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When it comes to discussing the state of the psychiatric enterprise and the manner in which psychiatry is perceived by the public, one of the common diagnostic terms is "myth". And once a diagnosis of mythology is pronounced, the treatment can begin which would return the discipline and the public to the shores of reality. Judith Warner's We've Got Issues is meant to illustrate -- and make a case for -- such a journey. The myth in question is that too many American children are too easily and too often labeled mentally ill when in fact they are simply different or having a hard time fitting in a deformed society. Difficult kids, it is claimed, are being unnecessarily and irresponsibly given psychotropic medicine as an easy way out for incompetent parents and lazy tutors. Overseeing this chemical numbing of difference and personality, the story continues, is a dark alliance of pharmaceutical companies and psychiatrists.
Warner's goal is to rejects this image as a simplistic stereotype. As all myths, it has elements that are true or plausible. For example, pharmaceutical companies do have an inordinate level of influence on psychiatric research and on treatment patterns. But, on the whole, the myth paints a misleading, if seductive, picture of the facts. So seductive this image and so intricately rooted in larger cultural currents that many, Warner tells us, ignore the calls of reality and cherish this view with religious fervor. Indeed, Warner herself was among those who thought "That the helping professionals who appeared to be propagating like weeds in our communities were essentially parasites [...]. That what lay, at base, behind all those kids' purported "issues" [...] was nothing more than parental -- and societal -- neurosis." (p.8). We've Got Issues begins accordingly with the story of the author's personal "odyssey" out of this enchantment -- a toy version of Cartesian doubt. The main purpose of the book, however, is to convince others by bringing into proper light at least some of the facts about children with mental illnesses, their families, and their doctors. While the book is certainly worthwhile, its central argument is a mixed story of partial success, occasional weakness and relentless personal engagement.
Warner comes after a career in journalism and a successful first book, Perfect Madness -- a critical account of the culture of motherhood in the US. The current book was anticipated by a widely-read New York Times blog. Those already familiar with her writing will not have face surprises in her new book. Warner writes for the general reader, making abundant use of examples and taking time to explain, situate and summarize important points. Her prose is clear, personal and fast-paced. She is not an expert or a scholar, but she tries to be a well-informed mediator between experts and scholars, and wider audiences. On the down side, if readability and rhythm are never compromised in Warner's writing, depth, balance and accuracy sometimes are. Even if We've Got Issues is not an academic volume and should not be weighted as such, Warner manifests occasionally a certain journalistic lack of patience that erodes her case.
Warner's method too is tributary to her profession. Her research bifurcates into a more important set of interviews and lateral bibliographical documentation. The interviewees are about 60 parents of children suffering from "fashionable" psychiatric illnesses like ADHD, autism, Asperger's, or bipolar disorder. They are quoted directly quite frequently and the reader is invited to draw lessons from the often dramatic situations these parents have described to Warner. This primary material is contextualized using bits and pieces from the usual secondary sources: studies, statistics, scholarly and popular analyses. On top of that there is a third layer of exchanges with experts, direct or indirect discussions which were part of Warner's research effort. Given that Warner's sample is large in journalistic terms, but cannot support any general conclusions -- e.g. epidemiological -- she tries to show that her own experience in conducting the interviews is consistent with the data revealed by systematic research, i.e. that her claims have a larger evidential support. This background is welcome, even if it is not always clear that it tells the story Warner would like it to tell.
The arguments and examples presented in the 11 chapters of the book vary significantly in terms of significance and soundness. It is best, in this context, to focus on some recurrent themes. Perhaps the most important is the reality of mental illness in children. Warner does not write about severe psychosis. Few people would have qualms about the reality of illness in such cases, even if more than a few may have doubts about the conceptual integrity of the diagnostic categories used to describe and classify these conditions. Warner concentrates instead on the disputed territory of the maladies which led to the "Med scare", illnesses such as OCD, ADHD or autism which, in the public eye at least, came out of nowhere and reached epidemic proportions within a decade or two. Unlike in the case of, say, schizophrenia, many believe that these are not biological conditions and that, consequently, children thus diagnosed are being senselessly "pumped full" of medicine by irresponsible psychiatrists and reckless parents.
Warner's response is to stress the distinction between "personality and pathology", arguing that "there is a world of difference between unique personality traits that may be quirky, annoying, or charming, and actual signs of pathology" and that "the difference between personal style and pathology resides in pain, distress, and impairment." (p. 159) If the existence of mental illness in general had been in question, this would have been an adequate point to make. In the cases Warner discusses, however, the distinction between healthy difference and malignant bizarreness is a more sensitive issue -- conceptually and in the actual medical practice. It is not that the distinction loses validity, but one needs to note that only extreme symptoms are clearly separated from the vague domain of typical behavior, and, to take one particularly delicate example, the very way of defining ADHD excludes such extremes. Since symptoms are distributed between more and less serious, there will be a lot of borderline cases in all the illnesses in question, though the distribution in each syndrome will be different. Which means that diagnosis will remain a messy business, even at the conceptual level. This is not for the most part what Warner suggests to her readers. Some will be led to believe that a diagnosis of ADHD is on all fours with one of diabetes or heart disease, a Scientific Fact. We are very far from that, even if these clinical categories are useful tools. The diagnoses Warner defends may be fully legitimate in the current state of psychiatry, but it is plausible that these categories, which are based exclusively on signs and symptoms, will not remain in place once biological mechanisms are better understood. So only limited bets can be placed on them, especially in the case of children.
A connected topic is that of exposing the theoretical and ideological motivation of those who question the reality of the "issues" Warner discusses. There is, for example, the legacy of the "sixties". Warner is vehement when it comes to antipsychiatry and its surrounding intellectual milieu. Reading Healy's The Creation of Psychopharmacology, she has a revelation when she encounters a few words of Sartre's: it must all be worthless. It is as if these names -- Sartre, Foucault, Laing, Szasz, Derrida -- contaminate everything they touch. Warner tells us that she had an infatuation with "theory" as a student, but then "grew up" (p. 25). Perhaps she would have been well advised to skip such observations. They are almost irrelevant for her case, and an example of rhetorical abuse. Of course, the dubious intellectual legacy of antipsychiatry and its sympathizers should be exposed, but caricature is not the way to do it. In a book which makes a timely effort at debunking some stereotypes, the author's irritation with a certain intellectual camp comes close to reaffirming other.
Warner's criticism of the idea that what passes for mental illness in children is in fact a manifestation of social pathology is far more convincing and surely more relevant for the argument of the book. We may lament the state of our societies, but social problems are nothing new. Hardship, ruthless competition, peer-pressure, inequality, violence have all been part of human history since forever. So have war and famine -- powerful stressors if there ever were any -- which have not been part of the experience of American children for a long time. So why claim that it is society that drives kids crazy these days? Because, Warner explains, worries about children's mental health function as a proxy for general worries about society, fairness, human condition and so on. These are all legitimate concerns, but they are "only superficially about diagnosis and medication. [...] For most people, they're rooted in a discomfort with our world generally." (p. 169) She continues: "Prozac is now a metaphor for how unhappy life has become for many adults and how mechanistic and inhuman society seems." (p. 172) One can see why social evils are blamed and why certain segments of the population are more inclined to accept this view. But this claim is false nonetheless: "life alone -- with the exception of experiences of trauma, neglect, and abuse -- does not cause mental pathology." (p. 186) Environmental factors cannot provide a sufficient explanation of psychiatric conditions, since only a fraction of those exposed to these factors develop such conditions.
This fundamental point is given support by another excellent observation. If society is the root cause of children's problems, then individual pathology should more or less reflect the environmental factors which trigger it. This is not the case: "After all, kids with mental health issues are not necessarily "sick" the way those who soak up all the worst aspects of our culture are: grossly competitive, materialistic, entitled" (p. 189). One can only agree with Warner that "sick" as a moral concept should not be substituted for "sick" as a medical concept. This is also an opportune gesture in the direction of the crucial distinction between social vulnerability (e.g. being poor) and vulnerability to mental problems (e.g. being inclined to prolonged sadness). The two may overlap, but they do not need to. As Warner shows, because of their privileged access to medical services, the children of better-off parents -- presumably less vulnerable socially -- are more often diagnosed with some psychiatric ailments. Surely it is plausible that the greater incidence of mental illness in children of affluent families is an artifact of social arrangements. For example, they get to see qualified doctors. But what cannot be assumed, given the available information, is that these children have less chances of developing a psychiatric condition, which is what the "life conditions cause mental illness" narrative would predict.
Structurally, the prevalent argumentative device in the We've Got Issues is the "yes, but" move. Warner uses this kind of rhetoric to qualify or reject some of the most worrisome claims of those who deplore the overdrugging of American children. One such thematic thread is woven around the question of numbers -- is it or is it not true that ADHD, autism or bipolar disorder have reached epidemic proportions in recent years? If true, what is the explanation for the explosive growth in the incidence of these conditions? Is it perhaps an artificial phenomenon, the result of the lax diagnostic practices of child psychiatrists and the aggressive marketing policies of drugmakers?
Warner's first step in this case is to admit that there has been significant increase in incidence. For example, she notes that "Since the early 1990s , the number of children receiving diagnoses of mental health disorders has tripled." (p. 36) She also quotes experts who have observed that "From 1991 to 2006, there was a 3,500 percent increase in American children identified as autistic in special-education programs" (p. 50), and she mentions that in the case of bipolar disorder too "diagnoses exploded, increasing a massive fortyfold from 1994 to 2003." (p. 60) Isn't this already accepting the point of the critics? No. For Warner their view remains an instance of "hysteria" and "poisonous" rhetoric. The second step of her argument takes back most of what she conceded.
Yes, the numbers went up. But. The problems were there before, only they were less visible, since the clinical concepts were lacking. The numbers have not really exploded, what we see is in fact "diagnosis substitution", children that were labeled retarded yesterday are labeled autistic today. Parents did not have incentives, such as special-ed programs, to have their problematic children tested for mental illness. There were no effective treatments, so why diagnose? And so on. The issue, it may seem, gets deflated. Warner goes so far as to claim that what the numbers are really showing is a failure of reach. Not enough children are getting treatment: "Five percent of kids in America take psychotropic drugs. Five to 20 percent have psychiatric issues." (p. 70)
Some of these points fare better than others. Visibility is a largely valid argument, I think. The point about incentives is crucial, though it can be given very different readings (e.g. Warner admits that some rich parents took advantage of special-ed programs). And clearer conceptual lens combined with less stigma can work wonders. That being said, I find Warner's easiness in dealing with large numbers stunning. What, on reflection, could support the idea that one in five children might be mentally abnormal? Do we still have a grip on notions such as rational behavior, mental health, individual difference or normality when we consider such a perspective? Isn't this, in fact, a case where we can suspect that the sense of "sick" is no longer strictly medical? Perhaps such skating on thin ice is unavoidable if one takes relatively fragile clinical concepts like ADHD or OCD and treats them as tangible entities. Warner may have a point when she argues that not enough disadvantaged children (e.g. those in foster care) are getting treatment. But to generalize and to sketch an image in which a large portion of the general young population requires psychiatric intervention is unreasonable.
Deflation, then, only goes so far. A recent example should show that numbers really are a problem. There is an ongoing debate about the stricter criteria for autism included in the new edition of the diagnostic manual of the American Psychiatric Association, the DSM-V, which is supposed to be published in the near future. These criteria would deny a diagnosis of autism to many people that are currently so diagnosed. Experts too, it would seem, found the diagnostic tendencies of recent years alarming. Note, moreover, that this is a socio-economic as much as it is a medical issue, which shows once more the relative fragility of psychiatric categories. The explosion in diagnoses meant an explosion of the cost of special-needs programs. Cancer treatments too are very expensive, but we should not expect the "criteria" for cancer to change very soon.
Another theme which gets the "yes, but" treatment is the relation between pharmaceutical companies and psychiatrists. Warner refers, for example, to the case of Professor Joseph Biederman (Harvard), who made 1,6 million dollars between 2000 and 2007 -- money paid by the companies which were selling the atypical antipsychotics used to treat bipolar disorder. Biederman was at the same time promoting the diagnosis of bipolar disorder in children. Warner also mentions, among many other examples, analyses which have shown that the results of research sponsored by pharmaceutical corporations differ significantly from independent studies, and that diagnostic patterns of doctors who get money from companies tend to vary accordingly. But she thinks that these examples do not compromise the basic soundness of the child psychiatry enterprise. Basic science has survived commercial interferences, the medical agenda has not been essentially derailed, the isolated rotten apples should not share the blame with an otherwise noble profession.
This may seem a bit far-fetched, but I think that it is merit of Warner's book that it avoids demonizing the usual suspects. Psychiatrists, like all doctors, have been tempted by the opportunity to make an extra buck. And drug companies went too far with direct-to-consumer advertising and other pushy methods of promoting their products, including the perpetual courting of doctors. According to Warner, however, the situation could, in principle, be restored to a healthier state. Her suggestions in this case -- allow research grants, but bar commercial control of research, disclose payments, ban direct-to-consumer ads, enforce corporate responsibility and medical ethics -- make sense. They are also an example of a lucid approach to an extremely heated issue. Deflation, in this case, should be welcome.
A greater merit of the book and its main emotional tissue is Warner's plea for empathy with the parents of mentally ill children: "These kids, and their parents, have been shut in the cold. It isn't just that the money isn't there to do right by their needs. There's a deficit of compassion, too." (p. 238) An accurate statement, no matter what one may think about the nature or dimensions of the wave of psychiatric diagnoses affecting children in the US and worldwide. To begin with, simply facing such a diagnostic for one's child is traumatic. The very decision to have one's child screened by a psychiatrist can be life changing. And then, as Warner emphasizes, few parents are willing, especially in the current climate of epidemic suspicion, to have their kids take psychotropic medicine for trivial issues. In most cases Warner documented -- and it is probably safe to assume they are not the exception -- parents resist medication to the breaking point. The sense of failure, loss and meaninglessness which follows the switch from the psychological talk of temperament, personality and character to the bio-medical talk of broken neural circuits and imbalanced neurotransmitters is a terrible wound many find themselves carrying, in silence, for their entire lives. Warner's book defends these people from the facile contempt of their luckier fellows. Whatever qualms one may have about style or rhetorical overtones, her stance is laudable.
We've Got Issues is true to its title. One may dispute the details of the nature and extent of the issues Warner brings to the table. But issues they are. One may have doubts about the overconfident image she paints of effective treatment -- an image not unlike that emanating from the sunny half of Sacks's Awakenings. But Warner's effort to picture the suffering of having a child with "issues" in an often uncaring society and the promise psychiatric treatment often brings is convincing. The mythology Warner has targeted will survive, if only because it is built on half-truths, but one will hopefully be less inclined to weight others' imagined wickedness against one's own imagined virtue.
© 2012 George Tudorie
George Tudorie is a PhD student in philosophy, Central European University, Budapest; and teaching assistant, College of Communication and PR, Bucharest.