“the one thing I know is that suicide is the totality of life experiences perceived by a person who cannot see themselves with a future and cannot continue to live in the past, and they cannot see themselves the way you do.”
This comment states, in one sentence, the most important aspects in understanding suicide. While the mental health industry prefers to always relate suicide to “mental illness”, suicide is alomst always a result of life-long struggles. It is no one’s right to judge another person’s life or final actions. It is only through empathy for the totality of another’s experience can we possibly help someone feel life may be worth living, or accept a person’s final decisions. The importance of respecting the experience of another person, and understanding that we can never fully understand is crucial.
The feeling that it’s cheaper to use meds rather than good therapy is based on short sightedness and an ignorance of the cost of human suffering. There are studies that indicate that longer term therapy is cost effective, with less cost of medication, fewer costly hospitalizations, better ability to work (and pay taxes) as well as contribute to society. Bad treatment leads to higher costs in every way.
The point about over estimating possible short term change and under estimating possible long term change is very relevant, both in terms of looking at the help people receive and in possibly feeling optimistic about changes in the system.
Part of the corruption in psychiatry has been due to the pressure to prove short term change is possible with the subsequent promotion of medication and simplistic therapies. Clearly this model is to the financial benefit of drug companies, psychiatrists and insurers, but is disastrous for people in need. We should also be focusing on long-term change for the system, even if immediate change is necessary. The foundation of modern psychiatry is being eroded by advocates for change as well as significant research.
I don’t feel that a complete tearing down is necessary or will likely happen. In the past, there were some good training centres in psychiatry that taught psychotherapy based humanistic treatments. There are many people who want to return to a more humanistic model of training, with a greater emphasis then ever on people’s real experience. I think that we should take some of the building blocks that have existed, throw out the corrupt blocks, add in non-dismissive real life experiences, and build a new structure. There can be hope. We need to identify what is valuable and what has to be discarded. Many people have had excellent experiences with good therapists. There is a growing body of research to indicate what makes a good therapist. This information, and approaches that allow good psychotherapists to be created and valued needs to be promoted. Let’s work on what is possible to achieve by continuing to fight against abuse and corruption, but value what may deserve to be saved.
I think that we can understand that people who have suffered from emotional traumas should have access to caring, well trained professionals who have studied hard to understand how to best help those in need. It is a tragedy that so many mental health professionals are causing harm rather than helping people, and that often peer groups can offer better support.
A very interesting book that adds some other perspectives to the problems and issues in psychiatry training is “Of Two Minds: An Anthropologist Looks at American Psychiatry” by T.M. Luhrmann. Luhrmann describes the distortion and emotional politics that occurs in psychiatry with people being pulled to believe more in narrow points of view than in actually understanding and helping people.
Perhaps in the DSM V-R, the wish to own a machine gun or sem-automatic rifle should be named as a “mental illness”. The movement to restrict gun ownership to people deemed “mentally ill” might then make some sense.
I completely agree with you. Every time someone in the mental health industry comes up with a “new” program or catch phrase, it is just an excuse for not getting people better care or actually working for reducing the causes of emotional distress. These things are always just marketing, letting bureaucrats believe they are doing something, and expanding the inappropriate (ab)uses of psychiatry.
While it certainly may be one possible factor in what is being called treatment resistant depression that benzodiazepine use may directly cause more chronic symptoms, this study points to some other disturbing issues as well. As the researchers point out, benzodiazepines may lead to emotional numbing and less opportunity to deal with emotional issues. Yet all the people in the study group were then treated with various and often multiple antidepressants, which, as we all know, are major zombifiers. It would not be surprising that people who are inappropriately treated with medication, and deprived of the opportunity to actually get better would seem to be resistant to “treatment”. It is also not surprising that poorer people may not be given the opportunity to get therapy. The researchers also seem to partially define “treatment resistance” as those people who feel they haven’t improved on medication. So maybe we are talking about two different groups: those content to be zombies, and those who are trying to reject bad treatment.
Bpdt raises some important issues about the connection between psychiatric drugs and violence. The emotional impact of being diagnosed, drugged, yet given little help to deal with real emotional issues are probably the most crucial issues as to why violence may be committed by people taking these medications. The emotional numbness created by SSRI’s could also lead to a disconnect with feelings of guilt, as well as contributing the feelings that life isn’t worth living. A direct increase in agitation and violent feelings is also possible, but one needs to consider all the avenues in the present state of mental health care that can lead to tragedies.
While there are probably many factors, both environmental and social that are leading to kids seeming more fragile these days, a large aspect of the use of the ADHD diagnosis has to do with a mismatch between normal variations in children’s make-up and the expectations and pressures of our society and school system. There is no true evidence supporting ADHD as a disease. As I explain to people who have applied this diagnosis to themselves, people have different brains with varied abilities. Some people are good at focusing on one thing at a time, and others are good at multi-tasking. If we look at our evolutionary heritage, as hunters, we would have needed to to pay attention to many different stimuli, and then focus primarily on one for brief periods of time. This is how most boys are, with considerable variation in different traits. Our school systems, and to a large extent our family systems expect children to sit quiet and focus on tasks that may not be oriented towards holding interest. On top of that, as people here have pointed out, modern technology, including video games, may accentuate the brain’s ability to only pay attention to intense stimuli.
Children do not have malfunctioning brains. We have a malfunctioning society and mental health system.
Thanks for your questions. It is good to clarify these points.
Firstly, the commonly made statement that a combination of therapy and medication is best treatment is based on the type of simplistic and biased research that is should always have been questioned and is now coming under scrutiny. I do not believe that a combination of therapy and medication is best treatment for most people.
I believe that DSM diagnoses are bunk for the most part, and that psychiatric medications are psychoactive drugs but do not treat the causes of distress. Psychiatric drugs are highly overused, and the whole field of psychiatry has become corrupt and unethical.
I do prescribe medications at times, but cautiously and with full disclosure. Sometimes people are in severe distress, and it is helpful for them in the short term to have some chemical help with their distress. I prefer not to prescribe medication, and almost always start off recommending natural healthy alternatives such as omega-3 fatty acids. Some people are adamant about wanting medication, though I always spend time trying to inform them about then limits and dangers of medication.
I strongly believe that screenings are dangerous. As I said, the most common outcome of a screening is for someone to be placed on medication without recommendations for psychotherapy. I do not feel that being placed on medication with a recommendation for therapy is proper response to a screening. Psychotherapy is always preferable to medication, and the medications inappropriately called antidepressants should rarely if ever be prescribed without psychotherapy. The psychiatric medications we have are all bad medications with little true efficacy and lots of side effects and negative long term effects. I could go into another time what I do prescribe at times and why, but that is a complex issue.
I was not implying at all that people should be treated with medication. I was just saying that screening will lead to people being prescribed medication.
For many years an organization in Montreal tried to bring depression screening into universities. I managed to block that despite some end run attempts. Fortunately, after some years of this organization running depression screenings for the general public this program was stopped due to clear failure of actually getting people proper help.
It is true that many doctors are now using screening questionnaires. I have never seen this cause anything but problems.
I have fought adamantly against screening for depressed moods for many years. (see “McGill University is wasting Bell $500,000 donation, http://www.drnormanhoffman.com) There are many important aspects as to why screening is inappropriate.
1) Screening tools are poorly validated, and are only validated for a diagnosis of Major Depression. Many depressed moods do not fall into simplistic diagnostic schemas, and so people are likely to be misdiagnosed as having a “mental illness” rather than emotional problems.
2) Treatment resources usually are inadequate. There is no point trying to assess more people when there are not good resources. Money is better spent trying to create resources.
3) Given points 1 & 2, the most common outcome of depression screening is people being placed on medication without proper therapy. This is clearly bad treatment.
4) While this may not apply as much to a postpartum population, it is unlikely that people with the most severe forms of depression will participate in a screening, making it even more likely that false diagnoses will be made.
5) Many screening tools have been developed with funding from the pharmaceutical industry, with items that promote the idea of a biological cause fro depressed moods.
The issue of postpartum depression is important, but all practitioners need to be more sensitive to the many issues, both emotional and hormonal that may affect people in the postpartum period. Screening can tend to decrease the responsibility that a professional may feel to actually talk to the new parent, leading to many important emotional issues being missed.
Like many initiatives we see these days in mental health, the emphasis is often on campaigns that make the bureaucrats and marketers feel good, but that actually do nothing to help people.
I agree with so many of the points made. A truth is that often doctors will resort to prescribing medication becasue of a lack of time, or willingness to spend time looking into the causes of emotional distress. Sometimes the patients does want something to take away the pain without having the eomtional willingness to delve into ditressing issues. Often patients have been brainwashed to beieve in “chemical imbalances”
Given all that, what would people recommend that a doctor due in these circumstances: A patient comes to the office saying “I think I have depression”. The doctor tries to explore the issues that may be distressing the patient. The patient indicates that he doesn’t want to talk, he just wants a pill. The doctor attempts to inform the patient about the truth about medication, but the patient is still insistant. The doctor tells the patient that the so-called anti-depressants are actually just numb emotions, and have lots of side effects and can impair actually getting better, but the patient still wants a prescription. What do you, as the doctor, do?
I totally agree. If one understands how this type of research has always had biases and was never confluent with other forms of evidence, it has been clear for decades that the type of research that has promoted many of the modalities presently used is of limited use.
I agree with your comments about DBT. It is also another form of therapy that has been overly promoted and manualized. While your comments about how DBT frames BPD are true, it is probable that DBT as it was done by Linehan’s group was helpful as it provides a lot of support for both patients and therapists and a lot of consistency and empathy. I’ve never believed, ( as is probably true of most therapies) that it has been specific techniques of DBT that may be most helpful. However, many centres are taking the techniques, dropping the holding and humanistic aspects, and marketing the resulting therapy. This seems ridiculous to me.
The lack of efficacy of psychiatric drugs has always been clinically evident. The same is true for simplistic manualized psychotherapies. Now in addition to the study reported in MIA showing CBT is losing it;s effectiveness, there is another study indicating that manualized psychotherapy research has been tainted by the same publishing bias found in anti-depressant trials (http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0137864).
The psychiatric industry has been plagued by the push for so-called evidence based treatments that has ended up supporting obviously inadequate and often damaging treatments.
People are not paint-by-number kits. Real people need expert therapists who will treat them as individuals and work with them in a humanistic manner to deal with real emotional issues.
For many years now, expert therapists have been thinking “WTF” in seeing ridiculous forms of superficial therapy promoted and expert complex therapies being devalued. It’s time to reject all the bunk and put our efforts to finding ways to really help those in need.
You point out many aspects that seem troubling about this program. Certainly it seems oriented towards having primarily people who the system feels it has helped being the ones who speak to psychiatric residents. One can see that the major aspect of dialogue could be comments about some services problems or lack of empathy, but collusion with poor treatment modalities. As placebo responses in psychiatry are always high, one can always find people who feel they have been helped to recover.
A significant problem with psychiatric training these days is a strong orientation towards hospital based “mental illness” with not enough focus on the poor treatment received by the average person who ends up being medicated by their family doctor or a psychiatrist. It doesn’t seem like this patient/resident dialogue will change that.
Another important question is why residents are not being trained to listen to and learn from every patient throughout their residency? To give residents this experience in their last year seems to be too little, too late. The implication appears to be that during their residency, they won’t have the opportunity to actually see “recovered” patients so that they need this experience at the end. It is true, and a problem, that as most rotations in residency are for six months, that residents don’t tend to see the longer term evolution of patient care. This consumer feedback program may be partially aimed at this problem, but is unlikely to actually indicate the true problems in psychiatric care.
Like so much of what we see these days, institutions tend to come up with programs that make for good marketing but actually accomplish little.
Whatever one believes about psychoanalysis, the psychoanalytic model highlights the importance of an individual’s emotional experience of life from the time of infancy. Modern psychoanalytic schools all consider real trauma to be crucial in understanding a person’s emotional reality. Psychoanalytic writings tend to explore the importance of emotions and real experience and while at times might be overly nuanced, can add to the appreciation of the complexity of the human mind. In this way, psychoanalysis and psycho-dynamics oppose biological psychiatry with its emphasis on numbing emotions rather than understanding them.
You have made the point that there is no way of knowing when there is a suicide what may have helped prevent the individual going down that road. This is another very important aspect. Many people tend to assume that it always in the person’s best interest to make sure they’re safe, but forced treatment will often make people feel worse.
I’ve been training volunteers who work on sexual abuse and suicide hotlines for many years. In training, I give what I call my “don’t panic, do nothing” talk. The main points of the talk is that one needs to stay calm to be able to hold the pain of the other, one needs to not rush into action, and certainly not run to recommending hospitalization, and one has to not try to play detective and feel that one has to figure out whether a suicide is likely. The main role of a volunteer on a phone line, and basically of anyone offering some kind of emotional support, should be to simply be present, show respect and try to make some type of emotional connection. The focus should be on the present interaction, rather than on trying to figure out what to do. We can’t know for sure with anyone what actions may be helpful, but we can try to be emotionally present for someone. In this way one can possibly give some hope.
Opting for short term “safety” (which is actually for the mental health worker) rather than looking at long term emotional growth can not give an individual hope that someone trusts in them or in life enough to take the chance that one’s life can improve. As you have written, people don’t abruptly come to the point where they feel hopeless, so short term solutions are unlikely to help. One always has to consider longer term progress, and try to begin the process towards that progress with respect and building trust.
Excellent article!
The point that you make about suicidal feelings coming about after years of hopelessness and helplessness is crucial. Maybe there are people who suddenly feel suicidal without long standing struggles, but I have never met someone like that. I never send people to hospital, as it is crucial when working with someone who does feel intense emotional pain to be able to build a trusting relationship and to be able to sit with and hold their pain in some way. As you point out, psychiatric hospital tend to increase the very feelings of futility that people may struggle with.
About the only time I have seen people benefit from psychiatric hospitalization is when the poor treatment they receive allows them to express anger or rage that previously has been turned against themselves. The provocation of this anger sometimes help people recognize the abuse they have suffered in life, and helps them to stop feeling hopeless and self hating. However, more often, psychiatric hospitalization just increases feelings of hopelessness.
I agree. Clearly child abuse and trauma ends up being very costly, both emotionally and financially to our society. Unfortunately, our society is not yet prepared to invest in an creating an emotionally healthier society, and sees only the short term cost, and not the long term gain in making the investment.
Certainly giving some groups more rights has changed the balance of financial power, but I thin these groups won rights both through effort, but also as there was some financial benefit overall to society.
It is difficult for a non-visible minority to get organized because our society doesn’t want to recognize the problem. There can be an economic advantage to the governmental and corporate world to give more rights to some oppressed groups, but the corporate world still needs it’s slaves. The emotionally distressed are the new slaves. From a narrow minded business perspective what one wants to do with people who seem not to fit in, is to use them until they burn out and then discard them.
Other groups won rights when it was financially advantageous to our society to give them rights. The only advantage our corporate world can see for the emotionally traumatized is to create a mental health industry that makes billions while people continue to suffer.
There is no mystery as to why mainstream media has been slow to expose the mental health industry. Media these days is run by corporations for profit, and is more interested in entertaining populations to increase sales than to follow through with good investigative journalism. The corporate world is a large part of the problem of emotional distress and trauma. While we can blame psychiatry for all the distortions and abuses it has evolved, we also need to look at the underlying causes of growing emotional distress in society.
We live in a fractured society, where individuals and families get less and less support. Governments and the corporate world basically prefer people to just shut up and work, despite the stresses that individuals may have to deal with. No major institution is willing to look at how our society has to change to prevent emotional trauma. Institutions tend to look for simplistic solutions to complex issues. This is one reason why psychiatry has gotten away with bad medicine. The powers that be want people to be numbed and zombified, rather than having to deal with real issues. Even if the field of psychiatry collapses, it is likely that unless there is substantial social change, that people will still end up in emotional distress, with the corporate world finding some way to disregard people’s pain.
The belief that the “chemical imbalance” theory has not been highly promoted by the APA and numerous other official bodies can only be described as delusional, It is also irrelevant if certain individuals or organizations are turning away from one false theory ad taking up another. The truth is that when so many mental health organizations continue to talk about “clinical depression” or “depression” as a disease entity, it impacts on how people think about themselves, and strongly effects the orientation of the whole mental health field.
While years ago, when I first began in practice, most individuals would talk about feeling sad or depressed, now almost everyone that I see who are feeling down will at some point say “I think I have depression”.
The damage that has been done to individuals and society goes far deeper than the promotion of any one erroneous theory. There has been great harm done to how people think of their very emotional being. This is the crime of the APA and other similar organizations.
I agree with you. Love is crucial and it is a shame their love did not survive an uncaring system. I would have liked to have the chance to meet Pierre prior to his having been medicated for over ten years. He was quite an amazing person even after years of medication. You are right that I chose to focus primarily on the love, though the damage the system caused is evident. I did want to bring out how inhumane the original plan to break up this couple was
I do not doubt at all your experience or the validity of your perspectives. However clearly you can not state with any credibility that you have more experience than Margie and me combined, as you really don’t know what our experience has been. If we want to be “scientific” than we shouldn’t make comments that have no substantiation.
Your experience is truly valuable, and I agree that someone who has worked with people directly in a humanistic way, and has experienced mental health care directly has a lot to offer.
We do need opinions from divergent points of view, and we also need to show respect for the experience of others.
Thanks for your comments.
I wish we lived in a utopian society where all diversity was celebrated, and people who exhibited any form of emotional distress would get the true care they would need. But that is not our reality, not will it ever be.
We all know that there are so many aspects wrong with mental health care now that drastic change is needed. It is also unfortunately true that the powers that be will always see those who express outrage at the whole system as fanatics who don’t deserve to be listened to. This is unfortunate, as often it is those who are most outraged who truly have experienced the problems in our systems.
I wrote this piece partially in response to your last piece to show how constructive care can be beneficial, and how the system tends to think, and ultimately tends to act.
As I posted on your piece, I do believe that we need more dialogue and empathy between people who work within the system and those who have been abused by the system. We need to work together for change if change is going to occur. It is ironic and sad, that many of those people who have felt most marginalized in their lives are so quick to want to label others.
While the anger many people exhibit in their posts is fully understandable, it is not always constructive.
This piece is mostly about Pierre and Shelley. They were able to succeed despite the system, and despite mind numbing drugs. They were able to be role models and friends to others. The system failed them throughout their struggles. This piece is also about how sometimes within the system, small changes are possible that can make a difference. Many think we need to tear down the whole system. Maybe we do, but that is unlikely to happen. We can, though make numerous small changes that with time can make a substantial difference.
I do agree with you. Over the past twenty years I don’t think that I’v seen anyone who has been hospitalized in psychiatry who haven’t described their experience as horrifying. The sad reality is that there are far too many people in our society who end up dying because of the problems in our society and lack of resources to help them. The only way to not give up on people like Mary is to fight for better, non-psychiatric resources. We need to understand that a large aspect of the fight is not just whether we refuse to commit vulnerable people to psychiatric hospital l ,but how we can fight for change. If people like Margaret refuse to hospitalize anyone, then those people would be fired from their jobs and replaced by lackeys. We need our Margarets and our CatNights and our Marys. I do feel that people like Mary should not end up as casualties of the battle for change. The answer of how one should proceed in the present reality is not clear.
I believe that we all need to have empathy for other people, whether they be individuals in emotional distress or mental health workers. No doubt that the psychiatric system is screwed up, but so is our society. I would like to believe that all people have free will, though the reality is that our society has robbed many people of the opportunity to have free and clear will and judgement. The sad truth is that it is highly likely that Mary, and many like her will be dead within 3-4 years, because our society will not help her, advocate for her, protect her, or get her into the position where she can have the free choice of how to best live her life. She will end up dead under a bush, killed by exposure, violence or malnutrition.
We also all know what could be best action. That would be for Mary to have a place where she could go, voluntarily, where she could be respected, safe, and cared for; a place that would respect her autonomy, and help her work towards being able to take care of herself. Without proper resources, there is no hope for people like Mary; only pain and eventual death. Margaret tried to forestall the inevitable by using a resource available to her. Whether she should or should not have is a point that can be discussed, but it is not a discussion on what would allow Mary to survive, either emotionally or physically. It is a political discussion that various people have strong opinions on, based on their own experience of the mental health system. Mary’s outcome is unlikely to be affected by Margaret’s choice. We need to have real choices that save both life and dignity.
You are pointing to the real issue. One needs proper support options that don’t leave either the individual or the worker in a position where any choice is wrong. There are models that do work, and we need to keep fighting to have these other options become more available.
I think that you express the dilemma that many mental health workers feel. I also feel that it is unfair for people on this board to criticize when they have not been placed in a position of responsibility for someone’s life. Most of the people who post here have thought hard and insightfully about their own experiences. We all know the importance of respect and autonomy of the individual. Yet sometimes for those of us who work in the mental health field, we have to deal with situations where a person’s life may be in imminent danger. We know that the hospital system will not provide optimal care and respect, yet we also now that the outside world can be hostile and abusive.
In my own practice I never send people to hospital any more, as I know that they will not get reasonable help. I am willing to, with the individual, take the chance that suicidal feelings will result in death. Most of the time, showing this respect and understanding leads to a better therapeutic relationship, and the feeling in the patient that I am willing and able to accept their pain. But sometimes it doesn’t work. A few years ago a very troubled young man, who had been hospitalized in the past, asked me to promise never to hospitalize him. I agreed that I would only do so with his consent. He did end up taking his life a while later, just a day after I had seen him, though had kept any plans he may have had secret.
The main issue is that there often is no best action. Many people who suffer emotionally don’t have agency of their own, and may not be in a position to make the best choices for themselves. Sometimes, we just can’t abandon them to the world. The points you bring out are excellent. Sometimes we do things that we would prefer not to have to do, but are simply trying our best in a bad system.
We all need to have empathy for others, including others who may see life differently, or are in positions of authority. It is easy to find fault with mental health workers, but not so easy to find better ways of negotiating the present system.
Excellent review of the facts about anti-psychotics. It is clear that these drugs are being used for off-label prescriptions in children. Using these drugs for behaviour problems ends up with the child being blamed for the complex family and social issues that can lead to behaviour problems. The psychological ramifications of a child being labelled and being forced to take medication cannot be neglected. As well, one has to be concerned with any prescriptions to children about the effects on the developing brain. Anti-psychotics can also have serious effects on cognition in many people.
One problem with allowing the use of these medications for on-label prescriptions is that it is very easy within the structure of the DSM to stick a label on almost any child. Thus “bipolar” has become a fad diagnosis, applied to anyone who has mood changes. As children in difficult circumstances will almost always have variable moods, it is very easy for a physician to justify the use of medication with these kinds of diagnoses.
There needs to be a ban on these medications in children, except perhaps under extreme circumstances within psychiatric hospital settings. It is just too easy for a doctor to reach for a prescription pad when confronted with complex issues.
While I agree with many of your points and of the problems our dysfunctional society is creating, I don’t agree that proper therapy can’t help. Proper therapy has to address these issues so that the individual can recognize some of the sources of anxiety or depressed mood. It is much better to discuss with someone the societal issues that may be part of the root of the problem, so the person doesn’t end up blaming themselves, feeling they have a “mental illness”, or feeling alone with their painful feelings.
This is one reason why I am so adamantly against superficial symptom based therapies. We need to address both the family and societal issues that leave a person feeling vulnerable. While we should be also working on general social dysfunction, in the meantime, we cannot abandon individuals in need and refuse to help them understand how our society has impacted on them.
Unfortunately, this is what most college counselling and mental health services are doing these days: colluding with the dysfunction by blaming “mental illness”, and only attending to symptoms, and not treating the real problems.
Universities used to have more humanistic counselling services. With the increase in demand, college administrators have gotten involved, and are often dictating policy. Then one has service directors buying into the direction that the administrators are going. One also has the university lawyers getting involved and demanding on “risk management”.
One of the problems with the older style counselling approach is that counsellors tended to follow a non-directive approach that didn’t address issues that quickly. This approach did not work when demand began increasing. This led to the adoption of more superficial approaches that also don’t tend to work, but allow the college to say it’s offering services. One often sees university counselling and mental health services having many “programs” like suicide watch programs, but no proper treatment services.
There is no excuse for any college not to provide proper help. These days colleges are more interested in protecting themselves and appearing to care, than really providing good service.
Having worked at McGill Student Mental Health Service for 35 years and having been Director there for 15 years, I can say with reasonable authority that the information being promoted in this report is a large aspect of the problem.
Firstly, they are talking about “anxiety” and “depression as diagnoses rather than as symptoms. Students may come in with various symptoms, but diagnoses are fairly irrelevant in this population, with students usually presenting with complex emotional issues. The idea of using primarily short-term modalities is bound to fail, as it leaves it almost impossible to address anything but symptoms if students are told that they will not necessarily have the time to explore real issues. Colleges are tending towards management of students rather than real treatment. Workshops and Group support may be useful, but do not replace expert therapy modalities. Sending students off campus for treatment, or insisting on medical leaves just puts students at higher risk.
There is no truth that students are appearing more due to less stigma. There is also no truth to the often repeated statement that more students are arriving in universities requiring treatment due to the use of medication making it possible for students to achieve academic success.
There are two major reasons for the increase in numbers of students coming for help. One reason is that parents and our society are treating children more like products than like people. There is less and less room for normal emotional expression and growth. Students begin feeling that achievement is all that counts in life, leading to both anxiety and depressed moods. These students arrive at university, start to experience falling grades and then fall apart.
The other major reason , which ties into the first, is the overuse of diagnoses, medication, and simplistic symptom reduction treatments. These modalities all collude with the “product and achievement” model of life, and make student more fragile in the long run.
There are good expert models of psychotherapy that work well in university students. These models quickly address real emotional needs, and provide safe emotional space for students. However many universities either are not aware of the efficiency of these models, or are turning to diagnoses, medication and symptom control techniques that tend to undermine real emotional progress.
It is unfortunate, that so many universities simply don’t know what they are doing. I’ve seen these changes from being student oriented, to being bureaucratic oriented in many institutions, including McGill where labelling students is now mandatory for a student to be treated at the Mental Health Service
There should be no question that the use of anti-psychotic drugs in children without signs of psychosis should be made illegal. It would be nice if the use of all psychiatric drugs in children and adolescents was banned, but unfortunately this is unlikely to happen.
The problem, of course, is that doctors can always make a diagnosis, such as bipolar, to substantiate the inappropriate use of medication. However, one could make anti-psychotics restricted drugs that only psychiatrists can prescribe, and then have clear indications, with the necessity of two psychiatric opinions before prescribing psychiatric medication to children.
It should be evident that children and adolescent brains are in the process of developing, and that any outside contamination of the brain will interfere with normal development.
Behaviour problems in children should always be seen in a family and social context. Whatever happened to the concept of the “identified patient” that saw the behaviour problems of a child as a symptom of a system dysfunction?
The last thing we need to reduce negative stigma about psychiatrists is to better market bad psychiatry.
One should, though, understand that the stigma of being a psychiatrists is entrenched in medicine. When I went in to psychiatry, a friend of mine commented “what a waste”. Throughout residency and beginning practice it was clear that most other doctors saw psychiatrists as being useless ( perhaps with reason), but if they needed us, expected miracles.
The role for psychiatry should be to be able to have a degree of clinical training that is considerable, and which can take into account both the physiological and the emotional. Knowing medicine should expand the knowledge base of psychiatrists so we have an expertise and an ability to understand the mind body connection better than psychologists.
It is partially the stigma that the medical profession places on psychiatrists that has caused psychiatrists to disavow humanistic principles and embraced an overly medical and biological view of psychiatry.
We need to get back to our roots as psychotherapists and humanists. We should be good empathetic psychotherapists who also understand disease and the human body, and who have experienced in our medical training the pain of illness and suffering. We should not be this mockery of pseudo-science that we have become.
Jeanene, your words certainly echo the experience of so many who have felt deep pain, yet whose feelings have been denied or medicalized by our society and the psychiatric industry. I have always remembered the writings of the first patient that I treated who self-injured, “When I feel the pain and see the blood, I feel that I just may be alive”.
We seem determined as a society to deny or cover up the pain that so many feel. I think that the emotional pain of many people who have suffered, scares many people as it touches on some aspect of deeper pain that many people experience. I was taught that by listening to the life experiences and the emotional depth of those who have been traumatized, that we can better understand all human experience.
People who show what the DSM calls symptoms are telling us about their personal experience and about aspects of our society. We should feel respect for all those who cry out in one way or another as they are telling us what can go wrong in life, and possibly what changes in our world are necessary.
I like the words digest and metabolize, because in psychotherapy, and relationships, these words describe what often is helpful. People feel overwhelmed with their emotions, and we, by sitting with them, hearing them, and being able to engage these emotions, do actually help in the metabolism of feelings. Children, and grown-ups too need to be able to feel that sense of another person being with them to break down overwhelming feelings into smaller bits and gradually be able to digest these feelings.
some of my writings can be found at drnormanhoffman.com, and others at studentmentalhealth.ca.
I look forward to further communications with you.
Thanks for this article, Margaret.
The issue of society’s responsibility needs to be further addressed. To a significant degree, it is the problems within our societies that cause emotional distress to begin with. Society then blames the individuals and just wants them to disappear.
For many years, I have taught a concept that I call the “ascending and descending ladder of emotional pain metabolism”. This basically states that in a well functioning society, people in positions of responsibility help hold and metabolize emotional pain for those more vulnerable or with less power. Thus, parents attend to their children’s emotional distress, extended families and friends help parents, local communities take responsibility for extended families, and ascending levels of government take care of communities. In many societies, we are seeing a descending, or inverse triangle of responsibility for emotional pain metabolism, with vulnerable individuals and children ending up feeling and being left alone with the emotional pain dumped down by society. Thus federal governments dump responsibility on State and Provincial governments, who dump on municipalities that dump on families. Vulnerable individuals end up showing symptoms of this emotional pain, and are then labelled as aberrant.
Until societies take true responsibility for taking care of families and children, many will continue to suffer.
It is sad and troubling that so many supposed “mental health” organizations are actually mental illness promoting organizations, including the NIMH and the CMHA. There are also organizations started by parents who after their children’s suicides have decided that their child must have been mentally ill. One organization like this, Ulifeline, has been trying to promote the diagnosis of bipolar illness in college students.
There is no place in emotional health advocacy for self promoting individuals or organizations that hope to alleviate their own guilt or responsibility by disseminating damaging misinformation. We need to get away from promoting mental illness. I address this issue more on my blog post: “The need to stigmatize the (overuse of) the term “Mental Illness”
I think that people are missing the real importance of this study. While it is certainly true that children are being over diagnosed and medicated, a major concern should be why children and families are showing increased signs of distress. There is clearly something going very wrong with our society when so many children are being brought to emergency rooms with emotional problems.
The increased use of the psychiatric industry is not just because psychiatry is trying to drum up business. There are many indications that our societies are just not providing the type of holding environments that families and individuals need. Speak to any elementary school teacher, and they will all tell you of the growing distress and behaviour problems in children. As long as our society continues to be dysfunctional, psychiatry will be called upon to control the distress.
This study should come as no surprise. It would be interesting, though not necessary to test clinical studies in the same way. It is not necessary as all clinical studies have already shown that the treatment modalities tested in studies are highly inadequate, and should not be applied in a blanket manner to real people. If one wants to follow true empirically advisable treatment then, if one interprets the research properly, one has to possibly use a variety of approaches that engage the person who is coming for help.
Research in psychology and psychiatry can never take the place of clinical experience and patient reports. Psychology research itself has become an industry that often has little actual value
I agree wit bpd’s comments about Major Depression. Not only have studies repeatedly indicated that in adolescents, anti-depressants do not appear to be effective, but the diagnosis has to be questioned for it’s validity. In treating around 4000 adolescents and young adults over a 30 year period, I did not see anyone who fit well into this diagnosis. In general with both younger and older populations, the more one gets to know someone, the less the diagnosis of Major Depression makes sense. The DSM has kept loosening the criteria so now one could fit almost any person with some depressed mood into the diagnosis, but this just decreases any validity this diagnosis may have.
In psychiatry, it is fairly easy to structure an interview to elicit one’s favourite diagnosis just by asking certain questions and limiting one’s exploration of a person’s true emotional experience. I know what to ask and how to phrase the questions to elicit a diagnosis of Major Depression, Bipolar Disorder or ADHD in just about any distressed person.
It is crucial that adolescents with emotional struggles need proper support and therapy. The evolving adolescent brain will be impaired by the use of medication. The push to medicate adolescents and children has to stop.
Excellent article!
Part of the issue tat this brings out is the growing divide between true clinicians, researchers, and psychiatry bureaucrats. Research used to be more clinically driven to test out observations that clinicians were concerned about. Now, research has become an industry in itself, with many researchers having little actual clinical experience. This leads to research being done, and results being accepted, even if there is little clinical relevance or sense to it.
An other aspect that falls into the category of biological research is genetic research. There is a lot of money wasted in looking for genes that may be connected with various DSM diagnoses or symptoms. These studies, though few actual positive results have been found, tend to be presented as if they are looking for “diseased” genes. The truth, if any gene connections are ever found, is more likely to be that certain traits in response to environmental trauma may effect the emotional outcomes. For example, a child who is more emotionally in tune may respond differently to abuse than a child who has natural traits of self assertion. For suicide, a person who has some genetic predisposition to risk aversion may be less likely to make a fatal attempt. While any genetic links could be of some interest, very few are that likely to indicate the most important aspects of aetiology.
If we want to truly help people have better lives, we need to address the true causes of distress, as is well pointed out by Noel and William.
A major problem in psychiatry has not been the adoption of the “medical model” but the corruption of the medical model. This model, as it applies to medicine, and should be applied to psychiatry, is that one uses symptoms to lead to an understanding of aetiology. One can then only state that something may be a disease if one does know the underlying cause. In psychiatry, this would mean that the underlying causes of distress would often be trauma and social situations. The “diseases” would not lie in the brain but in our society. In psychology, the medical model has come to mean something entirely different: that despite no evidence one assumes a biological cause.
The DSM III acknowledged that it was not aetiologically based, but the psychiatric industry has highly promoted a biological model. The DSM system in making research easier has led to a circular argument: if a biological treatment appears to work than the aetiology must be biological. This “empirical evidence” has created a monster.
I strongly disagree with the point that Spitzer had the public interest at heart. He has always been on a strong campaign to remove all indications of emotional roots and psychodynamics from the DSM. He is largely responsible for the direction that DSM and psychiatry has taken.
I have always treated people according to the true medical model Without understanding the cause of someone’s pain, and with only looking at symptoms and a superficial analysis of research, one cannot truly help someone. Psychiatry has abandoned basic principles in medicine.
No one is saying that people don’t have severe distress or or not significantly impacted by certain symptoms. Having categories to give clinicians rough guidelines can be helpful, but the DSM should have a big disclaimer on it’s cover saying : These Disorders Are Not Diseases. Any Research Done On These Descriptions Has To Be Interpreted With Extreme Caution.
As Bpdtransformation points out below, may psychiatrists these days only look at symptoms and then write a prescription. If one doesn’t investigate underlying causes, then one can’t help a person significantly.
Doctors are trained to believe that diagnoses are based on etiology. The DSM is not, and so confuses doctors, and also leads to bad research.
Good article. There should be no doubt that nay anti-psychotic should not be used in childhood and adolescence. Aripiprazole is no the top selling drug in the U.S., based largely on its marketing to be used in non-psychotic conditions. There needs to be a total ban on the use of any of these drugs in young people for any “diagnosis”, as without a total ban, doctors will continue to misdiagnose bipolar and psychosis so that they can use drugs that will in the short term appear to control some bahaviour. As was reported in MIA, the child and adolescent branch of the Canadian Psychiatric Association has called for the use ofthese drugs to be controlled. There may be hope yet, but a strong fight is needed.
The problem with this “diagnosis”, as is the problem with all the DSM diagnoses, is that it is not based on etiology. Off the top of my head, I can think of numerous types of people who could fit into this diagnosis: any normal person who is under severe stress, many children or adolescents who have some emotional struggles, people who have experienced traumas and have certain triggers to that trauma, people who get pulled into gangs, people who come from very socio-economic disadvantaged backgrounds and may feel frustrated with society, people who try to protest significant issues in our society, as well as people with some criminal orientation. Any diagnosis that is not based on a common etiology, and does not lead one to deal with the underlying causes with appropriate treatment is absolutely useless. Of course, the psychiatric industry will do studies with some symptom reduction modality on this diagnosis, show positive results compared to some ridiculous placebo conditions, and then use those results to “prove” that this diagnosis actually exists and that there are “good” treatments for it. It’s this type of circular arguments over made up diagnoses that is destroying psychiatry. Funny, I feel like exploding right now.
I actually have submitted a couple of articles with more to come. You can also read some posts at my blog site: drnormanhoffman.com or at my website http://www.studentmentalhealth.ca. I’ve been impressed with your comments too. I would be interested in communicating with you as it seems that your experience coincides with my interests. I’ve spent most of my career devoted to trying to help people who fit the diagnosis of “borderline personality” to live happy and healthy lives. I have no interest in simplistic techniques to just reduce some symptoms. All people, especially those who have been deeply traumatized, deserve respect and support, as they struggle to regain a sense of themselves. The psychiatric industry tends to just want these people to go away and stop showing up in the emergency rooms without offering any hope for a real future. Transformation is possible but it takes dedication on the part of the therapist and the individual.
In my whole life experience the one thing that has impressed me the most is how some deeply traumatized individuals can hold onto empathy and hope despite their experience of how horrific some people can be. We can all learn from the values some abused individuals hold onto despite their experiences that should leave them giving up on the human race. These people leave me in awe and with deep respect.
The first rule in treating anyone who has been traumatized is don’t re-traumatize the person! This should be obvious and should not need research to support this approach. This first rule leads to a second rule: Establish a trusting positive working relationship.
Some people may feel a need to talk about the traumatic events quickly. Other people want first to feel safe with the person that they are talking to. As bpdtransformation points out therapy can take years, partially because it can take years to establish a trusting relationship when someone has been badly traumatized in life.
Safe space is crucial in any therapy, but is not achieved just by being nice to someone for a few weeks. One always has to show utmost respect for the person’s real life experience and their time frame. This is one reason why it is so hard to do research on trauma, as unless one takes an individualized approach, results will always be mediocre at best.
Part of the problem has always been doctors actually not reading the research. Many, if not most doctors, will read the abstracts and conclusions of research and skim the rest. Most research on various treatments in psychiatry have always shown the same thing. The relatively little difference between placebos and treatments would seem to indicate that many treatments appear to work, but that they all work poorly. One always has to consider in reading research the biases introduced, the nature of the research population, the validity of the diagnoses, and the clinical significance of the findings. For example, in many psychiatric medication studies a 50% reduction on a particular scale is used to determine a positive outcome. In many of these studies, one gets an average drop from 30 on a scale to 14 for the drug and 16 on the placebo with a statistical significance between the two groups. But one has to ask whether this minor difference is clinically significance, especially if one takes into account sedation by the drug and all the possible biases.
Research in psychiatry has always shown most treatments to be clinical failures. The only conclusions one can reach, if one actually reads the studies, are that psychiatric conditions are heterogeneous, that DSM diagnoses are not diseases, and that simplistic uni-modal treatments don’t work. This means that we always have to treat people as individuals, trying to help them with their problems and issues, and possibly consider some researched modalities have having some limited value in some people. When it comes to medication, the published research has clearly shown that we have no idea what these medications actually do, and that there are possible negative long-term consequences, but little long-term benefit.
It is crucial in reading research to understand that in order for research to be considered valid, the results from all research done from various viewpoints, clinical experience, and patient experience should all point in the same direction, with little controversy. If the whole picture doesn’t make sense together, then there is something wrong. This is clearly the case for research on medication. It is also the case for research on psychotherapies, where research on the therapies themselves often focus on showing that a particular technique works, while research on what actually works in therapy indicates that it is not any particular technique that shows value.
One just has to actually read, in detail, the research in psychiatry to understand how far off the rails psychiatry has come.
I totally agree with you that a distress model rather than a disease model is much more appropriate in helping a person with emotional struggles. A distress model was a fundamental aspect of what was called the biopsychosocial approach in psychiatry where all aspects of a person;s life that could contribute to distress were considered important. This model has been largely dropped in favour of the ridiculous and dangerous biological model.
In medicine, the medical model has always had value. One main problem in psychiatry is that the medical model is no longer being followed. The medical model is based on the importance of understanding the underlying causes of distress. In this model one elicits problems and symptoms to then investigate the underlying etiology. One then attempts to treat the causes of distress to help the individual. If one uses this model in psychiatry and psychology, then one always ends up using a distress model and attending to the underlying causes of the distress. The DSM is not, nor was it ever intended to be based on etiology. In fact, it was created to avoid having to address etiology at all, as previous classifications had been based on implied etiologies that could not be proven. However, one of the main reasons for the rise of biological psychiatry is that doctors end up assuming DSM diagnoses do imply etiology. They end up trying to use the medical model with a classification system where it doesn’t apply. Big pharma also push their drugs in this way.
We need to continue to promote the importance of looking for the underlying causes of distress, whatever those causes may be.
It’s good to see more psychiatrists speaking out against fad diagnoses, and the overuse of diagnoses and medication in general. Joel Paris was my first teacher and mentor in psychiatry. One of his roles was being in charge of the screening clinic in psychiatry where beginning residents learned how to interview and assess people. The most important part of the assessment was the “dynamic formulation” where we would try to understand all the complexities in the person’s distress. While we would put down possible diagnoses, these were seen as only being vague guides and not particularly important or useful most of the time.
A major issue about all the overuse of diagnoses and medication these days is that it indicates that many people are distressed, and many doctors don’t know what to do about the distress. We could use a “dynamic formulation” on our society to understand why people are struggling so much and what can be done to start to address real problems that are afflicting people.
Thanks Joel!!
your comments on raising children are very pertinent to the issue of our sense of connectivity. An interesting book that is directly on this subject is: Diamond, J. (2012) The World Until Yesterday, What Can We Learn From Traditional Societies? New York NY. Viking Penguin. In this book the child rearing practices of some tribal cultures are described. In the Efe and Aka tribes, fro example studies have shown that infants are passed between various adults between 8 and 14 times. Children are in constant contact, not just with their own parents, but also with many other caregivers.
We do live in a very isolating environment, where most people feel solely responsible for their own emotional lives.
I think many of the comments point to part of the reason for the anxious state of Americans, though I believe that there is an underlying issue that is not being addressed. Over the centuries humans have moved far away from the life of our evolutionary origins. While some aspects of this have led to greater health, there are aspects that have left individuals feeling fragile. We evolved to live in communities with strong ties and support. There is substantial evidence that states of emotional distress are linked to the lack of emotionally supportive communities. The United States idealizes individuality yet pathologizes the individual who becomes distressed.
There are two aspects to the sense of social connection. One develops an internalized sense of one’s social connectiveness through childhood and adolescence. One’s emotional life then is also affected by the actual social network that is available. Any fragility, either in one’s internal sense of social identity or in one’s actual social network can lead to emotional distress, including feelings of anxiety, depression or isolation.
Countries where people rate themselves as happiest tend to have strong social bonds. It makes no sense to diagnose and medicate individuals who are suffering in society, without looking at the structures of the society that may be contributing to the distress.
I was in training as a psychiatry resident when the DSM III came out. We were taught, and I believe that it was stated in the DSM III, that the diagnoses were meant as a guide only, especially as they were not etiologically based. It seems that the message in the DSM V is that these diagnoses do actually exist and that etiology is totally irrelevent. This is a very frightening affair. The implication is that any investigations into cause of distress is not important as treatment should be based on diagnosis only and in trying to reduce symptoms on each diagnostic list. Say goodbye to humanistic psychotherapy and prevention of child abuse.
A major health problem these days is the vast over-diagnosis of bipolar disorder in children and adolescents. Almost all the adolescents and young adults that I’ve seen who have been given that diagnosis, have no real history of true mania or hypomania, but have had histories of emotiol trauma. This study both doesn’t account for the effect of medication on the brain, nor is it convincing of the diagnosis to begin with.
The most important factor, from a clinical point of view, of the main cause of emotional distress is trauma, and not “brain disease”.
A worry with the publication of this study is that it will encourage the continued over-diagnosis of bipolar disorder and the overuse of medications. Many doctors, both psychiatrists and family physicians, will interpret this study as indicating that people who can be squeezed into this diagnosis should be started on medication quickly in order to avoid brain atrophy. The reality is that it is not clear what this study is indicating, what diagnoses were valid, and is it certainly does not show that medication use will prevent brain loss.
I do like and agree with your distinction between medication and drugs. Perhaps we should be using the word medication for a chemical that makes an abnormal situation normal, such as an antibiotic, and the word drug for a chemical that makes a normal body response abnormal though it may alter symptoms. This does leave a grey area though, as in the case of using anti-histamines for allergies, where the release of histamines is a normal body response but the allergic response itself could be seen as abnormal.
If you believe that Jesus is the answer, then you should also be aware that Jesus was fundamentally a socialist. He fought against corporate and establishment interests and tried to bring equality to the people. Free health care, using a caring relationship as a basis, is one of the main points Jesus is known for. Americans tend to have a distorted view of socialism based on propaganda. All the countries in the world that are rated as the happiest places to live have strong socialistic policies.
Psychiatrists like that should have their licences revoked. There is no justification for such blatant disregard for facts and such misinformation being thrust on a patient.
One big problem with psychiatrists who call themselves experts in psychopharmacology is that they usually know nothing about people or therapy. Their only knowledge is of the DSM and a superficial understanding of biased research.
Your comment is important. There are many people who find small doses of these medications helpful. We always need to keep our mind on what is helpful to the individual. It is always the people who are more important than any single minded belief system. Many people who do take benzos use them just as you do.
The problem is how the system uses benzos and other drugs in ways that interfere with long term emotional well-being. People who have suffered from bad psychiatry have every right to be upset by how they’ve been treated.
Very clearly the way you were treated was very dangerous both on a humanistic and psychopharmacology level. There is no question that all psych meds are potentially dangerous and that they all interfere with normal brain functioning. The main issue to remember is that so many doctors are using more dangerous medications like antipsychotics and SSRIs that people end up being on for years. The short term use in small doses of benzos with proper education and consent and used only as an adjunct to other forms of therapy is preferable and safer than so many of the other approaches to medication. I am not calling any of these medications safe.
I think that your story about your experience with distress and medication is important. There are psychiatrists who believe, as yours does, that “all (psychiatric) medication is poison”, but who also understand that when used appropriately can provide some relief. One of the important issues in prescribing medication is to not buy into the diseased brain model nor to use medication in high doses or constantly add medication. Good psychiatrists will understand that medication does interfere with normal brain function, but can dull certain symptoms so that a person can feel somewhat better while trying to deal with underlying life problems.
On the other hand, the use of psychiatric medication in children and adolescents should be avoided at all cost. There is very little evidence that in young populations that these medications do anything useful. There is substantial evidence that they interfere with normal brain development and a young person’s ability to grow emotionally.
The issue of social change is crucial in looking at the mental health of our societies. There are so many people, who like Tibita, think that they are okay because they are going along with their societies norms. One has to sometimes look outside of one’s own society to understand how things can be different. If one looks at countries rated to be the happiest in the world they all appear to have two things in common: good maternity (and paternity) leave and good health care. In Quebec women get one year paid maternity leave. When we speak to people from the U.S. who have had babies, we are appalled by the poor social support given to young families. Happy babies and parents lead to happy children. Stressed families lead to emotional distress. Change is certainly needed.
Your story is both touching and frightening, though we all know that there are tens of thousands of young people who are getting similar mistreatment as your daughter, many of whom will never escape from the system.
Your point about changing society, and especially changing from a individualistic, competitive society to a more communal one is crucial . We have tended to see ourselves as primarily individuals in North American Society, but there is strong evidence that we are social beings strongly affected by our social environment. This aspect is especially important in the emotional lives of teenagers where peer influence can have a major effect on emotional development. The psychiatric industry tends to ignore this aspect, preferring to either blame the parents or the brain. As peer influences have become stronger and more pervasive, we are seeing an increase in emotional struggles in young people.
We do need to look at our society and how it is affecting our youth. There are so many issues to address, but efforts like yours are an excellent start and example to all of us.
When I was a psychiatric resident, I decided to do a research project on “difficult patients” at a chronic psychiatric hospital. I spent many days sitting in the lounge of a ward observing patients and staff and marking down every interaction. It became clear after a while that certain patient were quite sensitive to the atmosphere on the ward, and that tension in the atmosphere was usually created by the staff. So when certain staff members were in bad moods, certain patients would tend to become agitated. Of course, this led to the patient being excessively medicated or restrained, not the staff. It is always easy to blame patients fro their behaviour rather than looking for the causes of tension
I agree with you. It is a very sad and dangerous affair that benzos are among the safest of psychiatric medications. It points to how bad and potentially dangerous they all are. But they are among the safest in some ways:
1) When people are put on them it can be for the short term unlike SSRI’s where people are usually put on them for years with the message that they have a “chemical imbalance:
2) There are millions of people being given anti-psychotics fro anxiety ans sleep problems with major side effects. These drugs are more dangerous than benzos.
3) I have never had a patient who I prescribed benzos to who became addicted or was on high doses. When used appropriately almost all people use them sparingly and for short periods of time, unlike other psychiatric medications that people tend to be on for long periods of time.
There is no question that these drugs have caused major problems to many people. A large part of the problem is not in the drugs themselves but in the people who prescribe them. Long term benzo prescriptions are never okay. That is the problem.
As you clearly state, no one here is suggesting appropriate short term use should never be done. So we basically agree on just about everything. We may just be presenting the argument differently
While everything written here about benzodiazepines is true, the sad reality is that they are among the safest of the psychiatric medications. As it has been pointed out, most psychiatric drugs are prescribed by non-psychiatrists. These days, partially because of the bad reputations these the benzos have gotten, many family doctors are prescribing SSRI’s or anti-psychotics for anxiety and sleep problems. While I agree with Philip that it is society’s problems that lead to anxiety, when a person comes in to see a doctor in great distress, one can’t change society or have the person avoid the stress caused by society. Sometimes the short-term use of some medication to help with sleep can greatly help an individual, and avoid the situation where a person eventually gets put on a long-term medication that will have greater negative impact. One also has to look at the impact and negative effects of the Z drugs that are being used to commonly for sleep problems. Given the options, I’d rather give a highly distressed individual a little oxazepam for a few days to help them sleep while starting a therapeutic process, then to have the person fall apart more, or end up on more dangerous medications.
The problem with nay kind of restraint or control is that it becomes a very slippery slope. Anyone who works in an emergency room will tell you that there are situations, such as a person coming in high on alcohol or drugs, aggressive and with a weapon, where there is a clear danger to staff and other patients that has to be contained. I don’t think that anyone would argue that an establishment doesn’t need some way of preventing people from getting hurt. I know of a number of nurses who have been assaulted and have felt very traumatized. So I think that there can be a dialogue on what are the best ways to deal with potentially dangerous situations. It has to be recognized that any procedure to deal with violence will likely end up being abused as staff become accustomed the discomfort that should always be there in any violent situation.
I know that you are in Trois Rivieres, but you may be interested in this study group in Montreal: Groupe d’étude sur l’intersubjectivité. Their website is http://intersubjectivite.com/drupal/
you are not alone. Many young psyvhologists feel a sense of isolation. Most of published research in psycitry and psychology has little to do with real people and their emotional distress. I have a group practice in Montreal. If you would like to discuss any of these issues in person, or would be interested in supervision, please contact me. You can find my contact information at http://www.studentmentalhealth.ca.
I think that it is important to have open dialogue and balanced views. I believe that there is a place for good psychiatry. Many of us old school psychiatrists have been practising psychotherapy and using medications appropriately fro many years, with good results. I believe that it is a problem that many people these days aren’t even sure what good psychiatry is or what to expect.
Without a doubt, constraints, whether chemical or physical are used primarily to control people and to make life easier for the systems that mandate this control. People who show aggressive behaviour are usually terrified themselves, and the last thing they need is to be further terrorized. When people are frightened they do need a calm and caring environment, and sometimes might need the presence of a containing environment. Let me share a couple of stories to highlight these points.
When I was a psychiatric resident at the Douglas hospital in Montreal, the Douglas did not have a restraint team for the emergency room. They had Vince. Vince was around 6″4″, probably weighed 280 pounds, with hands like baseball mitts. He was also as gentle as a lamb. When a person came in agitated, Vince would just talk to them quietly, say “settle down buddy” and perhaps put one of his big hands on the person’s shoulder. The person would almost always calm down immediately, and you could almost see the anxiety just flow out of them. I don’t remember restraints ever being necessary.
At another Montreal hospital there used to be a patient that frightened people in the emergency. She would come in about once a month, and often would throw things around the ER, ending up being put in restraints or arrested. I was called one evening to find her in the psych room of the ER in restraints. I sat with her, talking quietly. After about ten minutes I asked her if she would like me to remove the restraints. She said yes. We then talked for about another 15 minutes, and she then said she felt better and left. She came in the next evening that I was on call. She said she felt violent inside and was frightened that she couldn’t control the feeling. I asked her if she would like to be put in restraints, and she said yes. Again we talked for while, with her pushing against the restraints at times, and then the restraints were taken off and we talked some more. She stopped coming to the ER except when I was on call. Eventually she would come in to talk and did not want or need the restraints. After that year she stopped coming, and I heard that she was doing well.
The important aspect here is that any type of “treatment” should only be used for the benefit of the patient. We need to recognize when someone is frightened and to do what we can to reduce their fear. Sometimes outside limits or containment may be helpful, but we need to be very careful with using any type of outside control because these modalities can be so easily misused and abused.
As you point out, we all have our areas of expertise and we all have things to learn. Thanks for your comments.
I don’t particularly appreciate any of theloniusmonk’s criticisms of Robert Whitaker. Bob has done a tremendous job of bringing to light and promoting discussions of the horrible state of mental health care. All people who write essays will put foreward a particular view and provide evidence for that view. No one presents in equal balance all the counter arguments. It is not reasonable to expect anyone to do so. Clinicians should be responsible for understanding various sources of evidence and to come up with reasonable approaches to human care. Many clinicians in mental health are failing to do so.
I do agree with his point that we should not just be trying to tear things down, nor just accepting alternate points of view without adequate evidence.
That is not at all what I said. You are taking things out of context. I’m not sure why you are looking for an argument. Everyone has different areas of expertise and different perspectives. What I clearly stated is that we need to have respect for various perspectives. I also directly implied that it would be unfair to expect Bob to be an expert in all areas.
I appreciate the comments by theloniusmonk as well as the other comments. We should all be trying to understand the complexities of emotional life, and be hoping to build up helpful resources and approaches for people, and not just tearing things down. None of us, ( or anybody) knows enough about mental health to make definitive statements about etiology. We do know that taking simplistic approaches, and interpreting research in superficial ways, whether to agree with it or debunk it is dangerous.
My own opinion on the topic on the topic of this essay is that “depression” is neither a physical or emotional “illness” as it can not be simply categorized as an illness. A significant part of the problem with modern psychiatry has been because of the misinterpretation of the DSM word “disorder” as meaning “disease” or “illness” I have assessed and treated over 5000 people in my career., and few fit well into any DSM diagnosis. There is no such thing as “depression” as a singular entity. The real life reality of what one sees in practice are individuals who have some life-long emotional issues, who have made certain life choices partially because of those issues, and then have some critical life events that leaves them in distress of one kind or another. Most people will show a mix of symptoms with some sadness, anxiety, ruminations or relationship difficulties. It is the role of a psychiatrist or psychotherapist to help people deal with their life problems, their traumas, predisposing emotional issues, and their symptoms. No single diagnosis or modality of intervention can address all the factors that need to be addressed in any individual. Nor should we, as theloniusmonk points out, just throw away certain modalities because they’ve been overused or misused. We always have to keep our minds on the most important aspect: the helping of people in distress. Part of this is being aware of the resources people are able to access, their financial abilities to afford certain treatments, and of course the possible short term and long term gains and problems with any modality offered. Various people who are encouraging these debates have different backgrounds. Robert Whitaker is a journalist. His work has been very valuable, but I wouldn’t expect him to be an expert clinician, nor would I criticize him fro not having clinical expertise. Many clinicians have not had the time or opportunity to explore all areas of writing. I wouldn’t expect them to. We all have something to offer to the debate, and we all have limitations. Lets value our various perspectives, the same way we hope the mental health field could eventually value the perspective of all individuals.
This report should come as no surprise, especially considering the overuse of the ADHD diagnoses, with no evidence that ADHD is anything but some children’s behavioural response to life conditions that don’t fit their needs. A major problem with this report and the studies it is based on is the way people tend to interpret research. As research tends to look at one modality of intervention at a time, no research in mental health should be interpreted as if one is trying to find the best single modality as compared to others. Research always has to be evaluated in the light of other research and people’s real life experience. So we can take all the research on ADHD and be able to say that together exercise, proper sleep, teaching methods that don’t chain children to desks and expect them to be robots. good family environment and good teacher-child relationships are all important, and should be promoted for all children. Any individual piece of research can never represent the whole picture or solution. Empirically based practices need to include holistic interpretations of all evidence.
There will always be people who fit diagnoses as,after all, DSM diagnoses are just lists of symptoms and behaviours. Then there are psychiatrists who try to fit people into diagnoses, which is usually problematic as most people don’t fit simply into one list of symptoms. The only possible value of the DSM is it’s use as a rough guide. As Ted points out sometimes it can be helpful to be able to put a description to peoples’ behaviour. The dangers in how the DSM has been used though far outweigh any value it may have. Certainly BPD is often used as a go to label for people psychiatrists or doctors don’t like. That observation actually supports the findings in the study, and would imply that psychiatrists with heightened fear of death may be more likely to label people as BPD inappropriately.
Interesting article. It also explains why many psychiatrists may send too many patients who reveal suicidal feelings to hospital and also over prescribe medications. One should not practice psychiatry defensively, either through overt fear of a person attempting suicide, or as this study brings out, more subconscious fears of death. It is crucial to help people who are in distress to be able to sit with intense painful feelings. This means not feeling one has to “do something” to protect oneself against liability or to protect the patient. Especially when treating people who have been traumatized, like many who psychiatrists fit into the diagnosis of borderline personality, change occurs over the long term by helping a person with their most intense painful feelings. This article brings to mind Maltsberger’s seminal article “Countertransference Hate in the Treatment of Suicidal Patients. (http://archpsyc.jamanetwork.com/article.aspx?articleid=491132 ). It’s interesting that 40 years after that article was written, there is a study substantiating the basic points in that article.
The media does not to be a target. Studies have indicated that a very high percentage of people don’t read past the headlines. (It also appears to be true that many doctors only read the abstracts and conclusions in scientific papers). The media is in the entertainment and money-making business, and often doesn’t tell the complete story in nay article. Truth is often found in the details, as is evident here.
You are absolutely right. . Universities are now doing what the rest of the psychiatric industry has been doing for a long time. Take people with emotional distress caused by family or societal issues, give them a mental illness diagnosis, then spend resources saying how terrible mental illness is and how we need to de-stigmatize it and say people need help but not on our territory. Proper help is then not given and underlying problems leading to the distress are not addressed.
You’ve pointed to a very common and serious problem. Many fundamentally wrong and dangerous beliefs are becoming the norm, with institutions buying into the marketing of biological psychiatry and other beliefs. It is now the norm for people to start of psychiatric assessments saying “I think I have depression”, and for doctors to use the ridiculous “It’s like diabetes” analogy. It’s become acceptable for parents to be more concerned about achievement for their kids than kids emotional well-being. It’s now the norm, as Someone Else points out below for families not to have meals together. It is the norm for universities to buy into the biopsychiatry model, looking at emotional distress as being an illness. It is the norm for universities to emulate a corporate attitude where they want to market their success and distance themselves from what should be their goal: to help develop intellectual and emotional growth in young people. Universities should be safe space for students but instead are productivity mills where emotional distress, suicide and sexual harassment are common, largely due to the attitudes of the universities. ( one can read my piece on “Sexual Assault on Campus at http://www.drnormanhoffman.com)
As a former director of a major university mental health service, I’ve been appalled by the growing superficial concern for students by university with the undermining of actual service provision. There is an annual conference Austin-Riggs psychiatry institute on college mental health, and in attending many of these conferences, a major concern among service providers was the intrusion of administrators on the quality of mental health services. Basically, bureaucrats and university lawyers want to distance universities from responsibility for care, with resulting policies of forced medical leaves and referring students off campus for services. There is no reason why colleges and universities can’t have adequate services on campus. Clearly forced medical leaves are dangerous, especially as often the root cause of the problems that students have can be the home environment, with school life frequently being more of a safe space, even with academic pressures. Keeping students in university is usually crucial to their emotional progress. Universities are also encouraging the prescribing of medication, or simplistic symptom control modalities, rather than providing proper therapy. A major issue that one sees in students these days is that often they have been brought up more as products than as people, with not enough space for their emotional lives. Both medication and symptom control modalities collude with the message that the only thing that is important in life is achievement and functioning. These modalities will lead to increased emotional distress in the long run, as they interfere with emotional development. Students deserve and need proper help and room to grow, rather than being treated as if there is something fundamentally inadequate about them.
Your points are well taken and important. Boundaries and power issues are always present in therapy, and especially with people who are most traumatized in life, the boundaries are always blurred. This is a difficulty. One has to work with and address the real relationship while being aware of transference issues. It is never easy, either for the individual in therapy or the therapist. While therapy does involve a financial agreement, it can also be a caring relationship. One has to recognize that there are power imbalances and aspect of personal gain in so many relationships. Certainly for those who come from traumatic backgrounds there has almost always been huge power imbalances with parental figures often acting for their own emotional benefit with a lack of empathy for the child. These issues will get activated in any therapy. However, in a good therapy, despite the financial consideration, the person in therapy will experience the therapist as being more truly concerned with the persons welfare than with their own needs. There are usually significant aspects of teaching, mentorship and other parental types of interactions in therapies with traumatized individuals. A therapy is not a replacement for parenting, but it can be transformative.
I understand your point, but there can be reasons why someone would seek out a psychiatrist who is also a good therapist. I do think thatDr. Berezin knows that there are many good therapists who aren’t psychiatrists. I think that he is concerned that many psychiatrists these days have no clue about being a good therapist, which leads to many problem. Any psychiatrist that hasn’t been trained and doesn’t do therapy can have no idea of what can actually help a person to feel better and what is the natural evolution of any condition with good therapy. This makes the assessments of these psychiatrsits next to useless.
As you pointed out medication can be useful to some people. One of the benefits of a psychiatrist therapist is the ability to prescribe medication as an aid to the therapeutic process while seeing first hand how the two modalities can work together.
Another benefit, where I live, is that people can see me in therapy with no cost to them, and with no limits on the number of sessions that they can have. It is true that I can get paid significantly more for medication work, but I choose to devote most of my time to doing psychotherapy. I do think that it would be good if psychologists could be covered under Medicare here the way psychiatrists are. For now, I tend to refer people who can afford it to psychologists, and treat in psychotherapy people who can’t afford private therapy.
As usual, your comments are well stated and highly appropriate. I believe that there are psychotic conditions that are not necessarily due to trauma, but most of what is called “psychotic” is related to the traumas that you described. I don’t tend to call individuals who experience breaks in society’s view of reality secondary to abuse and trauma “psychotic”, as I think that there is nothing out of touch with reality about how they have come to see the world or their inner lives. In fact, they are mostly giving a view of their reality that is emotionally accurate.
The prescribing of anti-psychotics for anyone who is showing behaviour that someone doesn’t like, or who is expressing how their inner reality feels based on what their real life experience has been, should be prohibited. Psychiatrists should be in the business of healing people and not controlling people.
I particularly like your comment that trauma can only be healed through human relationships and love. In treating people who have been traumatized, love always becomes a crucial issue, even though the psychiatric and psychotherapy professions hate the use of the “L” word. When trying to help someone who hasn’t been loved and who feels unlovable, the issue of whether that person can be or is loved is always present and has to be addressed. When a therapist tries their best to be there for someone, truly cares about who the person is, wants to wade through all the muck with them, bears witness and tries to hold or sooth some of the pain, and does this over periods of years, then one can say that real love is present. People in therapy do feel and respond to this, though often both the therapist and the patient are frightned to name it.
Without doubt the treatment of high cholesterol can be inportant, includig the use of statins. However this class of drugs are now among the top profit earners for pharmaceutical companies, and while useful also have many side effects. I know of many family doctors who are backing away from prescribing these drugs without first doing other tests (like Dopplers) to see if the prescription is necessary. There are also ther things like exersize, diet, and some natural substances that can lower cholesterol and improve cardiovascular health. The issue that Jill raises is not whether certain drugs, prescription or otherwise, are helpful, but why certain drugs or practices become so popular at certain times. The fad aspect can be dangerous because it can stop people from following or recommending alternatives that may be better for many people.
Another aspect related to why drugs come and go is why diagnoses come and go. I have seen many fad diagnoses in psychiatry, such as the present emphasis on diagnosing “bipolar” in anyone who has up and down moods, but there are also fad diagnoses in general medicine, such as diagnosing hypercholesterolemia, and giving statins even when there is no evidence of arterial disease. In psychiatry, many of the fad diagnoses that I’ve seen through the years have similar symptoms: variable moods, insomnia, periods of lower functioning. The diagnoses that are given, are often driven by the mental health industry’s need to create a niche to treat, as well as by Big Pharma’s need to create a market. So, the use of street drugs, prescription drugs, and diagnoses is so often industry driven, and not responsive to actual social problems.
I think that an important aspect of this issue is that the widespread use of drugs, whether prescription or street drugs, is evidence of social dysfunction. One could say that governments and corporations prefer to encourage drug use in many ways rather than have people vocalize social discontent. Our society has not shown the courage to attend to serious fundamental problems, and has allowed drug industries to flourish.
I certainly agree with you that being a good therapist does not require medical training. In my experience people need a certain empathetic quality to be a good therapist, and that can’t be trained. On the other hand, a medical training “should” give one the following abilities that can add to the perspective from people of different trainings.
Medical doctors should be able to:
Read scientific research and distinguish between clinically valuable findings and simple statistical findings.
Understand a vast array of human suffering.
Understand the interplay between biology and the mind in a complex manner.
Know when an emotional issue may be related to a physical disease.
Know that every treatment may have a down side.
Know that a patient’s needs should always take priority.
Know that we can never be certain and need to be humble.
Know the first rule of medicine “Do no harm”
Doctors are (or should be) trained to understand all these points. We should be asking ourselves, not why we might need medical professionals in mental health, but why so many doctors who work in this field have forgotten their basic training.
You points are well taken. I am writing a piece now for MIA on the value and shortcomings of psychiatrists and a medical education. Clearly in the mental health field, and in psychotherapy having people who come from various education and life backgrounds is very valuable, though I do think that the medical profession should be able to have particular value. let me address quickly for now some of the points I intend to write about. Medical education is highly clinically based. By the time a psychiatrist has finished medical school and residency, one will have been involved in the treatment of hundreds of people. As medical students, we see life coming into the world and leaving it. Don’t we all remember our first delivery and first death? I remember very clearly as a beginning third year student the patient who died when I was on call, and having to fill out the death certificate and call in, and talk to the family. We all are exposed to all manner of human suffering. In psychiatric residency we assess and treat many patients with all different kinds of problems. In my program, and probably Dr Berezin had the same experience, we had comprehensive psychotherapy training and teaching throughout the program. I remember how psychology PhD interns would be carrying 2-4 patients for their rotation in the same service that I would be responsible for 10-15 patients. The experience in medical school and residency should leave someone better trained and having more empathy for patients due to the intensity of the training. It is unfortunate that instead the training can leave many doctors distancing themselves from human emotion and arrogant about their knowledge. There are many other possible advantages of a medical education for the mental health field, but some of the same aspects that lead to advantages can also cause serious limitations.
I do agree with you that there is a place for medication, and certainly medication if used properly can help people. We should not be withholding pain relieving medication from people in distress, especially when other resources may not be available. I have been teaching psychopharmacology to therapists for over forty years now. An important issue is how to use medication in minimal doses when necessary, but to not distort the reality of the meaning of diagnoses and the downside of medication. The larger issue in Robert’s article is the way modern psychiatry is hijacking the understanding of human suffering and reducing everything to a simplistic and erroneous biological model. In general, the results achieved by this new model of psychiatry are poor, with many people suffering from the ramifications of inadequate treatment and serious physical and emotional side effects. It is often, though that individual practitioners like yourself do find through their clinical experience what can actually be helpful to people, separate from what may be most marketed. If you would like some practical tips on using psychiatric medication, feel free to contact me.
lovely post. There certainly is such a thing as good psychiatrists and good psychiatry, though sadly it does appear to be disappearing. As you brought out clearly, the practice of psychiatry should be primarily the practice of psychotherapy, as human suffering, related to various aspects of societal dysfunction is the main cause of distress in almost all the people we see. I read psychiatric research, and I am usually appalled as the research appears to have little relevance to a real life clinical population. How often do you see “an anxiety disorder” or a “major depression”? I don’t even know where they find people who have a single “disorder” with no complex personal issues for research studies. All the people that I treat have complex issues that require proper attention and time. There is no short-cut to treating real people. One can’t just pay attention to symptoms, though in my experience if one attends to the underlying issues, symptoms tend to disappear fairly quickly. Psychiatry has almost been destroyed, though it is possible that both people in distress and many therapists are getting fed up with all the distortions and self-serving institutions. It’s encouraging to read your words.
Alex, you are not alone in this battle. There are many people who now buy into the marketing by the “empire” who really want to do good, but have just come to believe in the wrong information. Your efforts, and organizations like MIA are going to make a difference in the long run. The cost to the system, and to thousands of individuals is just too high the way things are now. Many professionals in the mental health field do believe in real science. We just need to continue to show that the way certain research has been promoted and marketed does not represent the whole reality. Real people are not research subjects and all research has to be interpreted in the light of people’s real experiences. I don’t treat “subjects”. I treat real people with real life problems, and rarely see anyone who has a simple “panic disorder” or “Major Depression”. Therefore, even the best research, properly interpreted is only a rough guide. All mental health professionals need to understand this. Many are discouraged by the poor results achieved by simplistic measures based on research models. They will come to understand the truth behind the industry with time. We just need to keep getting out a better message.
Thanks for your comment. I’m sorry that you were treated with such disrespect, though unfortunately this is no at all uncommon. As someone born of Jewish faith, I would like to assure you that not all Jewish doctors would respond to someone the way you were, regardless of your name. Much of Jewish teachings and culture is based on learning and wisdom. it is sad, that many people who follow various religions end up believing in superficial doctrines rather than holding to the spirit if the religion. There is a parallel between this and the mental health industry where many professionals don’t follow fundamental humanistic principles, but end up believing in easy to follow, highly marketed modalities. Most religions start with variations of the Golden Rule “do unto others…”. The medical Golden Rule is “do no harm” taken from the Hippocratic oath, “and I will take care that they suffer no hurt or damage”‘ Clearly the medical profession is often not following this basic rule.
Thank-you for your comment. I totally agree with you that it is about trust, and you point out some of the crucial issues in trust: competency, wisdom, integrity and humanity. Too few psychiatrists possess these attributes. As psychiatrists, we do need to have a strong understanding of our field and a wise understanding of research. Most of all, we need to have an open mind and to listen to our patients primarily for concern for their feelings and needs. Sometimes this means meeting them halfway; for example, while trying to educate them about various aspects of emotional care,, at their request, using medications, though cautiously, to help engage them in a therapeutic process. I’ve called this “back-door therapy”; first meeting their request for medications, with full disclosure, but then once engaged to begin a real therapeutic process. Everyone is entitled to their own comfort level about treatment, and one can start to build trust in many ways, as long as the patient’s own perspective and needs remain central. I also want to make it clear that I tend to use the word “patient” despite the shortcomings of that term to denote a recognition of my responsibility to attend to the person, and of the power imbalance that exists regardless of all respect given to the person. It is not a term that I use to denote that the person has an inherent illness, that they are a victim, or that they need to collude with a particular role. I don’t like the term client which can imply a business arrangement rather than a caring relationship.
Alex, you are so right. I have come to believe that the quality of care that is actually received is inversely proportional to the number of “programs” a governing body announces. These programs are usually just marketing to make it look like something is being done, while not providing solutions to the problems that cause people distress. The labelling of people as mentally ill and then focusing on reducing stigma for mental illness falls into this category of wasting money. The industry gorges on the vulnerable, wastes money to protect themselves from liability and to placate the masses, but overall creates more chronic problems with questionable help to people in need.
This article, and the comments all bring out crucial issues. The financial rewards to the mental health industry is driving the extremely poor and often dangerous standards of care to people in emotional distress. It is more lucrative for a psychiatrist, or any doctor to just pull out prescription pad rather than listening to the person. The article referred to in the New York Times is chilling, as it brings out how much psychiatrists convince themselves that they are being helpful while treating people with profound disrespect. I am a psychiatrist, who does mostly therapy, but does prescribe medication (cautiously), mostly to people in therapy. From my experience, I can state that the degree to which people will tell you about their real feelings and problems varies greatly with the time that they are given, and the empathy the treating person shows. If a doctor only shows interest in symptoms and doesn’t have nay time or empathy for the individual, then that doctor will know nothing, either of how the person feels or how the person is doing. This can lead to a doctor being convinced good is being done, when a patient is actually doing very poorly. The acceptance of poor results has become the norm, with many people seeing “mental illness” as a chronic “disease”, and not understanding that it is actually the widespread use of inadequate, and possibly dangerous, treatment modalities that is causing the problem. We do need good resources to help people, but billions are being wasted, people are not being properly helped, and tens of thousands are being turned into chronic patients by the system.
There is a major problem with studies on psychotherapies that are aimed at deeper emotional change and growth as compared to studies on modalities, including medication, that focus on symptom reduction. In short term studies, as emotional growth therapies encourage emotional expression, these studies should show poorer results when rating only symptoms as compared to symptom reduction focused modalities. In reality, emotional growth therapies show just a good results for most types of problems in the short-term and better results in the long term. It is a misinterpretation of research that tends to promote simplistic and numbing modalities.
I do love my province, despite some annoying political issues. First, the child and adolescent branch of the Canadian Psychiatry Association comes out against drugging kids and youth and against using anti-psychotics as sleep aids in all people, and now this very important report on supporting the use of psychotherapy. Maybe a warm wind is now blowing in from the north. I have been very fortunate living in Quebec to be in a province that i more socially minded, and that also allows me to treat people from all socio-economic backgrounds at no cost to them. We are also fortunate to have greater influence from various European schools of thought.
The proper interpretation of research is crucial in psychiatry and the general mental health field. As this report, and research indicates, short-term numbing of symptoms is not only less useful in the long run, often leading to chronic or recurrent conditions, but is not economically reasonable or advisable.
Vive le Quebec!! Vive les personnes libres!!
Great article and review of research. There are clearly numerous problems these days with the diagnosis and treatment of bipolar disorder. A major health hazard presently is that bipolar disorder has become the newest fad diagnosis, with many doctors using it for anyone who has mood changes, including in children. These doctors then follow standard protocols and pharmaceutical marketing to put people on concoctions of medications. As your article brings out, any medication that has sedating effects will appear to reduce symptoms from the doctor’s point of view, though these medications can often interfere with well-being and functioning. So much of apparent statistical significance in medication research can be attributed to sedation and other enhanced placebo effects. You point out clearly how variable is the progress and recurrence of what could be called actual bipolar disorder. There are many people who have just one or a few manic episodes. I have seen people who have had some symptoms in adolescence or early adulthood and then never again. Some people may get symptoms later in life. However, psychiatrists who are primarily hospital based, as well as many other psychiatrists, tend to assume the bipolar is a life long condition, partially because they may see primarily people who might have more severe conditions, or who might appear to have increased morbidity due to treatment. I have had many experience with patients who do very well with medication as needed approaches or, as has been pointed out in the comments, with little or no medication and psychological intervention when needed. Of course, in order for these approaches to be successful, people need, good supportive environments, as well as quick access, and good follow-up from treating physicians. I do not use lithium with patients as there are better alternatives. One also needs to work with individuals within their comfort zone, when deciding on what approaches to use. There is no excuse for practicing simplistic flow-chart psychiatry, as all patients are individuals that have different life histories, evolution of symptoms and needs. This is why being a psychiatrist can be difficult, as one has no simple protocols to follow, apart from treating everyone with respect and true care. Psychiatrists are often scared when treating a person who has been diagnosed with bipolar illness, as the possible consequences of episodes can be devastating. Being worried about possible deterioration in a patient is no excuse for over-treating or mistreating people. We can not practice psychiatry defensively and get best outcomes for our patients. Being a patient is even more difficult, as one is putting one’s life in the hands of doctor who can’t have complete knowledge of all possible ramifications of treatment, and cannot know the full picture of an individuals life.
A wonderful piece! It certainly supports the view that there is good psychiatry, but that good psychiatrists are always questioning their views and are aware of the fragilities in our field. I think what some people fail to appreciate, and part of what makes many psychiatrists limited in their ability to help people, is that we as psychiatrists live in doubt every moment of our professional lives. We go on vacation, or are away for just a weekend, and we never know what tragedy may await us when we return, and whether perhaps we missed something or said something not quite empathic enough. We are never sure of our theories or our treatments. We can’t predict with any accuracy the value of our work with any individual. We can’t know with any certainty how much of the whole story our patients are telling us, or whether their perceptions match the perceptions of those around them. We work largely in the dark, often grasping at straws, and then, as you point out, find ways of feeling more secure with our perceptions. Some psychiatrists cling tightly to certain theories, techniques or flow-chart psychiatry. Some of us understand that whatever uncertainty we live with is nothing compared to he emotional uncertainty that many of our patients live with every moment of their lives. This understanding leaves one with more empathy for those we treat, and more incentive to always explore and question. We all need reminders that working to improve people’s lives is a worthwhile endeavour, but that we can never be complacent in our knowledge.
We do need to expose more the root causes of misery and the inequities in our society. The chasm between rich and poor is a major issue in most countries, and the psychiatric industry is being used as a tool of those in power to placate the common folk. The notion, promoted by the positive thinking movement, that anyone can just “think happy” if they want to, is an insult to anyone who suffers from personal trauma or social injustice. Therapists who work with a broad range of people from various socio-economic backgrounds usually understand this. In good therapy, whatever techniques one may use, one should strive to help people understand the roots of their pain, whether family, or socially related. (and thee is often a link between the two). We also need to stand up for the under privileged, and not collude with either neoliberal or neoconservative doctrines.
There is an important issue apart from the way ADHD is being pushed for the benefit of the industry. Speak to elementary school teachers who has been working for over 15 years, and they will all tell you about the increase in classroom behaviour problems. There are important societal changes that have occurred that is leading to more chaotic kids and frustrated teachers. Teachers who usually have access to limited resources, may then end up encouraging psychiatric assessments and the use of medication. While teachers should not suggests diagnoses to parents, it is not teachers’ faults that they are overwhelmed in the class. In addition to blaming self-interests of the industry , we need to address numerous social problems that are leading to the diagnosing and the drugging of kids. All children need a safe, stable, sensible and connected world to grow up in.
As knowledge about good therapy evolves, the practice of CBT is evolving to become closer to the good therapy models that have been around for decades. This is the case for both Schema therapy, that is very similar to active models of psychodynamic therapy and mindfulness based CBT that allows a more positive approach to “negative” thoughts. But, I agree with Richard that the way CBT is used in institutions is often very negatively oriented. Often the same tools, such as using thought records are just stated over and over again until the patient either shuts up about symptoms or drops out. I have heard from numerous people of their bad experiences with CBT (not that I haven’t heard many reports about bad experiences with other therapies). There are stereotypes of all kinds of therapies, but unfortunately, there are too many therapists who do represent these stereotypes. The most common types of psychotherapy research tends to be done on therapies that do resemble these stereotypes, as therapies need to be standardized to do this type of research. A lot of the research that has been used to support the massive use of CBT in institutions is this type of research, which for all forms of therapy shows statistically significant but overall poor results (typically 50% reduction of symptoms in 65% of patients). We need expert models of therapy to be promoted, and not research models.
You point out a major problem with our system, and also how CBT is being used (or misused) CBT can ann is being used by the mental illness industry to support the idea that people have “wrong” brains and the only thing one has to do is to focus and push away symptoms. Cognitive techniques can and are being used by good therapists who strive to help people with real life problems. Working with cognitive distortions has always been an aspect of good therapy, far before CBT was conceived, but CBT has highlighted the importance of being more active in working with cognitions. The whole debate of whether one is working with thoughts or feelings is often overstated, as thoughts and feelings are implicated all the time, as Kermit pointed out. Therapy is always an emotional experience, and this aspect, especially understanding the impact of the therapeutic relationship, is crucial. So, we should really be talking about good therapy and limited therapy. When a therapists works with a person’s real life problems, helps them understand and deal with their symptoms, feelings and relationships, and honours the importance of the therapy experience, that is good therapy. If a therapist sticks to a few tools without listening well to the person, and gives the person the message that their is something essentially wrong with them as a person, that is limited therapy. As this article on anxiety and serotonin brings out, brain chemistry is complex, and the biological model knows too little to make claims about the value of medication. The same can be said of the therapy field. People are complex, and research will never show what will be most helpful to any individual. This is where listening to our patients becomes so important, because they are the people who will always teach us more than research about what can be helpful.
A major problem with psychiatric treatment of psychosis (as well as most other conditions) is that in general the psychiatric institutions focus more on symptom reduction than on functioning and well-being. It is more “cost-efficient” from their point of view to heavily medicate someone so the person will not need to use system resources. Whether the person feels well or can function becomes irrelevant. There was a patient who was in medical school who had been diagnosed as bipolar. When he appeared to be having a manic episode, his behaviour was a concern to his supervisors, and he was in danger of having to discontinue his education. However his symptoms were able to be calmed down enough with the short-term, occasional use of just 50 mg of chlorpromazine. He continued to function well, was never on other medication, and would need this medication for about a month, once a year. After a few years he didn’t appear to have any further episodes. I have another patient who was on high doses of anti-psychotics and had multiple hospitalizations, yet had heard voices that never went away. She’s been on almost no medication for over twenty years now, is happy and functions well, though does have her, mostly friendly voices. I know when she is having a harder time when her voices turn less friendly, and I then spend more time with her, but have not resorted to medication changes. Functioning and happiness should always take precedence over symptom extinguishing.
Stan Kutcher is a well known Big Pharma pawn, and clearly is tied financially to Big Pharma. I think it is a major problem these days that so much money is being spent on “de-stigmatizing” campaigns that allow organizations and governments and companies like Bell Canada, to market themselves as caring about Mental Health, while actually then doing nothing or actually cutting treatment resources. I posted a piece on my blog titled “The Need to Stigmatizing (the overuse of the term) Mental Illness” that discusses this issue.
Your views. like anyone views, are crucial to all of us understanding life’s ups and downs. One of the issues with CBT, is that many of life’s problems are not caused by negative or wrong thoughts, but are caused by life’s pain. We evolved to have adaptable brains that learn from our environment. Many people’s life experience has been traumatic, with their brains being properly vigilant or sensitive to possible trauma. Life is not all happy, and it is often very reasonable to feel sad, or anxious about life. Losing someone close to you is always very painful. There is no way of talking or thinking away the pain. I remember being at a funeral for a friend’s mother, and someone said to the father “It will get better”, and I replied,” no, it doesn’t get better, it just gets different”. There are all kinds of theories on grief, and all different ways that people find to feel somewhat more at peace with death, but the reality is that we are not able to comprehend or deal well with death. From an emotional and attachment point of view, death doesn’t make any sense. A person we love is there, and then they are not, and a huge hole is left in our hearts and minds. People’s feelings are always important and we should not be trying to explain them away, or diagnose them. One always has to be careful in helping people to handle certain feelings or symptoms better to not inadvertently invalidate their pain. I wish you some peace.
and thank-you for sharing your story and thoughts. When one considers the use of medication with a patient, it has to be thought of as doing so in partnership with the patient. Medication should never be thought of as the solution to a problem, but only as an aid. The crucial aspects to focus on is well-being, functioning and emotional growth, rather than on symptoms. These days too many practitioners are only concerned with symptoms, which can lead to the many horror stories we are all aware of.
Service availability is certainly a problem as is having so many schools of thought in psychotherapy. I find that many therapists these days, who claim one approach or another, or call themselves “eclectic” tend to have their own limited basket of tools that they pull out based on their comfort or discomfort level. So if one thing doesn’t appear to be working they quickly pull out another modality. Using various modalities is important, but should be in response to understanding what will be helpful to any individual, and not to serve the comfort level of the therapist. I advocate what I call the “One Therapy Model”, which is that for any individual there should be a specific combination of approaches and way of understanding the person that will be optimal, and that it is the job of the therapist to try to discover this therapy. Clearly to find this “one therapy” is not completely possible, but one should always attempt to make the therapy fit the client and not the other way around. One of my concerns with CBT is that, according to many patient reports, many CBT therapists insist that the patient adopts to the therapy, and will berate people if they don’t.
Well stated, and thanks for the interesting information. As you point out, CBT does not aim at the root of the problem, certainly not for depression. When a symptom has taken on a life of its own, then that symptom may become the problem itself, and working towards eliminating that symptom makes sense. When deeper issues are causing a symptom, if one controls that symptom, then other ones will arise, and the underlying problem continues. In my experience, symptoms are not usually the problem in themselves, and in most of the people that I see, the type of symptoms that respond to CBT usually dissipate quickly with normal integrative therapy, without having to make them the focus of the therapy. My main objection to the CBT movement is how it is being used in the industry, with many systems dropping therapy services that will work with more complex emotional issues in favour of short-term CBT clinics that work from a DSM diagnosis model and only look at the particular set of symptoms for which the individual was assigned to a therapist. Thus, if a person was assessed for panic symptoms, that person will receive 12 weeks of CBT for panic, and nothing else. I have rarely seen anyone who just has symptoms and not complex life issues that they need to address. While their are many good therapists that use CBT techniques, the overall trend in the mental health industry has been to treat symptoms and not people by using simplistic and made up diagnoses to direct treatment and then methods like medication and superficial CBT to dull symptoms enough so the patient will go away, and the system can continue to believe that it is doing its job.
My personal view is that it is better not to take these drugs, and for a person to be able to work with their emotions. A major problem these days is that many people, both treating and being treated, no longer believe that one can live through and work with emotional pain. It is very hard sometimes to convince people that emotions are a signal to ourselves that we need to listen to and respect. It is also not my way to force my thoughts on other, but to show respect for where they are in life, though I do try to educated. So I always try to emotionally respond to the patient, attempt to settle down their worries, educate them to the meaning of emotions, and try to reassure both patients and therapists that emotional work can take time, but that progress is possible. Sometimes though people feel too raw to be able to wait things out, or be able to work in therapy. In these cases, medication, in the short term, may be helpful, always starting with the least invasive, least dangerous, and smallest dose possible, and always trying first to use medication that can be taken on an as needed basis, rather than daily. While this may not be the ideal way of treating someone, it is at times the best choice for helping the person move forward in life. One has to always be aware of the downsides, and work with the person to help them tolerate painful feelings rather than letting them be numbed down. It can be a fine balance. Of course, one then wants to get the person off medication as soon as possible. More to come on this issue.
I’ve had a patient who had quite severe TD after being treated by anti-psychotics for trauma related problems. This is a devastating condition. I believe that the use of any anti-psychotic for non-psychotic conditions should be illegal. (one can debate how they are used for conditions called psychotic as well).
Thanks for this. Honestly, I am often dumbfounded by my profession. I really don’t think that my thoughts or approach or so special. To me it’s mostly common sense. I just can’t believe how off the rails the mental health industry has gone.
Wonderful piece. The imagery seems to indicate that these men on hooks see themselves as the new Messiahs.
The DSM is such a flawed and potentially dangerous tome whose evolution I would describe this way:
A Den of Sanctimonious Men
on a Decidedly Self-serving Mission
Declaring Scientific Method
Determined to Supplant Moderation
and aid Dr. Spitzer’s Motive
to Destroy Sigmund’s Memory
while Debasing the Search for Meaning
by Describing Sensitivity as Madness
in their Dehumanizing Saddening Mockery
and Dangerous Sardonic Manual.
Excellent report. I truly hope that it has an impact. The labelling and drugging of children, adolescents and young adults is one of the most serious emotional well-being issues of our time. We are setting up our young people for a lifetime of misery, rather than dealing with the important social and family issues. In 2005, I presented to the Kirby Commission on mental health, with similar concerns. Unfortunately, that commissions report gave more support to the mental illness industry than to addressing real issues. I’ve just posted a copy of my report to the commission at http://www.drnormanhoffman.com for those interested.
Bipolar disorder is clearly the latest fad diagnosis. It allows psychiatrists to stick a label on anyone with up and down moods, with no further investigation into the causes of these moods. Of course, if you medicate people enough, these moods may go away, but then so does thought, functioning and healthy emotions. Especially as this diagnosis is being applied to children, it represents one of the biggest health hazards being thrust upon people by the industry.
I agree with you. All the evidence is that psychiatric medications interfere with the normal functioning of the brain. They make a normal brain abnormal. That does not necessarily mean that blocking normal function may at times be helpful, just a marijuana may be helpful emotionally in some circumstances. I do prescribe the medications known as antidepressants at times, cautiously, in particular circumstances (more to come on this later, as I do intend to wade into the bog), but I always tell patients that these are emotion dampeners, that they do interfere with the normal functioning of the brain, and that they are likely to dampen or numb all emotions, not just the bad feelings. (one may wonder why anyone would want to take these medications after this description, but as I’ve said, there is more to come on this). So , certainly honesty is important, and I think that this is one aspect in which the psychiatric industry had failed miserably.
I agree with you, Bonnie. The term ‘mental illness” is clearly not medical. you can read part of my view on this on my blog drnormanhoffman.com in a piece talking about the need to stigmatize the term “mental illness”. The Soviet Unio used to be accused of using the term mental illness to incarcerate people who they saw as socially undesirable. We are clearly doing the same in our society. If one is not just willing to be a cog in the wheel, and one has emotions about aspects of life, then one must be medically ill. This is clearly a dangerous way of viewing emotions. However, despite the distortions and lmitiations of psychiatry, and the way it is being used by the power structures in our society, i am not yet willing to resign from my profession and give up. We need many people, from all different backgrounds to fight the good fight.
you call yourself a layman, but you clearly have a better view of the issues than many professionals. The points that you raise are excellent, and we really do need reasonable protocols in the field. As you point out, and as is evident in the link you provide, most protocols at the present time largely presume a biological cause of depressed feelings. Many practitioners are encouraged to use screening tools that are only validated ( and poorly at that) for Major Depression which as we know is a made up diagnosis to begin with. The common protocol is then exactly as you pointed out, with lip service being paid to alternatives to medication and prescriptions being written quickly, often with poor follow-up. One of the reasons why these type of approaches and protocols continue is that doctors want to feel their treatments are successful, and as antidepressants are primarily emotion dampeners, patients initially often report not feeling quite as bad. Without further investigations of the person’s happiness or functioning, and with infrequent follow-up appointments, the doctor then feels comfortable in the perception that the patient is doing better. From the viewpoint of many doctors, if the patient initially wasn’t feeling quite as bad after being started on meds and then months later describes feeling worse, then the problem is biological and more meds are needed. These perceptions need to be challenged. We do need a whole new approach to treatment.
It is absolutely true that many psychiatrists are prescribing anti-psychotics for sleep and other problems. It is frightening that Abilify is now the top selling medication in the U.S.. On a good note, as reported on MIA, the Canadian Psychiatric Association has come out strongly against the use of anti-psychotics for sleep problems in all people, and for the use of these drugs in children. Maybe some reform is possible. The common practice of prescribing psychiatric medication, and then continuing increasing dosages and additional medications when the person doesn’t seem to improve has to stop.
I totally agree with you. Some people can go off more quickly, and have a miserable few weeks, but for most, slow and steady is necessary. It can take up to a year to get off these meds, as they do change your brain, and it takes time for the brain to re-grow neuroreceptors. One of the problems with modern psychiatric drugs is that they are only available in large increments. So, for example, Prozac, only comes in a minimal dose of 10 mg. Some pharmacies will compound smaller doses, but this can be expensive, or with capsules one can divide up capsules oneself. It’s a larger problem with the extended release pills that some drugs come in. One thing that I do at times, if people have trouble weaning off, is adding a small amount of nortriptyline which is available in small increments. While it is not ideal to start using a second medication, it can help some people eventually get off all “antidepressants”.
Thanks for your kind response. I understand that this is a difficult issue. I see people every day whose lives have been deeply hurt by the psychiatric industry and psychiatric drugs. The present practice of psychiatry in North America is overall abysmal. I think that many people who have come out as totally against all psychiatric medication have had or heard of mostly bad experiences, and therefore don’t know that there are other possibilities. The lack of proper resources and the selling of the bio-psychiatry model is clearly a huge problem, that we need to fight against.
I would like to keep the dialogue about medication use open, though for now, let me give a simple example of reasonable drug use. It has become a common practice, and major health hazard, for family doctors to prescribe quetiapine (or shutupapine as I prefer to call it) for sleep problems. People who have been prescribed this medication, even though it has many side effects, are often afraid to stop it as their insomnia caused severe problems. In this situation I will wean them off the quetiapine, using small doses of a benzodiazapine. This approach usually works and then allows the person to continue to function while we look at underlying issues and other solutions for the insomnia.
I understand and appreciate your comments and confusion. Certainly psychiatric medications are grossly overused, often dangerous, and corrupt our society’s attitudes towards emotional pain. I hope to be able to with time, explain that there can be certain benifits from cautious use of certain medications in appropriate circumstances, but for now let me say this:
In a perfect world people wouldn’t come to me in severe emotional distress with no money for proper therapy or even an adequate diet.
In a perfect world, I would be able to spend 3-4 hours a week with each of them ,helping them with their emotional issues, and then spend the rest of my time fighting poverty, social dysfunction, child abuse, work place abuse, and corporate power.
In a pefect world, people would have the incentive to seek proper help, do exercise, yoga, meditation, or anything necessary rather than take psychiatric medications.
In a perfect world, I would be able to convince people that “chemical imbalances” don’t exist and that psychiatric diagnoses are made up.
In a perfect world, I wouldn’t be prescribing modest amounts of medication to stop people from seeking it elsewhere from doctors who will overprescribe with no concern for more complex issues.
In a perfect world, I wouldn’t have to prescribe any medication to help people with some aspects of their emotional pain, but then, in a perfect world, there wouldn’t be any emotional pain.
In this world, I am asking you to not judge me too harshly for having to take some shortcuts to deal with reality while trying to provide people with some relief from their pain.
I totally agree with you. What I was referring to ias what psychiatry calls “narcissism”. Robin was vulnerable to feeling badly about himself at times, but in my mind was an amazing person. The point is that life can not be put down to a DSM diagnosis. It is dangerous to do so on many levels. We need to see people as whole complex people. I just wish that someone could have helped Robin Williams with his demons whatever they were. He is sorely missed, especially in a world with not enough humour.
I stand corrected on that point. I agree with you in that there is good therapy and some good research. I was referring mostly to the simplistic diagnosis and symptom based research with standardized models of therapy. We do need to show that both research and therapy can be done in ways that address complex issues.
I agree with you entirely. One of the aspects of some humanistic therapists that frustrate people is the inability to help in practical ways. We also need to be able to speak people’s emotional and cultural language, and not expect them to understand ours. There can be a certain arrogance in some psychodynamic therapists who feel that patiients “should” be “insightful” but who don’t address issues in ways that actually speak to the person. A number of years ago I gave a presentation at the yearly Austin-Riggs conference on student mental health, on a particular, and reasonably active, approach to short-term therapy for university students. Many of the counsellors objected to an approach that they saw as “too directive” as I proposed beign helpful and active from the first session. I also agree with you that there are many things one can say that are helpful and therapeutic, and in fact many experiences outside of formal psychotherapy are therapeutic. I stand humbly corrected.
Part of the issue with CBT is as much how it is being used by the industry to not offer proper help and to cut expenses. CBT is sometimes taught with more depth, as is the case with Schema Therapy teaching, but as you pointed out, integration of ideas is difficult in our field, and many people end up practicing superficially. I’ve seen dozen’s of people who’s experience of CBT has been of the therapist having a couple of tools that are repeatedly stated, but little ability to help with real life problems and emotions. We shouldn’t want any superficial, bureacratic approaches to therapy taking over the mental health field.
We certainly agree that the discipline is fundamentally faulty. It is a major problem as well that just about every approach in psychiatry has a way of blaming the patient when things don’t go well. Maybe some day we can debate the issue of whether to abolish the whole field or to try to salvage some good. I am presently working on a book called “Real Life Psychiatry” that does address the flaws of the field but proposes ways of helping people .Beyond what can or can’t be done by individuals, it’s clear we need societal change on many levels.
Great article Jay. Very thoughtful and educational. As you bring out, the emphasis some researchers place on finding genetic influences or causes of DAM diagnoses is troublesome. The implication in the industry and certainly how it is often presented by the media is that certain people carry a “diseased gene”. Of course, this has never been found for any psychiatric diagnosis. The reality is that we all have varied traits. Different traits may lead to varying effects of certain environments. For example, a child who may have a trait of higher emotional sensitivity may react differently to an abusive home than a child who is less sensitive and more assertive. Both will be affected by abuse, but may develop different personality traits or problems later in life. Dr. Hallie Frank and myself did a study years ago on “borderline empathy”: the observation that many individuals who receive this diagnosis seem to tune in to the underlying emotions in others. Our study did find some evidence of heightened emotional perceptiveness in people diagnosed with Borderline Personality and the data seemed to indicate a constitutional variable. The important aspect in this, and in many other possible genetic correlations, is that emotional perceptiveness is not a disease, but is a potentially positive trait that under more ideal family environments is likely to lead to highly beneficial traits. Of course, this issue of emotional sensitivity brings up the whole issue of the wish of the mental health industry to numb people, rather than address societal causes that hurt our emotional development. The crucial issue, is that there are many different traits that create our amazing diversity that will lead to positive outcomes in good environment, but may shape the nature of emotional distress in poor environments. A similar argument applies to the search for a “suicide gene”. There may be traits, like for example the degree of risk aversion or pain tolerance, that may correlate with suicide. This does not mean that these are problematic genes. It will always be problematic social causes that lead to suicide. It might be helpful to know what traits may make it more likely that a person will actually commit suicide, but it will usually be more helpful to deal with the emotional and social issues involved. Genetic traits are not diseases.
This is an excellent well balanced article, though personally I find that the way CBT is used and marketed is a major problem in the mental health field. Certainly cognitive and psycho-educational techniques can be helpful to people though these have been a part of good therapy long before CBT was invented. A significant issue with CBT is the way it is taking over in mental health institutions, often used in the most simplistic manner, despite the lack of substantive evidence to show that it works well. By this I mean that pretty much all of the diagnosis and symptom based research, whether using medication or therapy, tends to show mediocre results, though showing statistical significant difference with placebo or sham therapies. The results obtained in these research studies are far worse than one would want to achieve in clinical practice. So empirically based therapy is not the same as good therapy. Furthermore, if one wants to consider a body of research to be substantive then it should be cohesive. One should find that the results from looking at an issue from various forms of research, as well as including clinical experience and patient reports all hang together. The research on aspects of therapy and therapists that correlate with good outcomes all point to relational issues. This research does correspond well with clinical experience and what patients report useful in therapy. The only research that supports CBT is at odds with these other forms of evidence. In may years of practice, I have never seen anyone who reports significant change with CBT or has described CBT techniques as highly useful. Patients do speak of the empathy, understanding and wisdom of their therapists. So while CBT claims to be empirically based, to date, hard evidence about the effectiveness of the techniques is lacking. What makes the situation fro the mental health field worse, is that many institutions are taking any relational component out of the CBT type therapy they offer, and focusing only on teaching techniques. This is troublesome. You refer to the article comparing therapies for bulimia. That is an important study as it does point to the idiocy of certain approaches. Having headed an eating disorder unit for many years, it is clear that nutritional, psycho-educational, and structural approaches are necessary, though one would ideally also want to address emotional issues. There are very good therapists, who use multiple modalities to address the real needs of patients. We should learn what we can from different approaches. The problem is the way CBT is being promoted and taught. Many CBT therapists do not know enough developmental and emotional theory to help people in emotional distress, yet claim superiority on limited empirical evidence. I have seen many people who have felt worse after their experience with CBT therapists who have tended to prohibit any talking about “negative” feelings, and have given n overall pejorative message that a person should be able to control their feelings with their thoughts. There is good therapy and there is bad therapy. Empathy and in-depth understanding of a person is always an aspect of good therapy. Any therapy that claims this is unnecessary has to be questioned.
I’m looking forward to reading your book, and I certainly agree with many of your views and points. However, as long as there are people who society deems to be mentally ill, we will never get rid of psychiatry. There is also, believe it or not, such a thing as good psychiatry. The problem is that the psychiatric profession has gone totally off the rails, not that it ever had a great grasp on reality. There are many reasons for this, but one important aspect is that there are very few psychiatrists who don’t owe allegiance to some body outside of the patient. Most psychiatrists work within hospital systems and therefore end up functioning for the benefit of the system. Others work in research and owe their allegiance to funding organizations. Many others owe their allegiance to their pockets and need to promote and market themselves in order to make the incomes they desire. You and I are fortunate to live in Canada where we have decent health care, and as an independent psychiatrist, I don’t have to owe allegiance to anyone but my patients. I applaud your work to bring down the psychiatry industry, but we should never forget the needs of people in distress.
There has been a huge change in the very language that people are using to describe themselves and their emotional lives over the past thirty years. When I started in practice, people would come in saying things like “I’m feeling sad lately” or “I’ve been upset” or “I’m not feeling like myself”. The most common opening statement that people are likely to say these days is “I think I have depression”. The language of the mental health industry is taking over from the language of emotion. Of course, I always respond by saying “Can you tell me how you feel and what’s going on in your life?’ Nonetheless, a significant aspect of doing assessments and therapy these days is helping people to understand that they have emotional and not chemical difficulties. It is not surprising that the pharmaceutical industry prefers and promotes forms of therapy that collude with the “there is something wrong with your brain or the way you think” message, and devalues humanistic therapies.
It is possible that certain of the techniques of CBT may have their uses, but the evidence that they do is lacking. Research on what actually works in therapy supports relational frameworks and show that techniques themselves have minimal impact. The research on which CBT’s tremendous rise in popularity is based is all quantitative symptom and diagnosis based research. This mode of research, on whatever therapy or drug is being tested, has always shown only very moderate results, and far poorer results than one would expect in clinical practice. A 20-30% difference from placebo in people showing greater than a 50% reduction in symptoms is not impressive. If one then takes into account the fact that these therapy studies are never double-blind that their are biases that favour CBT, and that therapeutic allegiance tends to account for a significant part of successful outcomes in research models, then one has to really question all research done by these models, especially if the results aren’t in line with research on outcome variables. Relational frameworks have always, will always , and have been shown in more sophisticated and qualitative models., to be the gold standard in psychotherapy. The value of any technique remains to be proven.
There appears to be numerous problems with Early Psychosis Intervention programs. One is that they tend to be diagnosis based, and tend to push the use of anti-psychotic medication. If one works outside of hospital system one learns that there are many youth who have one episode of a schizophreniform psychosis, but if treated conservatively with the emotional and social issues attended to, may not have further episodes. So these programs may tend to over diagnose and over treat medically and under treat psychologically. Any hospital based program will tend to have a predetermined idea of diagnoses, modalities and outcome expectations. Youth who show symptoms of psychosis, like anyone else, are best off treated as individuals with in depth assessments of all possible causes of symptoms.
I’m glad to hear that those are the requirements in the U.K. While in Quebec one does need to log many hours of supervision to be certified as a psychotherapist, I know many people in Canada and the US who have received a certificate in CBT after a 3-4 month training. The main issue is that to be a good therapist, one should have a solid knowledge of developmental psychology, and many hours of practice and supervision. There are many people who have received certification in CBT in North America with little in depth knowledge of crucial developmental issues.
I think your piece is balanced and thoughtful. Psychiatric diagnoses should only be used as a guide, and can be useful both with colleagues and patients to aid communication and at times to relieve guilt and anxiety. The issue is more with how society and the mental health industry has misused diagnoses to the detriment of the population. Many institutions, including the NIMH in the U.S. and the CMHA in Canada, as well as many government bodies tend to spend much needed funds on marketing campaigns to “de-stigmatize” mental illness rather than addressing causes of emotional distress. It makes no sense to try to stick a label on everyone who suffers emotionally, to not try to help prevent emotional distress ,and then to focus on de-stigmatizing, mostly to show to the public that you are “concerned”. A welcome relief from the mental illness and stigma advertising has been ads put out by longlivekids.ca which focus on emotional wellness and common factors that can cause emotional distress. We need more emotional wellness promotion, less labelling, and more concern about conditions in our society that can lead to emotional distress. We shouldn’t want to get rid of diagnoses as a guide, but to start training practitioners to understand the possible benefits and limitations of diagnoses. Let’s all work towards a world where diversity is appreciated, labels are irrelevant, but that good descriptions and words that promote understanding are valued
You are failing to understand the issues, the facts and limitations of research. Quantitative psychotherapy research has clearly shown that many forms of therapy appear to work equally well, with CBT having no advantage over many other forms of therapy. CBT is much easier to do research on because it is fundamentally a manualized therapy to begin with, while other forms of therapy need to be standardized (or dumbed down) in order to fit research protocols. The fact that there is so much research on CBT does not make it batter or even a valid form of therapy. There is plenty of research evidence that indicates that the type of variables that correlate with good outcomes are very different to the type of approach that CBT promotes. I stand fully behind my opinion which is well backed by research.
One aspect that should be obvious and common sense about research is that research done from various aspects should make sense together and should correspond to clinical experience and patients’ experience. When research results depart from common sense, don’t fit together and don’t bear any resemblance to actual experience there is clearly something wrong with the research. All symptom and diagnosis based quantitative psychiatric research suffers from this problem. We need to interpret all research in the light of actual clinical experience and stop forcing clinical practice into superficial research models. Hence the title of my blog “Real Life Psychiatry”
This study should come as no surprise. Research has always indicated that CBT is no better than other studied therapies, and if one takes into account inherent biases in research, it is clear that CBT has always been worse than other therapies. The most obvious artefact of research regarding CBT is that if one trains someone to report less symptoms, then less symptoms will be reported regardless of whether a person had actually improved. CBT, as it is practiced in research models does the opposite of what research on what actually works in therapy shows. Research on therapists variables and patient therapist relationships clearly indicate that a therapist being able to have an in-depth understanding of the person and being able to relate this to the individual in a comprehensive, empathetic manner is crucial for therapy to work. CBT tends to claim that a deep understanding of someone is irrelevant, while technique counts a lot. Research has indicated that technique is the least important variable in outcome. Training in other forms of therapy, like psycho-dynamic takes 2-3 years. One can get a certificate in CBT in 12-16 weeks. We need to move away from superficial therapies performed by poorly trained therapists with a poor grasp of humanistic approaches, and focus on helping real people with real issues.
It is a certainy in the Mental Health Industry that as soon as one sees an agency focusing on “programs” it means that they have given up on prevention and proper treatment. Rather than using resources properly, most institutions, whether it’s hospitals, government or education, the easy way out is to promote some kind of mental health program that may beb good for public relations, but does nothing to relieve suffering. It’s a positive note that this study has exposed the worthlessness of this approach, though this should have been obvious to anyone who understands the real problems.
This article naturally raises the question: why are so many kids and adolescents being prescribed drugs in the first place. The medical profession is opting for short term solutions that have long-term ramifications. Prescribing medication to young people recklessly clearly gives the messages that problems in life require medication and that emotional distress has biological causes. Both these messages can impair the development of identity and autonomy that is so crucial in adolescents and young adults.
The over emphasis of the biological view can lead the physician and initially the patient to feel better, yet often makes the patient feel worse in the long run. It should be clear that the biological reductionist view leaves physicians less empathetic to the emotional suffering of the patient and leaves the patient stuck with the inner sense of being fundamentally damaged. The decreased empathy of physicians then makes it less likely that the patient will feel comfortable to tell the doctor about ongoing suffering, thus letting doctors continue to believe that their approach works.
“the one thing I know is that suicide is the totality of life experiences perceived by a person who cannot see themselves with a future and cannot continue to live in the past, and they cannot see themselves the way you do.”
This comment states, in one sentence, the most important aspects in understanding suicide. While the mental health industry prefers to always relate suicide to “mental illness”, suicide is alomst always a result of life-long struggles. It is no one’s right to judge another person’s life or final actions. It is only through empathy for the totality of another’s experience can we possibly help someone feel life may be worth living, or accept a person’s final decisions. The importance of respecting the experience of another person, and understanding that we can never fully understand is crucial.
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I totally agree. It is about profit.
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The feeling that it’s cheaper to use meds rather than good therapy is based on short sightedness and an ignorance of the cost of human suffering. There are studies that indicate that longer term therapy is cost effective, with less cost of medication, fewer costly hospitalizations, better ability to work (and pay taxes) as well as contribute to society. Bad treatment leads to higher costs in every way.
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Noel, and bpdt,
The point about over estimating possible short term change and under estimating possible long term change is very relevant, both in terms of looking at the help people receive and in possibly feeling optimistic about changes in the system.
Part of the corruption in psychiatry has been due to the pressure to prove short term change is possible with the subsequent promotion of medication and simplistic therapies. Clearly this model is to the financial benefit of drug companies, psychiatrists and insurers, but is disastrous for people in need. We should also be focusing on long-term change for the system, even if immediate change is necessary. The foundation of modern psychiatry is being eroded by advocates for change as well as significant research.
I don’t feel that a complete tearing down is necessary or will likely happen. In the past, there were some good training centres in psychiatry that taught psychotherapy based humanistic treatments. There are many people who want to return to a more humanistic model of training, with a greater emphasis then ever on people’s real experience. I think that we should take some of the building blocks that have existed, throw out the corrupt blocks, add in non-dismissive real life experiences, and build a new structure. There can be hope. We need to identify what is valuable and what has to be discarded. Many people have had excellent experiences with good therapists. There is a growing body of research to indicate what makes a good therapist. This information, and approaches that allow good psychotherapists to be created and valued needs to be promoted. Let’s work on what is possible to achieve by continuing to fight against abuse and corruption, but value what may deserve to be saved.
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Excellent article Noel,
I think that we can understand that people who have suffered from emotional traumas should have access to caring, well trained professionals who have studied hard to understand how to best help those in need. It is a tragedy that so many mental health professionals are causing harm rather than helping people, and that often peer groups can offer better support.
A very interesting book that adds some other perspectives to the problems and issues in psychiatry training is “Of Two Minds: An Anthropologist Looks at American Psychiatry” by T.M. Luhrmann. Luhrmann describes the distortion and emotional politics that occurs in psychiatry with people being pulled to believe more in narrow points of view than in actually understanding and helping people.
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thanks for this. One has to laugh sometimes despite how disturbing the DSM actually is.
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Perhaps in the DSM V-R, the wish to own a machine gun or sem-automatic rifle should be named as a “mental illness”. The movement to restrict gun ownership to people deemed “mentally ill” might then make some sense.
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Hi Philip,
I completely agree with you. Every time someone in the mental health industry comes up with a “new” program or catch phrase, it is just an excuse for not getting people better care or actually working for reducing the causes of emotional distress. These things are always just marketing, letting bureaucrats believe they are doing something, and expanding the inappropriate (ab)uses of psychiatry.
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While it certainly may be one possible factor in what is being called treatment resistant depression that benzodiazepine use may directly cause more chronic symptoms, this study points to some other disturbing issues as well. As the researchers point out, benzodiazepines may lead to emotional numbing and less opportunity to deal with emotional issues. Yet all the people in the study group were then treated with various and often multiple antidepressants, which, as we all know, are major zombifiers. It would not be surprising that people who are inappropriately treated with medication, and deprived of the opportunity to actually get better would seem to be resistant to “treatment”. It is also not surprising that poorer people may not be given the opportunity to get therapy. The researchers also seem to partially define “treatment resistance” as those people who feel they haven’t improved on medication. So maybe we are talking about two different groups: those content to be zombies, and those who are trying to reject bad treatment.
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Bpdt raises some important issues about the connection between psychiatric drugs and violence. The emotional impact of being diagnosed, drugged, yet given little help to deal with real emotional issues are probably the most crucial issues as to why violence may be committed by people taking these medications. The emotional numbness created by SSRI’s could also lead to a disconnect with feelings of guilt, as well as contributing the feelings that life isn’t worth living. A direct increase in agitation and violent feelings is also possible, but one needs to consider all the avenues in the present state of mental health care that can lead to tragedies.
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While there are probably many factors, both environmental and social that are leading to kids seeming more fragile these days, a large aspect of the use of the ADHD diagnosis has to do with a mismatch between normal variations in children’s make-up and the expectations and pressures of our society and school system. There is no true evidence supporting ADHD as a disease. As I explain to people who have applied this diagnosis to themselves, people have different brains with varied abilities. Some people are good at focusing on one thing at a time, and others are good at multi-tasking. If we look at our evolutionary heritage, as hunters, we would have needed to to pay attention to many different stimuli, and then focus primarily on one for brief periods of time. This is how most boys are, with considerable variation in different traits. Our school systems, and to a large extent our family systems expect children to sit quiet and focus on tasks that may not be oriented towards holding interest. On top of that, as people here have pointed out, modern technology, including video games, may accentuate the brain’s ability to only pay attention to intense stimuli.
Children do not have malfunctioning brains. We have a malfunctioning society and mental health system.
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Hi Saul,
Thanks for your questions. It is good to clarify these points.
Firstly, the commonly made statement that a combination of therapy and medication is best treatment is based on the type of simplistic and biased research that is should always have been questioned and is now coming under scrutiny. I do not believe that a combination of therapy and medication is best treatment for most people.
I believe that DSM diagnoses are bunk for the most part, and that psychiatric medications are psychoactive drugs but do not treat the causes of distress. Psychiatric drugs are highly overused, and the whole field of psychiatry has become corrupt and unethical.
I do prescribe medications at times, but cautiously and with full disclosure. Sometimes people are in severe distress, and it is helpful for them in the short term to have some chemical help with their distress. I prefer not to prescribe medication, and almost always start off recommending natural healthy alternatives such as omega-3 fatty acids. Some people are adamant about wanting medication, though I always spend time trying to inform them about then limits and dangers of medication.
I strongly believe that screenings are dangerous. As I said, the most common outcome of a screening is for someone to be placed on medication without recommendations for psychotherapy. I do not feel that being placed on medication with a recommendation for therapy is proper response to a screening. Psychotherapy is always preferable to medication, and the medications inappropriately called antidepressants should rarely if ever be prescribed without psychotherapy. The psychiatric medications we have are all bad medications with little true efficacy and lots of side effects and negative long term effects. I could go into another time what I do prescribe at times and why, but that is a complex issue.
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Hi Saul,
I was not implying at all that people should be treated with medication. I was just saying that screening will lead to people being prescribed medication.
For many years an organization in Montreal tried to bring depression screening into universities. I managed to block that despite some end run attempts. Fortunately, after some years of this organization running depression screenings for the general public this program was stopped due to clear failure of actually getting people proper help.
It is true that many doctors are now using screening questionnaires. I have never seen this cause anything but problems.
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I have fought adamantly against screening for depressed moods for many years. (see “McGill University is wasting Bell $500,000 donation, http://www.drnormanhoffman.com) There are many important aspects as to why screening is inappropriate.
1) Screening tools are poorly validated, and are only validated for a diagnosis of Major Depression. Many depressed moods do not fall into simplistic diagnostic schemas, and so people are likely to be misdiagnosed as having a “mental illness” rather than emotional problems.
2) Treatment resources usually are inadequate. There is no point trying to assess more people when there are not good resources. Money is better spent trying to create resources.
3) Given points 1 & 2, the most common outcome of depression screening is people being placed on medication without proper therapy. This is clearly bad treatment.
4) While this may not apply as much to a postpartum population, it is unlikely that people with the most severe forms of depression will participate in a screening, making it even more likely that false diagnoses will be made.
5) Many screening tools have been developed with funding from the pharmaceutical industry, with items that promote the idea of a biological cause fro depressed moods.
The issue of postpartum depression is important, but all practitioners need to be more sensitive to the many issues, both emotional and hormonal that may affect people in the postpartum period. Screening can tend to decrease the responsibility that a professional may feel to actually talk to the new parent, leading to many important emotional issues being missed.
Like many initiatives we see these days in mental health, the emphasis is often on campaigns that make the bureaucrats and marketers feel good, but that actually do nothing to help people.
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I agree with so many of the points made. A truth is that often doctors will resort to prescribing medication becasue of a lack of time, or willingness to spend time looking into the causes of emotional distress. Sometimes the patients does want something to take away the pain without having the eomtional willingness to delve into ditressing issues. Often patients have been brainwashed to beieve in “chemical imbalances”
Given all that, what would people recommend that a doctor due in these circumstances: A patient comes to the office saying “I think I have depression”. The doctor tries to explore the issues that may be distressing the patient. The patient indicates that he doesn’t want to talk, he just wants a pill. The doctor attempts to inform the patient about the truth about medication, but the patient is still insistant. The doctor tells the patient that the so-called anti-depressants are actually just numb emotions, and have lots of side effects and can impair actually getting better, but the patient still wants a prescription. What do you, as the doctor, do?
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I totally agree. If one understands how this type of research has always had biases and was never confluent with other forms of evidence, it has been clear for decades that the type of research that has promoted many of the modalities presently used is of limited use.
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I agree with your comments about DBT. It is also another form of therapy that has been overly promoted and manualized. While your comments about how DBT frames BPD are true, it is probable that DBT as it was done by Linehan’s group was helpful as it provides a lot of support for both patients and therapists and a lot of consistency and empathy. I’ve never believed, ( as is probably true of most therapies) that it has been specific techniques of DBT that may be most helpful. However, many centres are taking the techniques, dropping the holding and humanistic aspects, and marketing the resulting therapy. This seems ridiculous to me.
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The lack of efficacy of psychiatric drugs has always been clinically evident. The same is true for simplistic manualized psychotherapies. Now in addition to the study reported in MIA showing CBT is losing it;s effectiveness, there is another study indicating that manualized psychotherapy research has been tainted by the same publishing bias found in anti-depressant trials (http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0137864).
The psychiatric industry has been plagued by the push for so-called evidence based treatments that has ended up supporting obviously inadequate and often damaging treatments.
People are not paint-by-number kits. Real people need expert therapists who will treat them as individuals and work with them in a humanistic manner to deal with real emotional issues.
For many years now, expert therapists have been thinking “WTF” in seeing ridiculous forms of superficial therapy promoted and expert complex therapies being devalued. It’s time to reject all the bunk and put our efforts to finding ways to really help those in need.
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Hi Lucy,
You point out many aspects that seem troubling about this program. Certainly it seems oriented towards having primarily people who the system feels it has helped being the ones who speak to psychiatric residents. One can see that the major aspect of dialogue could be comments about some services problems or lack of empathy, but collusion with poor treatment modalities. As placebo responses in psychiatry are always high, one can always find people who feel they have been helped to recover.
A significant problem with psychiatric training these days is a strong orientation towards hospital based “mental illness” with not enough focus on the poor treatment received by the average person who ends up being medicated by their family doctor or a psychiatrist. It doesn’t seem like this patient/resident dialogue will change that.
Another important question is why residents are not being trained to listen to and learn from every patient throughout their residency? To give residents this experience in their last year seems to be too little, too late. The implication appears to be that during their residency, they won’t have the opportunity to actually see “recovered” patients so that they need this experience at the end. It is true, and a problem, that as most rotations in residency are for six months, that residents don’t tend to see the longer term evolution of patient care. This consumer feedback program may be partially aimed at this problem, but is unlikely to actually indicate the true problems in psychiatric care.
Like so much of what we see these days, institutions tend to come up with programs that make for good marketing but actually accomplish little.
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Whatever one believes about psychoanalysis, the psychoanalytic model highlights the importance of an individual’s emotional experience of life from the time of infancy. Modern psychoanalytic schools all consider real trauma to be crucial in understanding a person’s emotional reality. Psychoanalytic writings tend to explore the importance of emotions and real experience and while at times might be overly nuanced, can add to the appreciation of the complexity of the human mind. In this way, psychoanalysis and psycho-dynamics oppose biological psychiatry with its emphasis on numbing emotions rather than understanding them.
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Hi Noel,
You have made the point that there is no way of knowing when there is a suicide what may have helped prevent the individual going down that road. This is another very important aspect. Many people tend to assume that it always in the person’s best interest to make sure they’re safe, but forced treatment will often make people feel worse.
I’ve been training volunteers who work on sexual abuse and suicide hotlines for many years. In training, I give what I call my “don’t panic, do nothing” talk. The main points of the talk is that one needs to stay calm to be able to hold the pain of the other, one needs to not rush into action, and certainly not run to recommending hospitalization, and one has to not try to play detective and feel that one has to figure out whether a suicide is likely. The main role of a volunteer on a phone line, and basically of anyone offering some kind of emotional support, should be to simply be present, show respect and try to make some type of emotional connection. The focus should be on the present interaction, rather than on trying to figure out what to do. We can’t know for sure with anyone what actions may be helpful, but we can try to be emotionally present for someone. In this way one can possibly give some hope.
Opting for short term “safety” (which is actually for the mental health worker) rather than looking at long term emotional growth can not give an individual hope that someone trusts in them or in life enough to take the chance that one’s life can improve. As you have written, people don’t abruptly come to the point where they feel hopeless, so short term solutions are unlikely to help. One always has to consider longer term progress, and try to begin the process towards that progress with respect and building trust.
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Hi Noel,
Excellent article!
The point that you make about suicidal feelings coming about after years of hopelessness and helplessness is crucial. Maybe there are people who suddenly feel suicidal without long standing struggles, but I have never met someone like that. I never send people to hospital, as it is crucial when working with someone who does feel intense emotional pain to be able to build a trusting relationship and to be able to sit with and hold their pain in some way. As you point out, psychiatric hospital tend to increase the very feelings of futility that people may struggle with.
About the only time I have seen people benefit from psychiatric hospitalization is when the poor treatment they receive allows them to express anger or rage that previously has been turned against themselves. The provocation of this anger sometimes help people recognize the abuse they have suffered in life, and helps them to stop feeling hopeless and self hating. However, more often, psychiatric hospitalization just increases feelings of hopelessness.
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I agree. Clearly child abuse and trauma ends up being very costly, both emotionally and financially to our society. Unfortunately, our society is not yet prepared to invest in an creating an emotionally healthier society, and sees only the short term cost, and not the long term gain in making the investment.
Certainly giving some groups more rights has changed the balance of financial power, but I thin these groups won rights both through effort, but also as there was some financial benefit overall to society.
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Ted,
It is difficult for a non-visible minority to get organized because our society doesn’t want to recognize the problem. There can be an economic advantage to the governmental and corporate world to give more rights to some oppressed groups, but the corporate world still needs it’s slaves. The emotionally distressed are the new slaves. From a narrow minded business perspective what one wants to do with people who seem not to fit in, is to use them until they burn out and then discard them.
Other groups won rights when it was financially advantageous to our society to give them rights. The only advantage our corporate world can see for the emotionally traumatized is to create a mental health industry that makes billions while people continue to suffer.
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There is no mystery as to why mainstream media has been slow to expose the mental health industry. Media these days is run by corporations for profit, and is more interested in entertaining populations to increase sales than to follow through with good investigative journalism. The corporate world is a large part of the problem of emotional distress and trauma. While we can blame psychiatry for all the distortions and abuses it has evolved, we also need to look at the underlying causes of growing emotional distress in society.
We live in a fractured society, where individuals and families get less and less support. Governments and the corporate world basically prefer people to just shut up and work, despite the stresses that individuals may have to deal with. No major institution is willing to look at how our society has to change to prevent emotional trauma. Institutions tend to look for simplistic solutions to complex issues. This is one reason why psychiatry has gotten away with bad medicine. The powers that be want people to be numbed and zombified, rather than having to deal with real issues. Even if the field of psychiatry collapses, it is likely that unless there is substantial social change, that people will still end up in emotional distress, with the corporate world finding some way to disregard people’s pain.
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The belief that the “chemical imbalance” theory has not been highly promoted by the APA and numerous other official bodies can only be described as delusional, It is also irrelevant if certain individuals or organizations are turning away from one false theory ad taking up another. The truth is that when so many mental health organizations continue to talk about “clinical depression” or “depression” as a disease entity, it impacts on how people think about themselves, and strongly effects the orientation of the whole mental health field.
While years ago, when I first began in practice, most individuals would talk about feeling sad or depressed, now almost everyone that I see who are feeling down will at some point say “I think I have depression”.
The damage that has been done to individuals and society goes far deeper than the promotion of any one erroneous theory. There has been great harm done to how people think of their very emotional being. This is the crime of the APA and other similar organizations.
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Hi Frank,
I agree with you. Love is crucial and it is a shame their love did not survive an uncaring system. I would have liked to have the chance to meet Pierre prior to his having been medicated for over ten years. He was quite an amazing person even after years of medication. You are right that I chose to focus primarily on the love, though the damage the system caused is evident. I did want to bring out how inhumane the original plan to break up this couple was
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Katie,
I do not doubt at all your experience or the validity of your perspectives. However clearly you can not state with any credibility that you have more experience than Margie and me combined, as you really don’t know what our experience has been. If we want to be “scientific” than we shouldn’t make comments that have no substantiation.
Your experience is truly valuable, and I agree that someone who has worked with people directly in a humanistic way, and has experienced mental health care directly has a lot to offer.
We do need opinions from divergent points of view, and we also need to show respect for the experience of others.
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Hi Margaret,
Thanks for your comments.
I wish we lived in a utopian society where all diversity was celebrated, and people who exhibited any form of emotional distress would get the true care they would need. But that is not our reality, not will it ever be.
We all know that there are so many aspects wrong with mental health care now that drastic change is needed. It is also unfortunately true that the powers that be will always see those who express outrage at the whole system as fanatics who don’t deserve to be listened to. This is unfortunate, as often it is those who are most outraged who truly have experienced the problems in our systems.
I wrote this piece partially in response to your last piece to show how constructive care can be beneficial, and how the system tends to think, and ultimately tends to act.
As I posted on your piece, I do believe that we need more dialogue and empathy between people who work within the system and those who have been abused by the system. We need to work together for change if change is going to occur. It is ironic and sad, that many of those people who have felt most marginalized in their lives are so quick to want to label others.
While the anger many people exhibit in their posts is fully understandable, it is not always constructive.
This piece is mostly about Pierre and Shelley. They were able to succeed despite the system, and despite mind numbing drugs. They were able to be role models and friends to others. The system failed them throughout their struggles. This piece is also about how sometimes within the system, small changes are possible that can make a difference. Many think we need to tear down the whole system. Maybe we do, but that is unlikely to happen. We can, though make numerous small changes that with time can make a substantial difference.
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Dear Cat,
I do agree with you. Over the past twenty years I don’t think that I’v seen anyone who has been hospitalized in psychiatry who haven’t described their experience as horrifying. The sad reality is that there are far too many people in our society who end up dying because of the problems in our society and lack of resources to help them. The only way to not give up on people like Mary is to fight for better, non-psychiatric resources. We need to understand that a large aspect of the fight is not just whether we refuse to commit vulnerable people to psychiatric hospital l ,but how we can fight for change. If people like Margaret refuse to hospitalize anyone, then those people would be fired from their jobs and replaced by lackeys. We need our Margarets and our CatNights and our Marys. I do feel that people like Mary should not end up as casualties of the battle for change. The answer of how one should proceed in the present reality is not clear.
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I believe that we all need to have empathy for other people, whether they be individuals in emotional distress or mental health workers. No doubt that the psychiatric system is screwed up, but so is our society. I would like to believe that all people have free will, though the reality is that our society has robbed many people of the opportunity to have free and clear will and judgement. The sad truth is that it is highly likely that Mary, and many like her will be dead within 3-4 years, because our society will not help her, advocate for her, protect her, or get her into the position where she can have the free choice of how to best live her life. She will end up dead under a bush, killed by exposure, violence or malnutrition.
We also all know what could be best action. That would be for Mary to have a place where she could go, voluntarily, where she could be respected, safe, and cared for; a place that would respect her autonomy, and help her work towards being able to take care of herself. Without proper resources, there is no hope for people like Mary; only pain and eventual death. Margaret tried to forestall the inevitable by using a resource available to her. Whether she should or should not have is a point that can be discussed, but it is not a discussion on what would allow Mary to survive, either emotionally or physically. It is a political discussion that various people have strong opinions on, based on their own experience of the mental health system. Mary’s outcome is unlikely to be affected by Margaret’s choice. We need to have real choices that save both life and dignity.
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You are pointing to the real issue. One needs proper support options that don’t leave either the individual or the worker in a position where any choice is wrong. There are models that do work, and we need to keep fighting to have these other options become more available.
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Hi Margaret,
I think that you express the dilemma that many mental health workers feel. I also feel that it is unfair for people on this board to criticize when they have not been placed in a position of responsibility for someone’s life. Most of the people who post here have thought hard and insightfully about their own experiences. We all know the importance of respect and autonomy of the individual. Yet sometimes for those of us who work in the mental health field, we have to deal with situations where a person’s life may be in imminent danger. We know that the hospital system will not provide optimal care and respect, yet we also now that the outside world can be hostile and abusive.
In my own practice I never send people to hospital any more, as I know that they will not get reasonable help. I am willing to, with the individual, take the chance that suicidal feelings will result in death. Most of the time, showing this respect and understanding leads to a better therapeutic relationship, and the feeling in the patient that I am willing and able to accept their pain. But sometimes it doesn’t work. A few years ago a very troubled young man, who had been hospitalized in the past, asked me to promise never to hospitalize him. I agreed that I would only do so with his consent. He did end up taking his life a while later, just a day after I had seen him, though had kept any plans he may have had secret.
The main issue is that there often is no best action. Many people who suffer emotionally don’t have agency of their own, and may not be in a position to make the best choices for themselves. Sometimes, we just can’t abandon them to the world. The points you bring out are excellent. Sometimes we do things that we would prefer not to have to do, but are simply trying our best in a bad system.
We all need to have empathy for others, including others who may see life differently, or are in positions of authority. It is easy to find fault with mental health workers, but not so easy to find better ways of negotiating the present system.
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Hi Jill,
Excellent review of the facts about anti-psychotics. It is clear that these drugs are being used for off-label prescriptions in children. Using these drugs for behaviour problems ends up with the child being blamed for the complex family and social issues that can lead to behaviour problems. The psychological ramifications of a child being labelled and being forced to take medication cannot be neglected. As well, one has to be concerned with any prescriptions to children about the effects on the developing brain. Anti-psychotics can also have serious effects on cognition in many people.
One problem with allowing the use of these medications for on-label prescriptions is that it is very easy within the structure of the DSM to stick a label on almost any child. Thus “bipolar” has become a fad diagnosis, applied to anyone who has mood changes. As children in difficult circumstances will almost always have variable moods, it is very easy for a physician to justify the use of medication with these kinds of diagnoses.
There needs to be a ban on these medications in children, except perhaps under extreme circumstances within psychiatric hospital settings. It is just too easy for a doctor to reach for a prescription pad when confronted with complex issues.
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B,
While I agree with many of your points and of the problems our dysfunctional society is creating, I don’t agree that proper therapy can’t help. Proper therapy has to address these issues so that the individual can recognize some of the sources of anxiety or depressed mood. It is much better to discuss with someone the societal issues that may be part of the root of the problem, so the person doesn’t end up blaming themselves, feeling they have a “mental illness”, or feeling alone with their painful feelings.
This is one reason why I am so adamantly against superficial symptom based therapies. We need to address both the family and societal issues that leave a person feeling vulnerable. While we should be also working on general social dysfunction, in the meantime, we cannot abandon individuals in need and refuse to help them understand how our society has impacted on them.
Unfortunately, this is what most college counselling and mental health services are doing these days: colluding with the dysfunction by blaming “mental illness”, and only attending to symptoms, and not treating the real problems.
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Thanks Steve,
Universities used to have more humanistic counselling services. With the increase in demand, college administrators have gotten involved, and are often dictating policy. Then one has service directors buying into the direction that the administrators are going. One also has the university lawyers getting involved and demanding on “risk management”.
One of the problems with the older style counselling approach is that counsellors tended to follow a non-directive approach that didn’t address issues that quickly. This approach did not work when demand began increasing. This led to the adoption of more superficial approaches that also don’t tend to work, but allow the college to say it’s offering services. One often sees university counselling and mental health services having many “programs” like suicide watch programs, but no proper treatment services.
There is no excuse for any college not to provide proper help. These days colleges are more interested in protecting themselves and appearing to care, than really providing good service.
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Having worked at McGill Student Mental Health Service for 35 years and having been Director there for 15 years, I can say with reasonable authority that the information being promoted in this report is a large aspect of the problem.
Firstly, they are talking about “anxiety” and “depression as diagnoses rather than as symptoms. Students may come in with various symptoms, but diagnoses are fairly irrelevant in this population, with students usually presenting with complex emotional issues. The idea of using primarily short-term modalities is bound to fail, as it leaves it almost impossible to address anything but symptoms if students are told that they will not necessarily have the time to explore real issues. Colleges are tending towards management of students rather than real treatment. Workshops and Group support may be useful, but do not replace expert therapy modalities. Sending students off campus for treatment, or insisting on medical leaves just puts students at higher risk.
There is no truth that students are appearing more due to less stigma. There is also no truth to the often repeated statement that more students are arriving in universities requiring treatment due to the use of medication making it possible for students to achieve academic success.
There are two major reasons for the increase in numbers of students coming for help. One reason is that parents and our society are treating children more like products than like people. There is less and less room for normal emotional expression and growth. Students begin feeling that achievement is all that counts in life, leading to both anxiety and depressed moods. These students arrive at university, start to experience falling grades and then fall apart.
The other major reason , which ties into the first, is the overuse of diagnoses, medication, and simplistic symptom reduction treatments. These modalities all collude with the “product and achievement” model of life, and make student more fragile in the long run.
There are good expert models of psychotherapy that work well in university students. These models quickly address real emotional needs, and provide safe emotional space for students. However many universities either are not aware of the efficiency of these models, or are turning to diagnoses, medication and symptom control techniques that tend to undermine real emotional progress.
It is unfortunate, that so many universities simply don’t know what they are doing. I’ve seen these changes from being student oriented, to being bureaucratic oriented in many institutions, including McGill where labelling students is now mandatory for a student to be treated at the Mental Health Service
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There should be no question that the use of anti-psychotic drugs in children without signs of psychosis should be made illegal. It would be nice if the use of all psychiatric drugs in children and adolescents was banned, but unfortunately this is unlikely to happen.
The problem, of course, is that doctors can always make a diagnosis, such as bipolar, to substantiate the inappropriate use of medication. However, one could make anti-psychotics restricted drugs that only psychiatrists can prescribe, and then have clear indications, with the necessity of two psychiatric opinions before prescribing psychiatric medication to children.
It should be evident that children and adolescent brains are in the process of developing, and that any outside contamination of the brain will interfere with normal development.
Behaviour problems in children should always be seen in a family and social context. Whatever happened to the concept of the “identified patient” that saw the behaviour problems of a child as a symptom of a system dysfunction?
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Great Article!
The last thing we need to reduce negative stigma about psychiatrists is to better market bad psychiatry.
One should, though, understand that the stigma of being a psychiatrists is entrenched in medicine. When I went in to psychiatry, a friend of mine commented “what a waste”. Throughout residency and beginning practice it was clear that most other doctors saw psychiatrists as being useless ( perhaps with reason), but if they needed us, expected miracles.
The role for psychiatry should be to be able to have a degree of clinical training that is considerable, and which can take into account both the physiological and the emotional. Knowing medicine should expand the knowledge base of psychiatrists so we have an expertise and an ability to understand the mind body connection better than psychologists.
It is partially the stigma that the medical profession places on psychiatrists that has caused psychiatrists to disavow humanistic principles and embraced an overly medical and biological view of psychiatry.
We need to get back to our roots as psychotherapists and humanists. We should be good empathetic psychotherapists who also understand disease and the human body, and who have experienced in our medical training the pain of illness and suffering. We should not be this mockery of pseudo-science that we have become.
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Jeanene, your words certainly echo the experience of so many who have felt deep pain, yet whose feelings have been denied or medicalized by our society and the psychiatric industry. I have always remembered the writings of the first patient that I treated who self-injured, “When I feel the pain and see the blood, I feel that I just may be alive”.
We seem determined as a society to deny or cover up the pain that so many feel. I think that the emotional pain of many people who have suffered, scares many people as it touches on some aspect of deeper pain that many people experience. I was taught that by listening to the life experiences and the emotional depth of those who have been traumatized, that we can better understand all human experience.
People who show what the DSM calls symptoms are telling us about their personal experience and about aspects of our society. We should feel respect for all those who cry out in one way or another as they are telling us what can go wrong in life, and possibly what changes in our world are necessary.
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Hi Margaret,,
Norman, please.
I like the words digest and metabolize, because in psychotherapy, and relationships, these words describe what often is helpful. People feel overwhelmed with their emotions, and we, by sitting with them, hearing them, and being able to engage these emotions, do actually help in the metabolism of feelings. Children, and grown-ups too need to be able to feel that sense of another person being with them to break down overwhelming feelings into smaller bits and gradually be able to digest these feelings.
some of my writings can be found at drnormanhoffman.com, and others at studentmentalhealth.ca.
I look forward to further communications with you.
Norm
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Thanks for this article, Margaret.
The issue of society’s responsibility needs to be further addressed. To a significant degree, it is the problems within our societies that cause emotional distress to begin with. Society then blames the individuals and just wants them to disappear.
For many years, I have taught a concept that I call the “ascending and descending ladder of emotional pain metabolism”. This basically states that in a well functioning society, people in positions of responsibility help hold and metabolize emotional pain for those more vulnerable or with less power. Thus, parents attend to their children’s emotional distress, extended families and friends help parents, local communities take responsibility for extended families, and ascending levels of government take care of communities. In many societies, we are seeing a descending, or inverse triangle of responsibility for emotional pain metabolism, with vulnerable individuals and children ending up feeling and being left alone with the emotional pain dumped down by society. Thus federal governments dump responsibility on State and Provincial governments, who dump on municipalities that dump on families. Vulnerable individuals end up showing symptoms of this emotional pain, and are then labelled as aberrant.
Until societies take true responsibility for taking care of families and children, many will continue to suffer.
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It is sad and troubling that so many supposed “mental health” organizations are actually mental illness promoting organizations, including the NIMH and the CMHA. There are also organizations started by parents who after their children’s suicides have decided that their child must have been mentally ill. One organization like this, Ulifeline, has been trying to promote the diagnosis of bipolar illness in college students.
There is no place in emotional health advocacy for self promoting individuals or organizations that hope to alleviate their own guilt or responsibility by disseminating damaging misinformation. We need to get away from promoting mental illness. I address this issue more on my blog post: “The need to stigmatize the (overuse of) the term “Mental Illness”
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I think that people are missing the real importance of this study. While it is certainly true that children are being over diagnosed and medicated, a major concern should be why children and families are showing increased signs of distress. There is clearly something going very wrong with our society when so many children are being brought to emergency rooms with emotional problems.
The increased use of the psychiatric industry is not just because psychiatry is trying to drum up business. There are many indications that our societies are just not providing the type of holding environments that families and individuals need. Speak to any elementary school teacher, and they will all tell you of the growing distress and behaviour problems in children. As long as our society continues to be dysfunctional, psychiatry will be called upon to control the distress.
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This study should come as no surprise. It would be interesting, though not necessary to test clinical studies in the same way. It is not necessary as all clinical studies have already shown that the treatment modalities tested in studies are highly inadequate, and should not be applied in a blanket manner to real people. If one wants to follow true empirically advisable treatment then, if one interprets the research properly, one has to possibly use a variety of approaches that engage the person who is coming for help.
Research in psychology and psychiatry can never take the place of clinical experience and patient reports. Psychology research itself has become an industry that often has little actual value
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I agree wit bpd’s comments about Major Depression. Not only have studies repeatedly indicated that in adolescents, anti-depressants do not appear to be effective, but the diagnosis has to be questioned for it’s validity. In treating around 4000 adolescents and young adults over a 30 year period, I did not see anyone who fit well into this diagnosis. In general with both younger and older populations, the more one gets to know someone, the less the diagnosis of Major Depression makes sense. The DSM has kept loosening the criteria so now one could fit almost any person with some depressed mood into the diagnosis, but this just decreases any validity this diagnosis may have.
In psychiatry, it is fairly easy to structure an interview to elicit one’s favourite diagnosis just by asking certain questions and limiting one’s exploration of a person’s true emotional experience. I know what to ask and how to phrase the questions to elicit a diagnosis of Major Depression, Bipolar Disorder or ADHD in just about any distressed person.
It is crucial that adolescents with emotional struggles need proper support and therapy. The evolving adolescent brain will be impaired by the use of medication. The push to medicate adolescents and children has to stop.
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Excellent article!
Part of the issue tat this brings out is the growing divide between true clinicians, researchers, and psychiatry bureaucrats. Research used to be more clinically driven to test out observations that clinicians were concerned about. Now, research has become an industry in itself, with many researchers having little actual clinical experience. This leads to research being done, and results being accepted, even if there is little clinical relevance or sense to it.
An other aspect that falls into the category of biological research is genetic research. There is a lot of money wasted in looking for genes that may be connected with various DSM diagnoses or symptoms. These studies, though few actual positive results have been found, tend to be presented as if they are looking for “diseased” genes. The truth, if any gene connections are ever found, is more likely to be that certain traits in response to environmental trauma may effect the emotional outcomes. For example, a child who is more emotionally in tune may respond differently to abuse than a child who has natural traits of self assertion. For suicide, a person who has some genetic predisposition to risk aversion may be less likely to make a fatal attempt. While any genetic links could be of some interest, very few are that likely to indicate the most important aspects of aetiology.
If we want to truly help people have better lives, we need to address the true causes of distress, as is well pointed out by Noel and William.
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A major problem in psychiatry has not been the adoption of the “medical model” but the corruption of the medical model. This model, as it applies to medicine, and should be applied to psychiatry, is that one uses symptoms to lead to an understanding of aetiology. One can then only state that something may be a disease if one does know the underlying cause. In psychiatry, this would mean that the underlying causes of distress would often be trauma and social situations. The “diseases” would not lie in the brain but in our society. In psychology, the medical model has come to mean something entirely different: that despite no evidence one assumes a biological cause.
The DSM III acknowledged that it was not aetiologically based, but the psychiatric industry has highly promoted a biological model. The DSM system in making research easier has led to a circular argument: if a biological treatment appears to work than the aetiology must be biological. This “empirical evidence” has created a monster.
I strongly disagree with the point that Spitzer had the public interest at heart. He has always been on a strong campaign to remove all indications of emotional roots and psychodynamics from the DSM. He is largely responsible for the direction that DSM and psychiatry has taken.
I have always treated people according to the true medical model Without understanding the cause of someone’s pain, and with only looking at symptoms and a superficial analysis of research, one cannot truly help someone. Psychiatry has abandoned basic principles in medicine.
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No one is saying that people don’t have severe distress or or not significantly impacted by certain symptoms. Having categories to give clinicians rough guidelines can be helpful, but the DSM should have a big disclaimer on it’s cover saying : These Disorders Are Not Diseases. Any Research Done On These Descriptions Has To Be Interpreted With Extreme Caution.
As Bpdtransformation points out below, may psychiatrists these days only look at symptoms and then write a prescription. If one doesn’t investigate underlying causes, then one can’t help a person significantly.
Doctors are trained to believe that diagnoses are based on etiology. The DSM is not, and so confuses doctors, and also leads to bad research.
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Good article. There should be no doubt that nay anti-psychotic should not be used in childhood and adolescence. Aripiprazole is no the top selling drug in the U.S., based largely on its marketing to be used in non-psychotic conditions. There needs to be a total ban on the use of any of these drugs in young people for any “diagnosis”, as without a total ban, doctors will continue to misdiagnose bipolar and psychosis so that they can use drugs that will in the short term appear to control some bahaviour. As was reported in MIA, the child and adolescent branch of the Canadian Psychiatric Association has called for the use ofthese drugs to be controlled. There may be hope yet, but a strong fight is needed.
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The problem with this “diagnosis”, as is the problem with all the DSM diagnoses, is that it is not based on etiology. Off the top of my head, I can think of numerous types of people who could fit into this diagnosis: any normal person who is under severe stress, many children or adolescents who have some emotional struggles, people who have experienced traumas and have certain triggers to that trauma, people who get pulled into gangs, people who come from very socio-economic disadvantaged backgrounds and may feel frustrated with society, people who try to protest significant issues in our society, as well as people with some criminal orientation. Any diagnosis that is not based on a common etiology, and does not lead one to deal with the underlying causes with appropriate treatment is absolutely useless. Of course, the psychiatric industry will do studies with some symptom reduction modality on this diagnosis, show positive results compared to some ridiculous placebo conditions, and then use those results to “prove” that this diagnosis actually exists and that there are “good” treatments for it. It’s this type of circular arguments over made up diagnoses that is destroying psychiatry. Funny, I feel like exploding right now.
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Thanks!
I actually have submitted a couple of articles with more to come. You can also read some posts at my blog site: drnormanhoffman.com or at my website http://www.studentmentalhealth.ca. I’ve been impressed with your comments too. I would be interested in communicating with you as it seems that your experience coincides with my interests. I’ve spent most of my career devoted to trying to help people who fit the diagnosis of “borderline personality” to live happy and healthy lives. I have no interest in simplistic techniques to just reduce some symptoms. All people, especially those who have been deeply traumatized, deserve respect and support, as they struggle to regain a sense of themselves. The psychiatric industry tends to just want these people to go away and stop showing up in the emergency rooms without offering any hope for a real future. Transformation is possible but it takes dedication on the part of the therapist and the individual.
In my whole life experience the one thing that has impressed me the most is how some deeply traumatized individuals can hold onto empathy and hope despite their experience of how horrific some people can be. We can all learn from the values some abused individuals hold onto despite their experiences that should leave them giving up on the human race. These people leave me in awe and with deep respect.
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The first rule in treating anyone who has been traumatized is don’t re-traumatize the person! This should be obvious and should not need research to support this approach. This first rule leads to a second rule: Establish a trusting positive working relationship.
Some people may feel a need to talk about the traumatic events quickly. Other people want first to feel safe with the person that they are talking to. As bpdtransformation points out therapy can take years, partially because it can take years to establish a trusting relationship when someone has been badly traumatized in life.
Safe space is crucial in any therapy, but is not achieved just by being nice to someone for a few weeks. One always has to show utmost respect for the person’s real life experience and their time frame. This is one reason why it is so hard to do research on trauma, as unless one takes an individualized approach, results will always be mediocre at best.
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Part of the problem has always been doctors actually not reading the research. Many, if not most doctors, will read the abstracts and conclusions of research and skim the rest. Most research on various treatments in psychiatry have always shown the same thing. The relatively little difference between placebos and treatments would seem to indicate that many treatments appear to work, but that they all work poorly. One always has to consider in reading research the biases introduced, the nature of the research population, the validity of the diagnoses, and the clinical significance of the findings. For example, in many psychiatric medication studies a 50% reduction on a particular scale is used to determine a positive outcome. In many of these studies, one gets an average drop from 30 on a scale to 14 for the drug and 16 on the placebo with a statistical significance between the two groups. But one has to ask whether this minor difference is clinically significance, especially if one takes into account sedation by the drug and all the possible biases.
Research in psychiatry has always shown most treatments to be clinical failures. The only conclusions one can reach, if one actually reads the studies, are that psychiatric conditions are heterogeneous, that DSM diagnoses are not diseases, and that simplistic uni-modal treatments don’t work. This means that we always have to treat people as individuals, trying to help them with their problems and issues, and possibly consider some researched modalities have having some limited value in some people. When it comes to medication, the published research has clearly shown that we have no idea what these medications actually do, and that there are possible negative long-term consequences, but little long-term benefit.
It is crucial in reading research to understand that in order for research to be considered valid, the results from all research done from various viewpoints, clinical experience, and patient experience should all point in the same direction, with little controversy. If the whole picture doesn’t make sense together, then there is something wrong. This is clearly the case for research on medication. It is also the case for research on psychotherapies, where research on the therapies themselves often focus on showing that a particular technique works, while research on what actually works in therapy indicates that it is not any particular technique that shows value.
One just has to actually read, in detail, the research in psychiatry to understand how far off the rails psychiatry has come.
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I totally agree with you that a distress model rather than a disease model is much more appropriate in helping a person with emotional struggles. A distress model was a fundamental aspect of what was called the biopsychosocial approach in psychiatry where all aspects of a person;s life that could contribute to distress were considered important. This model has been largely dropped in favour of the ridiculous and dangerous biological model.
In medicine, the medical model has always had value. One main problem in psychiatry is that the medical model is no longer being followed. The medical model is based on the importance of understanding the underlying causes of distress. In this model one elicits problems and symptoms to then investigate the underlying etiology. One then attempts to treat the causes of distress to help the individual. If one uses this model in psychiatry and psychology, then one always ends up using a distress model and attending to the underlying causes of the distress. The DSM is not, nor was it ever intended to be based on etiology. In fact, it was created to avoid having to address etiology at all, as previous classifications had been based on implied etiologies that could not be proven. However, one of the main reasons for the rise of biological psychiatry is that doctors end up assuming DSM diagnoses do imply etiology. They end up trying to use the medical model with a classification system where it doesn’t apply. Big pharma also push their drugs in this way.
We need to continue to promote the importance of looking for the underlying causes of distress, whatever those causes may be.
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It’s good to see more psychiatrists speaking out against fad diagnoses, and the overuse of diagnoses and medication in general. Joel Paris was my first teacher and mentor in psychiatry. One of his roles was being in charge of the screening clinic in psychiatry where beginning residents learned how to interview and assess people. The most important part of the assessment was the “dynamic formulation” where we would try to understand all the complexities in the person’s distress. While we would put down possible diagnoses, these were seen as only being vague guides and not particularly important or useful most of the time.
A major issue about all the overuse of diagnoses and medication these days is that it indicates that many people are distressed, and many doctors don’t know what to do about the distress. We could use a “dynamic formulation” on our society to understand why people are struggling so much and what can be done to start to address real problems that are afflicting people.
Thanks Joel!!
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Hi Steve,
your comments on raising children are very pertinent to the issue of our sense of connectivity. An interesting book that is directly on this subject is: Diamond, J. (2012) The World Until Yesterday, What Can We Learn From Traditional Societies? New York NY. Viking Penguin. In this book the child rearing practices of some tribal cultures are described. In the Efe and Aka tribes, fro example studies have shown that infants are passed between various adults between 8 and 14 times. Children are in constant contact, not just with their own parents, but also with many other caregivers.
We do live in a very isolating environment, where most people feel solely responsible for their own emotional lives.
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I think many of the comments point to part of the reason for the anxious state of Americans, though I believe that there is an underlying issue that is not being addressed. Over the centuries humans have moved far away from the life of our evolutionary origins. While some aspects of this have led to greater health, there are aspects that have left individuals feeling fragile. We evolved to live in communities with strong ties and support. There is substantial evidence that states of emotional distress are linked to the lack of emotionally supportive communities. The United States idealizes individuality yet pathologizes the individual who becomes distressed.
There are two aspects to the sense of social connection. One develops an internalized sense of one’s social connectiveness through childhood and adolescence. One’s emotional life then is also affected by the actual social network that is available. Any fragility, either in one’s internal sense of social identity or in one’s actual social network can lead to emotional distress, including feelings of anxiety, depression or isolation.
Countries where people rate themselves as happiest tend to have strong social bonds. It makes no sense to diagnose and medicate individuals who are suffering in society, without looking at the structures of the society that may be contributing to the distress.
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I was in training as a psychiatry resident when the DSM III came out. We were taught, and I believe that it was stated in the DSM III, that the diagnoses were meant as a guide only, especially as they were not etiologically based. It seems that the message in the DSM V is that these diagnoses do actually exist and that etiology is totally irrelevent. This is a very frightening affair. The implication is that any investigations into cause of distress is not important as treatment should be based on diagnosis only and in trying to reduce symptoms on each diagnostic list. Say goodbye to humanistic psychotherapy and prevention of child abuse.
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A major health problem these days is the vast over-diagnosis of bipolar disorder in children and adolescents. Almost all the adolescents and young adults that I’ve seen who have been given that diagnosis, have no real history of true mania or hypomania, but have had histories of emotiol trauma. This study both doesn’t account for the effect of medication on the brain, nor is it convincing of the diagnosis to begin with.
The most important factor, from a clinical point of view, of the main cause of emotional distress is trauma, and not “brain disease”.
A worry with the publication of this study is that it will encourage the continued over-diagnosis of bipolar disorder and the overuse of medications. Many doctors, both psychiatrists and family physicians, will interpret this study as indicating that people who can be squeezed into this diagnosis should be started on medication quickly in order to avoid brain atrophy. The reality is that it is not clear what this study is indicating, what diagnoses were valid, and is it certainly does not show that medication use will prevent brain loss.
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Hi Richard,
I do like and agree with your distinction between medication and drugs. Perhaps we should be using the word medication for a chemical that makes an abnormal situation normal, such as an antibiotic, and the word drug for a chemical that makes a normal body response abnormal though it may alter symptoms. This does leave a grey area though, as in the case of using anti-histamines for allergies, where the release of histamines is a normal body response but the allergic response itself could be seen as abnormal.
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If you believe that Jesus is the answer, then you should also be aware that Jesus was fundamentally a socialist. He fought against corporate and establishment interests and tried to bring equality to the people. Free health care, using a caring relationship as a basis, is one of the main points Jesus is known for. Americans tend to have a distorted view of socialism based on propaganda. All the countries in the world that are rated as the happiest places to live have strong socialistic policies.
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Psychiatrists like that should have their licences revoked. There is no justification for such blatant disregard for facts and such misinformation being thrust on a patient.
One big problem with psychiatrists who call themselves experts in psychopharmacology is that they usually know nothing about people or therapy. Their only knowledge is of the DSM and a superficial understanding of biased research.
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Well said. This is the crux of the whole issue.
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Your comment is important. There are many people who find small doses of these medications helpful. We always need to keep our mind on what is helpful to the individual. It is always the people who are more important than any single minded belief system. Many people who do take benzos use them just as you do.
The problem is how the system uses benzos and other drugs in ways that interfere with long term emotional well-being. People who have suffered from bad psychiatry have every right to be upset by how they’ve been treated.
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Very clearly the way you were treated was very dangerous both on a humanistic and psychopharmacology level. There is no question that all psych meds are potentially dangerous and that they all interfere with normal brain functioning. The main issue to remember is that so many doctors are using more dangerous medications like antipsychotics and SSRIs that people end up being on for years. The short term use in small doses of benzos with proper education and consent and used only as an adjunct to other forms of therapy is preferable and safer than so many of the other approaches to medication. I am not calling any of these medications safe.
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I think that your story about your experience with distress and medication is important. There are psychiatrists who believe, as yours does, that “all (psychiatric) medication is poison”, but who also understand that when used appropriately can provide some relief. One of the important issues in prescribing medication is to not buy into the diseased brain model nor to use medication in high doses or constantly add medication. Good psychiatrists will understand that medication does interfere with normal brain function, but can dull certain symptoms so that a person can feel somewhat better while trying to deal with underlying life problems.
On the other hand, the use of psychiatric medication in children and adolescents should be avoided at all cost. There is very little evidence that in young populations that these medications do anything useful. There is substantial evidence that they interfere with normal brain development and a young person’s ability to grow emotionally.
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The issue of social change is crucial in looking at the mental health of our societies. There are so many people, who like Tibita, think that they are okay because they are going along with their societies norms. One has to sometimes look outside of one’s own society to understand how things can be different. If one looks at countries rated to be the happiest in the world they all appear to have two things in common: good maternity (and paternity) leave and good health care. In Quebec women get one year paid maternity leave. When we speak to people from the U.S. who have had babies, we are appalled by the poor social support given to young families. Happy babies and parents lead to happy children. Stressed families lead to emotional distress. Change is certainly needed.
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Hi Tabita,
Your story is both touching and frightening, though we all know that there are tens of thousands of young people who are getting similar mistreatment as your daughter, many of whom will never escape from the system.
Your point about changing society, and especially changing from a individualistic, competitive society to a more communal one is crucial . We have tended to see ourselves as primarily individuals in North American Society, but there is strong evidence that we are social beings strongly affected by our social environment. This aspect is especially important in the emotional lives of teenagers where peer influence can have a major effect on emotional development. The psychiatric industry tends to ignore this aspect, preferring to either blame the parents or the brain. As peer influences have become stronger and more pervasive, we are seeing an increase in emotional struggles in young people.
We do need to look at our society and how it is affecting our youth. There are so many issues to address, but efforts like yours are an excellent start and example to all of us.
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When I was a psychiatric resident, I decided to do a research project on “difficult patients” at a chronic psychiatric hospital. I spent many days sitting in the lounge of a ward observing patients and staff and marking down every interaction. It became clear after a while that certain patient were quite sensitive to the atmosphere on the ward, and that tension in the atmosphere was usually created by the staff. So when certain staff members were in bad moods, certain patients would tend to become agitated. Of course, this led to the patient being excessively medicated or restrained, not the staff. It is always easy to blame patients fro their behaviour rather than looking for the causes of tension
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Hi Richard,
I agree with you. It is a very sad and dangerous affair that benzos are among the safest of psychiatric medications. It points to how bad and potentially dangerous they all are. But they are among the safest in some ways:
1) When people are put on them it can be for the short term unlike SSRI’s where people are usually put on them for years with the message that they have a “chemical imbalance:
2) There are millions of people being given anti-psychotics fro anxiety ans sleep problems with major side effects. These drugs are more dangerous than benzos.
3) I have never had a patient who I prescribed benzos to who became addicted or was on high doses. When used appropriately almost all people use them sparingly and for short periods of time, unlike other psychiatric medications that people tend to be on for long periods of time.
There is no question that these drugs have caused major problems to many people. A large part of the problem is not in the drugs themselves but in the people who prescribe them. Long term benzo prescriptions are never okay. That is the problem.
As you clearly state, no one here is suggesting appropriate short term use should never be done. So we basically agree on just about everything. We may just be presenting the argument differently
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I agree with you. There is no justification or defence for the insane over medication that is the norm these days.
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While everything written here about benzodiazepines is true, the sad reality is that they are among the safest of the psychiatric medications. As it has been pointed out, most psychiatric drugs are prescribed by non-psychiatrists. These days, partially because of the bad reputations these the benzos have gotten, many family doctors are prescribing SSRI’s or anti-psychotics for anxiety and sleep problems. While I agree with Philip that it is society’s problems that lead to anxiety, when a person comes in to see a doctor in great distress, one can’t change society or have the person avoid the stress caused by society. Sometimes the short-term use of some medication to help with sleep can greatly help an individual, and avoid the situation where a person eventually gets put on a long-term medication that will have greater negative impact. One also has to look at the impact and negative effects of the Z drugs that are being used to commonly for sleep problems. Given the options, I’d rather give a highly distressed individual a little oxazepam for a few days to help them sleep while starting a therapeutic process, then to have the person fall apart more, or end up on more dangerous medications.
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The problem with nay kind of restraint or control is that it becomes a very slippery slope. Anyone who works in an emergency room will tell you that there are situations, such as a person coming in high on alcohol or drugs, aggressive and with a weapon, where there is a clear danger to staff and other patients that has to be contained. I don’t think that anyone would argue that an establishment doesn’t need some way of preventing people from getting hurt. I know of a number of nurses who have been assaulted and have felt very traumatized. So I think that there can be a dialogue on what are the best ways to deal with potentially dangerous situations. It has to be recognized that any procedure to deal with violence will likely end up being abused as staff become accustomed the discomfort that should always be there in any violent situation.
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Hi Victor,
I know that you are in Trois Rivieres, but you may be interested in this study group in Montreal: Groupe d’étude sur l’intersubjectivité. Their website is http://intersubjectivite.com/drupal/
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Hi Victor,
you are not alone. Many young psyvhologists feel a sense of isolation. Most of published research in psycitry and psychology has little to do with real people and their emotional distress. I have a group practice in Montreal. If you would like to discuss any of these issues in person, or would be interested in supervision, please contact me. You can find my contact information at http://www.studentmentalhealth.ca.
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I totally agree with you.
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Thank-you.
I think that it is important to have open dialogue and balanced views. I believe that there is a place for good psychiatry. Many of us old school psychiatrists have been practising psychotherapy and using medications appropriately fro many years, with good results. I believe that it is a problem that many people these days aren’t even sure what good psychiatry is or what to expect.
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Without a doubt, constraints, whether chemical or physical are used primarily to control people and to make life easier for the systems that mandate this control. People who show aggressive behaviour are usually terrified themselves, and the last thing they need is to be further terrorized. When people are frightened they do need a calm and caring environment, and sometimes might need the presence of a containing environment. Let me share a couple of stories to highlight these points.
When I was a psychiatric resident at the Douglas hospital in Montreal, the Douglas did not have a restraint team for the emergency room. They had Vince. Vince was around 6″4″, probably weighed 280 pounds, with hands like baseball mitts. He was also as gentle as a lamb. When a person came in agitated, Vince would just talk to them quietly, say “settle down buddy” and perhaps put one of his big hands on the person’s shoulder. The person would almost always calm down immediately, and you could almost see the anxiety just flow out of them. I don’t remember restraints ever being necessary.
At another Montreal hospital there used to be a patient that frightened people in the emergency. She would come in about once a month, and often would throw things around the ER, ending up being put in restraints or arrested. I was called one evening to find her in the psych room of the ER in restraints. I sat with her, talking quietly. After about ten minutes I asked her if she would like me to remove the restraints. She said yes. We then talked for about another 15 minutes, and she then said she felt better and left. She came in the next evening that I was on call. She said she felt violent inside and was frightened that she couldn’t control the feeling. I asked her if she would like to be put in restraints, and she said yes. Again we talked for while, with her pushing against the restraints at times, and then the restraints were taken off and we talked some more. She stopped coming to the ER except when I was on call. Eventually she would come in to talk and did not want or need the restraints. After that year she stopped coming, and I heard that she was doing well.
The important aspect here is that any type of “treatment” should only be used for the benefit of the patient. We need to recognize when someone is frightened and to do what we can to reduce their fear. Sometimes outside limits or containment may be helpful, but we need to be very careful with using any type of outside control because these modalities can be so easily misused and abused.
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Hi Richard,
As you point out, we all have our areas of expertise and we all have things to learn. Thanks for your comments.
I don’t particularly appreciate any of theloniusmonk’s criticisms of Robert Whitaker. Bob has done a tremendous job of bringing to light and promoting discussions of the horrible state of mental health care. All people who write essays will put foreward a particular view and provide evidence for that view. No one presents in equal balance all the counter arguments. It is not reasonable to expect anyone to do so. Clinicians should be responsible for understanding various sources of evidence and to come up with reasonable approaches to human care. Many clinicians in mental health are failing to do so.
I do agree with his point that we should not just be trying to tear things down, nor just accepting alternate points of view without adequate evidence.
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That is not at all what I said. You are taking things out of context. I’m not sure why you are looking for an argument. Everyone has different areas of expertise and different perspectives. What I clearly stated is that we need to have respect for various perspectives. I also directly implied that it would be unfair to expect Bob to be an expert in all areas.
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I appreciate the comments by theloniusmonk as well as the other comments. We should all be trying to understand the complexities of emotional life, and be hoping to build up helpful resources and approaches for people, and not just tearing things down. None of us, ( or anybody) knows enough about mental health to make definitive statements about etiology. We do know that taking simplistic approaches, and interpreting research in superficial ways, whether to agree with it or debunk it is dangerous.
My own opinion on the topic on the topic of this essay is that “depression” is neither a physical or emotional “illness” as it can not be simply categorized as an illness. A significant part of the problem with modern psychiatry has been because of the misinterpretation of the DSM word “disorder” as meaning “disease” or “illness” I have assessed and treated over 5000 people in my career., and few fit well into any DSM diagnosis. There is no such thing as “depression” as a singular entity. The real life reality of what one sees in practice are individuals who have some life-long emotional issues, who have made certain life choices partially because of those issues, and then have some critical life events that leaves them in distress of one kind or another. Most people will show a mix of symptoms with some sadness, anxiety, ruminations or relationship difficulties. It is the role of a psychiatrist or psychotherapist to help people deal with their life problems, their traumas, predisposing emotional issues, and their symptoms. No single diagnosis or modality of intervention can address all the factors that need to be addressed in any individual. Nor should we, as theloniusmonk points out, just throw away certain modalities because they’ve been overused or misused. We always have to keep our minds on the most important aspect: the helping of people in distress. Part of this is being aware of the resources people are able to access, their financial abilities to afford certain treatments, and of course the possible short term and long term gains and problems with any modality offered. Various people who are encouraging these debates have different backgrounds. Robert Whitaker is a journalist. His work has been very valuable, but I wouldn’t expect him to be an expert clinician, nor would I criticize him fro not having clinical expertise. Many clinicians have not had the time or opportunity to explore all areas of writing. I wouldn’t expect them to. We all have something to offer to the debate, and we all have limitations. Lets value our various perspectives, the same way we hope the mental health field could eventually value the perspective of all individuals.
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This report should come as no surprise, especially considering the overuse of the ADHD diagnoses, with no evidence that ADHD is anything but some children’s behavioural response to life conditions that don’t fit their needs. A major problem with this report and the studies it is based on is the way people tend to interpret research. As research tends to look at one modality of intervention at a time, no research in mental health should be interpreted as if one is trying to find the best single modality as compared to others. Research always has to be evaluated in the light of other research and people’s real life experience. So we can take all the research on ADHD and be able to say that together exercise, proper sleep, teaching methods that don’t chain children to desks and expect them to be robots. good family environment and good teacher-child relationships are all important, and should be promoted for all children. Any individual piece of research can never represent the whole picture or solution. Empirically based practices need to include holistic interpretations of all evidence.
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There will always be people who fit diagnoses as,after all, DSM diagnoses are just lists of symptoms and behaviours. Then there are psychiatrists who try to fit people into diagnoses, which is usually problematic as most people don’t fit simply into one list of symptoms. The only possible value of the DSM is it’s use as a rough guide. As Ted points out sometimes it can be helpful to be able to put a description to peoples’ behaviour. The dangers in how the DSM has been used though far outweigh any value it may have. Certainly BPD is often used as a go to label for people psychiatrists or doctors don’t like. That observation actually supports the findings in the study, and would imply that psychiatrists with heightened fear of death may be more likely to label people as BPD inappropriately.
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Interesting article. It also explains why many psychiatrists may send too many patients who reveal suicidal feelings to hospital and also over prescribe medications. One should not practice psychiatry defensively, either through overt fear of a person attempting suicide, or as this study brings out, more subconscious fears of death. It is crucial to help people who are in distress to be able to sit with intense painful feelings. This means not feeling one has to “do something” to protect oneself against liability or to protect the patient. Especially when treating people who have been traumatized, like many who psychiatrists fit into the diagnosis of borderline personality, change occurs over the long term by helping a person with their most intense painful feelings. This article brings to mind Maltsberger’s seminal article “Countertransference Hate in the Treatment of Suicidal Patients. (http://archpsyc.jamanetwork.com/article.aspx?articleid=491132 ). It’s interesting that 40 years after that article was written, there is a study substantiating the basic points in that article.
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The media does not to be a target. Studies have indicated that a very high percentage of people don’t read past the headlines. (It also appears to be true that many doctors only read the abstracts and conclusions in scientific papers). The media is in the entertainment and money-making business, and often doesn’t tell the complete story in nay article. Truth is often found in the details, as is evident here.
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Hi Squash,
You are absolutely right. . Universities are now doing what the rest of the psychiatric industry has been doing for a long time. Take people with emotional distress caused by family or societal issues, give them a mental illness diagnosis, then spend resources saying how terrible mental illness is and how we need to de-stigmatize it and say people need help but not on our territory. Proper help is then not given and underlying problems leading to the distress are not addressed.
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Hi Ted,
You’ve pointed to a very common and serious problem. Many fundamentally wrong and dangerous beliefs are becoming the norm, with institutions buying into the marketing of biological psychiatry and other beliefs. It is now the norm for people to start of psychiatric assessments saying “I think I have depression”, and for doctors to use the ridiculous “It’s like diabetes” analogy. It’s become acceptable for parents to be more concerned about achievement for their kids than kids emotional well-being. It’s now the norm, as Someone Else points out below for families not to have meals together. It is the norm for universities to buy into the biopsychiatry model, looking at emotional distress as being an illness. It is the norm for universities to emulate a corporate attitude where they want to market their success and distance themselves from what should be their goal: to help develop intellectual and emotional growth in young people. Universities should be safe space for students but instead are productivity mills where emotional distress, suicide and sexual harassment are common, largely due to the attitudes of the universities. ( one can read my piece on “Sexual Assault on Campus at http://www.drnormanhoffman.com)
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As a former director of a major university mental health service, I’ve been appalled by the growing superficial concern for students by university with the undermining of actual service provision. There is an annual conference Austin-Riggs psychiatry institute on college mental health, and in attending many of these conferences, a major concern among service providers was the intrusion of administrators on the quality of mental health services. Basically, bureaucrats and university lawyers want to distance universities from responsibility for care, with resulting policies of forced medical leaves and referring students off campus for services. There is no reason why colleges and universities can’t have adequate services on campus. Clearly forced medical leaves are dangerous, especially as often the root cause of the problems that students have can be the home environment, with school life frequently being more of a safe space, even with academic pressures. Keeping students in university is usually crucial to their emotional progress. Universities are also encouraging the prescribing of medication, or simplistic symptom control modalities, rather than providing proper therapy. A major issue that one sees in students these days is that often they have been brought up more as products than as people, with not enough space for their emotional lives. Both medication and symptom control modalities collude with the message that the only thing that is important in life is achievement and functioning. These modalities will lead to increased emotional distress in the long run, as they interfere with emotional development. Students deserve and need proper help and room to grow, rather than being treated as if there is something fundamentally inadequate about them.
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Hi Alex,
Your points are well taken and important. Boundaries and power issues are always present in therapy, and especially with people who are most traumatized in life, the boundaries are always blurred. This is a difficulty. One has to work with and address the real relationship while being aware of transference issues. It is never easy, either for the individual in therapy or the therapist. While therapy does involve a financial agreement, it can also be a caring relationship. One has to recognize that there are power imbalances and aspect of personal gain in so many relationships. Certainly for those who come from traumatic backgrounds there has almost always been huge power imbalances with parental figures often acting for their own emotional benefit with a lack of empathy for the child. These issues will get activated in any therapy. However, in a good therapy, despite the financial consideration, the person in therapy will experience the therapist as being more truly concerned with the persons welfare than with their own needs. There are usually significant aspects of teaching, mentorship and other parental types of interactions in therapies with traumatized individuals. A therapy is not a replacement for parenting, but it can be transformative.
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I understand your point, but there can be reasons why someone would seek out a psychiatrist who is also a good therapist. I do think thatDr. Berezin knows that there are many good therapists who aren’t psychiatrists. I think that he is concerned that many psychiatrists these days have no clue about being a good therapist, which leads to many problem. Any psychiatrist that hasn’t been trained and doesn’t do therapy can have no idea of what can actually help a person to feel better and what is the natural evolution of any condition with good therapy. This makes the assessments of these psychiatrsits next to useless.
As you pointed out medication can be useful to some people. One of the benefits of a psychiatrist therapist is the ability to prescribe medication as an aid to the therapeutic process while seeing first hand how the two modalities can work together.
Another benefit, where I live, is that people can see me in therapy with no cost to them, and with no limits on the number of sessions that they can have. It is true that I can get paid significantly more for medication work, but I choose to devote most of my time to doing psychotherapy. I do think that it would be good if psychologists could be covered under Medicare here the way psychiatrists are. For now, I tend to refer people who can afford it to psychologists, and treat in psychotherapy people who can’t afford private therapy.
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dear bpdtransformation,
As usual, your comments are well stated and highly appropriate. I believe that there are psychotic conditions that are not necessarily due to trauma, but most of what is called “psychotic” is related to the traumas that you described. I don’t tend to call individuals who experience breaks in society’s view of reality secondary to abuse and trauma “psychotic”, as I think that there is nothing out of touch with reality about how they have come to see the world or their inner lives. In fact, they are mostly giving a view of their reality that is emotionally accurate.
The prescribing of anti-psychotics for anyone who is showing behaviour that someone doesn’t like, or who is expressing how their inner reality feels based on what their real life experience has been, should be prohibited. Psychiatrists should be in the business of healing people and not controlling people.
I particularly like your comment that trauma can only be healed through human relationships and love. In treating people who have been traumatized, love always becomes a crucial issue, even though the psychiatric and psychotherapy professions hate the use of the “L” word. When trying to help someone who hasn’t been loved and who feels unlovable, the issue of whether that person can be or is loved is always present and has to be addressed. When a therapist tries their best to be there for someone, truly cares about who the person is, wants to wade through all the muck with them, bears witness and tries to hold or sooth some of the pain, and does this over periods of years, then one can say that real love is present. People in therapy do feel and respond to this, though often both the therapist and the patient are frightned to name it.
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Hi John,
Without doubt the treatment of high cholesterol can be inportant, includig the use of statins. However this class of drugs are now among the top profit earners for pharmaceutical companies, and while useful also have many side effects. I know of many family doctors who are backing away from prescribing these drugs without first doing other tests (like Dopplers) to see if the prescription is necessary. There are also ther things like exersize, diet, and some natural substances that can lower cholesterol and improve cardiovascular health. The issue that Jill raises is not whether certain drugs, prescription or otherwise, are helpful, but why certain drugs or practices become so popular at certain times. The fad aspect can be dangerous because it can stop people from following or recommending alternatives that may be better for many people.
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Another aspect related to why drugs come and go is why diagnoses come and go. I have seen many fad diagnoses in psychiatry, such as the present emphasis on diagnosing “bipolar” in anyone who has up and down moods, but there are also fad diagnoses in general medicine, such as diagnosing hypercholesterolemia, and giving statins even when there is no evidence of arterial disease. In psychiatry, many of the fad diagnoses that I’ve seen through the years have similar symptoms: variable moods, insomnia, periods of lower functioning. The diagnoses that are given, are often driven by the mental health industry’s need to create a niche to treat, as well as by Big Pharma’s need to create a market. So, the use of street drugs, prescription drugs, and diagnoses is so often industry driven, and not responsive to actual social problems.
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I think that an important aspect of this issue is that the widespread use of drugs, whether prescription or street drugs, is evidence of social dysfunction. One could say that governments and corporations prefer to encourage drug use in many ways rather than have people vocalize social discontent. Our society has not shown the courage to attend to serious fundamental problems, and has allowed drug industries to flourish.
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I certainly agree with you that being a good therapist does not require medical training. In my experience people need a certain empathetic quality to be a good therapist, and that can’t be trained. On the other hand, a medical training “should” give one the following abilities that can add to the perspective from people of different trainings.
Medical doctors should be able to:
Read scientific research and distinguish between clinically valuable findings and simple statistical findings.
Understand a vast array of human suffering.
Understand the interplay between biology and the mind in a complex manner.
Know when an emotional issue may be related to a physical disease.
Know that every treatment may have a down side.
Know that a patient’s needs should always take priority.
Know that we can never be certain and need to be humble.
Know the first rule of medicine “Do no harm”
Doctors are (or should be) trained to understand all these points. We should be asking ourselves, not why we might need medical professionals in mental health, but why so many doctors who work in this field have forgotten their basic training.
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Hi Sandra,
You points are well taken. I am writing a piece now for MIA on the value and shortcomings of psychiatrists and a medical education. Clearly in the mental health field, and in psychotherapy having people who come from various education and life backgrounds is very valuable, though I do think that the medical profession should be able to have particular value. let me address quickly for now some of the points I intend to write about. Medical education is highly clinically based. By the time a psychiatrist has finished medical school and residency, one will have been involved in the treatment of hundreds of people. As medical students, we see life coming into the world and leaving it. Don’t we all remember our first delivery and first death? I remember very clearly as a beginning third year student the patient who died when I was on call, and having to fill out the death certificate and call in, and talk to the family. We all are exposed to all manner of human suffering. In psychiatric residency we assess and treat many patients with all different kinds of problems. In my program, and probably Dr Berezin had the same experience, we had comprehensive psychotherapy training and teaching throughout the program. I remember how psychology PhD interns would be carrying 2-4 patients for their rotation in the same service that I would be responsible for 10-15 patients. The experience in medical school and residency should leave someone better trained and having more empathy for patients due to the intensity of the training. It is unfortunate that instead the training can leave many doctors distancing themselves from human emotion and arrogant about their knowledge. There are many other possible advantages of a medical education for the mental health field, but some of the same aspects that lead to advantages can also cause serious limitations.
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Hi/
I do agree with you that there is a place for medication, and certainly medication if used properly can help people. We should not be withholding pain relieving medication from people in distress, especially when other resources may not be available. I have been teaching psychopharmacology to therapists for over forty years now. An important issue is how to use medication in minimal doses when necessary, but to not distort the reality of the meaning of diagnoses and the downside of medication. The larger issue in Robert’s article is the way modern psychiatry is hijacking the understanding of human suffering and reducing everything to a simplistic and erroneous biological model. In general, the results achieved by this new model of psychiatry are poor, with many people suffering from the ramifications of inadequate treatment and serious physical and emotional side effects. It is often, though that individual practitioners like yourself do find through their clinical experience what can actually be helpful to people, separate from what may be most marketed. If you would like some practical tips on using psychiatric medication, feel free to contact me.
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Hi Robert,
lovely post. There certainly is such a thing as good psychiatrists and good psychiatry, though sadly it does appear to be disappearing. As you brought out clearly, the practice of psychiatry should be primarily the practice of psychotherapy, as human suffering, related to various aspects of societal dysfunction is the main cause of distress in almost all the people we see. I read psychiatric research, and I am usually appalled as the research appears to have little relevance to a real life clinical population. How often do you see “an anxiety disorder” or a “major depression”? I don’t even know where they find people who have a single “disorder” with no complex personal issues for research studies. All the people that I treat have complex issues that require proper attention and time. There is no short-cut to treating real people. One can’t just pay attention to symptoms, though in my experience if one attends to the underlying issues, symptoms tend to disappear fairly quickly. Psychiatry has almost been destroyed, though it is possible that both people in distress and many therapists are getting fed up with all the distortions and self-serving institutions. It’s encouraging to read your words.
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Alex, you are not alone in this battle. There are many people who now buy into the marketing by the “empire” who really want to do good, but have just come to believe in the wrong information. Your efforts, and organizations like MIA are going to make a difference in the long run. The cost to the system, and to thousands of individuals is just too high the way things are now. Many professionals in the mental health field do believe in real science. We just need to continue to show that the way certain research has been promoted and marketed does not represent the whole reality. Real people are not research subjects and all research has to be interpreted in the light of people’s real experiences. I don’t treat “subjects”. I treat real people with real life problems, and rarely see anyone who has a simple “panic disorder” or “Major Depression”. Therefore, even the best research, properly interpreted is only a rough guide. All mental health professionals need to understand this. Many are discouraged by the poor results achieved by simplistic measures based on research models. They will come to understand the truth behind the industry with time. We just need to keep getting out a better message.
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Thanks for your comment. I’m sorry that you were treated with such disrespect, though unfortunately this is no at all uncommon. As someone born of Jewish faith, I would like to assure you that not all Jewish doctors would respond to someone the way you were, regardless of your name. Much of Jewish teachings and culture is based on learning and wisdom. it is sad, that many people who follow various religions end up believing in superficial doctrines rather than holding to the spirit if the religion. There is a parallel between this and the mental health industry where many professionals don’t follow fundamental humanistic principles, but end up believing in easy to follow, highly marketed modalities. Most religions start with variations of the Golden Rule “do unto others…”. The medical Golden Rule is “do no harm” taken from the Hippocratic oath, “and I will take care that they suffer no hurt or damage”‘ Clearly the medical profession is often not following this basic rule.
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Thank-you for your comment. I totally agree with you that it is about trust, and you point out some of the crucial issues in trust: competency, wisdom, integrity and humanity. Too few psychiatrists possess these attributes. As psychiatrists, we do need to have a strong understanding of our field and a wise understanding of research. Most of all, we need to have an open mind and to listen to our patients primarily for concern for their feelings and needs. Sometimes this means meeting them halfway; for example, while trying to educate them about various aspects of emotional care,, at their request, using medications, though cautiously, to help engage them in a therapeutic process. I’ve called this “back-door therapy”; first meeting their request for medications, with full disclosure, but then once engaged to begin a real therapeutic process. Everyone is entitled to their own comfort level about treatment, and one can start to build trust in many ways, as long as the patient’s own perspective and needs remain central. I also want to make it clear that I tend to use the word “patient” despite the shortcomings of that term to denote a recognition of my responsibility to attend to the person, and of the power imbalance that exists regardless of all respect given to the person. It is not a term that I use to denote that the person has an inherent illness, that they are a victim, or that they need to collude with a particular role. I don’t like the term client which can imply a business arrangement rather than a caring relationship.
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Alex, you are so right. I have come to believe that the quality of care that is actually received is inversely proportional to the number of “programs” a governing body announces. These programs are usually just marketing to make it look like something is being done, while not providing solutions to the problems that cause people distress. The labelling of people as mentally ill and then focusing on reducing stigma for mental illness falls into this category of wasting money. The industry gorges on the vulnerable, wastes money to protect themselves from liability and to placate the masses, but overall creates more chronic problems with questionable help to people in need.
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This article, and the comments all bring out crucial issues. The financial rewards to the mental health industry is driving the extremely poor and often dangerous standards of care to people in emotional distress. It is more lucrative for a psychiatrist, or any doctor to just pull out prescription pad rather than listening to the person. The article referred to in the New York Times is chilling, as it brings out how much psychiatrists convince themselves that they are being helpful while treating people with profound disrespect. I am a psychiatrist, who does mostly therapy, but does prescribe medication (cautiously), mostly to people in therapy. From my experience, I can state that the degree to which people will tell you about their real feelings and problems varies greatly with the time that they are given, and the empathy the treating person shows. If a doctor only shows interest in symptoms and doesn’t have nay time or empathy for the individual, then that doctor will know nothing, either of how the person feels or how the person is doing. This can lead to a doctor being convinced good is being done, when a patient is actually doing very poorly. The acceptance of poor results has become the norm, with many people seeing “mental illness” as a chronic “disease”, and not understanding that it is actually the widespread use of inadequate, and possibly dangerous, treatment modalities that is causing the problem. We do need good resources to help people, but billions are being wasted, people are not being properly helped, and tens of thousands are being turned into chronic patients by the system.
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There is a major problem with studies on psychotherapies that are aimed at deeper emotional change and growth as compared to studies on modalities, including medication, that focus on symptom reduction. In short term studies, as emotional growth therapies encourage emotional expression, these studies should show poorer results when rating only symptoms as compared to symptom reduction focused modalities. In reality, emotional growth therapies show just a good results for most types of problems in the short-term and better results in the long term. It is a misinterpretation of research that tends to promote simplistic and numbing modalities.
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I do love my province, despite some annoying political issues. First, the child and adolescent branch of the Canadian Psychiatry Association comes out against drugging kids and youth and against using anti-psychotics as sleep aids in all people, and now this very important report on supporting the use of psychotherapy. Maybe a warm wind is now blowing in from the north. I have been very fortunate living in Quebec to be in a province that i more socially minded, and that also allows me to treat people from all socio-economic backgrounds at no cost to them. We are also fortunate to have greater influence from various European schools of thought.
The proper interpretation of research is crucial in psychiatry and the general mental health field. As this report, and research indicates, short-term numbing of symptoms is not only less useful in the long run, often leading to chronic or recurrent conditions, but is not economically reasonable or advisable.
Vive le Quebec!! Vive les personnes libres!!
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Hi Joanna,
Great article and review of research. There are clearly numerous problems these days with the diagnosis and treatment of bipolar disorder. A major health hazard presently is that bipolar disorder has become the newest fad diagnosis, with many doctors using it for anyone who has mood changes, including in children. These doctors then follow standard protocols and pharmaceutical marketing to put people on concoctions of medications. As your article brings out, any medication that has sedating effects will appear to reduce symptoms from the doctor’s point of view, though these medications can often interfere with well-being and functioning. So much of apparent statistical significance in medication research can be attributed to sedation and other enhanced placebo effects. You point out clearly how variable is the progress and recurrence of what could be called actual bipolar disorder. There are many people who have just one or a few manic episodes. I have seen people who have had some symptoms in adolescence or early adulthood and then never again. Some people may get symptoms later in life. However, psychiatrists who are primarily hospital based, as well as many other psychiatrists, tend to assume the bipolar is a life long condition, partially because they may see primarily people who might have more severe conditions, or who might appear to have increased morbidity due to treatment. I have had many experience with patients who do very well with medication as needed approaches or, as has been pointed out in the comments, with little or no medication and psychological intervention when needed. Of course, in order for these approaches to be successful, people need, good supportive environments, as well as quick access, and good follow-up from treating physicians. I do not use lithium with patients as there are better alternatives. One also needs to work with individuals within their comfort zone, when deciding on what approaches to use. There is no excuse for practicing simplistic flow-chart psychiatry, as all patients are individuals that have different life histories, evolution of symptoms and needs. This is why being a psychiatrist can be difficult, as one has no simple protocols to follow, apart from treating everyone with respect and true care. Psychiatrists are often scared when treating a person who has been diagnosed with bipolar illness, as the possible consequences of episodes can be devastating. Being worried about possible deterioration in a patient is no excuse for over-treating or mistreating people. We can not practice psychiatry defensively and get best outcomes for our patients. Being a patient is even more difficult, as one is putting one’s life in the hands of doctor who can’t have complete knowledge of all possible ramifications of treatment, and cannot know the full picture of an individuals life.
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Hi Sandra,
A wonderful piece! It certainly supports the view that there is good psychiatry, but that good psychiatrists are always questioning their views and are aware of the fragilities in our field. I think what some people fail to appreciate, and part of what makes many psychiatrists limited in their ability to help people, is that we as psychiatrists live in doubt every moment of our professional lives. We go on vacation, or are away for just a weekend, and we never know what tragedy may await us when we return, and whether perhaps we missed something or said something not quite empathic enough. We are never sure of our theories or our treatments. We can’t predict with any accuracy the value of our work with any individual. We can’t know with any certainty how much of the whole story our patients are telling us, or whether their perceptions match the perceptions of those around them. We work largely in the dark, often grasping at straws, and then, as you point out, find ways of feeling more secure with our perceptions. Some psychiatrists cling tightly to certain theories, techniques or flow-chart psychiatry. Some of us understand that whatever uncertainty we live with is nothing compared to he emotional uncertainty that many of our patients live with every moment of their lives. This understanding leaves one with more empathy for those we treat, and more incentive to always explore and question. We all need reminders that working to improve people’s lives is a worthwhile endeavour, but that we can never be complacent in our knowledge.
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Brilliant article Philip,
We do need to expose more the root causes of misery and the inequities in our society. The chasm between rich and poor is a major issue in most countries, and the psychiatric industry is being used as a tool of those in power to placate the common folk. The notion, promoted by the positive thinking movement, that anyone can just “think happy” if they want to, is an insult to anyone who suffers from personal trauma or social injustice. Therapists who work with a broad range of people from various socio-economic backgrounds usually understand this. In good therapy, whatever techniques one may use, one should strive to help people understand the roots of their pain, whether family, or socially related. (and thee is often a link between the two). We also need to stand up for the under privileged, and not collude with either neoliberal or neoconservative doctrines.
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There is an important issue apart from the way ADHD is being pushed for the benefit of the industry. Speak to elementary school teachers who has been working for over 15 years, and they will all tell you about the increase in classroom behaviour problems. There are important societal changes that have occurred that is leading to more chaotic kids and frustrated teachers. Teachers who usually have access to limited resources, may then end up encouraging psychiatric assessments and the use of medication. While teachers should not suggests diagnoses to parents, it is not teachers’ faults that they are overwhelmed in the class. In addition to blaming self-interests of the industry , we need to address numerous social problems that are leading to the diagnosing and the drugging of kids. All children need a safe, stable, sensible and connected world to grow up in.
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As knowledge about good therapy evolves, the practice of CBT is evolving to become closer to the good therapy models that have been around for decades. This is the case for both Schema therapy, that is very similar to active models of psychodynamic therapy and mindfulness based CBT that allows a more positive approach to “negative” thoughts. But, I agree with Richard that the way CBT is used in institutions is often very negatively oriented. Often the same tools, such as using thought records are just stated over and over again until the patient either shuts up about symptoms or drops out. I have heard from numerous people of their bad experiences with CBT (not that I haven’t heard many reports about bad experiences with other therapies). There are stereotypes of all kinds of therapies, but unfortunately, there are too many therapists who do represent these stereotypes. The most common types of psychotherapy research tends to be done on therapies that do resemble these stereotypes, as therapies need to be standardized to do this type of research. A lot of the research that has been used to support the massive use of CBT in institutions is this type of research, which for all forms of therapy shows statistically significant but overall poor results (typically 50% reduction of symptoms in 65% of patients). We need expert models of therapy to be promoted, and not research models.
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Well said Richard,
You point out a major problem with our system, and also how CBT is being used (or misused) CBT can ann is being used by the mental illness industry to support the idea that people have “wrong” brains and the only thing one has to do is to focus and push away symptoms. Cognitive techniques can and are being used by good therapists who strive to help people with real life problems. Working with cognitive distortions has always been an aspect of good therapy, far before CBT was conceived, but CBT has highlighted the importance of being more active in working with cognitions. The whole debate of whether one is working with thoughts or feelings is often overstated, as thoughts and feelings are implicated all the time, as Kermit pointed out. Therapy is always an emotional experience, and this aspect, especially understanding the impact of the therapeutic relationship, is crucial. So, we should really be talking about good therapy and limited therapy. When a therapists works with a person’s real life problems, helps them understand and deal with their symptoms, feelings and relationships, and honours the importance of the therapy experience, that is good therapy. If a therapist sticks to a few tools without listening well to the person, and gives the person the message that their is something essentially wrong with them as a person, that is limited therapy. As this article on anxiety and serotonin brings out, brain chemistry is complex, and the biological model knows too little to make claims about the value of medication. The same can be said of the therapy field. People are complex, and research will never show what will be most helpful to any individual. This is where listening to our patients becomes so important, because they are the people who will always teach us more than research about what can be helpful.
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A major problem with psychiatric treatment of psychosis (as well as most other conditions) is that in general the psychiatric institutions focus more on symptom reduction than on functioning and well-being. It is more “cost-efficient” from their point of view to heavily medicate someone so the person will not need to use system resources. Whether the person feels well or can function becomes irrelevant. There was a patient who was in medical school who had been diagnosed as bipolar. When he appeared to be having a manic episode, his behaviour was a concern to his supervisors, and he was in danger of having to discontinue his education. However his symptoms were able to be calmed down enough with the short-term, occasional use of just 50 mg of chlorpromazine. He continued to function well, was never on other medication, and would need this medication for about a month, once a year. After a few years he didn’t appear to have any further episodes. I have another patient who was on high doses of anti-psychotics and had multiple hospitalizations, yet had heard voices that never went away. She’s been on almost no medication for over twenty years now, is happy and functions well, though does have her, mostly friendly voices. I know when she is having a harder time when her voices turn less friendly, and I then spend more time with her, but have not resorted to medication changes. Functioning and happiness should always take precedence over symptom extinguishing.
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Hi Patricia,
Stan Kutcher is a well known Big Pharma pawn, and clearly is tied financially to Big Pharma. I think it is a major problem these days that so much money is being spent on “de-stigmatizing” campaigns that allow organizations and governments and companies like Bell Canada, to market themselves as caring about Mental Health, while actually then doing nothing or actually cutting treatment resources. I posted a piece on my blog titled “The Need to Stigmatizing (the overuse of the term) Mental Illness” that discusses this issue.
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Your views. like anyone views, are crucial to all of us understanding life’s ups and downs. One of the issues with CBT, is that many of life’s problems are not caused by negative or wrong thoughts, but are caused by life’s pain. We evolved to have adaptable brains that learn from our environment. Many people’s life experience has been traumatic, with their brains being properly vigilant or sensitive to possible trauma. Life is not all happy, and it is often very reasonable to feel sad, or anxious about life. Losing someone close to you is always very painful. There is no way of talking or thinking away the pain. I remember being at a funeral for a friend’s mother, and someone said to the father “It will get better”, and I replied,” no, it doesn’t get better, it just gets different”. There are all kinds of theories on grief, and all different ways that people find to feel somewhat more at peace with death, but the reality is that we are not able to comprehend or deal well with death. From an emotional and attachment point of view, death doesn’t make any sense. A person we love is there, and then they are not, and a huge hole is left in our hearts and minds. People’s feelings are always important and we should not be trying to explain them away, or diagnose them. One always has to be careful in helping people to handle certain feelings or symptoms better to not inadvertently invalidate their pain. I wish you some peace.
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Dear Cat,
and thank-you for sharing your story and thoughts. When one considers the use of medication with a patient, it has to be thought of as doing so in partnership with the patient. Medication should never be thought of as the solution to a problem, but only as an aid. The crucial aspects to focus on is well-being, functioning and emotional growth, rather than on symptoms. These days too many practitioners are only concerned with symptoms, which can lead to the many horror stories we are all aware of.
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Hi Joe,
Service availability is certainly a problem as is having so many schools of thought in psychotherapy. I find that many therapists these days, who claim one approach or another, or call themselves “eclectic” tend to have their own limited basket of tools that they pull out based on their comfort or discomfort level. So if one thing doesn’t appear to be working they quickly pull out another modality. Using various modalities is important, but should be in response to understanding what will be helpful to any individual, and not to serve the comfort level of the therapist. I advocate what I call the “One Therapy Model”, which is that for any individual there should be a specific combination of approaches and way of understanding the person that will be optimal, and that it is the job of the therapist to try to discover this therapy. Clearly to find this “one therapy” is not completely possible, but one should always attempt to make the therapy fit the client and not the other way around. One of my concerns with CBT is that, according to many patient reports, many CBT therapists insist that the patient adopts to the therapy, and will berate people if they don’t.
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Hi Saul,
Well stated, and thanks for the interesting information. As you point out, CBT does not aim at the root of the problem, certainly not for depression. When a symptom has taken on a life of its own, then that symptom may become the problem itself, and working towards eliminating that symptom makes sense. When deeper issues are causing a symptom, if one controls that symptom, then other ones will arise, and the underlying problem continues. In my experience, symptoms are not usually the problem in themselves, and in most of the people that I see, the type of symptoms that respond to CBT usually dissipate quickly with normal integrative therapy, without having to make them the focus of the therapy. My main objection to the CBT movement is how it is being used in the industry, with many systems dropping therapy services that will work with more complex emotional issues in favour of short-term CBT clinics that work from a DSM diagnosis model and only look at the particular set of symptoms for which the individual was assigned to a therapist. Thus, if a person was assessed for panic symptoms, that person will receive 12 weeks of CBT for panic, and nothing else. I have rarely seen anyone who just has symptoms and not complex life issues that they need to address. While their are many good therapists that use CBT techniques, the overall trend in the mental health industry has been to treat symptoms and not people by using simplistic and made up diagnoses to direct treatment and then methods like medication and superficial CBT to dull symptoms enough so the patient will go away, and the system can continue to believe that it is doing its job.
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Hi Stephen,
Hi Stephen,
My personal view is that it is better not to take these drugs, and for a person to be able to work with their emotions. A major problem these days is that many people, both treating and being treated, no longer believe that one can live through and work with emotional pain. It is very hard sometimes to convince people that emotions are a signal to ourselves that we need to listen to and respect. It is also not my way to force my thoughts on other, but to show respect for where they are in life, though I do try to educated. So I always try to emotionally respond to the patient, attempt to settle down their worries, educate them to the meaning of emotions, and try to reassure both patients and therapists that emotional work can take time, but that progress is possible. Sometimes though people feel too raw to be able to wait things out, or be able to work in therapy. In these cases, medication, in the short term, may be helpful, always starting with the least invasive, least dangerous, and smallest dose possible, and always trying first to use medication that can be taken on an as needed basis, rather than daily. While this may not be the ideal way of treating someone, it is at times the best choice for helping the person move forward in life. One has to always be aware of the downsides, and work with the person to help them tolerate painful feelings rather than letting them be numbed down. It can be a fine balance. Of course, one then wants to get the person off medication as soon as possible. More to come on this issue.
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Hi Jeffrey.
I’ve had a patient who had quite severe TD after being treated by anti-psychotics for trauma related problems. This is a devastating condition. I believe that the use of any anti-psychotic for non-psychotic conditions should be illegal. (one can debate how they are used for conditions called psychotic as well).
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Hi Jeffrey,
Thanks for this. Honestly, I am often dumbfounded by my profession. I really don’t think that my thoughts or approach or so special. To me it’s mostly common sense. I just can’t believe how off the rails the mental health industry has gone.
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Wonderful piece. The imagery seems to indicate that these men on hooks see themselves as the new Messiahs.
The DSM is such a flawed and potentially dangerous tome whose evolution I would describe this way:
A Den of Sanctimonious Men
on a Decidedly Self-serving Mission
Declaring Scientific Method
Determined to Supplant Moderation
and aid Dr. Spitzer’s Motive
to Destroy Sigmund’s Memory
while Debasing the Search for Meaning
by Describing Sensitivity as Madness
in their Dehumanizing Saddening Mockery
and Dangerous Sardonic Manual.
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Excellent report. I truly hope that it has an impact. The labelling and drugging of children, adolescents and young adults is one of the most serious emotional well-being issues of our time. We are setting up our young people for a lifetime of misery, rather than dealing with the important social and family issues. In 2005, I presented to the Kirby Commission on mental health, with similar concerns. Unfortunately, that commissions report gave more support to the mental illness industry than to addressing real issues. I’ve just posted a copy of my report to the commission at http://www.drnormanhoffman.com for those interested.
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Bipolar disorder is clearly the latest fad diagnosis. It allows psychiatrists to stick a label on anyone with up and down moods, with no further investigation into the causes of these moods. Of course, if you medicate people enough, these moods may go away, but then so does thought, functioning and healthy emotions. Especially as this diagnosis is being applied to children, it represents one of the biggest health hazards being thrust upon people by the industry.
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Hi Erin,
I agree with you. All the evidence is that psychiatric medications interfere with the normal functioning of the brain. They make a normal brain abnormal. That does not necessarily mean that blocking normal function may at times be helpful, just a marijuana may be helpful emotionally in some circumstances. I do prescribe the medications known as antidepressants at times, cautiously, in particular circumstances (more to come on this later, as I do intend to wade into the bog), but I always tell patients that these are emotion dampeners, that they do interfere with the normal functioning of the brain, and that they are likely to dampen or numb all emotions, not just the bad feelings. (one may wonder why anyone would want to take these medications after this description, but as I’ve said, there is more to come on this). So , certainly honesty is important, and I think that this is one aspect in which the psychiatric industry had failed miserably.
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I agree with you, Bonnie. The term ‘mental illness” is clearly not medical. you can read part of my view on this on my blog drnormanhoffman.com in a piece talking about the need to stigmatize the term “mental illness”. The Soviet Unio used to be accused of using the term mental illness to incarcerate people who they saw as socially undesirable. We are clearly doing the same in our society. If one is not just willing to be a cog in the wheel, and one has emotions about aspects of life, then one must be medically ill. This is clearly a dangerous way of viewing emotions. However, despite the distortions and lmitiations of psychiatry, and the way it is being used by the power structures in our society, i am not yet willing to resign from my profession and give up. We need many people, from all different backgrounds to fight the good fight.
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Hi Saul,
you call yourself a layman, but you clearly have a better view of the issues than many professionals. The points that you raise are excellent, and we really do need reasonable protocols in the field. As you point out, and as is evident in the link you provide, most protocols at the present time largely presume a biological cause of depressed feelings. Many practitioners are encouraged to use screening tools that are only validated ( and poorly at that) for Major Depression which as we know is a made up diagnosis to begin with. The common protocol is then exactly as you pointed out, with lip service being paid to alternatives to medication and prescriptions being written quickly, often with poor follow-up. One of the reasons why these type of approaches and protocols continue is that doctors want to feel their treatments are successful, and as antidepressants are primarily emotion dampeners, patients initially often report not feeling quite as bad. Without further investigations of the person’s happiness or functioning, and with infrequent follow-up appointments, the doctor then feels comfortable in the perception that the patient is doing better. From the viewpoint of many doctors, if the patient initially wasn’t feeling quite as bad after being started on meds and then months later describes feeling worse, then the problem is biological and more meds are needed. These perceptions need to be challenged. We do need a whole new approach to treatment.
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It is absolutely true that many psychiatrists are prescribing anti-psychotics for sleep and other problems. It is frightening that Abilify is now the top selling medication in the U.S.. On a good note, as reported on MIA, the Canadian Psychiatric Association has come out strongly against the use of anti-psychotics for sleep problems in all people, and for the use of these drugs in children. Maybe some reform is possible. The common practice of prescribing psychiatric medication, and then continuing increasing dosages and additional medications when the person doesn’t seem to improve has to stop.
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Hi Johanna,
I totally agree with you. Some people can go off more quickly, and have a miserable few weeks, but for most, slow and steady is necessary. It can take up to a year to get off these meds, as they do change your brain, and it takes time for the brain to re-grow neuroreceptors. One of the problems with modern psychiatric drugs is that they are only available in large increments. So, for example, Prozac, only comes in a minimal dose of 10 mg. Some pharmacies will compound smaller doses, but this can be expensive, or with capsules one can divide up capsules oneself. It’s a larger problem with the extended release pills that some drugs come in. One thing that I do at times, if people have trouble weaning off, is adding a small amount of nortriptyline which is available in small increments. While it is not ideal to start using a second medication, it can help some people eventually get off all “antidepressants”.
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Hi Ted,
Thanks for your kind response. I understand that this is a difficult issue. I see people every day whose lives have been deeply hurt by the psychiatric industry and psychiatric drugs. The present practice of psychiatry in North America is overall abysmal. I think that many people who have come out as totally against all psychiatric medication have had or heard of mostly bad experiences, and therefore don’t know that there are other possibilities. The lack of proper resources and the selling of the bio-psychiatry model is clearly a huge problem, that we need to fight against.
I would like to keep the dialogue about medication use open, though for now, let me give a simple example of reasonable drug use. It has become a common practice, and major health hazard, for family doctors to prescribe quetiapine (or shutupapine as I prefer to call it) for sleep problems. People who have been prescribed this medication, even though it has many side effects, are often afraid to stop it as their insomnia caused severe problems. In this situation I will wean them off the quetiapine, using small doses of a benzodiazapine. This approach usually works and then allows the person to continue to function while we look at underlying issues and other solutions for the insomnia.
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Dear Saul, Duane et al,
I understand and appreciate your comments and confusion. Certainly psychiatric medications are grossly overused, often dangerous, and corrupt our society’s attitudes towards emotional pain. I hope to be able to with time, explain that there can be certain benifits from cautious use of certain medications in appropriate circumstances, but for now let me say this:
In a perfect world people wouldn’t come to me in severe emotional distress with no money for proper therapy or even an adequate diet.
In a perfect world, I would be able to spend 3-4 hours a week with each of them ,helping them with their emotional issues, and then spend the rest of my time fighting poverty, social dysfunction, child abuse, work place abuse, and corporate power.
In a pefect world, people would have the incentive to seek proper help, do exercise, yoga, meditation, or anything necessary rather than take psychiatric medications.
In a perfect world, I would be able to convince people that “chemical imbalances” don’t exist and that psychiatric diagnoses are made up.
In a perfect world, I wouldn’t be prescribing modest amounts of medication to stop people from seeking it elsewhere from doctors who will overprescribe with no concern for more complex issues.
In a perfect world, I wouldn’t have to prescribe any medication to help people with some aspects of their emotional pain, but then, in a perfect world, there wouldn’t be any emotional pain.
In this world, I am asking you to not judge me too harshly for having to take some shortcuts to deal with reality while trying to provide people with some relief from their pain.
Sincerely,
Norm Hoffman
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I totally agree with you. What I was referring to ias what psychiatry calls “narcissism”. Robin was vulnerable to feeling badly about himself at times, but in my mind was an amazing person. The point is that life can not be put down to a DSM diagnosis. It is dangerous to do so on many levels. We need to see people as whole complex people. I just wish that someone could have helped Robin Williams with his demons whatever they were. He is sorely missed, especially in a world with not enough humour.
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I stand corrected on that point. I agree with you in that there is good therapy and some good research. I was referring mostly to the simplistic diagnosis and symptom based research with standardized models of therapy. We do need to show that both research and therapy can be done in ways that address complex issues.
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Hi Ron,
I agree with you entirely. One of the aspects of some humanistic therapists that frustrate people is the inability to help in practical ways. We also need to be able to speak people’s emotional and cultural language, and not expect them to understand ours. There can be a certain arrogance in some psychodynamic therapists who feel that patiients “should” be “insightful” but who don’t address issues in ways that actually speak to the person. A number of years ago I gave a presentation at the yearly Austin-Riggs conference on student mental health, on a particular, and reasonably active, approach to short-term therapy for university students. Many of the counsellors objected to an approach that they saw as “too directive” as I proposed beign helpful and active from the first session. I also agree with you that there are many things one can say that are helpful and therapeutic, and in fact many experiences outside of formal psychotherapy are therapeutic. I stand humbly corrected.
Part of the issue with CBT is as much how it is being used by the industry to not offer proper help and to cut expenses. CBT is sometimes taught with more depth, as is the case with Schema Therapy teaching, but as you pointed out, integration of ideas is difficult in our field, and many people end up practicing superficially. I’ve seen dozen’s of people who’s experience of CBT has been of the therapist having a couple of tools that are repeatedly stated, but little ability to help with real life problems and emotions. We shouldn’t want any superficial, bureacratic approaches to therapy taking over the mental health field.
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Hi Bonnie,
We certainly agree that the discipline is fundamentally faulty. It is a major problem as well that just about every approach in psychiatry has a way of blaming the patient when things don’t go well. Maybe some day we can debate the issue of whether to abolish the whole field or to try to salvage some good. I am presently working on a book called “Real Life Psychiatry” that does address the flaws of the field but proposes ways of helping people .Beyond what can or can’t be done by individuals, it’s clear we need societal change on many levels.
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Great article Jay. Very thoughtful and educational. As you bring out, the emphasis some researchers place on finding genetic influences or causes of DAM diagnoses is troublesome. The implication in the industry and certainly how it is often presented by the media is that certain people carry a “diseased gene”. Of course, this has never been found for any psychiatric diagnosis. The reality is that we all have varied traits. Different traits may lead to varying effects of certain environments. For example, a child who may have a trait of higher emotional sensitivity may react differently to an abusive home than a child who is less sensitive and more assertive. Both will be affected by abuse, but may develop different personality traits or problems later in life. Dr. Hallie Frank and myself did a study years ago on “borderline empathy”: the observation that many individuals who receive this diagnosis seem to tune in to the underlying emotions in others. Our study did find some evidence of heightened emotional perceptiveness in people diagnosed with Borderline Personality and the data seemed to indicate a constitutional variable. The important aspect in this, and in many other possible genetic correlations, is that emotional perceptiveness is not a disease, but is a potentially positive trait that under more ideal family environments is likely to lead to highly beneficial traits. Of course, this issue of emotional sensitivity brings up the whole issue of the wish of the mental health industry to numb people, rather than address societal causes that hurt our emotional development. The crucial issue, is that there are many different traits that create our amazing diversity that will lead to positive outcomes in good environment, but may shape the nature of emotional distress in poor environments. A similar argument applies to the search for a “suicide gene”. There may be traits, like for example the degree of risk aversion or pain tolerance, that may correlate with suicide. This does not mean that these are problematic genes. It will always be problematic social causes that lead to suicide. It might be helpful to know what traits may make it more likely that a person will actually commit suicide, but it will usually be more helpful to deal with the emotional and social issues involved. Genetic traits are not diseases.
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Hi Ron,
This is an excellent well balanced article, though personally I find that the way CBT is used and marketed is a major problem in the mental health field. Certainly cognitive and psycho-educational techniques can be helpful to people though these have been a part of good therapy long before CBT was invented. A significant issue with CBT is the way it is taking over in mental health institutions, often used in the most simplistic manner, despite the lack of substantive evidence to show that it works well. By this I mean that pretty much all of the diagnosis and symptom based research, whether using medication or therapy, tends to show mediocre results, though showing statistical significant difference with placebo or sham therapies. The results obtained in these research studies are far worse than one would want to achieve in clinical practice. So empirically based therapy is not the same as good therapy. Furthermore, if one wants to consider a body of research to be substantive then it should be cohesive. One should find that the results from looking at an issue from various forms of research, as well as including clinical experience and patient reports all hang together. The research on aspects of therapy and therapists that correlate with good outcomes all point to relational issues. This research does correspond well with clinical experience and what patients report useful in therapy. The only research that supports CBT is at odds with these other forms of evidence. In may years of practice, I have never seen anyone who reports significant change with CBT or has described CBT techniques as highly useful. Patients do speak of the empathy, understanding and wisdom of their therapists. So while CBT claims to be empirically based, to date, hard evidence about the effectiveness of the techniques is lacking. What makes the situation fro the mental health field worse, is that many institutions are taking any relational component out of the CBT type therapy they offer, and focusing only on teaching techniques. This is troublesome. You refer to the article comparing therapies for bulimia. That is an important study as it does point to the idiocy of certain approaches. Having headed an eating disorder unit for many years, it is clear that nutritional, psycho-educational, and structural approaches are necessary, though one would ideally also want to address emotional issues. There are very good therapists, who use multiple modalities to address the real needs of patients. We should learn what we can from different approaches. The problem is the way CBT is being promoted and taught. Many CBT therapists do not know enough developmental and emotional theory to help people in emotional distress, yet claim superiority on limited empirical evidence. I have seen many people who have felt worse after their experience with CBT therapists who have tended to prohibit any talking about “negative” feelings, and have given n overall pejorative message that a person should be able to control their feelings with their thoughts. There is good therapy and there is bad therapy. Empathy and in-depth understanding of a person is always an aspect of good therapy. Any therapy that claims this is unnecessary has to be questioned.
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Dear Bonnie,
I’m looking forward to reading your book, and I certainly agree with many of your views and points. However, as long as there are people who society deems to be mentally ill, we will never get rid of psychiatry. There is also, believe it or not, such a thing as good psychiatry. The problem is that the psychiatric profession has gone totally off the rails, not that it ever had a great grasp on reality. There are many reasons for this, but one important aspect is that there are very few psychiatrists who don’t owe allegiance to some body outside of the patient. Most psychiatrists work within hospital systems and therefore end up functioning for the benefit of the system. Others work in research and owe their allegiance to funding organizations. Many others owe their allegiance to their pockets and need to promote and market themselves in order to make the incomes they desire. You and I are fortunate to live in Canada where we have decent health care, and as an independent psychiatrist, I don’t have to owe allegiance to anyone but my patients. I applaud your work to bring down the psychiatry industry, but we should never forget the needs of people in distress.
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Well said Al!
There has been a huge change in the very language that people are using to describe themselves and their emotional lives over the past thirty years. When I started in practice, people would come in saying things like “I’m feeling sad lately” or “I’ve been upset” or “I’m not feeling like myself”. The most common opening statement that people are likely to say these days is “I think I have depression”. The language of the mental health industry is taking over from the language of emotion. Of course, I always respond by saying “Can you tell me how you feel and what’s going on in your life?’ Nonetheless, a significant aspect of doing assessments and therapy these days is helping people to understand that they have emotional and not chemical difficulties. It is not surprising that the pharmaceutical industry prefers and promotes forms of therapy that collude with the “there is something wrong with your brain or the way you think” message, and devalues humanistic therapies.
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It is possible that certain of the techniques of CBT may have their uses, but the evidence that they do is lacking. Research on what actually works in therapy supports relational frameworks and show that techniques themselves have minimal impact. The research on which CBT’s tremendous rise in popularity is based is all quantitative symptom and diagnosis based research. This mode of research, on whatever therapy or drug is being tested, has always shown only very moderate results, and far poorer results than one would expect in clinical practice. A 20-30% difference from placebo in people showing greater than a 50% reduction in symptoms is not impressive. If one then takes into account the fact that these therapy studies are never double-blind that their are biases that favour CBT, and that therapeutic allegiance tends to account for a significant part of successful outcomes in research models, then one has to really question all research done by these models, especially if the results aren’t in line with research on outcome variables. Relational frameworks have always, will always , and have been shown in more sophisticated and qualitative models., to be the gold standard in psychotherapy. The value of any technique remains to be proven.
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There appears to be numerous problems with Early Psychosis Intervention programs. One is that they tend to be diagnosis based, and tend to push the use of anti-psychotic medication. If one works outside of hospital system one learns that there are many youth who have one episode of a schizophreniform psychosis, but if treated conservatively with the emotional and social issues attended to, may not have further episodes. So these programs may tend to over diagnose and over treat medically and under treat psychologically. Any hospital based program will tend to have a predetermined idea of diagnoses, modalities and outcome expectations. Youth who show symptoms of psychosis, like anyone else, are best off treated as individuals with in depth assessments of all possible causes of symptoms.
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Hi Josephine,
I’m glad to hear that those are the requirements in the U.K. While in Quebec one does need to log many hours of supervision to be certified as a psychotherapist, I know many people in Canada and the US who have received a certificate in CBT after a 3-4 month training. The main issue is that to be a good therapist, one should have a solid knowledge of developmental psychology, and many hours of practice and supervision. There are many people who have received certification in CBT in North America with little in depth knowledge of crucial developmental issues.
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James,
I think your piece is balanced and thoughtful. Psychiatric diagnoses should only be used as a guide, and can be useful both with colleagues and patients to aid communication and at times to relieve guilt and anxiety. The issue is more with how society and the mental health industry has misused diagnoses to the detriment of the population. Many institutions, including the NIMH in the U.S. and the CMHA in Canada, as well as many government bodies tend to spend much needed funds on marketing campaigns to “de-stigmatize” mental illness rather than addressing causes of emotional distress. It makes no sense to try to stick a label on everyone who suffers emotionally, to not try to help prevent emotional distress ,and then to focus on de-stigmatizing, mostly to show to the public that you are “concerned”. A welcome relief from the mental illness and stigma advertising has been ads put out by longlivekids.ca which focus on emotional wellness and common factors that can cause emotional distress. We need more emotional wellness promotion, less labelling, and more concern about conditions in our society that can lead to emotional distress. We shouldn’t want to get rid of diagnoses as a guide, but to start training practitioners to understand the possible benefits and limitations of diagnoses. Let’s all work towards a world where diversity is appreciated, labels are irrelevant, but that good descriptions and words that promote understanding are valued
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Brett,
You are failing to understand the issues, the facts and limitations of research. Quantitative psychotherapy research has clearly shown that many forms of therapy appear to work equally well, with CBT having no advantage over many other forms of therapy. CBT is much easier to do research on because it is fundamentally a manualized therapy to begin with, while other forms of therapy need to be standardized (or dumbed down) in order to fit research protocols. The fact that there is so much research on CBT does not make it batter or even a valid form of therapy. There is plenty of research evidence that indicates that the type of variables that correlate with good outcomes are very different to the type of approach that CBT promotes. I stand fully behind my opinion which is well backed by research.
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Thanks Steve,
One aspect that should be obvious and common sense about research is that research done from various aspects should make sense together and should correspond to clinical experience and patients’ experience. When research results depart from common sense, don’t fit together and don’t bear any resemblance to actual experience there is clearly something wrong with the research. All symptom and diagnosis based quantitative psychiatric research suffers from this problem. We need to interpret all research in the light of actual clinical experience and stop forcing clinical practice into superficial research models. Hence the title of my blog “Real Life Psychiatry”
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This study should come as no surprise. Research has always indicated that CBT is no better than other studied therapies, and if one takes into account inherent biases in research, it is clear that CBT has always been worse than other therapies. The most obvious artefact of research regarding CBT is that if one trains someone to report less symptoms, then less symptoms will be reported regardless of whether a person had actually improved. CBT, as it is practiced in research models does the opposite of what research on what actually works in therapy shows. Research on therapists variables and patient therapist relationships clearly indicate that a therapist being able to have an in-depth understanding of the person and being able to relate this to the individual in a comprehensive, empathetic manner is crucial for therapy to work. CBT tends to claim that a deep understanding of someone is irrelevant, while technique counts a lot. Research has indicated that technique is the least important variable in outcome. Training in other forms of therapy, like psycho-dynamic takes 2-3 years. One can get a certificate in CBT in 12-16 weeks. We need to move away from superficial therapies performed by poorly trained therapists with a poor grasp of humanistic approaches, and focus on helping real people with real issues.
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It is a certainy in the Mental Health Industry that as soon as one sees an agency focusing on “programs” it means that they have given up on prevention and proper treatment. Rather than using resources properly, most institutions, whether it’s hospitals, government or education, the easy way out is to promote some kind of mental health program that may beb good for public relations, but does nothing to relieve suffering. It’s a positive note that this study has exposed the worthlessness of this approach, though this should have been obvious to anyone who understands the real problems.
drnormanhoffman.com
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This article naturally raises the question: why are so many kids and adolescents being prescribed drugs in the first place. The medical profession is opting for short term solutions that have long-term ramifications. Prescribing medication to young people recklessly clearly gives the messages that problems in life require medication and that emotional distress has biological causes. Both these messages can impair the development of identity and autonomy that is so crucial in adolescents and young adults.
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The over emphasis of the biological view can lead the physician and initially the patient to feel better, yet often makes the patient feel worse in the long run. It should be clear that the biological reductionist view leaves physicians less empathetic to the emotional suffering of the patient and leaves the patient stuck with the inner sense of being fundamentally damaged. The decreased empathy of physicians then makes it less likely that the patient will feel comfortable to tell the doctor about ongoing suffering, thus letting doctors continue to believe that their approach works.
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