Treating the Poor: A Personal Sojourn Through the Rise and Fall of Community Health

EVERYONE IN MEDICINE LIKES A CLASSIC CASE, A PATIENT WHO CUTS through the dross of biological variability and presents a textbook picture of "a disease." This assures us of comforting categories with neat boundaries, as opposed to the nebulous states of dis-ease, generalities whose manifestations are diffuse if not arbitrary....



Psychiatry, despite the pretenses of a diagnostic system organized to the hundredth of a decimal place, deals after all with human behavior, with all its ideological, cultural, and linguistic ambiguity about what is crazy and what is not. So there was something reassuring about seeing a classic case of what we used to call "involutional melancholia," a mid-life sinkhole draining away one's energy.

Here I was [...], running around with my grab bags of drugs and psychotherapy and kindness, when I should have been thinking about lead.

In medical school, we were taught only a few bare facts about lead. It was not a matter of great interest to our professors, who were researching esoteric metabolic disorders. We were told to look for a blue edging to the gums and X-ray densities in the long bones of children who had developed acute encephalopathy. We were not taught about the huge numbers of children whose marginal elevations in lead levels affected their learning and behavior. And we were not told about the effects of lead on the emotional lives of adults.

Here appeared to be a textbook case of involutional melancholia, complete with the appropriate intrapsychic and family dynamics, including the emergence of instinctual rage internalized as depression after the breakdown of obsessional defenses, and all the time she was lead poisoned.



I thought, if this "classic" case was largely, if not primarily, a result of lead poisoning, what about everybody else who came to the clinic, the non-classic cases?

How much lead was in the bodies of all the other depressed and anxious people, all the hyperactive kids and acting-out adolescents, the psychotic adults and the demented elderly?

The company, which prepared meals for airlines, was using large amounts of an insecticide containing a substance know as di-thiocarbamate. In the presence of the acidic environment created by the phosphates used in cleaning of the commercial cooking equipment, di-thiocarbamate releases another compoud know as carbon disulfide.



The classic textbook of industrial toxicology by Hamilton and Hardy reports on a German study "of no less than fifty patients with carbon disulfide insanity. The early symptoms consisted of headache, dizziness, increasing sense of weariness, loss of strength, transient excitement, and slight delirium very like alcoholic intoxication. Later came deep depression and loss of memory, increasing indifference, and apathy. This might change suddenly to acute mania or delusions of persecution with hallucinations... Some [cases] ended in recovery, others in incurable dementia.

Long ago, I became accustomed to being at odds with my profession. Being obsessed with poverty as a source of psychopathology does not permit much discourse with psychiatrists who insist that illness is entirely a matter of chemistry. I was tolerated, at times even celebrated, in the condescending way practical men acknowledge issues of social justice. At academic conferences, I played something of the role of the fool at court. I was a lefty, a philosopher, a scholar with a mouth who could be counted on to say something amusing, maybe even incisive or interesting, but never thought to be quite relevant. Biological psychiatry had a seriousness, a correctness that no social issue, no matter how authoritatively documented, could possibly approach.



Here I now was, stumbling into a whole new dimension of biological psychiatry. I, too, had become interested in chemicals. But try as I could, I was no able to get the serious attention of my colleagues. I wrote an article about neurotoxins and behavior, which reviewed the literature, described some case histories, and offered the modest recommendation that clinicians inquire, as a matter of routine, about the possibility of exposure to neurotoxic substances. Rejected by two psychiatric journals as not being scientific or relevant enough for their readers, it finally appeared in an international journal of medical sociology.

Contemporary psychiatry is not interested in the biochemical abnormalities underlying mental illness unless those abnormalities are inherent and genetic or, as the Nazi psychiatrists used to say, constitutional. The economic, social, and political realities that govern our professional life dictate that mental illness not be seen as in any way environmental in origin. And this, I discovered, includes the physical as well as the social environment. [pp. 123-124]

Carlos' mother did not know what kind of factory he had worked in, but when I called his wife [...] she told me that it was a place that made "lacquers," and she hated the smell on his breath and, yes, several other men in the factory had "gone mental." [...]



The psychiatry residents at Lindemann were only mildly interested in lacquer. We had entered the age of computer-assisted, two-minute psychiatric diagnoses and polypharmacy.[*] Once thought a schizophrenic, a patient would be subjected to a mix of antipsychotic drugs as well as Lithium, anticonvulsants, beta blockers like Inderal, and a little assist from benzodiazepines like Ativan or Klonopin.

Spitzer was the prophet of the new god, Science, before whose enthusiasts none could stand. [...] Spitzer's great insight was not psychological or psychiatric, but sociological and anthropological: he saw that the ring in the nose of the bull of the entire profession of psychiatry was the membership of the APA's Committee on Nomenclature, and their authority to dictate the definitions of mental disorder. Spitzer had a philosophical commitment to biological psychiatry, and he saw that if psychopathology could be defined in certain ways, it would strongly favor the paradigm he championed.



When Spitzer and his comrades in biopsychiatry were in position on the Committee on Nomenclature, poised to do something, they had an interesting challenge. They wanted to overthrow the predominant paradigm in their field. The predominant paradigm has a posse, of course. It was backed by the reigning powers in the field; it wouldn't go down easy. They needed a way to get away with imposing a strict new order on the profession. If they couldn't get the rank-and-file to buy in, their efforts would simply be rejected, and they ousted.



What they needed to do – though I don't know that they realized this at the time – was to discredit Freudianism. It wasn't enough to show it incorrect in some part or another. They needed to make it look hateful. They needed to make it look like something only bad people would endorse. They needed bodies to lay at the feet of psychoanalytic psychiatry.



And then Spitzer met Ron Gold, of the Gay Activists Alliance. Turns out, there were bodies. Gay bodies.



[...]



On the issue of the greatly unjust and entirely unscientific pathologization of homosexuality Spitzer and his comrades had the grounds to burn the whole thing down and start anew. Look what a cruel and superstitious thing Freudianism is. Science would have saved us from these enormities, and Science can save us yet.



[...]



What he got out of doing it was getting to usher in a brave new world of "scientific" psychiatry. [...] That psychiatry has an ontological system of disease entities that may not actually represent natural kinds – i.e. the actual discrete disease entities of reality – and consequently that much to all of the "scientific" psychiatric research done proceeding from the assumption that these conditions are "real" may be fatally confounded by it, is also because of what Spitzer did. So too is that with the imprimatur of "Science!" on it and astronomical amounts of money sunk into it, psychiatry has become invested in the DSM being right. The "science" that the DSM is based on is not the sort of science that permits or even encourages the field to self-correct on the basis of new evidence (q.v. the dimensional model of personality disorders; Developmental Trauma Disorder); the "scientific" psychiatry of Spitzer's DSM has arguably become as much of a doctrinaire and defensively rigid orthodoxy as the American Freudianism it replaced.

Trauma and Recovery

"Let me get our mental health expert involved. He can arrange a special investigation. He's a psychiatrist and will be interested in this. He'll call you."



He didn't call, so several weeks later, I called him.



"Oh, yeah. I had a note somewhere about this thing. Let me find it and call you back."



He didn't call, so several weeks later, I called him, again.



"Yes, I might be interested in this, but not from the point of view of environmental toxins. I've been collecting instances of what I call 'mass environmental hysteria.' Patients can mimic a whole range of somatizing symptoms, and I find that there are clusters of similar complaints from people who think they are being exposed to toxic chemicals. I would appreciate it if you would send me copies of their records." [p126]

Silent Spring

* Fans of The Last Psychiatrist will recall polypharmacy as one of the bad clinical habits he often railed against (scroll down to #8).



** That's actually deeply embedded in the etymology of the word, or so some theories have it. English's "science" comes from Latin's "scientia", a noun which means "knowledge", from the present participle of the verb "scire", "to know", which is theorized probably originally "to separate one thing from another, to distinguish," related to scindere "to cut, divide," from PIE root *skei- "to cut, split" which is also the root of our words "scizzors" and "shit".







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This concerns the excerpt I just previously posted from Dr. Matthew Dumont's, which I titled "A View from the Bridge", because the original title it was published under as a stand-alone journal article has a spoiler in it.You should read that before proceeding to read this.0.So, how many double-blind, randomized controlled trials for antidepressants, do you think, pre-screen their research subjects for lead poisoning?1.There's a lot of ways to be shocked and horrified about the information in what I titled "A View from the Bridge" by Matthew Dumont, MD . The obvious ones are "How could the state do that to those poor people?!" and "How could the state do that to poor people?!" and "How could this still be going on?!" and "How could human beings do that to other human beings?!"I'd like to broaden, perhaps, the full spectrum of appall you experience by pointing out some of the ramifications of what you read that are less obvious.Dumont wants you to be shocked and horrified about what was done – and apparently is still being done – to the people of Chelsea, indeed. He also has some larger points.Having read the whole thing, you might find you understand the opening two paragraphs differently. Here they are again:That's foreshadowing.Dumont's point is not only that an outrage has been perpetrated on the people of this community; it's about what this experience of his illuminated about psychiatry, itself. As he says later on in the article:His account of this patient case is, he is very clear, an account of his failing to even think to consider the possibility that the patient's psychiatric illness might be caused by lead.And this is interesting, to the journal on public health policy that published it and to us, because this was not a personal failing. As he points out:Indeed, the fact that he figured it out and thought to test all the other Chelsea residents receiving care at his clinic was brilliant, especially in light of the fact that nothing in his professional training ever suggested he should suspect lead – or any other – poisoning when presented with a "classic case" of "involutional melancholia":Indeed. But that just raises an even more appalling question...Nothow much lead was in the bodies of all the other depressed and anxious people, all the hyperactive kids and acting-out adolescents, the psychotic adults and the demented elderly who came to that clinic.Nothow much lead was in the bodies of all the other depressed and anxious people, all the hyperactive kids and acting-out adolescents, the psychotic adults and the demented elderly in Chelsea.How much lead is in the bodies ofthe depressed and anxious people,the hyperactive kids and acting-out adolescents, the psychotic adults and the demented elderly,And this isn't just about lead. As I mentioned in the epilogue, the excerpt is merely the beginning of the chapter, which then discusses other cases of "psychotic" people who turned out to be (or seemed highly likely to be) poisoned.Here's a bit from later on in the chapter:My point here, and Dumont's, is not "Gee, carbon disulfide poisoning is terrible". Our point is that it seems that psychiatrists do not consider, when presented with a patient presenting with any of 'deep depression and loss of memory' or 'acute mania' or 'delusions of persecution with hallucinations' that the patient should be assessed for carbon disulfide poisoning.Now, in my case, I'm a talk therapist, and worrying about patients maybe being poisoned is not even supposed to be on my radar. I'm supposed to trust the MDs to handle it.Dumont, however, is just such an MD. And that this was a clinical possibility was almost entirely ignored by his training.Dumont's point here is that while "medical science" knows about the psychiatric effects of lead poisoning and carbon disulfide poisoning and other poisons that have psychiatric effects – as evidenced by his quoting from the scientific literature – psychiatry as practiced in the hospitals and clinics behaves as if it knows no such thing. Dumont is arguing that, in fact, he knew no such thing, because his professional training as a psychiatrist did not include it as a fact, or even as a possibility of a fact.Dumont's point is that psychiatry, as a practical, clinical branch of medicine, has acted, collectively, as if poisoning is just not a medical problem that comes up in psychiatry. Psychiatry generally did not consider poisoning, whether by lead or any other noxious substance, as a clinical explanation for psychiatric conditions. By which I mean, that when a patient presented with the sorts of symptoms he described, the question was simply never asked, is the patient being poisoned?Dumont wants you to be shocked and horrified by what was done to those people, yes. He also wants you to be shocked and horrified by this: psychiatry as a profession – in the 1970s, when (I believe) the incidents he relates where happening, in the 1990s, when he wrote it in his book, or in 2000 when a journal on public health decided to publish it – psychiatry as a profession did not ask the question is the patient being poisoned?And it didn't ask the question, becauseAnd that, when you think through what it means for psychiatry, is absolutely chilling.Dumont, who described himself and his professional training in the introduction to the book, "I was trained in the psychoanalytic [Freudian] tradition, with that vocabulary and grammar, wearing that persona", goes on to write later in the chapter at hand:I'd like to stop here and point out that when this excerpt of his book was finally published in an academic journal, it wasn't in a psychiatric journal. It was in, "the official journal of the U.S. Public Health Service and the U.S. Surgeon General [...] [It] publishes original research and commentaries in the areas of public health practice and methodology, original research, public health law, and public health schools and teaching".Dumont goes on to say, in a later part of the chapter than was published in that journal article:2.Somebody out there is going, "But, Siderea, Dumont was writing almost 20 years ago about events many years previously."Surely that's the bad old days, right? From back before psychiatry got all scientific? When they blamed everything on people's mothers, and before the ascendency of biological psychiatry? You tell me. He writes:Yeah, that's pretty much exactly how my patients were and are medicated, too, both in-patient and out. Today.Obviously, I'm not a psychiatrist so I don't know how psychiatrists are being trained, nor can I speak to what the various psychiatrists I've worked with are supposed to be doing according to the standards of their profession.But I can tell you that, standing here in 2018:• No mental health clinic I've worked at ever had the facilities for, nor doing urine testing for anything other than commonly abused intoxicants (alcohol, opioids, amphetamines, etc), and then only the clinics that specialized in substance abuse treatment. The clinic I work for now can't even do urine screens. Psychiatrists' offices, here abouts at least, are not places blood tests are or can be performed, unless they are attached to a general medical practice. Such tests have to be referred out, usually to the patient's PCP's office.• No psychiatrist has ever asked me to arrange blood draw test from the PCP for anything other than white blood cell count, thyroid panel, or Lithium blood level.• Though I've seen documentation in patient charts of psychiatrists ordering two of those three tests from PCPs themselves, I've never seen documentation of ordering any other tests. I have literally never seen a psychiatrist order a test for any sort of poison.• I have never seen any sort of toxicology report for poisons in any of the blood test results I have found in my patients' discharge paperwork from psychiatric hospitalization.• I have never, in all my case discussions with psychiatrists in-patient and out, or with hospital staff at psychiatric hospitals and hospital departments, ever heard anyone suggest anything about poisoning be a possibility in our mutual cases. Nobody has ever said anything like, "We don't want to prescribe anything until the tox report comes back, in case it's an environmental toxin" or "R/o env tox" or even "We don't think there's much chance of an environmental toxin, so we're not bothering to test for it. It has literally never been mentioned.• Not even when, due to the suddenness of the onset of psychotic symptoms, psychiatrists were discussing with me the possibility that a patient was intoxicated on some street drug that somehow just wasn't showing up in his/her urine screens and blood draws.Maybe it's not fair for me to generalize from the psychiatrists I've worked with. Maybe it's just that the psychiatrists I've worked with – including at MGH and McLean – aren't representative, being somehow really bad doctors, or poorly educated, and that, contrariwise, normal psychiatrists, basically adequately well-trained psychiatrists, generally do stop to consider poisoning as a cause for severe presenting symptoms, especially when they've proved refractory.I'm not getting that impression though.I'm not getting that impression from the many interactions I've had with psychiatrists and other psychiatric professionals over the last decade, and neither have I been subject to exhortations of what I, as a clinical mental health counselor, should be alert to as evidence of possible poisoning in my patients.When I was in grad school, it was briefly mentioned that most disorders in the DSM (this was version IV-tr) had a "caused by a General Medical Condition" variety, and then it was never spoken of again.So as far as I can tell, nothing has changed.This is not merely an incidental failure of instruction on the part of Dumont's med school professors, nor of mine in grad school. This is, at the most charitable, a massive blindspot, of precisely the sort that "scientific" field of endeavor should never have, and it seems to afflict the entire profession.3.This is not science.From time to time, people ask me what I have against "evidence based practice" (and related buzzwords) in psychiatry. The list is longer than my arm by now, but surely what I have just described is near the top.Science is a GIGO – "Garbage In, Garbage Out" – process. We don't usually think of it that way, because ostensibly the whole point of science is to separate garbage from the gold.** But the scientific method is a method of testing hypotheses, not generating them. Science, reasonably enough, can only comment on the hypotheses submitted to it. If entire spaces of potential explanatory hypotheses are eliminated as candidates for scientific examination, a priori, for political reasons, for reasons of intellectual fads, for self-serving or emotional reasons, science has no innate ability to correct for that. If a field of science is constrained to only subject to scientific inquiry certain hypotheses none of which are right, because the right hypotheses are not socially acceptable, all the scientific method can report is, "Nope, that's not right", over and over and over again.Which, you may note, is a pretty fair description of the state of psychiatric research since biological psychiatry became the dominant paradigm.In the 1950s or so, American psychiatry was overwhelmingly dominated – socially, intellectually and numerically – by the Freudians. Psychoanalysis. A cadre of young turks psychiatrists, who came to be termed the neo-Krapelineans, formed the beginning of a movement to wrest control of psychiatry away from the psychoanalysts, and to (IIRC, this is an exact quote from somebody, but it's been than a decade since I looked at these sources) "put psychiatry on a more scientific footing".Some of you will recall my writing previously about how the neo-Krapelineans allied with (or perhaps more properly used) gay rights activists in the early 1970s to conduct a palace coup in the American Psychiatric Association Spitzer's DSM – DSM-III, the DSM that was biological psychiatry's great weapon against Freudianism – came out in 1980. From about that day to this, partisans of and apologists for biological psychiatry have rhetorically positioned "biological psychiatry" as a kind of sciencey savior that protects the intellectual integrity of the field from those ignorant, inhumane, irrational, and above all unscientific Freudians.I'm not here to defend Freudians. They may have in fact eaten babies. I don't care, at least for purposes of this conversation. I'm not on their side, either.My point is that "biological psychiatry" – and I think Dumont makes it clear why that needs to be in sneer quotes – has been using Freudians as a bogeyman and a scapegoat for at least forty years, and toIt has promulgated the notion that there are only two sides: the virtuous, humane, scientific neo-Kraepelinians and the deceptive, evil, unscientific neo-Freudians; the enlightened scientist-healers who see psychiatry in terms of "mental illness" "no different than diabetes" and the superstitious crackpots and quacks who want to talk to you about your mother; with us and against us.As Dumont says, that a priori philosophical commitment is that "Contemporary psychiatry" – that is, "biological psychiatry" – "is not interested in the biochemical abnormalities underlying mental illness unless those abnormalities are inherent and genetic or, as the Nazi psychiatrists used to say,. The economic, social, and political realities that govern [we psychiatrists'] professional life dictate that mental illness not be seen as in any way environmental in origin."Within the mental health professions, we've been struggling with this – and against this – for most of half a century. The most obvious places this can be observed has been in the area of how experiences might cause "mental illness". Biological psychiatry, for most of this time span, has been deeply invested in the idea that, for instance, child abuse doesn't actually cause any substantial, lasting harm. The idea that anything that happened in your childhood might have something to do with your psychological problems today was attacked by neo-Kraepelinians as a crackpot notion of those superstitious Freudians.This is why all the really important work coming out today about the adult psychological and physical consequences of childhood maltreatment is coming from researchersConsider the ever-increasingly famous ACEs study which finally scientifically established that, yes, "adverse childhood experiences" have extensive long-term health consequences, both mental and more generally physical. That was an epidemiological study, conducted by an HMO. Because, bluntly, the HMO wanted to know the truth for its own actuarial purposes, and had the money to fund it, and didn't give a damn about the ultimate publishability of the research in psychiatric journals.(There are exceptions - there have always been a resistance comprised of psychiatrists like Dumont, some of whom were researchers, who have tried to conduct this science in psychiatry. For instance, mad props to Judith Lewis Herman, MD , author ofwhich proposes the diagnosis of Complex PTSD, which has not been included in either of the two subsequent DSMs, to Martin Teicher, MD, PhD , of McLean Hospital, and his collaborators, who did brain imaging studies into adolescents and adults who had been abused as children, and, of course, to Bessel van der Kolk, MD , of the Trauma Center, whose proposed diagnosis Developmental Trauma Disorder has also never made it into the DSM.)This, by the way, is why it's now something of a thing for therapists to self describe as providing "trauma-informed treatment". That's a buzzword that means the therapist rejects the "biological psychiatry" orthodoxy that insists basically trauma doesn't exist, or isn't really all that bad, and certainly couldn't have anything to do with your presenting problem, or well even if it does therapists shouldn't waste their time trying to address that because it's unscientific. Basically, it's the therapist saying "I believe in trauma", which you would think would go without saying, but since it doesn't, here we are.This is a bit of a digression, but it provides a useful context to understanding why Dumont's account is – or should be understood to be – so scandalous.For better than four decades, "biological psychiatry" – the neo-Kraepelinians – have been making psychiatry, the scientific field, bitterly hostile to any sort of scientific exploration of how social and emotional experiences could give rise to mental illness. And they have done this under the rubric of claiming and insinuating, in defiance of mounting scientific evidence from outside psychiatry, that it was all just Freudian crackpottery.They got away with it because it sort of fit their contentions: yes, Freudians believed that early childhood emotional experiences could have persistent deleterious psychological effects into adulthood, so they could get away with slandering as Freudians those who believe that emotional experiences can cause psychopathology. And, indeed, a psychiatrist who was trained as a Freudian, as was Dumont, is far more likely to be open to the possibility that psychological experiences can give rise to psychopathology, than someone brought up in the intellectual tradition that scorned the possibility as something only superstitious nuts ever considered.But their contention was that the Freudians (and all ascribed-Freudians, by virtue of considering the possibility of psychologically caused mental illness) were irrational and unscientific because they were unconcerned with biology. That's why they called what they were up to "biological" psychiatry – as opposed to (and in pointed contrast to) the psychological psychiatry of those irrational, unscientific Freudians. Their psychiatry was valid and scientific and virtuous because it involved studying chemicals.And that's what makes Dumont's account so incendiary. It's an account of how, actually, no, so-called "biological" psychiatry is not interested in chemicals, or biology. The organizing principle of "biological" psychiatry is not biology, but the a priori commitment that mental illness is intrinsic to the subject – that mental illness is "constitutional".Dumont's account blows "biological psychiatry"'s ideological cover.Now, for me, in the belly of the beast, dealing with this fact day in and day out, Dumont's account is a delicious one of catching the bastards with their pants down, but it's not something I didn't know. For those of you who only deal with the monster from the outside, it may be more novel information.I've been aware for quite a long time now that this ideological bias has run rampant through psychiatric research, and had opportunity to think through some of the disturbing ramifications for this.This brings me to the question I opened with: how many double-blind, randomized controlled trials for antidepressants, do you think, pre-screen their research subjects for lead poisoning?Since psychiatry has effectively decided to collectively "not know" about lead poisoning – or any other sort of poisoning – as a cause of depression, to what extent can we assume that research on depression controlled for lead poisoning?Obviously, we can't. We can't assume that any possible environmental cause of depression, whether biological or experiential, has ever been controlled for in any so-called controlled trial.Think about this for a moment. Think about a trial of a novel antidepressant, where it's possible that some unknown percentage of the subjects have depression secondary to poisoning, and – Dumont: "Lead poisoning is like being bashed in the head with a baseball bat" – cannot possibly respond to the antidepressant.Basically, all clinical trials of medications have been conducted in the faith that such poisonings are impossible, or at least vanishingly rare. But we don't really know how rare they are or aren't.(Except all that information about how widespread elevated lead levels were compared to historical norms. See previous .)But as I pointed out above, this isn't just about lead specifically. Lead poisoning is one example of environmental poisoning, and poisoning is but one example of biomedical causes of psychopathology that "biological psychiatry" largely or entirely ignores in the clinic.For instance, consider malnutrition; there's various scientific evidence that insufficiencies of vitamins can have psychiatric sequelae, but I have literally never even heard of a psychiatrist ordering any sort of blood test to assess nutrition, nor have I ever had a patient instructed by their psychiatrist to take a multivitamin or specific vitamin supplement. I have had patients put on supplementary vitamin D – but by their PCPs, not by their psychiatrists.And these biomedical causes of psychopathology are, themselves, one subset of a larger class of ignored causes of psychopathology that are environmental or experiential, rather than innate.So, in light of all the above, I hope it's coming into focus, why I have enormous skepticism about what gets bandied about as psychiatric discoveries.Perhaps you can begin to imagine what it's like in my mind, every time some breathless news article comes out about the hopes of finding a blood test for some mental illness or another. A blood test for depression? Wea blood test for depression: the test for lead poisoning. But we don't use it. In fact we have a bunch of blood tests for depression: tests for diabetes, for hypothyroidism, for vitamin deficiencies, for who knows what other environmental toxins. And we use them only erratically, if at all.No, what biological psychiatry is seeking is a test to prove that depression is a disease entity that springs forth sui generis from the organism's body, written into the very blood. A test for constitutional depression. That's the only test that will "count".And see in what light this casts the ever more frantic and still ultimately fruitless quests to find the genes for what "biological" psychiatry has a priori decided must be genetic mental illnesses. It starts looking compulsive, neurotically urgent, dogmatic; it reminds me of the Fundamentalist Christian archeologists scouring the Holy Land for evidence of Noah's Flood.I hope this also clarifies some of why, even before we get to the problems of inept experiment design, of wacky choices in operationalization, of P-hacking, of cherry-picking trials for publication, of industry money buying favorable science, of biased subject recruitment, of straight-up scientific book-cooking fraud, I feel there's a much more fundamental problem with experimental science in psychiatry.4.I want to clarify a brewing confusion. I am not saying there's no such thing as constitutional depression. I'm saying wouldn't it be nice if somebody did some science on that? I'm saying that psychiatry under the ideological hegemony of the neo-Kraepelinians – and before them the neo-Freudians – has been so ridiculously biased in its premises that I'm pretty sure we don't know.I have this vision of what an actually scientific psychiatry would look like. It's one in which one of the first things that happen when you see a psychiatrist and report serious psychiatric symptoms is that they order a psychiatric blood panel. It's one in which trials – of medications, of talk therapies – are done on populations that are at least screened for potential environmental causes of the condition being targeted. It's one in which there's no substantial bias, in either treatment or research, for one particular type of cause. It's one in which research is conducted into if and how the psychiatric presentations of a given mental illness depend on differing causes. It's one in which such research informs the DSM, which in turn actually describes them as psychiatric conditions of interest to psychiatrists. It's one in which researchers turning over unturned stones are not attacked for their heresy, but praised for their innovation and curiosity. It's one in which "mind-body" medicine is not heard as signifying "new age" woo, but the perfectly conventional, allopathic medical recognition that minds are something bodies do and mechanical problems with bodies can be the causes of mind problems.It's one in which psychiatry decides on which answers are correct after asking the questions, and trying some science out on them.5.Biological psychiatry's proponents have had an appalling tendency to nastily discredit people – patients, treaters, or researchers – who have had the temerity to try to explore the possibility that a psychopathology could be other than "constitutional". People who ask the question of whether psychiatric symptoms might be the product of something that happened or is happening to you, are characterized as quacks, as pseudoscientific, as conspiracy theorists, as hysterical.Biopsychiatry's conceptual war on environmental and experiential causes did not stay confined to professional circles. It took its contention to the court of public opinion. It has done much to shape American culture to be scornful and invalidating of concerns about environmental causes of problems of mental health.Consider the following from Dumont, later in the same chapter. Dumont, after having four patients all working at the same worksite abruptly develop the same psychiatric and physical symptoms calls OSHA to try to get some help finding out what they might have been exposed to in the workplace. OSHA refers Dumond to NIOSH, the National Institute of Occupational Safety and Health, where someone he's talking to says...:Just to emphasize this, in case you missed it: this is not only a psychiatrist who is assuming, a priori, that these cases another psychiatrist is asking for help with must be "hysteria", and not, as the referring psychiatrist is concerned about, a poisoning, this is the psychiatrist working for the Federal government's research organ for occupational safety. The person whose job it is to investigate workplace causes of psychopathology.We live in the world biological psychiatry made. In American culture, being concerned about – "believing in" – the effects of various chemicals in one's environment on oneself and one's family is considered something only tree-hugger hippies and the precious paranoid hypochondriacs (usually presumed women) worry about. And certainly it's never really happening.I mean, I have literally had to write this whole damn thing without using the phrase "environmental toxin" because since the 1970s – when it invoked concepts like DDT and Rachael Carson's– it's come to be associated with people who are assumed to be nuts.Biopsychiatry has a lot to do with that attitude. It had help, of course. Biological psychiatry's radical deprecation of the biological environment was very convenient to industrial interests, for instance those that wanted to go on polluting. Any political or industrial interest that was getting away with damaging the public's health would benefit by biopsychiatry's interest in discrediting the whole notion of environmental effects on mental health.Worse, it set up a self-fulfilling prophecy. By slandering anyone who was too concerned with possible environmental causes of their patient's presenting conditions, they set up a filter whereby the only practitioners willing to risk the loss of professional esteem it entailed were the very brave – and the very foolish. So now, to some unfortunate extent, it is almost exclusively in "alternative" medical circles that you find practitioners who try to address environmental causes.I want to make this clear: I really am contending that biological psychiatry has driven actual biologically-based clinical psychiatry out of allopathic medicine, to shelter among the crystalfuckers and charlatans.(For that alone I would burn them to the ground.)You, my reader, have been soaking in a culture they have relentlessly shaped to advance the social validity of their questionable unquestionable scientific paradigm. You have been soaking in the astonishing bias that hypothesizing environmental causes for mental illness is intrinsically unscientific, and so only kooks do it.Please leave comments on the Comment Catcher comment, instead of the main body of the post – unless you are commenting to get a copy of the post sent to you in email through the notification system, then go ahead and comment on it directly. Thanks!