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.
Thought Broadcast 
I appreciate this post about the need for psychiatrists to be the leaders in the “critical psychiatry” field because of their expertise (in order to improve diagnoses and interventions?), and while I’m delighted to see your self-examination, your openness, and your optimism, I wonder at the legitimacy of your point, especially considering that some of the most powerful criticisms (and calls for positive change) have come from non-psychiatrists (psychologists, journalists, people who have been diagnosed with an illness, etc.), and so few in pharmacology have criticized what is the single most common intervention.
The only psychiatrist I know who is currently critical of psychiatry is Thomas Szasz, and he’s been (rightfully) marginalized for being so acerbic, dogmatic and vitriolic. Historically, the few other psychiatrists who have taken “critical” positions have, likewise, been marginalized, even when their criticisms have merit: Michel Foucault, R.D. Laing, Franco Basaglia, and David Cooper.
And, why does one not read much from psychiatry professors about the need to change curricula, methods, emphases in school?
And, since neuroscience is now the buttress of psychiatry, where are the critical neurologists and neuroscientists?
Many psychiatrists are grumbling. The front page of Psychiatric Times has articles: “How American Psychiatry Can Save Itself” detailing how the DSM has brought us the worst of all worlds. Hardly fringe complaints! We are rewarded monetarily by a grab and dash diagnosis followed by a pill. I know of outpatient psychiatrists who book 8 patients an hour.
Ultimately, though, the psychiatrist is uniquely positioned in medicine. I feel sometimes like the last bastion of doctoring, the only one who can afford to spend any time with the patient not checking off some managed care quality assurance list of labs to check. I feel like a combination between the clean-up crew and a medical detective. Reducing meds, almost always reducing, figuring out missed medical issues (hypovitaminosis D, hyperparathyroidism, epilepsy just these past two months), and teaching folks that it is okay to feel. Even if we feel bad sometimes.
I wish Whitaker had done a better job studying the history of psychiatry. In Anatomy of an Epidemic, he blames meds for the issues. But there are reports of major depressive disorder, bipolar disorder, anxiety and psychosis as long as there have been written records. Somewhere there has to be a middle ground between psychiatry being an entirely invented profession and 20% of the US population on psychotropics.
I will carry on trying to piece together pathology and psychiatry and human health and disease in my own way, with nutrition, lifestyle, sleep modification, exercise, stress reduction, and yes, medication. When I have to.
Emily,
Great points. It’s truly unfortunate that the good psychiatrists I know follow precisely your lead: “piec[ing] together pathology and psychiatry and human health and disease… with nutrition, lifestyle, sleep modification, exercise, stress reduction, and… medication.” Even though most psychiatrists would welcome the opportunity to practice in this manner, most of us don’t have luxury of time to do so… and, moreover, most patients have little interest in any of the above.
(BTW, before anyone accuses me of “blaming the patient,” I would invite you to spend a day trying to talk patients out of a non-indicated benzo, stimulant, sleeper, or Seroquel, or an SSRI for “stress.”)
Steve,
Oh, totally. And The Carlat Report last year highlighted a study where the patient who didn’t want meds benefited from meds the same as everyone (around 50-60%), whereas the patient who didn’t want therapy found therapy to be 0% effective!! But I work from a stages of change model, so that everyone always gets the push to better lifestyle, the push differing dependent upon their stage. Some will remain in precontemplation forever. C’est la vie.
I note in those Psychiatric Times articles, Dr. PIes yet again says the problem with psychiatry is bad press, the solution being better public relations.
Could someone please help Dr. Pies out with his anosognosia? The problem with psychiatry is bad outcomes arising from bad science. There are so many injured patients now that no amount of advertising or PR or grandstanding by psychiatry silverbacks is going to overcome the bad word-of-mouth. The reality demands to be addressed.
Whitaker never denies that there have been the phenomena of mental illness forever…in fact he lays out the numbers very well referring to those who got labeled and institutionalized before the use of medications many times. And there were, indeed, people with psychiatric phenomena prior to meds. What he underscores is the explosion and increased chronicity since drugs came on the scene. To say he denies the existence of any illness at all seems to suggest not having read his book.
In my opinion drugs are just one thing fueling the epidemic. From speaking with Bob, I would say he’d agree. The book however is focused and looks very closely at how the over-use of medications have aided that process.
Yes there was an epidemic before meds and even psychiatrists. They called the epidemic sin and moral failing. Had much better treatments for it too (sarcasm). Doctors don’t create the problem ex nihilo. People decide to seek help for their problems from different groups of people. When they sought priests the epidemic was sin. Now doctors and the epidemic is disease.
Dr. Balt,
I still say, “stop blaming the patient.”
Duane
Here’s where the critical neuroscientists are http://www.danielbor.com/dilemma-weak-neuroimaging/ , and they’re not happy about the travesty psychiatry is making of their esoteric and exacting discipline.
“Diseased brain circuits” found by neuroimaging are going to be the biopsychiatry fad of this decade, now that the “chemical imbalance” theory is dead.
Altostrata,
You’ve gotten more passionate lately.
Good!
Duane
When I read of people being “anti-psychiatry”, I can only conclude that they’ve never suffered a severe, psychotic illness or known anyone who has. And I very much doubt if these patients looking for a diagnosis are looking for a diagnosis like schizophrenia or personality disorder.
We need psychiatrists because some people are mentally ill: truly and indisputably ill, and suffering. There may not be a cure for people with such illnesses, but a lot can be done to ease their suffering.
There’s a lot of low-level “mental distress” about, which might be where all these patients in search of a diagnosis are coming from. But I’m not convinced psychiatry is really the solution to their problems, anymore an orthopedic surgeons is a solution for hangnails. Maybe the answer is for psychiatrist to treat only actual mentally ill people?
Extreme emotional suffering is not an “illness”. It’s just another point on the spectrum of natural human emotional/psychological states. Your judgments about so-called “anti-psychiatry” people are in error.
fifteen years. twelve (or so) psychiatric hospitalizations (maybe one or two voluntary). five overdoses. i’ve never been truly psychotic, but have spent years depressed as hell. horribly depressed– can’t even IMAGINE a life worth living depressed.
i don’t have a chemical imbalance or a brain disease. but i’ve met the criteria for several dsm IV diagnoses…
i’m finally off all psychiatric meds and working my ass of in dialectical behavior therapy, and i’ve never been healthier. i’ve learned skills. i’ve changed my thinking. i’m recovering. all with the help of family, friends, a counselor, and a psychologist. one psychiatrist told me my life had a “bleak outlook.” if i’d let people like him rule my life, he would have been right. however, with the RIGHT sort of support, i’m proving him dead wrong.
i’m not sure if i’m “anti-psychiatry.” i am all for humane, supportive, evidence based treatment. and so far, medications don’t seem to fit the bill, for me. and judging by the behavior of my friends from the hospital who are on “cutting age” medications, closely supervised by qualified psychiatrists and are still delusional and hallucinating, it doesn’t seem so effective for them, either.
MT, you are concerned with being right, not helping anyone. Annalaw81 is sharing her experience of the pain of being related to someone with the what doctors label as Schizophrenia. Call it whatever you want. Feel free not to label. Here is a family suffering. Why don’t you offer her a solution or suggestion that she could use to help her sister, her family or herself suffer less? One that basically isn’t, “change the entire mental health system in the Western World. If you’re not willing to do that you’re victimizing your sister and your family.” I’m sure you’ll find a way to feel good about being right in reply, while you’ve added slight definite pain to this family. Good job one whom I shouldn’t refer to with a label (name) because we can’t objectify this recurrent pattern in the larger pattern of the biggest pattern that the rest of us understand (labels) as you.
@Emerzen,
That’s a ridiculous characterization of what I’ve written, and it’s self-serving. I really don’t know what good you think you’re doing by making up your own version of my motivations and deciding what I must *really* mean.
And since there has been censorship going on with this comment thread, I’ve chosen not to participate in the dialogue any further.
Really, this thread is censored? I’ll simplify it. Provide one practical step that she and her sister can take that will improve their well being? I’m rooting for u here. I think they deserve some actionable advice. If it helps, I’m happy to watch u help.
I try not to censor this site and I welcome unpopular or controversial opinions. However, on rare occasions I will remove comments that make direct attacks on other individuals or which advertise services.
Yes, Anna’s right. My sister is schizophrenic. She is an educated woman who used to work as a master’s level counselor and whose world fell apart in her late twenties. What’s followed is 30 years plus of revolving-door hospitalizations, meds of all sorts, alienation from family, friends and career, and now, she lives in a group home, and attends a ‘program’ where participants do menial tasks of some kind and where she attends a group of some kind. She goes off her meds occasionally and is rehospitalized. I don’t claim to be a doctor or to understand the biological basis of schizophrenic illness, but I do know a lot about how someone can be truly, seriously mentally ill, and how that can affect her and her family, and how meds, for good or bad, have been the only thing that has really allowed her to live outside a state hospital.
No, she’s not right. And your objectification of your sister as a “schizophrenic” is telling. No one knows of any biological basis for so-called “mental illness”, including psychiatry. It’s all conjecture at this point. But what is known is that the drugs do worsen the outcomes, and that one has a great chance of full recovery from “schizophrenia” in third world country such as Nigeria, but in the US, it’s usually a death sentence. The main difference is that they don’t drug patients and keep them drugged, but the US does. Your sister’s brain has suffered with the chemical assault of psychiatric drugs for so many many years now, that it’s highly unlikely that she could ever go off safely and recover. Other people have and do and are achieving that recovery without psych drugs every single day. You’ll never know what your sister could have done.
I am not ‘objectifying’ my own sister. You don’t know what I have lived through or what she has lived through, more to the point. Perhaps the psychiatrists ‘objectified’ her. I don’t claim to know how the meds work or even if they truly work, however, I do know that when she is on them she can live in the world; when she is not, she ends up in a hospital in typical ‘revolving door’ fashion, because non-drug, supportive interventions don’t seem to be that available. It’s nice to think there should be a calm, safe environment where folks who are experiencing what has been defined by the medical profession as ‘schizophrenia,’ where the ‘village’ would care for such persons. Wasn’t that sort of the idea when they opened the doors to the mental hospitals back in the 70’s? Only the money didn’t follow? Am I missing something here? Well, the money is still not there. I agree that my sister won’t recover, and I also wonder myself – who knows what she could have done? But I also know I was attacked physically by her when I intervened when she attacked my mother. In a perfect world, perhaps, there’d be a safe place and caring counselor who could ‘work with her’ to help her understand and thus not repeat that afternoon. Unfortunately, there wasn’t and as far as I know, still isn’t such a place. Before you blame me for not having my sister live ‘at home,’ know that she WAS living at home. Families try – and in our current scheme, the hospital and meds are often all that stand between them and a lack of safety, both for themselves and their ill loved ones. (Note that I realize this does not relate to ALL persons disagnosed with schizophrenia or any other mental illness. I’m simply offering my opinion through the prism of my own experience.
and you *did* tell us your sister “is schizophrenic”. That’s objectification. Your sister is a person, not a label or some psychiatric “disease” construct. Labels are for jars.
I have a schizophrenic uncle, and I do not see a problem with saying that. I saw MT jumped on you for calling your sister schizophrenic. It’s not just schizophrenics. What about diabetics? I don’t always say my late grandfather had diabetes. Sometimes I say he was diabetic. I also call my brother gay. Sure, I could say he has homosexual tendencies, but it doesn’t roll off the tongue in quite the same way. My diabetic grandfather was diabetic, gay brother has same sex tendencies, schizophrenic uncle has schizophrenia…whatever. It’s just a way of talking.
As a practicing primary care clinician with 34 years of post-residency learning behind me, I would suggest that the problem is partly definitional: what constitutes a psychiatric illness, and how does this differ from a psychiatric symptom or psychiatric distress? Who (sufferer or clinician) decides?
I’ve begun to think that these questions are unanswerable. Or, at least, unanswerable in a way that makes practical sense to me when I am sitting with a patient or family in an exam room. So I now approach this differently – and perhaps my approach offers a paradigm for answering the questions raised by this post.
I start with attempting to sort out what the patient perceives as the problem, how much dysfunction this is causing in the patient’s universe, and how the patient understands this. I then try to sort out what I think the problem is, how it impacts the patient, and what the causes and prospects are. On rare occasions these overlap well. Sometimes there is no overlap. Most often there is a significant amount of overlap. I talk to the patient about these two perspectives and suggest we work on the areas of commonality as a start. (If there is no commonality, I suggest we work on finding or creating one.)
It is common for us to collaboratively identify a mismatch between an external and internal issue: inadequate financial resources because of job changes in the setting of maladaptive expectations, inability to cope with uncertainty, negative internal dialogue. We can then try to deal with both symptoms (poor sleep, irritability, comfort eating…) and issues without confusing problems with the distress.
Making my process with patients practical and operational rather than theoretical or dogmatic has worked better for me. More important, it works MUCH better for my patients.
I would suggest approaching psychiatry (and the role of psychiatrists) as a field where experts in the ways patients think and feel attempt to identify and resolve the internal and external causes of distress and maladaptive responses.
They don’t get paid to work that way. They get paid to write prescriptions. Psychologists, social workers and other master’s level therapists can do what you suggest. The only “edge” they have in psychiatry is the precsription pad and the police powers.
With regard to pay, what MT says is true enough. Neither do I get paid to work that way. But they tend to have illnesses (or at least symptoms) for which I can get paid.
My patients do come to see me in varying degrees of distress. Those psychologists, social workers and other master’s level therapists you describe expect payment and, at least where I work, most of my patients do not have coverage for this and cannot easily pay out of pocket. The wait time for a psychiatrist when I make a referral of an insured patient is usually 3 months or more. Most refuse MaineCare patients.
The point of my post, though, was that from where I sit, all this talk about what psychiatry and psychiatric care are and how they should be oriented is irrelevant.
@pheski
I would say those things are totally “relevant”.
And as a primary care physician, you treat real illnesses, not constructs.
Psychiatry takes human suffering, assigns a label to it and then drugs the patient with respect to that label. That’s a very seriously flawed approach.
“And as a primary care physician, you treat real illnesses, not constructs.”
I try very hard to treat patients, not illnesses, a distinction with a difference.
Try as you might, all of allopathic medicine is generally flawed in its approach. It’s mainly symptom supressants all around. If you’re working differently, I applaud you, but most doctors aren’t treating patients. They’re covering up the uncomfortable manifestations of the real problem. Psychiatry is not the only branch of medicine to do that, but in the case of psychiatry, they invent “diseases” as the apparent “cause” of the distress. That too, is a distinction with a difference.
Yes, yes, yes. A real Psychiatrist, er, um, primary care physician. I think all docs who care reach some working method along the above lines. Fresh out of training the tools–DSM, Harrison’s, pharma, psychodynamics, expert opinion, etc– structure the problem because “solutions” are readily at hand and we feel confident in them. However, if we are paying attention, Procrustes will be seen casting his shadow. Occasionally the tools fit and work, but at least as often don’t. If you really want to help this person, you’ll be forced to “leave the nest,” so to speak, and become master, not slave, of the tools.
Example: 25yo JAF who feigns burns to gain hospitalization. Problem grew out of a traumatic childhood that experienced the hospital as the only safe haven after an initial accidental burn. Problem is, her behavior has had increasingly severe consequences, and it has become a mortal condition. Lots of tools have already been thrown at it, but the view of addiction had not been applied. Decided to “taper” the hospital in a planned manner while DBT/Exposure Tx started and increased to decrease the fundamental anxiety that fueled the need. Sprinkled in a little prazosin to help kick off better quality sleep, and ssri to provide a “cast” for his damaged trust. Wasn’t wedded to meds, but given low risk, the reasonable benefits seemed worth trying.
Guess what, things are different. It has been a record number of days since self-injury, or need for ICU. Cured? No. But it’s a start and better than giving up. Where did I learn this algorithm from? I created it out of my educated understanding of the problem, possible treatments, and elements that go into human problems. Don’t think you could find it in any one place. Oh yeah, did it in a community setting, no lack of resources when you think you can make a difference. Don’t see how anyone but a Psychiatrist would have been able to put it all together.
In my opinion the problem with Psychiatry is that we forget our context (medical doctors) and allow others to hold us to standards no other subspecialty considers appropriate. We lack self-esteem as a profession, and this leads to easy manipulation by forces having nothing to do with clinical goals. Pharma is one force, the government another, and patients ARE another. “I know he’s bipolar, his teacher/counsellor/case worker said I should ask you about it.” Can you imagine going to a Cardiologist INSISTING you had CHF? No test/sign or symptom consistent, but patient gets angry enough, and well, maybe that EF is a new variant of CHF? This is routine in Psychiatry. Jaw dropping as so many Psych’s simply capitulate. And why are we singled out? Why the split? Remember splitting? Notice patients in one corner, evil Psychiatrists in another? Sound familiar? Aren’t we all supposed to sit in a room TOGETHER, bring all these parts TOGETHER to integrate the person and reduce recapitulation? Or are we supposed to choose a side and commiserate with the awfulness of the other?
Why didn’t Whitaker write a book about the Fibromyalgia epidemic? Or the “low back pain” epidemic? Or the myth of spinal fusion (Szasz)? (Yes, there is an anatomical lesion, ask any spinal surgeon and he’ll show you one, doesn’t seem to be a difference that makes a difference Dr. Szasz.) How about the “hypercholesterolemia” epidemic now hyperLDL now hyper TGs now some combo? Those REALLY cause heart disease any more than too much dopamine causes psychosis or too little 5-HT depression? IBS, chronic Lyme, Chronic fatigue… MS, the one we were wrong about. MRI showed it REALLY is a disease. Funny, I’ve met more MS patients without lesions than with. In fact, you don’t even need them for a Dx. Pt insists their symptoms match what they’ve read. What does that Neurologist know anyway, practically a Psychiatrist. Soon enough we serendipitously DISCOVER all kinds of antibodies that shouldn’t be there, but don’t REALLY need those either, it’s a clinical diagnosis.(I’m not saying MS isn’t real, I’m trying to show that it’s delimitations share many features of less “real” disorders.)
Why isn’t there an “anti-PCP” movement? If one wants to look at damaging treatments, what can compares to the prescription pain killers? That is a REAL epidemic. Chronic pain, who makes that diagnosis? Psychiatry used to PREVENT that diagnosis. Used to call it Somatization and warn that pt’s are at RISK from unnecessary medical treatment. Remember? Dr. Whitaker, why don’t you take a look at that. I’ve buried many an opiate dependent patient, seen many an orphaned family, which practically was orphaned before they died thanks to Oxycontin. Dr. Szasz, lots of lesions for pain problems. Take a look at the CT again, look long enough and you’ll see something, kind of like a rorschach Dr. Szasz. There’s that lesion to justify this REAL disease. Do you feel better now? Are you a REAL doctor now? That guy any less dead now or his life any less evacuated? Open up the obits, guarantee there is some young person who died (no reason given) and everyone is shocked. Think it was Prozac causing suicidal thinking, or the Flexeril, Oxycontin, Xanax, Percocet PRN combo? I’ve met these patients because now they have “sleep problems” and they’re “moody probably bipolar like dad.” “Are you an alcoholic like dad?” “Never touch the stuff doc.” Well, maybe all these pain meds are the problem? No, that’s a REAL disease? it has nothing to do with getting your ass kicked routinely growing up by dad, or mom’s BF?
Dr. Szasz and Mr. Whitaker, I’m glad you continue to prove your theories are tautologically correct while ignoring that the theory has no connection with empirical clinical reality. And you validate non-professional laymen who are a force that DOES make a difference, one that degrades the profession of Psychiatry. I have met, cried over, fought with, and now am haunted by many faces and families that have been my patients. I can count on one hand the suicides I’ve known, none of them due to Prozac. The worst epidemic in this country is a result of a LACK of Psychiatrists in my opinion. Medicine lacks the healthy dialectic Psychiatry once balanced it with.
We continue to demean, demoralize, disincentivize, and villainize Psychiatry yet wonder why “it take 3 months to get in with a Psychiatrist.” The 5 of us left in the country would love not to be a “prescription pad.” So, stop writing books and blogs about how destructive and unnecessary we are. Maybe you should promote the field, so that thoughtful caring people would choose it in greater number, actually relieving the problem.
If more social workers, MS therapists, and Psychologists are preferred, then that is what will happen. Maybe the medical doctor and his framework are expensive, unnecessary or harmful? Obviously, I think it’s the most comprehensive and practical approach but I may be wrong, time may tell. Doesn’t really matter though, cause I love being a doctor, and especially a Psychiatrist. When done right, you can be discussing Nietzche in the AM, Stahl at lunch, Linehan and Rogers for dinner, and Fonagy for bed. In between you get to work with human being and try to help them solve their problems, which keeps all the ideology in check. I’m proud I’m a Psychiatrist, and I’m proud of what we do and try to do.
The lashing from Mad in America was intense, but the readership has put a lot of thought and energy behind their beliefs/words. Dr. Moffic’s article did not making a convincing case for “why we still need psychiatrists,” a more honest or sophisticated take on the issue than he provided might have gotten a difference response.
Dr. Steve, I hear you speaking from the tough position of dealing with patients coming to you already “bought in” to brain disease models of psychiatric distress/disorder. I know that the vast majority of psychiatrists did not necessarily lead the way in this and others (KOL, drug comapnies, managed care, etc.) colluded to market this idea to the public. Psychiatrists did, however, go along with it. This could be because they really did/do believe in the effectiveness of new diagnoses and treatment options, it was the only way to continue making a living they were used to, and/or they wanted to please their patients.
If doctors get significant training in research methodology and critically reviewing medical/scientific literature (which I don’t think they get nearly as quality training/experience doing so as phd psychologists or some other masters level clinicians), do put their patients health first, and strive for truthfulness/integrity, then psychiatrists have a responsibility that insurers and drug companies don’t have to speak plainly and honestly about the value of treatments being offered/developed and the misleading bombardments of advertising that potential patients receive. It is up to psychiatrists to actively put on the breaks in prescribing something to someon that it isn’t indicated for, training other physician providers to do the same, and educate patients differently. If you really do just prescribe as placebo because a patient refuses to take no for an answer and really believes that a certain pill can change a lot for them, then it is important to be honest about that to patients.
Patients may be influenced by all sorts of powers that do not have their best interest at heart, leading them to believe certain things about themselves and treatments that are just not true or helpful. Psychiatrists are supposed to be the people in the equation of influencing patients that patients can depend on to have their interest and wellness as their concern. If not, then patient/doctor relationships begins with the healthy mistrust a patient/insurer or patient/pharmaceutical company relationship would have. I’m sure many over at MiA are folks who have experienced, often to great detriment, tremendous pain because psychiatrists had not thoroughly understood the medical literature and colluded with the greediest of folks. I really can’t fault people for being mistrustful of and even hostile to psychiatrists, especially ones who espoused nothing new or in any way expressed understanding of their pained experiences, ones made much worse when seeking help from the people they expect and are expected to trust.
Nathan, I agree with you 178.94%
Psychiatrists and other doctors who see how the system is broken may be uncomfortable being put in this position — “hey, can I just practice in peace!” — but history demands that they be the agents of change.
This sort of argument always fascinates me:
“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.”
Have you ever considered the fact that people also seek out and request, even go to great lengths to be subjected to pain and restraint during sexual activities? Or that they pay good money to be pierced in all sorts of gruesome ways? Or that they stay in abusive relationships, because they feel they deserve no better, and that kind of “love” is familiar and “comfortable to them? Or that many people think it’s more acceptable, and certainly it’s legal, to obtain prescription drugs froma doctor? People seek out all sorts of things that are probably not in the best interest of their health.
I knew a kid who found his brother dead after he shot himself. (Both boys were abandoned by a mom who ran home Mexico to be a painter.) He never dealt with that pain and turned to cocaine and heroin instead as a very young adult. He also held down two jobs and had a creative life doing amazing photography. Then he got caught buying drugs and was sent through drug court. They forced him into the psych system and all the drugs treatments and labeled him, switched him from illicit drugs to psych drugs, and now his life is reduced to a measly little disability check, a one room apartment and a life lived out through facebook in between his doses of “meds”. And he’s not the only time I’ve seen this happen.
There are many, and I mean MANY survivors of psychiatry who used to tell people the same thing…that the drugs were helping. Many even sought out the psychiatric “care” and started off voluntarily before getting sucked into the psychiatric downward spiral toward disability and, in some cases, death. Just because people ask to be chemically tweaked so as not to feel a certain way, that doesn’t mean it’s morally correct of medically safe. Psychiatry has created a nation of prescription dope addicts.
Psychiatry can charge ahead on it’s death march, ignoring the “fringe”, but your profession has dug itself a deep hole, and I don’t see you crawling out of it any time soon, if ever.
I am not a doctor, psychiatrist or mental health professional, MT, but as a lawyer I take exception to your quote:
Or that they stay in abusive relationships, because they feel they deserve no better, and that kind of “love” is familiar and “comfortable to them?
You included this in a larger list of ways people seek out things that are ‘not in the best interest of their health.’ While some folks may stay in abusive relationships for the reasons you cited, there are many more who stay in them because they feel for economic or other reasons that they can’t ‘get out.’ To leave a relationship, abusive or not, often with young kids in tow, and reestablish a new residence, hold down a job and attend to one’s kids can be difficult, particularly if your partner controlled or controls the purse strings, or if you’ve been out of the workforce for a while. Again, you need to consider the wider ramifications of generalizations you post as your comments do not represent all of those who might be in a certain category, e.g. people in abusive relationships. This view is a common enough mistake folks make when trying to figure out ‘why someone stays.’ Just sayin…
Dr. Balt,
The only question at hand is whether pscyhiatry is dying or already dead.
I suppose it would be best to call on a doctor to make the determination, huh?
I say, “dead.”
But hey, I’m not doctor.
Duane Sherry, M.S.
discoverandrecover.wordpress.com
But, I’m not in a position to make the diagnosis, because I’m not a doctor.
I’m tempted to ask for the opinion of your profession, but none of you use stethoscopes (in spite of prescribiing drugs that injure the heart)!
Duane
oops, duplicate comment above (typo)
Dr. Balt,
What you and other psychiatrists are witnessing is a backlash that IS NOT GOING AWAY!
Duane
What you are reading on Mad in America, and other places is a problem that is NOT GOING AWAY!
Duane
Dr. Carlat, do you have a credible source for the statement: “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.” I make my living evaluating mental health programs, and I’d like to see the data that supports this assertion.
Scooter52,
First of all, just for clarification, the posts here are written by me, not by Dr Carlat. (For more information about me, see the “About Me” page.)
Second, as this is a blog featuring my opinions and not a refereed scientific article, I don’t have a reference for the above statement. But I will justify it by my first-hand experience. I have worked in three county mental health systems (and three private-practice settings, plus a VA clinic); I have seen, in my own experience, literally hundreds of people who have come to me and who, in my opinion, do not have a clear psychiatric diagnosis (which begs the question: what is a psychiatric diagnosis anyway?) but who insist that they do and, moreover, who demand the same drugs that people on sites like Whitaker’s and SurvivingAntidepressants regularly denounce. It’s a very interesting quandary.
I wouldn’t call that a “quandry”. People seek out drugs all the time. Being a prescription drug dealer, why wouldn’t they seek you out? Street drugs are illegal and not covered by insurance.
I don’t know how this fits into your hypothesis, Dr. Steve — most of the people on my site SurvivingAntidepressants asked for the medications. I did this myself, after seeing the sad bubble turn into the happy bubble after taking Paxil, and I pride myself to being fairly impervious to advertising.
(The few who didn’t ask for drugs were hoodwinked into them by general practitioners, who insisted their physical ailments were psychiatric.)
Forgoing self-blame for having been conned is a difficult turning point for almost all of them.
I don’t know if you watch TV in the evening, but Cymbalta ads are shown roughly every 9 minutes. Then there are all the pop media articles about doing something for your depression.
Pharma has done very, very well by investing some $$$ millions in advertising, public relations, and funding AstroTurfed organizations such as NAMI, reaping $$$ billions.
Also, the population visiting county clinics may self-identify as failures, being “in the system” and therefore in need of all kinds of authoritarian interventions.
Alto,
I was referring to patients who demand medications even when (a) there is no clear evidence of a mental illness (and never was one); (b) other, less dangerous alternatives exist to manage whatever ‘symptoms’ the patient complains about; (c) the natural course of their disorder precludes the need for ongoing medication; and/or (d) the patient has received a full explanation (ie, informed consent) about potential risks and dangers.
Early in the course of an illness, when symptoms do exist to warrant a diagnosis, the risk/benefit ratio often favors the medication. Furthermore, this is the standard of care, so docs like me avoid any malpractice risks by prescribing the drug, regardless of whether we think it’s the best option. But as you know, each illness has its own natural course, and symptoms wax and wane. What’s appropriate upon initial presentation is often not appropriate later on (which is why I always work out a tentative “taper” or “discontinuation” strategy at the outset with each patient– for every drug). Unfortunately, many of our drugs have addictive qualities (or street value), and many patients are too heavily invested in the belief that the drugs “fix them,” both of which lead to their demands for more.
The course of what illness, Steve? You’re not working with “illnesses” when you prescribe psychotropics. You’re suppressing feeling and behavior with chemicals the harm the body and brain. A diagnosis cannot be made by the DSM. It’s a checklist of human suffering. It says nothing about etiology, and the expected courses these days have been altered by the damaging treatments of the past 50+ years. People are not getting better. There truly is an epidemic of iatrogenic psychiatric disability.
You’ve read Anatomy of an Epidemic, no? I wonder, because Whitaker clearly lays out how the long-term outcomes for the “disorders” have worsened with the drugs treatment paradigm. And in response to something Emily Dean said earlier about Whitaker blaming the “meds” for the issues that existed in history long before people started taking “meds”…that’s an absolutely FALSE characterization of what Whitaker has written. What he talks about in Anatomy is how the drugs have created the CHRONICITY in the course of so-called “mental illness”. People would have a single episode of “psychosis” or “mania” or severe depression, maybe even spend time in a psychiatric hospital, BUT…they would go home, go back to work and never have the problems again. Obviously, there would be a few exceptions to that. Not everyone is going to recover, but for a multitude of reasons other than that they are not getting toxic pharmaceuticals dumped into their bodies. The drug treatments have caused the worse outcomes and the chronicity, and in some cases, the drugs ARE the underlying problem in suicidality and “psychosis”.
The argument given about prescribing for certain patients, because it’s the standard of care, is sickening to me. Why did it become the standard of care? Not because it’s effective. Clearly, it’s not. It’s the pharmaceutical industry deep pockets and campaigns that made it so, and psychiatry has benefited from that in numerous ways. Patients, not so much.
Here are a couple of references. Is suicide a “real” disease? Have we “objectivised it too much?:
Am J Psychiatry 2006;163:1898-1904.
PLoS Med 3(6): e220.
http://www.plosmedicine.org/article/info%3Adoi%2F10.1371%2Fjournal.pmed.0030220
Arch Gen Psychiatry. Published online March 5, 2012
According to the CDC http://www.cdc.gov/nchs/data/databriefs/db76.htm, about 11% of the US population over the age of 12 is taking an antidepressant. Most of these people have no psychiatric diagnosis, much less intractable major depression. Of the approximately 30 million people taking antidepressants are only a third of those with MDD (about 6 million people).
The US suicide rate is .01% of the population, or 33,900 US suicides per year.
While suicide is a terrible tragedy — there’s no denying that — can you really justify exposing 11% of the population to medication risks so as to prevent suicide in .01%?
About medication risks: For instance, antidepressants almost double the diabetes risk. The rate of death from diabetes is more than twice that of suicide, and rising.
The bloody shirt of suicide is waved to shout down debate about the risks of antidepressants and the present direction of biopsychiatry. The overuse of antidepressants has nothing to do with preventing suicide, but everything to do with bad science directing bad clinical practice.
I agree that medications are overemphasized in mental health treatment for a sizable percentage taking them, ignoring the psychosocial dimension. BUT, who prescribes the vast majority of antidepressants? It’s not Psychiatrists. As a psychiatrist, I’m much more likely to discriminate complex-PTSD/personality disorders, dysthymia, etc than MDD. As a psychiatrist I’m aware that therapy is more efficacious and essential than meds in this type of disorder, not that they may not have a subsidiary role. If more people asking for help were accessing it from Psychistrists only, the number of people on them would be a fraction. ALSO, antidepressants are used to treat more disorders than just depression. ANXIETY d/o’s are also a large share. The risk of diabetes was also correlated in the case control study with weight gain. Are all antidepressants the same? Does Wellbutrin really carry the same risk as Paxil? Pritiq? Parnate? Does depression itself correlate with increased risk? What is the morbidity and mortality of depression itself? Depends on the specifics of the pt. The risk/benefit equation will vary and the patient will largely have to see it as worthwhile.
I’m not arguing that we should be putting these medications in the water. I’m trying to point out that antidepressants aren’t unequivocally “bad” and more importantly that Psychiayrists aren’t responsible for the vast majority that are prescribed. I’m pointing out that there are many cohorts of patients who would find them valuable and worth the risks; I. E. those struggling with suicide or debilitating depression, OCD, Panic, and PTSD. Above posters are stating that ALL antidepressant use is WRONG for any reason and FORCED on unsuspecting dupes by malanthropic psychiatrists. If u agree that they provide some benefit, in some situations, then the question becomes discriminating the appropriate use. Who had the most training to help make this discrimination?
emerzen, the generalization that psychiatrists know their drugs, diagnose accurately, and prescribe appropriately is questionable. From what I’ve seen, good psychiatrists are in the minority.
Since they make the claim for being psychiatric drug experts, they’re going to get the blame for allowing the drugs to be hyped. Also, there is that little problem of all that garbage research in psychiatric journals going unquestioned by the rank-and-file and flowing out to the rest of medicine.
Psychiatrists should be on the front lines demanding patient safety. They should be pounding the table calling for research in adverse effects and long-term drug efficacy. They should be pounding the table to recall compromised studies. They should be pounding the table to curb pharmaceutical advertising.
Instead, they complain that psychiatry is being treated unfairly. They point the finger at those poor duped GPs. How many psychiatrists are going to local medical society meetings educating their colleagues about the proper, minimal use of psychiatric drugs?
Why do we we require failure to lead, that only is going to lead to more failure.
Psychiatry really does take the urine, maybe they should literally, would least be a valid means to test although for what? Serotonin in the brain! Obvious where to find serotonin in the brain? Would laugh if not those billions of dollars and the loss of life and damage to the people they label and call patients.
On the subject of those whom disagree, we keep to science, that right science and the pseudo science of those claiming a cure, just show me the actual method of action – thats it take a long walk and think about the answer, least shall get all fit.
Psychiatry might burn itself out in time, hope I’m around to see that light, be the biggest burnout in the history of man and those patients that defend blind I’m all for equality and they in part are responsible for those whom never had a choice, were never given a choice, and those that cannot support choice shame on you all.
End invasive compulsory dose.
Well, Alto, we really have to stop communicating like this on a post this old but….to be bold, antidepressants can cause suicide, example, Del Shannon.
Yeah, I know you are suspicious of bipolar, but how many MDD’s are saved compared to Bipolars killed by these drugs. I think a lot of people speculate in fact that a lot of suicide is a phenomenon of mixed state bipolar.
Poor well-meaning Dr. Moffic. I believe he intended his next post to be “How to find a good psychiatrist.”
I think someone suggested the best way to go about finding a good psychiatrist, but he didn’t like the solution. ;o)
At first, I was really offput by this comment on the Dr. Moffic’s post. After thinking about it though, I realized that 1) the comment isn’t a threat, just a very strong opinion, and 2) people make the same joke and then some about lawyers. What I find interesting, is that in my experience lawyers think it is hilarious but psychiatrists are deeply offended. Lawyers laugh because they know it’s often their job to screw people for profit. Not all lawyers are in the role, but a great many are, a great many choose to be, and a great many are proud that they are so good at it. Lawyers laugh because they are ok with the truth of what they often do, and are ok hiding behind an intentionally false notion of “justice” or being straight up profit-driven. It’s not right, they know it’s not right, but they made a choice that using their particular skills, knowledge, years of training, and societal influence to make money in by abusing the legal system and people involved is worth it to them.
Psychiatrists, who I think people expect to have more self-knowledge and display and value honesty, especially the ones with extensive training in psychopharm, many therapeutic interventions, and critically engaging scientific literature, can get much more riled by such comments. I think this happens for a lot of reasons. Psychiatrists who believe they do effective work and have their patients interest at heart are offended because in negates their understanding of their experience and self-image. However, evidence shows a lot of problems with contemporary psychiatric interventions and the evidence and indications for their use are much more limited and sometimes down right missing/falsified. Psychiatrists who don’t face that really can’t face simple and straightforward aspects of what they have chosen to do, and don’t seem to have the ability to hold both what they hope/believe they do/are with what they actually do together at the same time, and then choose to disavow critical engagement with science underpinning what they do in order to protect their sense of selves as “helpful” or “healers.” Ones who are more critical/honest of the care they and their field offers get offended because they have to at least present the illusion that what they do is helpful in order to stay in business. The psychiatrist featured in the New York Times who both bemoaned his transition to an 11 hour a day psychopharm practice with a caseload of 1200 and that he had high expectations for his retirement that he doesn’t want to give up so it’s worth it to do what he does, got slammed by both psychiatrists and patients a like. Being publicly both critical of contemporary practice and welcoming/pursuing its material benefits makes psychiatrists seem like jerks (or worse). People like their lawyers to be jerks, but people don’t trust mean/jerky mental health professionals. Psychiatrists who have a better understanding of the limits/harms of what they were trained to do but still need a job have to act offended as (sometimes illusionary) proof that they do really care about patients’ well-being first and foremost and they do somethings right . Basically, it’s a defense summed up with something like, ” Yes, so much of Psychiatry is messed up but it’s not our fault. See, I’m not a jerk!”
Again, I guess this comes down to the crappy bind psychiatrists find themselves in now that Dr. Steve talked about a few weeks ago in his post about the APA missing an opportunity. One option is to eschew science and critics in order to maintain belief in goodness of what psychiatrists do (diagnose, prescribe, non-specific therapies, get paid out by industry) and hence remain demanding for their high salaries (“we do great, under-appreciated work that takes 8 years of training and such high intelligence that we are the only ones who can do it!” The other is to be upfront about the major problems and damage the profession experiences and has committed, take ownership of that, and call for and engage in new directions. Problem is, I think doing that AND wanting to maintain their lifestyle as respected and well-paid physicians will make them look too much like jerks for anyone to continue engaging with the psychiatric establishment.
I agree, Nathan.
Psychiatry expects gratitude and often works from the arrogant and disrespectful position of, “You will thank me later”…when is it comes to their forced “treatments”. They will present examples of patients who expressed gratitude to support their position. Yet, as many of us know. if one is placed in a position of being involuntarilt detained in a psychiatric unit/hospital, they only way to get out and stay out may be to express that gratitude. It’s taken as a sign of “insight”. The patient is expressing an “understanding” that they are now doing what is deemed “appropriate.
What psychiatry fails to understand is that coercion and blatant force or the threat of loss of liberty all lead to the same thing…survival mode. Many of us have expressed gratitude to psychiatric professionals when it was not genuine. It’s common.
Sylvia Caras wrote a piece on gratitude in relation to psychiatry, and it’s well worth the read. http://www.peoplewho.org/readingroom/caras.gratitude.htm
Regarding involuntary detention/forced treatment, you raise some interesting points.
In my experience at three different hospitals, I can say that the vast majority, if not all, patients who were involuntarily hospitalized truly did need to be briefly sequestered for the safety of themselves or others (or were obviously disorganized and incapable of managing their own affairs). I don’t think many disinterested observers would disagree with that assessment. Now, whether that was due to mental illness is an entirely different question. (Most of the time, drug/ETOH intoxication or withdrawal was a major contributor.) As a result, one could argue that forced drugging was unnecessary and inappropriate, and yes, simply “calming down” was often interpreted as “insight” or “acceptance of treatment.”
As I read your comments, I’m reminded about the training program in which I currently work. The first-year residents (whose psychiatry exposure is limited to the inpatient psych units) spend most of their time (a) writing notes (see my posts about EMRs), and (b) learning to argue in favor of involuntary detention. Indeed, twice a week at “probable cause” hearings, the residents argue for continued involuntary treatment of their patients in front of a county judge and a patients’ rights advocate (who represents the patients). The residents consider it not only a “badge of honor” to “win” their cases, but an important part of their education. More important, in fact, than proper diagnosis and treatment (which, IMHO, is virtually impossible in the chaotic environment of the inpatient unit).
Dr. Balt,
How can you possibly discuss “involuntary hospitalization” and “proper diagnosis and treatment” in the same sentence?
The vast majority of people who undergo such an experience describe it later with horror… being locked up with strangers, placed in a fight/flight environment, with “professionals” who are often cold and distant (at best)… and the only tools at your disposale as a doctor end up causing injury… and trauma.
Altostrata and some others keep jumping in to your aid, and frankly its getting pretty old…
You talk out of both sides of your mouth.
You call for reform. Then a moment later, you justify your own conventional behavior (from the biopsychiatric handbook you were issued in residency)… as if your conscience bothers you, and like a child, you are asking for permission to keep doing what it is you do.
Is what you do okay?
Ask yourself.
And stop asking for permission from your professional peers and the non-medical folks who think you’re just the best…
Act.
If you are a real reformer, it’s time to break loose from the broken model you were taught.
It really is time, Dr. Balt.
It’s time to make some decisions in your professional life.
Who are you?
What are you all about?
What is it you’d like to do with your life?
It’s time to have a talk with yourself.
And to stop these games.
Duane
Oh, and if you want my opinion, what you do is wrong.
There.
Duane
Dr. Balt,
My words crossed over the line.
I may adamantly disagree with the methods of conventional psychiatry, but I’m hardly in the position to judge another human soul.
I apologize.
Duane
stevebMD says:
(BTW, before anyone accuses me of “blaming the patient,” I would invite you to spend a day trying to talk patients out of a non-indicated benzo, stimulant, sleeper, or Seroquel, or an SSRI for “stress.”)
That’s *exactly* what you’re doing there.
Who told all these people that all their emotional discomfort and distress results from things like “chemical imbalances” and “mental illness”? Who made them believe that if their “symptoms” go on for more than a couple of weeks, that they need a doctor and a prescription? Who taught the public that problems concentrating on their boring tasks, trouble sleeping after a day loaded with stress and caffiene, and perhaps now…prolonged grief…requires medical intervention and psychiatric drugs? Seroquel HAS been marketed for anxiety and sleeplessness. Prozac and other SSRIs have been marketed for anxiety and other issues. And if Pharma did all that advertising, but no one was getting the scripts from the doctors, that behavior would go away. But that’s not the case. These drugs have been doled out like PEZ.
You’ll discuss this knowing it’s going to bring the fanatical extremeists out of the closet, and yet you still won’t discuss.your opinions on “bipolar” disorder. Come on! 😉
I think psychiatrists all know what they need to do, and some do already do it, but the fear of what it means and how to apply it draws too many to “old” ways. Psychiatrists need to take a step back, regain some of the benefits that psychiatry had in the past, like actually talking to the patient for more than fifteen minutes and helping them to sort out more than simply medications. I think if, “talk first, change second, meds last” were implemented as the typical route a session, or multiple sessions, took, the meaning of psychiatry wouldn’t be so in question, and both parties would benefit in the end. Problem is, of course, worries about the pocketbook and insurance. How does one force insurance to comply with what’s healthy and beneficial in the long run versus their curren’t pinholed short-term-gain view? That I can’t answer, but it’s in my view the only way to really repair the failure that psychiatry has become.
I’ll take the time to write something positive about psychiatry. It’s a great field and a great idea…But there are a lot of outside forces (insurance companies, stupid/reckless parents, burnt out caregivers, public agencies, etc) that are making psychiatry into a giant failure.
Maybe if we paid for people to become doctors that might make it easier to break away from insurance companies and make care affordable? If a person is smart enough to become a doctor, maybe their education should be paid for. That and/or shorten the educational time. Maybe make the first two years of med school the junior and senior year of undergrad. It sounds like a big issue is that psychiatry is both a shortage field and a field where the doctors don’t have time or money to practice how they want. I think the field probably just needs to be remodeled.
Mara, psychiatrists do have free will. Yes, they are under many societal and structural pressures to cut corners, but I disagree that they are helplessly compelled by outside forces to do the wrong thing.
In particular, I personally have seen many in absolute denial of obvious adverse effects of medication right in front of their faces. They should know potential side effects inside and out; this information is readily available in the PDR, in the medication package insert, and on sites such as the NIH’s MedlinePlus.
I’ve seen thousands of reports from patients about the very same thing. There is no excuse for this ignorance, most psychiatrists do nothing but prescribe the same 2 dozen drugs all day long.
Perhaps they are acting out unconscious hostility to a role they despise and refuse to put the effort in to minimize risk to patients. Or maybe they just hate their patients.
Any way you slice it, it’s bad medicine, and the individual doctors are responsible.
“In particular, I personally have seen many in absolute denial of obvious adverse effects of medication right in front of their faces.”
On that I completely agree. In my situations, I noticed that the PCP was more likely to believe it was a result of the medicine than the prescribing psychiatrist was. I had a nightmare withdrawal from Paxil back in the late 90’s. The psychiatrist really believed something was physically wrong with me. The GP thought it was Paxil withdrawal and tried a different taper method (quite successfully) by utilizing celexa. I don’t know how the GP thought of it (I don’t know if she invented the taper or read about it). But I got better. The psychiatrist was in total denial the entire time I was withdrawing and later said that he had never heard of such a thing happening from coming off Paxil.
I have had varying experiences with psychiatrists which just leave me confused. Reading all of the posts here about whether meds are “good” or “bad” or whether shrinks foist them on the helpless, unsuspecting public or whether we are just a nation of folks who clamor for them because we believe in the magic of pills, just reminds me that there is no one easy answer for patients – or psychiatrists – aside from educating oneself about meds and psychiatry (patients and parents) and in providing good care, which includes judiciousness in prescribing and perhaps, as some suggest, a return to more old-school methods, such as actually talking to the patient for more than 10 or 15 minutes. I’m taking meds and while they have helped somewhat, I have gained a significant amount of weight. I have been through 2 psychiatrists in little over a year, as I obtain services at a clinic where the first one left about 7 months after I started with her and the second only 3 months after I began. I have just been ‘assigned’ a new one, and I hesitate to start anew. I am asking myself now whether the benefits I have experienced from the meds are worth what appears to be a game of musical shrinks, not to mention the weight gain which I believe is due, at least in part, from my SSRI. Each of the two psychiatrists I have seen gave me a different answer as to that so I’m in the dark. On the other hand, I do notice a difference and I don’t think it’s just the placebo effect. This is a voice from the other side of the desk – this is the process at least one patient goes through when determining whether to continue on this road or not.
Dr. Steve,
I’ve been mulling over a little and feeling troubled by the it “takes more energy to say ‘no’ than ‘yes'” comment. I don’t like using analogies as big parts of my arguments, but I have been trying to think of other situations where avoiding expending some extra energy in order to prevent/reduce risk of harm is considered ok, especially when the benefits of not putting in the energy are all that high.
When approaching a red light when driving, it is easier to keep my foot on the gas peddle, as moving it to the breaks would take more energy (intervening with a patient demanding a medication that is not likely to be helpful for them, even if they believe it). While there is a chance that I could just barrel through the red light unharmed and actually reach my destination (robust outcome) faster than expected, I think nearly everyone would agree that the risk of crashing or causing an accident (adverse effects) is not worth the potential benefit of getting to where I’m going faster or spending the energy to move my foot over.
Dogs love the idea of chocolate, but they don’t know that while in the short term it may feel good, it is likely to be harmful/deadly to them. People who take care of dogs do not give chocolate to dogs and try to keep them away from it. While I don’t want to compare people to dogs, as people can be receptive to reason and dialogue. Even people/patients who you say are so deadset on having a brain illness demanding a specific drug that will cure that illness, you are in the position and have the responsibility to honestly explain the extent of support the particular drug has for what a person presents with and deny it to them if it is not helpful and just adds risk of harm. The patient may not like this, as a dog may not like not getting chocolate, but if we are going to be throwing around oaths, remembering (and I paraphrase), help, but at least don’t harm, applies here. Giving a medication that has no evidence to be likely helpful but has evidence that risks harm is pretty against that oath.
These are not the best analogies. There is of course a lot more going on when doctors and patients communicate. But your comment implies that the critics of the way psychiatrists routinely practice, that they just dispense drugs, even when they know they can be dangerous and not helpful, seems accurate. People may come to you seeking drugs, but it is not your job to dispense drugs. What people pay you for (whether they want it or not) is your time, expert knowledge, and ability to think through and discuss a helpful treatment plan (or decide that no plan is really necesary). It is your job to give sound consult, attention, be thoughtful, and act in ways that “put the patient ‘s health first.” Let people go to drug dealers to buy drugs. People should go to doctors for medical consult, the result may be prescription for a medication. Even if they don’t go for that intent, it is the responsibility of doctors to hold to their own job and expend that extra energy to explain and say no sometimes.
I did not have time to read everyone’s post – however, it seems to me, from reading the article, that in these debates, some opinions and /or positions tend to become oversimplified. The world isn’t as cut and dried as some portray. Witness this quote from the article, which particularly caught my attention:
“BTW, before anyone accuses me of “blaming the patient,” I would invite you to spend a day trying to talk patients out of a non-indicated benzo, stimulant, sleeper, or Seroquel, or an SSRI for “stress.”)”
I get that you are a psychiatrist and this may not be an uncommon occurrence for you. However, you post this almost as saying this is what psychiatrists ‘do.’ My shrink (when I had one – I’m between them now and all of this reading makes me raise questions as to whether I want to continue on my meds journey…) had to talk me IN to taking the lowest dose benzo she could throw at me. I feared becoming addicted, having heard horror stories of folks who’d done just that. More than once, she and I went a round or two over this issue. Finally, I went up only a milligram, and my primary care doc asked me if I felt “loopy” at a visit. He saw something I didn’t even realize – I was just in a ‘good mood.’ Next time at the psychiatrist, she’d backed off, admitting that some folks are ‘sensitive’ to meds… and she was already pretty judicious in prescribing. So not all patients are just beggin for benzos and not all psychiatrists are trying to talk them out of more Vals. Remember at least ONE of us fought meds for months, and one doctor out there took her time and went slow with meds. She was one of the ‘good guys’ and I miss her. Now I’m on the same dose, and thinking I don’t have enough. How much does that suck. But I am not going to ask for more – I’d ask to be taken off, first.
It’s nice to have these debates, but please consider that not everyone fits your sterotypes.
What your doctor did, talking you into taking a dependency-inducing drug (in my opinion, irresponsibly), is much more what psychiatrists *do* than what Dr. Steve is describing.
Since you’ve reached tolerance on your benzo dosage — I hear benzobuddies.org is a good peer support site.
To annalaw81:
This is in response to both your 4/17 and 4/22 comments. Life is uncertain, putting things in timeless categories gives us the illusion of certainty and, at the same time, less anxiety about life. But, the only two things I’m certain about produce more anxiety than all the uncertainties put together.
For example, should you see a Psychiatrist because they are “good” or not because “bad.” If you see one, sooner or later he or she will fall short of your ideal. You will be anxious again and react by trying the opposite, “I must have misjudged, I won’t do that again, those evil Psychiatrists.” But some time later you reflect, “well, I do kind of miss sitting in that nice leather chair.” And so, back and forth you go. Please, I’m sure you are much more sophisticated than that, but I’m trying to characterize a natural human tendency that has a beneficial (under time pressure) and negative (when we could have reflected) effect.
One essential, I believe, to happiness is acceptance of uncertainty. When you let go of the desire to have perfect answers, you will settle into a much more persistent and practical state. The ability to “balance attributions” versus “polarize attributions” if you want the jargon.
I once romanticized that Native Americans were a perfect society that we should emulate in every way (Adam and Eve before the fall) until I read the historical accounts of the atrocities that some Natives perpetrated on other Natives, or Native peoples (Easter Island) who decimated their environment. Turns out they they got the boot just like the rest of us. I still do admire them, far more than many other cultures West or East, but see that there are aspects I like and dislike. I had many of these experiences in my early days, idealizing some philosophy or “Way of Life” until it inevitably showed it’s flaws leaving me devastated. I learned to approach it the other way around eventually. I stopped looking for an outside solution that would guarantee me happiness (or what have you) because of it’s Truth or Beauty or Naturalness or Conformity or Rebelliousness. (I also lost the certainty of what was Bad, hence my antagonism to many of the posts here). I realized (thank you Nietzsche, quantum physics, Wittgenstein, and Dr. K.) that starting from the inside — my values, who and what I wanted — and judging things relative to the inside, gave me more realistic and dependable appraisals, although not certain ones.
So, to your question, first you have to know what or where you are trying to get to, your goals to use a term I’ve come to loathe because of it’s false impression of finality. Be careful though, “our” goals are rarely “our” goals. Maybe you are already there and you don’t know it? Regardless, it can be essential to have an outside guide help you figure this out or, even better, some situation in life if you are lucky. I would start with an “analyst” if you don’t know your goals (psychodynamically oriented therapist most likely) to help you explore. If you are not looking for the answer from them – Spirituality, Art, Myth, Sport, Parenting, Gardening, etc.- can also be excellent. The only benefit to a therapist, is that it is explicit that they are not there to provide the answer to you, but to guide you in finding your own (google: ‘finger moon’ or ‘buddha raft’ for more info).
If you already know where you want to go, then the next part is much less difficult. Will seeing your problem as a disease like diabetes, provide answers that get you there? If so, go tell a doctor about your problem. Of course, nothing is exactly like diabetes, not even diabetes, so these solutions will not be perfect. They will have some downsides. To be concrete, if you have overwhelming fear, out of the blue, several times a day that makes you certain death is at hand, thinking of it as Panic disorder – a medical condition – is enormously helpful. Medication combined with CBT can take you from not leaving your house to leading a relatively normal life; and, it can do it in a way that no other current method can. You will have side-effects, some more, some less. You may always need that medication (like a type II needs orals), or you may really follow the CBT plan like a trooper and kick them (like some type II’s do with diet and exercise), because it shares a lot with things like diabetes. You may decide that CBT gets you to the grocery store and work, and that’s enough and better than always having to have a dry mouth. You may decide that therapy is too burdensome in your already hectic life, and don’t mind the dry mouth so you’ll just take your pills thank you very much.
Or, you may have a goal that you know has been there since “as long as you can remember.” Some mild discomfort, some sense that things aren’t okay or could be better. You know you’ve “overcome” terrible adversity, but why all the problems still? Why hasn’t it all come together yet? Problems like this don’t share as much in common with diabetes, and you’ld better find a guide. If you decide on a Psychiatrist, make sure he or she doesn’t “over-medicalize” problems; i.e., is also a therapist. No special reason to see an MD; good, a Psychologist, social worker, etc. will be able to help. And, although I agree that a good relationship is necessary as it is the medium of healing these things, it should not be the point of the process. In other words, check in and make sure you are growing or progressing towards your goal every once in awhile, not “paying for an ear an hour a week.”
Finally, a private Psychiatrist is far more likely to remain in his practice than a staff Psychiatrist at a community clinic. Many docs work at those clinics because they are in transition (residents, immigrants, locum’s). Many insurances provide reasonable reimbursement, even if they ask for cash up front. I’ve worked with some strong NPs lately, and a good therapist can work with a PCP if they communicate regularly. Continuity is more important than the exact configuration.
I hope this is in some way helpful, as it is hard to provide specific suggestions without knowing the case (and please don’t provide them as I ethically can’t respond.) If not, maybe at least it will help with your next bout of insomnia.
Thank, you, Emerzen for your kind and full response to my posts, including the one about my sister. I am interested in the topics discussed in this blog, although i do not claim to be a scientific person who understands it all. i am, however, not a fool, and I have a good idea of what works and what doesn’t, both innately and from my educating myself, here, and by reading. I have more to say, but not on a blog.
Dr. Balt,
Thank you for your thoughtful response to Dr. Moffic. I also appreciate the concern of others responding to your post.
I agree with you on much, and I admire and respect your willingness to take risks and engage in this dialogue.
Here are my comments:
Dr. Moffic says psychiatry should lead the remaking of the “mental health” system because psychiatry’s “…extensive training, our knowledge of the brain, and our ‘dedication to the patients.” First, even Dr. Carlat wants psychiatric training to be greatly shortened because so much of it is irrelevant to mental problems. Second, psychiatry is, more than any other profession, the problem: much of its “knowledge” is “pseudoscience,” corrupted by PhARMA’s billions. Many commentators – David Healy, Edward Shorter, David Antonuccio, Irving Kirsch, Marsha Angell, Grace Jackson, Joanna Moncreiff, Mary Boyle, Richard Bentall, Robert Whitaker, and yes, Peter Breggin – apply real scholarship to support the truth of your statement, ” .. and much of what we do might legitimately be called ‘pseudoscience’.” Why would the profession that most champions pseudoscience be leading the way to a rational system?
PhARMA’s financial manipulation of the “science” and scientific literature is so pervasive and insidious that there is no reliable way to sort out what might be valid from the lies and manipulation. Thus just about ALL of modern psychiatry’s “knowledge,” and its interpretation must be regarded as what Healy regards it (See Healy’s Mania, at p. 236: “… clinical trials … have become … a set of methods designed to smooth the development cycle of new pharmaceuticals… It would make more sense to conclude that most of what is happening belongs to the domain of commerce rather the domain of science…”p. 242: “The publicly available data are close to worthless.” Also, at p. 240: ‘When we arrive at a situation in which the mental sets of clinicians have been captured so that it is difficult for them to conceive of alternatives to those being sold to them, there are reasonable grounds to state that such a field is no longer scientific. When there is almost no possibility of discrepant data emerging to trigger a thought that might be unwelcome to the marketing department of a pharmaceutical company, these marketing capabilities would seem appropriately described as totalitarian.”).
With psychiatry, there is just no way to reliably distinguish the wheat from the chaff.
You write, “… dozens – hundreds – who INSIST they DO have these disorders and who don’t just accept but REQUEST drug treatment…”; also, “Lots of people have already “bought in”…”I routinely see patients who want to believe that they have a ‘brain disease,’ …don’t want to hear about the side effecters. They often appreciate the fact that there’s a ‘chemical deficiency’ or ‘imbalance’ to explain their behavior …”.
This is no argument in favor of psychiatry’s leadership. It is testament to the $60 billion spent annually by PhARMA on saturation medical model marketing, resulting in millions who have re-defined themselves as chemically imbalanced – a claim Dr. Carlat acknowledges as fiction. This profession still promotes the fiction and needs to come clean with the public.
Psychiatry bears a heavy, heavy burden for abetting PhARMA’s campaign. Trusting psychiatry to lead a clean up is like asking Lehman Brothers to lead the cleanup of Wall Street.
Before psychiatry can lead anybody, the profession must address – point for point – the criticisms put forth by scholarly critics. Such as:
Psychiatry must stop imposing simplicity on the most complex subject (human behavior) in the universe. Each of us has 100 billion neurons and an equal number of glial cells. Gerald Edelman, 1972 Nobel laureate in medicine, calculated that the number of possible different connections between just the 30 billion neurons in the human cortex, each with from 2,000 and 10,000 possible connections to other neurons, is greater than the number of atoms in the known universe: atoms in universe = 10 plus 79 zeroes; possible neuronal connections = 10 plus 1 million zeroes. (I don’t know if that’s true, but it makes the point). And when each of us interacts with other individuals, small groups, large groups and myriad other environmental variables, the complexity is staggering. Why then, when relative little is known, does psychiatry ASSUME its conjectures to be true, and fail to seriously consider the potential of other fields – psychology, social psychology, sociology, anthropology – to explain phenomena psychiatry BELIEVES (but has not proven) are best addressed primarily on a biological basis?
This human complexity totally overmatches psychiatry’s effort to cram human reality into the medical model. I’ve seen the number of our neurotransmitters estimated at between 100 and 200; yet psychiatric research focuses on maybe 6. It’s the extreme of the street light effect – cop finds a drunk on hands and knees under a street light, asks what he’s doing. Drunk: looking for my glasses. Cop: where’d you drop them? Drunk: over there (other side of the street in the shadows). Cop: then why are you looking here? Drunk: the light’s better here. PhARMA can do easy non-ground breaking “research” on “me too” drugs and sell the results to the public; and psychiatrists, med schools and research mills have a good gig getting paid to go along for the ride. So why look at the whole brain or all the possible social, psychological and environmental explanations for human behavior?
And it gets worse: 80% of RCT’s are funded and controlled by drug companies (the other 20% by NIH, which is heavily influenced by PhARMA’s $60 billion/year promotion and lobbying budget, not to mention PhARMA’s power in financing academic research). The companies have their finger on the scale every step of the way. Placebo washout gets rid of placebo responders; placebo washout also throws subjects into withdrawal from whatever drug they were on before the study began. So when those assigned to the drug group resume taking the experimental (most likely “me-too”) drug, their withdrawal is halted and that’s counted as improvement. But placebo can’t restore the subject’s chemistry to the prior status, so those in the placebo group just continue to experience withdrawal symptoms – and so they are classified as “no improvement.” Clinical trial designs are often transparently biased: comparing one drug at a moderate dose with another drug at an extremely high dose; designing assessment tools to filter out or mis-categorize adverse effects, etc.
Moreover, around 70% of subjects and doctors break the blind because placebos don’t cause side effects – that enhances the difference between the drug and placebo groups. But when active placebos (which produce side effects) are used, the blind isn’t broken and the drug advantage (when it occurs) frequently disappears.
Non-responding drug subjects in RCT’s are often replaced by other subjects within the 1st 2 weeks of the trial – another thumb on the scale. Add to this: selective publication, ghost writing, financial conflicts of interest for investigators, journals and med schools, and you have the reason David Healy calls psychiatric literature “propaganda.” Edward Shorter, in an otherwise flawed Before Prozac, cites chapter and verse from minutes of FDA drug approval meetings (including direct quotes from David Kessler) acknowledging the drug approval process as a sham. Companies can run studies ’til the cows come home and eventually get two positive ones, and hence get FDA approval. Oh – and the FDA drug approval arm gets 40% of its funding from user fees paid by the drug companies. Psychiatry needs to state clearly and often the obvious fact that the randomly assigned, placebo controlled clinical trial – piously called a “gold standard” – is as flawed as we all know it is – and as flawed as Irving Kirsch has shown it to be. It is regularly manipulated for marketing purposes by drug companies.
So I don’t think any of these studies, and the journal articles flowing from them, are reliable. There’s just no way to draw inferences from them. And especially when you throw in speculation about genetics. Check out Jay Joseph’s books (The Gene Illusion and I forgot the other name). He actually read all the adoption and twin studies cited as pillars of psychiatric genetics – and found the studies (and their interpretation) hugely flawed. Looking at the least flawed, he concluded they support the importance of psychosocial factors, not genetics, as causes of mental problems. Psychiatry needs to publicly address Joseph’s arguments point for point, based on what’s actually in the twin and adoption studies.
We know also that each “discovery” of genes responsible for mental problems has failed to be replicated, and psychiatry is left with a vague fall back – “cascades” of small effects from many genes, none of which has been proven either. Psychiatry needs to
address this – point for point – not just with self-serving platitudes. Organized psychiatry has allowed PhARMA’s and academic psychiatry’s noise machine to put out press releases about “promising new discoveries,” successfully distracting the public from the consistent failure to replicate.
Psychiatry must reject unproven analogies of mental problems – however severe – to diabetes, heart disease, cancer or whatever. These are all known physical conditions; they can be detected by physical tests and have at least somewhat known patho-physiologies; we know at least something about how their treatments work; and none of these diseases involve organs anywhere near the complexity of the human mind.
I’m sure drugs do help some people some times, but psychiatry has not shown that positive responses (when they occur) are for the reasons we think, and not without exacting unrecognized tolls. Check out Joanna Moncreiff’s The Myth of the Chemical Cure, citing chapter and verse to dispute the idea that psych drugs “work” by correcting chemical imbalances. A fair look at psychiatry’s own literature shows no compelling basis for the chemical imbalance theory; Marcia Angell’s New York Review of Books 6/23/11 and 7/14/11 pieces, on Kirsch, Dr. Carlat and Whitaker, quotes Steve Hyman, former head of NIMH: psych drugs cause “substantial and long-lasting alterations in neural function …. qualitatively as well as quantitatively different from the normal state.”
Moncreiff argues that psych drugs are not so much “medications,” but are on the level of sedatives or elixers – like alcohol or cocaine – creating global abnormalities in brain function (in “normal” and “abnormal” subjects). They are marketed as “for” depression, anxiety, psychosis, bipolar etc. because one or more of the many abnormalities they cause can be said, in some sense, to alleviate part of what bothers the patient or others. Psychiatry needs to take on her arguments, point by point in a public forum – and show whether or not psychiatry has real answers.
You write, “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.”
This is simply not true. The “muck” was largely created by the PhARMA/psychiatry partnership. And the average PhD psychologist is more sophisticated in evaluating clinical trials and statistical analyses than the average psychiatrist; psychologists and neuroscientists are more likely to do unbiased, scientifically meaningful research into behavior and brain function than psychiatrists, whose investment in the current model largely precludes serious consideration of other models.
Your “only psychiatrist” statement shows how even thoughtful psychiatrists ASSUME the important answers are to be found in brain research – assuming the primacy of the medical model BEFORE scientific evidence supports that assumption. Psychiatry is free to research brain function; but to be credible, it must be fully open to the possibility that, if other fields also had hundreds of billions for their own research, they might validate theories equally or far more effective than what psychiatry has or will produce.
As you said, this is an uphill battle. Psychiatrists like yourself, Dr. Carlat and others do have an important role to play in setting things right. The most important role at present is simply to not let PhARMA/mainstream psychiatry’s misrepresentations pass unopposed. I respect and admire clinicians struggling in their practices to really serve each patient while struggling with time, economic, logistical and institutional barriers. This thing won’t move until large, determined, organization is brought to bear over a long period of time. As Grace Jackson, David Healy, Peter Breggin, and the late Loren Mosher could attest, efforts at change not only meet “resistance,” but also retaliation, reprisals, suppression, threats to jobs, careers and licenses. You and others who seek to reform psychiatry have my admiration and my best wishes. I continue to do what I can as well.
Peter,
Many, many thanks for your thoughtful and detailed reply. I agree with virtually everything you wrote.
When you write about psychiatry’s assumptions and conjectures, and the infamous “street-light effect” that guides what we do, I’m reminded of an exercise I used to give my students (psychiatry trainees): Go into a room with a patient and forget everything you know about the DSM, psychiatric diagnosis, and medications. Instead, talk to the patient as a fellow human being. Get to know him as you would a new acquaintance. Pretend you’re meeting him for coffee or at a social gathering. Try to understand the nature of his suffering, but also his personal strengths and ways in which he can use those strengths or develop new ones. Treat him as a teammate or partner, and identify some goals to achieve together. And so on…
Interestingly, when one approaches patients in this nonjudgmental, unbiased way, true mental “illness” (as much as some commenters here may disagree with that term), when it exists, does present itself, and often quite convincingly. On the other hand, many patients start to be seen as pretty “normal,” with certain quirks or idiosyncrasies, but nothing too foreign or disturbing.
Indeed, the DSM tells us how to think about human behavior; the drug companies tell us precisely which neurotransmitters are responsible for sadness, elation, irritability, and fatigue; and our practice & payment arrangements effectively prevent us from using any other construct with which to understand our patients. But this simple exercise– sort of like trying to write with one’s non-dominant hand– sheds a great deal of light on the biases we bring to the everyday practice of psychiatry. Moreover, it shows us how easy it would be to do things differently.
You’re never approaching those patients in a non-judgmental way. You’re there to “observe” and then make judgments. Observation is always problematic. It’s not clean. We’re never able to observe others out there in a way that’s separate from ourselves. You cannot remove your bias, and you’re definitely not removing your psychiatric filters if you’re looking for “illness” or “normality”. You’re deluding yourself if you think otherwise.
The “true mental illness” concept fascinates me. How do you know when it is “true” vs false or something else? How do you decide that? You haven’t yet enlightened us as to how some thoughts, feelings and actions qualify as “illnesses”, and those that are not “illnesses”.
Dr. Balt and MT,
I agree with both of you on this. Dr. Balt’s student exercise can help re-frame the doctor/patient encounter, revealing both as human – which is the corrective most of us are seeking. MT is also right about the roles/power relationships/contexts of these encounters; much must be done to make the context support the humanity on both sides.
I apply a human Heisenberg Principle to this: there are always two full human beings in the room – not one observer/diagnoser/treater (doctor) and one observed/diagnosed/treated (patient). Per Heisenberg, you can’t observe another person without influencing that person. And you can’t observe another person without being influenced BY them. As you check them out, they are checking you out. What you’re scared of influences them; what they’re scared of influences you.
(Digression: I think we decide someone is “truly mentally ill” at the point where they overwhelms us – become too scary or we can’t imagine getting them to stop being upsetting/discouraging/confusing without the magic of a physical solution. At that point we marshal physical manifestations of their state as evidence of an underlying physical defect – ignoring that there are always physical manifestations of all our mental states, and the existence of such manifestations – extreme or not – by itself does not PROVE that the problem is either initiated or sustained by physical defects, or is best corrected by physical interventions).
In J Seikkula’s March 2006 Psychotherapy Research article on Finland’s largely drug free Open Dialogue method for first episode psychosis, “tolerance of uncertainty” is cited as a key factor in the program’s success. Read that carefully, that means “people not panicking when scary stuff happens.” When the “patient” gets “out of control” in a way that would prompt U. S. psychiatry to hospitalize, or change to drug treatment, Open Dialogue sees it as part of the working-through process. They don’t radically change course; instead they focus on supporting long term relationships within the treatment team, which includes family, friends, employers, teachers and treatment professionals (who stay with the “patient” for years, if necessary). Things generally settle down over a few years, relying on relationships, connection, problem solving, and largely without medications; five year follow up finds 80 to 90% of “patients” functioning well in the community (in school, employed or job seeking, living independently, not on disability, largely symptom free).
My life partner, a social worker in a major medical center, often sees patients whom doctors describe as impossible, uncooperative, violent. She spends an hour or so with them, and the next day doctors and staff ask, “What did you DO? He’s a different person.” It isn’t what she does (although she does plenty) – it’s who she IS. She’s not afraid of them; she believes they are smart, interesting and good – often despite appearances. AND – Heisenberg here – what she gives out, they respond to; and then she respond to their response. They laugh, cry, tell their life story, reveal things about themselves that nobody else has gotten out of them – and very often they decide to cooperate with staff and doctors. She starts her work where others panic – and the solution turns out NOT to be organic. (Any future for this as a rhymed slogan?)
“Mental health” workers face extreme/frightening/saddening/overwhelming things. None of us has any business offering assistance to others unless we also actively engage in an on-going, rigorous program of self-maintenance – e.g., therapy, mindfulness, yoga, peer counseling, support group. To keep the job-induced stress from piling up – for sure. But also: we ask a “patient” to stand his/her world on its head – try being non-depressed – re-enter a world without the voices or paranoia – do what scares you. Heisenberg operates big time here – when “patients” need to borrow a little reassurance, a little confidence, to see someone model what it might be like out there if they choose to join us – they can “smell” whether we’re also scared, unsure ourselves, afraid of our/their feelings, not really convinced we or they can do it. Beyond our knowledge, we need to offer them our unafraid humanity. We need to be real – we can’t blow smoke about personal change unless we have that commitment for ourselves.
To be unaware of our own personal involvement in the Heisenberg encounter is to plunge our field into pseudoscience. Here’s how it works: The hallmark of a pseudoscientific profession is that, built into its theoretical framework, are ready made excuses allowing the profession to avoid examination of its knowledge and assumptions. When we are in denial about our 50% contribution to our interaction with a “patient,” it’s easy to jump to these ready-made, professionally sanctioned templates that deep-six failure: the “patient” has a DSM label that is very hard to work with, is medication non-compliant, or “manipulative,” or “unmotivated,” or “lacked insight,” or “borderline.” Or it’s the fault of other professions or of the “system” (this one IS often true, but still distracts us from reflection).
Failure should prompt questions about what went wrong; what didn’t we understand; what do we need to do better; are our assumptions off base. But our professions provide relatively little systematic critique of what we do and what we assume. Except for Barry Duncan’s methods ( See: On Becoming a Better Therapist,, and The Heart and Soul of Change), there is little systematic feedback from “patients” about how we are doing. PhARMA, and those they control at NIMH and academia, drive “mental health research,” and PhARMA’s overriding motivation is not better outcomes, but the bottom line – planning for when their current big seller goes off patent. So PhARMA pretends its seeking knowledge and squashes those who ask questions that threaten its bottom line.
An initiative to reverse cluelessness in all “mental health” fields – especially psychiatry, whose devotion to the medical model really gets in the way on this: ditch the word “intervention,” which conjures images of mechanics working on cars – no mutually influencing feedback loop between doctor and “patient.” Instead, call it what it really is: what we THINK are “interventions,” are actually “INTERACTIONS.” I have a small hope that the focus on interaction will remind us that WE bring assumptions, prejudices to “patient” encounters – a first step in seeing the need to ask real questions about what worked and what didn’t work. It’s always better to see 100% of the picture than to see 50% of it.
Peter,
Your comments are the best comments ever. Thank you, so much. I hope you’re out there writing too.
I’m an alternative medicine practitioner, and I know one thing without a doubt from my own healing process and from the work I do with others…It’s the relationship that makes the healing happen. It’s how we relate to others that starts the healing and makes it possible. Healing cannot happen in an environment of fear, frustration and coercion and force. The therapist/healer *must* be unafraid and fully present.
Peter,
Wonderful words. Interestingly, I almost deleted my previous comment about my exercise of simply “getting to know” the patient. It seemed embarrassingly naive and far too simple-minded.
But your description of the “Heisenberg effect” (if I may call it that), and particularly the example of your partner, shows the importance of the “interaction” rather than the “intervention.” If only we were taught to interact more and intervene less. Or, better yet, some strategies for effective interaction. Unfortunately, those are hard to define. They also seem to be skills that some people just seem to have from birth and just can’t be taught. (Yes, I know about the literature on common factors of good therapists or effective psychotherapies…)
I’m afraid, like you, that psychiatry has built this scientific facade (on the basis of very scant evidence) in order to keep itself relevant in modern medicine. In reality, what’s truly relevant (at least until we have better “interventions”) is not scientific at all. It’s what we say and do, and how we do it.
Dr. Balt,
I agree that some people seem “born with” whatever it takes to put others at ease and really communicate. But I think we are all capable of getting there. If we identify that as a key ability for all of us in the field, and devote even a fraction of the resources that so far have gone elsewhere, I think we could make big gains.
Again, thanks for hosting this site, and for the stimulating posts and conversations that are taking place
Thanks, MT – I agree so strongly with you about relationship. I do intend to write.
I very much appreciate your kind words after years of swimming upstream in the foster care wars. I was a social worker, supervisor and for 9 years director of a treatment foster care program trying in a small way to deal with the wreckage produced by the downside of the lovely City of Baltimore.
Wonderful kids struggling so hard, foster parents doing such a demanding thing, staff throwing themselves on grenades left and right – and a just awful system based on medical model symptom check sheets, rating sheets, bureaucracy, psychiatrists with faces buried in lap tops (not even glancing up at foster kids).
I kept saying over and over, “It’s relationship, relationship, relationship.” We lost spectacularly some times, often battled to a draw with irrational forces, and won a few here and there.
Julie Zito, a prof. at the Univ. of Md. School of Medicine, did a nationwide study in about 2005. She found that kids in foster care were 17 times more likely to be on psych drugs than other kids on Medical Assistance. The medical model, especially the drugs, rules foster care with an iron hand, and drugs are given out like candy to kids.
Good for you, focusing on human beings and relationships. It makes a big difference.
Dear Mr. Dwyer,
Thank you. I found your writings to be most interesting especially about the Heisenberg Principle as that would be an ideal initial approach to some very challenging patient situations/illness in my opinion. Unfortunately all of life or should I say patient challenges do not neatly compartmentalize under a single approach as you would lead one to believe.
As I pointed out to Mr. Sherry elsewhere and now to MT and to you, what happens when you treat and/or learn, if you do, that your patient(s) does not have situational issues? No parental childrearing issues, no foster care or parental abuse issues, no serious sibling rivalries to lay one’s hat upon, no trauma issues, no recreational drug use, no educational and/or work issues, no marital and childrearing issues of their own etc., etc.
What alternatives do you then suggest when a patient(s) has gone through decades of talk-therapies, nutritional regimens, holistic approaches, medications etc., etc. and still experience severe depression with suicidal ideations?
I am one who very much appreciates Dr. Balt’s understanding, thoughts and approach as well as a number of other professionals I have collaborated with and who have attended to my spouse and acknowledge that it’s not that simple.
Once again, I appreciate your thoughts and the efforts of your significant other but the fact remains there does exist a large seriously ill patient population that could adjunctively benefit from the Heisenberg Principle who need more than you, Mr. Sherry and MT have offered up from my vantage point as a support person and health care advocate approaching 5 decades.
Warmly,
Herb
vnsdepression@gmail.com
http://www.vnstherapy-herb.blogspot.com
What scares you about the truth?
Lots of folks like to talk in het up generalities, including this writer. Maybe if we could all slow down a bit things might impove. Example:
A few years back there was an article in Discover Magazine about orchids and dandilion kids. The orchids react badly to stress but also react well, even creatively, to support. The dandilions are stable. This sounds a whole lot like “bipolarity”, except the word is so rediculously charged that no one can talk about it sensibly. Can we not, however, talk about hyper reactivity to stimuli?
Maybe the idea is just wrong or misguided. But is it possible to say that some folks are genetically programed to respond to the slings and arrows and joys of life more than others. These folks, more often than others, find themselves in a state of suffering and/or incapacity. There are perhaps many ways to help this individuals—-one of which is to humanize and American culture on which people are too often regarded as commodities.
So there is just one psychiatic issue. We don’t quite know what we are talking about when we use the word “bipolar” but there is evidence there is something to the idea, and that it is genetic/environmental.
So, let’s end by quoting Steve from above. Prescibing meds on the basis of encounters as pasted below may make lots of sense:
stevebMD says:
April 18, 2012 at 12:44 pm
Peter,
Wonderful words. Interestingly, I almost deleted my previous comment about my exercise of simply “getting to know” the patient. It seemed embarrassingly naive and far too simple-minded
From whom should people seek counsel if they suffer? Fever and chest congestion? Chest pain? Broken arm? Should I go to my priest? My mechanic? Google?
If you suffer from sadness? A conviction that a rope around the neck with one’s body weight underneath is preferable to this feeling? Voices that chatter constantly, “the CIA is behind every face and radio you see”? The feeling that God wants me to drown the children? Should I go to my priest? The DMV? Google? My mother-in-law?
The fact is, people who suffer seek doctors. If there were NO psychiatrists, there would still be psychiatrists, because people would still be suffering. And the idea will come to some of them that maybe a doctor could help. It’s actually happening every day, ask any family physician.
Some people don’t go voluntarily you say? Society drops people off at the hospital, “doctor, you better do something, because if you don’t it’s jail or the January blizzard.” “Look here,” says doctor, “he says he wants to go, so really, here’s a blanket, he’ll be fine out there.” Is that what a doctor should do? We are not American Founding fathers. That’s what they are supposed to do. That’s their problem, our problem is relieving suffering. We are doctors.
So, if a doctor is going to be asked to help with these kinds of problems, they out to learn whatever there is to know about them. That’s one of the things that goes into being a doctor, you’re supposed to learn everything there is to know about your subject.
Or maybe this brain self-consciousness thing is really quite elementary? Wouldn’t any Neurologist you that? Maybe Psychiatrists are a bit small in the neo-cortex if you know what I mean? Or maybe they’re just evil capitalists and they’ve stolen some real doctor’s coat. Really? The difficulty has nothing to do with the subject matter?
What other reason may lead someone think of a doctor for that chattering? Hmm, they’re dedicated to alleviating human suffering, mastering all there is to know about the subject (rational/empirical), and they keep chirping about a “differential diagnosis.” What’s that all about?
A Rabbi probably cares about human suffering, but has he gone about learning all there is to know about it? Every angle or just one? He probably has A solution with AN answer for you. If you’re lucky, it might work. How about going to a lady who spent her life getting to know all there is to know about you and your kind of problems. She thinks it sounds like these 5 things, probably the 1st thing but will keep her eyes open just in case it’s one of the others. She has helped a lot of people with that kind of problem, but not everyone and not completely. But, being real interested in these problems, she’ll keep looking for new information and new solutions. She’ll even talk to everyone else who knows about these problems to ensure she’s giving you the best advice there is to give (which may still not be that much, but it’s something).
“No thanks. I’ll take myself, my son or daughter, mother, father, to…,” you say. Got it, there’s a ‘therapist’ who is real nice and says he will help, knows just the thing. Isn’t any “human prescription pad” either.
You sure he’s not going to try to talk you out of a brain tumor? Sure he’s thought of everything? Wouldn’t want to be talked to for years for ‘fibromyalgia’ when I’m just too scared to tell you I’m sad because my husband is a vacant alcoholic, my kid hates me, and my boss expects me to work 70 hours/week. “Can’t question that FM because your doc said you have it,” say the therapist, “why don’t you ask him for some Lyrica or, even better Opana, works really well my wife says. She does have a nasty sleep problem all the sudden though, and MOODY. She might even be ultra-extreme-exponential-rapid-cycling Bipolar but, enough about her, let’s get back to you.”
Doctor’s, people are going to seek your help for these problems. Society is going to ask you to help them. Call yourself whatever you have to, know one else will even try. Heck, most doctors won’t even try. Don’t believe me? Go to any ED on any night and ask for volunteers.
I don’t think anyone here said people and their distress/suffering is not complex. I don’t think many are pushing for a models of care where the choices are just a hospital or the “January Blizzard.” I don’t think anyone wants people to experience unnecessary suffering. What many are calling for are more sophisticated ways in understanding wellness/suffering, ways of interacting that are humanizing and not objectifying, an open discussion on how interests that are neither interested in people’s health or in advancing our understanding of the brain/wellness/illness/relationships/policy/etc. have led to detrimental care and a skewing of research/practice goals/interests for the future.
I have no doubt that physicians and psychiatrists intend to be helpful. Just having the intention can be useless or even harmful if much of the training, science, and policies underpinning psychiatric care are intentionally misleading/false and stacked to benefit many others more or at the expense of patients.
Do you really believe psychiatrists have studied “every angle” of suffering, or studied every angle well? That would be quite the claim given the current mental health burdens people continue to face. Do you really believe our diagnostic system identifies valid disorders that have known etiologies that help lead to specific “personalized” treatments? Psychiatrists never talk someone out of a brain tumor (I can think of MD analysts who have)? Do most even ever order scans or examine folk? Treatments offered by psychiatrists, primarily drugs and some, usually non-specific psychotherapies, have shown limited benefits (with no way to determine what would be helpful beyond trial and error or placebo) and significant risks. Many psychotherapies have yet to be shown to be helpful for particular issues with risks mostly not assessed, with the theories of why doctors engage people in them yet to have much evidence to support them.
Many people here went to doctors specifically because we did believe that they were the ones who could alleviate or at least explain our suffering/distress, and point the direction to what may be helpful. Many of us wish we chose to start with a rabbi/clergy, friends/family, etc. or investigated more deeply many of the problematic parts of psychiatric care before we sought consult. Many of our experiences of putting trust in doctors (and time and money and health) ended up being harmful, precisely because of the great lack of understanding of much of the “angles” of mental health psychiatrists have, their own confidence in their abilities to be helpful and disregard of concerns, and experiencing adverse effects that were never disclosed to us were possible (many of which doctors didn’t even know about because the science behind treatments are so skewed/flawed.)
I’ll speak for myself when saying I wish doctors knew what they say they do and actually had the vast knowledge/experience to help the many people in many experiences of suffering as you suggest. But the admitted gaping holes in psychiatric care coupled with the attempt to ignore/stigmatize/silence critics and those pushing for agendas that are patient-centered and science-based makes the protection of the whole endeavor as is seem contrary to helping patients and somewhat sympathetic to “evil capitalists.” Not seeing this makes many psychiatrists and others seem “small in the neo-cortex.” Until doctors know more, I’d settle for acknowledgement of what they don’t know, that what they go one now is pretty limited, and that they are willing to work to start pursuing an agenda guided by Dr. Steve’s “pillars” of honest/open research and patient-centered care.
Hawkeye,
You write,
“But is it possible to say that some folks are genetically programed to respond to the slings and arrows and joys of life more than others?”
Yes, it’s possible to say that, but not a good idea. Better to just say, “For whatever reason, some folks respond to …” . This avoids our pre-judging the cause of their response, as well as prejudicing the choice of how we respond to their behavior.
Psychiatry is off the rails, in part because of what I said above in an earlier response (I’ll be merciful and condense it):
“… we decide someone is “truly mentally ill” at the point where they overwhelms us – become too scary or we can’t imagine getting them to stop being upsetting/discouraging/confusing without the magic of a physical solution. At that point we marshal physical manifestations of their state as evidence of an underlying physical defect – …… (but) the existence of such manifestations – extreme or not – by itself does not PROVE the problem is either initiated or sustained by physical defects, or is best corrected by physical interventions.”
Saying something is “genetic” is a variant of this. “It’s genetic” is our default position when we are flummoxed by behavior that seems to come out of nowhere, without an obvious psychosocial cause. But the simple fact that we can’t explain it doesn’t mean it has to be genetic. It just means WE DON’T KNOW – it could be psychosocial, genetic or some of both. And if some of both, the relative contribution of genetics could be anywhere from minuscule to overwhelming. And even if it’s overwhelmingly genetic, it still doesn’t mean drugs or other invasive medical interventions are appropriate – think of treating PKU with diet.
Instead of saying everything without an obvious psychosocial explanation must be genetic, we could as easily say everything without an obvious genetic explanation must be PSYCHOSOCIAL. And since no gene (or “cascade of genes of small effect”) has been convincingly shown to “cause” “mental illness,” that would mean it’s ALL psychosocial. Psychiatry would wildly protest this conclusion, yet it is as logical as what psychiatry does.
Psychiatry claims “genetic components” in “mental illness” – as though there is already coherent, non-contradictory convincing (and honest) evidence of this, and as though the assumed contribution of ANY genetic effect requires that physical interventions be used. Psychiatry would have us assume that anything without an obvious psychosocial cause (and I mean obvious – think of grieving for more than two weeks being redefined as depression) is a solid candidate for genetic causes – and it’s just a matter of time ’til these whiz bang scientists find the gene.
Now more plagiarism from my own prior comment, above (again, condensed):
“Each of us has 100 billion neurons … (and) the number of possible different connections between just the 30 billion neurons in the human cortex … is greater than the number of atoms in the known universe. And when (we interact) with other individuals, small groups, large groups and myriad other environmental variables, the complexity is staggering. Why then, when relative little is known, does psychiatry ASSUME its conjectures to be true, and fail to seriously consider the potential of other fields – psychology, social psychology, sociology, anthropology – to explain phenomena psychiatry BELIEVES … are best addressed … on a biological basis?”
So what’s the score so far on genetic/medical causes versus psychosocial causes? After PhARMA and government funding sources have spent over a trillion dollars on genetic and medical research, NO major “mental illness” has been reliably established as genetically/medically caused. With perhaps a thousandth of the expenditure, psychosocial research has shown powerful psychosocial influence on all kinds of human behavior, including “mental illnesses.”
You don’t have to argue that psychosocial causes are 100% of the picture to see the disparity here, and to ask why psychiatry is so hell bent on the medical model.
A totally theoretical challenge: let’s spend a hundredth of the resources, now poured into medical model research, on psychosocial research, and see what the “mental illness” picture looks like in 20 years.
Meanwhile, let’s not ASSUME every unexplained thing is genetic. Genetics is like potato chips on the plate with your burger – once you dip into the chips, you are likely to eat them all, even if you aren’t really that hungry. Same with genetics – how often have we read of “discoveries” of “genetic contributions” to schizophrenia/depression/anxiety/bipolar? The ad copy (excuse me – article) goes on to enthuse that surely more discoveries are just around the corner, and that this puts us well on the track to new medications or gene-level treatments for the “disorder.” If we bother to look into it, we find the discovery might explain only 3% of cases, and the discovery is later found not to be replicable. Yet many of us keep coming back for more, as though genetics’ case has already been proven.
A better way to look at the “butterfly”: just say that we don’t know the cause of what might be predispositions. But even without knowing causes, we know most predispositions can break good or break bad – depending on the psychosocial response to the child’s predisposition.
An aggressive adventure seeker might become the next explorer or successful entrepreneur, or if raised in a neighborhood rife with violence, drug dealing and disfunction, might become a major drug dealer. A “sensitive” person can become creative, academically successful, a really good therapist – or hopelessly depressed, neurotic, phobia-driven.
As long as we’re talking butterflies (which I like), here’s my own analogy: If we ASSUME there are biological predispositions, our best response could still be psychosocial. Consider: a racehorse would break down if hitched her to a plow; a clydesdale would break down if raced her flat out for a mile and a quarter. It is the job of parents and adults to figure out what each child’s strengths, weaknesses, interests and needs are, and to nurture them accordingly. At a minimum, like the horses, we all need not to be abused. We also need adults to distinguish whether we are dispositional equivalents of clydesdales, quarter horses, thoroughbreds, shetlands … whatever, and be nurtured accordingly.
To Peter Dwyer:
I am with you in spirit and in fact live my life very much as you suggest, but I am very lucky to be able to do that. I am required by my work to be creative, but not everyone has that delicous option, and even living a life of creative abandon has cost me.
I am seriously tempted to just tell the whole profession to go to hell. In fact I would sooner sleep in a cage with a(well fed) Siberian Tiger than take an anitdepressant. On the other hand many a marraige has been saved by low doses of mood stabilzers.
The best and the most thoughtful public psychiatrists do advocate profound moderation.
Genetic inclinations are just that, inclinations. We don’t have to call a tendency a disease but even if we do we don’t have to treat it. I believe, sort of metphorically, if I could trade some gulatmate receptors for some GABA receptors I’d be a more contented person. Except in serious circumstances I am not going to take drugs to be a more contented person, I will settle for being a more interesting person—maybe.
Psychiatry has been profoundly, and I mean profoundly, damaging. But at its very moderate best it can releive much suffering.
Psychaitrists need to be the best and the brightest. Generally they are not.
Any patient who trusts a psychaitrist is crazy. Any patient who does not look for help to save his or her family is crazy.
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