David H. Jacobs, 2014
American medical psychiatry: A contemporary case of Lysenkoism in D. Holmes, J. Daniel Jacobs, and A. Perron (Eds.), Power and the psychiatric apparatus (pp. 287-296). Burlington, VT: Ashgate Publishing Company.
In a 2005 publication Robert Spitzer, the psychiatrist who spearheaded the APA’s official paradigm shift to unsullied medicine, admitted that the false positive problem in psychiatry has proven to be insoluble. A symptoms-only approach to the problem of psychiatric diagnosis, although consistent with medical reasoning, ignores background and is thus blind to adversity and to the false positive problem. I argue that recognizing the reality of adversity, which can only be ascertained via dialogue and which ineradicably includes first person subjective components, cannot be assimilated to either medicine or science. Indeed the psychiatrist-patient encounter, in contrast to the physician-patient encounter, is nothing but social interaction, dialogue, and interpretation. The difference is so obvious and dramatic that it is hard to see how the claim that the psychiatrist-patient encounter is a medical encounter can be presented seriously. Recognizing the reality of adversity shifts the subject matter from medicine and science to something else entirely. I argue that the APA’s paradigm shift at the end of the 1970s should be understood sociologically, i.e., in terms of the profession’s adaptation to external threats and demands that were too powerful to ignore. I end by arguing that it is barely possible that the DSM-5 Task Force’s insistence on applying medical reasoning to all aspects of life may have created an enduring backlash among the non-medical mental health professions.
David H. Jacobs – 2014
‘Mental Disorder or ‘Normal Life Variation’? Why it Matters’
Research on Social Work Practice
January 2014; vol. 24, 1: pp. 152-157.
DSM-5 promises a refined definition of mental disorder, which is tantamount to acknowledging that prior DSM definitions have failed to clarify what mental disorder is and why a person should be considered mentally disordered. Since the DSM promotes the position that what is actually the matter, as in medicine generally, is an impersonal, anonymous affliction, the universe of considerations that goes along with thinking about an individual as a person becomes ancillary at best. Incorrect diagnosis of mental disorder present is a form of person-negation, with unlimited possible iatrogenic consequences. The new definition, like the old, is simply a form of double-talk. The APA continues to be unconcerned with the practical consequences of person-negation.
The Diagnostic and Statistical Manual of Mental Disorder (5th ed.; DSM-5) Task Force’s recommendation to reduce the limit of normal bereavement to 2 weeks has provoked a wave of negative public and professional reaction not seen since the 1960s and 1970s. I argue that the Task Force is correct to insist that excuses have no place in medicine, which is how psychiatry promotes itself, and therefore for the sake of consistency, bereavement should not count as the only exception to what would otherwise be diagnosed as a mental disorder. But the reclassification of bereavement as mental disorder should focus attention on psychiatry’s overall inability to clearly say what they are talking about when they refer to mental disorder and to provide objective evidentiary grounds for detecting ‘its’ presence. Detecting something is illusory (think of witches) if there is no way to distinguish between true-positive detection and false-positive detection.
David H. Jacobs and David Cohen, 2012.
‘The End of Neo-Kraepelinism’
Ethical Human Psychology and Psychiatry
Volume 14, Number 2, 2012 , pp. 87-90(4)
In 1980, the American Psychiatric Association asserted that its subject matter was straight-forwardly medical and created a diagnostic manual- Diagnostic and Statistical Manual of Mental Disorders (3rd ed.; DSM-III)-consisting of supposedly discrete and independent mental disorders based on what were meant to be low-inference, easily observed sets of symptoms. It was taken for granted that such mental disorders existed and that biological research over time would unearth their specific somatic causes. The idea was to purge psychiatric diagnosis of jargon and unverified and unverifiable psychosocial theories of etiology and thereby place psychiatry on the road to discoveries regarding somatic pathology and causation that has proven so fruitful in the rest of medicine. When DSM-5 is published in 2013, however, biological information about the individual being diagnosed will play the same role as it did in DSM-III-namely, nothing. This article summarizes why adopting medicine as a model for conceptualizing personal distress and social difficulties was and is naive and misguided. It is time for the mental health industry to stop pretending that psychological difficulties can be reduced to morbid physiology.
‘Is the DSM formulation of mental disorder
a scientific-technical term?’
The Journal of Mind and Behavior, 32, 63-80
Although the ‘Introduction’ to the DSM makes it clear that the presence of ‘clinical’ distress or impairment is insufficient for a diagnosis of ‘mental disorder’ (the distress or impairment must be deemed a manifestation of a biological or psychological dysfunction), in practice the clinician is completely unshackled from the conceptual definition and is free to decide on a case-by-case basis if ‘enough’ distress or impairment is present, regardless of circumstances, to judge that ‘mental disorder’ can be diagnosed. It is argued that reference to a biological or psychological dysfunction cannot raise ‘mental disorder’ from a judgment quite like ‘This is pornography, not literature’ to a technical, scientific term because (a) ‘biological dysfunction’ must be tied to an outcome that is itself less ambiguous than ‘mental disorder,’ and (b) ‘psychological dysfunction’ erroneously assumes that how people are supposed to think, feel, and act, regardless of circumstances, can be as uncontentious as ideas about physical well being, and in addition erroneously assumes that human behavior can be causally explained.
David H. Jacobs and David Cohen, 2010.
Does ‘Psychological Dysfunction’ Mean Anything? A Critical Essay on Pathology Versus Agency.
Journal of Humanistic Psychology
July 2010 Volume 50, Number 3, pp. 312-334
Any effort to discuss or study psychopathology (by any name) must decide how to distinguish between psychopathology and narratively comprehensible reactions to adverse circumstances of life. A pathology framework, which views the distressed individual as acted on by impersonal forces, is incompatible with an agential framework, which views the individual as the protagonist in a unique story. Although the Diagnostic and Statistical Manual of Mental Disorders (DSM) recognizes this issue, it addresses it by postulating that ‘primary mental disorder’ results from a ‘psychological dysfunction’ and non-culturally sanctioned reactions to life events indicate mental disorder. In this essay, the authors examine whether the concept of ‘psychological dysfunction’ can withstand an analogy to that of biological dysfunction. They also examine the DSM’s view that ‘culture’ has already prepared an official evaluation of any reaction to the vicissitudes of life. They conclude that the DSM has failed to convincingly distinguish between psychopathology and reactions to life’s vicissitudes. They suggest that the DSM’s insistence on separating people’s feelings and actions from their own unique circumstances and context amounts to a moral, not scientific enterprise. The study of how people fare in living should abandon the concept of mental disorder and related terms.
David H. Jacobs, 2010.
Is there really mental disorder?
The Humanistic Psychologist
pp. 38, 355-374.
Proponents of the reality of mental disorder claim that mental disorder is ontologically real in the same sense that the variola virus and smallpox are ontologically real. The chief architect of the DSM-III revolution, Robert Spitzer (Zimmerman & Spitzer, 2005 ), candidly admits that a diagnosis of primary mental disorder present must be arbitrary because the distress or social impairment under consideration could well be a normal-range reaction to stressful events. Based on Jerome Wakefield’s harmful dysfunction thesis, Spitzer hopes that research in evolutionary psychology can solve the perennial ‘false positive’ problem in psychiatric diagnosis. Interestingly, in 1988 Wakefield argued that the study of meaning (i.e., human behavior and the products of human behavior, such as art and literature) could not be assimilated to empiricism (science), but evidently he subsequently changed his mind. The present paper sides with the 1988 Wakefield. It is an illusion to hope that research in evolutionary psychology will reveal how people are supposed to react to stressful events and thereby rescue psychiatric diagnosis from the false positive problem. The identification of mental disorder will remain akin to the identification of pornography, i.e., a case of reification based on interpretation and moral reasoning. The fiction that mental disorder is real turns attention away from past and present conditions of living. This may serve some interests, but it is not likely to serve the patient’s interests.
Cohen, D., and Jacobs, D.H. 2010.Randomized controlled trials of antidepressants: Clinically and scientifically irrelevant. The Journal of Mind and Behavior, 33, 1-22.
This contribution to the ‘antidepressant debate’ (republished here from a 2007 article in the now-defunct journal, Debates in Neuroscience) focuses on the validity of randomized controlled trials. We argue that: (a) randomized controlled trials do everything possible to methodologically stamp out high placebo response rates rather than reveal the clinical implications, (b) assessing a psychoactive drug’s effects greatly exceeds the purpose of a randomized controlled trial, requiring substantial investigation on normal volunteers, (c) made-up psychiatric diagnostic categories destroy the purpose and logic of the randomized controlled trial as a medical experiment, and (d) adverse drug reactions remain under-studied, under-recognized, and under-appreciated, in parallel with the muting of subjects’ voice and the reliance on surrogate measures of efficacy. The standard psychopharmacotherapy trial has lost virtually all clinical and scientific relevance, and needs complete revamping. The backdrop for the discussion is American biopsychiatry’s insistence that personal difficulties must be viewed as the expression of idiopathic somatic diseases, and the pharmaceutical industry’s dominance of the entire drug treatment research enterprise. Jacobs, D. H., and Cohen, D. 2010. Does ‘Psychological Dysfunction’ mean anything? A critical essay on pathology vs. agency. Journal of Humanistic Psychology, 50, 297-311.
Jacobs, D. H., and Cohen. 2010. The make-believe world of antidepressant randomized controlled trials. The Journal of Mind and Behavior, 33, 23-36.
This afterword extends and refines the arguments presented in Cohen and Jacobs (2010). The main point made by the authors is that the antidepressant randomized controlled trial world is a make-believe world in which researchers act as if a bona fide medical experiment is being conducted. From the assumed existence of the ‘disorder’ and the assumed homogeneity of the treatment groups, through the validity of rating scales and the meaning of their scores, to the presentations of researchers’ ratings as the genuine outcome of interest, all aspects of such trials are make-believe. The continued acceptance of randomized controlled trials as appropriate mechanisms to ascertain the actual effects of psychoactive drugs on human beings in distress confirms that researchers are inextricably dependent on large-scale organizational and financial interests that require the sustained production of make-believe results about psychoactive drugs.
Jacobs, David H. 2009. Is a correct psychiatric diagnosis possible? Ethical Human Psychology and Psychiatry, 11, 83-96.
The desire on the part of American psychiatry in the 1970s to ‘rejoin medicine’ resulted in DSM-III and subsequent editions. The form of medical conditions is imitated as closely as possible by listing criteria symptom sets for supposedly discrete, autonomous clinical entities, although relevant biological phenomena remain conspicuously lacking. As in somatic medicine, symptoms are unconnected to social background, history, context, and so on. But the necessity to interpret what people say and to depict behavior as the basis for diagnosis inevitably leads to intractable problems of meaning and evidence, as illustrated by a close examination of Major Depressive Episode. Plausible description and understanding of personal problems requires patient-supplied depiction of the nature and scope of the problem, history, and context, and when these are fleshed-out clinical entities and the usefulness of mental disorder disappear.
Cohen, D. and Jacobs, D. (2007). Randomized Controlled Trials of Antidepressants: clinically and scientifically irrelevant. Debates in Neuroscience, Volume 1, Number 1, 44-54.
This contribution to the ‘antidepressant debate’ focuses on the validity of randomized controlled trials (RCTs). We argue that: (a) made-up psychiatric diagnostic categories destroy the purpose and logic of the RCT as a medical experiment, (b) RCTs do everything possible to methodologically stamp out high placebo response rates rather than reveal their clinical implications, (c) assessing a psychoactive drug’s effects greatly exceeds the RCT’s purpose, requiring substantial investigation on normal volunteers, and (d) adverse drug reactions remain understudies, under-recognized, and underappreciated, in parallel with the muting of subjects’ voice and the reliance on surrogate measures of efficacy. The standard psychopharmacotherapy RCT has lost virtually all clinical and scientific relevance, and needs complete revamping. The backdrop for the discussion is American biopsychiatry’s insistence that personal difficulties must be viewed as the expression of idiopathic somatic diseases and the pharmaceutical industry’s dominance of the entire drug treatment research enterprise.
Jacobs , D. , & Cohen , D. ( 2003 ). Hidden in plain sight: DSM-IV’s rejection of the categorical approach to diagnosis Review of Existential Psychology and Psychiatry, 26 , 81, 96 .
The DSM-IV reflects the neo-Kraepelinian approach which proposes that psychiatry treats people who are sick, and that there is a boundary between the normal and the sick, and that there are discrete mental illnesses. In a seeming paradox, however, DSM-IV also explicitly repudiates the three critical positions listed above. The first proposition finds no support in any diagnostic category in the manual (besides substance-induced disorders and those due to medical conditions). The other two propositions are rejected in the rarely reviewed ‘Limitations to the Categorical Approach’ introductory section of DSM-IV. In this article, the repudiation is briefly examined and the reason for its presence in the manual interpreted. An alternative, more realistic and more complex framework than disease categories is suggested for depicting and understanding clinical problems. The alternative emphasizes the centrality of the patient’s own personal story, the narrative, in answering the basic ‘diagnostic’ question (‘What is the matter with this person?’).
PUBLISHED IN BOTH JOURNALS
Cohen, D., Jacobs, D. A model consent form for psychiatric drug treatment. International Journal of Risk & Safety in Medicine 11 (1998) 161-164.
Given the notorious lack of informed consent in the practice of psychiatry and a tendency to use typical consent forms to protect professionals rather than inform or empower patients, the authors propose a ‘model consent form’ for psychiatric drug treatment. This form seeks to highlight the dubious nature of medical knowledge about psychological problems diagnosed and treated, to describe regulatory processes that result in truncated knowledge about prescribed drugs, and to present realistic and understandable information about somatic and psychological effects of drug use and drug withdrawal.
Jacobs, D. and Cohen, D. (1999). What is really known about psychological alterations produced by psychiatric drugs. International Journal of Risk & Safety in Medicine 12 (1999) 37-47.
This paper argues that information about psychiatric drugs derived from conventionally conducted randomized controlled clinical trials (RCTs) is inadequate to form an accurate picture of drug-induced psychological alterations. Two main lines of argument are presented. The first concerns the disparity between adverse effects established in RCTs and the broader range of adverse drug reaction reports which derive from non-RCT formats. The second concerns the contention that information about drug-induced psychological alterations obtained from RCTs is too limited to address the meaning of observed ‘target symptom’ reduction which occurs during the course of the (typically very brief) investigation. The paper considers the possibility that nominal ‘therapeutic’ drug effects may only be part of a larger, inadequately discerned picture of drug-induced psychological toxicity.
Jacobs, David. H. 1995. Psychiatric Drugging: Forty Years of Pseudo-Science, Self-Interest, and Indifference to Harm. The Journal of Mind and Behavior, Autumn 1995, Volume 16, Number 4, Pages 421-470.
The ‘modern’ era of psychiatric drug treatment began with the introduction of chlorpromazine into the chaotic mental hospital setting in the 1950s as a new psychotropic agent for controlling excitement, agitation, and aggressivity. In that setting the urgency of management problems operated to shrink the complexity of the patient as a psycho-social being down to specific ‘symptoms’ targeted for chemical subjugation. From this beginning, a chemically produced quieting or ‘tranquilization’, there emerged a revitalized psychiatric movement to expand the ‘strictly medical’ understanding and treatment of psychological disturbance that acknowledges no limits. This state of affairs has achieved a position of dominance and respect in the mental health industry, based upon social forces operating within psychiatry as a profession and outside of psychiatry in the larger political-economic realm. The catastrophe of widespread and expanding medically-produced disease has failed to alarm psychiatry into taking stock of the determinants of the catastrophe, indeed the existence and magnitude of the tragedy is barely recognized within psychiatry. This conclusion is illustrated by detailed examination of the psychopharmacologic agents alprazolam (Xanax) and fluoxtine (Prozac).
The present paper intends to clear the way to considering all psychopathology as responses to failures in the human environment by examining three common sources of error in scientific reasoning about psychopathology: (i) the false identification of ‘biological considerations’ with the sub-interest of organic pathology, (ii) the idea that a person could be genetically predisposed or vulnerable to psychopathology, (iii) the failure to distinguish between causal forms of explanation and explanation based upon connections of meaning and significance.
Jacobs, David. H. (1994). On the Conflict between Emergence and Embeddedness in Adult Life: Loss of Potentiality Troubles the Hegemony of Adaptation. Psychoanalysis and Contemporary Thought, 17, 563-590.
Jacobs, David H. (1992). A Critical Review of Psychoanalytic Adult Developmental Psychology. Psychoanalysis and Contemporary Thought, 15, 523-547.
Cohen, D., Hughes, S., and Jacobs, D.H. 2009. The deficiencies of drug treatment research: The case of Strattera. In S. Timimi and J. Leo (Eds.), Rethinking ADHD (pp. 313-333). New York: Palgrave Macmillan.