A Conversation in Critical Psychiatry with Peter J Whitehouse, MD, PhD.
CONVERSATIONS IN CRITICAL PSYCHIATRY
Conversations in Critical Psychiatry is an interview series aimed to engage prominent critics within and outside the profession who have made meaningful criticisms of psychiatry and have offered constructive alternative perspectives to the current status quo.
Peter Whitehouse MD, PhD—neurologist, cognitive neuroscientist, and bioethicist by formal training and transdisciplinarian in practice—is Professor of neurology, psychiatry, cognitive science, neuroscience, and organizational behavior at Case Western Reserve University, with additional past appointments in the departments of psychology, bioethics, history, and nursing. He is also a Professor at University of Toronto, honorary research fellow at University of Oxford, and the founding president of Intergenerational Schools International. He has served in national and international leadership positions in neurology, geriatrics, and public health. He has authored numerous academic, peer-reviewed research publications. His current main foci are on ecopsychosocial models of brain health and aging, as well as the role of the arts and humanities in health. He considers himself a wising-up, intergenerative, transdisciplinary, action-oriented scholar, and an emerging artist. He is the author of The Myth of Alzheimer’s: What You Aren't Being Told About Today's Most Dreaded Diagnosis (co-written with Daniel George, published in 2008, St Martin’s Press) in which he criticized the conceptualization of Alzheimer disease as a disease distinct from the aging process.
I became acquainted with Dr Whitehouse and his ideas during my geriatric psychiatry fellowship as I explored conceptual and philosophical issues related to aging. Up to that point I had considered dementias to be relatively immune to social constructivist ideas given that the underlying neurodegeneration had been convincingly demonstrated. What I had not accounted for, however, was the complexity of the relationship between aging and AD, and to what extent these two constructs—the former considered a natural, universal feature of human existence, the latter a horrendous disease—are enmeshed with each other. There is a provocative side to Dr Whitehouse’s ideas, and it is easy for some to get distracted by that—but the underlying arguments are well-constructed and backed by scientific evidence. It helps that Dr Whitehouse has the stellar academic credentials that he has, along with the experience of working with pharmaceutical companies in the development of acetylcholinesterase inhibitors, because his views cannot be summarily dismissed as a product of lack of expertise. Dr Whitehouse forces us to challenge our preconceived notions and to think anew about aging from a very different perspective.
Aftab: Let’s talk about The Myth of Alzheimer’s. It’s a very well-written and provocative book that challenges conventional wisdom in how we understand this condition. Some themes that stood out to me in your arguments:
• We tend to think of Alzheimer disease (AD) as a single entity, but it is actually highly heterogenous and is an umbrella term for many different conditions.
• We think of AD as a “disease” but its status as a disease is questionable because it is a consequence of “natural” aging processes; seeing it as related to aging still acknowledges that the individuals diagnosed with AD do suffer, can be highly impaired, and are in need of help.
• We have focused so much of our efforts in trying to “cure” this “disease” with a medication that we have forgotten the issue that really matters: how do we create social conditions in which the aging members of the community—including those with dementia—can flourish and have some measure of well-being.
Do you agree with this characterization? Have your views changed much since this book was published in 2008?
Whitehouse: Thanks, Awais, for your positive comments and the opportunity to speak with you. My writing and academic collaboration with Danny George has been a productive joy and is manifesting in a second coauthored book tentatively called Brain Health in an Unhealthy Society (forthcoming Johns Hopkins University Press) that addresses exactly your first questions. We do believe time has supported the claims of The Myth that AD is heterogenous and intimately related to aging processes, although I might argue with the label “natural” for all the changes that occur with aging or dementia.
In this new book, we argue that the potentially more modifiable causes of dementia lie in economics, politics, and ecology, not only in aging processes themselves. Eleven years have passed since our first book was published and income inequity and environmental deterioration are increasingly deadly forces affecting health. In Brain Health we present further evidence, not available in 2008, that the excessive emphasis on medicalized approaches is harmful to individuals and society, and once again argue for broader public health and more fundamental cultural responses to the challenges of age-related cognitive decline.
Aftab: How was the book received by the medical community? Did it have the impact you were hoping it would?
Whitehouse: The dominant power players either rejected it with uncritical anger or more commonly ignored it. Prominent lay organizations (and their “experts”) locally and nationally publicly rejected the book as irresponsible and inaccurate apparently before reading our gift copies. The title was too provocative for them. Their livelihood is based on, in our view, an irresponsible and inaccurate social construction of “Alzheimer’s.” Many of my friends and other dementia experts would privately agree with us. So, I think we did serve to get people thinking about different ways of framing AD and related conditions. Slowly we are moving more toward prevention and care rather than sticking with our obsession with drugs, biologics, and cure.
Aftab: Was the title of your book The Myth of Alzheimer’s in any way a hat-tip or nod to Thomas Szasz’s infamous The Myth of Mental Illness?
Whitehouse: Yes, it was. Szasz influenced me during my training in neurology and psychiatry at Johns Hopkins. As my mentor Jerry Frank said to me “the medical model is not even good for medicine.” So, I extended the ideas of social construction into neurological conditions and beyond biopsychosocial to ecopsychosocial, especially in the new book. This latter term emphasizes that health is imbedded in ecosystems and that often biomedicine gets the biology wrong by focusing too much on reductionistic and static models rather than systemic and evolutionary conceptions. We wanted to call the book The End of Alzheimer’s to mimic other concept-based books like The End of History and The End of Nature, but the publisher wisely thought that would imply promising a cure. The Myth title rightly emphasized the power of grand stories.
Aftab: Even if we accept that AD is a form of brain aging, one may argue that AD should nonetheless be seen as a disorder of brain aging. This could be in a qualitative sense, such that some aging process has gone awry (for instance, genetic mutations in pre-senile dementias) or quantitative sense, such that AD is at the extreme end of the spectrum of biological aging.
Whitehouse: First, we must keep the plural in mind. AD includes various forms of brain aging and a panoply of biological processes we may never fully understand. Each person’s “AD” is unique to them because of the personal nature of their own genetic makeup and their life circumstances over time. Since both AD and brain aging are heterogenous, it is very difficult to define the boundaries between them. Yes, we think it better to call AD a “disorder,” “condition,” “illness,” or “syndrome” rather than well-defined disease. Eventually it is all about economic and political power surrounding who gets to control the labeling process. Do we want the often self-serving professional purveyors of false hope and profit-at-any-cost Big Pharma to control our brains (and minds) and our aging or do we want to embrace our collective responsibility to create opportunities for and with each other in community?
Aftab: You’ve had a hard, unforgiving look at AD. What about other dementias, such as frontotemporal or Lewy body? Do you approach them with the same sort of skepticism that you do AD? Or do you accept the standard biomedical narratives of these dementias?
Whitehouse: Awais, this is a fundamentally important question. After our new chair of neurology praised (excessively I thought) our book in a department meeting for the second time, I tongue-in-cheek suggested we need a series of books emanating from our department—the Myth of Parkinson Disease and the Myth of Stroke! What I say is that every disease is socially constructed, and everyone has a biology (however complex). Lewy body dementia was controversial in the beginning as to whether it was a variant of AD or a separate entity with UCSD and Newcastle advocating different views.
Similarly, we can take a look at how the labels arteriosclerotic, multi-infarct, and vascular dementia have evolved over time. What of studies that show some decline in executive functions with “normal” aging? The essential issue is how do we help people at risk for or who suffer from brain conditions that impair quality of life. Yes, I am skeptical of essentially all claims from modern medicine which has lost a bit of its soul in my view, no thanks to the proliferation of bioethicists who do not in my opinion adequately challenge the incessant claims of progress in medicine.
Aftab: Every disease is socially constructed in the sense that there is a particular inter-subjective way in which we describe it, classify it, treat it, understand its relationship with other conditions, and these particular ways are influenced by a host of social-historical-political factors. I would like to think that different conceptualizations of disease differ in the degree to which they capture the objective reality or “carve nature at its joints.” “Neurasthenia” and “tuberculosis” may both be socially constructed but their correspondence to nature is likely very different. I guess what I’m trying to say is that if we are not careful, we are at risk of trivializing the notion of social construction and what it may have to offer medicine. If everything—whether Parkinson disease, or stroke, or glioblastoma multiforme—is a “myth,” then calling something a “myth” (such as AD) doesn’t possess much of a significance or sense of alarm that something is amiss.
Whitehouse: I would not want to trivialize social construction! All diagnostic labels are words first that we agree (with varying degrees of controversy) to use that signal something about patterns that we think we see in nature. Before we understood the role of bacteria in disease, the clinical phenomenology of diseases such tuberculosis and syphilis and so on were socially constructed in different ways. Social construction is informed by biology—but the real issue for me is how dis-ease and suffering are viewed and who gets the power over attempts to relieve them.
Dr Aftab and Dr Whitehouse have no relevant financial disclosures or conflicts of interest.