the agenda…

Posted on Friday 25 March 2016

In Annie Proulx’s novel, The Shipping News, emotionally broken protagonist Quoyle and his young daughter move to his ancestral home in Newfoundland to reclaim his life. He goes to work for the local paper, The Gammy Bird, where reporter Billy tries to show him the ropes:

    Billy: It’s finding the center of your story, the beating heart of it, that’s what makes a reporter. You have to start by making up some headlines. You know: short, punchy, dramatic headlines. Now, have a look, what do you see? [Points at dark clouds at the horizon]
    Billy: Tell me the headline.
    Quoyle: Horizon Fills With Dark Clouds?
    Billy: Imminent Storm Threatens Village.
    Quoyle: But what if no storm comes?
    Billy: Village Spared From Deadly Storm.

Those are my favorite lines from a favorite book [and movie]. They come to mind whenever I watch the news in the evening. It’s a habit I’ve developed to remind me not to get too caught up in the dramatic rhetoric of journalism. And they came to mind reading this article in Mad in America:

Mad In America
by Robert Whitaker
March 17, 2016
Some lead-in references…
Drs. Pies and Frances had both gone out of their way to clarify areas of agreement in the dialog that lead up to this piece before talking about areas of disagreement. As I’ve read their comments, their concern is that Robert Whitaker and others at Mad in America are encouraging psychotic patients on medications to discontinue them and in doing so put themselves in harms way from relapse – promoting something like a  morality that being on medications is bad – being off medications is good. Yet in that headline, we read something quite different – that Drs. Pies and Frances are themselves [unwittingly] indicting the profession of psychiatry.

Robert Whitaker does the same thing most of the bloggers on his site do – he anthropomorphizes psychiatry as a unitary entity that is of a single mind. Psychiatry says… "one size fits all." Psychiatry says… "medications for life." Parenthetically, that notion of psychiatric one-mindedness has made my own discussions with people who are MIA followers quite difficult. And that problem continues here. When Drs. Pies and Frances clarify their positions, and they turn out to be fairly close to Whitaker’s, he sees them as going against this singular psychiatry he apparently thinks of as making universal recommendations.

On the other hand, it’s not hard to see why he might think that. From Harrow [Does Long-Term Treatment of Schizophrenia With Antipsychotic Medications Facilitate Recovery? 2013]:
As a consequence of positive results from numerous short-term [1–2 years] studies, prolonged use of antipsychotic medications over a long period has become the current standard of care in the field. Thus, antipsychotic medications are viewed as the cornerstone of treatment, in both the short-term and the long-term treatments of patients with schizophrenia.

American Psychiatric Association [APA] guidelines suggest clinicians to consider antipsychotic discontinuation for schizophrenia patients who have been symptom free for a year or more. Nevertheless, many clinicians keep schizophrenia patients on antipsychotics indefinitely assuming that the medication is essential for continued stability.

Antipsychotics are also viewed by some as leading, over a prolonged period, to eventual recovery for some patients with schizophrenia. A comprehensive review from the World Psychiatric Association section on Pharmacopsychiatry notes “Antipsychotic treatment has a significant impact on the long-term course of schizophrenic illness and can significantly facilitate recovery…”
The American Psychiatric Association [APA] guidelines do indeed make that recommendation, but it’s embedded in 100+ pages, a lot of which are about how to encourage "medication compliance." Like most in private practice, my post-training experience with Schizophrenic patients was limited, and they were "good prognosis" patients. I was inclined towards using medications only for psychotic episodes, but most ended up on some version of maintenance medication by their own request because of disruptive relapses. I think much of my leaning towards no medications, except when required, had to do with fear of tardive dyskinesia. I was not aware of the APA guidelines which are, by the way, listed as outdated, and seven years beyond the update date [and I wouldn’t personally see the American Psychiatric Association as representing the Institution of Psychiatry for any number of reasons].
Originally published in February 2004. This guideline is more than 5 years old and has not yet been updated to ensure that it reflects current knowledge and practice. In accordance with national standards, including those of the Agency for Healthcare Research and Quality’s National Guideline Clearinghouse, this guideline can no longer be assumed to be current.
But I’m not writing to enter this specific debate. I’m writing because of Whitaker’s final paragraphs:
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.

And that finding, in turn, supports a demand, based on Frances and Pies own writings, for a radical rethinking of psychiatry’s use of antipsychotics.

In a follow-up blog, I will respond to their review of the “evidence” for the long-term effects of antipsychotics. That provides another an opportunity to watch their minds at work as they sift through the evidence. What studies do they dismiss? What studies do they embrace? This is a review that ultimately leads to this question: Do we see, in their assessment of the scientific literature, evidence of the critical thinking that we want to see present in a medical specialty that has such a large impact on our lives? And if not, what shall we do?
I’m writing this because here at the end, even though he sees Dr. Pies and Frances essentially agreeing with him, he’s questioning their capacity for critical thinking almost implying that they have devious minds. And why is there such a theme of "all psychiatrists think …" instead of "this psychiatrist thinks …" versus "that psychiatrist thinks …"? Why isn’t the title of the article above, "Deep down, Drs. Pies and Frances agree with me after all"? It’s because there’s a much larger agenda on the table – clarified in this next blog post, but made much more explicit in his most recent book, Psychiatry Under the Influence.
Mad in America
By Robert Whitaker
May 7, 2015

When you write a book, you usually do so in response to a prompt of some type, and in the process of researching and writing the book, you will come to see your subject in a new way. Psychiatry Under the Influence, a book I co-wrote with Lisa Cosgrove, provided that learning experience, and this is what I now know, with a much greater certainty than before: Our citizenry must develop a clear and cogent response to a medical specialty that, over the past 35 years, has displayed an “institutional corruption” that has done great injury to our society. In fact, I think this is one of the great political challenges of our times…

As I noted in the beginning of this post, co-writing this book led me to “see” this subject of psychiatry and its influence on our society in a new way. It puts the focus on society as the injured party, and it is easy to see that the social injury arising from this corruption is vast and profound.

The institution of psychiatry, with its disease model, has dramatically changed our society over the past 35 years. It has given us a new philosophy of being, and altered how we view children and teenagers, and their struggles. It has touched every corner of our society, and this societal change has arisen because of a story told to the public that has been shaped by guild and pharmaceutical influences, as opposed to a record of good science. That is the nature of the harm done: our society has organized itself around a “corrupt” narrative…
The Pies/Frances article seems a mighty indirect way to approach this agenda. And I just wanted to clarify what all of this seems to be about…
    March 25, 2016 | 5:18 PM

    “Robert Whitaker does the same thing most of the bloggers on his site do – he anthropomorphizes psychiatry as a unitary entity that is of a single mind. Psychiatry says… “one size fits all.”

    Exactly Mickey,

    But it also takes a lot more rhetoric past that point to create the illusion:

    Joseph Arpaia
    March 25, 2016 | 6:27 PM

    In that last quoted paragraph, it sounds like Whitaker is engaging in a bit of hyperbole, blaming “psychiatry” for so many social ills. I can think of quite a number of other factors which are causing people problems. I get about 20 people calling for intakes per week, and it is rare that even one of them is calling because of problems caused by “psychiatry”, unless its because their psychiatrist no longer takes their insurance. Usually it is an unhappy or abusive relationship, overwhelming work stress, chronic medical conditions, addiction, or some combination thereof.

    March 25, 2016 | 11:39 PM

    Gee, I wonder where this has been said before. Maybe check out a thread from a recent post here?

    If Whitaker had said in his title that Pies and Frances’ commentaries lead to some “quantity” of psychiatrists are failing patients, and not ALL of them, then he might have a legitimate story.

    But, as I wrote in my last post, I think AA per one comment sums up both Whitaker’s true agenda thus echoed endlessly by the choir that just alienates debate and efforts to work at progress, nope, these folks revel in regress (as was written in the thread noted above and by me prior):

    “Finally, I am going to repeat a point that I have made previously on this blog that may sound extreme but I think is appropriate. Since commentators on this blog had horrific experiences with psychiatry, asking them to moderate their views is like asking rape victims not to be so angry. They have ever right to feel the way they do and to be heard.”

    I can’t speak for anyone else but myself, but when do people finally wake up to this failed, hideous notion that because one was abused, it gives validation to then become abusive? I know Dr N does not want this to make the thread take on flames, but, it has to be said and pondered by those who want to dialogue, not monologue.

    Oh, and to show how intolerant the MIA folk are, Philip Hickey this week at MIA wrote a post about another Dr Frances’s post at Huffington Post, and the usual “folk” in the thread complained about being moderated.

    Surprise surprise surprise, and not from Gomer Pyle, but from Joel Hassman, what type of usual internet commenters, and not commentators as AA refers to thread writers, expect carte blanche in their retorts?

    People who read me know that answer.

    You opened this door per the post here, Dr N, and I think we as moderates and wanting sincere and honest advocating want people to entertain truth and options, not partisan agendas and zealot narratives.

    Happy Easter, hope the weather is kind and pleasant, and things are well and nourishing to all who are willing to embrace the changes that are Spring.

    March 26, 2016 | 4:06 AM

    Dr. Hassman, I am flattered that you quoted my post on the MIA site. 🙂 Hmm, I think you are misinterpreting what I said as I never claimed that it was ok to be abusive.

    Again, my point is that when someone has had a horrific experience in a situation, be it psychiatry or anything else, that it is understandable that they would be very angry. It would be also hard for them to moderate their views. I am just perplexed as to why that is so hard for you to understand this as a psychiatrist.

    March 26, 2016 | 1:42 PM

    Here’s the real problem, I think: To a large extent, you and your more “shrill” critics live in different worlds. There’s a fairly thoughtful discussion about the complex interplay between life experience, biology and intangibles like will and hope. It really does happen, among some psychiatrists, and in some of the symposia and journals where they engage with each other. It even informs the care of a few thousand patients in this country. Most are from the economic and cultural elite. Some are just lucky.

    Then there’s the Prolefeed : that simplistic, triumphalist vision of well-understood Biological Brain Diseases and the Magic Bullets that can absolutely correct them, if we can just have more complex “cocktails” and fewer “misguided civil liberties.” The smug medical-industrial complex which tries to dismiss all its critics, internal and external, as wicked or backward people who Stigmatize the Mentally Ill. Think NAMI and all the high-priced PR agencies it shares with Eli Lilly or Otsuka, think the APA with their single-minded mantra that Drugs Save Lives. Think Jeffrey Lieberman. Most psychiatrists, given any chance to reflect, would not truly endorse even 50% of this.

    But the Prolefeed is what controls the practice and policy of 95% of “psychiatric care” in this country. Through its dominance of the mass media, it controls the “health education” 95% of us get, including most health professionals. And remember: about 80% of psych med scripts are written by non-psychiatrists, and the vast bulk of psychiatric consults that do happen are 15 minutes or less. With one of my HMO shrinks, it was three minutes. Most research on psychiatric treatment is aimed at commercial success in this, the market that “serves” millions, not a few thousand.

    Mickey, I’ve come to think of you as the poet laureate of the Prolefeed—and one of the few serious students of its effects. Your stories of the patients in your charity clinic, and the “treatments” they find themselves on, are worth more than your most passionate and well-thought-out critical analyses of the literature (though these are valuable!) They are what “Psychiatry” – and individual psychiatrists as well – need to engage with: the reality on the ground. How did things get this way? Who doled out this treatment, and who taught them to do it? Would you want it for your own brother, lover, child or best friend? And if not, how do we change it?

    Sandra Steingard
    March 26, 2016 | 1:48 PM

    There is a quote without attribution in the last Frances post indicating Whitaker thinks that people would be better off if antipsychotic drugs did not exist. I wrote to ask for the reference but got no response. I do not believe this is an actual quote and it distorts what I think Whitaker’s position is.

    March 26, 2016 | 1:49 PM

    Correction: Not the Poet Laureate! Blame my extremely weak grasp of the classics. A Poet Laureate sings the praises of something, I guess, while you do just the opposite. But you talk about this reality as a poet and a scientist, which very, very few of your colleagues can be bothered to do. The world needs to listen.

    March 26, 2016 | 4:37 PM

    The crux of the matter is the power invested in psychiatry by the *state*–

    This is a good place to start a NEW discussion:

    I doubt anyone would argue against the freedom to choose psychiatric care, but sadly that has not been the case in America for the past 100 years.

    Expanding the dialogue is always an option– though shutting it down seems to be the tenor of most psychiatrists who are defending their own practices with no regard for feedback from those who were not allowed to choose.

    March 26, 2016 | 5:50 PM

    To AA:

    I’m sure you want the right to change your opinion of how you’ve presented that comment above. None the less, you come across is basically saying it’s okay to be abusive, as I felt you were with Stevie in the thread that prompted your rebuttal.

    I sense now you’re just trying to either backpedal, or do some damage control?

    Misinterpretations can happen, I’ve been there and that can be a dynamic, but, you’ve written things here as well as very often at MIA that are just downright inappropriate to the person you’re basically demeaning and being rude to almost often because the other commenter does not bash psychiatry.

    Unfortunately, I’m sure this is not where Dr. Nardo wants the thread to go, but since you’ve commented here, I have the right to rebut what you claimed was the real intent.

    Hey, how about telling us about what Phillip Hickey’s post this past week was inferring about demeaning Dr Frances, and a lot of those comments in his thread were so wonderful and appropriate?

    People who read there not going to see that MIA commenters are being respectful and engaging. It’s an abuse fest, and we who are moderate and fair know that!

    So, the likes of Whitaker and Hickey are just about demeaning Psychiatry as a whole, which is only going to get people like me to reject his kind of ignorant overgeneralization that is rude, insensitive and demeaning. Debate that all you want, when you polarize and overgeneralize, you alienate people you really should consider wanting to have as allies.

    But anyway, I’m done, Happy Easter, be safe and well and let’s hope future posts continually promote healthy and responsible dialogue.

    March 26, 2016 | 5:53 PM

    I let these pass, but you’re right, these back-and-forths don’t work well here. As most probably know, I’m not keen on being a comment cop, but over the years, I’ve had to learn that if I don’t do that – nothing good comes from the result. Which is why it says:
    Your opinions are welcomed, but categorical or ad hominem comments to or about each other are not.”

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