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Friday, February 29, 2008
The Scientistic Fallacy: Peter Kramer, Judith Warner, and the Debate Over Psychiatric Medication
(x-posted to The Kugelmass Episodes)
For scholars in the humanities, there is no way to avoid reflecting on what’s ahead for the discipline, a question that branches in two directions. First, how do scholars respond to the perception that they need increasing amounts of “hard evidence,” particularly historical evidence and cognitive research, in order to justify their claims? A strange disequilibrium has emerged: scientists who appreciate and cite cultural materials are heralded as Renaissance men, while literary scholars and philosophers who draw upon work from other disciplines are merely being faithful to the necessity of rigor, and saving themselves from laughable kinds of theoretical speculation. Second, what can we do with the expanding field of cultural studies? Its impact has been enormous: it has eroded traditional distinctions between media-specific fields (art history and literary studies, for example) as well as between modes of analysis (e.g. anthropology and “close reading"). What kind of work can cultural studies perform for the culture?
The real value of cultural studies is the revival of the broad study of rhetoric, with the aim of creating a more self-aware culture. A case in point is the current debate over medication prescribed for psychiatric disorders. For years now, one of the most recognizable voices in this debate has been that of Peter Kramer, a psychiatrist who rose to fame after publishing an anxious little volume entitled Listening to Prozac. Listening to Prozac was, essentially, a plea for caution. Kramer was impressed by what he’d seen then-newer antidepressants accomplish for suffering patients, but he was concerned that they would be over-prescribed or used to enforce conformity. Then as now, Kramer used amateur credentials as a lover of culture (he has, among other things, published a novel) to add depth and shading to his claims. Over time, Kramer has responded to the evolving conversation about psychiatric medication by taking on the new critics of antidepressants. Instead of urging us to be cautious about medications like Prozac, he now works to neutralize the perceived threat of books like Charles Barber’s Comfortably Numb: How Psychiatry Is Medicating A Nation.
Judith Warner, writing for The New York Times, recently applauded Kramer’s deeply critical review of Barber, published on Slate. Both Warner and Kramer make extremely poor arguments, arguments whose weaknesses appear to be invisible to them because of their disciplinary confidence and ways of understanding expertise. What is remarkable about both columns is the absolute lack of rhetorical understanding: blindness to the rhetorical function of certain medical practices in the context in a given culture, and a worrisome readiness to ground claims about the culture in irrelevant scientific data. What we need is not Kramer’s misleading “hard evidence,” but rather knowledge of what cultural factors are producing the debate over psychiatric drugs, and a sense of how the discourse can be not “disproven,” but transformed.
To begin with Kramer’s ending:
We may—this concern was at the core of Listening to Prozac—be using medication to achieve the assertiveness and confidence that our society demands. Or, as Barber suggests, we may be numbing ourselves. But two other possibilities remain on the table. We may be doing pretty well with the imperfect medicines we have. Or we may still be failing to reach numbers of people with substantial mental illness.
Kramer has got to get over the idea that his credentials as a sensitive and concerned individual are guaranteed for perpetuity because he once wrote Listening to Prozac. His penchant for leaving questions open is misleading, since he has no patience at all with Barber and his ilk. Instead, Kramer’s guarded language is designed to camouflage the fact that he uses Listening to Prozac, a book about vigilance and the value of concern, to justify incredibly complacent statements like “we may be doing pretty well with the imperfect medicines we have.” For someone who takes such an active interest in the culture, he has no inkling of how much his own comments echo similar rhetorical moves by ex-radicals, and before them, ex-Communists like Sidney Hook. Warner’s solution is to list all the panicky volumes that reside on the shelf at her office, as though the mere fact of having purchased these books at Borders implies her full and serious consideration of them.
In addition, Kramer has for a long time tried to set inadequate mental health services against criticisms of therapeutic practice, as though Charles Barber’s book had the power to keep impoverished Americans with mental illness from receiving needed prescriptions. How Americans with access to health care are treated is almost entirely separate from the American health care gap. You might just as well argue that attempts to reform nursing homes hurt elderly citizens who haven’t been able to find or afford assisted living. In fact, the health care industry quite cynically advances versions of this argument all the time, for example around the issue of malpractice suits.
These logical fallacies aside, there is a problem with the way Kramer and Warner put such absolute faith in diagnoses of mental illness, at the expense of every historicist anxiety. For example, Warner writes,
We don’t know how many adults suffered from things like depression in the distant past because no one ever asked. The words and concepts through which we understand common mental health disorders today didn’t exist until the last few decades.
In other words, finally, after untold millenia of darkness, we have attained a clear and objective understanding of the human mind. Yet consider what Henry James wrote in 1902, when he published The Varieties of Religious Experience:
Scientific theories are organically conditioned just as much as religious emotions are [...] It is needless to say that medical materialism draws in point of fact no such sweeping skeptical conclusion. It is sure, just as every man is sure, that some states of mind are inwardly superior to others, and reveal to us more truth, and in this it simply makes use of an ordinary spiritual judgement. It has no physiological theory of the production of these favorite states, by which it may accredit them; and its attempt to discredit the states which it dislikes, by vaguely associating them with nerves and liver, and connecting them with names connoting bodily affliction, is altogether illogical and inconsistent [...] for aught we know to the contrary, 103 or 104 degrees Fahrenheit might be a much more favorable temperature for truths to germinate and sprout in, than the more ordinary blood-heat of 97 or 98 degrees.
James is already fully aware of schizophrenic symptoms, which he terms “hereditary degeneracy” and attributes to George Fox and Saint Francis among others. He is aware of manic states, which he calls “auto-intoxication” and attributes to Carlyle, as well as “melancholy,” various anxiety disorders, and epilepsy. The key difference between James’s pragmatism and Warner’s scientism is James’s willingness to uphold those epiphanies that exert a consistent fascination for a human being and her sympathizers, because they seem to possess “immediate luminousness,” which James parses as “philosophical reasonableness and moral helpfulness.”
Warner has no feeling whatsoever for the tensions that exist between “ordinary spiritual judgement” and “immediate luminousness” within the discourse of psychiatry. She assumes that if we could establish a historical baseline for psychological problems like depression, we could then evaluate whether current levels of treatment are scaled appropriately. This misses the fact that even if you could explain to someone from the 17th Century that “melancholy” was actually the illness “depression,” there is no guarantee that you could convince them to accept modern causal explanations or forms of treatment. Differences of psychological and medical vocabularies do not merely divide truth from error; they express competing and potentially unresolvable value judgements. Warner makes no allowance for the contemporary paradigm that would condition such historical research, despite the fact that even while she imagines a complete history of depression, relying completely on the fixity of modern diagnostic words and concepts, Kramer is trying to stretch the definition of treatable illness to cover any person who has “suffered mental illness in the past” or has “one of three other indicators of need.”
In Kramer’s review, inattention to these implicit value judgements plays out when he describes his research on Valium. In response to complaints that Valium was substituting for other kinds of therapy, Kramer observes that women received more talk therapy than men, then announces cheerfully that “Prescribing did not replace ‘quality time’; it supplemented it.” Looking at that data, either the women were being condescended to, therapeutically speaking, or the men were getting inadequate treatment, but this does not worry Kramer. All such concerns must be sacrificed to the grand narrative of “doing pretty well with the imperfect medicines we have.” He continues:
A quarter century later, the evidence about mother’s little helpers is no clearer, but the case can be made that what was at stake had less to do with medication than with society at large. Yes, Valium had its beneficiaries and its victims. But the broad trends now look to have had their own momentum—more conflicting responsibilities for women, less time with patients for doctors, and a loss of cohesion and gravitas throughout the culture.
That’s right—women were taking Valium because all that social turmoil was giving them a pain! There was a serious loss of gravitas (a vitamin found in deep manly voices) causing distress everywhere! Nowhere does Kramer note that women faced “conflicting responsibilites” due to a combination of frozen wages, which forced many women to go to work, and patriarchal domestic life, which forced them to continue doing most of the work of the household. Nor does he talk about the women’s movement, which encouraged many women to take up careers, and the psychological toll involved in thus challenging the expectations of husbands, families, and friends. Any of these explanations would raise questions about the relationship of American psychiatry to ongoing conditions of oppression and injustice—questions, not accusations, designed to maintain our awareness of the historically contingent nature of mental illness and legitimate mental health treatment. Instead, he gives a suspect and reactionary account that detaches psychiatry from “broad trends” that “look to have had their own momentum,” and so turns psychiatry into something it must not be: a discipline that takes no responsibility for its role in American society, existing unconscious of its own ideological foundations.
***
Most troubling of all, though, is Kramer’s (and then Warner’s) trump card: the fact that other industrialized countries prescribe Valium and antidepressants as well, sometimes at a higher rate per capita. As a result, Kramer concludes that “little in the scientific literature suggested a crisis or even a uniquely American response to anxiety.” Warner ties this to her amazingly out-of-character (for a psychologist) statement about the irrelevance of our sentiments in light of Human History Since The Beginning Of Time:
Just because it feels like, just because it sounds like, just because soaring drug company profits and obnoxious direct to consumer advertising seem to indicate that everyone around us is popping pills like mad doesn’t mean that they are doing so. Nor does it mean that we’re in the grip of some new, previously unheard-of, and uniquely epoch-defining social phenomenon.
People have been unofficially drugging themselves for as long as they’ve had the capability to do so. They smoked cigarettes to boost their concentration. They drank cocktails with lunch and dinner — and more — to deal with anxiety and despair. Prior to the modern era of F.D.A.-regulated prescribing practices, they slugged down untold quantities of tonics and bromides.All of which suggests that what social critics now identify as the signature event of our time (the urge to manage psychic pain through substance use) may, in fact, almost always have been a facet of the human condition. It may just be that we’re better at it than ever before – with cleaner, safer, less addictive and debilitating tools at our disposal.
This is the cognitive version of James’s “medical materialism.” Since neurotransmitters and drug interactions have always been the same, there is nothing unique to a time or place about “drugging.” Imagine Kramer following this train of thought even further:
I was able to help compile research that proved that vodka was being exported out of Russia in enormous quantities; vodka is consumed in almost every country in the world, and even plays a prominent role in the “cosmopolitan” cocktail that is so central to the American experience of “Sex and the City.” Little of this evidence suggests a uniquely Russian relationship to vodka.
Based on the evidence I have compiled at Starbuck’s and countless independent coffeeshops in the West, little suggests a uniquely Japanese response to green tea; human beings have been consuming caffeine for as long as they’ve had the capability to do so.
People love wine; they love its smooth and complex flavor, and they often have it as the delicious complement to their dinner, just as their ancestors did. It seems hardly likely that Catholics attending religious ceremonies have a different experience of fermented grape juice than anybody else.
The point should be clear enough; but in addition to these examples of “drugging” in their real social contexts, there are all the cases where human beings have reacted with fear and moral concern against self-medication. Examples range from religious abstainers, including Mormons and Muslims, to atheistic teetotalers like Percy Shelley and Friedrich Nietzsche. Presumably, none of these individuals are interested in “cleaner, safer, less addictive and debilitating” forms of intoxication.
Warner deploys the tools of cultural studies; she calls fears about psychiatric medication “one of the defining tropes of our era,” and later refers to the “storyline” or “narrative” of “mentally vulnerable children and adults” as a fable without an upside. Kramer is similarly eager to engage with culture through its own products: “The world is too much with us; late and soon, getting and spending, we lay waste our powers,” he writes, sounding a bit like Wordsworth. But neither writer can see what we’re prescribing along with the somewhat plastic drugs themselves when we prescribe psychiatric medication in the United States. Naturally, these implicit cultural narratives affect not only patients under treatment, but everyone else as well, for whom the drugs create dividing lines between what is pathological and what is not. Kramer and Warner make their forays into cultural analysis in order to protect against it, a bad methodology that leads to wildly untenable statements about history and culture. Quoting Wordsworth begins to seem tactical, rather than earnest. Their approach will only entrench both sides, particularly when they try to use facts like prescription rates in Sweden to devalue felt responses to the current situation. If Kramer and Warner are serious about protecting the mental health of Americans who need psychiatric medication, they have to accept the challenge of discovering what it is about the ideology of treatment that is making lots of people so uncomfortable: not just drugs that help people resume their lives, but tropes and narratives they can live with.
Comments
William James. His psychological work remains remarkably sane and, uh, pragmatic.
Here’s a recent Salon article in which brain science once again confirms James, whose ideas about live and dead beliefs speak to the issues Joseph raises above:
http://www.salon.com/mwt/mind_reader/2008/02/29/certainty/
Could it be that they are expressing fatigue with the popular trend of strong criticism of psychiatric drugs?
Elijah,
I’m sure they are tired of it, just as Stanley Fish seemed tired of the moral triumphalism that is always going to “save” the humanities from crisis. Nonetheless, they haven’t taken the criticism seriously, except when it comes from them: they’re the ones who get to prescribe the drugs, they get to decide when and how to worry (Listening to Prozac). That stance lends itself to complacency and arrogance; much as the Pink Floyd reference of “Comfortably Numb” annoys me, I can’t sympathize with Kramer’s exasperation.
Luther, thanks for the link!