Why I Became a Critical Psychiatrist

Sandra Steingard, MD
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I was asked to give a talk to the Osher Lifelong Learning Institute of the University of Vermont.  This is a program that offers courses and programs for adult learners – mostly people who are retired.   I decided to title my presentation, “Why I Became a Critical Psychiatrist,” thinking that the kind of Vermonter who would attend something like this was intelligent and well-educated but not necessarily familiar with psychiatry. I imagined that this might be a person who believes in science and modern medicine and assumes that the advances in my profession that are often widely promoted in the media were sound.

The talk explains my own evolution as a psychiatrist and addresses the development of the Critical Psychiatry Network.  I focus on three main areas: psychiatric diagnosis, the influence of the commercial forces of the pharmaceutical industry on medicine in general and psychiatry in particular, and the evolution of the use of neuroleptic drugs (in that order).  It is a long talk (~ 90 minutes), so if you are only interested in some of these topics you can skip around to find them.

13 COMMENTS

  6. Hi Sandra, we’ve had some conversation about this before, so it’s kind of a continuation. I’m encouraged by your honesty, candor and willingness to challenge your colleagues while maintaining what seems to be a respectful dialogue–even your willingness to take some rather sharp criticism (at times) from some psychiatric survivors on this site who have been badly burned by the status quo.

    I resonate strongly with one of your last comments during the Q & A at the end of this presentation; that is, the real problem with the short time frame imposed on current acute care for psychosis (ten days!). This clearly fuels the reliance on heavy drugging with neuroleptics, and stands in the way of alternative non-drug approaches. Even with all the drugs (actually, because of them i would say) my daughter underwent several protracted, torturous “treatments” in which they put her brain through the wringer. Ironically, i believe it was this “rush to stabilize” (with drugs) that actually undermined her recovery! (The last time she was in an acute psychiatric ward of the local hospital for about three months, followed by a couple more months in the local state hospital).

    In response to the concern I expressed previously (and still have) about the lack of non-drug options that exists in our country (and most others) in treating psychosis, you stated something to the effect that it would be a great improvement if psychiatrists would at least adhere to the principle of prescribing the least effective dosage–a practice which is very robustly supported even “within the mainstream”. I’ve been thinking a lot about that recently and heard some very encouraging news that one of the agencies in New York State that works with people with developmental disabilities (it may be DDSO) has the policy that a psychotropic drug for any client will only be approved if it comes with a plan to taper it from the outset! I hope this is true (I plan to look into it further), and i hope such a policy expands to other state agencies. Actually, it would be even better, in my opinion, if they had policies and practices that sharply curtailed the use of these medications altogether.

    Now here’s the really good thing, at least in my mind at this point: Since we know that people have successfully tapered off of every psychotropic drug, the possibility that the “least effective dose” might be zero for any given person should always be considered. Of course, the tapering process would need to be done in a very careful, very individualized manner.

    What do you think?

  7. The New York State Department of Mental Health is sponsoring a meeting in October to discuss the topic of neuroleptics and long term outcome. They have invited Courtenay Harding and Martin Harrow as well as some other leading researchers. I am attending and will report back. This is very hopeful and promising NY also has Parachute NYC in which they have peers and professionals offering dialogic approaches, Intentional Peer Support, peer respite this is also very promising.
    I am not sure if I have answered your questions. I do think dose is enormously important and it is a message – more than no drugs- that could get traction within medicine.

  8. Wow! That’s more good news, and I’ll be VERY interested in what comes out of that discussion. As for answering my questions, you have in a general way. But more specifically, (1) do you think the idea of the state agency i mentioned not approving a drug unless there’s a tapering plan attached to it is a sound practice; and (2) doesn’t it make sense to never rule out that the POSSIBILITY of the minimum effective dosage (eventually) of any psychotropic medication would be zero?

    The reason I’m so interested in these questions is that most folks on psychotropic meds who want to try tapering are forced to do this on their own at present. It seems to me that if such a policy, and more importantly such a mindset, comes more into the medical/psychiatric mainstream, more people will have support in carefully tapering these toxic substances in a way that will have more chance of success. Now, when i call them “toxic substances” to be honest I cannot say that is ALL they are. I have seen instances, both with my daughter and others, where clarity of mind followed closely on the heels of the administration of a neuroleptic medication. However, in the cases I’m familiar with the question still remains as to what brought about the psychotic state in the first place, including medical “brain tinkering” that appeared dubious, at best. My experiences with doctors, psychiatrists and even mental health therapists, to date, tends to leave me discouraged and sometimes very angry. I sometimes see these professionals as little more than shills for the pharmaceutical industry, even though I don’t believe most of them are consciously so. “Commercialism masquerading as education”, to use your words. That’s a huge part of the problem, as i see it.