When you write a book, you usually do so in response to a prompt of some type, and in the process of researching and writing the book, you will come to see your subject in a new way. Psychiatry Under the Influence, a book I co-wrote with Lisa Cosgrove, provided that learning experience, and this is what I now know, with a much greater certainty than before: Our citizenry must develop a clear and cogent response to a medical specialty that, over the past 35 years, has displayed an “institutional corruption” that has done great injury to our society. In fact, I think this is one of the great political challenges of our times.
The specific “prompt” for this book can be traced back to a phone call. In 2011, Lisa Cosgrove, who is a professor at UMASS Boston, was finishing up a year as a fellow in a research lab at the Edmond J. Safra Center for Ethics at Harvard University that had been set up to study “institutional corruption.” She called and asked if I would be interested in jointly applying with her for a fellowship at the Safra lab in the coming year. The thought was that we would investigate the American Psychiatric Association through this lens of institutional corruption (a subject I admittedly knew nothing about), and write a monograph as our fellowship project. However, midway during the fellowship year, we settled on a larger book-length project. We would investigate the “institution” of psychiatry, and we conceptualized that institution as being comprised of the American Psychiatric Association and academic psychiatry. We thought that our book, in addition to investigating the institution of psychiatry, might also serve to illustrate how the framework of institutional corruption provides a way to see the corruption in a clear light, and illuminate possible solutions.
The Framework of Institutional Corruption
The Safra lab on institutional corruption, which just completed its five-year run, was the brainchild of Lawrence Lessig. A professor at Harvard Law School, Lessig is known for his creative thinking and political activism on a number of issues fundamental to our society’s democratic well-being. He was a founder of Creative Commons, which has sought to expand and protect the public’s access to creative works, and he also founded Rootstrikers, a citizen’s group devoted to fighting political corruption in the United States. In his 2010 book Republic Lost, he told of the corrupting influence of lobbyists and special interests on Congress.
As Lessig and others have developed this field of study, they have noted that it is important to distinguish individual, quid-pro-quo, corruption from institutional corruption. The former is a story of “bad apples.” For instance, a politician takes a bribe in return for a political favor. That is quid-pro-quo corruption. Institutional corruption is of a different—and more societally damaging—type. Institutional corruption is a not a “bad apple” problem, but a “bad barrel” problem.
The basic concept of institutional corruption is this: There are “economies of influence” that create “incentives” for behaviors by members of the institution that are antithetical to the institution’s public mission. When this happens, the “corrupt” behavior may become “normative,” and even go unrecognized as problematic by those within the institution. Institutional corruption is of a systemic type, subtle, and yet ultimately corrosive to our democracy.
For example, politicians running for office must raise money to finance their campaigns. They may get such funding from industry lobbyists and from political action committees (PACs) established by special interest groups. As a result, the elected officials may develop an “improper dependency” on the funding from the special interests and will become subtly beholden to these funders, even though the members of Congress are supposed to be beholden to the citizenry. Moreover, politicians know they need to raise campaign funds, and taking PAC money has become an accepted method for doing so. This is just the way that the system works.
“These are not bad souls bending the public weal to private ends,” Lessig wrote. “We can presume that the individuals within the institution are innocent; the economy of influence that they have allowed to evolve is not.”
The framework developed at the Safra center also provides a concise guide for investigating institutional corruption. First, identify the economies of influence that may be creating “perverse” incentives. Then document the corrupt behaviors by members of the institution (which, although unethical, can be expected to be legal.) Next, detail the resulting social injury, and explore why the members of the institution remain largely unaware of the corruption. This investigatory process is designed to illuminate possible solutions to the corruption: the economies of influence that have led the institution astray must be neutralized, either through government regulation or some other means.
Our Study of Institutional Corruption
In our study of the “institution of psychiatry,” we focused on psychiatry’s behavior since 1980, the year that the American Psychiatric Association published the third edition of its Diagnostic and Statistical Manual (DSM). This was the moment that the APA adopted a “disease” model for diagnosing and treating psychiatric disorders, and it is easy to identify two “economies of influence” that have been present ever since.
The first is the influence of the pharmaceutical industry, which, following the publication of DSM III, dramatically increased the amount of money it provided to the APA and to academic psychiatrists, who were paid by pharmaceutical companies to be speakers, advisors, and consultants. This “economy of influence” is well recognized by the public, and there has already been considerable societal discussion about how it could be neutralized. The amount of money flowing from industry to the APA and to academic psychiatrists has also diminished in recent years (partly because of that public attention), and so this corrupting force may be somewhat on the wane already.
However, the second “economy of influence,” which isn’t as well recognized by the public, is much more problematic. This is the influence of psychiatry’s own guild interests.
Once the APA adopted a disease model in 1980, it laid claim to having societal authority over three domains: diagnosis of psychiatric disorders, research into their biological causes, and drug treatments. As such, from a guild perspective, it had a need to inform the public that its diagnoses were valid, that its research was producing an understanding of the biology of psychiatric disorders, and that its drugs were safe and highly effective treatments for such problems. Moreover, unlike many medical specialties, psychiatry has to compete for patients with those who provide alternative therapies (psychologists, social workers, and so forth), and thus it could be said to have a particularly pronounced need to protect the guild interests that allow it to prosper in this marketplace.
If science subsequently supported telling such a story, one that informed the society of great progress being made in this field, than there would be no problem. Our society would simply be well informed of this advance. But if science did not support it, then the potential peril was this: Psychiatry, because of its guild interests, would be tempted to tell a story to the public that was out of sync with science, and in that way, betray its public mission.
With that potential for “corruption” set up, we then ask in our book: is there a historical record of such influences “corrupting” the behavior of the institution? And now this is what is great about the institutional corruption framework, when it comes to this particular topic of psychiatry. We tried to answer that question by applying an ethical standard that all of society can embrace. The inquiry does not need to focus on whether psychiatric disorders are “real,” or on the risks and benefits of psychiatric drugs, which are topics that can produce such an immediate division in readers. Instead, the inquiry focuses on whether the institution has fulfilled its duty to the public.
So we need to ask: what does the public expect—ethically speaking—of a medical specialty? The public expects that it will put the interests of patients first, and that this moral obligation will guide the institution in its conduct of research, its reporting of research results, its development of clinical practice guidelines, and its pronouncements to the public. This is a well-understood expectation, and corruption is revealed when the institution, as it performs such tasks, privileges the interests of pharmaceutical companies, or its own guild interests, over its duty to the public.
Many of the specific examples of corruption detailed in Psychiatry Under the Influence will be familiar to readers. I have written about a number of them in Anatomy of an Epidemic and other writings; Lisa has written about some of this corruption in her journal articles; and numerous critics of psychiatry have written about some of them as well. Still, presenting this behavior in a historical way, as stretching across three decades and present in every domain of psychiatry’s activities, is rather breathtaking. And it also becomes quite clear that this behavior, within the institution, became the norm.
As I noted in the beginning of this post, co-writing this book led me to “see” this subject of psychiatry and its influence on our society in a new way. It puts the focus on society as the injured party, and it is easy to see that the social injury arising from this corruption is vast and profound.
The institution of psychiatry, with its disease model, has dramatically changed our society over the past 35 years. It has given us a new philosophy of being, and altered how we view children and teenagers, and their struggles. It has touched every corner of our society, and this societal change has arisen because of a story told to the public that has been shaped by guild and pharmaceutical influences, as opposed to a record of good science. That is the nature of the harm done: our society has organized itself around a “corrupt” narrative.
Prescriptions for Reform
Now, what can be done about this? The first thought is that once this corruption is revealed, then perhaps the institution can reform itself. After all, institutional corruption is conceived as a problem of “good people” doing “bad things” because of the corrupted environment. Good people within the institution might be expected to lead the reform. However, cognitive dissonance theory predicts that it is difficult for people within the institution to see their own actions in this light. Our favorite quote to sum up this perception problem comes from Sinclair Lewis: “It is difficult to get a man to understand something if his salary depends upon his not understanding it.”
Given that internal reform isn’t likely, the responsibility lies with society to develop a solution. In many cases of institutional corruption, the solution may be regulatory reform that legally constrains the behavior of the institution. In this case of psychiatry, it is evident that society must find ways to neutralize the two corrupting economies of influence: the pharmaceutical influence and psychiatry’s own guild interests.
There are many strategies being proposed for neutralizing the pharmaceutical influence, which, as noted above, has waned in recent years. However, there has been little public discourse on how to neutralize the guild interest. While we offer a proposal in our book—we believe that the only possible solution is that psychiatry’s authority over this domain of our lives must be diminished, and that such societal authority must come from a broader, more diverse group of professionals and thinkers—the truth is that solving this problem requires a societal discussion about this corruption, and what we, as a society, can do about it.
As I think about this, I am personally inspired by Lessig’s own activism. He wrote about the corruption of Congress by PACs, and subsequently launched “Mayday, U.S.” a crowd-funded, non-partisan Super PAC that provides funding for political candidates who promise to enact campaign-finance reform designed to eliminate the influence of lobbyist-driven PACs. His may be a Quixotic battle, but it is a fight, in essence, to save our democracy and create a Congress that is beholden to the people, as opposed to one that is beholden to special interests.
And with that example of activism in mind, I am now thinking of whether MIA could host a public discussion on “solutions,” and also mount a public campaign to publicize this issue. The institutional corruption framework, which puts the focus on whether psychiatry has met its ethical obligations to the public, even provides the possibility of creating a non-partisan campaign. All of the public wants a medical specialty to fulfill that obligation.
More on these possibilities shortly.