What a shock to hear of Darby Penney’s death — it is a huge loss for all who have ever thought that the mental health system should be and could be transformed. It is also a reminder that a “second generation” of activists, organizers, and psychiatric survivors is passing on…
From the many times I heard Darby in NARPA and other conferences starting in the 1990s, I remember her as one of the most dignified people I met, projecting an aura of quiet but formidable determination, a power that sprang from her deep convictions and vast knowledge. But I knew also that she could be fearsome! Darby was impressive, she had class. She did not desist from the task — she spoke forthrightly, labored tirelessly.
Joanna Moncrieff performs another public service by submitting the modern, sanitized, “public health” craze about psychedelics to skeptical evaluation. Benefits gained from occasional psychedelic trips are not health effects unless that concept is stretched silly. Supervised short-term use recommended by authorities steeped into the dogma of mental illness and psychopharmacology is likely to become long-term use with inevitable complications. As disillusionment with 70 years of usual prescription psychotropics sets in, people looking for alternatives may too easily fall for claims (old and worn that they are) that, finally, *these* drugs, recommended by *these* experts, and taken *these* ways, are the solution. Buyer beware.
Thank you Philip Hickey for your elegant, readable deconstruction of the recent version of the dopamine hypothesis.
Researchers with years of training and experience should know that even statistically different mean values do not establish that meaningful differences exist between two groups if the individual values in both groups largely overlap, and if the group sizes are small. Unfortunately, studies with small samples are common in neuroscience. They overestimate the strength of postulated relationships and yield findings that are very difficult to reproduce. The systematic construction of ignorance is an expensive, wasteful, and dangerous activity.
Thank you Sandra for keeping the discussion on focus. If tomorrow all psychiatrists were to refuse to coerce anyone to go into a mental hospital, we would probably have to push people away from requesting room and board in mental hospitals.
Involuntarily hospitalized people present with many different kinds of problems, and many different varieties of disruptiveness. I’d like to take some time to characterize these differences, and propose in the near future in these pages how to replace involuntary mental hospitalization following a bold move by a morally renewed psychiatry.
It appears therefore that coercive activities are part of your professional identity, something that evolved and strengthened over time. But they’re also something which you could give up if you wished. Your livelihood wouldn’t be threatened.
Doing something distasteful or against your principles because if not, someone else would be asked to do it, seems to me to deserve more critical analysis on your part. It may be understandable the first time you’re asked to do it, but after a while I believe you should be extricating yourself from the situation for good. (Of course most things are easier said than done.)
The discussions below, from Jonah and TheSystemisBroken, are on the money I think. The criminal justice system does have, in principle, different ideas about what constitutes an offense and how to deal with an accused person, than the psychiatric system. In practice,however, both systems have morphed into a larger social control system, much like it was 120 years ago, so of course your own disavowal of coercion might not, in the immediate, make a difference to most of the coerced. But it surely would set an example to the rest of psychiatry. It would say that one does not need to make the practice of coercion part of one’s professional identity. Otherwise, you’re agreeing with my suggestion (despite stating that you disagree), that most practicing psychiatrists would give up any intervention except coercion.
To the extent that your own practice and livelihood does not depend on maintaining your occasional coercive activities, and to the extent that your practice is representative of psychiatric practice in the U.S., then your explanations provide, for me, some evidence that psychiatric physicians choose to coerce, they are not forced or compelled to do so. Thus I call on them, as their colleagues Szasz and Borelli and Breggin (and Mosher?) and Bracken and Thomas and others have also called on them, to relinquish coercion.
I believe that intellectually, this would “free their minds” — and the minds of many other people throughout society — to entertain vastly more possibilities about what they could do as helpers, and what all of us could do. The so-called “medical model” would become just another culture of healing, not the law of the land, pursued or practiced only by those interested in it.
Thank you very much Sandra for posting your comment and question.
The direct issue I am addressing, as you understand correctly, is that of psychiatry as the instrument of coercion.
To replace this instrument, I suggest the police or the military, which in civil society are typically granted the monopoly of force. Psychiatrists who want to coerce can work for the police or the military, and they should wear police or military uniforms. There would be less confusion in people’s minds about what they are there to do. There would also be the expectation that they are bound by the same laws that bind police.
Since you write that you “would gladly give up this power,” I naturally wonder what might prevent you from doing so.
In an undated paper, British psychiatrists Pat Bracken and Phil Thomas (MIA blogger) suggested, as one step to tackle coercive psychiatry, “to remove doctors from the processes that lead to compulsory admission,” (1) relinquishing this to whichever other professionals would wish it. I believe this is an admirable suggestion. It recognizes that civil society coerces, but it reminds us that professionals make a choice when they participate in coercive social control. However, perhaps relinquishing this power is, for individual psychiatrists, more complicated than it might seem. In America, the tiny handful of individual psychiatrists who have publicly urged such limits for their peers have been severely ostracized, as you know, though they simultaneously rejected other psychiatric ideas and practices.
That’s why it would be truly enlightening, truly exciting, if you would consider discussing this in practical terms, from your perspective. I’m unaware of any such discussions in the literature.
Thus my respectful question to you: Do you (believe that you) have a choice to give it up? Do you perceive constraints, e.g., expected negative consequences like formal or informal reprisals, removal of hospital privileges, ineligibility for certain third-party reimbursement, etc.? Or is it a choice with mainly moral consequences?
It seems to me that professions like medicine and social work have seldom resisted initiatives to increase their power (like mandatory reporting of confidential information, or committing people to psychiatric institutions). Thus, too few role models exist of professional associations urging their members to limit their power. The only example that comes to my mind is when, in 2003, librarians in several cities in the U.S. resisted the strictures of the Patriot Act (to inform the FBI concerning certain research activities by library patrons).
Thank you kindly Steve for your appreciation of Mad Science.
As I tried to point out (too briefly perhaps) in the article, coercion predates the medical model of madness. We chained madmen and madwomen before we believed they suffered from any sort of biological disease.
Coercion needs no justification, except the coercer’s view that it’s necessary. All sorts of ideologies and views—supernatural or scientific, theological or medical—have justified coercion (in and out of psychiatry).
I’m afraid I don’t have any valuable insights into “how [to] influence public opinion” besides the usual banalities, although I’m a great believer in the power of art to change hearts and minds.
Perhaps a committee of 10-15 people from this website could draw a list of extraordinarily creative suggestions.
But I do know, from Ghandi and King, and of course Alinsky, that very dedicated people influence the public by radically changing their own behavior in line with their clearly stated non-violent principles, no matter the circumstances. By doing so unwaveringly, they attract people to their cause, who try to act like them and in doing so, keep the cause in the public eye. Eventually, public opinion changes.
No one in the mainstream challenges psychiatric coercion. No one in the mainstream states publicly that coercion distinguishes psychiatry from every other caring discipline (although again these disciplines are moving in the psychiatric direction). There does not even exist a number indicating how many people are officially coerced psychiatrically each year (perhaps 3 to 5 million?) with the aiding and abetting of the state. This silence, akin to a reverence, is more telling about the importance of psychiatric coercion than any case I could make.
Thank you for this heart-warming appreciation. I’m especially gratified that you find the piece “clearly stated.” To assist people to think clearly, if it can’t be said in plain language, perhaps it shouldn’t be said.
There is no Ultimate Truth to which I have access! Just some insights and hypotheses gleaned from observations, conversations, debates, and reading… and life. But I have been at it for some time.
(I’ll be happy to send you some or many of my publications if you contact me directly by email at cohen_at_luskin_dot_ucla_dot_edu)
Thank you.
Without knowing just what Patrick McGorry meant by people “not get[ing] access” to treatments (whether they’re not available, or they’re too expensive, or people are diverted away from them by first-line drugging, etc.), it’s difficult to respond clearly.
It’s possible that Patrick McGorry meant by psychiatric treatments the whole range of interventions–individual, group, social, educational–available in the mental health system, which could make his comment reasonable.
It is probably true that many people simply do not have access to alternatives to the usual “care,” principally for economic reasons, and secondly because these might not be offered in their community (again for various reasons).
But, there are so many physical illnesses and so many treatments for them, that I’m not sure what is the accepted effectiveness rate for medical treatments–or if anyone has truly tried to estimate this for the whole range of medical treatments.
There are various claims that both medical and psychiatric drug treatments are effective for about 70% of those who take them, but these have been refuted, lately, by the large CATIE, STAR*D, and STEP-BD studies: over a year or more, only about one third of people who take antipsychotics, antidepressants, and various other drugs report feeling better or not “relapsing.” (Neither of these studies included placebo controls, however.)
But the notion of a “culture of holistic care” does sound quite appealing.
Overall, I believe that less coercion would mean many, many more choices available in society for helping people in distress, because all of us would invest more creative energy and resources in trying to prevent breakdowns and crises that lead to the use of coercive measures. I believe that Richard Lewis makes this point in his recent blog on abolishing coercive treatment.
Some of the precisions you bring forth make me re-emphasize the broad differences between the French and American way of handling what we usually call, in the US, “ADHD” and what is still not usually called “ADHD” in France. The bottom line is that mass medicating of children (10-20% or more in North America, depending on region) is not known in France. Naturally, as I tried to state, what we observe today may be different in the next few years.
The reference to the medical system — and to France’s SECU’s extremely generous approach to subsidizing medications relative to the US — is that some people view the lower prescription of stimulants to French kids as a sign that the country is not “medically” oriented. Whether the French health care system is #1 or #5 in terms of access and performance (given whatever standards on is using to judge) is not the point: the point is that France is extremely medically oriented and people flock to their GPs for medications for anything and everything. And that is precisely why the lower use of stimulants among children (and the official non-prescription to pre-schoolers) is noteworthy.
The recent assault on psychoanalysis in France is well documented. Perhaps it is particularly virulent because psychoanalysis has been so dominant there, and for years squelched other perspectives and cultures of healing. Nonetheless, a substantial number of practicing child psychologists have been steeped in the psychodynamic tradition, and this appears to contribute to the situation I sketched in my post.
You are right about the influence of the pharmaceutical industry in France, and indeed France chose the strategy of encouraging internal consumption of pharmaceutical products rather than international competition of its firms. One result is the sheer number of different drug preparations (most without therapeutic value) on the French market relative to other countries. But again this supports my point about the cultural difference in viewing childhood between countries, regardless of the structure of the health care system.
The popularity of the DSM in France is growing, as I hinted. But it remains completely unclear how it is used, and whether it is used extensively in extra-medical and extra-hospital settings, and especially so in child assessment. The critiques of the DSM have been just as pronounced as here, with at least six or seven books on the market there railing against the DSM approach. Other systems such as the CFTMEA may be no better, of course, but that tool is based on a completely different, psychodynamic, approach to problems, which does not view them as distinct disorders.
I did not intend to present a rose-tinted view of France as a paradise for children, merely to emphasize the differences between the French and American management of young children who present problems for their schools and families.
Excellent, excellent article, right on target. Congratulations for all your posts. You have laid down the challenge: <>
To complete the challenge, we will also need to come up with alternatives to psychiatric *excuses* for criminal behavior.
What a shock to hear of Darby Penney’s death — it is a huge loss for all who have ever thought that the mental health system should be and could be transformed. It is also a reminder that a “second generation” of activists, organizers, and psychiatric survivors is passing on…
From the many times I heard Darby in NARPA and other conferences starting in the 1990s, I remember her as one of the most dignified people I met, projecting an aura of quiet but formidable determination, a power that sprang from her deep convictions and vast knowledge. But I knew also that she could be fearsome! Darby was impressive, she had class. She did not desist from the task — she spoke forthrightly, labored tirelessly.
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Joanna Moncrieff performs another public service by submitting the modern, sanitized, “public health” craze about psychedelics to skeptical evaluation. Benefits gained from occasional psychedelic trips are not health effects unless that concept is stretched silly. Supervised short-term use recommended by authorities steeped into the dogma of mental illness and psychopharmacology is likely to become long-term use with inevitable complications. As disillusionment with 70 years of usual prescription psychotropics sets in, people looking for alternatives may too easily fall for claims (old and worn that they are) that, finally, *these* drugs, recommended by *these* experts, and taken *these* ways, are the solution. Buyer beware.
Report comment
Thank you Philip Hickey for your elegant, readable deconstruction of the recent version of the dopamine hypothesis.
Researchers with years of training and experience should know that even statistically different mean values do not establish that meaningful differences exist between two groups if the individual values in both groups largely overlap, and if the group sizes are small. Unfortunately, studies with small samples are common in neuroscience. They overestimate the strength of postulated relationships and yield findings that are very difficult to reproduce. The systematic construction of ignorance is an expensive, wasteful, and dangerous activity.
Report comment
Thank you Sandra for keeping the discussion on focus. If tomorrow all psychiatrists were to refuse to coerce anyone to go into a mental hospital, we would probably have to push people away from requesting room and board in mental hospitals.
Involuntarily hospitalized people present with many different kinds of problems, and many different varieties of disruptiveness. I’d like to take some time to characterize these differences, and propose in the near future in these pages how to replace involuntary mental hospitalization following a bold move by a morally renewed psychiatry.
Report comment
Thanks Sandra for your reply.
It appears therefore that coercive activities are part of your professional identity, something that evolved and strengthened over time. But they’re also something which you could give up if you wished. Your livelihood wouldn’t be threatened.
Doing something distasteful or against your principles because if not, someone else would be asked to do it, seems to me to deserve more critical analysis on your part. It may be understandable the first time you’re asked to do it, but after a while I believe you should be extricating yourself from the situation for good. (Of course most things are easier said than done.)
The discussions below, from Jonah and TheSystemisBroken, are on the money I think. The criminal justice system does have, in principle, different ideas about what constitutes an offense and how to deal with an accused person, than the psychiatric system. In practice,however, both systems have morphed into a larger social control system, much like it was 120 years ago, so of course your own disavowal of coercion might not, in the immediate, make a difference to most of the coerced. But it surely would set an example to the rest of psychiatry. It would say that one does not need to make the practice of coercion part of one’s professional identity. Otherwise, you’re agreeing with my suggestion (despite stating that you disagree), that most practicing psychiatrists would give up any intervention except coercion.
To the extent that your own practice and livelihood does not depend on maintaining your occasional coercive activities, and to the extent that your practice is representative of psychiatric practice in the U.S., then your explanations provide, for me, some evidence that psychiatric physicians choose to coerce, they are not forced or compelled to do so. Thus I call on them, as their colleagues Szasz and Borelli and Breggin (and Mosher?) and Bracken and Thomas and others have also called on them, to relinquish coercion.
I believe that intellectually, this would “free their minds” — and the minds of many other people throughout society — to entertain vastly more possibilities about what they could do as helpers, and what all of us could do. The so-called “medical model” would become just another culture of healing, not the law of the land, pursued or practiced only by those interested in it.
Report comment
Thank you very much Sandra for posting your comment and question.
The direct issue I am addressing, as you understand correctly, is that of psychiatry as the instrument of coercion.
To replace this instrument, I suggest the police or the military, which in civil society are typically granted the monopoly of force. Psychiatrists who want to coerce can work for the police or the military, and they should wear police or military uniforms. There would be less confusion in people’s minds about what they are there to do. There would also be the expectation that they are bound by the same laws that bind police.
Since you write that you “would gladly give up this power,” I naturally wonder what might prevent you from doing so.
In an undated paper, British psychiatrists Pat Bracken and Phil Thomas (MIA blogger) suggested, as one step to tackle coercive psychiatry, “to remove doctors from the processes that lead to compulsory admission,” (1) relinquishing this to whichever other professionals would wish it. I believe this is an admirable suggestion. It recognizes that civil society coerces, but it reminds us that professionals make a choice when they participate in coercive social control. However, perhaps relinquishing this power is, for individual psychiatrists, more complicated than it might seem. In America, the tiny handful of individual psychiatrists who have publicly urged such limits for their peers have been severely ostracized, as you know, though they simultaneously rejected other psychiatric ideas and practices.
That’s why it would be truly enlightening, truly exciting, if you would consider discussing this in practical terms, from your perspective. I’m unaware of any such discussions in the literature.
Thus my respectful question to you: Do you (believe that you) have a choice to give it up? Do you perceive constraints, e.g., expected negative consequences like formal or informal reprisals, removal of hospital privileges, ineligibility for certain third-party reimbursement, etc.? Or is it a choice with mainly moral consequences?
It seems to me that professions like medicine and social work have seldom resisted initiatives to increase their power (like mandatory reporting of confidential information, or committing people to psychiatric institutions). Thus, too few role models exist of professional associations urging their members to limit their power. The only example that comes to my mind is when, in 2003, librarians in several cities in the U.S. resisted the strictures of the Patriot Act (to inform the FBI concerning certain research activities by library patrons).
1. Bracken, Pat, and Thomas, Phil. (no date). Mental health legislation: Time for a real change. Available from: http://www.critpsynet.freeuk.com/OPENMiND3.htm
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Thank you kindly Steve for your appreciation of Mad Science.
As I tried to point out (too briefly perhaps) in the article, coercion predates the medical model of madness. We chained madmen and madwomen before we believed they suffered from any sort of biological disease.
Coercion needs no justification, except the coercer’s view that it’s necessary. All sorts of ideologies and views—supernatural or scientific, theological or medical—have justified coercion (in and out of psychiatry).
Report comment
Thank you for your comment Frank.
I’m afraid I don’t have any valuable insights into “how [to] influence public opinion” besides the usual banalities, although I’m a great believer in the power of art to change hearts and minds.
Perhaps a committee of 10-15 people from this website could draw a list of extraordinarily creative suggestions.
But I do know, from Ghandi and King, and of course Alinsky, that very dedicated people influence the public by radically changing their own behavior in line with their clearly stated non-violent principles, no matter the circumstances. By doing so unwaveringly, they attract people to their cause, who try to act like them and in doing so, keep the cause in the public eye. Eventually, public opinion changes.
Report comment
Thank you Ted.
No one in the mainstream challenges psychiatric coercion. No one in the mainstream states publicly that coercion distinguishes psychiatry from every other caring discipline (although again these disciplines are moving in the psychiatric direction). There does not even exist a number indicating how many people are officially coerced psychiatrically each year (perhaps 3 to 5 million?) with the aiding and abetting of the state. This silence, akin to a reverence, is more telling about the importance of psychiatric coercion than any case I could make.
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Thank you very kindly Carina.
Yes. Deeds and actions. Each of us has a duty to determine where our skills can best be used, and to act.
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Dear Jonah,
Thank you for this heart-warming appreciation. I’m especially gratified that you find the piece “clearly stated.” To assist people to think clearly, if it can’t be said in plain language, perhaps it shouldn’t be said.
There is no Ultimate Truth to which I have access! Just some insights and hypotheses gleaned from observations, conversations, debates, and reading… and life. But I have been at it for some time.
(I’ll be happy to send you some or many of my publications if you contact me directly by email at cohen_at_luskin_dot_ucla_dot_edu)
Report comment
Thank you.
Without knowing just what Patrick McGorry meant by people “not get[ing] access” to treatments (whether they’re not available, or they’re too expensive, or people are diverted away from them by first-line drugging, etc.), it’s difficult to respond clearly.
It’s possible that Patrick McGorry meant by psychiatric treatments the whole range of interventions–individual, group, social, educational–available in the mental health system, which could make his comment reasonable.
It is probably true that many people simply do not have access to alternatives to the usual “care,” principally for economic reasons, and secondly because these might not be offered in their community (again for various reasons).
But, there are so many physical illnesses and so many treatments for them, that I’m not sure what is the accepted effectiveness rate for medical treatments–or if anyone has truly tried to estimate this for the whole range of medical treatments.
There are various claims that both medical and psychiatric drug treatments are effective for about 70% of those who take them, but these have been refuted, lately, by the large CATIE, STAR*D, and STEP-BD studies: over a year or more, only about one third of people who take antipsychotics, antidepressants, and various other drugs report feeling better or not “relapsing.” (Neither of these studies included placebo controls, however.)
But the notion of a “culture of holistic care” does sound quite appealing.
Overall, I believe that less coercion would mean many, many more choices available in society for helping people in distress, because all of us would invest more creative energy and resources in trying to prevent breakdowns and crises that lead to the use of coercive measures. I believe that Richard Lewis makes this point in his recent blog on abolishing coercive treatment.
Report comment
Thank you Anne-Laure for your comment.
Some of the precisions you bring forth make me re-emphasize the broad differences between the French and American way of handling what we usually call, in the US, “ADHD” and what is still not usually called “ADHD” in France. The bottom line is that mass medicating of children (10-20% or more in North America, depending on region) is not known in France. Naturally, as I tried to state, what we observe today may be different in the next few years.
The reference to the medical system — and to France’s SECU’s extremely generous approach to subsidizing medications relative to the US — is that some people view the lower prescription of stimulants to French kids as a sign that the country is not “medically” oriented. Whether the French health care system is #1 or #5 in terms of access and performance (given whatever standards on is using to judge) is not the point: the point is that France is extremely medically oriented and people flock to their GPs for medications for anything and everything. And that is precisely why the lower use of stimulants among children (and the official non-prescription to pre-schoolers) is noteworthy.
The recent assault on psychoanalysis in France is well documented. Perhaps it is particularly virulent because psychoanalysis has been so dominant there, and for years squelched other perspectives and cultures of healing. Nonetheless, a substantial number of practicing child psychologists have been steeped in the psychodynamic tradition, and this appears to contribute to the situation I sketched in my post.
You are right about the influence of the pharmaceutical industry in France, and indeed France chose the strategy of encouraging internal consumption of pharmaceutical products rather than international competition of its firms. One result is the sheer number of different drug preparations (most without therapeutic value) on the French market relative to other countries. But again this supports my point about the cultural difference in viewing childhood between countries, regardless of the structure of the health care system.
The popularity of the DSM in France is growing, as I hinted. But it remains completely unclear how it is used, and whether it is used extensively in extra-medical and extra-hospital settings, and especially so in child assessment. The critiques of the DSM have been just as pronounced as here, with at least six or seven books on the market there railing against the DSM approach. Other systems such as the CFTMEA may be no better, of course, but that tool is based on a completely different, psychodynamic, approach to problems, which does not view them as distinct disorders.
I did not intend to present a rose-tinted view of France as a paradise for children, merely to emphasize the differences between the French and American management of young children who present problems for their schools and families.
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Tina’s challenge in her article was missing from my reply above. It is: What do we want to see in a world without forced psychiatry?
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Excellent, excellent article, right on target. Congratulations for all your posts. You have laid down the challenge: <>
To complete the challenge, we will also need to come up with alternatives to psychiatric *excuses* for criminal behavior.
Report comment