Regular readers know that I’ve been a big Star Trek geek (more or less) ever since I first discovered reruns of the original Star Trek episodes in the 1970s, having been too young (but not by much!) to have caught the show during its original 1966-1969 run. True, my interest waxed and waned through the years—for instance, I loved Star Trek: The Next Generation, while Star Trek: Enterprise and Star Trek: Voyager pretty much left me cold—but even now I still find myself liking the rebooted movie series. In the original series, my favorite characters tended to alternate between Spock, the Vulcan first officer and science officer on the Enterprise, and Dr. Leonard “Bones” McCoy, the ship’s chief medical officer. I sometimes wonder if my love of these two characters had anything to do with my becoming a doctor and researcher myself. It probably did.

One aspect of all the Trek shows that always interested me was its portrayal of medicine in the 23rd and 24th centuries. After all, what doctor wouldn’t like to have a device like the tricorder that he could wave over the patient and come up with an instant diagnosis and course of treatment? Who knew, of course, that nearly 50 years after the first Trek episode first aired, we would have technology that makes the communicators on the original series (TOS, for those Trek non-fans) look primitive and large by comparison and that we’d be well on the way to developing devices that can do some of what tricorders did on the show. Throughout all the shows and movies, the medical technology of a few hundred years in the future is portrayed as vastly superior to what we have now, with 20th century medicine at times denigrated by “Bones” McCoy and other Star Fleet medical personnel as barbaric quackery.

A confluence of events and media led me to want to explore a couple of questions. First, which procedures that we consider state-of-the-art science-based medicine will be considered “barbaric” 50 or 100 years from now? Second, is the contempt expressed for the medicine of the past (e.g., by “Bones” McCoy) justified? These are questions that I’ll explore a bit with the help of the Star Trek universe, a recent new cable television drama series, and a couple of articles that appeared on medical sites as a result of the premier of that series.

Star Trek: 23rd century medicine vs. 20th century medicine

Perhaps the most amusing example of McCoy’s contempt for the “primitive” medicine of the 20th century occurs in the 1986 movie Star Trek IV: The Voyage Home. (I found it particularly amusing because I was a third year medical student when the movie came out.) For the purposes of this post, you don’t need to know the plot, other than that it involves the crew of the Enterprise time traveling to San Francisco in the year 1986 to obtain something from the past that would save the Earth of the year 2286. During their mission one of the crew, Chekov, is seriously injured fleeing from the military, captured, and as a result taken to Mercy Hospital for emergency surgery. When Dr. McCoy learns of this, he begs Captain Kirk not to leave Chekov in the hands of 20th century medicine. So Kirk and McCoy disguise themselves as doctors and infiltrate the 20th century hospital where Chekov is about to undergo emergency surgery in order to rescue him. It is during this part of the movie that this hilarious exchange occurs:

For those of you who can’t play the YouTube video, here’s a transcript that shows you what I mean. First, “Bones” encounters an old woman on a gurney in the hallway and asks her a question:

McCoy: What’s the matter with you?

Patient: Kidney… dialysis.

McCoy: Dialysis?! What is this? The Dark Ages? Here! You swallow that and if you have any more problems, just call me!

Later, as the crew is escaping, McCoy encounters the woman again, who’s telling everybody that McCoy had given her some pills and she grew a new kidney.

In another scene, Kirk and crew are in an elevator with some interns, and McCoy overhears the following conversation, not being able to stop himself from butting in:

1st Intern: So, Weintraub says radical chemotherapy or she’s gonna croak. Just like that…

2nd Intern: And Gottlieb?

1st Intern: Well, what’d you expect? All he talked about was image therapy. I thought they were going to punch each other.

McCoy [Muttering and shaking his head]: Unbelievable…

1st Intern [Turning to McCoy, having heard his muttering]: You…have a different view, Doctor?

McCoy: Sounds more like the goddamned Spanish Inquisition!

Kirk [Turning to the interns and shrugging shoulders]: Bad day…

Later, Kirk and McCoy kick a neurosurgeon about to operate on Chekov to drain what sounds like an epidural hematoma out of his operating room at phaser-point, and McCoy proceeds to save Chekov’s life with his 23rd century technology.

You get the idea: In the fictional Star Trek universe, to a physician of the 23rd century what physicians of the 20th century do appears as barbaric as the practices of 18th century physicians appear to us physicians of the 21st century. What really got me thinking about this question again was the premier of a new historical medical drama on Cinemax entitled The Knick, which tells the story of Dr. John Thackery, fictional chief surgeon at the Knickerbocker Hospital in 1900. As a surgeon, I can’t help but apply the same sort of eye to surgery as practiced 114 years ago as Dr. McCoy did to medicine practiced in 1986. Unlike McCoy, however, I can’t lather up the same level of contempt for the fictional surgeons of the Knick that McCoy can for the hapless doctors of Mercy Hospital.

The Knick: What a difference 114 years makes!

Although I subscribe to HBO, I don’t subscribe to Cinemax. Consequently, I was only able to view the first episode of The Knick using On Demand, and have since only seen the first three episodes because HBO happened to show them all in a block about a week after the third episode aired. I haven’t seen episodes four or five yet, although I’m seriously tempted to subscribe to Cinemax for the remainder of the season just to see the show and then to drop it after the show’s run ends. However, the episodes I’ve seen are enough to pique the interest of any surgeon interested in the history of surgery. Producer Steven Soderbergh likes to brag about the measures his team has taken to assure historical accuracy with respect to the medicine practiced and the surgical procedures portrayed, particularly how extensively his show has used the Burns Archive, a trove of more than a million historic photographs (a few of which are digitized and displayed here, unfortunately without much in the way of text or captions to tell the viewer what they are), to recreate the look of medicine in the early 20th century.

Of course, it being a fictional show, there are things that The Knick takes some creative license with, such that I wondered about them immediately. For instance, body snatching to supply hospitals with medical cadavers and fights between ambulance drivers over who gets to pick up patients were apparently not as prevalent as The Knick portrays, given that New York was one of the first states to pass “anatomical acts” in the mid-19th century to discourage trade in bodies and body snatching. By 1900, such activities would be a risky, at best, crime not likely to be particularly profitable. On the other hand, given the level of endemic corruption in New York in 1900, characters like corrupt Health Inspector Jacob Speight who takes kickbacks to refer patients he finds with reportable infectious diseases for which the city mandates treatment to the Knick and the equally corrupt hospital administrator who works with him are not implausible.

One thing I noticed in the very first operating room scene (and in all the operating room scenes in the episodes I’ve seen thus far), surgeons are depicted operating bare-handed. Instead of scrubbing up and using rubber gloves, as surgeons have done for many decades now, they dipped their hands into antiseptic solution right before the start of surgery. It turns out that the great surgical pioneer upon whom Dr. Thackery is loosely modeled, Dr. William Stewart Halsted had pioneered the use of rubber gloves in 1889 or 1890 because his scrub nurse (with whom he later fell in love and who ultimately became his wife) had begun to develop severe contact dermatitis as a result of the nasty chemicals (mercuric chloride and phenol) used to disinfect the hands of the operating staff at the time. Rather than have her reassigned, Halsted requested the Goodyear Rubber Company, as an experiment, to make “two pair of thin rubber gloves with gauntlets.” At first, only assistants used them, but within a couple of years, the surgeons at Johns Hopkins, where Halsted practiced, were using them. So it seems a bit of creative license that the surgeons at the Knick would still be operating bare handed. On the other hand, it’s not too beyond the pale that some surgeons might still be operating bare handed in 1900, given that it wasn’t until 1899 when Halsted’s protégé Dr. Joseph Bloodgood (what an awesome name for a surgeon!) published a report of 450 hernia operations using gloves, observing that the infection rate fell by nearly 100%. Bloodgood’s report led Halsted to take himself to task, asking “Why was I so blind not to have perceived the necessity for wearing them [rubber gloves] all the time?”

Think of it: A man with one of the most brilliant minds in the entire history of surgery responsible for so many surgical innovations, from emergency blood transfusions, to cancer surgery, to something as mundane as a bedside chart to track a patient’s vital signs and the use of surgical gloves operating room, a man who first laid down surgical principles still taught to all surgeons today, such as a completely sterile surgical field, hemostasis, gentle handling of tissue, careful anatomic dissection, and exact approximation of tissues, and Halsted couldn’t immediately figure out that wearing sterile rubber gloves instead of dipping one’s hand in caustic chemicals to disinfect them was a superior means of preventing surgical infection!

Other examples, although perhaps anachronistic, are found in the fictional world of The Knick. For example, the very first OR scene in the very first episode portrays the attempt by Dr. J.M. Christiansen and Dr. Thackery to perform a Caesarian section on a woman with placenta previa, after having failed at this procedure eleven times before. They fail again, with the mother and baby both dying. As a surgeon, I found this scene particularly disturbing and effective. As I watched the impressively realistic pools of blood form, overwhelming the ability of the pedal-driven suction to clear them, the surgeons frantically working, and the nurse reporting a faster and faster pulse (and ultimately no pulse), all as dozens of doctors and trainees observe the procedure, I couldn’t help but wonder how surgeons could actually save anyone in such an environment.

The same question came up later in the same episode, when a man with a bowel perforation had his injury repaired primarily. The surgeon who did the repair was taken to task by Thackery on rounds for not resecting. Later, the patient develops intra-abdominal sepsis, requiring Thackery to operate on him using an instrument he had constructed himself to resect the nonviable bowel and sew it back together. While I admit that this part made me wonder (bowel anastomoses were pretty standard procedures by 1900; so I’m not sure why this would have been so revolutionary), I still had to marvel how any surgeon could expect any patient with a bowel resection to survive intra-abdominal sepsis after a bowel perforation with no antibiotics as adjunctive care for the drainage and resection.

More examples included a man with an aortic aneurysm, for whom the treatment would be a galvanic procedure (using electricity to induce thrombosis of the aneurysm), an attempt to reconstruct a woman’s nose lost to syphilis using a tissue flap from the arm that necessitated the arm to be attached to the nose for several weeks to provide a blood supply (a technique still in use today for some reconstructive procedures), and the portrayal of Dr. Thackery anesthetizing a patient using a cocaine epidural. A lot of these weren’t exactly 1900 medicine, although they were generally from within a few decades. Dramatic license again. The point, however, is that medicine always operates within the context of the existing scientific and clinical knowledge of the time. Of course, The Knick is a vision of what medicine was like in 1900 imagined by a man of 2014. However, it’s also informative to look at medicine as portrayed in the media contemporaneously, as we will see.

To do that, I leap from the world of The Knick to 50 years in its future. Remember that post I did a couple of years ago about the old time radio show featuring the fictional young surgeon Dr. Kildare? In it, I discussed an episode in which a young woman, who used to be a famous pianist but had ceased performing due to an inability to tolerate being on stage and as the episode opened was showing signs of paranoid schizophrenia in her calling Dr. Kildare to tell him she thought her husband (who just so happened to be a friend of Kildare’s) was trying to kill her?

From the perspective of 2014, this episode is disturbing in any number of ways. First, there is the demonization of mental illness that shows through even a seemingly sympathetic script. Words like “lunatic” and “lunacy” were thrown about not by lay people but by Drs. Gillespie and Kildare themselves to describe Mrs. Kester’s mental illness. In some ways, the desperation is understandable. 64 years ago, there was little that could be done in such cases, and it is not entirely surprising that a sense of desperation led to the conclusion that desperate conditions call for desperate measures, such as insulin shock therapy (a dangerous therapy that didn’t work), ECT (which could work and is still occasionally used in the case of severe depression refractory to medication but was hugely overused then), and, of course, prefrontal lobotomy. Interestingly, this particular episode of Dr. Kildare aired right at the height of the lobotomy craze (and, quite honestly, that’s what it is best described as, as is evident from Mo Costandi‘s description of the rise and fall of the lobotomy). It’s therefore no coincidence that this episode aired in 1950. No doubt the writers were doing what writers of medical series frequently do now: Feature a new medical or surgical treatment as the focus of drama.

Discovering this episode a couple of years ago simultaneously fascinated and appalled me. Like most TV and radio shows, Dr. Kildare is a time capsule both of the popular perception of how medicine was practiced during its time and of how medicine actually was practiced at the time. We had the young gun surgeon, highly skilled and compassionate, willing to take risks and push the boundaries paired with the old curmudgeon of a doctor who serves as his mentor and, despite his crankiness, is often revealed to have a heart of mushy gold. The show featured portrayals of medicine as practiced then, and, much like medical TV shows today, had medical advisors to guide the writers. In 1950, the prefrontal lobotomy, although admittedly controversial even then, was an accepted standard of care that we now view with horror—the very sort of thing that appalled the ever-irascible Dr. McCoy (who, by the way, bears a strong resemblance to the perhaps even more irascible Dr. Gillespie, except that he didn’t have the excuse of being really old). But how many others are there?

A rebuke to Dr. McCoy

As much as I love Dr. McCoy as a character, in that famous Star Trek IV hospital scene, he is dead wrong in his sneering contempt for medicine 300 years before his fictional time, just as I would be wrong to express the same sort of contempt for physicians from 1714 for believing diseases were a result of imbalances in the four humors, surgeons in 1900 who practiced without the benefit of antibiotics, or physicians in 1950 who were believing the case reports about frontal lobotomy. Physicians all practice according to the standard of the time, and that standard is based on the science as understood at the time. It is ridiculous to criticize physicians for not knowing something that hasn’t been discovered yet. In 2014 I hold in the palm of my hand a computer (my iPhone 5s) that is hundreds of times faster, drives nearly 2.5x more pixels, and holds thousands of times more data than my clunky Mac LCII. Should I heap scorn on the computer engineers of a mere 22 ago because computers then were so much less powerful than what we have now? Those engineers did the best they could with the technology they had.

I would also point out that science advances incrementally, building on what is known before, although there have been moments of rapid advance. It turns out that 1900 was a time of such advances in the field of surgery and medicine, and The Knick is infused with an attitude, from the perspective of 2014 writers, of hope for the future of medicine. This attitude shows itself in small and large ways. For instance, near the beginning of the second episode of The Knick, a flashback shows Thackery’s mentor and friend Dr. J. M. Christiansen giving him a tour of his pathology laboratory, complete with a morgue and lab benches full of test tubes and bottles of chemicals. Christiansen exults that this, not doing more house calls, is the place where disease will be understood and conquered in the future, by studying the dead and using the laboratory to understand physiology and disease. We know it’s a flashback, because Dr. Christiansen, having failed to save the life of the mother and child with placenta previa in the first episode, placed a sheet over the couch in his office, picked up a gun, laid himself on the couch, and shot himself in the head..

This flashback mirrors the scene in the first episode where Dr. Thackery gives a remarkable eulogy for his friend Dr. Christiansen. This eulogy is particularly remarkable for its view of medical progress:

In particular, Thackery notes:

We now live in a time of endless possibility. More has been learned about the treatment of the human body in the last five years than was learned in the previous 500.

Many have said the similar things during the last few years, given the revolution in genomic medicine in which we currently find ourselves, and it’s true. We do live in a time of endless possibility, with amazing technology and science almost unimaginable by even the generation that preceded us. So, yes, I’d be shocked if some, or even a lot, of what we do right now as the standard of care is overturned even in the remainder of my career. I’ve already seen it just since I first entered medical school in the 1980s. It will continue, and that’s a good thing.

We are all products of the time in which we live, and we all have a tendency to view history through the lens of what is known now. To have a true understanding of the history of science, however, it’s important to try to put yourself in the shoes of physicians and scientists of long ago and take into account what they knew then and what tools they possessed. For example, the Halsted radical mastectomy is often decried as a “brutal” and “barbaric” operation. And so it seems to a surgeon of 2014. But remember: In the 1880s, when Halsted first conceived the operation, there was no chemotherapy, no radiation therapy, no adjuvant therapy of any kind. Breast cancers tended to present at an advanced stage. If a woman with breast cancer was to be saved, surgery alone was what would have to do it, without the highly effective help we surgeons now receive from our colleagues in medical and radiation oncology. In context, based on the understanding of cancer of the times, the operation made sense, and Halsted’s results were better than those of other surgeons. Similarly, today chemotherapy seems “brutal,” but it works. It’s the best that we have.

Going back to the fictional past of the Knick (and the real past), physicians in 1900 were just as clever, just as dedicated, and just as desirous of curing their patients as physicians are now. What they lacked then is the knowledge and technology that we have now that allow us to do what we do now. Medicine stagnated for hundreds of years, until the latter half of the 19th century, when it began to embrace science, and its failures tend to occur when it forgets science. Yet medicine advances nonetheless, thanks to science. It might do so in fits and starts. It might go down blind alleys. It might fall for fads based on less than rigorous science. But eventually, it advances, and we obtain the knowledge and develop the technology necessary to improve. Even in the fictional universe of Star Trek, I’d bet that the physicians of 1986 were no less clever and dedicated than Dr. McCoy. The difference is that Dr. McCoy had tricorders and other products of the science and technology of 2286. Science is what got us from the world of the Knick to where we are now, and science is what will get us to the world of Dr. McCoy.

Comments

  1. #1 Krebiozen
    September 22, 2014

    I wondered if anyone else here had been watching ‘The Knick’ – I’m thoroughly enjoying it – the class and racial inequalities back then add to the medical interest. I can only imagine the frustration of doctors back then having little or nothing to offer for conditions that are easily cured today. However, I’m worried about Dr. Thackeray’s opiate addiction – it will surely end in tears (the Great Man is running out of viable veins).

    I agree with Orac about seeing anachronistic medical practices within their historical context. Stephen Jay Gould’s essays often looked at what appear to be bizarre historical beliefs (mostly about natural history), and showed how they made perfect sense given the knowledge of the time.

    Speaking of medical dramas, did anyone else see ‘Rush’? It’s set in present day Los Angeles and is about a freelance physician who self-medicates with a bewildering variety of pharmaceuticals while getting paid ridiculous amounts of money to discreetly treat the rich and famous for conditions they don’t want to take to a hospital. The season has just finished; it got poor reviews but I found it quite entertaining as an unwind after working. I do suspect that restarting hearts and treating opiate ODs on someone’s living room floor isn’t quite as straightforward as the program makes it look.

  2. #2 Denice Walter
    September 22, 2014

    I saw two episodes – both involved drug abuse. Nice depiction of an opium den in Chinatown-btw-, I also enjoyed ( naturally) the period costumes and interiors as well as the fact that the abortionist moonlights from her other career ( heh).

    When viewing the operation scenes I *thought* that the gloveless surgeons looked a bit off , that they did indeed use gloves by then- not that I studied the history of medicine HOWEVER I am familiar with the realist art of Thomas Eakins whose scenes of operating rooms were circa 1875-1889 ( the Gross Clinic and the Agnew Clinic, respectively) which were sans gloves and rather bloody. Perhaps these works of art may have had an influence.
    Minions might take a peek at these paintings and articles about Eakins @ wikip-

  3. #3 Denice Walter
    September 22, 2014

    Krebiozen said: ” the class and race inequalities…”

    You left out another inequality.

  4. #4 Wesley Dodson
    September 22, 2014

    The problem is when, as with pre-frontal lobotomies or blood-letting, quackery is in vogue with the medical establishment. Not yet knowing better is a poor excuse for taking a stab in the dark at a patient. Your attitude can be ‘Hey, it’s a learning process’ but of course the physician’s first principle is to do no harm. It is a lot easier to inadvertently harm someone when, like a doctor, you are assured of being right. Doctors have been around for a lot longer than the science that has refuted some of their grotesque practices.

  5. #5 Krebiozen
    September 22, 2014

    Denice,

    You left out another inequality.

    Very true; I certainly wouldn’t have wanted to be a woman back then.

  6. #6 DLC
    September 22, 2014

    The local hospital here has a collection of antique medical instruments in a case out in the lobby, with little cards explaining what each item is. The collection includes a drill, for opening a hole in a patient’s skull. Me, I don’t know if I’d want some 19th century surgeon using a bit and brace on my skull.
    I have to agree with Dr McCoy, it looks fairly barbaric by comparison.

  7. #7 Johnny
    127.0.0.1
    September 22, 2014

    On the other hand, it’s not too beyond the pale that some surgeons might still be operating bare handed in 1900, given that it wasn’t until 1899 when Halsted’s protégé Dr. Joseph Bloodgood (what an awesome name for a surgeon!) published a report of 450 hernia operations using gloves, observing that the infection rate fell by nearly 100%.

    We (sorta) have pictures –

    I’ve mentioned in the past that I enjoy Shorpy, a web site that post old photographs. These are high resolution scans of photos (mostly) from the Library of Congress. The scans are lightly processed, and tagged according to subject matter. One of the tags is Medicine, at
    http://www.shorpy.com/image/tid/196

    In that group is a photo captioned “New York circa 1900. “Operating room, Brooklyn Navy Yard Hospital” ” .
    http://www.shorpy.com/node/8009?size=_original#caption
    It shows what appears to be the preparation for a leg amputation. Note the bare hands, street shoes, and no masks. (You can click on the picture to be taken to a comments page.)

    (Also see this high tech operating room at
    (shorpy url)/node/8297?size=_original#caption )

    Compare with
    (shorpy url)/node/5945?size=_original#caption
    a view of surgery from 1922.

    One other thing they jumps out at me looking at the medical pictures from back in the day is the nurses. How did the function in those uniforms?

    Examples –
    (shorpy url)/node/18450?size=_original#caption
    (shorpy url)/node/16515?size=_original#caption

  8. #8 Denice Walter
    September 22, 2014

    Johnny wonders how nurses functioned in those uniforms and I wonder how women in general even walked around in what they wore.
    Long dresses, staricases, dirty streets, horses…

  9. #9 Denice Walter
    September 22, 2014

    STAIRCASES

  10. #10 nutritionprof
    September 22, 2014

    I, too, am a huge Star Trek Fan -and when my students had no idea who Locutus of Borg was…well, let’s say I’m not feeling any younger.

  11. #11 Johnny
    127.0.0.1
    September 22, 2014

    I wonder how women in general even walked around in what they wore.

    The horses back in the day kept unemployeement down. Street sweeper was a job, not a piece of equipment – see
    http://www.shorpy.com/node/11119?size=_original#caption
    lower right. The women seem to be walking around just fine.

    The long dresses didn’t seem to prevent women from enjoying themselves. See
    (shorpy url)/node/13005?size=_original#caption

    Of course, some of the women are in bathing suits, and I do mean [b]suits[/b]. I’ve been soaked while wearing clothes, and it’s uncomfortable. I’m not sure if a dry dress or a wet bathing suit would be worse.

    One thing to note is no beach towels, and people are just sitting in the sand. Also, note the ropes to hold on to as you walked into the surf. When you don’t know how to swim, the surf can be a scary place.

  12. #12 sadmar
    The Language Lab
    September 22, 2014

    I think to call something ‘barbaric’ typically means: “we’ve come a long way since people did that, and it would stupid and cruel to do that now.” That is, the term references a comparison between present and past. If we call blood-letting ‘barbaric’, we’re not saying pre-modern physicians should have known better. It was hardly ‘quackery’ when it was common practice. On the other hand, pre-frontal lobotomies may have been ill-advised from the moment they were conceived. Again, with hindsight we see the error, but it may have been a very different sort of error at the time: one borne out of prejudice rather than mere lack of medical knowledge.

    McCoy’s contempt is directed at anything to which he knows better. This is part of his cantankerous character, and I think, meant as a bit of a joke by Trek’s creators, especially in Voyage Home where Scotty as well shows some future-arrogance by thinking the computer mouse is a microphone. We’re supposed to think his judgements of our time are a iittle unfair. So, no, for us to have a similar contempt of the era of The Knick is unwarranted.

    However, a more specific contempt for certain practices may well be justified…

    What “procedures that we consider state-of-the-art science-based medicine will be considered ‘barbaric’ 50 or 100 years from now”? I’d guess few if any. But science-based medicine did exist in the 1950s, and had a state-of-the-art at the time, but pre-frontal lobotomies were not part of that. They may have been part of the standard practice of care, but to label them SBM is to insult the care and rigor SBM physicians and researchers employ. The “sense of desperation came from the demonization of ‘lunacy’ and the conclusion that desperate measures were called for had no basis in science. Anyone who has even a passing knowledge of the practices in mental asylums during most of the 20th Century will understand the difference between ‘standard of care’ and ‘ethical medical science.’

    So, yes, elements of our contemporary standards of care will be considered barbaric in the future, but those will mostly be treatments which have very weak scientific foundations: and following the lobotomy example, I would expect many if not most of those to lie in the realm of mental health. Medical science has a good handle on most of the afflictions of the body, cancer notwithstanding. But afflictions of the mind are something else. Neuroscience is still in it’s infancy, and medical psychiatry is basically blindfolded folks throwing un-aerodynamic darts at a small target — they just have a better chance of hitting something that helps a little than the patients have i getting along by themselves. CBT — the current all-but universal ‘standard of care’ in talking therapy is just Norman Vincent Peale boot-strapping wearing a lab coat: intellectual bulldrop. Ask a therapist to justify it, and you might as well be talking to a chiropractor: “it makes a lot of people feel better.”

    I don’t know if or when the day will come when ECT and mood stabilizers will be seen as being barbaric as we see pre-frontal lobotomies now, but it can’t come too soon.

  13. #13 squirrelelite
    September 22, 2014

    Remarkable set of pictures, Johnny.

    My mother could have been one of those nurses in the 1942 photos, except she was training in Texas, not New York.

    Mostly, the nurses functioned just fine in those clothes. They did spend a lot of time getting them washed and starched and ironed though. Uniforms in the 50’s and 60’s weren’t that different, just updated a bit. As I recall, there was a general relaxation from the formal style nurses uniform in the 60’s and 70’s. It’s only in the last 20 or 30 years that casual style scrubs have become the norm in hospitals.

  14. #14 doug
    September 22, 2014

    “…surgeon using a bit and brace on my skull”
    I would guess that the bit was probably made specifically for the purpose, and a brace gives pretty good control.
    One of the things that really makes me cringe on “doctor” TV programs is the emergency use of a power drill with an ordinary twist drill bit for boring holes in skulls. Anyone who has ever used such knows that controlling the breakthrough is remarkably difficult on lots of materials, and it only takes 3 or 4 turns of the bit, at most, to run it in right up to the shank. This is not a happy situation for the brain, though it may tend to stifle complaints from the patient.

    For those unfamiliar, here’s a video (good stuff starts at about 1:20) that shows the sort of things that happens (on plastic, not a skull).

  15. #15 sadmar
    Still at The Language Lab
    September 22, 2014

    I really enjoyed this essay when I first read it on ‘SBM,’ but the last sentence stuck in my craw. Reading it again today, I think I’ve identified ‘the problem,’ and moreover I think it goes directly to a lot of the conflicts circling around ‘science’, especially, say, the tension between scientists and sensible folks in history/philosophy/sociology of science. And the problem is the word “science” means more than one thing, and in fact quite different things, but may too many people are using the term in undifferentiated ways that conflate things that ought to be considered separately and just get everybody confused and talking at cross purposes when they’re lumped in the same linguistic pot.

    In my academic career, I made the acquaintance of a few well-known folks in ‘science studies’ (Andrew Ross and Stanley Aronowitz most notably) and various ‘lesser lights’ in history/philosophy/sociology of science, all before the ‘Sokal Hoax’ poop-storm. I would not have considered a one of them to be ‘enemies of science’ in the slightest degree, and to see them characterized as such just left me gob-smacked. As humanities folks, they look to modes of inquiry outside science to explore questions science can’t effectively address, but they’re as happy to have good data and solid findings as anyone. Devotees or reasoned argument and critical thinking all, and I never heard a peep from any of them endorsing CAN, AGW denial, creationism, mysticism, etc. etc. Rather, these would things they Did Not Like, and would ‘go to the facts’ to oppose (though wrapping said facts in a larger ‘Theoretical Framework’ to be sure).

    Anyway, my first hypothesis: When scientists talk about ‘science’ their primary referents are ‘scientific knowledge’, ‘the scientific method’, ‘the process out scientific research’, the facticity of the results achieved, and so on. When humanities folks talk about ‘science’ they are talking about the social institutions in which science work is embedded, and how the results of scientific inquiry make their way back out into the social realm. I hope it’s obvious that these are quite different things. The problem, IMHO is that when scientists champion the truths revealed by science, the social conditions of scientific work tend to dragged in for celebration in an absence of critical thought. And when social theorists critique how science works in the social realm, it sounds to many like an attack on the validity of knowledge produced by scientific research.

    And then various unscrupulous woo-ists come along, appropriate elements of the critique, run it through a fun-house of distortions and come out with “Reiki works, because ‘Scientism’!” And Feyerabend, Horkheimer, Kuhn, and Popper all spin in their graves… The New Fontana Dictionary of Modern Thought defines ‘scientism’ as “the view that the characteristic inductive methods of the natural sciences are the only source of genuine factual knowledge and, in particular, that they alone can yield true knowledge about man and society.” So, yeah, the philosophers say ‘there are other ways we can know stuff.’ But they don’t say ‘anything goes’ at all, and they don’t say another of those other ways are even remotely useful for gaining knowledge in physics, chemistry, biology, medicine, etc. etc.

    Another way of stating it: there’s a difference between ‘knowledge in’ and ‘knowledge about’. I have very little knowledge in Chemistry, (I remember the high school basics), but I know some things about Chemistry, in the sense I have some idea what chemists do, the uses to which Chemistry has been put in the world, and the crimes against people and nature that Chemical companies have committed (e.g. Love Canal). See, depending on how you take the word, those crimes have nothing at all to do with ‘science’, or everything to do with ‘science.’ The word just doesn’t work…

    My second hypothesis: We’d all be better off if everybody stopped talking about ‘science’ as if the work and the context were all of a piece. I don’t have any bright ideas for simple pragmatic terms to denote the distinction… but surely someone could think of something.

    The ‘scientist’ proclaims, ‘Science Works!’ The historians/philosophers/sociologists of science ask, ‘But whose work does it do?’ The ‘scientist’ is befuddled by the question, and has no reply.

  16. #16 sadmar
    Not at my regular computer
    September 22, 2014

    (Crazy trackpad does ‘Submit’ apparently by Reiki… continued from previous post…)

    Orac wrote: “Science is what got us from the world of the Knick to where we are now, and science is what will get us to the world of Dr. McCoy.” That statement is absolutely false. Progress in scientific research was essential to getting us from the world of the Knick to where we are now, but so also was politics. And Dr. McCoy practices in an imagined future where the people of Earth are no longer at war with each other, live in peaceful co-existence with alien races, and explore the Galaxy in search only of knowledge, not power or profit. Obviously, we’d never to get to any similar utopia, interstellar or terrestrial without great progress in scientific research. But science alone? I shall answer by synecdoche: AFAIK Edward Teller was a brilliant physicist. He was also a thoroughly despicable human being. Who put him in charge? Why did his research get an unlimited budget while other physicists went wanting for funds? The ‘science’ science-studies studies is the institution that has never been run by ‘scientists’. And not always or even mainly for ill, just too often. If ‘scientists’ were given the reins of ‘science’ in that sense, would they know what to do with it? I’m pretty sure I’d trust Orac to stay in his domain and do the right thing for the common good. Richard Dawkins? Hell no.

  17. #17 Antaeus Feldspar
    September 22, 2014

    CBT — the current all-but universal ‘standard of care’ in talking therapy is just Norman Vincent Peale boot-strapping wearing a lab coat: intellectual bulldrop. Ask a therapist to justify it, and you might as well be talking to a chiropractor: “it makes a lot of people feel better.”

    I’ll give you the benefit of the doubt and assume that your only encounters with CBT have been with incredibly poor practitioners, but still, this comment of yours is so ignorantly wrong, you might as well be one of the antivaxers who show up here declaring that vaccine manufacturers put preservatives in vaccines “for no reason”. Not doing some actually very easy research to find out the reason behind a practice, or the model on which a major approach in a field is based, does not mean it does not exist.

  18. #18 Erp
    September 22, 2014

    I haven’t seen the show but are the nurses wearing different types of caps? It was traditional for each nursing school’s graduates to have their own cap style. I’ve heard stories from my mother of her nursing training in the 1950s (the starching and ironing of uniforms including the cap took a lot of time).

  19. #19 sadmar
    Singin' Patsy Cline
    September 23, 2014

    Antaeus:

    I have mental health issues. Do you? Have you ever been hospitalized with, say, depression? Have you ever, say, made a specific plan to end your life? See, if you had, I would really hope you’d have enough empathy not to attack someone who has as “so ignorantly wrong” they might as well an anti-vaxer.

    I am quite aware that CBT (and DBT) have a model, a rationale, and I know something about it. I stand by my conclusion that said model is intellectual crap. And yes, given that it’s, you know, hyperbole, I stand by the power-of-positive thinking crack. My multiple encounters with CBT have either not-helped or made things worse. I have seen my share of Marsha Linehan videos, and if that juvenilea is in any way comparable to vaccine science then my cat is a Reiki master.

    If you’ve got valid science for the CBT/DBT model, bring it! In the meantime, go back to my post and make an attempt at high-school level reading comprehension:

    I DID NOT SAY ANYONE SHOULD NOT GET CBT! I SAID I HOPE NEROSCIENCE SOLVES ENOUGH BRAIN RIDDLES IN THE FUTURE SUCH THAT MORE EFFECTIVE MENTAL HEALTH TREATMENTS CAN BE DEVISED!

    As far as mental health goes, “it makes people feel better” is all we have right now, and, trust me, I’m all for anything that works and doesn’t do permanent brain damage (which my dad suffered from repeated old-school ECT back in the effing barbaric day, BTW). Have you ever been on an anti-psychotic or anti-epileptic? That s*** is f***ing barbaric, but if you need it, you take it because not taking it is worse. (I didn’t need it, but they put me on it anyway, because they were just throwing darts in the dark.)

    If CBT/DBT has helped you, hooray for Marsha, and three more cheers for anybody else it helps, because if even one person finds something, anything, that helps them get out of that pit of hell, it’s all good, whether it CBT or Jesus (as long as they keep it to themselves anyway.) But don’t tell me either the off-label meds or the talking therapy is ‘science’ unless you have the goods to back it up, and it better damn well have the proper controls and not be merely correlative because I will switch your naked behind if it doesn’t. And one of those controls damn well better be 12-step-programs because they work too, and God is in 7 of the 12 steps, and if your outcomes can’t whup faith healing you can put your Linehan tapes where the sun don’t shine.

    Anti-vax? Dude, if you are not on meds and in therapy right now, pick up the phone right now. And while you’re waiting for a spot to open at the local shrink-shop, take a look in the mirror so you know what despicable arrogant sub-human scum looks like.

  20. #20 Antaeus Feldspar
    September 23, 2014

    Thank you for confirming that it would have simply wasted my time if I’d carefully explained the model behind CBT and the evidence base supporting it. You are not interested in giving a fair evaluation of CBT, because that would be too painful for you, and I understand that.

    However, it means that you probably shouldn’t bring up such issues on a forum like this one where people actually CHALLENGE statements that have no factual basis, instead of just nodding their heads and saying “Hyperbole! Therefore factual accuracy is unimportant.”

    I’m not going to discuss my mental health issues with you except to say that like all your other assumptions (I’m “sub-human scum” because I contradict a statement you made which was not factually accurate? Would I still be human if I wrote off your views as “bulldrop”, or is it simply contradicting you that makes me sub-human, no matter what the phrasing?) your assumption that I could not possibly have suffered as much as you have in this regard or I’d be agreeing with you is … well, since you don’t like “ignorantly wrong”, you’re going to have to fill in whatever is the *allowable* antonym to “correct” in your carpeted world.

    As a final note: who the hell is Marsha Linehan? In the twenty-five-plus years I’ve known about CBT, I have never, ever encountered that name – which puts the idea that if she can be shown to be full of sh*t the entire field of CBT goes down with her *also* in that category of “ideas which are the antonym of right”.

  21. #21 JGC
    September 23, 2014

    Re: the valid CBT data you asked for, I’d start with PMID:23459093 and PMID:16199119

  22. #22 Denice Walter
    September 23, 2014

    Because Antaeus is doing such a fine job I don’t feel the need to step in – I’m swamped with other work as well and don’t want to get involved in an entangled debate- CBT is based upon demonstrable effects ( see JGC) which have been observed for a long time.

    In short, people can have unrealistic beliefs, which if acted upon create undesirable outcomes: this can be fixed.

    And -btw- I’ve never heard of LInehan either: I note that her therapy is called DBT- which I never heard of until I looked her up today.

    I am not a practiitioner of CBT althoughI have studied it and what I have done in the past occasionally resembled it somewhat .- I usually just help clients to develop skills which will enable them to achieve more of what they choose and present viable alternatives that they haven’t considered yet- frequently I help young and older( mostly) EFL/ ESL women to get a better education and change their careers and lives as they like

  23. #23 sadmar
    Carpeted Black Hole
    September 23, 2014

    JGC: Thank you for the references. I’ll look into them further when I get a change.

    Andreas:
    1. “You are not interested in giving a fair evaluation of CBT.”
    I have already made a fair evaluation of CBT. Fair evaluations, however, may still be incorrect. Regardless, you continue to miss or ignore my points.
    A. My evaluation of CBT has nothing to do with it’s effectiveness as treatment, but rather it’s intellectual principles.
    B. As we are in the stone-knives-and-bearskins age of mental health treatments, intellectual rigor of any sort is essentially irrelevant if a form of treatment helps people. E.g. as an atheist I would not benefit from a 12-step-program, as I would recognize its fundamental principles as woo. 12-step-programs, however, seem to be a significant public good, and I would never tell an addict NOT to go to one.

    2. “statements that have no factual basis…”
    I have plenty of factual basis for my statement. It’s just not relevant to what you seem to want to discuss, which is the general efficacy of CBT practice.

    3: “Would I still be human if I wrote off your views as ‘bulldrop’?”
    Yes. That’s infinitely preferable to ‘ignorantly wrong,’ as it makes no assumption about my knowledge. People can know a lot about something and still be spectacularly wrong.

    3. “Is it simply contradicting you that makes me sub-human, no matter what the phrasing?” (Hmm, sophistry or continuing comprehension fail? No matter…) No. You may contradict me as much as you like, though I shan’t be impressed unless you mount an actual argument.. What makes you sub-human scum is the utter lack of empathy you displayed in saying “you might as well be one of the antivaxers.” For the record, I do not advocate refusals of medical treatments, I condemn selfish practices that put other people’s health and lives at risk, and I do not consider autistic children to be ‘broken’. You basically called me a murderer. You apparently still think that’s OK, and are trying to change the subject…. Wait… Richard, is that you?

    4. “Your assumption that I could not possibly have suffered as much as you have in this regard or I’d be agreeing with you…” (Hmm, sophistry or continuing comprehension fail? This is getting old.). I made no assumption about any comparative suffering whatsoever, and said nothing resembling ‘you would be AGREEING with me if such-and-such.’ I said, plain as f***ing day, that I HOPED if you had suffered to any degree (less, equal, more??) you would have the empathy not to equate me with Andrew Wakefield. GOT THAT??

    5. “since you don’t like ignorantly wrong’, you’re going to have to fill in whatever is the *allowable* antonym to ‘correct’ in your carpeted world.”
    a. Carpeted world? Is that like a rubber room? (Hint: unless you actually have a Poetic License, you might want to double-check your attempts at metaphor before you click “Submit Comment”.) Or is it a reference to acoustic treatments? If you don’t have carpeting, you might think about getting some. It cuts down on room ambiance, thus increasing the chance you can hear things other than the echo of your own voice. You might try here or here if you’re a more Think Global, Act Local guy, or here if you’re of a less terrestrial mind. (There used to a Carpet Universe in Dalton, GA, but it apparently no longer exists. Could be a Big Bounce thing so, so maybe it will come back with a Bang.)

    b. I do have some cheap carpet tiles in a couple rooms of the double-wide, but the primary acoustic dampener here is the shelves of books. So I checked a thesaurus and got ‘inexact’ ‘false’ ‘mistaken’ ‘inaccurate’ ‘erroneous’ ‘faulty’ and ‘wrong’ as antonyms of ‘correct’.. ‘Ignorant’ is not in there. Antonyms of ‘ignorant included ‘knowing’, ‘aware’, ‘conscious’, ‘perceptive’ and ‘astute’. Perhaps if you had been consciously aware of how “ignorantly” you would be perceived by some one who knows something about language, you might have been astute enough to choose ‘mistaken’.

    6. You excoriate me for not doing “very easy research” on a subject I have researched very easily, yet having never heard of Marsha Linehan you can’t be bothered to cut-and-paste into the Google?

    “Marsha Linehan, Ph.D., is a Professor of Psychology at the University of Washington. She is the developer of Dialectical Behavior Therapy (DBT), a treatment originally developed for the treatment of suicidal behaviors and since expanded to treatment of borderline personality disorder and other severe and complex mental disorders. In comparison to all other clinical interventions for suicidal behaviors, DBT is the only treatment that has been shown effective in multiple trials across several independent research studies. It is currently the gold-standard treatment for borderline personality disorder. Linehan has written four books, including: Cognitive-Behavioral Treatment for Borderline Personality Disorder and Skills Training Manual for Treating Borderline Personality Disorder. She serves on a number of editorial boards and has published extensively in scientific journals.”

    I have participated in group sessions at three different hospitals in different cities where I have lived. All three identified as ‘CBT’ but in practice mixed CBT and DBT. In all three we watched some of Dr. Linehan’s instructional videos. One of these groups was a sort of lecture/discussion format, where the patients had minimal opportunity to discuss their own cases. That one did-no-harm to me. One of them included sessions where patients actually got to talk. I was in that one for a month, during which time I improved. The only ‘therapy’ option offered by my current health plan is a lecture format where patients are only supposed to ask questions of clarification. That actually brought back my depression, so I stopped going. In all three situations, though the method was doing nothing for me, I could see that it might be benefiting other patients, many of whom were much worse off than I was, so I kept my reservations to myself, tried to roll with the flow, and chip in with supportive comments when other members of the group spoke.

    Finally, how you can twist my explicit statement, “I’m all for anything that works… whether it CBT or Jesus” (or Buddha in the case of DBT, though neither the programs I’ve been in or Linehan’s videos bring that to the surface) into “the entire field of CBT goes down” is beyond my comprehension.

    In sum, I have intellectual issues with CBT/DBT. I have no opposition to it’s use as therapy. I do have issues with health care systems in which CBT/DBT is the only treatment option available. According to the NIH meta-analyses, the response for CBT in treating Generalized Anxiety Disorder (my current recurring problem) is 46%. I’m in the 54% for whom they’ve got nothin’ but meds.

    In years past, under other health plans, I also had individual talking therapy that wasn’t CBT. I don’t know what the methods were called, if anything (they certainly weren’t psychoanalytic) but they were distinctly more helpful to me. If only CBT/DBT is offered to streamline costs and maximize efficiency why not limit the formulary so Seroquel is the only med that can be prescribed for any psych patient with any condition?

  24. #24 sadmar
    Wrapped in high pile
    September 23, 2014

    Denice:
    Andreas is indeed doing a fine job of providing low-hanging fruit of stupid. And you’re doing a fine job of supporting Dawkins-wanna-be asshats upchucking calumny at people who come here in good will. Kudos all around on your brilliant strategies to build a community in support of raising immunization rates!

  25. #25 squirrelelite
    September 23, 2014

    @sadmar,

    Thanks for your comment #23.

    It was much more informative and useful than your earlier comments on CBT.

    From that I see that in one case, there was no benefit or harm; in the second case, you benefited at least for a while; and in the third case which only involved watching videos, you didn’t benefit. You also mentioned that CBT or CBT/DBT seemed to help some of your fellow patients.

    I would also note that you are specifically discussing CBT for treatment of depression, which depending on the severity may also benefit from prescribed medicine.

    You might want to be aware that the pros and cons of CBT are occasionally discussed here and at SBM as therapy for people with ASD.

    This is a contrast to your earlier statement, which I would summarize as:

    1. CBT doesn’t work and is a waste of time.
    2. You hate CBT.
    3. Anyone who disagrees with 1 is stupid (or something to that effect).

    It also doesn’t help further a discussion to refer to someone who disagrees with such an assessment as “providing low-hanging fruit of stupid”.

    And since, according to the Linehan Institute,

    Dialectical Behavior Therapy (DBT), developed by Marsha Linehan, Ph.D., ABPP, at the University of Washington, is a comprehensive cognitive-behavioral treatment that was originally developed to treat chronically suicidal individuals suffering from borderline personality disorder (BPD).

    Someone receiving CBT (not DBT) for something other than suicidal depression might not have been exposed to Linehan and her treatment methods.

  26. #26 Peebs
    September 23, 2014

    I don’t know about Generalised Anxiety Disorder but there certainly seem to be anger issues.

    Back on topic, I’m sure I’ve mentioned in the past that I was taught how to carry out a trephining/trepanning when in the Royal Navy. The surgeons who taught us all said it was likely to be useless but have a go anyway. We would’ve used those bit and brace drills.

    Not mentioned so much are the drug advances. I’ve mentioned before the development of H² receptor antagonists which rendered surgery for peptic ulceration more or less redundant but there was also the development of NSAID’s.

    When I began my practical training there was a young lad (18/19) with severe Rheumatoid Arthritis. The only anti-inflammatory available to him was aspirin.

  27. #27 Denice Walter
    September 23, 2014

    @ Sadmar:

    Well, you’ve obviously had negative experiences and that’s a shame. Unfortunately costs limit treatment.

    I believe that Antaeus fairly represented CBT as SB which is correct: it is amongst the few therapies that can be characterised as such. The bottom line is that which works: if what you experienced ( _whatever_ it was) didn’t help, it doesn’t mean that CBT helps no one. Actually, your therapy doesn’t sound like much to me: perhaps a waste of time and money but you didn’t get to make that choice yourself.
    Unfortunately.

    Actually, depression is not only an academic issue for me because many people in my life suffer from it- I also experience a mild form – dysthymia- myself. I know how much people struggle to find solutions and how meds only help sometimes for some people. A few of my cohorts have devised means of dealing with their own depression outside of therapy and meds- which some have also utilised. There aren’t easy solutions.

    But seriously, that’s what we have: do I think that there will ever be perfect solutions for SMI and other conditions? Frankly no, there are too many other variables involved and a person is the product of heredity, environment and learning- the problem isn’t strictly biological but social and educational as well and it extends over life long experiences; in other words, there’s a great deal to fix. And people make choices of their own that limit outcomes.

    I could go on but won’t- let’s just say I’ve discussed this often with people I care about who suffer as well.

    RI is a place where we discuss issues related to SBM and share ideas from our common interests : although vaccine coverage is important, it’s not the only issue. And atheism is sometimes relevant, sometimes not : Dawkins is not especially of interest to me: and I’m an atheist also.

    I hope you feel better.

  28. #28 Antaeus Feldspar
    September 23, 2014

    Only a few points worth responding to:

    My evaluation of CBT has nothing to do with it’s [sic] effectiveness as treatment, but rather it’s [sic] intellectual principles.

    Anyone who intends to criticize the intellectual principles on which a major approach in a field is founded should show that they understand what those intellectual principles are.

    I consider the ‘discipline’ of homeopathy to be absolute bunk, because I consider the intellectual principles it is founded on (i.e. the Law of Similars and the supposed effects of the ‘potentization’ process) to absolutely not match what actually happens in the real world.

    But if I started declaiming about how homeopathy was absolute junk because “meridians are imaginary” and “jabbing people with needles is just sadism dressed up in a lab coat” then I would have no one but myself to blame for people concluding that I actually knew nothing about homeopathy, and that I certainly didn’t know enough to give a meaningful critique of its ‘intellectual principles”.

    Even those who do not believe in homeopathy either would be completely justified in concluding that I was speaking out of an ignorance of the subject so profound that, in the best Dunning-Kruger style, I did not even realize that I wasn’t well-informed on the subject.

    What makes you sub-human scum is the utter lack of empathy you displayed in saying “you might as well be one of the antivaxers.” For the record, I do not advocate refusals of medical treatments, I condemn selfish practices that put other people’s health and lives at risk, and I do not consider autistic children to be ‘broken’. You basically called me a murderer.

    The comparison I used was, to quote, “one of the antivaxers who show up here declaring that vaccine manufacturers put preservatives in vaccines ‘for no reason’.”

    Which of the following is more likely:

    * That I alluded to that specific practice because there is a similarity between those who think preservatives are put in vaccines ‘for no reason’ (because they don’t know the reason, not because there isn’t one or because it’s awfully hard to discover it) and those who say ‘there is no scientific base of evidence to CBT’ (because they don’t know the scientific base of evidence, not because there isn’t one or because it’s awfully hard to discover it)?

    * That I alluded to that specific practice because I had other objectionable beliefs and practices of antivaxers in mind, and somehow felt that “declaring that vaccine manufacturers put preservatives in vaccines ‘for no reason'” was my clearest and most direct way of saying “You! You refuse medical treatments, you selfishly put others’ health and life at risk, you demonize autistic children as broken – you are basically a murderer!!”?

    Which is the interpretation that would be taken by someone correctly applying the principle of charity?

    Carpeted world? Is that like a rubber room? (Hint: unless you actually have a Poetic License, you might want to double-check your attempts at metaphor before you click “Submit Comment”.)

    This is an allusion to an aphorism of Al Franken’s character Stuart Smalley, that “it’s easier to wear slippers than to carpet the world”. I figured that a decent number of people, if not all, would get the implication in saying “in your carpeted world” rather than “in your world”, even if they’d never heard that original aphorism.

    In the past twenty-four hours, I have been called “sub-human scum”. I can remember a younger self of mine, far more fragile in so very many ways, who would have experienced that condemnation (especially once it had been reiterated by the one who hurled it) as the emotional equivalent of a nuclear attack. He would have thought (incorrectly) “I can’t have peace with myself when there is someone out there thinking, and worse, saying, something so terrible about me!” He would have launched a furious, driven campaign to make those literally dehumanizing words be taken back.

    He would have tried to solve the problem in a fruitless way that was doomed to fail, trying to make the world adapt to suit him, rather than adapt himself to the world. Trying to carpet the world, rather than finding a good pair of slippers.

    Of course, adapting to the world, which is what he finally learned to do with enough success to make life comfortable, was nowhere near as easy as finding a good pair of slippers to ease on. No analogy’s perfect. It was still far easier than it ever would have been to solve the problem at the world level.

    Do you think that, if I could somehow go back and coddle my old self – eliminate to the best of my ability anything he would perceive as intolerable, such as, oh, the description of a lack of knowledge he displayed as “ignorant”, which is a word which denotes lack of knowledge – would I be doing him any favors? No? Then would I be acting morally to say to anyone else “Oh, no, really, you can’t be expected to deal with the consequences of your own choices; here, let me carpet this part of the world for you”?

    You excoriate me for not doing “very easy research” on a subject I have researched very easily, yet having never heard of Marsha Linehan you can’t be bothered to cut-and-paste into the Google?

    If someone says “modern filmmaking is creatively bankrupt; I’ve gone through all of Roy Sullivan’s movies and all of them are tired and cliche,” that argument very obviously rests on an unspoken premise that “the whole of modern filmmaking is represented so accurately by the works of Roy Sullivan that the former can be judged by the latter.” That would be a very hard premise to sell even if we were talking about Woody Allen, or a Steven Soderbergh, or a Stephen Spielberg – someone whose name doesn’t have to be Googled for someone fairly conversant with the field to figure out “wait, they’ve contributed something to the field? what was it?”

    Again, the argument only works with that unstated premise, and “they can be Googled once their name comes up” does nothing to support that premise. Anyone who Googles the name of Maurice Hilleman will quickly discover that his contribution to the field of vaccines was amazing. Yet no one – or rather, no one who actually knew what they were talking about – would say ‘I’ve evaluated Hilleman’s work; it’s simplistic and crappy, and so vaccines lack a scientific basis.’ The field is simply not founded on so narrow a basis. (Personally, I really have a hard time imagining that anyone would believe it was, if they had formed their conclusion by any other means than wishful thinking.)

  29. #29 sadmar
    Stage Left
    September 23, 2014

    @ squirrelite
    Thank you for the polite reply:
    “I would also note that you are specifically discussing CBT for treatment of depression, which depending on the severity may also benefit from prescribed medicine.”

    Of the 3 instances I mentioned, the first two were for depression, the third for Generalized Anxiety. I had been on various meds for about 6 years before the first trip to the looney bin. The psychiatrist there tweaked my ‘cocktail’ by adding a supplementary med. My regular meds-provider had actually sent me to the wrong hospital for my condition. Most of the patients were there for drug rehab or by order of a criminal court. The psychiatrist recognized the error quickly, but it took him awhile to arrange a transfer to the other hospital in a different part of the state. (There being no facilities whatsoever near where I lived. The first hospital was essentially a prison. Locked down, regimented schedule, nothing to do but go to groups and watch TV in the evening. There was no exercise equipment of any kind, and you couldn’t walk the halls. They let everybody out into a tiny closed courtyard for 15 minutes twice a day, but I couldn’t go out there as all the other patients were smokers and attempting to breath in the little courtyard would have been like inhaling a half-pack of tar.

    When I finally got set-up at the second hospital, the psychiatrist there, who I thought was very good, took time to get my history, reviewed my meds carefully and agreed with the tweak the first guy had prescribed (rather off-handedly: he was very overloaded with patients, including a two or three of the guys in for violent crimes who had targeted him in paranoid delusions.)

    “You might want to be aware that the pros and cons of CBT are occasionally discussed here and at SBM as therapy for people with ASD.”

    I didn’t know that. What aspects of ASD does it help? Do ASD folks also frequently suffer from depression/anxiety/bipolar etc.? If so, is the consensus that this comes with the ASD genetically, or as a result of people mistreating them due to their difference? Depression and anxiety disorders run in my family, but I think I might have been OK had I not been psychologically abused by my stepfather from age 11 on.

    “I would summarize your earlier statement as:
    1. CBT doesn’t work and is a waste of time.
    2. You hate CBT.
    3. Anyone who disagrees with 1 is stupid (or something to that effect).”

    Please re-read the earlier post. I said none of those things. CBT does not work for me, however I did not consider it a waste of my time. I do not ‘hate” it. I find it’s premises to be woo-ful. As I referenced in terms of 12-step, if woo helps anyone’s depression or anxiety, I’m all for it. I said nothing whatsoever about anyone who might disagree with me about the scientific validity of the premises of CBT.

    I took exception to Andreas labeling me a no better than an anti-vaxer. I did not, at that point, call him stupid. I called him ‘despicable arrogant sub-human scum.’ A rhetorical flourish. I do not know Andreas, and should have avoided attributing anything to his character, even figuratively. So I shall correct that: labeling me a no better than an anti-vaxer is despicable arrogant sub-human scummy thing to write.

    None of the 3 programs i was in identified as DBT or did much in the way of DBT specific things. The Linehan videos were presented in what I would call a ‘straight’ CBT context, and their content did not seem DBT-specific to me. People who find CBT helpful, including the folks Denice mentioned trying to find ways to deal outside of meds or formal therapy may want to check them out. The therapists who showed them were all well-qualified, so I assume they use them because they work for a significant number of patients.

    @Peebs
    I only write angry, and only sometimes. I have zero anger management issues IRL. I actually dislike internet text communication, as I think in tone of voices and facial expressions, all of which would shade the context of the words used away from anger, hostility, aggression, etc. Of course, none of that comes out in a blog post, but I think text tone is a pretty common problem, and I try to take anything on the web with a grain of salt. My main UG major (I had 3) was Drama, and I consider blog wars a kind of theater, I guess.

    @Denice:
    Gotta run (!!) but thanks for the well wishes. I feel fine actually, at least on my scale of things. I wouldn’t mind feeling better, but I’m OK. All in all, again I’d say I had one ‘bad experience’ with the CBT/DBT and that may have been more of a meds issue as my new shrink at Kaiser wanted to check removing a certain med as I would have been better off w/o the side effects if it wasn’t actually helping. Didn’t work.

    Anyway, the worst CBT experience wasn’t hat bad, and i have never generalized ‘bad for me’ to ‘bad for anybody else.’

    What you seem to have taken as anti-CBT angst is being-compared-to-Andrew-Wakefield angst. No more.

    more later re: treatment effectiveness research…

  30. #30 Meow
    Meow Meow
    September 24, 2014

    I have had one very negative experience with CBT.

    I was in therapy and had just started dating a man who admitted having severe depression but who also seemed unusually controlling. I tried to bring this up with the therapist, and she said I needed to use CBT to stop having such negative thoughts, because she knew he loved me and would never hurt me.

    The boyfriend went on to be severely controlling and emotionally abusive. I had been told to ignore the early warning signs as just “bad thoughts.” He went on to sever my contacts with all my friends by telling me they had told him they didn’t want to see me again. He had made up false negative quotations from me, telling them I had been insulting them behind their backs. He attempted to sabotage my college exams by starting fights and drama when I was trying to study. I won’t go into more detail, but there was worse stuff, and the therapist completely gaslighted me.

    Sometimes negative thoughts are correct perceptions of the world, and it is dangerous to suppress them. I am also still suffering from the effects of being gaslighted by the therapist, unable to determine which of my thoughts are reasonable and how I can defend them to others.

  31. #31 Narad
    September 24, 2014

    Have you ever, say, made a specific plan to end your life?

    Sure. What do you want, a fυcking prize? I’ll even bet that mine was better than yours.

  32. #32 Antaeus Feldspar
    September 24, 2014

    Meow –

    I’m so sorry that you had to endure such a terrible experience. I was also in a relationship where the other person went out of their way to knock the supports out from under me, and that was bad enough, but at least I didn’t have anyone telling me from a position of authority that I should be trusting that person more and giving them even more power to hurt me.

    This may sound like a “No True Scotsman” argument, but from the way you’re describing it, what your therapist was doing wasn’t CBT. The goal of CBT isn’t to reduce negative thoughts, it’s to distinguish realistic (positive and negative) thoughts from distorted thoughts (which are frequently negative) and minimize the destructive influence of the latter.

    A good therapist should in fact be focused on giving you the tools to distinguish accurate (if unhappy) perceptions of the world from distortions. My current therapist (I don’t know if he formally practices CBT – the question of his exact approach hasn’t come up) will say, when he catches me in a distorted statement, “It’s not clear to me …” Instead of simply invalidating a perception that certainly feels real to me, he pushes me to examine why I perceive it as real. Sometimes I have to conclude, after we’ve examined it, that my basis for holding that belief isn’t because the belief holds up in the light of day. (I sure wish I’d been seeing someone like him when I was being abused by A.; he could have said “It’s not clear to me why you would have to be the one responsible for the way her treatment of you has become so negative.” I would have had to acknowledge that maybe this relationship, which had been so happy for so many years, was going or gone because of factors that I couldn’t affect and hope to somehow undo.) Sometimes negative thoughts are entirely correct, which is why CBT doesn’t try to reduce negative thoughts, but rather distorted thoughts.

    I’m sorry you had such a bad experience, both with the abusive boyfriend and the incompetent therapist. I hope you’re in a better place now.

  33. #33 dedicated lurker
    September 24, 2014

    I look at the medicine of the past and remind myself that it had to start somewhere. By the time of this show (I haven’t seen it) germ theory/anasepsis/, microscopes, stethoscopes, and anesthesia were all things developed in the past fifty years. They were starting to figure out how to cure people. When I look at the last fifty years of medicine I see all sorts of diseases practically wiped out by vaccines, leukemia in a child has gone from a death sentence in weeks to ninety percent curable in the best cases, organ transplants are a thing, defective hearts can be fixed… It’s really very encouraging.

  34. #34 dedicated lurker
    September 24, 2014

    As a side note – I was reading the classic book Intern by Doctor X, and when a patient was diagnosed with Hodgkin’s disease I said to myself “Oh, the good kind,” before remembering the book was fifty years old and there was no good kind then. Lots of horror stories about measles and mumps, too.

  35. #35 sadmar
    Land of happy cats
    September 25, 2014

    Meow:

    As you’ve read I’m no fan of the theory behind CBT. But I’ve had enough experience with it to know Andreas is absolutely right: your ‘therapist’ was incompetent within the domain of CBT to the point of major malpractice, and the advice you were given is NOT NOT NOT representative of CBT as a whole, nor compatible with the concepts of CBT/DBT.

    As Andraeus says: ‘A good [behavioral] therapist should in fact be focused on giving you the tools to distinguish accurate perceptions of the world from distortions.” In practice, this can sometimes appear to be ‘replace negative perceptions with positive perceptions’ as the therapist is more concerned with correcting ‘false’ negativity. And it’s true that behavioral therapists sometimes have difficulty distinguishing between justified negative perceptions and unjustified ones. But your ‘therapist’ was going way out of bounds by 1) getting into value judgements “I know he loves you” and 2) offering ANY kind of suggestion about what you SHOULD perceive instead of just questioning the bases and logic of what you DO perceive. Again, Andreas is right about standard behavorial therapy practice emphasizing tool/skills/exercises to help you make better evaluations of your situation, rather than the ‘therapist’ telling you what you should or shouldn’t think.

    That sad fact is that the bar for admittance to the ‘therapy’ profession is very low, and the variations in method even among practitioners claiming the same rubric is extremely wide (calling something CBT doesn’t make it CBT). There are LOTS of bad practitioners out there, and unfortunately they get away with it for the very reason you you seem to have gotten misled: you know you’re messed up, so you tend to think the therapist’s perceptions are more accurate than your own instincts. I don’t know how good this woman was at gaslighting, but a good rule of thumb for depression/anxiety patients is to get the vibe of the therapist as a human being in general, only listen to them after you feel you can trust them, and run like hell if you feel you can’t, preferably to another practice rather than a colleague under the same roof as the gaslighter-or-whatever. If the ‘therapist’ that creeped you out was raising valid concerns, and you develop a trust-relationship with a competent therapist, they’ll bring up the same issues but in a, well, trustworthy and sensible way.

    And it sure sounds to me like Andreas has found ‘a keeper’:
    ‘Instead of simply invalidating a perception that certainly feels real to me, [my therapist] pushes me to examine why I perceive it as real by asking a question “It’s not clear to me …” And Andreas is right again that it doesn’t matter what you call it, that’s just good therapy. Hell, if anybody had ever used that approach with me, I’m sure I would have done better — not that my providers were dangerously incompetent, just not that good, and also limited to certain extents by the context of groups with constantly changing memberships.

    I had the misfortune of living in an area where very few psych providers belonged to my PPO, and most of them were minimally qualified and had IQs I’d estimate as ranging to 15-50 points below mine, which caused me a real problem. They’d keep saying things like “you’re overthinking things!” HELLO, I’m a professional intellectual with a PhD in the Humanities, what the hell do expect me to do, Take stupid pills before I come to the office!

    Anyway, I finally made an effort to ‘shop around’ after giving up on the psych-shop down the street, and I must have made 20 inquiries that hit dead ends. I finally located the one-and-only-one provider in my coverage area with an MD psychiatrist with a good rep I could see for meds AND a PhD psychologist I could see for talking therapy who was ‘eclectic’ and pragmatic in method rather than attempting to fit every patient into any orthodoxy, CBT or otherwise. But I only saw them for a few months before I decided to move all the way across the country… Life is better here overall, but the only available health plan has bupkiss for talking therapy. At least I’ve got a competent meds MD. (The REAL horror story from my previous place of residence involved a horrid APRN doing my meds…)

    In conclusion, Meow, the best FWIW advice I can offer from my own (admittedly perhaps idiosyncratic experience) is hang in there, and don’t take your bad experience as representative of talking therapy in general or ‘CBT/DBT’ in general. As Andreas says, labels don’t necessarily mean anything and the specific skills of the individual practitioner tell the tale. It can be as hard to find the right therapist as to find the right meds, so the odds of encountering another loser are not insignificant. But help is most likely out there somewhere, so I’d ask, “Why not keep looking?”

    🙂 Best wishes.

  36. #36 sadmar
    SMH city
    September 25, 2014

    Have you ever, say, made a specific plan to end your life?
    “Sure. What do you want, a fυcking prize? I’ll even bet that mine was better than yours.”

    Narad: I was asking Andreas. The question was sincere. Especially having been ‘dysthymic’ for some time before developing the major depression, I can say that no-one who hasn’t been there can ever have the slightest fucking clue what its like. I don’t want a prize. I want people who are lucky enough to ‘not get it’ to understand they don’t get it, and exercise due care around anyone they know who might be in that situation (which, thankfully, I am not at present). And what it’s like is something I would not wish on my worst enemy. You have my sympathies, sir. I sincerely hope you are past the point to which you referred, and that you may continue to feel better.

    Let’s not contest that bet by revealing and comparing plans, or even contemplate what unpacking “better” in this context could mean. From what I gauge of your internet persona, I’d guess that if “better” meant ‘effective’, the referee would rule the bet a draw.

    Take care of yourself, good sir.

  37. #37 Denice Walter
    September 25, 2014

    @ sadmar:

    Because I do have time now…
    My education and training is in psychology but at a critical – altho’ late- point I decided not to go along with the standard career path ( probably because of intervening and heavy personal responsibilities as well as becoming jaded) and focused my energies upon both developmental and cognitive approaches. I acquired a series of positions which included working with at-risk youth, hiv+ patients, families of the SMI, EFL students and others. I worked for a non-profit where I wore many hats- as I also had previous experience in advertising and studied liberal arts: I interviewed and counselled clients and wrote brochures and educational material for them.

    You expressed interest in my account of people who used additional actiivities to deal with depression- so here’s my take:
    my family members suffered from dysthymia or depression BUT I believe that their coping skills saved them ( also, it may not have been the most severe form of depression)- some coping skills seem to have been passed on as a tradition in family folktales. For example, we have a few ancestors/ relatives who wrote about their experiences with both business and personal travailles.My father had a stock of aphorisms – many sarcastic- that helped him ( and me) very frequently: some of it sounds astonishingly like attribution theory and CBT but more snarky OBVIOUSLY.

    I regard people as constantly developing skills over a lifetime and “therapy” is a means of continuing that process: researchers know that not every person develops the diverse abilities lumped together as ‘executive functioning’ by the age of 25 ( or ever) . Learning about what makes you ‘tick’ or feel better or worse is part of that process.

    A few of my droogs**, have managed to keep their heads ‘above water’ despite having more serious depression than I experience- how physiologially based these conditions are, I cannot say, altho’ one of them had a horrendously nightmarish event happen to a family member which re-echoes to this very day ,often precipitating depression- these activities may be used in addition to professional help and meds. I do believe that meds are very important although they’re not perfect.

    So what do these people do? Mostly, keep active both physically and intellectually.They have things to do: wrk, family, hobbies. They discuss life issues with those they trust regularly. They use self-talk and self-criticism. They maintain an active interest in the world OUTSIDE themselves.

    I find that I need to exercise, search out new experiences like day trips and travel and have “something to work on” – whatever that is, a project of sorts. Finding ways to deal with and/ or avoid stress is invaluable. And right, I sometimes pretend to be alright and go ahead as if all is well, even if it isn’t. I take great pride in the fact that I manage a lot of stuff and have diverse skills- a few of them actually useful which can earn me money. Money helps.

    ** from Russian *druga* -i.e. second / see Burgess, A.

  38. #38 Narad
    September 25, 2014

    Narad: I was asking Andreas [sic].

    The only reason I turned off the killfile was because Antaeus responded to you. You put it out, it’s fair game.

    The question was sincere.

    No, to my eye, it was undisguised dіck-waving. This is why I didn’t even bother with your halfwitted attempt at likening CBT to 12-step programs on the strange assumption that the latter “work” and so must be comparable.

    HTH. HAND.

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