On February 22, Allen Frances, MD, published an article titled Psychiatry and Anti-Psychiatry on the HuffPost Blog. The general theme of the article is that psychiatry may have some problems, but it is basically sound, wholesome, and necessary.
Here are some quotes, interspersed with my comments:
“Psychiatry used to be a biopsychosocial profession that allowed time to get to know the person, not just treat the symptom. But drastic cuts in the funding of mental health services have dramatically reduced the quality of the service they can provide. Psychiatrists are now forced to follow very large panels of patients. Most of the limited time they are allowed with each is spent discussing symptoms, adjusting the meds, and determining side effects. Little time is left to forge a healing relationship, provide support, and teach skills through psychotherapy. And patients usually get to a psychiatrist- if at all- as a last resort, only after other things have failed- and with the expectation by the patient and referral source that the main purpose of the visit is just to prescribe medication.”
The impression being conveyed here is that psychiatry’s abandonment of a biopsychosocial approach and embracing of the brief med-check was the result of “drastic cuts in the funding of the mental health services.” This is very misleading, in that psychiatry’s interest in, and enthusiasm for, psychosocial concepts was largely confined to the psychoanalysts, the great majority of whom worked in private practice, and were paid directly by their clients. There was some acceptance of psychoanalytic concepts in the asylums, but for the most part psychiatrists working in those facilities had always shown a marked propensity for biological “cures,” and enormous creativity in the development of these “treatments,” which included: fever therapy; insulin coma; rotational therapy; hydrotherapy; mesmerism; malaria therapy; chemically induced seizures; lobotomy; high voltage electric shocks to the brain; etc.
It is also worth noting that when Thorazine was introduced to American psychiatry in the early 1950’s, the psychoanalysts objected strenuously, but their objections were swept aside by the enthusiasm of their colleagues. By about 1965, the bio-bio-bio approach dominated psychiatry, but it was not forced on psychiatry. Rather, it was embraced avidly, and for two self-centered reasons: firstly, it provided misplaced credibility and prestige for psychiatrists, who could now claim to be real doctors, treating real illnesses with real medications; and secondly, because it enabled psychiatrists to make a great deal more money than was possible providing psychotherapy.
The contention that psychiatrists “are now forced to follow very large panels of patients” is not only false, it is absurd. The notion that tens of thousands of psychiatrists in the US would really like to be practicing psychotherapy, where they could forge “healing relationships,” “provide support,” and “teach skills,” but are frustrated in these desires and “forced” to trudge endlessly the tiresome treadmill of the 15-minute med check is pure fiction. Heartrending, but still fiction. The fact is that psychiatry set its own course when it jumped enthusiastically on the pharma bandwagon, and apart, from a miniscule minority who remained aloof from the drug-pushing, has made no attempt to alight.
. . . . .
“Psychiatrists didn’t invent this system, but they have to live within it (except for those whose patients can pay out of pocket for much more personalized care).”
Actually, psychiatrists did invent this system. They pursued the pharma money shamelessly, embraced and pushed pharma’s products, conducted the fraudulent research, drafted the treatment guidelines, invented “diagnoses” to justify the administration of the drugs, and pocketed the money. If, as Dr. Frances contends, this was all “forced” on psychiatrists, then it has to be acknowledged that the victims of this coercion have put an extremely good face on the matter, and have borne the yoke of their servitude with unstinting courage and valor.
. . . . .
“Another important factor in treatment failure is that most ‘psychiatry’ is not done by psychiatrists. Primary care doctors prescribe 90% of benzodiazepines; 80% of antidepressants; 60% of stimulants; and 50% of antipsychotics. Some are great at it, but most have too little time and too little training and are too subject to sales pitches from drug salesmen. Psychiatrists are clearly responsible for some of the harm done by excess medication, but the bigger problem by far is rushed primary care doctors, prescribing the wrong meds, to patients who often don’t need them. Misleading drug company marketing increases inappropriate prescription by convincing both doctor and patient that there is a pill for every problem.”
The blame-it-on-the-poorly-trained-and-naïve GPs has become a common theme among psychiatry’s elite in recent years. But it is seldom acknowledged that not a single one of these prescriptions could be written if psychiatrists hadn’t invented the “illnesses” for which they are prescribed.
Note also how Dr. Frances deftly moves the blame to “misleading drug company marketing.” And indeed, a great deal of pharmaceutical marketing in this field has been misleading – actually to the point of blatant falsehood. But it is also the case that psychiatrists – including eminent and prestigious psychiatrists, the “thought-leaders” of the profession – have been hand-in-glove with pharma in this process. Remember the conference jamborees where “CEU’s” were awarded to psychiatrists for listening to one of their colleagues present a pharma infomercial? Remember the not-so-distant days when psychiatric associations (including the APA) ran misleading pharma ads in their own journals?
And note the blaming of GP’s for “prescribing the wrong meds to patients who often don’t need them.” This is truly exquisite spin. Psychiatry creates a “diagnostic system” called the DSM, the essential message of which is that every significant problem of thinking, feeling, and/or behaving is a medical illness. The DSM provides simplistic lists of “symptoms” to enable any practitioner who can read to make – and more importantly to justify – any of these hundreds of “diagnoses.” And in addition, the psychiatric researchers (and I use the term loosely) fill reams of journal pages with “research” proving the effectiveness of the spurious drug companies’ products in the “treatment” of these so-called illnesses. But now here comes the very eminent Dr. Frances castigating these GP’s for believing, what has been the central pillar of psychiatric “treatment” for at least 50 years: that there is a pill for every problem, that these pills correct chemical imbalances in the brain, and in many cases, need to be taken for life.
Pharma-psychiatry’s bogus hype has been so successful in fact that a conscientious GP, who failed to prescribe a drug for a significant problem of thinking, feeling, and/or behaving, could conceivably find himself defending a malpractice suit, if his refusal to prescribe was followed by a serious adverse event.
Portraying psychiatry as the helpless innocent spectator in this scenario is not consistent with the facts.
. . . . .
“Psychologists criticize psychiatry for its reliance on a medical model, its terminology, its bio-reductionism, and its excessive use of medication. All of these are legitimate concerns, but psychologists often go equally overboard in the exact opposite direction- espousing an extreme psychosocial reductionism that denies any biological causation or any role for medication, even in the treatment of people with severe mental illness. Psychologists tend to treat milder problems, for which a narrow psychosocial approach makes perfect sense and meds are unnecessary. Their error is to generalize from their experience with the almost well to the needs of the really sick. For people with severe mental illness- eg chronic schizophrenia or bipolar disorder- a broad biopsychosocial model is necessary to understand etiology- and medication is usually necessary as part of treatment. Biological reductionism and psychosocial reductionism are at perpetual war with one another and also with simple common sense.”
Some psychologists do indeed criticize psychiatry for its reliance on an inappropriate medical model and its bio-reductionism. But, at least in my estimation, most psychologists do not. On the contrary, most psychologists, and I say this with a measure of professional embarrassment, have bought the psychiatric agenda lock, stock, and barrel. In some states they are legally authorized to prescribe psychotropic drugs, and they continue to lobby for this in other jurisdictions. The American Psychological Association has even published a list of “practice guidelines” for this activity.
Dr. Frances’s contention that psychologists “go…overboard” with what he calls “psychosocial reductionism” in the same way that psychiatrists do with bio-reductionism has a nice ring of fairness and equability. But it misses the point. There is no argument among psychologists, or any other group, that brain injuries and malfunctions can have an adverse effect on a person’s thinking, feeling, and behaving. Where psychiatry has gone wrong is in making the spurious leap from this obvious reality to the false conclusion that all problems of thinking, feeling, and /or behaving are caused by brain malfunctions.
When those of us on this side of the debate contend, for instance, that depression is caused by depressing events or depressing life circumstances, this is not some kind of distortive reductionism. It is simply the most parsimonious way of looking at the matter. To assume, without evidence, a neurological etiology in all such cases isn’t just blind doctrinaire reductionism, it is frankly inane, particularly in that no biological etiology has ever been discovered, despite psychiatry’s fraudulent claims to the contrary, and despite decades of highly-motivated, and lavishly funded, research.
Dr. Frances then attempts to score cheap points by undermining the credibility of psychologists. They “tend to treat milder problems”; they haven’t worked with the “really sick”; their work is with the “almost well.” The implication being that only psychiatrists can understand the problems of “people with severe mental illness…schizophrenia or bipolar disorder.” In working with the latter individuals, Dr. Frances tells us that “a broad biopsychosocial model is necessary to understand etiology …” The implication here is that psychiatrists understand the biological etiology in those individuals that they label schizophrenic and bipolar. In reality, no such biological etiology has ever been discovered.
. . . . .
“The most important and troubling attacks on psychiatry come from people who feel harmed by it. It has been surprising to me that my many forceful critiques of psychiatry have met so little criticism from psychiatrists, while my much less frequent and muted defenses of psychiatry have drawn such flak from dissatisfied patients. Whenever I twitter or blog anything suggesting that psychiatric treatment is valuable for some people but not others, I receive a flurry of angry responses declaring it is totally harmful for everyone.”
Well, Dr. Frances should not be surprised by this at all. His criticisms of psychiatry have always been of the excessive-drugging-is-bad, or drugging-people-who-don’t-need- it-is-bad. Criticisms of this sort are the injunctive equivalent of tautologies. They are always valid, and for that reason, are empty and void.
For instance, although I know next to nothing about bridge engineering, I can say authoritatively and without the slightest fear of contradiction, that excessive measurement tolerance in the construction of box-girders is a bad thing; or that the use of steel rivets in situations in which they are inappropriate is a bad thing. The point is that words like excessive and inappropriate already contain within themselves the value judgment, and the statements amount to nothing more than pious platitudes. In effect, all that Dr. Frances is saying is that bad things are bad, the appropriate modern response to which is: “Duh!” His psychiatrist readers feel no threat from this kind of “criticism,” precisely because there is none.
. . . . .
“Typically, they [dissatisfied patients] have had a disastrous experience with psychiatric medication that was prescribed in too high a dose and/or for too long and/or in odd combinations and/or for a faulty indication. They are angry for a perfectly understandable reason- meds made them worse & going off meds made them better. Their natural conclusion is that medicine is bad stuff- for everyone.”
These are the kind of injunctive tautologies that I discussed above. Perfect examples, actually.
. . . . .
“The shameful coercion today is the criminalization of mental illness and being forced to live in dungeons.”
This is nice rhetoric, but it’s false. In the US, and I believe in all western democracies, people get sent to jail and prison for committing crimes. Whether or not an accused individual carries a stigmatizing psychiatric label is a secondary matter, and is usually adduced by his defense, and accepted by the bench, as a mitigating factor.
. . . . .
“People with psychiatric problems who used to be coerced in state mental hospitals now suffer the much worse coercion of extended jail time (about 350,000)…”
Dr. Frances apparently considers this number excessive, but if we remember that, according to psychiatry’s own much-touted figures, one-fifth of the population at large have a diagnosable “mental illness” in any given year, it is clear that these individuals are underrepresented in prison and jails. One-fifth of 2.2 million (the number of people incarcerated in the US) is 440,000. This is particularly striking in that several psychiatric “diagnoses” are heavily weighted with blatantly criminal activity (e.g., conduct disorder, antisocial personality disorder, intermittent explosive disorder), which should have the effect of skewing the numbers in the opposite direction.
It is also highly questionable whether the coercion experienced in jails and prisons is “much worse” than that in the state mental hospitals.
. . . . .
“The Psychiatry/Antipsychiatry rift has had a devastating effect on the lives of people with severe psychiatric problems. For them, this is the worst of times and the worst of places – the lack of effective advocacy has many of them shamefully neglected in prison dungeons or living on the street. The wrong battle lines have been drawn. We should all be fighting together so that our most vulnerable citizens will have access to a decent place to live and to humane and comprehensive care.”
Note the beautiful spin: people with “severe psychiatric problems” are experiencing great difficulties because of: the lack of effective advocacy, and the Psychiatry-Antipsychiatry rift. If those of us on this side of the issue would just stop being so obtuse; if we would just be reasonable and accommodating (like, e.g., Dr. Frances); if we would just get on board and stop challenging psychiatry, and pull together; then our “most vulnerable citizens” will have decent homes, and will receive humane and comprehensive care.
Why, oh why, dear readers, are we not convinced by the logical and conciliatory tone of Dr. Frances’s compassionate pleas? Why do we, in the manner of stubborn children, reject the wisdom and assertions of those who know better than we do? Why do we remain so willfully blind to the “patient-centered and humanistic” quality of psychiatry, and to its unstinting devotion to the welfare and care of “our most vulnerable citizens”?
And the answer is clear: because psychiatry is not something good that needs minor corrections. Rather, it is something fundamentally flawed and rotten, based irretrievably on spurious premises, and, in its practices, destructive, disempowering, and stigmatizing. No amount of rhetoric or spin can alter these realities, in the creation of which, Dr. Frances himself has been, and continues to be, a major player.