On February 27, 2015, European Psychiatry published a paper titled EPA guidance on how to improve the image of psychiatry and of the psychiatrist. The paper was authored by D. Bhugra et al. EPA is the European Psychiatric Association. Dr. Bhugra is a psychiatrist who works at the Institute of Psychiatry, Psychology, and Neuroscience, King’s College, London, and is also President of the World Psychiatric Association. There are thirteen co-authors, most of whom are also psychiatrists.
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The paper opens with the statement:
“Psychiatry, psychiatric patients and psychiatrists have always been stigmatised against. Reasons for the stigmatisation are many. Fear, prejudices and discrimination are a result of the lack of knowledge.”
This is the abiding theme of the article: people don’t like us because they don’t know us. If people knew what we are really like, our image would improve. Here are some quotes:
“The image of psychiatry and psychiatrists may be affected by aspects not strictly related to stigma: the past of psychiatry includes dark centuries in which asylums and prepharmacological interventions (physical restraints, coercion, etc.) have been adopted and may still influence the image of the discipline and psychiatrists.”
Translation: People don’t like us because we used to be scoundrels – that was in the bad old days. We’re not like that any more. Back then psychiatrists used physical restraints and coercion.
I thought they still use physical restraints and coercion.
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“In the majority of worldwide healthcare system, mental health care is separated from physical health care, and inevitably very few medical colleagues understand the role of psychiatry, particularly so if liaison psychiatry departments are weak or non-existent, and if they have not had adequate exposure to psychiatry during their undergraduate or post-graduate training. The fact that physicians did not work routinely in contact with psychiatrists and that the only way of being in contact with psychiatry is during liaison activities or in emergency settings could contribute to the negative image of psychiatry.” [Emphasis added]
Translation: Other physicians don’t like us because, due to lack of contact, they don’t understand our role. If they understood our role, they would like us more.
This strikes me as extremely condescending towards other physicians. They don’t understand the role of psychiatry!
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Under the heading “General Public”:
“Psychotropic medication and ECT are seen as more negative interventions in comparison with psychotherapies and counselling. The lack of knowledge may be responsible for negative attitudes.”
Translation: The poor ignorant man (or woman) in the street simply doesn’t realize how helpful psychotropic drugs and high voltage electric shocks to the brain really are.
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“The media and its portrayal of mental illness and how it is treated play a major role in affecting attitudes towards mental illness. The way in which stories related to mental health are covered and the emphasis placed on making fun of patients with mental illness does lead to negative attitudes. Negative images often get translated into generalised negative attitudes.”
Translation: People don’t like us because the media make fun of psychiatry’s clients when they write their stories! And because of this, people don’t like us.
I can’t recall ever reading a story where a journalist made fun of psychiatric clients.
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“Filmmakers’ attitudes reporting large negative portrayal of psychiatry play a major role in informing and forming negative attitudes.”
Translation: People don’t like us because movies portray us in a bad light.
Here again, this has not been my experience. Most of the movies I’ve seen which feature psychiatrists portray them as concerned, empathetic listeners, working diligently to help clients disentangle or resolve some life crisis: a portrayal, incidentally, which is in marked contrast to the reality of the 15-minute, drug-pushing med-check.
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And then there’s this truly extraordinary quote:
“The negative portrayals of psychiatry pandering to stereotypes of the specialty even in novels written by psychiatrists continue to perpetuate the myth of psychiatry as ineffective and psychiatrists themselves as suffering from psychiatric disorders, not taking reality into account.”
It’s a complicated sentence, but let’s see if we can disentangle it:
– psychiatry is negatively portrayed in novels;
– even novels written by psychiatrists;
– these portrayals contribute to the myth of psychiatry as ineffective;
– and to the myth that psychiatrists themselves might have “psychiatric disorders”.
So, here we have a team of European psychiatrists producing a guidance document on how to counter the stigma and negative attitudes that are often directed towards psychiatry and its clients. And one of the specific points that they make is that portraying psychiatrists as having psychiatric problems is, in itself, a stigmatizing myth! In other words, the drafters of the guidance document on overcoming stigma are themselves stigmatizing their own clients! Psychiatrists tell us that psychiatric disorders are illnesses, “just like diabetes”; that they can afflict anybody; that at any given time about a fifth of the population “has” one of these disorders; and that the life-time prevalence is around 50%. Why should it be stigmatizing for novelists to portray psychiatrists as any less vulnerable to these “disabling illnesses” as anybody else? There are approximately 46,000 psychiatrists in the US. According to psychiatry’s own numbers, about 9,200 of these individuals should have a mental illness at any given time, and about 23,000 should have a mental illness at some time in their lives. In depicting this “reality”, if indeed they do, aren’t novelists merely reflecting psychiatry’s own assertions? Why is it stigmatizing to portray psychiatrists as having these illnesses? Unless, of course, Dr. Bhugra and the EPA don’t really believe their own rhetoric.
The Guidance Committee’s Suggestions
Dr. Bhugra et al offer fourteen suggestions for improving psychiatry’s image. Most are vague or platitudinous. Here are the main points:
- “Psychiatrists as professionals must take the lead in taking pride in clinical practice, looking after the most challenging and underserved patients.”
I have long believed that in their hearts, all, or almost all, psychiatrists know that their concepts are spurious, and that their “treatments” are destructive and disempowering. Dr. Bhugra et al’s admonition to their colleagues to “take pride in clinical practice” strikes me as self-deception. I can’t imagine a leading surgeon or cardiologist or nephrologist broadcasting such advice to their colleagues. Real doctors already take pride in their work. They have no need for cheerleading or pep talks.
- “Evidence based research should be circulated widely.”
Indeed it should: Particularly the negative results that pharma-psychiatry routinely suppressed for decades.
- “… networks of policy development, clinical intervention and research must be established”
I’m not sure what this means. Expand the empire?
- “… physical and mental health services integration…”
This has been a common theme here in the US for years – a mental health worker in every GP’s office. The eminent psychiatrist Jeffrey Lieberman, past president of the APA, pushed this notion relentlessly. And, of course, it’s also being pushed in Europe. So a person gets sick, goes to see his GP. He is despondent because he’s sick. Consequently his depression “screening” is positive, and he comes out with a prescription for an SSRI and a handful of free samples. Tried and true marketing.
- “… exposure to enthusiastic and charismatic teachers in undergraduate settings should be encouraged…”
Enthusiastic and charismatic! I’m picturing scenarios in which psychiatry lecturers are refused tenure because they are too dull, or that they lack sparkle. Lecturers should, of course, be able to engage their students, but charisma strikes me as a consideration more pertinent to high school pep rallies than university lectures.
- “clinical exposure to right patients and the right number of patients must be delivered.”
I can’t even begin to imagine what Dr. Bhugra and his colleagues mean by the “right patients”. But whoever these “right” individuals are, trainee psychiatrists need to be exposed to them – clinically.
- “Especially tailored placements [for psychiatry students] should be made available across different national and international settings”
So that they can learn what established psychiatrists do in faraway places. My guess is that it’s assigning “diagnoses” and pushing drugs.
- “Engagement in short research projects [for psychiatry students]”
So that they can learn how to manipulate the results to show psychiatry in a good light.
- “Regular audit of clinical services will enable clinicians to understand what changes are needed and how to deliver services. Audits about patient satisfaction and complaints will encourage staff to provide better services”
These kinds of quality assurance audits have been an integral part of general medicine for decades. But for audits to have any value, they must be accompanied by a generous measure of critical self-appraisal: a willingness to subject one’s own performance and concepts to critical scrutiny. This is not a quality for which psychiatry is noted. Indeed, within psychiatric circles, negative outcomes are routinely blamed on the client, and complaints or protests from clients are routinely adduced as evidence of pathology. The kind of audits I’ve come across in psychiatry are mostly empty paper exercises.
- “Regular courses, information leaflets and newer methods such as phone apps and web-based learning may provide relevant information so that patients, families and their carers can work to identify early signs, signs of relapse and management”
And undoubtedly, pharma will continue to provide the funding for these “learning” opportunities. And note the inclusions of “early signs”. Bring us your troubled children and we will diagnose them and give them drugs.
- “Working with patient organisations is an important aspect in spreading education as well as engaging policy makers.”
For instance, educating people that depression is caused by a chemical imbalance in the brain, for which it is necessary to take antidepressants for the rest of one’s life.
- “Collaboration across different sectors–voluntary and statutory, primary care and secondary care and social and health care…”
Let’s get psychiatry’s tentacles into the voluntary organizations, the GP’s offices, the general hospitals, and social services.
- “Training the media on reporting and working with them to convey positive messages will help improve the public image.”
So psychiatrists are going to train journalists on how to report, and get them to say nice things about psychiatry. More patronizing grandiosity. I don’t think journalists are that gullible.
- “Sharing information with policy makers about accurate outcomes and therapeutic interventions…”
Like telling politicians that neuroleptic drugs cause tardive dyskinesia and akathisia? Or that there is no scientific basis to any of the psychiatric diagnoses, except those “due to a general medical condition”? Or that research results show that people with a diagnosis of schizophrenia, who come off neuroleptics, have a better long-term outcome than those who stay on the drugs? Or that neuroleptic drugs are being used for behavior control in foster care, in nursing homes, and in group homes for people with disabilities? Or that long-term use of lithium can lead to permanent kidney failure? Yes! That’s a great idea! But somehow I don’t think that’s what the guidance committee had in mind by “accurate outcomes”.
Summary and Discussion
As is often the case in discussing psychiatry papers, it’s difficult to know where to start. Perhaps the most obvious feature of the EPA document is the complete and total failure to recognize that the negative appraisals of psychiatry, that are finding voice in the past decade or two, are entirely valid and deserved. Psychiatry is being perceived negatively, because, as a profession, it is intellectually and morally bankrupt. Its failings are huge, and its lack of integrity glaring, yet there is no hint of this in the EPA paper. Instead, the authors cling to the self-serving notion that the stigma attached to psychiatry derives from ignorance of its true nature, and from unwarranted negative media portrayals.
So in the interests of setting the record straight, let me state as clearly and unambiguously as I can why psychiatry is being increasingly criticized and marginalized.
- Psychiatry’s definition of a mental disorder/ illness, as set out in DSM III, IV, and 5, embraces virtually every significant problem of thinking, feeling, and/or behaving. Psychiatry uses this definition to fraudulently medicalize problems that are not medical in nature.
- Psychiatry routinely presents these so-called illnesses as the causes of the specific problems, when in fact they are merely labels: abbreviated rewordings of the presenting problems with no explanatory function or value. These labels, which cause enormous damage to the individuals to whom they are assigned, serve only to legitimize the pushing of drugs, and to enable psychiatrists to bill for the services they provide. Unlike real diagnoses, they provide no insight into the nature or essence of the presenting problems, but are nevertheless defended tenaciously by psychiatrists and their pharma funders.
- Psychiatry has routinely deceived, and continues to deceive, their clients, the public, the media, and government agencies, that these vaguely defined problems are in fact illnesses with known neural pathology. The classic example of this is the chemical imbalance theory of depression – a blatant hoax which was pushed so heavily by psychiatry that it has now become “common knowledge”. And the most noteworthy aspect of this is that although the hoax has been exposed repeatedly – (most recently by Terry Lynch in his book Depression Delusion), psychiatry has taken no concerted steps to correct this misinformation, and indeed in many quarters is still promoting this fiction as established medical fact.
- Psychiatry has blatantly promoted drugs as corrective measures for these illnesses, when in fact it is well-known in pharmacological and psychiatric circles that no psychiatric drug corrects any neural pathology. In fact, the opposite is the case. All psychiatric drugs exert their effect by distorting or suppressing normal brain functioning. It is also well known that the adverse effects of these products are often devastating and permanent.
- Psychiatry has collaborated and conspired with pharma in the development of a vast body of fraudulent research, all designed to “demonstrate” that psycho-pharmaceutical products are safe and effective. The methods by which this fraud has been perpetrated include: the routine suppression of negative results; the use of ridiculously short follow-up intervals; over-stating of marginal results; etc., etc.
- A great many psychiatrists have shamelessly accepted large sums of pharma money for very questionable activities. These activities include the widespread presentation of infomercials in the guise of CEUs; the ghost-writing of books and papers which were actually written by pharma employees; targeting of captive and vulnerable audiences in nursing homes, group homes, and foster-care systems for prescription of psychiatric drugs; etc., etc… Two glaring examples of this kind of venality are:
- The promise made by psychiatrist Joseph Biederman to Johnson & Johnson that his research would produce a positive finding for their drug Risperdal, provided they ponied up $700,000 for a center on pediatric bipolar disorder at Harvard’s Massachusetts General Hospital.
- The promise, also to Johnson and Johnson, by psychiatrist Allen Frances and two colleagues (psychiatrists John Docherty and David Kahn) that they would produce a document on schizophrenia treatment guidelines that would help Janssen (Johnson & Johnson subsidiary) succeed in its effort to “increase its market share and visibility” for their drug Risperdal “in the payor, provider, and consumer communities.” (Rothman Report, p 15-16)
In addition, 70% of the DSM-5 task force members had received funding from the pharmaceutical industry.
7. Psychiatry’s labels are inherently disempowering. To tell a person, who in fact has no biological pathology, that he has an incurable illness, for which he must take psychiatric drugs for life, is an intrinsically disempowering act which robs people of hope, and encourages them to settle for a life of drug-induced dependency and mediocrity.
8. Psychiatry’s “treatments”, whatever transient feelings of well-being they may induce, are always destructive and damaging in the long-term. Neuroleptic drugs cause tardive dyskinesia. Extended use of antidepressants produces a state of chronic joylessness. Benzodiazepines are addictive. High-voltage electric shocks to the brain erase memories. Psychiatry’s notion that one can solve people’s problems by tinkering irresponsibly with their brains, betrays a degree of arrogant naivety unequalled in other professional groups.
9. Psychiatry’s spurious and self-serving medicalization of every significant problem of thinking, feeling, and/or behaving, effectively undermines human resilience, and fosters a culture of powerlessness, uncertainty, and dependence. Powerful, time-honored concepts such as the need for critical self-appraisal, and personal improvement through effort, have been systematically marginalized by psychiatry’s expanding list of “illnesses”, and ever-flowing supply of drugs. Relabeling as illnesses, problems which previous generations accepted as matters to be addressed and worked on, and harnessing billions of pharma dollars to promote this false message, is morally and professionally repugnant.
10. Psychiatry’s primary agenda over the past four or five decades has been the expansion of its list of “illnesses”, and the assignment of these illnesses to more and more people. It has now become routine practice to prescribe neuroleptic drugs to elderly nursing home residents who become “unmanageable” and to young children for temper tantrums!
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Some Remedial Suggestions for Psychiatry
Here are my suggestions for any psychiatrist who is genuinely concerned about the stigmatization of his/her profession:
- Repudiate the spurious medicalization of non-medical problems;
- Acknowledge the destructive and disempowering nature of the “treatments”;
- Apologize to all concerned;
- Find honest work.
No amount of mental gymnastics or PR can address psychiatry’s fundamental flaws.