Tag Archives: drug

Psychiatrists Are Drug-pushers

There’s an interesting article on the New York Times website: Talk Doesn’t Pay, So Psychiatry Turns Instead to Drug Therapy (March 5, 2011).

The essence of the article is that psychiatrists no longer engage in talk therapy to any great extent, but instead prescribe behavior-altering drugs.

What’s interesting about this is that the author, Gardiner Harris, seems almost surprised at this “discovery.”  In fact, the change from talk to pills occurred decades ago – during the 70’s I would say, and was more or less complete by 1980.

There are some interesting passages in the article, which focuses on the work of a Pennsylvania psychiatrist, Donald Levin.

Then, like many psychiatrists, he treated 50 to 60 patients in once- or twice-weekly talk-therapy sessions of 45 minutes each. Now, like many of his peers, he treats 1,200 people in mostly 15-minute visits for prescription adjustments that are sometimes months apart. Then, he knew his patients’ inner lives better than he knew his wife’s; now, he often cannot remember their names. Then, his goal was to help his patients become happy and fulfilled; now, it is just to keep them functional.

“I’m good at it,” Dr. Levin went on, “but there’s not a lot to master in medications.”

A psychiatrist can earn $150 for three 15-minute medication visits compared with $90 for a 45-minute talk therapy session.

In 2009, the median annual compensation for psychiatrists was about $191,000, according to surveys by a medical trade group.

“You have to have a diagnosis to get paid,” he said with a shrug. “I play the game.”

“I don’t need a half-hour or an hour to talk,” said a stone mason who has panic attacks and depression and is prescribed an antidepressant. “Just give me some medication, and that’s it. I’m O.K.”

“The sad thing is that I’m very important to them, but I barely know them,” he said. “I feel shame about that, but that’s probably because I was trained in a different era.”

So, as I have said on this blog many times, psychiatry today is drug-pushing.  Psychiatrists sell prescription slips for about $50 each.  The drugs involved are not medication – they are drugs, the function of which is to alter people’s behavior and mood.  There have been some interesting responses to the Gardiner Harris article.

Daniel Carlat, psychiatrist, author of the blog post Dr. Levin, Modern Psychiatrist – Unfulfilled, Bored – But Wealthy comments that since the introduction of the drugs “psychiatrists no longer needed to do therapy to make good money.”

He also notes that:

“Many psychiatrists will recognize the sense of tedium and boredom described by Dr. Levin. He went through psychiatric training to do therapy and is now a pill-pusher.”

If you’ve read Daniel Carlat’s book Unhinged I think you will find him refreshingly honest, although he clings (almost desperately) to the notion that psychiatry is a helping profession and that the drugs are administered to treat illness.  If he ever gets truly honest, however, he will have to find honest work – and that’s daunting.

Another comment, from Christopher Lane, author of the blog post I’m Not Your Therapist, But I Could Adjust Your Medications:

The power of the article lies less in stating what’s already well-known about American psychiatry—that it favors drug treatments over talk therapy, despite growing evidence that the latter strongly outweighs the former in terms of efficacy and freedom from side effects. The article’s power lies instead in tracking the myriad decisions that Drs. Levin and Lance make on an ordinary day full of appointments with dozens of suffering Americans.

And so it goes.  It’s good that the article was written and that it has received a great deal of attention. The widespread medicalization of human problems for profit is a destructive rot within our society, and anything that draws attention to the drug-pushing nature of psychiatry is helpful.  Depression, anxiety, anger, misbehavior, crazy speech – these are not illnesses.  They are human problems.  They can be masked by drugs.  But as any recovered addict can tell you – drugs are not the answer to life’s difficulties.


Drugs and Alcohol (Part 3)

This post was edited and updated on June 29 2014, to include additional thoughts.

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A Rational Policy on Drugs and Alcohol

In my last post I argued against government prohibitions against drugs and alcohol.  My position is that substances such as cocaine, heroin, methamphetamines, etc., should be legal in the same way that alcohol and tobacco are today.  I believe, however, that the distribution and marketing of these substances should be brought under direct government control.  All of the commonly abused addictive substances are dangerous, and they have taken – and continue to take – an enormous toll on society.  This cost includes lives, health, lost opportunities, money and general suffering and anguish.  But it’s difficult to put old heads on young shoulders, and it seems that each generation – indeed each individual – has to learn these lessons anew.  I don’t believe we can ever eradicate substance abuse entirely.

What seems especially wrong to me, however, is that we allow individuals and groups to prosper and thrive by actively marketing these products – an endeavor in which they have been extraordinarily successful. So we have various government agencies trying to reduce the incidence of alcohol and nicotine abuse while huge corporations are working towards the opposite end.  I realize, of course, that most of the major alcohol producers say that they abhor alcohol abuse, and that they only encourage “responsible” drinking.  These kinds of statements, however, always remind me of Hitler insisting that he had no expansionist agenda.  The fact is that alcohol and tobacco manufacturers spend millions (billions?) of dollars promoting their products and linking their products with sexiness and success in the minds of potential consumers.  To my way of thinking, this is simply wrong.

Here’s the system I would like to see in place.  The manufacturers of these substances could continue to operate, but could sell their products only to the government.  The government (federal, state, or county) would wholesale the products and would also have a retail outlet in each county.  In heavily populated areas, there could be more than one per county.  These outlets would be similar to the state-run stores in Virginia, Pennsylvania, and Vermont, except that they wouldn’t just sell liquor.  They would sell all alcohol and tobacco products as well as heroin, cocaine, methamphetamines, etc…  All the addictive drugs would be available for adults to purchase through the government outlet, but nowhere else.  Customers would be required to show an ID, and each purchase would be registered in a database.  Customers whose consumption seemed excessive would be required to talk briefly to a counselor.  The counselor would encourage them to think about their consumption of addictive substances – but if they wanted to pursue the purchase, they would not be prevented from doing so.  People who came to the store in a state of intoxication would be taken involuntarily to a detox center where they would be detained until it was safe to let them go; i.e. that it was medically safe to discharge them.

All profits generated from the sale of addictive substances would be used to fuel preventive efforts and to support the detox centers.  Prices of products would be set as high as practicable, but not so high as to encourage bootlegging and black markets.

Of course there are many who will decry the notion of government interference in the free market.  But under the free market system, we have 450,000 tobacco-related deaths, and 85,000 alcohol-related deaths, and 17,000 illegal drug-related deaths each year in the United States.

Others will say that the government couldn’t run such an operation successfully.  But the stores in Pennsylvania have operated successfully since 1933.  Anyway, there it is:  my humble suggestion for a more rational way for our society to deal with these dangerous substances, which we, as a species, seem to find so attractive.

Next Post:  More exciting stuff.

Drugs and Alcohol (Part 2)

In my previous post on this subject, I discussed addiction to alcohol and other drugs.  I made the point that addiction to these substances is not an illness, but rather an extremely strong habit.

Treatment Programs

The notion that alcoholism is a disease gained popularity in the 50’s and 60’s.  At about the same time, employers were beginning the practice of offering medical insurance to their staff, and insurance companies routinely included 30 days of treatment per year for alcoholism and/or drug addiction.  At the time, there were very few treatment units for these problems, and little use was made of the drug and alcohol provisions in the insurance policies.

America, however, is nothing if not entrepreneurial, and soon private treatment units began to appear, fuelled by insurance dollars.  At the same time, a quasi-religious group named Alcoholics Anonymous was thriving, and the commercial treatment units forged a symbiotic alliance with this organization.  The treatment units hired senior members of AA as counselors, and “patients” were required to attend AA meetings as part of their treatment.  In fact, for most of the units, treatment consisted of induction into the AA fellowship.  Group therapy, individual therapy, lectures, films, etc., were all aimed towards encouraging and fostering membership of AA (and, of course, Narcotics Anonymous for people addicted to other drugs).  Because alcoholism and drug addiction were conceptualized as illnesses, these programs were technically under the direction of a physician director, but his/her role seldom extended beyond the physical issues of detox, alcohol-induced tissue damage, etc…  The actual running of the unit was in the hands of a counselor director (usually a recovered alcoholic and a member of AA).

By the late 80’s, chemical dependency treatment had become one of the fastest-growing (possibly the fastest-growing) industries in the United States.  Around 1990, however, the insurance companies decided to pull the plug. And just as the treatment unit boom had been fuelled by insurance dollars, so its demise occurred when these dollars stopped flowing.  I was involved in the chemical dependency treatment arena when these changes were occurring, and there was undoubtedly a good deal of hardship on the individuals who lost their employment.  But in hindsight, I find myself on the side of the insurance companies.  Their position was (and still is, I presume) that alcohol and drug addiction are not in themselves medical problems.  So they would pay for detoxification, where this was medically necessary, but not for the 30 days of group therapy and induction into AA.  Sometimes they would pay for these kinds of psycho-social interventions in an outpatient setting – but the days of the 30-day-residential (inpatient) programs were over.

There are still a small number of units serving individuals who can foot the bill from their own resources.  And of course, there is still a publicly funded system.  Most (perhaps all) states provide an involuntary commitment procedure for alcohol and drug addicts who have become dangerous to themselves or others.  These individuals are committed to treatment units, sometime at the state hospital, sometimes free-standing.  These programs are usually operated on the same general lines as the private units mentioned earlier, and are often described as “revolving doors”.  This is because the “clients” routinely return – sometimes two and three times a year -for further “treatment”.

War on Drugs

The war on drugs has been around since the 60’s, but gained enormous momentum in the early 80’s under the Reagan administration.  This so-called war which the United States government (along with the governments of many other nations) is waging against its own citizens, has to date cost the tax payer an estimated one trillion dollars (thirty-nine billion dollars so far this year).   In addition, it has criminalized literally thousand (millions?) of ordinary people, has filled our prisons to overcrowding and beyond, has fuelled the biggest prison-building program in our nation’s history, has destroyed quality of life in many of our urban areas, and has turned the Mexico-US border area into a war zone.

And all for what?  All for the US government’s claim that it has the right to tell people what they may and may not ingest.

First, let me clarify my position.  The only drug I have ever used is alcohol.  I have had a great deal of illness in recent years, and have occasionally received morphine and dilaudid for pain during inpatient stays at hospitals.  I do not advocate the use of drugs for recreation, self-medication, or coping with life’s difficulties.  Alcohol, nicotine, cocaine, heroin, etc., are all drugs, and they are all bad for you.  And the more you ingest, the worse it gets.  And some of the damage is permanent.

However, it is also my position that governments have not the right to tell people what they may or may not put into their bodies.  In a democratic republic, political power ultimately resides in the people.  And we surrender some of this power to an elected government in the interests of mutual safety, organization of services, etc.. But the notion that the government has the right to determine what an individual may or may not ingest is a throwback to a monarchical type of tyranny that should have no place in a country such as the United States.  And as the War on Drugs has clearly demonstrated, they aren’t able to enforce their prohibitions.

So my position is legalize everything.  But I would have certain safeguards and protections in place, which I will outline in my next post.  Stay tuned.

Next Post:  Drugs and Alcohol (Part 3)

Drugs and Alcohol (Part 1)

The APA’s DSM lists two broad categories of diagnoses in this area: dependence and abuse. So we have alcohol dependence and alcohol abuse; amphetamines dependence and amphetamines abuse; cocaine dependence and cocaine abuse. And so on.

Dependence is defined by the presence of three or more of the following criteria:

  1. tolerance, as defined by either of the following:
    1. a need for markedly increased amounts of the substance to achieve intoxication or desired effect
    2. markedly diminished effect with continued use of the same amount of the substance
  2. withdrawal, as manifested by either of the following:
    1. the characteristic withdrawal syndrome for the substance …
    2. the same (or a closely related) substance is taken to relieve or avoid withdrawal symptoms
  3. the substance is often taken in larger amounts or over a longer period than was
  4. there is a persistent desire or unsuccessful efforts to cut down or control substance use
  5. a great deal of time is spent in activities necessary to obtain the substance… use the
    substance … or recovery from its effects
  6. important social, occupational, or recreational activities are given up or reduced
    because of substance use
  7. the substance use is continued despite knowledge of having a persistent or recurrent
    physical or psychological problem that is likely to have been caused or exacerbated by
    the substance …

Abuse is defined as one or more of the following:

  1. recurrent substance use resulting in a failure to fulfill major role obligations at work,
    school, or home …
  2. recurrent substance use in situations in which it is physically hazardous …
  3. recurrent substance-related legal problems …
  4. continued substance use despite having persistent or recurrent social or interpersonal
    problems caused or exacerbated by the effect of the substance …

Let’s consider alcohol dependence, which to all intents and purposes is what most people would refer to as alcoholism. A person who drinks, say, half a bottle of whisky every day, who never appears particularly drunk, who becomes extremely sick if he stops drinking, who has made numerous unsuccessful efforts to quit, who has incurred some liver damage, and whose social life has been severely curtailed because of drinking, would normally be called an alcoholic. Some people prefer the term addicted and would describe him as addicted to alcohol. DSM would say that he has a mental disorder called alcohol dependence. The problem with all three terminologies is that they encourage us to blur the distinction between a description and an explanation. This distinction is the central theme of this blog.

The term “alcoholic” for instance, looks like an explanation, is constantly presented as an explanation, and is widely accepted as an explanation, but in fact it is purely descriptive. In the example cited above, imagine the man’s wife confiding in a friend about the problem. She ends by asking: “Why won’t he stop – why can’t he see that he’s killing himself?” And the friend replies: “Because he’s an alcoholic.” But “alcoholic” means a person who continues drinking large quantities of alcohol despite adverse consequences. So all that the friend has said is that the husband is drinking large quantities of alcohol despite adverse consequences because he is drinking large quantities of alcohol despite adverse consequences. Nothing has been added in the way of an explanation. And yet the words themselves often have a measure of comfort for the listener.

Let’s consider another example – a battered woman. She asks a friend: “Why does he beat me all the time? Why is he so mean to me?” The friend replies: “Because he is a jerk!”

Here again, it looks like an explanation. It looks and feels as if the “why” question was adequately answered. But when we remember that a “jerk” is someone who routinely hurts people, we see that the substance of the reply is: he hurts you because he hurts you.

This practice – of presenting descriptions and labels as if they were explanations and their being accepted as such – is deeply embedded in our language and in our communications generally.

Staying with the battered woman – imagine another friend commenting on the situation, saying: “Why does she keep going back to him when he mistreats her so?” And receiving the reply: “Because she is co-dependent.” Here again, it looks as if the “why” question has been answered. But co-dependent means being excessively dependent on the approval of others. So the reply essentially means: she goes back to him because she goes back to him. Co-dependency is simply a label for this kind of self-destructive, overly dependent behavior. Putting a name on a problem can be emotionally soothing, and is perfectly acceptable in ordinary interactive speech. But what the APA has done is take this naming process and presented it as if it were a scientifically validated explanatory system, which DSM most emphatically is NOT.

In addition, it needs to be pointed out that even as a labeling system, the DSM falls short. A person who meets criteria 1, 3 and 5, for instance, receives the same “diagnosis” as a person who meets criteria 2, 4 and 6, even though their history, presentation, and general circumstances may be entirely different.

As with the other human problems addressed in these posts, genuine explanations of alcoholism and drug addiction require a detailed knowledge of the history and circumstances of the individual, coupled with an understanding of the principles underlying behavior acquisition. The general principles are as follows:

1. Alcohol and other drugs of abuse (nicotine, cocaine, heroin, amphetamines, etc.) act on the brains of most individuals in a way that induces a feeling of pleasure.

2. When an activity is followed by a feeling of pleasure, there is an increased probability that the behavior will be repeated. This is the fundamental principle underlying habit formation.

What’s commonly called addiction to alcohol and others drugs is in fact an extremely strong habit. So the question arises: why do some people become addicted (in other words, form this very strong habit), while others do not? In my view, the fundamental issue here is critical self-scrutiny. It is important that as children, we acquire the habit of critical self-scrutiny: the habit of reviewing our actions and deciding from day to day what needs to be changed. One of the realities of life is that if you start drinking large quantities of alcohol, you will begin (quite soon) to incur negative consequences. Hangovers, wasted time, wasted money, painful indiscretions, broken relationships, and lost opportunities are the routine lot of the heavy drinker. Now most people, when faced with this reality, eventually look at themselves in the mirror and say something to the effect: “This is just ridiculous. I have to make some changes.” And they do. The person who has not developed the habit of critical self-appraisal, however, can always find another way of looking at things. A dishonest way – a way that somehow lets him off the hook for the excessive drinking. Examples of this kind of distorted thinking are:

You’d drink too if you had a wife like mine, …troubles like mine, … a job like mine, … children like mine, etc..

I don’t drink as much as _________.

Winston Churchill drank a fifth of whisky a day – it didn’t do him any harm.

These other people are just uptight. They don’t know how to have fun.

I’d be ok if people would stop nagging me.

Etc., etc., etc.

The fact is, there is only one appropriate response to heavy drinking, and it goes something like this:

I’m drinking too much. It’s causing problems in my life. It’s common knowledge that these problems just get worse as long as the drinking continues. I need to cut down drastically or stop altogether.

But the further question arises: Why do some people make this kind of critical self-appraisal and follow through – while others don’t? And this is where we get down to individual cases. How do children acquire the habit of critical self-appraisal? Why is it that some children acquire this habit, while others don’t?

Next post:

Alcohol and other drugs (cont)
Treatment programs
War on drugs