In recent years, in what I have come to call my “Adventures with Whitaker,” I have had the privilege of communicating with people with whom I would have otherwise had little contact. Some of this has been through this website and the rich exchange of ideas I have had with those of you who comment on my blogs. I have read many posts and often followed up by reading books written by some bloggers as well as books mentioned in various posts. I have had some “off line” exchanges with people I would have only met through this site and I have ventured to meetings whose existence I only learned of through these connections.
If you read my posts, you know that I have come to identify myself as a critical psychiatrist. But I remain a psychiatrist working in a busy clinic and it is imperative for me to understand the implications of my critical stance not only for me but also for the people who end up in my office.
One of my guiding principles is to try to be authentic to my own ideas, opinions, and values no matter the setting. When one is struggling and uncertain, it is tempting to lean one way in a setting that supports a particular view and lean another way in a setting that supports an alternative. While I try to resist, it is impractical to always explain. However, from time to time, I find myself feeling the urge to articulate my views and delineate them from people with whom I may be identified. Rightly or wrongly, I feel that way with this website. Although the goal is to have wide ranging views there is nevertheless a distinct perspective represented here. Every so often, I feel the urge to articulate where I part ways with some of the opinions expressed here. I do this in the spirit of discourse. I am not certain I am correct. I may someday change my mind. I am just expressing my perspective.
Three recent posts have caught my attention in this context and what follows are the thoughts provoked by these posts.
A few weeks ago, Daniel Mackler wrote a post, “Ode to Biological Psychiatry.” At the time, I made the following comments in response to this post.
“This work feels like a shutting down of dialogue. There is little room for response. I am hoping to open up the conversation and I see no room for that with the rhetoric used here.”
A lively discussion ensued.
More recently, Philip Hickey, PhD has written a series of posts on neuroleptics and their use in nursing home residents. One of them was written in response to a physician who wrote, “All drugs can be dangerous toxic chemicals when not used appropriately.”
I am an avid reader of Dr. Hickey’s posts and I agree with much of what he writes, but I often feel a vague discomfort. I think I traced it to a comment he wrote to this last post:
“My general position is that psychiatry is spurious, destructive, disempowering, and stigmatizing. To me, it is something fundamentally rotten; something intellectually and morally bankrupt; a wrong turning in human history.”
I appreciate his honesty. At the same time, it helps me to understand our differences.
The post that helped me to clarify my own thinking was written by Bonnie Burstow, PhD, “On Fighting Institutional Psychiatry With the ‘Attrition Model’.” It – and the referenced article she has written – provide some history of the anti-psychiatry movement as well as define a strategy – the attrition model – to abolish psychiatry.
This helps me to clarify why I may have trouble having a discourse with some of you. Your goal may be the abolition of psychiatry and mine is to reform and critique. It is understandable that in this context our strategies and rhetoric might differ. I am not going to argue with any of you about this. Good luck in your efforts. But we may find ourselves talking past one another given our differing goals.
But I would highlight one concern about the abolitionist approach. Some writers here appear to consider psychiatry as an anomalous construct of a modern medicine that is otherwise doing well. Dr Hickey writes about “real medicines” in contrast to drugs used by psychiatrists. Although I have criticisms that are specific to psychiatry, I do not share his faith in the rest of the profession.
Last month, we lost one of the great figures of modern medicine, Arnold S. Relman, MD. He was a professor of medicine at Harvard Medical School and for 14 years in the late 70’s and 80’s, the editor in chief of The New England Journal of Medicine, arguably the most influential medical journal in the world. In 1980, he wrote an article entitled, “The new medical industrial complex” in which he warned of the dangers of profit driven entities in altering the structure of modern medicine. He argued then, as he argued for the rest of his life, for enacting a single payer health care system and eliminating the profit motives in the practice of medicine.
That was 1980. If one looks at the evolution of modern psychiatry, this was an important year. DSM-III was published that year. In the next two decades, what had been a more open debate in the profession – how to think about the problems and personal crises psychiatrists were asked to evaluate and treat, the role of drugs vs. other interventions, the need for a technological approach vs. a humanistic one, appeared to be settled. Whatever flaws one finds in psychiatry, the ascendancy of certain ideas over others has as much to do with market driven forces as with anything else. We ignore that at our own risk.
Dr. Relman along with his wife, Marcia Angel, M.D., also a former editor of NEJM, went on to tirelessly challenge all profit-driven entities in medicine including the pharmaceutical industry. Their writing was crucial to my enlightenment and development and this is an opportunity to honor Dr. Relman’s memory and to publicly thank them for their courageous efforts.
So what is my point?
Medicine – in all senses of the word – is not going away. Drugs will continue to be developed. The human desire for psychoactive substances which long precedes the business of psychiatry – modern or otherwise – is not likely to abate. To take aim at psychiatry without looking at the larger medical/industrial complex in which it is so firmly based is not likely to achieve the goals some of you hope to achieve.
I recently finished reading a book by the psychologist, Richard Noll, entitled, “American Madness.” It details the development of the construct of schizophrenia from the late 1890’s in Germany when Kraepelin coined the term Dementia Praecox through the 1930’s when Schizophrenia became the accepted label. There is much of value in this book for anyone interested in the history of the profession. One thing that struck me is that 100 years later, we continue to have the same debates. Kraepelin was influenced by the advances in medicine at the time. He approached the problems of those who were in insane asylums with the approach of his medical colleagues – study the history, course, signs and symptoms as a way to understand an underlying pathophysiology that was presumed to be common among individuals regardless of their social context.
As this line of research was unproductive, there were others – Adolf Myer, Sigmund Freud – who rejected this and sought answers in the individual and his social or psychological experience. This was never resolved and is still not resolved. We just have more professions who have joined the fray. But an odd thing happened. The label stuck and with it the belief that it signified something essential. So today, I may have a colleague say something like, “I do not think he has schizophrenia because he is so social.” That comment only makes sense if one adheres to an unproved 100 year old hypothesis that there is an entity that exists in nature whose constellation of symptoms we have definitively identified.
There is a lot of blame to go around. I would not discount the responsibility of the individual psychiatrist but at the same time, all of us are products of our context. If one finds oneself in medical school, one is likely to have some fundamental notion that the brain is involved in the spirit and the mind. If one is told that there is a 100 year-old profession that addresses these problems and one finds satisfaction in meeting with people who consult with psychiatrists, then one might end up training to be a psychiatrist and begin with the notion that one’s teachers have something of value to say.
On a personal level, it took me many years to evolve my critical stance. I needed to learn the profession before I could even form a cogent opinion. In that time, I guess I was fortunate to develop a critical view of all dominant paradigms – the psychoanalytic, the neo-Kraeplenian categorical approach, and the pharmaco-centric approach. I have learned that psychiatry is a broad entity. Many varying ideas are encapsulated within the profession. There are forces at play that include guild interests both within and outside of medicine, varying theoretical constructs, the needs of profit-driven entities (including non-profit hospitals!), as well as the individual actions of physicians. Maybe I am too close to have perspective but lumping it all together under the umbrella of an abolitionist approach ignores too much from my vantage point.
I continue to think we are better off criticizing specific ideas, themes, treatment approaches, even specific doctors if they have acted badly. I also think we are obligated to shine the light on all solutions. For those of you whose goal is to topple the beast, think carefully about who will come in to take its place.
