Why the Medical Model Won’t Go Away, Part Two

Bob Fancher, PhD
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The intellectual shortcomings of mental health care have never been a secret. Pick most any year in the last century, and you can find plenty of books, articles, and scholarly or scientific papers explaining why then-current mental health ideas were wrong.

Today’s rich market for exposés of the ills of medication and the outrages of DSM is, in a sense, nothing new. The complaint that mental health professionals just don’t deserve the credulity, respect, and patronage they demand has long been with us.

And yet the mental health industries grow—in patients, practitioners, public influence, and revenue. And grow. And grow. The medical model—the idea that the variety of psychosocial ills that befall us result from, and reveal, mental health problems—just won’t die.

Before we get up in arms about the distance between the mental health industries’ influence and their scientific credentials, though, we should take a deep breath and get a little perspective: Generally, belief has precious little to do with knowledge. Even the most assiduous, conscientious scholars and scientists believe far more than they know.

And social practices are just that: practices. They’re things we do, which we evaluate by the effects they seem to have on our experience. We rarely, if ever, require of social practice a spotless intellectual pedigree.

Believing is itself sometimes—perhaps most times, for most people—social practice rather than intellectual exercise. Religious services, political rallies, gossip sessions, reading your alumni magazine or trade organization newsletter, posting inspirational messages to Facebook or Twitter, joining an internet discussion or debate—countless activities that look like seeking or sharing information would be more aptly characterized as formulating, solidifying, and reaffirming social arrangements.

In asking why the medical model won’t die, then, the question becomes not, “Why do people believe such ill-founded things?” but “What’s being done here? What social needs are served by the services and ideology of the mental health industries? Why do we need to believe and do the things its practitioners tell us?”

The short answer is that “health” has supplanted virtue or righteousness or sanctity as our culture’s prime normative ideal in personal behavior. “Mental health” is just a subsidiary of the lust after healthiness; mental illness seems, on the face of it, simply its corollary.

As a guiding ideal, “health” has several things going for it:

Health seems to be objective, in some sense. Kidneys, livers, bellies, skins, brains, etc., do what they’re supposed to, or not.

Health seems harmonious with—part of—Nature, which is bigger than ourselves and, we think, has its own forces at work beyond anything we may choose or do. Nature, like God, promises us goodness if we get with the program.

Health offers guidance for relieving or avoiding suffering—healthy actions.

Health can be studied and served by science. In principle, we should be able to discover objective truths about nature, hence about health, hence about healthy actions.

Health doesn’t seem to depend on ethereal fictions like God, reincarnation, Nirvana, or karma.

For a secular age, then, “health” seems a good organizing principle. It offers us ways to understand suffering, teaches ideals that transcend our current situation, and enlists the demonstrable power of science on our behalf.  As a body of beliefs, then, our notions about health provide us clarity, reassurance, and promise.

As practice, ‘health’ gives us institutions, industries, and positive reinforcement for virtuous—“healthy”—actions.

It’s important to realize that health care professionals never got the job—the social tasks institutionalized in the health care industries—because they showed up with well-developed bodies of knowledge. Quite the opposite: health professionals are those who’ve taken on the job of finding out what needs to be done for our health. Health practitioners have work to do, to which disseminating information is instrumental, not foundational.

The question, “Why won’t the medical model die?” can be more precisely framed, then, as “How did physicians get the job, how do they keep it—and how do they manage to ‘rule the roost’ over the rest of the mental health world?”

The answer involves a great deal of politics and money. But it also involves hope and faith. Physicians promise to bring to bear on our behalf multi-billion dollar research efforts, limning the secrets of Nature, so that we may understand and transcend our suffering, living (in due course) as we’re supposed to live. They promise to fix what’s broken.

That’s a powerful promise. In an age where we trust God less and less to attend to our travails, where we are less and less likely to believe there’s a “home over Jordan” where we’ll “understand it better by and by,” where our lives are less and less within our own control as the economy becomes global and corporate, where social mobility and rising individualism make families and neighbors less and less likely to care for us when we’re in need—but where we’re more apt to romanticize Nature, while the fruits of science and medicine do in fact make many things much better—we’d be hard pressed to refuse it.

As a culture, we’re unlikely to give up our faith in science and technology, or our romantic notions about nature. They serve us very well, and probably need to be strengthened if we’re to save our planet while surviving economically.

As humans, we simply will not give up the demand for ideology that explains suffering, provides ideals, and offers guidance for our thoughts and actions.

We’re likely to insist on better science, and on not being misled. But we’re unlikely, any time soon, to give up the faith that health holds the promise of happiness. And for now, the mental health industries are firmly ensconced as stewards of that promise.

 

66 COMMENTS

  1. I think it is worth our time and mental effort to consider how our society’s view of ” mental health” would be effected by the widespread dissemination of a very fundamental truth: There was never any scientific evidence to substantiate the *brain disorder/chemical imbalance” etiology of mental illness. I think that coming to grips with the medical model used in psychiatry is simply a matter of confronting the truth regarding how it came to be applied to mental health, and why, despite the evidence of adverse effects of this erroneous story, the myth continues to be propagated by the medical profession and mental health professionals.

    We, the people, have the capacity to unravel this mystery, given the facts. the simple, unadorned truth of the matter is all we need to decide whether *medical model* and mental health should be connected, in any way.

    I doubt that our society, even as uninformed as we always are, would develop consensus around our need or desire to be exploited and harmed by the profession that receives our most sincere trust.

    The medical model lives, because the lies are thriving!

  2. I agree that the medical model of health won’t be going away anytime soon. Yet I wonder just how accurately we can assess just what is happening within the medical model of mental health, from our mainstream viewpoint?

    I agree with “We’re likely to insist on better science, and on not being misled.” Yet I wondered if that better science is already here, while being largely ignored through our common beliefs, or social practices? Example;

    Polyvagal Theory: Why This Changes Everything

    How to use heart rate variability as a portal to self-regulation.
    The key missing ingredient in the fight/flight theory.
    How polyvagal theory clarifies the role of fear in unresolved trauma.
    Why vagal regulation affects our interactions with others.
    How music cues vagal regulation and why this could help your trauma patients.
    Polyvagal theory and working with children.
    How to increase psychological safety in hospital settings.

    “The theory proposes that physiological state limits the range of behavior and psychological experience. In this context, the evolution of the nervous system determines the range of emotional expression, quality of communication, and the ability to regulate bodily and behavioral state.” _Stephen Porges, PhD.

    The best video presentation, of this emerging new paradigm in emotional regulation and mental health can be found at this Grand Rounds presentation at Columbia University.

    http://columbiapsychiatry.org/videos/polyvagal-theory-neural-mechanisms-mediating-social-behavior-emotional-regulation-and-health

    Sadly, it is the kind of science which many may find hard to accept, in its articulation of the autonomic nervous system, and its role in emotional-mental, self-regulation.

    Interestingly, it is exactly the kind of pure, untainted science which could lend much support to the survivor community, and the belief in a person centered approach. Yet may be discounted for its articulation of our evolved nature? Two words conflicting with common social practices spring to mind? Evolution and God?

    Can the medical model change, Bob? Is there change happening beyond the madding crowd, and our headline focused attention? Do we usually only recognize change in hindsight?

  3. This, to me, seems not only a hopelessly pessimistic way to explain the pervasiveness of mental health care but also a rather suspect way to justify mental health professionals’ perpetuation of it. I think I hear you saying something I agree with very much: the mental health industry persists largely because families and communities are broken and hence more and more unsupportive of their members, so we are defeated into looking for support wherever it is being offered. But to then concede to seeking out the promise of that support from behind Door #3, even though Door #3 has by now proven beyond a doubt deleterious, and say that it’s the best we’ve got; well, this is certainly reason enough to close Door #3 and try a new one entirely.

    Please dig deep to find the courage it will take to accept fully the implications of this definition of mental health care as faith-based, and then take the next difficult step and THROW OUT its scientific yearnings. These unachievable yearnings are the unfounded but believable justification for dividing families, eschewing responsibility of and alienating community members, and incarcerating the innocent. Many mental health professionals certainly did not sign up to be religious purveyors; I suppose in that way some of them are victims of its empty promises as well. But now is the time to connect the harm being done with its false justifications, be accountable, and act with integrity.

  4. ‘Why won’t the medical model die?’

    As Lakoff once pointed out, the metaphors that are used to describe disease and moral behaviour are closely entwined within human cognition. Disease/illness and deviant (mis)behaviour/sin are both associated with notions of cleanliness. ‘Dirty girls’ are ‘sinful’ and, as the AIDS epidemic has shown, ‘sin’ causes ‘disease’. The emotion of human disgust at ‘uncleanliness’ results in moral transgressions, defined by society, framed as the consequences of a disease. Is James Holmes, or Breivik even, mad or bad? Thinking ‘unclean’ thoughts is therefore the result of a disease. As Thomas Szasz has repeatedly pointed out, the secular therapeutic state (disease model) has now replaced religion but ‘witches’ are still being scapegoated for the ‘benefit’ of society. The medical model of unclean behaviour is now so deep rooted within the human psyche that I doubt it will be replaced in the short term since a total paradigm shift will be required.

  5. I think this is an essay written a while ago for a different audience. Otherwise, it might have been helpful to respond to some of the ongoing ideas about using language that is more empowering to those of working for change.

    The disease model won’t go away if you are willing to campaign against it. It will if you are. That’s all it takes. African Americans made the the disease model of slavery go away, “drapetomania.” Gay rights advocates made sexual orientation as an illness go away. We can do it too. Have hope.

  6. I don’t understand the joke. It may be possible, with a big enough campaign, to get the medical model sufficiently discredited that it withers and dies, but it would be a very big campaign for a considerable length of time.

    Bob gives the ideas and dreams that the mental health industry offers to society. The marketeers of Big Pharma are probably familiar with these dreams and use them to write there advertising and PR copy. The mental health industry is firmly embedded in our societies, so it would take a lot of work for it to go. His analysis gives some tools that may help dismantle it – but it might be a long battle. Or it might never go but it might be ameliorated somewhat.

  7. All societies have central mythologies, which most people in the society take to be “truth” as a matter of course. They are built into our children’s stories and our interactions from birth onward, and are often deeply embedded and unconscious.

    To challenge a central social myth is to garner the outrage of those who have committed to it as a fundamental basis of their daily decision making. Some have even gone so far as to suggest that the definition of “madness” is operating (in a way observable to others) outside of society’s mythological agreements. (Read Zen and the Art of Motorcycle Maintenance for a great analysis of how this works.)

    The problem I have with the medical model as a myth, and especially as it applies to “mental health,” is that the mythology itself violently opposes the idea that it is or could be a mythology. It is the mythology of “science is truth,” which any real scientist (and I am one) can tell you is not the case. In fact, science is based on the idea that our subjectivity and mythology blinds us to the truth, and we need the scientific method to force us to look at the things we can’t directly observe or don’t want to see.

    So it’s not just a mythology, it’s a mythology that aggressively seeks to wipe out any other mythology, or the idea that it is a mythology or that anything like a mythology exists in our culture. And Bob is right – it isn’t going away any time soon. But I don’t think I agree that it “serves us well.” This “scientism” that pervades our society is a cover for all kinds of evil all around the world, just as the Great Crusades were a cover for a big Middle East land grab and in truth had little or nothing to do with Christianity.

    I wouldn’t really mind the medical model so much if it actually adhered even mildly to the dictates of science. But it doesn’t. So it’s got to go. Unfortunately, people give up on their myths only with violent protest, especially those who are profiting from them. But to undo a myth, we actually need a new and more effective mythology to replace it.

    All societies need their mythology. We can’t just get rid of the “medical model” – we need a new model that people will buy into and that gets us better results. What that is remains to be seen, but it seems like it has to start with the idea that human beings are free agents and that healing takes place in many different ways, not all moderated by the Holy Priests of Medicine. It will be a long haul!

    — Steve

    • Human beings as free agents? Yes, but free to do what exactly?

      This is where I find the works of Jonathan Edwards (“Freedom of the Will”) and Luther’s “On the Bondage of the Will” to be so interesting.

      I think Bob is making a very sound argument in both his blogs on this subject for why this particular myth won’t go away quickly. I do think it can go away, but as many have said, it’s hard to see that happening quickly.

      • Free agents, yet to what degree, David?

        How do we decipher the extent to which we are autonomously self directed and the the same time bound by our innate dependence? How we decipher the degree of our emotional-intellectual function, in the anxiety of the lived moment, where we may confuse emotionally charged subjective awareness, with the nature of reality, “out there?”

        How do I differentiate the operation of my triune brain-nervous systems, in my response to stimulus which challenge both my need for individuality and belonging at the same time? How do I differentiate my need to appease consensus reality, and its mythologies in my innate need for the protection of the group? Consider;

        ” Differentiation of Self

        Families and other social groups tremendously affect how people think, feel, and act, but individuals vary in their susceptibility to a “group think” and groups vary in the amount of pressure they exert for conformity. These differences between individuals and between groups reflect differences in people’s levels of differentiation of self. The less developed a person’s “self,” the more impact others have on his functioning and the more he tries to control, actively or passively, the functioning of others. The basic building blocks of a “self” are inborn, but an individual’s family relationships during childhood and adolescence primarily determine how much “self” he develops. Once established, the level of “self” rarely changes unless a person makes a structured and long-term effort to change it.

        People with a poorly differentiated “self” depend so heavily on the acceptance and approval of others that either they quickly adjust what they think, say, and do to please others or they dogmatically proclaim what others should be like and pressure them to conform. Bullies depend on approval and acceptance as much as chameleons, but bullies push others to agree with them rather than their agreeing with others. Disagreement threatens a bully as much as it threatens a chameleon. An extreme rebel is a poorly differentiated person too, but he pretends to be a “self” by routinely opposing the positions of others.

        A person with a well-differentiated “self” recognizes his realistic dependence on others, but he can stay calm and clear headed enough in the face of conflict, criticism, and rejection to distinguish thinking rooted in a careful assessment of the facts from thinking clouded by emotionality. Thoughtfully acquired principles help guide decision-making about important family and social issues, making him less at the mercy of the feelings of the moment. What he decides and what he says matches what he does. He can act selflessly, but his acting in the best interests of the group is a thoughtful choice, not a response to relationship pressures. Confident in his thinking, he can either support another’s view without being a disciple or reject another view without polarizing the differences. He defines himself without being pushy and deals with pressure to yield without being wishy-washy.

        Every human society has its well-differentiated people, poorly differentiated people, and people at many gradations between these extremes. Consequently, the families and other groups that make up a society differ in the intensity of their emotional interdependence depending on the differentiation levels of their members. The more intense the interdependence, the less the group’s capacity to adapt to potentially stressful events without a marked escalation of chronic anxiety. Everyone is subject to problems in his work and personal life, but less differentiated people and families are vulnerable to periods of heightened chronic anxiety which contributes to their having a disproportionate share of society’s most serious problems.” http://www.thebowencenter.org/pages/conceptds.html

        Regards

        David Bates.

        • Thanks for your thoughts David.

          “Free agents, yet to what degree, David?
          How do we decipher the extent to which we are autonomously self directed and the the same time bound by our innate dependence?”

          We disagree on many things Batesy but one area where we have some small continuity is this notion of human “freedom” I think we need a blog just on this subject. Fancher might be the guy to right it. My references to Luther and Edwards explore this issue from an Orthodox Christian perspective, I know you approach the issues from other perspectives. People are who they are. People do who they are. We have limits both imposed from without and limits from within. None of this is “illness” diagnosable or the absence of “mental health” Here’s my stuggle with Porges stuff:
          “The polyvagal perspective emphasizes how an understanding of neurophysiological mechanisms and phylogenetic shifts in neural regulation, leads to different questions, paradigms, explanations, and conclusions regarding autonomic function in biobehavioral processes than peripheral models. Foremost, the polyvagal perspective emphasizes the importance of phylogenetic changes in the neural structures regulating the autonomic nervous system and how these phylogenetic shifts provide insights into the adaptive function and the neural regulation of the two vagal systems”

          These words/concepts are non-sensical to me. I need someone to translate this theory to me before I can form an opinion.

          • Ok David, as best as I can,

            Those limits from within, of which you speak, are hard wired, prime affect/emotions, like the universal birth cry of distress, or the universal startle reaction, to an unexpected gun shot.

            These innate reactions are features of our evolved nervous system and its regulation of the heart. An evolution which gradually shifted from pure fight/flight survival reflexes, to social reflexes which further modulate heart-rate like a spontaneous, heartfelt smile.

            These inborn reflexes are mother nature, not learned social behaviors and ideological, cognitive constructs, such as orthodox Christianity or Islam or Atheism. These inborn reflexes, happen beneath any kind of conscious awareness.

            This new discovery, points out, how the muscles and nerves of our head and face, contribute to overall physiological functioning, via the nervous systems control of heart-rate and its vital affect on metabolism, (spontaneous mobilizing or immobilizing, internal energy shifts.)

            What psychologists are now calling, up-spiral and down-spiral effects? Example, joy is a spontaneous up-spiral effect, and embarrassment (a derivative of innate shame-humiliation) is a down-spiral effect. These are spontaneous physiological reactions, not cognitive constructs, like orthodox faith and beliefs?

            In people suffering from unresolved trauma experience, physiological functioning becomes dominated by fight/flight influences on the heart, and social reflexes like spontaneous facial expressions and gestures, are severely restricted.

            In a computer analogy, its like having two distinctly different operating systems, (1) survival, (2) social, “the two vagal systems.” If our spontaneous social functioning is “turned off,” by unresolved trauma experience, we cannot form healthy human relationships, no matter what cognitive constructs of social ideology, we place our faith in.

            It comes down to understanding that physiological processes are primary, and cognition is a secondary process. This new discovery does change everything, because it explains the very roots of “spontaneous” human behaviors, like never before in our history.

            Healthy spontaneous, physiological function, lies at the “heart” of human vitality and health, and Porges, shows the hidden plumbing, (so to speak) which stimulates what others have called “flow,” or being in the moment, or the care free joy of being alive. This is the essence of “two vagal systems.”

            No matter our ideology David, we all have the same human heart and the same nervous control of its unconscious, “autonomic” functioning, beneath all our ideological differences?

            Polyvagal theory is about the heart, David, not ideology? The human heart upon which the whispering muse of creative intuition and inspiration, plays her silent chords?

            If you get the time David, please watch this video presentation of the theory and then watch Steven Morgan’s interview about being with someone, in a first episode psychosis? Its about the art of “in the moment,” presence and body language communication, affected by the heart?

            http://columbiapsychiatry.org/videos/polyvagal-theory-neural-mechanisms-mediating-social-behavior-emotional-regulation-and-health

            Read Dr Micheal Cornwall’s comment about how his body, listened to a young person in distress? And what is said by both Steven and Michael about NOT coming to that encounter with any kind of preconceived ideology? I suggest, they both “listen” with their heart?

            This is what Porges means by an evolved face-heart connection?

            Warm regards.

            David Bates.

  8. “We’ve expanded its reach into everyday life, and people willingly seek out mental health diagnoses and treatments. We don’t usually willingly brand ourselves negatively. I’m trying to explain why the mental health industries have grown, and become part of conventional wisdom.”

    Isn’t it true that the practice of prescribing is what convinces people to see psychiatry as “medical”? What does it become when there are no pills or injections (medicines) involved?

    In my experience, there has been nothing medical (or even healthy) about psychiatry and the mental health industry.

  9. Steve,

    Is the “medical model” really our mythology? The story has some of the elements of mythology, but there is no *true* hero; no one who braved great odds to blaze a new trail, make a new discovery and offer it for the greater good of all. The would-be-heroes concealed their failure to make new discoveries. On purpose! The would-be-heroes capitalized on the myths of true heroes and heroines in medicine, or rather, they re-enacted a sure bet and skipped over the part where their personal sacrifice yielded life saving medicine for the masses. The medical model heroes made no actual medical discoveries , but claimed they had, setting the stage for a return to our mythology. We need a hero. And, as Dr. Healy suggests, it will most likely be a woman who saves us from Pharmageddon, the destiny of the medical model!

    The medical model of mental illness is not a myth, it’s a lie. Discussing it as though it is a valuable falsehood serving a purpose, is fine–so long as we realize that it is a lie that supports the lifestyles of an elite group who have forgotten what it means to be human.

    • That is VERY well said! It stands in the place of a myth, but while a real myth serves a purpose of uniting a group and focusing its attention on group survival, this one divides and humiliates and serves only the interests of those who benefit from others’ subjegation that the myth promotes. It is certainly NOT a sacrifice for the good of all – the “boon” that is brought back has more in common with Sauron’s ring of power than it does with Prometheus’s gift of fire.

      The hero in our new mythology needs to be the humble “sufferer” of mental distress, and the enemy, it seems, is the mental health/medical/pharmaceutical system itself. In a way, that’s what we seem to be doing here – creating a new mythology that actually empowers us to improve the society we’re in, rather than sitting as passive victims hoping for salvation from our medical intermediaries interceding with the Almighty Gods of Science.

      Thanks for your cogent and pointed addition. There is a definite difference between a myth and an intentional deception that serves self-interest, and helping us all understand that is critical to moving forward in promoting a healthier world view. In essence, that was exactly what I was objecting to – this particular mythology serves only its creators!

      —- Steve

      • From an “insider”, I think this focus on a “medical model”, whatever that is, is a bogeyman. I don’t know many who work together with those who want our help who think in terms of a medical model. The model we use most often is biopsychosocial (formed by the internist George Engel in the 1970s), and some of us add spiritual onto that.

        • I have heard a lot about the “biopsychosocial” model, but the truth is, for 99% of the psychiatrists I’ve met, it’s really the “bio-bio-bio–oh-right,i-have-to-mention-psycho-and-social-in-my-notes-or-i’ll-get-in-trouble” Model. Some talk a good game about social supports, but it’s generally very secondary to making sure that the “patient” is “on his/her meds.”

          It’s not a “bogeyman” just because of difference in terminology. You can call it whatever you want, but it’s the idea that a “professional” can “diagnose” what is “wrong with” an individual psychologically or spiritually, and prescribe a “treatment” that will “cure them” of the identified “disease.” But who gets to decide what’s a disease, or what is right or wrong with someone psychically, or what a “cure” would look like? Unless there is some real ability to identify a physical malfunction (and as we’ve seen with cholesterol numbers, even that is subject to manipulation), there is no value to calling something a “diagnosis”, except insofar as it gives the “diagnoser” an extra power over their “patient” to tell them what to do and, protects the “diagnoser” from responsibility when their wise advise is somehow not so helpful after all.

          It’s really quite a scam, in my view. Insider or not, the pretense that we can somehow determine from someone’s thoughts, emotions or behavior that they have a malfunction in their brain is quite disingenuous and, according to Whitaker’s devastating review of the literature, can be quite destructive, both to individuals and to society at large. It’s not OK for “insiders” to allow this pretense to continue. You guys are the ones who the general public trusts. If the idea that mental distress is a medical problem is to be changed, it will most easily come from YOU, who already has the power to influence both the medical profession and public opinion. I know it’s not a politically popular position at the moment, but perhaps you can contribute some of your well-intended energy toward changing the “bio-psycho-social-(spiritual)” model to the “spiritual-social-psycho-bio” model, where biology takes its appropriately back-seat position to the human spirit and social conditions, which clearly drive the bulk of mental/emotional distress that we are supposedly “treating” with purely or primarily biological approaches.

          • To the other Steve,

            I respect your perspective, but most of us do not think the way you think we do. We have trouble using the biopsychosocial model due to other forces – really!. So, we do the best we can with the short time we have. Diagnostically, we do know that we use DSM only because we have to for insurance and usually don’t even pay attention to the criteria! We try to see the patient as a person. And, we certainly don’t think a “cure” is likely – full recovery maybe. Criticizing us for something we don’t use or believe in is a waste of time.

        • I find that the biopsychosocial model is often used as a cover for biobiobio models (No matter what the mental health concern, if there is a medicine that can be thrown at it, it often will be, no matter if there is good research supporting its use), a way for psychiatrists to in show welcome perspectives of other mental health professionals while still ruling the roost, and even if the best intentioned clinicians deny/avoid the above two uses of the model and try to use the biopsychosocial model seriously, in practice it is a sloppy framework for addressing people’s concerns.

          When in social work school, I found the big push for biopsychosocial model to be social worker’s in to increased share of insurance reimbursement, as finally “social” has a role in legitimate mental health treatment. But in gaining entry to the club of folks who can get paid by insurance, they had to submit to medical model of mental health work, and actually do not bring much of their unique training/perspectives/research to clinical work, but continue to expand the medical model into their own ethos. This mostly benefits psychiatrists, in that it forces deference to Medicine by other mental health professionals, and because everyone is not seen as doing similar work, psychiatrists feign expertise in psycho/social/spiritual issues to seem comparable to other professionals, and psychiatrists are still the bio-experts who can prescribe, psychiatrists are still viewed as the most expert/definitive mental health experts deserving of most pay/respect.

          As to psychiatrists only using the DSM for insurance purposes without paying attention to criteria, that is a huge scam, loaded with a lot of hubris. It assumes that mental health professionals (psychiatrists in this instance), are willing to give someone a stigmatizing label that they carry through their life without assessing criteria, willing to lie to to payers about the health/treatment of their patients, and the most distressing part to me, that they are confident enough in their knowledge/skill to treat someone with all sorts of interventions (bio, psycho, social, spiritiual, or whatever,) without having a strong evidence base to support those actions(especially if DSM criteria is what APA funded/sponsored/partnered journals require test interventions on.)

          Basically, Dr. Moffic, you’re saying you and other psychiatrists are actively involved or knowingly complicit in a scamming of insurance companies, scamming patients/public in regard to the importance of your own diagnostic criteria, all for the sake of getting payment to treat patients in a way that you would like and believe is helpful (despite lack of evidence for that belief). I may be ok with this as long as the treatments psychiatrists used have been shown to be robustly helpful to justify the time/cost/risk, but the evidence for this is poor. I think most people here are reasonable enough to recognize that if treatment is a lot more helpful with some more time, it is prudent and cost-effective to fund effective treatments that take time (as opposed to mediocre treatments that take less time), but I have yet to be convinced that longer term treatments (be they bio/psycho/social/spiritual as administered in current practice are generally all that much better than non-professional intervention or placebo.

  10. The medical model won’t go away because it is not entirely wrong: there is some truth in it. Our emotions and our fears upset our brain functioning. Insomnia disregulates our brain chemistry etc, if we “overdo” it our body stops functioning properly. There is a biological side to a mental break down We might not like it but it just is.It is all part of the ” mens sana in corpore sano” thing. That’s probably where medical doctors come in and why people ask for their help.

  11. Bob, I suggest it’s not ‘“health” [that] has supplanted virtue or righteousness or sanctity as our culture’s prime normative ideal in personal behavior’ but “productivity.”

    Individuals feel they have to be always “on,” ready for action, on the road to success, happy and alert, and, most importantly, invaluable to their employers.

    While “health,” good looks, and youth play into this, the goal is to be an indefatigable machine. Fear, sadness, and boredom slow the machine down and must be banished to return it to top working order.

  12. In Stevie’s response to Steve above an interesting, sad , but very real dynamic is revealed. Our current system of “care” be it for mental health, addictions, or primary health is designed (gulp) first and foremost with the payor source in view. I know it’s ugly and terrible and criminal, but that’s the reality in everyday healthcare. Many people have used the expression, “He who pays the piper calls the toon” and that’s what we have. Payors call the toon and the toon is a dirge (for those in Rio Linda, that’s not a happy song). “Professionals” everywhere like the good Dr. are just going thru the motions to get reimbursed. As we all know on this site, those “motions” are often deadly.

    • Not that you need a reminder, BUT… the payor system is only holding doctors accountable for what they claimed they WERE doing (DSM) and CAN do (treat mental illnesses with drugs). In other words, this is not a chicken and an egg quandary — but more like..”oh what a tangled web we weave…”. I point this out, because it is not so much that I have disdain for whiners, but that I am just predisposed to pointing out that it would behoove them to take stock of their transgression and dedicate themselves to resolving the situation. Or, another way of putting it could be; they broke it, so they need to fix it… and stop acting like the victims of some horrifying conspiracy against *good medical practice*!!!

      • Sinead, I don’t think you are placing the real blame and power where it should be. Yes, doctors could have collectively tried to oppose the insurance companies and their control over what is “authorized” for healthcare, but they we would have faced a class action lawsuit over restraint of trade. And we can do better nevertheless. But, just for a minute, compare what psychiatrists can do – and do do – in Canada, which has a single payer system, allowing for adequate time with patients and reimbursements. There is much less reliance on medication there. Of course, maybe Canadian psychiatrists and family practitioners are just very much more humanistic and caring than their USA counterparts.

        • Stevie (Steve Moffic),

          Where do you get your facts on Canadian psychiatrists and family practitioners? Please read the following news items carefully…

          Via CTV News:

          The Canadian Press
          Published Tuesday, Aug. 23, 2011 8:18PM EDT

          TORONTO – Despite being intended as procedures of last resort, a significant proportion of patients admitted to mental health beds in Ontario [(Canada’s most populous province)] are subjected to behavioural control measures such as physical restraints, medications and seclusion, a study has found.

          The report by the Canadian Institute for Health Information (CIHI) says one in four patients with mental health issues admitted to a general hospital or psychiatric facility in the province are physically or chemically constrained to prevent them from harming themselves or others.

          “We looked at over 120,000 people admitted for mental health services over four years,” said co-author Ian Joiner, CIHI’s manager of rehabilitation and mental health. “In looking at the data, we found about 30,000 people had experienced some form of control intervention.

          “And control intervention is a broad term we use to describe things such as physical restraint, which is holding someone down, (and) mechanical restraint, which is the application of a belt or a strap to either hold down their arms or restrict movement,” he explained.

          Seclusion involves putting a patient in a room alone for a set period, while medications typically administered are fast-acting antipsychotics, sedatives or tranquillizers.

          Full Story:
          http: //www.ctvnews.ca/1-in-4-mental-health-patients-controlled-with-drugs-restraints-1.687010

          Also this…

          The Globe and Mail:

          Published Sunday, Feb. 05 2012, 4:00 PM EST
          Last updated Friday, Feb. 03 2012, 4:28 PM EST

          The number of atypical antipsychotic prescriptions dispensed from retail pharmacies for Canadians under age 18 rose from about 772,000 in 2007 to more than 1.3 million in 2011, according to IMS Brogan, a company that tracks the pharmaceutical industry. The dollar value of those prescriptions shot up from about $38 million in 2007 to nearly $54 million in 2011.

          The drugs are being used to treat attention deficit hyperactivity disorder, depression, developmental disabilities, autism, conduct disorder, anxiety and even insomnia, all conditions for which they have not been approved by health regulators.

          Full Story:
          http://www.theglobeandmail.com/life/parenting/the-risks-of-prescribing-antipsychotics-to-kids/article543497/

        • Stevie,

          You said: ” Yes, doctors could have collectively tried to oppose the insurance companies and their control over what is “authorized” for healthcare, but they we would have faced a class action lawsuit over restraint of trade.”

          So much for heroes-eh?

          Perhaps there is more to your considering the threat of a lawsuit by insurance companies over a “trade” issue to be a valid concern for psychiatrists. The first thing that comes to mind is that “medicine” is not a trade, it is a profession. Hard to imagine a professional being intimidated by the business who is engaged in the trade of paying for his professional service. One might wonder if the medical professionals were just not deeply convinced of the value, or even the validity of their professional service. Now, THAT is cause to feel intimidated.

          On the other hand, who isn’t familiar with the lengths psychiatrists will go to in order to receive payment from insurance companies? Bob Whitaker wrote a revealing tale under the heading: “If you are a ward of the state, you must be bipolar” , in”Anatomy of an Epidemic”.

          Again, I have to say, “Oh, what a tangle web you weave, when first you practice to deceive.”

          No disrespect intended, Dr. Moffic. I am glad you are participating here, and hope that you find MIA’s open dialogue as enlightening as it is educational.

          • The unbearable place conventional psychiatry finds itself is not the fault of:

            1) Managed care
            2) Drugmakers
            3) “Anti-psychiatry”

            These are “talking points” from the field’s leadership (lack thereof).
            And many of us have grown tired of the finer-pointing.

            Now that psychiatrists are experiencing the fallout, the public outrage; they are whining…and it’s getting old!

            Psychiatry made its own bed… and now it can die in it!…

            Because it’s time its myths died!

            Sweet dreams, psychiatry!

            Duane

        • Calling all psychiatrists! There are enough wounded, damaged victims of psychiatry in need of psychiatric drug withdrawal and other attention to keep a generation of psychiatrists engaged in genuine good work. See Dr. Breggin’s newest book ‘Psychiatric Drug Withdrawal: A Guide for Prescribers, Therapists, Patients and Their Families’ for detailed discussion on how to go about assisting patients off of their psychiatric drugs and into a process of recovery in a person-centered manner.

          Psychiatrists and psychiatry are responsible for the biological psychiatry model and power base, not insurance companies and not even drug companies.

          1. Psychiatrists got into bed with the pharmaceutical companies: Psychiatrist Peter Breggin MD reported in 1991 in his book: “Toxic Psychiatry” the decision on the part of APA’s Board of Trustrees to discard their ethics, principles and professionalism by embracing “Pharmaceutical Support.” Then the floodgates of pharma money poured in to APA, into psychiatrists’ pockets via speaking, research and junkets etc.

          2. Psychiatrists formulated the DSM and have expanded it at every turn, solidifying and expanding diagnoses that justify the biological psychiatry monolith

          3. Psychiatrists as practitioners have accepted and use the DSM and accepted the conclusions of flawed studies, which if read fully and intelligently reveal their flaws (Dr. Breggin has extensively examined and deconstructed the flawed ‘scientific’ conclusions of many of the most influential studies and has been doing so for decades. See his book Brain Disabling Treatments in Psychiatry 2008 for instance. He is a psychiatrist, and he actually reads the studies not just the advertisements and the abstracts.)

          3. Psychiatrists indeed have sought and practiced biological psychiatry from the days of wet wrapping with sheets and spinning chairs. “Social psychiatry,” the Quaker movement, Soteria house, and all forms of psychotherapy have been suppressed and discarded by psychiatry. Psychoanalysis is a straw man, embraced very briefly by a small number of elite intellectuals and in the ivory towers of universities for a short time.

          In my personal opinion psychiatry has tainted medicine and medical doctors by spear-heading the practices of ignoring patients and instead turning to cookie cutter diagnoses and so-called treatments that desperate, wounded souls submit to in the vain hope that they can find some comfort and relief…. only to be saddled eventually with a host of disabling iatrogenic conditions resulting from toxic treatments (both drugs and ECT).

          I appreciate Bob Fancher’s elegant essay that touches upon deeper societal and human tendencies to turn to destructive treatments. We need that conversation as individuals and as cultures.

          But let us not delude ourselves about where the blame lies for destructive biological psychiatry.

      • Hi Sinead, is the tangled web we weave, more unconsciously stimulated than we care to admit?

        Unconscious, used to be a word which created great interest and excitement in a previous century, yet here we are discussing human motivation, and the word is surprisingly absent from the pages of this webzine.

        Is this because post world war two education, has seen us grow to the extent that we are now fully conscious of our internal stimulation, and can rest assured in our intellectual insights, into the problems of society?

        When we seek to explain problems in a cause & effect paradigm of responsibility, are we fully cognizant of the stimulus to apportion blame? Is our ritual tendency to blame & shame, a primal function of our evolved nature, in a world of life eats life, survival?

        Can we change the “system” out there, while remaining in denial of the system within? The dominance-sub-dominance dance of the twin branches of our autonomic nervous system? When we see the external reality of the “identified patient,” can we also recognize the reciprocal behavior involved?

        Is the “identified patient,” a passive recipient of well meaning domination, or a willing sufferer, for the sake of survival? Do we deny this reciprocal dynamic in society, by projecting shame onto others, in our endless blame & shame games? Shakespeare’s, “slings & arrows of outrageous fortune?” Do we perceive and critique a reality “out there,” or do project an internal need?

        Consider;

        “mental illness stigma, and a compass of shame?

        Mental Illness Stigma is entwined in the compass of shame which binds us all together. Shame is the emotional force which shapes society. Shame is the glue which keeps us together in structures of social order, underpinning social rank and status.
        It can be great fun to watch politicians debate and rationalize this unconscious motivation, in their reactive opposition to each other?

        At the North end of the Compass is “Withdrawal”. It is hiding from others and living in fear of exposure of what we perceive as a defect or weakness. It leads to isolation and gradual absorption into a darker insulated world. It would tend to defeat our human need to belong, for the sake of survival.

        At the East end of the Compass is “Attack Self”.
        With this set of behaviors we diminish ourselves in the presence of others. In a sense it is “heading off at the pass” the fear of rejection. Unlike Withdrawal, we can stay connected, as it is not hard in this competitive world to find a person who wants to feel like a winner by connecting to a loser. In its safety it just worsens the pain and degrades the soul.

        There is a danger in living at the North and East poles. Because the feelings are not processed, they can build up inside and can lead to explosions or extreme violence (a notable example was the story of the murderous teens in the shootings at Columbine).

        At the South end is the opposite of “Withdrawal”, what Dr. Nathanson calls “Avoidance”.
        The goal of this strategy is to hide the feelings of shame entirely from consciousness, if possible. The use of alcohol and other illicit drugs leading to addiction is a way of avoiding the feelings. It is said that shame is dissolved in alcohol, melted by narcotics and boiled by cocaine and amphetamines.

        Another strategy used at this pole of Avoidance is to call attention to oneself in ways meant to distract others by “showing off” or being an exhibitionist. It is also at the core of a theory about the development of Narcissistic Personality Disorders, whose self aggrandizement is seen as an avoidance of shame to the point of complete unawareness. Like the East pole, people remain connected with others, although in a way that is devoid of true intimacy (i.e. the sharing of vulnerabilities). It creates a hollow, false sense of self and, like the addiction strategy, seems never to be enough to satisfy the underlying need.

        At the West end is the “Attack Others” pole. Simply put, this strategy refers to the bully who metes out their own inner sense of shame on another. It is these people who prey on the vulnerable, leading to damage that scares people, often for the rest of their lives. Even the most stringent of rules to contain their behaviors does not solve the problem that promotes these actions. Until the matters of shame are addressed, these people remain a risk to those in their sights.”

        The Unconscious Web we Weave?

        Regards

        David Bates.

        • Hi David!

          Thanks for this. I have viewed my work as my own great fortune to develop my differentiated self ( personal/development-education, training, exposure to lived experience) and move toward a greater self, capable of contributing to the happiness of everyone– at every level of our so-called, mental health system. It has been through seeking to connect with patients and staff— viewing only external (circumstance) as different from myself, that I have been able to grow in every area of my life. If I had never experienced madness (through connection) I can’t imagine myself as hopeful and optimistic. If I had the language I would express it better, but this is a testament to the vital purpose for madness… , a built in human capacity to lead us all to a higher level and more meaningful existence. IT has been grossly misunderstood — and all of us suffer for this… Thank you so much for always keeping this in mind; that we each have a mission, so to speak…For me, yours proves invaluable!

          xoxo,
          Sinead

      • And let me add Sinead ( I don’t consider this whining, just talking about current dynamics); Payors hold doctors accountable for what they claimed they were doing, only in part. The payors looked at those claims through the lens of profit and further set reimbursement criteria based on a hybrid model of error combined with profit…so you’re tangled web metaphor is apt. I’m not trying to engage in “victim” labeling but we all need to agree this mess is a MESS and will take some time to reform/correct. I’m glad to read of your own personal efforts as a reformer!

        • It makes sense that payors were focused on financial gain, profit. That’s business mentality. But what rationale explains how psychiatrists (and doctors, in general) began to manipulate the business end of their practice for personal financial gain? Beginning in the 80’s doctors were manipulating payors for their own profits. The patient and quality care has deteriorated during the escalation of the ‘battle’ for profit. BUT, who is most accountable? Who has transgressed to the greatest degree in compromising patient care? And WHO passes the buck, whines and complains and basically says: “It is not our fault that we can’t provide the best care for patients?

          Everyone here seems to want to make this a very complex issues. To me, it is not. There are fundamental differences in the identities of doctors, insurance companies, pharmaceutical companies. the most important difference lies is the way in which the public, their “gravy train” views them. We expect to deal with competing businesses and even being exploited between them. WE do not expect to have our best interests, our health, our very lives become last on the priority list of “doctors”. And our expectations come from a well established expectation that the medical profession is dedicated to — upholding their own standards, ethics and hippocratic oath.

          Hard to fathom the thinking of anyone who refers to the patient end of this complex web of greed as a *medical* anything. And while i have appreciated that even doctors can make human errors, this one is completely lacking the” human” element.By that i mean IT lacks evidence of the human capacity to reason. Doctors have forgotten the REASON they hold the position they have in our society, and the REASON, their profession is viewed as a caring profession, human service. You can excuse doctors, only if you discount their identities in our society, and the trust we place in them. You can excuse doctors by saying they studied hard, made personal sacrifices and work hard, so deserve to be compensated… but AT the expense of the well being of their patients? or their personal integrity? (as in lying and even labeling patients for their own profit?

          David Bates wrote a very revealing essay on the differentiation of the self and the unconscious motives operating in this process. I am rereading it for the third time, thinking that the only reason this so-called complex medical model fiasco has progressed to this point is that we all try to connect on the unconscious level to understand each other — and in this pursuit, doctors are “only human”… and their self preservation has replaced greed as the human weakness that elicits compassion…. from many. So, in the final analysis, we are all equal and IF that’s the course du jour, then first order of business is remove them for a position of superiority in our society.

          For those (doctors) who want human compassion and high rank, it is time to hold their heels to the fire! Will a hero emerge from their ranks and create (for the first time) the “myth” of the medical model that saves us all?

          I don’t see how it is possible to predict or even suggest what will happen next, unless we fully come to grips with what is happening NOW and why this has happened to all of us.

          • Very well stated. Biopsychiatrists themselves have proven that they are not doctors of any kind, for every time they force the toxic meds on someone, or keep people locked up they break the first law of medicine. “First, do no harm.”

          • I like a lot of what you’re saying Sinead, I just worry a bit that we’re not focusing on the power of the person seeking services. Of any kind. That person has power too. That’s why coercize laws, shock, drugs, hospitalization generate so much discussion on MIA, rightly so, but I don’t want us to lose sight that a person choosing to see a physician has power too.

  13. Please,

    Let’s not replace the *one-size-fits-all*, broken bio-psychiatric model, with *only* psychotherapy.

    Depression can be the result of a sad childhood, bad relationships, trauma… and it can be *also* be caused by *real*, underlying physical conditions…

    And all the *talk therapy* in the world will not help a serious thyroid condition, causing the depression…

    Can we learn from our mistakes… please?!

    We do NOT need *another* one-size-fits-all paradigm of care!
    We do NOT need another *monopoly* from mental health *experts* – be they psychiatrists or psychotherapists! –

    http://disccoverandrecover.wordpress.com/wellness

    Duane

  14. There are many little gems in your text, and I think it provides a more reasonable narrative for some aspects of mental care (based on history, cultural expectations, human limited intelligence, institution dynamics) than other too-easy explanations based on systematic fraud, lies and willful deception (even if greed and fraud do exist).

    I particularly like that sentence: “The short answer is that “health” has supplanted virtue or righteousness or sanctity as our culture’s prime normative ideal in personal behavior.”

    On that topic, the interesting thing in the field of “positive psychology” is that it found a strong link between happiness and being virtuous (that finding might save civilization, we would be doomed if the finding had been different). The shocking thing is that often, that finding is presented in a way that make it clear the happy-effect is the main/only justification for being virtuous (and some people even attempt to understand that specific happiness effect in terms of individual psychology, I am afraid to speculate that the intent is to find a way to still get the happy benefits while bypassing the virtuous part).

    • Ultimately, Stanley, you are commenting on the full spectrum of human nature and the ever present potential for the expression of any aspect along the spectrum from pure goodness to down right evil!

      There is a formula for human happiness, I think. it is the creation of “value”— a potential we all have to use our lives for greater good. Each of us had a unique talent, gift, attribute to bring forth and develop. At this point in our history we have to make a simple choice— follow the ‘top of the food chain” or seek another path. The top of the top is corrupt— stuck in the lower life states of greed, animal survival and sheer foolishness in terms of what holds true meaning in life. Folllow them? Seek out their “expensive” advice?

      The day we all wake up and don’t look for a “professional”, a “specialist” to lead us to happiness, we will have arrived at day one: “The true joy of life starts here”!

      • I like the concept of seeing happiness/emotional-health as strongly linked to the creation of “value” (I have personally learned that concept in the blog and books from Steve Stosny, I like him and his emotional theory a lot, even if I suspect his approach is more justified by ethics rather than psychological science).

        When you say “There is a formula for human happiness”, I think you get to the core of Bob’s topic about who should be in charge of offering answers about that formula. That formula is not a good fit for medical science (as the ‘mental health’ terminology tend to imply). There will always be a ethic/cultural/spiritual factor at the core of such a formula, which is such a different perspective from the rest of medicine (you can operate on a kidney without knowing the person’s religion, whereas even assuming some mental illness is valid, I doubt you could reliably diagnose it without knowing the person’s religion).

        • or, Stanley… you could go further and say that one cannot ‘help’ another person’s “mental illness” without understanding how he views what is happening to him. Have you read, “The Spirit Catches You and Then You Fall Down” ? A very profound piece of literature that points out the major flaw in considering medical professionals “knowledge” superior to a patient’s innate wisdom— culturally transmitted wisdom, that is.

          No one should be considered superior or “in charge” of offering answers; that is no designation of title, education or even professional standing can be correlated reliably with “knowing the formula for human happiness’– even if happiness=health. WE have a big error in the premise… of the so-called “medical model”: status and rank; $$$$ for services. Some believe it is a huge mistake to create a business based on “health” and “education” services… asking for trouble…

          .

      • Funny, Sinead, that you should mention the word “evil” in your comment. I was thinking a lot about what you said about mythology, and I realized that there’s another element missing from the “mental distress as disease” myth. Specifically, most cultural mythology has GOOD and EVIL elements, and part of the role of the myths is to help discern what is good behavior and how we should act in the face of evil.

        But this “medical model” of mental distress does not allow for evil at all! Apparently, all distress is caused by biological dysfunction – it can’t be caused by poor social conditions or overt oppression of an individual or group or race, or by unhealthy or inhumane social expectations like going to work day after day after day in a dead-end job you hate in order to keep from starving to death.

        Removing good and evil also removes MEANING from behavior, which is another role that mythology plays in society. If our behavioral choices are just a result of biology, why does it matter what we do? All behavior becomes equivalent, except to the degree that it is decreed “abnormal” by the larger society. This puts an end to the value of heroism, courage, sacrifice, spontaneity, accomplishment, and maybe even love. It’s all just biochemistry, and when we feel bad, it’s because our chemistry is awry, rather than meaning something about how we’re leading our lives or how we need to impact the groups and society we’re a part of.

        It’s a very nihilistic “mythos.” Never realized it until last night. We NEED to be working for good or against evil, or at least toward betterment of our condition, or we will all lapse into depression. But not to worry, there’s always a drug to take away our perception that things aren’t as they ought to be…

        Thanks again for your insights!

        — Steve

  15. Steve,

    Our discussion led me back to the prime point that joseph Campbell makes about mythology; that it is our divining rod for the spiritual growth required for our survival on the planet! We are hard wired to take the journey in quest of discovery the *self* and that all varieties of *mental* pathology arise from the prohibition of this process.

    For this perspective and your comment above, I am considering the diagnosing and treating- (with psychotropic drugs) the signs of a personal, existential crisis as a severe prohibition of access to a *survival mechanism*.

    I define evil as the pathology of divisiveness— an unreasonable attachment to difference that blinds one to the commonalities among all human beings.I have focused quite a bit on the myriad ways psychiatry has divided people from people, but am starting to look at the deeper significance of creating a chasm between an individual and his/her true self— as the root of this evil dividing strategy.

    Our unsung heroes(psychiatric survivors) are writing their stories — the quest, the obstacle laden journey, the discovery of something “new”… what is still missing is their sharing, or gifting of this new mythology for the greater good. The impediment is the vigilance of the old guard mentality… which includes, I have to say; when a person reveals the truth of their predicament, while caught in the snare of psychiatry, his *truth* becomes evidence of his lacking *insight* into his disordered/diseased brain… and his NEED for psychiatric treatment –even against his will is supplied and supported.

    This opens the door for another brand of hero, who can slay this dragon. I think that is where we come in…. exposing the dragon, telling the truth and opening the way for the next –long overdue— stage of human spiritual development.

    • Exactly – the “treatment” mythology takes away that sense of direction and leaves us aimless and separated. It is ultimately not the drugs that are the core of the issue – it’s the believe system that makes it seem reasonable to drug any and all distress out of existence, and to redefine “goodness” as being happy or at least OK with things just the way they are. “Insight” always involves seeing that you are wrong and the authorities are correct. It’s quite the vicious trap.

      You are, indeed, a hero(ine) – keep telling your story and we’ll keep building on it and perhaps a functional mythology will emerge and we can kill the psychiatric/medical/pharmacological dragon in its own den!

      —- Steve