I saw Steven Pinker's tweet about Oliver Sacks making up enormous amounts of his case studies, symbolically projecting his own life's obstacles onto his patients, and thought about this throughout the day at odd moments. When I got home I read the whole article in the New Yorker. I found it fully sickening while reading it, the sheer range of his dishonesty in his writing staggering for one who was trained to treat a clinical record with literalist accuracy. Anything subjective had to be identified, such as an interpretation by a community clinician of what has been happening. "Her community psychiatrist identifies having to move to a less-supervised setting as the primary stressor." Anything in the chart is subject to be entered into a court record. When a particular case is discussed outside the circle of confidentiality, such as at a conference, the name and any identifying details have to be disguised sufficiently to prevent disclosure. Yet one cannot disguise them by changing them, saying "a young black male" when it is a young black female. It is simply not allowed to pretend that someone who has political paranoia has religious paranoia for purpose of discussion.
To describe twin autistic patients as having an obsession with prime numbers and uncanny abilities to discover them, spending their day trading them playfully back and forth when they don't do anything like this is an enormous breach of trust. To further claim to have brought a lengthy prime into discussion with them, so that they make a place for you in their little world would be grounds for immediate firing.
I believed every one of the cases Sacks described. If you told me that Witty Ticcy Ray was a actually bass player rather than a drummer, I would have felt deceived.
It speaks to the power of the fantasy of the magical healer that readers and publishers accepted Sacks’s stories as literal truth. In a letter to one of his three brothers, Marcus, Sacks enclosed a copy of “The Man Who Mistook His Wife for a Hat,” which was published in 1985, calling it a book of “fairy tales.” He explained that “these odd Narratives—half-report, half-imagined, half-science, half-fable, but with a fidelity of their own—are what I do, basically, to keep MY demons of boredom and loneliness and despair away.” He added that Marcus would likely call them “confabulations”—a phenomenon Sacks explores in a chapter about a patient who could retain memories for only a few seconds and must “make meaning, in a desperate way, continually inventing, throwing bridges of meaning over abysses,” but the “bridges, the patches, for all their brilliance . . . cannot do service for reality.”
Sacks was startled by the success of the book, which he had dedicated to Shengold, “my own mentor and physician.” It became an international best-seller, routinely assigned in medical schools. Sacks wrote in his journal,
Guilt has been much greater since ‘Hat’ because of (among other things)
My lies,
falsification
He pondered the phrase “art is the lie that tells the truth,” often attributed to Picasso, but he seemed unconvinced. “I think I have to thrash this out with Shengold (ed. his psychoanalyst)—it is killing me, soul-killing me,” he wrote. “My ‘cast of characters’ (for this is what they become) take on an almost Dickensian quality.”
Who was harmed?
The patient is potentially harmed, but in many of these cases the patient experienced the doctor's attention and even projected interpretation as a positive. For people abandoned by the world, someone simply showing up and showing consistent focus would be precious. Oliver Sacks rather obviously cared about these people and tried to see something special in each, to the point of overidentification. That matters. That counts. But the subsequent storytelling to the world is not a necessary part of that. A sincere and kindly person with no clinical training could do the same. Being seen inaccurately is not as good as being seen truly, but it must be better than remaining invisible. This comes up in the discussion of AI therapists which reflect back to you what you want to hear. Is that good for you? We crave being understood deeply - an imitation of that might well meet the craving. I thought of Ray Bradbury's The Man In The Rorschach Shirt. Couldn't the doctor have just done that instead? No, despite his very real compassion, Dr. Sacks was in it to "work through" (vacuous phrase) his own issues. It might have kept his nose to the grindstone, to his patients' benefit, but the risk of spilling his own pathology into them would be real. Treatment decisions, including independence, medication, and legal status are decided on the basis of reported information. It could matter. I have seen entire treatment approaches to a patient reversed on the basis of discovering some new information, or the disproving of old information. Not often, but it happens.
The public was harmed. New Yorker writer Rachel Aviv stresses the importance of the compassion and (ahem) empathy people might feel for damaged individuals. That's fine. Keeping up general fascination with the brain and research could have good effect. I draw the line at clinicians. Teaching therapists, prescribers, and outreach workers false information must in the end be bad for their patients. I did not read The Man Who Mistook His Wife For a Hat thinking "How inspired I am to see the ultimate value of every human being," I was looking for brain understanding, thinking how wonderful it was that we are learning such intricacies on the basis of these oddities. We now know looking back that Postwar psychology was more a literature than a science - which would have been fine if everyone had been clear about that. The Stanford Prison Experiment, Kinsey's mythology of sexual behavior, delayed gratification prediction, priming, stereotype threat - all pretty much useless. But it would be so cool if this were true. Let's all talk about what it would mean if it were true. No thanks. These are people's lives we are screwing with.
My title was "Too Good to Check" but how would I have checked? It would be more accurate to say "Too Cool to Question," and I didn't. I am quite distressed about what this means in general for my standards. I have been wondering if this is another time of upending for me, one of those periods that comes along every decade or so from which I emerge with my mind changed about things. I find I have been unable to force this to happen and also, only recognise it when I am more than halfway through. Hey! I might be halfway through! I wonder what has changed?
11 comments:
I picked up "The Man Who Mistook His Wife for a Hat" because of the title, found it fascinating, and wound up reading most of his other books. This is profoundly disappointing, and a little embarrassing. Now, I wonder: should I have been more skeptical? I spent my career working in R&D, and one of the things you learn, if you are a good researcher, is to be skeptical of results that seem too good (or too cool) to be true. Well, I'm an engineer, not a psychiatrist, so maybe I shouldn't be too hard on myself. But what about people in the field of psychiatry? Shouldn't someone have read his stuff, and raised some alarms?
A neurologist or neuropsychiatrist would be best placed to smell a rat, but a lot of us are on the hook for this.
Does this raise the profile of that great British/German psychologist, Hans Eysenck? He was profoundly sceptical of psychoanalysis and insisted on the scientific method at all times. There were actual post-war psychologists who were proper scientists
My father was a physiology professor and often reviewed popular medical books for our local newspaper. He was chagrined by the huge sales of "Hat" because he had reviewed it as an interesting book that was unlikely to attract a large readership. I never read "Hat" but know something about the shelf-life of much social science research. It is not just that it panders to transitory political programs and economic interests, but that it closely tracks the zeitgeist and seldom outlives its age.
The Sacks case reminds us how easily we are imposed upon by men who are gifted and bored. They spin fables to pass the time and flaunt their gifts of language and imagination, while the dull rubes mistake them for sages who are telling the truth. Some of us are guilty of doing this ourselves. These gifted and bored men do not aim to mislead or deceive. They are not sly propagandists. They are just bullshitters in the technical sense of that word. And that in the end may be worse.
I read the Divine Comedy this summer, and one of the things that was interesting to me is that fraudsters were put in a lower circle of hell than your basic murderer. The reasoning was that a murderer hurts one person and their circle, but fraud undermines the trust level in an entire society.
I see a lot of that here. I understand the need to be skeptical, but on some level it bothers me that we feel the pressure to approach every interesting thing someone tells us with an air of "but what if you're lying to me". Self protecting? Sure. But a pretty sad way to have to go through life.
@ Sutton - psychoanalysis was already going out of fashion when I started in mental health in the 1970s, but it has hung on in some corners even until now. Eysenck gets a mixed review these days.
I read and enjoyed The Man Who Mistook His Wife for a Hat many years ago, but I do remember that more than a little skepticism existed at the time. I remember one doctor saying that no neurologist had that many interesting patients.
An excellent skepticism. That they fit so neatly should also have been a warning sign.
It's far enough outside my area that I've never heard of Oliver Sacks before today. Nevertheless, I believe you and bs king when you say that this sort of fraud affects the whole society. How would you characterize the effects it has had, which someone like me might be affect by without being aware of them? It obviously affected your profession and several others, which each exercise influence, for example.
I had to think about that one, Grim. There may be no direct effect. Anything that affects the whole culture of medicine and psychology will bleed out into the rest of the culture. I would compare it to Elie Wiesel's "Night," which is at best based on a true story. It seems to have done much good in the world. But has it? Doesn't the lie as foundation eventually crumble?
From my perspective, I took Dante to mean that being a fraud victim (or even merely aware of fraud) erodes trust in society in general, so each new case will keep chipping away at how we all view each other. So if I took Sacks writing at his word and found I was deceived, I will subsequently distrust your writing more merely to ensure I’m not deceived again. It’s a reality of life I guess, but it just strikes me as sad that everything I read my first thought needs to be “is this person fabricating this”? So my comment mostly wasn’t about Sacks himself, but about how much skepticism we need to carry to operate in the world. There’s downsides to that.
For Sacks specifically, case studies are often the first step in medical research. Some diseases or problems are simply uncommon enough that the first person to notice it can’t do a whole study, so they write up a “here’s a weird thing I saw in a patient” report and then see if anyone else has seen it too. This was the first step in discovering HIV for example. Sacks writing was basically case reports, and they influenced a lot of people’s thinking about where the margins of brain function were. These are supposed to be teaching tools so you wouldn’t particularly expect people to make them up….theres no block buster finding on the other end, it’s just one persons “hey I saw some weird others should be aware of in case they see it too”. Sacks books were often assigned in classes because they were so accessible (that’s where I first read him), so a huge number of people were fed erroneous information as part of their learning. Even if it just impacts their idea of how the fringes operate, it’s still incorrect information. That it was done knowingly is even sadder. So overall I agree with AVI, it’s likely not a direct effect, but it means the foundation is shakier than we suspected.
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