don’t take sides…

Posted on Wednesday 12 August 2015

While it’s not fashionable these days to acknowledge that Sigmund Freud even existed other than as a caricature, a container for the things he got wrong, this is one of those places where I would evoke something he got right – neutrality. Actually, his daughter Anna wrote it down in the most frequently quoted form, saying the analyst "takes his stand at a point equidistant from the id, the ego, and the superego." In just plain English that means, "Don’t take sides."
by Renée Binder, M.D.
July 13, 2015

… In June, I arranged for the Board of Trustees to tour San Quentin in northern California. It was a powerful, moving, and formative experience, and I’m thankful to Dr. Paul Burton, the chief psychiatrist, and to the California Department of Corrections and Rehabilitation for giving us that access. Our visit was important because, if one wants to understand firsthand the toll mental illness is taking on our country, one just needs to peer beyond the bars of our nation’s jails and prisons. It’s also important to have a detailed and nuanced understanding of the situation. Our tour was a no-holds-barred look at San Quentin State Prison. For three hours, we were shown various aspects of prison life…. We specifically saw the psychiatric facilities, which are highly used by the inmates. In many ways they are state of the art. As you’d expect, sharp angles in the halls and cells, down to the door hinges and door handles, were filed smooth to prevent inmates from using them to aid in a suicide attempt. Many cells provided a sanctuary for inmates, nearly always curled up on a plain bed with a blanket covering them head to toe.

But the rooms that captivated our group were the group therapy rooms. Separate enclosures or “modules” formed a semi-circle for people who are at once both dangerous and needing and deserving of help. We briefly observed one group. Those participating highly praised the care they were getting. One patient’s body language told us when he had enough of our interruption; in a visceral way, it was clear he valued his treatment.

The four psychiatrists with whom we interacted were obviously compassionate and concerned about each of their patients. At each stop, it was abundantly clear that the care provided by the staff psychiatrists was superb and professional. Even if incarceration itself is likely a detriment to many individuals’ mental health, the physician-patient interactions we witnessed gave us hope…

Jails and prisons have become the front lines of treatment for mental illness. The data indicate that San Quentin is an anomaly in the quality of care that’s available in such a setting. This is likely due to its proximity to a highly desirable metropolitan area and its affiliation with the University of California, San Francisco, Department of Psychiatry.

According to a 2010 study by the Treatment Advocacy Center and the National Sheriff’s Association, there was one psychiatric bed for every 300 Americans in 1955. By 2005, that rate dropped to one psychiatric bed for every 3,000 Americans. Over time mental illness has been criminalized, and our jails and prisons take up the slack, despite being seriously ill-equipped to do so. Our jails and prisons have turned into warehouses for those with mental illness; the number of people with mental illness in jails is three to six times higher than that of the general public.

This is why APA and the American Psychiatric Association Foundation have joined forces with the National Association of Counties and the Council of State Governments Justice Center in the “Stepping Up” Initiative. The initiative seeks to reduce the number of people with mental illness in our prisons and jails by promoting the use of mental health courts and diverting minor offenders who have mental illness to treatment resources rather than incarceration…

We must reduce the use of our jails and prisons as warehouses for Americans with mental illness, partly to help our patients, but also because of what this tragedy says about the kind of nation we are. This is an effort for our patients, for our profession, and for our nation.
I personally couldn’t be more pleased that Dr. Binder wants to do something about this very real  problem, but this reporting doesn’t acknowledge the layers of history and controversy that lie embedded in this particular mustard seed – dating all the way back to Philippe Pinel and beyond. It frames the problem from one particular vantage point. But as soon as one does that, you hear:
… 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…

However, I do agree with Allen Frances on this point: Any effort to remake mental health care in this country needs to include a focus on what can be done to help the multitudes of poor people and disenfranchised people who show up in distressed emotional states in emergency rooms and homeless shelters, and the eventual routing of many such people to jails and prisons.  But, in my opinion, if we want to find a solution, we should focus on providing housing, social support and jobs that help people lead meaningful lives. If we want to reduce the number of people said to be mentally ill and in jail, then we should focus on reducing poverty in this country. Substantially raising the minimum wage would, undoubtedly, be a good first step in addressing this problem…
Sound familiar? Here’s another version from the last time around:
For some time now I have maintained that commitment—that is, the detention of persons in mental institutions against their will—is a form of imprisonment; that such deprivation of liberty is contrary to the moral principles embodied in the Declaration of Independence and the Constitution of the United States; and that it is a crass violation of contemporary concepts of fundamental human rights. The practice of "sane" men incarcerating their "insane" fellow men in "mental hospitals" can be compared to that of white men enslaving black men. In short, I consider commitment a crime against humanity. In the first place, the difference between committing the "insane" and imprisoning the "criminal" is the same as that between the rule of man and the rule of law: whereas the "insane" are subjected to the coercive controls of the state because persons more powerful than they have labeled them as "psychotic" "criminals" are subjected to such controls because they have violated legal rules applicable equally to all…

The fundamental parallel between master and slave on the one hand, and institutional psychiatrist and involuntarily hospitalized patient on the other, lies in this: in each instance, the former member of the pair defines the social role of the latter, and casts him in that role by force…

In this therapeutic-meliorist view of society, the ill form a special class of ”victims” who must, both for their own good and for the interests of the community, be "helped"  — coercively and against their will, if necessary — by the healthy, and especially by physicians who are "scientifically" qualified to be their masters. This perspective developed first and has advanced farthest in psychiatry, where the oppression of "insane patients" by "sane physicians" is by now a social custom hallowed by medical and legal tradition. At present, the medical profession as a whole seems to be emulating this model. In the Therapeutic State toward which we appear to be moving, the principal requirement for the position of Big Brother may be an M.D. degree.
I want to say "ditto" to my last post. Dr. Binder seems to be a decent person, and I expect her concern for the jailed psychotic people is genuine. But she isn’t talking like she knows what awaits her up ahead. The collective other have decided that the problem isn’t mental illness but something else. She should probably go to the Mad in America site and read a few blogs, then read the British Psychological Society’s report, then think about this era of KOLs we’ve just been though, before proceeding as if good intentions will carry the day. She doesn’t seem to grasp that she’s now representing an organization that many see as the problem rather than part of the solution.

Right now, there’s an enormous and somewhat understandable back lash to the recent era of psychopharmacological/neuroscientific goings on, and pressing ahead without addressing all the conflicts in the air is likely to be a lesson in futility. The sentiment expressed above by Robert Whitaker and in the British Psychological Society’s Report suggests that psychotic conditions aren’t, in fact, mental illness at all, but rather some barometer of social ills and imbalances, or even a sign of psychiatrists not listening.

If Dr. Binder is serious about approaching this problem, she’s going to have to address all of the views. The official mouthpieces in psychiatry right now seem to think that they can just ignore what’s happened in these last 20 or 30 years if they start behaving in more rational ways now. They think that they can avoid acknowledging the sins of the fathers. That is unlikely to help anyone at this point.  All they’re going to hear about is forced drugging, imprisonment, overmedication, "bio-bio-bio," medical models, the DSM-whatever, pharma this and pharma that.

Dr. Lieberman had a shot at attacking and discounting the critics which was decidedly ill-conceived. Dr. Summergrad was more balanced, but didn’t address or acknowledge the conflicts in the air. Dr. Binder has the opportunity to take a different and more realistic tack, but I’m afraid that the course she’s setting here could use a bit more thought because it raises specters she’s failing to mention. For the moment, it would be a much better idea to look into problems like this one, and get input from as many players as she can find. "We must reduce the use of our jails and prisons as warehouses for Americans with mental illness" is totally correct. But for the moment, she needs to listen to some time honored advice, "Don’t take sides." At least not yet…
    August 12, 2015 | 7:14 PM

    I am assuming that Dr. Binder has a more comprehensive strategy at some point, but past performance of APA leaders would suggest that may not be a valid assumption. Simply saying that you want to address the nation’s “shame” of incarcerating the mentally ill can be a recipe for disaster. Whitaker and Szasz certainly have absolutely nothing to offer. The “sins of the father” in this case have nothing to do with the waxing and waning debate over the mind and psychotherapy versus the brain and medicine. Psychiatrists everywhere can learn a lot from two of the old men in the field – Kandel and Kernberg and how these political differences fall away with a more comprehensive and convergent formulation of the field.

    If “sins of the father” is relevant at all, it has to do with the inability of physicians and psychiatrists in particular from preventing the exploitation of their patients and themselves by the federal and state government and the health care industry. Only by addressing that dynamic will people with serious mental illnesses and addictions get the level of care that is required. That is care that in many cases was invented by community psychiatrists in the 1970’s.

    My idea about neutrality is that it exists in therapeutic relationships but not political ones. In politics it is reasonable to react to your detractors and antagonists at multiple levels. Dr. Lieberman’s mistake was getting too rhetorical. The critics of psychiatry have such severe shortcomings in their arguments that excessive rhetoric is unnecessary. Any politically savvy advisor would have suggested to him that the public reaction to a psychiatrist being rhetorical is very predictable, particularly when critics have psychiatry boxed in with fallacious conflict of interest arguments.

    August 12, 2015 | 8:40 PM

    There is no way this woman will be as realistically and effectively unbiased and objective to provide a true impact for the better. At the very least she is a puppet for the real players behind the scenes at the APA. More likely I think she puts on a good show but, to even run for president of an organization like the APA, you have to agree to tote the party line.

    Frankly people running for office, be it in politics, business, even organizations like the APA in medicine or other fields that don’t have an outward bottom line agenda, are usually people who have ulterior motives.

    Yeah yeah yeah, cynicism, pessimism, and lack of hope. It is what it is.

    August 13, 2015 | 1:42 AM

    In 2013, then-APA president Lieberman, along with Dr. Saul Levin and Dr. Pedro Ruiz, wrote to the United Nations’ Special Rapporteur on Torture asking for a variance for psychiatrists. Another of his letters revealed his enthusiasm for inhuman treatment of arrestees that NYPD had banned.

    “We Have to Talk about Jeffrey” has the letters.

    August 13, 2015 | 8:39 PM


    I wonder reading this, how many of your very distressed clients found it helpful to be labelled “mentally ill”? Did you tell them that you considered them mentally ill? What was their response?

    I’m honestly curious – maybe you are more humane and less out of touch than I think. I wonder what your position is on severe psychotic distress being “an illness”. Probably you can admit that there are no reliable biomarkers behind labels like schizophrenia or bipolar. These labels refer to behaviors that are, in my opinion, usually the results of overwhelming neglect, stress, trauma, abuse, and confusion. Each person’s “madness” is individual, not a common illness which can be studied as if it were one consistent entity reoccurring across different people.

    Interestingly, Allen Frances implied that the cause of psychotic-spectrum distress is primarily environmental when he said, “But, in my opinion, if we want to find a solution, we should focus on providing housing, social support and jobs that help people lead meaningful lives. If we want to reduce the number of people said to be mentally ill and in jail, then we should focus on reducing poverty in this country.”

    He’s so right. “Mental illness” does discriminate and does target blacks, poor people, and the disadvantaged much more frequently than other social classes.

    It’s not coincidence that jails are full of poor black people and that jails also happen to be the nation’s largest warehouses for the “mentally ill.” The psychiatric idea that mental illness doesn’t discriminate by ethnicity or class is, unfortunately, a bunch of bullshit.

    August 13, 2015 | 9:53 PM

    Why do you tolerate this writer above, insults me in a recent post, and now insults you. Think it’s time that you start setting a limit with these anti Psychiatry instigators.

    August 14, 2015 | 9:57 PM

    Joel Hassman, my comments above were blunt and direct, but not intended to insult. I am aware that BoringOldMan was a psychiatrist who did more psychotherapy than medicating and probably helped a lot of people. On the other hand, he seems to be buying into myths the validity of DSM diagnoses and talking about emotional-relational-life problems as “illnesses”, and in that sense, he seems to me to be out of touch. So, I was asking him about whether that perception is correct or not.

    Regarding my points about mental “illnesses” like schizophrenia and bipolar being essentially arbitrary, unreliable labels for a variety of loosely related problems arising from severe trauma, abuse, neglect, and overwhelming anxiety… surely you agree with that characterization? No one can argue that there are biomarkers for these illusory illness labels, because there aren’t. To give him credit, that is something that BoringOldMan acknowledges.

    As for Jon Stewart, relax! His primary intention was to entertain and ridicule the status quo, which he did very well. It seems like you lost your sense of humor somewhere along the way.

    August 14, 2015 | 11:58 PM

    tbh i always found personality disorders to be invalid, but that’s just me.

    to put those in the DSM was the straw that broke the camel’s back imo.

    Bernard Carroll
    August 15, 2015 | 1:36 AM

    Do we really have to go over once more the old ground about validity of psychiatric diagnoses? In reply to Edward Dantes, no we don’t agree that “mental “illnesses” like schizophrenia and bipolar (are) essentially arbitrary, unreliable labels for a variety of loosely related problems arising from severe trauma, abuse, neglect, and overwhelming anxiety…” Here is my take on it from some time ago on this blog. Enough said, I hope. Sufficient for the day is the A-list.

    August 15, 2015 | 10:39 AM

    Is it coincidence you yet again come after me personally, and then one of my email accounts was hacked this morning?

    If you have nothing to do with it, then not an issue, eh? If you do have something at hand, please leave me alone in your ad hominem attacks, I don’t go after you moment one and have no interest to dialogue with people who think their agenda trumps every single other persons that does not replicate such attacker’s narrative.

    Key word there, dialogue, I have no problem with reasonable dissent, but, you had no business writing that comment at earlier post about the rod!

    My apologies to Dr Nardo, but, letting people write rude things that stay printed gives validity, in my opinion.

    Joel Hassman, MD

    August 15, 2015 | 10:40 AM

    sorry, that above comment is to Mr Dantes, my bad for not being clear.

    August 15, 2015 | 11:07 AM


    “I wonder reading this, how many of your very distressed clients found it helpful to be labelled “mentally ill”? Did you tell them that you considered them mentally ill? What was their response?”

    Usually I pass over such comments. But this one seems so odd. My post is a warning to Dr. Binder to look at all sides of this issue, and not “take sides” up front. I quote Whitaker and Szasz and preach a gospel of neutrality, I go on to suggest acknowledging the “sins of the fathers.”

    And you’re off and running with the stock “myth of mental illness” bit? talking about “labels?” Did you read this post? Who are you talking to?

    August 15, 2015 | 2:00 PM

    For me this is the problematic sentence:

    “The sentiment expressed above by Robert Whitaker and in the British Psychological Society’s Report suggests that psychotic conditions aren’t, in fact, mental illness at all, but rather some barometer of social ills and imbalances, or even a sign of psychiatrists not listening.”

    When I read this comment I thought you were speaking about Whitaker and the PBS report in a sarcastic way, (but maybe your weren’t); and I worried that this comment would allow many people to discount the very real concerns and contributions brought to the field of psychosis by both Whitaker and the PBS report. For example I think it would be very important for Dr. Binder to consider Whitaker’s concerns about the long term use of antipsychotic medication in any discussions that involved “diverting minor offenders who have mental illness to treatment resources rather than incarceration.” Likewise the PBS report’s emphasis on choices in treatment would be very valuable information for her (That is not to say that other treatment frameworks are not supportive of choice of treatments.)

    August 15, 2015 | 2:02 PM


    Not much longer…

    August 15, 2015 | 2:08 PM


    So what else does “don’t take sides mean?”

    August 15, 2015 | 2:09 PM


    Not enough said, unfortunately. Your earlier comment gave no evidence that the major labels are reliable. Here is an article citing 1BoringOldMan and others, discussing (DSM-5) reliability of labels like schizophrenia and major depression:

    Having kappa ratings close to 0.2, as for Major Depression, is arbitrary, and even the ratings for schizophrena are pretty poor at around 0.5

    Your comment in the other article, Bernard, while making some valid general points, also has some unevidenced, muddled thinking. You say that various labels are candidates for presumptive underlying brain malfunction. But the key word here is presumptive – you cite no evidence proving a brain malfunction specific to any of these labels. And you’re not able to, because none have been discovered!

    And despite admitting that “the line is fuzzy” for many conditions, you think there is a clear boundary and that it’s pretty clear where a person lies in relation to it for most labels. However, the actual data from field trials of DSM labels doesn’t support that contention – in other words, different psychiatrists often, sometimes more often than not, disagree about which person has which disorder.

    You can sound as authoritative and dismissive as you want, Bernard, but unless you actually have strong data supporting reliability/validity, it’s unclear why people should take the idea that there is strong reliability and validity for mental illness diagnoses seriously.

    August 15, 2015 | 2:11 PM

    Joel Hassman, I don’t even know what your email address is, let alone know how to hack a person’s email. Mostly likely the origin is in Brazil, Russia, and China – that’s where 90% of these types of hacks originate. I hope you get your account back.

    August 15, 2015 | 2:20 PM


    I did read your whole post, and most of it is fair and good. I read this blog because it is usually interesting and filled with relatively unbiased looks at current controversies. I agree with a lot of your writing.

    The problematic part for me was, as Sally referenced, this paragraph:

    ““The sentiment expressed above by Robert Whitaker and in the British Psychological Society’s Report suggests that psychotic conditions aren’t, in fact, mental illness at all, but rather some barometer of social ills and imbalances, or even a sign of psychiatrists not listening.”

    The implication here was that you considered psychotic diagnoses to be actual illness, or perhaps even a brain disease. I don’t know whether that’s right or not – perhaps it is a mistaken assumption on my part, or perhaps it has to do with semantics. That’s why I asked how you think about the mental illness label in relation to psychosis, and whether you told your clients that you thought their psychotic experience were illnesses. I was curious.

    As I said in an earlier post, I had the impression that you were primarily a psychiatrist who does psychotherapy with limited medication where indicated, so you were probably better at helping psychotic people than psychiatrists who overfocus on medication and do very little therapy.

    August 15, 2015 | 2:40 PM

    Great – I am thankful that I was mistaken about how I `read’ that comment, and grateful that you are asking Dr. Binder to consider all the sides.

    I am someone who believes very strongly in mental illness, but my personal circumstances leaves me extremely frightened of some of the aspects of treatment resources such as AOT,…. maybe that is why I find myself often in the ‘ready to pounce position’.

    August 15, 2015 | 2:51 PM

    Getting back to the post here, why is it we leave it to the APA and flawed KOLs to set the dialogue and agendas?

    I still don’t read anything of genuine sincere interest by any rep from the APA to show an interest in the public’s welfare. I think the dissent by Whitaker et al has some validity, but even he makes sweeping generalizations at times that diminishes his perspective.

    After all, MIA is his blog…

    August 15, 2015 | 3:32 PM

    For some, “not taking sides” is taking a side. Holding a centrist or balanced position often invites attack from both extremes. In contrast, extremists always know which direction their critics will come from. (This can be a good test for anyone wondering if they’re an extremist.) Those who can tell babies from bathwater, i.e., not taking sides, make up in nuance and insight what they lack in cocksure self-righteousness.

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