Editor’s Note: After Allen Frances and Robert Whitaker spoke recently at the Society for Ethical Psychology and Psychiatry conference in Los Angeles, where they had a brief debate, Frances wrote to Whitaker suggesting that they should continue this debate in print. They do so here. Whitaker’s response follows Frances' post.
Allen Frances writes:
I have had two recent debates with Robert Whitaker - in October at the Mad In America Film Festival in Boston, and in November at the International Society for Ethical Psychology And Psychiatry meeting in Los Angeles. Both were spirited and interesting.
Bob and I agree on lots of things, but disagree on what are the biggest ethical and clinical problems facing our field and what needs to be done to solve them.
Let me trace where I see our agreements and disagreements and express the hope that we can find increased common ground.
1) On The Role Of Psychiatry
Bob is one of the most eloquent and well-informed critics of psychiatry, and certainly the most influential. He views the American Psychiatric Association as a powerful and corrupt organization that is largely to blame for spreading a misguided medical model that results in widespread inappropriate psychiatric treatment.
I am no defender of the APA and have harshly condemned its incompetence and financial conflict of interest in producing a rushed and poorly done DSM 5. I have recommended that DSM should become a public trust, not an APA publishing cash cow; that APA has lost any credibility as guarantor of the diagnostic system; and that it should lose the DSM franchise to a new neutral, broader based, more competent, and not financially interested entity.
I also agree with Bob's critique that the APA drifted away from its original rounded bio/psycho/social model and instead has promoted an excessively biological, medical model of care. And I agree that it became far too dependent on drug company money — although this has improved considerably in recent years.
But I disagree with Bob's interpretation that APA is powerful enough and clever enough to have sold the world on the bio/medical model and excessive drug treatments. Instead, I see the APA as a hapless, sad sack organization — not very powerful, and not at all clever. The APA's only real power is its control of DSM and even this is greatly overestimated because the harms of DSM mostly come from its misuse by powerful external forces. APA is an easy target, but a useless one. I maintain that we could disband the APA altogether and the world would change very little.
The real gorilla in the room is Big Pharma. The drug companies are rich, are powerful, are clever, and are highly motivated to spend billions of dollars selling ills to push pills. Big Pharma's massive marketing campaign has convinced the public and doctors that life's everyday distresses and problems are really undiagnosed mental disorders caused by a chemical imbalance requiring a pill solution. Some people in APA helped promote this view, others opposed it — both were largely irrelevant. The effective marketing muscle is all with Big Pharma — on TV, in magazines, on the internet, and with beautiful salespeople in doctor's offices. And Big Pharma has succeeded in taking most of psychiatry out of the hands of psychiatrists — 80% of psychiatric medicines are now prescribed by primary care doctors, often after 7-minute appointments for patients who don't need them.
Bob and I strongly agree on the goal of reducing over-medication, but disagree on the method. He thinks this can be achieved by taming the power of psychiatry. I think fighting the APA is a pointless distraction. The only meaningful way to contain the quick-draw craze for medication is to end all direct-to-consumer Big Pharma advertising (allowed only in the US and New Zealand) and all marketing to doctors. This strategy of ending marketing propaganda worked to contain previously impregnable Big Tobacco — it could also work also to stop Big Pharma and to protect people from pills they don't need.
2) The Role Of Medication
Bob accepts that medication is occasionally necessary, but reads the literature in what I believe is a one sided way that emphasizes its harms and minimizes its benefits. Bob believes that medication can often be replaced by empowerment and psychosocial approaches.
I couldn't agree more with Bob that medication is used way too often for people who don't need it, but my clinical experience, research experience, and reading of the literature convince me that it has an essential role in stabilizing people during what are often risky acute psychotic episodes and also in reducing the risk of relapse. Bob and I agree that many people do well in the long term without medicines, but I believe it is risky and clinically unsound to argue against medication for people in the midst of an acute episode of psychosis.
The testimony of many people I have met at Hearing Voices and Mad In America is convincing evidence that they themselves did not need the medication they were prescribed and did much better without it. This accords with my own experience with hundreds of over-medicated patients — 'deprescribing' has often resulted in marked improvement. But this doesn't generalize to everyone. No one size fits all and there are people who desperately do need medication and do terribly without it.
Which brings us go what I believe is by far the the biggest ethical problem facing all of us- the fact that at least 300,000 people with severe psychiatric problems are inappropriately imprisoned and more than 250,000 are homeless. These are not common criminals, as Bob seems to assume. The closing of 600,000 psychiatric beds during the last 50 years, without the provision of adequate community services and housing, has resulted in a barbaric criminalization of the mentally ill.
This has been exacerbated by the "broken window' policing policies that have spread from NYC to many jurisdictions across the country. The theory is that major crimes can be prevented by increasing the sense of order in the community and that this is best done by rigorously arresting people who commit even the most minor offenses. The burden falls heaviest on the severely ill who are usually picked up for nuisance crimes — stealing food, shouting in the night, sleeping on a park bench — that could easily have been avoided if they had a place to live and adequate services and treatment.
Cops are forced into being first responders because services are so thin. They have learned not to bother taking the mentally ill to hospitals because there are no beds, no services, and only a useless appointment in the distant future. Jail seems like the only option and leads to the horrible coercive abuses. And sometimes the outcome is even worse. Cops are scared of those amongst the severely ill who are psychotic and agitated. All too often this results in pulling a gun; sometimes it results in death.
So I heartily support Bob's crusade against over-medication when it is inappropriate, but worry that it can be harmful when extended to those who really do need medication to stabilize symptoms that will otherwise get them into prison or on the street. My guess is that if Bob spent time in emergency rooms, prisons, and with the homeless, he would probably agree with me on the individual cases. It is always easier to recommend against medication in the abstract than when faced with people having real life psychiatric crises. And we can all join forces in supporting adequate housing as the first and necessary and uncontroversial step.
3) The Role Of Involuntary Treatment
Bob and I agree on the crucial role of empowering people with psychiatric problems. I have written for 30 years about the need to negotiate treatment decisions, allowing patients to choose what suits them best among all available options. Tom Szasz' courageous crusade against involuntary treatment was absolutely on target when 650,000 people were involuntarily and inhumanely warehoused in state hospitals. But times have changed dramatically. Things are a lot different now that 90% of those beds are closed and there are ten times as many patients in prisons as in hospitals. It is now much harder to get into a hospital than to get out of one. Hospital stays are about a week; prison can go on for years.
And prison conditions for the severely ill are degrading and outrageous. They don't do well with prison routine and disproportionately get dumped into solitary confinement — which can drive anyone crazy and is devastating for those who start out with compromised reality testing. Many slam against the walls or smear excrement all over them or are medicated into zombie-like states. There are 200,000 prison rapes each year — and those with psychiatric problems are most vulnerable. They are also frequent victims of physical abuse.
So I heartily support Bob's goal of empowerment, but think he has the wrong target. Psychiatric coercion was once the overwhelming threat, but now the primary fight must be against the cruel criminalization of mental illness and the much more horrible coercion that follows from it. Psychiatric coercion is rarely necessary when there are appropriate services available and should be used only to prevent the much worse coercion imposed by prisons.
Bob is probably too modest to recognize that his is now one of the most powerful voices in the country, influencing both attitudes and policies. My plea is for him is to use his mighty pulpit to advocate for the most vulnerable and neglected and coerced people in our country- those with severe psychiatric problems who are inappropriately imprisoned and homeless. Sad to say, it is now police and sheriff associations that are the biggest supporters of increased mental health funding to accommodate the desperate needs of the severely ill. Shouldn't Bob and Mad In America be refocusing its attention on the real and horrible coercive prison and street experience of today rather than continuing to fight the battle against the psychiatric coercion of the past. And how about going after the real engine of over medication - the powerful drug companies that profit so ruthlessly from drug peddling.
Robert Whitaker’s Response
In his post, Allen Frances raises these four points for discussion:
- The importance — or relative non-importance — of the American Psychiatric Association and academic psychiatry in creating the system of care we currently have.
- The role of psychiatric medications.
- The imprisonment of people with mental illnesses and homelessness among this population.
- Involuntary treatment.
These are big topics, but I’ll try to cover them one by one.
1. The Power of the APA and Academic Psychiatry
My own thinking about this subject during the past several years has been refined by the time I spent as a fellow at Edmond J. Safra Research Lab on Institutional Corruption at Harvard University. The lab, under the direction of Lawrence Lessig, has fleshed out a framework for investigating instances of “institutional corruption” in our society, and I have spent the past two years co-writing a book that looks at the behavior of the American Psychiatric Association — and academic psychiatry in the United States — through this lens. My co-author is Lisa Cosgrove, a psychology professor at the University of Massachusetts Boston who, among other things, has done research on the influence of pharmaceutical industry on psychiatry. She has been a fellow at the Safra lab for several years.
In our book, which is titled Psychiatry Under the Influence: Institutional Corruption, Social Injury and Prescriptions for Reform (to be published in April), we focus on the behavior of the APA and academic psychiatry since 1980. This is the year that the APA published the third edition of its Diagnostic and Statistical Manual, and this is the moment that the APA adopted a disease model for categorizing psychiatric disorders.
That was a fateful decision, and it certainly wasn’t one made by pharmaceutical companies. The APA did so for a variety of reason; there was a scientific impulse behind that move, but it also served the interests of the APA as a guild, which was in competition with other professions for patients at that time. And as the authors of DSM III admitted, most of the diagnoses in the manual were to be considered hypotheses, as they had yet to be “validated.” The thought was that research would eventually prove that the diagnoses told of “real” diseases.
However, once the APA published DSM III, it began regularly conducting “educational” campaigns that were designed to sell this new disease model to the public. And the story that the APA came to tell was this: psychiatric disorders were known to be brain diseases; psychiatric researchers were making great progress in identifying the biology of mental disorders; these disorders were often “underrecognized” and “undertreated;” and drugs for these treatments were quite safe and effective.
The chemical imbalance story brought all of these story-telling elements together. The etiology of many mental disorders was now apparently known, and psychiatry had drugs that fixed those abnormalities, like insulin for diabetes. That was a story that told of a remarkable scientific advance. The drug companies then exploited that story to sell their drugs, but it was the APA and academic psychiatry that provided it — and the larger disease model story — with a scientific legitimacy.
This story-telling fundamentally changed our society. More than ten percent of our school-age children are now diagnosed with a mental disorder and one in five adults now takes a psychiatric drug on a daily basis. And this might all be fine if the disease-model story told to the public was grounded in science. Unfortunately, science was in fact telling a very different story.
The story told in the scientific literature was this: Research was failing to “validate” the DSM disorders; the chemical imbalance hypothesis had not panned out; and the etiology of mental disorders remained unknown. Prozac and the other SSRI antidepressants provided little benefit over placebo for those with mild to moderate depression; the atypical antipsychotics were no better than the first-generation antipsychotics. Meanwhile, long-term studies of drug treatments for ADHD, depression, and schizophrenia were failing to find that the drugs provided a benefit, with outcomes for the unmedicated patients in the depression and schizophrenia studies better than outcomes for the medicated patients.
That is the “corruption” that has so harmed our society: Since 1980, the APA and academic psychiatry have not fulfilled their public obligation to tell us what science has been revealing about their disease model. As a result, our society has organized its treatment of psychiatric disorders — and its policies and laws in this domain — around a false story, a story of a disease model that had been validated and of drug treatments that are quite effective and safe. While the pharmaceutical industry has surely played a role in telling that false story, it is psychiatry as a medical profession that has given it public credibility.
Thus, my disagreement with Allen Frances on this first point. He sees the APA as “a hapless, sad-sack” organization and thus as mostly an innocent bystander, with the corruption arising from a powerful pharmaceutical industry. I don’t know whether the APA should be considered as a “hapless” organization, but I do know this: Our society has looked to the APA and academic psychiatry as the medical institution that should govern our societal thinking about psychiatric care. Yes, the pharmaceutical industry is a powerful force, but it is the medical institution that is seen as the “trusted” authority by society. And if our system of care is a mess today, then that failure ultimately can be traced back to the APA and academic psychiatry for telling a story that benefitted the field’s guild interests, but was not a faithful record of science.
But here is where I agree with Allen Frances: The APA has lost its credibility as “guarantor of the diagnostic system, and that it should lose the DSM franchise to a new neutral, broader based, more competent, and not financially interested entity.” I couldn’t agree with that more. Our society needs a new “public trust” that will give us a new “diagnostic manual” for thinking about psychiatric disorders. The current DSM manual should be thrown out (much as NIMH director Thomas Insel wrote not too long ago), and a new multidisciplinary group should take on the task of drawing up a new one.
2. The Role of Psychiatric Medications
I wrote about this at great length in my book Anatomy of an Epidemic. And here is my disagreement with Allen Frances on this point: I don’t think the problem is simply one of “overmedicating,” which makes it seem that that when people are “properly diagnosed,” the drugs necessarily provide a clear benefit. I think that science is telling our society that the medications do not meet that standard of “efficacy,” and thus our use of these drugs needs to be fundamentally rethought.
Here is a quick summation of the “evidence base” for psychiatric drugs. In short trials, there is evidence of the efficacy of these drugs (at least to a certain extent.)
There also are people who do fine on them long-term, and will attest to that. However, over the long-term, I believe there is clear evidence in the scientific literature of the following:
- Antipsychotics, antidepressants and benzodiazepines increase the chronicity of the disorders they are used to treat, and increase the risk that a person will become “disabled”.
- Stimulants fail to provide a long-term benefit to children diagnosed with ADHD, and thus, once their risks are considered, do more harm than good over the long-term.
- The cocktail of drugs given to bipolar patients is associated with a notable worsening of long-term outcomes, particularly in terms of how patients function.
Given that evidence base, I believe that protocols for prescribing the drugs need to be dramatically changed. The protocol for using antipsychotics in the Open Dialogue approach in northern Finland provides a model to emulate. Try to minimize immediate use of the drugs in first-episode cases (and thus employ other non-drug treatments first), and if the drugs are used, try to minimize long-term use. The protocol in northern Finland is best described as a selective-use protocol, which has produced outcomes markedly superior to our own, and thus there is an “evidence-based” rationale for using the drugs in this way.
Allen Frances writes that he thinks that I “read the literature” in a “one sided way that emphasizes its harms and minimizes its benefits.” Here is what psychiatry can do to prove that is so: It can point to the research that shows the medications improve long-term outcomes, and improve the functioning of people so treated. I published Anatomy five years ago, and I am still waiting to hear of such evidence.
Frances also writes that the solution to “over-medicating” of the American people is to stop direct-to-consumer advertising and industry marketing of the drugs to doctors. That would be a good step, but I think the real solution would be for the APA and academic psychiatry to incorporate the long-term outcomes data into their clinical care guidelines. If they did so, I think they would find compelling reason to dramatically alter their protocols for prescribing these drugs.
3. The imprisonment of people with mental illnesses (and the problem of homelessness.)
I almost don’t know where to start here. I think we lack even a language that can discuss this problem in a sensible way.
First, let us start with a broad perspective. The United States imprisons its citizens at a higher rate than any other country in the world (according to a 2013 study.) We make up five percent of the world’s population and yet our citizens make up 25% of the total world population of prisoners. So the problem we are talking about here is not just the “imprisoning” of the “mentally ill,” but a problem of a society that imprisons people at a grotesque rate.
Second, the term “mentally ill” today is such a vague, imprecise term that it lacks any real meaning. The APA, through its DSM, has set up such broad definitions of “psychiatric disorders” that more than 30 percent of Americans are said to suffer a bout of mental illness each year. Unwanted behaviors — oppositional defiant disorder and ADHD in children, substance abuse in adults, etc. — get classified as mental illness. Given such definitions, one would expect that a high percentage of people in jail and prison could be said suffer from a diagnosable mental illness. In fact, it is hard to imagine that there could be many inmates who wouldn’t qualify for a DSM diagnosis. My point here is this: When we hear that our jails and prisons are filled with the “mentally ill,” I honestly don’t know what that means.
However, I don’t doubt that there are “mentally disturbed” people in jails and prisons, and that many got there for “nuisance” crimes. But, given the imprecise definition of “mental illness, I don’t think we have a good sense of how many such people we are talking about. It would be nice to see research that looked at how many people were diagnosed as “severely mentally ill” before being arrested.
In addition, any inquiry into this problem should look at these two questions. Many of our prisons today are run in a very harsh manner. Inmates are isolated for long periods of time. Such treatment could turn the most sane person mad. Is this part of the reason we have so many “mentally ill” in prison? In addition, those who run prisons know that if inmates are diagnosed as severely mentally ill, that makes it possible to put them on antipsychotics, which will make the inmates easier to manage. Is this part of why we hear that so many inmates are mentally ill?
Third, psychiatry’s concern about the imprisonment of the mentally ill is being used by advocates of forced outpatient treatment as a Trojan Horse. The advocates for forced treatment in outpatient settings (such as the Treatment Advocacy Center) argue that forced drug treatment would prevent the mentally ill from ending up in prison, and thus their legislation, which in fact curbs the civil rights of citizens in profound ways, comes cloaked in the rhetorical garb of “humanism.” If we are going to have an honest societal discussion about the shame of imprisoning the “mentally ill,” then it needs to be completely decoupled from that legislative agenda.
Indeed, an argument can be made that the growing imprisonment of the “mentally ill” is yet another example of how our drug-based paradigm of care has failed us. The use of psychiatric medications in our society has exploded over the past 25 years; there is great societal pressure put on people diagnosed with schizophrenia or bipolar disorder to take their medications; and yet we now have this problem of hundreds of thousands of “mentally ill” in prisons and jails.
However, I do agree with Allen Frances on this point: Any effort to remake mental health care in this country needs to include a focus on what can be done to help the multitudes of poor people and disenfranchised people who show up in distressed emotional states in emergency rooms and homeless shelters, and the eventual routing of many such people to jails and prisons. But, in my opinion, if we want to find a solution, we should focus on providing housing, social support and jobs that help people lead meaningful lives. If we want to reduce the number of people said to be mentally ill and in jail, then we should focus on reducing poverty in this country. Substantially raising the minimum wage would, undoubtedly, be a good first step in addressing this problem.
In short, forced drug treatment isn’t an answer to the “prison” problem; creating a more just and supportive society is. I also think we could borrow a page from the Quakers in the early 1800s. They built moral therapy asylums for the “mad”, with the idea that such refuges — where people could be near nature and were to be treated in a kind, humanistic way — could, with time, help many people get well. Such places would surely be a good alternative to jails and prisons, where inmates today may be isolated for 23 hours each day.
I don’t think that “psychiatric coercion,” as Allen Frances writes, is mostly a thing of the “past.” I think that psychiatric coercion, in subtle and less subtle forms, is more of a problem than ever. We have the subtle coercion that occurs in schools, when teachers and administrators urge certain parents to get their children treated for ADHD. We have the dramatic expansion of the prescribing of antipsychotics in situations that basically lack consent: to foster children, to prison inmates; to “mental” patients in hospitals; and to older adults in nursing homes. Finally, we have the passage of state outpatient commitment laws that, in essence, force people to take antipsychotic medications.
Indeed, ever since the popularization of the ADHD diagnosis and the arrival of the atypical antipsychotics, psychiatric coercion has been on the march in our society, so much so that it hangs like a cloud over our society today. Such coercion is a marker for a fearful, less-free society, and thus if we want to list important battles to be fought today, I would argue that the fight against this expansion of “psychiatric coercion” should be at the top of the list.
I am thankful to Allen Frances for stirring this discussion/debate. In essence, it goes to the heart of what we are trying to do with madinamerica.com, and that is bring these fundamental issues to light, and hopefully make them better known to the public.
Allen Frances was the chairperson of the DSM-IV Task Force, a former chair of the Department of Psychiatry and Behavioral Science at Duke University School of Medicine, and is the author of two new books: Saving Normal and Essentials of Psychiatric Diagnosis.
In the News: A journalist’s review of reports in medical journals and the media on psychiatric disorders and treatments.