"Words to the Wise"

As I write this, I am sitting in a computer lab with a copy of Thomas Szasz's "Words to the Wise". It's an utterly fascinating collection of quotes and sound-bites on a wide-ranging collection of topics by one of the most controversial authors in the field of clinical psychology. Some of the quotes I agree with; others I don't. All, however, are thoughts worth considering. Despite the format, it's one of the most thought-provoking books I've seen in a long time.

Ten of the quotes more relevant to today's autism issues:

If a person ingests a drug prohibited by legislators and claims that it makes him feel better, that proves that he's an addict.

If he ingests a drug prescribed by psychiatrists and claims that it makes him feel better, that proves that mental illness is a biomedical disease.

When and why do we say that a behavior is caused rather than willed?

We say that chemicals in the brain cause depression and suicide; but we don't say that chemicals in the ovaries or testicles cause lust and marriage.

The child cannot match the adult in most accomplishments. Hence, we reward him for effort as well as achievement. Yet, the child must learn that what counts in life is not effort but achievement. The child over-rewarded for effort may grow up to seek approval for trying instead of for succeeding. This dooms him to failure. If he succeeds, he succeeds only at trying hard. If he fails, he fails miserably.

When a woman finds having a fetus in her body annoying, she can abort it by taking an abortifacient drug or having a surgical abortion.

When a woman finds having a child in her home annoying, she can abort his persona by having a child psychiatrist give him a chemical straitjacket.

Diagnoses are not diseases.
Diagnoses are names, human fabrications.
Diseases are phenomena, facts of nature.

Demonstrable bodily lesion is the gold standard of medical diagnosis. Without practical convertability into gold, the value of paper money rests only on faith. Without conceptual convertability into bodily lesion, the diagnosis of disease rests only on faith.

A patient with cancer says: "If I had refused my surgeon's suggestion that I have my tumor removed, the cancer would have killed me."
A patient with depression says: "If my psychiatrist had let me refuse the electroshock treatment he recommended, I would have killed myself."
The difference between these two sentences sums up the difference between bodily illness and mental illness.

Three principal rules of conduct:

1. The Golden Rule: Do onto others as you want them to do unto you.

2. The Rule of Respect: Do unto others as they want you to do unto them.

3. The Rule of Paternalism: Do unto others as you in your superior wisdom know ought to be done unto them in their own best interests.

Formerly, debasing the Other by calling him a "nigger" was considered politically correct: the speaker was viewed as a protector of the race or nation from those bent on defiling it.
Today, debasing the Other by calling him "sick" is considered politically correct: the speaker is viewed as a protector of the debased person's best mental health interests and of the nation from a danger to the public health.
Replacing the former rhetoric by the latter is considered moral progress.

Today, everyone claims to be working for the patient's best interests. No wonder the patient is in deep trouble.

Note that I selected these quotes based on relevance, not agreement. I don't, as a matter of fact, agree with a lot of Szasz's thinking. This said, he's an incredibly thought-provoking author. In this blog post, I'm not going to take a stance on any of these. Instead, I'm going to give an "assignment" of sorts to each of my readers.

Read these quotes. Think about them. What does each of them mean? What do they imply? Is this statement -- or implication -- accurate? Is Szasz right or wrong? Why?

Then post an explanation here, answering at least one of these questions for at least one of these quotes. Feel free to do so anonymously or pseudonymously. I don't care about that (although I will delete SPAM posts or personal attacks). If you aren't the first to reply to this, also reply to at least one of the previous replies.

My own replies here will be mostly playing "devil's advocate", issuing responses also intended to make people think and facilitating discussion. Unless I state specifically that a position is my own personal belief, please don't think that it is. I will likely issue arguments against your position even if I agree with it.

The point, after all, is to get people thinking about this sort of thing.

In addition to the obvious, this exercise should give you a pretty good idea of why I highly reccommend this book. It has nothing to do with agreement (although I strongly agree with both the contents and sentiments of many of the quotes, this cannot be said about many others). It has everything to do with the way the book makes you think.

Oh, and it's a treasure mine for anyone who wants quotes for articles, the beginnings of book chapters, and the like. Lots of grade-A quotes here... which is the entire point of the book.

Edit: Added a link.

On "Inclusive Resource Lists"

I wrote the following in response to a request for assistance in putting together a directory of resources for the parents of autistic children. I've edited the formatting and changed a few details to reflect the formatting options I have here on Blogger; other than a few formatting things (parentheses and quotes replaced with a block quote, etc.) and one spelling correction, the message remains substantially unchanged.

In other words, you want to create the resource-list version of Wheeler's (2003) thought experiment.

To quote:

Suppose a medical centre were to propose creating a programme in 'unproven and dubious medicine'. In this programme, physicians would learn how to give patients not only conventional treatments, but also treatments not known to be safe and effective. Some of these would have plausible mechanisms of action, but others would make no sense. The treatments would include experimental drugs of unknown purity. There would be research concerning the methods, but in the meantime the methods would be used before the results were known. Patients would have the benefits of both worlds – treatments that work and treatments that probably don't work.

A programme with such a title would find little acceptance. But change the name to 'integrative medicine', downplay the lack of evidence, claim that it deals with healing the person and employs new paradigms, and for some reason there is much greater acceptance. (p. 8)

You want to list people who make their living chemically castrating autistic children in the middle of people who've dedicated their lives to helping treat actual disease; you want to list people who make their living torturing kids next to people who've spent their lives trying to protect children. You want to list fear-mongering hate propaganda next to legitimate resources on parent education.

Err... no. I have no intention of helping with the development of such a "list". There are more than enough of them already.

This sort of thing is a tremendous problem in the autism world.

What would people make of a "resource list" that deliberately put legitimate stockbrokers and investment funds next to known con-artists? Yet, for some reason, people seem to think that lists that do this sort of thing are okay for parents of autistic children.

Some of this comes from the postmodernist belief in constructed reality. If you don't believe in an objective reality -- if people agreeing that something is true is enough to make it true -- then the question of what's actually going on is both meaningless and irrelevant within your paradigm. Despite what postmodernism would say, however, ignoring objective facts and attempting to construct your own reality independent from them is better known as "self-delusion" and acting on this sort of thing tends to produce tragic results. Quite frankly, this sort of attitude is patently absurd.

Despite this, however, many parents somehow view fraudulent resources as equal to real ones, "alternative" medicine as equal to real medicine, and hate propaganda which gives them false hope as superior to truths which offers them real hope (if at the expense of accepting things they don't want to hear).

I don't get it. I really, literally, don't... at least on an emotional level. Intellectually, maybe (at least somewhat), but that's the difference between "knowing" and "understanding".

Unfortunately, postmodernism only accounts for part of the problem. Bigotry, normocentric bias, and countless other factors also contribute. The results, however, speak for themselves. Parents of newly-diagnosed children usually lack the ability to distinguish between legitimate and illegitimate resources. They are at their most desperate, their most confused, and their most emotional. They seek a helping hand from anyone who offers it... and rarely notice the metaphorical dagger aimed at their backs. They are prime victims for frauds and con-men.

Many of them get wiser as time passes. Many of them learn the skills they should have been taught from the beginning... but it's easy for irreparable harm to have been done by then. If they're lucky, they'll only have been scammed out of money. If they're less so... the potential dangers are difficult to underestimate. In countless ways and for countless reasons, fake help is worse than no help.

I'd be more than happy to help someone assemble a genuine, reliable resource list. I will not, however, help with this sort of "project".

On My Recent Conference Presentation

My Autreat presentation went pretty well, I think. I uploaded the slides to the conference's Yahoo group, if anyone's interested.

Or, alternately, feel free to ask and I'll send them to you.

On the flip side, things have been extraordinarily hectic here. Between an "interesting" (one of my professors has decided that deducting points from my grade for autistic literalism is acceptable behavior), being swamped with schoolwork, and being otherwise preoccupied, I haven't really been able to spare much energy for blogging.

That said, however, I really should have written more. Sorry.

In any case, I just realized that I'd only posted one of the two essays I sent in as supplementary material for my presentation. As such, I'm posting the other:

How does it harm autistics?

Pseudoscientific medicine intended to "cure autism" harms autistics in a wide variety of ways. First and most obviously, the treatments themselves are often harmful. The financial harm to families is often substantial, with many families spending simply absurd amounts of money – some even mortgaging their homes – to pay for "treatments" that can be considered fraudulent at best. Many pseudoscientific treatments require considerable effort to implement while delivering illusory or placebo-equivalent benefit (or even producing harm). Families become emotionally invested in the method, and are often incredibly disappointed when it doesn't work. Sometimes the family avoids this disappointment by seeking out ever deeper and darker depths of woo.

The acceptance of pseudoscientific medicine promotes substandard care due to undertrained practitioners who bypass the relevant licensure requirements. It imposes double-standards on pseudoscientific and scientific practitioners, standards which inevitably favor the pseudoscientists and undermine the constant efforts of scientific practitioners to improve standards of care. It provides false knowledge of how to deal with real problems, and encourages people to ignore, disregard, or remain ignorant of a wide variety of standards of medical and research ethics, and encourages default logic in treatment.

It provides countless confounds to research aimed at helping professionals understand and help autistics and interferes with the conducting of such research, making it harder for genuine scientists to recruit participants.

It encourages the reification of autism, demonizes our neurology, and acts to dehumanize autistics. It promotes a culture of desperation and prevents acceptance of our differences. It legitimatizes the exploitation of us and our neurology by various political groups. It even distracts from real issues and endlessly complicates the discussion on autism.

Perhaps it is more meaningful to ask, "How doesn't pseudoscientific medicine harm autistics?" It would certainly be a far shorter list.

It's worth noting that the list in the presentation itself was longer -- I added several items after I wrote the above. Sometimes "Gyah" doesn't quite cut it.

On Disease

As I've mentioned before, "disease" is defined: "an impairment of the normal state of the living animal or plant body or one of its parts that interrupts or modifies the performance of the vital functions, is typically manifested by distinguishing signs and symptoms, and is a response to environmental factors (as malnutrition, industrial hazards, or climate), to specific infective agents (as worms, bacteria, or viruses), to inherent defects of the organism (as genetic anomalies), or to combinations of these factors".

This seems rather straightforward, but it's decidedly not the conceptualization most people have of disease. Most people think of "disease" as equivalent to "infectious disease" -- the cold, the flu, and so on. The concept of disease, however, is much more expansive than this, covering such diverse conditions as broken bones, cancers, malnutrition, radiation poisoning, and countless other things.

Any good description of a disease has at least three key elements: etiology, symptomatology, and course. Some other commentators will add a fourth, prognosis, but I consider this a part of the course. Others may disagree, caveat lector, etc.

In other words, diseases are defined by what causes them, how you tell someone has them, and what happens to the people who have them. Many times, each of these factors can be incredibly complex or variable. Often, the lines between them are blurred. Medicine is anything but simple.

Very frequently, we don't know the course of a disease. This is especially true for a while after a disease process has been discovered: until the disease runs its course in someone, we don't know what to expect. For instance, we didn't know that Ebola hemorrhagic fever was fatal until people started dying from it (although, given some of the symptoms, we certainly had reason to suspect!). We know that it's not universally fatal because people have survived.

From here, discussions of the study of diseases' courses and prognoses rapidly get a great deal more complex (with discussions of prognostic factors, modified courses, and the like). While interesting and useful, further discussion really isn't needed to address the core issue of this essay -- which is just what makes something a disease.

While diseases are often grouped together by course in speech, this is almost always through adjectival modifiers (e.g. "fatal disease", "overnight bug", "crippling injury", etc.). Diseases are not defined in terms of their course, and the same disease can have drastically different courses depending on any number of factors (hence the complexity). This is fairly easy to intuitively grasp when illustrated: while some people survive pertussis infection without treatment, others die even with it. Some people recover completely from a simple fracture of the femur; some people never do. Either way, the disease is pertussis or a simple fracture of the femur, respectively.

So -- what about symptomatology? Again, the same illness can have different symptoms in different people (although this effect is less extreme than in the course). It's interesting to note that the symptoms of a disease often can be considered diseases in and of themselves (but they usually aren't thought of that way). Then there's the matter of complications of a disease... which, again, starts making things get really complex, really fast.

While symptomatology plays a huge role in diagnosis, it's not (usually) how we classify disease. Sure, we talk about symptoms a lot ("He has a fever","His stomach hurts", etc.), and we do occasionally group illnesses this way (e.g. chemical, thermal, and radiation burns -- which are grouped together because of large similarities in symptomatology and minor similarities in etiology)... but we mostly group things together in etiology.

In other words, etiology is the "most important" part of a disease -- what defines a disease and separates it from other diseases. Sure, there are diseases of unknown etiology. Keep this in mind for future discussions. It's important.

For My Upcoming Conference Presentation

The following was written for my upcoming conference presentation on pseudoscientific medicine. It is one of two essays which, collectively, make up my contribution to the conference's program packet. All links within the essay are added for this blog and not in the packet itself.

Throughout society, people are being constantly bombarded with unprecedented amounts of medical information. Unfortunately, much of this information is distorted or wrong… and most people don't have the ability to separate the good from the bad.

It doesn't help that making sense of medical information requires a good deal of expertise. There are entire disciplines of study within medicine dedicated to doing this, and it is quite possible to go to college and get a master's degree or even a Ph.D. in the study of doing so. Some of the most influential doctors in academic medicine today have done exactly this, granting them degrees in such seemingly esoteric disciplines as medical bioinformatics and biostatistics.

Any discussion on all of the ways that things can go wrong and misinformation can arise would need to be absurdly long – it happens in many and myriad ways, and even listing all of them could easily fill an entire book. This presentation is intended to cover one tiny subset of one tiny aspect of one tiny facet of a broader problem: the issue of autism-related pseudoscientific medicine – medicine and medicinal information within the field of autism which pretends to be based on science but actually isn't.

Medicine is commonly defined as the science or practice of the treatment of disease. While this seems fairly straightforward, it actually isn't – the concept of disease is complex, multifaceted, and often controversial. MedLine Plus provides the following definition:

Disease – An impairment of the normal state of the living animal or plant body or one of its parts that interrupts or modifies the performance of the vital functions, is typically manifested by distinguishing signs and symptoms, and is a response to environmental factors (as malnutrition, industrial hazards, or climate), to specific infective agents (as worms, bacteria, or viruses), to inherent defects of the organism (as genetic anomalies), or to combinations of these factors.

In other words, a disease is a harmful dysfunction – a "breakdown" of the body, regardless of its source. A traumatic injury is a disease. Heavy-metal poisoning is a disease (or, more accurately, a type of disease). Polio is a disease. Geneticists can't agree on just what a genetic disease is, but some genetic conditions are indisputably diseases.

As such, medicine is the study – or attempt – of keeping the body from breaking down. Medical views of autism must necessarily look at autism as some form of breakdown of the body: views that do not do this are not medical in nature.

Within scientific medicine, the ideal is to provide information and to practice based on critical evaluation of the sum totality of the available scientific knowledge on any given topic. Unfortunately, this is often not possible or practical in a clinical environment for a variety of reasons… but I have tremendous respect for those doctors who put in an earnest effort towards achieving this lofty goal.

Others simply practice the way they were taught to, or as experts recommend. They may parrot their lessons from back when they were in medical school, or simply repeat what various authorities tell them. This usually yields results which technically work – experts often know what they're talking about and medical schools usually teach effective treatments – but new research is always coming out; new developments occur on a regular basis; new findings constantly change the landscape of medicine; and experts, no matter how revered, are never infallible and are sometimes misunderstood. As such, people who practice this way often have information which is out of date, and are at heightened risk of error.

Some people eschew the framework of science entirely and attempt to heal or prevent illness through other means entirely. Ranging from Christian faith healers to psychics to traditional practitioners of Eastern medical systems, their advice has little to do with what we call "science". These systems range from the relatively harmless to the utterly destructive, from the daughter who prays in church in hopes that her mother will recover from illness to the African witch-doctor who tells desperate seekers of help that AIDS can be cured through sexual intercourse with a child.

And, finally, there is the subject of this presentation: those people who do not practice based on science, but simultaneously pretend to. Whether out of financial interest, political ideology, devout cronyism, or simple ignorance, their advice is usually poor, commonly ineffective, frequently bewildering, often harmful, and collectively stands as an ongoing threat to the lives and welfare of countless people throughout the world.

Welcome to the weird and wonky world of pseudoscientific medicine. For the sake of your health and sanity, you're probably better off if you don't move in.

Yet Another Example of Over-the-Top Woo

I just discovered that some people are selling levodopa as a dietary supplement.

Yes, levodopa -- arguably the world's most infamous anti-antipsychotic. Yes indeed, legal home psychopharmacology has reached a new low. Just when I think the quacks can't get any more outrageous...

For those of you who don't understand my reaction, levodopa, also known as L-dopa, is a particularly infamous anti-Parkinson's drug and the basis of Dr. Oliver Sacks's well-known book, "Awakenings". It is an extremely potent drug with a host of known side effects which include (but are not limited to):

• Nausea
• Gastrointestinal bleeding
• Disorientation and confusion
• Auditory and visual hallucinations
• Drowsiness and narcolepsy
• A condition which strongly resembles stimulant psychosis
• Hair loss
• Emotional effects (it tends to make emotions more "extreme" or "vivid", which wouldn't be such a bad thing if anxiety and libido weren't the aspects most notably/commonly amplified).
• Cardiac arrhythmia

And then there are the effects of chronic use. This is not a safe drug.

And yet people are selling it as a dietary supplement, completely absent any sort of real regulation. Thank you very much, DHSEA.

On Freudian Psychoanalysis

As part of my theories and practice course, we're being asked to summarize the various theories and modalities of therapy by answering a series of questions. We started with classical Freudian psychoanalysis.

The following are the questions and my answers -- somewhat cleaned up.



1-How does the theory conceptualize the basic beliefs about people...does the theory see people as "good", "bad", neutral, capable of growth, proactive or reactive to the environment?

Based solely upon extremely low-quality evidence of dubious validity, Freud believed that we were unaware of the majority of our mind's content and essentially at the mercy of forces beyond our direct perception. As such, Freudian psychoanalysis views people as the deterministic result of conflicts between postulated and reified constructs that exist within a non-falsifiable system. To the extent that people are able to grow within this context, it is the result of the client coming to exert control over these constructs and derivative reified "forces".


2-How does the theory describe the function of personality..what is the purpose of our "personality"; what needs does the personality meet..?

In essence, the ego serves to regulate forces/instincts, to manage anxiety, to plan, and to maintain reality focus.


3-How does the theory describe the "structure" of personality -- what IS our personality; what does it consist of?

In essence, Freud believed that the "self" (ego) serves to mediate between a person's "higher" desires (superego) and "lower" desires (id). As such, one's personality is determined by one's ability to balance and control these often-reified constructs and resulting also-reified "forces".



4-How does the theory describe how we develop into a "normal person"?

Freud believed that there was one true course of development (all departures necessarily being harmful) which could be described as going through a series of "psychosexual stages". Specifically, one passes (or should pass) through the oral stage during infancy, the anal stage during early childhood, the phallic stage during preschool, the latency stage during early school-age, and the genital stage during adolescence and onward. The oral stage accounts for the ability to delay gratification and to trust others. The anal stage accounts for independence, the ability to manage and express negative emotions, and acceptance of personal power. The phallic stage accounts for sexuality. The latency stage accounts for socialization and the ability to form relationships. The genital stage, once reached, accounts for all post-adolescent development.


5-How does the theory describe how we develop into "abnormal" people?

If one is derailed from this one true path of healthy development, one develops a number of problems (which may or may not actually be problems). These include (but are not limited to) mistrust and rejection of others, an inability to form intimate relationships, obsession over rules, a lack of appropriate sexuality, and a lack of relationships.



6-How does the theory conceptualize the process of counseling? How does it work, in general?

Freud believes that one developed in therapy by coming to understand and believe in the existence of constructs of questionable validity (except, perhaps, as a metaphor) which describe phenomena which probably can't be appropriately generalized to them, as well as developing control over these phenomena ("achieving insight" or "strengthening the ego", respectively).



7-How does the theory conceptualize the specific techniques of counseling?

Generally speaking, the techniques of psychoanalysis include maintaining a consistent analytic framework and a reliable therapeutic environment, engaging in free association (i.e. having the client talk about whatever (s)he wants without inhibition) in order to allow the therapist to make logical leaps regarding what is within the client's questionably existent unconscious (i.e. interpretations) and to teach the client to accept these conclusions as real, engaging in possibly inaccurate analysis of the content of dreams for meaning which may or may not actually exist in order to teach the client to accept the conclusions of these analyses as accurate, helping the client to overcome any resistance to the acceptance of the therapist's view of who the client is and what the client's problems are, and engaging in possibly-inaccurate analysis of the feelings the client develops towards the therapist during this process (analysis and interpretation of transference).



8-How does the theory conceptualize the roles/responsibilities of the counselor?

Classical psychoanalysis views therapists as "blank screens" for clients to project their feelings for past individuals onto. If the therapist maintains a neutral demeanor and does not engage in self-disclosure, any feelings the client develops toward the therapist are largely assumed to be the client projecting feelings for other people onto the therapist. Additionally, the therapist must listen closely to the client as (s)he free-associates, analyze what is said, and occasionally make interpretations of what (s)he hears, teaching the client to accept the existence of the various constructs created by Freudian theory and to assign causal attribution for feelings and beliefs in a manner consistent with Freudian theory. By aligning the client's view of his self with the therapist's frame of reference and beliefs in Freudian theory, "progress" is achieved.



9-How does the theory conceptualize the roles/responsibilities of the client?

Generally speaking, the responsibilities of the client in a Freudian framework are to cooperate with he therapist as he engages in his responsibilities, to attempt to overcome resistance to his or her acceptance of the therapist's view of who the client is, and to help the therapist develop such a view based on analyses of dubious reliability and validity.



10-What is the utility of the theory...strengths, weaknesses, limitation, applicability?

While our text discusses a number of comparatively minor limitations, these are largely secondary to the lack of empirical validation for large portions of psychoanalytic theory, the non-falsifiable (and thus unscientific) nature of the psychoanalytic framework, the lack of adequate empirical validation of the benefits of therapy (I am unaware of even a single well-controlled RCT which shows a beneficial effect for Freudian psychoanalysis relative to simply having someone to talk to), the focus on teaching the client to accept the analyst's questionable analyses as accurate, the (occasionally realized) potential for severe harm due to this emphasis, and vague criteria for termination of therapy which require therapist/client agreement (and therefore are subject to the various financial disincentives for the termination of a therapist/client relationship).

In terms of strengths, psychoanalysis recognizes the possibility of bias due to a limited set of factors (e.g. countertransference, racial stereotypes) and attempts to teach therapists to counter these. It emphasizes the necessity of a therapist recognizing and accepting who he or she is, recognizes humans as individuals, and emphasizes the importance of understanding the client and the client's problems, and teaches about the importance of a person's history in determining their present. Additionally, it was chronologically the first of the major therapeutic modalities and many of its techniques have contributed to their development.

Also, the couch can be relaxing.