What Will Cause Psychiatry to Change?

Andrew L. Yoder, MSW
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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?

18 COMMENTS

  1. Maybe a modern day computer hacking genius Robin Hood will appear to electronically overnight to remove funds from bio-psychiatrists and big pharma corporations and make available the funds needed to open Soteria houses ,open dialog ,Esalon and other respites ,peer run of course,FIRST DO NO HARM of course, to help the wounded . We must return the power to the people to dissolve organizations that commit crimes against humanity.

  2. If pharma executives went to prison for committing the crimes they are constantly getting busted for instead of just using a small portion of there companies illegal gains to pay fines things might change.

    These companies are constantly loosing class action lawsuits, federal lawsuits or both for not disclosing adverse findings in clinical trials, lying about known health risks, directly causing death and chemical injury and even illegally marketing their most powerful and unpredictable drugs like Risperdal off label to children.

    No one ever goes to prison ever. WHY ???

    • Yes, no one goes to prison, because they are rich and powerful. Until some of them go to prison, they will all continue abusing people.

      Lawsuits won’t do it, because the insurance companies pay the awards. Psychiatrists can kill people, lose a suit for $40,000,000 (as happened recently in Boston) and it doesn’t have any effect on them at all.

      But the most important court is the court of public opinion. We have to go out there and show the general public that they are endangered by the power of psychiatry.

      Anyway, thanks to the author for this thought-provoking article.

  3. Hi Andrew, Good to read your post.

    Enough can’t be said about the cult of authority and the outsized business interests attaching to this failed paradigm.

    Obviously, the idea of shocking people, detaining them, and giving them instructions that make short work of their own ideas appeals to many who take up the job, here.

  4. Dear Andrew,

    Psychiatry is a medical profession that naturally seeks a medical solution to emotional distress; its perspective and the livelihood of its practitioners is not conducive to understanding emotional distress. The powerful interests of the pharmaceutical industry and vested interests of other groups also promotes the erroneous medical model. I believe that only through understanding the natural biology of emotional distress will the tide shift.

    Thank you, Steve

  5. here was a time that social justice could be achieved through the legal system, but for the most part, the law follows, it does not lead. In all areas of the law there is a tendency to not take evidence and not hold hearings. Judges’ salaries are the same regardless of how much or how little they work hearing testimony. Involuntary commitment hearings and forced drugging hearings not uncommonly take a minute or two, if that. “Evidence” is either not taken at all, or is in the form of a letter from a psychiatrist who often doesn’t usually even shoTw up. Commonly the only evidence might be a hospital form in which the psychiatrist has checked a few boxes. The poor are represented by court appointed attorneys who have a financial incentive to spend as little time as possible in a hearing listening to evidence, and many, for expediency’s sake, will simply agree with the government lawyer that what is “best” for the client is to be locked up. Caselaw often says that judges should no longer determine whether a person is so mentally ill that they should be hospitalized “for their own good” – that this is the job of psychiatry. Compounding the problem is that legislatures take as a given that that anyone who has ever been hospitalized will be on medication for life, and that a person who disagrees with their psychiatrist about the level of medication is probably a danger to society. Other government agencies that are supposed to provide oversight over psychiatrists typically fail to do that. The only thing, as you suggest, that stands a chance of changing psychiatry is for the profit motive to disappear.

  6. Good question Andrew. I think you have identified one of the main ways that will cause the practice of psychiatry to change- the legal avenue. AWe have seen a chipping at psychiatry this way – black box labeling, GSK no longer paying doctors for “educating” people, opiate prescriptions are going down…all the result in part due to lawsuits. But these are all minor, small chips that psychiatry has given up in order to preserve the bottom line.

    The main way to change psychiatry is to affect its financing. And psychiatry is financed by the insurance industry. If the insurance industry, as well as Medicare and state insurers, favored alternative models of care that were less expensive and equally if not more effective, that would cause a deep blow to the practice of psychiatry.

    However, as you know, once you have been taking psych drugs for a while, it is deeply hard to go off of them. This is where psychiatry has the upper hand. There is no easy alternative model for the millions of people currently taking these meds. Even if they want to taper down, (and a large percentage don’t), they will still need more prescriptions, more refills, more psychiatry.

    If there is one area that I think we can truly make a change it is to present the case of not starting meds. As you said, Insel has already tacitly agreed that the current plan of medicate hard and medicate for life is an erroneous model. Perhaps media campaigns showing what happens to people who are medicated such as videos of people who have experienced tardive dyskinesia, parkinsonian symptoms, obesity, diabetes, heart disease, strokes, SSRI withdrawal symptoms due to meds.

    Just as “Faces of Meth”, and anti-smoking campaigns changed people’s opinions, strong media footage and commercials could show people some of the true harms inflicted by psych drugs. There needs to be a public mind change before there can be a true change in psychiatry. Thanks Andrew for your post!

  7. You may be right re: the need for litigation, but to take this one step back, legal services short of litigation are just as hard to find. Attorneys familiar with iatrogenic illness may not be found among the local hospital’s office of Mental Hygiene Legal Services. In-patients may look in vain to them for help. Most recently, I sought the help of a toxicologist to review the medication utilization of a hospitalization gone wrong , SINCE THE STATE DECLINED OUR REQUEST FOR THAT SERVICE. I was not looking for money, just professional validation of our concerns. Her response was that she would like to speak with our attorney. I’m still looking for one . I contacted a law group that recently won the release of someone with NO history of mental illness who was held without legitimate cause. They gently declined, but offered consolation that their response did not imply that we had no valid concerns.

    A new monstrous obstacle to reform may be on the horizon. The international community and the International Corporation for Assigned Names and Numbers (ICANN) have been lobbying the current administration to grant oversight of the internet in the USA to a global international committee. Currently robust social media networks exist because of our freedom to access the internet. Communication with others of like mind , freedom to assemble in cyber space,
    is foundational to advocacy of all forms. To lose local control of this freedom parallels the loss of control of our brains and bodies to psychiatry. It has been said that prior to the recent invasion of the Crimea, a signal was used to jam communications there. To protect ourselves we need to protect our social networks. We need to take back control of our lives.

  8. What will cause psychiatry to change? Like the plethora of global institutions that have brought harm, misery, suffering, and death to so many on the planet–through lying, cheating, bullying, avoiding, and general hypocrisy and betrayal to their own professed causes and missions–they will hang by their own ropes. The changes that are occurring in the world will leave it unrecognizable.

    My own personal belief is that rude awakenings are just around the corner for systems that operate via dark and dense energies–that is, those devoid of conscience, consciousness, and which utterly lack integrity. How these events will manifest is anyone’s guess.

    I imagine that a lot of people are, eventually, going to be arrested for the crimes they have perpetrated on humanity. The ones that survive, physically, will, more than likely, descend into madness. Then they’ll start to get it.

    At that point, the real healing will begin.

  9. Andrew,
    You may never know how persuasive this article has been for me. I’ve chosen to review my son’s hosp records almost 3 yrs ago, in a locked unit, in spite of the pre-arranged drug rehab progrm my son agreed to enter there that I, personally, set up along with thousands of dollars upfront because this facility was ” out of network” from my son’s PPO ins. If anyone could imagine the horror of reading why and how my son was instead tricked to go inside their locked unit, then psychologically and medically tortured inside this unit. And now knowing he ended his life, and finally finding the pieces to the puzzle of what he endured at the hands of this supposedly well-regarded facility that he ONLY entered for drug rehab (which was denied him).

    Your message ” What Will Cause Psychiaty To Change?” I ask myself daily. I hope in my deceased son’s case, in the coming months, I will prove the Hippocratic Oath ” do no harm” the adm p-doc at this facility so outrageously violated by over-medicating my son into a drugged, stuporous state revealed by my son’s medical records and actual voice msgs he sent us while in this locked unit for almost 2 weeks. And the consequences from the muliple neuroleptics IMO triggered thoughts which are why the black box warning for ages 24 and < exist, compounded by the brainwashing he, and our family, were told we must accept that he had a severe MI. Instead of the TRUTH the "rcreational" drug my son tested + on his toxicology report had altered his sense of reality. Now, I've educated myself, I can not fathom how any facility can be legally allowed to assign a severe MI label when the DSMs own coding and criteria invalidates such a dx label when a person is under the influence of a drug substance, as my son's toxicology report clearly showed.

    I'm repeating blogger Ted's pearls of wisdom:
    "But the most important court is the court of public opinion. We have to go out there and show the general public that they are endangered by the power of psychiatry."

    Thanks, Andrew. I only hope I can expose how " the MH BUSINESS" contributed, if not fully, to my son's untimely and horrific death.

    • I am so sorry . I pray for you to have the victory in this matter.
      Your statements about the voice messages and how you’ve pieced together the evidence
      sounds SO familiar , it resonates with our situation. Would some kind
      of independent review service available to advocates when their loved one is in hospital, help to “sort things out” ? Like you, I am “thinking hard” to see how we can get more traction in these matters. I’m wondering, If we used a template to organize the warning symptoms of “hospitalizations-gone-wrong” so that we could present the evidence, of these repeat tragedies in a way that shows the “typical pattern” that occurs, to the ” powers -that-be”, perhaps they would begin to listen and respond better. I think the legislators stay clear of our pain because they perceive it as a confusing matter best left to the experts, which unfortunately amounts to trusting the fox in the hen house.

  10. What would cause psychiatry to change?

    Certainly money would have an effect. However I believe that it would most likely occur in the same manner as the flat earth hypothesis collapsed. Someone will present irrefutable evidence that they got it soooo wrong.

    Cogito ergo sum.

    Isn’t this to put Descartes before the horse?

    I hope that someday people figure out that psychiatry is a major contributing factor in suicides and behavioural problems, and not the solution to them. As long as they have the public convinced that the cart comes before the horse, things will not change significantly.

  11. This is excellent analysis, as far as it goes, and I completely agree with it. But the situation is even more ingrained, complex, and difficult to change rapidly. It’s not just the money, it’s that the whole cultural apparatus for dealing with what we in this culture have come call “mental illness” has become a rather fixed reality. The DSM, the very architecture of hospitals, the gradual erosion of community mental health clinics, what insurance will and won’t pay for, the language available for discussing and trying to understand a life crisis, the phone numbers you can find listed, the set protocols for responding to a 911 call, and many, many more interlocking details, all these things work together to make it very possible to respond to a person in crisis in some ways and nearly impossible to respond in other ways. There are no Soteria houses in Chicago (for example). Not trying to be a pessimist here, I subscribe to Mad in America for the community, hope, and solidarity in working for change, I’m just trying to help name the many things we have to work at changing.

  12. Until there is performance accountability I see little chance for change. It is long past due that MH providers of all stripes cease representing broadly that which they can evidence narrowly, anecdotally or not at all.

    The story of Susie or Billie or a recovery speaker is hardly evidence that Wellness or Recovery are a provider’s predominate clinical, functional, and personal outcomes nor is it evidence of systemic change or that treatment is appropriate or evidence based.

    As the saying goes, “If it can’t be measured it isn’t going to happen.”

  13. The only thing that would cause psychiatry to change is money and power.

    Either psychiatry finds a way to maintain it’s power and earning potential whilst moving to a model that is less damaging OR it comes under enough opposition and lack of engagement that it’s forced to disband, change, become less influential etc.

    It’s true that you don’t really get therapy from a psychiatrist anymore, but odds are when someone is seeing a clinical psychologist, they were referred to them by a psychiatrist and the clinical psychologist is still sending regular updates to a psychiatrist. In essence, psychiatry still in charge, still with the authority.

    It’s not like psychology doesn’t also rest on shaky ground either. It’s potentially just a less damaging fraud, you the kind without type II diabeties, or a shrunken brain or a working thyroid glan etc.

  14. Psychiatry will change when it arrives in it’s proper place in the dustbin of history. At that time it will have changed to dust and only to be read about in the history books under the category organized crimes against humanity along with witch burning, the Holocaust,along with names and photographs of the perpetrators.The only question is will it take a real life Madame Defarge to help make the change ???