One-Minute Book Reviews

May 29, 2010

Psychiatrist Daniel Carlat Diagnoses His Profession’s Ills in ‘Unhinged: The Trouble With Psychiatry’


“Psychiatry has become a proving ground for outrageous manipulations of science in the service of profit.” Unhinged

Unhinged: The Trouble With Psychiatry. By Daniel Carlat. Free Press, 256 pp., $25.

By Janice Harayda

Has the profession of psychiatry lost its mind? You might think so after reading this relentless and mostly successful assault on current practices in the field.

Daniel Carlat focuses in Unhinged on the harm that he believes has resulted from the march of psychiatry away from psychotherapy and toward the better-paying practice of prescribing drugs. And he forges links between that shift and many ills in his field, including scandals at top-flight hospitals, one-sided articles in medical journals, and pharmaceutical-company payments to doctors who hawk questionable drugs to their peers.

Some of the statistics in Unhinged are chilling. In 2006, an estimated 10 percent of all 10-year-old boys in the U.S. were taking the stimulant Ritalin or an equivalent each day, and shabby medicine often accounts for its use or that of other psychotropic drugs. Psychiatrists routinely write prescriptions after 15- or 20-minute consultations. They know so little about the biology of most mental illnesses that they prescribe based on little or no science. And they mislead patients by presenting as fact theories formed by working backward from the discovery that a drug seemed to ease the symptoms of a disease. One of the most popular of those theories holds that depression results from a “chemical imbalance” in the brain:

“… the fact that many antidepressants increase levels of serotonin has led to a serotonin deficiency theory of depression, even though direct evidence of such a deficiency is lacking. By this same logic one could argue that the cause of all pain conditions is a deficiency of opiates, since narcotic pain medications activate opiate receptors in the brain.”

Carlat delivers his indictment in a crisp, journalistic style that serves him well, though he writes with less depth and elegance than his fellow physician Atul Gawande. But he doesn’t take his critique of the profession as far as it warrants. He clearly wants psychiatrists to do more psychotherapy but doesn’t make a strong case that patients would benefit from this – only that they would benefit from fewer bad drugs. He seems to take for granted that psychotherapy “works.”

This view clashes with that of respected critics of the profession such as the social scientist Robyn Dawes, who drew on decades of research for his brilliant House of Cards, which argues that psychotherapy itself is a con game: There is no evidence that psychiatrists or psychologists are better at counseling than minimally trained civilians, and both types of professionals have strayed so far from their roots in the study of human behavior that they offer little more than glorified intuition.

Unhinged may have the worthy effect of prompting patients to demand better explanations for why certain drugs are recommended for them — and it would be welcome for that reason alone — but it has little to say to people who remain unconvinced that psychotherapy would be better than the cavalier prescribing of Prozac or Wellbutrin. If psychiatrists are as willing as Carlat suggests to pimp for drug companies, why should Americans trust them with their deepest secrets?

Best line: “ … psychiatry has become a proving ground for outrageous manipulations of science in the service of profit.”

Worst line: Carlat says that an Ambien drug rep named Valerie once gave him a gift worth about $25, and later that day, he saw a patient and thought, “Why not prescribe Valerie’s drug for this patient?” That phrasing is too neat. Carlat also appears to be rationalizing in some of his comments on why he served briefly as a paid drug-company rep for the maker of Effexor.

Caveat lector: This review of Unhinged was based on an advance reading copy. Some material in the finished book may differ, and some people in it are composites.

Furthermore: Carlat is a psychiatrist in Newburyport, MA, specializing in psychopharmacology, and an associate clinical professor of psychiatry at Tufts University School of Medicine.You can follow him on Twitter at a @dcarlat (www.twitter.com/dcarlat). Carlat tells why he quit giving paid talks for drug companies in the New York Times article “Dr. Drug Rep.” Some of the material in Unhinged about brain scans appeared in different form in an article he wrote for Wired, “Brain Scans as Mind Readers?”

Contrary to the date you see under the headline, this review was posted on May 31, 2010. WordPress appears to be having technical problems that have led to scrambled dates. For this reason, I’ve removed a May 30 post about my forthcoming review of the young-adult novel The Things a Brother Knows.

You can follow Jan Harayda (@janharayda) on Twitter at www.twitter.com/janiceharayda.

© 2010 Janice Harayda. All rights reserved.
www.janiceharayda.com

October 27, 2009

‘Smile or Die’ – Barbara Ehrenreich’s ‘Bright-sided: How the Relentless Promotion of Positive Thinking Has Undermined America’

Taking aim at the “prosperity gospel,” “positive psychology” courses, and teddy bears designed for breast-cancer patients

Bright-sided: How the Relentless Promotion of Positive Thinking Has Undermined America. By Barbara Ehrenreich. Holt/Metropolitan, 235 pp., $23.

By Janice Harayda

When I was a book editor, I often had to reassure freelancers that they had the right to give negative reviews. Critics never apologized for praising books, but they did apologize for panning them – even when they had done so brilliantly.

At first, I thought freelancers were worried that they would get fewer assignments if they wrote unfavorable reviews, because some editors do prefer to publish praise. But many seemed reluctant to criticize books even after I had explained that I didn’t care whether reviews were positive or negative: I cared whether they were fair, honest and well written.

Barbara Ehrenreich suggests a possible explanation for the reluctance in Bright-sided, a spirited broadside against enforced optimism in medicine, psychology, business, religion and other fields. She argues that faith in “positive thinking” has become so ingrained in American society “that ‘positive’ seems to us not only normal but normative – the way you should be.”

Ehrenreich found when she was diagnosed with breast cancer that a cult of optimism pervaded articles and books about the disease that made her feel isolated instead of supported. “No one among the bloggers and book writers seemed to share my sense of outrage over the disease and the available treatments,” she writes in a chapter ironically called “Smile or Die: The Bright Side of Cancer.” “What causes it and why is it so common, especially in industrialized societies? Why don’t we have treatments that distinguish between different forms of breast cancer or between cancer cells and normal dividing cells?”

Instead of finding answers, Ehrenreich kept coming across articles by women who claimed that they owed their survival to a “positive attitude” – even though the death rate from breast cancer has changed little since the 1930s and there is no consistent evidence that staying upbeat extends the life of those who have the disease, though it may have many other benefits. She also found that “positive thinking” can exact a terrible price in self-blame if a cancer defies treatment. As the oncology nurse Cynthia Rittenberg has written, the pressure to think positively is “an additional burden to an already devastated patient.”

“Smile or Die” recycles some of the material from Ehrenreich’s award-winning essay, “Welcome to Cancerland,” but is still the strongest chapter in Bright-sided. Other sections of the book describe the wholesale effects of “positive thinking” better than they show their retail cost to ordinary Americans. Ehrenreich argues cogently that the emerging field of “positive psychology” is based heavily on bad or no science. But the same is also true of some older forms of therapy that apply similar principles, as the Robyn Dawes documented in his superb indictment of the betrayal of scientific standards in psychotherapy, House of Cards (Free Press, 1996). So why focus on “positive psychology” when other types of therapy have done more damage, if only because they are more widely used? Ehrenreich describes an unflattering interview with the high priest of “positive psychology,” the psychologist Martin Seligman. But she seems to have talked to no one burned by his teachings – which shouldn’t have been hard to do, given that more than 200 schools and colleges offer courses in his field.

In a chapter called “God Wants You to Be Rich,” Ehrenreich faults the so-called “prosperity gospel” preached by superstar pastors like Joel Osteen, whose churches offer “services that might, in more generous nations, be provided by the secular welfare state,” such as pre- and after-school programs. Certainly those ministries may foster self-blame. (If God wants you to be rich and you’re not, you don’t have enough faith.) But if the churches that promote the “prosperity gospel” are offering low- or no-cost day care that enables parents to seek prosperity by holding jobs, doesn’t that count for something? You sense that such programs are exactly kind of thing that Ehrenreich might love, if only they weren’t endorsed by pastors who wear too much gel in their mullets.

No less important: A blurred line exists between innate optimism – which may be genetic — and the enforced optimism of disciplines like “positive psychology” and the “prosperity gospel.” To what extent are advocates of “positive thinking” creating an attitude and to what extent are tapping or reinforcing one that’s already there? Ehrenreich sidesteps the question. But if optimism is in our genes, it may do little good to argue as she does that we need replace “positive thinking” with a “vigilant realism.” Joseph Hallinan takes a less extensive but more practical approach to the subject in his Why We Make Mistakes (Broadway, 2009), which deals in part with the research on errors based on overconfidence – a trait often indistinguishable from “positive thinking.”

Overall Bright-sided is much more theoretical than Nickled and Dimed, for which Ehrenreich took a series of low-wage jobs to show how corporations exploit blue-collar workers, or her more recent Bait and Switch. But it makes a needed assault on an idea that too often goes unchallenged in America: that “positive thinking” is always a good thing. Ehrenreich is right that a deep and unacknowledged anxiety often underlies efforts to block out unpleasant thoughts. “Positive thinking” requires a continual effort to deflect “negative” ideas, she notes, and it can be exhausting. “The truly self-confident, or those who have in some way made their peace with the world and their destiny within it, do not need to expend effort censoring or controlling their thoughts,” she writes. “Positive thinking may be a quintessentially American activity, associated in our minds with both individual and national success, but it is driven by a terrible insecurity.”

Best line: Ehrenreich notes that breast cancer has given rise to a highly commercialized industry of products for patients, including “infantilizing” teddy bears: “Certainly men diagnosed with prostate cancer do not receive gifts of Matchbox cars.”

Worst line: “All the motivators and gurus of positivity agree that it is a mistake to watch the news.” How does Ehrenreich know? Has she talked to them all? In my experience the self-styled motivators, with a few exceptions including Rhonda Byrne (The Secret), urge people to limit – not eliminate – exposure to bad news.

Editor: Sara Bershtel

Published: October 2009

Read an excerpt (the first pages) from Bright-sided or listen to an audio excerpt.

Furthermore: For more on optimism and illness, see the post “‘The Tyranny of Positive Thinking’ and Cancer Patients — A Physician-Author Says That It’s Not Always Best to Tell People to ‘Be Optimistic’.”

© 2009 Janice Harayda. All rights reserved.
www.janiceharayda.com

September 3, 2009

What If You Had an Autistic Disorder and Didn’t Know It? Tim Page’s Memoir of Growing Up With Undiagnosed Asperger’s Syndrome, ‘Parallel Play’

Filed under: Memoirs,News,Nonfiction — 1minutebookreviewswordpresscom @ 12:40 pm
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Tim Page is a friend, and I’m in the acknowledgments of his acclaimed biography of the novelist Dawn Powell, which – you will not be surprised to hear – I love. So I can’t review his new Parallel Play: Growing Up With Undiagnosed Asperger’s (Doubleday, 196 pp., $26). But Janet Maslin writes in today’s New York Times that this “improbably lovely memoir” shows in “fascinatingly precise detail and often to pricelessly funny effect” what it’s like to have his autistic disorder and not know it. And nothing in her review conflicts with what I know about Tim, who won the Pulitzer Prize for his music criticism for the Washington Post before he decamped to academia. The Times has also posted an excerpt from Parallel Play, a book that is an expanded version of material that appeared in The New Yorker.

www.twitter.com/janiceharayda

August 15, 2007

Self-Help Books by Quacks, Frauds and Incompetents: Why Don’t They Get the Kinds of Clinical Trials That Drugs Get? (Quote of the Day)

Filed under: Quotes of the Day — 1minutebookreviewswordpresscom @ 1:02 am
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How many times have you read or heard about a self-help book that struck you as pure quackery? Probably a lot. Some publishers make preposterous claims for how their books will improve your physical or mental health, or claims that the Food and Drug Administration would never allow other kinds of companies to make without proof that they were true. But publishers are rarely held accountable for false advertising.

Should some of this snake-oil-in-print be subjected to the kinds of clinical trials that drugs get? The Wall Street Journal ran a fascinating article recently suggesting that this is starting to happen. Here’s part of what it said about health-related how-to books:

” … this category is reminiscent of the market for elixirs, oils and pills before the advent of federal regulation. Despite the growth in research, fewer than 5% of the tens of thousands of self-help books on the market have been subjected to randomized clinical trials. And authors with no scientific credentials are just as likely to hit the jackpot as are renowned physicians. ‘When the book cover announces that it’s a bestseller, that means nothing,’ says John Norcross, a University of Scranton professor of psychology and researcher on the effectiveness of self-help books.

“Now, mental-health professionals in the U.K., the U.S. and elsewhere are determined to distinguish the most proven offerings. The aim is to recommend books that have been shown to be successful in published trials conducted by reputable, independent researchers.”

Kevin Helliker in “Bibliotherapy: Reading Your Way to Mental Health,” the Wall Street Journal, July 31, 2007, page D1. I couldn’t link to the article from this site but could find the story by cutting and pasting the following link into the address bar in my browser, so you might try that it if you want to know more: http://online.wsj.com/public/article/SB118583572352482728.html. You can also find this article easily by Googling “helliker + bibliotherapy.”

Comment by Janice Harayda:

I’m all for the kind of testing the Journal described. I’d also favor stricter regulation of advertising by book publishers, whether or not clinical trials were conducted. How about you?

(c) 2007 Janice Harayda. All rights reserved.

www.janiceharayda.com

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