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Nederlog
  Apr 28, 2012                  
     

DSM-5: Question 1 of "The six most essential questions in psychiatric diagnosis"


   " It is wrong always, everywhere, and
      for anyone,
to believe anything
      upon insufficient evidence
".
     -- W.K. Clifford
  "If we believe absurdities,         
    we shall commit atrocities."    
     -- Voltaire 
    " If mankind had wished for what is
   right,  they might have had it long ago.
   The theory is plain enough; but they
   are prone to mischief, 'to every good
   work  reprobate.'
"
   -- William Hazlitt
   “Pseudoscience: (..)
   A pretended or spurious science; a 
   collection of related beliefs about the
   world mistakenly regarded as being
   based
  on scientific method or as having
   the
status that scientific truths now
   have.

   -- Oxford English Dictionary

Introduction to this text

This is a long review of the Contributions to the first of the six questions that have been billed as The six most essential questions in psychiatric diagnosis in a series that appears in Philosophy, Ethics, and Humanities in Medicine, that is still in the process of being published, with two parts fully or provisionally published, and two more to come.

I have reviewed the introduction to The six most essential questions in psychiatric diagnosis in the first of the two links in this paragraph. The second link is to the pdf version of part 1 of the series, and there also is a html-file of the same, that I use for the present review of Question #1.

As it happens, this review of the first of the six most essential questions in psychiatric diagnosis is a large html-file (over 500 Kb). The reasons for this are that (i) I think the subject is important and (ii) I am quite learned about several of its main aspects (having degrees in psychology and philosophy, and having recently found people with my real, painful and invalidating disease have been slandered and defamed since 1988 as not physically ill but as mad or malingering, which made it impossible for the last 25 years to get any help people with other illnesses get as a matter of course, while (iiii) I take the matter of psychiatry, its diagnoses, its power, and its public reception quite serious, especially since having learned how dangerous it is, and how it has been used against persons with the same disease as I have, and therefore have taken the quite considerable trouble of quoting all and also of explicitly discussing all arguments by all contributors to the discussion.

This makes my text long, and probably rather complicated, even for persons who are quite informed about psychiatry, philosophy, psychology or logic.

Here is a table of contents that links to all the main sections in this text, that should enable you to pick and choose, rather than read from the beginning till the end - though what's on offer is a thorough, mostly rational if occasionally satirical discussion by a psychologist and philosopher of science of the arguments by a highly trained largish lot of psychiatrists concerning the merits, demerits and foundations of their own supposed science.

Contents by Section:

Introduction to this text

Question #1
General introduction to the following discussion

       Backgounds:

Presuppositions and rational and logical standards
A. Real philosophy of science
B. Clifford's and Voltaire's dicta + Philosophical Dictionary
C. Scientific Realism and Postmodernism
Tabular exposition
D. Pseudoscience
E. Weasel words, bullshit, propaganda, rhetoric

         The discussion:

0. Phillips' Introduction to Question 1

The dangerous nonsense of the x out of y diagnostic schema

1.  Dr Zacher & Dr Lobello
2.  Dr Pouncey
3.  Dr Ghaemi
4.  Dr Cerullo
5.  Dr Wakefield
6.  Dr Pierre
7.  Dr Greenberg
8.  Dr Pincus
9.  Dr Szasz

10.Dr Martin

11. Allen Frances responds
      To 1 - To 2 - To 3 - To 4 - To 5
      To 6 - To 7 - To 8 - To 9 - To 10

            
My conclusions :

       Endnote:

What follows is an extended rational discussion of the mostly not very rational prose of the contributors to The six most essential questions in psychiatric diagnosis and specifically, and in this file only, its first question, which is as follows:


Question #1: How do we Choose Among the Five
Umpires of Epistemology?
Are DSM diagnoses more like constructs or more like
diseases? We would like to have the positions of each
of the five epistemological umpires stated as clearly
as possible.
Umpire 1) There are balls and there are strikes and
I call them as they are.
Umpire 2) There are balls and there are strikes and
I call them as I see them.
Umpire 3) There are no balls and there are no
strikes until I call them.
Umpire 4) There are balls and there are strikes and
I call them as I use them.
Umpire 5) Don’t call them at all because the game
is not fair.
Could you please the position of the umpire which
you endorse?


There is an endnote with some of my own conclusions and there are at various places instances of this link: ->Contents that enables you to read the sections in any order you wish.

I am sorry that this is so much text, but I thought it both fair and desirable to discuss all contributions and most arguments, because (i) I do have the requisite expertise about philosophy of science and (ii) much experience of the harm psychiatry does, simply by furthering pseudoscience and misdiagnosis that hugely benefit psychiatrists while much harming millions of patients with real diseases or quite other problems or illnesses than the pseudoscience psychiatry diagnosed them with.

Finally, my text is long because (iii) unfortunately psychiatrists ignore all criticisms of their field, pretensions, methodologies and treatments that do not come from fellow psychiatrists, thus pretending and suggesting in their own publications there is no criticism from other sciences while (iv) other scientists and most philosophers of science are so much disgusted by what they have read from the abundantly nonsensical and hugely pretentious books by psychiatrist that they tend to ignore it because they have far more interesting things to do. Also, (v) as it happens I seem to have talents for both logical argument and satire, and I don't like being slandered, defamed and harmed by what I consider medical frauds abusing the authority of their medical degree in the name of "evidence based medical science".

Therefore it seemed justified to me to write a long and thorough criticism. If you find this too long, as well you might, the ->Contents feature allows you to read those parts that interest you most.


General introduction to the following discussion

The following criticism has been written  with some background, that stands apart from my main motive to write it:

That my explicitly non-psychiatric neurological illness ME/CFS, according to the WHO's classification of diseases, that apply since 1969 to this day, that I have since 1.1.1979, turned out to be a disease that since 1988 has been stigmatized as a non-existing form of suffering, that is due to a psychiatrically diseased "dysfunctional belief system", that can be cured, it is claimed, by paying psychiatrists to give one "cognitive behavioural therapy", to launder one's brain free from the notion that the medical doctors of the WHO are NOT insane and not incompetent: From what these psychiatric frauds have lied about me and millions of ill people with my disease it follows logically that thousands of medical doctors, who are not psychiatrists must be at least as insane as I and these millions of ill people are, if not more, since they have medical degrees and do not claim to be ill.

This form of psychiatric insanity has been introduced by psychiatrists and clinical psychologists, who clearly are groups of professionals who will profit hugely from getting this scam accepted, and do so basically on the ground that any disease that is unexplained by real medical scientists is explained by the pseudoscientists who are psychiatrists, namely as a psychiatric disease, the patients of which are to be exclusively treated and research by psychiatrists, while the patients of this painful and exhausting disease are to be forced to work, without pay, until they have learned work discipline.

As is, these insanities and immoralities in the name of medical science are now the received notions for "treating" people with this disease in Great Britain and in Holland, and have driven many ill patients to suicide.

Apart from the above main motive to force my ill body to produce this text, I write it because

        • I have - excellent - degrees in psychology and philosophy, both
          acquired while I and my ex-wife were ill with ME/CFS (after a
          bout of Epstein-Barr in January 1979)
        • I have a large website about philosophy, logic, computing and
          ME/CFS since 1996
        • I had hoped to have an academic career in philosophy of science
          or logic, in both of which I am very well-read:
        • I can do so - unlike most people with ME/CFS - because I am gifted
          and besides nearly 62, and do not risk forced labour and forced
          brainwashing anymore, having succeeded in forcing the City of Amsterdam
          to that extent, with my site, personality and great talents
        • I have received decades of sickening discrimination on the simple ground
          that I honestly said and believed that I have ME/CFS, as I have also been
          diagnosed with by at least four competent medical doctors, and am
          exceedingly angry about what I see as sick sadism on the part of the
          psychiatrists who manufactured this scam, against the rulings of the WHO,
          against medical morality ("first do no harm"), and against rational biomedical
          science, in the name of a pseudoscience maintained and furthered by liars,
          who play the public, the politicians and the parliament rather than face
          their competent medical colleagues.                          ->Contents

Presuppositions and rational and logical standards

Also, there are, next to my presupposed large knowledge of philosophy of science and logic, that I explicitly assume, having recently read tens of intellectually and morally incompetent and scientifically mostly ignorant psychiatrists and clinical psychologists on the subjects of my disease ("dysfunctional belief system"), character ("malingerer"), reputation ("somatoformer"), integrity ("liar or insane"), and motives ("wimp, laziness"), which I take as personal slander and defamation of myself and millions of others with my disease, a number of further presuppositions and criterions I will assume as known in the following texts in the next five introductory sections, that you can skip - very unwisely - at your own risk, using  ->Contents.

Backgrounds:


A.  Real philosophy of science

Since most that psychiatrists discuss or will discuss in The six most essential questions in psychiatric diagnosis does directly relate to philosophy of science, about which psychiatrists have been lying and misleading people for several generations now and still do so, let me provide the reader with a list of books that give the real thing, that you should know to be able to judge the poses and deceptive writings of psychiatrist on the subject of real science and on the subject of their own pseudoscience:

Real philosophy of science

Stegmuller Probleme und Resultate der Wissenschafts- theorie und Analytischen Philosophie
Bunge Treatise on Basic Philosophy:
Carnap and Gardner Philosophical Foundations of Physics.
Nagel The Structure of Science: Problems in the Logic of Scientific Explanation
Sneed The Logical Structure of Mathematical Physics
Skyrms Choice and Chance: An Introduction to Inductive Logic
Howson and Urbach Scientific Reasoning: the Bayesian Approach

Real philosophy of science for beginners

Nagel and Cohen An Introduction to Logic and Scientific Method
Kyburg Philosophy of Science: A formal approach
Gardner Fads and Fallacies in the Name of Science

Science: Good, Bad, and Bogus

Psychiatrists, psychologists and others who have not read a good part of the above or can't handle the more formal parts should shut up about philosophy or science or the excellencies of psychiatry: They are posturing in a very immoral dishonest way, for which see my Morningstar shines a bright light on postmodernism.


B. Clifford's and Voltaire's dicta + Philosophical Dictionary

Clifford's dictum, formulated and argued by the English mathematical genius William Kingdon Clifford stems from his "The Ethics of Belief", that is highly relevant for the discussions that follow and reads thus:

" It is wrong always, everywhere, and for anyone,
 
to believe anything upon insufficient evidence".

The above is also a link to the full text of "The Ethics of Belief" on my site, that also has my extensive notes on this text.

What happens when one does not abide by Clifford's dictum or is otherwise irrational or unreasonable was very well expressed by Voltaire:

  "If we believe absurdities,         
     we shall commit atrocities."    
     -- Voltaire 

This manages to diagnose the Inquisition, the regimes of Hitler, Stalin, and Mao, and the cruel inanities of psychiatrists (and much more) I have been forced to read because I am physically ill with a disease it is very profitable for them to lie about, and also applies to much of psychiatrists' beliefs and acts at large, though it is true there are some sane and decent psychiatrists as well, even though the psychiatrically received doctrines are far from rational and not reasonable at all. (Patients and their rights, as will also be seen in what follows, by its absence, are the least of the worries of most psychiatrists). Also: I do have excellent degrees since decades: I am not in the dole because I could not earn well if I were healthy.

I also presume my

Philosophical Dictionary

This is on my site, and contains over 600 brief and clear definitions of the meanings of philosophical and logical terms. I include it because, unlike psychiatrists, I am quite clear about the senses of the words I use, and as it happens these matter, if only because (i) one psychiatric peculiarity, as will be amply illustrated below, is the use of impressive sounding terms from philosophy or other sciences than psychiatry in a quite new psychiatric sense, and because (ii) very much of psychiatry is best understood as - intentional or acquired - abuse of words, intentional rhetoric and verbal acrobatics, and as an evident scam to help psychiatrist earn incomes in the highest income brackets by practicing a craft that is mostly bogus, but comes with much authority derived from clever propaganda by psychiatrists and the ignorance of the public, politicians and parliamentarians who believe their pretenses for lack of knowledge.                 ->Contents


C.  Scientific Realism and Postmodernism

What I shall argue, among other things, is that

  • Modern psychiatry has all the features of postmodernism,
    none of the features of science.
     
  • Psychiatry is an art rather than a science; intellectually
    psychiatry is bad philosophy or secular theology rather than honest medical science.

My reference here is my own brief essay on the subject, that I here partially repeat in a somewhat rewritten form to have my reasons and my reasoning explicit and in one and the same file and text - and the reader should notice, and will find out below, that my own text is very much clearer and more sensible than what psychiatrists offer, when asked to reflect on the intellectual foundations of their "science" - that is not a real science but a pseudoscience, and these days comes in the full regalia of carefully crafted and twisted postmodernism:


Scientific Realism versus Postmodernism


The subject is not only large but also too complex to receive an adequate and complete treatment in these brief essays in Nederlog which are always written fast, in poverty and in some pain.

After a little thinking I have prepared, like a finger pointing to the moon, a table of contrasts and oppositions between the things I call scientific realism and postmodernism:
 



Scientific  realism Postmodernism


Properties

Assumption:   There is an independently existing reality that is best known by means of scientific methods and is best explained by and written in mathematics.
 
Both inside and outside the academic world careers, position, power and status are reached most easily by pretentious poses, moral delusions and general - cultural - relativism.
End:   Empirically tenable testable rational explanations of natural facts, that may be used to relief human suffering and satisy human desires.
 
Cant, waffle, purple prose and moral postures that may be used to further a career for the propounders by way of the media, politics or bureacracies.


Methods

Cognitively:  1 realism relativism
 2 probabilistic totalitairian
 3 objective ideological



Morally:  4 personal emancipation social levelling
 5 change freedom/empowerment (soi-disant)
 6 personal and a-political political en politicised



Practically:  7 technologically oriented power oriented
 8 scientifically oriented media oriented
 9 individual thinking groupthinking

One can draw other constants, stress other oppositions, or make a more refined analysis, but for the moment this should do, though I will give brief clarifications of these 9 contrasts between the methods of real science on the one hand and the modern fraudulence or delusion that is called postmodernism, and start with the two different assumptions on which they are based:

Assumption:   There is an independently existing reality that is best known by means of scientific methods and is best explained by and written in mathematics.
 
Both inside and outside the academic world careers, position, power and status are reached most easily by pretentious poses, moral delusions and general - cultural - relativism.

This is the fundamental contrast, opposition and distinction, and it is that between honest people trying to find the truth, and conmen and fools who exploit and/or believe in wishful thinking.

This is also what makes postmodernism and its rhetorical techniques among politicians, bureaucrats, and the more stupid run of intellectuals: It requires no talents or knowledge whatsoever, other than knowing how to pose, pretend, deceive and manipulate, and any stance that pleases one's audience is ipso facto valid.

End:   Empirically tenable testable rational explanations of natural facts, that may be used to relief human suffering and satisy human desires. Cant, waffle, purple prose and moral postures that may be used to further a career for the propounders by way of the media, politics or bureacracies.

This is what is directly implied by the above fundamental contrast, opposition and distinction, and indeed thus it works - where it should be noted that the postmodern target group is that of the vast so called democratic ignorant or untalented majority, who are not interested in truth,  reality, rationality or reason but in what personally pleases and flatters them and in wishful thinking, that unfailingly succeeds in believing what their mediamanipulated prejudices and desires suggest to them.
 

 1 realism relativism

Science is realistic: Statements are true or not, provable or not and are or are not well supported by tested facts and/or repeatable experiments; postmodernism denies the existence of truth and serves as the propaganda of academic, political and bureacratic postmodern impostors and careerists, also strongly concerned with relativizing everything that does not serve their personal careers or incomes.
 

 2 probabilistic totalitairian

Science is fundamentally probabilistic: Theories and beliefs can be rationally estimated as more or less probable on the basis of objective evidence and many things can only be investigated and represented adequately by means of statistics; postmodernism presents totalitairian ideology of freedom/empowerment centered around a so called epistemology that reduces all human beliefs and desires to the same level that can be democratically voted upon and that depends on what The Media say and The People believe, in majority, in their universal equality of all with all.
 
 3 objective ideological

Science is based on knowledge of and interest in objective facts, established by objective observers, and on repeatable experiments, established by honest experimenters; postmodernism calls this an ideology but is itself explicitly ideological and totalitairiar, in a usually phony moral way: Whatever seems to oppose the postmodern rhetorics and propaganda of freedom that are presently in fashion, is postmodernisically decried as out of fashion, as lacking in solidarity, as tending to fascism (racism, sexism, homophobia etc.)

 4 personal emancipation social levelling

A very important motive of the real sciences and of real scientists is the personal emancipation of human individuals in accordance with their talents and the relief of suffering of all human beings; the postmodern freedom consists in the social levelling and equalisation nivellering, gelijkschakeling, en gelijkmaking of all and everyone until each is the equal or equivalent of all (except that postmodern leaders are just a little bit more equal than the rest, for which reason all well-paying jobs morally speaking ought to be reserved for them, for proper postmodernists).

 5 change freedom/empowerment (soi-disant)

Science is concerned with truly understanding reality and with finding the means to change the world in accordance with human desires, needs and interests; postmodernism is concerned with getting the best - most paying and most powerful - jobs to postmodernist academic, bureaucratic, political and journalistic careerist, by making them the most prominent Talking Heads of the day or age, and always does so by pretending To Emancipate, Liberate and/or Empower repressed women, blacks, gays and (after these all have postmodern well cushioned jobs) repressed humans of other fashionable kinds. (And this Emancipation / Empowerment in turn manifests itself -"physical 'reality' ... is at bottom a social and linguistic construct" - in the enforcement of the totalitarian language and terminology that is called Politically Correct.) 

 6 personal and a-political political en politicised

Real science is oriented towards the individual emancipation of all, and is produced by the intellectually most gifted individuals, for whom real knowledge of reality is a personal instrument of civilisation, liberation and emancipation; postmodernism is oriented towards liberating all by reducing everyone - but the leaders - to the same common level of humanity that is open to even the most stupid, the most lazy and the least moral (and especially of professors of postmodern philosophy and literary "science"), in the interest of all, or so it is postmodernistically claimed.

 7 technologically oriented power oriented

Real science - and only real science - leads to real human technology: New artefacts and constructions created by humans, that as really existing things, such as medicines, apparatuses and instruments, that are useful for others also if they lack the knowledge that was necessary to create them, and without having to pray, to have faith or to have to rely on priests, clergy, shamans, or postmodern media-sophists; postmodernism is driven by the lust for power and the desire to level all except the leaders to common folks one should respect, and in the end depends on rhetorics, lies, poses and their eventual democratic success because of the ignorance of the majority and misrepresentations in the media of nearly everything (that is not fit for being understood by ignorant common men and women, who are always in democratic majority).

 8 scientifically oriented media oriented

Real scientists address mostly other real scientists to receive criticism or support ('peer review'); the postmodernists are mostly media oriented because their message is in fact populistic, levelling, canting, and directed at the average (lacks of) qualities of the masses, and is in fact directed at furthering the emancipation, careers, incomes, and media fame of postmodern leaders and their philosophical and journalistic servants.

 9 individual thinking groupthinking

A real scientist is an human individual who has both the courage and the talents to think rationally for himself; the postmodernists, from lack of talent, lack of knowledge or lack of courage reason only in terms groupthinking, and swear by democratic majorities, however much deceived and manipulated, and swear by so called equality and equivalence of all for all, always in the name of human liberation and emancipation, except in the proportionally few individual cases (like me) who oppose the moral pretenses and irrational delusions of the postmodernists, and who generally cannot find any function in postmodern politics, institutions, and universities, other than as whipping boys.

I hope this little list of contrasts and oppositions is of some help, and if you want to know more you can follow the links or go to my site, that from a postmodern point of view is a horror show composed by a kind of fascist freak. (See my 39 questions about the qualities of education and government in the Netherlands for the reasons why I was repeatedly removed from the postmodern University of Amsterdam "because of your outspoken public opinions", something that happened only to me in Holland since World War II ended.)                   ->Contents


Finally, I presuppose two lemmas from the Wikipedia, that I will partially quote to have these in the text that contain my criticisms. The first concerns the actual contents and scientific tenability of psychiatry, which is a pseudoscience as defined:

D. Pseudoscience

Quote:

The distance between pseudoscience and science is filled with protoscience (and fringe science) which can be understood from the following table:[32][not in citation given]

        Systematized as scientific definition
    Treated with scientific method
  Presented as science or looks like science  
Superstitions Pseudoscience Fringe science Protoscience Mainstream science

A field, practice, or body of knowledge might reasonably be called pseudoscientific when (1) it is presented as consistent with the norms of scientific research; but (2) it demonstrably fails to meet these norms.[2]

Karl Popper stated that it is insufficient to distinguish science from pseudoscience, or from metaphysics, by the criterion of rigorous adherence to the empirical method, which is essentially inductive, based on observation or experimentation.[33] He proposed a method to distinguish between genuine empirical, non-empirical or even pseudo-empirical methods. The latter case was exemplified by astrology which appeals to observation and experimentation. While it had astonishing empirical evidence based on observation, on horoscopes and biographies it crucially failed to adhere to acceptable scientific standards.[33] Popper proposed falsifiability as an important criterion in distinguishing science from pseudoscience.

To demonstrate this point, Popper[33] gave two cases of human behavior and typical explanations from Freud and Adler's theories: "that of a man who pushes a child into the water with the intention of drowning it; and that of a man who sacrifices his life in an attempt to save the child."[33] From Freud's perspective, the first man would have suffered from psychological repression, probably originating from an Oedipus complex whereas the second had attained sublimation. From Adler's perspective, the first and second man suffered from feelings of inferiority and had to prove himself which drove him to commit the crime or, in the second case, rescue the child. Popper was not able to find any counter-examples of human behavior in which the behavior could not be explained in the terms of Adler's or Freud's theory. Popper argued[33] that it was that the observation always fitted or confirmed the theory which, rather than being its strength, was actually its weakness.

Unquote.

"And thus it was and is until this very day", as far as the contents of psychiatry is concerned, when considered realistically, and without prejudice in favour of psychiatry.

As far as the methods of psychiatry are concerned: While psychiatrists pretend they are medical scientists (they have a medical B.A. and then specialized in their pseudoscience, very probably in most cases without really understanding at first they specialized in a pseudoscience):

It is very much a rhetorical science, full of fallacies and tricks, that cannot be rationally understood in terms of scientific method, since what methods there are that seem scientific are often only there for make-belief, and is best understood as deliberate propaganda or - for its true believers - as intellectually and morally very bad philosophy, that pretends to be informed by scientific methods, but isn't, a few small parts - Parkinson's, Azheimer's, syphilitic insanity excepted (that psychiatrists always pretend can stand as pars pro toto, which is a fallacy):              ->Contents


E. Weasel words, bullshit, propaganda, rhetoric

First weasel words, the preferred method of nearly all psychiatrists I have read (a few of which may have been so unintelligent as to believe them):

-- Quote:

A weasel word (also, anonymous authority) is an informal term[1] for equivocating words and phrases aimed at creating an impression that something specific and meaningful has been said, when in fact only a vague or ambiguous claim, or even a refutation has been communicated.
(..)
The use of weasel words to avoid making an outright assertion is a synonym to tergiversate.[2] Weasel words can imply meaning far beyond the claim actually being made.[3] Some weasel words may also have the effect of softening the force of a potentially loaded or otherwise controversial statement through some form of understatement, for example using detensifiers such as "somewhat" or "in most respects".[4
(..)
The expression first appeared in Stewart Chaplin's short story "Stained Glass Political Platform" (published in 1900 in The Century Magazine),[8] in which they were referred to as "words that suck the life out of the words next to them, just as a weasel sucks the egg and leaves the shell". Theodore Roosevelt attributed the term to Dave Sewall, claiming that Sewall used the term in a private conversation in 1879.[9] Winston Churchill wrote: "The reserve of modern assertions is sometimes pushed to extremes, in which the fear of being contradicted leads the writer to strip himself of almost all sense and meaning." Current examples include governing parties in various countries commenting upon their country's financial state with statements such as "the budget deficits we inherited" rather than specifically blaming their predecessors.

Additionally, the definition of the word 'weasel' includes: n. a sneaky, untrustworthy, or insincere person; v. to manipulate shiftily. [10] A weasel word (or phrase) can quite likely be understood to come from a position of intending to manipulate the communication, in a sneaky or underhanded manner.

In the political sphere, this type of language is used to "spin" or alter the public's perception of an issue. In 1916, Theodore Roosevelt argued that "one of our defects as a nation is a tendency to use ...'weasel words'; when one 'weasel word' is used ... after another there is nothing left".[11]

-- Unquote

Next, there is bullshit, a favourite psychiatric game, often played, as we shall see, by pretending a scientific subject is best discussed by metaphors and words sung apart from their meanings in the real sciences (see Sokal for other examples:

--Quote:

From "On Bullshit":
"It is impossible for someone to lie unless he thinks he knows the truth. Producing bullshit requires no such conviction. A person who lies is thereby responding to the truth, and he is to that extent respectful of it. When an honest man speaks, he says only what he believes to be true; and for the liar, it is correspondingly indispensable that he considers his statements to be false. For the bullshitter, however, all these bets are off: he is neither on the side of the true nor on the side of the false. His eye is not on the facts at all, as the eyes of the honest man and of the liar are, except insofar as they may be pertinent to his interest in getting away with what he says. He does not care whether the things he says describe reality correctly. He just picks them out, or makes them up, to suit his purpose."

   -- professor Harry Frankfurt, on Bullshit (<-Wikipedia)
       
My bolding and coloring.

-- Unquote

Of course the purpose of pseudoscience is to make money, as in quackery, which is what psychiatry is, as pseudoscience and carefully crafted bullshit ever since Freud showed how to get famous and rich with psychiatric bullshit. (See also my: More on Freud and psychiatry.)

And then there are two other favourite ploys of psychiatrists to get their views prevailed, which are techniques at which they are much better than real scientists, who tend to speak the truth, or at least do not lie. For psychiatrists as for postmodernists, there is not truth, if not sanctioned by their professional organizations, and so there are no lies, at least not by psychiatrists: See how clever they prevent being refuted!

-- Quote:

Propaganda is a form of communication that is aimed at influencing the attitude of a community toward some cause or position. Propaganda is usually repeated and dispersed over a wide variety of media in order to create the desired result in audience attitudes.

As opposed to impartially providing information, propaganda, in its most basic sense, presents information primarily to influence an audience. Propaganda often presents facts selectively (thus possibly lying by omission) to encourage a particular synthesis, or uses loaded messages to produce an emotional rather than rational response to the information presented. The desired result is a change of the attitude toward the subject in the target audience to further a political agenda.

--Unquote

And the "political agenda" may as well be a psychiatric one, for psychiatrists are much interested in power and control over their patients and over the ways psychiatry is publicly discussed.

Finally, psychiatrists, from Freud and Jung onwards, tend to excel in rhetoric, quite possibly not because they closely studied it, but because they are fundamentally at heart and in outlook postmodernistic bullshitters who just don't believe in "truth", and who are convinced a well-composed "narrative" is far more effective, socially and for one's career, than honest real science (which unfortunately is true if one tries to gain one's end by convincing the public of one's baloney, as has been the way of psychiatry ever since Freud got famous by provoking his contemporaries, and then soothing them by the tale that "empirical medical science" had "discovered" his fictions).

-- Quote:

Rhetoric is the art of discourse, an art that aims to improve the facility of speakers or writers who attempt to inform, persuade, or motivate particular audiences in specific situations.[1] (..) Its best known definition comes from Aristotle, who considers it a counterpart of both logic and politics, and calls it "the faculty of
observing in any given case the available means of persuasion."
[

-- Unquote.                   ->Contents


Please note - whatever your beliefs about psychiatry are - that to understand most of my criticism you need to have some knowledge of the above sections

A. Real philosophy of science
B. Clifford's and Voltaire's dicta + Philosophical
     Dictionary
C. Scientific Realism and Postmodernism
   Tabular exposition
D. Pseudoscience
E. Weasel words, bullshit, propaganda, rhetoric

Besides: This should be helpful to you in also judging many other subjects than psychiatry in a rational way: There is much bullshit, deception and delusion in the human world, and there is little better than real philosophy of science to help you see through it and explain why such and such is bullshit, fraud or delusion.

Indeed, for a full appreciation of how psychiatry works in practice, you really need to consider these two references:

-   The Rosenhan-experiment - illustrating psychiatric abuse
-   Donald Ewen Cameron - ex chief of the Canadian, American and World Psychiatric Associations, and clearly a truly monstrous man, with a morally depraved mentality. (See my Corporate psychopaths - part A for what I have in mind - and incidentally, the talented Mr. Fuld you'll find portrayed there is a colleague of the very talented o so "pragmatic" dr. Pincus below.)


The discussion


Introduction

Question #1 involves both ontological and epistemological issues: what are psychiatric disorders, and how do we know them
?

Let me just note three points here that I will return to in the rest of my text at various places:

        • This is not at all as in real sciences: These generally have fairly
          sophisticated and worked out methodologies and epistemologies:
          See good readings in philosophy of science above.
        • What seems pretty immoral and dishonest to me, with the exception
          of dr. Szasz and possibly two others in this text: Nearly all psychiatrists
          choose not to mention the fact that psychiatry is different from other
          sciences as regards the freedoms and rights of its patients:

          Of all scientists only psychiatrists can have people locked up without
          these people having done anything illegal, while only psychiatrists can
          force people to take medicines.

          These are anyway great differences - practically, legally, morally - and to know that the "science" that is allowed to do so is for the most part bullshit or delusion does not make it more palatable that its purported "scientists" decline to discuss the special legal privileges and powers they have.
        • The five many dicta to judge practices like psychiatry and the Catholic Inquisition by (also folks who public claimed to be specialists who meant it all very well) should be these:

          - Hippocrates: "First do no harm."
          - Clifford: "It is wrong always, everywhere, and for anyone, to
                            believe anything upon insufficient evidence."

          - Voltaire:
          "If we believe absurdities, we shall commit
                            atrocities.

          -
          Chambers/Dr Johnson: "We never hurt each other but by error
                            or by malice.

          - Rev. Sidney Smith:
          "As long as the patient will suffer, the cruel
                            will kick.
          "

More dr. Phillips:

Framing these questions with the metaphor of umpires and balls and strikes comes from Allen Frances’s response to commentaries in Bulletin 1, “DSM in Philosophyland: Curiouser and Curiouser.” That response offered the positions of three umpires: the realist first umpire, the nominalist second umpire, and the constructionist third umpire.

It's a simplification anyway, that is not adequate, and also quite pomo-ish. Then again this sort of question, to the effect of what are the basic assumptions on which psychiatry is founded and how one knows this, is a fair one, if also a very curious one for a discipline that is supposed to be a science: Where is the description of its subject matter and its methodology? (Answer: The psychiatrists - after 100 years of locking people up and misdiagnosing them "in the name of science" - still do not know what their subject is or how to define "mental illness" or "mental disorder", and do not have any rational idea or indeed often: do not have real knowledge, of what sort of methods they should use, for studying a subject they do not know how to define, and that many of them declare to not exist or at least not exist as claimed in their profession the last 100 years.)

And the names are somewhat misleading, to say the least:

A brief visit to the excellent and free Stanford Encyclopedia of Philosophy should have provided dr. Frances and the others with the standard meanings of philosophical terminology they bandy around as if they understand it. (I suppose not, and if they do, so much the worse for their consciences.)

The author sided with Umpire 2, espousing a nominalist stance to the effect that he knows that there is real psychopathology out there but has no guarantee that his diagnostic constructs sort it out correctly.

"Nominalism" is a mistaken term in this context, and the whole false opposition between the first two alternatives could have been avoided by a formulation on the lines of "There are psychiatric disorders or diseases and I believe they probably are as I say they are, for else I wouldn't be doing science but would be engaging in fiction or deception".

Besides, in a science or supposed science like psychology the received methodological wisdom is that one's theories are hypotheses that involve hypothetical terms - say: 'intelligence', 'personality', 'judgment' - that are fairly called constructs, because they involve empirical and theoretical parts in their definitions, and often also are operationalized for doing empirical research, where the operationalization refers to assumptions and methods - say: standardized tests in standardized conditions - to make the terms and theories testable.

He wrote: “This brings us to me a (call’um as I see’um) second umpire. In preparing DSMIV, I had no grand illusions of seeing reality straight on or of reconstructing it whole cloth from my own pet theories. I just wanted to get the job done - produce a useful document that would make the fewest possible mistakes, and create the fewest problems for patients” (Bulletin 1, p. 22).

That sounds well, but is a bit of a pose, it seems to me: No scientists in any science can do better than proposing hypotheses. Also, it presumes answers it does not give:

A. Is there at all a useful DSM possible and are "fewest possible mistakes" and "fewest possible problems"
(1) intellectual consistent and
(2) morally fair for patients?! And

B. Where is a recognition of the unique position psychiatry has with regards to its patients, and the admissions that
(1) many persons have been misdiagnosed and mistreated in the past 100 years or so of applied psychiatry and
(2) at least part of the reason for the fact stated in (1) is that so much of psychiatry was quite unscientific, except that lip-services were paid to science and medicine, because psychiatry got admitted as a science as a branch of medicine, as are neurology, urology etc. - always
(3) with the difficulty Question I addresses, if in a fanciful somewhat bantering way, namely that other parts of medicine have clear subjects that clearly empirically exist psychiatry does not have a clear subject that empirically exists, nor agreed upon truly scientific methods of studying that possibly non-existing subject.

More dr. Phillips:

For this article we have added two more umpires: a pragmatist fourth umpire and a fifth umpire who rejects the entire exercise. We were motivated to add these umpires by the fact that some of the responses required them.

This is a bit unfortunate for at least two reasons. First, it suggests that there is a fourth position that somehow is practical/pragmatical, which seems to confuse several things, such as practice and theory, and truth and value. I'll come to these later. Second, it suggests that the fifth alternative is singular, whereas it clearly isn't, as one may reject psychiatry as a science or as a practice for theoretical reasons (such as: there is not enough knowledge to base it on, either as science or as a practice) or for moral reasons (such as: a medical doctor should not engage in policing or forcing persons or consort with authorities to lock them up) or indeed for both kinds of reasons.

I'll turn to this later also, though of all contributors to this Question 1 only a minority - most clearly and unambiguously: Dr. Szasz - seems to be aware of any moral problems involved in practising "a science" they can't define the subject or methods of, that in its practice may be very dangerous to its "patients": One may be locked up, misdiagnosed or forced to use medicines because a psychiatrist said so, merely on the basis of his supposed authority as a claimed "medical scientist".

Further, we recognize that in asking respondents to choose one position and defend it, we have made an unreasonable demand. Why should an individual not say, I’m a combination of these two umpires, or, I’m a lot of this umpire and a little of that, or finally, I’m a first umpire if we’re talking about Huntington’s disease, but a second umpire if we’re talking about schizoaffective disorder. So, quite understandably, in some our responses we witness the same problem we have with our diagnoses: comorbidity - in this case epistemological (or ontologic) comorbidity rather than diagnostic comorbidity.

As I said, I think the distinctions were not clear enough and not well phrased. And clearly in any halfway tenable science of something there will be various theories with various probabilities or plausibilities, depending on the subject and the state of research.

The problems with psychiatry are rather that

(1) it is so far and has been based for some hundred years on the presumption that there are "mental illnesses" (rather than: deviant opinions of abnormal acting that is not illegal) that

(2) have turned out psychiatrists cannot even agree about amongst themselves how to define, recognize, establish the existence of, treat, or cure "mental illnesses", that they also, unlike somatic illnesses that have been researched deep and long enough,  have no biological markers for, except for some rare cases, while

(3) the whole practice of psychiatry is about people who often have no clear somatic ill health whatsoever, but whose behaviour is considered somehow strange, improper, immoral, dangerous, or based on delusions, who "therefore"

(4) risk being locked up (as used to happen to heretics) in what are called "mental hospitals" but effectively are much like prisons not because they committed a crime but because they have been declared mad by some doctor with a B.A. in basic medicine, while finally

(5) not only can psychiatrists not clearly define, describe, recognize or classify many of the mental illnesses they attribute to patients, and that they claim - falsely, seen in historical terms - to be able to give paid professional help for; they also widely disagree amongst themselves about most or all aspects of their supposed "science":

(6) There also have been very many admitted false diagnoses on the basis of false psychiatric theories, e.g. about the causes of peptic ulcers, multiple sclerosis, and homosexuality, that destroyed the lives and chances of untold many millions, though their psychiatrists generally flourished economically and socially.

But apart from dr. Szasz's contribution none of the contributors, including dr. Frances, seems willing to discuss these serious moral and intellectual problems in a serious way: Instead, much of the discussion is conducted in terms of vague and misleading moral talk, while abusing standard philosophical and scientific terms, and spinning metaphorical tales about the supposed ends of fictional umpires in baseball.

In this debate over the nature of psychiatric disorders we experience a tension among the umpires that reflects the status of nosologic science. 

No, I don't think so - rather, as is also the case with most psychiatric terms and concepts, the real logical and empirical problems arise out of their bad definitions and unclear theoretical presuppositions to start with, as in the present case a clear ad hoc metaphor, that now is boldly but quite misleadingly declared to "reflect(..) the status of nosologic science": Sorry, that is bullshit or delusion.

On the one hand our patients suffer greatly from psychiatric symptoms, and it seems wildly foolish to theorize away their suffering. On the other hand our efforts to organize and classify their suffering can seem arbitrary and confusing. 

This also is quite misleading, in leaving the personal interests of the psychiatrists completely out of consideration: What about their making up supposed diseases only their unique kind of medical science can sell the cure or treatment for? They are in their business not as warranted holy men without blame or dishonesty, but simply as professionals who are in it for the money, aren't they? Doesn't that invite distrust about their motives, practices and theories if in the end these are about their personal incomes and social status, and about the special kinds of power they have to incarcate person they accuse of being "mentally ill"

?

Also, the second statement seems to presume - "can seem", without further clarification - a competence in psychiatrists that many other scientists, including medical doctors with other specialisms, have seen little or no evidence of.

We organize or categorize a symptom cluster and give it  a diagnostic name, and it overlaps with another cluster.  Or a patient simply has symptoms of both. 

Let's set the patients with symptoms in two diagnostic categories apart as a red herring: The problem is that the whole notion of "symptom cluster" as used in psychiatry is obscurantistic and seems set up as if it is meant to confuse:

The totally mistaken and misguided idea that the "5 out of 9 of the following attributes" style of "definition" is a clear diagnosis (apparently because it looks "mathematical") I criticized in my On confusions and misunderstandings concerning the DSM-5, and I here repeat the main mathematical part

The following table suffices with instances of in how many ways x things can be taken out of y things, with x <= y, and 1 of x always in x ways and x of x in 1 way :

The dangerous nonsense of the x out of y diagnostic schema

2 of 3=3 2 of 4=6 2 of 5=10 2 of 6=15 2 of 7=21 2 of 8=28 2 of 9=36
  3 of 4=4 3 of 5=10 3 of 6=20 3 of 7=35 3 of 8=56 3 of 9=84
    4 of 5=5 4 of 6=15 4 of 7=35 4 of 8=70 4 of 9=126
      5 of 6=6 5 of 7=21 5 of 8=56 5 of 9=126
        6 of 7=7 6 of 8=28 6 of 9=84
          7 of 8=8 7 of 9=36
            8 of 9=9

But this is merely a hopefully instructive aside, as to the number of distinct ways in which one can have an ailment "X" on any diagnostic schema that is written around the "x out of y" attributes: 5 out of 9 (a common couple of figures in the DSM) in fact defines 126 different ways of having that ?same? "ailment" defined by 5 out of 9 attributes.

Suppose you show symptoms 1 to 5, and your neighbour symptoms 5 to 9: Do you both have the "same" "disease"?!

And since all there is in psychiatry for diagnosing people, in virtually all cases, are collections of symptoms, you have not the least assurance of any rational kind that any of these 126 different ways of having that "ailment" are not specific "diseases" that differ from each other depending one one, two ... or possible 126 of the different ways in which 5 symptoms can be selected from 9.

This seems and is presented as if it is "a mathematically precise way of diagnosing".

To me it appears as either a cleverly contrived way to infuse enormous amount of vagueness and ambiguities in psychiatric diagnoses - or indeed seems sheer incompetence and ignorance of elementary combinatorics and mathematics.

Back to dr. Phillips:

We start off with the expectation that there will be a match-up between therapeutic agent and diagnostic cluster, and we discover that, at the extreme, most of our pharmacologic agents seem to treat most of our disorders. 

If so, the honest rational conclusion must be: Therefore psychiatrists did not know what they were talking about. (Then what is the point or content or competence of this supposed "science"?!)

Finally, we somehow want to resolve this confusion by getting at the underpinnings of the identified disorders, and we discover that the genetics and neuroscience don’t support our groupings.

Again: If so, the honest rational conclusion must be: Therefore psychiatrists did not know what they were talking about.

In view of this confusion it’s not surprising that opinion divides itself in various ways. Focus on the real suffering out there, along with a conviction that the diagnostic clusters reflect distinct, real conditions, and you end up as a first umpire. Focus on that suffering with uncertainty about the isomorphism between label and disorder, and you become a second umpire. Switch your focus onto the arbitrariness of the labeling, and you end up questioning whether there is anything but the labeling and become a third umpire. Or switch away from the issues of these umpires onto the effects of one label versus another, and you are now a fourth umpire. Finally, decide that it’s all nonsense, and you are our fifth umpire.

By now I find this sounds rather like an exercise in trivialization, where the real problems are avoided by misleading and trivializing terminological oppositions that have no real foundation in philosophy of science or in the subject of psychiatry: It's like discussing the theology of Catholicism with the help of fairytales only.

This gets well illustrated by the first contribution. Readers who want rational clarity rather that a playful cleverness better move to contribution 1.               ->Contents



Commentary: A Game for Every Kind of Umpire (Almost)
Peter Zachar, Ph.D. and Steven G. Lobello, Ph.D.
Auburn University Montgomery Department of Psychology.

Messrs Zachar and Lobello jump into playing the game with a boys' scout eagerness:

One might think that a philosophical pragmatist should identify with either the pragmatist or the nominalist position in Allen Frances's clever analogy, but that isn't the case. From a pragmatist perspective, philosophical -isms such as realism, pragmatism, nominalism, and constructionism are conceptual distinctions that we make for certain purposes. The question is what information or response options are gained from making these distinctions that would not be gained were other distinctions made. 

For example, let's take the pragmatist's view that I call balls and strikes as I use them. If taken too literally this is a recipe for a shallow utilitarianism.

"One might think" so, but one who know philosophy knows the two gentlemen play-pretend with names - not even concepts - pinched from philosophy, that have been misapplied and misused in Question 1, which is here followed up with dedication - while the terms "philosophical", "pragmatist",  "nominalist", "realism",  and "constructionism" have either not been defined or have been misleadingly redefined in the context of a psychiatric game of "let's reflect on our assumptions, or at least pretend to".

As postmodernists do, Messrs Zachar and Lobello feel free to use terms without showing any real understanding how these are used or defined in real philosophy, and they show a level of sophistication that involves "From a pragmatist perspective" people make "conceptual distinctions" (..) "for certain purposes".

Actually, "From a non-pragmatist perspective" as well, but then the two gentlemen are neither philosophers nor logicians. Their question is perfectly academic and has nothing to do with pragmatism properly conceived while "utilitarianism" again seems to bear a sense they give it in their private language game that hardly anyone else uses in the same way.

Next we get this truly Freudian move:

One of the ethical principles of umpires is to try to make the game as fair as possible

Hardly have "the umpires" been introduced as metaphorical banter or two psychiatrists - just like Freud in his Introductory Lectures : I know for I was examined on the text of this book in the study of psychology - presume or pretend or at least write as if their existence is real, and as if one can start pontificating about umpires and their ethical principles, and turn the discussion into one of baseball, rather than psychiatry, philosophy or epistemology.

I am sorry, but this is not serious rational science: This is arbitrary mockery an abuse of then reader. And yes: we get spates of arbitrary but - I grant - playful waffle:

- so every batter and pitcher should face the same strike zone (for that umpire). An umpire should attempt to call the pitches as they are (to the best of his ability), and not widen the zone for batters he favors and narrow it for those he does not. Also, in most games, a degree of unreliability in deciding what counts as a ball or strike may not matter, but it can matter a lot in big games. Presumably every psychiatric patient should be treated like a big game, but with 15 minute medication management sessions that is not likely the case.

Perhaps not - but then a psychiatrist gets very well paid for these 15 minutes, I presume, and apparently is playing the game too well to even think about ethical issues involved in treating patients - sorry  "big game": that seems to be one's place as a patient in a psychiatric perspective - on a tight time schedule.

More mock serious playful psychiatric banter, of gentlemen whose tenure probably is comfortable and secure:

So a kind of realist attitude is important for keeping the game fair. This is true of psychiatric nosology as well. We should always attempt to classify the world as it is not how we want it to be. A pragmatist would not deny the spirit of this ethic.

Really now?! Never heard of the pragmatist William James's "The Will To Believe", that he was much in favour of, at least if it concerned (his kind of) religion? Nor of his concept of "overbelief". Probably not, or long ago - and bogus, especially in a playful way, is easily produced by the bucket full.

More buckets full or arbitrary waffle (I call'um as I see'um, gentlemen!):

Most pragmatists would point out that the purpose of the strike zone is to assure that the batter has a chance to hit the ball well enough to get on base. He cannot do so if the pitch is too high, in the dirt, or wide of the plate. This makes the strike zone a practical kind. There are also practical constraints on the strike zone's location that create a kind of objectivity - but beyond that there is no gold standard. Furthermore, it is not true that every pitch that goes through the zone on the way to the catcher is a strike. For example, spit balls have such unpredictable trajectories that batters have very little chance of hitting them, and they are therefore illegal whether or not they are in the zone. Psychiatry lacks fixed gold standards as well, and the social implications of giving a diagnosis that is contrary to the purpose of diagnosing can also affect whether something is considered to be an official disorder (e.g., pedophilia).

So there you are: "Psychiatry lacks fixed gold standards" so sometimes "spit balls" ("Nudge, nudge. Know what I mean?") "(e.g., pedophilia)" ("Know what I mean? Say no more!") must be thrown according to "official" "umpires" but don't we shrinks all know that in ancient Greek times ("Nudge, nudge. Know what I mean?") the "umpires" had other "official" rules, more "platonic" ("Know what I mean? Say no more!").

More waffle:

What of the nominalists who say I call balls and strikes as I see them? Perhaps a better way to think about nominalists is that they deny both that the criteria for balls and strikes were created by the Platonic baseball gods and that competent umpires can recognize what is naturally a ball and naturally a strike. Cousins to the pragmatist, the nominalists say that what exist are particular pitches, and we tend to group them into the ball category or the strike category for various and sundry reasons. Very different pitches like fast balls, curve balls and sliders can all be strikes. These groupings can also be altered. For example up until the 1920s the spit ball was a legitimate pitch (as homosexuality was once considered a legitimate psychiatric disorder).

You see? It's all a matter of what the "official" rules are: Psychiatrists are gladly willing to accomodate who is going to be locked up for breaking which rule of what umpire - as long as they get well paid and are not held responsible. They play "A Game for Every Kind of Umpire (Almost)", the two mock philosophical psychiatric Humpty Dumpties contend.

You see, it's all a game psychiatrists enthusiastically play, as long as their pay is real, and not monopoly money, and also does not depend on the free consent of their patients as "umpires" of whether their psychiatrists are worth their pay.

The game, the tale, and the waffle continues, as if the writers never heard Harry Frankfurt's name:

So nominalists and pragmatists are uncomfortable when realists start talking about fixed world structures and natural kinds. There are, however, kinds - fastballs, curve balls, etc. With the realists, the pragmatists and nominalists recognize the value of understanding the causal mechanisms that produce these kinds (e.g., Vaseline helps you throw good spit balls), but individual pitches can be grouped in a plurality of ways.

The constructionist position is the easiest to defend in this example because baseball is a social construction, and like other social constructions such as the U. S. Government and currency, baseball is a real thing.

See? Concentration camps, waterboarding, Mao's Cultural Revolution and Pol Pot's prisons also are "social constructions", you see, and also each and all  "a real thing". And "Vaseline helps you throw good spit balls" ("Nudge, nudge. Know what I mean?"). How to judge them all depends on "umpires", you must understand: Everything is one if not a plurality of  "social constructions", that is, presumably, as long as the monthly psychiatric tenure is promptly and correctly paid each month.

The two securely tenured gentlemen continue with their kind of wit and wisdom:

So what information do we gain from the constructionist analysis? Rather than saying There are no balls and strikes until "I" call them, it is more accurate to say that social construction is a historical and community activity.

As were the Gulags - and don't you believe for one moment Messrs Zachar and Lobello's "umpire" will hold them personally responsible or accountable for anything (except cashing pay  checks: Even pomo shrinks need income to be able to spout their wisdom). No, no! Precisely as during Stalin's purges all that happens is "a historical and community activity", and how one calls it depends on one's "umpire".

You see - and there is more waffle to follow:

Baseball proper did not exist in 1800 and a pretty good story can be told about the social and economic factors that helped shape the game we have today. A similar narrative could be developed for psychiatry, for example, there is a good story to be told about how degeneration theory in the 19th century and pharmaceutical marketing practices in the 20th century both shaped the classification system. Social constructionists would also point out that something like the introduction of the designated hitter was not a deductive consequence of the rules of the game. Its legitimacy has to be understood with respect to the baseball community and its chosen authorities. Something similar is true of the scientific community and its designated authorities, including the process by which the DSM and the ICD is developed. The pragmatists consider this useful information.

By which these tenured gentlemen mean that "Anything goes!", in baseball and shrinkery, as long as the salaries are duly paid. And if so, they call'um as their own state's umpire sees'um, and they will not be to blame: It's all in the game, doncha see?

Having thus disposed of everything in psychiatry, epistemology, philosophy and ethics, our brave authors turn to dispose of Satan himself:

Finally we come to the Szasian. It is a category mistake to lump a political and ethical position such as I refuse to play because the game is not fair with realism, pragmatism, nominalism and constructionism.

Thus dr. Szasz is hoisted with the petard that dr. Frances forged: He is a living category mistake, according to these two clowns, and not even an "umpire" - but yes, I do agree, for the nonce, that those who deny psychiatry is a legitimate form of baseball and think it throws spitballs all the time, except that it doesn't call'um thus (but then all name calling is a "social construction", doncha see?), do have some sort of point, modulo terminology and psychiatric posturing and liberal if non-admitted using of "vaseline" to grease their own balls.

And dr. Szasz is put next to the garbage thus, by these two psychiatric clowns, who love to pretend that psychiatry did not make millions of nonsensical harmful diagnoses that were pretended to be "medical science":

Anti-psychiatry is better considered a behavioral option available to a disillusioned realist.

He needs some cognitive behavioral therapy to learn to cope with the problems of old age, or so I decode the psychiatric duo's prose. Then again, the gentlemen turn to their favourite mode of talk:

In terms of baseball, the claim would be that in the rest of sports, things like field goals and holes-in-one are objectively fixed, but there is so much variation between umpires in terms of the strike zone, that any rational person would see that the so-called objectivity of the game is a myth. Other like-minded critics would point out that there seems to be statistical evidence that the strike zone gets wider when the count is full - which keeps the game exciting. It is also economically convenient for the sport as a whole if pitchers are allowed some leeway when being close to throwing perfect games and batters allowed leeway when being close to breaking hitting records. Field goals and holes-in-one do not work like that, say the critics, yet baseball wants its consumers to think it is like those other sports.

So there: That's what real psychiatry and real philosophy is in the hands of psychiatric academic clowns with secure tenure: Playing baseball

But then they have a moral-of-the-story, in the "Vade retro me" tradition:

Perhaps the best argument against the Szaszian view is to point out that if they studied football and golf more closely, they might see that things are not as always as objective over there as they assume. Baseball should not be evaluated with respect to an idealized image of other sports just as psychiatry should not be evaluated with respect to an idealized image of other medical specialties.

These Satan's followers didn't even do their homework well, doncha see?! They confuse baseball with football, while messrs Zachar and Lobello are certain-sure concentration camps and Gulags "should not be evaluated with respect to an idealized image of" reality or morality!" O no! What matters is who is the "umpire" who signs the pay check!

And that was the contribution of two gentlemen who also may be clinical psychologists (apparently being no M.D.s) who may be praised for playing the game as pros, and having the patter and the postures pat.    ->Contents

I turn to a vastly more rational contribution.

This is by dr. Pouncey, whose contribution has the considerable merit of being a clear explanation of the terminology dr. Frances introduced in a sort of jest or else a sort of postmodernist move to relativize all rational discussion to reflections on texts and terms rather than on realistic theories and real things.

I reproduce her text with hardly a note:


Commentary: Mental Disorders, Like Diseases, Are Constructs. So What?
Claire Pouncey, M.D., Ph.D.
Philadelphia, PA.

The literature on the philosophy of psychiatric nosology often conflates questions of ontology - i.e., whether mental disorders exist as abstract entities- with questions of epistemology - i.e., how we can know anything about them if they do. To ask whether mental disorders are (actual) diseases or (mere) constructs confuses these two types of questions about mental disorders, as I will use the first three umpire positions to illustrate. This error is prevalent in academic discussions about psychiatric nosology.

Ontologic commitments are basic metaphysical commitments about what exists in the world. Most of us, by virtue of the fact that we operate in our physical and social worlds as we do, are committed to the existence of intersubjectively appreciable mid-level objects, such as plants, buildings, bodies of water, and other persons, to name just a few. That is, we are realists about (and realism is always local to a particular question) mid-level objects, as evidenced by our behaviors.

This is all fair enough, but I want to add that the conflation mentioned in the start is one that also was known to Hobbes and Charles II of England, who was taught by Hobbes, and liked to ask pretentious theologians questions like "how do you know fishes are lighter in water than on land?", only to make fun of them when they had let themselves be tricked into assuming the question asserted a matter of fact (as in "how do you know God burns psychiatrists everlastingly?"). Also, Kant made the same mistake - which is a mistake, because knowledge is true belief, and there is none of that without a reality for the beliefs to be about and true of.

Also, while dr. Pouncey may believe that she and I "are committed to the existence of intersubjectively appreciable mid-level objects" I can assure her confidently that we very probably are committed to rather a lot more, if we believe in dates, elementary physics and chemistry, and in some basic medicine and simple calculus (I do, and she should, if she is practising medical science on people). But this was not said in criticism, but to make plain that almost everyone accepts and assumes as a matter of course quite a lot - including the mental life of all others, and its similarities to one's own.

It is easier to be skeptical (a.k.a. antirealist) about invisible, microscopic, macroscopic, and abstract objects. Most of us are ontologically committed to the existence of oxygen, given what we know about basic physiology and the chemistry of our natural environment, although it is microscopic in its elemental form and undetectable by the senses in its macroscopic form. Our commitments to microscopic entities such as muons, macroscopic entities such as red giants, intangible phenomena such as global warming, or second-order (categorical) entities such as phyla may be much weaker, and more prone to debate.

Not really, I'd say: The reason that many of the concepts of physics, chemistry and mathematics are hard to gainsay (by rational and scientifically informed people) is that the technologies that involves them are vast, and completely without explanation (other than: God willed it, by His divine fiat, and you better believe it if you don't want to burn) without these assumptions (of atoms, molecules, electric and magnetic forces, differentials, vectors, Maxwell's equations and more that the modal psychiatric mind probably does not contemplate every day, what with the joys of discoursing about baseball and umpires).

Mental disorders generate ontological skepticism on several levels. First, they are abstract entities that cannot be directly appreciated with the human senses, even indirectly, as we might with macro- or microscopic objects. Second, they are not clearly natural processes whose detection is untarnished by human interpretation, or the imposition of values. Third, it is unclear whether mental disorders should be conceived as abstractions that exist in the world apart from the individual persons who experience them, and thus instantiate them. Together, these reasons to doubt the ontic status of mental disorders become quite persuasive.

Indeed. And it should be added that this does not amount to a denial that people get mad, drunk, disorderly or depressed: What is denied or at least argued as open to rational doubt is the theoretical explanations invented by psychiatrists to account for mad, drunk, disorderly or depressed behaviour or people.

The analogy with religion is close here: Atheists do not deny there is a real world - they deny that the explanations theologians invented for it are true or rationally credible.

To continue with dr. Pouncey's prose:

Setting ontological antirealism aside, we can ask epistemological questions separately: if we assume that mental disorders do exist as abstract entities, how do we go about studying them, and on what basis can we possibly gain genuine knowledge about them? Even if we collectively agree that, for example, a particular person at a given time were experiencing a major depressive episode, on what grounds can we know that 'major depressive disorder' exists as an abstract entity? On what grounds can we infer that the broader class 'mood disorders', or 'mental disorders' as the most general class, exist as further abstractions? Epistemic realists may be realists about Hector's depression, about the existence of an abstract entity that is major depressive disorder, or about the existence of mental disorders in the world generally. They may not be realists about all three.

Quite so - and I should note that in the real sciences the answer to this kind of questions is provided by a combination of theories that postulate entities and relation and experiments that test these theories by finding out whether their deducible predictions are verified or falsified in repeatable objective tests.

Also, I should add that if psychiatrists insist or believe that in psychiatry things are otherwise, they need rational arguments and empirical evidence why a supposed science with rules no other science has would indeed be a real empirical science - rather than an ad hoc theology of human suffering, with some possible relief for sufferers thrown in as justification for its existence.

But to return to dr. Pouncey:

Similarly, epistemic antirealists may doubt one or more of these commitments. Umpire #1 is both an ontological realist and an epistemological realist about balls and strikes in baseball. Balls and strikes are real things (events) that exist (happen) in the world, and Umpire 1 has the means and ability to detect them in accurate and unbiased ways: "There are balls and there are strikes and I call them as they are." This tends to be the position attributed to psychiatry. Psychiatry's rhetoric, if not the actual commitments of all practitioners, says both that mental disorders are abstract entities that exist in the world and manifest in individual persons, and that these processes can be intersubjectively appreciated and elucidated as they truly are. Let's call this the Strong Realist position.

To be really fair I should add that most psychiatry I have read pretends in public to know the facts about mental illness, and thereby to be justified in prescribing asylum to one, electroshocks to another, lithium to a third, and prefrontal lobotomy to stubborn cases that don't respond to the first three treatments as psychiatrists deem correct, while the very same psychiatrists qualify their understanding in all sorts of fanciful ways when prodded by methodologically, logically and philosophically qualified critics.

Then suddenly the same psychiatrists who lobotomized a stubborn paranoid schizophrenic will explain that "really" they are not certain whether "paranoia" and "schizophrenia" are "valid" or "appropriate" or "correct" "nosological categories", sub species aeternitatis, at least, after which the more sophisticated ones of the tribe will start a public song and dance about the need for being "pragmatic" and for "trust" in such o so very well-intending medical doctors as psychiatrists all are.

And also I should here remark that "the Strong Realist position" is too much of an idealization: Every realist knows there are always margins of errors in measurements and in probabilities, and that all empirical theories, even the strongly confirmed ones, on which a real human technology has been constructed, may be proven (partially) false, and are not certainly true.

To return to dr. Pouncey:

Such confidence is not exhibited by Umpire #2, who shares the ontological realism of Umpire #1, but not the epistemological realism. In tempering his epistemological position to "I call them as I see them," Umpire #2 maintains that balls and strikes exist apart from his perception of them, but softens his position to recognize that he may not always perceive them as they exist in the world. That is, Umpire #2 is ontologically committed to the existence of balls and strikes, but does not assume that he always has epistemic access to that reality. Let's call this the Strong Realist/Weak Constructivist position.

Within the rather limp analogy of dr. Frances, this may count as fair enough an elucidation for methodologically naive psychiatrists - but "Umpire #2" gets saddled with a rather crazy position. Here is an analogy involving inquisitioners: While being "ontologically committed to the existence of" witches and warlocks, these gentlemen are supposed to be, if dr. Frances' metaphor makes sense, doubtful whether they "perceive them as they exist in the world" - for which reason they invented experiments to test whether she or he is a witch, a warlock or a heretic: Pull their nails, see whether they float if thrown in the river with bound arms and legs, test their veracity with red hot pokers and iron maidens, etc.

I concede dr. Frances' metaphor may make sense for inquisitioners, but it really is rather misleading.

Back to dr. Pouncey:

Umpire #3 is an ontological and an epistemological antirealist about balls and strikes: no balls or strikes exist in the world regardless of who thinks they might. In calling them, the umpire constructs the truth. This is not necessarily to say that all his calls are unfounded fictions, but rather it is to say that although the umpire describes his perceptions as accurately he can, there is no ultimate, underlying reality to which those perceptions could be compared, even in the absence of epistemic limitations. Let's call this the Strong Constructivist position.

Again: Within the rather limp analogy of dr. Frances, this may count as fair enough an elucidation for methodologically naive psychiatrists, but it should be stated right away that - whatever the pretence and verbal claims - this is not science: If "there is no ultimate, underlying reality to which those perceptions could be compared" the whole issue of describing one's "perceptions as accurately he can" is mere pretence to keep the naively realistic yokels credulous: There is - then - nothing to be or fail to be "accurate" about - but I do concede that the yokels may pay one handsomely for a fictional cure of their neuralgias and blisters and Parkinson's, so almost all may be quite happy, strong realists apart (to keep up the limp analogy of dr. Frances).

Back to dr. Pouncey:

Psychiatry's strongest critics tend to make strong constructivist arguments: mental disorders do not exist, so any diagnosis, treatment intervention, or research finding is exempt from ultimate confirmation or refutation.

This seems to me confused and confusing: "Psychiatry's strongest critics" tend do be scientific realists who insist there is nothing real corresponding to most of its theories and terms; "psychiatry's strongest" defendants play what dr. Pouncey calls the Strong Constructivist game, that insist strong realists fail to acknowledge there is no reality a psychiatric theory or term can fail to be true of. (They are like chastened liars, who tell all the world that they have told everyone lies all the time, from which they infer that, "therefore" there are no lies, or at least lying can't be reprehensible.)

Dr. Pouncey's next argument also doesn't hold:

In their strongest form, calling mental disorders 'constructs' is meant to communicate that they are mere fictions, completely unfounded medical lore.

Not in psychology or philosophy of science: There calling a term a "construct" means that one believes it is hypothetical or contains hypothetical elements, and needs empirical testing to be supported, if the construct was an empirically tenable one.

But then dr. Pouncey returns to common sense:

However, note that on the Strong Realist/Weak Constructivist view this is not the case. Calling a mental disorder a 'construct' does not imply invention so much as it serves as a reminder that our epistemic access to the reality of things is always limited. On this view, every abstract entity is a construct, and constructs can be legitimate objects of scientific investigation. Often, there is broad agreement about the nature of scientific constructs, such as phyla, subatomic particles, or diseases, even if the construct is construed as a working hypothesis, or a category of disparate entities that does not lend itself to simple definition or characterization.

As I use terms, this simply is the realist position, and dr. Frances' artful distinction of umpires 1 and 2 is mostly misleading about what real science is like:

Real science always is mostly a hypothetical affair, where one strives to find hypotheses that are so well verified that a technology can be based on them, such as metallurgy, electric light, or polio-vaccines, none of which involves the additional hypothesis that everything knowable about these subjects is known, or everything established about them certain. (Then again, completely unlike psychiatry, a physical theory that lends itself to technological use, that benefits human beings, tends to be highly probable on an objective testable scale - for that's why bridges and buildings do not collapse spontaneously and unpredictably, and vaccines help on a far better than random chance basis.)

I come to the last of dr. Pouncey:

On this view, mental disorders are like diseases: they are a heterogeneous class of abstract entities that have uncertain ontic status apart from the persons who instantiate them. In formalizing its nosology, psychiatry is trying to call them as we see them.

Let's call "this view" "scientific realism". If I presuppose that, which I do, methodologically and philosophically, mental disorders either are like diseases, and there is objective evidence for their existence that is quite good (since one treats people on its basis, and it is immoral to treat them on the basis of what one believes to be probable falsehoods or nonsense) or else there is no such objective evidence, and the logical and realistic and scientific conclusion is that the hypothetical entity probably does not exist other than in fiction.

And as to dr. Pouncey's concluding statement: As I said before, any scientist who calls his subject other than he sees them is misleading his colleagues. He doesn't have to be certain or confident about what he sees, but he must honestly say what he thinks is there, so that other scientists can attempt to establish whether he is right or mistaken.

In conclusion: While not agreeing with all of dr. Pouncey's statements, at least this was a competent exposition of what is involved in dr. Frances' rather too playful and too sloppily formulated five-fold distinctions. But both she and he are mistaken about what scientific realism involves:

I turn to the next contributor:



Commentary: Why Umpires Don't Matter
Nassir Ghaemi, M.D.
Tufts University Department of Psychiatry.

He gets a bad press from dr. Frances (see below), I think unjustifiedly so. Let's consider:

Nietzsche said truth is a mobile army of metaphors. If you get your metaphor wrong, you'll miss the truth. I think this is the case with the umpire metaphor that seems to be the central concept underlying the thinking of my interlocutor. I think it is simply wrong-headed. It sets up psychiatry and science and knowledge as a game, where the rules can be changed, and where there may be no truth. If you are a postmodernist extremist, this may make sense. But if you accept that there are truths in the world (such as that if you take very high doses of lithium, you will get toxicity), then it makes no sense.

I agree considerably more than not:

First, the umpires analogy is too imprecise; too misleadingly formulated; uses all manner of philosophical words - "realism", "nominalism", "pragmatism" etc. - in a new sense that these terms do not have in any decent encyclopedia of philosophy; and thus manages to trivialize what should have been a serious discussion of the intellectual foundations of psychiatry into a game with words that have been sung loose, intentionally it seems, from their received meanings in philosophy of science.

And second, I agree with dr. Ghaemi that a realistic position, in the philosophical sense, is the only intellectually and morally tenable position for a practising rational empirical scientist: Either there are things as proposed by science, and there is evidence there are, or there are no things as proposed by science, and that means there is no science of these things at all, because then they are pieces of fiction until there is good evidence that makes their hypothetical existence plausible.

A mistaken metaphor has no response except to say that it is mistaken.

I agree: Dr. Frances is displeased with dr. Ghaemi's rejection of his fivefold classificatory schema of metaphysical positions, but then I think dr. Ghaemi is right the classification is much more misleadingly phrased than it should have been, and besides there is the logical point that any classification of empirical things, including public stances on philosophical issues, needs the category "none of the others" to be logically air tight.

Before offering a better metaphor, let me say that I accept the realist position, that is, that diseases exist independent of me and you that are expressed as psychiatric symptoms like the chronic delusions of schizophrenia, or the mood states of manic-depression. To prove this fact, I suggest three approaches. One, suggested by Paul McHugh, is to actually see people who have these symptoms, the old kick the table test of realism. The second is to debate the merits of the positions pro and con; I won't do so here, but I think others have done so in reasonably persuasive ways, such as Roth and Kroll's Reality of Mental Illness. The third is to apply the pragmatic test, and see the consequences of one position or the other. I accept the realist view in at least some psychiatric diseases, but I would add that if one does not, he or she should think of the consequences. I don't see how one can reject the reality of psychiatric disease, and still practice psychiatry, especially with the use of harmful drugs.

Again I mostly agree.

That is, meeting really mad people should convince most skeptics there is madness, if also it should not convince them that the labeling and classification system they can find in any DSM is an adequate definition or description of their problems.

And while I did not read Roth and Kroll's Reality of Mental Illness, I concede there are some cases where people definitely are out of their normal mind and are reasoning and presumably feeling or valuing in terms that have no rational relation to the empirical reality they live in - though again this fact does not prove the validity of any system of psychiatric classification, definition, description or diagnosing.

Also, I quite agree with dr. Ghaemi that it is is immoral (and should be forbidden in law) for a medical doctor to treat people with medicines or therapies if the medical doctor does not oneself believe he has good evidence that the people he thus treats are ill; if he does not know that his diagnosis is probably correct; or if he does not know that the medicines or therapies he prescribes have been shown to help people with such an illness and diagnosis.

It is quite disheartening that most of the things said in the previous paragraphs do not seem to hold for most psychiatrists, most of their diagnoses, most of their treatments, and many of their medicines - which in my opinion makes much of the practice and theory of psychiatry pseudoscience, and also, in as much as this is used on people, fraudulent, dangerous, and often harmful and not consistent with the medical Hippocratic oath and principle "first do no harm".

More dr. Ghaemi:

This metaphor brings out those stark choices, as well as provides further rationale for the reality of at least some psychiatric diseases based on how matters have gone in other examples of similar problems in the history of science and medicine.

Indeed - but I, for one, would like to see the evidence for "the reality of at least some psychiatric diseases". I am willing to believe - having met  mad people - there is such evidence, and in some cases it is fairly good, but I also believe this holds in fact only of a relatively small proportion (far less than 50%) of the actual psychiatric diagnosis made and of the actual mental illness distinguished in handbooks.

This again is for me an important reason to hold that psychiatry as is is not a real science.

Here then is a better metaphor for understanding psychiatric nosology, one that I heard from Kenneth Kendler and which I am expanding here. In a presentation on "epistemic iteration," building on work in history of science, Kendler described how we can understand any scientific process as involving an approximation of reality through successive stages of knowledge. The main alternative to this process is "random walk" where there is no trend toward any goal in the process of scientific research.

The Kendlerian metaphor seems old hat, and can be found in Mill or Bacon: What's new about it - "epistemic iteration", "recursion" - are only modern cant terms. But I agree it corresponds to how real science proceeds: By proposing models of reality that are tested by their specific empirical consequences, and that try to approximate how things really are according to the Biblical injunction (1 Thessalonians 5:21) "Test all things; hold fast that which is good."

However, I do not quite agree to the opposition dr. Ghaemi offers: That it is either that - the testing of hypotheses about real things - or else comes down to a random walk. I'd rather suggest the real opposition is between using the methods of science, realistically and fairly, and not using the method of science, for various reasons, notably the reasons dr. Frances and dr. Pincus (below) insist - misleadingly again - are to be called "pragmatical".

I will come to that when I discuss dr. Pincus' contribution. Here I only conclude that dr. Ghaemi's opposition should have been drawn in other terms. I draw it in terms of using the method of science and not using the method of science

Given that clarification, I agree with dr. Ghaemi's next bit:

Kendler points out that epistemic iteration won't work if there are no real psychiatric illnesses. If these are all, completely and purely, nothing but social constructions, figments of our cultural imaginations, then there is no point to scientific research at all. (I would add: to be honest doctors, we should stop thereby killing patients with our toxic drugs - since all drugs are toxic - stop taking their money to buy our large houses, and retire.) The random walk model is a dead end for any ethical practice of medicine, because if there is no truth to the matter, then we should not claim to have any special knowledge about the truth.

What Kendler points out is as old as the ancient Greek skeptics: If you are talking about fictions or methodological artefacts, as if these are "evidence based medicine" you are not doing real science.

And the "random walk model" is an unfortunate term of what I think should have been called "psychiatry not based on the scientific method" or "postmodern psychiatry" or "pseudoscientific psychiatry", but with these clarifications in place I agree, also with dr. Ghaemi's moral point, and with his concluding logical and realistic conclusion.

If there is a reality to any psychiatric illness, then epistemic iteration makes sense, and indeed it has been the process by which much scientific knowledge has been obtained in the past. Take temperature. A long process evolved before we arrived at the expansion of mercury as a good way to measure temperature. There was a reality: there is such a thing as hot and cold temperatures. How we measured that reality varied over time, and we gradually have evolved at a very good way of measuring it. Temperature is not the same thing as mercury expansion: our truth here is not some kind of mystical absolute knowledge. But it is a true knowledge.

Actually - I am not clear whether dr. Ghaemi is aware of this - there used to be a whole brach of physics called "calorimetry", associated with the names of Fourier and Joule, that was based on the insight - derived from the boring of holes in iron to make canons - that heat is due to friction and in the end is molecular movement. This also lead in the hands of Fourier to some great mathematics.

A similar rationale may apply to psychiatric diseases. We may, over time, approximate what they are, with our tools of knowledge, if we try to do so in a successive and honest manner, seeking to really know the truth, rather than presuming it does not exist.

I agree in principle, with a proviso, which is this: While it is true that if there are mental illnesses, their existence have to be based with the help of the same methods of science - formulation of testable hypotheses; deduction of empirical consequences; experimental testing whether these consequences hold in fact - as were so successful in real science, my proviso is that many of the mental illnesses posited in the DSMs, and especially in the DSM-5, have no good empirical support whatsoever, and should therefore not be in a diagnostic manual: You cannot diagnose what you do not know probably exists in the manner that you diagnose it, and to do so is either fraudulent or intellectually incompetent.

The better metaphor, then, which captures epistemic iteration versus random walk alternatives would be to think of a surface, and a spot on that surface, which we can label X, representing the true place we want our disease definition (see figure). If we were God, we would know that X is the right way to describe the disease. Let A be our current knowledge. How do we get from A to X. One way is to go from A to B, from B to C, from C to D, in a zig zag pattern, as our research takes us in different directions, but gradually and successively closer to X. This is epistemic iteration.

As I explained, I think "epistemic iteration" is useless fancy talk, and the opposition as dr. Ghaemi formulates it is unfortunate, as there is not so much a random walk in those who practice pseudoscience as a dishonest pose that is firmly focused on making money or gaining power or status with what is in fact pseudoscience.

Then again dr. Ghaemi seems mostly right in what follows:

The random walk pattern would involve the same starting point A, and multiple movements to B, C, and D, but with no endpoint, because no X would exist (see figure). In this process, movement is random, there is no reality pulling scientific research towards it, like gravity pulling objects closer, and there is no end, and no truth. If this is the nature of things, then our profession has to admit to everyone everywhere that this is what we are doing. We should then give up any claims to specific knowledge and stop treating - and harming - people.

The reason he is mostly right is that a science that is not about an objectively testable experimental reality is a "science" in name only, and should be terminated as an empirical science, and replaced in philosophy or theology - without permissions to force drugs into people or lock them up if they have committed no crime! - whose practitioners are free to entertain any hypothesis, also if it has no empirically ascertainable scientific foundation.

Dr Ghaemi continues:

The history of medicine and the history of science gives many examples of both approaches. So the question really is an ontological one: do mental illnesses exist as realities in the external world, as biological diseases independent of our social constructs and personal beliefs?

Indeed - and I'd add that while this is the proper approach, the proper consequence for psychiatry as is,  is that it is not a real science at present, nor was it the last 100 years: Only in a small percentage of the cases it treats - patients prescribed medicines, given advice, or locked up, all in the name of "evidence based medical science" - is there anything like a rational empirical foundation for the treatments, prescriptions and diagnoses offered and made.

We arrive at dr. Ghaemi's last part:

The umpire metaphor assumes, but does not answer, that question. The epistemic iteration metaphor shows how the answer to that question faces us with two opposed choices about how we understand science and psychiatry. If psychiatry is like the rest of medicine, if there are some psychiatric diseases that are independent biological realities just as there are some medical diseases, then the epistemic iteration metaphor would seem valid in some cases, and the umpire metaphor, useless as it is, should be discarded. Figure11.

I mostly agree - but I find dr. Ghaemi's picture quite confusing, and think he should have phrased his opposition been science and non-science without mentioning random walks, while the point of his picture can be better expressed in words:

A supposed science that has no real subject is not a science but is fiction: Science fiction dressed up in the terminology, phrases and figures pirated from real science, but nevertheless fiction presented as fact in order to make money.

We have arrived at the next contribution:             ->Contents


Commentary: The Three Umpires of Metaphysics
Michael Cerullo, M.D.
University of Cincinatti Department of Psychiatry.

My guess must be that dr. Cerullo wrote this before "the three umpires" got expanded to five. He starts of thus:

The debate about the nature of the external world has been a central question of metaphysics since the first pre-Socratic philosophers. Most working scientists and philosophers today would be classified as modern realists who believe there is an independent objective external reality. Within the realist camp there is further debate about just how much we can know about absolute reality. Immanuel Kant termed the underlying reality of the world "the thing in itself" (das Ding an sich) and believed we could never truly know this ultimate reality [34]. Opposed to the realists are the anti-realists who hold that there is no independent objective reality separate from our own subjective experience. Allen Frances' umpire analogy is a good way to frame the major positions in this debate [2](Francis 2, 21-25). Frances' first umpire who believes there are balls and strikes and calls them as they are is a modern realist. Umpire two is a Kantian realist who believes there are balls and strikes but can only call them as she sees them. Umpire three is an anti-realist who believes there are no balls and strikes until he calls them.

My main problems with this are three:

First, I know philosophy, so rehashes by people who don't know it as well as I do get a bit tiresome real soon.

Second, I have read Kant, which is a reason to advice to leave him alone: It is extra-ordinarily difficult to see through the infelicities of his prose to what he may have meant - and that is apart from whether what he meant made sense.

Third, meanwhile my conclusion is that "Allen Frances' umpire analogy is a good way to frame the major positions in this debate" is not true: It turned out to be too misleading, too trivializing, to involve too many arbitrary new usages of received terms, and too glib and postmodern in proposing what sounds like halfway real halfway mocking debate - with limping analogies, fake suggestions psychiatrists can or should do philosophy of science - that raises more unclarities than it settles.

But then none of that seems dr. Cerullo's fault.

These days it is hard to seriously defend an anti-realist position in science. Neuroscientists contend that all behavior, from depression to extroversion to a dislike of tomatoes, is dependent and explainable by the workings of the brain. On the other hand there is still a real debate as to whether subatomic particles are the final bedrock of reality or a mere appearance of a deeper reality (strings? more particles all the way down?). However this latter Kantian uncertainty doesn't seem to have much relevance to the debate about the brain. After all, it doesn't seem to make any difference in our understanding of neurons if their atoms are ultimately made of strings or point particles.

I don't think there is "Kantian uncertainty" in physics, and since I agree physics is not very relevant here it seems to me redundant. Then again, I agree the only rationally tenable position for an empirical scientist is scientific realism (though dr. Cerullo may be less outspoken than I am) and that one who does not want to do science with the help of scientific realism should not be in science and should not claim to be a scientist.

Outside of metaphysics there is another parallel to the umpire analogy in epistemology. Within epistemology there is a subfield interested in the taxonomy of illness. The two major groups in this debate are the naturalists and normativists [35,36]. Naturalists believe disease can be defined objectively as a breakdown in normal biology. The naturalist position corresponds to the first umpire. Normativists believe our definitions of disease are subjective and culturally driven and thus identify with the third umpire. The second umpire seems to mix elements of both epistemological positions.

Here we get into trouble again that is due to the vagueness and glibness of the umpires metaphor, but if I concentrate on the naturalists and the normativists I am - it seems - with dr. Cerullo, or indeed ahead of him:

The normativist position is not scientific but is philosophical or theological, and should have no place in science. The whole notion that "our definitions of disease are subjective and culturally driven" is obfuscating bullshit that attempts to replace the attempts of doing real science by "the idols of the tribe". To offer an analogy: That "our definitions of ANYTHING are subjective and culturally driven" is a media- and pop-culture approach that sets aside all definitions that have been based on more than "subjective and culturally driven" norms, criterions, considerations and knowledge, such as are required in a university education in physics, chemistry or mathematics.

Dr. Cerullo may agree to this, but he is loosing me in his next paragraph:

My own sympathies lie with modern realism when it comes to behavior and a combination of normativist and naturalist positions when defining disease. Although there is physical explanation for all behavior (hence my realist position), not everything in the universe is physical. Definitions of disease require value judgments, and while each value judgment surely has a physical explanation in the brain, nothing physical can decide which judgment is correct. Even in areas of medicine outside psychiatry there is often a strong normativist element in how diseases are defined.

I am a scientific realist - that is, someone who believes you and me are part of a reality that exists outside our skins and that is best studied by the methods of science - but I deny the "normativist and naturalist positions when defining disease" are on a par. At best, the former is pre-scientific talk by laymen, and the latter what scientific specialist have come to see as the currently most plausible scientific theories and terms to explain the medical problems, concerns or conditions of laymen.

Also, I am logically completely at loss when I read claims like "while each value judgment surely has a physical explanation in the brain, nothing physical can decide which judgment is correct": Did dr. Cerullo discover - in the tracks of dr. McDougall - that there is a non-physical soul, where the judgments of value are made?! Presumably not - but it does seem to me that dr. Cerullo confuses some things, including the ethical and moral concerns of citizens, and the ways of science that seeks to answer those concerns.

And my point is not that there are value judgements: my point is that value judgements cannot and should not decide what the real facts are or may be.

Dr. Cerullo continues, it seems in explanation:

Many diseases such as hypertension or hypercholesterolemia require making arbitrary cut off points in laboratory values. Deciding these cut off points requires making hard decisions about public health and considering the risk/benefit ratio of any decision. There is clearly a strong normativist element in theses definitions, yet clearly that does not make them bad or incorrect descriptions. Many psychiatric diseases also have a similar logic.

Again I fail to follow the reasoning: I grant that deciding on such cut off points involves both ethical norms and science - but I do not see how these decisions are part of the science of psychiatry, rationally speaking: They are policy decisions that should be made on ethical, social and political grounds, informed by the findings and possibilities of science. Such policy decisions should not be the sole or main responsibility of psychiatrists (nor should butchers be the ones to decide on the norms for hygiene in slaughterhouses) and to believe or pretend they are or should be is a fallacy - for which reason I am afraid the last statement in the above paragraph is both false and misleading.

While everyone has some sad mood or anxiety there are obvious extremes which are justifiably labeled as mood or anxiety disorders. Once again there may be certain arbitrary cut off points when deciding how much sadness or anxiety is too much but that does not invalidate these definitions anymore so that it would the "physical" illness listed above.

I suppose the last "that" should be "than", but my position is a lot stronger and clearer than dr. Cerullo's and indeed than the secret committees that design the DSM-5, it seems: If there are no physical criterions, there is no real science.

That is: While I agree that some states of great anxiety - say - may very well be symptoms of real physical illness, without physical criterions and measurements there is no rational scientific content to saying that a person showing such great anxiety is physically or indeed mentally ill in any clear sense, beyond a common sense agreement that being so anxious is very unpleasant and that it would be nice to have some treatment for it.

Back to dr. Cerullo's prose:

This being said, there are also many diseases that are much better defined from a more naturalist perspective. For example, in psychiatry schizophrenia seems to be better defined from the naturalist perspective along with other physical diseases like Parkinson's disease or dementia. It seems easier to define these diseases using the naturalist ideal of disease as a breakdown in the "typical" human biology.

With this I agree. I also want to infer a consequence: The naturalistic understanding of supposed mental illnesses, indeed aside from a few cases like Parkinson's and dementia, is far smaller and far less certain than very many psychiatric stances, sayings, postures, diagnoses and decisions to lock people up on "medical" grounds acknowledge.

And this means that psychiatrists, as a matter of course and common psychiatric practice, take far going normative decisions they falsely pretend can be justified on grounds of natural science that have not been proven.

That is: Much of psychiatry is the imposing of moral norms in the name of medical science that in fact does not exist or has been shown to be not tenable (as with homosexuality). To my way of thinking and valuing that is abuse of science and is quite immoral.

Dr. Cerullo's last paragraph does not make this any better:

The lesson in these debates is that psychiatrists (and the public) should recognize that all definitions of disease have normativist and naturalist elements even in a world described by a scientific realism. None of Frances' umpires fits with my combined metaphysical and epistemological positions. Therefore I suggest a different umpire, one who believes in an objective physical world that we can access to determine exactly what are balls and strikes. Yet it is the umpire and players who first must choose the rules of the game, some of which may always seem arbitrary but the majority of which are constrained by the physics of balls and bats and the semantic and historical notions of games and baseball.

He seems to want to have his cake and eat it, and he seems to systematically confuse "the normative" - ethical, moral, personal, health - concerns of human beings (looking for some kind of medical help for something they know only in layman's terms) with "the professional" practices of psychiatrists.

And then the whole stance get thoroughly trivialized and rather mocked by his reverting to the metaphor of the umpires and playing the game of baseball - and you cannot have your cake and eat it, as dr. Cerullo seem to want, for all I can see:

'That psychiatrists should have the right to make what are in fact normative decisions about the lives and opinions and practices and chances of what they call patients, and should have the right to do so in the name of natural science' - that they generally can and should know hardly exists and anyway is not fit to decide those normative issues.

I insist that psychiatrists should not have those rights: Not the first, because these are the rights of patients or of society at large, and then settled by political discussions and decisions; and not the second, because it is a sophisticated kind of lying and misrepresentation.

We have arrived at the next contribution:             ->Contents



Commentary
Jerome C. Wakefield, Ph.D., D.S.W.
School of Social Work and Department of Psychiatry,
New York University.

Unfortunately, dr. Wakefield is again one of the contributors who enters into the terminological umpires game with enthusiasm:

Regarding the Umpires: First, to avoid confusion, one has to distinguish the role of Umpire calls within the rules of baseball from the call as an attempt to state what happened. The Umpire calls them as he/she sees them, with the goal of getting it right - and understands that the way it looks can be misleading. But, whether correct or incorrect, the Umpire's call "stands" despite any later evidence that emerges to the contrary, and to that extent the call constitutes/constructs the game's reality. Diagnosis, too, has dual aspects - a game in which one plays by the rules to justify reimbursement, and a hypothesis about what is going on in the patient.

Meanwhile, I think the analogy of the umpires created a lot of needless confusion, though I like the first mention - after quite a few words by quite a few of presumably quite well paid psychiatrists - of "reimbursement", though I fear that I may be more cynical than is dr. Wakefield about the real motives, competence and honesty of most psychiatrists (who are - if halfway sane, or better - in it for the money).

Not wanting to waste more time on trying to see through the vagueness and ambiguities of the umpires metaphor, I fall into more of it from dr. Wakefield:

I focus on the hypothesis-testing aspects of both Umpire calls and the DSM. In attempting to make a call that reflects the truth, Umpires 1 and 3 embrace intellectual doctrines designed to deal with their epistemic anxieties - Umpire 1 can't stand uncertainty, and Umpire 3 can't stand the arrogance that comes from Umpire 1's certainty.

Now it seems as if the reader and I must psychoanalyze the motives of non-existing metaphorical umpires so as to make up our minds whether psychiatry is a real science...

Well, I am sorry: If that is the level of sophistication psychiatrists have about the foundations of their own supposed "science", my conclusion must be that most of them know they are not doing a real science, and are mocking laymen by rephrasing all serious questions about their businesses in terms of games of one upmanship about metaphorical and vague terms about fictional entities that have been  introduced for just that purpose: Avoid any real and rational discussion of fundamental issues, for fear of being found out.

We get more of this waffle:

Ironically, Umpire 1 and Umpire 3 fall into the same fallacy, that of collapsing ontology and epistemology into one. Umpire 1 naively sees his/her judgment as being a direct impression of reality without epistemic mediation, thus epistemological uncertainty is avoided. Umpire 3 sees his/her judgment as creating or constituting "reality" from his/her perspective, so again epistemological uncertainty is avoided. On the other hand, Umpire 2, while closest to the correct approach, describes his/her reality and his/her perception in a rather disconnected way.

Why not talk instead of the sex life of Father Christmas, or the anal personalities of angels? Here is the learned dr. Wakefield's lesson from his tales:

So, I vote for Umpire 1.5 (humble realism): There are balls and there are strikes (plus some ontologically fuzzy cases), and based on how I see them and any other available evidence, I call them as I believe they are, and because the evidence in these cases is usually a pretty good indicator of reality, calling them as I see them usually equals calling them as they are. But, I can be wrong! The truth does not necessarily correspond to my call, and fresh evidence can always be brought to bear to help get closer to the truth.

Just possibly this is fair enough, but I feel like a philosopher who is lectured by a political activist, and I think dr. Wakefield is conducting a mock discussion of a mock problem, for which he has a mock solution, that does not even start to touch the relevant ethical, judicial, medical, and methodological facts and problems.

Dr. Wakefield sees this differently or at least pretends he does:

Common sense offers the best guide here.

I say! Then why this whole contorted discussion in terms of explicitly mislabeled explicitly fictional entities? In reply, dr. Wakefield has more news from baseball, in the best postmodernist tradition also (where anything whatsoever may be, by fiat of the postmodern author, be declared "relevant" for anything else):

Recently, Tigers' pitcher Armando Galarraga was one pitch away from achieving baseball immortality with a perfect game, an extremely rare event. In a close call at first base, Umpire Jim Joyce called the runner safe, destroying Galarraga's chance. But, as everyone saw from the instant reply, in fact the runner, Jason Donald, was out. Jim Joyce said to the press; "I just cost that kid a perfect game... I thought (Donald) beat the throw. I was convinced he beat the throw, until I saw the replay... It was the biggest call of my career and I kicked the (expletive) out of it." He then went to Galarraga and explained what he saw, and made it clear that he was wrong ("Imperfect" Umpire Apologizes by Steve Adubato, Ph.D., Star-Ledger). Fortunately for the lessons we and our kids take away from baseball, Joyce was not Umpire 1 or 2 or 3, but humble realist Umpire 1.5 who understood the possibility of error inherent in the attempt for mind to represent reality.

Wow! Awesome! Cool dude! Should be on dr. Phil's awesome show!

To dr. Wakefield's concluding paragraph:

As to the other part of the question, the dichotomy between constructivism and realism is a false one. 

Like a good pomo lit.crit. and indeed like a cardinal or Stalin's henchmen, dr. Wakefield does not argue: He announces.

Presumably his reasons are made from the cloth of Lacan and Derrida, viz. that everything is text and nothing but text, but I am not going to bother about pomos.

Here are further Wakefieldian ukases:

Our diagnostic categories are constructs (as are all concepts) intended in the long run to refer to underlying diseases/disorders. Current DSM diagnoses are constructs that are starting points for a recursive process aimed at getting at disorders. 

I only observe that in the best pomo traditions (of stealing terms from real sciences, and then use them in one's own way, as if stealing is moral and abuse of terms psychiatric science) the "epistemological iteration", already a creature of astroturf and waffle, gets up market by calling it "a recursive process"....

Wow! Awesome! Cool dude! Should be on dr. Phil's awesome show! 

And here is a final nugget of Wakefieldian pomo "insight":

We somewhat misleadingly refer to them now as "disorders," although frequently we acknowledge that one of these categories likely encompasses many disorders. Close attention to the way revise our views and the grounds on which our judgments are made suggests that the individuation of disorders ultimately depends on the individuation of dysfunctions (see the answer to question 6).

Waffle, waffle, waffle, who knows with what are, for a psychiatrist, good intentions.

I'm done with it, and turn to the next contributor:


Commentary
Joseph Pierre, M.D.
UCLA Department of Psychiatry.

Doctor Pierre has another metaphor or analogy, that has some merit - although again I conclude from the lack of real rational discussion of real problems, replaced by postured talk about made up ill-defined entities with the suggestion that this is the way real science works, and is really true, is probably the main meme - trope, scheme, trick, fallacy - of psychiatry, as indeed it is also in bad philosophy and theology.

To turn to yet one more metaphor:

Consider the brief history of Pluto as a planet, as told in the recently published book, How I Killed Pluto and Why It Had It Coming [37]. A few thousand years ago, during the era of Greek geocentrism, the Earth was considered to be the center of the universe, while the sun and moon were regarded as two of the seven planets that orbited around it. Later in the 16th century, as Copernicus' mathematical models of heliocentrism were embraced, the Earth and the sun traded categories at the expense of the moon. The subsequent discoveries of Uranus in 1781, Neptune in 1846, and Pluto in 1930 resulted in the total of nine planets that most of us learned about in elementary school. However, in 2006, Pluto was officially downgraded from classification as a planet, in part because of the discovery in 2005 of a larger mass of rock and ice called "Xena" orbiting not that far away. Now our children will be taught that there are only eight planets, and will perhaps eventually learn that there are also heavenly bodies called "dwarf planets," among them Pluto and Eris (the new, official name for "Xena").

We are discussing the intellectual foundations of psychiatry in the ways psychiatrists tend to discuss things: As a form of mockery, with made up or stolen terms, and with the constant - false - assurance that this is real science because it's proponents have a basic degree in medicine.

More astronomy:

To anyone that really relies on taxonomy in their daily work, it inevitably becomes apparent that such efforts at classification never seem to do a perfect job of "carving nature at its joints." This is especially true with scientifically-based taxonomies - they change based on the evolution of underlying definitions; new categories and sub-categories emerge while previous entities are re-categorized in order to accommodate new data; and challenges to classification at border-zones linger on. Although this kind of change sometimes causes the general public to regard science with skepticism, it is this very adaptability in the face of new data that is the strength of science and the feature that most distinguishes it from dogma.

Actually, so far all of this is a fallacy, that means to suggest - but does no way prove or even argue - that psychiatry is a science like astronomy, wherefore - presumably - the lessons learned by astronomers should apply to psychiatry... whereas in fact the learned Pierre has not even given a single ground to believe that psychiatry is a real science rather than a mock one, nor a single ground why this particular example is at all appropriate to discussing the very ill laid grounds of the purported "science" of psychiatry.

But we get a little information about how dr. Pierre sees himself:

The belief that this dynamic process is both acceptable and necessary for the Diagnostic and Statistical Manual of Mental Disorders (DSM) would seem to place myself in the category of Allen Frances' "Umpire #2," where I suspect the vast majority of clinicians reside.

Let me suggest to the dear dr. Pierre that this is an artefact of how the alternatives were presented by dr. Frances, something psychiatrists seem to be well-trained in: Treating something in borrowed ill-used terms as if these are appropriate, scientific and rational.

And let me note this whole discussion is about this "belief" - and not whether dr. Pierre or dr. Frances have this belief, but whether that belief is true or plausible in any rationally defensible sense.

Then again, dr. Pierre has seen some problems with his presentation as well:

Still, since I have just suggested that reality often defies simple classification, allow me to state my position more clearly. I believe that psychiatric disorders do exist and that they are brain-mediated diseases (leaving aside for the moment the challenge of defining "disease") with genetic, biologic, and environmental etiologies and influences.

I am sorry, but this another mocking gem from the psychiatric kitchen: They do not quantify their terms (nor do they clearly define them, nor do they use them as they are in other sciences): What one wants to know is not whether some tame tenured psychiatrist has the "belief" "that psychiatric disorders do exist", though I note in passing the learned dr.  is so strategically clever in a lawyers' way that he does not even call them "illnesses", but this: how many or what percentage of the "psychiatric disorders" in the psychiatric handbooks are real, as defined or described in those handbooks, according to dr. Pierre.

Furthermore, I should remark that making these hypothetical entities (of which many definitions and descriptions may be safely assumed to be as pseudoscientific as so much of psychiatry has been these last 100 years) may conceivably be "brain-mediated", if that is not a tautology or pleonasm, to say that these hypothetical entities also have "genetic, biologic, and environmental etiologies and influences" - like angels, ghosts or zombies, perhaps? - is a rather bold hypothesis, that also introduces lots of leeway and possibilities for more terminological obfuscations.

How does dr. Pierre know this? He doesn't tell, and if he honestly would, then he would be bound to say that all he has are his imprecise guesses, and that not about all or most hypothetical "psychiatric disorders ("leaving aside for the moment the challenge of defining "disease"") but only about a few he knows about.

Meanwhile he has been confusing his non-psychiatric readers, but also has managed to suggest that psychiatry is a science like astronomy is (no, it is not); that it uses the scientific method as astronomy does (no, it does not); that psychiatrists have knowledge to the effect "that psychiatric disorders do exist and that they are brain-mediated diseases (..) with genetic, biologic, and environmental etiologies and influences" (no, they do not have such knowledge: they claim they have it).

I conclude that dr. Pierre must be a clever man with most of the trappings and tricks that make a psychiatrist these days, it seems. Here follows some more to make at least that worthy of belief, even if what the clever Pierre says is not:

The disorders (not diseases) cataloged in the DSM represent our best attempts at achieving consensus definitions of these conditions, seriously limited as we are by diagnosis that is based almost exclusively on describing manifest symptoms.

First note that dr. Pierre, in a trained psychiatric way (it meanwhile seems from my readings in psychiatry) has shifted what were in his previous paragraph "diseases" to "disorders" - as usual, for psychiatrists, without offering any rational explanation.

Next, note how clever he is at innuendo and suggestion: It is precisely at issue whether the hypothetical entities "cataloged in the DSM" "represent" anything real at all - but the clever dr. Pierre knows how to twist this verbally around to their doing so, and not only do these hypothetical entities exist, by dr. Pierre's hidden fiat: they also are his and your and perhaps even my ("our") "best attempts at achieving consensus definitions".

No, they are not. They are most definitely not. Something far better, far more rational, far more honest, far more moral, far more scientific could have been made from the DSMs than has been made in their stead, which is part of the sorry lot of rot that I have come to see looms up its ugly head as soon as one starts to do some serious reading in psychiatric handbooks, armed with some relevant knowledge of real science, of methodology, and of psychology.

Then again, presumably the clever dr. Pierre is a lot younger than I am and dr. Frances is, and he surely knows - even without psychiatric training - how effective flattery of the leaders of one's own chosen field of career is.

We are not done yet, for dr. Pierre has yet another bit of clever trickery, that turns around his phrase "seriously limited as we are by diagnosis that is based almost exclusively on describing manifest symptoms":

Because of this limitation, it is unavoidable that psychiatric diagnosis is overly simplistic, just as many medical diagnoses would still be if not for technology-driven discoveries about pathophysiology. As such, DSM diagnoses are constructs, and DSM-IV's chief utility is as a "good enough rough guide for clinical work [38]."

Again a clever - false - suggestion that the problems psychiatry are in are due to its diagnoses being "based almost exclusively on describing manifest symptoms". Not so!

The reason that I find this a pretty sickening piece of trickery is that psychiatrists have known this for hundred years, and should have been far more humble in their pretensions about what they could "deduce" from behavioural symptoms - which turned out to be anything whatsoever, from the wishes of dr. Pierre to sleep with his mother, to the uncertainties and dishonesties of dr. Pierre in the face of authorities, to his tendencies towards polymorphic perversities (and I could make many more inferences about the character of dr. Pierre, based on my extensive reading in "our best attempts at achieving consensus definitions of these conditions").

And there is another clever suggestion the clever dr. Pierre foists on his readers, while simultaneously flattering dr. Frances, viz. that "DSM-IV's chief utility is as a "good enough rough guide for clinical work [38]".

Not so: This is what dr. Frances may have thought or hoped for originally, but since he has found that the DSM-IV has been abused to prescribe anti-psychotic medicines to young children by the millions ("ADHD, doncha know? It's in the DSM-IV, so it must be true, for psychiatrists should work according to "first do no harm", doncha see?") and has also created a true epidemic of "autism" and "Asperger's".

I am not quite done with dr. Pierre. Here is his last paragraph, again cleverly phrased in - what might be - the best mocking traditions of psychiatry, that might be a science, if we may rely on dr. Pierre and his clever ways of phrasing:

As an imperfect work in progress, the DSM-IV contains diagnostic constructs of variable validity. In the tradition of Umpire #1, I believe that many of the disorders in DSM do a good job of describing the essential symptomatic features of what are probably "real diseases" (e.g. obsessive-compulsive disorder). However, I can also acknowledge the concerns of Umpire #3, including that some DSM disorders may tread dangerously close to pathological labeling of socially unacceptable behaviors (e.g. paraphilias) [39], while others might be better understood as "culture-bound syndromes" (e.g. anorexia) [40].

Again, he cleverly tries to twist around things: The issue is not whether the DSM-IV is "perfect", nor is the issue whether it contains "diagnostic constructs of variable validity":

The questions are whether it was good enough for the purposes it was designed for (I say no, and I think dr. Frances cannot in consistency do otherwise, but then dr. Frances is a clever psychiatrist with a way with words as well); whether it was anything in the way of a scientific diagnostic manual (I say no: psychiatry does not have sufficient knowledge of the brain to be a real science about mental illnesses that cannot be shown by some empirical pathology in the brain); and whether there are not too many "diagnostic constructs of variable validity" in it (and I say yes, and think dr. Frances should agree, having seen his worries about prescribing anti-psychotics to rowdy small children in the name of the science or "science" he is a professor in).

But the clever dr. Pierre has more: He has a belief! It is this: "I believe that many of the disorders in DSM do a good job of describing the essential symptomatic features of what are probably "real diseases" ". Now a man may believe what he pleases, but being rather rational myself I am at a total loss at seeing how dr. Pierre could come to this belief: How "many"? Why? "Disorders" not "diseases"? Since when is a psychiatrist a policeman dealing with "disorders" that are not due to "diseases"?! And "essential" in just what refined sense? And what are "features" of "symptoms"? And how does one measure - quantify, judge, attribute infer - "probably", especially if what is "probably" so is embedded in scare quotes that makes its whole existence questionable, let alone its capacity of being measured by probability?

Finally, the clever dr. Pierre may be a psychiatric guru of great potential, for he has really mastered the game with "may" and "might" that is so essential in all psychiatric writing, and which comes to this:

If you know that what you write must strike anyone intelligent who is not hopelessly in love with you as difficult to keep apart from being bogus, bullshit, pretense, mockery, game playing, verbal acrobatics, plain dishonesty, salestalk, propaganda, prejudice or general loonyness or delusions, you insert at all proper places "may" or "might" for "is", and you keep insisting that your personal kind of baloney is - kneel down, laymen! - "evidence based medicine".

The basic trick of the psychiatric "may" and "might" is to plant an innuendo in the reader's mind, without being logically being committed to it, and so always being capable of pleading innocence. Thus, paraphilias may be no diseases, but a man as clever as dr. Pierre may be won't say they are not: he wants to innuendo they may not be, but wants to keep being able to say that he did not say they are not, or indeed that they are.

In the same way, one may wish to suggest that there may have been no concentration camps in Germany under Hitler, or that they may in fact have been asylums for the ill or may have been genuine humanitarian efforts of dealing with the problem of foreigners. You see? Be as clever as psychiatrists may be, and you may get away with suggesting almost anything you want your hearers to believe, while not really saying it, because all you're saying has been that what you're saying may be true - which it logically may be, however insane, unfair, or crazy, for anything that is not an explicit logical contradiction may be true.

Let's see how the clever dr. Pierre does it:

He says "some" ("forgetting" to mention what proportion, as if patients have no right to know how often they have been had by bogus and bullshit) "DSM disorders may tread dangerously close" to taking the place of the reverend minister and policeman in one, this time in the name of  - kneel down, laymen! - "evidence based medicine".

Next, to top this, the clever doctor says (after having carefully and cleverly "forgotten", in an appropriate Freudian way, just how many of "some DSM disorders" this amounts to) that "others" (of those "disorders" that may be "diseases", or may be not, that you may have been diagnosed with by him) "might be better understood as "culture-bound syndromes" - but again he has the careerist wit not to say this explicitly or indeed to deny this explicitly: To be always on the safe side, he said merely that things "might" be so (or not, but being so clever, he omits that).

In brief, I feel again rather mocked, by what may be an intentionally mocking psychiatrists, who just might have been engaging in a bit of careerist prose that he may very well know to be mostly ambiguous if carefully phrased bogosity, that suggests much, but says almost nothing, and makes no contribution of any cognitive kind to the Question 1 it may have been trying to answer.

I have arrived at the next contributor:                   ->Contents



Commentary
Gary Greenberg, Ph.D.
New London, CT.

Of dr. Greenberg I know a little more than I do from most contributors (whose existence escaped my notice, till very recently) because I read an interview he did with dr. Frances. You find it here:

     Inside the Battle to Define Mental Illness

Also, he is a psychotherapist whose degree is in psychology: He is not a psychiatrist, and maybe for that reason his take is somewhat different from the ones we have seen so far. He starts as follows:

"There are no balls or strikes until I call them" is not the postmodern fantasia that it sounds, nor is it a throwback to the idealism that Samuel Johnson refuted so thoroughly by kicking Bishop Berkeley in the knee. Or, to put it another way, it is neither the death knell of psychiatry nor a straw man for psychiatrists to use to refute their critics.

I will not attempt to tease out the references and word play, or whatever it is (dr. Johnson did not kick Bishop Berkeley, for example, in case you believe this), and merely observe that it seems to me that dr. Greenberg has been considerably misled by the terms and phrasings of dr. Frances' question.

I may be mistaken, so let's see. Dr. Greenberg continues thus:

What it is, really, is just plain common sense. To question diagnosis is not to question the existence of suffering, or of the mind that gives us the experience of suffering, or of the value of sorting it into category. It is merely to point out that before we can do that sorting, we have to posit those categories. Where do they come from? Are there really diseases in nature?

No, what dr. Frances was pleased to call - quite misleadingly - "constructivism" is definitely not "plain common sense": In fact, it is one of the more corrupt forms of postmodernistic posturing. Then again, it is my firm guess dr. Greenberg wasn't aware of this, and really means what he either is or seems to be saying, which I would express as follows:

MM: While there is little that is real science in psychiatry, and much that is false or bogus, psychiatry as an attempt to help people with life problems is a worthy enterprise. But given the lack of real science of the brain, much of psychiatry must be discarded, and their practice must be based on common sense rather than mockery or pretenses that one is doing real science. Moreover, this can be done quite well in common sense terms, for all one needs to help people with life problems are intelligence, kindness, empathy, some knowledge of psychology, some information about the person's situation, and the possibilities of society for a person thus situated. One does not need science, or indeed psychiatric "science", to help people with problems: All that is needed next to what has been said is common sense and good will.

Then again, this is my guess, and what I would say were I a psychotherapist like dr. Greenberg (which I am not and never was). What he wrote is this:

Consider this question. What is the difference, from nature's point of view, between the snapping of a branch of an old oak tree and the snapping of a femur of an old man? We rightly recoil from the suggestion that there is no difference, and yet to assume that there is in nature a difference is to assume that nature cares about us enough to provide us with categories of broken hips. There is ample evidence, most stunningly Darwinian theory, that this is not true. Nature is indifferent. Unlike Major League Baseball, nature doesn't provide the rules by which the world can be divided into balls and strikes.

If there is a difference between the hip and the branch, it is surely to be found in the difference between the man and the tree, which is that the man is capable of caring about his femur, as are the people that love him. The only reason to distinguish one break from the other is to create a category--intracapsular transcervical fracture, Stage II, let's say. Naming the suffering, we bring it into the human realm. (It is not a coincidence that the authors of Genesis tell us that the first task given to Adam and Eve in Eden was to name the creatures of the earth; naming is how we put our stamp on the world.) By inventing categories like this one, we give ourselves a way to get hold of it, which in medicine means among other things a way to talk to other professionals about it, a way to determine treatment options, and a way to provide a prognosis to the patient and family. What we don't do is to discover that nature intends hips to break in certain ways, that there exist in nature intracapsular transcervical fractures and trochanteric fractures, any more than nature provides a branch with different ways to snap off a tree.

This much is uncontroversial, largely because whether you buy the argument or not, you are still going to treat the problem more or less the same way. The difference between fracture as a man made and a natural category is trivial, unless you're in a philosophical argument. But when it comes to psychiatry, something changes. To call a snapped femur an illness is to make only the broadest assumptions about human nature--that it is in our nature to walk and to be out of pain. To call fear generalized anxiety disorder or sadness accompanied by anhedonia, disturbances in sleep and appetite, and fatigue depression requires us to make much tighter, and more decisive, assumptions about who we are, about how we are supposed to feel, about what life is for. How much anxiety is a creature cognizant of its inevitable death supposed to feel? How sad should we be about the human condition? How do you know that?

I would not have made or phrased the argument like dr. Greenberg does, but his last paragraph makes sense, that I will try to restate in my terms:

MM: Most of the attributions psychiatrists make about the causes and forms of human problems of life are much infected by obscure jargon and cant ordinary people are not at all helped with and that in real fact are probably - like the majority of the concepts that were introduced by psychiatrists - fictional or mostly fictional. Moreover, most of the attributions psychiatrists make about the causes and forms of human problems of life are useless for effective treatments of these problems, as the history of psychiatry shows, since that is full of misdiagnoses of untold and uncounted millions of human beings. Finally, almost none of that ballast is helpful for a practicing psychotherapist who means well, is informed, and helps people through being humane, rational, kind and commonsensical.

Again, I must say this is my guess, and what I would say if I were a psychotherapist like dr. Greenberg (which I am not and never was).

In any case, in my formulation I agree. Dr. Greenberg may also agree, for his last paragraph starts as follows:

To create these categories is to take a position on the most basic, and unanswerable, questions we face: what is the good life, and what makes it good? It's the epitome of hubris to claim that you have determined scientifically how to answer those questions, and yet to insist that you have found mental illnesses in nature is to do exactly that.

I mostly agree, and like to add that much of what psychiatrists in fact do or say has very little to do with science or research of any kind, but is the kind of work and admonishments priests, clergy or policemen used to do, or else falls in the category of preaching or of adult education.

Whether that is "the epitome of hubris" I do not know; what I do know is that one does not at all need to study psychiatry nor speak in the manner and jargon of psychiatrists to do this kind of work well - and indeed if one does not talk or think like a psychiatrists, chances are one is more effective and helpful than if one does.

And now we have arrived at dr. Greenberg's plea for more common sense and less quasi-scientific posturing and talk:

But that's not to say that you can't determine scientifically patterns of psychic suffering as they are discerned by people who spend a lot of time observing and interacting with sufferers. The people who detect and name those patterns cannot help but organize what they observe according to their lived experience. The categories they invent then allow them to call those diseases into being. They don't make the categories up out of thin air, but neither do they find them under microscopes, or under rocks for that matter. That's what it means to say that the diseases don't exist until the doctors say they do. Which doesn't mean the diseases don't exist at all, just that they are human creations, and, at their best, fashioned out of love.

Again I would have formulated this quite differently - and rather than abide by dr. Frances' umpires I would have cast them away and would have insisted I prefer the road of common sense and ordinary psychology much rather than the normal psychiatric road of pretentious jargon in obscure grammar.

Also, I might have added a point to the effect that, for somebody engaged in the practice of psychotherapy, there is little use for digging through the academic and besides quite vague, uncertain and often pretty useless categories and classifications of supposed "diseases" one finds in psychiatric handbooks: Not all is nonsense, not all is false, but there is far too much uncertainty and ignorance about the causes and etiologies of most supposed psychiatric diseases to be useful for a practician.

But then I am interpreting again, and agree with dr. Greenberg's concluding words:

If psychiatry were to officially recognize this fundamental uncertainty, then it would become a much more honest profession--and, to my way of thinking, a more noble one. For it would not be able to lose sight of the basic mystery of who we are and how we are supposed to live.

Or to rephrase the last bit in my terms: For it would not need to pretend to know and understand where it only guesses, with little evidential support, and thus leave much more room for real science and for a humane practice.

We have arrived at the next commentator:           ->Contents



Commentary
Harold A Pincus, M.D.
Columbia University Department of Psychiatry.

Doctor Pincus has been credited by dr. Frances as being responsible for the fourth umpire, the one called "pragmatic" by both, although they really mean "practical" - but then it seems the psychiatric habit, or professional disease, to always use the longest Latinate terms, also or especially if not used in their received senses, and do verbal acrobatics with these, as if psychiatrists always know what they are talking about.

Let us see. Dr. Pincus starts thus:

The fourth umpire has a very pragmatic perspective and understands that a classification of diagnostic categories is used for many different purposes by many different groups and individuals. Umpire 4 also understands that these various "user groups" approach their tasks with varying empirical, philosophical and historical backgrounds and, and with this proliferation of users and backgrounds, there needs to be a balance between (to mix metaphors) letting "a thousand flowers bloom" - creating a Tower of Babel with little ability to effectively communicate among these groups - and a single approach that cannot be tailored to particular needs.

I call'um as I sees'um (sorry), and I sees this as relativism disguised as if it makes sense - which it does if (and presumably only if) one wants to defend one's profession, business and colleagues against aspersions and doubts articulated by whoever is not blessed with the profession of psychiatrist.

As happens so often with psychiatrists, the first statement is in fact a truism: "different folks like different strokes". As also happens so often with psychiatrists, the conclusions derived from truisms are not true or are misleading and not what they seem, and I read the contorted second sentence of dr. Pincus as being contorted and full of varying claims just because dr. Pincus wants to hide the fact that he has kicked truth out of the window, and replaced her by - what I suppose he would call - "pragmatism", and what he would defend by its "utility", its "usefulness".

And rather than attempting to take apart the innuendos, references, vagueness, ambiguities, and unfoundedness of dr. Pincus second statement, I'll explain why this psychiatric concern with "pragmatism", "utility" and "usefulness" is fallacious.

The main reason is that "utility" (Ve reelly neet deh concentration camps, mine Führer! Zey aar so ferry useful!) presupposes, for its rational and non-manipulative use, two conditions or frameworks: An ethical one that considers the question whether such and such really is as useful and practical as it is claimed to be by its proponents; and a logical-empirical one that considers the question whether such and such a useful end can really (probably) be reached with such means as are proposed or available.

I do not believe dr. Pincus is not aware of this; I do believe he is intentionally bullshitting his readers - unless (I graciously concede) one can get these days to be a professor at Columbia with a very low IQ, and even then I think dr. Pincus is not as stupid as the things he writes.

For consider how he continues the above:

From this perspective, there is a recognition that the world has changed and the management of information has become the pre-eminent task of a classification system, overshadowing (but also enhancing), the clinical, research and educational goals of a classification. As such, the ICD/DSM should serve a critical translation function to anchor communications among multiple user groups that apply psychiatric classification in their day to day functions.

I must assume the "perspective" is that of "a pragmatist", in psychiatric terms, which are not those of people who know what "pragmatism" means - but OK: These most enlightened psychiatric folks have made a discovery that yet again finds a new role for what they falsely insist is "the science" of psychiatry:

Since "the world has changed" these days, dr. Pincus pontificates, the task of psychiatry, that most pragmatic of "sciences", or at least that of  its "classification system", that once pronounced so confidently on the causes and etiology of multiple sclerosis, homosexuality, and peptic ulcers (all due to "dysfunctional belief systems" of those who had them), these days the "goals of" that "classification system" have been changed, possibly by some ukase from the department of psychiatry at Columbia, to that of... "the management of information"!

Yea verily, forsooth! Psychiatry as public relations: All classification system suddenly should further the - "pragmatic"?! - end of serving "a critical translation function to anchor communications among multiple user groups".

Of course, for a "pragmatic" mind like dr. Pincus, this discovery of his, that classification systems exist "to anchor communications among multiple user groups" (rather than help one find one's way to a complex territory that is for the most part in the dark) probably went together with the joyful realization that such non-"pragmatic" notions as "truth" can be completely ditched. As long as the "multiple user groups" can "anchor communications" in such a communicating classification system!

And dr. Pincus - who hasn't even mention truth or patients or "first do no harm", or a hundred years of pretended but false, phoney and dishonest pretended psychiatric insights into the minds of non-psychiatrists - immediately proceeds to dream like a utopian:

This information management goal intersects with multiple user groups in terms of:

-health policy
-clinical decision making
-quality measurement
-epidemiology
-educational certification/accreditation
-multiple areas of research from genetics to psychopharmacology to cognitive science, etc.

Why ever not?! There is after 100 years not even a proof in sight that psychiatry is a real science, rather than a set of delusions or a con game by doctors without talents for neurosurgery or unable to cope with ordinary patients, but the "pragmatic" psychiatric dr. Pincus sees utopia around the corner!

To what end, as one may ask of a "pragmatist", who in its psychiatric incarnation is one to be able to get around all demands of proofs that it works, is true, makes empirical sense, is not a delusion or fraudulence - none of that matters to the pomo psychiatric pragmatist: He just pretends that all that matters is "utility". O, and "communication between user groups".

But to what end? World hegemony, I must infer from the almost transcendentally clear Pincusian prose:

The way this would work is that the ICD/DSM classification would remain relatively stable, serving as a kind of "Rosetta Stone" to facilitate communication among the various user groups. Each individual user "tribe" (or individual scientist) would be free to identify various alternative classifications. However, all journals or other public reporting mechanisms would require that any clinical population also be described in the ICD/DSM classification in addition to whatever tribal criteria for the "Syndrome XYZ", 70% met ICD/DSM criteria for GAD, 40% OCD, and 30% Anxiety Disorder, NOS).

Note dr. Pincus's rhetorically trained assurance that his utopia "would work". True believers, including the "pragmatic" ones always believe so, but they rarely are as brazen:

First, the existing system, that is full of bullshit, obscure terminology, untested theorizing, non-existing constructs, and ill-supported classifications, must remain - and no less as a glorified puzzle piece, namely "a kind of "Rosetta Stone"".

Second, this obscure mostly mistaken system is blandly asserted, in the most confident if not really honest psychiatric way, to "facilitate communication".

Third, it must, in dr. Pincus fond conception, become much like the Vatican office of censors used to be: "all journals or other public reporting mechanisms would require that any clinical population also be described in the ICD/DSM classification".

There is that desire for world hegemony of dr. Pincus: He wants to see to it that "all journals or other public reporting mechanisms" conform to his pet "pragmatic" notions already - one must suppose: dr. Pincus is conservative - contained in the DSM.

And then he has fond dreams about percentages of required accordance with his favourite - "pragmatic", don't you see?! - classification system, it seems.

I wonder why he not just turns Catholic, since that "pragmatic" system has already much in place that moves him to such enthusiasm.

For consider his ideals:

Changes in future (descriptive) classifications should be infrequent and guided by a highly conservative process that would only incorporate changes with strong evidence that they:

1. Enhance overall communication among the "tribes"
2. Enhance clinical decision-making
3. Enhance patient outcomes

Conservatism is built in as core value: "Changes" (..) "should be infrequent". Indeed, if truth is not relevant to this most "pragmatic" of psychiatric belief systems, I don't see why there would be changes at all.

And indeed truth is not relevant: What Pincusian psychiatry is for is to "enhance" the communications of ""tribes""; of what I must assume are the ""tribes"" of decision-makers; and of patients' ... lives? problems? well-being? health? incomes? chances? happiness?... All wrong: "patient outcomes". (God knows what it means, except that patients should definitely not expect anything they might want from a most "pragmatic" professional like dr. Pincus.)

I am not done yet with the doctor from Columbia University (also, I noticed a colleague of that great leader Dick Fuld): He keeps on dreaming fond dreams of hegemony by mediating communications between what he styles, very humbly or humorously, as ""tribes"":

However, ICD/DSM would have a section describing the relationships among the various tribal concepts that could be updated on a more frequent basis.

It's again the wet dream of a Vatican head of censorship, but then "it takes all kinds to make a world".

If at this point you think I have been misrepresenting dr. Pincus: Not so! I have not, and he does not believe in such boring non-"pragmatic" psychiatric layman's notions as "truth":

Note that this approach gives up the ideal (or even a focus) on validity, per se.

See? A Pincusian Psychiatric "Pragmatist" has no need for such old-school pre-postmodern useless notions as "truth": That should emphatically not be "the ideal (or even a focus)" of Pincusian Psychiatry, at least as long as dr. Pincus monthly pay-check arrives without fail, and as long as no joker in Columbia has struck out a few zeroes in the amount to be paid on the ground that this would be so pragmatically useful for the university's finances.

You see, dr. Pincus has decided that in fact psychiatry and psychiatrist are a cross between journalists and whores:

Maintaining effective communication (most notably, effective use, reliability and understandability) and client satisfaction clinical utility (either the more limited improvement of sexual clinical and organizational decision-making processes or the ideal of outcomes improvement) become the principal goals of the whorehouse classification

I am sorry: My strikethroughs are justified "pragmatically". And did I mention world hegemony? I did, and here is the dear doctor, fondly dreaming on:

In other words, while a psychiatric classification must be useful for a variety of purposes, it cannot be expected to be simultaneously at the forefront of, for example, neurobiology and genetics, psychoanalysis, and the education of mental health counselors, primary care providers and psychologists.

See? In the dear doctor's delusional dreams it is pragmatic psychiatry that leads, circumscribes, defines, and controls ("pragmatically", of course) "neurobiology and genetics" and also "mental health counselors, primary care providers and psychologists".

I don't see why the "pragmatic" doctor does not extend his kindness and guidance ("pragmatically", of course) to physics, chemistry, mathematics and logic.

However - dr. Pincus loves starting sentences with "However": check it out ("pragmatically", of course) - our "pragmatic" doctor has already divided and approved the workloads:

However, multiple groups can continue their work on epistemic iteration using genetic approaches and others can develop ways to better measure quality or costs of care and yet others can study dimensional ratings of personality.

Isn't he merciful?! There is even "epistemic iteration", although the "pragmatic" doctor himself insisted that his "approach gives up the ideal (or even a focus) on validity".

However, as dr. Pincus loves starting sentences with "However", and as he's an inspiring communicator:

However, each tribal group would need to be able to communicate across the commons using the "Rosetta Stone".

How is that for "effective communication" (most notably, effective use, reliability and clarity)?! 

Here is the "pragmatic" doctor last statement, if you can believe it:

Thus, we would not be wobbling toward the asymptote of true validity, but, instead, be very slowly, but continually, rising toward the goal of better outcomes for patients.

From which you can learn - "pragmatically", to be sure - that truth and validity are not good for patients, who instead ought to believe - perhaps: if they want to avoid "pragmatic" incarceration, of course in their "own very best interests" - that "very slowly, but continually", and also very mysteriously, the Pincusian "Pragmatic" Psychiatry for ""Tribes"" will, eventually, who knows before 3000 AD, arrive at what will be "pragmatically" presented as "better outcomes for patients".

On this most happy thought it ends. As the reader may have surmised, somehow, it strikes me as total bullshit, but then I know more of physics than of psychiatry.              ->Contents

I have arrived at the next contributor, who I welcome with gladness:



Commentary
Thomas Szasz, M.D.
SUNY Upstate Medical University.

Dr. Szasz (<- Wikipedia) just got 92 and is still going strong, quite possibly - having just survived dangerous doses of psychiatric "pragmatism" - because he has spoken and written the truth as he sees it during his long life, instead of playing games of "let's pretend".

He starts thus:

I thank Dr. James Phillips for inviting me to comment on this debate. I am pleased but hesitant to accept, lest by engaging in a discussion of the DSM (the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders) I legitimize the conceptual validity of "mental disorders" as medical diseases, and of psychiatry as a medical specialty.

I agree and also thank Dr. Phillips. Dr. Szasz' concern also seems justified to me, but I don't think it holds in the context in which his contribution stands, though that is not something he could know when he wrote this.

And I quite agree that "mental disorders" are not at all the same, either in meaning extensionally or intensionally, as "medical diseases", and that I too have come to conclude that psychiatry should be terminated as a medical psychiatry, or changed altogether, namely into something that is more like counseling or social work; that is not coercive nor punitive; that does not function as an extension of the law or the police; and that is based on terms, concepts and hypotheses that are consistent with real science and its methods, and written in clear English, and supported by objective and repeatable evidence.

More of dr. Szasz, who is one of the most, quite possibly THE most, effective critics of psychiatry the last half century:

Psychiatrists and others who engage in this and similar discussions accept psychiatry as a science and medical discipline, the American Psychiatric Association (APA) as a medical-scientific organization, and the DSM as a list of "disorders," a weasel word for "diagnoses" and "diseases," which are different phenomena, not merely different words for the same phenomenon.

I have added the link to weasel word of which Wikpedia's definition follows, because it explains so - awfully - much of the prose I am working through:

an informal term[1] for equivocating words and phrases aimed at creating an impression that something specific and meaningful has been said, when in fact only a vague or ambiguous claim, or even a refutation has been communicated.

And I quite agree with dr. Szasz: Psychiatry is not a real science and cannot be one as long as there is so little knowledge of how the brain produces conscious experience, rather like there was no real science of colour or heat or paints until rather a lot of physics and chemistry had been discovered, in spite of the fact that there were colours, heat and paints long before the reasons for their being as they are were known.

In short: Psychiatry at present and the last 100 years, in spite of the large choirs of psychiatric voices who claimed otherwise, for financial reasons mostly, is much more like alchemy or astrology than like a real science such as chemistry or astronomy, and the most disappointing fact about the rather large "tribe" - I quote the pragmatically learned eminence dr. Pincus - of its professional exploiters is that they pose as if they are scientists, but they write and talk as if they are politicians, priests, salesmen or conmen. And I find this this both dishonest and reprehensible, as they could help patients with problems in a better way if they were more honest and less pretentious.

Further with dr. Szasz - after remarking that he has the great merit of writing far more clearly than any other psychiatrist I could name:

In law, the APA is a legitimating organization and the DSM a legitimating document. In practice, it is the APA and the DSM that provide medical, legal and ethical justification for physicians to diagnose and treat, judges to incarcerate and excuse, insurance companies to pay, and a myriad other social exchanges to be transacted. Implicitly, if not explicitly, the debaters's task is to improve the "accuracy" of the DSM as a "diagnostic instrument" and increase its power as a document of legitimation.

Quite so, and as has been amply illustrated by the commentators before dr. Szasz. And it is a considerable relief to have, at long last, a clear if brief mentioning of what psychiatrists do in fact, rather than endless elaborations of vain metaphorical distinctions that seem to have been designed to talk trash or flummox readers.

Long ago, having become convinced of the fictitious character of mental disorders, the immorality of psychiatric coercions and excuses, and the frequent injuriousness of psychiatric treatments, I set myself a very different task: namely, to delegitimize the legitimating authorities and agencies and their vast powers, enforced by psychiatrists and other mental health professionals, mental health laws, mental health courts, and mental health sentences.

This was and is a very noble end, precisely because psychiatry is for the most part not a science, and because so many of its diagnoses are false, dangerous and unjust.

In Psychiatry: The Science of Lies, I cite the warning of John Selden, the celebrated seventeenth-century English jurist and scholar: "The reason of a thing is not to be inquired after, till you are sure the thing itself be so. We commonly are at, what's the reason for it? before we are sure of the thing." In psychiatry it is usually impossible to be sure of "'what a thing itself really is," because "the thing itself" is prejudged by social convention couched in ordinary language and then translated into pseudo-medical jargon.

As it happens, I have read only one book of dr. Szasz, so far: "The myth of mental illness", which I read some 40 years ago, and found quite convincing, except for some reservations to the effect that there may well be mental illnesses, although Szasz was quite correct, I thought then and think now, in claiming there was far too little evidence that there are, except in a few cases (Alzheimer's, Parkinson's, madness associated with syphilis), and even these are very ill understood till this very day.

Then again, in case the reader is interested: I did write a long review of the presentation of dr. Szasz's ideas on Wikipedia: DSM-5: Thomas Szasz's ideas about psychiatry.

More dr. Szasz:

Seventy-five years ago, in my teens, I suspected that mental illness was a bogus entity and kept my mouth shut. Twenty-five years later, more secure in my identity, I said so in print. Fifty years later, in the tenth decade of my life, I am pleased to read Dr. Allen Frances candidly acknowledging: "Alas, I have read dozens of definitions of mental disorder (and helped to write one) and I can't say that any have the slightest value whatever. Historically, conditions have become mental disorders by accretion and practical necessity, not because they met some independent set of operationalized definitional criteria. Indeed, the concept of mental disorder is so amorphous, protean, and heterogeneous that it inherently defies definition. This is a hole at the center of psychiatric classification." This is as good as saying, "Mental illness, there ain't no such thing," and still remain loyal to one's profession.

Quite so - and I for my part am probably a bit amazed by it, as is dr. Szasz, though most psychiatrists clearly are not. Most psychiatrists verbally trick around it, but the position seems to be as dr. Szasz says: Psychiatrists are like priests who lost their faith in God, but who remain in the business of being priests.

In fact, there are some in Holland, and one - in this case, a Protestant minister who turned atheist - just recently won a courtcase that his flock has to keep paying him till his pension, in spite of his writing books to the effect that their religion, the one he gets paid for preaching to them, is nonsense.

So I should briefly state my response to psychiatrists who are willing to agree with me (or dr. Szasz) for the most part, but insist that they should be in business, because they are specialists in alleviating human suffering of a certain kind.

My response is that they may be right, but they can't be right in doling out the psychiatric teachings they learned ("You've such major personal problems because you want to fuck your mother | kill your father | are a repressed homosexual | have an inferiority complex | didn't sort your archetypes properly" etc.) because these are fictions, attributions or accusations without any good evidence.

More dr. Szasz:

The fallacy intrinsic to the concept of mental illness - call it mistake, mendacity, metaphor, myth, oxymoron, or what you will - constitutes a vastly larger "problem" than the phrase "a hole at the center of psychiatric classification" suggests. The "hole" - "mental illness" as medical problem - affects medicine, law, education, economics, politics, psychiatry, the mental health professions, everyday language - indeed the very fabric of contemporary Western, especially American, society. The concept of "psychiatric diagnosis," enshrined in the DSM and treated by the discussants as a "problem," is challenging because it is also a solution, albeit a false one.

Quite so - and this is precisely why I have become increasingly more irritated as I am reading through this collection of psychiatric reflections on the shortcomings of their craft: Most are not honest, it appears to me, but are playing verbal games they should have the intelligence to know are games, and are fallacious as rational scientific communication, for this is what they are decidedly not, with some - unfortunately rare exceptions, of which dr. Szasz is one.

Also, the above key paragraph mentions the real problems that should have been discussed, in clear non-metaphorical English, and without very confusing abused terminology from other sciences or disciplines, like philosophy, and with a clear awareness of the very many social and personal problems modern psychiatry has created by misdiagnosing them and/or by recommending or enforcing treatments and medicines that are harmful rather than helpful, except for those selling them: psychiatrists and pharmaceutical companies.

More dr. Szasz:

Medicalization, epitomized by psychiatry, is the foundation stone of our modern, secular-statist ideology, manifested by the Therapeutic State. The DSM, though patently absurd, has become an utterly indispensable legal-social tool.

Dr. Szasz is a libertarian, which is a political stance that probably has informed his wording here. I am not a libertarian - though I probably agree with a part of Dr. Szasz's convictions, since I describe myself politically as a classical liberal (think: Jefferson, Tocqueville, Mill) - and I don't fear the "Therapeutic State" so much as an authoritarian state.

Then again, the "legal-social" use that is being made of psychiatry, with psychiatrists as "willing executioners" of state policies is frightening, and should stop, if only because psychiatry isn't a science and medicine isn't a legal profession.

Here is dr. Szasz's last paragraph:

Ideologies - supported by common consent, church, state, and tradition - are social facts/"truths." As such, they are virtually impervious to criticism and possess very long lives. The DSM is here to stay and so is the intellectual and moral morass in which psychiatry has entwined itself and the modern mind.

Here he seems to me to be quite right again: As long as policies are decided on ideological grounds, as they usually are, rather than on real (as opposed to pseudo or quasi) scientific grounds and scientific knowledge, they will be far more often mistaken or misdirected, if sincere, for a reason Voltaire gave: "If we believe absurdities, we shall commit atrocities", or at least do harm where we could do good.

I arrive at the last contribution, that is a little strange, in that it again fondly engages on metaphorical talk about baseball, but this time not so much to defend psychiatry and its practices, but to make a valid point, albeit in a partially obscure and metaphorical way.               ->Contents 


Commentary: On Inviting the Gorilla to the Epistemological Party
Elliott Martin, M.D.
Yale University Department of Psychiatry.

What makes the epistemological umpire analogy so enticing is its capacity for adaptation, the fact that the strike zone must be different for every batter. If I call 'em as I see 'em, then of course what is a ball thrown to one batter may be a strike thrown to another.

Quite so, as one probably - if one has read all or most of the above, with some rational understanding - has also has come to realize: This is at best a mock serious way to discuss the intellectual scientific foundations of psychiatry, and not a really rational and responsible attitude, indeed not more so than one would object to a collection of Catholic cardinals who insist on discussing the intellectual basis of Catholicism in terms of analogies and terms from soccer, while using all manner of philosophical terms with new meanings, that generally also are not explicitly given, but shown in use: "philosophical", "pragmatist", "nominalist", "realism", "pragmatism", "nominalism", and "constructionism"  (see above) all come with uses that suggest the users do not know how these terms are use in serious philosophy, or else know but insist on confusing their readers.

And I do believe this was done on purpose: If dr. Frances had wanted a serious discussion he would and should have phrased his question differently. I will return to this below, when I consider his answers to the contributors. Here and now I continue with dr. Martin's prose:

As applied to the broadly descriptive nosology of DSM IV there is hardly an argument to be made against this.

Perhaps dr. Martin is speaking mock-seriously (an attitude that seems as common in psychiatrists as in Catholic apologists, that simply is not honest, as it is neither rational not polite). In any case, I have given above a series of arguments against this manner of discussing fundamental and serious questions.

But let's add a missing piece to the scenario. Let's cast the eight hundred pound gorilla in the analogy, the insurers, as 'the owner'. More specifically, let's call the beast 'the hometown owner'. And then let's say the umpire's salary is paid by the owner.

What dr. Martin really is concerned with, forgetting about baseball for a moment, is the role of the pharmaceutical corporations, and their relations with the so called "medical scientists" who are psychiatrists, who in the US alone help move billions of dollars each year from the pockets of patients or insurance companies to the bank accounts of psychiatrists and pharmaceutical corporations.

This is highly commendable of dr. Martin, for it surely is an important fact about psychiatry and psychiatrists: Unlike all other sciences in their abilities to lock people up and drug them against their will, psychiatrists and psychiatry also are unlike all other sciences in being the willing collaborators of both the law in practice as of the selling of medicine in practice - and the last, since they are rewarded for this by the pharmaceutical corporations, gives their "science" and their persons and activities a decidedly corruptible position, though I concede gladly that this is quite profitable for psychiatrists and also psychiatry, as it seems e.g. the American Psychiatric Association also gets funded by the corporations whose medicines they help sell for a percentage.

I return to dr. Martin, who in fact starts singing the praises of the past, of baseball to be sure:

With the game yet played on rural fields, before the advent of electronic pitch-tracking devices, before the price of every pitch was calculated, before the global media contracts, the strike zone was a sacred space, the tiny, arbitrary, marked off piece of ether from which intimacy the entire game was decided. Before the 'owners' blew the entire field up to stadium-size the game was about conceptualization and process; before psychiatry was snatched up by the insurers the pathologies were sought in subjectivity over objectivity. Artfulness existed alongside science. What, after all, did psychiatrists care for nosology before the rise of private insurance over the past several decades? Disordered thinking, as opposed to ordered thinking, was just that. Slapping a name on it did little to change the fact. One man's depression is another man's 'blues', and what does the patient care for the label?

This patient does, since he knows that being diagnosed in any way by any psychiatrist makes him liable to receiving legally very harmful "diagnoses", as we have seen from the above discussions, normally without rational or empirical scientific foundation.

My advice to anyone with "psychological problems" must be to avoid psychiatrists, since these have far too much power and authority, and hardly any rational knowledge of what they confidently judge, and instead rely on their GP or - if they feel they must - a psychologist.

Having wrestled through the above, my brief justification of my advice is: If you read psychiatrists, with some intelligence and education, you will find that most of them lie most of the time, and do so very trickily and with much dishonesty, for they also want to be seen as medical saviours and benevolent persons, which at best only a small proportion of them is: Most have a very well-paying job with few really exactable personal responsibilities and are protected by a powerful professional brotherhood of likeminded similarly motivated colleagues, who all feel that their first loyalties are to themselves and their colleagues, and not to their patients or rational science.

More dr. Martin:

'Carving nature' does require a measure of reliability, true, but the only conversations I have had in which I have coughed up the full DSM criteria have been those over the telephone, most often in the emergency room, with insurance reviewers 'objectively' determining, from up to thousands of miles away, whether a particular patient warrants two days or three days in which to be cured. And at that, for the benefit and safety of my patients, my strike zone widens tremendously after five minutes, and my diagnoses tend to reduce to the very non-DSM, if at times heavily punctuated, 'imminently suicidal!' or 'imminently homicidal!'. The arguments tend to end there, and it is apparent that what is missing in the epistemological umpire analogy is the hard baseball rule against arguing balls and strikes.

In other words, dr. Martin suggests that much of the DSM is in the everyday practice of psychiatrists mostly hogwash - it looks impressive in court and on one's coffee table, but it is not really serious, and those who hide behind it as their professional Bible don't really take it serious either (in spite of assurances like those of dr. Pincus, dr. Pierre, dr. Corullo etc.)

As a former academic, however, I simply have to believe that there is an inherent value in the pursuit of knowledge for knowledge's sake, that all sciences, veiled or not, are interwoven, regardless of the current paradigms, and the loss of even one is somehow crippling to the others.

While I believe in "the pursuit of knowledge for knowledge's sake" I have in the last two years learned that psychiatry is not a science and is very dangerous to literally millions of genuinely ill and suffering patients in my own position:

With an unexplained medical disease, admitted as real and non-psychiatric, that droves of psychiatrists nevertheless feed on as vultures by declaring all these millions, and thousands of medical doctors who are not psychiatrists and insist these people are really ill, to be insane albeit it normally in weasel words: These medical doctors who believe me, like myself, must suffer from "dysfunctional belief systems" and must be subjected to verbal and physical therapy by the authorities, to learn them to think well, that is according to what psychiatrists claim, and to learn to work, by being forced to do so without pay.

By what hair's breadth is this different from undiluted fascism and terrorism? Those who want to protest this question or suggestion are advised to consider my family background, my degrees, my age (nearly 62), and my 'career' as a 'student leader' who protested the postmodern relativization of all standards and all morals. Also, potential protestors should take a close look at the Action T4:

Aktion_T4
This poster (from around 1938) reads: "60,000 Reichsmarks is what this person suffering from a hereditary defect costs the People's community during his lifetime. Fellow citizen, that is your money too. Read '[A] New People', the monthly magazine of the Bureau for Race Politics of the NSDAP."

What is the logical difference in moral and legal principle between Nazi-doctors then and those psychiatric doctors who want to force ill people to work, without pay also, as is the case now in Holland? On what basis can any psychiatrist defend the forced brainwashing (CBT) and the forced - unpaid! - daily work (GET) of people who are seriously ILL according to most medical folks who are not psychiatrists including the WHO and the ICD?! (Answer: On the basis that our proud ordinary men, that form the solid majority in any democracy, are not willing to pay for the ill: See the picture and its translated text: "So it goes".)

Is that moral? Is that rational? Is that consistent with medical ethics? No, no and no: It is sick sadism that plays with the lives and chances of millions of ill people from a desire to hurt or from total indifference to the pain of another human being, and on the basis of no real rational scientific knowledge whatsoever, while pretending - "I am a medical doctor!" - to be medical scientists, and abusing the authority and trust ordinary people have in medical doctors (who are not psychiatrists).

But 'the owners', despite the fact that they stand oblivious, willfully or not, to the devastation they create, can no longer be ignored in these arguments. Whatever the historical mechanisms, the pursuit of knowledge has come up hard against the pursuit of profit in these last few decades.

I believe dr. Martin and Lord Acton ("All power corrupts"), and I appreciate that he was the only psychiatrist, next to dr. Szasz, with the guts to raise this - very realistic: human-all-too-human - spectre of psychiatric corruption on a large scale.

And dr. Martin has a further interesting, serious and credible claim:

I contend that the process of classification is the process that, if not created by, than at least has been manipulated ever since by the owners.

He says - or at least suggests, if one subtracts the baseball metaphor - that in fact the pharmaceutical companies have a large voice in determining the contents of the DSMs, at least the DSM-IV and DSM-5.

Dr Frances, in his response, will deny this. Since I have no direct evidence, I must judge inferentially, and my judgment is that dr. Martin's affirmation is far more credible than dr. Frances's denial: Most men and women are much moved by money; "All power corrupts"; human beings are on average much more egoistic than altruistic; and Mencken's "It is hard to believe that a man is telling the truth when you know that you would lie if you were in his place" very much applies. And if it happens, then it is VERY profitable - which makes it likely to the extent that it is profitable.

As students of the human mind, arbitrary classification of disorders of the mind does not inform us; it informs the gorilla. Describing 'normalcy' and 'variants thereof' only serve to destroy further an already hobbled subjectivity.

It is certainly true nobody who is ill will be helped by "arbitrary classification of disorders of the mind" and meanwhile it seems very likely that almost any "diagnosis" on the basis of the DSM-IV or 5 was reached on the basis of a deeply flawed and biased system of definition, description and classification (that is not so much "arbitrary" as it is pseudoscience or delusion) that serves nobody's real interests - except those paid for using it to diagnose others and those paid for the medicines prescribed on the basis of such diagnoses.

As to normalcy: I learned in 2010 that according to the DSM-IV in practice, according to the Brit. Jn. Psychiatry: 78% of the British are not sane. Well ... that's a rather insane finding, that strongly supports the notions that (i) psychiatrists don't really know what they are talking about; that (ii) the DSM-IV is worse than useless, as it implies 4 out 5 human beings are insane when judged by its terms; and consequently that (iii) the DSMs should not be used to diagnose or judge people, because it is an obscure, invalid mess that invites all manner of misdiagnosis if relied upon.

More from dr. Martin:

Nosology destroys narrative, and where formerly our patients were more appropriately likened to novels, they are now become, for the ease of illiterate overlords, more like newspapers.

Put otherwise, dr. Martin's counsel is: Beware of les terribles simplificateurs, also when they are one's colleagues who compiled a manual.

Here is dr. Martin's last paragraph:

As the noted Assyriologist, Jean Bottero, put it in defense of his own limited field, "Yes, the university of sciences is useless; for profit, yes, philosophy is useless, anthropology is useless, archaeology, philology, and history are useless, oriental studies and Assyriology are useless, entirely useless. That is why we hold them in such high esteem!" [[42], p. 25] Psychiatry finds itself in a unique position among the 'useless' sciences. Like the umpire offered a bribe by the owner, if the field chooses utterly to subserve profit it likely stands to gain tremendously. If the field chooses to uphold an ideal of humanism in the face of gorilla-ism then we will likely be faced with the same fate as philosophy, anthropology, archaeology, philology, and history. In which case let us all call 'em as we see 'em, keep the paperwork tidy, and at the very least be ever mindful of the watchful gaze of the gorilla.

I don't quite agree on the uselessness of science, though I agree many sciences are not good for making a profit from, so if one's criterion for what is useful is that useful things make monetary profits, disciplines like Assyriology are useless.

But I don't agree with the criterion, and besides: Modern psychiatry is quite useful by that criterion I reject: It is quite profitable for psychiatrists, who tend to live lives in the highest income bracket, and also is quite profitable for pharmaceutical companies, whose medicines psychiatrists help peddle.

And while I agree with dr. Martin that it is desirable that if there are psychiatrists they are rational an not corrupt, what I have learned the last few years about the actual modern practice and theorizing of psychiatry has convinced me it is far better if is terminated as part of medical science.

This may be an unpractical desire as things stand in the world, though in fact it would save a lot of money for governments and insurances, and it would save many lives that risk being wasted or destroyed through psychiatric misdiagnosis in the name of "medical science".

Therefore, if the monster can't be killed, e.g. because its continued existence is much desired by the powers that be and also popular with large parts of the thoroughly misguided public, the least that should be done is to have it use a rationally and morally defensible diagnostic system, instead of an irrational and immoral one, as is the case - even if, with dr. Frances, one only looks how the DSM-IV has practically unpacked: As a justification for epidemics of prescriptions of anti-psychotic drugs to children, and of diagnoses of "autism" .

I have arrived at dr. Frances replies to the contributors:        ->Contents


Here I will be more brief, and provide links in the titles to the starts of my own responses, that are considerably different from dr. Frances, who - after all - turns out to be a much more ordinary psychiatrist than his recent criticisms of the DSM-5 suggest:

Allen Frances responds: There Is A Time And Place For Every Umpire

None of the five umpires is completely right all of the time. And none is totally wrong all of the time. Each has a season and appropriate time at the plate.

Well... having anyway had my fill of prancing and posturing shrinks who for the most part just refuse to be rational and reasonable, I concede dr. Frances has cleverly tricked me into believing he was willing to try to be rational and reasonable.

But this is just relativistic rot, and a dishonest evasion of an anyway trickily posed metaphorical question, that I guess was posed that way to enable his dear colleagues to bullshit to their hearts' content.

This is just too pat, too slick, too slippery, too evasive an answer to some very fundamental problems with the foundations of psychiatry, and my conclusion must be that dr. Frances loves psychiatry and psychiatrists; knows very well it is mostly bullshit, but doesn't really care, because he chooses to be skeptically uncommitted to most or all positions to allow himself the greatest leeway and freedom for discussing others.

I had hoped that, having safely reached his pension and 70th year, he would be able to be mostly honest, rational and reasonable, but he chose not to be: He acts like a referee on the question which religion is the true one, and blatantly insists they all must be.

Forty years ago, Umpires 1, 3, and 5 were in competitive ascendance. The nascent school of biological psychiatry was a confident Umpire 1- convinced that mental disorders would soon yield their secrets and be as fully understood as physical illnesses. In fact, there was a heated controversy whether the new diagnostic manual (DSM III) then being prepared was a catalog of 'disorders' or of their much preferred term 'diseases'.

O please, stop this prancing posturing metaphorical bullshit! Your profession and your diagnostic manual fucked up very badly! Be honest and fair about it, instead of prancing about with tales full of bull and - probably intentionally - abuse of terminology that does not even belong to psychiatry!

In sharp contrast, the competing models that dominated psychiatry forty years ago were very much like the skeptical Umpires 3 and 5- in their different ways, all were nihilistic about the value or reality of psychiatric diagnosis. Psychoanalysis dealt with highly inferential concepts impossible to reduce to reliable diagnosis. Family, group, and community psychiatry went so far as to deny that the individual patient was a proper or very relevant unit for diagnostic assessment, preferring models that diagnosed the system at larger aggregates of interpersonal affiliation. When Szasz, then as now, decried the 'myth of mental illness', there was little coherent opposition outside the group of the smugly confident pioneers of biological psychiatry (who soon would be hoisted by their own petard).

Again, the supposed "Umpire 3" is not "skeptical" in any received sense of that word: He is a postmodernistic posturer, impostor and liar. And dr. Szasz is only "skeptical" about psychiatry in the commonsensical sense of not believing it, with the additional impressive rationale of having written many books about its many failings - scientifically, morally, morally, intellectually - and its many betrayals and misdiagnoses of its patients, that dr. Frances is clearly quite incapable of refuting on their intellectual or moral merits.

The years have not been kind to umpires 1, 3, and 5. Each still stakes some small claim to attention, but umpire 2 now clearly rules and welcomes the collaboration of his close cousin, the ever practical umpire 4.

I am at this point in time - after several days of work on this bullshit - thoroughly disgusted with this facile, mocking and dishonest falsification of the fundamental epistemological failings of psychiatry and psychiatrist - who turn out to be liars en masse, I am very sorry to say, who differ far less from Catholic priests, in outlook, morality, and manner of arguing their case, than they differ from real scientists: Deception for money is fraud, not science, even if the ignorant public in majority can be deceived in thinking otherwise, and it must be "medicine" if some plausible seeming fraud has a B.A. in that.

Why the revolution in epistemological sentiment? Biological psychiatry helped spark a wondrous neuroscience revolution that is perhaps the most thrilling focus of twenty first century biological science. But the findings have revealed a remarkably complex brain unwilling to yield any simple answers. There is thus far almost no translation from the glory of basic science discovery to the hard slog of understanding the etiology and pathogenesis of the 'mental disorders'. These no longer seem at all reducible to simple diseases, but rather are better understood as no more than currently convenient constructs or heuristics that allow us to communicate with one another as we conduct our clinical, research, educational, forensic, and administrative work.

I am sorry, but this is more dishonest bullshit - and I am sorry less for dr. Frances, who must have had a most enjoyable life and career compared with the life I have been forced to lead, through the political and immoral manipulations of a bunch of psychiatric frauds, than for the chances of stopping the awful and disgusting fraudulence that is the DSM-5.

Here is my reason: By phrasing it as he does, dr. Frances manages to suggest that there ever was any chance that the brain would conform to the ravings of psychiatry half a century ago. Not so: The chances are of the order of the topography of hell being like Dante imagined it to be - and it is more likely that Dante had a direct line to the divinity than any psychiatrist.

Most hard core biological psychiatrists have lost heart in the naive faith of umpire 1 that he can define simple models of illness. Those who were hunting (and reporting) the gene or genes for schizophrenia, bipolar, and other disorders have been forced repeatedly to retract and eat humble pie. Initial findings never achieved replication for what became the obvious reason that there is no 'disease' of schizophrenia- that instead schizophrenia is better understood as just a construct (albeit it a very useful one) with hundreds of different 'causes'.

I merely interpose that psychologists have learned in their education, since several generations at least, and in the US perhaps since William James wrote, that all psychological concepts are "constructs", if only for the simple reason that no person has access to the mental life and experiences of any other person. It is amazing that psychiatrists seem to have never arrived at even that level of minimal sophistication, and it is a great moral and medical and legal shame that so many psychiatrists have blandly led a life of wealth while financing it by deceiving their patients about their own competence and about their patients' causes of feeling unwell.

Meanwhile the diagnostic nihilism of Umpires 3 and 5 also became less relevant when DSM III proved that psychiatric diagnosis could be a reliable and useful tool of communication.

Well, that's just what dr. Regier has denied: See my Introduction to the six questions, where he is quoted to thaf effect

Umpire 2 now rules. Mental disorders are no more and no less than constructs. And Umpire 4 is quick to point out that they are very useful constructs. The current dominance of Umpires 2 and 4 is temporary, and certainly not complete. In some very gradual and piecemeal way, the future holds hope for an increased role for Umpire 1. As we slowly discover the biology of mental disorders, small subunits will cohere around a common pathogenesis and declare themselves as a disease. This is beginning to happen for the dementias of the Alzheimer's type. But it will always be necessary to retain the corrective voices of the skeptical Umpires 3 and 5- to remind us just how little we know and how feeble are our tools for knowing.

But the falsely called "skeptical" type 3 psychiatrists freely invent away on the arbitrary false assumption they are justified in doing so by insisting they are doing something "practically useful" and don't believe in truth or validity (except about their own pay check and the amount on it). See dr. Pincus' contribution.

->Contents

Reply to Drs Zachar and Lobello

Thank you for your contribution which I received after writing my own. You have stated my position with much greater clarity and erudition than I could muster.

I suppose this is the truth as dr. Frances sees it. My review (under the link in the title, as is true of all replies that follow) shows I wholy disagree.

Reply to Dr Pouncey

Thank you for your clarification of the Umpire metaphor. Your analysis nicely demonstrates the similarities and the differences in the positions of Umpires 1 and 2- both accept the possibility of an independent reality, but differ sharply in there estimation of our current ability to apprehend it.

I agree dr. Pouncey wrote a useful clarification of a wrongly posed question with wrongly used terms, but I disagree about the differences dr. Frances seems to see between what he calls (misleadingly) "realism" and (very misleadingly) "nominalism". By the way... since the Stanford Encyclopedia of Philosophy is quite good and freely available on line, I completely miss the need for all the abuse of philosophical terms dr. Frances and most of his commentators engage in, and am cynically realistic enough to infer they do it on purpose and not out of hard to avoid ignorance.

Reply to Dr Ghaemi

Dr Ghaemi sets up a false and totally unnecessary dichotomy between his true believer version of realism and what he calls "taking a random walk". It is possible, indeed necessary, to take a very modest position regarding the current state of certitude of psychiatric knowledge on the causes of psychopathology without assuming that we know nothing or are walking totally blind or that our constructs have no current heuristic value. Umpire 2's honest admission that he can do no better than call them as he sees them does not deny the possibility of real strikes and real balls- it just states the very constrained limits of our apprehension. I have no problem at all with the metaphor of epistemic iteration- it is obviously the route of all science. But let's realize how early in the path we are and how uncertain is its best direction.

I think dr. Frances manages to misjudge dr. Ghaemi's text: While I agree his opposition is not very realistic or helpful, he does articulate something like a realist perspective on psychiatry, and he also is, next to dr. Szasz, one of the few who does not mistreat his readers on a meal of misconceived philosophical terms served in a porridge of misleading metaphorical talk.

From here on I have not written my replies to dr. Frances' replies, which the reader may infer from my replies to the originals that are linked in the title, except for dr. Frances' reply to dr Szasz and idem to dr. Martin.

Reply to Dr Cerullo

How comforting to be a first umpire. I admire the magisterial confidence of Dr Cerullo's statement, "Most working scientists and philosophers would be classified as modern realists who believe there is an independent objective external reality". I wish I could feel so firmly planted in a "real" world and possess such naςve faith in mankind's capacity to apprehend its contours. Alas, as I read it, the enormous expansion of human knowledge during the last hundred years is enough to make umpire 1's head spin with confusion. The more we learn, the more we discover just how much we don't (and perhaps can't) know. Einstein gave us a four dimensional world that even physicists have trouble visualizing. Then the string theorists made it exponentially more complicated by expanding the dimensions into double figures and introducing conceptions of reality that may or may not ever be testable. The quantum theorists describe a "spooky" (Einstein's term) and inherently uncertain world that lends itself to extremely accurate large n prediction, but totally defies our intuitive understanding of the specific mechanics. It also turns out that we are pathetically limited in our sensory capacities, even when they are extended with our most powerful sensing instruments. Evolution allows us to detect only 4% of our universe, the rest of energy and matter being "dark" to us. Indeed, there may be a vast multiplicity of multiverses out there and we may never know them. So I don't see human beings as having great status as judges of reality- we are like mice describing the proverbial elephant- having available only fallible and very temporary constructs.

To get back to our umpires, the connections between brain functioning and psychiatric problems are definitely real, but they are so complex and heterogeneous as to defy any simple "realist" faith that we are close to seeing them straight on, much less solving them.

Response to Dr Wakefield

Drs Wakefield and Pouncey have made many of the same important points. Dr Wakefield's "humble realism" (associated with an honest and flexible willingness to admit fallibility and the possibility of error) works for a great baseball umpire and is not a bad model for a psychiatric diagnostician. The difference between umpire 2 and umpire 1.5 depends on how close you think our field is to understanding the reality of psychopathology. I am even more humble than Dr Wakefield and will stick with umpire 2.

Reply to Dr Pierre

I agree.

Reply to Dr Greenberg

In defending Umpire 3, Dr Greenberg assumes a grandly, neutral view of man's place in the world and makes clear how limited are our abilities in naming and classifying its manifestations. Greenberg rightly suggests that the distinction between a broken branch and a broken femur may be extremely meaningful to the patient and his doctor, but is really trivial in the grand scheme of an indifferent nature. He might equally have pointed out that from a bacteria's perspective, pneumonia is not a disease- it is just an opportunity for a good feed. Diseases, according to Greenberg's argument, are no more than human constructs made up de novo by us as inherently self interested third umpires.

From Greenberg's lofty perch, mankind's attempts to label do seem pathetically self referential and solipsistic, extremely limited in their apprehension of reality (even assuming that there is a graspable reality ready to be apprehended). But it seems to me that his level of philosophic detachment works only in the exalted theoretical realms, and contrary (to his statement) fails badly to do justice to the needs and opportunities of our everyday, "common sense" world.

Greenberg and I do agree completely on several points: 1) if mother nature had the gift of speaking our language and the motivation to do so, she would probably indicate she couldn't care less about our names and that she doesn't feel particularly well described by them; 2) our categories are no more than tentative approximations and are subject to distortion by personal whims, cultural values local to time and place, ignorance, and the profit motive; and, 3) psychiatry's names should be used with special caution because they lack strong external validators, carry great social valence, and describe very fuzzy territorial boundaries.

Where my umpire 2 position differs from Greenberg's umpire 3 is in our relative estimations of how closely our names and constructs can ever come to approximating an underlying reality. My umpire 2 position is skeptical about umpire 1's current ability "to call them as they are" and advises modesty in the face of the brain's seemingly inexhaustible complexity. But I remain hopeful that there is a reality and that, at least at the human level, it will eventually become more or less knowable. We may never fully figure out the origin and fate of the universe or the loopy weirdness of the quantum world. But the odds are that decades (or centuries) of scientific advance will gradually elucidate the hundreds (or thousands) of different pathways responsible for what we now crudely call "schizophrenia".

Greenberg is more skeptical than I about the progress of science and is, at heart, a platonic idealist who finds life cheapened by excessive brain materialism. He sees psychiatric disorders as no more than human constructs - metaphors, some of which are useful, some harmful. His umpire 3 does not does not believe the glory and pain of human existence can or should be completely reduced to the level of chemical reactions or neuronal misconnections. This is a fair view for poets and philosophers (and Greenberg is both), but I see a ghost in his machine and dispute that allowing it in makes "common sense".

Reply to Dr Pincus

Thank you for inventing the fourth umpire. Dr Pincus is the most practical of men and he has created a handy metaphor for describing the ultimate goal of any DSM- to be useful to its users. There is only one problem with the fourth umpire's position- but it is a big one. There is no external check on his discretion, no scientific or value system that guides what is useful. Everything depends on the skill and goodwill of the umpire. In the wrong hands pragmatism can have dreadful consequences- commissars who treat political dissent as mental illness or judges who psychiatrically commit run of the mill rapists to keep them off the streets. But to ignore the practical consequences of psychiatric decisions leads to its own set of abuses- most recently diagnostic inflation and excessive treatment.

Reply to Dr Szasz

I have enormous respect for intellectual reach and depth of Dr Szasz' critique of psychiatric diagnosis and for the moral power of his lifelong efforts to prevent its misuse. He skillfully undercut the pretentions of the Umpire I position at a time when its biological proponents were at their triumphalist peak, loudly trumpeting that they were close to finding the gene for schizophrenia and to elucidating its brain lesions. He anticipated and exposed the naivete of these overly ambitious and misleading claims. He has fought the good fight to protect the rights, dignity, and personal responsibility of those deemed to be "mentally ill".

But pray: If so, why hasn't dr Frances been more critical of the profession he professed and wrote the presently used diagnostic manual for, if he really agrees with dr. Szasz? I can only conclude that dr. Frances in his laudatio is not quite honest, at least, and that the next part is far closer to what he really thinks about dr. Szasz:

My argument with Dr Szasz is that he goes too far and draws bright lines where there are shades of gray.

No, that is trivializing bullshit and a fallacy: What dr. Szasz has been saying is that the intellectual and empirical rational foundations for such diagnoses as are made in psychiatry is absent, and that therefore it is fallacious and immoral. The reply of dr. Frances simply bypasses that and pretends dr. Szasz should abide by these distinctions while also suggesting - falsely, for sure - that if he only did that dr. Frances would be more willing to embrace his criticisms of psychiatry. Well, if you believe you'll go to heaven, but I don't believe dr. Frances.

Surely, he is right that schizophrenia is no "disease", but that does not mean it is a "myth".

Bullshit: What dr. Szasz has been saying is that there is no empirical or logical basis to suppose the theory that schizophrenia is a disease. Would it be fair if he had stated the same not about schizophrenia as a disease but about the Catholic religion that dr. Frances' would reply that this does not prove that Catholicism is a myth? In real science you need logical grounds or empirical evidence to speak sensibly and rationally about something.

What dr. Frances' articulates, in an authoritarian way, is that the unfounded concepts of psychiatrists are not myths. He gives no arguments. That is not the rational scientific way, but are the contortions of faith healer whose bogus terms are rationaly criticized.

Here is more of it:

Surely, he is right that psychiatric diagnosis can be misused and misunderstood, but that doesn't mean it is useless or can be dispensed with.

Two fallacies (at least) rolled into one: Begging the question and pretending to be an authority whose ukases must be accepted: What dr. Frances should have discussed or at least taken up is the question how, if psychiatry has been abused and misunderstood, something can be done about it to lessen especially that abuse.

He answers as if dr. Szasz has spoken in vain and merits no real answers, except vague praise.

Here is dr. Frances' final blooper about dr. Szasz:

Dr Szasz is correct in defining the many of problems with psychiatric diagnosis, but doesn't have alternative solutions. There is a baby in there with the bath water he is so eager to discard.

How stupid or unfair can one get, as psychiatrist? Since when is it required to have solutions for the falsehoods and immoralities one criticizes? Since when must one be a baker to be able to tell whether bread is rotten?! And what if the baby is an evident monster with as many heads as there are psychiatrists, who are all as mendacious as Catholic bishops on the subject of pedophilia and as rapacious, if they can get their way, as Attila the Hun, or as cruel and degenerate as dr. Mengele?

Reply to Dr Martin

I agree that we can't always assume the Umpires are acting only from the purist and most disinterested of motives. Games can be fixed for financial gain and psychiatry operates in a real world of large drug company, insurance, and publishing profits. My experience has been that the actual framers of DSM IV and of DSM 5 have not been shills for industry- but that heavy drug marketing has led to much over-diagnosis using DSM IV and that the risks are greatly heightened because of the new diagnoses being suggested for DSM 5. Dr Martin's comment makes clear that we must be aware the diagnosis of a given patient can be distorted by real world economic factors and must be ever vigilant to protect the integrity of the process.

We're back at the silly conversational game of umpiring. I will only comment briefly on two points:

As to "My experience has been that the actual framers of DSM IV and of DSM 5 have not been shills for industry": Totally unsatisfactory, because dr. Frances can not possibly have experienced more than a very small fraction of what there is to experience, especially of DSM-5's editors, who don't even answer him publicly. He would be equally credible for me if he had said: "I swear you are mostaken - Trust me!". My reply: This matter should have long ago been properly investigated by qualified investigators who are not psychiatrists.

As to: "but that heavy drug marketing has led to much over-diagnosis using DSM IV and that the risks are greatly heightened because of the new diagnoses being suggested for DSM 5". Actually, this is not evidently consistent with the statement just criticized: What if this "over-diagnosis " has been engineered by some of dr. Frances' colleagues? Again: This matter should have long ago been properly investigated by qualified investigators who are not psychiatrists.

->Contents

 



Having struggled through all of this my main impression is one of having been deceived by loads of bullshit and dishonesty - this "umpire" calls'um as he sees'um:

He now has 25 years of constant physical pain because a handful of psychiatric frauds have insisted that his disease, which is real and serious according to the World Health Organization, and explicitly not psychiatric, is due to the "dysfunctional belief systems" of the millions of sufferers, and merits no treatments or help whatsoever, except for Cognitive Behavourial Therapy to cure his "dysfunctional belief systems" and Gradual Exercise Therapy to acquire a desirable work ethic - which he thinks are very sick and and very sadistic lies that so perfectly fit politicians' and bureaucrats' desires to save money to help bank managers that they have let themselves be convinced by these psychiatric frauds, who started the lies in a bid for more power, more patients, higher incomes, and more governmental assistance for their kind of pseudo-medicine.

This is despicable sadism or moral degeneracy of a very frightening kind - I can't make anything else from it, for the only alternative for this load of metaphorical bollocks is that psychiatrists are a kind of "scientist" that has an average IQ under 115, and thus can be honestly deceived into thinking that their metaphorical, stilted, artificial crap about the intellectual foundations of their purported science makes sense.

Besides, I have now for 25 years continuously the pains that belong to my disease as classified by the World Health Organization, and I can get no help whatsoever, because a bunch of psychiatric frauds got the ears of the government with non-scientific lies about my disease, and with the deeply disgusting slander that I feel "pain" only because I have "dysfunctional belief systems".

And both the intellectual foundations and the moral foundations of the purported science of psychiatry are a shambles and a mess of fictions, cant, jargon, evasions and intentionally manufactured obscurity ambiguity and multi-interpretability that is a deep shame and a fraud to present as if it is real science or based on real knowledge or real evidence:

Mencken had it quite right with his cynical observation that

"It is hard to believe that a man is telling the truth when you know that you would lie if you were in his place".

I know that I would be lying myself blue in the face about science, methodology, logic, and known explanations about how the human brain produces human conscious experience - understanding of selfs, other persons, meanings, mathematics, ideas, ideals, music: all unknown to this day - if I wrote like the above psychiatrists, with one single exception, namely dr. Thomas Szasz.

And I would also know that if I wrote or spoke that manner of rot, a man with my mental capacities and knowledge has just one plausible ground for doing so, apart from sadism, which is something I detest: Financial greed, and perhaps the great joys in tricking lots of people with verbal acrobatics and facile and irresponsible cleverness into paying me lots of money for cleverly deceiving them.

Of all the above authors - who I do not think are all dishonest: There are many possible explanations for misconceptions or metaphorical fudging and astroturfing - only dr. Thomas Szasz made intellectual and moral sense to me. Only he named the many real problems; only he seems to be aware of the deep and very worrying and frightening immorality and dishonesty of much of psychiatry, and only he seems to be aware of what real philosophy of science and real science are really like.

He is to be much thanked for this, which I hereby do, also on behalf of the many psychiatric patients whose human rights, human integrity and personal dignity he fought for, for fifty years, while those of his colleagues who criticized him stood by laughing while people perished because of the moral failings and lack of personal courage of the majority of - admittedly very well paid - psychiatric colleagues of his.

It is very saddening to see how a man of his moral calibre and intellectual sophistication is smeared or mistreated by his nominal colleagues, who compared to him seem to have a hole or a fanciful show of deception at the place where dr. Szasz has a conscience and great personal moral and intellectual courage.

So here is my endnote with my main conclusions relating to the above for the most part either incompetent or dishonest discussions of the intellectual foundations of the purported "science" of psychiatry - and I write this as I wrote all of this text: Not with the hope of being widely believed or praised, but because I prefer the truth over a career based on misleading and deceiving the majority that is less intelligent or less well educated than I am.

Endnote:

  • Modern psychiatry has all the features of postmodernism,
    none of the features of science.
     
  • Psychiatry as an art rather than a science (and may have a right of existence as a humanitarian practice); intellectually psychiatry is bad philosophy or secular theology rather than honest medical science.
     
  • It is therefore desirable, in the interest of patients of many kinds, and of mankind in general, that this fraudulent pseudoscience is removed from medical science.
     
  • While this unlikely to happen soon or easily, it is meanwhile very desirable that the DSM-5 gets stopped, and replaced by something far more rational, reasonable, scientific, clear, less pretentious, less dangerous, and a far more useful, truly moral and honestly legal diagnostic manual, that also is written by more than just psychiatrists, namely also by psychologists, lawyers, social workers, counselors and philosophers.
     
  • As the option of writing a better diagnostic manual seems difficult to many: If - as seems to have happened - dr. Spitzer could produce the DSM-III mostly by himself with help of his typewriter, and as it is easy for intelligent informed people of good will not to write bullshit, it should not be difficult to do it better with some competent qualified people from the various relevant disciplines, seeing also that what is known about the contents of the DSM-5 is mostly atrocious bullshit. See my A good plan for the DSM-5 and 50 reasons to stop the DSM-5.
     



P.S.
Corrections, if any are necessary, have to be made later.
-- April 29, 2012: Meanwhile I've corrected quite a few typos and unclarities
and added quite a few internal and external links. The file is almost 540 Kb, and will probably not be corrected further. Later today - I expect - there will be a P.S. with a few additions and clarifications.
-- November 4. 2012: This long text seems to be quite popular, and I have reformatted some: A few parts had fonts of too large a size.

 

As to ME/CFS (that I prefer to call ME):
1.  Anthony Komaroff Ten discoveries about the biology of CFS (pdf)
2.  Malcolm Hooper THE MENTAL HEALTH MOVEMENT: 
PERSECUTION OF PATIENTS?
3.  Hillary Johnson Th Why
4.  Consensus of M.D.s Canadian Consensus Government Report on ME (pdf)
5.  Eleanor Stein Clinical Guidelines for Psychiatrists (pdf)
6.  William Clifford The Ethics of Belief
7.  Paul Lutus

Is Psychology a Science?

8.  Malcolm Hooper Magical Medicine (pdf)
9.
 Maarten Maartensz
ME in Amsterdam - surviving in Amsterdam with ME (Dutch)
10.
 Maarten Maartensz Myalgic Encephalomyelitis

Short descriptions of the above:                

1. Ten reasons why ME/CFS is a real disease by a professor of medicine of Harvard.
2. Long essay by a professor emeritus of medical chemistry about maltreatment of ME.
3. Explanation of what's happening around ME by an investigative journalist.
4. Report to Canadian Government on ME, by many medical experts.
5. Advice to psychiatrist by a psychiatrist who understa, but nds ME is an organic disease
6. English mathematical genius on one's responsibilities in the matter of one's beliefs:

7. A space- and computer-scientist takes a look at psychology.
8. Malcolm Hooper puts things together status 2010.
9. I tell my story of surviving (so far) in Amsterdam/ with ME.
10. The directory on my site about ME.



See also: ME -Documentation and ME - Resources
The last has many files, all on my site to keep them accessible.
 


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