1 Boring Old Man

A Debate Between Allen Frances and Robert Whitaker

Mad in America

by Allen Frances, M.D. and Robert Whitaker

December 4, 2014

[full text on-line]

It’s there for all to read so I won’t try to summarize it here. I’d suggest reading it, actually reading it several times. Because it’s so familiar, I tended to skim it the first time through. And it deserves a more thorough reading. The other thing I would suggest is to pretend you are a psychiatrist if you’re not. And pretend you’re not a psychiatrist if you are. We’re in such a rut with all of this, that about all you’ll come away with is having rooted for your home team if you don’t do something to break the frame of your well-worn ideas or ideology.

I have a lot of respect for these men. Both have done something creative and courageous by running against the tide of the times. They’ve inserted themselves into the center of important debates that had grown monotonous, moved things into a much more productive though certainly no less divisive trajectory. I’ve read their writings with interest, and like most, I feel the better informed for having done it. But after reading this debate several times, I was surprised to find that I didn’t really think that either one of them had it quite right – too many straw men [heroes and villains]. But after writing multiple versions of this post, and then erasing them, I decided that I’m not really capable of transcending my own experience of the major issues covered in this debate and would start by talking about that experience.

a·sy·lum  (-slm)
noun.
1. An institution for the care of people, especially those with physical or mental impairments, who require organized supervision or assistance.
2. A place offering protection and safety; a shelter.
3. A place, such as a church, formerly constituting an inviolable refuge for criminals or debtors.
4. The protection afforded by a sanctuary.
5. Protection and immunity from extradition granted by a government to a political refugee from another country.

Even in its inadequately funded days, the Community Mental Health Movement was partially successful. The Asylums disappeared and the patients were, indeed, back in the community. As a psychiatry resident in the first year, I spent my days with the patients who didn’t fit, who were too ill to manage being in open society and were brought or came to the "Emergency Receiving Unit" where I was assigned. In those days, I encountered the writings of Thomas Szasz early from a fellow resident [see Szasz by proxy…]. The model of the times was focused on relapses, episodes of intense psychosis, and the idea was to treat them with medications and return the patients to the community as quickly as possible. It was a laudable goal, but only when it worked. Unfortunately, chronic psychosis doesn’t respond to the medication like the acute illness does, and the patients don’t like to take it for reasons easily discovered if you take only one pill yourself. And so there was a subset of "revolving door" patients who came or were brought back to the hospital regularly. And there was the specter of Tardive Dyskinesia, a potential neurologic consequence of long term medication that you only have to see once to live in terror of causing.

I had not come to psychiatry to be in charge of keeping the streets of Atlanta safe nor to involuntarily treat anyone. I had discovered that many of the patients who came to my office as an Internist were there because of emotional tangles. I could see what was wrong, but I had no idea what to do, so I came to a psychiatry residency to find out. I knew nothing of psychosis – meeting it for the first time in my early thirties in a big city charity hospital in a difficult historical epoch. And that part was, indeed, difficult. I struggled with the same issues I now read about on Mad-in-America. Besides the fellow resident who was Szaszian, I was fortunate to have an advisor, Dr. Jonas Robitscher, a psychiatrist, psychoanalyst, lawyer who had famously written The Power of Psychiatry. While his conclusions were similar to those of Szasz, he was not a "blamer." He was a Civil Libertatian who believed that the right to due process belonged in our courts, not our doctors. As he related it, the historical addition of psychiatrists to the commitment process antedated the coming of medication, and was originally conceived as a reform movement to keep small town judges from "sending away" undesirables to mental hospitals.

Some years later, I had the opportunity to work with a lawyer friend tasked with drafting a new version of our State’s commitment law for the legislature. We changed it to make judicial review mandatory rather than voluntary. On the next iteration, he was able to change it further to take "psychiatrist" out of the mix altogether [see a clarification…]. That was years ago. I believe that’s now a general trend among the States. But what I’m arguing with is not the details. It’s the implication in Whitaker’s debate piece and among those who write on his site that psychiatrists want that power, or hang on to it  [the power to commit] as a tool to retain some kind of hegemony among the mental health disciplines or power over patients. I’ve not seen that to be true. My own complaint is the opposite – that psychiatry proper has ignored the care of the chronic mental patients during the last quarter century just like everyone else – including the other mental health disciplines and governmental agencies. From my perspective, there are no heroes in this story.

While I am much more on the side of Bob Whitaker in looking at what happened in 1980 in terms of the APA and academic psychiatry, I see the forces at work and the motives in a very different way. Both Allen Frances and Bob Whitaker leave out too much of that story for my tastes, and neither addresses what I consider to be the central player in the piece – money. In the 1970s, the major third party payouts by medical insurance in mental health were for inpatient hospitalizations and long psychotherapies. That was not going to continue, and mental health coverage was under attack. That was a major factor in the medicalization of psychiatric diagnosis in 1980 – legitimizing access to third party payments. In that regard, it was successful for psychiatrists and the other mental health disciplines. I doubt it would’ve happened otherwise. What then happened was unexpected, at least by me. The insurance carriers took charge and split up mental health care. The [more expensive] psychiatrists were paid for medical things like medication management. The psychotherapy/counselling was partitioned to other disciplines in carefully controlled and monitored contracts. In-patient reimbursement essentially disappeared. The non-psychiatrists were happy to get access to covered care. Many psychiatrists migrated to medication management. And voila` – that was that. Most referrals to participating psychiatrists came from the now covered psychologists, counsellors, and social workers. It was a symbiosis and many patients/clients spoke of "my psychiatrist" and "my therapist" as an inter-related pair. Psychiatry and the other mental health disciplines needed to change in those days, but the changes that came were driven by economics, and that trend escalated when PHARMA jumped onboard. The chronic psychotic patients were marginalized in the process and the criminal justice system did the only thing it knows how to do – put many of them in jail.

I left those years being involved with the treatment of the psychotic patients feeling much the same way about psychotic illness as that advocated by Dr. Sandra Steingard in the current Mad-in-America CME – antipsychotics for acute psychosis with a constant drive towards as little as possible or none thereafter. I followed some patients with those diagnoses long term and was impressed that a practical psychotherapy tailored to fit the illness was more effective than I might have imagined [see 1. from n equals one…  and the posts that follow]. But I was less successful in sustaining zero medication than I would’ve hoped, but I still never stopped trying.

I agree with Robert Whitaker about what happened when Managed Care, PHARMA, academic psychiatry, and the APA got together – it was a perfect storm of the worst kind. Pick any post on this blog to confirm that, though most of mine focus on the corruption involved in the clinical trials and promotion of drug treatments. But I don’t at all agree with his blanket indictment of psychiatry in the plight of our chronic mental patients. Psychiatry was just one of many who ignored them, including the other mental health disciplines, our governments, and our culture. I have nothing but respect for those psychiatrists, psychologists, and social workers who stuck with these patients on the front lines in the face of so little support. But I likewise have little positive to say about the KOLs who pontificated about their care from afar and generated guidelines of questionable scientific validity.

Third, psychiatry’s concern about the imprisonment of the mentally ill is being used by advocates of forced outpatient treatment as a Trojan Horse. The advocates for forced treatment in outpatient settings [such as the Treatment Advocacy Center] argue that forced drug treatment would prevent the mentally ill from ending up in prison, and thus their legislation, which in fact curbs the civil rights of citizens in profound ways, comes cloaked in the rhetorical garb of “humanism.” If we are going to have an honest societal discussion about the shame of imprisoning the “mentally ill,” then it needs to be completely decoupled from that legislative agenda.
Indeed an argument can be made that the growing imprisonment of the “mentally ill” is yet another example of how our drug-based paradigm of care has failed us. The use of psychiatric medications in our society has exploded over the past 25 years; there is great societal pressure put on people diagnosed with schizophrenia or bipolar disorder to take their medications; and yet we now have this problem of hundreds of thousands of “mentally ill” in prisons and jails.

"I venture to suggest that most practicing psychiatrists, if pressed, would choose to replace or discard any existing treatment or intervention save one: the power to impose a treatment or intervention."
It’s the Coercion, Stupid! by David Cohen

Nothing in life prepared me for the complexity of the schizophrenias – the acute psychoses, the chronic forms, the residual or negative symptoms, or even the miraculous recovery seen in some. It took years to get a feel for the many different ways they affect the lives of those afflicted, and there are surprises aplenty – good and bad for even the most experienced clinicians. Looking back over the history of the our various approaches, a clear pattern emerges. Each new reform movement has been built on the failures of what came before and ultimately replaced it – accompanied by great expectations bolstered by small samples of evidence. Over time, the refuges of the Quakers became the asylums of Dorthea Dix became the snake pits of the 1950s. The liberation of de-Institutionalization lead to a lot of desperate homelessness with people living under bridges. Szasz’s Myth of Mental Illness was a factor in inappropriately filling our prisons – just another kind of Institutionalism. The miracle of Thorazine became the cause of Tardive Dyskinesia and Chemical Restraint. I like the current Recovery meme, and the Open Dialog approaches of Northern Finland Whitaker mentions. They are hopeful hypotheses awaiting pilot projects and careful study with an eye to what kind of support is needed to see if they can work in an urban America. And while I am personally an advocate of minimizing the use of antipsychotics, I wasn’t nearly as successful as I wished to be. Medications overused? oh yes. Medications essential? more often than I thought. Likewise, I am a lifelong Civil Libertarian, but have seen many psychotic people who can’t manage with no restraint and end up losing all freedom when they would fare much better with much less restriction.