Introduction: Anatomy of a Psychiatric Practice


In anticipation of this first blog post, I have spent some time wondering how I arrived at  this point in my career.  I have practiced psychiatry for 30 years. My work has primarily been with people who are experiencing psychotic illnesses. I work in a fairly typical community mental health center in Vermont and I think most would consider my practice to be mainstream.  I value the so-called medical model but most of all I value empiricism.  I had no idea when I started in the field that it would be fraught with such controversy, and early in my career I had the idea that because I was a thoughtful and basically well intentioned person,  I would be able to figure out the best thing to do, the best thing to recommend to my patients.  I thought that due to my fundamental goodness and common sense I would win over any critics of my profession.  I look at this now as a remarkably naive perspective. 

I had a strong reaction to Robert Whitaker’s book, Anatomy of an Epidemic.  I had already grown frustrated with many aspects of my profession, most notably the tendency for findings to be distorted in the pharmaceutical marketing process.  I already agreed that the efficacy claims for certain classes of psychiatric medications, such as the antidepressants, were overstated.  However, I believed that antipsychotic medications were helpful to many people.  I certainly understood their many limitations but at the same time thought they were important components of the treatment of  people with psychotic symptoms.  His book, however, seemed extremely well documented and I could not easily dismiss his conclusions. I felt compelled to review the primary data to which he referred.  In that process I began corresponding with Mr. Whitaker and talking to many colleagues about his book.  I summarized my opinions about his book in an article published in Clinical Psychiatry News

In this blog I will describe how I am evaluating my current practice and incorporating the conclusions I have drawn since reading Anatomy of an Epidemic. I will also try to explain the complexities of psychiatric diagnosis and treatment.  When I read accounts about what psychiatry is or what psychiatrists do, regardless of whether  from critics or advocates of my profession, I often do not find accurate reflections what I do or how I practice.  I will write about the kinds of things I discuss with my patients as I explain my diagnostic formulations and treatment recommendations. This will be a forum to help me expand on topics that arise frequently in my practice.  I will also discuss the process of redesigning the mental health care system in Vermont in the aftermath of the flooding and subsequent closure of our state hospital.  I hope to address some of the most fraught areas in our field, particularly the use of involuntary treatments.  This has been a part of my practice for most of my career.  I have always felt the need to address this topic openly and honestly.  I look forward to this process and I look forward to sharing it with readers and commentators.


Mad in America hosts blogs by a diverse group of writers. These posts are designed to serve as a public forum for a discussion—broadly speaking—of psychiatry and its treatments. The opinions expressed are the writers’ own.


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  1. Doctor,
    I am a person with biopolar disorder.
    I am in treatmentand use various
    modalities to ascend the depths
    of an illness that is hard on the
    soul and body. I combine meds, support,
    spiritual, therapy,change of mind-set
    CBT, and alternative medicine to grow
    into a healthy person. I’ve been blessed
    to have achieved many goals. One has to treat
    the whole person. This isn’t achieved in
    a year but over time.

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  2. I first became concerned with this issue when a close relative of mine had what might be viewed as a psychotic breakdown in school one day. He resisted being picked up by his mother and ran and hid. This was very soon after the Virginia Tech massacre and I would attribute this to the overreaction of the vice principal of his school at the time. The VP called the cops to take him to a mental health clinic where he was interviewed by a doctor who checked him as ‘suicidal, hears voices in head telling him to kill himself’ even though his mother clearly heard him respond “No.” to the question of whether he heard voices telling him to kill himself. She prescribed med that made him feel heavy and blunted so he secretly spit them out. When he told the nurses that he wasn’t suppose to be in there and asked them to let him leave they surmised that the drugs weren’t having effect and the doctor doubled his dosage. We later looked up the drug and discovered that it could be fatal for adolescents. They refused to let him leave. He was finally discharged after his mother threatened not to pay the medical bills. He had no insurance. One of his mothers friends was a retired nurse from the facility and told her that most patients who went in the facility never fully recovered. She was thus extremely concerned. Afterwards the HS VP refused to let him back to school until he received a psychiatric assessment confirming his bill of health. As there was no longer any trust in the psychiatrist who assessed him they had to pay to get a referral. And then pay more to get his assessment. After six months, the VP then only allowed him back to school part of the day, even though he was acting perfectly normal by this time (immediately after being discharged and had gone off the meds they gave him, though the VP said he had to be on them) and bored out of his mind not being able to go to school.

    The entire process was a total abuse of the system and our family felt that our rights were entirely violated. His rights as a citizen to go to a public school were also violated – based on one incident in one day that did not reoccur. I shudder to think of what the process would have done to him if the system had had its way with him ; if my family had not fought back and believed in his mental health.

    Thus I very much look forward to your blog and hope that, step by step, efforts of conscientious doctors like you can help reform the way mental health care is conducted in the US, and also change the public perception of mental health cases as irretrievable castoffs of society.

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  3. Dear Dr. Steingard,

    I am new to this website, but am very interested in learning of your views on involuntary commitment. Since my son Dan Markingson was ‘involuntarily’ committed in 2003, coerced into a clinical study, and subsequently chose to end his life May 8, 2004, I have had much time to learn about mental illness. (You can Google Dan Markingson to read about him, if you wish.) I have long ago reached the conclusion that to take away a person’s liberty without representation is a travesty. I want to work to change this nationwide, and to hopefully in the not to distant future incorporate an approach to mental illness in our country to that of the Finnish model of Open Dialogue.

    Thank you for being a part of this site.

    Mary Weiss
    Cottage Grove MN

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  4. I saw the article about your work in the Burlington Free Press — so I wanted to check out your blog. And say Hello.

    I am working at the Center for Creative Leadership these days ( in the library — hope you are all well!

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    • Why aren’t psychopaths known to harm most people who cross their paths not involuntarily drugged, committed and tortured like others falsely accused of bogus future crimes not committed to advance the bogus mental death profession as the SS thugs of our growing totalitian dictatorship? Psychos really are dangerous while those falsely accused of other fraud psych stigmas are most likely to be victims of crimes rather than perps. You must love Ralph Torrey who was more honest in the past saying psychiatry is no better than witchcraft!

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    • That assumes that you have REAL treatments for a REAL illness. Provide some scientific evidence that these people have a REAL disease and that the supposed treatment you wish to prescribe will actually treat the condition and then we might be able to consider what you are saying seriously.

      No one diagnoses diabetes sitting four feet away from someone with a pen and paper and yet you expect me to believe that I have a brain based disease without ANY tests at all being done?? I’m not the one who is in need of help here, you are. I had strange behaviour, which we all have at certain times. Provide the evidence that I will become a mass murderer, or even EVER attempt to assult someone. We let pedophiles walk free and yet we have a great deal of evidence that they have committed the most henious of crimes and they are highly likely to commit them in future. Yet you are more than happy to allow them to walk free but also happy to lock me up so I don’t do something I have NEVER done before, and there is NO evidence that i will do something!!

      In order to find a treatment for something you actually have to know what it is you want to treat. For example in order to develop antibiotics you first had to be able to put bacteria into a test tube and then you could try different substances on that to find out one that killed it.

      We do not know what these strange behaviours are. Some people feel sad, some anxious, some hear voices, some space out, some become really exited. NONE of those things can be put into a test tube and hence you cannot develop a treatment for them.

      There are times when people do need to be kept safe. I dont’ propose giving someone who is suicial a loaded gun. I also do not propose giving someone who is homicidal a loaded gun, but involuntary detention is VERY different to involuntary treatment. Of course if one treated us like human beings you would not have those problems.

      Soteria House and many similar programs, successfully put people who were acutley psychotic in the community without medication without locks and without issue. They just accepted them for who they were and were willing to be with them. NO ONE chooses to be in states of profound emotional distress. Yet again NO ONE ASKS us what we would like or what is happening for us.

      A person who is suicidal is not asked why they want to die. Instead we say they have a brain based disease, we put electricity through their brain and then put toxic drugs into there bodies that make them feel a thousand times worse. Surely ASKING the person WHY they want to die is the most important step in making sure they don’t die. If they are living with a rapist or abuser then you might be able to help them to become safe. If they have been raped, you can refer them to counselling, but all of those things are ignored and we see a brain based disease instaed.

      A close friend was locked in a psych ward and forced to take medications they did nothing. The voices which were telling her that people wanted to kill her were getting louder and louder. In an attempt to stop them she started banging her head on the wall. The next thing she sure was 8 security guards and a nurse with a hyperdermic needle running towards her. How did that make her better??!?? It reinforced all the voices were saying to her. After jubbing her and making her unconccious she was stripped naked and placed in a concrete seclusion room without even a bucket to toilet in. She has a long history of sexual abuse. Again HOW did that help her. Perhaps simply sitting quietly with her and talking to her might have helped. At an absolute minimum she deserved that respect. She was not voilent or aggressive and was not hurthing other people. She did not have a weapon and was not a threat to others.

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  5. My heart breaks, my family is destryoed and my life changed dramatically when my mum suddenly passed away, leaving my brother that suffers from a brain injury alone. I was grieving, & in a terrible state, so entrusted him to “the so-called friend” (Nancy Pattinson) who offered to look after him while I found him suitable accomodation.
    After some weeks I noticed a change in his personality that rang alarm bells. He became erratic,hyperactive, confrontational, and was not able to communicate.
    I had spent several months weaning him off the disgusting psyche drugs that had been forced into him for many years, and into a “naturally healthy” lifestyle, with incredible results. He lost massive amounts of weight (healthy: he was obese), he was able to communicate, was active and there was hope of him even getting some work.
    Then this evil woman started feeding him presciption drugs, without my knowledge or consent (thus the above mentioned changes in him).
    She later only admitted this under legal duress.

    I reported her to many organisations, but no one cared.
    Even legal people shrugged there shoulders.

    Then one horrible day, my loving, beautiful brother tried to approach a neighbour, who was scared by his seeminlgy “disorientated, scary dissposition” and reported him to the police, (who later admitted they did not have the knowledge of how to treat brain injured), who then came and dragged him out of his house like an animal & because he was disorientated and scared, so was “unco-operative” (who would be!!) was brutally treated by police and taken to a hospital and involuntarily drugged on very high doses of psyche drugs that I later had confirmed by a blood test by an independant source as “toxic levels not suitable for someone with a brain injury”….
    This was the beginning of an absolutely disgusting run of events that forced my brother many hours away from his family & friends so that we couldnt visit, in a mental insitute (The Flynn Ward Traralgon Hospital), who have been nothing short of abusive and negligent, and have systematically segregated my brother from his loved ones and then lodged a successful application to the courts to have his guardianship given to the State, just so they could take control of him and keep him drugged.
    The judge was a rude, nasty “thing” (who I later lodged a formal complaint against, as he didnt even allow family to speak, let alone consider any FACTS about what had happened.

    He willingly signed my brothers life over to a life of HELL that he know lives, uneccessarily drugged and seperated from his loved ones. And I suspect he will die in there, as the last I was able to find out, his vital organs were already showing signs of failing due to the drugs.

    So, I have nothing but a hatred that I cannot possibly explain for the disgusting “system” that is abusing so many people that cannot speak out or act for themselves, such as my brother.

    I could go on about this for hours, but it hurts too much.
    I just hope this little blog gives SOMEONE enough info to say they SHOULD NOT accept these so called “authorities” as knowing what is best.

    Most of it is a farce. They outright lie, (I have the HEAD PSYCHE ON TAPE admitting he was at fault for administering inappropriate drugs), nrsing staff outright abusing and neglecting patients, and on it goes…

    It is a total disgrace that just because the big drug companies can afford to “pay off” so many others down the food chain, including doctors, psychiatric staff, researchers, teachers, legal authorities and more that all benefit from these poor people being on these disgusting lethat and toxic drugs, it will NEVER change unless people band together and STOP THIS ABUSE!

    And if you think I am “ranting”, then do your research on the subjects I have mentioned. Be prepared to be stunned at what the “truth” is. here is a few subjects worthy of you investigating to educate yourself:
    1) “The Big Pharma”. Big drug companies covering up what the drugs they push onto the masses REALLY do.
    Many are TOXIC and LETHAL. There are MANY studies done that have killed people, or made them very ill that have been covered up by these companies.
    2) READ & LEARN about what the actual INGREDIENTS & SIDE EFFECTS (that are often not printed) of the psyche drugs in question are. Many state things like:
    *VITAL ORGANS to be permanently destroyed
    *Heart attack
    & on it goes….
    3) Psyche ward protocol: How they REALLY tend to “patients”
    (Truly heartbreaking: Bashings, rapes, and foul maltreatment is COMMON)
    4) How police are “trained” to handle mentally ill & disabled
    (Some have NO training, so these poor people are treated like criminals, or worse becasue they CANT comply)
    5) How does an involuntary patient get legal representation?
    (They dont unless they say they need it! So how the hell does a mentally ill person even know they need legal help!)
    And on it goes….
    I cry almost daily, suffering intense guilt that I have failed my darling brother, and that my mum who worked her fingers to the bones for ten long years just to keep my brother out of these hell holes, has also been let down.
    Ultimately, all her hard work was a complete waste of time.

    Ultimately, it is only all the disgusting “animals” in the system that are abusing him that are now benefitting.

    God help all of you who ever end up in the “system”
    But maybe this post may just stop some of you ending up in it.
    Look at it this way: Humans are merely “business” to all those in the psyche system that will gain from these people being in it.

    Did you know that psyche wards can operate WITHOUT ANYONES PERMISSION on these poor, unsuspecting people?
    And it COULD BE YOU, or your LOVED ONE!

    DO NOT, EVER EVER EVER just “believe” some so-called “professional” that you or your loved one is “menatlly unfit”. IT is often a misdiagnosis, often on purpose so they can get their “stats” for the drug companies, to provide them their commissions, and other “benefits” (also common knowledge this goes on, just research it.)

    I expect many of you will not like this message. But then I would say you are either ignorant, (intentionally or unwittingly) or have some reason to try & hide these facts.
    Either way, you are doing an incredible diservice to those (or yourself) that need to know, by withholding or by not being willing to learn about these TRUTHS.

    Good luck to those on the path to freedom from the chains that bind you to the psyche system.

    Stand up & be counted, and DO NOT let these organisations and individuals kill you or your loved ones.

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