If anyone’s looking for a brief primer on the popular perception of psychiatry and the animosity felt by those who feel hurt or scarred by this (my) profession, a good place to start would be a recent post by Steven Moffic entitled “Why We Still Need Psychiatrists!” on Robert Whitaker’s site, Mad In America.
Moffic, a psychiatrist at the Medical College of Wisconsin, is a published author, a regular contributor to Psychiatric Times, and a member of the Group for the Advancement of Psychiatry. Whitaker is a journalist best known for his books Mad in America and Anatomy of an Epidemic, both of which have challenged modern psychiatric practice.
Moffic’s thesis is that we still “need” psychiatrists, particularly to help engineer necessary changes in the delivery of psychiatric care (for example, integration of psychiatry into primary care, incorporating therapeutic communities and other psychosocial treatments into the psychiatric mainstream, etc). He argues that we are the best to do so by virtue of our extensive training, our knowledge of the brain, and our “dedication to the patient.”
The reaction by readers was, predictably, swift and furious. While Whitaker’s readers are not exactly a representative sample (one reader, for example, commented that “the search for a good psychiatrist can begin in the obituary column” – a comment which was later deleted by Mr Whitaker), their comments—and Moffic’s responses—reinforce the idea that, despite our best intentions, psychiatrists are still not on the same page as many of the people we intend to serve.
As I read the comments, I find myself sympathetic to many of Moffic’s critics. There’s still a lot we don’t know about mental illness, and much of what we do might legitimately be called “pseudoscience.” However, I am also keenly aware of one uncomfortable fact: For every patient who argues that psychiatric diagnoses are fallacies and that medications “harm” or “kill” people, there are dozens—if not hundreds—of others who not only disagree, but who INSIST that they DO have these disorders and who don’t just accept but REQUEST drug treatment.
For instance, consider this response to Moffic’s post:
Stop chemically lobotomizing adults, teens, children, and infants for your imaginary psychiatric ‘brain diseases.’ Stop spreading lies to the world about these ‘chronic’ (fake) brain illnesses, telling people they can only hope to manage them with ‘appropriate’ (as defined by you and yours) ‘treatments,’ so that they are made to falsely believe in non-existent illnesses and deficiencies that would have them ‘disabled’ for a lifetime and too demoralized about it to give a damn.
I don’t know how Moffic would respond to such criticism. If he’s like most psychiatrists I know, he may just shrug it off as a “fringe” argument. But that’s a dangerous move, because despite the commenter’s tone, his/her arguments are worthy of scientific investigation.
Let’s assume this commenter’s points are entirely correct. That still doesn’t change the fact that lots of people have already “bought in” to the psychiatric model. In my practice, I routinely see patients who want to believe that they have a “brain disease.” They ask me for the “appropriate treatment”—often a specific medication they’ve seen on TV, or have taken from a friend, and don’t want to hear about the side effects or how it’s not indicated for their condition. (It takes more energy to say “no” than to say “yes.”) They often appreciate the fact that there’s a “chemical deficiency” or “imbalance” to explain their behavior or their moods. (Incidentally, family members, the criminal justice system, and countless social service agencies also appreciate this “explanation.”) Finally, as I’ve written about before, many patients don’t see “disability” as such a bad thing; in fact, they actively pursue it—sometimes even demanding this label—despite my attempts to convince them otherwise.
In short, I agree with many of the critics on Whitaker’s site—and Whitaker himself—that psychiatry has far overstepped its bounds and has mislabeled and mistreated countless people. (I can’t tell you how many times I’ve been asked to prescribe a drug for which I think to myself “what in the world is this going to do????”) But the critics fail to realize is that this “delusion” of psychiatry is not just in psychiatrists’ minds. It’s part of society. Families, the legal system, Social Security, Medicaid/Medicare, Big Pharma, Madison Avenue, insurance companies, and employers of psychiatrists (and, increasingly, non-psychiatrists) like me—all of them see psychiatry the same way: as a way to label and “pathologize” behaviors that are, oftentimes, only slight variants of “normal” (whatever that is) and seek to “treat” them, usually with chemicals.
Any attempt to challenge this status quo (this “shared delusion,” as I wrote in my response to Moffic’s post) is met with resistance, as illustrated by the case of Loren Mosher, whom Moffic discusses briefly. The influence of the APA and drug companies on popular thought—not to mention legislation and allocation of health-care resources—is far more deeply entrenched than most people realize.
But the good thing is that Moffic’s arguments for why we need psychiatrists can just as easily be used as arguments for why psychiatrists are uniquely positioned to change this state of affairs. Only psychiatrists—with their years of scientific education—can dig through the muck (as one commenter wrote, “to find nuggets in the sewage”) and appropriately evaluate the medical literature. Psychiatrists should have a commanding knowledge of the evidence for all sorts of treatments (not just “biological” ones, even though one commenter lamented that she knew more about meds than her psychiatrist!) and argue for their inclusion and reimbursement in the services we provide.
Psychiatrists can (or should) also have the communication skills to explain to patients how they can overcome “illnesses” or, indeed, to educate them that their complaints are not even “illnesses” in the first place. Finally, psychiatrists should command the requisite authority and respect amongst policymakers to challenge the broken “disability” system, a system which, I agree, does make people “too demoralized to give a damn.”
This is an uphill battle. It’s particularly difficult when psychiatrists tenaciously hold on to a status quo which, unfortunately, is also foisted upon them by their employers. (And I fear that Obamacare, should it come to pass, is only going to intensify the overdiagnosis and ultrarapid biological management of patients—more likely by providers with even less education than the psychiatrist). But it’s a battle we must fight, not just for the sake of our jobs, but—as Whitaker’s readers emphasize—for the long-term well-being of millions of patients, and, quite possibly, for the well-being of our society as a whole.