22 Comments

I listened to this, and to your earlier conversation with Bari. Taken together, they offer a very thoughtful and balanced perspective on a difficult issue. Really appreciate your promotion of his critique, it's very much in character, and is one of the reasons I subscribe to your newsletter.

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Nov 28, 2022Liked by Freddie deBoer

I have been a psychiatrist for almost 30 years. I found Daniel Bergner’s statements and attitude typical of people who think they know about a field but have not actually experienced working in that field.

Daniel bases his expertise on talking with a lot of people who have mental illness and having a family member with mental illness. But, there is a big difference between talking with people who have mental illness or having a family member with mental illness and being RESPONSIBLE for the safety of a hundred or more people with mental illness, and the safety of the people they associate with. When I have a suicidal patient, I am personally responsible for the safety of that patient, just as a surgeon is personally responsible for the safety of the person they are operating upon. The difference is that the surgeon has far more control over the situation than I do. I don’t hospitalize most patients who tell me they are having suicidal thoughts. I spend time and energy evaluating other factors that increase their risk or mitigate it. So, most of the time we can work with the suicidal thoughts and the underlying issues without resorting to hospitalization. I have also had patients expressing thoughts about wanting to harm their family, or at times myself. Again, I don’t reflexively put them in a hospital. I look for other factors, but I must take my responsibility very seriously because if I make a mistake someone is going to die. While Daniel is trying to address the problem of medication overuse, without the experience of being responsible for the safety of others I do not think he appreciates how self-absorbed and condescending his statements can come across as.

Second, individualizing treatment takes TIME. We have a tremendous shortage of psychiatrists, especially in rural areas. While there are psychiatrists who just do cookie-cutter medicine, a lot of us want to spend time with patients to give that individualized care. But there are not enough of us to do that. If your schedule is full and someone is suicidal then you can’t just make an hour or two available to individualize the care for that patient. They have to access emergency psychiatric services. Those services are overwhelmed, if they even exist. If they exist and the person gets emergency psychiatric care then those providers will tend to err on the side of extreme caution because that is what our society demands of its medical institutions. If the emergency psychiatric services don’t exist, then the person will be treated by healthcare professionals who are well-meaning but unlikely to have the expertise to make the helpful connections with a severely mentally ill person. Its not that they don’t want to; they don’t have the expertise, the staff or the time to do so.

Third, Americans in general do not want to pay higher taxes or higher insurance premiums for helping mentally ill people. Or at least Americans with political power do not. Today many of the patients with symptoms of severe and chronic mental illness are housed in jails or are homeless. There is a lot of handwringing over that, but no political will to fund the necessary changes. As an aside, we may have had a chance to do that back in the 80’s but the Regan budget cutting spirit led to the closure of the public mental hospitals and discharged the patients to the streets. The excuse was that the mental hospitals were just warehousing patients, and drugging them, but that was not always the case and with continued funding and research things might have been different. See the book “The Great Pretender” by Susan Callahan.

Fourth, it is true that nothing on any brain scan consistently distinguishes someone with a mental illness from someone without. But concluding that there are no changes in the brain is not valid. Multiple sclerosis was thought to be malingering because there were no physical findings associated with the disease. Until our tests became more sensitive. So, concluding that a negative scan means that the symptoms are not caused by a physical change is a false conclusion, especially when the symptoms cause such a profound deficit in the ability to function.

Fifth, Bari made the good point that often people with mental illness are medicated against their will because they are perceived as dangerous. Daniel equated treating people with mental illness preventatively with medication as the same as incarcerating minorities or young men because those groups have a greater percentage of people who commit violent crimes. This is a strawman argument (and Bari missed that). No one is talking about blanket involuntary treatment of people who have mental illness. We are talking about involuntary treatment of people who are having symptoms of a mental disorder indicating that they are at significant risk of IMMINENT danger to themselves or others because of that mental illness.

Sixth, when Bari brought up the examples of someone swinging a machete or defecating in the street he stated that since those are crimes then we should just treat them as crimes. Seriously!!! I couldn’t believe my ears. Calling law enforcement to handle the mentally ill in crisis. I am NOT suggesting that the police would necessarily use force. I know that police often handle mental health crises with high levels of expertise, but where do they bring the person? To the jail? I know that is often done because there is nowhere else for them to go, but that is his answer??? They are committing crimes so put them in jail? Sounds pretty fascist. Certainly not what I would consider compassionate.

These are some of the points I could make. Overall I found the conversation difficult to listen to. Daniel had nothing to offer that has any chance of actually coming into being for the general population, largely because you would need years of massively increased funding to train enough people to perform the tasks that he wants done. He comes across as a know-it-all who thinks that without any experience working in the trenches he knows enough about the field to make sweeping statements about what is needed. He bases his conclusions on a completely unrepresentative sample of cases and when given observations that disprove his conclusions, he uses illogical analogies to dismiss those observations or simply ignores them. His final suggestion was that we avoid involuntary treatment of the mentally by allowing the criminal justice system to handle them.

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This stuff is difficult. While I appreciate all of the points of view, and gravitate to some more than others, I am more impressed by how this “debate” is playing out. The level of respect is refreshing and needed and I thank you, Bari, Daniel, and others involved for the conversation. I second other comments, this is exactly why I subscribe to you and Bari. Thank you.

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As a layperson, I find Bergner’s biographical narratives and arguments interesting in a way that suggests the need for further clinical research. It might be that some cases of psychosis can be adequately managed without medication and it would be useful to understand that. Specifically to know how to differentially diagnose those cases and what non-medication therapy works best for those cases.

Yet, I find Bergner totally unconvincing in his request for changing our current medical and social approach to managing psychosis. Further, I find it a little terrifying that he fully rejects the usage of the word “sick” to describe any cases of mental illness. I’d be greatly relieved if he could at least admit that some individuals cannot function in our society without medication; barring that involuntary commitment is our only option. I’d even give him the copout that such approaches could change over time as we learn more about non-medication therapies.

In their discussion, he even concedes that anorexia may be a different type of mental illness for which we cannot simply allow someone to embrace their delusions. It would seem that Bergner could similarly concede that some cases of psychosis cannot be managed without medicine or involuntary commitment given our current understanding of these diseases. He could still make the argument that medical researchers and practitioners should explore non-medication treatment.

And he could further ask the rest of us in society to be open to changing how we think about psychosis as the medical understanding and therapies evolve. Yet Bergner’s failure to concede that some people are truly sick in a way that currently requires antipsychotic medication has me outright rejecting his argument as being too dangerous.

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As a fan of Bari’s podcast I commend you, Bari, and Daniel for such thorough discussions of a deeply challenging and layered topic. I have some renewed perspectives from both sides, which I think is the best possible outcome for any conversation- especially one about such an important issue. Love to you all.

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It was a good conversation but I found Bergner’s argument to be pretty weak. We all agree how bad this field of psychiatry is …. But He seems to want perfect to be the enemy of the good here because intervention is too problematic. I hope we look back at these conversations in 20 years in horror at how ignorant we were because it means our ability to treat illness, whether through drugs or not, will have improved. But I fear his framing of these illnesses that we do not really understand into the identity affirming woke jargon is just not helpful. But because this woke jargon is everywhere in our culture it allows people who are sympathetic to these points of view to feel as if Bergner is speaking new truth that they can easily buy into. Unfortunately it won’t help the truly ill

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I had also already listened, but fair play to you for linking it.

I don’t think you’re sparring over exactly the same point… you seem to be describing the state of mental health care writ large, in which more access and more treatment is, on the balance, better. Vital, even.

He seems to be arguing more of an individual/anecdotal point that mental health care remains somewhat of a dark art in which the benefits do not outweigh the harms in enough cases so as to warrant broader attention.

For sure you are both right, and argue your points with compelling and personal experience and data. Bravo to Bari for taking on this challenging topic with rigor and focus. Maybe not much was settled in the end, but all of us are more aware and empathetic to the issues because of it.

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Heh, already listened last week, thanks, and it was a great episode. I can't say I found most of Bergner's arguments compelling, but they made me think, and that's always a good thing.

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Weiss notes that Bergner’s book focuses on three gifted individuals. He seems to have over-extrapolated from their experience. It reminds me of the whole language movement where a bunch of college professors, married to other college professors, noticed that their 4 year old kids had taught themselves to read and assumed that’s how it should work for everyone.

He’s assuming that the average severely mentally ill person, who doesn’t have an ocean of extra cognitive bandwidth, financial resources, family support, etc. to manage their illness, can make it work without medication. And it’s just not realistic.

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fantastic interview by BW. She did a great job of giving him an opportunity to "steel man" his own argument, and in the end I thought he fell quite short.

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Agree with everyone here...great job on demonstrating what rational disagreements can and should look like. Wow...no name calling or personal insults. Mr Bergner made a lot of good points about the sorry state of mental health care, but none that are really new and his conclusions are specious

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I think Bergner's opinion is valid and should be considered. I would like to hear Bob's opinion too.

I was a little taken aback by Bari's strong opposition to Bergner's position, but having seen people walking down the street banging their heads with large scraps of lumber, and dealing with patients in the hospital, I side with treatment, even if the patient refuses. Perhaps Bob is able to live with his condition, many patients aren't so fortunate.

Unfortunately in our society, we rarely have good balance, jumping from one extreme to the other, then back again.

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It sounds like Bari Weiss is doing a good job with her podcasts. I'll definitely check these two out.

She was the first writer I subscribed to on substack. I liked the articles she'd written for the NYT.

However, I unsubscribed after about six months because she wasn't doing most of the writing, it was her friends and family....incidentally, that was where I learned about Freddie's substack. What really led me to unsubscribe was the out of control trolls who commented.

I like comment sections. It gives me a chance to read others thoughts and opinions. I learn a lot, it gives me other windows to look out of instead of the view a 65 year old woman who lives a pretty peaceful life in a rural area. But many of these commenters were ignorant and abusive.

Thank you Freddie for taking control of the comment section and imposing a decent level of civility and good manners.

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I, too, listened before your post. I just appreciate you linking the contrasting position. Bari, in drawing Daniel into conversation rather than ignoring what was hinted to be a pointed critique shows her desire for truth telling rather than side taking. Happy to learn from you both.

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Already listened to it. An excellent pod.

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