On January 29, the APA’s online bulletin Psychiatric News, published Psychiatry Embraces Patient-Centered Care, by Jeffrey Lieberman, MD, and Lisa Dixon, MD. Dr. Lieberman is President of the APA, and chair of psychiatry at Columbia University. Dr. Dixon is a professor of psychiatry at Columbia.
Here’s the opening statement:
“Psychiatry has long been considered the medical specialty most attuned to listening to the patient.”
This is a little difficult to reconcile with the fifteen minute med-check that has been pretty much the standard of care in most psychiatric offices for the past 25 years. It is also difficult to reconcile with reports from psychiatric survivors.
The authors are willing to concede, however, that “…the nature of the doctor-patient relationship was traditionally one-sided.” What they mean by this is:
“Patients talked and their physicians listened, and then the doctor prescribed the treatment and the patient followed.”
Note, in passing, Dr. Lieberman’s use of the word physician rather than psychiatrist. He is desperate to promote the notion that psychiatrists are real doctors, and you will find these plaintive claims for medical legitimacy in virtually everything he writes. You don’t find this from cardiologists, nephrologists, pulmonologists, etc…, because those folk are real doctors – they treat real illnesses, unlike psychiatrists, who invent their illnesses and then don’t actually treat them, but instead prescribe neurotoxic chemicals.
So psychiatry has been one-sided. But Drs. Dixon and Lieberman tell us that this is all about to change:
“But now psychiatry is changing as the field of medicine adopts patient-centered care.”
Let’s back up. He begins with the fiction that psychiatrists are the great listeners. And having listened, carefully and attentively, they told their patients what to do. With hindsight he concedes that perhaps this was a little one-sided (Lieberman-speak for patronizing and condescending), but, he assures us that psychiatry is now changing. But – and this is Dr. Lieberman at his self-exculpating best – it wasn’t really a fault within psychiatry; rather the entire field of medicine was “one-sided” and is now adopting patient-centered care.
Dr. Lieberman has got to be the only person in the world who can acknowledge a failing in one sentence and expunge it entirely in the next.
And this takes us to the second theme that permeates the eminent doctor’s writing: psychiatry is blameless. Regardless of how it might seem, regardless of the damage done, psychiatry is unreservedly wholesome and blameless.
The fact is that real doctors abandoned the patronizing doctor-knows-best approach decades ago. But patronization and condescension are a built-in factor in psychiatry, where the patient’s statements are routinely conceptualized as “symptoms,” where complaints of intolerable adverse effects are seen as “non-compliance,” and where ultimately all transactions are conducted under the threat of involuntary commitment.
But let’s move on. There’s more to come.
So, Drs. Dixon and Lieberman tell us, psychiatry is adopting patient-centered care. This involves “shared decision-making” which
“…requires that psychiatrists assess the patient’s interest in participating in decisions, providing information to them on the risks and benefits of specific treatments…”
This innovation, which incidentally has been standard practice in real medicine for decades
“…brings the hope that patients will be more inclined to adhere to treatment and share important information about their response (including side effects), thereby enabling their physician to make adjustments as needed.”
This, the authors tell us, will be an important innovation, because:
“In psychiatry, as in all of medicine, patient adherence is a prevalent problem and major limitation of treatment.”
With the phrase “as in all of medicine,” Dr. Lieberman is trying, yet again, to promote the notion that psychiatrists are real doctors. But he’s also trying to suggest that treatment refusal is no more common in psychiatry than in other medical specialties.
What he doesn’t mention, however, is that many, perhaps most, of the psychiatric clients who unilaterally discontinue their pills do so either because they don’t believe they are ill, or because they hadn’t noticed any benefit from the drugs, or because they had become aware of the devastating adverse effects. With regards to their not believing they are ill, psychiatrists routinely dismiss this as anosognosia – which is a “symptom” of a “mental illness.” How’s that for a closed loop.
Psychiatrist: “You’re very sick.”
Client: “I don’t think so.”
Psychiatrist: “Ah ha – that proves it.”
The fact is that psychiatric “diagnoses” are routinely made on the basis of brief interviews, during which no attempt is made to understand or conceptualize the presenting problems from anything other than psychiatry’s standard formula – a brain illness which requires “medication” for life. And clients – despite psychiatry’s built-in condescending and patronizing attitude – are not stupid. They may play along from considerations of expediency or misplaced deference, but in their hearts, they know they’ve been railroaded. They know it’s a sham. They know that psychiatry is damaging them. And they try to extricate themselves from its clutches.
But Drs. Lieberman and Dixon aren’t having any of that:
“For numerous reasons, many patients are unable or unwilling to follow through on ‘doctor’s orders,’ with worsening symptoms as a consequence.”
How’s that for condescending grandiosity? Patients who stop taking their pills get worse. There’s no reference to the hundreds of thousands (millions?) of survivors worldwide, who are doing better since they stopped taking the pills; there’s no mention of the research (e.g. Harrow and Jobe, Faber et al, Wunderink et al) that shows that people who come off neuroleptics do better than those who stay on. There’s no reference to the truly horrendous and irreparable side effects of neuroleptics. There’s no reference to the fact that SSRI’s induce suicidal and homicidal urges in some people. There’s no reference to the addictive effect of benzodiazepines. And so on.
No. Just the same old mantra: keep taking your pills as the “doctor” ordered, or everything will get a great deal worse. There’s not even the beginning of a trace of a smidgen of a hint that some of psychiatry’s “treatments” are intrinsically damaging and destructive.
And it gets worse:
“This new paradigm is not without its challenges. Empowering patients to be active participants in their care often requires educating them about their disorder and options for therapy to ensure they are prepared to ask relevant questions and understand the answers.”
So this new and improved client-centered, shared decision-making paradigm does not really involve shared decision-making. Clients have to be “educated” about their disorders (“You have a brain illness called schizophrenia”) and options for therapy (“These anti-psychotic drugs keep the illness in remission; you must take them for life”). This way, clients will be prepared to ask relevant questions (“Could this have anything to do with the fact that I was abused as a child?”) and understand the answers (“No.”)
The belief that people who disagree with me simply don’t understand the issues is the hallmark of arrogance. It is also an abiding feature of organized psychiatry.
Drs. Dixon and Lieberman tell us that client-centered care will be more difficult for those
“…patients whose disorders impair their cognitive and decision-making abilities.”
“In fact, these concerns are cited by some psychiatrists as the reasons they are reluctant to embrace this care model.”
So psychiatrists’ enthusiasm for client-centered care isn’t universal.
The authors tell us that “one study,” for which no reference is cited, used group training on shared decision-making with people who had been assigned a “diagnosis” of schizophrenia. The individuals who received this training
“…were more involved in their own care, and more likely to continue to take their medications.” [Emphasis added]
Which suggests that at least from Drs. Lieberman and Dixon’s perspective, the client-centered shared decision-making may be more a tool to persuade people to take neuroleptic drugs, rather than a mechanism to help them explain why they should not. Perhaps what the authors are promoting here is not so much genuine client-practitioner collaboration, as using group dynamics to overcome people’s legitimate and understandable reluctance to go on consuming neurotoxic chemicals.
Incidentally, I did search for the unreferenced study, and the only likely candidate I could find was Hamann et al. This was a German inpatient study which compared the results of “shared decision-making training” vs. “cognitive training.” The authors reported a non-significant (P = 0.1) increase in “medication” compliance by client report. By contrast, the psychiatrists’ estimate of medication compliance was higher for the control group, again not significant (P = 0.8). What is particularly interesting in this study, however, is that:
“Patients in the intervention group became more skeptical of treatment and were perceived as more ‘difficult’ by their psychiatrists.”
Imagine that! Psychiatrists are keen on shared decision-making training if it makes clients more compliant, but not if it makes them more skeptical of treatment. The Randle P. McMurphy syndrome.
But back to Drs. Lieberman and Dixon.
“CommonGround, a web-based application that facilitates shared decision making among individuals with mental illness, received APA’s 2013 Psychiatric Services Gold Achievement Award.”
The APA’s Psychiatry Online has a brief piece on the Gold Achievement Award. In the article it states that CommonGround is a unique software program developed by Patricia Deegan, PhD. You can see her site here, and if you wish, you can purchase CommonGround and other materials, including toolkits, videos, training manuals, etc… The licensing fee for CommonGround for 500 users is $1,000 per month.
In the Gold Achievement Award article, the APA states that CommonGround
“…helps individuals organize and express their treatment concerns clearly. Even people with low literacy and no computer skills can readily use the program’s touch screens.”
This sounded pretty good, so I took a look at Pat Deegan and Associates’ (PDA) promotional video. Here’s how it works. A computer is set up in the mental health center waiting room. The client, arriving for his psychiatrist appointment, first navigates his way through the program, responding to questions like:
“Since my last appointment I had trouble concentrating and paying attention to the things I need to do.”
“Since my last appointment, I have been concerned about side effects from my mental health medication.”
The client has a range of answers in some cases, and a yes/no choice in others. When he’s finished, he receives a printed page which summarizes his concerns/perspectives, and he is instructed to bring this page into the meeting with the psychiatrist. Meanwhile, the psychiatrist has already seen a copy of the summary on his own screen. The idea is that the client is thereby empowered to discuss his concerns openly and comprehensively with the psychiatrist, and everything goes a great deal better. At the end of the session, the client and the psychiatrist agree on a plan of action. An example of this is shown in the video:
“Our Shared Decision: Between now and my next appointment my doctor and I agree that I will review the lithium fact sheet with a peer staff person. I will also review the tip sheet on how to manage anger.”
In theory there’s nothing especially wrong with this general concept. If one goes to see a urologist or a dermatologist or other medical specialist, one is often asked to fill out a form while waiting, and this obviously saves time during the consultation. I’m a little skeptical of the notion in the mental health arena, however, because I don’t think the subject matter lends itself to these kinds of perfunctory communication devices. I’m an old-fashioned sort of guy who believes that people won’t share important and sensitive information about themselves unless: 1) they trust me, and 2) I’ve taken the time to get to know them and let them get to know me.
With regards to CommonGround, I also have the uncomfortable feeling that it’s more about securing “medication compliance” than genuine dialogue and collaboration.
So I looked a little deeper, and here’s what I found. Community Care Behavioral Health Organization (CCBH) is a large managed care company based in Pittsburgh. It is part of the University of Pittsburgh Medical Center, and it has developed peer-run Decision Support Centers at 12 sites in Pennsylvania. David Kupfer, MD, DSM-5 architect, is one of their board members. According to the APA’s Gold Achievement article, CCBH
“…began a collaboration with Pat Deegan and Associates (PDA) in 2007 to develop a replicable version of CommonGround…”
In addition, CCBH was
“…the first of PDA’s partners to take the program to scale, playing a crucial role in the migration of CommonGround into medical practice.”
On the PDA website, you can find an interesting page titled CommonGround Can Help With Treatment Adherence. Here are some quotes:
“In the U.S., $32.5 billion dollars a year is spent on treatment of schizophrenia alone, with the bulk of those dollars spent on hospital care due to significant rates of medication nonadherence…CommonGround may increase treatment adherence because it helps people express and work through concerns about prescribed treatment upstream, before non-adherence becomes a problem.”
“In addition to flagging these concerns, CommonGround recommends strategies to resolve decisional uncertainty about using medicine as prescribed. In this way, CommonGround empowers doctors, therapists and case managers with the tools to engage clients about their concerns upstream before non-adherence becomes a problem.” [Emphasis added]
Again, there’s the suggestion that CommonGround may be geared more to empowering “doctors, therapists, and case managers” than clients.
In all of this, there’s a clear underlying assumption: that people who decide to stop taking psychiatric drugs, as the “doctor” ordered, are making a terrible mistake, and that one of the great “benefits” of CommonGround is that it enables the practitioners to anticipate this eventuality and take proactive preventive measures.
No cognizance is taken of the fact that these individuals may have perfectly rational and justifiable reasons for their decisions. Nor is there any suggestion that their decisions should be respected simply on the grounds of human dignity. Instead, a client’s decision to “come off meds” is routinely seen as flawed – a challenge to psychiatric infallibility, and something that needs to be changed.
A great irony here is that Dr. Deegan herself is a psychiatric survivor. Here’s the lead-in to an interview she gave Forbes in October 2012:
“Pat Deegan is the creator of CommonGround, a web-based application that empowers patients recovering from mental illness to take a more active role in their recovery. Pat’s own journey began in her adolescence. At 17 she was diagnosed [with] schizophrenia. Psychiatrists told her that schizophrenia is a disease from which nobody recovers. They advised her to retire from normal life, avoid stress, and take high dose antipsychotic medication regularly.
It turned out that the treatment was as disabling as the disorder. Most disabling of all was the prognosis of doom and hopelessness surrounding the diagnosis and treatment. Faced with a future as a chronic mental patient, Pat forged a survivor mission for herself.”
So, apparently, Dr. Deegan became empowered and successful by rejecting psychiatry’s disempowering message, and by not taking high doses of neuroleptics daily for life.
But she is now selling a product to psychiatrists that, by her own account, can increase “treatment adherence,” and this product has been awarded the APA’s Gold Achievement Award.
Many of the things Dr. Deegan says make sense. She stresses client empowerment and points out that her CommonGround program enables the clients to inject their concerns and objectives into the discussion. It may be that I’m overstating the “medication compliance” aspect of the matter, and I’m certainly open to additional information and correction in this regard. But as of this point, I have concerns.
Back to Drs. Lieberman and Dixon. Their final paragraph reads:
“Psychiatry has always been the field of medicine that prided itself on emphasizing the doctor-patient relationship. We now need to extend this practice, to enhance patient involvement, and begin listening—and talking—to our patients in new ways. To do so will only enhance the physician-patient relationship and the quality of health care.”
Note the tired old themes: psychiatry is a “field of medicine;” psychiatry emphasizes the doctor-patient relationship. And now psychiatrists are going to start listening and talking to their “patients” in new ways!
As my readers know, I have a great fondness for Dr. Lieberman. After all, he makes my job so much easier. So in that spirit, I offer my suggestions as to how psychiatrists might start talking to their clients.
1. Stop telling clients the stigmatizing and disempowering lie that their problems are illnesses.
2. Stop telling clients that their problems are caused by chemical imbalances, neural circuitry malfunctions, or whatever next fad is coming down the line.
3. Stop telling clients that psychotropic drugs correct these neural problems, and that the drugs must be taken for life.
4. Start telling clients the truth: that the drugs are neurotoxic chemicals that, like street drugs, may take the acute edge off a problem in the short term, but will inevitably do a great deal of damage in the long run.
5. Start telling clients that there are much better ways to deal with life’s problems.
6. Apologize for the damage already done, become skilled in the matter of detoxification, and humbly offer their services in detoxing clients from these dangerous, dependence-inducing drugs.