Tag Archives: Psychiatric “spin”

The APA’s New Image

On April 25, 2014, Jeffrey Lieberman, MD, then President of the APA, announced that the association had engaged the services of Porter Novelli, a prestigious PR company based in Washington DC and currently operating in 60 different countries.

“Mindful of the continuing stigma associated with mental illness and psychiatric treatment, we retained an outside consultant agency (Porter Novelli) to review APA’s communications capabilities, needs, and opportunities. Based on its report, we are now moving forward with an initiative to enact a sophisticated and proactive communications plan that will be directed both internally to APA members and externally to the media, mental health stakeholder groups, and the general public.”

I expressed the belief at the time that it would take a lot more than some PR embellishments to remediate the fundamental flaws in American psychiatry’s concepts and practices.  Here is what I wrote:

“And that is what it’s all about.  Psychiatry remains blind to the fact that it is its own spurious pathologizing of its clients that creates the stigma.  It has no interest in genuine reform, but instead is embarked on a tawdry PR campaign to whitewash its transgressions and sell its concepts to the media, stakeholders, and the general public.  Dr. Lieberman even acknowledges the APA’s need to sell this bill of goods to its own members!

And apparently nobody at APA headquarters can see how inherently insulting this is.  Nobody can see that treating people as marks, whose thoughts and beliefs are to be manipulated by a professional PR company, is no way to treat people.  But psychiatry has been treating human beings as non-people for decades.”

In the intervening year and a half, I’ve been watching the APA closely for any indications of fundamental change; any hint of critical self-appraisal; any suggestion of genuine reform or remediation.

But I’ve seen nothing of this sort.  It’s still the same old APA, with its same old spurious diagnoses, and the same old assurances that their “treatments” are efficacious and safe, and that the great neurological insights are just around the corner.

For instance, Paul Summergrad’s final address as president, at this year’s annual meeting, contained the following:

“[W]e are in the midst of a profound transformation of our understanding of neuroscience, genetics, and epigenetics,” Summergrad said. “That we have not yet achieved interventions based on these insights or diagnostic tests is not because we will not achieve them, but because of the complexity of what we are studying.”

Psychiatrists are  “…in the midst of a profound transformation…”

But I’ve seen not one shred of substantive reform:  no formal repudiation of the chemical imbalance hoax; no apologies for perpetrating this hoax; and no reduction in the enthusiasm for medicalization, high voltage electric shocks to the brain, and drugs.  In short, there’s been nothing to suggest that the APA has subjected itself, or its concepts, to any kind of serious scrutiny.

But I’ve recently discovered, I was looking for the wrong things.

I went to Porter Novelli’s website, and found an interesting document.  I’m not sure what to call it, but it’s a “look-at-the-great-things-we’ve-done-for-the-APA” kind of document.  It’s in a section called “Jack’s Garage”, which is described as “Porter Novelli’s global creative group”.  Apparently, if a company or association goes to Porter Novelli and asks for help with their image, Porter Novelli sends them to Jack’s Garage.  Why it’s called Jack’s Garage, I can’t begin to imagine.  Perhaps to convey the impression that they fix things?

Then, there’s a document titled:  American Psychiatric Association: Rebranding to move the field forward.  Rebranding, according to Oxford Dictionaries online, means:  to “change the corporate image of (a company or organization)”.   In this document, there’s a sub-heading called “The Ask”, which I gather means what the client organization asked Jack’s Garage to do:

“The national association for psychiatrists was seen as the knowledgeable literary leader, a resource for published research and advances in the field, but the membership wanted a true leader that could advance the field, which still suffers from old stigmas and lack of understanding of the true science behind psychiatry.”

So apparently, the APA told Jack or someone in his garage, that they (the APA) were seen as “…the knowledgeable literary leader, a resource for published research and advances in the field…”, but that the members wanted them to be “…a true leader that could advance the field…”

This isn’t entirely clear, but the gist seems to be that the APA wanted to change their image from a kind of back-room research repository to one of active leadership.

And the problems facing psychiatry are identified as:

  • old stigmas
  • lack of understanding of the true science behind psychiatry

This has been standard fare from psychiatry for the past twenty years or so, not only here in the US, but also in Europe.  (See the February 27, 2015 European Psychiatric Association’s EPA guidance on how to improve the image of psychiatry and of the psychiatrist).

In fact, the problems facing psychiatry are that they have irreversibly committed themselves to the patently spurious notion that all significant problems of thinking, feeling, and/or behaving are illnesses, and that these “illnesses” need to be “diagnosed” by experts (specifically, themselves), and are best “treated” by neurotoxic drugs and high-voltage electric shocks to the brain.  It is because of this that psychiatry is the only medical specialty that has an anti group.  And it is because of this, and its consequent destructiveness and disempowerment, that psychiatry is widely and accurately perceived in a negative light.

With regards to the “lack of understanding of the true science behind psychiatry”, it needs to be pointed out that there is no true science behind psychiatry.  What’s behind psychiatry is a massive pharma-funded hoax masquerading as science, and leaving in its wake a shameful trail of human destruction and disempowerment.

But that is a problem way beyond the reach of any PR firm, even one as prestigious as Porter Novelli.

Nevertheless, the APA went to PR and told them that they needed to change their image, and here’s Porter Novelli’s synopsis of their response:

“The Answer

Repositioning American Psychiatric Association from wise sage to caring ruler, we changed everything from messaging to their logo to support the new brand persona. APA also suffered from poor brand awareness, with many divisions within the organization using their own branding that did not ladder up to a central visual or verbal tone. We worked with the organization and each division to identify the best architecture that would strengthen the central brand while still allowing for flexibility within a successful framework.”

So, Porter Novelli “repositioned” the APA from “wise sage” (I kid you not), to “caring ruler”.  And to accomplish this, they changed “everything” from “messaging” to their logo.  I assume that messaging means communicating one’s message.  Psychiatry’s message is that all significant problems of thinking, feeling, and/or behaving are brain illnesses that need to be “treated” with high voltage electric shocks to the brain or with neurotoxic drugs.  Presumably Porter Novelli has improved the APA’s delivery of this message.  This is interesting, because I certainly haven’t noticed any changes in the way American psychiatry delivers this message.  It’s still the same tired old unsubstantiated assertions, trotted out at every opportunity, coupled with systematic dismissal and marginalization of anyone who challenges these assumptions.  And, of course, the need for “early intervention”, and endless lamenting of the “fact” that vast numbers of “mentally ill” people are not receiving “treatment”!

Anyway, according to Porter Novelli, the APA suffered from “poor brand awareness”.  I’m not sure what this means, but as best as I can figure from the document in hand, it refers to the APA’s use of their logo, or, more correctly, logos, plural.  You see, prior to Porter Novelli’s intervention, the APA had six different logos.  Yes, six!

They had:

  • the familiar bust of Benjamin Rush, the founder of American psychiatry;
  • a stylized rod of Asclepius flanked by the words American Psychiatric Association and underpinned with the slogan “Healthy Minds, Healthy Lives”;
  • a rather nondescript logo for their foundation (APF);
  • a logo for their publishing group;
  • a red, white, and blue logo for their Political Action Committee;
  • and a logo for their annual meetings.

And all of this chaos and confusion is now gone – swept away by the tireless mechanics at Jack’s Garage.  Now the APA has only one logo:  a stylized rod of Asclepius in white, superimposed on (guess what?) a blue brain viewed from above.  The words American Psychiatric Association appear to the left of the brain.  The various divisions of the association use the brain logo with the appropriate wording (Foundation; Publishing; PAC; Annual Meeting) underneath.

But one picture is worth a thousand words.  If you go here, and click through the images, you can find a pictorial summary of how Porter Novelli transformed the APA’s “confusion” into “strength”.

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So, as often happens to me when I’m writing about psychiatry, I don’t know whether to laugh or cry.  It is clear from Dr. Lieberman’s remarks, quoted earlier, that the decision to engage the services of Porter Novelli was based on the fact that psychiatry is widely perceived in negative terms.  It is also the case – though I don’t think Dr. Lieberman would ever concede this – that the negative perceptions are accurate and justly deserved.

The notion that one can even begin to address these issues by tinkering around with the association’s logo, borders on the bizarre.  But perhaps it’s not all that surprising.  After all, psychiatry is the profession that purports to ameliorate the most profound feelings of despondency, fear, anger, loneliness, and unfulfillment by tinkering with people’s brains!

But maybe I’m being too shallow.  Perhaps there’s some profound but arcane message in the logo:  “We’ll clean the snakes out of your brain!”  Or “Snake oil for the brain.”  Or maybe it’s meant to be a plumber’s snake:  “We’ll clean the s… out of your brain!”  Or perhaps the reference is to venom:  “We can poison your brain!”  Or snake-charming:  “We can charm your brain snakes.”

And to guard against any misunderstanding, this article is not a criticism of Porter Novelli, who presumably delivered what was asked of them.  This is a criticism of organized American psychiatry, who apparently struggle under the illusion that a hundred years of systematic deception, fraudulent research, and destructive, disempowering “treatments” can be washed away by a blue picture of a brain.  This is a criticism of the APA, who apparently imagine that their brain chemical hoax, thoroughly discredited by competent authorities, can be sneaked subliminally back into play by incorporating a picture of a brain into their logo.

I have no way of knowing what the APA paid Porter Novelli for this work.  But if I were a member of the APA, I would certainly be asking.

Stigmatization of Psychiatry and Psychiatrists

On February 27, 2015, European Psychiatry published a paper titled EPA guidance on how to improve the image of psychiatry and of the psychiatrist.  The paper was authored by D. Bhugra et al.  EPA is the European Psychiatric Association.  Dr. Bhugra is a psychiatrist who works at the Institute of Psychiatry, Psychology, and Neuroscience, King’s College, London, and is also President of the World Psychiatric Association.  There are thirteen co-authors, most of whom are also psychiatrists.

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The paper opens with the statement:

“Psychiatry, psychiatric patients and psychiatrists have always been stigmatised against. Reasons for the stigmatisation are many. Fear, prejudices and discrimination are a result of the lack of knowledge.”

This is the abiding theme of the article:  people don’t like us because they don’t know us.  If people knew what we are really like, our image would improve.  Here are some quotes:

“The image of psychiatry and psychiatrists may be affected by aspects not strictly related to stigma: the past of psychiatry includes dark centuries in which asylums and prepharmacological interventions (physical restraints, coercion, etc.) have been adopted and may still influence the image of the discipline and psychiatrists.”

Translation:  People don’t like us because we used to be scoundrels – that was in the bad old days.  We’re not like that any more.  Back then psychiatrists used physical restraints and coercion.

I thought they still use physical restraints and coercion.

. . . . . . . . . . . . . . . .

“In the majority of worldwide healthcare system, mental health care is separated from physical health care, and inevitably very few medical colleagues understand the role of psychiatry, particularly so if liaison psychiatry departments are weak or non-existent, and if they have not had adequate exposure to psychiatry during their undergraduate or post-graduate training. The fact that physicians did not work routinely in contact with psychiatrists and that the only way of being in contact with psychiatry is during liaison activities or in emergency settings could contribute to the negative image of psychiatry.” [Emphasis added]

Translation:  Other physicians don’t like us because, due to lack of contact, they don’t understand our role.  If they understood our role, they would like us more.

This strikes me as extremely condescending towards other physicians.  They don’t understand the role of psychiatry!

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Under the heading “General Public”:

“Psychotropic medication and ECT are seen as more negative interventions in comparison with psychotherapies and counselling.  The lack of knowledge may be responsible for negative attitudes.”

Translation:  The poor ignorant man (or woman) in the street simply doesn’t realize how helpful psychotropic drugs and high voltage electric shocks to the brain really are.

. . . . . . . . . . . . . . . .

“The media and its portrayal of mental illness and how it is treated play a major role in affecting attitudes towards mental illness. The way in which stories related to mental health are covered and the emphasis placed on making fun of patients with mental illness does lead to negative attitudes. Negative images often get translated into generalised negative attitudes.”

Translation:  People don’t like us because the media make fun of psychiatry’s clients when they write their stories!  And because of this, people don’t like us.

I can’t recall ever reading a story where a journalist made fun of psychiatric clients.

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“Filmmakers’ attitudes reporting large negative portrayal of psychiatry play a major role in informing and forming negative attitudes.”

Translation:  People don’t like us because movies portray us in a bad light.

Here again, this has not been my experience.  Most of the movies I’ve seen which feature psychiatrists portray them as concerned, empathetic listeners, working diligently to help clients disentangle or resolve some life crisis:  a portrayal, incidentally, which is in marked contrast to the reality of the 15-minute, drug-pushing med-check.

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And then there’s this truly extraordinary quote:

“The negative portrayals of psychiatry pandering to stereotypes of the specialty even in novels written by psychiatrists continue to perpetuate the myth of psychiatry as ineffective and psychiatrists themselves as suffering from psychiatric disorders, not taking reality into account.”

It’s a complicated sentence, but let’s see if we can disentangle it:

– psychiatry is negatively portrayed in novels;
– even novels written by psychiatrists;
– these portrayals contribute to the myth of psychiatry as ineffective;
– and to the myth that psychiatrists themselves might have “psychiatric disorders”.

So, here we have a team of European psychiatrists producing a guidance document on how to counter the stigma and negative attitudes that are often directed towards psychiatry and its clients.  And one of the specific points that they make is that portraying psychiatrists as having psychiatric problems is, in itself, a stigmatizing myth!  In other words, the drafters of the guidance document on overcoming stigma are themselves stigmatizing their own clients!  Psychiatrists tell us that psychiatric disorders are illnesses, “just like diabetes”; that they can afflict anybody; that at any given time about a fifth of the population “has” one of these disorders; and that the life-time prevalence is around 50%.  Why should it be stigmatizing for novelists to portray psychiatrists as any less vulnerable to these “disabling illnesses” as anybody else?  There are approximately 46,000 psychiatrists in the US.  According to psychiatry’s own numbers, about 9,200 of these individuals should have a mental illness at any given time, and about 23,000 should have a mental illness at some time in their lives.  In depicting this “reality”, if indeed they do, aren’t novelists merely reflecting psychiatry’s own assertions?  Why is it stigmatizing to portray psychiatrists as having these illnesses?  Unless, of course, Dr. Bhugra and the EPA don’t really believe their own rhetoric.

THE GUIDANCE COMMITTEE’S SUGGESTIONS

Dr. Bhugra et al offer fourteen suggestions for improving psychiatry’s image.  Most are vague or platitudinous.  Here are the main points:

  1. “psychiatrists as professionals must take the lead in taking pride in clinical practice, looking after the most challenging and underserved patients.”

I have long believed that in their hearts, all, or almost all, psychiatrists know that their concepts are spurious, and that their “treatments” are destructive and disempowering.  Dr. Bhugra et al’s admonition to their colleagues to “take pride in clinical practice” strikes me as self-deception.  I can’t imagine a leading surgeon or cardiologist or nephrologist broadcasting such advice to their colleagues.  Real doctors already take pride in their work.  They have no need for cheerleading or pep talks.

  1. “evidence based research should be circulated widely.”

Indeed it should:  Particularly the negative results that pharma-psychiatry routinely suppressed for decades.

  1. “… networks of policy development, clinical intervention and research must be established”

I’m not sure what this means.  Expand the empire?

  1. “… physical and mental health services integration…”

This has been a common theme here in the US for years – a mental health worker in every GP’s office.  The eminent psychiatrist Jeffrey Lieberman, past president of the APA, pushed this notion relentlessly.  And, of course, it’s also being pushed in Europe.  So a person gets sick, goes to see his GP.  He is despondent because he’s sick.  Consequently his depression “screening” is positive, and he comes out with a prescription for an SSRI and a handful of free samples.  Tried and true marketing.

  1. “… exposure to enthusiastic and charismatic teachers in undergraduate settings should be encouraged…”

Enthusiastic and charismatic!  I’m picturing scenarios in which psychiatry lecturers are refused tenure because they are too dull, or that they lack sparkle.  Lecturers should, of course, be able to engage their students, but charisma strikes me as a consideration more pertinent to high school pep rallies than university lectures.

  1. “clinical exposure to right patients and the right number of patients must be delivered.”

I can’t even begin to imagine what Dr. Bhugra and his colleagues mean by the “right patients”.  But whoever these “right” individuals are, trainee psychiatrists need to be exposed to them – clinically.

  1. “Especially tailored placements [for psychiatry students] should be made available across different national and international settings”

So that they can learn what established psychiatrists do in faraway places.  My guess is that it’s assigning “diagnoses” and pushing drugs.

  1. “engagement in short research projects [for psychiatry students]”

So that they can learn how to manipulate the results to show psychiatry in a good light.

  1. “regular audit of clinical services will enable clinicians to understand what changes are needed and how to deliver services. Audits about patient satisfaction and complaints will encourage staff to provide better services”

These kinds of quality assurance audits have been an integral part of general medicine for decades.  But for audits to have any value, they must be accompanied by a generous measure of critical self-appraisal:  a willingness to subject one’s own performance and concepts to critical scrutiny.  This is not a quality for which psychiatry is noted.  Indeed, within psychiatric circles, negative outcomes are routinely blamed on the client, and complaints or protests from clients are routinely adduced as evidence of pathology.  The kind of audits I’ve come across in psychiatry are mostly empty paper exercises.

  1. “regular courses, information leaflets and newer methods such as phone apps and web-based learning may provide relevant information so that patients, families and their carers can work to identify early signs, signs of relapse and management”

And undoubtedly, pharma will continue to provide the funding for these “learning” opportunities.  And note the inclusions of “early signs”.  Bring us your troubled children and we will diagnose them and give them drugs.

  1. “working with patient organisations is an important aspect in spreading education as well as engaging policy makers.”

For instance, educating people that depression is caused by a chemical imbalance in the brain, for which it is necessary to take antidepressants for the rest of one’s life.

  1. “collaboration across different sectors–voluntary and statutory, primary care and secondary care and social and health care…”

Let’s get psychiatry’s tentacles into the voluntary organizations, the GP’s offices, the general hospitals, and social services.

  1. “training the media on reporting and working with them to convey positive messages will help improve the public image.”

So psychiatrists are going to train journalists on how to report, and get them to say nice things about psychiatry.  More patronizing grandiosity.  I don’t think journalists are that gullible.

  1. “Sharing information with policy makers about accurate outcomes and therapeutic interventions…”

Like telling politicians that neuroleptic drugs cause tardive dyskinesia and akathisia?  Or that there is no scientific basis to any of the psychiatric diagnoses, except those “due to a general medical condition”?  Or that research results show that people with a diagnosis of schizophrenia, who come off neuroleptics, have a better long-term outcome than those who stay on the drugs?  Or that neuroleptic drugs are being used for behavior control in foster care, in nursing homes,  and in group homes for people with disabilities?  Or that long-term use of lithium can lead to permanent kidney failure?  Yes!  That’s a great idea!  But somehow I don’t think that’s what the guidance committee had in mind by “accurate outcomes”.

SUMMARY AND DISCUSSION

As is often the case in discussing psychiatry papers, it’s difficult to know where to start.  Perhaps the most obvious feature of the EPA document is the complete and total failure to recognize that the negative appraisals of psychiatry, that are finding voice in the past decade or two, are entirely valid and deserved.  Psychiatry is being perceived negatively, because, as a profession, it is intellectually and morally bankrupt.  Its failings are huge, and its lack of integrity glaring, yet there is no hint of this in the EPA paper.  Instead, the authors cling to the self-serving notion that the stigma attached to psychiatry derives from ignorance of its true nature, and from unwarranted negative media portrayals.

So in the interests of setting the record straight, let me state as clearly and unambiguously as I can why psychiatry is being increasingly criticized and marginalized.

1.  Psychiatry’s definition of a mental disorder/ illness, as set out in DSM III, IV, and 5, embraces virtually every significant problem of thinking, feeling, and/or behaving. Psychiatry uses this definition to fraudulently medicalize problems that are not medical in nature.

2.  Psychiatry routinely presents these so-called illnesses as the causes of the specific problems, when in fact they are merely labels: abbreviated rewordings of the presenting problems with no explanatory function or value.  These labels, which cause enormous damage to the individuals to whom they are assigned, serve only to legitimize the pushing of drugs, and to enable psychiatrists to bill for the services they provide.  Unlike real diagnoses, they provide no insight into the nature or essence of the presenting problems, but are nevertheless defended tenaciously by psychiatrists and their pharma funders.

3.  Psychiatry has routinely deceived, and continues to deceive, their clients, the public, the media, and government agencies, that these vaguely defined problems are in fact illnesses with known neural pathology. The classic example of this is the chemical imbalance theory of depression – a blatant hoax which was pushed so heavily by psychiatry that it has now become “common knowledge”.  And the most noteworthy aspect of this is that although the hoax has been exposed repeatedly – (most recently by Terry Lynch in his book Depression Delusion), psychiatry has taken no concerted steps to correct this misinformation, and indeed in many quarters is still promoting this fiction as established medical fact.

4.  Psychiatry has blatantly promoted drugs as corrective measures for these illnesses, when in fact it is well-known in pharmacological and psychiatric circles that no psychiatric drug corrects any neural pathology. In fact, the opposite is the case.  All psychiatric drugs exert their effect by distorting or suppressing normal brain functioning.  It is also well known that the adverse effects of these products are often devastating and permanent.

5.  Psychiatry has collaborated and conspired with pharma in the development of a vast body of fraudulent research, all designed to “demonstrate” that psycho-pharmaceutical products are safe and effective. The methods by which this fraud has been perpetrated include:  the routine suppression of negative results; the use of ridiculously short follow-up intervals; over-stating of marginal results; etc., etc.

6.  A great many psychiatrists have shamelessly accepted large sums of pharma money for very questionable activities. These activities include the widespread presentation of infomercials in the guise of CEUs; the ghost-writing of books and papers which were actually written by pharma employees; targeting of captive and vulnerable audiences in nursing homes, group homes, and foster-care systems for prescription of psychiatric drugs; etc., etc…   Two glaring examples of this kind of venality are:

In addition, 70% of the DSM-5 task force members had received funding from the pharmaceutical industry.

7.  Psychiatry’s labels are inherently disempowering. To tell a person, who in fact has no biological pathology, that he has an incurable illness, for which he must take psychiatric drugs for life, is an intrinsically disempowering act which robs people of hope, and encourages them to settle for a life of drug-induced dependency and mediocrity.

8.  Psychiatry’s “treatments”, whatever transient feelings of well-being they may induce, are always destructive and damaging in the long-term. Neuroleptic drugs cause tardive dyskinesia.  Extended use of antidepressants produces a state of chronic joylessness.  Benzodiazepines are addictive.  High-voltage electric shocks to the brain erase memories.  Psychiatry’s notion that one can solve people’s problems by tinkering irresponsibly with their brains, betrays a degree of arrogant naivety unequalled in other professional groups.

9.  Psychiatry’s spurious and self-serving medicalization of every significant problem of thinking, feeling, and/or behaving, effectively undermines human resilience, and fosters a culture of powerlessness, uncertainty, and dependence. Powerful, time-honored concepts such as the need for critical self-appraisal, and personal improvement through effort, have been systematically marginalized by psychiatry’s expanding list of “illnesses”, and ever-flowing supply of drugs.  Relabeling as illnesses, problems which previous generations accepted as matters to be addressed and worked on, and harnessing billions of pharma dollars to promote this false message, is morally and professionally repugnant.

10.  Psychiatry’s primary agenda over the past four or five decades has been the expansion of its list of “illnesses”, and the assignment of these illnesses to more and more people. It has now become routine practice to prescribe neuroleptic drugs to elderly nursing home residents who become “unmanageable” and to young children for temper tantrums!

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SOME REMEDIAL SUGGESTIONS FOR PSYCHIATRY

Here are my suggestions for any psychiatrist who is genuinely concerned about the stigmatization of his/her profession:

  • repudiate the spurious medicalization of non-medical problems;
  • acknowledge the destructive and disempowering nature of the “treatments”;
  • apologize to all concerned;
  • find honest work.

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No amount of mental gymnastics or PR can address psychiatry’s fundamental flaws.

Allen Frances Saving Psychiatry From Itself?

On October 12, 2014, the eminent psychiatrist Allen Frances, MD, participated in a panel discussion at the Mad In America film festival in Gothenburg, Sweden.  After the festival, he wrote an article – Finding a Middle Ground Between Psychiatry and Anti-Psychiatry – for the Huffington Post Blog, summarizing the positions he had discussed at the festival. The article was re-published on MIA on October 26, 2014.

The article is ostensibly an attempt to find common ground between psychiatry and its critics, but the piece contains numerous distortions and omissions which I think need to be identified and discussed.

Here are some quotes from the article, interspersed with my comments.

“There will never be any compromise acceptable to the die-hard defenders of psychiatry or to its most fanatic critics.

Some inflexible psychiatrists are blind biological reductionists who assume that genes are destiny and that there is a pill for every problem.

Some inflexible anti-psychiatrists are blind ideologues who see only the limits and harms of mental-health treatment, not its necessity or any of its benefits.

I have spent a good deal of frustrating time trying to open the minds of extremists at both ends — rarely making much headway.”

This is Dr. Frances’s opening passage.  Essentially what he’s saying here is that there are “extremists” on both sides of this issue.  Although he doesn’t say that these individuals are minorities, I think that this is implied.  Certainly those of us in the anti-psychiatry camp are a minority, but the implication that psychiatrists who are  “blind biological reductionists” represent a minority is, I suggest, simply false.  I have been retired now for 13 years, but in the previous twenty-five years, I doubt if I encountered more than three or four psychiatrists who were not “blind biological reductionists”.  The phrases “chemical imbalance” and “illness just like diabetes” were standard fare in psychiatry’s narrative, and the 15-minute “med check” was the standard “treatment” for all problems.

With regards to “inflexible anti-psychiatrists” being “blind ideologues”, I think I can speak from personal experience.  I am indeed inflexibly anti-psychiatry.  My position in this regard is based entirely on the fact that the various problems listed in the DSM (apart from those indicated as due to a general medical condition) are not illnesses, and that conceptualizing these problems as illnesses has done, and continues to do, vastly more harm than good.  I am – to use Dr. Frances’s term – inflexible on this matter in the same way that I am inflexible on the matter that the Earth is round rather than flat.

But, on the other hand, as I’ve stated many times on my website, if psychiatry will adduce convincing evidence that the various items catalogued in their manual really are illnesses, (i.e., stem from an identified biological pathology), then I will accept this evidence, apologize for my errors, and close the website. At the risk of understatement, this evidence is not to hand, and at present, psychiatry’s contentions, explicit and implicit, that the various problems that they “treat” are illnesses are nothing more than destructive, disempowering, self-serving, unsubstantiated assertions.

And lest there be any perception that psychiatry’s love-affair with biological reductionism is a thing of the past, here’s a quote from Jeffrey Lieberman’s June 19, 2012 video Causes of Depression.  Dr. Lieberman is Psychiatrist-in-Chief at New York Presbyterian/Columbia University Medical Center, and at the time of the video was President-elect of the APA.  The video was made by The University Hospital of Columbia and Cornell.

“…the way nerves talk to each other, and communicate, is through the secretion of a chemical called a neurotransmitter, which stimulates the circuit to be activated.  And when this regulation of chemical neurotransmission is disturbed, you have the alterations in the functions that those brain areas are supposed to, to mediate.  So in a condition like depression, or mania, which occurs in bipolar disorder, you have a disturbance in the neurochemistry in the part of the brain that regulates emotion.”

And lest there be any perception that Dr. Frances did not contribute to psychiatry’s ardent embrace of biological reductionism, here’s a quote from the Introduction to DSM-IV, of which Dr. Frances was the Task Force chairman:

“The terms mental disorder  and general medical condition are used throughout this manual.  The term mental disorder is explained above.  The term general medical condition is used merely as a convenient shorthand to refer to conditions and disorders that are listed outside the ‘Mental and Behavioral Disorders’ chapter of ICD.  It should be recognized that these are merely terms of convenience and should not be taken to imply that there is any fundamental distinction between mental disorders and general medical conditions… (p xxv) [Boldface added]

. . . . . . . . . . . . . . . . 

“Fortunately, though, there are many reasonable people in both camps who may differ markedly in their overall assessment of psychiatry but still can agree that it is certainly not all good or all bad. With open-mindedness as a starting point, common ground can usually be found;”

At the risk of appearing cynical, I see this as a rather facile attempt at divide-and-conquer.  Psychiatry is the Goliath here, and the anti-psychiatry movement is a very weak and poorly-provisioned David.  What Dr. Frances is doing is marginalizing the more extreme members of the anti-psychiatry camp, and attempting to gather the more moderate members into psychiatry’s fold, under the pretense that most psychiatrists are reasonable people who will welcome their input with “open-mindedness”.  In reality, apart from a truly tiny number of psychiatrists, there is no receptivity within psychiatry to the anti-psychiatry concerns.  In fact, the dominant feature of the present debate is psychiatry’s increased insistence that the problems they “treat” are indeed real illnesses, and that their “treatments” are safe and effective.

In a recent radio interview with Michael Enright on Canadian Broadcasting Corporation’s The Sunday Edition, Jeffrey Lieberman, MD, one of the most eminent and prestigious psychiatrists in the world, characterized Robert Whitaker as “a menace to society” for daring to suggest otherwise!  And there was scarcely a ripple of protest from psychiatry.

. . . . . . . . . . . . . . . .

“And finding common ground has never been more important. We simply can’t afford a civil war among the various advocates of the mentally ill at a time when strong and united advocacy is so desperately needed.”

Note the term “civil war” with its connotations of brother against brother, families torn apart, etc…  The message here is:  that those of us who are “open-minded” basically want the same thing, so why are we engaged in this struggle?  But note also the phrase “the mentally ill”.  The essential core of the anti-psychiatry movement is that the various problems embraced by psychiatry’s catalog are not illnesses.  But Dr. Frances dismisses this entire issue in the guise of being open-minded and conciliatory.

In addition, the phrase “the mentally ill”, with its connotations of amorphousness, homogeneity, and anonymity, is extraordinarily stigmatizing.  I would concede that person-first language is sometimes promoted to an excessive degree, but the phrase “the mentally ill” is not at all helpful.

Ironically, Dr. Frances uses this phrase in the context of advocacy!  “…various advocates of the mentally ill…”  I respectfully suggest that a good first advocacy step for Dr. Frances would be to stop calling the individuals concerned “the mentally ill”.

Incidentally, the phrase “the mentally ill” occurs in Dr. Frances’s paper three times; the phrase “the severely ill” occurs once.

And why is this “strong and united advocacy…so desperately needed”.  Because:

“Mental-health services in the U.S. are a failed mess: underfunded, disorganized, inaccessible, misallocated, dispirited, and driven by commercial interest. The current nonsystem is a shameful disgrace that won’t change unless the various voices who care about the mentally ill can achieve greater harmony.”

But, and Dr. Frances fails to mention this, it is psychiatry itself that has been running this “shameful disgrace” for the past 150 years or so.  And psychiatry was, and still is, a very willing and devoted partner to pharma, the major commercial interest.

Also note the guilt-trip:  if you’re not joining the great Allen-Frances coordinated unification drive, then you just don’t care about “the mentally ill”, (that phrase again).

 

. . . . . . . . . . . . . . . .

“…those who don’t need psychiatric medicine get far too much: We spend $50 billion a year on often-unnecessary and potentially dangerous pills peddled by Big Pharma drug pushers, prescribed by careless doctors, and sought by patients brainwashed by advertising. There are now more deaths in the U.S. from drug overdoses than from car accidents, and most of these come from prescription pills, not street drugs.”

But Dr. Frances neglects to mention that his own DSM-IV had a clearly expansionist agenda, details of which I’ve discussed in an earlier post.  It is the proliferation of “diagnoses” and the progressive relaxing of the criteria that enables the increases in prescribing.  And Dr. Frances has been a major player in this area.

He also neglects to mention his own interest-conflicted collaborative relationship with Janssen Pharmaceutica in the mid-1990’s in the promotion of Janssen’s drug Risperdal (risperidone).  In that regard, Dr. Frances was quoted in a witness report as stating:

“We are also committed to helping Janssen succeed in its effort to increase its market share and visibility in the payor, provider, and consumer communities.” [Boldface added]

. . . . . . . . . . . . . . . . 

“The mess is deeply entrenched because 1) there are few and fairly powerless advocates for the most disadvantaged; 2) the commercial interests are rich and powerful, control the airwaves and the politicians, and profit from the status quo; and 3) the mental-health community is riven by a longstanding civil war that distracts from a unified advocacy for the severely ill.

The first two factors won’t change easily. Leverage in this David-vs.-Goliath struggle is possible only if we can find a middle ground for unified advocacy.

I think reasonable people can readily agree on four fairly obvious common goals:

1.  We need to work for the freedom of those who have been inappropriately imprisoned.

2.  We need to provide adequate housing to reduce the risks and indignities of homelessness.

3.  We need to provide medication for those who really need it and avoid medicating those who don’t.

4.  We need to provide adequate and easily accessible psychosocial support and treatment in the community.”

There is indeed a David and Goliath aspect to this issue.  Pharma-psychiatry is Goliath; and the struggling anti-psychiatry movement is David.  But note how Dr. Frances has reconfigured this. Goliath is now “the commercial interests” (presumably pharma), and David is psychiatry (without, of course, the few “blind biological reductionists”) plus those “reasonable” members of the anti-psychiatry movement who genuinely care for “the mentally ill”.  Casting pharma and psychiatry as being on opposite sides of this issue, and portraying psychiatry as the powerless, innocent victim, are extraordinary feats of mental gymnastics.

. . . . . . . . . . . . . . . . 

“Eighty percent of all psychiatric medicine is prescribed by primary-care doctors after very brief visits that are primed for overprescribing by misleading drug-company advertising.”

But not a single one of those prescriptions could have been written if psychiatrists had not invented, and avidly promoted, the “illnesses” for which they are prescribed.

. . . . . . . . . . . . . . . .

 “Many psychiatrists also tend to err by being too quick to write prescriptions.”

But isn’t this an integral part of the medical model:  diagnose the illness, prescribe the treatment; follow-up.  This isn’t some kind of unforeseeable aberration.  Rather, this is psychiatry as psychiatrists – leaders as well as rank and file – have consciously and deliberately sculpted it over the past 50 years.  This spurious and destructive travesty is the inevitable culmination of psychiatry’s efforts to establish itself as a bona fide medical specialty.  The fact that it is such a colossal failure is not a reflection on the efforts of the participants, or the pharma money that fuelled those efforts.  Rather, it reflects the obvious fact that the medical model is not a useful way to conceptualize or approach non-medical problems of thinking, feeling, and/or behaving.   

. . . . . . . . . . . . . . . . 

“I think reasonable people can agree that we need to reeducate doctors and the public that medications have harms, not just benefits…”

Doctors need to be re-educated to the fact that medications have harms, not just benefits!  Don’t they read the PDR?   And note the use of the generic term “doctors” rather than psychiatrists, even though it was psychiatrists who routinely proclaimed the safety and efficacy of the drugs they pushed, and downplayed adverse reactions, when they mentioned them at all.  And it was the pharma-funded psychiatric research mill that churned out, and continues to churn out, the spurious studies that “established” the safety and efficacy of these products.

. . . . . . . . . . . . . . . . . 

“…it is equally ludicrous that anyone should be sent to jail for symptoms that would have responded to medication if the waiting time for an appointment had been one day, not two months.”

First, note the implication that the criminal behavior is a “symptom” that “would have responded to medication.”  But what of the increasing number of very serious criminal acts committed by people who are actually taking psychiatric drugs, particularly SSRI’s?

. . . . . . . . . . . . . . . . 

“When, more than 50 years ago, Tom Szasz began to fight for patient empowerment, freedom, and dignity, the main threat to these was a snake-pit state hospital system that warehoused more than 600,000 patients, usually involuntarily and often inappropriately. That system no longer exists. There are now only about 65,000 psychiatric beds in the entire country, and the problem is finding a way into the hospital, not finding a way out.”

This is not entirely accurate.  The late Thomas Szasz, MD, was indeed concerned about coercive psychiatry, but he was even more concerned about psychiatry’s spurious medicalization of non-medical problems: what Dr. Szasz called the myth of mental illness.  And this latter concern is one that Dr. Frances consistently fails to address, or even acknowledge.  To abuse the late Dr. Szasz’s legacy in this way strikes me as dishonorable.  And to suggest that the concerns so forcefully expressed by Dr. Szasz are now a thing of the past is simply false.

. . . . . . . . . . . . . . . . 

“Anti-psychiatrists are fighting the last war. Psychiatric coercion has become largely a paper tiger: rare, short-term, and usually a well-meaning attempt to help the person avoid the real modern-day coercive threat of imprisonment.”

So psychiatric coercion is rare, short-lived, and is essentially an act of kindness to keep people out of prison.  But on August 28, 2014, Dr. Frances wrote an article on the Huffington Post Blog in which he lionizes D.J. Jaffe, whom he describes as “one of a small group of stalwart defenders of the 5 percent” (people with “severe mental illness”).  Dr. Frances provides an extensive quote from D J. Jaffe in which Mr. Jaffe clearly supports the infamous Tim Murphy bill, which, if implemented, would increase vastly the amount of coerced psychiatric “treatment” in the US.

. . . . . . . . . . . . . . . .

Depression is not an illness.  Childhood inattention is not an illness.  Painful and distressing memories are not illnesses.  Habitual criminality is not an illness.  Psychiatry’s routine medicalization of these and other non-medical problems is a disaster of monumental proportions, and Dr. Frances has been a major contributor to this process.

At the present time, psychiatry is being exposed as the self-serving, disempowering, and destructive charlatanism that it is.  The anti-psychiatry movement, though still the David, is gaining ground and adherents daily.  Psychiatry has no defense, and can see the edifice, so carefully and deceptively constructed over decades, crumbling by the day.

What Dr. Frances is trying to do is co-opt the anti-psychiatry movement, by marginalizing its more extreme members, while gathering the rest under a dubious banner of reasonableness and compromise.  But beneath the thin veneer of amenability, there are still the spurious, self-serving concepts and the destructive, disempowering practices of a system that is intellectually and morally bankrupt, and has no legitimate claim to being a medical specialty.

The Spurious Chemical Imbalance Theory is Still Alive and Well

On April 5, 2015, Scott Alexander, MD, a trainee psychiatrist, posted an article titled Chemical Imbalance on his website Slate Star Codex.  (The writer tells us that Scott Alexander is a blog handle and not his real name, but for convenience, I will refer to him as Dr. Alexander.)

Dr. Alexander begins by noting that there have been a number of articles recently that have criticized psychiatry for “botching the ‘chemical imbalance’ theory.”

“According to all these sources psychiatry sold the public on antidepressants by claiming depression was just a chemical imbalance (usually fleshed out as ‘a simple deficiency of serotonin’) and so it was perfectly natural to take extra chemicals to correct it.”

“This narrative is getting pushed especially hard by the antipsychiatry movement, who frame it as ‘proof’ that psychiatrists are drug company shills who were deceiving the public.”

[Actually, it’s proof that psychiatrists are either very misinformed or very deceptive.  Proving that many of them are drug company shills is a separate matter.]

. . . . . . . . . . . . . . . .

As an example of this trend, he cites an article of mine that was published on Mad in America on June 6, 2014.  The article was titled Psychiatry DID Promote the Chemical Imbalance Theory, and was written specifically as a response to three statements made by the eminent psychiatrist Ronald Pies, MD.  Here are the three statements:

“…the ‘chemical imbalance theory’ was never a real theory, nor was it widely propounded by responsible practitioners in the field of psychiatry.” (April 15, 2012)

“In truth, the ‘chemical imbalance’ notion was always a kind of urban legend – never a theory seriously propounded by well-informed psychiatrists.’ (July 11, 2011)

“But I stand by my claim that no respected representatives of the profession seriously asserted a simple, ‘chemical imbalance’ theory of mental illness in general.” (September 2, 2011; response to comment on July 11, 2011 article)

My article was lengthy (6079 words), and I quoted seven prestigious psychiatrists in which a simplistic chemical imbalance theory was promoted unambiguously.

“In the last decade, neuroscience and psychiatric research has begun to unlock the brain’s secrets.  We now know that mental illnesses – such as depression or schizophrenia – are not “moral weaknesses” or “imagined” but real diseases caused by abnormalities of brain structure and imbalances of chemicals in the brain.”  Unlocking the Brain’s Secrets, by Richard Harding, MD, then President of the APA, in Family Circle magazine, November 20, 2001, p 62.

“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.”  Paying Attention to ADHD, by Timothy Wilens, MD, Associate Professor of Psychiatry at Harvard Medical School, and Psychiatrist at Massachusetts General Hospital.  Op. Cit., p 65

“…the way nerves talk to each other, and communicate, is through the secretion of a chemical called a neurotransmitter, which stimulates the circuit to be activated.  And when this regulation of chemical neurotransmission is disturbed, you have the alterations in the functions that those brain areas are supposed to, to mediate.  So in a condition like depression, or mania, which occurs in bipolar disorder, you have a disturbance in the neurochemistry in the part of the brain that regulates emotion.”  Causes of Depression, a video by Jeffrey Lieberman, MD, Psychiatrist-in-Chief at NewYork Presbyterian/Columbia University Medical Center, and then President-elect of the APA.  Video made by The University Hospital of Columbia and Cornell. (June 19, 2012)

“The various forms of mental illness are due to many different types of brain abnormalities, including the loss of nerve cells and excesses and deficits in chemical transmission between neurons; sometimes the fault may be in the pattern of the wiring or circuitry, sometimes in the command centers, and sometimes in the way messages move along the wires.” (p 221) [Emphasis added] Nancy Andreasen’s book The Broken Brain: The Biological Revolution in Psychiatry (1984).  Nancy Andreasen, MD, PhD, is Chair of Psychiatry at the University of Iowa.  She served on the DSM-III and DSM-IV Task Forces, and is past president of the American Psychopathological Association and the Psychiatric Research Society.

“Since the pharmacological agents that ameliorate depression and mania appear to act upon and alter the concentration and metabolism of the biogenic amines in what are presumably corrective directions, it may be inferred that in the affective disorders there exists a chemical pathology related to these compounds…positive evidence is slowly accumulating and negative evidence is thus far lacking.” [Emphasis added] opinion piece for the American Journal of Psychiatry (September, 1970, p 133), titled Affective Disorders:  Progress, But Some Unresolved Questions Remain, by Morris Lipton, PhD, MD.  The late Dr. Lipton was Chair of Psychiatry at Chapel Hill at the time of writing.

“Depression is known to be caused by a deficit of certain neurochemicals or neurotransmitters, especially norepinephrine and serotonin.” (p 47) Daniel Amen, MD, from his bestselling book Change Your Brain, Change Your Life (1998)

 I also provided the following quote from the psychiatry textbook Psychiatry (2003),  Tasman, Kay, and Lieberman (eds.)

“A final reason for studying the mechanisms of psychopathology is to inform our patients, their families, and society of the causes of mental illness.  At some time in the course of their illness, most patients and families need some explanation of what has happened and why.  Sometimes the explanation is as simplistic as ‘a chemical imbalance,’ while other patients and families may request brain imaging so that they can see the possible psychopathology or genetic analyses to calculate genetic risk.” (p 290, Vol 1)

I made the point that although this passage is not entirely clear, it does suggest that it is OK to tell clients and their families the chemical imbalance lie if they ask for an explanation.

Dr. Alexander reproduces two of my quotes – those from Drs. Harding and Lieberman – and continues:

“I have no personal skin in this game. I’ve only been a psychiatrist for two years, which means I started well after the term ‘chemical imbalance’ fell out of fashion. I get to use the excuse favored by young children everywhere: ‘It was like this when I got here’. But I still feel like the accusations in this case are unfair, and I would like to defend my profession.”

And here’s his defense: [incidentally, he confuses Mad In America with me personally, but his meaning is clear.]

“I propose that the term ‘chemical imbalance’ hides a sort of bait-and-switch going on between the following two statements:

(A): Depression is complicated, but it seems to involve disruptions to the levels of brain chemicals in some important way

(B): We understand depression perfectly now, it’s just a deficiency of serotonin.

If you equivocate between them, you can prove that psychiatrists were saying (A), and you can prove that (B) is false and stupid, and then it’s sort of like psychiatrists were saying something false and stupid!

But it isn’t too hard to prove that psychiatrists, when they talked about ‘chemical imbalance’, meant something more like (A). I mean, look at the quotes above by which Mad In America tries to prove psychiatrists guilty of pushing chemical imbalance. Both sound more like (A) than (B). Neither mentions serotonin by name. Both talk about the chemical aspect as part of a larger picture: Harding in the context of abnormalities in brain structure, Lieberman in the context of some external force disrupting neurotransmission. Neither uses the word ‘serotonin’ or ‘deficiency’. If the antipsychiatry community had quotes of APA officials saying it’s all serotonin deficiency, don’t you think they would have used them?”

In other words, he’s saying that the quotes from Drs. Harding and Lieberman were not simplistic chemical imbalance assertions, but were in fact more nuanced, and that they recognized the complicated, contextual aspects of depression.

So let’s take a look at the quotes in detail.  First, Dr. Harding:

  1. Neuroscience and psychiatric research has begun to unlock the brain’s secrets.
  2. We now know [note the unambiguous expression of certainty]
  3. that mental illnesses such as depression or schizophrenia
  4. are not ‘moral weaknesses’ or ‘imagined’,
  5. but real diseases
  6. caused by abnormalities of brain structure and imbalances of chemicals in the brain.

And Dr. Lieberman:

  1. Brain circuits are activated by neurotransmitters.
  2. Disturbances in this chemical neurotransmission lead to disturbances in function.
  3. So [implying causality],
  4. in depression or mania, there is a disturbance in brain neurochemistry.

Dr. Alexander contends that these quotes do not promote a simplistic chemical imbalance theory because:

1.  Neither mentions serotonin by name! I had never said that they mentioned serotonin by name.  Nor had there been any mention of serotonin in Dr. Pies’ original statements.  The issue was (and still is) that they promoted the chemical imbalance theory.  Dr. Alexander’s introduction of serotonin is irrelevant, and is, I suggest, an example of precisely the kind of intellectual dishonesty which he attributes to me.

2.  Both talk about the chemical aspect as part of a larger picture. This is simply false.  Dr. Harding clearly cites “imbalances of chemicals’ as a cause of mental “diseases”.  The fact that he also promotes abnormalities of brain structure does not modify or contextualize the primary contention.  And the fact that his article was embedded in a five-page “Special Advertizing Feature” for Paxil leaves little room for doubt as to his meaning. 

3.  Dr. Alexander contends that Dr. Lieberman’s statements about chemical imbalance was made in the context of  “…some external force disrupting neurotransmission.”  This, I suggest, is a very creative reading of Dr. Lieberman’s statement:

“And when this regulation of chemical neurotransmission is disturbed, you have the alterations in the functions that those brain areas are supposed to, to mediate.  So in a condition like depression, or mania, which occurs in bipolar disorder, you have a disturbance in the neurochemistry in the part of the brain that regulates emotion.”

Dr. Lieberman makes no reference to an external force disrupting neurotransmission, but even if such an external force were implied, the fundamental message is clear:  conditions like depression and mania are caused by disturbances in chemical neurotransmission, i.e. chemical imbalances!

. . . . . . . . . . . . . . . . 

It’s noteworthy that Dr. Alexander made no mention of the other quotes in my article, e.g:

Nancy Andreasen, MD, an eminent psychiatrist:

“The messages passed along these circuits are transmitted and modulated primarily through chemical processes.  Mental illnesses are due to disruptions in the normal flow of messages through this circuitry” (p 219)

Daniel Amen, MD, successful CEO and Medical Director of six psychiatric clinics, and a Distinguished Fellow of the APA:

“Depression is known to be caused by a deficit of certain neurochemicals or neurotransmitters, especially norepinephrine and serotonin.”

There’s not much ambiguity there.

And, incidentally, Dr. Alexander’s statement:  “If the antipsychiatry movement had quotes of APA officials saying it’s all serotonin deficiency, don’t you think they would have used them?” is a red herring.  In Dr. Pies’ original statements, to which I was responding, there’s no mention of APA officials.  Rather, Dr. Pies’ contentions embraced “responsible practitioners in the field of psychiatry”; “well-informed psychiatrists”; and “respected representatives of the profession”.

. . . . . . . . . . . . . . . . 

In addition, I also provided numerous unambiguous quotes promoting the chemical imbalance theory from :

  • Child and Adolescent Bipolar Foundation;
  • Depression and Bipolar Support Alliance;
  • Mental Health America; and
  • National Alliance for the Mentally Ill

and I pointed out that all of these organizations had eminent psychiatrists on their advisory boards, and that it was reasonable to infer that these advisers approved, or at least had made no objection to, the chemical imbalance messages.

. . . . . . . . . . . . . . . . 

Nevertheless, Dr. Alexander concluded:

“So if you want to prove that psychiatrists were deluded or deceitful, you’re going to have to disprove not just statement (B) – which never represented a good scientific or clinical consensus – but statement (A). And that’s going to be hard, because as far as I can tell statement (A) still looks pretty plausible.”

Dr. Alexander himself concedes that statement (B) is false, but he refuses to accept the evidence I presented in the quotes – clear evidence that leading psychiatrists did promote the simplistic and false chemical imbalance theory.  And I should stress that I limited my search to psychiatrists who had achieved a measure of eminence and stature in their field (because that was the challenge presented by Dr. Pies).  If I had widened my search to include less prestigious psychiatrists, I’m sure I could have found a great many more.  The fact is that the promotion of the chemical imbalance theory is no secret.  I have personally heard dozens of psychiatrists proclaim it with total confidence, and I truly could not begin to estimate the number of clients I’ve talked to over the years who told me that their psychiatrists had told them they had a chemical imbalance in their brains, and that they needed to take the pills for life to correct this imbalance.  Even today, I regularly receive emails from readers contesting the assertions in my posts and telling me in no uncertain terms that they have chemical imbalances in their brains that cause their problems.

In addition, the simplistic chemical imbalance theory is still being promoted by some prestigious psychiatrists.  Cognitive Psychiatry at Chapel Hill (CPCH) has published 10 Common Myths About Psychiatry on their webpage.  Here are two quotes:

“Actually, the majority of patients we see have an actual illness or imbalance (much like diabetes), that with the proper treatment, the imbalance is corrected and they are no longer ill.”

“… many patients that see a Psychiatrist actually have an illness or imbalance that is causing a mental discrepancy. Once this imbalance is corrected, they are, in fact, cured of their mental illness.”

. . . . . . . . . . . . . . . . 

Dr. Alexander’s article was critiqued on Mad in America by Rob Wipond on April 15, 2015.  Rob’s article cites numerous other examples of psychiatrists promoting the chemical imbalance theory of depression.

The promotion of the chemical imbalance theory did occur, and continues to occur, and is a most shameful chapter in psychiatry’s history.  It is arguably one of the most destructive, far-reaching, and profitable hoaxes in history.

. . . . . . . . . . . . . . . .

But, although the chemical imbalance theory has been soundly refuted, and the more astute psychiatrists, such as Dr. Pies, are actively distancing themselves from it, Dr. Alexander is clearly still a believer.  Here’s his final paragraph:

“So this is my answer to the accusation that psychiatry erred in promoting the idea of a ‘chemical imbalance’. The idea that depression is a drop-dead simple serotonin deficiency was never taken seriously by mainstream psychiatry. The idea that depression was a complicated pattern of derangement in several different brain chemicals that may well be interacting with or downstream from other causes has always been taken seriously, and continues to be pretty plausible. Whatever depression is, it’s very likely it will involve chemicals in some way, and it’s useful to emphasize that fact in order to convince people to take depression seriously as something that is beyond the intuitively-modeled ‘free will’ of the people suffering it. ‘Chemical imbalance’ is probably no longer the best phrase for that because of the baggage it’s taken on, but the best phrase will probably be one that captures a lot of the same idea.”

This paragraph is not entirely clear, but here’s my best shot at a paraphrase:

  1. Psychiatry never promoted a simple chemical imbalance theory.
  2. But psychiatry did promote a complicated chemical imbalance theory.
  3. The complicated chemical imbalance theory is plausible.
  4. There are chemicals involved in depression. [This is non-contentious.  Brain chemicals are involved in literally everything humans do, think, and feel, from the simplest eyeblink, to writing great works of art, and everything in between.]
  5. It’s useful to emphasize that brain chemicals are involved in depression, in order to convince people that depression is a serious problem that can’t be conceptualized in ordinary human terms.
  6. But we can’t use the term “chemical imbalance” any more because it’s been outed as a hoax.
  7. We need a new phrase that will mean essentially the same thing.

How about Chemical Imbalance, Version II?

And lest I be accused of putting words in Dr. Alexander’s mouth, here are some quotes from earlier in his paper:

“In other words, everything we do is caused by brain chemicals, but usually we think about them on the human terms, like ‘He went to the diner because he was hungry’ and not ‘He went to the diner because the level of dopamine in the appetite center of his hypothalamus reached a critical level which caused it to fire messages at the complex planning center which told his motor cortex to move his legs to…’ – even though both are correct. Very occasionally, some things happen that we can’t think about on the human terms, like a seizure – we can’t explain in terms of desires or emotions or goals an epileptic person is flailing their limbs, so we have to go down to the lower-level brain chemical explanation.

What ‘chemical imbalance’ does for depression is try to force it down to this lower level, tell people to stop trying to use rational and emotional explanations for why their friend or family member is acting this way. It’s not a claim that nothing caused the chemical imbalance – maybe a recent breakup did – but if you try to use your normal social intuitions to determine why your friend or family member is behaving the way they are after the breakup, you’re going to get screwy results.”

So if a person is despondent because of a marital break-up, one can’t conceptualize his despondency in ordinary human terms.  Doing so will produce “screwy results”.

“There’s still one more question, which is: are you sure that depression patients’ experience is so incommensurable with healthy people’s experiences that it’s better to model their behavior as based on mysterious brain chemicals rather than on rational choice?”  [Note the spurious implication that there are only two options.]

“And part of what I’m going on is the stated experience of depressed people themselves. As for the rest, I can only plead consistency. I think people’s political opinions are highly genetically loaded and appear to be related to the structure of the insula and amygdala. I think large-scale variations in crime rate are mostly attributable to environmental levels of lead and probably other chemicals. It would be really weird if depression were the one area where we could always count on the inside view not to lead us astray.”

And there it is – the very core of bio-psychiatry!  Political opinions (and, presumably political activity), criminal behavior, and, by implication pretty much anything else that we do think, or feel, are all best conceptualized in terms of brain structure and chemicals.

. . . . . . . . . . . . . . . .

Twenty-five years ago an elderly friend of mine lost his wife in a car accident.  They had been married for sixty years.  I visited him, and found him understandably despondent.  His demeanor, normally active and curious, was downcast and withdrawn.  His face was haggard; his shoulders slumped; he was at times tearful; and his gait was slow and heavy.  We talked, and he told me that he felt utterly lost.  I asked him what was the worst thing about his situation.  He thought for a long while, then said:  “I have nobody to talk to.”

His words, which I’ve never forgotten, seemed to me to embody some of the essential elements of grief and despondency:  loneliness, helplessness, and isolation.  But according to Dr. Alexander, this kind of thinking is “screwy”.  Despondency is really a matter of chemicals, and we need to “convince” people to abandon their intuitive assessments of their feelings of despondency, and to recognize the psychiatric “truth” that, whatever its trigger, depression is essentially  “…a complicated pattern of derangement in several different brain chemicals…”.  And we should embrace this “truth”, despite the fact that several decades of highly motivated research has failed to identify any such “derangement” or “imbalance” or whatever similar term Dr. Alexander would choose.

So, just when we imagined that we had begun to lay this particular piece of inanity to rest, here it is surging back from a brand new psychiatrist, prescription pen poised, ready to put the world to rights, one aberrant molecule at a time.

This isn’t just faulty logic and poor science.  It is a fundamentally dehumanizing and intrinsically disrespectful way of conceptualizing human loss and suffering.

 

Psychiatric Diagnoses:  Labels, Not Explanations

On March 16, Ronald Pies, MD, published an article in the Psychiatric Times.  The article is titled The War on Psychiatric Diagnosis, and the sub-title synopsis on the pdf version reads:  “A recent report that argues against descriptive diagnosis in medicine is historically ill-informed and medically naive, in the opinion of this psychiatrist.”

Dr. Pies is a very prestigious and eminent psychiatrist.  He is a professor of psychiatry at both Syracuse and Tufts.  He was the first editor of Psychiatric Times, which, by its own account, provides “News, Special Reports, and clinical content related to psychiatry” for “…psychiatrists and allied mental health professionals who treat mental disorders…Circulation of the monthly print publication is approximately 40,000.”

The report that Dr. Pies considers “historically ill-informed and medically naïve”, is the BPS November 2014 paper Understanding Psychosis and Schizophrenia, which has been widely discussed in recent weeks.

. . . . . . . . . . . . . . . . 

There is much in Dr. Pies’ paper that warrants critical examination, but I would like to focus here on just one topic:  the explanatory value of diagnoses.

Dr. Pies himself acknowledges the centrality of this matter, and writes:

“But there is a larger issue raised in the BPS report that goes to the very heart of psychiatric diagnosis, which the report tries to discredit with the following argument:

We normally expect medical diagnoses to tell us something about what has caused a certain problem, what the person can expect in future (‘prognosis’) and what is likely to help. However, this is not the case with mental health ‘diagnoses,’ which rather than being explanations are just ways of categorizing experiences based on what people tell clinicians. . . . For example, someone who says that they are hearing voices might be given a diagnosis of schizophrenia. Since this says nothing about cause, it makes little sense to say that the person hears the voices ‘because of ‘ the schizophrenia.

Actually, it makes a good deal of sense, in precisely the same way it makes sense to say, ‘Mr Jones has severe facial pain because he has tic douloureux;’ or ‘Smith has severe left-sided head pain and nausea because he has migraines.’ We still do not know the precise causes of these conditions; moreover, the diagnosis of  tic douloureux (literally, ‘painful tic’) or migraine headache (etymologically, headache ‘in half the cranium’) is made almost entirely on the basis of ‘what people tell clinicians’—not on the basis of an abnormal laboratory value, x-ray film, or anatomical finding. (Of course, certain tests, such as a CT scan of the head, can help rule out other diagnostic possibilities, such as a brain tumor.)”

The essence of Dr. Pies’ contention here is that psychiatric diagnoses are just as valid as diagnoses in general medicine, and that, in particular, the absence of knowledge concerning causes does not diminish their status or usefulness.

It has long been my contention that psychiatric “diagnoses” have no explanatory value, and in fact constitute nothing more than vague, unreliable re-labeling of the presenting problems.

This is clearly demonstrated in the hypothetical conversation:

Client’s parent:  Why is my son so paranoid?  Why does he just sit in his room all day?  Why won’t he do anything?

Psychiatrist:  Because he has an illness called schizophrenia.

Parent:  How do you know he has this illness?

Psychiatrist:  Because he is so paranoid, sits in his room all day, and won’t do anything.

The only evidence, and I stress the only evidence, for the so-called illness is the very behavior that it purports to explain.  The psychiatric explanation essentially comes down to:  he is paranoid, sits in his room all day, and won’t do anything, because he’s paranoid, sits in his room all day, and won’t do anything.  There is nothing more to it than that.

I realize that I’ve labored this matter to the point of tedium. But I’ve done so for two reasons.  Firstly, because it is one of the core flaws in psychiatry.  Its diagnoses have no explanatory value.  They are nothing more than labels.  Secondly, because psychiatry consistently fails to respond to this particular criticism, and with equal consistency presents these labels as if they did have explanatory value.

The present article by Dr. Pies is a perfect example of the second point, because although Dr. Pies appears to address the issue, he actually side-steps it.

Let’s go back to the quote from the BPS article.

We normally expect medical diagnoses to tell us something about what has caused a certain problem…

This is absolutely accurate.  When a person consults a physician concerning a medical problem or concern, there is a general expectation that the diagnosis, if forthcoming, will provide an explanation of the problem.  And in practice, this is normally the case.  If a person reports exhaustion, pulmonary congestion, elevated temperature, pain in the chest, and nasty-looking phlegm, his diagnosis might be pneumonia.  Pneumonia is a viral or bacterial infection of the lung tissue.

What is noteworthy here, in the present context, is that we have two distinct elements:  the symptoms and the cause of the symptoms.  The person consults a physician because of the symptoms, and, from the physician, he learns the cause of these symptoms.  This is what diagnosis means:  determining the cause and nature of a pathological condition.  Wikipedia gives the following definition:

“Medical diagnosis…is the process of determining which disease or condition explains a person’s symptoms and signs.” [Emphasis added]

Another critical factor in this issue is that there has to be a clear logical link between the symptoms and the diagnosis.  If, for instance, the physician’s diagnosis in the above scenario were “incorrect curvature of the spine”, there would, I suggest, be an enormous burden of proof as to how this particular pathology could cause these particular symptoms.  But with a diagnosis of pneumonia, the logical link is clear:  the infection causes exudation of blood and other fluid into the lung tissue; the immune system triggers an increase in temperature, etc..

So let’s see how our consultation conversation might run in this case.

Patient:  Why am I so tired; why did my temperature spike; why am I spitting up such dreadful-looking phlegm?

Physician:  Because you have pneumonia.

Patient:  How do you know I have pneumonia?

Physician:  Because I can hear characteristic sounds through the stethoscope; your chest X-ray shows large quantities of fluid in both lungs; your sputum labs are positive for pneumococcus; and because everything you have told me is consistent with this diagnosis.  I can show you the X-rays if you like.

The difference between this kind of conversation and the psychiatric conversation is obvious.  In the pneumonia case, the physician has progressed from the symptoms to the essential underlying nature of the illness.  In psychiatry, no such progress has occurred or can occur.  In psychiatry, the so-called symptoms are the essence of the problem.  There is no underlying reality to which the symptoms point.  The “symptoms” and the “illness” are identical.

Back to the BPS quote:

“For example, someone who says that they are hearing voices might be given a diagnosis of schizophrenia. Since this says nothing about cause, it makes little sense to say that the person hears the voices ‘because of ‘ the schizophrenia.”

Again, this is accurate.  “Schizophrenia” is a label, not an underlying explanatory entity that enables us to understand the symptoms.  The phrase  “…because he has schizophrenia” is a form of words that looks like an explanation, but in fact isn’t.

To illustrate this, let’s consider another example.  Imagine a small child running tearfully to his mother with the complaint that another child has been hitting him.  Mother gathers the victim to her arms and soothes him.

Mother:  It’s OK.  I’ve got you.  It’s OK. etc.

Child:  Why does he keep hitting me?

Mother:  Because he’s a bully.  Don’t mind him.

The phrase “because he’s bully” looks like an explanation, and will be accepted by the child as an explanation, but in fact it has no explanatory value.  All we have to do to see this is ask the question:  “How do you know he’s a bully?”, and the only possible answer is “because he keeps hitting you”.

The statement “he beats you because he is a bully” is logically equivalent to the statement:  “He beats you because he beats you.”  It contains no explanatory insights into the aggressor’s action.  And psychiatric explanations are exactly of this kind.

Now, please don’t misunderstand me.  This is not a logical critique of mothers who try to comfort their children.  As parents, we do what we can to comfort our children, and there is no great onus with regards to logic or science.  But psychiatric concepts and assertions do need to pass the tests of logic and science.

The statement:  “Your son hears voices because he has schizophrenia” is logically equivalent to “Your son hears voices because he hears voices.”  Schizophrenia is nothing more than the label that psychiatry gives to that loose cluster of vaguely defined thoughts, feelings, and/or behaviors that are listed on page 99 of DSM-5.  These are:

  1. Delusions
  2. Hallucinations.
  3. Disorganized speech (e.g., frequent derailment or incoherence).
  4. Grossly disorganized or catatonic behavior.
  5. Negative symptoms (i.e., diminished emotional expression or avolition)

The simple fact of the matter is that the reasons underlying these thoughts, feelings, and behaviors are as varied as the individuals who experience them.  But psychiatrists make no attempt to explore these reasons.  Instead, they rely on the medical-sounding, but facile,  “because-he-has-schizophrenia” form of words.  As in so many areas, psychiatry has become intoxicated by its own rhetoric, and individual practitioners seem to believe that this form of words actually has some explanatory value.

Back to Dr. Pies:

“Actually, it makes a good deal of sense, in precisely the same way it makes sense to say, ‘Mr Jones has severe facial pain because he has tic douloureux;’ or ‘Smith has severe left-sided head pain and nausea because he has migraines.’  We still do not know the precise causes of these conditions; moreover, the diagnosis of  tic douloureux (literally, ‘painful tic’) or migraine headache (etymologically, headache ‘in half the cranium’) is made almost entirely on the basis of ‘what people tell clinicians’—not on the basis of an abnormal laboratory value, x-ray film, or anatomical finding.”

So there is a fairly profound disagreement.  The BPS say that the explanation “because he has schizophrenia” makes little sense.  Dr. Pies says it makes a good deal of sense. Let’s take a closer look.  First, let’s go back to the BPS statement which Dr. Pies quoted and which I reproduced above.  Although there are no quotation marks around this passage, it is actually a verbatim quote from the BPS paper, but a crucial piece of the quote has been omitted.  (The omission is indicated by an ellipsis in the regular online version, but there is no ellipsis in the pdf version.)

The omitted passage is:

“The Diagnostic and Statistical Manual of the American Psychiatric Association (DSM) explicitly states that its categories say nothing about cause – in its own words it is ‘neutral with respect to theories of aetiology’.”

So a summary of the BPS passage might look something like this:

  1. medical diagnoses give us the cause or explanation of a problem
  2. psychiatric diagnoses, by contrast, do not give causes or explanations
  3. psychiatric diagnoses are just ways of categorizing clients’ reports
  4. the APA acknowledges that its diagnoses say nothing about cause
  5. therefore the label schizophrenia has no explanatory value
  6. so, to say that a person hears voices because he has schizophrenia makes little sense

What Dr. Pies has omitted is item 4 arguably the most important part of the passage.  So Dr. Pies is accusing the BPS of leaping from

psychiatric diagnoses are just ways of categorizing clients’ reports

to

therefore the label schizophrenia has no explanatory value

and ignores the interim premise which is crucial to the issue.  Dr. Pies then uses this distortion to make the point that some diagnoses in general medicine are based entirely on patient report but are nevertheless considered valid and useful.  This, of course, is non-contentious.  There are, indeed, genuine medical conditions which are diagnosed largely on the basis of patient report. Dr. Pies mentions tic douloureux as an example, and states that the precise cause of this illness is unknown. But he is, I suggest, being less than candid, because a great deal is known, and has been known for decades, about the cause of tic douloureux, which, incidentally, is now usually called trigeminal neuralgia.  Here’s the entry for this illness in the 1963 edition of Taber’s Cyclopedic Medical Dictionary:

“Degeneration of or pressure on the trigeminal nerve, resulting in neuralgia of that nerve…The pain is excruciating.  Usually occurs after forty.  Pain is paroxysmal, radiating from angle of the jaw along one of the involved branches.  If the first branch, a shocklike pain is felt along the eye and back over the forehead.  If it is the middle fiber, the upper lip, nose, and cheek under the eye are affected.  If it is the third branch, pain is in the lower lip and outer border of tongue on affected side.  Pain is momentary but returns again and again.” (p T-30)

More up-to-date information is provided by drugs.com, a service of Harvard Health Publications:

“In some cases, the cause of trigeminal neuralgia is unknown. In many people, however, something seems to be irritating the trigeminal nerve, usually in the area of the nerve’s origin deep within the skull. In most cases, the irritation is believed to be caused by an abnormal blood vessel pressing on the nerve. Less often, the nerve is being irritated by a tumor in the brain or nerves. Sometimes, the problem is related to a rare type of stroke. In addition, up to 8% of patients who have multiple sclerosis (MS) eventually develop trigeminal neuralgia as a result of MS-related nerve damage.”

So, if a patient were to ask his physician why he is experiencing excruciating stabbing pains in his face, the response “because you have tic douloureux” is a perfectly logical explanation.  It might, or might not, be correct – that is not the issue.  But it is a coherent, valid explanation, and is not simply a relabeling of the presenting problems, which is  the essential status of all psychiatric diagnoses, other than those specified as being “due to a general medical condition”.

What’s particularly interesting here is that the BPS document is in fact very clear on this matter.  The sentence following the passage quoted by Dr. Pies reads:

“An analogy with physical medicine might be a label such as ‘idiopathic pain’, which merely means that a person is reporting pain, but a cause of that pain cannot be identified.”

Idiopathic means “of unknown cause, as a disease.”  (Random House Webster’s College Dictionary, 1992).  So if a patient were to ask a physician why he was experiencing severe facial pain, the response “because you have idiopathic pain” would simply be a restatement of the presenting problem, and would have no explanatory value.  The point being made in the BPS report is that a relabeling of the presenting problem that entails no understanding of cause has no explanatory value.  The phrase “because you have schizophrenia” is precisely on a par, logically, with “because you have idiopathic pain.”  Dr. Pies’ introduction of, and comparison to, “because you have tic douloureux” is an enormous red herring.  His use of the etymological annotation “painful tic” is also a red herring, in that etymology is a poor guide to current meaning.  The etymology of the word “mortgage”, for instance, is “death pledge”, because the original meaning of a mortgage was a pledge that a debt would be repaid from one’s estate after one’s death.  This is interesting, of course, but has no relevance to the current meaning of the term.

Certainly there are disease entities that general medicine has named, and can identify with reasonable accuracy, prior to establishing the etiology or cause of these illnesses.  But this is fundamentally different to the situation that prevails in psychiatry.  Firstly, in general medicine there are always prima facie reasons for believing that the condition is an organic pathology.  Secondly, the quest of general medicine for explanations and causes has been remarkably successful.

Neither of these conditions exists in psychiatry.  In fact, despite an enormous amount of highly motivated research in this area, no psychiatric “illness” has ever been reliably established to be the result of a specific neural pathology.  Even Thomas Insel, MD, Director of NIMH, wrote on April 29, 2013:

“While DSM has been described as a ‘Bible’ for the field, it is, at best, a dictionary, creating a set of labels and defining each. The strength of each of the editions of DSM has been ‘reliability’ – each edition has ensured that clinicians use the same terms in the same ways. The weakness is its lack of validity. Unlike our definitions of ischemic heart disease, lymphoma, or AIDS, the DSM diagnoses are based on a consensus about clusters of clinical symptoms, not any objective laboratory measure. In the rest of medicine, this would be equivalent to creating diagnostic systems based on the nature of chest pain or the quality of fever. Indeed, symptom-based diagnosis, once common in other areas of medicine, has been largely replaced in the past half century as we have understood that symptoms alone rarely indicate the best choice of treatment.”

Whilst I don’t agree with Dr. Insel in all areas, on this matter he has hit the nail squarely on the head.

The bottom line is this:  if one doesn’t know the cause of something, then one can’t explain it.  Explanation is the presentation of causes.  And despite their frequent claims to the contrary, psychiatrists do not know the cause of the loose collection of thoughts, feelings, and/or behaviors that they call schizophrenia.  They assume that any decade now they will discover this cause in the form of some neural pathology.  Meanwhile, they go on telling their clients the falsehood that they have chemical imbalances, or neural circuitry anomalies or whatever is the latest fashion, and that these putative illnesses can be corrected by drugs or electric shocks to the brain.  And they ignore the reality:  that the best (indeed only) way to understand people is to talk to them patiently, compassionately, and with humility, and without the assumption that one already knows the source of their troubles.  It is only in this way that we discover that people’s so-called symptoms are understandable within the context of each person’s unique history and current circumstances, and that the facile labels cataloged so conveniently by the APA are an irrelevant travesty.

And, indeed, Dr. Pies himself, even though he clings tenaciously to the need for psychiatric “diagnoses”, acknowledges the additional need to take the time to get to know clients:

“Finally, while diagnosis is a necessary first step in helping the patient with emotional, cognitive, or behavioral problems, it is far from sufficient. We must enter empathically into the patient’s ‘inner world,’ and provide a safe, trustworthy environment for the exploration of the patient’s troubles. This takes time—it can’t be done in 15 minutes!—and it requires what psychoanalyst Theodor Reik eloquently called, ‘listening with the third ear.’ “

But what Dr. Pies neglects to add is that the 15-minute med check has become standard practice in psychiatric care.  Douglas Mossman, MD, Professor of Psychiatry at the University of Cincinnati, has written unambiguously:

“Even psychiatrists who deplore 15-minute med checks recognize that they have become standard care in psychiatry.”

Glen Gabbard, MD, a widely published professor of psychiatry at Baylor and Syracuse, has written on Psychiatric Times:

“There can be little doubt in our current era that the brief ‘med check’ is becoming standard practice in psychiatry.”

Dr. Pies himself, in an earlier paper (Psychiatrists, Physicians, and the Prescriptive Bond) has written:

“Unfortunately, many prescriptions for psychotropics are written in haste—often after the infamous ’15-minute med check’ – and without any real understanding of the patient’s inner life or psychopathology.”

Dr. Pies, incidentally, also failed to mention that Theodor Reik (1888-1969) was a psychologist, not a psychiatrist, and in fact, had to fight a lawsuit against the medical community in order to establish the principle that psychoanalysis could be practiced by non-physicians.

Nor does Dr. Pies seem to recognize that psychiatry’s contention, that the DSM entities are bona fide illnesses, is, in fact, the primary driving force behind the cursory treatment which he decries so ardently.  After all, if people’s problems are caused by brain malfunctions, and if psychiatric drugs correct these malfunctions, what need is there for dialogue or understanding?

There is no factual or logical evidence that the loose collection of vaguely defined thoughts, feelings, and/or behaviors that psychiatrists call schizophrenia is a coherent entity, much less an illness.  Nevertheless, psychiatrists continue, not only to make this groundless assertion, but also to prescribe neurotoxic chemicals to “treat” this pseudo-illness, often against the vehemently expressed wishes of the victims.  This is not the practice of medicine.  It is a travesty which no amount of Dr. Pies’ sophistry can mitigate.

. . . . . . . . . . . . . . . . .

With regards to the title of his piece –  The War on Psychiatric Diagnosis – Dr. Pies has this to say:

“If ‘war’ seems a somewhat overheated term in the title of this piece, I would recommend perusal of some of the anti-psychiatry Web sites, on which the ritual evisceration of psychiatry and psychiatrists is unapologetic and unrelenting.*”

The asterisk refers to a footnote:

“*In my view, the Web site of ‘Mad in America’ is particularly abusive toward psychiatrists, though it is far from the worst of the bunch”

Well, of course, there’s anger and vitriol on both sides of this issue, though I must say that MIA has always struck me as the epitome of civility and restraint.  But it’s important in this, as in any human endeavor, to rise above the rhetoric, and deal honestly and squarely with the issues.  And the issue on the table here is that psychiatric diagnoses – other than those clearly identified as “due to a general medical condition” – have no explanatory value, but are routinely and deceptively presented by psychiatrists as if they did.

And, Dr. Pies has not addressed that issue. 

Psychiatry is under criticism because its concepts are spurious, and its treatments are destructive.  The problems that psychiatry guards tenaciously as its turf are not medical in nature, but for the sake of that turf, are shoe-horned shamelessly into psychiatry’s bogus nomenclature, and are “treated” with neurotoxic drugs and electric shocks to the brain.  Petulant complaining about the “ritual evisceration of psychiatry and psychiatrists”, is no substitute for rational, honest, and informed debate.

Thomas Insel: “Are Children Overmedicated?”

Thomas Insel, MD, is the Director of the National Institute of Mental Health.  In June of last year, he published, on the Director’s Blog, an article titled Are Children Overmedicated?  The gist of the article is that children are not being overmedicated, but rather that there is an increase in “severe psychiatric problems” in this population.

Here are some quotes, interspersed with my comments.

“The latest estimate from the National Center for Health Statistics reports that 7.5 percent of U.S. children between ages 6 and 17 were taking medication for ’emotional or behavioral difficulties’ in 2011-2012. The CDC reports a five-fold increase in the number of children under 18 on psychostimulants from 1988-1994 to 2007–2010, with the most recent rate of 4.2 percent. The same report estimates that 1.3 percent of children are on antidepressants. The rate of antipsychotic prescriptions for children has increased six-fold over this same period, according to a study of office visits within the National Ambulatory Medical Care Survey. In children under age 5, psychotropic prescription rates peaked at 1.45 percent in 2002-2005 and declined to 1.00 percent from 2006-2009.”

Dr. Insel points out that psychiatrists, parents, schools, and drug companies are often blamed for these increases. He challenges these perspectives.

“…most of the prescriptions for stimulant drugs and antidepressants are not from psychiatrists.”

This is a frequently-heard psychiatric assertion, but it is beside the point.  It is indeed the case that GP’s and various medical specialists prescribe psychiatric drugs for various problems of thinking, feeling, and/or behaving, but they can only do so because psychiatry has developed and promoted the fiction that these problems are illnesses, and the drugs are medications.  In fact, it’s even worse than that.  Psychiatry’s spurious medicalization of all human problems of thinking, feeling, and/or behaving has been so thoroughly integrated into mainstream medical care, that a physician who doesn’t prescribe psychiatric pills in certain situations could find himself legally liable for malpractice in the event of an adverse outcome.

Dr. Insel provides equally facile reasons why parents, schools, and drug companies are not to blame for the increased drugging of children. And with that whole issue out of the way, he continues:

“If psychiatrists, parents, schools, or drug companies are not the culprit, who is? The answer is potentially more complicated and more worrisome. Is it possible that the increased use of medication is not the problem but a symptom? What if more children were struggling with severe psychiatric problems and actually the problem was not over-treatment but increased need? Surely, if we discovered more children were being treated for diabetes or immune problems, we wouldn’t blame the providers or the parents. We’d be asking what drives the increase in incidence.”

Note how Dr. Insel equates psychiatric problems with real illnesses such as diabetes and immune problems.  The big difference, of course, is that real physicians don’t invent the illnesses they treat, as do psychiatrists.  Yes, more children today are “struggling with severe psychiatric problems”, but the primary reason for this is that pharma-psychiatry has been so successful in promoting the notion that virtually every problem that a child could display is an illness which needs to be “treated” with psychiatric drugs.  Former generations regarded childhood temper tantrums as a problem that needed to be addressed by parents using the normal time-honored ways.  Today these temper tantrums are a “symptom” of “disruptive mood dysregulation disorder”, a severe “psychiatric illness” warranting the attention of psychiatrists and the prescription of drugs.  There is, in fact, no difference between the temper tantrums of former years and disruptive mood dysregulation disorder of today. All that’s changed is that psychiatry has, once more, expanded its turf through the simple expedient of creating yet another “illness” by voting it into existence.  Similar observations apply to childhood inattentiveness, defiance, misconduct, boredom, etc…

. . . . . . . . . . . . . . . .

“Skepticism regarding increased rates of emotional and behavioral difficulties as opposed to increases in other medical disorders can be attributed in part to the absence of biomarkers or laboratory tests for psychiatric diagnosis comparable to glucose tolerance tests for diabetes or anaphylactic reactions for allergies. Absent these kinds of consistent, objective measures for mental disorders, we cannot distinguish between a true increase in the number of children affected or simply changing values or trends in diagnosis. Clearly context matters. What one parent might consider hyperactivity, another parent might consider healthy exuberance.  What physicians once called attention deficit hyperactivity disorder (ADHD), often now elicits a diagnosis of childhood bipolar disorder, leading to a 40-fold increase in prevalence from 1994-1995 to 2002-2003.”

So, skepticism regarding the increased rates can be attributed partly to the absence of biomarkers.  This is true, but it is not the central issue.  The central issue is that for at least the last fifty years, organized psychiatry’s primary agenda has been the medicalization of all significant problems of thinking, feeling, and/or behaving.  They have asserted, without evidence, that these problems are illnesses and have even concocted baseless neurological pathologies as putative causes of these so-called illnesses.  By comparison, the absence of biomarkers or lab tests is a trivial issue.

And note the extraordinary dexterity with which Dr. Insel trivializes the 40-fold increase in the prevalence of “childhood bipolar disorder”.  This increase was driven largely by the efforts of Joseph Biederman, MD, and caused such a scandal that the APA created the label “disruptive mood dysregulation disorder” for the express purpose of reducing the use of the bipolar label.  This whole business was a very black chapter in a profession not noted for its moral or intellectual integrity, and resulted not only in a 40-fold increase in the “diagnosis of bipolar disorder”, but also an unprecedented increase in the prescription of neuroleptic drugs to children.  But Dr. Insel spins Dr. Biederman’s excesses as comparable to two parents holding different views as to the significance of a child’s hyperactivity.  Oh my!  What a fuss about nothing!

And incidentally, on the subject of biomarkers and lab tests, there are still vast numbers of psychiatric “patients” who have swallowed the psychiatric lie, and who believe that a scan of their brains would reveal the putative pathology.  Why is it that the Director of the NIMH will acknowledge on his blog that no biomarkers or lab tests exist to confirm a psychiatric “illness”, but has taken no steps to enlighten the general public on this matter?  Why is the NIMH not screaming this message from the rooftops, and calling for the censure of those psychiatrists and drug companies who continue to deceive their clients and the public in this way?

“No question, in a field without biomarkers, there is a risk of over-diagnosis. No question, subjective diagnosis could invite unnecessary treatment and over-medication. But what if the increased use of medication reflected more children with severe developmental problems and more families in crisis? What if the bigger problem is not over-medication but under-treatment? Hearing that 7.5 percent of children are on medication (4.2 percent on psychostimulants) seems stunning, but knowing that 11 percent of children have a diagnosis of ADHD raises a possibility of under-treatment.”

Dr. Insel concedes a “risk of over-diagnosis” and the possibility of “unnecessary treatment and over-medication”.  But his terminology is problematic.  “Over-diagnosis” or, for that matter “under-diagnosis”, inevitably implies that there is a correct level of diagnosis.  To take an analogy from general medicine, there is a rare autoimmune disease called Wegener’s granulomatosis.  It is generally acknowledged that this illness is under-diagnosed.  In other words, a certain proportion of people who really have this disease are not so diagnosed during medical examinations. But the point is that the terms under-diagnosis and over-diagnosis only have meaning in reference to something that is reliably definable, a condition which does not apply to psychiatric “illness”.  Psychiatric “illnesses” are nothing more than loose clusters of vaguely defined problems of thinking feeling, and/or behaving.  There is no accurate or real level of diagnosis against which judgments of over-, or under-, diagnosis can be made.

But Dr. Insel makes no attempt to address this question of possible “over-diagnosis” and “over-medication”.  Instead, he goes straight to the heart of psychiatry’s ever-expansionist agenda:  “What if the bigger problem is not over-medication, but under-treatment?”

This, incidentally, is the same Dr. Insel who in April 2013 wrote:

“While DSM has been described as a ‘Bible’ for the field, it is, at best, a dictionary, creating a set of labels and defining each. The strength of each of the editions of DSM has been ‘reliability’ – each edition has ensured that clinicians use the same terms in the same ways. The weakness is its lack of validity. Unlike our definitions of ischemic heart disease, lymphoma, or AIDS, the DSM diagnoses are based on a consensus about clusters of clinical symptoms, not any objective laboratory measure. In the rest of medicine, this would be equivalent to creating diagnostic systems based on the nature of chest pain or the quality of fever. Indeed, symptom-based diagnosis, once common in other areas of medicine, has been largely replaced in the past half century as we have understood that symptoms alone rarely indicate the best choice of treatment.” [Emphasis added]

 So, although “symptoms alone rarely indicate the best choice of treatment”, here he comes, a year later, expressing concern that only 4.2% of America’s children are taking stimulant drugs, when 11% have “a diagnosis of ADHD.”  The clear implication being, that if a child has this invalid diagnosis, he should be taking the pills.

 “What I hear from families in crisis is lack of access, poor quality care, and a desperate need for answers. In the media reports on over-medicating children, this perspective is missing. The possibility that there is a real increase in the number of children suffering with severe emotional problems, just as there is a real increase in the number of children with diabetes and food allergies, is not even considered. Shouldn’t we be asking why so many children, at younger ages, are being seen for emotional and behavioral problems?”

To which I can only reply:  “Yes, Dr. Insel, we certainly should!”

And we should also be asking why the Director of the NIMH, the nation’s think-tank on mental health matters, is addressing these profound and controversial issues in such misleadingly simplistic terms.

Cures For Brain Disorders

On January 18, Thomas Insel, MD, published an article on The World Economic Forum Blog.  The article is titled 4 things leaders need to know about mental healthDr. Insel is the Director of the National Institute of Mental Health.  The World Economic Forum “is an International Institution committed to improving the state of the world through public-private cooperation.”

Dr. Insel’s paper makes a number of assertions, some of which are misleading.  Here are some quotes, interspersed with my comments.

“Too many people dismiss mental illnesses as problems of character or lack of will, rather than recognizing these disorders as serious, often fatal, medical  disorders.”

This is a fairly standard psychiatric assertion.  Note particularly how Dr. Insel has couched the issue as a choice between two alternatives:  “mental illnesses” are either:

problems of character or lack of will
or
serious, often fatal, medical disorders

In reality, the many problems of thinking, feeling, and/or behaving that psychiatrists list as mental illnesses can be conceptualized in a great many other ways.  It is inconceivable that a person of Dr. Insel’s stature and prestige isn’t aware of this, and so the question needs to be asked:  why would he present such an important and controversial question in such a misleadingly simplistic way?

. . . . . . . . . . . . . . . .

“For anyone who has not experienced depression, the most common mental illness, it is important to distinguish the disorder of depression from the sadness, disappointment, or frustration we all experience in our lives.”

This is another piece of standard psychiatric orthodoxy:  depression (the “mental illness”) is not at all the same kind of entity as depression (the “sadness, disappointment, or frustration we all experience in our lives”).  And although this is repeated frequently by psychiatric practitioners and leaders alike, no one, to my knowledge, has ever provided proof of this assertion.  Indeed, the APA itself provides fairly convincing indications to the contrary.  The first item in their list of criteria for major depressive disorder is:

“Depressed mood most of the day, nearly every day, as indicated by either subjective report (e.g., feels sad, empty, hopeless) or observation made by others (e.g., appears tearful).  (Note: In children and adolescents can be irritable mood.)” (DSM-5, p 160)

I suggest that feeling “sad, empty, hopeless” or appearing “tearful” to others, or irritability are pretty much the hallmark of depression (the “sadness, disappointment, or frustration” that we all experience from time to time).  The remaining DSM criterion items reflect the severity or depth of the depression, but there is nothing in the list to suggest that depression (the “mental-illness”) is something that needs to be distinguished in any dichotomous sense from less severe depression.  Nor, it needs to be stressed, does Dr. Insel provide us any evidence to support this assertion.

. . . . . . . . . . . . . . . .

“In extreme forms, depression can be so disabling that the thought of getting out of bed or making a phone call becomes overwhelming.”

The word “disabling” is ambiguous.  It can mean that a person is literally incapable of performing the act in question (for instance, a paraplegic’s inability to walk), or it can mean that a person finds the act difficult.  An example of the latter would be a person who had the flu, describing his plight as “disabling” – in the sense that it made it difficult to go about his ordinary activities.  The term “overwhelming” has similar ambiguity.

But Dr. Insel’s statement occurs in the section of his paper titled “When you can’t get up or make a call” [Emphasis added].  So I think it’s clear that he’s using the term “disabling” in the former sense.  In other words, he’s asserting that a severely depressed individual might be as incapable of getting out of bed or making a phone call or presumably engaging in other ordinary activities, as a paraplegic is of walking around the block.

There are two observations that need to be made.  Firstly, there is no way that psychiatrists – or anyone else, for that matter – can know what a depressed person is not capable of doing.  We can know what a person is capable of doing by observing what he/she actually does.  If an individual does something, then clearly he can perform this act.  But the fact that a person does not engage in a certain activity provides no logical grounds for assuming that he can’t  This is not particularly abstruse.  It is Logic 101.  Secondly, to tell depressed people that they are incapable of getting out of bed or engaging in other normal activities is a fundamentally disempowering act, and is a grave disservice to the individuals in question.  It also, incidentally, serves to trivialize and devalue the plight of people who really can’t do these things.

. . . . . . . . . . . . . . . .

“In the United States, approximately 7% of people suffer an episode of depression and about one in five people experience some form of mental illness each year. With prevalence rates so high, the human and economic case for leaders to take mental health more seriously is clearly compelling. What do they need to know?”

Psychiatry’s so-called prevalence figures have to be seen against a context in which they can inflate the numbers at will, by the simple expedient of widening the criteria items or by inventing new “illnesses”. Examples of this in DSM-5 are:  the removal of the bereavement exclusion in major depression; the removal of the inexplicability requirement in somatization disorder; the invention of disruptive mood dysregulation disorder, and attenuated psychosis disorder; etc., etc….  The paradigm example from DSM-IV was the removal of the need for a manic episode for a “diagnosis” of bipolar disorder.

. . . . . . . . . . . . . . . .

But setting all that aside, let’s take a look at the five items that Dr. Insel believes leaders “need to know”.

“First, mental disorders are brain disorders. The brain is a bodily organ just like any other. We should no more blame ourselves or others for a malfunctioning brain than for a malfunctioning pancreas, liver, or heart.  People with brain disorders deserve exactly the same level and quality of medical care as they expect for disorders of any other part of the body.”

The reality is that apart from those “mental disorders” clearly identified as being “due to a general medical condition”, or to “the effects of a substance”, there is no published evidence to support the notion that the various problems of thinking, feeling, and/or behaving catalogued in DSM-5 are brain disorders.  Dr. Insel must be aware that his assertions in this regard are controversial, and if he has evidence to support his contentions, there is, I suggest, an onus on him to cite it.

Note also how Dr. Insel has injected the same spurious dichotomy mentioned earlier into this first item that leaders “need to know”.  The suggestion is that one must either accept his contention that “mental disorders” are brain disorders, or one is blaming the individuals concerned.  In reality, there are multiple other perspectives.

. . . . . . . . . . . . . . . .

“Second, mental illnesses are tied inextricably to physical illness beyond the brain. Brain disorders like depression and schizophrenia greatly increase the risk of developing chronic diseases such as cardiovascular and respiratory diseases. People with mental illnesses and substance abuse are at increased risk of certain infectious diseases such as HIV/AIDS.”

In real medicine it is widely recognized that some illnesses are frequently associated causally with other illnesses.  Chronic hypertension, for instance, is a leading cause of kidney failure, as is diabetes.  Head colds sometimes progress to pneumonia, etc…  In most of these situations, the causal sequence is well understood.  High blood pressure, for instance, can damage the vessels in the kidney, and in extreme cases can cause kidney failure.

There is in Dr. Insel’s second item a suggestion that something similar is at work with regards to “mental illnesses.”  The assertion that “…brain disorders like depression and schizophrenia greatly increase the risk of developing chronic diseases such as cardio-vascular and respiratory disease” implies a causal link.  But the implication is spurious.  Psychiatry defines major depression by the presence of five or more problems of thinking, feeling, and/or behaving from a checklist of nine.  One of these items is weight gain of more than 5% of body weight.  Another item is diminished interest in activities.  It is known that weight gain leads to cardiovascular problems.  So the notion that major depression causes cardiovascular illness is simply an artifact of the APA’s definition.

Similarly with regards to inactivity, the World Heart Federation writes:

“…if you do not keep active, the risk to your cardiovascular health is similar to that from hypertension, abnormal blood lipids and obesity.”

So by making reduced activity a criterion for major depression, psychiatrists are in effect selecting into this diagnostic category people at increased risk for cardiovascular disease.  Then, like Dr. Insel, they announce that depression “increases the risk” of cardiovascular disease.  What a surprise! 

. . . . . . . . . . . . . . . . 

“Third, mental illnesses can be as fatal as physical ones. Suicide causes more deaths than homicide.”

Here again, we have the implication that the psychiatric “illness” called major depression is causing people to kill themselves, when in fact suicidal thoughts/activity are one of the defining features of this condition.  What Dr. Insel is saying, in effect, is that people who think a lot about suicide, and/or make suicide attempts, have a high incidence of suicide.  This is not very profound.

. . . . . . . . . . . . . . . . 

“Fourth, effective treatment can be low-cost and low-intensity. Not everybody with a mental illness needs expensive drugs, hospital care, or even direct access to highly trained psychiatrists. In low resource environments, locals or family members can be trained to provide brief, effective psychotherapies that treat moderate forms of depression or anxiety. Even phone- or internet-based therapy can be used to help recovery. While we don’t have the equivalent of a vaccine for measles or the bed net for malaria, there are low-cost, highly effective interventions for most people either at risk for, or already suffering from, a mental illness.”

The general concept expressed here is non-contentious, but the vast majority of psychiatrists routinely prescribe drugs (some of which are very expensive indeed) to virtually everyone who comes through the door.

. . . . . . . . . . . . . . . .

“Finally, this is an area where policy makers need to do more than ‘build it and they will come.’  It is not enough simply to make treatment available. People with psychotic disorders may deny they are ill and those with depression may be too consumed by self-loathing to feel worthy of help. Even in the developed world, it is estimated that only about half of all people with depression are diagnosed and treated. In the developing world, WHO estimates that 85% of people with a mental illness are untreated. We need sensitive ways to identify those at risk and to help those who are most disabled receive treatment.”

So only half the people “with depression” in the developed world are “diagnosed and treated”.  This is another standard psychiatric assertion.  The much more interesting statistic, of course, would be:  which of these groups does better – those who receive psychiatric treatment or those who don’t.  Psychiatry’s widespread promotions of their treatments, including Dr. Insel’s article, imply that those who receive psychiatric treatment do better, but here are three references and quotes that suggest otherwise:

Do nations’ mental health policies, programs and legislation influence their suicide rates? An ecological study of 100 countries. 

“Contrary to the hypothesized relationship, the study found that after introducing mental health initiatives (with the exception of substance abuse policies), countries’ suicide rates rose.”

The relationship between general population suicide rates and mental health funding, service provision and national policy: a cross-national study

“The main findings were: (i) there was no relationship between suicide rates in both genders and different measures of mental health policy, except they were increased in countries with mental health legislation; (ii) there was a significant positive correlation between suicide rates in both genders and the percentage of the total health budget spent on mental health; and (iii) suicide rates in both genders were higher in countries with greater provision of mental health services, including the number of psychiatric beds, psychiatrists and psychiatric nurses, and the availability of training in mental health for primary care professionals.”

National suicide rates and mental health system indicators: an ecological study of 191 countries.

“Significant positive correlations between suicide rates and mental health system indicators (p<0.001) were documented. After adjusting for the effects of major macroeconomic indices using multivariate analyses, numbers of psychiatrists (p=0.006) and mental health beds (p<0.001) were significantly positively associated with population suicide rates.”

. . . . . . . . . . . . . . . .

The notion of people denying that they “are ill”, or feeling that they are not “worthy of help”, as well as the asserted need to find “sensitive ways” to help those who are “most disabled” reads very much like coerced “treatment”.

There is certainly a great push at present among many psychiatrists and their supporters to persuade political leaders that coercive “treatment” needs to be expanded and made more accessible.  It appears that Dr. Insel is supporting this drive, but his words aren’t entirely clear, and I may be misinterpreting.

. . . . . . . . . . . . . . . .

Then Dr. Insel appears to reverse his general stance.

“…it should be acknowledged that treatments for mental illness remain far from infallible. Of those who get treated, only about half get the right treatment, and only about half of those remit.”

So – of the people that do get drawn into psychiatry’s web, only half get the “right treatment”, and only half of those “remit”.  Which leaves me wondering:  what happened to the half who got the wrong treatment?  And, is wrong treatment the same as malpractice?  And if so, then what is organized psychiatry doing about this?  If half the people who receive psychiatric treatment are getting the “wrong treatment”, shouldn’t this be a cause for major concern within the APA?  Shouldn’t the APA be holding press conferences to alert the public to such a scandalous state of affairs?  Shouldn’t  there be Congressional inquiries?  Shouldn’t we be seeing full-page cautionary ads in newspapers and online?

. . . . . . . . . . . . . . . .

” But for many people, today’s treatments are not good enough.”

And who could argue with that?

Tragically, Dr. Insel’s recipe for remediation is to go on with more of the same:

“Biomedical research gives us hope for cures, for brain disorders as much as any other part of the body. With better policies for providing existing evidence-based treatments in the near-term and research for developing better treatments in the long-term, we can aspire eventually to consign mental illness to the history books.” [Emphasis added]

So we’ll all have our brains corrected.  No more depression; no more defiant or inattentive children; no more crazy people disturbing the peace; no more delinquency; no more anxiety; no more temper tantrums; no more obsessiveness; no more substance abuse;  . . . .  There will be a drug to cure every human problem of thinking, feeling, and/or behaving.

Oh Happy Day!

Antipsychiatry Stigma

The current issue of Acta Psychiatrica Scandinavica is devoted to the topic of psychiatry’s poor image, and what steps might be taken to improve it.

Central to the discussion is a study Images of psychiatry and psychiatrists, by H. Stuart et al, – and seven commentaries on this study by various authors.  The Stuart et al paper describes a survey of 1057 teaching medical faculty members from 15 sites in Europe and Asia.  The overall response rate was 65%, and the results indicate clearly that general medical teaching staff have a poor opinion of psychiatry and psychiatrists.  For instance, 90% of respondents endorsed the item “Most psychiatrists are not good role models for medical students.”

“Over a third thought that their colleagues generally did not speak well of psychiatry, and almost a third thought that a bright student would not be encouraged to enter psychiatry by their mentors or teachers. As a career, psychiatry was seen as having low prestige relative to other specialties. Approximately one in five thought that students were attracted to psychiatry because of their own problems or that students chose psychiatry because they could not get in to other specialties.”

The Stuart et al findings are discussed in seven short editorial comments by various psychiatrists and one psychologist (John Read).  The primary thrust of the psychiatrists’ comments is that the poor image of psychiatry is essentially unwarranted, and that the situation calls, not for any substantive reforms, but rather for improved communication between psychiatry and other medical specialties, and for “…profession-related self-assertiveness…”  One psychiatrist, D. Wasserman, did call for  “…changed behavior on our part”, but from his text it is clear that the change he has in mind is improved sharing of the recent advances in psychiatry with other medical practitioners.

“Psychiatry needs to be proactive in providing easily readable and readily accessible scientifically grounded information to medical staff in general hospitals and in General Practitioners’ (GP) offices about modern psychiatric treatments. As we know, education generally requires repetition, and while all physicians in training are exposed to the field of psychiatry, it behoves us as psychiatrists, to continually inform our medical colleagues about the advances in our field.”

This strikes me as condescending to the point of arrogance, and, to the extent that it reflects psychiatric attitudes generally, could, in combination with psychiatry’s spurious foundations and destructive “treatments,” go a long way to explaining the negative perceptions of other medical professions.

. . . . . . . . . . . . . . . .

I had planned to write a detailed critique of the seven editorial comments, but yesterday on Mad in America I read Psychiatry’s Poor Image: Reflecting on Psychiatrists’ “Apologias”, by Bonnie Burstow, PhD.  The article is a critique of the APS editorials.

Bonnie, in her usual measured but forthright tone, has made all the points that I had wished to make, and many more besides.  Here are some quotes:

“Before I proceed further, I would point out that there is a conspicuous void in this collection. While all authors in their own different ways address what might be done to improve psychiatry’s image, significantly, not a single psychiatrist thinks to ask what by humanistic standards would appear to be the compulsory question: Insofar as any of the bad image is deserved, exactly how are the ‘patients’ being ill served and what is owed them?”

“Most of these responses can be divided into several categories, and all entail some level of evasion. Emergent themes or claims in this regard include: 1) The evidence that psychiatry has a bad image is either not credible or is limited and as such, claims based on it are misleading; 2) Insofar as psychiatry and psychiatrists have a bad image, it is not primarily psychiatry’s fault but the fault of others; 3) The bad image is not exactly anyone’s fault—it goes with the territory; 4) While psychiatry is partially to blame, it is only one or two things psychiatry is doing wrong—none of which are substantive.”

“Ironically, what surprises most of us who are aware of psychiatry’s baselessness, is not how critical other doctors are of psychiatrists but how silent they are about the fraudulence of the medical claims—at least as a big a dynamic as the putative unfairness.”

“The primary purpose of the construction of course is to absolve psychiatry by transferring blame onto others. The various people blamed throughout this collection include: other medical teaching faculty; funders (who allegedly are not  providing sufficient resources to make psychiatry attractive to enter (see, for example Bhugra, 2015), and, finally, the media.  Note in this last regard Bhugra’s curious reference to the “antipsychiatry media coverage.” This of course is ironic given the enormous complicity of the press in furthering psychiatry (see Whitaker, 2002). Moreover, as those of us who organize against psychiatry but receive negligible coverage are well aware, if there is antipsychiatry press out there, it is keeping itself well hidden.”

“Finally comes the very common contention that while psychiatry is wonderful and amazingly successful (and all the psychiatrists more or less concur on this point), it is in fact doing but one or two things wrong, none of which are substantial, albeit they facilitate the “stigma”. Generally, the deficits identified relate to not having a game plan for fighting back and not properly communicating (e.g., what we are being asked to believe is that despite the enormity of the funds spent on promulgating its message—see in this regard Whitaker, 2002—psychiatry is failing to communicate how very scientific and advanced it is—hence the ‘misperceptions.'”

“That these ‘solutions’ will hardly get rid of psychiatry’s fundamental deficits is clear. How can you get rid of shortcomings by putting all your energy into attempting to persuade everyone that they don’t exist?  How can you deal with the problem of a faulty paradigm by further entrenching oneself in that paradigm? But, of course, addressing actual deficits is not the point of the exercise.”

Bonnie’s article is characterized by cogency, lucidity, and fearless honesty.  It’s a superb critique which I strongly recommend.

 

 

Psychiatry: Still Trying To Rewrite History

On October 15, psychiatrist Allan Tasman, MD, published an article in Psychiatric Times.  The title of the article is The Most Exciting Time in the History of Psychiatry.

Psychiatric Times describes itself:  “Our Focus:  News, special Reports, and clinical content related to psychiatry. Our Audience:  Psychiatrists and allied mental health professionals who treat mental disorders.”

According to Wikipedia:  “Psychiatric Times is a medical trade publication written for an audience involved in the profession of psychiatry.”  It is published by UBM Medica and is distributed to about 50,000 psychiatrists monthly.

Dr. Tasman is their recently appointed editor-in-chief, and this article is his inaugural piece.  Dr. Tasman is Chair of the Department of Psychiatry at the University of Louisville, Kentucky.  He was President of the APA from 1999 to 2000 and has held various other offices.  His research, according to his bio,  “…has emphasized the role of brain mapping techniques in the study of the neurophysiology of cognitive processes…”  His research has been supported by grants from Upjohn, Pfizer, Forest Laboratories, and Lilly.

The article’s lead-in is interesting:

“Advances in psychiatric research, spanning the entire spectrum of biological, psychological, and social aspects of mental processes and functions, have transformed the field of psychiatry.”  (Since publication of the article, this lead-in has been deleted, but an almost identical sentence is retained in the article.)

I was immediately intrigued at the notion that advances in psychological and social research have transformed the field of psychiatry, and I read on expectantly.  But, as I suppose I should have known, one can’t judge the article by the opening blurb.

Dr. Tasman begins by telling us that he is honored and excited to be appointed Editor-in-chief of Psychiatric Times.  He assures us that he will continue the “visionary approach” of the previous editors, who were committed to ensuring that “Psychiatric Times” provided “an unparalleled source of high-quality information” aimed to assist psychiatrists in their practice.

He continues:

“We live in what is arguably the most exciting time in the history of psychiatry. At the dawn of the 20th century, though, the themes that would occupy psychiatry in the coming century were already in evidence. One theme has been the emphasis on understanding brain pathology in psychiatric illness, building on the work of the generation of Eugen Bleuler, Emil Kraepelin, and Adolf Meyer.”

Note the phrase:  “…brain pathology in psychiatric illness…”  This is standard, unadorned bio-psychiatry, i.e. that all significant problems of thinking, feeling, and/or behaving are illnesses, caused by brain damage/malfunction.  Dr. Tasman’s identification of Eugen Bleuler, Emil Kraepelin, and Adolf Meyer as early proponents of this position is misleading.  Here are some quotes from Drs. Bleuler and Kraepelin that suggest otherwise.

Eugen Bleuler:

“The conclusion that the development of paranoic delusions is essentially the same as the formation of errors in normal people is therefore warranted.” [p 104]

“Since he [a case study] was sensitive, grounds were not lacking for the feeling that he was being injured by other men and for ascribing to these his failures.  And, since the abyss between the wish and its accomplishment always remained, these ideas were continually maintained, and the patient became paranoic.” [p. 97-98]

Emil Kraepelin:  Dr. Kraepelin was indeed committed to the general concept of biopsychiatry, but was also honest enough to admit:

“As long as we are unable clinically to group illnesses on the basis of cause, and to separate dissimilar causes, our views about etiology will necessarily remain unclear and contradictory.” [As quoted in The Lancet Editorial of April 5 1997]

Adolf Meyer, according to Wikipedia:

“…is most remembered for reframing mental disease as biopsychosocial ‘reaction types’ rather than as biologically-specifiable natural disease entities. In 1906 he reframed dementia praecox [i.e. schizophrenia] as a ‘reaction type, a discordant bundle of maladaptive habits that arose as a response to biopsychosocial stressors.” [Emphasis added]

Clearly Dr. Meyer was not a supporter of biopsychiatry.  It was, in fact, largely through his influence that the various entities listed in DSM-I (1952) were referred to as reactions.  This practice was unceremoniously dropped in DSM-II (1968), as psychiatry and its pharma allies embraced the practices, profits, and deceptions of unambiguously biological psychiatry.  This decision was deceptively rationalized in the Introduction to DSM-III on the grounds that it  “…did not imply a particular theoretical framework for understanding the nonorganic mental disorders.”  In fact, its purpose was to clear the way for an entirely biological, and incidentally, fictitious, psychiatry which had to be developed and maintained in order to take advantage of the drugs that were beginning to come on stream.  Note in passing the quaint phrase “unorganic mental disorders,” which was also allowed to slip quietly into the black hole of psychiatric revisionism.

It’s possible that Dr. Tasman isn’t aware of these heretical tendencies on the parts of Drs. Bleuler, Kraepelin, and Meyer.  Or it’s possible that he is ignoring these troubling deviations from psychiatric orthodoxy in order to convey the impression of a long history of unanimity within his profession.  Either way, his statement is inaccurate and misleading.

 . . . . . . . . . . . . . . .

Back to the article:

“Also, 1900 marked the publication in Europe of Freud’s Interpretation of Dreams, and the beginnings of the modern understanding of psychological development and our emphasis on psychotherapeutic treatments.”

Ah!  Perhaps this is where Dr. Tasman is going to tell us about “the great psychiatric advances in psychological and social research.” [Emphasis added]

Alas, no!  For as soon as Dr. Tasman has mentioned Freud’s psychological work, he immediately dismisses it.  Watch this:

“Less well known, however, is another work on which Freud was laboring at the same time. In the ‘Project for a Scientific Psychology,’ Freud was attempting to understand the neural basis for psychological processes. While the ‘Project’ was not discovered or published until 1953, this century-old quest has marked one of the most important preoccupations of modern psychiatry.” [Emphasis added]

So we’re back to good, old, thorough-going biological psychiatry.  But wait!  There’s a glimmer of hope.  Dr. Tasman describes the quest for brain pathologies as one of the most important preoccupations of modern psychiatry.  What were the other preoccupations?  Dr. Tasman poses that very question, and obligingly provides us with an answer:

“Providing humane and effective treatment for psychiatric disorders, developing a meaningful diagnostic classification, and overcoming substantial societal forces working against rational diagnosis and humane treatment were clearly at the forefront.”

Well there’s nothing there to suggest anything other than broken brain psychiatry.  And the notion of psychiatry providing humane and effective treatment is a little difficult to reconcile with innovations like lobotomies, insulin comas, rotational chairs, hydrotherapy, and chemically and electrically induced seizures.

Also the notion of psychiatry “…overcoming substantial societal forces working against rational diagnosis and humane treatment” is simply false.  The major consequence of psychiatry’s assumption of control of the asylums was the collapse of what was known as “moral therapy”, a model that was based on the view that “insane” people were essentially normal people who had undergone severe psychological and social stressors. James Coleman, in his classic psychology text, Abnormal Psychology and Modern Life, (Fourth Edition, 1972) writes:

“There seems little doubt that moral therapy was remarkably effective, however ‘unscientific’ it may have been.” (p 43)

and

“Despite these impressive results, moral therapy declined in the latter half of the nineteenth century – in part, paradoxically, because of the acceptance of the view that the insane were ill people.” (p 43)

and

“In any event, hospital statistics show that recovery and discharge rates declined as moral therapy gave way to the medical approach.” (p 44)

Other writers have made similar comments on this matter.

. . . . . . . . . . . . . . . .

Then Dr. Tasman gets into some serious cheerleading:

“Building on the tremendous scientific advances of the late 19th century, the beginning of the past century marked a time of great optimism for what 20th-century science would bring to psychiatry.

We have not been disappointed, and we are all aware of the broad range of amazing advances that have occurred.”

Well, Dr. Kraepelin, as we saw earlier, was honest enough to admit that his classification system, lacking as it did any clear understanding of etiology, would inevitably remain “unclear and contradictory.”  And today, 118 years later, psychiatry is in the same position. Apart from those DSM items listed as “due to a general medical condition” or “due to the effects of a substance,” no psychiatric disorder has to date been definitively linked to any specific neural pathology.

So whatever “amazing advances” Dr. Tasman has in mind, it is not in the area of basic causes.  Nor is it in the area of abandoning this futile quest, and recognizing what has been common knowledge for thousands of years:  that distress is largely the ordinary human response to distressing circumstances.

But in fairness, Dr. Tasman takes a small step towards acknowledging this:

“We are still preoccupied with many of the same issues as our colleagues from a hundred years ago.”

But that precipice looks too scary:

“…but, of course, in ways transformed by over a century of experience and newly discovered knowledge.”

Well, certainly, psychiatry has had over a century of experience, but I’m not aware of much in the way of newly-discovered knowledge – certainly there have been no breakthroughs in the quest for neural explanations of problems of thinking, feeling, and/or behaving.  But, “…transformed by over a century of experience and newly discovered knowledge” sounds good.  It’s good spin, and when everything one does is flawed and spurious, spin is all one has left, which is why psychiatry is becoming extraordinarily skilled in the use of spin!

Now, emboldened perhaps by his own cheerleading, Dr. Tasman takes another look at the issues that have preoccupied psychiatry for over a century.  But his choice of issues is somewhat selective:

“Social ostracism, stigmatization, discriminatory government and corporate policies, and discriminatory limits on access to and reimbursement for optimal care are but a few manifestations of these ongoing concerns.”

So, there it is:  all the wicked things that big bad government and big bad insurance companies are perpetrating against psychiatry – the lily-white injured innocent!, the provider of “optimal care.”  There’s not one iota of critical self-scrutiny.  No mention of invalid basic concepts.  No mention of fraudulent research.  No mention of ghost-written textbooks.  No mention of damage from psychotropic drugs.  No mention of corrupt payments to psychiatrists from pharma.  No mention of pharma commercial-fests being accepted as continuing education.  Nothing but:  Oh, my!  How everyone hates us!

And then, just to cement himself firmly into place as a psychiatric leader:

“And, we are still working to develop more effective treatments based on a growing understanding of brain structure and function and an etiologically based system of diagnosis.”

An etiologically based system of diagnosis!  The most fundamental issue in the entire debate tossed in like an after-thought – after social ostracism and reimbursement limits!  Proof of neural pathology underlying every conceivable problem of thinking, feeling, and/or behaving is just around the corner where, incidentally, it’s been for the past forty years.

. . . . . . . . . . . . . . . . 

At this point, Dr. Tasman restates the optimistic assurances of his lead-in: 

“Advances in psychiatric research, spanning the entire spectrum of biological, psychological, and social aspects of mental processes and functions, have transformed our field and our clinical work.”

Ah, the hopeful reader thinks, now we’re going to hear about psychiatry’s embracing of psychological and social concepts.  This is what we’ve been waiting for.  But again our hopes are dashed by the very next sentence:

“We are, though, only in the early years of studying underlying mechanisms of both normal and abnormal brain function and structure via direct functional imaging and sophisticated lab techniques. More exciting findings lie ahead.”

More exciting findings lie ahead from functional imaging and sophisticated lab techniques.  But don’t expect too much.  We’re still in the “early years.”  And don’t expect anything from psychiatry in the psychological or social areas.  Those references were window dressing, designed to create the impression that psychiatry is taking these kinds of issues seriously, even though they aren’t.  And in case there’s any doubt:

“We will undoubtedly, at some point, learn to influence these [neural] processes with more precision than is now possible.”

New drugs?  Different voltages on the shock machines?  More exciting findings lie ahead!  It reminds me of the old serialized movies from my childhood.  Can Captain Marvel escape the molten lava?  More exciting adventures next week!

. . . . . . . . . . . . . . . .

And then the ultimate dismissal of any kind of psychosocial interventions:

“It is also true, however, that interpersonal experiences, such as in psychotherapy, can alter brain function in the same way as medications, as we have seen in studies of OCD and depression.”

There’s no need to talk to anybody; no need to acquire new skills or coping strategies.  Pills have exactly the same effect in the brain as these old-fashioned folk remedies.  Pills are modern.  Who has time for all that old-fashioned stuff anyway?  Life shouldn’t be difficult.  There’s a pill for every problem.

Dr. Tasman then directs his attention towards the biopsychosocial model.  This is an interesting notion. A  biopsychosocial approach to problems of thinking, feeling, and/or behaving means that one acknowledges the obvious reality that these kinds of problems can arise from biological, psychological, and/or social factors, and that interventions should be based on a realistic assessment of the relative weight of each of these factors in individual cases.  It is emphatically not what is found in psychiatry today, where all significant problems of thinking, feeling, and/or behaving are conceptualized as biological illnesses, best “treated” by drugs and/or electric shocks to the brain.  Under the present psychiatrically-managed mental health system, the biopsychosocial approach means, at best, the development of a “good bedside manner” and at worst, the use of non-psychiatric personnel to persuade clients to take their pills, keep their appointments, and be generally compliant.

But watch Dr. Tasman at work.  He describes the biopsychosocial model as “…an integrative approach to understanding not only what the illness is, but also who the person with the illness is – both areas providing essential information for optimal clinical understanding and intervention.”  Note the term “illness,” with its clear implications of biological etiology.  The notion of needing to know “who the person with the illness is…”,  is a caricature of the biopsychosocial model, designed to create the impression of an integrative approach while requiring no deviation from the status quo.  A genuinely biopsychosocial approach in this field would entail, as a fundamental prerequisite, the recognition that most of the clients don’t have an illness at all, and don’t need medical care.

DISCUSSION

Psychiatry clings to the broken brain theory, because without it, there is no justification for the employment of medical techniques in this area.  Without the broken brain theory, psychiatrists are unnecessary, and even counterproductive.  In their hearts, all psychiatrists know this, which is why they never address the fundamental question:  why should all significant problems of thinking, feeling, and/or behaving be considered illnesses?  Instead, they rely on simplistic, unsubstantiated assertions, and dismissive sidestepping of anything that challenges these assertions.  They also make extensive use of spin, cheerleading, and outright deception.  Self-congratulatory rhetoric has become the hallmark of psychiatric writing.

Psychiatry’s edifice is crumbling.  It’s crumbling because it was founded on spurious premises, and has shamelessly embraced destructive and disempowering “treatments”.  But it will not address these issues.  Instead, it conceptualizes the problem as PR.  They believe that they need to become better at “educating” the media and the public.  They feel the need to maintain a constant flow of spin, both internally – to convince themselves that they are a benign institution, and externally – to convince the world that the cries of their detractors are baseless.

But there’s only so much mileage in spin and PR.  And for psychiatry, time is running out.

More Cheerleading from the Royal College of Psychiatrists

On October 23, Simon Wessely, MD, a British psychiatrist, published an article, The real crisis in psychiatry is that there isn’t enough of it, at the online site The Conversation.  Dr. Wessely is the Professor of Psychological Medicine at King’s College, London, and is also the President of the Royal College of Psychiatrists.

The Conversation is an independent non-profit online media outlet that delivers “…news and views from the academic and research community…” directly to the public.  Their aim is “…to promote better understanding of current affairs and complex issues.”

Here are some quotes from Dr. Wessely’s article, interspersed with my comments and observations.

“Psychiatry is apparently in crisis – again. On the one hand, psychiatrists are agents of social control, carrying out society’s bidding to ensure that the socially deviant are kept locked up out of sight and mind. And, despite having little idea of what causes the disorders they claim to treat (which some critics claim don’t exist), they remain set on medicalising more and more aspects of human existence. More still, psychiatry is a pawn of the pharmaceutical industry, peddling drugs that either don’t work or make you worse.”

This is Dr. Wessely’s first paragraph, and is as interesting for its general tone as for its content.  The three links in the paragraph are to articles by:

  • David Pilgrim, Professor of Health and Social Policy at the University of Liverpool
  • Kate Kelland, a Health and Science Correspondent with Reuters
  • John Read, Professor of Psychology at the University of Liverpool

All three articles are cogent, well-written, and relevant, and all three raise serious concerns about psychiatry; concerns which Dr. Wessely, as president of the Royal College of Psychiatrists, might reasonably be expected to address.

Instead, he dismisses these articles in a mocking tone.  And watch where he goes next:

“The thing is, none of these claims are either new, or radical. Look up ‘psychiatry in crisis’ on Google. And then stand well back. Since I started my psychiatry training in 1984, not a year has passed without a clutch of articles, papers and opinion pieces discussing this ‘crisis’. A random selection of articles shows that we have been in crisis because of recruitment (1982), lack of political clout (1984) and public image (1985). In 1997 The Lancet published an article on perceived biological bias. A few years later in the British Journal of Psychiatry it was for not being biological enough … You get the picture.”

In other words:  we’ve heard it all before, and we’ll take no more cognizance of the present criticisms than we’ve taken of those that came earlier.  Criticism of psychiatry is just part of the turf – not anything that needs to be taken seriously.

And incidentally tucked away in the Lancet article that Dr. Wessely so glibly dismisses, you’ll find this:

“In 1896, Emil Kraepelin rejected his previous adherence to a biologically based psychiatry when he urged his readers to shun disease categorisation and return to the richness of simple clinical observation:  ‘As long as we are unable clinically to group illnesses on the basis of cause, and to separate dissimilar causes, our views about etiology will necessarily remain unclear and contradictory’.” [Emphasis added]

What Dr. Kraepelin – who incidentally is biological psychiatry’s historic hero – is stating here is that psychiatric “diagnoses” are simply labels with no explanatory value.  This is perhaps the central criticism of those of us on this side of the debate, and is as true today as it was in 1896.  But psychiatry has consistently refused to address, or even acknowledge, this matter.

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PSYCHIATRIC DETENTION

On the matter of psychiatric detention, Dr. Wessely acknowledges that this happens, but points out that “…only 1.2% of those being managed by psychiatric services were detained.”  But watch where he takes this:

“Any humane society has a duty to try and look after its citizens when, as a result of a mental disorder, they pose a serious risk to themselves or others. And if this is the case, then it is better that it is sanctioned by law and implemented by health professionals, rather than by vigilantism and mobs. True, we don’t have the balance right yet, but not in the way the ‘crisis’ lobby would have you believe. Take jail, for example, there are far too many people in prison with serious mental illness – not too few.”

So, people are involuntarily committed when “…as a result of a mental disorder, they pose a serious risk to themselves or others.”  The phrase “…as a result of a mental disorder…” presupposes that psychiatric diagnoses have explanatory value.  To clarify this, consider the hypothetical conversation:

Family member:  Why is my mother so depressed?  Why does she want to kill herself?
Psychiatrist:  Because she has an illness called major depressive disorder.  The illness causes the depression and the suicidal tendencies.
Family member:  How do you know she has this illness?
Psychiatrist:  Because she is so depressed and wants to kill herself!

In other words: your mother is depressed and suicidal because she is depressed and suicidal.

This is the central flaw in psychiatry’s sand castle:  there is no evidence for its diagnoses other than the very behavior that these “diagnoses” purport to explain.  Psychiatric diagnoses have no explanatory value.  This is what Thomas Insel, MD, Director of the NIMH, meant in his blog post Transforming Diagnosis when he said that the DSM is:

“…at best, a dictionary, creating a set of labels and defining each.”

But Dr. Wessely trots out the standard formula – “as a result of a mental disorder” – and dismisses this entire issue with customary psychiatric arrogance.  And he attempts to obscure this logical fallacy by couching it within the framework of the duties of a “humane society”.  In this regard, it is worth pointing out that psychiatric “management” of those who “pose a serious risk to themselves or others” has not been consistently humane, as is evident from the accounts of survivors.

But Dr. Wessely is only warming up.  He tells us that legally sanctioned psychiatric care for those involuntarily detained is better than “vigilantism and mobs”.  This is spin of a very high order.  Firstly, Dr. Wessely’s words imply that these are the only two options:  psychiatrists or mobs; and but for the staying hand of psychiatry, the mobs would be roaming the streets dragging these individuals from their homes and – what? – hanging them from lampposts?  Secondly, he’s conveying the impression that those of us on this side of the debate who seek to undermine psychiatry’s “humane” efforts in this area are in fact promoting mob violence!

Dr. Wessely concedes that psychiatry doesn’t have “…the balance right yet, but not in the way the crisis lobby [that’s us, by the way] would have you believe”.  The next sentence is obscure, but from the context, he seems to be saying that there needs to be more use  made of involuntary detention, and that many of the people who should be in psychiatric detention are actually in prison (“…there are far too many people in prison with serious mental illness – not too few.”)

So, if I understand the passage correctly, people with “serious mental illness” who commit crimes should be diverted from the justice system to the psychiatric system.

In support of his contention, Dr. Wessely cites a brief report from the Prison Reform Trust which provides the following statistics:

  • 14% of women and 7% of men serving prison sentences have a psychotic disorder
  • 26% of women and 16% of men said they had received treatment for a mental health problem in the year before custody
  • 62% of male and 57% of female prisoners have a personality disorder
  • 49% of women and 23% of male prisoners have anxiety and depression
  • 46% of women prisoners reported having attempted suicide at some point in their lives

And from these statistics, Dr. Wessely concludes that far too many people with “serious mental illnesses” are in prison.  Firstly, note his injection of the word “serious”, which is not found in the PRT’s report.  Secondly, we are routinely assured by psychiatry that at any given time, fully 20% of the population meets the DSM criteria for a mental illness, and that the lifetime figure approaches 50%.  So it’s no great wonder that a great many people in prison also meet these criteria.  Thirdly, one of the DSM’s personality disorders is antisocial personality disorder, which essentially means:  habitual lawlessness and disregard for the rights of others.  Is it surprising that these individuals are over-represented in prisons?  Fourthly, the criteria for several “mental illnesses” include acts of violence, anger, defiance, etc… (e.g. conduct disorder, intermittent explosive disorder, PTSD, etc.) and, again, it is scarcely surprising that many of these individuals are in prisons.  Fifthly, prisons are – and are designed to be – depressing, anxiety-provoking places.  Why should we be surprised to find that inhabitants of these places are anxious and depressed?  And sixthly, a great many people in prison seek drugs to take the edge off their understandable sense of helplessness and distress.  In this regard, they have two options:  run the risk of smuggling in street drugs, or go see the prison psychiatrist and get some pharmaceutical products.  The second option, of course, entails a “diagnosis of mental illness.”

But over and above these demographic issues, there is an unspoken assumption in Dr. Wessely’s contention, that people who meet the criteria for serious mental illness should not be held accountable for their criminal activity in the same way that other people are.  I realize that this issue is intertwined with the more fundamental question of the efficacy and morality of imprisonment, but a discussion of this would take us too far afield.  At the present time, imprisonment is the procedure routinely used in western countries as punishment for serious crime, and Dr. Wessely seems to be endorsing the belief that this procedure should not be used in cases where the miscreant meets the criteria for a “serious mental illness.”

Dr. Wessely provides no argument for this assertion, but presumably his “logic” would go something like this:

Question:  Why did this individual commit this act of violence?
Answer:  Because he has a mental illness called……
Question:  How do you know he has this mental illness?
Answer:  Because, among other things, he is given to acts of violence.

So we’re back to the same circular nonsense that we saw earlier.  And Dr. Wessely appears to have no appreciation of the fact that his casual assertions are underpinned and driven by such fallacious reasoning.  He has bought the psychiatric philosophy, hook, line, and sinker, and clings to its mantras with the blind faith of a true zealot.  And with the faith of a true zealot, he trivializes and dismisses the protests of his critics, and with each assertion mires himself deeper in error.

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TREATMENT AND CAUSES

Remember that the title of Dr. Wessely’s paper is an assertion that we need more psychiatry, so he now embarks on the arduous task of showing how helpful and efficacious psychiatry is.

“Treatments are certainly far from perfect. But no more than in the rest of medicine; a recent review showed that treatments used by psychiatrists, both physical and psychological, compare well to treatments in routine use in other branches of medicine.”

This quote includes a link to a British Journal of Psychiatry article Putting the efficacy of psychiatric and general medicine medication into perspective: review of meta-analyses by Leucht et al.  The first thing that the observant reader might notice is that although Dr. Wessely asserted that psychiatric treatments both physical and psychological compare well to those in general medicine, there is no reference in the Leucht et al title to anything other than treatment with “medication”.   And the title is not deceptive.  Leucht et al runs to nine pages, with several additional supporting documents online, but there is no reference anywhere to any kind of treatment other than drugs.  So when Dr. Wessely asserts that the Leucht et al study shows that psychiatric treatments, physical and psychological, compare well to those used in general medicine, he is making a false assertion.  And besides, how many psychiatrists are using psychological treatments?

Here are the results of Leucht et al as written by the authors:

“We included 94 meta-analyses (48 drugs in 20 medical diseases, 16 drugs in 8 psychiatric disorders). There were some general medical drugs with clearly higher effect sizes than the psychotropic agents, but the psychiatric drugs were not generally less efficacious than other drugs.”

And here’s a schematic of the results:

Fig 1 Leucht et alEach circle represents a study.  The vertical scale is the effect size (drug vs. placebo) expressed as a standardized mean difference.  A score of zero means no drug effect; a negative score indicates that the drug did worse than the placebo; and a positive score indicates that the drug did better than the placebo.  As can be seen, the results for both general medical drugs and for psychiatric drugs cluster around the 0.4 – 0.5 area, i.e. a positive difference of about half a standardized mean difference.

A detailed critique of Leucht et al would take us too far afield, but the following points are worth noting:

  1. Most trials of psychiatric drugs use rating scales and other soft measures, which do not provide the kind of objectivity that characterize research in general medicine.
  2. It is generally easier for participants in psychiatric studies to identify whether they have been given the drug or the placebo, than is the case in general medicine. So the noted effectiveness of a psychiatric drug is more likely to be inflated by placebo contamination.
  3. Leucht et al specifically excluded any consideration of side effects, which in psychiatry frequently eclipse any reported drug benefits.
  4. Conflicts of interest. Both Stefan Leucht and Werner Kissling (one of the other authors) have received payments for consulting and lecturing from several pharmaceutical companies.

But back to Dr. Wessely.

“There remain doubts and uncertainties about the causes of many of the disorders we see. But this is not because we are ignorant, lazy or complacent; it is because psychiatric disorders, such as major depression, arise out of a complex set of circumstances – starting from your genetic inheritance, early upbringing, the relationships you make and the physical and psychological traumas and adversities to which you are exposed to in adult life. The issues with which we grapple are rarely simple or straightforward.”

The observant reader may notice that Dr. Wessely’s listing of the causes of major depression does not include neural chemical imbalance.  This strikes me as odd, because in the past 30 years or so, every psychiatrist I’ve encountered has asserted confidently and vigorously that chemical imbalances in the brain were the only causes of depression.  The impact of early upbringing, relationships, and the adversities of life were dismissed as irrelevant and distracting, and drugs were ladled out by the proverbial boatload to “cure” these supposed pathological imbalances.

Now, it may well be that Dr. Wessely has never been an adherent of the chemical imbalance school.  It may be that, throughout his career, he has steered clear of this inane nonsense.  But in the paragraph quoted above, it is clear that he is not speaking solely for himself, but rather for psychiatry in general.  He refers to the disorders that “we” see; he assures us that “we” are not ignorant, lazy, or complacent; and he refers to the issues with which “we” grapple.

So from his assertions concerning psychiatry’s analysis of the complex genesis of depression, I can only conclude that, either Dr. Wessely is grossly out of touch with what’s going on in his field, or is primarily concerned with rewriting history.

And then:

“Not for us the simplicities of some other parts of medicine. Here is a cancer – take it out. There is a bug – kill it. In psychiatry, the ability to tolerate uncertainty is an essential skill. Because we have to negotiate fuzzy boundaries – between eccentricity and autism, between sadness and clinical depression, between hearing voices and schizophrenia – and there will always be boundary disputes.”

The simplicities of some other parts of medicine!  “Here is a cancer – take it out”!  “There is a bug – kill it”!  Is this meant to be a serious description of general medicine?  Frankly, it reads more like a Monty Python skit with John Cleese reciting the lines.

It is obvious that Dr. Wessely is caricaturing general medicine, which is founded on real science, in order to promote psychiatry, which is founded on unsubstantiated assertions and logical fallacies.  And the notion of psychiatrists tolerating uncertainty strikes me as bordering on delusional.  Psychiatrists in fact routinely challenge the open-mindedness of other professions in favor of their glib assertions concerning chemical imbalances and the restorative effects of their drugs and shock machines.

“Far from backing away from such debates, my experience of psychiatry is that we relish them.”

“If there is a little bit of crisis, like argument and discussion it keeps us on our toes, alert to new developments, and is an antidote to complacency.”

Obviously Dr. Wessely and I move in very different circles.  The only “debating” I’ve ever heard from a psychiatrist could be paraphrased as:  “We’re right; you’re wrong.  And your position is damaging patients and increasing stigma.”  And “Denying the existence of mental illness is like denying evolution or the Holocaust.”

THE EVIDENCE THAT MORE PSYCHIATRIC SERVICES ARE NEEDED

Dr. Wessely then provides his evidence that more psychiatric services are needed.  This evidence is not based on any kind of comprehensive needs assessment.  No demographic statistics are provided.  No references to outcome findings.  Dr. Wessely has no need of those kinds of complications.  He knows that more psychiatrics services are needed because: he gets lots of letters from individuals who tell him so!  “Not all letters I’ve received have been complimentary, but the main themes have not been about our services, but the lack of them.”

And from this evidence, Dr. Wessely confidently concludes:

“The real crisis in psychiatry is that there isn’t enough of it.”

And this is the same Dr. Wessely whose profession is noted for its “ability to tolerate uncertainty” and welcomes new developments “as an antidote to complacency”.

AND INCIDENTALLY

There are at least three studies that demonstrate a positive correlation between suicide rates and psychiatric expenditures.

Burgess P, Pirkis J, Jolley D, Whiteford H, Saxena S. Do nations’ mental health policies, programs and legislation influence their suicide rates? An ecological study of 100 countries. Aust N Z J Psychiatry. 2004 Nov-Dec; 38(11-12):933-9.

Results: “Contrary to the hypothesized relationship, the study found that after introducing mental health initiatives (with the exception of substance abuse policies), countries’ suicide rates rose.” [Emphasis added]

Shah A, Bhandarkar R, Bhatia G., The relationship between general population suicide rates and mental health funding, service provision and national policy: a cross-national study., Int J Soc Psychiatry. 2010 Jul; 56(4):448-53. doi: 10.1177/0020764009342384. Epub 2009 Aug 3

Findings:  “The main findings were: (i) there was no relationship between suicide rates in both genders and different measures of mental health policy, except they were increased in countries with mental health legislation; (ii) there was a significant positive correlation between suicide rates in both genders and the percentage of the total health budget spent on mental health; and (iii) suicide rates in both genders were higher in countries with greater provision of mental health services, including the number of psychiatric beds, psychiatrists and psychiatric nurses, and the availability of training in mental health for primary care professionals.” [Emphasis added]

Rajkumar AP, Brinda EM, Duba AS, Thangadurai P, Jacob KS. National suicide rates and mental health system indicators: an ecological study of 191 countries. Int J Law Psychiatry. 2013 Sep-Dec; 36(5-6):339-42. doi: 10.1016/j.ijlp.2013.06.004. Epub 2013 Jul 17.

Results:  “Significant positive correlations between suicide rates and mental health system indicators (p<0.001) were documented. After adjusting for the effects of major macroeconomic indices using multivariate analyses, numbers of psychiatrists (p=0.006) and mental health beds (p<0.001) were significantly positively associated with population suicide rates.” [Emphasis added]

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CONCLUSION

Psychiatry is intellectually and morally bankrupt.  Its concepts are spurious, and its “treatments” are destructive, disempowering, and stigmatizing.  The conditions and problems that it purports to address are not illnesses, and are simply not amenable to remediation by psychiatric drugs.  The temporary relief that these drugs afford some individuals is essentially similar to that obtained from alcohol and street drugs.

Psychiatry has no cogent response to these criticisms, and routinely relies on the kind of fatuous cheerleading exemplified in Dr. Wessely’s article, as a substitute for genuine debate.

I imagine that people expect more from the President of the Royal College of Psychiatrists, but those of us on this side of the debate have long recognized that psychiatry, when all is said and done, has nothing cogent or substantive to offer.