still meandering about…

Posted on Friday 18 March 2016

In my time in psychiatry, the specialty has often been shaped by its critics. When I arrived in 1974, Thomas Szasz was one of those major critics. While his principle focus was on civil liberties in his opposition to involuntary hospitalization and treatment, his argument was more fundamental – that the whole notion of mental illness was a myth as there was no evidence for biological causation. He went further, saying that the real motive for the whole complex of mental illness and psychiatry was to pathologize aberrant behavior in order to control it – short circuiting the due process of the law – that psychiatrists were the agents of a non-benevolent State. Though I came to psychiatry from the world of hard biological science, Szasz’s idea that Medicine and Illness are defined by abnormal biology was something I’d actually never heard anyone say before. I might have even thought something like that after medical school, an Internal Medicine Residency, and an NIH Fellowship in Immunology, I don’t recall. But it hadn’t taken very long as a practitioner to get over it. For one thing, three fourths of the people I saw in a referral only practice had sick-ness, ill-ness, disease, sure enough – but without any abnormal biology. For another, for those with biologically based chronic illnesses, treating the biology part was relatively straightforward. It was the human experience of ill-ness that was the challenge. So I didn’t come to psychiatry to bring or find more biology. I had plenty enough already. I came to learn more about human experience.

Well that was the best decision I ever made … until it wasn’t. To my amazement, some ten years later, organized and academic psychiatry embraced Szasz’s definition that Medicine and Illness are defined by abnormal biology and drove head long into the world of biological causation. There were a gajillion other forces at work other than setting out to prove Szasz wrong. Who knows, maybe the new movers and shakers didn’t even think about Szasz, but that’s what they did nevertheless. So for me, another big change –  from a busy tenured academic position in a psychiatry department to a private office of my own down the road. From my perspective, that period didn’t feel like the swinging of a pendulum. It felt more like the Invasion of the Body Snatchers. I can say a lot about the why of that now, but then I was just at sea looking for dry land. As it played out, it was the second best decision I ever made, or had made for me, or both. I had been busting ass to hold our way-under-financed program in the road and hadn’t noticed the personal toll … until I didn’t have to do it any more. But what I’m getting at here is that for whatever myriad of reasons, mainstream organized and academic psychiatry embraced the biological definition with a passion, a definition popularized by their greatest critic. And it wasn’t the biological psychiatrists I knew or knew of from before leading the charge, it was a new breed. While some, like Tom Insel, were ideologues – many others were more in the entrepreneurial category, a group I now call the KOL Psychiatrists [borrowing the "Key Opinion Leader" term from PHARMA marketing lingo]. Only a few from that second group made it to Grassley’s List in the last post, but there are many more that should’ve been on it.

by Bruce Levine
March 5, 2014

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…
As I’ve said before [see the guilded age…], I don’t recall this Talk Therapy Cession Decree of 1980. None of us do, because it didn’t happen. What did happen, however, was that the third party carriers contracted with psychologists, counselors, social workers and so forth to do therapy/counseling [on their terms at their fees], and only reimbursed psychiatrists for medication visits. So the outcome was as Whitaker describes, but the process that got there was slightly different. Psychiatrists doing psychotherapy were either paid as out-of-network providers or paid out-of-pocket.
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…
Whitaker is assuming that the Szaszian notion that Medicine and Illness are defined by abnormal biology is, in fact, psychiatric dogma. But beyond that, he’s conceptualizing medical care in terms of the various guilds involved and the relative success of their products in the marketplace.
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. 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…
Sticking with his marketing terminology, I think what he’s proposing here for psychiatry is called a niche market. Pressing forward with my thesis that psychiatry has often been shaped by its critics, many of the powers that be in psychiatry right now are doing exactly that – promoting Collaborative Care, something that follows what Whitaker suggests here to a tee [see two versions… and my say…] – medication experts who don’t [often? ever?] see the patients they’re "experting" on.

The split between therapists and psychiatrists [medication managers] that developed after the DSM-III came along is usually discussed in terms of ideology or guild membership, but it was largely the creation of the third party payers based on cost accounting. And some of the current plan to move the point of contact for mental health to primary care physicians with Collaborative Care feels like more of the same. So in a way, Robert Whitaker is completely right to discuss these matters in marketing terms, but his comments are based on a fiction that all psychiatrists are obligatory pan-diagnosis biomedical ideologues. Outside the class of the KOL Psychiatrists [who are themselves in a marketing frame of mind], the guild/ideology split is in part an artifact actively created and maintained by the Managed Care system. Far and away, the major source of referrals to the medication management psychiatrists are psychologists, counselors, social workers and so forth. And those who can’t find a psychiatrist to prescribe for them find someone in primary care who is willing. Likewise, there are many psychiatrists who practice outside this system altogether and are as put off by the antics of the the KOL Psychiatrist set as anyone else.

In meandering about…, I was musing about some [unscientifically derived] signs in the American Psychiatric Association Preliminary Scientific Program that psychiatry might be awakening from its long sleep during the era of the KOL Psychiatrists and Clinical Neuroscience. How much of that is fact and how much is wish is for others to judge. But that aside, there’s the obvious question whether psychiatry itself will be viable in the long term. The specialty is under active siege from Managed Care, the other mental health disciplines, and the those writing on Robert Whitaker’s Mad in America site [eg the end of psychiatry, BEHAVIORISM AND MENTAL HEALTH, etc]. Those outside forces have been both fueled and abetted by the academic/pharmaceutical alliance [a synonym for the KOL Psychiatrists] inside psychiatry and, to some extent, the NIMH of the last twenty years.

As for how that will play out over time, while I can’t help but have thoughts about such things [as evidenced by these two posts], I actually see that future as "no country for old men." I really did come to psychiatry to "learn more about human experience," and found what I was looking for. On the other hand, I do see the quest for integrity in medical science as an open territory for physicians without any age or specialty restrictions. That’s not something to be legitimately determined by the forces of the marketplace or business majors, and it has been, not just in psychiatry but throughout medicine. So there’s plenty enough grist for this mill…
    March 18, 2016 | 3:13 PM

    I have never understood the fascination of listening to proclamations about psychiatry by people who clearly know nothing about it. If there is one flaw that psychiatrists have that other medical specialists do not – that is it. Self doubt is the logical extension.

    March 18, 2016 | 5:58 PM

    Without rehashing the tortuous path to the current situation, and having contact every day with dozens of people having bad experiences with psychiatric drugs, IMO the question for psychiatry is “How can we provide better psychiatric care than non-psychiatrists?”

    This would require real-world analysis of what’s going wrong, and doubtless lead to an understanding of misdiagnosis, overprescription, failure to recognize adverse effects, and failure to properly discontinue drug treatment.

    This study would be necessary to define best practices for psychiatry — those that lead to best outcomes and patient well-being, superior to those achieved by arbitrary treatment from general practitioners trained by pharmaceutical company representatives.

    However, visionary leadership would be necessary to move the profession in this direction, as the soul-searching involved clearly is beyond the present leadership and, indeed, many of the practitioners of the specialty.

    March 19, 2016 | 8:21 AM


    I have never understood the fascination of listening to proclamations about psychiatry by people who clearly know nothing about it…

    It’s not fascination in my case. It’s more like the hypervigilance of PTSD. First, people outside can often see things that are inapparent to insiders. In those cases, self doubt is a good thing. but second, if they’re wrong, it seems to me that one is better placed to know what’s wrong with their argument in detail in advance than to discount it out of hand and then later be blind-sided.


    Running Clinical Trials is an expensive proposition. That has been one of the major problems in that the ‘deep pockets’ are obviously the drug companies. But the Publicly funded trials [NIMH] have been exploratory rather than replicative. Another problem has been that the trials have been ‘short’ – 6 to 8 weeks. Answering the important questions you raise definitely requires long-term studies. My impression is that people who are interested in this topic are looking to ongoing monitoring schemes – things like Healy’s RXISK, careful attention to the health plan databases. Goldacre proposes using the NHS EMR system. All, as you say, “real world” longitudinal studies. While the FDA has the power to require Phase IV studies, it hasn’t been used very much and when it has, those studies are in the hands of the manufacturer.

    In the past, one effective tool had been individual case reports. But with the modern “pace,” individual doctors aren’t able to spend the time to pick up on these things so much, and publishing a case report is extremely difficult. I’m not arguing with your point. I’m just saying that it takes not onlyvision, it takes mechanisms by which to put that vision into action.

    James O'Brien, M.D.
    March 19, 2016 | 11:27 AM

    The last time I used a knife on a patient was 1983 but I can spot bad plastic surgery which seems to be more popular than medical marijuana in California. As Dylan said, you don’t have to be a weatherman to know which way the wind blows.

    March 19, 2016 | 11:36 AM

    I honestly don’t know why you turn to Robert Whitaker, he is as much a fraud and an extremist as the psychiatrists he attacks as clueless and disruptive, and then Whitaker overgeneralizes it to all of psychiatry.

    That offends me. Read his latest roast, er, post, and then the usual suspects at the thread. Hmm, seems to echo another lame effort to pretend to be a leader in wanting change for the alleged better, that being the Trump campaign and his growing hoard of choir members wanting vengeance!

    the post:

    at the end, this from “Dr” Whitaker:

    “It is easy to imagine what Frances and Pies might say in response to this blog. They would likely argue that most psychiatrists are able to distinguish between those who need the drugs and those who do not, and regularly taper many of their psychotic patients from antipsychotics. Indeed, here is what Frances wrote in his third blog: “Most psychiatrists do a good job of diagnosis, prescribing meds, and providing support . . . Results overall for psychiatric treatment are good. The majority of patients improve at rates equal to, or above, those achieved by doctors treating medical illness.”

    But, as was seen above, psychiatry’s evidence base for antipsychotics, which states that the drugs are effective over the short term for curbing psychosis and effective for reducing the risk of relapse, does not promote such selective-use prescribing, and, indeed, any survey of 100 people diagnosed with a psychotic disorder in the past 25 years would find that most had been told they needed to take the drugs for life. Frances and Pies, in their blogs, were seeking to defend psychiatry’s prescribing practices and the long-term effectiveness of antipsychotics, but the caveat they expressed—that the drugs are effective for a certain subset of psychotic patients—naturally focuses attention on the drugs’ effects on those who don’t need them long-term, and that leads to a finding of great harm done.”

    I have been called on using terms like “most”, and I think responsible critics and observers would like to know what that means, so is it 50.1%, or 67%, 80%, or 95%?

    What is hilarious and hideous simultaneously over at MIA is Whitaker proposes what Pies or Frances would say if they replied there, and yet, they won’t, because Whitaker allows his attack dogs to ravage anyone who does not spew their narrative and rhetoric like the genuflection of mindless minions.

    Hell, I wrote a rebuttal yesterday that was fair but critical, but, it wasn’t printed, because I was critical of the Leader. And I come here and read your post giving some credibility to this guy?

    Come on, maybe I need to read more, but I sense so do you, Dr N.

    Where are the moderates in this debate about responsible and appropriate mental health care interventions? Or, maybe the better question is where are the professionals with intestinal fortitude to take a stand, against both these loser polarized ends hijacking the debate to “our way or no way”.

    Politics, everything degrades into politics…

    March 19, 2016 | 5:27 PM

    Mickey, one needn’t run clinical trials to identify patterns of drug injury and mispractice. Data mining can do this — if one has the will.

    March 19, 2016 | 5:41 PM

    Have to admit that the more I have read the Mad in America site, having come to it initially because of its posting of critiques of Lieberman and the handling of the Kupfer affair, and through your (1bom) references to it, the more I have become convinced that the enemies of my enemy are not necessarily people I agree with. Selective representation of information driven strongly by ideology, and a focus on the erection and destruction of straw people, gets wearing. No matter the “side” of the issue. Over time I have come to wonder how different some of the posters on MIA are, at least in style of thought, from the Lieberman’s on our “side.”

    In addition, it is not clear to me who are the equivalents to you 1bom, and to Carroll, over on MIA or similar sites. You and Carroll will take a paper to task on its merits, even if you agree philosophically with the overall point it is trying to make. Even if it fits your party line. You question the leadership and the excesses of the movements with which you are most aligned. Who at MIA challenges Whitaker or Gotzsche or BPS for their excesses/fudges? Or the excesses of fellow bloggers on the site? You and Carroll are Mavericks (gadflies in the good sense) of groups with which you have kinship, with whom you have chosen to affiliate. MIA reflects an affiliation, a group. I may need to read MIA more extensively, but I have not so far come across there the kind of rigorous gadflies that the two of you seem to represent.

    P.S. Phillip Dawdy of the sadly now defunct and totally “of the air” Furious Seasons blog is perhaps the voice on the other “side” that might be closest I can think of. It would have been cool to have seen your blogs cross pollinate each other.

    I have learned a lot from both your voices. I had hoped to find some more of the same at MIA. I find myself in surprising agreement with some of the other posters here in that that hope was not realized.

    March 19, 2016 | 6:02 PM


    I sure agree with that 110%. Having just been involved with some of that, it’s harder than I might have thought because the “cleanliness” of the protocols and design of structured trials makes analysis easier. On the other hand, there are few datasets that don’t yield up valuable information. The problem, of course, is getting one’s hands on the dataset “in the raw.” Again, no argument here with what you say, but data mining takes datasets to mine. The Phase 1 of the EMA transparency releases will have Clinical Study Reports. They haven’t said yet, but I hope Phase 2 will bring IPDs [Individual Participant Data]. But that’s all trial stuff. The Health Plan data would be beyond nice, but there’s not much of it in the public domain. Actually, looking into the availability of that kind of data sounds like a good project…

    March 19, 2016 | 7:36 PM


    Thanks for the nice things. I came in at the end of furious seasons and share your sense of loss. It was a powerful voice. I also miss PsyCritic, who seems to have gone dark. On MIA, I’ve followed Sandra Steingard and though we have had our disagreements, I think she’s a solid thinker and at least from my side, our disagreements are just that – disagreements. Real Psychiatry is always a pleasure. I think George thinks I’m too soft on … whatever … but different stokes as they say. Some of the narratives on MIA are really good [like Regarding the Impossibility of Recovery]. I don’t mind their disagreeing with Drs. Pies and Frances. It’s the name of the game to disagree, but not the ad hominems bordering on mockery. My main disappointment is their anthropomorhizing “psychiatry” as if we’re a unitary group having one mind, one theory, one approach – which even in the difficult era we’ve just been through is way off the mark. But if it’s a ‘psychiatry has to go’ site, I’ll go from it peacefully. I just didn’t know that’s what it was…

    March 19, 2016 | 7:57 PM

    Starting to read “Regarding the Impossibility of Recovery.” Thank you. It brought to mind this post that I deeply enjoyed, and that I’m passing along in case you might enjoy it too:

    March 19, 2016 | 9:33 PM

    Psychiatry has made mistakes, make no mistake about that, but, to vilify everybody just because we share the same title is, as respectfully as can be noted, is rude.

    People who have read my comments know what I’m about, I practice the way I was trained and I hold people accountable to a standard of care we all should have equally been trained to provide, and if colleagues seem to relate they don’t maintain a respectable and ethical standard of care that is defensible, then yeah, I’m going to be critical.

    That said, I’m sick of the anti-psychiatry people, because I know in my heart a lot of them are personality disordered, and their rhetoric and attacks are just unacceptable.

    I think that Dr Nardo here does a good job of moderating that, which is appreciated. However, I’m not really clear why he would want to quote or highlight people who comment with regularity at MIA who seem to be widely accepted there. That seems to be a bit inconsistent to me.

    But, your blog, your space, and your rights.

    I’m just noting I don’t really understand why you put a lot of faith in Robert Whittaker. Case in point, do you know that MIA recently had a fundraising drive to raise a quarter of a million dollars? What is that about, and I ask obviously in a rhetorical fashion because I know no one here could explain that to me.

    If I offend, then I am sorry. You’re dealing with a psychiatrist who is just trying to find a home where I can practice the way I was trained, patients will mostly benefit, and I can be left alone for the most part.

    Anyway, have a nice rest of the weekend, to you basketball fans, let’s hope the tournament is as enjoyable as it’s been so far.

    March 20, 2016 | 2:10 AM
    March 20, 2016 | 11:40 AM

    Excuse me Dr. Hassman but Whittaker did publish your rebuttal. I just read it.

    March 20, 2016 | 11:58 AM

    Yeah, so did I about a 1/2 hour ago, and yet, it was submitted on Friday but appears today on Sunday, and I have written about it here and at my blog earlier, so coincidence, or, damage control, or maybe even set me up for more abuse?

    But more importantly, sorry this may not be related to this post, I think physicians need to realize what is going on that has nothing to do with patient care, or honest and true continuity of care, or allowing physicians to exhibit the judgment graduating from a medical school and earning a license from a state to practice:

    “Some studies have suggested digital prescribing carries risks of its own, such as mistyping or choosing the wrong item from a drop-down menu. Minnesota health professionals reviewing their state’s e-prescribing progress noted some problems in changing and canceling prescriptions electronically, including a case in which a patient doubled up on cholesterol drugs and died of the complications, according to a presentation at the state’s e-Health Summit last year.”

    Who’s gonna be liable for these problems? What, the state of New York?

    Cue Ayn Rand’s point in “Atlas Shrugged”:

    “I have often wondered at the smugness with which people assert their right to enslave me, to control my work, to force my will, to violate my conscience, to stifle my mind—yet what is it that they expect to depend on, when they lie on an operating table under my hands? Their moral code has taught them to believe that it is safe to rely on the virtue of their victims. Well, that is the virtue I have withdrawn. Let them discover the kind of doctors that their system will now produce. Let them discover, in their operating rooms and hospital wards, that it is not safe to place their lives in the hands of a man whose life they have throttled. It is not safe, if he is the sort of man who resents it—and still less safe, if he is the sort who doesn’t.”

    Yeah, all you folks just loving Obamacare and other government intrusions, good luck with that, you think just a bunch of lame psychiatrists are your sole enemy. Supporters of Obamacare and an intrusive government in large, you deserve what you reap.

    The real enemy to be educating the public about are those who want to mangle health care into a weapon, and it is happening, Dr N and other readers, but, what do I know…

    March 20, 2016 | 12:49 PM
    Thought provoking article. Off topic but thought it worth a share.

    James O'Brien, M.D.
    March 21, 2016 | 11:05 AM

    Some of the biggest critics of psychiatry are other physicians and many if not most of their complaints are valid. I would also add we have a right and a duty to criticize the prescribing practices by FPs of CNS drugs. We also have a right to criticize other specialties such as pain management. Andrew Kolodny is a psychiatrist.

    Peter C. Dwyer, LCSW-C
    March 21, 2016 | 9:19 PM

    Dr. Nardo,

    This is a great web site. I very much appreciate the in-depth critiques you provide, and your even-handedness. Your contributions are immensely valuable.

    I am concerned about the discussion here of Mad in America. You want others not to see psychiatry as monolithic; I wish psychiatrists would see critics of psychiatry as non-monolithic. Some see specific problems; others have broad critiques; some want psychiatry to disappear; others seek reform. Many such people write for or read Mad in America – I don’t believe it is dedicated to making psychiatry disappear. That is the goal of some, but not of others.

    I read Mad in America (plus about 125 books pro and con biological psychiatry, and journal articles). If, as you say, psychiatry is non-monolithic, so are the authors and readers of Mad in America. You mention Sandra Steingart; Philip Hickey and David Healy also come to mind, among others, who make well-informed points about psychiatry.

    You are right that many see psychiatry as monolithic. Regarding specific psychiatrists, they are over-generalizing. But regarding psychiatry as a whole, they are more right than wrong. I think it is hard for those with power to understand how they are viewed by those without power. Here is what psychiatry has looked like to me:

    I am a licensed clinical social worker who, after careers in law and college teaching, spent 9 years as a program director in treatment foster care.

    Dr. Julie Zito, of the University of Md. School of Pharmacology, did a national study that found children in foster care 17 times more likely to be on psychiatric drugs than other kids on M.A.. This should raise eyebrows. Moreover, Maryland foster care regs. require children entering foster care to be examined by a psychiatrist. Many are immediately put on psych. drugs – before they ever have a psychosocial evaluation. And once on, they are almost never taken off.

    My social workers’ caseloads averaged 7 to 8 children; they sometimes spent hundreds of hours with the children and their biological and foster families building relationships and performing in vivo therapeutic interventions – yet their input was often dismissed by psychiatrists who saw the children only in monthly 15 minute med checks.

    Some psychiatrists never even looked at the children, sitting with their backs to them and their foster parents, asking questions and typing on laptops. Foster parents told me they were almost never advised of adverse effects when children were put on new drugs. My strong impression after 15 years in the field: of all the professionals in contact with foster children, psychiatrists generally had the least relationship with the children and the least inkling of what actually went on in their lives. And this was in Baltimore – think the Kennedy Krieger Institute, Johns Hopkins, University of Maryland Medical Center, Sheppard Pratt …

    Yet it was abundantly clear who the “experts” were – the psychiatrists. I and my social workers often appeared in court for case reviews. No matter how many hours we had spent with children, how much we knew about them, or how good our treatment plans – if something went wrong and we had not involved a psychiatrist in the child’s care, we were vulnerable to malpractice. If, however, we had done 1/10th the work, and simply had the child go through the monthly med check + 3 psych. drugs, we were safe from malpractice.

    I found few instances where psychiatrists seriously considered weaning children off drugs, or even knew what the children’s treatment plans were.

    I think psychiatry’s status as “monolith” is determined, not by how many psychiatrists have misgivings about their profession, but by the face the profession presents to patients, other professionals and the public. By that measure, the influence of the KOL/academic psychiatry/PhARMA complex is overwhelming:

    PhARMA spends $60 billion a year on promotions – much of it for psychiatric drugs. Probably 90% of Americans believe their emotional problems are caused by “chemical imbalances” and that, as one ad series claimed “only our doctor can diagnose depression.” While PhARMA blares ad copy on TV and in women’s magazines, only a few voices like yours run against the current. I have challenged the ad copy at Sheppard Pratt grand rounds, in CEU courses, letters to the editor, letters to the National Association of Social Workers, in trainings I’ve given – feeling like I’m hollering down a rain barrel.

    People I know – Peter Breggin and Grace Jackson – have spent tens of thousands of dollars defending their licenses to practice psychiatry because they dared to contradict the bio-bio-bio model of psychiatry. A good friend within psychiatry is under constant pressure because he spends more than 15 minutes per patient and thinks psychosocial stressors are relevant to teenagers’ problems – contrary to the opinion of the psychiatrist who directs his service.

    Psychiatry’s “partner,” PhARMA, has almost infinitely deep pockets to defend lawsuits or to sue those who rattle its cage. Even so, it doesn’t much mind the occasional billion- dollar settlement for fraud – virtually every large drug company has at least one, and the preponderance of those settlements involved psychiatric drugs. The individual patient or practitioner is virtually helpless in the face of PhARMA’s resources. That’s a good ally for psychiatry to have – one nobody else has – patients, psychologists, social workers or counselors can’t even dream about such connection to power.

    I don’t doubt most psychiatrists go into their field out of compassion for those who suffer, working hard for decades, often under difficult conditions. I don’t doubt many search their souls over what they do.

    But I think psychiatry as an institution is a monolith. If an individual psychiatrist publicly questions biological psychiatry, he/she’s got a problem. Some, like Carlat, know how to go up to the line, but not cross it. But until large numbers of psychiatrists openly insist on retraction of the Study 329 article; until many say clearly the evidence for “chemical imbalances” is thin and contradictory and demand PhARMA and psychiatrist stop trading on it at their convenience; until compulsory rules are enacted and enforced regarding ghost-written journal articles and other transparency issues; until psychiatry demands that Phase 4 studies actually be done …. I could go on … until those things happen, the institution of psychiatry will look pretty monolithic to me.

    I am critical of social workers for being subservient to psychiatry, for mindlessly accepting whatever the system tells them to do – and for too often doing it half-heartedly. Ditto psychology, for not thinking clearly, not speaking out, and too often being motivated by the desire to be junior psychiatrists. And ditto the entire medical system.

    Most big problems of the health care industry are, one way or another, financially driven. But psychiatry has a special role in the mental health industry – at the top of the pyramid. A thought just came to me – maybe ludicrous, I don’t know. But aren’t we all “wage workers” within this juggernaut – some with perks, but wage workers just the same? In our guts we want to lend a real hand to our fellow humans who suffer, and it eats at us to think that our work is so distorted by cross currents of the crazy health/mental health industry.

    Aren’t we in the position of pre-union era workers? If only a few point out where the emperor is au naturale, we are without influence and vulnerable to retaliation. But if large numbers pull together in the same direction …

    Bravo to you, Dr. Nardo for speaking out so intelligently for honest science and transparency, and for avoiding the ad hominem. We need many more like you, and we need non-retired psychiatrists, psychologists, social workers, counselors and those “served” by the mental health industry to get together, really talk and listen to each other, and not leave it to PhARMA and the compromised APA and medical journals to run the show.

    This isn’t about pro-or-anti-psychiatry. It isn’t about different guilds jockeying for market share. It is about how to effectively care about our fellow human beings. If we keep that in mind, we can read and respond to each other’s blogs and think more clearly.

    Going ad hominem on each other just locks problems in place. That can surface in Mad in America. It is generally destructive, but is, I think, an understandable reaction to the frustration of confronting the monolith of institutional psychiatry. It can also come from institutional psychiatry, and sometimes from individual psychiatrists. Time to do things differently.

    March 21, 2016 | 11:00 PM

    While Peter Dwyer makes some valid points, you can’t turn to an equally rigid and inflexible polar opposite for developing and maintaining healthy and effective debate about real issues. And yes, the APA and their ilk are not worthy of giving much if any credibility to the over-medicating of American society and what I firmly say with true belief there is a criminal element to SOME in that upper echelon.

    Just read Robert Whitaker’s title of his March 17 post, “Dr. Pies and Dr. Frances Make a Compelling Case that Their Profession is Doing Great Harm”, it would have been a more accurate and respected intro if he instead said something of the sort “…compelling case that too many in their profession are doing…”.

    But, that is not the narrative at the end of the day for what MIA is selling, and, interesting we never hear from psychiatrists who have dissenting but fair and reasonable points of view that do have some validity for diagnoses and treatment interventions for mentally ill people who have been able to comment there without fairly overt abuse. I know personally.

    The difference here is Dr Nardo does moderate, as he did with me last weekend, which was accepted and respected by the way, so, pay attention to threads at blogs as much as the post itself. What is tolerated and at the very least supported by very loud silence of the blog authors speaks volumes for what the blog attracts.

    I am and will continue to be very offended by the pervasive over-generalizations that ALL psychiatry is bad, that ALL medications are bad, and, that there is no such thing as mental illness.

    I leave Peter with this observation having noted it at MIA and with those commenters at other sites these past couple of years: if you do not want psychiatry to be a valid resource to people struggling with psychological problems, and think medication should be an infrequent choice for treatment, then what else do these people have to turn to for care?

    That is, again, the loud silence from the loudest critics seem to either deny, deflect, minimize, or just pathologically rationalize, which all lead to the same conclusion from them: people don’t have psychological problems, and therefore don’t need care.

    Hey, if you think I am either making this up, or over exaggerating, wait until the next post that demonizes psychiatry and mental health diagnoses at MIA and then try to make a comment that there is legitimate psychological distress, and then prepare for the attack.

    It will come, again, I know for having been there.

    Remember per that Whitaker post I note above, he rhetorically relates what would Drs Pies and Frances say if they would comment there, and they won’t , because they have been rudely and inappropriately attacked in the past when they tried. So, what does that say about the people who control the blog? Would it not be educational and instructive to have their rebuttals noted if they would be received respectfully?

    Just my opinion, and, experience…

    March 22, 2016 | 3:33 AM

    Peter. I do not say that MIA is monolithic. I also agree with 1bom that narratives on the site can be thoughtful and of much value. However, with the possible exception of Steingard, I would repeat to you the question I posed in my earlier comment:

    “In addition, it is not clear to me who are the equivalents to you 1bom, and to Carroll, over on MIA or similar sites. You and Carroll will take a paper to task on its merits, even if you agree philosophically with the overall point it is trying to make. Even if it fits your party line. You question the leadership and the excesses of the movements with which you are most aligned. Who at MIA challenges Whitaker or Gotzsche or BPS for their excesses/fudges? Or the excesses of fellow bloggers on the site? You and Carroll are Mavericks (gadflies in the good sense) of groups with which you have kinship, with whom you have chosen to affiliate. MIA reflects an affiliation, a group. I may need to read MIA more extensively, but I have not so far come across there the kind of rigorous gadflies that the two of you seem to represent.”

    Or even just a “hmm, I wonder if I am getting this wrong” kind of reflection post on the MIA site? Again, Steingard aside. This isn’t saying they definitely aren’t there. Not just asking rhetorically. Who are they? Whatever their other merits, it’s certainly not Healy or Hickey.

    March 22, 2016 | 5:11 AM

    Thanks for the thoughtful comment. I just have a few comments. First, when you mention the Institution of Psychiatry, I expect you are talking about the American Psychiatric Association [APA]. I haven’t been a member since the 1980s, so I can’t really speak for or to them. I don’t think that the APA has always been seen as the Institution of Psychiatry. That happened in the 1980s with the introduction of the DSM-III and was the result of an active process [see which nail…]. In the 1960s and 1970s, the dominant influence in psychiatry were the psychoanalysts who occupied the chairs of many academic departments, and psychiatry itself was “eclectic” to a fault. The DSM-III Revision was organized by Medical Director Mel Sabshin, Dr. Spitzer, and the group primarily in the midwest who wanted to rein the specialty into mainstream medicine. It was a reform movement and a coups to diffuse the psychoanalytic hegemony – one that succeeded beyond its dreams. So the APA assumed the position of the Institution of Psychiatry. At the same time, the psychologists sued the psychoanalytic establishment for training only physicians, and won. So psychoanalysis changed dramatically and moved to the side where it remains – increasingly “non-denominational”.

    The way I understand it, having assumed “emergency powers,” the APA never relinquished them. If the massive shift to what you call bio-bio-bio was planned then, I can’t document it. As it appears to me, that was the result of a perfect storm: Managed Care; the entrance of PHARMA; and a new breed of psychiatrists in high places in academia. Psychiatry departments were broke, and the group I speak of were the ones who could raise the money, which came from PHARMA in the form of trials, grants, and probably under a table or two. That’s how I understand it in retrospect. At the time, I was a psychoanalytic candidate and primarily interested in psychotherapy. So it was no place for me so I fled my academic position to a private office where I did what I did and involved myself in other things.

    I am not and never have been “anti-biology,” but the medication madness that followed was something I only “sort of” knew much about. During those years, many psychologists, social workers, etc. opened private offices as they had gained access to third party payments, and the “psychiatrist/therapist” split became the front burner practice model – something of a symbiosis from where I sat. And there were a lot of psychiatrists like me who practiced solo outside the managed care arena.”

    If you’ve read much of this blog, you’ll know that I’m not an anti-psychiatrist or anti-biologist. And it’ll be equally apparent that most of what I write about is anti-corruption of science in the service of commercial interests. In my own mind, I’m the physician I set out to became. I don’t define physician as biologist only. If I did, I wouldn’t have moved from Internal Medicine to Psychiatry. They called the mainstream changes in psychiatry medicalization, but it appears they meant giving medicine and talking biology. I see medicine as taking care of sick people by whatever means necessary. When they say Disease, they seem to mean biological pathology. I mean biological pathology and the other things that lead to human dis-ease. I guess my own interest was in biographic pathology, but biologic and sociologic pathology and treatment are important too.

    So I appreciate your comments, but find little on MIA that has much to do with me. Even Sandra Steingard who I consider a colleague thinks that being a psychotherapist isn’t something a physician should do, wasting my medical education. I could go on for hours arguing about that, but why bother. That’s her right to think. Mainly, in every interaction I’ve had there, I’ve been talked to as if I’m something I’m not and been challenged to defend many of the very things I, myself, am fighting against. There is much talk on MIA of patients not being engaged on a human or personal level but I have’nt felt engaged in that way in the interactions I’ve had there. And the people there don’t seem to make make room for any psychiatrists except the ones they either deplore or venerate. Patients rightfully resent being simplified, and so do I. And there are a lot of psychiatrists that don’t fit that template. 1bym used the term “disappointed” in his comment. I’ve felt some of that too. Many of my peers, teachers, colleagues, and students have been psychologists, social workers, pastoral counselors, etc…

    Again, I am trying to give you an honest answer. I particularly appreciate your acknowledging the guild aspects of MIA which are certainly prominent. And Dr. Hassman is right. The last time I responded to a comment about MIA, this site was literally bombarded and I’m not going to allow that again. I’ve got nothing I really want to argue about. As they say, “been there, done that.” I responded to your comment because it felt genuine and avoided polemics. As to your last paragraph, ditto

    March 22, 2016 | 11:49 AM

    vive le differance !!

    James O'Brien, M.D.
    March 22, 2016 | 1:41 PM

    Read the article about New York and electronic prescriptions. The CURES database in California doesn’t work. Really, they’re going to criminalize paper prescriptions? This is what it comes to? You’re going to send out people with firearms to throw a doctor in jail for this? This is the same crowd supporting early release for violent crimes.

    The saying in the Talmud is that who are kind when they should be cruel are cruel when they should be kind. Or something like that, I am paraphrasing.

    Just one more reason that more doctors are opting out of patient care. Everything central planning has done in the past ten years with medicine has been a disaster.

    Oh and I bet the legislators who voted for that fiasco are getting campaign contributions from the electronic prescription software vendor who probably got a crony deal, just like Epic did with Obamacare EHR.

    Sandra Steingard
    March 24, 2016 | 1:37 AM

    One point of clarification – if I ever seemed to indicate that I thought you had wasted your education or career, then I apologize for my lack of clarity. As Dr. Carroll has sometimes pointed out, I could be clearer in my communication. What I have tried to ponder is how we balance a number of factors- the cost of medical education, the salaries doctors expect to earn, the varied professions who offer overlapping skills, knowledge and services, and the elements that are unique to a medical education. This is not at all about your skills, expertise, or the help you have given your patients over the years which I believe is considerable. I would refer anyone to you and have the utmost confidence in your intellectual and clinical skills as well as your compassion and humanity.
    I am pondering the future. I am thinking about how to advise my own clinic. For what it is worth, my thinking evolves but my latest iteration is summed up in my blog called “Slow Psychiatry.” I am suggesting that we narrow our purview – in terms of who we see- but take our time to get to know a person when we are involved. I find much of value in Joanna Moncrieff’s drug-centered approach to using the drugs and I think that it is not only worthwhile but of critical importance that there is a branch of medicine that specializes in having a deep understanding of psychoactive drugs. I find much of value in the framework of need-adapted approaches as a kind of “hub” for this kind of work and any other kind of treatment approach can be added as a “spoke.”
    As for challenging others on MIA, I have done this to some extent although perhaps not to the extent I could. And I agree with others that your detailed critiques of drug studies is invaluable. I do not agree with everyone on MIA. But I will not clutter this comment section with links to some of my critical posts. However, I have personally found it of enormous value to hold back on some of the defensiveness that I feel sometimes after reading some blogs or reading my own comment section and just try to engage in an open way. In recent years, I have had many opportunities to talk to people who have been harmed by psychiatry, are anti-psychiatry (abolitionists) and this has enriched me in ways I can only begin to describe. That is just my own personal experience but I do not regret taking this perspective.
    Thank you for your generally kind remarks about my blogs and thank you for the important contributions you have made and continue to make.

    Sandra Steingard
    March 24, 2016 | 1:58 AM

    Since you put in a link to my earlier blog (End of Psychiatry), I thought I would provide the link to “Slow Psychiatry” which reflects my evolving thinking on this topic:
    If anyone wants to discuss outside of the MIA comment section, feel free to email me.

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