Tag Archives: dealing with problems of daily living

ADHD:  The Hoax Unravels

At the risk of stating the obvious, ADHD is not an illness.  Rather, it is an unreliable and disempowering label for a loose collection of arbitrarily chosen and vaguely defined behaviors.  ADHD has been avidly promoted as an illness by pharma-psychiatry for the purpose of selling stimulant drugs.  In which endeavor, they have been phenomenally successful, but, as in other areas of psychiatry, the hoax is unraveling.

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In 2001, the American Academy of Pediatrics published Clinical Practice Guideline: Treatment of the School-Aged Child With Attention-Deficit/Hyperactivity Disorder Here’s a quote:

RECOMMENDATION 3: The clinician should recommend stimulant medication (strength of evidence: good) and/or behavior therapy (strength of evidence: fair), as appropriate, to improve target outcomes in children with ADHD (strength of recommendation: strong).

The clinician should develop a comprehensive management plan focused on the target outcomes. For most children, stimulant medication is highly effective in the management of the core symptoms of ADHD. For many children, behavioral interventions are valuable as primary treatment or as an adjunct in the management of ADHD, based on the nature of coexisting conditions, specific target outcomes, and family circumstances.”

Clearly, this recommendation is pushing the drugs (evidence good), and is downplaying the usefulness of behavioral interventions (evidence fair).  The reference to behavioral interventions “…as an adjunct…” doesn’t inspire a great deal of confidence in their use as the primary intervention.  And, indeed, this is how “treatment” of “ADHD” has developed in the intervening years:  pills for all, and occasional behavioral programs, many of which were geared towards accepting one’s “illness” and promoting “medication compliance”.

And all of this in a context in which ADHD was being fraudulently promoted by psychiatry, and by its pharma partners, as a neurochemical imbalance which was corrected by stimulant drugs.  Here’s what the eminent Harvard psychiatrist Timothy Wilens, MD, wrote on the matter in the article Paying Attention to ADHD in Family Circle magazine on November 20, 2011:

“ADHD often runs in families.  Parents of ADHD youth often have ADHD themselves.  The disorder is related to an inadequate supply of chemical messengers of the nerve cells in specific regions of the brain related to attention, activity, inhibitions, and mental operations.”

“Contrary to what most parents think, medication is one of the most important treatments for ADHD and is essential for long-term success of these kids.” (p 65)

The above quotes were clearly aimed at mothers, were designed to break down parental resistance to drug-taking, and are typical of what psychiatry generally has been saying on this subject for decades.

Dr. Wilens is an Associate Professor of Psychiatry at Harvard, and works as a psychiatrist at Massachusetts General Hospital.  In 2014 he was named Chief of Staff in Child and Adolescent Psychiatry.  So promoting the chemical imbalance hoax has certainly not harmed his career.

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In recent years, psychiatrists have been experiencing increased scrutiny and criticism from the media, the general public, and some legislators, for the “pill for every problem” approach.  In this context, the American Academy of Pediatrics, in 2011, published an updated set of guidelines for ADHD under the title ADHD: Clinical Practice Guideline for the Diagnosis, Evaluation, and Treatment of Attention-Deficit/Hyperactivity Disorder in Children and Adolescents  In this revised document, their recommendations for treatment are divided into three parts:  preschool children (4-5); elementary school children (6-11); and adolescents (12-18).  Here is a quote from each section:

Action statement 5a: For preschool-aged children (4–5 years of age), the primary care clinician should prescribe evidence-based parent and/or teacher-administered behavior therapy as the first line of treatment (quality of evidence A/strong recommendation) and may prescribe methylphenidate if the behavior interventions do not provide significant improvement and there is moderate-to-severe continuing disturbance in the child’s function.

Action statement 5b: For elementary school-aged children (6–11 years of age), the primary care clinician should prescribe FDA-approved medications for ADHD (quality of evidence A/strong recommendation) and/or evidence -based parent- and/or teacher-administered behavior therapy as treatment for ADHD, preferably both (quality of evidence B/strong recommendation).

Action statement 5c: For adolescents (12–18 years of age), the primary care clinician should prescribe FDA-approved medications for ADHD with the assent of the adolescent (quality of evidence A/strong recommendation) and may prescribe behavior therapy as treatment for ADHD (quality of evidence C/recommendation), preferably both.

Note in particular that for preschool children, the recommended “first line treatment” is behavior therapy administered by the parent and/or teacher, and the pills are recommended only if the behavioral interventions are not effective, and the problem is moderate-to-severe.  This is a sea-shift from the earlier guidelines.

Note also that for older children, pills and/or behavioral therapy are recommended, “preferably both”.  Here again, behavioral interventions are being emphasized a good deal more than was the case in 2001.

Later in the guidelines document, the authors clarify what they mean by behavior therapy:

“Behavior therapy represents a broad set of specific interventions that have a common goal of modifying the physical and social environment to alter or change behavior. Behavior therapy usually is implemented by training parents in specific techniques that improve their abilities to modify and shape their child’s behavior and to improve the child’s ability to regulate his or her own behavior. The training involves techniques to more effectively provide rewards when their child demonstrates the desired behavior (eg, positive reinforcement), learn what behaviors can be reduced or eliminated by using planned ignoring as an active strategy (or using praising and ignoring in combination), or provide appropriate consequences or punishments when their child fails to meet the goals (eg, punishment). There is a need to consistently apply rewards and consequences as tasks are achieved and then to gradually increase the expectations for each task as they are mastered to shape behaviors.  Although behavior therapy shares a set of principles, individual programs introduce different techniques and strategies to achieve the same ends.” [Emphasis added]

Note that what’s being recommended here is that the parents be trained in the ordinary, time-honored principles of effective parenting.

And remember, this was in 2011 – five years ago, but the shift in the pediatric guidelines has not resulted in a significant shift in practice.

In response to this inertia, on May 3, 2016, the Centers for Disease Control and Prevention (CDC) issued a press release titled More Young Children with ADHD Could Benefit from Behavior Therapy.

Obviously the CDC considers ADHD to be a disease, but if you can bear with the medicalization wording, here are some interesting quotes:

“The American Academy of Pediatrics recommends that before prescribing medicine to a young child, healthcare providers refer parents to training in behavior therapy. However, according to the Vital Signs report, about 75% of young children being treated for ADHD received medicine, and only about half received any form of psychological services, which might have included behavior therapy.” [Emphasis added]

Note that what’s being stressed here is the need to refer parents to behavioral training.

“Parents of young children with ADHD may need support, and behavior therapy is an important first step.  It has been shown to be as effective as medicine, but without the risk of side effects. We are still learning about the potential unintended effects of long-term use of ADHD medicine on young children. Until we know more, the recommendation is to first refer parents of children under 6 years of age with ADHD for training in behavior therapy before prescribing medicine.” [Emphasis added]

“CDC is calling on doctors, nurses, and allied health professionals who treat young children with ADHD to support parents by explaining the benefits of behavior therapy and referring parents for training in behavior therapy.” [Emphasis added]

In addition to the press release, the CDC also provided a press telebriefing in which reporters were able to put questions to senior CDC officials.  One of the questions was from Ariana Cha with the Washington Post.  Her question was:

“Hi.  I had a quick follow-up question about the — about insurance.  And when you say that these should be covered, are you also talking about kind of the gold standard, which is A.B.A. [Applied Behavior Analysis]  Therapy, which is incredibly expensive and usually used for autism but also to address a lot of the same behaviors that you see in ADHD?”

Two CDC officials responded.  First was Anne Schuchat, MD, Principal Deputy Director for CDC:

“No, you know, the treatments are quite different.  And I’d like Dr. Georgina Peacock to comment on that because we don’t believe the same interventions for autism should be used for children with ADHD.”

And then Georgina Peacock, MD, MPH, FAAP, Director, Division of Human Development and Disability:

“So we are talking about behavioral therapy, but this particular behavioral therapy is parent training.  So parents learn skills that help promote positive behaviors in their children.  There’s also a strengthening of the relationship between the parent and the child.  And some of the other things, some of the examples of things that happen, is parents learn about limit setting.  They learn about applying appropriate consequences for inappropriate behaviors and learn about how to improve communication between the parent and the families.  That’s the type of behavioral therapy that we are talking about and the American Academy of Pediatrics recommends for families.” [Emphasis added]

It is clear from these responses that the CDC is not conceptualizing these recommendations as the provision of some kind of specialized treatment to the children, but rather as training the parents in the basic principles and practices of effective parenting.

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In other words, as we “mental illness deniers” have been saying for years, the problem does not reside in the child in the form of some hypothesized brain dysfunction.  Rather, the problem is the direct result of ineffective discipline, training, and correction on the part of caregivers.  And the truly ironic thing is that older people, with no particular training in psychology, psychiatry, social work, counseling, etc., have been saying this for decades, shaking their heads in sadness and disbelief as they watch their children and grandchildren accept pharma-psychiatry’s hoax, and feed the serotonin-disruptive drugs to their children in ever-increasing numbers.  Grandparents – nature’s own trainers in parenting skills – have been effectively silenced by pharma-psychiatry’s spurious, self-serving insistence that these kinds of misbehaviors constitute a brain illness which needs the attention of medically-trained experts.  These unsubstantiated assertions undermine parental confidence, open “uncooperative” parents to accusations of child neglect, and create an environment in which the levels of mastery and self discipline that were the norm for children fifty years ago, are rapidly becoming the exception.

Even CHADD, not noted for challenging the ideology of their pharma benefactors, makes some concessions in this direction.  Here’s a quote from their About ADHD document:

“Problems in parenting or parenting styles may make ADHD better or worse, but these do not cause the disorder. ADHD is clearly a brain-based disorder. Currently research is underway to better define the areas and pathways that are involved.”

This, incidentally, is a truly delightful example of typical psychiatric mental gymnastics.  Let’s take a closer look.

“Problems in parenting or parenting styles may make ADHD better or worse…”

Now, as is well known, ADHD is defined by the presence of six or more habitual behaviors from either or both of two checklists of nine items each.  So if it is being conceded that “problems in parenting” can make ADHD worse, this can only be in terms of a deterioration on one or more of the criterion items.  But since all the criterion items are continuous variables, this inevitably entails a recognition that problems in parenting can push a child past whatever threshold of severity or frequency is required to constitute a “hit”.  Which in turn entails the fact that problems in parenting can produce the six or more hits required to make the “diagnosis”.  In other words, problems in parenting, by CHADD’s own admission, can cause ADHD.  Obviously the drafters of the document realized that they had opened this door, and immediately tried to slam it shut by countering even their own logic with their customary mantra-like assertion:  “ADHD is clearly a brain-based disorder”, the proof of which will be forthcoming any decade now!

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And incidentally, the American Academy of Pediatrics guidelines includes a section on the adverse effects of stimulant drugs.  Here’s a quote:

“An uncommon additional significant adverse effect of stimulants is the occurrence of hallucinations and other psychotic symptoms.”

In 2009, Mosholder et al conducted a study on the incidence of these kinds of events and found:

“A total of 11 psychosis/mania adverse events occurred during 743 person-years of double-blind treatment with these drugs, and no comparable adverse events occurred in a total of 420 person-years of placebo exposure in the same trials. The rate per 100 person-years in the pooled active drug group was 1.48. The analysis of spontaneous postmarketing reports yielded >800 reports of adverse events related to psychosis or mania. In approximately 90% of the cases, there was no reported history of a similar psychiatric condition.”

Eleven cases in 743 person-years (i.e. one in 68 person-years) sounds like a small effect.  But in any given year, about 3.5 million American children take a stimulant drug for ADHD.  And if we assume that each of these children takes the pills for an average of six months (almost certainly an under-estimate), this amounts to approximately 25,700 drug-induced psychosis/mania incidents each year in the US alone.  To the best of my knowledge, no large-scale, systematic study of the outcome of these incidents has been undertaken.

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SUMMARY

The 2011 pediatric guidelines, reinforced as they were by the CDC’s recent press release and telebriefing, represent a formidable broadside against psychiatry’s promotion of ADHD as a brain illness residing within the child.  If this “illness” can be “cured” by improved discipline/correction on the parents’ part, isn’t it eminently reasonable to conclude that ineffective discipline was the precipitating cause of the problem in the first place?  We can be sure that pharma-psychiatry are already working on counter-measures to neutralize the impact of these documents, and we should not expect the bastions of bio-bio-bio psychiatry to crumble overnight. But as Andrew Lloyd Webber and Tim Rice put it so lyrically back in 1968:

“But if my analysis of the position is right,
At the end of the tunnel there’s a glimmer of light”
(Joseph and the Amazing Technicolor Dreamcoat)

On all sides the hoax is unraveling, and psychiatry has  no response other than the repetition of the same unsubstantiated assertions, laced generously with PR, obfuscation, and the assignment of blame to others for their own errors and deceptions.

 

Depression:  A Different Perspective

I have recently come across an interesting paper:  How to Understand and then Escape from Depression.  It’s written by Saul Youssef, a professor of physics at Boston University.

The central theme of the paper is that persistent or chronic depression is caused by “…an unconscious withdrawal of participation in a person’s own internal decision making processes.”

Here are some quotes:

“I have been depressed for most of my life, and, at various times, I have tried most of the recommended treatments for depression. I have tried Saint John’s Wort, exercise, Yoga, talk therapy, SSRIs, thyroid supplements and Cognitive Behavioral Therapy. In my case, I would say that thyroid supplements, exercise and Yoga helped the most and all of them helped at least a little bit.  Unfortunately, none of these treatments helped dramatically. Then, however, in late 2013 and early 2014, I finally figured it out. I came to understand what was happening in my own head and why it was causing my own depression and I was able to figure out a way to escape. I don’t mean that I am now successfully managing my depression. I mean it’s gone. I am writing up what I think is going on and what I did to escape because I don’t think that my case is unusual. I think that exactly the same thing will work for many people.”

“A depressed person continues to live, but they do not continue to decide.”

“A depressed person is mainly on autopilot without realizing that they are mainly on autopilot. A depressed person will do what they always do, say what they always say, feel what they always feel and think what they always think.”

“If a depressed person actually has to do something, and they don’t decide anything, how do they do it? The answer is that they wait until an unconscious process forces them to do it. If a depressed person has to do their taxes, for instance, they will not decide at some moment to do their taxes. Instead, they will wait until the fear of the consequences of not doing their taxes forces them into doing their taxes. Depressed people will procrastinate about almost anything that they do not habitually do. The process of doing almost any necessary task is then necessarily emotional, stressful and unpleasant, because each necessity of life brings with it a rising tide of negative emotions, which only recede when the action is eventually forced.”

“It has often been observed that a depressed person will suffer from compulsive, selfdefeating negative thoughts and feelings…The major problem is that negative thoughts, beliefs and ‘depressogenic assumptions’ are, once again, only symptoms of the underlying problem.”

“I am not an expert on depression, but, after all, it is happening in my own head and who knows more about what’s happening in my own head than I do?”

Dr. Youssef goes on to describe some very simple techniques that helped him break the autopilot habit, take charge of his life, and resolve his long-standing depression.

Dr. Youssef’s concepts resonated with me for three reasons.  Firstly, in both my personal and professional endeavors, I have always emphasized the need to take charge of one’s life vs. drifting along with the tide.  Secondly, Dr. Youssef’s ideas are a form of self-help, and represent an excellent counterpoint to the inherently dependence-inducing medical model.  Thirdly, psychiatry often confuses cause and effect.  It is psychiatry’s position that extreme depression causes indecisiveness; Dr. Youssef’s contention is that extreme indecisiveness causes depression.

Anyway, please take a look.  It’s a simple program with no costs, adverse effects, or downsides.  I would be interested in any feedback.

Antidepressants:  Drugs, Not Medication

On April 7, John Read, PhD, a psychologist at Swinburne University of Technology in Melbourne, published a short article on Mad in America.  The title is:  Largest Survey of Antidepressants Finds High Rates of Adverse Emotional and Interpersonal Effects.  The article presents the results of a survey conducted in New Zealand and published online in February, 2014 in Psychiatry Research.  The survey involved 1,827 individuals who were taking antidepressants.  Dr. Read is widely published.  

Here are some quotes from the MIA article:

“Eight of the 20 adverse effects studied were reported by over half the participants; most frequently Sexual Difficulties (62%) and Feeling Emotionally Numb (60%).”

Note that more than half (60%) of respondents reported feeling “emotionally numb” as a result of taking antidepressants.  In a clinical trial, these people would probably be counted as treatment successes!

“Percentages for other effects included: Feeling Not Like Myself – 52%, Agitation 47%, Reduction In Positive Feelings – 42%, Caring Less About Others – 39%, Suicidality – 39%, and Feeling Aggressive – 28%.   If one had to imagine a combination of feelings most likely to increase the chances of a tragedy involving the loss of multiple lives it would be hard to do better than emotional numbing, agitation, aggression, suicidality and caring less about others.”

“It is worth mentioning that even a group of people who had accepted a biological treatment for their difficulties and had (mostly) found it helpful, did not unquestioningly swallow the ‘chemical imbalance’ theory of depression (and everything else) espoused by biological psychiatry and the drug industry.  The most strongly endorsed causes were:  Family stress (90.8% ‘agreed’ or ‘strongly agreed’), Relationship problems (89.9%), Loss of loved one (87.5%), Financial problems (86.9%), Isolation (86.3%),  and Abuse or neglect in childhood (85.4%), with Chemical imbalance (84.8%) coming in 7th, Heredity 12th, and Disorder of the brain 13th.”

“Finally, we gave participants ten possible reasons that prescription rates of antidepressants are so high (in 2013 the number of prescriptions in England – 53 million – surpassed the total population – 52.6 million). Among the more commonly endorsed  explanations were:  ‘Drug companies have successfully marketed their drugs’ (61%), ‘Drug companies have successfully promoted a medical illness view of depression’ (57%),  ‘GPs don’t have enough time to talk with patients’ (59%), and ‘Other types of treatments are not funded or are too expensive’ (56%). The least endorsed explanation for high prescribing rates was ‘Anti-depressants are the best treatment‘ (20%).”

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The reality is that depression is not an illness, and antidepressants are not medication.  They are drugs that provide a transient feeling of well-being, or at least a feeling of numbness or “something different”.  They in no way address the root causes of depression, which are what they always have been:  the sad things that happen to us in our lives and/or a joyless, unfulfilling, treadmill-type of existence.

And it has long been my contention that in their “hearts”, both the psychiatrists and the recipients of these drugs know this.  The psychiatrists know that they are drug pushers, and the “patients” know that what they are getting is “a fix.”  And so the dance goes on.  The psychiatrists continue the pretense that they are real doctors; the “patients” settle for the fix; the APA invents the diagnoses; the psychopharma business booms; and the damage accumulates.

Psychiatry is not something good that needs some minor corrections.  Rather, it is something so fundamentally flawed and rotten as to be beyond redemption or compromise.  The blatant falsehood, that depression is an illness, has not only destroyed individuals, but eats at our personal and cultural resilience like a cancer.  It is time to put this lie to rest.  Please, if you’re not already doing so, speak out against this insult to human integrity and decency.

Peter Kinderman in Scientific American.  An Important Milestone!

On November 17, Scientific American published on its MIND blog website Why We Need to Abandon the Disease-Model of Mental Health Care, by Peter Kinderman, PhD.

Here are some quotes:

“The idea that our more distressing emotions such as grief and anger can best be understood as symptoms of physical illnesses is pervasive and seductive. But in my view it is also a myth, and a harmful one. Our present approach to helping vulnerable people in acute emotional distress is severely hampered by old-fashioned, inhumane and fundamentally unscientific ideas about the nature and origins of mental health problems. We need wholesale and radical change, not only in how we understand mental health problems, but also in how we design and commission mental health services.”

“It’s all too easy to assume that mental health problems — especially the more severe ones that attract diagnoses like bipolar disorder or schizophrenia — must be mystery biological illnesses, random and essentially unconnected to a person’s life. But when we start asking questions about this traditional disease-model way of thinking, those assumptions start to crumble.”

“But things are changing. Over the past 20 years or so, we’ve seen a very positive and welcome growth of the user and survivor movements, where people who have experienced psychiatric care actively campaign for reform, and signs of more responsible media coverage. We are just starting to see the beginnings of transparency and democracy in mental health care. This has led to calls for radical alternatives to traditional models of care, but I would argue that we do not need to develop new alternatives.
We already have robust and effective alternatives. We just need to use them.”

“This also means we should replace traditional diagnoses with straightforward descriptions of problems. We must stop regarding people’s very real emotional distress as merely the symptom of diagnosable ‘illnesses’. A simple list of people’s problems (properly defined) would have greater scientific validity and would be more than sufficient as a basis for individual care planning and for the design and planning of services.”

“This is an unequivocal call for a revolution in the way we conceptualize mental health and in how we provide services for people in distress, but I believe it’s a revolution that’s already underway.”

Dr. Kinderman is Professor of Clinical Psychology at the University of Liverpool.  He has been an ardent critic of psychiatry’s medical model, and has argued cogently and consistently for a genuinely psychosocial approach.

What is particularly noteworthy and gratifying is that Dr. Kinderman’s excellent article appeared on the website of Scientific American, a reputable, mainstream science magazine for the past 66 years.

For decades psychiatry has been very successful in selling the fiction that their concepts and practices are firmly grounded in empirical science.  With the help of their pharma allies, they marketed themselves as rigorous scientists delivering evidence-based treatment for every conceivable problem of thinking, feeling, and/or behaving.

But the reality has overtaken the spin.  And the publication in a mainstream scientific outlet of an article like Dr. Kinderman’s is a milestone to be noted and celebrated.

Evolution Or Revolution?

On July 22, Just Another Word Press.com site ran an article called Evolution not revolution: My thoughts on the DCP’s call for a paradigm shiftThe website is owned and operated by MTAS Psychology, an agency providing psychological therapy and expert witness services in Manchester, UK.  The article is unsigned.

The primary focus of the article is the paradigm shift paper issued on May 13, 2013 by the British Psychological Society’s Division of Clinical Psychology.  That paper, as readers may remember, drew attention to “conceptual and empirical limitations” inherent in psychiatry’s so-called diagnostic system, and called for a paradigm shift – “towards a conceptual system not based on a ‘disease’ model.”

The author of the MTAS article expressed the belief that a paradigm shift of this sort is too extreme a step, and argues instead for an illness model that recognizes the importance of psychosocial factors.

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Here are some quotes, interspersed with my comments:

“I find myself in an almost constant state of conflicted ambivalence about this debate, most likely attributable to the unpleasant and unhelpful polarization that has taken place within the field in recent years…”

I view the polarization differently.  For the past forty years, I have argued consistently that psychiatry’s central tenets are spurious, and their core practices destructive and disempowering.  I have tried – and I know that others have tried – to engage psychiatrists in these discussions, but to no avail.  Psychiatry steadfastly ignored all conflicting views, and continued on their mission to medicalize (spuriously) every conceivable problem of thinking, feeling, and/or behaving.  For the past ten years or so, however, there has been a distinct turning of the tide.  What the MTAS author describes as unpleasant and unhelpful polarization is nothing more than psychiatry’s opposition finding its voice and – finally – being heard.  Some of the dialogue can at times be acrimonious, but the polarization in itself is neither unpleasant nor unhelpful.  Rather, it is long overdue, and for most of us on this side of the debate, is welcome.

. . . . . . . .

“Maybe it’s a lack of vision on my behalf, but I can’t envisage a mental health system that does not involve medication and forced hospitalisation for clients at their most confused and distressed.”

Perhaps it is the author’s lack of vision.  I have no difficulty whatsoever envisaging a system in which people struggling with problems of thinking, feeling, and/or behaving could go for help; where they would be listened to attentively and respectfully with no agenda of pigeon-holing them into spurious diagnostic categories; where  they would be seen as individuals operating within a context; and where the entire message would be:  you can!, rather than you’re broken,  you can’t.  Within my vision, psychiatrists have either ceased to exist as a profession or, more likely, operate in a shadowy world in which their activities would be seen for what they are – drug pushing.  Their activities would be divorced from the genuinely helpful activity mentioned earlier, for the simple reason that genuine care-givers will refuse to work with them.  Clients who wanted drugs would go to the psychiatrists; client who wanted help in finding genuine solutions to life’s problems would go to psychosocial helpers.

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“I think a symptom/experience based focus could further our understanding of certain presentations, particularly when we remember that a proportion of people satisfying the criteria for a diagnostic category will not represent the archetype, and will sometimes have quite divergent experiences from one another.”

There is no archetype.  And the people embraced by any psychiatric “diagnosis” will always have gotten to the point they are by different routes, and they will always have very different experiences.  This is the essence of the matter.  Psychiatry’s so-called diagnostic system does indeed imply archetypes, but it’s all a fabrication.  Psychiatrists “see” these archetypes because they invented them, and they have become the distorting lens through which they view their clients.  The archetypes have no ontological reality.

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“…any symptom/experience based approach to research would have to include some system for organising participants into meaningful groups.”

This statement is simply false.  Much, perhaps most, research done in the behavior therapy/behavioral analysis field, for instance, is of the before-after, single-case design, where the object of the endeavor is to understand the dynamics of the situation, and to develop appropriate interventions.  Psychiatrists, by contrast, routinely pretend (or perhaps have even convinced themselves) that they achieve understanding of a client’s perspective by assigning him a label.  Consider the hypothetical conversation:

Client:  Why am I so depressed?
Psychiatrist:  Because you have an illness called major depression.
Client:  How do you know that I have this illness.
Psychiatrist:  Because you are so depressed.

This is the essence of psychiatric diagnosis:  a futile exercise in circular reasoning, whose only purpose is the justification of a prescription for psychotropic drugs.  The use of these spurious categories in psychiatric research is not only unnecessary, but actually introduces a huge measure of invalidity into the results.

. . . . . . . .

“Lumping all of these people together could be problematic for conducting reliable research, but separating them up is, essentially, just another way of categorising people.”

Research that uses unreliable grouping criteria, not only could be problematic, it is problematic.  And generalizing from such research is also problematic, but sadly is the norm in psychiatry.

Separating people up (i.e. treating them as individuals) is not just another way of categorizing people.  In fact, it is the opposite of categorizing people.

. . . . . . . .

“I just can’t conceptualise how one might start to meaningfully organise clients’ difficulties without using categories or groups.”

 I think there are a number of problems here.  Firstly, I don’t believe that most clients want, or need, to have their difficulties organized.  I can accept that a small minority of clients are confused and might appreciate some assistance with organizing matters, but, in my experience, the great majority of clients are able to express and explain their problem(s) clearly and unambiguously.  Secondly, and, more importantly, even if a person does need help organizing his difficulties, slotting these difficulties into arbitrarily defined and unreliable pigeon-holes is unlikely to be helpful, and is more likely to be seen as patronizing and condescending.  If a client states that he worries a great deal about all sorts of things, what possible value is provided by my telling him that he “has” generalized anxiety disorder?

. . . . . . . .

“In saying all of this, DSM 5 was an omni-shambles and there is surely a more scientifically sound way of organising the presenting problems of service-users. I am all for developing new, more robust systems, but calling for a wholesale ‘paradigm shift’, when a workable alternative has not yet been developed, never mind validated, is a bit of a misstep in my opinion.”

But there is a working alternative:  listen to what the client says; ask clarificatory questions as needed; listen to the client’s responses; discuss; help the client mobilize his strengths to alleviate his difficulties; coach; support, etc., as needed.  But above all, listen respectfully.  This is not the medical model, but it’s what’s needed.

Besides, what possible use can there be in categorizing people’s presenting problems with a framework that the author acknowledges is an “omni-shambles”?  The development of  “…a more scientifically sound way of organizing the presenting problems of service users…” has been psychiatry’s stated goal for six decades.  But in this regard, DSM-5 is no better than DSM-I (1952); and in many respects is a great deal worse!  Perhaps it’s time to acknowledge that people’s problems of thinking, feeling, and/or behaving are too individualized and too context-specific, to lend themselves to any kind of simplistic, pseudo-medical categorization.  Perhaps it’s time to acknowledge that slotting people and their problems into categories, whilst perhaps conferring some sense of control and efficacy to the practitioner, affords no benefit, and a good deal of harm, to the client.

. . . . . . . .

“I really don’t see why the two approaches must be mutually exclusive.  One of the therapy models I practice is Interpersonal Psychotherapy (IPT).  It takes the approach that depression is an illness.”

The word “illness” means a functional or structural pathology within the organism.  Depression is not an illness, and any attempt to treat it as such is deceptive, unhelpful, and ultimately disempowering.

And the two approaches must indeed be mutually exclusive, because treating depression as an illness is simply incompatible with treating depression as the normal human response to loss, other adverse events, or a meaningless, treadmill kind of existence.

. . . . . . . .

“Personally I despise the name BPD [borderline personality disorder], but, at the same time, certainly see the value in having a group or category that captures the kind of difficulties often experienced by this group of clients.”

The author is missing the point.  A spurious category by another name is still a spurious category.  Even groups that reflect very simple categorization criteria are extremely heterogeneous.  The eleven members on a soccer team could all be categorized as soccer players, but their outlook and motivation will inevitably differ enormously.  One person may be there for exercise; another to please his parents; another to aggravate his parents; another to show off to his girlfriend; etc…  For some, soccer is a lifelong passion, for others a passing whim.  How much more divergence will there be with DSM’s intrinsically unreliable criteria for the condition labeled borderline personality disorder, e.g.:

1.  Frantic efforts to avoid real or imagined abandonment.

At what point does an effort become a frantic effort?  No distinction is made between efforts that involve sending lots of emails, for instance, vs. kidnapping and physical confinement.  How do we assess “imagined” abandonment?, etc…

2.  A pattern of unstable and intense interpersonal relationships characterized by alternating between extremes of idealization and devaluation.

How do we define relationship instability – two break-ups in a year?  Three?  Five?  How do we define, or even begin to measure, the intensity of a relationship?  And “alternating extremes of idealization and devaluation” – how do we distinguish this from the ebbs and flows of “normal” relationships?  Does anyone seriously imagine that a criterion worded in this way is capable of consistent application?

3.  Identity disturbance: markedly and persistently unstable self-image or sense of self.

What does “identity disturbance” mean?  Doesn’t everyone’s self-image fluctuate and change over time?  How do we assess “markedly” and “persistently”?  And what in the world is “sense of self”?  And DSM-5 is not helpful:  “Although they usually have a self-image that is based on being bad or evil, individuals with this disorder may at times have feelings that they do not exist at all.”

And so on for the other six criteria.

And remember, even if we manage to make any headway with the individual criteria, the “diagnosis” is considered positive if five or more of the nine criteria are met.  From high school math we know that there are 256 ways to select five or more items from nine.  So “borderline personality disorder” subsumes at least that number of specific presentations.

. . . . . . . .

“…as psychologists I think we use categories all the time.”

I would say:  as psychologists we understand, or at least ought to understand, the conceptual limitations of categorizing people, or people’s thoughts, feelings, or behavior.  We also recognize the damage done by “diagnostic” categories in terms of stigmatization and reduced expectations, and we generally confine our interest and our attention to specific behaviors that can be reliably identified and discussed meaningfully.

. . . . . . . .

“Whilst I share some of my colleagues’ concerns regarding the relative dominance of a medical model for understanding human suffering, I think both can exist together, at the same time.”

To which I can only respond that the past 60 years of psychiatric hegemony suggests otherwise.  During this time, psychiatry has relentlessly promoted its spurious medicalization of all forms of human distress and has routinely marginalized and even ridiculed its critics.  It has developed a system that is simply incompatible with the conceptual framework employed by the great majority of social workers, counselors, psychologists, job coaches, etc…  Here in the US, childhood temper tantrums are now a mental illness, and we have toddlers as young as two years old being prescribed neuroleptic drugs!  What room is there in such a system for a context-sensitive, psychosocial approach?

. . . . . . . .

“A combination of perspectives is always favourable, surely?”

Compromise, and a combination of perspectives, are sometimes favorable.   Other times – as in the present matter – they are not.  Surely!  What kind of theory of fire would chemists have today, for instance, if the oxygenation proponents had compromised with the phlogiston theory adherents?  Some conceptual frameworks are just plain wrong, and need to be scrapped.  Psychiatry has been intellectually bankrupt for most of its history, particularly for the past fifty years.  At the present time it is being maintained on life-support by pharma money.

CONCLUSION

For the past ten or fifteen years valid criticisms have been directed at psychiatry’s “diagnostic” system, and at its range of treatments.  Psychiatry has not only ignored these criticisms, but has actually accelerated its medicalization agenda, and has asserted the putative efficacy of its treatments with increased vigor.  There has been no slowing down of the psychiatric juggernaut, and apart from the efforts of a small number of psychiatrists, there has been no indication that basic concepts or practices are being reconsidered, or re-evaluated in any way.

The human toll, in terms of ongoing damage, disempowerment, and stigmatization, is enormous, and continues to grow.

There is, in my view, no possibility that a system led by psychiatrists will ever become truly helpful in the alleviation of problems of thinking, feeling, and/or behaving.  There is an urgent need for a paradigm shift, and the BPS’s clinical division is to be commended for taking this initiative.  There is an urgent need to develop an alternative system, based, not on the notion that people are broken and need chemical adjustment, but rather on the notion that, with help, people can resolve their problems and find some peace and contentment.  The notion that such a system can develop and thrive under a psychiatric roof is simply unrealistic.

Blame the Clients?

On June 6, I wrote a post titled Psychiatry DID Promote the Chemical Imbalance Theory.  The article was published on Mad in America, and generated a number of comments on that site, five of which were from TherapyFirst, who in his first comment identified himself as Joel Hassman, MD, a practicing psychiatrist. 

Dr. Hassman did not argue with the general notion that psychiatric practice today consists almost exclusively of the prescription of drugs.  Indeed, in one of his own blog posts on June 16, 2013, he wrote in an open letter to newly qualified psychiatrists:

“…you are now agreeing to basically just prescribe medication and give limited, selective diagnoses that serve insurer and/or bureaucratic agendas first and foremost.”

 and

“…your interest will be narrowly directed to prescribing more likely multiple medications from moment one of meeting the patient…”

And this general position – that psychiatry consists essentially of prescribing drugs – continues to be evident in his comments on the MIA post.

But then he introduces a twist that I haven’t encountered before – he blames the clients for what he aptly calls the “chemicalization” of mental health.  Here are some quotes:

“Everyone rails about psychiatrists and other prescribers just dumbing down mental health care complaints to writing scripts, but, in the last 10 years or so, people come into treatment venues just wanting drugs, and dismiss any other intervention for care, irregardless of how appropriate and indicated as a standard of care such a treatment is warranted.”

“Seems to me it fits the antipsychiatry narrative at the end of the day. It is easier to crucify the doctors, harder to attack the general public who are reinforcing ‘better living through chemistry’, eh?”

 “Sorry, but if there is going to be a valid and honest discussion/debate about who is at fault in the ‘chemicalization’ of mental health, don’t just pick on the doctors. Patients are pervasively demanding drugs, often ones of abuse potential of late, and have little to no interest in problem solving nor wanting to implement real and effective change for the better.”

 “…where are the muzzle prints on these ‘victims’ foreheads that demand they take medication?”

 “…you as a patient come to someone with an expertise and then have the gall to argue and demand interventions that do not fit as treatment A for the problem in front of the clinician, and I am to refer to him/her as ‘victim’?? Get real!”

As I noted earlier, this is an unusual and complicated  perspective.  On the one hand, there’s an element of truth in Dr. Hassman’s position.  A great many people do indeed go to psychiatrists for the specific purpose of obtaining a prescription.  And I think we can believe Dr. Hassman’s assertion that some of these individuals may become impatient and dismissive, and perhaps even demanding, when invited to explore other options.

But on the other hand, drug prescriptions are psychiatry’s stock in trade.  It’s what the vast majority of psychiatrists offer, and what their customers have, reasonably and legitimately, come to expect.  I have even heard numerous reports from clients that they were pressured by psychiatrists into taking pills.

I’m old enough to remember a time when outpatient psychiatry was almost entirely a talking and listening profession.  Depression was considered a fairly ordinary and understandable phenomenon – part of the human lot, so to speak – and remediation was conceptualized as being largely a matter of seeking support and solace from friends and loved ones, and of making positive changes in one’s circumstances and lifestyle.  In extreme cases, people did consult psychiatrists, but the purpose of these visits was to discuss issues and problems – not to obtain drugs.

I imagine that psychiatrists in those days felt that their years of medical training were somewhat wasted.  The problems that they were helping people address were not considered medical in nature, except perhaps in very extreme cases, and there was nothing particularly medical about the “treatments.”  And, of course, there were fewer psychiatrists.

Obviously things are very different today, and I think the fundamental questions here are:  how did these changes come about? and, who’s to blame?

There is an obvious parallel between the growth of psychiatric prescribing and the growth of the illegal drug trade over the past fifty or sixty years.  It is also obvious, and generally accepted, that the illegal trade is driven by demand, and would collapse overnight if that demand were to dry up.

So the question arises:  is what Dr. Hassman calls the chemicalization of psychiatry essentially a product of consumer demand for drugs?  And, of course, the answer, at least to some extent, is yes.  If people stopped going to psychiatrists for prescriptions, then psychiatrists would have to either disband as a profession or find something else to do.

But there is another side to this coin.  People who deal in illegal drugs make no pretense that their products are medications.  For psychiatrists, however, this is their primary marketing tool.  For decades, they and their pharmaceutical allies have promoted this fiction using every means at their disposal.  Very few psychiatrists have distanced themselves to a significant degree from this position.

They have spread the seductive deception that virtually all significant problems of thinking, feeling, and/or behaving are caused by neurochemical imbalances which can be corrected only by ingesting their products.  They have issued, and continue to issue, dire warnings as to the consequences of not taking these pills.  They have persuaded parents that their children’s brains are impaired, and that even toddlers need to take the pills.  And so on.  The whole sordid tale has been exposed many times, but psychiatry, without a hint of shame or compunction, continues to spread this self-serving and destructive deception.  In fact, at the present time, psychiatry, as represented by the World Psychiatric Association and the American Psychiatric Association, is actively working to improve its tarnished image with a view to expanding its market even further.

So, Dr. Hassman is probably correct when he writes that some clients do come to psychiatrists to obtain drugs, and are resistant to alternative suggestions.  But I think there’s a bigger issue:

A steady stream of individuals, of all ages and from all walks of life, coming to psychiatrists for drugs is precisely the objective towards which the psychiatric leadership and vast majority of the rank and file have worked diligently for the past fifty years. 

It wasn’t the customers who invented and disseminated the term “a chemical imbalance, just like diabetes.”  And, it wasn’t the customers who wrote and expanded the DSM to provide an impression of legitimacy for the drug-pushing activity.  That was psychiatry!

* * * * * * * * * * * * * * * * * * * *

This article has also be posted at the Mad in America site.

 

 

Drugging Toddlers for Inattention, Impulsivity, and Hyperactivity

On May 16, the New York Times ran an article titled Thousands of Toddlers Are Medicated for A.D.H.D., Report Finds, Raising Worriesby Alan Schwarz.  Here is the opening sentence:

“More than 10,000 American toddlers 2 or 3 years old are being medicated for attention deficit hyperactivity disorder outside established pediatric guidelines, according to data presented on Friday by an official at the Centers for Disease Control and Prevention.”

The CDC official is Susanna Visser, MS, DrPh, Acting Associate Director of Science for the Division of Human Development and Disability, and she was speaking at the annual Rosalyn Carter Georgia Mental Health Forum.  I have not been able to find the text of Ms. Visser’s speech.  (It will probably be published later.)  Meanwhile, there is a good deal of information in Alan Schwarz’s article.  Here are some more quotes:

“The report, which found that toddlers covered by Medicaid are particularly prone to be put on medication such as Ritalin and Adderall, is among the first efforts to gauge the diagnosis of A.D.H.D. in children below age 4. Doctors at the Georgia Mental Health Forum at the Carter Center in Atlanta, where the data was presented, as well as several outside experts strongly criticized the use of medication in so many children that young.”

“The American Academy of Pediatrics standard practice guidelines for A.D.H.D. do not even address the diagnosis in children 3 and younger — let alone the use of such stimulant medications, because their safety and effectiveness have barely been explored in that age group. ‘It’s absolutely shocking, and it shouldn’t be happening,’ said Anita Zervigon-Hakes, a children’s mental health consultant to the Carter Center. ‘People are just feeling around in the dark. We obviously don’t have our act together for little children.'”

“Dr. Lawrence H. Diller, a behavioral pediatrician in Walnut Creek, Calif., said in a telephone interview: ‘People prescribing to 2-year-olds are just winging it. It is outside the standard of care, and they should be subject to malpractice if something goes wrong with a kid.'”

“Dr. Visser said that effective nonpharmacological treatments, such as teaching parents and day care workers to provide more structured environments for such children, were often ignored. ‘Families of toddlers with behavioral problems are coming to the doctor’s office for help, and the help they’re getting too often is a prescription for a Class II controlled substance, which has not been established as safe for that young of a child,’ Dr. Visser said. ‘It puts these children and their developing minds at risk, and their health is at risk.'”

But there was also some support for the practice, albeit cautiously worded:

“Keith Conners, a psychologist and professor emeritus at Duke University who since the 1960s has been one of A.D.H.D.’s most prominent figures, said that he had occasionally recommended it when nothing else would calm a toddler who was a harm to himself or others.”

“Dr. Doris Greenberg, a behavioral pediatrician in Savannah, Ga., who attended Dr. Visser’s presentation, said that methylphenidate can be a last resort for situations that have become so stressful that the family could be destroyed. She cautioned, however, that there should not be 10,000 such cases in the United States a year.”

The article finishes with quotes from Nancy Rappaport, MD:

“Dr. Nancy Rappaport, a child psychiatrist and director of school-based programs at Cambridge Health Alliance outside Boston who specializes in underprivileged youth, said that some home environments can lead to behavior often mistaken for A.D.H.D., particularly in the youngest children.”

“‘In acting out and being hard to control, they’re signaling the chaos in their environment,’ Dr. Rappaport said. ‘Of course only some homes are like this — but if you have a family with domestic violence, drug or alcohol abuse, or a parent neglecting a 2-year-old, the kid might look impulsive or aggressive. And the parent might just want a quick fix, and the easiest thing to do is medicate. It’s a travesty.'”

ADHD IN THE DSM

ADHD is listed in the DSM and is widely promoted by psychiatry as a brain illness which causes children and adults to be excessively inattentive, hyperactive, and/or impulsive.

DSM-III-R specified that the onset of this “illness” had to be prior to age seven, but set no lower age limit.  In fact, in this edition of the APA’s manual, the assignment of this “diagnosis” to preschool children is clearly endorsed.

“In preschool children, the most prominent features are generally signs of gross motor overactivity, such as excessive running or climbing.  The child is often described as being on the go and ‘always having his motor running.’  Inattention and impulsiveness are likely to be shown by frequent shifting from one activity to another.” [Emphasis added] (p 50)

and

“In approximately half of the cases, onset of the disorder is before age four.” [Emphases added] (p 51)

DSM-IV-TR states:

“It is difficult to establish this diagnosis in children younger than age 4 or 5 years, because their characteristic behavior is much more variable than that of older children and may include features that are similar to symptoms of Attention-Deficit/Hyperactivity Disorder.  Furthermore, symptoms of inattention in toddlers or preschool children are often not readily observed because young children typically experience few demands for sustained attention.  However, even the attention of toddlers can be held in a variety of situations (e.g., the average 2- or 3-year-old child can typically sit with an adult looking through picture books).  Young children with Attention-Deficit/Hyperactivity Disorder move excessively and typically are difficult to contain.  Inquiring about a wide variety of behaviors in a young child may be helpful in ensuring that a full clinical picture has been obtained.  Substantial impairment has been demonstrated in preschool-age children with Attention-Deficit/Hyperactivity Disorder.” (p 89)

DSM-5 is briefer but just as clear:

“In preschool, the main manifestation is hyperactivity.” (p 62)

So, as far as the APA is concerned, children of preschool age can, and do, “get” ADHD.

But what is ADHD?  Here again, the APA’s position, in their fact sheet titled “ADHD,” (2014) is  brief and clear:

“Attention-deficit/hyperactivity disorder (ADHD) is one of the most common mental disorders affecting children. ADHD is a brain condition that is often first identified in school-aged children when it causes disruption in the classroom or problems with schoolwork.” [Emphasis added]

Note, incidentally, the assertion of causality.  ADHD is a brain condition that causes classroom disruption and problems with school work.  In reality, the causal connection is spurious, and is just one more example of psychiatric “logic.”  To illustrate this, imagine a conversation between a parent and a psychiatrist:

Parent:  Why is my child so disruptive in class?  Why won’t he concentrate on his schoolwork?
Psychiatrist:  Because he has ADHD.  ADHD causes these problems.
Parent:  But how do you know he has ADHD?
Psychiatrist:  Because he is so disruptive in class and doesn’t concentrate on his school work.

Psychiatry defines ADHD by the presence of an assortment of vaguely-defined behaviors and then adduces this construct as the cause of these behaviors.  In other words, a child has ADHD because he is disruptive; and he is disruptive because he has ADHD!  This particular piece of psychiatric sophistry has been identified and highlighted, at one time or another, by virtually everyone on this side of the “mental illness” debate.  But I have never seen an attempt at rebuttal from any proponent of psychiatric orthodoxy.

But back to the question: what is ADHD?  There is a document titled ADHD: Parents Medication Guide published jointly by the APA and the American Academy of Child and Adolescent Psychiatry in July 2013.  Here’s a quote:

“Attention-Deficit/Hyperactivity Disorder (ADHD) is a neurodevelopmental disorder characterized by difficulty paying attention, excessive activity, and impulsivity (acting before you think). ADHD is usually identified when children are in grade school but can be diagnosed at any time from preschool to adulthood.” [Emphases added]

This document also stresses that:

“Early identification of ADHD is advisable…”

and lists the dire consequences if “ADHD is left untreated”:

  • “Increased risk for school failure and dropout in both high school and college
  • Behavior and discipline problems
  • Social difficulties and family strife
  • Accidental injury
  • Alcohol and drug abuse
  • Depression, anxiety and other mental health disorders
  • Employment problems
  • Driving accidents
  • Unplanned pregnancy and sexually transmitted diseases
  • Delinquency, criminality, and arrest”

The NIMH document Attention Deficit Hyperactivity Disorder (2012) states:

“Attention deficit hyperactivity disorder (ADHD) is one of the most common childhood brain disorders and can continue through adolescence and adulthood.” [Emphasis added]

So it’s pretty clear that organized psychiatry, as represented by the APA, AACAP, and NIMH, endorses the notion that preschool children can “get” ADHD, and that ADHD is a brain illness.  It is also widely promoted that ADHD should not be left “untreated.”

RESEARCH

In 2006, Greenhill L. et al. published Efficacy and safety of immediate-release methylphenidate treatment for preschoolers with ADHD, in the Journal of the American Academy of Child and Adolescent Psychiatry.  Here’s their conclusion:

“MPH-IR [methylphenidate-instant release], delivered in 2.5-, 5-, and 7.5-mg doses t.i.d., produced significant reductions on ADHD symptom scales in preschoolers compared to placebo, although effect sizes (0.4-0.8) were smaller than those cited for school-age children on the same medication.”

The paper lists 17 authors.  The lead author is Laurence Greenhill, MD.  Dr. Greenhill is a very eminent psychiatrist.  At present he is a professor of Psychiatry and Pediatric Psychopharmacology at Columbia University.  He is also Director of the Research Unit of Pediatric Psychopharmacology at the New York State Psychiatric Institute.  Dr. Greenhill has served as principal investigator on several NIMH studies, and on 14 pharma-funded studies.  He has also served as President of the American Academy of Child and Adolescent Psychiatry (2009-2011).

His 2008 conflict of interest statement which is on file with the AACAP, states that during the period when he was president-elect, he was spending 50% of his work time “…dedicated to the private practice treatment of toddlers, adolescents, and adults mostly with ADHD.” [Emphasis added]

Incidentally, according to the disclosure section at the end of the 2006 article, 11 of the 17 authors had ties to pharma.  (In addition, a twelfth author disclosed links in a 2009 paper that will be discussed below.)

This study was funded by the NIMH, and on October 16, 2006, NIMH issued a press release in which they described the study as:

“The first long-term, large-scale study designed to determine the safety and effectiveness of treating preschoolers who have attention deficit/hyperactivity disorder (ADHD) with methylphenidate (Ritalin) has found that overall, low doses of this medication are effective and safe.  However, the study found that children this age are more sensitive than older children to the medication’s side effects and therefore should be closely monitored.” [Emphasis added]

Thomas Insel, MD, Director of NIMH, provided a quote for the press release:

“‘The Preschool ADHD Treatment Study, or PATS, provides us with the best information to date about treating very young children diagnosed with ADHD,’ said NIMH Director Thomas R. Insel, MD. “‘The results show that preschoolers may benefit from low doses of medication when it is closely monitored, but the positive effects are less evident and side-effects are somewhat greater than previous reports in older children.'”

The press release concluded with a quote from Laurence Greenhill, MD, the lead author:

“‘The study shows that preschoolers with severe ADHD symptoms can benefit from the medication, but doctors should weigh that benefit against the potential for these very young children to be more sensitive than older children to the medication’s side effects, and monitor use closely,’ concluded Dr. Greenhill.”

MORE RESEARCH

There’s another piece of research by Abikoff, et al. published in the journal Advances in Preschool Psychopharmacology in 2009.  It’s titled Methylphenidate Effects on Functional Outcomes in the Preschoolers with Attention-Deficit/Hyperactivity Disorder Treatment Study (PATS)  Here’s the conclusion:

“Preschoolers with ADHD treated with MPH [methylphenidate] for 4 weeks improve in some aspects of functioning.  Additional improvements might require longer treatment, higher doses, and/or intensive behavioral treatment in combination with medication.” 

This paper lists as authors most of those who are also shown in the Greenhill et al. study cited above.

So, according to the best psychiatric authorities, the condition known as ADHD

  • Is a brain illness;
  • Can and does occur in children of preschool age;
  • Causes severe problems if left untreated;
  • Can be safely and effectively treated with stimulant drugs (with the caveat that children of preschool age should be closely monitored for adverse effects).

Against this well-orchestrated and heavily promoted background, it is easy to see how the drug-prescribing is drifting into the lower age range.  In fact, if one buys the psychiatry line, wouldn’t it be tantamount to criminal to deprive these preschoolers of “treatment” for their “brain illness”?  Wouldn’t it be unconscionable to expose them to the risks outlined earlier?  Surely the risk of taking a few pills – that have been proven safe and effective anyway – is justified when weighed against the dangers of “untreated ADHD.”

Besides, in their booklet on Mental Health Medication (2008), the NIMH state unambiguously:  “Stimulant medications are safe when given under a doctor’s supervision.”  I kid you not.

DISCUSSION

The critical issue here is that the loose cluster of vaguely defined behaviors that psychiatry calls ADHD is not an illness.  Rather, it is, in the vast majority of cases, a reflection of inadequate discipline and training on the part of the parents.

In former times, parents accepted, as an intrinsic part of their role, training their children: to sit still when required; to pay attention to authority figures; to be obedient; to complete chores; to stay focused when needed; to be quiet when needed; to wait his/her turn; not to interrupt when others were speaking; to respect other children’s property; etc…

But today, psychiatry tells us that children who have not acquired these habits are ill.  This is emphatically not something that psychiatry has discovered in the normal scientific manner.  Rather, it is something that psychiatry has decided.  Psychiatry has decided that all significant problems of thinking, feeling, and/or behaving are mental illnesses.  So, children who have not been trained in the skills listed above are ill – by definition.

And because they are “ill,” they must take “medicine.”

Despite the protestations and the expressions of outrage, the expansion of the ADHD “diagnosis,” and consequent drugging, into the preschool population is an inevitable consequence of psychiatry’s spurious medicalization of every conceivable human problem, and their eagerness to prescribe drugs to “treat” these problems.

Protesting that the drugs have not been approved for children under the age of four misses the point, for two reasons.  Firstly, because the approval process is intrinsically flawed, and secondly because drugs are not an appropriate response to these problems, for preschoolers or for older children.

Debates as to whether the preschoolers in question “really” have ADHD are meaningless.  ADHD is defined by the presence of certain vaguely-defined behaviors.  If a two-year-old is engaging in these behaviors, then he “has” ADHD.  This is the travesty that the APA has created.  There is no test or reality against which the child’s presentation can be compared to confirm or refute the “diagnosis.”  All that’s needed is the subjective opinion of a mental health professional that the child displays the misbehaviors in question to a degree that is “inconsistent with [his/her] developmental level and that negatively impacts on social and academic…activities.” (DSM-5, p 59).

And there is no lower age limit for this “diagnosis.”  Well, that’s not absolutely true.  The “symptoms” must have been present for at least six months, so I suppose 6 months is effectively the lower limit!  So the babies are still safe – at least until DSM 5.1!

Psychiatry’s primary agenda for the past fifty years has been the expansion of its “diagnostic” net, and the prescribing of more and more pills to more and more people.  Psychiatry promises joy, happiness, and a trouble-free life from a pill bottle, and tragically our society and our political leadership have bought it.  Today, no group is safe from psychiatry’s depredations.  Their net embraces people of all ages, all walks of life, and all circumstances.  There is truly no human problem that cannot be “diagnosed” as a “mental illness,” and for which psychiatry doesn’t have a pill.

Ten thousand American toddlers taking stimulants for ADHD is just business as usual.  By all means, let us speak out against this psychiatric assault on our toddlers, but let’s not lose sight of the greater tragedy – that this kind of approach has become the norm.  Feeding children psychoactive drugs as a substitute for instilling age-appropriate habits of discipline, self-control, and interpersonal respect is a tragedy beyond description.  If street-dealers were promoting their products to toddlers and their parents in this way, there would be outrage – and rightly so.  But psychiatrists, dressed in nice suits, and with their image polished by an international PR firm, are accepted.

As a society, as a culture, we have truly lost our way.

 Another Critique of the Schizophrenia Diagnosis

In January 2014, the journal Research on Social Work Practice ran a special issue called A Critical Appraisal of the DSM-5: Social Work Perspectives.  There are fifteen articles on this general theme, and together they present a wide range of arguments against the DSM system.

Social workers represent the numerically biggest group of mental health practitioners in the US, and it is particularly gratifying to see a major social work journal addressing this topic so forthrightly.

In this post, I want to focus on one of the articles:  A Critique of the Diagnostic Construct Schizophrenia, by Stephen Wong, PhD, BCBA-D, of the Florida International University in Miami.

Here are some quotes:

“Characterizing the many emotional, behavioral, functional, and social concerns listed in the manual as physical ‘diseases’ is a theoretical and ideological assertion.  And even though this assertion is repeated endlessly in professional and commercial media, the claim rests on faulty definitions, logical fallacies, and weak empirical evidence (Boyle, 2002; Moncrieff, 2008; Read, Mosher, & Bentall, 2004; Valenstein, 1998)”

“Equipped with the knowledge of these and other therapeutic techniques, social workers can take a more active role in the design and implementation of effective psychosocial interventions, rather than being handmaidens of psychiatrists and relying on the finite benefits of their pharmacological treatments (Cohen, 1997; Harrow & Job, 2007; Hegarty, Baldessarini, Tohen, Watternaux & Oepen, 1994; Whitaker, 2010).”

“While current mental health services focus primarily on treating unconfirmed biological or neurological diseases (Gomory, Wong, Cohen, & Lacasse, 2011; Kingdon & Young, 2007; Whitaker, 2010), social workers and other mental health professionals should not confine themselves to this narrow, reductionist perspective and should be sensitive to other factors contributing to severe mental and behavioral disturbances.”

“There is abundant research on environmental and social adversity factors contributing to the development of schizophrenic symptoms and psychosis to guide our practice in social advocacy, prevention, and treatment of mental and behavioral disorders.”

“The biggest question is, given the many conceptual, scientific, and technical shortcomings of the diagnosis of schizophrenia, and of DSM diagnoses in general, why are social workers, psychologists, and other mental health professionals so dutiful in their use of the DSM and not more outspoken in their criticism of these psychiatric labels?”

“However, simply acquiescing to this medical ideology also has direct consequences for individual clinicians and their professions.  For social workers, it means putting aside our person-in-the-environment approach, our appreciation of how life experiences and living conditions shape peoples’ thoughts and actions, and our professional independence.”

“Open criticism and resistance to the DSM would be a fitting starting point for organizing and opposing medical dominance and the biomedical hegemony over mental health services, and thereby better assisting members of our society with mental, emotional, and behavioral disturbances.”

I found Dr. Wong’s paper particularly encouraging not only for its intrinsic merit, but also for its rallying call to social workers to distance themselves from the DSM and from the concept of psychiatric illness generally.

I have often expressed the belief that a grassroots rebellion within the social work profession could be the tipping point in the marginalization of psychiatry, and in the development of an effective and truly person-centered framework for helping people in distress.

 

‘ADHD’ and Dangerous Driving

In 2006, Laurence Jerome, a Canadian psychiatrist, and two colleagues wrote a paper titled What We Know About ADHD and Driving Risk: A Literature Review, Meta-Analysis and Critique.  It was published in the Journal of the Canadian Academy of Child and Adolescent Psychiatry in August, 2006. The primary result of the meta-analysis was:

“Current data support the utility of stimulant medication in improving driving performance in younger ADHD drivers.”

The study is lengthy and well-referenced, but in keeping with standard psychiatric practice, it conceptualizes and presents ADHD as a “…common psychiatric disorder…” with symptoms of “…inattention, impulsiveness and hyperactivity…”  In other words, they present ADHD as something that a person has rather than as something that a person does. The problem with this approach is that it creates the impression that meaningful or significant correlations/effects have been found, where in fact all that has happened is an elucidation of the terms used.

For instance, the authors refer to a study by Fried et al. (2006) and state:

“Fried et al. (2006) evaluated driving behavior using the DBQ [Driving Behavior Questionnaire] and found that the ADHD group had significantly more lapses, errors and violations than controls.”

On the face of it, this looks like an interesting finding.  It purports to be an important fact that has been discovered about people who have this condition.  But in reality, lapses, errors, and violations are an integral part of the definition of ADHD.  The DSM criteria includes:  careless mistakes; difficulty remaining focused; mind seems elsewhere; easily distracted; forgetful; etc…  One doesn’t get into this group in the first place without a history of habitual lapses, errors, and violations.  The fact that these habitual lapses and errors carry over into a person’s driving behavior isn’t particularly surprising.

There are several other examples of this in Jerome et al., e.g.:

“A number of studies examined cognitive abilities associated with safe driving performance. Measures of both inattention and impulsivity were found to be higher in the ADHD groups as compared to controls.”

Here again, inattention and impulsivity are defining features of the condition labeled ADHD.  All that has actually been found here is that people who are inattentive and impulsive are inattentive and impulsive! The study reports that people who carry a “diagnosis” of ADHD are involved in more collisions, and receive more traffic citations than controls.  This is interesting, but again, hardly surprising for the reasons discussed above.  One could look at all this simply as benign, meaningless verbiage, but in reality, the constant repetition of these factoids reinforces the notion that the label ADHD refers to a real illness, and that this “illness” has real sequelae, in the same way that kidney failure, for instance, usually entails edema and anemia.

EFFECTS OF PSYCHOTROPIC DRUGS

The authors discuss several studies on the effects that stimulant and non-stimulant drugs that are used to “treat” ADHD have on driving behavior.  The results were mixed.  The authors draw attention to some methodological problems in this area and also concede that “…all currently available studies are industry sponsored.”

NEUROLOGY

Dr. Jerome et al. posit a neurological deficit as the source of the impulsivity and inattention.

“Core functional impairments in executive function related to response inhibition, working memory and flexible strategic response help explain both general ADHD pathology and its specific manifestations in problem driving in this group.”

This paper, as noted earlier, was written in 2006.  Note the cautious language in the quote above:  “…help explain…”  Today, eight years later, there’s still no definitive neural pathology known to be causally associated with these problem behaviors, and the “illness” is still being “diagnosed” by subjectively assessing, and counting, the individual’s actions.  In fact, and this is particularly compelling, the American Academy of Child and Adolescent Psychiatry in its current practice parameters for ADHD state unambiguously that unless there is a clear history of severe head injury, or other neural pathology

“…neurological studies…are not indicated for the evaluation of ADHD.” [Emphasis added]

At this point Dr. Jerome et al. make the great leap of faith:

“…it was not the knowledge base of driving skills that differentiated the driving problems in ADHD youth so much as their inability to apply these rules at the appropriate time and under the appropriate circumstances. In other words the problem is an output problem; they can ‘talk the talk but they can’t walk the walk’.” [Emphases added]

Note the words “inability” and “can’t.”  This is one of the fundamental problems in the “diagnosis” of ADHD and other psychiatric “illnesses” – the logically flawed leap from “doesn’t” to “can’t.”  And this unwarranted leap is the basis for the conclusion that the individuals in question have an illness, and, in extreme cases qualify for disability.  A person with kidney failure doesn’t and can’t produce urine.  But a person “with” ADHD can, with proper training, learn to behave in a more attentive and less impulsive manner.

In former times, children who were routinely inattentive and impulsive were considered to be in need of training and discipline.  By and large, school teachers and parents provided this.  In fact, the training was usually provided before the matter even became an issue.  Today these children are spuriously and arbitrarily labeled as ill, and are given pills.  The pills suppress the problem behavior, but in many, perhaps most, cases the underlying problem of self-discipline is never addressed.  So these children grow up and, not surprisingly, they become inattentive and impulsive drivers, with a reportedly 50% increased risk of negative driving outcomes.  The “diagnosis” of “illness” contains within itself the disempowering, and incidentally false, message that the individual was incapable of acquiring the level of discipline, attention, and self-control needed for successful classroom participation.  Psychiatry has given these parents, and the children themselves, the false message that their brains are malfunctioning, that the pills will correct the problem, and that attempts to teach discipline and self-control in the normal manner are futile.  With pharma-psychiatry’s successful expansion of this “diagnosis” to the adult population, the disempowerment has become a more-or-less permanent “disability.”

The role that the initial “diagnosis” and subsequent drugging played in transforming what used to be an eminently remediable problem into a permanent disability is seldom addressed or even acknowledged.  The psychiatric fiction has to be maintained:  these individuals were “sick” as children and are still “sick” as adults.  Their inattention and impulsivity are still “symptoms” of the same debilitating “illness.”  Psychiatrists for the past sixty years have insisted that they are discovering real illnesses.  They remain self-servingly blind to the fact that, firstly, they invented these illnesses, and secondly, that their active promotion of these “illnesses” has created a culture in which personal effort and self-discipline are routinely marginalized in favor of the spurious and inherently disempowering notion of pharmaceutically correctable impairments.

Jerome et al. do pay passing acknowledgement to the need for “psychological strategies,” but it is clear that they conceptualize the matter as a medical problem with a pharmaceutical remedy:

“Experimental studies indicate that stimulants and to a lesser extent non-stimulant drugs used to treat ADHD improve areas of driving performance.”

These, incidentally, are the same industry-sponsored studies mentioned earlier.

and

“In particular the question of adherence to medication regimens over time to improve driving skills is likely to be a critical question based on our knowledge of poor long-term medication adherence for young adults with ADHD.”

and

“The individual attending physician has an opportunity to reduce morbidity and mortality for the individual ADHD patient as well as contribute to improved public health for the driving population at large by making the roads safer one driver at a time.”

and

“A number of jurisdictions including Canada and UK now require physicians to report ADHD drivers thought to be at risk of problem driving to the Ministry of Transportation.”

and

“The question of medico-legal liability is in its infancy with no established case law for physicians found negligent of failing to adequately treat ADHD patients with the appropriate medications to reduce driving risk. Whilst the available literature does not yet provide clear evidence that stimulant medication should be the standard of care for problem drivers long term, it is probably only a matter of time before this question will be debated in a legal arena.”

DISCUSSION

At the present time the pharma-psychiatric system is being widely exposed as the spurious, destructive, disempowering fraud that it is.  Organized psychiatry is responding to these criticisms not by cleaning up its act, but instead by increasing its lobbying activity in the political arena.

In particular, they are actively promoting the notion of involuntary community “treatment” with coerced “medication.”  Under this system, which is established by law in more than 40 US states, a judge can order an individual to attend the local mental health center and to abide by the center’s “treatment” plan.  The plan usually entails a requirement to take psychiatric drugs, sometimes the long-lasting injectable variety.  Here’s how Jeffrey Lieberman, MD, President of the APA, describes the program:

“There’s also other forms of psycho-social treatment that are very, very helpful. Sometimes people who have schizophrenia don’t want treatment, or don’t feel they need treatment, or just plain forget about treatment. In those cases, with what’s called assertive community treatment, a case manager or somebody that’s assigned to work with that person will go out to find them, will go to their home, you know, ‘You haven’t come to the clinic, you haven’t come to the office, you haven’t shown up, what’s going on here, you need to get your medication, you need to go through your rehabilitation,’ so they’ll get after them.”

This all sounds very cozy and friendly, and you know – come on down to the mental health center, you know, we care about you, etc., etc… But within the silk glove, there’s the mailed fist of confinement and coerced drugging.  Readers can check out the other side of the story at National Coalition for Mental Health Recovery, PsychRights page on OutPatient Commitment, and by searching for assertive outpatient commitment on Mad in America.  Dr. Lieberman is talking about people labeled with schizophrenia, but it doesn’t take too much imagination to see how the concept could be adapted to a wide range of other “diagnoses,” including ADHD.

As of yet, the ominous prediction in the final Jerome et al. quote above has not come to pass.  But is the day approaching when individuals “diagnosed” with ADHD during childhood will be subjected to special screening when they apply for a driving license?  Might their licenses be made contingent on their ingestion of psychoactive drugs?  After all, impulsive, inattentive drivers constitute a danger to themselves and others.  If, as psychiatry claims, their impulsivity and inattention are the result of a “mental illness,” then doesn’t it make sense that they be committed?  Isn’t it in their own interests and the interests of the public at large that they be coerced to take their “medications”? Such a move would be consistent with psychiatry’s long-standing expansionist agenda and with pharma’s objective to sell more drugs.

And lest my concerns be considered groundless speculation, here are some interesting quotes.

From Oren Mason, MD, a blogger physician, co-owner of Attention MD, and associate professor at Michigan State University.  He specializes in the “…diagnosis and management of attention deficit disorders and related conditions” (Ritalin Saves Truckers’ Lives. Soccer Moms’, Too, February 2014):

“There is a public health issue when inattentive or impulsive behaviors occur on busy, public streets and highways.”

and

“…we could potentially prevent 100,000 injuries and deaths every year with consistent use of ADHD medications.”

Incidentally, according to Dollars for Docs, Dr. Mason received $208,459 from Eli Lilly for speaking, consulting, travel, and meals between 2009 and 2012.

And from Brian Krans, an assistant editor at HealthLine News (Could Ritalin Be the Way to Keep Truckers Safe on the Road? January 2014):

“Another new study says that undiagnosed attention-deficit hyperactivity disorder (ADHD) may be the cause of many safety issues for drivers on the road.”

Note how ADHD has become the cause of the problem behaviors, rather than just another name for them.

and

“… research shows that medications like Ritalin and Adderall may be beneficial to help them increase reaction time [presumably should read decrease], reduce accidents, and ultimately save lives.

Interestingly, Healthline.com runs a good many ads for ADHD “medications.”  They are clearly marked Advertisement, but the font is very small.

and

“So, should truckers be screened for ADHD instead of self-medicating with harder drugs?”

There is an implication here that ADHD “meds” will reduce the incidence of truckers driving under the influence of speed.  In fact, Ritalin and most other ADHD “meds” are stimulants and are widely abused.  RitalinAbuseHelp.com states that

“Ritalin is taken by recreational drug users for its cocaine-like high.”

and

“Ritalin is taken by workers such as truck drivers to stay awake for long shifts.” [Emphasis added]

Here are some more interesting quotes:

From the American Academy of Pediatrics 2011 practice guidelines on ADHD:

“Given the inherent risks of driving by adolescents with ADHD, special concern should be taken to provide medication coverage for symptom control while driving.  Longer-acting or late-afternoon, short-acting medications might be helpful in this regard.”

And from the American Academy of Child and Adolescent Psychiatry: ADHD Practice Parameters:

“Single daily dosing is associated with greater compliance for all types of medication, and long-acting MPH [methylphenidate] may improve driving performance in adolescents relative to short-acting MPH…”

And from psychologist Russell A. Barkley, PhD, Clinical Professor of Psychiatry and Pediatrics at the Medical University of South Carolina in Charleston, and author of numerous books and studies on ADHD, quoted in this New York Times article from 2012:

“Medication [for drivers who have ADHD] should not really be optional…”

And Dr. Barkley is an eminent man.  I know this because on his website it says that he is “…an internationally recognized authority on attention deficit hyperactivity disorder (ADHD or ADD) in children and adults…”  I also know that he is conscientious and caring.  His website states that he “…has dedicated his career to widely disseminating science-based information about ADHD.”  If proof is needed of his dedication to disseminating information, one need only open the “books” tab on his website.  He has 16 different titles for sale at prices ranging from $14.41 for some paperback book versions to $131.75 for his rating scale books.  One can also subscribe to his newsletter ADHD Report for $105 per year.

Dr. Barkley is well regarded by the pharmaceutical industry.  Dollars for Docs reports that between 2009 and 2012, he received $120,283 from Eli Lilly alone, for consulting, speaking and traveling.  In February of this year he conducted a five-day, multi-city lecture tour of Japan sponsored by Eli Lilly.  And according to  his CV, in 2004-2005, he was awarded a grant of $99,750 from Eli Lilly to study the “Effects of atomoxetine on driving performance in adults with ADHD.”

Dr. Barkley has also reportedly served as a consultant/speaker to Shire, Medice, Novartis, Janssen-Ortho, and Janssen-Cilag.

Dr. Barkley played a significant role in the relaxing of the age-of-onset criterion from 7 to 12 in DSM-5.  As early as 1997, he and the equally eminent Joseph Biederman, MD co-authored Toward a Broader Definition of the Age-of-Onset Criterion for Attention-Deficit Hyperactivity Disorder (Journal of the American Academy of Child and Adolescent Psychiatry, September 1997).  In this article they state, apparently without the slightest hint of irony:

“We can see no positive benefits of the recommended AOC [age of onset criterion] except that it would certainly limit the number of children (and probably adults) with diagnosed ADHD.  Some special education districts or managed health care companies who might wish to restrict the access of those with ADHD to their services could conceivably see such a restriction as advantageous, but this is purely financial self-interest.”

So, all things considered, when Dr. Barkley tells a New York Times reporter that medication for drivers with ADHD “should not really be optional,” perhaps we should be concerned.

Over the past 60 years, pharma-psychiatry has demonstrated, time and again, that there is no human problem that they can’t exploit for their own benefit and, in the process, make ten times worse.  I will be watching this latest foray into road safety with trepidation.

Psychiatry Fights Back – With More PR

About six months ago, I wrote a post called Health Care Reform and Psychiatry.  In that article, I gave a brief account of the APA’s Council on Communications, and I expressed the belief that the council seemed more concerned with PR (in the most tawdry sense of the term) than with any serious examination or reform of psychiatric practices.

Lately, I was browsing the APA blog Healthy Minds, Healthy Lives, and it seemed that a good deal of what I was reading seemed to have a fairly heavy PR component.  So I opened the Council on Communications tab and found that their lead page is pretty much as it was six months ago.

“The council is charged with transforming public attitudes towards psychiatry by:

  • Connecting the public emotionally to psychiatrists, ·
  • Creating excitement about psychiatrists’ ability to prevent and treat mental illness, and ·
  • Branding psychiatrists as the mental health and physician specialists with the most knowledge, training, and experience in the field.” 

Of course, public attitudes towards psychiatry are at a low ebb.  The survivor movement continues to grow, both in numbers and in outspokenness.  Psychiatry’s concepts and practices are being critiqued with increasing frequency on the Internet and in the mainstream media.  And even some psychiatrists are starting to speak out.  It’s understandable that the APA is concerned about public attitudes towards psychiatry.

But they’re not going to address this problem by mending their ways.  No.  That would require a degree of critical self-scrutiny that is entirely foreign to organized psychiatry.

They’re not going to improve their image by cleaning up their act.  Instead, they’re going to: connect the public emotionally to psychiatrists; create excitement about their skills and abilities; and brand themselves as the great healing experts that they aren’t.

I’ve commented on this drivel before, and I was truly surprised to find that it’s still prominently displayed on their site.  Is there nobody in the APA leadership who can see this inane, insultingly condescending nonsense for what it is?

What does “connecting the public emotionally to psychiatrists” even mean?  As my readers well know, I’m a concrete sort of a guy.  I think in pictures and little stories.

Sometimes on Thursday morning, I go over to McDonalds for a cup of coffee, which incidentally, in deference to my advanced years, they give me for 50 cents.  There’s always a bunch of other old geezers in there, and we talk about the weather, and our bladders, and the price of footwear, and so on.  It’s all very congenial.  So what I’m imagining is something like this.

Me:  “Guys, I’m getting very emotional about psychiatrists.”
Other geezer:   “You are?  I thought that was just me.”
Third geezer:  “Yeah, me too.  Every time I see Dr. Lieberman on the TV, a lump comes to my throat.”
Me:  “Whenever I read his articles in Psychiatric News, I want to cry.  In fact, sometimes I just bawl my eyes out.”
Other geezer:  “I thought I was the only one.”
Third geezer:  “No, we’re all connected emotionally to psychiatry.  It’s like one big happy family.”

And “creating excitement” about psychiatrists’ abilities conjured up this little scenario:

Me:  “What did you think of that final touchdown on Sunday?”
Second geezer:  “Never mind touchdowns.  Did you see Dr. Drugs-Galore sign that prescription?  The flourish!  The light glinting off his pen!  They must have done ten replays on EPsyN.  He’s got to be the greatest.”
Third geezer:  “Did you see that Dr. Fastlabel just broke the record for the number of diagnoses made in one day?”
Me:  “No. How many did he do?”
Third geezer:  “Eighteen!
Second geezer:  “Wow.  That is so exciting.” 

And don’t even get me going about psychiatrists “branding” themselves!

But seriously – what they’re actually saying here is:  We, the great and mighty psychiatrists, are going to manipulate the thoughts and attitudes of the little people (the public).  We are going to play upon their brains like the practiced magicians that we are, and transform their sadly mistaken misperceptions and evaluations of psychiatry into profound feelings of excitement and admiration.

And apparently nobody at the APA can see how insulting and patronizing this is.  Psychiatry is a great disrespecter of people.

Anyway, that’s the way they are.  But I thought I’d take a look at their blog and see how they were getting along with the task of transforming our attitudes.

The first post I found was How Psychotherapy Changes the Brain, by Serina Deen, MD.  (Thanks to Steve Hawkins on Facebook for the link.)  Dr. Deen is an Assistant Clinical Professor of Psychiatry at the University of San Francisco.  Her blog bio lists mindfulness, psychotherapy, and medical education as her interests.  She is a member of the APA’s Council on Communications, so presumably she’s committed to the council’s mission of getting us all excited about psychiatry.

Her post begins:

“When I first see patients for evaluation, they often tell me that they’ve debated starting a ‘biological’ treatment such as medication, versus a ‘psychological’ treatment such as psychotherapy. I’m happy to report that as brain imaging technology advances, we’re finding that this distinction may be obsolete.”

By any standards, this seems like an extraordinary claim:  the distinction between talk therapy and drugs is becoming obsolete?  How can this be?

“Psychotherapy is also ‘biological’ in that it can lead to real functional and structural changes in the brain.   In fact, sometimes psychotherapy and medication produce surprisingly similar changes in the brain.”

Dr. Deen provides no references in support of this position, but she does mention that researchers at UCLA

“…found that people who suffered from depression had abnormally high activity in an area of the brain called the prefrontal cortex.  Those who got better after they were treated with a type of therapy called interpersonal therapy (IPT) showed a decrease in activity in the prefrontal cortex after treatment.  In other words, IPT seemed to ‘normalize’ brain activity in this hyperactive region.”

The fact is that anything a person does, including talking to a therapist, produces changes in the brain.  It is also the case that the brain regulates our thoughts, feelings, and behavior.  So the brain activity of a person who is feeling contented and happy will, other things being equal, be different, in some characteristic ways, from the brain of a person who is feeling down.  These differences will be detectable in scans, provided the equipment is sufficiently sensitive.

Similarly, if a depressed person starts to feel better, whether through talking about his concerns in a supportive, non-judgmental context or by ingesting drugs, the brain activity will become more like “happy” brain activity.  This is not Earth-shattering.  In fact, it’s obvious.  The characteristic brain activity that elicits hunger pangs is reduced by eating food or by the introduction of appetite suppressant drugs.  But administration of the drug is not the same thing as eating.

Similarly, the alleviation of depression through personal interactions, problem-solving, empowerment, etc., is fundamentally different from taking a happy pill.  In addition, talking through one’s difficulties with a supportive and competent listener does not produce the kind of adverse events commonly associated with anti-depressants.

Dr. Deen’s article is spin.  The message is:  psychotherapy and drugs are basically the same thing.  She even has three insultingly simplistic drawings of brains embedded in the post, presumably to lend credence to her thesis.  Superficially the article gives the impression of balance.

“Even though we know that both medication and psychotherapy can change our brain, we still have a long way to go in learning exactly how that happens and when to use what treatment.”

But note the subtlety:  “…both medication and psychotherapy can change our brain…”.  People don’t go to a therapist to have their brains changed.  They go to a therapist to talk person to person about matters that are troubling them or causing them distress.  By couching the matter in terms of brains, Dr. Deen, while giving the appearance of impartiality, is in fact loading the dice in favor of drugs – which, after all, are promoted (spuriously) as cures for neurochemical imbalances, neural circuitry anomalies, etc…

I suggest that Dr. Deen was wearing her Council on Communications hat when she wrote this article.  Stressing the effect that psychotherapy has on the brain is actually a neatly-disguised ploy to undermine psychotherapy, and to “rebrand” psychiatry’s long-standing infatuation with chemical “solutions” for life’s problems.

I did some searching on the ‘net and I believe I have found the study to which Dr. Deen is referring.  It’s titled Regional brain metabolic changes in patients with major depression treated with either paroxetine or interpersonal therapy: preliminary findings, by Brody A.L. et al (2001).  The authors were markedly more cautious in their conclusions than Dr. Deen:

“These results should be interpreted with caution because of study limitations (small sample size, lack of random assignment to treatment groups, and differential treatment response between treatment subgroups).”

I think it’s also noteworthy that although the Brody et al study was published 13 years ago (2001), there has, as far as I can ascertain, been no large-scale replication.  I did, however, find an interesting meta-analysis by D.E.J. Linden – How psychotherapy changes the brain – the contribution of functional neuroimaging (2006).  Dr. Linden reviewed the research on this subject with regards to OCD, phobias, and depression.  He reviewed three studies in the depression section.  These were Brody et al (2001), which I’ve already mentioned; Martin et al (2001); and Goldapple et al (2004).  Dr. Linden’s conclusions with regards to depression were:

“Findings in depression, where both decreases and increases in prefrontal metabolism after treatment and considerable differences between pharmacological and psychological interventions were reported, seem still too heterogeneous to allow for an integrative account, but point to important differences between the mechanisms through which these interventions attain their clinical effects.”

But spin and PR pay no allegiance to logic or to facts.