Why Paul Steinberg Has It All Wrong (and Should Stop Seeing Patients)

(This commentary originally ran on Beyond Meds)

In his New York Times op-ed entitled “Our Failed Approach to Schizophrenia“ Paul Steinberg, a psychiatrist in private practice, proposes we all go back to the “golden age” of psychiatry, when patients spent years in institutions and were treated with a mixture of vastly experimental medication and supposedly therapeutic heaps of unbelievable abuse. You know, the age of cold packs, lobotomies, electroshock therapy without anesthetic, insulin shock therapy, and the systematic violation of their dignity as human beings.

We have a great many narratives from those times and know that the patients were nothing but barely-human, barely-sentient beasts to the doctors and the nurses who cared for them. You have read The Snake Pit, The Bell Jar, and I Never Promised You a Rose Garden. They were written by “schizophrenics” who managed to get away and get on with their lives.

If you haven’t, you should read Janet Frame’s Faces in the Water. The world-renowned New Zealand author, who died in 2004, was saved from receiving a lobotomy by a newspaper clip. On the day of her scheduled surgery the operating doctor read that his patient had just received a coveted literary prize for a collection of short stories the poor woman, who had been in the hospital for years and had received multiple ECT and insulin shock applications, had all but forgotten having written.

As MindFreedom International and patient after patient document (see for instance this and this), things have not gotten a lot better for mentally ill people of all stripes. Most of the overt brutality has been abandoned, but psychiatric patients are still subject to the removal of their civil liberties, being vulnerable to involuntary commitment to psychiatric wards and to receiving forced treatment in the form mostly of ECT and medication.

All of this has been covered abundantly and meticulously in this blog, Beyond Meds, one of the most valuable resources anywhere for ex and current mental patients and their families. Doctors come here too, and many speak up, taking severe beatings to their reputation in the profession. The Mad in America website, created by Robert Whitaker, an impassionate reporter of the sorry state of psychiatry in America, contains many of these brave voices.

Dr. Steinberg is not a critic of the status quo. In fact, he decries the fact of “too little institutionalizing of teenagers and young adults (particularly men, generally more prone to violence) who have had a recent onset of schizophrenia.” He blames this on our supposedly excessive concern with “the civil liberties of people who have horrifically distorted thinking.” As I have shown, this concern is far from excessive. It is, in fact, pathetically small. All it takes for anyone to be forced into a locked psychiatric ward (though the law differs from state to state in the US and from country to country) is the word of a family member, a psychiatrist, a police officer, or a judge. While there are safeguards built into the system (in most states, people cannot be detained longer than a few days), judges can easily overrule them. And they do. Unappealably. Watch this trailer for a documentary in the making for a sense of the enormous power of civil authorities over the mentally ill and their families.

Dr. Steinberg, however, feels that this is still too little. At the first sign of “schizophrenia” young people should be whisked from their homes and put in psychiatric wards for extended periods of time, in spite of the fact that, as patients report regularly, these stays don’t help and in fact prove extremely traumatic. Patients are not treated kindly in psychiatric wards. They are humiliated, bound, threatened, and treated more like a cross between children and criminals. The treatment that occurs in psychiatric wards consists in a lot of hanging out and a lot of being zombified by powerful drugs.

Again, this is a topic that is all too familiar to readers of this blog, but let’s spend a few words on antipsychotics. These drugs, which, according to Dr. Steinberg, “can be remarkably effective,” have been called into question by a number of researchers. In Mad in America, Robert Whitaker points out that in third world countries, where availability of antipsychotic drugs is much inferior, people who suffer psychotic episodes (and whom Dr. Steinberg would probably quickly diagnose as schizophrenic) have a much greater recovery rate than people with similar experiences in the United States. In Anatomy of an Epidemic, his next book, he proposes a thought experiment:

Imagine that a virus suddenly appears in our society that makes people sleep twelve, fourteen hours a day. Those infected with it move about somewhat slowly and seem emotionally disengaged. Many gain huge amounts of weight—twenty, forty, sixty, and even one hundred pounds. Often their blood sugar levels soar, and so do their cholesterol levels. A number of those struck by the mysterious illness—including young children and teenagers—become diabetic in fairly short order…. The federal government gives hundreds of millions of dollars to scientists at the best universities to decipher the inner workings of this virus, and they report that the reason it causes such global dysfunction is that it blocks a multitude of neurotransmitter receptors in the brain—dopaminergic, serotonergic, muscarinic, adrenergic, and histaminergic. All of those neuronal pathways in the brain are compromised. Meanwhile, MRI studies find that over a period of several years, the virus shrinks the cerebral cortex, and this shrinkage is tied to cognitive decline. A terrified public clamors for a cure.

Now such an illness has in fact hit millions of American children and adults. We have just described the effects of Eli Lilly’s best-selling antipsychotic, Zyprexa.

This passage is quoted in its entirety in a powerful piece published by Marcia Angell in the New York Review of Books in 2011. Dr. Marcia Angell, an M.D., is Senior Lecturer in Social Medicine at Harvard Medical School and former Editor in Chief of The New England Journal of Medicine.

These “effective” drugs act like a sledge hammer on the brain. Many psychiatric patients describe them as medical straight jackets, because of their slow-down effect. Their most painful side effect, though, is akathisia, a profound and unrelievable restlessness (hence the constant pacing and rocking; a patient described it as an urge to jump off the edge of the earth). No wonder many psychiatric patients can’t wait to get out of the hospital to stop taking them.

But this is not all. In spite of pharmaceutical companies’ titanic efforts to hide this (see the sorrowful saga that led to the insertion of a suicide warning label in SSRIs) these drugs are not entirely safe either. To stick with Zyprexa, Eli Lilly’s medication guide warns that among the drug’s side effects are “thoughts of suicide or hurting yourself.” A few lines down the guide states:

The symptoms of bipolar I disorder, treatment resistant depression, or schizophrenia may include thoughts of suicide or of hurting yourself or others. If you have these thoughts at any time, tell your doctor or go to an emergency room right away (emphasis mine).

Is the manufacturer really warning patients about the dangerous potential of their illness? Is it possible that it may be covering its legal behind concerning the possible effects of the drug itself?

In their paper “Neuroleptic Drugs and Violence,” published in madinamerica.com in August 2012, Catherine Clarke and Jan Evans admit at the start that “it is established that there is an increased risk of violence by people with a mental health diagnosis.” They add a few lines later:

People who are classified as SMI [Severe Mental Illness] i.e. with schizophrenia or bipolar often experience violent incidents following a diagnosis of SMI, even though they don’t consume alcohol or use street drugs, nor having a past history of violence or command hallucinations to harm others.

The paper proposes “to provide a referenced explanation of how neuroleptic medications are a potential cause of violence.” After presenting substantial evidence, it alarmingly concludes:

With ever increased prescribing of neuroleptic medications, it is reasonable to expect an increased amount of violent behaviour amongst those with a severe mental health diagnosis. Since neuroleptic prescriptions are increasing by 300,000 per year in the UK, it is hypothesized that the rise in violence for neuroleptic-treated patients will escalate, whether in the community or in acute wards, secure units, prisons or outpatient units.

This is not something you are likely to see in the mainstream media or medical journals. We all know that pharmaceutical companies have huge buying power in politics and in the mass media. Most of us however do not know about the profoundly incestuous relation between Big Pharma and psychiatrists. In the second part of the two-part article for the New York Review of Books, Marcia Angell says:

As psychiatry became a drug-intensive specialty, the pharmaceutical industry was quick to see the advantages of forming an alliance with the psychiatric profession. Drug companies began to lavish attention and largesse on psychiatrists, both individually and collectively, directly and indirectly. They showered gifts and free samples on practicing psychiatrists, hired them as consultants and speakers, bought them meals, helped pay for them to attend conferences, and supplied them with “educational” materials. When Minnesota and Vermont implemented “sunshine laws” that require drug companies to report all payments to doctors, psychiatrists were found to receive more money than physicians in any other specialty. The pharmaceutical industry also subsidizes meetings of the APA and other psychiatric conferences. About a fifth of APA funding now comes from drug companies.

Not only are pharmaceutical companies and psychiatrists, who, common sense dictate, should be separated by a very high wall, in bed with each other: Big Pharma is also hugely active in soliciting the collaboration of research psychiatrists (the people who publish in prestigious medical journals and write the DSM):

Drug companies are particularly eager to win over faculty psychiatrists at prestigious academic medical centers. Called “key opinion leaders” (KOLs) by the industry, these are the people who through their writing and teaching influence how mental illness will be diagnosed and treated. They also publish much of the clinical research on drugs and, most importantly, largely determine the content of the DSM. In a sense, they are the best sales force the industry could have, and are worth every cent spent on them. Of the 170 contributors to the current version of the DSM (the DSM-IV-TR), almost all of whom would be described as KOLs, ninety-five had financial ties to drug companies, including all of the contributors to the sections on mood disorders and schizophrenia.

Anyone who is armed with this and the above information might find Dr. Steinberg’s plea that young people get detained for longer hospital stays and that they be treated with the “remarkably effective” medications available on the market less than convincing. Yet it was published in the New York Times. Does our paper of record not know of psychiatric abuses? Does it not know about the unholy alliance between Big Pharma and the psychiatric profession?

Let me now move quickly through some of the other preposterous, inflammatory, and offensive claims that appear in Dr. Steinberg’s piece. As I have already mentioned, he attributes to young people experiencing a first psychotic episode “horrifically distorted thinking.” There is a name for this and it is fear-mongering. People in the clutches of psychotic episodes most certainly have distorted thinking, but “horrifically” distorted thinking? Is Dr. Steinberg hell bent on making us all terrified of psychotic people, most of whom are perfectly harmless (at least until medicated) and, in fact, much morevulnerable to violence against them than the general population?

When he says that “in our concern for the rights of people with mental illness, we have come to neglect the rights of ordinary Americans to be safe from the fear of being shot,” Steinberg draws an invidious and pernicious us vs. them line. Aren’t people suffering from mental illness also ordinary Americans? Who are these extra-ordinary Americans who prowl our streets terrifying us and our children with their shooting drives? Could they be the very people Dr. Steinberg sees in his practice? If so, is this how he views his patients, as these terrifying others?

But Dr. Steinberg’s schizophrenic patients are beyond worrying about what their doctor thinks of them. Medicated, hospitalized at the first sign of “horrifically distorted thinking,” they are blissfully “unaware of how strange their thinking is.” Lack of introspection is one of the bugaboos of the history of psychiatry and, I submit, one of the main reasons why the vast majority of psychiatrist do not talk to their patients (many psychiatrists see a patient for about 15 mins — just the time to discuss and adjust medication; a psychiatrist I know of sees patients for exactly 5 minutes). People who experience psychosis, it turns out, are well aware of the strangeness of their thoughts, as any first-person account of psychosis will easily prove. It is in fact quite ironic that Dr. Steinberg should use Elyn Saks’ remarkable memoir The Center Cannot Hold as evidence that “treatment works.” Elyn Saks, a schizophrenic and McArthur award recipient, is Professor of Law, Psychology, and Psychiatry and the Behavioral Sciences at the University of Southern California Gould Law School. She is a staunch advocate of those very rights for the mentally ill Dr. Steinberg so heinously dismisses, and in the memoir from which Steinberg quotes credits psychoanalytic treatment, as well as medication, as responsible for her survival and her thriving. She says she could not imagine being able to function without talk therapy. Talk therapy, not medication, saved her life. On the other hand, she doesn’t hide her horror of the forced hospitalizations Dr. Steinberg so pleadingly advocates. Finally, and most significantly, she demonstrates a remarkable amount of insight into her psychotic episodes, of which, as per her own account, she was (is?) entirely aware. (For more on sufferers of psychoses’ awareness of their distorted thinking see the astoundingAgnes’s Jacket, by Gail Hornstein).

At the end, though, I find Dr. Steinberg’s major sin the arrogance with which he assuredly diagnoses, not only the Newtown shooter, Adam Lanza, but also the shooters of Virginia Tech and of the Gabby Giffords event. As he himself admits, it goes against the ethics of his profession to diagnose patients he hasn’t seen. This ethical practice, he complains,

has had a chilling effect. After mass murders, our airwaves are filled with unfounded speculations about video games, our culture of hedonism and our loss of religious faith, while psychiatrists, the ones who know the most about severe mental illness, are largely marginalized.

How can one not feel sorry for poor marginalized psychiatrists, whose opinions, if we are to believe Dr. Steinberg, are never sought?

Let us all please remember that there is no evidence yet that Adam Lanza suffered from schizophrenia and there is evidence that Seung-Hui Cho, the Virginia Tech shooter, didn’t.

Of course psychiatrists are not “the ones who know the most about severe mental illness.” They know precious little about severe mental illness. As Marcia Angell documents in some detail, psychiatric drugs were discovered serendipitously, and there is no proof at all of the biological nature of mental illness (see Angell, Whitaker, and others for how psychiatry arrived at the conclusion that mental illness is caused by a “chemical imbalance in the brain,” and how this entirely unsubstantiated claim has gained so much credence that even school children now repeat it in the playground). Psychiatrists know little about severe mental illness precisely because they don’t talk to their patients, and when they do they don’t listen to them. In spite of what Dr. Steinberg, with remarkable arrogance and, one is tempted to say, lack of introspection, claims, we do not need more psychiatrists. We need more people who take mental distress seriously, talk to those who suffer from it, and are willing to engage in a mutually respectful relationship with them in order to find a way to healing.

Giovanna Pompele PhD teaches Women’s and Gender Studies at the University of Miami