“Psychiatry’s Myopia:” How Psychiatry Contributes to Worsening Mental Health Outcomes

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In a viewpoint article in JAMA Psychiatry, researchers lay the blame for worsening mental health outcomes at the feet of clinical psychiatry.

They note that outcomes for people with “severe mental illness” have worsened over the last 50 years and that people with schizophrenia continue to die up to 25 years younger than do their peers. They acknowledge multiple reasons for this increasing disparity. However, their article focuses on what they call the “myopia” of clinical psychiatry:

“We suggest that clinical psychiatry’s taken-for-granted, everyday beliefs, and practices about psychiatric disease and treatment have narrowed clinical vision, leaving clinicians unable to apprehend fundamental aspects of patients’ experiences.”

The article was written by Joel T. Braslow and Jeremy Levenson at UCLA and John S. Brekke at USC.

The authors begin by noting that throughout psychiatry’s history, researchers—and the public they serve—have urged the field to consider more than just the purported (and as yet unproven) biomedical basis for “mental illness.” For instance, they cite a 1998 article that elucidated psychiatry’s difference from other medical specialties: “Unlike cardiologists, psychiatrists are unable to go directly from the molecular structure of a bodily organ to the functional results of that organ’s action.”

Psychiatry’s overwhelming focus on trying to understand the biological underpinnings of “mental illness” (its “myopia,” in the words of the authors) has distracted from the well-known, well-researched, and obvious causes of “severe mental illness.” For instance, while genetic testing has as yet shown no clinical utility for classifying or predicting “mental illness,” life experiences like trauma, abuse, deprivation, poverty, and pain are much better predictors of whether one will receive a psychiatric diagnosis.

The researchers write, “By mistaking the parts for the whole, clinical psychiatry has aided and abetted the social alienation; social, medical, and psychiatric abandonment; and neglect inflicted on those with SMI over the last half-century.”

Quixotically, the authors then suggest that psychiatry is very much on the right track: “Nothing inherent in the biomedical paradigm precludes such a broad understanding,” they write—although the very word “biomedical” (“relating to both biology and medicine”) excludes the social and societal levels of understanding. They may have meant to state that the “public health paradigm” may be consistent with social and societal changes.

Braslow, Brekke, and Levenson have no concrete answers to this paradox, but they do propose an ideal to strive for:

“An empirically based, integrative approach will give clinicians the scientific justification and ethical imperative to insist that homelessness and incarceration are unacceptable either as locales for alleged treatment or outcomes for those with SMI.”

It is unclear what that “empirically based, integrative approach” is; the authors do not specify. They add:

“An expanded clinical gaze will remind us that responsible treatment requires more than prescribing a single modality, such as a psychotropic drug, but instead addressing multiple levels of interacting factors, including families, living situations, social networks, and what makes patients’ lives meaningful.”

It is also unclear exactly how psychiatrists can address homelessness, poverty, family life, and social networks. Braslow, Brekke, and Levenson provide no concrete directions for this. But as an aspirational statement of values, this can be considered a paradigm shift for the field.

 

 

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Braslow, J. T., Brekke, J. S., & Levenson, J. (2020). Psychiatry’s myopia—Reclaiming the social, cultural, and psychological in the psychiatric gaze. JAMA Psychiatry. Published Online: September 9, 2020. DOI: 10.1001/jamapsychiatry.2020.2722 (Link)

14 COMMENTS

      • The neuroleptics “are very handy in shutting up these ‘problem people’ without bothering to find out what is going on with them.”

        Yes, that’s what psychiatry is for, covering up easily recognized malpractice. And psychiatry’s primary societal function is covering up child abuse, according to the medical evidence.

    • We should be looking at the power and wealth disparities between different people in the country. Improvements would be seen in lessening these disparities I’m sure.

      It is easy for those “in power” to make snap judgments about those deprived of such power. Children are innocent, and by innocent I mean that they are even innocent of the illusion of “meritocracy”, and that they are therefor relatively innocent of the myriad deceptions that help maintain imbalanced and unfair social relationships.

  1. This is such important work … and beautifully reported by Peter Simons. Thank you, Peter.

    What a shame that even in the context of doing such important work, the authors (according to Peter) wrote that outcomes for people with “severe mental illness” have worsened over the last 50 years and that people with schizophrenia continue to die up to 25 years younger than do their peers.

    So they are trying to make some important steps forward, yet even they erroneously use the terms “severe mental illness” and “schizophrenia” as though they were clearly defined, scientifically supported, and innocuous constructs. They most definitely are not! I continue to marvel at how so many otherwise progressive thinkers in this field either actively use such terms in ways that reify them, present them as though they were valid and as though they were not damaging terms that have destroyed people’s lives. Why do people think that is the case?

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  3. “yet even they erroneously use the terms ‘severe mental illness’ and ‘schizophrenia’ as though they were clearly defined, scientifically supported, and innocuous constructs. They most definitely are not!”

    Thank you for the truth telling, Paula. And it’s a shame so many psychiatrists don’t know their antipsychotics / neuroleptics can create “psychosis,” and other positive symptoms of “schizophrenia,” via anticholinergic toxidrome. Not to mention, they can also create the negative symptoms of “schizophrenia,” via neuroleptic induced deficit syndrome.

    And, of course, Whitaker pointed out that the ADHD drugs and antidepressants can create the “bipolar” symptoms.

    Meaning the two most ‘severe mental illnesses’ are illnesses created with the psychiatric drugs. The ‘severe mental illnesses’ are iatrogenic illnesses, not “genetic” illnesses.

    But these medical truths do also help to explain “How Psychiatry Contributes to Worsening Mental Health Outcomes.”

    • Hello, Someone Else,
      I have greatly appreciated your comments on essays I have written here and on other people’s essays. I don’t know who you are, but I wanted to invite you to contact me (anonymously if you wish) via my Authors Guild website, which is paulajcaplan.net I will no longer be writing essays for MadInAmerica but will from time to time be posting my essays on my own website (there is a Blog section) and have been invited to post them elsewhere. I would love to continue to learn from you.
      Paula

        • Hello, Evanhaar,
          I was supposed to write a series of articles for MadInAmerica but will not now be doing that. I appreciate your interest in my essays. The closest I got to a series was the two-part essay about suicidal thoughts and behavior being pathologized and what to do instead, so both of those were published on MIA. If you are asking if one can sign up for my blog on my Authors Guild website at paulajcaplan.net, I actually don’t know the answer to that. It is so recently that the matter of publishing primarily on my own website (and I am exploring the possibility of publishing on a couple of other sites whose editors have kindly invited me) that I will need to check with the Authors Guild to see if there is a way for people to sign up to be notified when I post a new essay. Again, it is kind of you to care about this work. If you want to send me an email through my website, I will have your email address and can let you know what I find out.

          • Paula,

            I have enjoyed your articles. Keep up the good fight in whatever ways you can.

            I will send you my email address. I tried to donate a very modest amount to your Execution by Numbers doc, but it required $5, and I was only willing to do under that. Please keep me updated if you can.

            In line with your doc, I recently read Limits to Pain: The Role of Punishment in Penal Policy by Nils Christie. It is an oldie, but a goodie, if you haven’t read it:

            https://www.amazon.com/Limits-Pain-Punishment-Penal-Policy/dp/1556355971

  4. It’s no surprise that psychiatric diagnosticians haven’t made any progress with severe “mental” illnesses. Their “diagnostic” categories are invariably inhabitants of the diagnostic wastebasket, where syndromes are real, but their “diagnoses” aren’t.

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