need more help from other people, but all humans rely upon others.  If our current historical era is one of social conflict and disorganization, then many people lack the strong communities they need in order to be mentally healthy.  They would not benefit in the long-term from brief medicinal or psychotherapeutic treatments, but from permanent inclusion in a healthy social group, possessing a sense of shared identity and transcendent goals that give meaning to life.

4. If NIMH fails, or is only partially successful, then we will find ourselves in a confused period, like that described by Yeats in the wake of the First World War, replacing the word falcon with client, and falconer with therapist:

Turning and turning in the widening gyre
The falcon cannot hear the falconer;
Things fall apart; the centre cannot hold;
Mere anarchy is loosed upon the world,
The blood-dimmed tide is loosed, and everywhere
The ceremony of innocence is drowned;
The best lack all conviction, while the worst
Are full of passionate intensity.

5. Whichever of the first four scenarios is realized, there is another possibility, above and beyond them.  Increased scientific understanding of the human brain, and whatever advances in scientific understanding of human behavior can also be achieved, may offer the opportunity for a beneficial cultural movement to gain ascendancy, focused not narrowly on how to help problematic people escape disadvantage, but broadly on how to help all people to advance.  Shall we call it Transhumanism?

At the risk of gross oversimplification, there seem to be long-term cycles in human history.  Certainly this seems true for psychiatry.  Once upon a time mental problems were understood in religious terms, as resulting from sin or spirit possession.  Then early in the nineteenth century the nervous breakdown theory emerged and encouraged the building of insane asylums.  But they degenerated into prisons for mental deviance. 

Early in the twentieth century, more humanistic methods like Psychoanalysis offered gentle treatments, incidentally defining larger fractions of the population in psychopathological terms.  This was followed again by a more pessimistic and control-oriented theory, conceptualizing problems in chemical terms and prescribing long-term medications. 

Now, with the NIMH-APA battle, a new cycle may be beginning.  We can only guess what the next wave of transformations will be, but it could be utter chaos, or a solid dictatorship by one or another falsehood.  Those of us who are inspired by transcendent visions of a positive human future have the responsibility to guide these developments in a good direction.

Next installment: The Paradoxes of Transcendental Humanism

William Sims Bainbridge Ph.D. is an IEET Senior fellow, and a prolific and influential sociologist of religion, science and popular culture. Dr. Bainbridge serves as co-director of Human-Centered Computing at the NSF.

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