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]
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“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.
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“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).
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“…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]
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“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.
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“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.
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“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.
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“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.
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“…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?
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“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.
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“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.
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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.