Rebranding Psychiatry

Or, how to make a silk purse from a sow’s ear.

INTRODUCTION

In November of 2017, the British Journal of Psychiatry published a guest editorial titled “Shrink rethink: rebranding psychiatry.” The authors are Scottish psychiatrists Jim Crabb, MD and Neil Masson, MD, and Lee Barber, an advertising and marketing strategist. Both Drs. Crabb and Masson practice general adult psychiatry and also lecture in psychiatry at the University of Glasgow. They are both members of the Scottish Teaching and Recruitment Group (STARG), which “looks at ways of improving recruitment into psychiatry.”

Lee Barber works for Valenstein & Fatt of London, and “has developed award-winning campaigns for brands such as Coca-Cola, Peugeot, Nintendo, and Virgin Media.”

The British Journal of Psychiatry is published monthly by the Royal College of Psychiatrists.

Here’s the editorial’s summary:

“Negative public attitudes towards psychiatry hinder individuals coming for treatment and prevent us from attracting and retaining the very brightest and best doctors. As psychiatrists we are skilled in using science to change the thoughts and behaviours of individuals, however, we lack the skills to engage entire populations. Expertise in this field is the preserve of branding, advertising and marketing professionals. Techniques from these fields can be used to rebrand psychiatry at a variety of levels from national recruitment drives to individual clinical interactions between psychiatrists and their patients.”

The summary conveys the gist of the article — that better marketing will bring more recruits into psychiatry, and bring more clients in for “treatment.”

But note the unabashed hubris: “…we are skilled in using science to change the thoughts and behaviours of individuals…” Also note the exhortation in the final sentence for psychiatrists to use marketing techniques in their clinical interactions with “patients” to promote psychiatry. Isn’t there some conflict here? Shouldn’t the clinical session be focused on the client’s needs? Surreptitiously injecting pro-psychiatry commercials into these sessions (for which, incidentally, the client or his/her insurance is paying) strikes me as ethically very questionable.

LOW RECRUITMENT

The authors open by lamenting the fact that “rates of recruitment into psychiatry have been critically low in recent years…” and promptly identify the root of the problem: poor marketing. They also identify the solution: learn from the experts.

“Almost every choice we make throughout the day, right down to the brand of laptop the reader might be viewing this article on, as well as the coffee they are sipping has been overtly or covertly influenced by professionals working in these fields. If we have not recognised this influence, then it merely serves to highlight the skill and effectiveness of those involved. Furthermore, as psychiatrists we take great pride in changing the thought patterns and behaviours of the patients we serve on an individual basis. Why would we not wish to learn and adopt techniques from fields that have expertise at doing this on a population level?”

Clearly the closing question in this quote is rhetorical, but if I might offer an answer, it would be: because marketing of the kind being envisioned here is essentially dishonest and exploitative. “Things go better with Coca-Cola” may be a great marketing jingle when gauged by the number of cans of flavored sugar-water sold, but it is not true.  People who consume even relatively modest quantities of soda pop daily are more likely to develop type II diabetes, heart disease, and gout than people who consume soda pop rarely or never.

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“Some of the world’s biggest companies from Coca-Cola to Apple have for decades been using a range of techniques to help them build brands that are loved and cherished by consumers. We need to apply the very same thinking to the challenges we face.”

The essence of modern marketing is to create anxiety in the “targets.” The anxiety is delivered in carefully sculpted messages, like: your kitchen is old and drab; your car lacks style; your hair is too grey; your skin is too dry; etc., etc. The marketer then delivers the great lie: buy our product and, not only will your problems go away, you’ll get a stylish car, a great lifestyle, and an enchanting partner to boot. Of course it’s not true, and a great many people in our culture spend their entire lives on this purchasing treadmill, futilely chasing the promises implied in the glossy ads.

If there is any ethical role for a helping profession in this area, it is, I suggest, to offer training to people of all ages in how to resist this kind of tawdry huckstering, not to use it to promote their own agenda. But psychiatry has never been big on ethics.

“BUILDING A BRAND ARCHITECTURE”

“Developing a coherent brand that potential recruits can identify with might appear challenging. There are positive associations about psychiatry, however, even these can seem wildly disparate and contradictory, how can reassuringly scientific activities such as reading brain scans and intriguingly creative pursuits such as interpreting dreams possibly fall within the same specialty? However, we would argue that we should embrace these differences and incorporate them within our brand. We need to be clear that we are interested in the small number of doctors who can embrace the fields of science and the arts and also be confident enough to handle uncertainty and ambiguity. This of course does not appeal to the medical masses, however, it can also be a selling point. Niche brands such as Marmite have famously maximized their market share through making a virtue out of proudly advertising that they are not for everyone.”

There are several noteworthy points here, but the most critical is the clearly implied notion that there is nothing actually wrong with psychiatry; it just needs to be sold better. In reality, there is a great deal wrong with psychiatry.

1. Psychiatry’s definition of a mental disorder/mental illness embraces virtually every significant problem of thinking, feeling, and/or behaving, and psychiatry has been fraudulently using this definition to medicalize problems that are not medical in nature for more than a century, and particularly for the past four or five decades.

2.  Psychiatry routinely and deceptively presents these labels as the causes of the specific problems, when in fact they are merely labels with no explanatory significance.

3.  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, when in fact they are nothing of the kind.

4.  Psychiatry has blatantly promoted drugs as corrective measures for these so-called 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 functioning.

5.  Psychiatry has actively and profitably conspired with the pharmaceutical industry in the creation of a vast body of fraudulent research, all designed to “prove” the efficacy and safety of pharma products.

6.  A great many psychiatrists have shamelessly accepted 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; the acceptance of payment from pharma to act as so-called thought leaders in the promotion of new drugs and diagnoses; acceptance of fraudulent advertising in peer-reviewed journals; targeting of captive and vulnerable audiences in nursing homes, group homes, and foster-care systems for prescription of psychiatric drugs; etc., etc…

7.  Psychiatry’s spurious diagnoses 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 falsely 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 or docility they may induce, are always destructive and damaging in the long-term, and are frequently administered involuntarily.

9.  Psychiatry has failed to initiate a definitive study to explore the link between psychiatric drugs and the murder/suicides, despite a growing volume of prima facie evidence that such a link exists.

10.  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. 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 repugnant.

11.  Psychiatry neither recognizes nor accepts any limits on its expansionist agenda. In recent years, they have even stooped to giving neuroleptic drugs to young children.

But in what I would describe as fairly typical psychiatric fashion, the authors ignore these very real problems, and dive headlong into the business of building a better brand.

And note the arrogance: “This of course does not appeal to the medical masses…,” by which presumably the authors mean nephrologists, cardiologists, oncologists, gastroenterologists, primary care doctors, pulmonologists, etc., all of whom treat real diseases, none of whom seem to have any problem attracting recruits or customers, and none of whom have their very own anti movement.

“BRINGING OUR BRAND TO LIFE”

“How we conduct ourselves in communicating our brand is a critically important starting point. We know that psychiatrists are victims of stigma, and having internalized this we may be part of the problem. Nothing sells like confidence. We need to inject confidence about what psychiatry is and does in everything we do.

We also know that we do not need to appeal to each and every medical undergraduate. We only need to increase our recruitment from 4 to 8% of medical graduates for all training places in the UK to be filled.”

Note the self-exculpating assertion that psychiatrists “are victims of stigma.”  In reality, psychiatrists are the great stigmatizers of our time.  They routinely tell their clients that they have broken brains, and broadcast this stigmatizing message to the general public at every opportunity. If, as a group, they lack confidence, they keep this well hidden. Arrogance, I suggest, is far more characteristic of this profession than diffidence or timidity.

But the authors, heads buried firmly in sand, have identified a lack of confidence as part of the problem, and offer the following suggestions for remediation.

“…build a strategy around being selective.”
“…be proudly elitist.”
develop “an air of exclusivity…”
“…advertise the fact that we need the brightest and best doctors to enter psychiatry.”

In support of this approach, the authors assert:

“Telling people they cannot have something makes them want it more.”

So telling medical students that they can’t get into psychiatry will dispel their very real misgivings concerning this profession, and have them hammering at the gates. This seems very condescending. I wonder how medical students feel about the notion that they are such gullible marks.

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And it gets worse!

“The challenges involved in the job are vast (you know this), and a large number of doctors simply do not possess the mental agility to jump from biological to psychological to social paradigms within a single consultation. We should be telling students that we need the most special of them to come into our profession so that we can help develop them into a rare and exciting breed of doctor.”

The reality is that psychiatrists exercise a very limited range of highly dubious skills.  These are:  comparing the customer’s self-reports with arbitrary and hopelessly vague checklists to come up with something that can be passed off as a diagnosis; lying to the customers that they have chemical imbalances; pushing drugs to correct these non-existent imbalances; and delivering high-voltage electric shocks to the brain.

The assertion that large numbers of doctors lack the mental agility to become psychiatrists betrays, once again, an extraordinary level of arrogance, condescension and even narcissism.

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“We should celebrate the phenomenal progress that has been made to date in understanding the mind, however, at the same time we should be clear that the frustrating limits of our knowledge is another thing that makes psychiatry uniquely attractive, that we are a discipline for pioneers and explorers.”

Psychiatry, I suggest, has done absolutely nothing to further our understanding of human thinking and emotion. Dogmatic assertions and labels do not constitute understanding, particularly when the assertions are spurious, and the labels have no ontological validity.

The “frustrating limits” of psychiatric knowledge is an oblique reference to the fact that despite fifty years of lavishly-funded research, psychiatry has failed to produce a valid biological pathology basis for even a single one of their so-called diagnoses.  But in the best tradition of deceptive marketing, they attempt to convert this obvious liability into an asset, by describing themselves as pioneers and explorers.

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At this point the authors lose contact with terra firma — literally:

“Dare we communicate that neurology might be considered like understanding the electrical wiring to a light bulb in your house, whereas psychiatry in comparison is like building and flying a rocket to rescue a soul lost in the uncharted reaches of outer space?”

Neurology, which studies the interactions of the brain’s 86 billion neurons, is to be compared to the wiring to a light bulb, which comprises two copper wires!

And the rocket ship analogy? Well. What can I say? Houston, we have a problem?

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“Such a ‘competitive’ approach between disciplines may seem initially unpalatable…”

Yes. Unpalatable, narcissistic, self-aggrandizing, and even bizarre. I don’t think neurologists will be thrilled with the light bulb comparison, and I don’t think many psychiatrists would recognize themselves as rocket engineers or pilots. But the authors defend their approach on the grounds that it

“…allows us to embrace our rich and controversial heritage, and use this as a means of engagement rather than something to be nervously skirted around.”

In this context, the authors mention Ken Kesey’s One Few Over the Cuckoo’s Nest, but in fact, psychiatry’s “rich and controversial heritage” goes back much further than that. Psychiatry’s “rich and controversial heritage” includes lobotomies, insulin comas, rotational chairs, enforced immobility, fever therapy, mesmerism, malaria therapy, gynecological surgery, hydrotherapy, the crib, the tranquilizing chair, chemically and electrically induced seizures, etc., etc.

If the authors are suggesting that potential psychiatry recruits embrace this “controversial heritage,” or are even suggesting that this heritage could be remotely described as “rich,” then I suggest they have entirely lost contact with reality. Psychiatry’s history is one of unmitigated destruction, stigmatization, disempowerment, and frequently, torture. It is indeed not something to be nervously skirted around, but rather something to be condemned in a forthright and unequivocal manner. It also needs to be pointed out that a great many of these torturous “treatments” stemmed directly from the spurious notion that the problems involved were medical in nature, and therefore required medical (i.e., physical) treatments.

WHAT PSYCHIATRISTS CAN DO

The authors tell us that there will be no multi-million pound ad campaign, which, of course, is a considerable mercy.  Rather, the ad campaign, the brand, has to be promoted by every psychiatrist.

“We need every person involved in the profession to live and breathe our brand and bring it to life every day and every time they come in contact with colleagues and students.”

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So what, exactly, should psychiatrists be doing? The authors encourage psychiatrists to engage in the following eight practices:

“(a) Be unashamedly confident and proudly elitist when talking about psychiatry. Psychiatry is not, and should not be, for every doctor. Most doctors cannot handle the challenges, complexities, contradictions and uncertainties of the discipline. As a practicing psychiatrist you can, so walk tall. Carry this into each and every interaction with students and with your medical colleagues from other disciplines.”

In other words: in your interactions with students and real doctors, be a pompous ass.

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“(b) Have a ready explanation prepared for when someone asks what a psychiatrist is, and does. If you are not comfortable with our suggested mantra (see below), develop your own based on the brand architecture model.”

We rescue people who are lost in space! Whether they want to be rescued or not.

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“(c) Celebrate the achievements of psychiatry. Know of three psychiatrists whose work you admire and who have been influential and a force for good on a global scale. Tell others about them. (If you are stuck, shame on you, go Wikipedia Carl Jung, Karl Friston, Kenneth Kendler and Eric Kandel.)”

What about Sir Simon Wessely, MD, proud founder of the Anti Bash campaign; or Jeffrey Lieberman, MD, who forthrightly denounced anti-psychiatry activists as “rabid ideologues.” Or Charles Nemeroff, MD and Alan Schatzberg, MD, whose 1999 textbook Recognition and Treatment of Psychiatric Disorders: A Psychopharmacology Handbook for Primary Care was written by a pharmaceutical industry ghostwriter. Or Joseph Biederman, MD, the great American psychiatrist who invented childhood bipolar disorder. Or the illustrious psychiatrist Ronald Pies, MD, who insists that psychiatry never promoted the chemical imbalance theory of depression. Or Allen Frances, MD, architect of DSM-IV, who with two colleagues wrote to Janssen Pharmaceutica that they were “committed to helping Janssen succeed in its effort to increase its market share and visibility in the payor, provider, and consumer communities.” Or Walter Jackson Freeman, MD, who traveled the US, visiting mental institutions and performing lobotomies. Or the eminent British psychiatrist William Sargant, MD, “…who is remembered for the evangelical zeal with which he promoted treatments such as psychosurgery, deep sleep treatment, electroconvulsive therapy and insulin shock therapy.” (Wikipedia)

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“(d) Think about and prepare answers for questions on our rich and controversial heritage: Bedlam, lobotomies, electroconvulsive therapy, LSD (lysergic acid diethylamide), anti-psychiatry, etc (you will be asked at the next dinner party you go to anyway). Be able to explain that the psychiatrist’s role as a pioneer who searched out new ways to alleviate the suffering of those they serve was not, and still is not, without risk.”

My humble suggestion: Bedlam enabled us to keep the victims of poverty and abuse off the streets while providing inexpensive and much needed entertainment for the hard-pressed working masses. A win-win psychiatric breakthrough.

And note the self-exculpatory theme in the final sentence: pioneers always incur risk. In psychiatry, however, the risk always falls on the hapless “patient,” who, in a great many cases, hasn’t even been informed of the risks.

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“(e) Know of at least three celebrities who have had a positive experience of mental healthcare that you can tell others about (the British Royal Family have recently given you a head start).”

Pronouncements from celebrities, of course, as everyone knows, are always true.

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“(f) Think about and be prepared to tell others about cultural mega trends that link into psychiatry and that illustrate that we are the specialty of the moment, for the moment. Have at least two to hand (dementia, mindfulness, etc.)”

So dementia is a cultural mega trend?  What does this even mean?

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“(g) Survey your local core trainees to identify the most engaging and charismatic teachers in each hospital. Incentivise these teachers to have as much exposure to medical undergraduates as early in the preclinical curriculum as possible.”

“(h) Communicate the key messages about ‘brand psychiatry’ to medical students as early as possible in the undergraduate years. These messages should be emphasised at the start and end of every psychiatry block (to utilise the primacy and recency effect.)”

And the key messages of “brand psychiatry” as presented in the editorial are: We are the elite among physicians; other physicians are not capable of doing what we do; we must embrace the diversity of perspectives within psychiatry; we must embrace our “rich and controversial history.”

SAVING THE BEST FOR LAST

Here’s the finale, and I swear, I’m not making this up:

“Fundamentally, we all are ‘brand psychiatry’ and this should be our mantra:

‘Psychiatrists are doctors who feel with their mind and think with their soul. They are just as comfortable with poetry as pathology. They see the person as whole. Psychiatrists understand the connection between the mind, the body and the soul. They are doctors who want to make a radical and transformational difference to the whole life of their patients. Psychiatrists are people who have the rare ability to treat the person, not the problem. Psychiatrists save lives.'”

To which, all I can say is that this is not the psychiatry that I’ve been seeing for the past fifty years. Here’s my mantra: Psychiatry Kills!

COMMENTARY

The Royal College of Psychiatrists published the Crabb et al paper as an editorial in their flagship publication, the British Journal of Psychiatry. Whilst this does not imply complete endorsement of the contents, it does suggest that the College felt that the material was worthy of sufficient consideration to warrant dissemination in their journal. It is noteworthy that Sir Simon Wessely, MD, past President of the Royal College, “liked” the article on Twitter. It should also be pointed out that Kamaldeep Bhui, MD, present editor of the BJP, in the same issue, described the paper as “a bold editorial on branding psychiatry.” Dr. Bhui continued:

“Apart from presenting a progressive and enriching account of the achievements of psychiatric practice through the expert eyes of a branding company, there are some enticing one-liners with which to impress your friends, family, social and professional networks: psychiatrists wish to think and act differently; and the profession is of the moment for the moment.”

We can only guess, of course, how listeners might react to these “enticing one-liners,” but it would, I suggest, be a kindness if someone close to Dr. Bhui were to take him quietly aside, and point out that statements such as these will not enhance his reputation for cogency, articulateness, insight, or wisdom.

The central themes of the paper are that psychiatry can be sold to potential recruits and customers using the same tawdry methods found in ad campaigns for soft drinks, hair shampoo, video games, and breakfast cereal; and that every psychiatrist needs to embrace this perspective wholeheartedly.

What’s glaringly missing from the paper is the recognition that real medical specialties have no need for such vaunting self-promotion, because: their basic concepts are valid, their methods are salutary, and they routinely maintain a high level of critical self-scrutiny. Psychiatry, by contrast, is fundamentally flawed and rotten — a wrong turning in human history — which no amount of whitewash or fatuous window-dressing can retrieve. Encouraging psychiatrists to become cheerleaders to this pernicious hoax needs to be seen for what it is: a desperate, though futile, attempt on the part of a dying profession to forestall its inevitable fate.

Psychiatry cannot be fixed. It simply needs to go.