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.
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…