the guilded age…

Posted on Tuesday 5 May 2015

In guilding the lily… and in a guilded cage…  I discussed a sequence of articles that constitute a loose back and forth between Robert Whitaker and his followers with various psychiatrists. The debate is superficially about how the "Chemical Imbalance" metaphor came into being. I want to react further to the very first article in the bunch, the interview with Robert Whitaker by Bruce Levine, a Psychologist/Activist who blogs on Mad in America and is also an independent author.
Truthout
by Bruce Levine
March 5, 2014

Bruce Levine’s Question: Is it really possible for psychiatry to reform in any meaningful way given their complete embrace of the "medical model of mental illness," their idea that emotional and behavioral problems are caused by a bio-chemical defect of some type? Can they really reform when their profession as a financial enterprise rests on drug prescribing, electroshock and other bio-chemical-electrical treatments? Can psychiatry do anything but pay lip service to a more holistic/integrative view that includes psychological, spiritual, social, cultural and political realities?

Robert Whitaker’s Answer: I think we have to appreciate this fact: any medical specialty has guild interests, meaning that it needs to protect the market value of its treatments. If it is going to abandon one form of treatment, it needs to be able to replace it with another. It can’t change if there is no replacement in the offing. 

When the APA published DSM-III, it basically ceded talk therapy to psychologists, counselors, social workers and so forth.
Of course, that’s exactly what happened! But this is the first time I’ve ever seen it written down in this matter-of-fact way [or for that matter, written down at all]. But the Talk Therapy Cession Decree of 1980 must have been brokered in a back room and kept under lock and key, because it was never openly discussed – it just happened. Since I was  primarily a Psychiatrist Talk Therapist, I ended up leaving academic psychiatry, the APA, and the world of Managed Care and practicing for the next twenty-five years [which explains why I was so oblivious to so much of what happened in that quarter century]. I guess I’m glad the Talk Therapy Cession Decree of 1980 was such a well kept secret. If I’d known about it, I might have missed my whole career.
Psychiatry’s three domains, in the marketplace, were diagnostics, research, and the prescribing of drugs. Now, 34 years later, we see that its diagnostics are being dismissed as invalid; its research has failed to identify the biology of mental disorders; to validate its diagnostics; and its drug treatments are increasingly being seen as not very effective or even harmful. That is the story of a profession that has reason to feel insecure about its place in the marketplace.

Yet, as you suggest, this is why it is going to be so hard for psychiatry to reform. Diagnosis and the prescribing of drugs constitute the main function of psychiatrists today in our society. From a guild perspective, the profession needs to maintain the public’s belief in the value of that function. So I don’t believe it will be possible for psychiatry to change unless it identifies a new function that would be marketable, so to speak. Psychiatry needs to identify a change that would be consistent with its interests as a guild…
This particular view of psychiatrists is made even more explicit in Dr. Levine’s initial question:
Is it really possible for psychiatry to reform in any meaningful way given their complete embrace of the "medical model of mental illness," their idea that emotional and behavioral problems are caused by a bio-chemical defect of some type? Can they really reform when their profession as a financial enterprise rests on drug prescribing, electroshock and other bio-chemical-electrical treatments? Can psychiatry do anything but pay lip service to a more holistic/integrative view that includes psychological, spiritual, social, cultural and political realities?
There can only be one possible answer to those questions in their stated form – "No!" A decidedly loud "No!" at that. And following Whitaker’s logic, psychiatry has painted itself into such an impossible corner that it can only escape by coming up with some completely different thing to do with itself [like the Collaborative Care currently being suggested by SAMHSA and the APA]. So if you’re a psychiatrist who completely embraces the medical model of mental illness, or has the idea that emotional and behavioral problems are caused by a biochemical defect, or whose practice rests on drug prescribing, electroshock and other bio-chemical-electrical treatments, or who only pays lip service to a more holistic/integrative view, or who signed on to the Talk Therapy Cession Decree of 1980, or who accepts the APA as the representative guild that defines psychiatry – you’re in the group Whitaker is prognosticating about here.

Dr. Levine’s comment which contains a definition of psychiatry that I was talking about when I said "My own complaint about Whitaker and his followers is that they use the word «psychiatry» as if it represents a personified unitary entity, but I’ll clarify that point later" in my last post [in a guilded cage…]. In 1980, I was a trained psychiatrist running a psychiatry training program and was in training as a psychoanalyst. But what I really was was an Internist who had become fascinated with the psychology of my medical patients and decided that’s what I wanted to treat. I was doing psychiatry for obvious reasons, and psychoanalysis because those were the guys who I thought knew how and where to listen. It wasn’t the theories that mattered to me, it was listening to the background and I was well pleased with the training I was getting. And then the world went kind of crazy, and all that business in Dr. Levine’s definition came up. It’s not that I was opposed to biology. I had come from a background steeped in that. But, as they say, "Been there, Done that, Got my tee shirt."

I’m not giving my history as a template for others. It was my road, not a highway system. But I fled from the direction mainstream psychiatry was taking  because I didn’t want to go in that direction [and because I thought it was a bad idea]. I was absolutely fine with the ambiguity of psychology, philosophy, biology, and socio-something I had found. In the years that followed, "my kind of" psychiatry was vilified and I became pretty isolated. But I was plenty busy and found my work satisfying and effective enough for my patients. But here’s my only real point. I am and was a psychiatrist that whole time. Psychiatrists are physicians who specialize in the treatment of mental illnesses. The revolution of 1980 was because people thought that psychoanalysis had too much influence on psychiatry. They were right. I sort of knew that at the time, and I know it even more now. But changing over to a system where another dead european guy, Emil Kraepelin, got to have too much influence wasn’t okay with me either [all ears…, an open question…].

Dr. Levine’s questions have a lot of his guild in them too. Whitaker’s response, not so much – more balanced. But there’s something missing in what they’re both saying. They’re coming into a story in the phase of paradigm exhaustion and there’s an as yet undetermined paradigm shift in the offing. They’re using the term «psychiatry» as if their definition encompasses all psychiatrists [and it doesn’t, even now]. And they’re not taking into account that the winds are changing already [or even considering that they are part of the as yet undetermined paradigm shift in the offing]. They’re assuming that there really is a Talk Therapy Cession Decree of 1980 that’s binding [and there isn’t] and that psychiatrists as a group really are like the ones in this straw man version of «psychiatry». And speaking of paradigm exhaustion, Managed Care is wearing a bit thin these days too…
  1.  
    Steve Garlow
    May 5, 2015 | 6:27 PM
     

    The concept of chemical imbalance was first formally proposed by Joseph Schildkraut in 1965

    Schildkraut, J. J. (1965) The catecholamine hypothesis of affective disorders: a review of supporting evidence. Am J Psychiatry 122:509-522.

    It was based in large part on the observation of Julius Axelrod of the mechanism of action of imipramine blocking uptake of norepinephrine into synaptic vessels, an observation for which Julius Axelrod won the Nobel Prize and appropriately so. But at the time, the hypothesis of low neurotransmitter levels was logically derived from the observations of the biochemistry of synaptic transmission and action of antidepressants. An agent that appeared to increase availability of norepinephrine treats depression, so hypothesizing that depression might be due to low levels of that transmitter is a testable and logical hypothesis to propose and investigate. That the actual neurobiology of emotions and antidepressant action is much more complex is apparent now, but at the beginning this was a very logical starting place……

  2.  
    Bernard Carroll
    May 5, 2015 | 6:49 PM
     

    That’s a very good point, Steve. Those were the days of disinterested clinical science. Back then, the whole point of experimental therapeutics, backed up by preclinical psychopharmacology, was to give us a point of leverage into the proximate mechanisms of these successful new drugs. The follow-on goal was to advance our understanding of the mechanisms of clinical depression. The “business of psychiatry” was never a consideration in the construction of the catecholamine hypothesis or the serotonin theory of depression in the 1950s-1960s.

  3.  
    May 5, 2015 | 7:12 PM
     

    Drs. Garlow and Carroll,

    Great reminders! This story gets clearer when we have a contextual timeline.

  4.  
    May 5, 2015 | 7:39 PM
     

    This is a question I have for you. I ask this in all sincerity and I am not trying to be flip or contentious. You happened to go from internal medicine to psychiatry because you became interested in the psychology of your patients. Fair enough. Psychiatry was there, it intrigued you, it seemed to offer a way to work with people that would allow you to address these psychological problems. I believe that you did what many fine clinicians did then and do today. You took from your training what was valuable, you taped in to your basic sense of humanity, and common sense and you were helpful, no doubt to many. I have no doubt you were a wonderful clinician. But going forward, can you help me understand why you continue to believe that medical training is required in order for someone to do this kind of work? This is not a critique of you or any other psychiatrist. But given the cost of medical training, the thrust of medical training, and the cost of physicians, I just do not see why they would be the ones to be helpful to people in the future in the way that you have been helpful to people over so many years.

  5.  
    May 5, 2015 | 8:00 PM
     

    Sandra,

    “But going forward, can you help me understand why you continue to believe that medical training is required in order for someone to do this kind of work?”

    I don’t think it’s required [but it’s helpful] nor do I think a PhD in psychology is required nor a MSW. It’s in the temperament or something like that. I would never have moved in my direction had I not been in a medical setting where I had the time and freedom to follow my nose. As a psychiatrist, I treated patients who were on the more desperately ill end of the spectrum. I think my years with the “very sick” made it possible for me to do that. I had a number of residents and friends who came by the same route. Actually, everybody I practiced with was another kind of physician who changed over. I couldn’t have personally skipped either medical school or medical training on my road. As I have no sympathy for cost effective arguments, I’ll skip that part. I paid my own way. And while it was circuitous, it was the only way for me to get where I belonged [it helped to have a tolerant spouse who didn’t mind my lack of financial savvy or ambitions]. Oh yeah, doing BP checks and pushing Statins is very boring…

  6.  
    Tom
    May 5, 2015 | 8:04 PM
     

    Was Cession so bad? We hear a lot about how we do not have enough psychiatrists to meet the needs of the mentally ill. Actually psychologists have been pushing this idea so that they can get into the prescribing business. Which I think is a mistake. Can’t we all agree that there are classes of mental illness, disorder, and disease that require biochemical-electrical intervention? Like primary psychosis (at least early on and unfortunately for some, forever), manic depressive illness, and melancholia, and maybe panic disorder? And there are a lot of folks who suffer from mental “dis-ease” (often no less debilitating) who are best helped with non somatic interventions, provided by non-medical specialists (psychologists, social workers, etc)? And maybe some of these “dis-ease” states require both or at least are helped by medical and non-somatic interventions? I understand Dr. Mickey’s history, but can psychiatrists really be expected to be therapists in today’s world, when the demand for psychiatrists to treat the severely ill goes unmet? Isn’t this just a case of “Can’t we all just get along and collaborate and respect one another’s skills and training?”

  7.  
    May 5, 2015 | 9:05 PM
     

    One day a slumbering hypothesis awakened to find it had become a Theory of Everything.

    “How can this be?” wondered the hypothesis. “I lack confirmation. I was based on ex juvantibus reasoning. Maas and colleagues, a nice bunch from NIMH, put me to bed in 1984. What happened?”

  8.  
    Katie Tierney Higgins RN
    May 5, 2015 | 10:08 PM
     

    I had 14 years of nursing experience- mostly pediatrics and critical care nursing before I accidentally wandered into the field of psychiatry. In February 1988 , I was hired as a sort of residential school nurse- for 45 bed facility created from an old Nike base in Southern Maryland. The residents, ages 12-18 years were considered emotionally and behaviorally challenged that year. By the time I left, nearly three years later, they all had psychiatric diagnoses. I went on to Johns Hopkins Child psychiatry unit to learn how I could *make a difference*. Brief and to the point, I genuinely cared about the kids I met *in treatment*. I was an avid student of the new paradigm. The promise. The possibilities.

    What my medical surgical nursing background did for me , in the NEW world of *psychiatry, was create extreme moral duress and hopelessness.Fast forward a few decades. Now, when I even think the word, *psychiatry* it is as though ice picks are being jammed into my brain– and coherent thought is impossible through the pain.

    Inpatient pedi unit 2005: A 14 year old suffers a manic episode after increased dose of Prozac. Diagnosis: “Unmasked bipolar disorder”– immediately start a mood stabilizer (What ??- oh anti seizure meds, of course) and antipsychotics (what about the dystonic reaction the kid already suffered?) — let’s try an atypical- sure, why not?

    Problem: The case discussions and the supporting or opposing views are faces of kids with derailed lives. Deliberately, I now think. After years of offering ideas like:– the simple medical approach of a *wash out* after a toxic substance caused an adverse reaction- only to be admonished for my ignorance re: the serious underlying mental illness? I can handle criticism and am always willing to learn–.But. No information was ever provided that explained the deterioration of the quality of life for countless kid’s — other than to note how much better off they were for being *treated early*–

    Bigger problem: It was not until after I was no longer entrenched in the trenches where failure to notice *medical* bells and whistles was the norm, that I leaned of the means for creating a paradigm devoid of logic or humanity. I swear, I did not believe the narratives about Biederman and co.until I read David Healy’s “Mania”– . Now, it’s too late. I know.

    My first psych nursing job was an accident, but it was a great experience- in that I was very much a part of what worked so well for the kids. The successful formula was everything that psychiatry is not– human compassion, understanding, nurturing– strong role models, invested care givers- structure, resources– . Why did that youth and family center get converted to a residential psychiatric facility? Simple- third party payments, or that which insurance companies, or rather medicaid, could be billed for. 20 years ago, I had no idea that there was anything but improvements in the works–. Better salaries and more psych clinicians seemed like improvements in 1992.

    I have to add that- maybe– IF all psychiatrists and psych nurses had at least 5 years of medical experience — the egregious errors of judgment around psych drugs especially, might not have occurred. – But that is not really an endorsement for pre-requisite medical training- Actually take away the psych drugs all together– and you have the center where I worked in 1988 — as sort of a residential program/school nurse. There were LCSWs and MSW’s ; house/unit managers with college degrees; special Ed teachers; staff – well supervised by invested, role models–. …. Quite a successful program– until it was invaded by psychiatry –. Fairy tale narrative notwithstanding , it was what it was.

    Forgive my personalization of the word– psychiatry. I am fully responsible for having stayed in the field thru to the equivalent of “Jaws -#3”– for me it is personal.

  9.  
    James O'Brien, M.D.
    May 5, 2015 | 10:32 PM
     

    I want to know why psychiatry is being singled out for this. That doesn’t excuse it as intellectually lazy, but you could just as easily single out neurology for the same thing as far as an explanation for migraines. Google “serotonin depletion”. I found these in about 2 minutes:

    http://www.drkaslow.com/html/neurotransmitter_depletion.html

    http://www.achenet.org/resources/serotonin_and_headache/

    http://www.hopkinsmedicine.org/healthlibrary/conditions/nervous_system_disorders/how_a_migraine_happens_85,P00787/

    The Johns Hopkins site is confusing because its under the heading of theories but the syntax is more definitive.

    There are many more.

    I get the indictment. Why it focuses on one group is very interesting. Why is “Big Neurology” not a codefendant?

  10.  
    May 6, 2015 | 12:46 AM
     

    I think it’s silly to look at psychiatry (by which we mean “academic psychiatry” or “organized psychiatry”, of course) in isolation from what has happened in the broader world of medicine.

    Psychiatry embraced the biomedical model for the same reason that primary care doctors started seeing all their patients for 15 minute visits or that most doctors started ordering more unnecessary tests and procedures—this was what the health care system incentivized.

    It will bey very hard for organized psychiatry to change if the rest of medicine doesn’t change, though psychiatrists are fortunate enough to be able to remain relatively independent from the rest of the medical industry (including organized psychiatry), as I wrote about last year.

  11.  
    May 6, 2015 | 5:45 AM
     

    Even before the concept of chemical imbalance was first formally proposed by Joseph Schildkraut in 1965, wiser minds in behavioral pharmacology were noting the simplification: “The concept of humors, since it was clearly enunciated by Hippocrates, has been declared scientifically extinct at several periods of history, yet it has lingered on in such words as choleric and melancholic. In recent years there has been a resurgence of interest among biochemists in the doctrine of humors in brain and it comes in a form recognizably similar to that of the ancients. Nowadays, however, people speak of 5-hydroxy-tryptamine (serotonin) and catecholamines instead of black bile and yellow bile as related to depression and elation.” “HUMORS”, P. B. DEWS, Stanley Cobb Professor of Psychiatry, Harvard University, (Read April 24, 1964, in the Symposium on “Psychology: A Behavioral Reinterpretation) Proceedings of the American Philosophical Society 1964.

    i.e. in 1964 the error of this was clearly noted, along with its ancient origins.

  12.  
    May 6, 2015 | 5:59 AM
     

    Psycritic-
    I agree but it becomes almost circular – we can’t discuss psychiatry critically because the rest of medicine shares many of its flaws. This could go on. Medicine shares the flaws of many of our other large industries. Pointing to the many problems psychiatry shares with the rest of medicine sometimes seems like a way to escape critically evaluating the flaws of the profession.
    But with the ACA, the ability of psychiatry to survive independently is quickly fading. Mickey has addressed this in some of his posts about the move to integrated care. And speaking as a psychiatrist who has spent her career in public sector work – where some of the most impaired and disenfranchised seek care (and have no other option) – we do not have the option to ignore the economic issues.
    This is one reason why I believe that for change to occur, many of the current functions of psychiatry need to be taken away from psychiatry and medicine. I think it is legitimate and important for there to be branch of medicine whose practitioners truly understand the judicious use of psychoactive drugs. They are complicated substances. I just do not think that function needs to be at the core of what we offer to people who experience the vast array of emotional/cognitive problems that currently fall under the umbrella of psychiatric attention(and to re-state, this is not intended to criticize the work of those who found their ways into doing psychotherapy as physicians. This was a viable career path for many at the time).

  13.  
    May 6, 2015 | 6:34 AM
     

    “Some of the characteristics of the behavioural science of the future…” Prescient words spoken by BF Skinner, at the…
    EVALUATION OF PHARMACOTHERAPY IN MENTAL ILLNESS Conference sponsored by National Institute of Mental Health National Academy of Sciences – National Research Council American Psychiatric Association. Washington, DC.September 18 – 22 1956.

    1. Such measures as characterise improvement in, or cure of, psychiatric conditions are tied to current problems in psychiatry and medicine and will eventually be replaced by terms having no particular reference to illness or health.
    2. They behavioural science will not deal in mentalistic terms or in the description of feeling. What the psychiatrist cure is is not a feeling but a condition of the organism. The problem is not to find a drug to counteract anxiety but to find one to correct the condition which is “felt” as anxiety.
    3. An eventual science of behaviour will not emphasise adjectives describing states of behaviour, traits, personality attributes etc. What is going on in the individual organism will be measured continuously in time, not sampled from time to time with tests.
    4. I appreciate the value of controls and of measurements on large groups, but in the long run site behaviour will deal with individuals one at a time.

    As with Peter Dew’s comments above, even in the relatively early history of radical behaviourism (now known as Functional Contextualism – the strategy of science underlying Contextual Behavioural Science http://www.contextualscience.org) the problems of a mechanistic, medical (psychiatric) approach were clearly recognised. It has taken a while, but it seems that the profession of psychiatry as is it is in the main (not all), glued without awareness to elemental realism/mechanism, may be seen without clothes.

  14.  
    May 6, 2015 | 7:40 AM
     

    Sandra,

    Sounds familiar:

    … I don’t believe it will be possible for psychiatry to change unless it identifies a new function that would be marketable, so to speak. Psychiatry needs to identify a change that would be consistent with its interests as a guild. The one faint possibility I see – and this may seem counterintuitive – is for psychiatry to become the profession that provides a critical view of psychiatric drugs. Family doctors do most of the prescribing of psychiatric drugs today, without any real sense of their risks and benefits, and so psychiatrists could stake out a role as being the experts who know how to use the drugs in a very selective, cautious manner, and the experts who know how to incorporate such drug treatment into a holistic, integrated form of care. If the public sees the drugs as quite problematic, as medications that can serve a purpose – but only if prescribed in a very nuanced way – then it will want to turn to physicians who understand well the problems with the drugs and their limitations. That is what I think must happen for psychiatry to change. Psychiatry must see a financial benefit from a proposed change, one consistent with guild interests.

    from Robert Whitaker
    in Psychiatry Now Admits It’s Been Wrong in Big Ways – But Can It Change?
    Truthout by Bruce Levine; March 5, 2014.

    [see Primary Care Physician Describes Health Care ‘Hot Spotting’ and Collaborative Care: An Integral Part of Psychiatry’s Future]

  15.  
    May 6, 2015 | 7:53 AM
     

    I am not sure why this idea is controversial, really. In my neck of the words we have a huge shortage of psychiatrists so clarifying this narrow focus will not put people out of jobs. Older psychiatrists might not like it but most of them are able to have lucrative and busy practices outside of the insurance reimbursement system.
    But it also involves giving up some of the expertise. In my recent wanderings I have met some wonderful, humane, and compassionate people who have much to teach us. I am not pandering but of course you are one of these people. However, there are others who are far from the medical field.

  16.  
    May 6, 2015 | 8:29 AM
     

    Sandra,

    If it’s such a great idea, why is it resisted by psychiatrists who are in the position of doing it? Most people answer that question by making a derogatory personality assessment – MDeities etc. But those assessments don’t change things, or get more physicians into the clinics, at least for very long. People have been pushing this idea since the Community Mental Health Movement days and had the exact same problem [attrition]. It fits the “herding cats” metaphor. If you want to read about someone’s struggle with this problem who has no clue, see this evidence-based medicine I…

  17.  
    RKP, RN
    May 6, 2015 | 9:50 AM
     

    Please excuse my anonymous writing…I work full-time as an RN and this is not exactly how I would like to introduce myself to potential hiring managers. I also carry the diagnosis of bipolar with a I or II or NOS behind it, depending on the psychiatrist. Psychologist said “You don’t have bipolar, you had an old-fashioned nervous breakdown.” Whatever you want to call it when you go from Prozac (for fatigue) to Cymbalta and quit sleeping, and then have very disordered thoughts when you add Seroquel. The word iatrogenic seems more appropriate than old-fashioned.

    But in this context, I just want to say any doctor who practices in the manner Dr. Mickey describes is never going to lack for work and doesn’t need a “guild.” So many are longing for this kind of care. I just want to throw out a couple of websites that many psychiatrists could learn a lot from: psycheducation.org and kellybroganmd.com. To back up my assertion, the initial visit with Dr. Brogan, I have heard, is $840. That is the value the (Manhattan, granted) marketplace places on her work.

    Doctors, full cooperation with my doctors led to a six-drug cocktail. With highly symptomatic tapering over the past three years that probably only I believed was from drug withdrawal, I am down to subtherapeutic doses of a benzo and lithium now. I probably have a couple more years to go, but I work full-time and am married with two teens. I hope it frightens you that normal, kind, engaged psychiatrists could so miss the mark.

  18.  
    James O'Brien, M.D.
    May 6, 2015 | 11:12 AM
     

    The Brogan site is pretty out there. Thanks for the links. I guess the lesson is imagine how well you could do using real science.

    I don’t know why people in a demand specialty are acting so desperate. We talked about Dr. Lieberman earlier and one of his videos that blew my mind was this one:

    https://www.youtube.com/watch?v=Z8Kx0GxSle0&ab_channel=AmericanPsychiatric

    Brilliant. Let’s just agree to put ourselves in a position to be replaced by software.

    Sometimes psychiatrists are like Emma Watson using Tinder. Acting desperate for no rational reason. Say what you want about Dr. Brogan and Dr. Amen, they don’t suffer from low self-esteem.

  19.  
    RKP, RN
    May 6, 2015 | 12:32 PM
     

    Where would you send me for “real science?”

  20.  
    Sally
    May 6, 2015 | 12:46 PM
     

    “My own complaint about Whitaker and his followers is that they use the word «psychiatry» as if it represents a personified unitary entity…

    Although I wince at the word ‘follower’; I do admit that Whitaker is one of the two people I would give the largest credit for ‘saving’ my loved one, so I guess the word could apply to me. The other person I would give the lion’s share of the credit to is a ‘talk’ psychiatrist not unlike how Dr. Nardo describes himself.

    Despite this huge ‘help’ I have received from ‘psychiatry’, I feel that my loved one has been very gravely harmed by the psychiatry model as it exist today for the severely ill. I am someone who is guilty of describing psychiatry as a ‘unified entity’ simply because I do not know what other term to use when trying to talk about what I see is a crisis of horrific proportions.

    ‘Psychiatry’ regularly treats the severely ill with drugs, without giving informed consent -and sometimes with force – even though these treatments have not been proven to be effective in the long term for their particular case, and may be harmful in the long term for their particular case.

    No-one needs to tell me about the safety and survival needs of the severely ill. However, I believe if the loved ones of the severely ill were fully informed about the state of the research for long term recovery, many of them would prefer to support their loved ones in sanctuary/open dialogue approaches , at least at first.

    I would like to add that I understand that critical psychiatrists who participate in coercive treatment – either by sending their client to hospital or participating in AOT programs – often do so because they feel it is the safest option for their client at that particular time, and I do not blame them for that,and I am glad they are helping those people, rather than psychiatrists who have a less judicial approach to medication. What I do not understand, however, is that there isn’t more critical psychiatrists who are saying loudly that ‘it is wrong that we are giving drugs without informed consent when we do not have solid research about long term recovery to back us’, and that there aren’t more critical psychiatrists ‘leading the charge’ to find or support solutions -eg. ‘sanctuary type environments within or outside of medical establishments- that may allow for ‘forced safety’ while preventing coercive drug treatment. I believe that changing the practice of coercive drug treatment will eventually happen, but I believe it would be much quicker if pressure for this change came from within the psychiatry profession.

    I agree with RKP above that allowing people to choose their treatment option and their treatment provider would not result in the end of psychiatry. Some of the most amazing stories I have read about recovery in the past included psychiatrists. Also I know there have been many people helped by drug therapy, so taking the ‘power’ away from current mainstream psychiatry practices would also not mean the end of drug treatment. Indeed the more secure psychiatrists feel about their treatment approach, the less worried they should be about sharing the power. Also once ‘choice’ is allowed, clinical researchers will be able to access all the subjects they need to compare medicated/unmedicated patients and how they fare over the long term. I also believe that the only reason psychiatry has a so-called ‘anti’ movement is because the profession has the power to force treatment.

  21.  
    James O'Brien, M.D.
    May 6, 2015 | 1:42 PM
     

    RKP,

    The Amerio article she links to actually says the opposite of what she is claiming. Take a look at it carefully.

    Almost everything produces cancer in laboratory animals because of the insanely high dosages they use.

  22.  
    RKP, RN
    May 6, 2015 | 2:51 PM
     

    No, I understand the “out in the weeds-ness.” My question is genuine.

    However, she has helped a lot of people.

    One thing that she writes about extensively is gut health. I know that this is not considered part of psychiatry, but this is huge. One of life’s little ironies is that I worked for Big Pharma for eight years. Sub irony of sitting next to the Seroquel team the last several months. But mostly I worked with a PPI. It was very disconcerting to see how unevenly physicians respond to new information, or how unevenly they even become aware of it. And more disconcerting as years go by to see the problems that have surfaced with the drugs that no one vaguely anticipated.

  23.  
    Joseph Arpaia
    May 6, 2015 | 4:40 PM
     

    One factor which causes so much disagreement is attribution bias. Whenever something changes we attribute the cause to factor based on our particular bias. Everyone has some form of bias, and the best we can do is recognize it, disclose it, and hopefully realize that it may be causing us to reach erroneous conclusions.

    If someone believes in medications, then they will attribute benefits to a medication. If someone believes in acupuncture they will attribute benefits to acupuncture, etc. But maybe, for treating depression, the benefits came about because the person’s obnoxious boss got transferred to a different department. Or, there was more light than usual that winter. Or their husband stopped drinking. Etc, etc.

    Psychiatrists who believe in medications (not all do) can be blinded by their attribution bias and see benefits to medications that come from other sources. Their patients may confirm this, guessing that it will please their psychiatrist to hear that the medications are working. I have had patients who are clearly working hard in making changes improve and tell me that the medications I prescribed are working. I always point out that unless they were working hard to change the medications would be useless. I want them to believe in themselves more than medications.

    I have also seen therapists get very arrogant due to their own attribution bias. Those who treat eating disorders or addictions for example have told patient that they are “not ready for recovery” when the patient was being treated disrespectfully or even abusively by the therapist.

    The fact is that we don’t have any real clarity on the processes that initiate or maintain psychiatric disorders, or even most physical disorders. So we are making guesses, and sometimes our guesses enable us to help someone improve. Many times our support enables them to continue functioning until some other factor provides the healing effect.

    Got to run. Patient waiting.

  24.  
    Sandra Steingard
    May 6, 2015 | 5:29 PM
     

    Mickey-
    I am clearly not making myself clear. What I am suggesting has no correspondence to what you describe in your the blog linked above. Gosh, I said nothing about assessment scales. I am talking about being an expert who truly understands these drugs (and not just the promotional literature) and is able to discuss with people who they may or may not be helpful to them. This would involve an old fashioned doctor patient relationship and I am assuming that it would take some time to sort out how or how not the physician could be of help. I am appropriating Moncrieff’s drug based conceptualization so using the assessments scales to determine a diagnosis and fit treatment to some preprogrammed algorithm has no correspondence to what I have In mind.
    Honestly, it is pretty much how I have practiced most of my career. I have some long term relationships with patients and their families. I work as a part of a larger team and others – including our peers – have other kinds of expertise. It can be humane in the way that other areas of medicine can be humane but it is not inherently psychotherapy.

  25.  
    James O'Brien, M.D.
    May 6, 2015 | 6:37 PM
     

    If she is getting people off benzos and getting mildly depressed people off meds that aren’t working and into therapy I’m sure she is helping people. But the way to get them in the door is not to misrepresent your case or scare fragile people into thinking they are going to get cancer. Back to the noble lie problem.

  26.  
    EastCoaster
    May 7, 2015 | 6:37 PM
     

    Yes, Steve, thanks for that comment. I always find information about the historical background helpful.

  27.  
    James O'Brien, M.D.
    May 7, 2015 | 7:27 PM
     

    I take back my post. Upon further review, that site is promoting anti-vaxx, anti-Gardasil. That is just flat out dumb and dangerous.

  28.  
    Sandy Steingard
    May 8, 2015 | 7:23 PM
     

    http://www.ncbi.nlm.nih.gov/pubmed/25934397
    http://www.cbsnews.com/news/gardasil-researcher-speaks-out/

    I am not an anti-vaxxer and I honestly have no opinion at this time on the relative risk of cancer and antidepressant drugs. I just think it is ok to be able to raise questions without being vilified. If one reads this blog over a few years or even months, one would reasonably come to the conclusion that we do not always get a full accounting of the risks and benefits of drugs, even ones highly promoted by their respective professions.

  29.  
    James O'Brien, M.D.
    May 11, 2015 | 1:38 AM
     

    She wasn’t raising questions in an honest scientific manner, she was making a statement that directly contradicted her source to promote her practice by scaring vulnerable people based on nothing.

    Call me old fashioned, but I have problems with that.

    And getting on the antivaxxer train didn’t help her cause.

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