{"id":64114,"date":"2016-03-18T14:41:43","date_gmt":"2016-03-18T18:41:43","guid":{"rendered":"http:\/\/1boringoldman.com\/?p=64114"},"modified":"2016-03-18T15:17:47","modified_gmt":"2016-03-18T19:17:47","slug":"still-meandering-about","status":"publish","type":"post","link":"https:\/\/1boringoldman.com\/index.php\/2016\/03\/18\/still-meandering-about\/","title":{"rendered":"still meandering about…"},"content":{"rendered":"

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<\/font><\/em>. 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<\/font><\/em> and Illness<\/font><\/em> are defined by abnormal biology<\/font><\/em> 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<\/font><\/em>-ness, ill<\/font><\/em>-ness, dis<\/font><\/em>–ease<\/font><\/em>, sure enough – but without any abnormal biology<\/font><\/em>. For another, for those with biologically based chronic illnesses, treating the biology <\/font><\/em>part was relatively straightforward. It was the human experience of ill<\/font><\/em>-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.<\/p>\n

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<\/font><\/strong>. 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<\/font><\/em>. 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<\/font><\/em> 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<\/font><\/em>. 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<\/font><\/strong><\/em> [borrowing the "Key Opinion Leader<\/font>" term from PHARMA marketing lingo]. Only a few from that second group made it to Grassley’s List<\/font><\/em> in the last post, but there are many more that should’ve been on it.<\/p>\n

So now there’s a new crop of critics [see guilding the lily…<\/a>, in a guilded cage…<\/a>, the guilded age…<\/a>, the rise and ??? of the guild…<\/a>]:<\/div>\n
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Psychiatry Now Admits It’s Been Wrong in Big Ways – But Can It Change? <\/a><\/div>\n
Truthout<\/font><\/strong><\/div>\n
by Bruce Levine<\/div>\n
March 5, 2014<\/div>\n

<\/p>\n

Robert Whitaker’s Answer<\/font><\/strong><\/em>: 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…<\/font><\/strong><\/div>\n<\/blockquote>\n
As I’ve said before [see the guilded age…<\/a>], I don’t recall this Talk Therapy Cession Decree of 1980<\/font><\/strong>. 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<\/font><\/em> 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<\/font><\/em> providers or paid out-of-pocket<\/font><\/em>. <\/div>\n
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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…<\/div>\n<\/blockquote>\n
Whitaker is assuming that the Szaszian notion that Medicine<\/font><\/em> and Illness<\/font><\/em> are defined by abnormal biology<\/font><\/em> 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<\/font><\/em>.<\/div>\n
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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…<\/div>\n<\/blockquote>\n
Sticking with his marketing terminology, I think what he’s proposing here for psychiatry is called a niche market<\/font><\/em>. 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<\/font><\/em>, something that follows what Whitaker suggests here to a tee [see two versions…<\/a> and my say…<\/a>] – medication experts who don’t [often? ever?] see the patients they’re "experting<\/font><\/em>" on.<\/div>\n

The split between therapists<\/font><\/em> and psychiatrists<\/font><\/em> [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<\/font><\/em> 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<\/font><\/strong><\/em> [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<\/font><\/em>. 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<\/font><\/strong><\/em> set as anyone else.<\/p>\n

In meandering about…<\/a>, I was musing about some [unscientifically derived] signs in the American Psychiatric Association<\/font><\/em> Preliminary Scientific Program<\/a> that psychiatry might be awakening from its long sleep during the era of the KOL Psychiatrists<\/font><\/strong><\/em> 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<\/a> site [eg the end of psychiatry<\/a>, BEHAVIORISM AND MENTAL HEALTH<\/a>, etc]. Those outside forces have been both fueled and abetted by the academic\/pharmaceutical alliance [a synonym for the KOL Psychiatrists<\/font><\/strong><\/em>] inside psychiatry and, to some extent, the NIMH of the last twenty years.<\/p>\n

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<\/font><\/em>." I really did come to psychiatry to "learn more about human experience<\/font><\/em>," 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…<\/div>\n","protected":false},"excerpt":{"rendered":"

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 […]<\/p>\n","protected":false},"author":2,"featured_media":0,"comment_status":"open","ping_status":"closed","sticky":false,"template":"","format":"standard","meta":{"_bbp_topic_count":0,"_bbp_reply_count":0,"_bbp_total_topic_count":0,"_bbp_total_reply_count":0,"_bbp_voice_count":0,"_bbp_anonymous_reply_count":0,"_bbp_forum_subforum_count":0,"footnotes":""},"categories":[5],"tags":[],"class_list":["post-64114","post","type-post","status-publish","format-standard","hentry","category-opinion"],"_links":{"self":[{"href":"https:\/\/1boringoldman.com\/index.php\/wp-json\/wp\/v2\/posts\/64114","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/1boringoldman.com\/index.php\/wp-json\/wp\/v2\/posts"}],"about":[{"href":"https:\/\/1boringoldman.com\/index.php\/wp-json\/wp\/v2\/types\/post"}],"author":[{"embeddable":true,"href":"https:\/\/1boringoldman.com\/index.php\/wp-json\/wp\/v2\/users\/2"}],"replies":[{"embeddable":true,"href":"https:\/\/1boringoldman.com\/index.php\/wp-json\/wp\/v2\/comments?post=64114"}],"version-history":[{"count":19,"href":"https:\/\/1boringoldman.com\/index.php\/wp-json\/wp\/v2\/posts\/64114\/revisions"}],"predecessor-version":[{"id":64134,"href":"https:\/\/1boringoldman.com\/index.php\/wp-json\/wp\/v2\/posts\/64114\/revisions\/64134"}],"wp:attachment":[{"href":"https:\/\/1boringoldman.com\/index.php\/wp-json\/wp\/v2\/media?parent=64114"}],"wp:term":[{"taxonomy":"category","embeddable":true,"href":"https:\/\/1boringoldman.com\/index.php\/wp-json\/wp\/v2\/categories?post=64114"},{"taxonomy":"post_tag","embeddable":true,"href":"https:\/\/1boringoldman.com\/index.php\/wp-json\/wp\/v2\/tags?post=64114"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}