Sunday, October 22, 2017

Comments by Richard Lawhern, PhD

Showing 92 of 92 comments.

  • Richard, I believe I understand the resistance that many here on Mad in America may feel toward Methadone Maintenance programs and indeed anything that smacks of drug treatment, voluntary or otherwise. But I find that the published research is pretty conclusive: nothing else seems to arrest addiction or make it at all manageable for large numbers of people. Methadone is certainly not a “solution”. Just as opioid drugs are not a “cure” for the many types of medical diseases and disorders which generate chronic pain. But it is the most effective tool in a very limited toolbox.

    As for possible inflation of numbers of pain patients, I share your skepticism, as do a number of published medical professionals. The first of the references in my paper does a very workmanlike job of characterizing better numbers from multiple published studies.

    I don’t advocate for increased prescription of benzo drugs, though I’ve read medical professionals who do. There appears to be a significant safety hazard in co-prescription with opioids. Whether it is quite as significant a hazard as portrayed in some CDC reports, I think remains to be proven. And nobody should want to see that demonstration conducted in a manner that actually causes deaths by respiratory suppression.

    I would concur that opioids are not and should not be the immediate default protocol for people suffering with chronic pain. But I talk with pain patients in social media every day who have also had enormous side effects from anti-seizure drugs and tricyclic antidepressants, and who often cannot tolerate either. It is credibly arguable that the number of deaths per year from acetaminophen or ibuprofen overdose and liver toxicity (plus related sudden cardiac arrests) exceeds numbers where a medically prescribed and managed opioid is considered to be a factor in death.

    I am profoundly skeptical of claims that severe pain can be moderated adequately by behavioral therapies such as Cognitive Behavior Therapy. When such protocols work for people in severe pain, it is almost always “at the margins”. The evidence is better for medical marijuana and related products, despite the resistance of the DEA which has built an empire on the mythology of marijuana as a gateway drug.

    Respectfully
    Richard Lawhern

  • Given their long history of research cherry picking and illegal misrepresentation of outcomes in the name of corporate profits, we should expect no less from Big Pharma on the issue of anti-depressants. As noted in “Psychiatry Under the Influence – Institutional Corruption, Social Harms, and Prescriptions for Change” [Whittaker and Cosgrove], these bad actors don’t relent even when they’re caught and fined hundreds of millions of dollars. They simply pass on the fines in price hikes. Until entire Boards of Directors are tried, convicted and thrown in jail for fraud and as accessories to negligent manslaughter, I seriously doubt that much will change.

    Thanks for another insightful article, Peter. I look forward to interviewing with you again on your show.

  • I wonder if one element in the threads of change with respect to the DSM might have to do with outcomes. If there is no consistent record of effective strategies for improving outcomes in a given diagnostic label or category, then it seems to me that the validity of the label itself should be called into question. Such labels should be dropped from any effort to categorize cognitive and emotional issues in order to select modes of therapy or healing. Of course by this criterion, much of the DSM would disappear.

    That being said, one part of the challenge before both proponents and opponents of the DSM or its alternatives, is the reality that some people are so disabled by their cognitive and emotional issues, that they cannot function in the societies which exist around us. People who feel compelled to violence or bizarre behavior by the voices which only they can hear may comprise a real danger to others. Such dangers are unavoidably consequential.

    Not all hearers of voices are violent, nor do the majority of those in personal crisis hear voices. But even among the non-violent we must still face fundamental issues. We all live embedded in a society. When we perceive and behave in a manner which others around us do not understand, or which renders us unable to support ourselves independently as adults, then it seems to me that we cannot reasonably expect our families or the larger society to adapt itself to our eccentricities. There can be some elasticity in the interface between the individual and the larger society. But the rights of individuals are not infinite and we do not exist independently of the society.

  • As a former contributor to the Global Summit for Diagnostic Alternatives, I found the two years or so of its polylog interesting but ultimately empty of actionable content. The group seemed unable to move from observations and critiques into any sort of ordered approach or process for developing alternative frameworks that might guide the training and licensing of “professionals” who propose to assist people in emotional or cognitive distress. Of course, I’ve also been rather beaten up here at Mad in America for offering the same observation.

    It would seem that many people feel they have been damaged by the dominant paradigms of professionalized psychiatric care. Some would propose to simply abolish the whole mess, and walk away. I’ve found that such proponents can be quite punishing toward others who disagree with their particular brand of orthodoxy. I don’t see such an approach as helpful, for it leaves many people in severe distress without supports for any kind of healing. The alternative, it seems to me, is to allow any quack who can (figuratively) wave their arms or practice the laying on of hands, to victimize and defraud people who are hurting and their families who are at their wits end in dealing with bizarre behavior.

    The truism is none the less true: if you aren’t part of the solutions then you’re part of the problem.

  • For those concerned with government policies on addiction and physical dependence, there is an excellent TED talk that I believe contributes greatly to the discussion: “Everything You Think You Know About Addiction is Wrong” by Johann Hari. See https://www.youtube.com/watch?v=PY9DcIMGxMs . In this 15 minute talk, he explores the idea that addiction isn’t caused by drugs even when the drug becomes the physical agency of dependency. He suggests that the original research on drug addiction was mis-designed by placing rats in a highly negative and unstimulating environment where opioids became the only “stimulus”. But when placed in a “rat park” with abundant opportunities for normal rat social interactions, sex and play, the rats no longer preferred opioids.

    A large scale experiment with this concept is underway in Portugal. In that country, drug possession and addiction have been decriminalized. Law enforcement resources formerly dedicated to locking up addicts or forcing them through withdrawal programs are now being diverted to community reintegration and therapy programs. And guess what: rates of addiction are dropping, as are overall costs.

  • Thank you for your introduction, Dr. Wood. As you explore further the themes you have announced here, I do hope you will be able to address a basic issue that many who are still working (however uncomfortably) in psychiatry must be pondering. How may a former practitioner of a failed profession earn a living?

    This is not an issue for me as a retired engineer and continuing patient advocate for people in pain; but it is surely one of the real barriers to fundamental change. What are the conversion strategies for others who no longer embrace the assumptions and models of their former lives?

    I wish you and others of your dispositions well.

  • Mister Lewis,

    You posted five questions in what you and I both acknowledge to be a contentious discussion. In a spirit of fairness, I’d like to respond to your questions even if incompletely:

    ollowing questions:

    1) What percentage of chronic pain patients have also been given some type of psychiatric diagnosis along with various cocktails of psychiatric drugs?

    <<<<I don't know the percentages in this specific population (chronic pain patients prescribed psychiatric drugs). I rather doubt that much has been published, apart from some of the studies mentioned by Maia Slavovitz. But one thing I do know: depression and anxiety are widely known to be comorbid with chronic pain. They are natural reactions to the circumstances and isolation which chronic pain creates in family and social life.

    I also know that when a medical or psychiatric professional misinterprets cause and effect in these circumstances, chronic pain patients suffer. When a diagnosis of "psychogenic pain" is appended to a patient's medical records, the reliable result is that the patient will thereafter have much more trouble being taken seriously when they report symptoms — and that many will be labeled drug seekers. I have addressed this outcome in a researched paper published by the Society for Humanistic Psychology: "Psychogenic Pain and Iatrogenic Suicide."

    2) What role has the use of psychiatric drugs, with all their negative side and “main” effects (and the use of psychiatric labeling in these cases) had in the progression of the chronic nature of protracted pain disability?

    <<<<<The underlying and unspoken assumption of your question is that psychiatric drugs promote disability by causing progression of pain. That may be true in some people. The side effects of both antidepressants and anti-anxiety agents can include sexual dysfunction, mood swings, emotional volatility, cognitive and word finding difficulty, and a host of related problems that directly impact the patient's ability to work and function socially.

    An important reservation applies, however: these effects will vary greatly in any population placed on the same dose of the same medications. And the variation appears to be at a genetic level, in the efficiency of metabolism for the specific drugs. So it is very hard to draw seriously useful generalizations from this outcome.

    3) Should the use of antidepressants in these cases be looked at as a causative factor in the high numbers of suicides?

    <<<<It is now generally known that use of antidepressants in ALL cases (not just chronic pain patients) are associated with increased rates of suicide. One factor that may be operating in this outcome is that it is also known that antidepressants are no more effective than placebo in treating mild to moderate clinical depression. Patients expecting to improve markedly rather often have their expectations dashed. Some patients "crash" emotionally. So there is at least a plausible connection quite separate from the chronic pain experience.

    Suicide has been studied seriously for many years. One of the better studies of chronic non-cancer pain and suicide was done by Mark Ilgen and his colleagues at the Veterans Administration, following over four million VA patients with seven types of non-cancer pain for three years. The highest risk was in patients diagnosed with "psychogenic" pain, 90% of whom also had diagnoses of one of six other types of chronic pain. But the evidence supports the insight that it was the diagnosis itself which caused the increased risk, by driving patients into despair and denying them further medical support and investigation for their actual medical disorders.

    4) Should we call opioid dependency in some cases “iatrogenic dependency” as has been advocated for with benzodiazepine dependency?

    <<<<Note that physical dependency is not the same as addiction. Disproportionate drug-seeking behaviors and obsession do not occur in the great majority of chronic pain patients. Nor do they get a euphoric high.

    I am not at all sure that association of "iatrogenic" (caused by treatment) and "dependency" is particularly useful in this context. The patient is using opioids because nothing else works for their pain. Despite the over-confident assertions of some addiction specialists that alternatives exist and are effective, patient experience largely doesn't support that conclusion. These alternatives can be adjuncts in a larger treatment plan that includes opioids as a central element of pain management. But make no mistake: even when opioid dose levels can be decreased, total withdrawal of these meds will often plunge the patient into agony.

    5) Are a certain percentage of chronic pain patients victims of “iatrogenic opioid dependency” (that is, medically induced and damaging dependency encouraged by Big Pharma and poor medical practices) which initiates a cascade of unforeseen medical and psychological deterioration in these patients – all of which leads people into the clutches of Biological Psychiatry and their brain disease/drug based paradigm of “treatment?”

    <<<<Your premise is complicated, Mister Lewis. Without doubt, Big Pharma has fraudulently misrepresented the risks of opioid treatment. But whether psychological deterioration of chronic pain patients is among those risks, remains a speculation that clearly doesn't apply to all of those who are prescribed opioids under medical management. In many people with whom I have personally interacted, opioids have stabilized their lives and allowed them to function, to work, and to maintain a compromised but still viable family life. We don't typically see those outcomes in addiction to illicit drugs.

    There is no one size fits all "solution" for either chronic pain or addiction to illegal opioids. Many factors must come together. High on the list of those factors must be better doctor training in the management of chronic pain, and recognition that a large majority of properly screened and managed patients are at low risk for addiction. That said, there is definitely a need to better manage and restrict diversion of medications used at home.

    Regards, Red

  • Mr. Lewis, I can’t speak for all chronic pain patients. Neither can you. What I do know from talking for 20 years to chronic facial neuropathic pain patients, is that opioids are almost NEVER the treatment of first resort in this class of disorders. Treatments of choice — in order of physician offerings to patients with neuropathy of several types — are (1) anti-seizure meds like Tegretol and Trileptal used off-label for pain, (2) tri-cyclic antidepressant meds like Amitriptyline and Nortriptyline, which have a cross-over action in chronic neuropathy, and (3) combinations of drugs that may include muscle relaxants (flexeril, others), low-dose tranquilizers (Valium), anti-anxiety agents like Xanax, SSRIs, Steroids, Botox or Phenol nerve blocks, or NSAIDs (notably Naproxin Sodium). Over 70 combinations are sometimes offered in atypical forms of facial neuropathy. And for many patients, medication changes will be necessary over time, due to failure of combinations that once worked for them.

    I do now know with any precision the order of medications offered in chronic pain conditions such as failed back syndrome or psoriatric arthritis. But I DO know that thousands of chronic pain patients are being deserted by prosecution-shy doctors, and quite a number of pain managements docs are leaving practice. The docs have seen the actions of the DEA and heard the so-called “voluntary guidelines” which advise against prescribing more than 50 Morphine Equivalent Daily Dose levels. A particularly telling article on this issue is “DEA Inflicts Harm on Chronic Pain Patients [see “http://www.lynnwebstermd.com/dea-inflicts-harm-on-chronic-pain-patients/ ] Many of the over 600 comments on this article are written by doctors who have treated chronic pain for years and now feel that they can no longer do so.

    I personally know of one case where a patient was forced off high doses of opioids cold-turkey when their doctor discharged them without referral or management of withdrawal symptoms. The patient’s blood pressure went through the roof. He began projectile vomiting, fell in a shower and lay unconscious for two days after inhaling his own vomitus. He is now in a coma and not expected to wake up.

    It is cases like these that reveal just how wrong-headed and destructive the official suppression of opioids can be for pain patients who need them and have no other viable alternatives.

  • Dr. Littrell, at the very least tens (quite possibly hundreds) of thousands of chronic pain patients on opioid medications – and their doctors – have found that there IS NO BETTER SOLUTION! At least not yet.

    Significant numbers of patients are able to function, work, maintain a home and relationships when they are on opioid medications — and utterly UNABLE to do so when they aren’t. See Mrs. Spero’s post below, as but one example among thousands. What would you do for those who have chronic pain that doesn’t respond to non-opioid measures?

    For that matter, why is physical dependence on medication for pain control considered to be such a horror in view of the alternatives? Chronic pain patients on opioids are NOT addicts! Most do not get a high from using these medications, even if they may display both horrid pain and physical withdrawal symptoms if suddenly withdrawn from them.

    We cannot decrease opioid overdose deaths by ratcheting up the agony of millions of people!

  • Johanna, we agree that any public discussion of opioids is complicated by the frauds being worked by pharmaceutical companies. But I suggest that you also read the other side of the story, represented by chronic pain patients in this very thread. From years of doing just that, I am convinced that the great, great majority of people in chronic pain are not addicts. They are responsible, concerned people for whom properly managed opiates make possible the only quality of life that they are able to sustain. If they are denied these medications without realistic alternatives, some of them will commit suicide — but others will be driven into street drugs from sheer desperation.

    There is simply no way on the Green earth that driving more people in to agony and more doctors out of pain management practice is going to “reduce” deaths by opioid overdose. If anything, quite the opposite will occur.

  • Mr. Lewis, (to avoid confusion on which Richard is commenting), it is possible that you and I see or perceive very different worlds and people. I’m not just “trying” to advocate for people with chronic pain issues. I’m actually doing so, and I do it every day for over 12,000 members of 15 Facebook groups focused in this area of shared concerns.

    As noted in the article above, there are an estimated 100 million chronic pain patients in the US alone. Among these people, a minority are prescribed opioid medications to manage their pain. Such prescriptions are almost always a last resort in chronic pain — even though they are routinely prescribed (and over-prescribed) for acute post-surgical pain.

    People with intractable pain conditions are put on opioids when conventional medical therapy and alternative medicine have failed them. Though some are helped by acupuncture or chiropractic or aroma therapy or cognitive behavior therapy (and others), none of these modalities is reliable for the majority, and none of them is an acceptable substitute for pain medication.

    There are indeed risks to be managed when opioids become a part of a long term pain management plan. Hyperalgesia is one of those risks. As the body builds up tolerance, people can also experience severe breakthrough pain, requiring that they be tapered off one opioid before being tried on another.

    But these factors being acknowledged, I still talk with many people who have successfully used opioids under medical supervision for many years and frequently at high dose levels. One of the complicating factors in this public discussion is that (as far as I’ve been able to determine), medical researchers have not even TRIED to assess the long term outcomes of opiate therapy. So when somebody says “There is little to no evidence that opiate drug use appropriately manages chronic pain issues in the long term” they are both correct and perhaps unintentionally disingenuous. We don’t know because nobody as tried to find out.

    I do not minimize the horrid reality of opioid overdose deaths in the US. But I must point out that the significant majority of people do not become opioid abusers as a consequence of being medically treated for chronic pain. And statistics on prescription overdoses quoted by some of the more self-interested agencies in public health or law enforcement are seriously suspect.

    As I referenced in the article, “Opioid Addiction is a Huge Problem, but Pain Prescriptions Are Not the Cause.” Likewise, we cannot hope to reduce the death and destruction wrought by opioids if we are addressing the wrong end of the elephant.

  • There is also speculation in a few corners that Big Pharma may be encouraging the rejection of opioid medications that are no longer under patent, as a step toward blitzing the media with yet another wave of re-purposed or newly developed pain drugs that will be advertised as non-addictive (whether or not they are in actuality). The evidence is obvious and widespread that these companies have committed outright fraud in the past with anti-psychotic meds that they knew were ineffective or dangerous. It’s not beyond belief that they would do so again.

  • As a matter of fact,I’m not one of those “authorities”. There is ample evidence that Cannabis may have a constructive role to play in pain treatment for large numbers of people. Likewise, Acupuncture, osteopathic massage, and fascial release therapies seem to help some people some of the time. Cervical chiropractic also helps some people in chronic pain, though none of these therapies is a “cure” — and for the large majority, none of them are uniformly effective for periods of years.

    Prescription opioids are generally the last choice after many other approaches have failed. And they are not a panacea. Some patients aren’t helped by them at all, and others are hypersensitive (sometimes to *ALL* medications). In those whom opioids help, some will rapidly build tolerance, and may experience rebound pain when the nervous system becomes sensitized and hyper-reactive. No physician should prescribe opioids casually or without significant initial assessment, regular monitoring and follow-up.

  • A note of measured dissent on several points:

    (1) Diagnosis rates on Major Depressive Disorder are vastly inflated by drug company hype. See “Psychiatry Under the Influence — Institutional Corruption, Social Harms, and Prescriptions for Reform” by Robert Whitaker and Lisa Cosgrove.

    (2) While trials of psychotherapy are generally expensive, this might not be their most disabling aspect. Those who conduct them have a long term financial incentive to read patient outcomes in the most positive light, promoting acceptance of their practices of therapy. Likewise, the majority of these studies do not replicate when attempted by other than the original investigators.

    (3) When investigators say that psychiatric drugs are no more effective than CBT, they are omitting the comparison of both with outcomes of placebo. If psychiatric drugs are no more effective than placebo, then the clear implication is that CBT is likewise.

    (4) It’s been known since the 1950s from studies of Freudian and Adlerian therapy conducted at in-patient facilities serving moderately to severely depressed patients, that neither is more effective over periods of six months than simply placing the patient on a waiting list. About 50% of both the treated and untreated groups will report “improvement” after six months. Multiple studies are reported in Martin L. Gross’ “The Psychological Society — the impact and the failure of psychiatry, psychotherapy, psychoanalysis and the psychological revolution.”

    (5) The notion that psychotherapy can “force” a patient to confront past painful experiences is fundamentally an oxymoron of both process and ethics. If trauma is created by coercion and abuse, then how may it be healed by “forcing” the patient to do anything? This idea may also be contradicted by large numbers of patients who remain in therapy for years without gaining independence or moving on. This sense of “stuck-ness” was very much exploited by Big Pharma in its propaganda for medicalizing the treatment of emotional trauma in the 1970s. But the phenomenon itself was real and widely observed.

    Overall, I think it would be fair to suggest that both psychiatry and psychology have thus far failed to demonstrate reliable benefits to the people they are intended to serve.

  • It seems to me that a pertinent question is whether EITHER antidepressant medication or Cognitive Behavioral Therapy generate persistently better results than placing people on a wait list for treatment. When only half to two-thirds of the client population appears responsive to treatment, we need to ask how many folks report better results in six months without any treatment at all.

    When this experiment was done in the 1950s and 60s with in-patient psychotherapy programs for depression and anxiety, there was no statistically significant difference in outcomes for those placed on a waiting list versus those treated in community facilities as in-patients. About half of both groups reported “improvement” after six months. Granting that the psychotherapy of that day was Freudian or Adlerian in character, I must still doubt that modern therapies based on similar underlying premises do much better.

  • Ted — like you, I don’t know what the most effective path is from present reality to a better place in the healing arts. But I can confirm your instinct that many in the anti-psychiatry movement seem to lack an appreciation for the need to act effectively and in solidarity.

    Though I’ve had one editorial published here at Mad In America, and several commentaries to the work of others, I’ve been pretty much run out of the place by the more polarized among members. As nearly as I can tell, my “error” has been in daring to suggest that it’s unrealistic and self-defeating to expect psychiatry to wither away — and irresponsible to propose that it be forced to do so — without offering verifiable and reliable alternative means for assisting people who need help through emotional or cognitive crisis, and who ask for it.

    Revealing the failures of psychiatry and the brain chemical imbalance mythology is necessary. But it isn’t enough to bring about healing.

    Best wishes,

  • You write and speak thoughtfully, Carina Håkansson. I wonder, however, if you might share some thoughts on other dimensions of the frequent conflicts between psychiatric professionals and those who speak from experiential knowledge. Unless one happens to be independently wealthy, a care giver such as yourself must be paid, usually by some third party other than the client, and very often by medical insurance organizations that have no first-hand knowledge of what you do or who the client is as an individual. How does a third party develop confidence that what you are doing actually helps and works to a good end for people in distress? “Just trust me” seems a rather naive position to take in these things.

    A related issue pertains to the “how” or “process” of what you do. Care givers who are paid for their services are generally trained and licensed in some way. How does society or academia decide what their training should be? Or would you instead propose to abolish academic preparation of healers, as some at Mad in America seem to feel is needed.

    And finally, I would ask a question that has angered quite a number of people at Mad In America, in my commentaries on other articles. What are your thoughts on how society and professionals “get from A to B” — from the present prevalent conditions of largely drug-based practice or confinement of people who have experiences considered by family or the rest of us to be bizarre, to a more open system in which each patient is assessed and regarded as an individual within a matrix of supports? What needs to change in popular perception and public law to reduce the abusive excesses so often complained of at Mad in America?

    I write as a non-professional in the healing arts, who is never the less engaged as a website moderator and author in support to thousands of people who have chronic neurological pain. I have written at MIA and elsewhere in opposition to what I regard as the mythology of psychosomatic or “somatoform” medicine.

    Sincerely,
    Richard A “Red” Lawhern, Ph.D.

  • One observation on getting books read: Amazon is indeed the 600 pound gorilla in book sales. And I agree that if a book is to be read widely, it must be reviewed multiple times on Amazon — like fifty or more, not five or ten. But I wonder if authors in the anti-psychiatry movement really understand what steps are necessary in order to generate those reviews.

    To get your books reviewed, you must be prepared to give them away. That’s an especially harsh reality to new authors in any genre, but it is reality. You need to find Amazon reviewers who may have an interest in your subject matter, and then offer to gift them your books in return for a fair-minded review. Given the focused nature of your subject and concerns, you’ll need to locate reviewers who do serious non-fiction, which the majority don’t. But there is one venue which may help: “Author Meet Reviewer” provides a list of over 200 Amazon and Goodreads reviewers, some of them rated in the top 5,000 at Amazon. If highly rated reviewers are impressed by your stuff, it stands a much better chance of getting read by the general public. If such reviewers pan your stuff, then you might want to consider where you screwed up, because you have — at least as far as a general reading public is concerned. And oh, by the way — you’ll need to follow up and establish an ongoing presence in social media (facebook, twitter, goodreads, other critical book lists) to intereact with present and potential readers.

    See http://www.authormeetreviewer.com/

    Regards,

  • Well said, Bridget. As I’ve written elsewhere on Mad in America, “It’s NOT ‘all in your head'”.

    We can all acknowledge that when we are stressed, anxious, or emotionally down, we do experience measurable physical effects. There is also some evidence for neuro-elastic processes in the brain, by which stress or pain can become chronic beyond the initial external stimulus. But beyond that, we need to be profoundly cautious of over-generalizing a psychiatric delusional system. I am personally convinced that the entire field of so-called psycho-somatic medicine is better characterized as psychiatric malpractice and mythology practiced by arrogant and financially self-interested professionals “against” patients, not on their behalf. I am also concerned by the medical surmise and outright unsupported hype that have been loaded onto very modest results obtained with rational behavior therapy.

    When a patient presents to a medical doctor with symptoms that the doctor doesn’t understand, the most ethically sound assumption is that there is an as-yet undetermined medical issue — not a case of malingering, “conversion disorder” or psychogenic ANYTHING. Psychosomatic diagnoses say more about the doctor than about the incompetence of the doctor than about the difficulty of their patients.

    Keep up your good work.

    Sincerely,
    Richard A. Lawhern, Ph.D.

  • Larita, as I have heard from a few professional psychiatrists, there is ample reason to regard “Conversion Disorder” as a medical mythology rather than a valid medical entity. The DSM-5 has relabeled the set of symptoms as “Functional Neurological Symptom Disorder (Conversion Disorder)”. They might as well use a code that reads “I can’t figure out what medical problem she has, so she must be mental.”.

    Your case has parallels to quite a number of others I’ve heard about. This label was hung on you by doctors who basically didn’t know how to interpret the inconclusive results they got from testing. It may have been a means for their discharging you as a “problem patient”, thereby freeing up the time they would otherwise have needed to spend doing your workup from scratch with greater rigor and consults from other specialists (notably a rheumatologist familiar with auto-immune disorders).

    I would commend for your reading, Angela Kennedy’s book “Authors of Our Own Misfortune — Problems with Psychogenic Explanations for Physical Illnesses.” (mentioned in the thread above). I would also encourage you to request a peer review board at the practice where this label was hung on you, to have it removed from your medical records. The doctor who entered it there should be sanctioned for negligence and placed under supervision to ensure that he doesn’t do it to others.

    I wish you wellness.

  • Alex, perhaps there are communities “off the grid” from mainstream society, where people thrive in a context of more liberal (“less restricted”) norms of behavior and thought. However, it might be reassuring to identify large numbers of those who have done as well as yourself. I personally have no experience with such communities.

    Counter-examples to your vision seem wide spread, though one in particular comes to my mind. I grew up in the 1950s and 60s amidst poverty, a few miles south of the Haight-Ashbury district of San Francisco, with its “tune in, turn on, drop out” mind set and slogans. At least as far as I can observe, the “flower people” have mostly disappeared or been co-opted into the majority culture of work and property ownership. Aside from a wider acceptance for recreational pot, it’s unclear to me that the flower children changed a darned thing in the larger culture, for all of their fervently felt good intentions.

    I’m have no wish to be unkind or unfair to anybody. But I would agree with the sentiment that whining never changed anything. Real work and organization-building and changing of social perceptions and institutions are often bloody hard. But such steps seem a more realistic alternative to endless circling about the notion of what the world “should” be if (for example) those bloody-minded capitalists would only disappear overnight, or social authorities were discredited and deposed from power.

    Those versions of magic aren’t going to happen, Alex. Not on any large social scale. Maybe for exceptional individuals, but not for large numbers of the rest of us who have to work for a living in the context of the majority culture. I don’t see a transition strategy here. And without one, we might as well be walking on fly paper. We’re stuck.

    Regards,

  • Okay, Dr. Caplan. I understand your point. Perhaps one has to start small with targeted legal actions for negligent harms or fraud. That being said, what about the second question? What are the broad outlines of research to establish reliable and REPEATABLE practices among professionals in the healing arts, which aid people in emotional or cognitive crisis to come back from the brink of marginalization or suicide?

    Respectfully,

  • For Seth Farber and others: Psychiatrists are not the inventors or (despite the large egos of some of the worst of their profession) the custodians of the term “normal”. The rest of us are.

    We live in a society. By definition, no society exists without shared “norms” — concepts (sometimes standards) of normative behavior, of expected social interaction, of acceptable function. The norms, as we have all seen, can and do change — sometimes in remarkably unexpected ways. Who would have predicted 70 years ago that LGBT persons would ever be accepted as “normal and different” from the primary gender identifications of most people in society? Who would have predicted that some otherwise sensible people would declare with perfectly straight faces that hearing voices or being compelled to confrontational behaviors by those voices should be embraced as merely “odd”. This latter bit, of course, is far from universally accepted as a social norm.

    We can debate what the norms of society should be in an enlightened time. And perhaps we are doing just that in response to Paula Caplan’s article. But I don’t think we can credibly believe that there should be no norms. Another name for such a vacuum is chaos. There is a quite real and predictable consequence for dropping out of the majority culture: drop-outs and their families get marginalized just as weaker animals do in a herd. Those at the margin will either exist on the charity of others, become hunter-gatherers, or (sometimes) starve.

    So could we try just a bit to deal in practicalities instead of pie-in-the-sky philosophy?

  • Dr Caplan, thanks for a thoughtful and grounded article. I’ve been following the fracas between you and Dr Allen Frances in recent weeks. Yours comes across as the far more centered and constructive voice.

    It now seems established that mainstream medical psychiatry simply doesn’t consistently work to alleviate human emotional or cognitive suffering. Many of its treatments are actively dangerous or disabling. Antidepressants work no better than placebo for mild to moderate depression in millions of people, and neuroleptic drugs over long periods cause Tardive Dyskinesia in a third or more of those who take them. Over-diagnosis and treatment of ADHD in kids causes obesity and developmental problems in many. Regrettably, the track record for alternative non-medical therapies for human distress or cognitive disarray is equally weak. The hype over “Open Dialog” and similar approaches hasn’t been supported by controlled outcomes study over periods longer than a year or two, and the number of patients in the published studies is miniscule.

    These things being said, I would pose two questions that I’ve offered in other commentary threads here at Mad in America, to some degree of controversy. (1) If the entire edifice of psychiatry needs to be burned to the ground as a fraudulent enterprise, then why has nobody sued the APA out of existence in a massive class action? (2) What are the appropriate elements of a way forward to better outcomes for those who need assistance in major life crises (e.g. how can research or observation establish what actually works and for whom)?

    Criticism of the reigning psychiatric mythology is certainly appropriate and needed. But it isn’t enough. Where’s the action plan for doing something to clean up the mess? I invite your further thoughts on both of the questions above.

    Sincerely,
    Richard A. Lawhern, Ph.D.
    Resident Research Analyst
    Living With TN
    An online community within the Ben’s Friends cluster for patients with rare medical disorders

  • I have left the following comment at the Manchester Patch, in response to the article linked above.

    The NY State Attorney General has recently sued major chain retailers for selling vitamin supplements whose content doesn’t track with ingredients listed on the label. Why hasn’t anyone yet sued National Institutes for Mental Health (NIMH) or the American Psychiatric Association (APA) on the same grounds?

    The professions of psychiatry and psychology have entered a crisis of public confidence. Articles like Bev MacPheee’s help us to see some of the reasons why this is happening. Professionals in the healing arts are losing their credibility with a public which has realized that many of their theories would better be called “speculations”, and very nearly all of their asserted cures are illusory. Our kids are vastly over-medicated for ADHD, and one in ten Americans are taking an anti-depressant medication. But the evidence is strong that the anti-depressants don’t work for mild to moderate depression. And more powerful neuroleptic drugs used in the severely disturbed people (schizophrenia or other psychosis) can cripple them for life with permanent disorders such as tardive dyskinesia.

    It is long past time for the FDA to get off its fat duff and ban media advertising for prescription drugs of all types. We continue on the present path partly because FDA regulators and their Congressional masters have been bribed by pharmaceutical companies through the medium of political campaign contributions and “speaking” fees. Big Pharma is corrupt to the core, and many of its executives deserve long prison sentences for fraud and negligent homicide.

    Sincerely,
    Richard A. Lawhern, Ph.D,

  • Alex, I suspect we agree on more than we contest. Especially these days, many people make a distinction between organized religion and individual spirituality — and westerners are increasingly coming to favor the latter over the former. This is perhaps progress.

    That said, I still caution against suggesting that agnostics or atheists are somehow cut off from an essential inner dimension of themselves. Spirituality may be one framework for exploring meaning in life. But it is not the only framework or even necessarily the best one for people who are highly trained in science or observation.

  • Alex, there are many different shades of atheism and agnosticism, just as there are of mainstream religion or the individual spiritual quest. I believe it is a profound mistake to assume on behalf of anyone who identifies themselves this way, a refusal to embrace mystery or trans-personal phenomena as elements in life.

    If anything, observation may show us that agnostics generally have a far greater tolerance for mystery and ambiguity than do religious believers. “The buck stops here — with me and my actions and consequences” is a vastly different world view than “I know that I am saved.”

    The way less traveled may require enough bravery to get past traditional labels and invest belief in our own capacity to see and embrace a large world, to choose and to integrate what it has to offer us on many levels. This is a bravery that I personally observe rather less often in the religious, whatever other virtues we may assign to them.
    Regards

  • Alex, I suggest that you over-generalize concerning skepticism. Some atheists are doubtless unfeeling or angry. But the religious are no less so. And many on both sides of that divide are essentially kind and generous people who would like to see a kinder world.

    Personal spirituality and religion can be seen as quite different things. Likewise, humanists have no less a sense of connection to other people than do religious believers. However humanists seem to understand something that the religious deny and rather too often actively persecute in nonbelieves: that the buck stops here in our own existence, our own actions; that we are the creators of our own meanings, whether for good or ill. That WE and not some distant, unseen and ethereal sky god are responsible for ourselves and our actions.

    Scriptural organized religion is an essentially closed and authoritarian system. Personal spirituality doesn’t have to be. And humanist ethics definitely isn’t. If there is a miracle in any of this, it may be in the epiphany that we really are worth preserving for ourselves; and we get pretty much what we put out or accept from life.

    Regards.

  • At the risk of dragging this discussion thread off topic, I must suggest, S.E., that modern believers have very little access to the teachings of Jesus of Nazareth. What we see instead are the teachings of the Apostle Paul, disseminated by his followers who wrote most of the New Testament beginning nearly a decade after Jesus death by crucifixion.

    A book worth reading on this issue is “Paul and Jesus — How the Apostle Transformed Christianity”, by historian James D. Tabor. Also of interest is “Misquoting Jesus — The Story Behind Who Changed the Bible and Why” by Bart. D. Ehrman (on the NYTimes Best Seller list for weeks in 2005).

    To address the more central issues of the article: I believe from study and observation that it is legitimately contestable that any religion contributes to personal emotional healing in a therapy or counseling relationship. What is not contestable to anyone who reads history, is that ALL religion is prone to persecution of heretics and non-believers. Christianity and Islam are far from unique in this dynamic. By contrast, I don’t believe we’ll find a single instance in which the practice of humanistic ethics or the valuing of human beings for themselves apart from any belief in a supernatural being, has ever produced mass atrocity.

    Regards,

  • I suspect we may be seeing a false dichotomy in this question. We might equally ask “would you invest confidence in a Catholic priest to provide sex therapy or relationship counseling to two gay men?” There is a profound lack of common frames of reference in such a situation. And there are many cross-currents here that have little to do with whether (or not) belief in God is delusional or prayer is (or is not) effective as a healing influence.

    It seems to me as a person who has been in counseling and therapy successfully in the past, that any therapist must be able to ask the question “how’s that working for you?” And to benefit from counseling, the client must be able to examine their own outcomes critically and to consider alternate ways of acting and feeling in the world.

    We all grow up among multiple cultural mythologies, and outworn assumptions. At our best, we gradually work our way toward greater understanding and compassion. To survive its many critics, psychiatry must emulate that best. Professionals might begin by admitting to their lack of helpful answers for either atheists or believers alike. And both the religious and the irreligious might undertake to remove the beam from their own eyes before undertaking to take the splinter from their neighbors.

  • Dr. Tolbert, you attempt a very large scale discussion, and I sincerely hope you are successful in engaging serious responses. That said, I would offer one of the footnotes to the discussion.

    It seems to me that if you would encourage a dialog or build bridges between those who practice the healing arts and those who practice shamanism and psychiatry (in my view quite possibly allied disciplines), then you may also need to reconsider the foundations of both — and leave room for different foundations. Hundreds of millions of people in the world no longer accept the concepts of “spirituality” or “the divine other” in the forms most often discussed in Western or Eastern culture. For these people, Shamanism and religion are seen as hold-overs of prehistoric mythologies, frequently damaging to human progress and welfare, even as they attempt to explain us to our selves and reconcile us to the uncertainty and ambivalence of common experience.

    Thus I sense that we may need to permit even deeper questions related to those you pose: what if there is no real Agency or power in our Universe to which we can appeal for healing, other than ourselves and those nearest us in whom we invest significance? What if the buck stops here, rather than in an afterlife or a transcendent revelation? What if we are truly responsible for ourselves, the owners of our acts and feelings, rather than supplicants at various altars for the interventions of the Gods?

    The world which I briefly sketch may seem harsh to many who desperately want to believe in forces beyond themselves that can magically make us whole. But magic does not make us whole or free us from emotional shackles. However hard it may be, it is the truth that makes us free.

    Respectfully,
    Richard A. Lawhern, Ph.D.

  • Sometimes it is important to confront researchers who consider themselves “experts” with the weaknesses or occasional frauds embedded in their own methods. Though I am not a medical researcher, I am technically trained in experimental design and basic statistics. From that background, I would say that Peter Gotzsche’s analysis is quite devastating to people who perform research on antidepressant meds, out of a pre-existing personal agenda to validate medication effectiveness.

    I would hope that Professor Isometsä responds to this article with similar depth and scientific rigor. That does not appear to have happened thus far.

  • Mortal, I’m not leading the charge — in part because I don’t know enough about fund raising or grants or law. But also in part because I get poked in the eye by people who call me names every time I suggest that without ongoing organization and funding, this debate leads nowhere.

    You are at liberty to call me “the big PhD & MIA author, not to mention a wealthy white man in the global North”, and to dismiss my input in the zero-sum game called “us and them”. That’s partly what I was talking about when I used the phrase “my way or the highway.” You know NOTHING about me, but you feel comfortable using that kind of broad brush to dismiss whatever constructive input I might offer. You don’t know or care that education was my ticket out of the urban hell hole where I grew up as a scared white kid on black streets. Nor do you know that I’m already walking the walk that you suggest, by supporting and advocating for thousands of chronic face pain patients as a site moderator and author in other venues. I’ve seen the damage that can be done by the side of psychiatry called “psychosomatic medicine”, and I’ve been advocating for overturning that unsupported mythology.

    I’ve offered my thoughts on what an action program might look like in other discussion threads here at Mad in America, and on the Global Summit for Diagnostic Alternatives. I did so acknowledging that I don’t have all the answers, and inviting others to do better. What I got back was a ration of cr*p for not being one of the self-identified activists who think they can just wave their arms and magic will happen because they’re righteously right in principle.

    Mortal, you make it darned hard to cooperate and seek common cause. Especially when you won’t fill in the many blanks between the problem as you see it, and enactment of solutions for that problem. That’s somebody else’s job, I suppose. Well then WHO??? It certainly won’t be me, considering my reception here.

    Regards

  • Steve, if I may, I’ll tag a brief second-round thought to your comment, addressing in part the concerns of others who responded to my original remark.

    In all candor, folks, I still hear a lot of discussion, but no real plan for effective action. It is not enough to debate. Debate changes little. And it is not enough to say that psychiatry can be killed by denying money to abusive practices. Reality is that Big Pharma practically owns the FCC and the US Congress through the corrupting influence of campaign contributions. The money folks aren’t going to do the right thing or withdraw from the argument. Change won’t happen until they are legally bludgeoned into compliance or bankruptcy.

    Big Pharma will need to be successfully sued by large classes of people several times on grounds of misrepresentation, fraud, bribery and gross negligent harms to patients. Those lawsuits are not going to happen by magic, even if a lot of people agree on principle. Getting Big Pharma out of the pockets of Congress will need organization and years of funding to support multiple legal teams. The process might resemble attacks on Big Tobacco — and it could easily take as long.

    So I’ll ask again: Who will lead the charge? Who will organize and fund major legal attacks on corrupt organizations like the APA? If it’s not the people here, then who is it?

  • I’ve drawn a good bit of fire at Mad in America in previous debates, for suggesting that while debate is a useful initial step, it is is not enough. At the risk of seeming a skunk at the wedding, I’m afraid I must in conscience add this footnote again.

    From reading the exchange of views between Frances and Whittaker — and the commentaries which follow — it occurs to me that for many of those who commented here, no “solution” is acceptable that does not vindicate their experience and social viewpoints in total and without ambiguity. For them it seems to be “my way or the highway.” Coming from people who have been dictated to and harmed by mainstream psychiatry, this desire for moral vengeance seems at least a little ironic. Are you that certain of your moral purity? Do you want vindication or deep social change? The two might prove to be mutually incompatible.

    In the real world of societal politics, unambiguous outcomes in major social issues simply don’t happen. Examples abound, but one that comes quickly to mind is the emancipation of slaves. A hundred and fifty years after the US fought a civil war costing hundreds of thousands of lives, we are STILL struggling to define a more just and non-discriminatory society. The civil war didn’t decide those issues for all time, regardless of who nominally won or lost. In an issue as fundamental as psychiatric mythology and abuse of power, can we rationally expect a less uncertain outcome? I rather doubt it. The revolution is going to be messy if it happens at all. So we need to deal with the reality, not the wishful thinking.

    That said, there is a missing piece that I’d encourage Frances and Whittaker to address in a sequel: go talk to each other in person and come back with a list of possible elements of an action plan to enact real change. I realize that you (and your critics in the commentaries) will not agree on every step. But give us a menu of choices that individuals might get behind. Without programs that can enlist the engagement and resources of other people, what we end up with is an endless talk therapy session that occupies space and attention without really moving anything forward.

    Likewise, concretely what would the commentators propose to DO that’s different from what has gone before, or that the authors have outlined? Who does it? Who pays for it? Who gets sued or picketed or prosecuted, for what offenses? How do alternatives for the alleviation of human distress actually emerge? How does mainstream psychiatry die in less than another two generations?

    The devil is in the details.

  • Sera, I’m an old white man who grew up on black streets. I know a little about the threads of anger and racism that run through such places. And I mean this as I phrase it: “a little”. I don’t pretend to know how black people feel or how white people feel as classes. I’m unwilling to generalize broadly.

    That being given, I am still bothered by a frequent absence of certain words in discussions of human rights. I grew up understanding that rights and responsibilities are inextricably bound up together. We can’t have one without the other, and the relationship is truly two-way. Taking on responsibilities gives support to our rights, just as our rights inevitably generate responsibilities.

    What in your view are the responsibilities that people should feel toward each other in discussions of human rights? If we are not peers, then how can we truly relate to one another?

    Regards,
    Richard A “Red” Lawhern, Ph.D.

  • As I remarked on Psychiatric Times, the kind of uncritical thinking represented in Allan Tasman’s article may reasonably be regarded as “delusional”. Dr Tasman insists on repeating assertions about mainstream psychiatry that are widely contradicted by observation and simple common sense. There is little or no prospect that neuroscience will EVER explain the functioning of the human personality. The brain itself is too complex and too many of its processes are massively redundant, stochastic, nonlinear or parallel-processing in nature.

    This being said, there is still a huge missing piece in the puzzles of human distress and disturbance: how will professionals and patients come together to generate a new standard of practice which is humble in its assertions, reliable in its remedies, and repeatable between practitioners? I have thus far heard little beyond opposing arguments, accusations (however well founded), and the self-interest of entrenched psychiatric priesthoods.

    How can we move this issue meaningfully off dead center and toward better results for people who are in distress?

  • We know that suicide and psychiatric care are associated. But correlation is not cause and effect. What do we know about suicide among people placed on a waiting list for admission to a psychiatric care facility versus those admitted and medicated with anti-psychotic drugs?

    Some of the sound and fury now being generated on issues throughout psychiatry derives from studies done as far back as the 1950s. These studies demonstrated that at least for moderately depressed people who might then have been admitted to a resident facility and treated with talking therapies, there was no statistically significant difference in outcomes between those who spent six months in residence, versus those who were on a waiting list for the same time. About half of both groups declared themselves “improved” at the end of the observation period. And the type of talking therapy delivered in residence (Freudian analysis, Adlerian therapy, etc.) made no difference in outcomes.

    This type of observational trial was used (among other measures) in the 1970s as a support for restricting the number of resident beds available in treatment centers for the more severely distressed. As we should all know by now, such “cost consciousness” had the unintended consequence of throwing hundreds of thousands of people onto the street as homeless persons, or into prison as highly distressed and sometimes mentally disoriented inmates. Thus a mistake in cause-and-effect assignment can have profound consequence.

    Sincerely,
    Richard A. Lawhern, Ph.D.
    Contributor on Mad In America
    “It’s NOT All In Your Head”

  • Well written thoughts, among which… “the mental health field has an endless supply of licensed quacks. But at least when someone has a license there is standard of care you can expect from them. ”

    I would be interested to hear Daniel Mackler’s thoughts on how the quacks (both licensed and unlicensed) can be weeded out without burning the profession of psychotherapy to the ground and starting over from scratch. As others at Mad In America have written persuasively, the track record of outcomes from psychotherapy seems just as checkered (if less immediately destructive) as that of “anti-psychotic” drugs. Published trials and observational studies are notoriously manipulated and biased in both fields. NOTHING seems trustworthy.

    Where too from here, Daniel?

    Sincerely,
    Richard Lawhern, Ph.D.
    MIA Author “It’s Not All In Your Head”.

  • Yours is an interesting vision, Ted. The flower children of the 1960s, among whom I grew up, might recognize themselves in your proposal. But I still wonder why nobody has so far been able to put together a well-funded class action suit against the APA and NIMH for gross malfeasance and harm to patients. I also wonder whether there are any reliable and repeatable alternatives to forced incarceration and drugging for the assistance of people in severe delusional distress. So far I don’t see evidence of either initiative, though I’m certainly willing to be informed on the errors of my perception.

    For those who would rebel against the abuses of psychiatry, I wish you every good outcome. But so far I don’t see the evidence or even prospects of real or sustainable change. How is that going to happen in real life? What are the steps? Who will lead?

  • Nancy — thanks for a wide ranging and deeply chilling article. As a website moderator and advocate for chronic pain patients and their families, I see different dimensions of the same problems you highlight. Medical authority has too often of late chosen to stop being medical or ethical (“first do no harm”) as it becomes more authoritarian in character.

    The people I serve as an information miner and research analyst rather often report having been referred by a medical practitioner for mental health evaluation under an ASSUMPTION that their medically unexplained symptoms must signal a psychosomatic disorder. Once a diagnosis of psychogenic “anything” enters their records, they are reliably denied further medical investigation and care by doctors who write them off as “head cases”. Parents of kids in crisis are too often written off in the same manner, to be denied even access to their kids after being told they are “facilitating” a child’s mental distortions.

    This is nonsense!

    I personally believe that the medical abuse heaped on the Pelletiers has much in common with one of the most egregious scandals of modern psychiatry: the destruction of thousands of families of day care center staff during the 1980s and 90s, on grounds that kids in such centers “remembered” Satanic rituals and physical abuse when interviewed by psychologists and therapists. The kids’ “repressed” memories were, of course, conditioned and created by the therapists who interviewed them and “led the witnesses”.

    I would go so far as to assert that so-called “somatization disorder” of the DSM-IV, now transformed into “Somatic Symptom Disorder” in the DSM-5, is an outright delusional system among psychiatric professionals. There is simply no scientific evidence to support or validate any such mental health entity. None. I have written elsewhere on Mad In America on this conundrum, in an article titled “It’s NOT All In Your Head.” I have also examined the close connection between diagnoses of “psychogenic pain” and what is properly designated “iatrogenic suicide”. Doctors are literally killing some of the patients whom they label with psychosomatic illness, by driving them into despair and invalidating them as reporters of their own illness experience.

    For anyone dealing with an entrenched medical mythologist who (falsely) asserts the validity of SSD or its predecessor as a medical entity, I suggest a reading of Angela Kennedy’s challenging book, “Authors of Our Own Misfortune? — Problems with Psychogenic Explanations for Physical Illnesses.” The book is devastating to those who would use circular reasoning and self-interested bias as a substitute for medical evidence.

    Thanks again for bringing urgency and insight into this important issue of psychiatric abuse and excess.

    Sincerely,

    Richard A. Lawhern, Ph.D.
    Resident Research Analyst,
    Living With TN — an online community within Ben’s Friends

  • P.D., If the caring system no longer exists, then what would you recommend for re-creating it? Or should we assume that people will simply get better if they’re left untreated and unsupported? Hasn’t that already been tried in the non-benign neglect that so many in this thread have complained of?

    One may find justification for cynicism, and there’s plenty of blame to go around. But cynicism and blame have never been a healing influence that I could ever see, without offering something something new. So what do you offer that’s new?

  • Dr. Allen Frances MD recently published “Is The Worst Time Ever To Have A Severe Mental Illness?” on his blog on Huff Post. He quotes extensively from Professor Edward Shorter, an “eminent historian of psychiatry”, amplifying on themes suggested in the Wikipedia articles above.

    I’ve tangled with Dr. Frances on occasion for what I regard as a naive and self-interested defense of over-medication that his 2013 book “Saving Normal” does little to dispel regardless of the useful insights it provides into psychiatric fads and fallacies. But the article can be taken as stand-alone support for reconsideration of abusive practices in psychiatry.

    See http://www.huffingtonpost.com/allen-frances/is-this-the-worst-time-ev_b_5654808.html

  • Steve, perhaps you and boans and oldhead might consider having a conversation in a forum of your own choosing. Each of you has a vision of the past, and perhaps a vision of the future. But if that vision cannot be elaborated and shared with others across a range of variable feelings and opinions, then what chance do any of you have for substantively changing public policy and law?

    I find it exceedingly strange to be accused of something evil or arrogant or boorish for advocating that talk is cheap and real change may require organization. It seems pretty clear to me that a part of this group is disinterested in enlisting allies — if in that process they might need to reexamine anything in their own world view. How very like the analogy that oldhead offers up: are not the leaders of Hamas and the State of Israel engaging in something very similar?

  • I understand the distinction you’re making, “uprising”. What I don’t see and think is important, are the details of reliable replacement therapies for meds. Without that piece, I think the puzzle falls apart for many who have never walked the mile on nails that you and others who have been psychiatrized have. I sense that the moral case for abolishing psychiatric coercion won’t ultimately win an argument with public safety — either real or imagined, with Big Pharma flooding the airwaves with scare stories (a real possibility).

    The proposal isn’t important because it’s mine. I put it out here only as a platform for starting to move beyond discussion and toward some more concrete action that others in the forum might choose to participate in developing. I’ve long practiced the principle that you can get almost anything done if you don’t care who takes the credit. So by all means begin. I simply don’t expect a lot of success in changing public policy if you won’t talk to people outside the circle of those who have personally experienced harm. You’ll have to make the public at large care enough to look at alternatives. And the alternatives will really have to be there to be looked at, by friends and skeptics alike.

    Regards, Red

  • A couple of thoughts on this very long thread.

    (1) My original article “Lead, Follow, or Get Out of the Way” was written for participants at a website of the Society for Humanistic Psychology. That audience was heavily concentrated among psychiatric and psychology professionals. So yes — for that audience — I was writing to kick tail and take names among folks who would rather talk about changes in diagnostic practice, than actually do something concrete and make change real. In the context of the present thread, I was certainly suggesting that endless talk-talk-talk doesn’t seem likely to change anything of substance. I still believe that. I’m glad to see a few tentative steps being taken toward exploring tactics for changing public attitudes on forcible psychiatric drugging. If sustained, that could be progress.

    (2) Some others here who advocate with passion are convinced that there are proven alternatives to drug treatment for severe cognitive disturbance and human distress. Surely some people are coming off drugs and doing much better. And I applaud them. But before we generalize toward standards for an entire profession, please show me (and more importantly show the public whose support will be needed for changed standards of care) proof in repeatable double-blind randomized trials. If we are to disbelieve the claims of drug companies on the basis of the manipulation of such trials, then surely it is not too much to ask that alternative therapies be subjected to similar standards of evaluation that are NOT manipulated.

    (3) As clinical health psychologist James C. Coyne (among others) has written, consistency in application of trials protocols and repeatability of outcomes with various forms of psychotherapy have been “abysmal”. [See @CoyneoftheRealm] It is also at least arguable from sources other than Coyne that the single best predictor of success in aiding distressed people is not the method used, but the practitioner who uses it.

    (4) It’s been known for at least 50 years that the forms of talking therapy applied in the mid 20th century have very little effect in ameliorating severe patient distress in psychosis or schizophrenia. Multiple studies conducted in the 50s and 60s examined the outcomes of Freudian, Adlerian, and other therapies administered in resident treatment facilities, with people who enrolled themselves for help in major anxiety or depression. There was no significant difference in outcomes between the talking therapy modalities. More important, there was no difference in outcomes for applicants placed on a waiting list. After six months, about half of both groups reported improvement in the conditions that led them to seek resident treatment in the first place. These studies are summarized in Martin L. Gross, “The Psychological Society” — Random House, NYC, 1978, among other places. Gross is worth reading if you can find the book in a used book store. It’s no longer in print.

    (5) It is entirely conceivable that community support and talking therapies evolved over the past half century may be more effective and useful for severely distressed or cognitively disturbed people, than were their historical predecessors. If this is true, then trials data should demonstrate the improvements. Opinion and case studies don’t carry that argument, even if they offer useful indicators of methods worth looking at in greater depth.

    (6) I got into this discussion as a medical and mental health layman who thinks that mainstream psychiatry is a broken institution, and the brain disease model is an invention without backing in science. The article Donna put forward on August 8th, makes that case well. And to be fair, the article does indeed raise doubt on the credibility of studies of identical twins, sometimes touted by pharmaceutical companies. I personally sensed that the authors of the article reached a little hard for explanations of how separated identicals could be very similarly affected by environment. But they at least argued the issue to a deadlock. I don’t think the nature-versus-nurture argument in severe cognitive disorders is quite resolved yet.

    (7) My participation in this thread has been motivated in part by the 18 years I’ve spent helping chronic pain patients as a website moderator, online research assistant, and patient advocate for people with a rare neurological disorder called Trigeminal Neuralgia. More recently I’ve broadened scope to address the damage that psychosomatic medicine and mythology have done to thousands of people with subtle medical problems who are written off as “head cases” by medical doctors who haven’t been able to treat them. I clearly do NOT know it all in even one branch of mental health practice, but I’m doing what I can to speak on behalf of patients who deserve better from people licensed as healers. Part of my ongoing effort on behalf of pain patients occurred last Wednesday in an interview on the Dr. Peter Breggin Hour, around the subject “It’s Not All in Your Head”. Ginger Breggin invited me to join Dr Breggin for a talk after reading my editorial which Mad in America published by that title. If anybody wants hear more, the hour is archived at http://prn.fm/dr-peter-breggin-hour-080614/.

    (8) I don’t mind being referred to in the third person. I do mind being labeled “boorish” for having the temerity to speak out with passion on a subject that is just as meaningful to me as to others who have suffered more directly at the hands of professional psychiatry. Given that I seem to be considered by some here to be too ignorant to have anything useful to say, I hope I can be pardoned for wishing y’all well on that journey and standing aside. I really don’t sense that my participation is welcome here. I hope you can find a way to create allies among other people who differ in some details of whatever approach you work out.

    Sincerely,
    Richard A. “Red” Lawhern, Ph.D.
    Resident Research Analyst,
    Living With TN: An online patient community in the Ben’s Friends group.

  • For oldhead: I am a survivor of being a battered kid up to about age 6, and of pschotherapy in my 20s, but not of psychiatry in the sense that you intend. I don’t remotely want to be in charge — but I do want to see somebody take responsibility for more than talk, talk, and more talk. If I struck a nerve with you, that’s just fine. If you aren’t part of the solutions, then it might be that you’re part of the problem.

    Regards,

  • Jonah, I can relate to some of what you say — and for other elements, maybe not so much. I’m a child of the middle 1940s, formed in the 1960s. I’ve read a bit of Camus, Kahlil Gibran, Hermann Hesse, Carlos Castenada, Fritz and Laura Perls, Erich Fromm, and quite a number of other authors who might be counted philosophers. Learned a lot. Moved on to earning a living.

    There’s a practical side to my life too: I served 21 years as a US Air Force officer, systems engineer, and technology futurist. Did 23 more years in aerospace defense industry. I know some little about practical leadership, having been thrust into such roles. From this background I suggest a variation on an old cliche (sometimes also seen on placards): “A committee without an action agenda is an organism of six or more arms and no head.”

    I offer ill will or malice to nobody at MIA. But I would still remark that in all of the very stimulating discussion I’ve seen in the present thread and elsewhere on the site, I detect no evidence that anybody is willing to get organized for substantive changes to medical and mental health practice. You’d rather kvetch and pontificate than DO something. But until you organize, you might as well be having a discussion of Heaven rather than actually going there (to borrow an old joke that Unitarians sometimes tell each other in church).

    Proponents for abolition of forced psychiatric treatment are facing an entrenched and very well funded cabal of evil corporate interests that will NOT let go of their control and power voluntarily. Big Pharma and its APA shills can be compared quite meaningfully to the tobacco companies whose executives lied to Congress and in front of judges and juries with straight faces, that nicotine wasn’t addictive and their advertising campaigns weren’t targeted on kids. Both were in effect, racketeer-influenced and corrupt organizations.

    That being said, we no longer see cigarette advertising on television, do we? Look at what had to happen for even that incremental change. Opponents of the tobacco companies had to spend millions of dollars to get their voices heard in court and in the public consciousness (to use an imprecise term). The process is still unfinished, but it has started. Acknowledging that I haven’t read every author at MIA, I see no comparable movement toward changing the public climate on forced psychiatric care — either here or elsewhere.

    I wrote the article on “Lead, Follow, or Get Out of the Way” after participating for nine months of wide-ranging discussions at the Global Summit for Diagnostic Alternatives (a website of the Society for Humanistic Psychology). The discussions were circling endlessly. As far as I can see, they still are. I was candidly scolding the 150 0r so contributors at DxSummit.org for being more interested in talk than real action. I sense a parallel sentiment here.

    Talk is cheap. But there is no magic that transforms talk into change. If you will not organize, then your message will not miraculously become accepted truth for either the public or the law. And if you’ll pardon my scolding further, if you will not organize and thrash out a practical and concrete plan of action, then you will not DESERVE change because you’re not willing to do real work for it.

    Enough, already. I’m DONE!

  • I share Boans sentiment at least in part. If I may add: it may be useful for others of this view to send mail to the publisher or site administration, requesting that a blog be set up for development of an action plan to end forced psychiatric treatment. Such an objective may not comprise “the whole loaf” for those who are determined to abolish psychiatry in total as a field. But it might at least represent an incremental positive change.

    To have any lasting effect, the blog will ultimately need to go beyond “discussion” to some form or forms of confrontation and dialog with psychiatrists, psychologists, and “mental health” practice as it now exists. I believe somebody will also need to take responsibility for assembling a consensus position and plan from the discussions — or they will otherwise prove endless and ultimately futile. I’m willing to contribute to the process, but I’m not professionally qualified to lead it.

    So who will volunteer?

  • Chris Reed: Like others, I have problems with the lack of a reply button when the conversational threads develop beyond three or four-deep. However, I am responding through the next-highest level in the conversation, hopefully “close” to your most recent comment.

    You wrote in part: Richard: I watched the first 40 minutes of Ralph Nader’s presentation of his book on left right alliance at the Cato Institute. The key thing he was saying was that there needed to be specific institution building about a specific proposal-please direct me to your proposal.
    He posits that the biggest obstacle to such an alliance rests on the nature of funding to think tanks of all stripes. The funding tends to reinforce differences, since the funding tends to drive the issues that are divisive across the political perspective of Libertarians, Conservatives, and the left. So is your proposal one that can unite us to take a step forward in the immediate here and now. I believe that you are correct, that changing the perceptions of the public takes patience, and that it is something that we also need to be in your the long haul. However, in certain situations paradigmatic shifts can occur more rapidly under the right circumstances.

    ===============
    I’ve offered my thoughts about moving toward change in the institutions and practice of psychiatry on DxSummit in an article titled “Lead, Follow or Get Out of the Way — a Layman Perspective on Change” [http://dxsummit.org/archives/1290].

    I’m not sure my program outline has explicitly addressed your concept of trying to bridge the political left and right. But it does suggest a course of action to move toward change. I am not wedded to the words of that course of action — in fact I have invited others to point out where it may need revision to be effective. There — as apparently here — few folks seemed much interested in suggesting changes or improvements.

    Parenthetically, I worked a part of my professional career as a technology futurist. One of the principles that I encountered repeatedly over a ten year period was that paradigm change is rather often highly disorderly and unintentional. Perhaps such change might be regarded within a framework of chaos theory, as inherently unpredictable. To say that we’re going to create a particular paradigm change can rather often be an oxymoron.

    Sometimes we have to seek change for itself, and have a degree of personal faith that almost anywhere we might wind up seems likely to be better than where we are. But to get anywhere, I would concur that we do need to create alternate institutions and organizations of people, money, research and public advocacy.

    Thanks for your inquiry.
    Regards

  • Frank, you write “…Even if theoretically people are postulating the eventual demise of the profession, outlawing psychiatry itself can’t be such a pressing issue. It is a matter of supporting the same freedoms for everybody that are missing from the civil commitment process. I do think, on the other hand, that the pathologizing of any and every human behaviors requires popular resistance at all levels. ”

    My thought: if popular resistance is required, then how can the beliefs and advocacy of participants at Mad In America and elsewhere be turned into an effective movement for substantive change? Doesn’t the existing system need to be challenged in court, and its proponents sued out of practice for the frauds they’ve committed?

    In other words, if you’ll forgive my repitition, where is the program for making the abolition of forced drugging and incarceration happen in the real world? So far, I haven’t seen a sign of an action plan or organizational initiative in this thread. And nobody seems remotely interested in pursuing the particular version I offered for consideration.

    So how does all of this happen without organization, money, and thousands of people working actively and in concert to bring it about? Do we think a miracle will happen? How has that approach worked out for us so far?

  • Abolition of involuntary medication is not the same issue as abolition of psychiatry as a field. And even the abolition of forcible or coerced medication is not problem free. It comes with a cost to people who cannot or will not self-regulate their own behavior, and to others who are called upon to pay for facilities to house the truly dangerous. Whether we call such places prisons or asylums, that cost is still real.

    If you would abolish psychiatry, then with what would you replace it for the many people in contemporary society who experience mental and emotional agony? Or are we to simply tell them “get your act together and soldier on?”

  • Oldhead, Sometimes irony doesn’t convey well in print.

    Moreover, your accusation of arrogance might bear a bit more weight if it was accompanied by some slight evidence that you had bothered to read the program proposal I offered. Have you done better? If so, then where may I read and comment upon your proposals for substantive change in present conditions?

    The conclusion that the anti-psychiatry movement is heavily polarized seems well supported by what I read in this thread — and perhaps also by your dismissiveness and willingness to dismiss as “arrogant”, opinions that you consider “irrelevant”.

    It seems to me that effective change in psychiatric practice must be based not on opinion but on medical evidence. Not my opinion or yours, or that of self-proclaimed authorities in the field. That is ultimately what science is about.

  • Jonah, I’m a medical and mental health layman, not a professional. I don’t think anyone should take as authoritative, my opinion (or even yours) on which references in medical literature really are “authoritative” and which are not, with respect to the roles played by childhood trauma versus neurochemistry in the emergence of symptoms and behaviors we loosely call “schizophrenia.”

    What I do know, however, is that quite a number of psychiatrists rebelled during the 1970s from the then-prevailing orthodoxy that hearing voices or feeling observed by hostile unknown strangers was uniformly caused by early childhood trauma. Then-available modalities of psychotherapy had very little if any effectiveness in moderating or managing the bizarre experiences and acts of people believed to be schizophrenic.

    However, some of the other participants in this thread have far deeper study of these issues, to offer. Thus I invite anyone now in psychiatric practice who treats schizophrenics, to post references which establish the root sources or causes of this (these) disorder(s). When I read about schizophrenia in sources accessible to lay people, what I see are assertions that science has not yet established a definitive cause. I’ve also noted recent discussions of a study of genetics in the disorder, which suggests that more than a hundred different genes may contribute or be involved in it. So I don’t think we’re dealing with a single modality of disorder or a single environmental influence.
    Regards,

  • Oldhead, I must agree with your observation. Three whole days and nothing new. I suspect we have amply confirmed the earlier observation that many of those in the anti-psychiatry movement are so polarized that they will accept nothing less than abject surrender from those with points of view other than their own.

    That said, a basic suggestion to all who have participated here. This discussion isn’t going to finish the many arguments that need to be had or the many points of fact or principle that need to be resolved in order for something better to emerge. Nor SHOULD this discussion determine the future course of the psychiatric profession. That’s a task for a different and much larger group of people, and probably a minimum of three to five years of funded labor.

    Talk is cheap. Action and change are hard. Action without a program and a structured process for change will generate nothing of lasting value. When I wrote “Lead, Follow or Get Out of the Way” on DxSummit, it was precisely because I saw that worthy forum circling in the same way this MIA discussion has — endlessly. There are people of good will at DxSummit, as there are here. But I question whether they are either interested or even willing to embrace change that might cost them something more than evening time in commentary.

    Interestingly, there have so far been only three comments on the program I’ve suggested in the article, and one of those seemed to be in opposition to the entire idea as being in the category of “it will never be allowed to happen” (not the commentator’s precise phrasing). If we believe that premise, then we might as well fold up our tents and go home, because the rest is word noise.

    So what’s it going to be, folks? Is this group going to insist on purism or move toward practicalities of change? I’m waiting to hear an answer to that question.

    Regards,

  • Jonah, it seems to me as if you are trying to place me in the position of either agreeing with everything you say, or being run out of the forum for heresy.

    When I use terms like “may” or “might”, it is with a chosen respect for the uncertainties which prevail on issues of cause and effect. Experts have been having quite parallel arguments to those we have entertained in this thread, for the past sixty years at least — and yet here we find ourselves, stymied from making progress on betterment of conditions, because we’re still doing the routine where “you’re wrong and I’m right and I’ll never be convinced that what you’re doing or saying is constructive or helpful.”

    If you’re not willing to settle for half the loaf, then I suspect none of us are going to sit at a banquet of real change. I’d encourage you to leave room for new learning. If a process of change is ever to become possible, then both professionals and lay people alike are likely to find that there are plenty of things we’ll have to UN-learn because evidence collected with rigorous attention to scientific methods and consistency just doesn’t support a lot of the orthodoxy. And you may find that your particular form of orthodoxy is just as subject to that process, as you would have my insights become.

    Regards

  • For Nijinsky: I intended no stereotyping of Donna’s remarks or ad hominem attack on her as an individual. I merely fail to understand her logic. It seems to me that she is claiming that something about identical twins tends to get them treated similarly in whatever family environment they find themselves. But she (and presumably the authors whom she references) make the claim that environmental factors were not given sufficient weight as influences in the higher rate of diagnoses of schizophrenia in identicals. Would not the environment need to be similar for this outcome to occur? And if we credit dissociation as a major mechanism in emergence of schizophrenia, then wouldn’t the environment need to be abusive? Or is the assertion actually that rates of schizophrenia diagnosis are no higher in this population than the 1% or so estimated for all US citizens?

    Where am I going wrong here? Explain it to me.

    I can’t really respond to the accusation that investigators fudged the data in studies of twins. It’s certainly possible, and the practice is demonstrably widespread in other branches of psychiatry. But my focus was on the generalization that family environment creates schizophrenia. I haven’t seen persuasive evidence for that position, even acknowledging that traumatic family environment does play a serious role in later emotional adjustment problems and perhaps psychosis.

    I sense that my layman’s opinion in this issue may be influenced by the generation of psychiatrists from the 1970s and 1980s, who decided that there was little evidence that psychotherapy actually helped those diagnosed as schizophrenic or psychotic — and who then led their profession toward the medical and pharmacological models of practice which so many are now complaining of at Mad in America and elsewhere. The law of unintended consequences seems to reign supreme.

    I also offer that I may not be totally unbiased in this discussion. I was physically battered as a child, and grew up in an emotionally violent home. I later did therapy as an adult to deal with emotional insecurity that I associate with my early upbringing. Therapy helped, though I don’t generalize from my own sample of one. But neither do I accept without reservation, the assertion that people who hear voices “are that way” because of what was done to them as young children.

    Sometimes life is messy and highly individual. Wasn’t that a point that many others were trying to make?

  • Donna, you wrote “For example, if twins have the same IQ, looks and other factors, they are more likely to be treated in similar ways whether raised together or apart.” To which I respond “So what? Surely you cannot be suggesting that all adoptive homes are abusive? That would seem implied if one suggests that something about identical twins gets them both maltreated when adopted out.

    You may have a point when you suggest that “It’s the medicalization of injustice, poverty, sexism, racism, classism, and lots of other “isms” that have allowed the psychopaths to use the “shock doctrine” to hijack the globe and all its former democratic entities.” But I seriously doubt that the connections are quite that simple. I also wonder how you would propose to stop such a medicalization without changing the conditions themselves?

    It seems to me entirely too easy and unhelpful to attribute all of society’s bad outcomes to “isms”, as if that explained anything or led to an actionable program of change. It simply doesn’t.

    My focus is on finding the “actionable” and getting beyond the taking of positions in principle, to concretely change standards of medical and mental health practice for the better. If we make the problem one of eliminating the “isms” rather than changing the smaller domain of health practice, then I think we render the problem too large and too diffuse to solve.

    You write ” I’m not saying that bad families are always the problem because there are many other influences in one’s life like school, work, community, friends, enemies and the luck of the draw.” For whatever this is worth, neither am I saying that all severely disabling mental health issues are a consequence of brain chemistry defects. But some people DO seem to be dealing with such defects. I think it’s a mistake to leave these people in darkness by proclaiming that “dissociation” of childhood traumas accounts for the great bulk of severe mental health issues. The evidence for that proposition seems weak, at least from the reading I’ve done as a layman over the past 30 years.

    The underlying argument here is an old one: nature versus nurture. To the proponents of both positions, my suggestion is “stop generalizing and polarizing the issue. Maybe both play a role, and both need to be addressed in order to aid people in severe emotional and mental distress.”

  • Chris — I don’t think we can argue usefully that the delusional loners who kill school kids are mentally healthy.

    What, may I ask, does “concerted action by psychiatric survivors and their allies” actually comprise? Would the program of “Lead Follow or Get Out of the Way” be a useful starting point?

    I might also suggest that there is a morally and ethically sound rationale for court hearings specialized in issues of confinement of people whose behavior is bizarre or threatening to others. Few municipal or superior court judges have training in assessing reported or in-person bizarre human behavior to determine an appropriate course of action that protects the rights of the larger society as well as those of mentally disordered people. Even acknowledging that mental health professionals do a lousy job of predicting behavioral outcomes, they are at least formally trained for the task of human assessment. Judges and lawyers mostly aren’t. It’s not an ideal situation. Nor does it seem to me to be well addressed in either-or thinking.

    In all candor, I also have a hard time personally with the idea that the society “must” change to accommodate those who act out strangeness and threaten others. Society almost never changes en mass out of intention, and never out of threat by perceived “outsiders”. Society certainly evolves over time and education can be a part of our evolution. But this is a generational process, not done overnight. And before large numbers of people can be educated, the consensus beliefs of educators must first be changed.

    So a part of what I believe needs to happen if we are ever to see more humane treatment of people in mental and emotional distress, is that opinion leaders in the larger society must be *persuaded* that what they’ve been doing in the past hasn’t worked and is morally unsound. Persuasion is a different process than coercion or confrontation, as many here at Mad in America might testify. Only where persuasion appears impractical on the face of the evidence, does legal action seem warranted. In the case of the APA and DSM-5, I believe that condition is obvious. A lot of other areas of psych practice seem more ambiguous.

    Regards,

  • Tru, I hate to rain on your parade, but the evidence for “dissociation” and suppressed memory is very shaky in mental health literature. I would also point out that this supposed evidence was manipulated into a psychiatric witch hunt in the 1980s and early 1990s that resulted in the false imprisonment of large numbers of day care center operators on grounds of child abuse and satanic rituals (yes “satanic” — I kid you not!). The testimony of psychiatric professionals was a key element in creating this outrage.

    I recently participated in a major cat fight between proponents and advocates of dissociation and suppressed memory in the online journal “Psychiatric Times”. See “Reforming Mental Health Care: How Ending “Recovered Memory” Treatments Brought Informed Consent to Psychotherapy” .

    This being said, I would agree that there is sound medical evidence that childhood trauma and abuse can distort patterns of brain formation and personality development. Brainwashing of any type can result in similar outcomes. And there is clearly need for reliable and repeatable drug-free methods for helping people recover adult independence and function. I merely point out that there seem to be no one-size-fits-all methods or solutions for problems of this type.

    From reading as a medical layman, my going-away impression is that the collection of behaviors and symptoms which we call schizophrenia is not always associated with identifiable childhood trauma. Many young people who hear voices or harbor an unreasonable belief that they are being continuously observed and persecuted by a mysterious “they”, come from highly supportive and positive family backgrounds. By contrast, the incidence of such symptoms is significantly higher in identical twins separated early for adoption than in the general population. [among other sources, see Martin L. Gross “The Psychological Society — The impact — and the failure — of psychiatry, psychotherapy, psychoanalysis and the psychological revolution” , Random House, NYC 1978]

    Ultimately the medical evidence — not my personal opinion or anybody else’s — must become the basis for developing a new compendium of mental health assessment and practice. This is yet another reason why “structured and managed development” of such a standard is desperately needed. And it is a reason why this development must invite participation not only by psychiatrists (as was the case in the DSM-5 debacle by the APA), but also by the full range of affected stakeholders: psychologists, social workers, medical doctors, educated lay people and former patients damaged by the present system.

    Respectfully,

  • Jonah, I don’t accept your comparison of the use of tazers to the use of electro-convulsive shock. In both long-term effects and the circumstances of application, the two cannot be meaningfully compared. ECS is advocated as therapy by some people in professional psychiatry — and I believe this practice is deeply in error. Tazers, however, are employed to avoid applying even more dangerous methods in a high-threat situation that unfolds in mere seconds.

    Plenty of public attention is already given to the issue of excessive force when an uncooperative person is assaulted by a policeman with a tazer. Officers are being trained all over the US to avoid unless they or someone else is at risk of violence. However, police are *routinely* assaulted in domestic violence situations. The use of tazers is much preferable and FAR less damaging to life and limb than either a firearm or a nightstick used as a club. If you believe otherwise, then perhaps you might interview police who have been hospitalized after being beaten nearly to death by folks on PCP, who ignored their own severe injuries while assaulting an officer.

    As for Machiavelli — with that idea I candidly don’t know what to do. I find truth, however, in an observation which I believe is from either Mark Twain or humorist Will Rogers: it is usually a mistake to attribute to conspiracy, behaviors that are equally plausible as outcomes of simple human cussedness.

    We aren’t going to settle these differences in perspective tonight. And likely not in ten years. But if we do not begin a process of organizing to support change in psychiatric practice, then I believe we will ultimately change nothing.

    Regards,

  • Chris, the Committees you reference would never have “lifted the veil” without being confronted by a groundswell of outraged public opinion. Most recently, that outrage has been prompted by the unauthorized revelations of Edward Snowden. During the Vietnam era it was Daniel Ellsworth.

    The committee process is probably a lot more vulnerable to such persuasion than the FDA and NIMH, acting to protect the interests of politicians and political appointees. Thus I suspect the groundswell must become a social tsunami before such people will deign to notice.

    Part of the tsunami is almost certainly going to require lawsuits filed by people such as yourself, with the aid and support of well-funded organizations. My article on “Lead, Follow, or Get Out of the Way” (mentioned above) is my attempt at a first step toward building such organizations. I do hope that the proposal gets a serious publication and discussion here on Mad in America.

    Regards

  • Jonah, it seems to me that you pose an intentionally provocative scenario in your question. But I will try to answer it as fairly as I can. Please realize in this that I’m a medical layman, not a psychiatric professional. So I’m trying to apply common sense.

    We really don’t have a choice of the first people outside family who will respond to an individual acting out violent or bizarre behaviors. Police are the only institution we have, who are trained to intervene and to separate violent or threatening people from potential or actual victims. We may advocate that police need to be better trained to avoid use of tasers or night sticks. But whether we like it or not, they will likely continue to be the first called outside of immediate family. If you see a different world, Jonah, I’d be interested in hearing a practical response on this issue. But in so doing, please realize that “should” doesn’t carry the argument if you propose to impose it on the people paying the bills.

    In the matter of forced drugging, I am in principle against the practice entirely. But we must also look at practicalities. It is possible to confine a violently acting out person and to offer support for their calming down and regulating their own behavior without drugs. It is also possible to place patients in isolation if they physically attack facility personnel who are charged with humanely confining them. But in both cases, we need to ask for how long and at what expense, when the one who is confined persistently rejects or is unable to enact behavioral regulation on their own behalf or by others.

    To demand that each “mad” man or woman receive free support and housing for the rest of their lives without qualification or condition is simply unrealistic in the world as we find it. At our present state of knowledge, at least some of those who act out bizarre patterns of disturbance won’t get better. They will never be able to live independently of external constraints (different from “restraints” in this context). A responsible response to madness must include a standard of care in the larger society, with regard to such people. And just as you would have the patient agree to any therapy offered them, so too must the society agree to the use of limited resources in housing and regulating people who cannot function independently. This is a double-edged sword.

    This is an argument that western society has already had at least once with many unintended consequences. Two generations ago, most “asylums” for the mentally disordered were phased out in favor of community discharge for all except the relatively few who clearly comprise an immediate or on-going risk of harm to themselves or other people. Because the society of that time was unwilling to create community based mental health support for large numbers of people, this step produced hundreds of thousands of homeless people. And the society of our own time continues unwilling to do so. So what practical alternatives do you propose, Jonah?

    Please understand that I am fully aware of the reality that mental hospitals do harm to the less disordered by mixing them with the seriously deranged and by medicating them with drugs whose effects are in some people toxic. But we cannot focus on the civil rights of the inmates of such facilities alone. We must also give attention to the civil rights of the larger society which we ask to support our disabled.

    Again as a practical matter, I suggest that this issue has wide-ranging ethical implications. Thus if we have an ethicist among the authors at Mad In America, I invite the commentary of one who is more deeply trained than I am in negotiating such issues.

    Regards and Best,
    Richard A. “Red” Lawhern, Ph. D.

  • Jonah and Jonathan,

    Thank you for your kind remarks. By way of follow-up, you might consider writing to MIA site management support the proposal. I would be happy to edit a version of Lead, Follow or Get Out Of The Way specifically for MIA, with credit to DxSummit for the initial publication.

    I would also offer an olive branch to others who revile any and all government judgements of the mentally and emotionally distressed. I share the view that government should not — under most circumstances — be empowered to lock people up for being deranged or disordered, so long as they do not comprise a threat of violence.

    That said, there is still a dimension of law that I believe we need to consider. Legal action will almost certainly be required to break the strangle hold that Big Pharma now exercises over government and accepted medical / mental-health practice. Corporate officers need to be sent to jail for collusion and conspiracy to defraud. Corrupt professional institutions such as the APA need to be sued out of existence or their influence greatly curtailed. And “some” standard such as the Compendium I have suggested seems required in order to establish practice standards under which malpractice and quackery can be prosecuted when patients are palpably harmed. Government shouldn’t establish that standard, but it may be the only institution well enough funded to pay for its development.

    Further response to “Lead, Follow or Get Out of the Way” is invited and welcome. I have no monopoly on thoughtful concern and certainly no oracular powers of divination in what will work and what will not, for the improvement of the healing arts.

    Again, thanks for your kind remarks…

  • Dr Steingrad has started (or perhaps continued) a very wide ranging discussion here at Mad in America. For that start, my thanks added to those of many others. We have seen responses that span many moral, ethical, and philosophical positions. Some have related their own experiences and mis-adventures as patients coerced by psychiatry and the forced use of psychoactive drugs. Others have advocated for abolition or reform of psychiatry as a profession.

    But I must wonder: in three days of discussion, has anything fundamentally changed? Are we any closer to something actionable that might materially improve the ability of well-intended professionals to help people in distress, or protect patient autonomy and human rights when confronted by physicians convinced of their own omnipotence and insensitive to the harms they may be doing?

    There are many dimensions in the practice of the healing arts — both medicine and cognitive/emotional support and therapy. As a technically trained medical layman (engineer and chronic pain patient advocate), I make no claim to deep expertise. But I think I recognize when people are running around in ever-widening circles of polemic and avoidance. I see some of those circles revolving here and I find myself wanting to scream STOP!

    This is not the first time I have pointed out that g0od intentions and moral philosophy don’t matter unless something actually changes. Last September, I attempted a similar project in a different forum: The Global Summit for Diagnostic Alternatives, hosted by the Society for Humanistic Psychology. As I pointed out there and will risk repeating myself here, NOTHING that has passed in this otherwise very interesting thread of discussion will ultimately matter unless it can be turned into a program for substantive change that people can get behind with their dollars and their organized public advocacy. NOTHING.

    I attempted to suggest just such a program. I invite others here at MIA to read it at http://dxsummit.org/archives/1290 and to start a separate discussion at MIA of its implications. I realize that I may be naive, mistaken, or simply uninformed of medical literature. So nobody has to sign up to my personal vision. But can’t we agree to TRY to do more than just talk?

    The article on DxSummit was titled “Lead, Follow, or Get Out of the Way — A Layman Perspective on Change”. I invite authors, discussants and staff at MIA to create and nurture a process that might actually implement parts of that vision as reality. It won’t happen overnight. But if we can’t get beyond venting and arguing with each other, it won’t happen at all.

    Sincerely,
    Richard A. “Red” Lawhern, Ph.D.
    Resident Research Analyst, Living With TN,
    an online community within the Ben’s Friends cluster for patients with rare medical disorders.

  • Francesca, that is indeed what I had in mind. Thanks for pointing that out.

    And if I may, a footnote for those who believe that viable non-pharmaceutical protocols exist for the severely disturbed and distressed: how many such alternatives have generated repeatable results in controlled randomized double-blind trials?

    Regards,

  • In your own context, you take my point. Criticism is easy, but real change is disruptive and hard. But the question remains: HOW can this issue be moved off dead center? How can the distressed consciousness be helped or healed — or more realistically, how can we suppress entrenched interests for long enough to learn how? What’s the program? Where are the specifics?

    Lead, Follow, or Get Out Of the Way!

  • A demand for scientific rigor would likely result in abolition of the majority of the “diagnoses” in the DSM-5.

    I have written at other sites that even a minimal standard of accepted practice should demand that a “disorder” be identifiable by signs and symptoms, consistently distinguishable from other “disorders”, and have at least one recognized protocol for treatment that has been demonstrated to be both reliably effective and safe. Failing any of these three criteria, what we have is a person in distress whose treatment should be limited to the minimum needed to keep them from harming themselves or others — or otherwise limited to that which they request or to which they explicitly consent.

    This isn’t a trivial process of winnowing down. And it isn’t issue-free. But it might represent a major positive sea change for psychiatry as it is now practiced.

  • I write as a medical layman who advocates for and supports chronic pain patients in online media. I frequently observe the consequences of failures in both the medical and mental health practice systems, in what amounts to doctor abuse of patients with rare or unusual medical disorders, by writing them off as “psychosomatic”.

    From 18 years of active engagement with patients and wide reading in medical literature, I offer the following observations.

    1. There is real anguish in the world and in individuals. Psychiatry and psychology have done an awful and ineffective job of addressing or mediating that anguish. There is abundant evidence of professional psychiatric coercion of people in distress, and of intentional conspiracy to defraud in false claims of “safe” pharmaceutical treatment. Alternatives in psychotherapy equally lack valid science and repeatable outcomes.

    2. The DSM process and its parent institution, the APA, have been corrupted by pharmaceutical companies and by professional hubris. The diagnostic categories of the DSM are unsupported by science and the very concept of “mental disease” may be a misnomer. The National Institutes for Mental Health no longer employ the DSM as an organizing framework for research. It should also be abolished as a source of codes for insurance reimbursement.

    3. The human brain, consciousness and mind may be the most complex organism that we know. After 60 years of promised “progress”, the brain disease model for emotional and cognitive distress remains an abject failure, with little prospect of future breakthroughs in the amelioration of human distress.

    4. There are many critics of the state of affairs described above. Criticism is easy. It is real change that’s hard. None of the critics has set forth a detailed program or proposal for how society can get from where we are, to a better state.

    5. Arguing over the abolition versus reform of psychiatry doesn’t get us closer to a program or to any useful end goal. The argument is a mere distraction, an exercise in ego or misdirection which benefits only those who benefit from the current state of affairs.

    If you would abolish psychiatry, then tell us with what you would replace it, to aid people in distress. If you would reform the profession, then offer a realistic concept for beating into legal submission, the politicians that Big Pharma has bought and paid for with campaign contributions.

    STOP THINKING SMALL. As a wise sage informed us generations ago, the essence of madness is doing the same things over and over again and expecting the outcome to be different.

    Respectfully,
    Richard A. “Red” Lawhern, Ph.D.
    Resident Research Analyst
    Living with TN — an online community among Ben’s Friends
    Contributor, “Helping the Distressed Consciousness”, @psyguyots

  • What puzzles me is why none of the corporate perpetrators of these medical atrocities have ever been criminally prosecuted as individuals under Racketeer-Influenced and Corrupt Organizations laws. I would think that any moderately bright District Attorney who isn’t on the take from Big Pharma would immediately recognize the character of the participation of corporate boards in massive fraud, reckless endangerment, and negligent homocide.

    Does corporation law protect an individual from prosecution for second degree murder?

    Thank you for this and other alarm bells, Dr Gotzsche.

    Sincerely,
    Richard A. Lawhern, Ph.D.
    Resident Research Analyst
    Living With TN — an online community within the Ben’s Friends cluster for patients with rare medical disorders.

    Fair disclosure: I write as a medical layman and patient advocate, not as a medical professional.

  • Vera, would you have any objection to cross-posting this article and comments (with attribution to Mad in America and to you by name) to DxSummit.org, “The Global Summit for Diagnostic Alternatives”? I believe many of the points you make may have value as that group prepares for a conference on practice issues in contemporary psychiatry and psychology.

    Sincerely,

    Richard A. “Red” Lawhern, Ph.D.
    Resident Research Analyst
    Living With TN
    http://www.livingwithtn.org

  • I believe that many people of good will already realize that psychiatric atrocities exist and must be stopped. The rub has always been “how to make it happen.” A few months ago, I posted a long article on DxSummit.org, the “Global Summit on Diagnostic Alternatives” of the Society for Humanistic Psychology. It was titled “Lead, Follow, or Get Out of the Way — A Layman Perspective on Change”. It may be read at http://dxsummit.org/archives/1290 . It is very telling that among the 120 or so subscribers to that worthy forum, the response to the article has been a crashing silence. It would seem that many of the professionals who regularly contribute to the site may be more interested in discussing change, than they are in developing any program to actually make change happen in real terms.

    Ultimately, I intuit that a large part of what needs to happen will likely be facilitated by lawyers rather than even the most informed psychiatrists and psychologists who have sold their books by the tens of thousands. Insurance companies are going to have to decide that it is potentially ruinously expensive to protect physicians who apply prevailing “standards” such as the DSM-5 without a scrap of evidence that the disorders being diagnosed are even real — much less that the treatments forced on patients are actually effective. Class action suits may be needed to make the point that the American Psychiatric Association is in effect if not in detailed purpose, a Racketeer Influenced and Corrupt Organization.

    I will read your blog posting in the coming week.

    Regards, Red

  • For all of those who have been mistreated (aka “abused”) by medical practitioners who have applied mythical diagnostic labels of psychosomatic disease, there is a book which you may wish to share with your physicians. Angela Kennedy is tough reading but necessary: “Authors of Our Own Misfortune? Problems with psychogenic explanations for physical illnesses”. I will shortly be submitting a review to Amazon on this important book. It utterly demolishes the imprecise terminology, circular reasoning, bias, and outright incompetence of practitioners of so-called “psychosomatic medicine”.

    Even if you find the prose difficult to get through on your own, you may find it appropriate to buy a copy and deliver it to practitioners who still pretend that there is any “science” beneath their specious claims of psychogenic or psychosomatic illness. There isn’t.

  • Ms. Bradshaw,

    Thank you for a cogent and moving narrative. With your permission, may I cross-post this article with a short introduction to the Global Summit for Diagnostic Alternatives, sponsored by the US Society for Humanistic Psychology?

    There are many parallels in your article to points raised by several of the discussants at DxSummit.org . You may also find of interest, a paper which I published there on “Psychogenic Pain and Iatrogenic Suicide”. In that paper I offer evidence that the simple act of interjecting a psychosomatic diagnosis into the medical records of a chronic pain patient, is responsible for a 250% increase in suicide risk. See http://dxsummit.org/archives/1002

    Sincere best regards,
    Richard A. Lawhern, Ph.D.
    Resident Research Analyst and Moderator,
    Living With TN — An Online Community Within Ben’s Friends

  • I believe Rxisk is indeed run by Dr. Healy.

    There may also be something of value to you in the directions of advocacy, at “The Law Project for Psychiatric Rights” — http://psychrights.org/

    Increasing numbers of people are coming to see that many dimensions of psychiatry are misapplied — not only in medical cases like yours, but far more generally. The psychiatric establishment has refused to wake up and own up for their complicity in the vast over-medication of millions of people, and the forced medication of kids with psychoactive drugs that cause serious harm. The tendency of medical doctors to write off their harder cases as “head” cases is only one dimension within this overall context.

    I wish you well. Go talk with a lawyer. I think you may need one.

  • Menim,

    I am continuing to work at keeping the issues of chronic pain and the many abuses of psychosomatic medicine in the public eye. So far, Mad In America hasn’t chosen to support an ongoing blog for me. But I posted the following commentary on the personal Blog of Dr David Healy in the UK. Healy describes himself as a psychiatrist, psycho-pharmacologist, and author of over 150 peer-reviewed professional articles.

    ==========Comment as published============

    May I add to the discussion of the mistreatment of mental disturbance with psycho-active medications? As important as the issue is, over-prescription is by no means the only failing of modern psychiatry.

    As a patient advocate and online community moderator, I frequently interact with people who are under medication for chronic pain conditions. It is amazing and disheartening how many of these people have been labeled as psychosomatic, and thus effectively denied further medical evaluation or treatment for rare conditions that have little to do with mental health.

    Some are told explicitly that their depression or anxiety have “caused” a psychogenic condition of pain, fatigue, or generalized debility. Prior to the May 2013 publication of the 5th edition of the Diagnostic and Statistical Manual of the American Psychiatric Association, such patients might be diagnosed with “somatoform” disorders on grounds that they persistently presented with “unexplained medical symptoms (UMS)” that a doctor could trace to no known medical entity. The DSM-5 reversed that logic, proclaiming that any patient whose life is affected by prolonged “disproportionate concerns” for their medical condition can now be diagnosed with so-called Somatic Symptom Disorder — *whether or not* they have medically unexplained symptoms.

    Does anybody else detect a “Catch 22” in this disordered and illogical professional thinking by psychiatrists? You are anxious because six doctors have failed to find an explanation or treatment for pain which leaves you in a fetal ball on the floor several times a day. So now your anxiety becomes a mental health disorder? It’s your fault?

    By writing off “difficult” or “hysterical” patients as head cases, medical doctors and their psychiatric accessories are likely directly contributing to patient suicides. There is ample plausible evidence for this association in recent large-sample patient surveys. I offer this case in a paper titled “Psychogenic Pain and Iatrogenic Suicide”, published on the Global Summit for Diagnostic Alternatives of the Association for Humanistic Psychology. See http://dxsummit.org/archives/1002 .

    I believe it is time and past time that organizations like the APA and its non-US equivalents are sued for their complicity in massive patient harms. And legislators need to be held to account for taking political campaign contributions from pharmaceutical companies.

  • I should add one balancing precautionary note. Some few of the psycho-active medications do have a role to play in management of neuropathic pain such as can occur in a hip injury or any blunt trauma injury. The tri-cyclic antidepressant family (in low doses) has been demonstrated useful in managing neuropathic pain. It is felt by some researchers that the TCA’s reduce the sensitivity of a neurochemical “channel” which serves multiple functions in both acute pain and emotional affect involved in depression. That said, I would suggest that even the use of TCA meds should be carefully managed to assess the ongoing need and balance that need against untoward side effects.

    Keep on truckin’, Menim… I wish you wellness.
    Red

  • Menin, yours is a story that I hear entirely too often from women. It is well established in medical literature that proportionately more women than men will die from their first heart attack, because they have been ignored as “hysterical” by an examining doctor. Likewise, it is not uncommon for women to be labeled as “depressive” or “anxious” when they come to a general practitioner with complaints of breathing problems or chest pain. Anxiety can indeed be associated with these symptoms, but there is simply no excuse for a doctor refusing to do appropriate medical testing or imaging, to rule out physical disease.

    Early in 2013, an article in the Daily Mail, a UK newspaper, reported the sad story of Lisa Smirl, a female University professor. She was been written off this way by ” a string” of UK general practitioners. The woman died of lung cancer at age 37. I haven’t seen any evidence that the doctors have been disciplined, much less thrown into prison for voluntary manslaughter. But they should have been.

    See http://www.dailymail.co.uk/health/article-2290128/University-professor-37-dies-lung-cancer-doctors-dismissed-symptoms-anxiety-depression.html

    Regards and best, Red

  • Yours is a story that I hear rather often from patients with fibromyalgia, Lupus, Psoriatric Arthritis, and various auto-immune diseases. Medical symptoms are rather often mis-diagnosed in the early stages, and written off by general practitioners as “somataform” issues (a fancy word for “I don’t know what you have, so you must either be shamming for attention, or have a mental disorder.” In some cases, the misdirections created by assignment of a psychosomatic diagnosis can be traced directly to the death of the patient from the actual but missed disease, or from suicide induced BY THE DOCTOR due to the depression caused by dismissal and marginalization of the patient. If it were up to me, the entire DSM category of psychosomatic disorders would be embargoed as invalid, unproven, and actively dangerous to patient welfare.

    Regards and best, Red

  • In this blog, I will generally try to concentrate on issues of psychosomatic medicine as they impact pain patients and other medical patients. However, for Menim particularly, I can say in defense of doctors, that classic trigeminal neuralgia is so rare that many general practitioners never see a case in a 40 year career (estimated 12 new cases per hundred thousand per year is “in the noise” compared to mainstream illnesses like MS or heart disease).

    On the other side of this equation, however, it seems to be the case that dentists are generally very ill trained in the assessment of non-dental facial pain. In a demographic survey that I conducted among 1100 members of “Living With TN”, about a quarter attributed the beginning of their chronic facial pain to a dental procedure — almost always utterly disclaimed by the dentist. I is possible that some of these cases involved coincidental emergence of neurological pain that would eventually have occurred whether or not a root canal had been done. But we really have no way of knowing with precision.

    Regards, Red

  • Thank you for your good wishes, Menin,

    In the support work and online research that I do with chronic face pain patients, I see stories like yours fairly often. I find that a lot of physicians simply do not acknowledge that response to medications is highly individual and some people are clearly “hyper-sensitive” or outright allergic to a wide range of them. Several of the meds used to treat chronic trigeminal pain have been implicated in potentially lethal reactions by a few patients. So far, there are no FDA approved meds specifically targeted on the trigeminal system.

    In a case where traumatic injury is indicated, most specialists would probably attribute your face pain to neuropathy rather than to neuralgia. Neuropathy heals in some patients — and not in others. The tri-cyclic antidepressants seem to be one of the few classes of meds that work with neuropathy. But we don’t always know how to distinguish between who is a good candidate for medication against neuropathy and who isn’t. Likewise, follow-up and blood testing are needed periodically to ensure patient safety, and not a few doctors don’t seem to do this very well.

    In the more classic “spontaneous” emergence of classic TN with its volleys of electric-shock stabs, (as contrasted to constant burning, throbbing, achy pain in what is called “atypical” TN), the alternatives available presently tend to focus on off-label use of anti-seizure meds and anti-convulsants. Five different surgical procedures are available, each with their benefits, but each also carrying risks of horrid down-stream side effects if something goes wrong or if pain recurs after healing. Sometimes it’s a Hobson’s choice between them.

    For others concerned with chronic face pain issues, I would recommend the US National Institutes of Health fact sheet on trigeminal neuralgia as a place to start: http://www.ninds.nih.gov/disorders/trigeminal_neuralgia/detail_trigeminal_neuralgia.htm In a spirit of fair disclosure, I re-wrote this fact sheet and negotiated with NINDS for over a year to get it approved.

    Go in Peace and Power
    Red

  • Patrick, I’m coming in on your article and the comments threads a bit late in the game. But I wonder if you might be willing to amplify on one issue that seems to me a natural part of the polylog.

    If we accept as “given”, the malfeasance of the pharmaceutical industr, and the passive or active participation of some significant number of medical practitioners… then what should concretely be done about these conditions? Can your insights into a basic problem of ethics and medical practice be turned into an actionable program of change that materially improves standards of practice and public policy?

    This is not to disparage your insights at all. Merely to invite your thoughts on the natural next steps in correcting the conditions to which you speak.

    Sincere best regards…

  • Thanks for an illuminating article, Johanna. I quite agree with your points on patient right to know. I would perhaps go further, by lobbying for changes in US public law. We need to require pharmaceutical companies to submit not only their cherry-picked positive results, but indeed ALL of the data generated in trials, before a drug can be approved for use by the US Food and Drug Administration. Negative outcomes should be reported both to the FDA and the public.

    Keep up the good work.

    Regards and best,
    Richard A. Lawhern, Ph.D.
    Resident Research Analyst
    Living With TN — http://www.livingwithtn.org

  • Aria, I agree that general practitioners and even some neurologists are inadequately trained in the management or cure of chronic pain conditions. I also agree that women are disproportionately affected by this deficiency, which seems to have led many mainstream medical practitioners to write off their “difficult” female patients as hysterics. I am actively working to challenge these patterns and to recommend appropriate assertiveness training to patients who encounter casual dismissal of their reports of chronic pain from their physicians.

    Watch this space for further articles. I’ll try to get back every few weeks, around the edges of providing real-time online assistance to almost 5,000 chronic face pain patients in 117 countries.

    Regards and best,
    Red Lawhern, Ph.D.
    Resident Research Analyst
    Living With TN: http://www.livingwithtn.org

  • Appreciate your feedback, Ted. I hope to publish further articles here on Mad in America concerning the misapplication of so-called “psychosomatic medicine” to people with subtle or undiagnosed medical symptoms. Working with chronic face pain patients, I see the damage that this branch of medicine does to people in pain almost every day.

    Thanks again,
    Red

  • There is also a significant link between risk of suicide and the act of a medical or mental health professional in assigning a diagnosis of so-called “psychogenic pain”. Leveraging from a landmark US Veterans Administration study of 4.8 million patients over three years, I offer a case for abolishing this term, in “Psychogenic Pain and Iatrogenic Suicide”, on the Global Summit for Diagnostic Alternatives. See http://dxsummit.org/archives/1002

    Sincere best regards,
    Richard A. Lawhern, Ph.D.