Failures of the Medical Model

thanks for the post. I recently read John Abramson’s Overdosed America. This book details the misinformation fed to all doctors. Abramson talks about the journal articles, where the abstract fails to reflect the actual findings from the study. With the opinion leaders running the medical schools, the whole system is corrupt. I think the most egregious drugs are the statins and the bisphosphonates, two terrible drugs that are big sellers. America is the most expensive health care in the world, with outcomes that are really poor. I’m not certain how to clean up the mess.

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You make a very important point Sandra, the whole of medicine needs healing, not only psychiatry.
I have experienced what I can only define as torture within Emergency services [and resulting medical and surgical ward treatment] because of the objectification of distress; being sutured with no local anaesthetic as a punishment with verbal abuse and shouting if I so much as flinched [but use of LA recorded in notes], demands for medical photography of my injuries for no clinical reason and cursing my refusal with further punitive acts, plastic surgeons ripping off dressings adhered to wounds with no skin not bothering to loosen it with saline, being offered no choice about type of procedure despite one preserving contour of a limb and the other not doing so, being left half naked on a trolley with no regard for my bodily privacy, being talked about in the 3rd person with jokes, ridicule, with no knowledge that this precisely echoes the voices I hear. Watching instruments being dropped on a blood stained floor and picked up with no change of gloves, skin sutures used on injuries to the bone with no repair of underlying layers, sloppy clinical practise resulting in pre-gangrenous wounds where an area with clearly no blood supply was sewn back in rather than a proper debridement and closure, complete refusal of treatment on grounds of self-infliction resulting in having to go to another hospital, these are not my worst experiences and in terms of humiliation, and the interface with psychiatry [liaison services] that’s a whole other list of its own, these are just a few examples of poor medical treatment because they were treating a mad person whose actions they disliked and feared. Yet when medical students have the opportunity to listen to survivors, ideally very early in their training, it does make a difference to some. Medical education needs survivors talking to them, mentoring them, shadowing them along with clinical mentors because being human skills are just not taught, and although some can’t be taught we can help to train doctors in not making a disaster out of a crisis.

Jill, what you say about expense and outcomes is striking, I’d be interested in your thinking regarding Biphosphonates because I’m highly likely to be heading in that direction soon. If you could post a link of something relevant I’d be most grateful.

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That sound pretty horrific, Joanna. I am sorry for your suffering.

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Hi Sandra,
Great article, I am sharing.
Best wishes,
Javi

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Sandra,

As you know, I’m a big proponent of addressing underlying physical conditions, and have stated more than once on this site that I am therefore not against the medical model per say.

Although, with that said, I hope we can all agree that”severe mental illness” is never based upon a psychiatric drug deficiency.

But I wonder how many physical ailments, even real diseases have as their root emotional distress and the need to be listened to, heard. Emotions play havoc on our bodies if we have no place express them… IMO, if someone does not feel understood and appreciated, their body can get sick, and they can become “mentally ill” also – until they feel heard, appreciated… “okay”.

Duane

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@Sandra

The point for a lot of people is not to make the medical model “go away”. The point is elucidate the illegitimacy of the power that psychiatrists who use that model as a covert means of social control.

No other medical specialty operates as a covert social control mechanism under the guise of “biology”. Pointing to similarities won’t make this fact “go away” either.

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Gas-masks for life! http://imgur.com/rJY9YOc

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Old chair vs New chair http://imgur.com/VeSasLU

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The economics of the broader pharma industry carry grave consequences to patients and standards of care in many different contexts, apart from those involving psychiatric drugs (the promoters of which, to be sure, are among the chief offenders). Pharma companies invest billions into marketing and promotional efforts (including paying scores of millions to physicians and researchers to support their products) calculated to get doctors to prescribe drugs for uses not approved by the FDA, without sufficient (or, often, any) clinical support for those uses (which is illegal). This is particularly true when drugs only benefit small patient populations, such as treatments for rare cancers and other rare diseases, but the moral hazard extends even to drugs that have record on-label sales. The cholesterol drugs previously mentioned are a good example of this — just because lower cholesterol is better for people at risk for heart disease, it’s not necessarily better for anyone regardless of such risk, yet everywhere you look and from everyone you ask there is that message. When companies are caught engaging in these illegal promotional schemes, even if the companies have to pay criminal fines, no corporate executive is ever charged, and the fines paid by the companies, even if they seem large, are dwarfed by the profits they reap from the off-label sales. And since Medicare and Medicaid keep paying for the companies’ products, the fines are just the cost of doing business. This is an industry-wide problem, requiring an industry-wide solution. Psychiatrists are only one of many kinds of physicians who are paid by drug companies to sell their products for questionable uses, and — setting aside the validity of a given psychiatric diagnosis in general — many of the survivors who contribute to this site are victims of decisions by doctors to prescribe psychiatric drugs to treat emotional states for which the FDA has not approved drug therapy at all, or for which the FDA has not approved for the survivor’s particular psychiatric diagnosis (whether assigned rightly or wrongly). It’s not illegal for a doctor to prescribe a drug for an unapproved purpose, but the fake evidence in support of such uses (relied upon both by doctors and patients) appears everywhere, for psychiatric drugs to be sure, but for many other drugs as well.

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I heard recently that big Pharma are now putting less resources into developing drugs for psychiatric disorders and turning their attention to anticholesterol drugs.

Statins along with psych drugs however remain some of the most controversial products on the market, possibly reducing risk of death from an MI but raising the all cause mortality of the patient.

But hey, lets not worry about death as there is money to be had in this here treatment. We also give doctors something to give the patuients so they can have the illusion of doing something. Why would a doctor want to waste his time talking with the patient about diet and suggesting healthy ways of eating or living. The great bonus here is multinational food companies like Nestle have hijacked the diet industry too and in turn lobbied governments to promote their low fat, low nutrion , high sugar, chloestrogenic diets. Its win win win all the way down the line.

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Some great questions here Sandra, with what seems like a rather fatalistic tone though? I was surprised, to not read any references to your research of the “open dialogue” approach, when you wrote;

“My modern day Dr. K’s peppered me with questions about what they could do other than to give their unhappy patients SSRI’s and their sleepless patients hypnotic drugs.”

Duane makes very appropriate comments about emotion and illness;

“I wonder how many physical ailments, even real diseases have as their root emotional distress and the need to be listened to, heard. Emotions play havoc on our bodies if we have no place express them…”

Having grappled with my own emotional issues, with what the medical model labels bipolar disorder type 1, I’ve had to learn how to sense within my body, the ‘affective’ states of mania & depression. Six years ago, it was Allan N Schore’s book “Affect Dysregulation & Disorders of the Self,” which prompted a search within, for the roots of this strange term “affect.”

Most psychiatrists I ask about this term, shrug off the question with a quick acknowledgement that it relates to emotion and feelings, yet are quiet shy about being more specific. I can hardly blame them for their reluctance to discuss the subconscious nature of affect, although it does seem like we will have to face up to the primary role of “affect,” in the nature of mental illness.

Certainly, in my own recovery journey, the task of discerning my mind’s ‘affect’ on my body, and my body’s ‘affect’ on my mind, has been the challenge of a life time. I’ve had to stop making assumptions with my mind and learn to explore the sensations of emotional distress, within my body and its nervous system mediation. I had to give up the belief, “its all in my head.”

Over six years of intense self-education and experiential self-exploration, I’ve come to understand my psychoses, as combined, body-brain-mind states, rather than symptoms of a brain disease. I’ve experienced the painful process of sensing an internal constriction, as a defense against the trauma of my birth, and subsequent life experience. These days I understand, both within my mind, and within my body, the internalized sense of threat, that my euphoric psychoses, were attempting to overcome. My improved self-regulation, involves a new mind/body sense, of the respiratory, muscular and vascular nature of an internal constriction, with its variable affect on the thresholds of my sensory awareness. My awareness, of sensations, emotions, feelings and the thoughts in my mind. My approach involved gaining a more organic sense of my core emotions, to bring to mind their nervous stimulation and understand my internal functioning. Understanding the voluntary (conscious) and involuntary (unconscious) nature of my self-regulation, has slowly built a new paradigm of mental health. My experiential approach to self-therapy, accords with a recently emerging therapeutic view, described by Allan N Schore as “Toward a New Paradigm of Psychotherapy” Please consider;

“The current shift of attachment theory from its earlier focus on behavior and cognition into affect and affect regulation reflects the broader trend in the psychological sciences. In a recent editorial of the journal Motivation and Emotion, Ryan (2007) asserts:  

After three decades of the dominance of cognitive approaches, motivational and emotional processes have roared back into the limelight. Both researchers and practitioners have come to appreciate the limits of exclusively cognitive approaches for understanding the initiation and regulation of human behavior. (p. 1)

For the last two decades, I have argued that no theory of human functioning can be restricted to only a description of psychological processes; it must also be consonant with what we now know about biological structural brain development. Three other themes that continue from literally the first paragraph of the first book are that the early stages of life are critical to the development of all later evolving structures and functions, that emotion is central to a deeper understanding of the human condition, and that unconscious processes lie at the core of the self, throughout the life span. The book thus also attempted to reintegrate psychoanalytic ideas of the unconscious mind into developmental science. Affect Regulation and the Origin of the Self— which is now in its 14th printing— was the first book to document not the cognitive development, but the social-emotional development of the infant.

Now it is true that the current surge of research is being fueled by advances in a variety of cutting-edge neuroimaging technologies that can observe and document ongoing brain structure– function relationships. The reader should note there is a major limitation to current in vivo imaging techniques— their limited temporal resolution does not allow them to capture the real-time dynamics of brain function. But even future advances in technology would not be enough. We also need an integrative psychoneurobiological theoretical model that can not only generate testable hypotheses but also conceptualize the vast amount of research and clinical data in a meaningful way.

And we need an interpersonal neurobiological perspective that can account for brain-to-brain interactions. As editor of the Norton Series on Interpersonal Neurobiology, I see this quantitative leap and qualitative shift in emotion research as a powerful source of updated models of psychotherapeutic interventions that are grounded in developmental, affective, and social neuroscience. It is now clear that psychotherapeutic changes in conscious cognitions alone, without changes in emotion processing, are limited. In fact, a clash of psychotherapy paradigms can currently be seen, especially in the treatment of more severe disorders that present with a history of relational trauma and thereby a deficit in affect regulation. In such cases emotion more than cognition is the focus of the change process, and so CBT is now being challenged by updated affectively focused psychodynamic models, including ART. In his most recent book my colleague Philip Bromberg (2011) also describes the paradigm shift in psychotherapy:  

Interpersonal and Relational writers largely have endorsed the idea that we are in fact confronted with a paradigm change and have conceptualized it as a transformation from a one-person to a two-person psychology. I feel that this formulation is accurate, and that three central clinical shifts are intrinsic to the conceptual shift: A shift from the primacy of content to the primacy of context, a shift from the primacy of cognition to the primacy of affect, and a shift away from (but not yet an abandonment of) the concept of “technique.” (p. 126)

The current radical expansion of knowledge and paradigm shift has wider implications beyond the mental health professions to the cultural and political organization of societies. In my 2003 volumes I argued that the right hemisphere nonconscious implicit self, and not the left conscious explicit self, is dominant in human adaptive survival functions. Offering data at the neuropsychological, cultural, and historical levels, McGilchrist (2009) echoes this principle:

“If what one means by consciousness is the part of the mind that brings the world into focus, makes it explicit, allows it to be formulated in language, and is aware of its own awareness, it is reasonable to link the conscious mind to activity almost all of which lies ultimately in the left hemisphere” (p. 188).

He adds, however, “The world of the left hemisphere, dependent on denotative language and abstraction, yields clarity and power to manipulate things that are known, fixed, static, isolated, decontextualized, explicit, disembodied, general in nature, but ultimately lifeless” (p. 174). In contrast, “the right hemisphere … yields a world of individual, changing, evolving, interconnected, implicit, incarnate, living beings within the context of the lived world, but in the nature of things never fully graspable, always imperfectly known— and to this world it exists in a relationship of care” (p. 174). Indeed, the “emotional” right hemisphere “has the most sophisticated and extensive, and quite possibly most lately evolved, representation in the prefrontal cortex, the most highly evolved part of the brain” (p. 437).

An essential tenet of McGilchrist’s volume (2009) is expressed in its title: the right hemisphere is the master, and the left the emissary, which is willful, believes itself superior, and sometimes betrays the master, bringing harm to them both. Offering interdisciplinary evidence that spans the sciences and the arts, he convincingly argues that the left hemisphere is increasingly taking precedence in the modern world, with potentially disastrous consequences. I agree that especially western cultures, even more so than in the past, are currently overemphasizing left brain functions.

Our cultural conceptions of both mental and physical health, as well as the aims of all levels of education, continue to narrowly overstress rational, logical, analytic thinking over holistic, bodily based, relational right brain functions that are essential to homeostasis and survival. It is ironic that at a time when clinicians and researchers are making significant breakthroughs not only in right brain social-emotional models of optimal development but also in right brain models of the etiologies and treatment of a wide range of psychopathologies, strong economic and cultural inhibitory restraints and cutbacks are being felt by practitioners. How can we understand this? We are constantly told that the reason for this lies in objective economic factors. But the paradigm shift in psychology and neuroscience suggests subjective unconscious forces are at play here.

Listen to McGilchrist’s (2009) description of what the world would look like if the left hemisphere were to become so far dominant that, at the phenomenological level, it managed more or less to suppress the right hemisphere’s world altogether. He imagines that this left-brained world would lead to an increasing specialization and technicalizing of knowledge, as well as the following: increased bureaucratization, inability to see the big picture, focus on quantity and efficiency at the expense of quality, valuing technology over human interaction, lack of respect for judgment and skill acquired through experience, and devaluing of the unique, the personal, and the individual. Even more specifically; 

Knowledge that came through experience, and the practical acquisition of embodied skill, would become suspect, appearing either a threat or simply incomprehensible.… The concepts of skill and judgment, once considered the summit of human experience, but which come only slowly and silently with the business of living, would be discarded in favor of quantifiable and repeatable processes.… Skills themselves would be reduced to algorithmic procedures which could be drawn up, and even if necessary regulated, by administrators, since without that the mistrustful tendencies of the left hemisphere could not be certain that these nebulous “skills” were being evenly and “correctly” applied.… [F] ewer people would find themselves doing work involving contact with anything in the real, “lived” world, rather than with plans, strategies, paperwork, management and bureaucratic procedures.… Technology would flourish, as an expression of the left hemisphere’s desire to manipulate and control the world for its own pleasure, but it would be accompanied by a vast expansion of bureaucracy, systems of abstraction and control. (McGilchrist, 2009, p. 429)  

Sound familiar? I suggest that this “imagined” left brain worldview now dominates not only our culture but also the current mental health field in the following forms: an overemphasis on psychopharmacology over psychotherapy, an undue influence of the insurance industry on defining “normative” and “acceptable” forms of treatment, an overidealization of “evidence-based practice,” an underappreciation of the large body of studies on the effectiveness of the therapeutic alliance, a trend toward “manualization” of therapy, a training model that focuses on the learning of techniques rather than expanding relational skills, and a shift of psychotherapy from a profession to a business.

Can we reverse this current imbalance of the hemispheres? The paradigm shift has generated a quantum leap in our attempts to understand a number of fundamental questions of the human condition that can be elucidated by recent discoveries of the early developing right brain. A prime example is the surge of deeper explorations of our human origins by contemporary developmental science. In 2005 Insel and Fenton articulated this widely held principle:
“Most mental illnesses … begin far earlier in life than was previously believed” (p. 590). More recently Leckman and March (2011) are asserting that “A scientific consensus is emerging that the origins of adult disease are often found among developmental and biological disruptions occurring during the early years of life” (p. 333).

We need, now, to use recent knowledge in order to reflect more deeply and act more directly on what is required— at levels of the individual, family, and culture— to provide an optimal human context for both mental and physical health. In addition to culturally supporting the development of intellectual and cognitive abilities, we need to foster the individual’s adaptive capacity to relate socially and emotionally to other human beings via the right brain functions of intersubjective communication, affect processing, empathy, and interactive stress regulation. The large body of studies on the critical survival functions of the right brain can be applied not only to individuals but also to cultures (Bradshaw & Schore, 2007; Schore & Schore, 2008).

Here in the United States, how are we reacting to this crisis at the core of our culture? And if we are not responding, why not? In clinical models we speak of individuals having intrapsychic defenses against uncertainty, stress, and painful negative information. But defenses such as denial, repression, and even dissociation are collectively used by the culture to avoid more directly confronting the serious stressors that lie at its core. Forty years ago Jacob Bronowski offered the trenchant observation, “Think of the investment that evolution has made in the child’s brain.…

For most of history, civilizations have crudely ignored that enormous potential. In fact the longest childhood has been that of civilization, learning to understand that” (1973, p. 425). In a current attempt to overcome that resistance and bring this problem closer to the forefront of cultural consciousness, my colleagues and I are producing two multiauthored volumes: Evolution, Early Experience and Human Development: From Research to Practice and Policy (Narvaez, Panksepp, Schore, & Gleason, in press), and The Impact of Early Life Trauma on Health and Disease: The Hidden Epidemic (Lanius, Vermetten, & Pain, 2010).

Grounded in recent developmental neuroscience, psychiatry, and developmental psychology, these books cast light upon a number of serious psychological and social problems underlying our cultural blind spots. But more than that, contributing scholars from multiple disciplines offer practical thoughts about what types of early-life experiences are essential for optimal development of human brain and body systems— in order not only to generate greater understanding of scientific research and theory but also to promote informed public policy.

In a recent overview of contemporary developmental neuroscience, Leckman and March (2011, p. 333) conclude, “our in utero and our early postnatal interpersonal worlds shape and mold the individuals (infants, children, adolescents, and adults and caregivers) we are to become.” At this point in time there is converging evidence that we can maximize the short- and long-term effects of our interventions by concentrating on the period of the brain growth spurt— from the last trimester of pregnancy through the second year. Whether or not our governments will fund such sorely needed efforts remains to be seen.”

Excerpts from “The Science of the Art of Psychotherapy” by Allan N. Schore.

In your recent observations of the “open dialogue” approach, could you say that there was some “unconscious” affects going on, even though we lack the language to articulate, such unconscious processes?

It’s great to see you address this “where to now,” issue here, although I do believe that beyond the headline public debate, there is a quiet revolution taking place, as Allan Schore alludes to. His call for a multidisciplinary approach to mental health, makes so much sense, and I think we are, all too slowly of course, seeing this happen beyond the usual ‘turf wars’ of elite specializations.

Body oriented therapist’s are certainly embracing the paradigm, that Schore and others advocate.

Best wishes,

David Bates.

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Hi David,
Thank you for this incredibly detailed and thoughtful exposition. I am not sure any comment I make will do this justice but your discussion of the importance of recognizing affect and the potential limitations of cognitively based therapuetic approaches is important although I admit that I am not an expert on any of this.
Bill Anthony wrote an article on the importance of process as compared to technique; these non-specific factors that we all inuit to be important – empathy, connection, etc – may turn out to be as or even more critical than the techniques we promote.

I am just a beginner student of Open Dialogue and I have been become concerned that I have perhaps (inadvertently) presented myself as having some expertise I do not posess; however, it does strike me that process seems to be specifically and highly valued in that paradigm.

Sandy

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Hi Sandra,

Thanks for another intriguing post. As a counter point to the one you describe – I have had a very difficult time finding doctors (both PCPs and psychiatrists) who will prescribe anything. The emphasis it seems is on curing everything on its own – through diet, exercise, de-stressing, etc. After four years of living with terrible insulin resistance/pre-diabetes, I finally found a PCP (my fifth try) who would prescribe metformin. But he only did it after 20 minutes of me reciting every single scientifically based intervention I’d tried to lose weight from glycemic load diets, interval workouts, etc. I’ve had similar experiences with psychiatrists – it was the fourth one I went to after three psychotic episodes who agreed to do a trial of a neuroleptic (but only after I proved that I’d given talk therapy a try multiple times and it couldn’t ‘cure’ it.)

I’m curious why doctors are doing this. Is there another trend not to prescribe or require trials of non-pharmacologic interventions first? Or do I just have a very unusual experience with doctors?

Do doctors have some set period of time a patient should spend trying to deal with a problem some other way before resorting to medications?

Alexa

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Sandra

Your critique of the current state of medicine certainly raises important questions beyond just being critical Of Biological Psychiatry. Biological Psychiatry must be challenged and defeated, but this will not fully happen without major systemic changes in our political and economic system.

Your analysis only adds to my belief that as long as the medical profession takes place in a profit driven system we will continue to have the problems you have elucidated and they will only get worse.

Even in Canada where you have a single payer government run medical system (a system that I believe is more humane than what exists in the U.S.) you have the problem that it operates in an environment surrounded on one side by the U.S. capitalist system.

Skilled doctors in Canada often migrate into this country chasing higher incomes and more profitable practices leaving some shortages of doctors and longer waits for some medical procedures. Of course the profit system also encourages a culture of consumerism and the seeking of high standards of living from which even well intentioned doctors (and others throughout our society) are not immune.

In the right system and environment people entering the medical field could get back to the more basic human desire to help people and pursue genuine science as a means to reach that end. There should not be a gap between some doctors making 500,000 a year and others making 90,000 a year; for that matter, these types of discrepancies in income should not exist in any profession or area of work.

Richard

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Hi Richard,
I agree that the influence of profit and commercialization is what corrupts medicine. I am not sure that this can ever be eliminated completely – even in a single payer system there will always be some competition among resources – but we could improve it from where it is today. The NYT article on colonoscopy compared costs between the US and other developed countries that had different payment systems and US costs were higher by at least an order of magnitude.
Sandy

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