Freud’s Patients : A book of lives. Mikkel Borch-Jacobsen

The subtitle of this book is helpful. Read, or spoken, quickly it becomes ‘a book of lies‘, which, in essence, is what this book proves to be.

The book was initially a fascinating read as it reveals that much of what we think we know of Fred’s clinical work, and which was used to base his theorising, is incorrect. It is clear that Freud himself knew this and some of the claims he made were simply fabrications. Facts were bent to fit his theories, ignored if they did not fit the theory or manufactured if there were inadequate facts to fit his theories.

All doctors tend to exaggerate the case histories, which they use as anecdotal evidence , to support the case they are trying to make, and Freud was no different in this regard. However, the claim that there was scientific rigour in this process has long been shown to be risible and this book clearly lays out the evidence that this is the case.

However, the cases are all very similar. They usually start with the biography of an extremely wealthy Jewish person living in high society Europe, heirs of vast fortunes, who winter in Davos and summer in Vienna. Only really the surnames change. This is such a rarified and skewed sample that it is a surprise that, looking back, the medical establishment thought it might, in any way, be representative of people in general. It is not a good sample on which to build a universal theory of the human psyche.

This is also the major shortcoming of the book – after a few chapters the repetitiveness becomes rather tiresome. (As does the author’s delight in pointing out Freud’s foibles). However it is a useful reference text and a valuable source to cross reference if anyone raises Anna O, Dora or the Wolf Man in conversation.

A crooked path

It seems that everyone wants “to follow the science” and tends to get rather aeriated when others deviate from what they think science’s trajectory indicates. In the middle of a pandemic this is both important and also possibly a problem. The importance is self-obvious. No-one would disagree that this is the most important time for us to hone our scientific skills, flex our logical muscles and, through diligent application of reason. find the quickest and safest path through this crisis (if there is one).

The problem is not a disagreement about whether the scientific method is the best way we have of solving problems like this. The problem is a failure to understand how ‘the science’ works. Science works through repeated steps. A guess, or a hunch, leads to a hypothesis. This hypothesis is tested rigorously in an attempt to prove it false, or at least no more likely than chance. The hypotheses found to be wanting are disregarded but in the process of having been found to be false they may have suggested alternative, possibly better, hypotheses. These are then tested; positive findings are added (temporarily) to the scientific knowledge and negative findings discarded. The slow progress forwards depends as much on the negative findings and erroneous hypotheses as it does on the positive outcomes. All our successes rest upon a large, but known, pile of mistakes. There is no dogma in science, nothing is known to be always true and unquestionable, every idea is open to doubt, testing and adjustment.

This being the case science follows a very crooked path. Although it moves forward it may proceed down dead ends and cul-de-sacs before finding a new way to advance our understanding. Therefore “following the science” is a difficult task. We can not know where the science is heading, what seems reasonable today may be found to implausible next week. Science can help us guess our future, but it cannot predict it. If we are to truly follow the science we should be happy to say “Just now, on the information we have, this plan seems the most likely to lead to success, but we will change our course if testing suggests some of our assumptions are faulty” – this would be following the science. During my working life I started prescribing treatments which were the gold standard for their time, reported in the textbooks as the pinnacle of modern treatment, which now are consigned to the dustbin and history books. No longer seen as valuable treatments but only and interesting stepping stones to where we are now.

Science and politics do not therefore make good bedfellows. Science needs doubt, uncertainty and the repeated changing of course and discarding of out-dated ideas. Politics needs conviction, certainty and steadfastness in the face of disagreement. Perhaps if the scientific method infected politics this may not be too bad – we might have politicians who said they did not fully understand the situation, could not predict the future accurately and abandoned course when it was becoming clear a policy was heading us for the rocks. But is seems, alas, that the political attitude is infecting science with all the adverse effects we might imagine. Apparent scientists are informing us that they are certain what will happen if certain paths are followed, advisors are proving to be reluctant to change their plans when evidence suggests this is the best plan, and the media is encouraging us to view scientific opinions like political ones – something we can choose between. We don’t have the luxury of choice, what really faces us is the need to do the hard work of synthesizing data from various sources and working out our next best hypotheses and testing them (In the certainty that many times we will be wrong).

While I was working this was often referred to as “evidence based medicine” : no matter what your opinion, nor the opinion of the most esteemed specialists in the field; what mattered was the evidence. If the evidence showed the treatment to be a dud, it was a dud, regardless of your professor’s partial promotion of its use. There has been a call for “evidence based politics” during this pandemic which would make some sense. This would be valuable if we were all ready and able to change our opinions depending on the results of data and testing. We would need to be ready to jettison our preconceptions and to follow that crooked path even though it is sure to take us away from our original course. It seems unlikely that this will happen; we seem intolerant of our politicians if they express ignorance or doubt, and tend to punish them if they change tack or “do a U turn”. It seems much more likely that politicians will create “politics based evidence” when they give us the data that shows they were right all along, are correctly predicting the future, and deserve praise for standing up to the naysayers.

This strategy may well work for winning elections as it will find support in the media. Those supporting their teams will be able to cheer loudly knowing that they are on the right path, following the arrow if history, and feeling self-righteous that they are leading us out of the valley of death created by coronavirus. They might do, they might also be leading us over a cliff edge- if we were not so dogmatic, and were a little more accepting of our errors (so that we looked at them rather than hid them away as embarrassments) we might be able to tell the difference. I am not convinced we will.

Homo Deus by Yuval Noah Harari

If his prior book “Sapiens” could be considered the history of how we got here then this book, “Homo Deus” could be seen as a potential roadmap for where are now heading. A prequel and a sequel concerning life as it is now. There is lot to like in “Homo Deus” as the author manages to tackle broad and important topics with ease. Complicated scientific problems are deftly explained so the reader can understand the complexity of the situation. The riddles of philosophy, psychology and religion are presented in such a manner that their essence is clear, and often this is done with considerable wit and humour.

This is a book that stimulated thought and challenged some of my preconceptions. It is one of the few books which has made me seriously consider vegetarianism. Though it ultimately failed to change my mind. In some areas, in those where I have some expertise and knowledge (psychology, neuroscience) I did feel that his easy explanations verged on the glib and that he had not taken cognisance of the range of differing views in the scientific community – and declares debate settled when it is anything but. I only recognised this in the areas of my specialist knowledge, but this left me with a nagging doubt that I might be missing similar controversies in areas I am less knowledgeable.

The potential future he can foresee, if (God Forbid) we conquer age and death, is a worrisome place. The consequences of artificial intelligence, robotics and technocratic states allow him to reveal a future which few of us would opt to inhabit. Thankfully age, infirmity and death will ensure I never see this and in the meantime I will just plod along trying to make the best with my limited human intelligence and imperfect human morality.

The End of Gender by Debra Soh

Format matters; I listened to this book on Audible rather than read it as an eBook or a printed version. More on this a little later as it is possibly an important factor in how you may enjoy this book.

This book deals with several recent positions held by advocates in the field of transgender rights. She holds that their statements that “biological sex is a spectrum”, that “gender is a social construct” or that “sexual orientation and gender identity are unrelated” (and a number of others) are myths. Not only are they myths but they fly in face of both reason and the scientific evidence we have.

The first strand of the book is the clear exposition of the evidence that biological, innate, and evolved characteristics underpin much of our human behaviour and development. While reminding us of the importance of nature she does not ignore the importance of nurture which has a powerful modifying effect on these primal origins. However, she is right to remind us that, if we wish to understand ourselves and our sexuality better then we should not ignore these biological facts. If we pay no heed to causes it should be no surprise when we are unable to anticipate or undertand effects.

The second strand relates to how these inconvenient facts are dealt with. She details a clear anti-scientific lobby which will not brook any mention of this data. Science works and progresses through testing hypotheses, proving statements wrong and retesting improved hypotheses. Debate is not a perk of being scientific is the essential core of the scientific approach. It is true to say that science never proves anything true, it just manages to progress by proving wrong ideas are false.

In the world of gender studies the scientific method has been abandoned and a religious strategy adopted in its place. It now has its catechisms (“A trangender woman is a woman”), its purity tests, its sacred texts and, increasingly , its heretics. Debra Soh is one of these heretics and it is sobering to read how harshly the sect deals with those who try to maintain a scientific approach.

This is an interesting read and there is a lot of information here. However, I usually listen to audiobooks when I am doing some mundane physical task (turning over the vegetable garden in this case). When your companion is Philip Marlowe or Tess Durbeyfield this works well. But when you are trying to deal with studies and figures (4.5% of group A compared to 12.3% of group B in study group one) this demands more focussed concentration and is better obtained reading text. Further, fiction allows the reader to modulate their voice to match the emotion of the story; this is lost when a scientific book or paper is being. Consequently, while the author reads the text clearly and well it does, after a while, start to sound monotonous and dull, verging on the robotic. Also, with an audiobook there is no easy way to make annotations for future reference or to share in future debates or arguments.

So, in conclusion, while I would recommend this book, as a valuable corrective to the present scientifically illiterate misinformation which is circulating, I’d advice opting for a text version (paper or ebook) rather than the audiobook.

Boys will probably be boys.

I am obliged to go against the current cozy consensus, to say something different to the accepted viewpoint and, in the process, lay myself open for criticism. I am going to say something that is shocking, probably heretical, and in the current climate may lead to my being ostracized. I am going to say that there are differences between women and men, between boys and girls, which are not socially created but relate to our biology. There are innate differences in a some of our behaviours, our drives and our instincts which arose after millennia of evolution as a species. There, I have said it, let the heavens open. This is simply a fact, although unusually for one of my opinions, a fact with which most of science agrees.

Why have I found myself spouting heresies today ? Well, it all has to do with a racing car driver. I can confess that I actually felt rather sorry for Lewis Hamilton today. Why do I feel sorry for the handsome, wealthy, skilled and famous car racing star ? I felt sorry for him as he was forced to make an apology for a piece of playfulness with his nephew which revealed he did not toe the party line. In a piece of family banter, in a jovial mock-angry voice he said that “boys don’t wear princess dresses” while teasing his nephew, who seemed to be enjoying the attention from his famous uncle. Cue synthetic shock and horror from the social media watchmen who called out his “horrific” “transphobia“. After a short period of sustained attack, Lewis Hamilton came back with the required abject grovelling apology. However, it seems that this may not have been an adequate Mea Culpa as he is now being criticised  for inadequate sincerity in his shame. The intolerance of the social media clerisy is quite remarkable, they will not tolerate any views which deviate from the current accepted norms, no alternative views will be brooked.

Now I think Lewis Hamilton was wrong, of the things which might be social constructs I am pretty certain that styles of clothing is amongst them. In different cultures, and across different times, that which is suitable for girls and boys to wear has varied; style sense is not inherited (Although I can’t think of a culture promoting princess apparel to its boys). But it does not matter that he is wrong. He expressed his opinion and he has hurt no-one. He should be free to do this without the fear of mock outrage. Further, it is the family’s role to rear children and to instil values and attitudes in them – nobody else has that right. I disagree with many religions but believe that religious parents  have the right to instruct their children as they wish. I disagree with my conservative voting neighbours but do not feel that I have any right to stop them passing their opinions onto their children. Indeed, as long as they are not harming their children, I want families to instruct their offspring as it is them who teach the young how to be good, how to be moral, how to be a good man or a good woman. Sometimes their views on morality and goodness will not concur with mine, but these differences are the grit in the oyster of our culture which generates discussion and change. Tolerating these differences is one of the hallmarks of a civilised and open society. Watching people publicly shamed for unfashionable opinions is reminiscent of the stocks or the show trials and should cause free thinking people to be concerned.

The rights of the individual are closely allied to the family unit. The family unit allows us to act and exist outside of the state and the state has, for a long time, had an ambivalent view of the family : positive in that it cares for the young and the sick, negative as it may instil ideas of which it disapproves. It is still largely within the family that we develop our moral compass although the state’s roles in education and healthcare have reduced this somewhat. Capitalism sees less need for the nuclear or extended family, from the market’s viewpoint the more people producing and the more people consuming the better. Traditional families are perhaps inefficient in market terms in the developed west, the family model works best as a unit of production rather than as a unit of consumption. Socialist thinking has been more generally hostile to the family, it recognised that the family is a place of education and instruction which is not under state control and therefore potentially problematic. In 1920 Alexandra Kollontai wrote the set text on family organisation under communism. She wrote :-

The old family, narrow and petty, where the parents quarrel and are only interested in their own offspring, is not capable of educating the “new person”. The playgrounds, gardens, homes and other amenities where the child will spend the greater part of the day under the supervision of qualified educators will, on the other hand, offer an environment in which the child can grow up a conscious communist who recognises the need for solidarity, comradeship, mutual help and loyalty to the collective.

 and promised that :-

She need have no anxiety about her children. The workers’ state will assume responsibility for them

The woman who takes up the struggle for the liberation of the working class must learn to understand that there is no more room for the old proprietary attitude which says: “These are my children, I owe them all my maternal solicitude and affection; those are your children, they are no concern of mine and I don’t care if they go hungry and cold – I have no time for other children.” The worker-mother must learn not to differentiate between yours and mine; she must remember that there are only our children, the children of Russia’s communist workers.

Unfortunately it seems that this attack on the family where different opinions might flower continues. If we allow this censorious and intolerant development our future abilities to recognise and defeat authoritarianism will be sorely damaged.  Policing the family has always been a priority for authoritarian regimes, recall the importance given to the Hitlerjugend and the Komsomol in Germany and the Soviet Union, and remember that these were very early developments of fascist societies. A society which will not allow dodgy joke between family members is treading a dangerous path.

I used to be clumsy but I’m dyspraxic now.

via Daily Prompt: Clumsy

One of the trends of recent years has been the increasing medicalisation of our lives. Issues that previously were thought of as aspects of our personality or experience are viewed the rough the lens of health care. This trend has a long and venerable heritage. When Hippocrates wrote “On the Sacred Illness” and proposed fits, due to epilepsy,  were due to phlegm from the brain rather then a punishment form the Gods, this was a major scientific advance.In the middle ages the recognition of some forms of mental illness as diseases rather then proof of demonic possession save some unfortunates from the rack and the stake.  Shifting behaviours due to disease into the medical arena has been, without doubt, beneficial.

As our scientific knowledge increased  more and more conditions were recognised for what they were. Times when people might have been thought to be lazy and slothful (when they had anaemia, renal failure, and so on) are gone and it is recognised that these people in fact suffered from disease or illness. They are taken out of the social realm and placed in the medical realm and thus  excused from normal social responsibilities – we do not expect the lame or blind to work the same as others, we accept that those with schizophrenia may at times behaviour oddly or even rudely. This reduction of our responsibilities is beneficial as we are not then punished for behaviours not under our control.

However, this has not always been a change for good. In the nineteenth centuary a medical disorder of drapetomania was proposed by the American physician Samuel A. Cartwright. The essence of this condition was the desire to escape captivity and servitude; the ‘treatment’ was regular whipping to deter slaves from running away. More recently the KGB in the USSR worked with doctors, using the diagnosis of “sluggish schizophrenia” to incarcerate many dissents in mental hospitals. They used the diagnostic label to undermine the behaviours of political dissenters by making them symptoms of medical disorders there was no need to pay any heed to them – disagreement became madness.

It is with this in mind that recent changes concern me. There has been a tendency to identify difference as disorder. The socially awkward man with a liking for habit and routine becomes a man with Asberger’s Syndrome, the clumsy child becomes a patient with ‘dyspraxia’, the shy become ‘socially phobic’, the sad and disappointed become people with ‘minor depressive disorders’, and so on. There is a preoccupation with illness and an acceptance that it is almost universal we all have some disorder !

But this is a dangerous path. Placing people in the role of being ‘unwell’ has a number of risks. These might be outweighed by advantages as mentioned above, such as excusing us from our normal social responsibilities, or giving an explanation of our behaviour, or offering some form of treatment to improve our lot. But recent expansions of the ‘sick role’ seem to offer none of these. Someone who is clumsy knows no more about the origins of their clumsiness after the label of ‘dyspraxic disorder’ has been applied, they knew that their brain was less good than the average in motor tasks and dexterity already. We know no more about the socially awkward obsessive after we have labelled him as having Asberger’s syndrome, we have gained no new insights about him.

None of these, and many other disorders, have, at present, any treatments available for them. The steps one might take to mitigate against their signs and “symptoms” are common sense. Importantly, the steps which might help are not known only to medical professionals  they are things we can all work out. Thinking that these disorders are some form of illness or disease limits the sources of help people may receive. People may undervalue the advice of the non-professional and miss possibly useful assistance form their friends, family or themselves.

The exclusion from social responsibility is a double edged sword. While people may feel some relief following being  labelled as having some disorder and may benefit that others expect less of them – “I have X disorder, you can’t expect me to do Y” – what if the person want to be able to “do Y” ? The urge to overcome differences, that are seen as a disadvantage, might be suppressed. The socially phobic might not press themselves to gradually expand their repertoire of social activities and thus lead a smaller, less rewarding life than they may have been able to do otherwise.

Worse that curtailing the individual’s attempts to improve their lot is the danger that, now in the arena of healthcare, physicians will try and improve them. Already millions of unnecessary  and ineffective prescriptions for medication are given to the mildly depressed or socially anxious (as well as many other dubious ‘disorders’). Each time such a pill is swallowed someone takes a risk of harm without the prospect of any benefit. It is true to say that some people die as a consequence of  saying “I have disorder X” as opposed to accepting “this is the way I am”

Society as whole also looses out by this trend. Every time a deviation from the norm is categorised as a disorder we reduce what we consider the range of normal human life. We restrict the range of what is acceptable. While, in our present humane and liberal democracies, this may not be too risky there is no guarantee that this will always be the case.

Illness, ill-health and disorder are the exception we should fight to make sure that they remain so.

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Written in response to the daily prompt : Clumsy

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Can we be too careful ?

via Daily Prompt: Careful

I imagine that everyone hopes that they are careful. They believe that they assess risks and take steps to avoid or minimise them. They castigate themselves when they make errors and chide themselves, an others, when they are careless. It is held that there is a duty as we grow up to be careful, childhood is the time when we can be carefree. But can we be too careful ?

I think we all can remember times when our caution made us miss an opportunity, when in hindsight we regretted our hesitation. Certainly we can all recall the old adage “faint heart never won fair lady” and many of us have friends or acquaintances troubled by timid, over-cautious natures who lives are stunted by the problems of excessive care and anxiety. In the world of science, however,  a preferred adage might be “better safe than sorry” where the stakes are higher than winning the hand of the damsel. But is is possible that excessive caution and being too careful can be troublesome here also ?

In the scientific world this might be the case with the “Precautionary Principle“. This was brought in as Principle 15 in the United Nations Conference on Environment and Development in Rio de Janeiro in 1992. It might be well defined as follows :-

‘When an activity raises threats of harm to the environment or human health, precautionary measures should be taken even if some cause and effect relationships are not fully established scientifically.’

Similar descriptions of the principle have been placed in regulations such as the World Charter for Nature and  E.U.’s Treaty of Maastrich.  A basic tenet of the  this principle is that the ‘duty of care’ or ‘onus of proof’ is on those who those who propose change. Further, we are advised to err on the side of caution, even when there is no scientific evidence of harm.

While appreciation of risk and assessment of risk are a basic, and advisable, scientific task this principle can cause problems.  Were the instruction ” assess and avoid risk” this would be entirely reasonable and right. But avoid risk, even is there is no evidence of risk , is a much more troublesome statement.

Obviously when change is proposed there may well be risks, but after these have been dealt with, it will always be possible to imagine or fear further risks for which there is no scientific basis. People feared train travel would be so fast that it would be damaging to the human body, people feared radio waves would affect the human mind. It would not have been possible to show at the time that these things would not occur. Presently we see the precautionary principle pulled out to protect us from all sorts of risks ; GM crops, Fracking, mobile phone masts, vaccination – “Just because they don’t know it doesn’t do any harm, doesn’t mean it wont.” they cry.

But here lies the inherent anti-scientific nature of this principle. It is not possible to prove the existence of something which doesn’t exist. If someone states that there are spirits form past lives in the ether. I can not prove that they are there. I can say that we have never seen them, I can also say that there is no known mechanism for them to be there. This is what science can do. With regard to harm scientists can say ‘we have never seen it’ and there is ‘no known mechanism’ for it to occur. This would be inadequate for the precautionary principle which would suggest caution and hesitation even though there is no scientific basis for this.

All life entails risks. Scientific progress is no different. Each step forward we take carries some risk. However, looking back at our development we live happier, healthier and longer lives now as a consequence of taking these risks and the progress of science. We would have missed major steps if we had been so risk averse. Had we fully comprehended the risks of aspirin we would never have started using it. For every risk we take we must also consider the risk we take by not moving forward. Had Jenner not taken the risks of injecting his fellow countrymen with  cowpox, then smallpox would still blight our lives and would have caused millions of deaths.  Those deaths would be the cost of not taking the risk.

Similarly, this year, two million children will die from nutritional deficiency, entirely needlessly ,because we will not allow the use of “Golden Rice”. We allow them to die because of our fear of the possible ‘risks’ . This is nearing a “crime against humanity” say over one third of all living science Nobel Laureates in their recent letter. I don’t think they are being excessive in their complaint.

Two million children dead while we follow the precautionary principle. Yes, it is possible to be too careful.

Careful