I’ve been on hiatus for a few months now, and I decided that an informal entry would be most fitting at this time. I have had one question on my mind lately: what would motivate Psychiatry to drastically change its mission and practices in a way that is most consistent with contemporary evidence and moral responsibility?
I’ve been thinking about this in earnest again lately after a recent interview of Robert Whittaker by Bruce Levine referenced last year’s statement by the head of the National Institute of Mental Health, Thomas Insel. Insel’s statement publically acknowledged the validity of a body of research that consistently shows long-term use of “antipsychotic” medications may be contraindicated in the majority of cases, and called for a fundamental rethinking of best practices when it comes to psychiatric prescribing.
Obviously what was so striking about his statement is the fact that it comes from one of the most mainstream mental health bodies in the world. This was not a voice from the “fringe” – the term so often used by certain psychiatrists to trivialize evidence that disrupts their paradigm. This was a voice from the heart of the mental health machine. And 2013 was no stranger to staggering criticism and challenges to conventional psychiatric thinking from within some of the most respected and mainstream institutions of mental health.
In fairness, Mr. Insel seems to draw conclusions based on his stated premise (that a fundamental rethinking of best practices is needed) that differs from my own. Mr. Insel wants to devote even more NIMH money to finding biological root causes for “mental illness,” presumably with a goal of developing “better” medical treatments.
But all I am interested in right now, is the fact that Mr. Insel and scores of others from within mainstream mental health institutions are stating this premise: it is no longer possible to reasonably ignore the implications of available data, and we must question our long held assumptions about “best practices” in mental health. Different individuals will suggest different conclusions from this premise, many of which I will personally disagree with. But it should no longer be considered radical or “fringe” to question the dogmas which have long gone unchallenged in psychiatry. Asking questions is no longer radical.
This is combined with the continuing arrival of further research at increasing levels of sophistication and scholastic rigor which reinforce and build on past research findings which challenge or refute many of the core dogmas that have reinforced psychiatric “authority” for a generation. The result is that never before has there been more pressure to seriously question the paradigm of psychiatry as it has functioned for the past generation or longer.
Still, my personal sense is that the institution of Psychiatry is no closer to embracing serious changes to its ways than it has ever been. Why is this, and what would it take for Psychiatry to change?
Surprisingly, today I feel capable of taking a somewhat detached stance, and attempting to think of the current landscape through the lens of psychiatry. What I recognize is that, with no implied cynicism, psychiatry is a business. There may be individuals within the institution that care about human lives, and have values that include things like justice and compassion. But I have always been less interested in individual criticism and more interested in institutional analysis. So a simple fact of institutional analysis is that psychiatry is a business.
Crudely speaking, there are two major factors that have great impact on any business. The first is the ability to make money sufficient to stay in business and expand that business. The second is the perceived authority of the institution sufficient to make and keep business and influence other institutions and society in ways that reflect the institution’s own interests. These are two elements that are pretty much at the heart of any business institution.
Right now, all the of the emerging evidence that challenges traditional assumptions can only be seen by the institution of psychiatry as a threat to revenue and a threat to the institutions’ perceived authority. Now we might wish that we lived in a world where every human being was only motivated by selfless altruism, a sense of morality and justice and deep love and compassion for fellow human beings. I know I wish that. But we don’t. And I don’t think its too cynical for me to speculate that psychiatry is never going to be especially motivated toward change as long as change looks like a money and power loser.
Looking specifically at the money issue, both psychiatry and its almost indistinguishable partner, the pharmaceutical industry, have absolutely everything to lose and – at present – nothing to gain financially by embracing the evidence that psychiatric medications may be contraindicated in many, many cases. How can this change? One possible way is through an intense battle in which social justice advocates engage in an all out legal war against psychiatric, bring lawsuit after lawsuit until the cost of not changing becomes more expensive than the cost of changing.
I think we are just barely starting to be on the cusp of a time when lawsuits directly challenging psychiatric “best practices” could become feasible as counter-evidence continues to mount. But I don’t think we’re there yet, at least not on a large scale. And I’m not even sure if the courts is a path that would really lead psychiatry to change. Because psychiatry’s resistance to change is also based on the perceived loss of institutional authority that would result.
Psychiatry went “all in,” to use a poker metaphor, when it transitioned away from being known for psychoanalytical “talk” therapy to toward “medicalizing” the profession. These days, psychiatrists tell me that they spend greater than 75% of their time in “med checks” with patients – those 15-minute meetings in which medications are added, changed, or modified for a patient who is then sent back out the door. Some psychiatrists tell me that they engage in absolutely no “therapy” in any traditional sense.
Psychiatry ceded the therapy ground to social workers, psychologists and many other licensed disciplines (Such as marriage and family therapists.) And, today, a person would go to anyone but a psychiatrist if they wanted to see someone for therapy, counseling, life coaching, spiritual guidance, etc. So psychiatry bet everything on the medical model of mental illness and a pharmacological solution to extreme emotional states. And they are only now beginning to fear that they have lost that bet. But what can be done? Psychiatry has already surrendered everything that was once its traditional territory to other disciplines and fields. And an institution as authority-obsessed as psychiatric cannot bear the thought of a perceived loss of authority.
So what will motivate psychiatry to change? Is change possible, or will it one day be an institution that disintegrates as other (hopefully more just) organizational disciplines take its place?