Editor’s Note: Over the next several months, Mad in America is publishing a serialized version of Peter Gøtzsche’s book, Critical Psychiatry Textbook. In this blog, he discusses how the psychiatry textbooks barely mention the role of psychotherapy and therapists, instead focusing almost entirely on pharmacotherapy. Each Monday, a new section of the book is published, and all chapters are archived here.
There wasn’t much mention in the textbooks of an independent role of psychologists in mental health. Psychotherapy was often listed as an option, but almost always in a context that also involved drugs. It was implicitly understood that even psychotherapy was the responsibility of psychiatrists. When reading the books, I did not doubt that the psychiatrists had won the decades old battle with the psychologists and had absolute power over everything in mental health.
It was almost as if the psychological profession did not exist. When anything was specifically mentioned in relation to psychologists, they were reduced to being servants of the psychiatrists.
This was particularly clear in the textbook about child and adolescent psychiatry.19 All the editors were psychiatrists and they protected their guild. The book started out by saying that children and young people with mental disorders must be referred to a child and adolescent psychiatrist if there is psychopathology and the problem is too complicated for general practitioners or social workers.19:13 There was nothing about which help psychologists can offer and the advice contained a pleonasm: If a person has a mental disorder, there is psychopathology, which is just another name for the same thing.
Psychologists were mentioned only as testers.19:15,19:25 They test the cognitive level and attention and do projective tests like the Rorschach test where the patients are shown a series of irregular, symmetrical inkblots and explain what they see.
It was noted that the first clinical assessment could be made by a general practitioner, in healthcare, at a paediatric ward or in an emergency room.19:14 Psychologists were not mentioned but referrals could also come from school psychologists. And older children and young people could take the initiative themselves, for example by contacting a psychologist.19:14 However, many parents take their children, also young ones, to a psychologist and would never contact a psychiatrist as the first step. In one of my books, I write:8:4
“If you have a mental health issue, don’t see a psychiatrist. It is too dangerous and might turn out to be the biggest error you made in your entire life.”597 The quote is from Peter Breggin, a psychiatrist who avoids using drugs. As noted on the first page in this book, the public knows very well that there is a great risk that they or their children will be harmed if they contact psychiatry.12
In 1992, the UK Royal College of Psychiatrists, in association with the Royal College of General Practitioners, launched a five-year Defeat depression campaign.8:1,494 Its aim was to provide public education about depression and its treatment in order to encourage earlier treatment-seeking and reduce stigma. Campaign activities included newspaper and magazine articles, television and radio interviews, press conferences, production of leaflets, factsheets in ethnic minority languages, audio cassettes, a self-help video and two books.598 The colleges had accepted donations from all the major manufacturers of depression pills for the campaign, and the president of the Royal College of Psychiatrists, Robert Kendall, acknowledged that their motive was to sell more pills.8:2
When 2,003 lay people were surveyed before the launch of the campaign, 91% thought that people with depression should be offered counselling; only 16% thought they should be offered depression pills; only 46% said they were effective; and 78% regarded them as addictive.494
The psychiatrists replied pompously: “Doctors have an important role in educating the public about depression and the rationale for antidepressant treatment. In particular, patients should know that dependence is not a problem with antidepressants.” I fully understand why the survey also found that “the word psychiatrist carried connotations of stigma and even fear.”
It’s not the patients that need training, it’s the psychiatrists and other doctors that prescribe psychiatric drugs, but they are so much out of touch with reality that no amount of training will get them close to where the patients and the general public want them to be.
There is also institutional corruption.599 Just before fluoxetine (Prozac) reached the market in 1988, NIMH surveyed the public about its views on depression, and only 12% wanted to take a pill to treat it.5:290 However, the NIMH was determined to change this attitude and launched a public awareness campaign claiming that depression is a serious disease that can be fatal if untreated; depression is underdiagnosed and undertreated; and 70-80% get better on drug and only 20-40% on placebo. The postulated 45% difference in effect is fraudulent; even the FDA found only 10% in flawed trials,303 and the patients do not get better on drugs. They get worse, which is why 12% more patients leave the trials when they are on drug than when they are on placebo.301 The campaign was immensely successful, and the media praised Prozac as the new wonder drug.
A chapter on psychotherapy written by a psychologist, professor Nicole Rosenberg, was unusually well documented. She wrote that cognitive behavioural therapy has a small effect in schizophrenia; is effective against depression, also in preventing relapse and in getting people back to work; and works for anxiety, with large effects for generalised anxiety, social phobia and post-traumatic stress disorder (PTSD).16:597
This is important information, particularly that psychotherapy can get depressed people back to work. It has never been documented that depression pills have such an effect, and they seem to have the opposite effect. The rate of disability pensions follows the usage rates for psychiatric drugs,5:8,119:24 and most of these drugs are depression pills.7
Rosenberg mentioned many names in the text, e.g. a Cochrane review by Niewenhuijsen, a 2006 meta-analysis by Butler, and a 2007 meta-analysis by Norton and Price of 108 studies, but many of the papers didn’t appear in the literature list, which only had 16 references.
Textbook authors should not play hide and seek with the readers about important statements. It is often difficult, and sometimes impossible, to find the papers.
I found three Cochrane reviews with Niewenhuijsen as author. One was about interventions to improve return to work in depressed people, published in 2012 and updated in 2020.600 It found moderate quality evidence based on three studies that telephone or online cognitive behavioural therapy was more effective in reducing sick leave than usual primary or occupational care, effect size -0.23 (-0.45 to -0.01). In the 2020 update, there were more studies of psychotherapy, and the effect was now -0.15 (-0.28 to -0.03).601
When I searched on Butler in the author field, 2006 in the publication year field, and meta-analysis in the title field, there were no records on PubMed. People named Butler had published 663 articles in 2006, but only 161 had Butler as first author. Sorting these by best match yielded a review of meta-analyses as the top record.602
The authors had reviewed 16 methodologically rigorous meta-analyses and reported that the effect sizes for cognitive behavioural therapy were large for unipolar depression, generalised anxiety disorder, panic disorder with or without agoraphobia, social phobia, posttraumatic stress disorder, and childhood depressive and anxiety disorders, and that the effect of cognitive behavioural therapy was somewhat superior to depression pills in the treatment of adult depression.
When I searched on Norton as I had done for Butler, there were no records, but after having tried various strategies, I found “a meta-analytic review.”603 It included 108 trials of cognitive behavioural therapy and reported that this therapy and exposure therapy—alone, in combination, or combined with relaxation training—were efficacious for anxiety disorders, which included generalised anxiety disorder, posttraumatic stress disorder and social phobia.
The aim of psychological treatments is to change a brain that is not functioning well back towards a more normal state.8:89 Psychiatric drugs also change the brain, but by creating an artificial third state—an unknown territory—that is neither normal nor the malfunctioning state the patient came from.604
This is problematic because you cannot go from the chemically induced third state back to normal unless you taper off the drugs, and even then, it will not always be possible, as you might have developed irreversible brain damage.
A humane approach to emotional pain is very important, and treatment outcomes depend more on therapeutic alliances than on whether psychotherapy or pharmacotherapy is used.605 Furthermore, the more in agreement physicians and patients are about what is important when
being cured from depression, the better the outcomes for positive affect, anxiety and social relationships.606
Most of the problems patients face are caused by maladaptive emotion regulation. Psychiatric drugs make matters worse, as their effects constitute exactly this, maladaptive emotion regulation.607 In contrast, psychotherapy aims at teaching patients to handle their feelings, thoughts and behaviour in better ways, which constitutes adaptive emotion regulation. It may permanently change patients for the better and make them stronger when facing life’s challenges.
In accordance with this, meta-analyses have found that the effectiveness of psychotherapy compared with depression pills depends on the length of the trial, and psychotherapy has an enduring effect that clearly outperforms pharmacotherapy in the long run.497-501,503 In one meta-analysis, the effect size was 0.26 (P = 0.003).498 In another meta-analysis, there was a trend toward better long-term effect of acute psychotherapy compared with ongoing pharmacotherapy, odds ratio 1.62 (0.97 to 2.72).499 As in other meta-analyses, there were also more dropouts in the acute phase on drug than on psychotherapy, odds ratio 0.59 (0.34 to 0.99). The patients are better helped by psychotherapy, which is also what they prefer but rarely get (see Chapter 8, Part Fourteen).494-496
Short-term results are misleading. We should only take results into consideration if they have been obtained after at least a year. We also need to consider that trials that have compared psychotherapy with drugs are not effectively blinded, neither for psychotherapy nor for drugs. The prevailing belief in the biomedical model would be expected to influence the psychiatrists’ behaviour during the trial and to bias their outcome assessments in favour of drugs over psychotherapy.
Trials that show that the effects of a drug and psychotherapy combined are better than either treatment alone should also be interpreted cautiously, and I will not advocate the combination. Providing effective psychotherapy can be difficult when the patients’ brains are numbed by psychoactive substances, which may render them unable to think clearly or to evaluate themselves. As noted earlier, the lack of insight into feelings, thoughts and behaviours is called medication spellbinding.135,159 The main biasing effect of medication spellbinding is that the patients underestimate the harms of psychiatric drugs, which they have gotten used to.
In June 2022, I witnessed a PhD defence in Copenhagen.607 One of the examiners, a psychologist, made a lot out of saying that psychotherapy wasn’t any better than drugs for depression. It provoked me so much that – when I was allowed to comment after the defence was over – I noted that it was not appropriate to refer to short-term results obtained with the Hamilton rating scale when comparing the two treatments because this ignores that psychotherapy does not cause withdrawal symptoms or destroy people’s sex lives; that pills cannot teach patients anything which psychotherapy can; and that pills double the risk of suicide whereas psychotherapy halves this risk.272
The examiner did not reply, but the other examiner, a psychiatrist, noted that psychotherapy does not always work and when the patients come to him, they have already tried it in vain. This reply is typical for psychiatrists. But pills that do not have clinically relevant effects and double the risk of suicide, the most feared outcome of a depression, cannot be legitimised this way.
I shall not go into detail about psychotherapy. There are many methods and schools, and it is not so important which method you use. It is far more important that you are a good listener and meet your fellow human being where he is, as Danish philosopher Søren Kierkegaard advised us to do two centuries ago. As there are many trials with cognitive behavioural therapy, this tends to be the preferred method, but if used too indiscriminately, it can be a sort of cook-book approach that pays too little attention to the concrete patient’s special circumstances, wishes and history.
Psychotherapy seems to be useful for the whole range of psychiatric disorders including psy-choses7,253 (see also earlier chapters). It does not work for everyone. But this should not make us use inefficacious and harmful drugs. Some people cannot be helped no matter what we do, also in other areas of healthcare. We cannot help most patients with cancer and use chemotherapy far too much out of desperation,46 ruining people’s lives, rushing them in and out of hospital, instead of giving them a peaceful time with their loved ones without drugs.
Physical and emotional pain have similarities. Just like we need physical pain to avoid dangers, we need emotional pain to guide us in life.591 According to a Swedish psychiatrist who does not use drugs, we learn something important through the process of healing that can be useful if we get in trouble again, which can boost our self-confidence. In contrast, doctors may think they need not engage themselves as much when a patient is taking drugs.591
To see the list of all references cited, click here.
Mad in America hosts blogs by a diverse group of writers. These posts are designed to serve as a public forum for a discussion—broadly speaking—of psychiatry and its treatments. The opinions expressed are the writers’ own.
Mad in America has made some changes to the commenting process. You no longer need to login or create an account on our site to comment. The only information needed is your name, email and comment text. Comments made with an account prior to this change will remain visible on the site.