Fifteen Eighty Four

Academic perspectives from Cambridge University Press


Fads and Fallacies in Psychiatry

Joel Paris

This is a new edition of a book originally published 10 years ago. This is a major revision that updates data supporting the view that psychiatry has been susceptible to fads and fallacies, and that in some ways it continues to make that mistake. I therefore call for a more scientific practice, and for greater humility in the face of the complexity of mental illness.

            I chose psychiatry as a career because disorders of the mind have long been, and still are something of a mystery. As a student, I did not understand why I needed to be taught the history of medicine. Once ideas go out of date, why bother to learn them? Yet as I grew older, I came to realize that progress is not linear. Impeded by false beliefs, medical science can go off on serious tangents. Understanding past mistakes can help us to be appropriately skeptical about current theories and practices–some of which may one day be remembered as dangerous errors.

I have always been the type of person who questions everything.  When I was young, this attitude got me into trouble. I asked tough questions that threatened the certainty of my teachers. Since I did not accept received wisdoms, they saw me as a rebellious young man. Now, in old age, I have been called a curmudgeon for saying many of the same things. While psychiatrists do a lot of good, it remains important to criticize contemporary practice, with its susceptibility to fads and its penchant for fallacies. That is the passion that drives this book.

            My title is a deliberate paraphrase of a classic volume by Martin Gardner “Fads and Fallacies in the Name of Science”. Fads are ideas and practices based on temporary bursts of enthusiasm, while fallacies reflect cognitive errors or wishful thinking. When we think of fads, bizarre ideas come to mind, and Gardner’s book focused on some of the strangest and most pseudoscientific theories of the time. But fads in psychiatry have not only occurred on the fringe, but in the very mainstream of theory and practice. Some of the trendiest theoretical paradigms turn out to be unsupported by data. In diagnosis, currently faddish approaches to classification lack a secure base in etiology, and many are unlikely to last. In treatment, both psychopharmacology and psychotherapy have embraced interventions that have a weak base in evidence and that have made unjustified claims for their efficacy. These errors run the risk of doing harm to patients.

Should we be surprised or discouraged that psychiatry does not yet understand mental illness? No. The brain is the most complicated structure in the known universe. Neuroscience has not solved these problems fast enough to be applied to practice. We are often told that answers lie just around the corner, but that is where they tend to stay. The most important questions remain unanswered.

             Given that psychiatrists still have so much to learn, they need to remain humble. For example, the current rage to reduce everything about mental illness at a molecular or a neuronal level is an over-simplistic and hubristic idea. I am not criticizing basic research. But for clinical application, the biological processes behind mental disorders can only be understood in the context of interactions with psychological adversities and sociocultural stressors, i.e., within a biopsychosocial model. While multifactorial models can be intimidatingly complex, they explain why research on the origins of mental illness and their treatment is so difficult.

             Ironically, the main source of psychiatric fads is that its practitioners badly want to help their patients. Human nature being what it is, clinicians are uncomfortable with doubt and seek certainty. They have trouble maintaining a cautious stance in the face of scientific ignorance. Practitioners don’t want to wait a hundred years for answers, and they are tempted to believe they know enough to practice on the basis of current science. But that view embraces too much certainty and little doubt. And that is the main reason why psychiatry has been infected by fads and fallacies.

          I began my career as a clinician and an educator. In spite of having a contrarian temperament, I largely accepted the views of my teachers. Yet with time, I came to realize that the older generation was wrong about many things. They relied on clinical judgment to support theories and were barely familiar with empirical data. I eventually became committed to a scientific and empirical perspective, and, with the help of colleagues, trained myself to become a researcher. I became a passionate convert to evidence-based medicine. I no longer take clinical experience, including my own, for granted. In spite of the current fad for “lived experience”, I am not prepared to accept ideas that fail to be supported by quantitative data.

For this reason, I have taken care in this book to ensure that its conclusions are consistent with the scientific literature, and to refer the reader to relevant research. I will, however, also draw on my 50 years of work as a consultant. While one cannot base a practice entirely on experience, working with patients can illustrate points that can be confirmed by data. 

Since 1972, I have run a hospital clinic that sees hundreds of patients every year referred from primary care. I also worked in a university health service for 25 years and saw thousands of troubled students. In 2001 and 2007, I founded two specialty clinics for the treatment of personality disorders. Over the last two decades I have conducted many thousands of consultations on patients with these problems. While the patients I treat myself are highly symptomatic, like many of my colleagues, I now spend more time than on consultations to primary care providers.

            In total, I estimate that I have seen at least 30,000 patients over the last 50 years. When my students ask me how I reach conclusions fairly rapidly, I tell them that things get easier after the first 30,000 cases. Yet even the most extensive experience does not make you right. You could be making the same mistakes thousands of times. That is why I strongly support evidence-based psychiatry.      

            If you want to practice scientific medicine, you have to embrace doubt. We do a lot of good for our patients, but often lack the tools to achieve consistent and stable remissions of mental disorders. Our field is only beginning a very long journey.

            I have also been on a journey. A second career in research started rather late, in my mid-40’s. For that reason, I could not reach the same level as those who began earlier. Moreover, I am only one soldier in a vast army. Yet I benefited from more clinical experience that some of my research colleagues, tied to labs and desks, lacked. Being an active clinician also helped me to ask more relevant questions. In turn, conducting research affected my practice.  The doubt that characterizes the scientific culture is the best antidote to fads.

            The clinical trenches are far from the ivory tower of academia. While I aim to practice, as much as possible, in an evidence-based way, when I treat patients, I keep in mind what I can and cannot do. This book aims to map out some areas where psychiatry has failed to remain cautious and humble. It also suggests how we can move forward without replacing one set of fads and fallacies by another.

Fads and Fallacies in Psychiatry by Joel Paris

Title: Fads and Fallacies in Psychiatry

ISBN: 9781009245739

About The Author

Joel Paris

Joel Paris is Emeritus Professor of Psychiatry at McGill University, Quebec, Canada. He heads personality disorder clinics at two hospitals, is the former Editor-in-Chief of the Ca...

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