I was honored to both attend and participate in the recent Mad In America Film Festival. I was one of three psychiatrists who were asked to respond to the themes and questions explored in the festival. What follows are a lightly edited version of my remarks.
First of all, I want to thank Laura Delano for inviting me. She is a woman of great fortitude and bravery.
I also want to thank Robert Whitaker, our moderator and the inspiration for this festival. I first wrote to Bob on May 29, 2011. I had never written to an author before. I went back to look the first of a long and ongoing correspondence. This is how I concluded that first e-mail:
“I am almost immobilized at this point.”
Amazingly, Bob answered in the thoughtful and serious way which I have come to see is emblematic of him and this began what I have come to call “My Adventures with Whitaker”.
My response to Anatomy was in part the culmination of a long slide of disaffection I had for the major paradigms that have influenced modern psychiatry. I entered the profession enamored with psychoanalysis but by the time I ended my residency training I was disillusioned with that approach. I decided that it was a problem to have a branch of medicine in which the practitioner can not be wrong. If my analyst had said, for example, that my disaffection with psychoanalysis was rooted in my anger against our male dominated culture and I objected to her interpretation that response would have verified her observation, and if I agreed, well then she was also right.
I had a problem. By the end of my residency, I had decided that when it comes to problems of sadness and anxiety, the medical model was sorely lacking. I never found the DSM to be terribly helpful and I always thought most of these problems were highly complex and heterogeneous. Whereas early on, I thought psychoanalysis might be a way to approach that complexity, I had come to find that model to be seriously flawed. At that point, I would have left psychiatry if it hadn’t been for my fascination with extreme states – what psychiatrists call psychosis. To be honest, that was one area where I thought the medical model was valuable.
So I was that doctor who tried to convince people to take anti-psychotic drugs. I was fortunate to have come of age in the profession when judicious dosing was urged, but I nevertheless thought drugs were critical to the treatment of people experiencing psychosis.
By ~ 2000 though, I was utterly disgusted by the influence of the pharmaceutical industry and what I saw as the collusion of the leaders of my profession in the overselling of drugs.
Bob was not the first writer to influence me deeply. Marcia Angel’s book, The Truth about the Drug Companies gave the back ground information to what I saw happening right in front of me- the new anti-psychotics were grossly oversold. I do not think it is hyperbole to say that the entire data base of medicine is suspect especially when it comes to clinical trials.
But in the past 4 years, I have gone further to challenge some of my most basic assumptions.
What changed after I read Anatomy is that I basically decided that I would start over again and re-consider these problems from the ground up.
This has been a challenge because some notions are deeply embedded in my cognitive framework. But I decided that since I had been wrong so often I needed to drop a bit of my skepticism for at least a time and be open to other ideas.
So in this spirit, I have found Open Dialogue, the Family Care Foundation, the Hearing Voices Network, needs adapted treatment, and the many voices on Mad In America and the Critical Psychiatry Network. This is how I found myself at a Mind Freedom conference this summer; it is how I found myself in northern Finland and Norway.
This has been a deeply unsettling time for me and I still have many questions. I probably have more questions than answers.
But this is where I am today in my re-thinking:
In the current National Institute of Mental Health paradigm, we are wasting our time if we do not link behaviors to neural correlates. I reject that notion.
This is an issue of resource allocation. We are spending enormous resources on understanding brain function and I am no longer convinced that is required to figure out important ways to be of help to people.
But this is also an issue of a faulty paradigm. While the notion that we would identify compounds – drugs – that could improve mood and thought might have seemed reasonable in 1970, there is so much to suggest this is not likely to be attainable. Complex behaviors do not seem to yield so easily to the drugs we prescribe. The drugs we put into the brain have consequences – long-term ones – and we have not even begun to reckon with this. We need to be so much more cautious and humble than we have been over the past 60 years.
So is there a role for medicine?
Where I may part ways with some of my reformist medical colleagues is that I do not think one needs to be a physician in order to be helpful to people in the ways we learned about in some of the movies we viewed today.
However, the desire for psychoactive substances will not go away. It preceded psychiatry by thousands of years. We have been smoking and eating things to alter our mental states for a long time. Outside of this auditorium, people still want pills. Where there is demand, there will be supply. And while advertising has an enormous amount to do with this, this desire supersedes Madison Avenue and the modern psychiatric paradigms.
There is a role for a judicious, thoughtful medical expert on psychoactive drug use. I am not talking only about marijuana or LSD. The distinction between drugs used for recreational experiences and those prescribed by doctors to treat symptoms is an arbitrary one. Ketamine – special K – which historically has been given to rats to model psychosis and used recreationally is now prescribed for depression.
I am influenced by Joanna Moncrieff’s drug-centered approach. Some of these drugs may have advantages for some people at some times. But this is not because these individuals have a particular disease or disorder but because they have brains.
It is a worthy goal for some branch of medicine to understand what drugs do to the brain and offer people sound advice.
But physicians have a way to go to win your trust.
- We need to disengage ourselves from commercial interests.
- We need to do studies that are designed to understand drug effect – good and bad, short and long term – rather than to gain market share.
- We need full transparency in analyzing research and data need to be open to researchers who have no conflict of interest.
Mainly, psychiatry needs to step aside. We do not need to be the main players in the general process of helping people to recover.
You are the ones who lead the way – in a humane, person-centered, respectful manner.
* * * * *