One thing I’ve noticed in life is that the most desirable trait in other people, almost a magnet, is humility – people who are right-sized about what they know and what they are. And yet it might well be the most impossible thing of all to achieve in one’s own life. This morning, we heard President Obama use the African word Ubuntu, "I am, because you are", "I am me, because you are you" – meant to remind us of our interconnectedness. But there’s another less lofty perspective. Our self image is grounded in the reflection from others, and the temptation to self-aggrandizement is inescapable – to become the expert. We are, after all, the center of the universe, at least from the vantage of our own perceptions, and we startle when that expertise, that centrality, is challenged. It’s captured in the saying, "I changed my mind," acknowledging the gulf we have to cross to see things in a different way.
Sandra Steingard is a psychiatrist in Vermont, working in a system where many of the patients have psychotic illnesses, acute and chronic. Almost all psychiatrists trained in such a system, but most of us move on to careers working with less troubled patients. I was tempted to stay. in spite of other compelling interests, but the lack of resources was overwhelming. And frankly, I was too confused by the dilemmas involved in treating those patients to find a comfort zone, much less anything like expertise. Not long ago, Sandy noticed that in my writing, I spoke of Schizophrenia as an entity, a position she’s moved away from. I asked her to do a guest blog on the topic and she gave us a fascinating narrative of her own struggles with the same point [a guest post from Sandy Steingard…].
Sandra Steingard writes for Mad in America, Robert Whitaker’s website with a wide variety of bloggers who question the wisdom of current expert opinions in psychiatry. If you’ve read Whitaker’s books, you know that his central theme is a challenge to the long termed use of antipsychotic medications, based not only on their toxicity, but on outcome. From her perspective as a person in the field actually involved in the daily treatment of these patients, Whitaker’s book had a profound effect on Sandy – it changed her mind. And for her, this isn’t just a rhetorical topic – it’s something that came to inform her everyday work with the challenging patients she sees. Today, she brings the story of how that change is playing out in her clinical work to the pages of the Health & Science section of the Washington Post [A psychiatrist thinks some patients are better off without antipsychotic drugs].
The piece itself is both a descriptive history of the antipsychotic drugs and the story of her own relationship with the expert recommendations for treatment. The mind-changing for her came from Robert Whitaker’s book describing studies where antipsychotic medications were used for the management of acute episodes but not for maintenance [preventing relapse] leading to better long termed outcomes. Like many of her blog posts on Mad in America and here, rather than take the position of expert, she writes in the first person of how her changed mind is effecting her practice – and that’s why I started with humility.
Two years ago, I decided to invite my patients into this conversation. I explain to them what I have read and what conclusions I have drawn, as well as the conflicting views of other psychiatrists.
Mickey,
When I saw this article in the Post, I started to write you about it, but decided to check your blog first. Sure enough, you were already blogging about it.
Howard
The NIMH should be studying ways to clone Sandy Steingard.
Ha! The NIMH dropped the ball on rigorous evaluations of the so-called second generation antipsychotic drugs. Finally they may be starting to sing a different tune. NIMH quashed the nonconforming voice of Loren Mosher regarding quality of life outcomes, and they neutered the Psychopharmacology Research Branch. So when Risperdal, Zyprexa and the rest appeared with their marketing blitzes, there was no defense against the propaganda, at least until CATIE came along. Through the 1990s Pharma had open field running while NIMH directors like Steven Hyman maundered on officiously about translational research pie in the sky. He is still doing it.
That said, two important lessons to take from Dr. Steingard’s article are that one size does not fit all concerning long term antipsychotic use, and that such decisions need to occur within the context of an established therapeutic relationship.
There is no change for the good without humility. Thank you for your good work, Sandra. Chipping away may be tiring, but it’s the only way. Rome wasn’t built in a day, and it didn’t fall in a day either.
Thank you for this lovely blog and the many fine comments although I may have betrayed a lack of humility by promptly posting this to my facebook page. I will say that being a mom and a psychiatrist has left me no option but humility. Any tme I got to feeling too good about myself, I would hit something that utterly confounded me.
Dr. Carroll- Do you have more to say about Loren Mosher and the quality of his work? I think the reason why so many are angry with psychiatry is that they find value in his work and yet they see that he was completely marginalized. You were already a prominet academic researcher at the time he was doing his work and I would be interested in your perspective on this.
Sandy
Sandra, I met Loren Mosher only once, on a visit to NIMH in 1970, before I relocated to the US from Australia. Our paths did not cross thereafter, mainly because I was deep into studies of mood disorders, lithium, and antidepressant drugs rather than schizophrenia and antipsychotic drugs. He and I wore different sweatshirts, as Danny Freedman liked to put it. I followed the controversy from a distance but with no direct involvement. I can say feelings ran high on both sides of the debate. He had his energetic supporters, mostly not power players, while many traditionalists in the clinical and research establishment felt he overstated his case. He did continue to receive some federal research funding until 1996, according to the Soteria website. By then, however, the new antipsychotic drugs were sweeping in and his ideas were further marginalized by the “new and improved” propaganda favoring medications.
Thanks.
Dr Mickey: I read this post and Dr Steingard’s Post article, and was prompted to write about this from a bit of a different viewpoint at my blog. Hope it is of interest if you choose to read it.
This post of yours is thought provoking and prompting of what psychiatry needs to be doing, not forcing. But, it is not a black or white matter.
If humility is the most desirable trait (and I concur), then can one assume arrogance is the least desirable? Sad that it is so omnipresent.It’s an epidemic.
I want to thank Dr. Steingard for the mention in her article of very gradual tapering as a way to get people safely off psychiatric drug. This can be a fraction of a milligram (counted in hundreds or even thousandths) per month or even longer, and it is very effective.