Showing 93 of 100 comments.
Thank you for posting this beautiful article.
Thank you, Bob, for this brilliant article. Your message is of great societal importance. I’d like to add the observation that in contrast to the 25% prevalence for past-year “mental illness,” lifetime prevalence estimates are approximately 50% (e.g., https://en.wikipedia.org/wiki/Prevalence_of_mental_disorders). More sophisticated studies show that the vast majority of the population will meet diagnostic criteria for one or more “mental disorders” by middle age (e.g., https://www.div12.org/is-abnormal-psychology-really-all-that-abnormal/). My point is this: an additional reason for criticising blaming gun violence on the “mentally ill” is that most people are members of that group.
Wonderful article as usual, Phil. I appreciate you and the great work you do. Regarding Dr. Pies’ “myth” that psychiatry as a profession endorsed the chemical imbalance theory, here is a quote from the Royal Australian and New Zealand College of Psychiatrists (RANZCP) official website:
“How do medications treat mental illness? Medications work by rebalancing the chemicals in the brain.” (https://www.yourhealthinmind.org/treatments-medication/medication)
The Australian government, presumably in concert with the RANZCP, also promotes the chemical imbalance theory. For example, this Department of Health pamphlet claims, “Depressive disorders are thought to be due, in part, to a chemical imbalance in the brain. Anti-depressant medication treats this imbalance.” (https://www1.health.gov.au/internet/main/publishing.nsf/Content/01583965211717A9CA257BF0001E8D74/$File/whatdep2.pdf).
Nothing has changed.
Since you’re calling out people, it would be interesting to know of whom you speak. I’ll volunteer myself. Who else?
Hi Julie. Thank you for the thoughtful reply. I appreciate your perspective and honestly all that you have to say! Nothing you’ve written has insulted me and I’m glad you are free to speak your mind, as you should be. I’m just trying to wrap my head around what kind of environment MIA is for someone like me, whether or not I belong here and in what capacity, and whether or not I can ever contribute anything of any kind to MIA that can be seen for what it is and isn’t misconstrued in a manner that creates more of a problem than it’s worth for me.
Not having gone through such an experience myself, I definitely cannot *understand* what it’s like. Which is why I said I’m “well aware” of the hell survivors experience, as opposed to “I understand” it, but that language obviously struck you as too far. What language do you recommend to convey the fact that I have read extensively first-hand accounts of bad experiences in the MH system, and discussed such experiences extensively with my clients, and witnessed such experiences first-hand, and know all about how and why such experiences are dehumanising, disempowering, debilitating, and based on a rationale of scientific BS that crumbles with even a small amount of critical analysis, and have fought this BS paradigm aggressively at great risk to my career and livelihood?
I’m not a psychiatrist and I don’t practice medicine. I’m a psychologist and I reject psychiatry’s biomedical model.
Hi Julie. Can you please clarify which statement you believe is unfair? I’m not sure which profession “psych” represents, and I see psychiatry and psychology as different, in some ways quite fundamentally, though I know in the real world they are often 2 sides of the same coin. I’m well aware of the hell survivors have gone through and am grateful not to have gone through it myself. My question to the new “sheriff” was asked in the spirit of clarifying whether some groups here are extended the latitude to violate the posting guidelines whereas others are not.
For what it’s worth, I emailed Ben Carey in 2015 shortly after the special issue of the Behavior Therapist (http://www.abct.org/docs/PastIssue/38n7.pdf) criticising the biomedical model was published. This was kind of a big deal in that it included articles from a host of prominent and credible authors that basically ripped the biomedical model to shreds. I’m posting the email below; Carey’s reply was “I will take a look at the issue, thanks for sending. I am long familiar with all these issues, good to see more discourse on them. I look forward to reading the latest.” That was all the reply I received in response to what could/should have been a bombshell story.
I also note that in 2015, Carey accepted the “Distinguished friend to ABCT” award from the Association of Behavioural and Cognitive Therapies. This award was bestowed on him by ABCT for penning stories friendly to the organisation’s ideological positions. I was disappointed in my organisation for what I saw as compromising a journalist’s objectivity by essentially rewarding/bribing him for his friendly work, and I was surprised he accepted an award so obviously and awkwardly associated with journalistic bias.
Long story short, my experience suggests Ben Carey isn’t likely to champion this issue, though I could be wrong.
Email to Ben Carey sent Oct 14, 2014:
Dear Mr. Carey:
I’m writing to inform you about an important scientific development that may be of interest to you for an article. My name is Brett Deacon, and I am an associate professor of psychology at the University of Wollongong (Australia; I recently moved from the US) and member of the Association for Behavioral and Cognitive Therapies (ABCT). I am also editor of the ABCT journal, the Behavior Therapist.
This month’s edition of the journal is a special issue devoted to critical analysis of the biomedical model (it’s available here, select the October 2015 issue: http://www.abct.org/Journals/?m=mJournal&fa=TBT). In this issue, numerous highly respected authors take aim at the biomedical model of psychological problems. This model posits that psychological problems are brain diseases caused by biogenetic abnormalities and emphasizes biological research and treatment. This approach has dominated mental health research and practice in the US since 1980 and has been embraced as the status quo in psychiatry. The biomedical model is the declared position of the National Institute of Mental Health and the National Institute on Drug Abuse. It is also becoming increasingly apparent that the biomedical approach has been a failure, and in some respects has made matters worse. Until recently, academic leaders who do not support the biomedical model have largely avoided acknowledging their concerns in public. However, given its societal implications, this uncomfortable topic is too important to ignore. Our special issue was published to contribute to a growing critical analysis of the biomedical approach.
This special issue features 11 articles that present critical analyses of different aspects of the biomedical model. Collectively, the authors contend that the biomedical approach is based on flawed assumptions and that the available scientific evidence does not support its validity and utility. For example, authors offer compelling defenses of the following claims: (a) the chemical imbalance theory of depression is not scientifically credible, and never has been, (b) industry-funded drug trials are better regarded as marketing than science, (c) psychiatric medications appear to worsen the long-term course of the problems they are used to treat, and (d) the directors of the National Institute of Mental Health and National Institute on Drug Abuse are misrepresenting scientific knowledge to market biomedical ideology.
Contributors to this special issue include award-winning scientists and journalists, three ABCT presidents, the president-elect of the British Psychological Society, and individuals from clinical psychology, counseling psychology, journalism, neuroscience, psychiatry, and social work. This is an all-star cast of highly credentialed authors that cannot be dismissed as “anti-psychiatry” conspiracy theorists. The issues raised in this special issue cut to the very core of the American mental health system and argue that we have been heading in the wrong direction for too long and now require a course correction.
I am writing to you in the hope of drawing national attention to the special issue because of its societal importance. Our special issue is also an unprecedented development in the American scientific community and I wish to encourage further discourse on this topic among professionals and the public. If you are interested in further discussing this matter, I would be most eager to speak to you. Thank you very much for your consideration.
Brett Deacon, Ph.D.
Fiachra, the problem is when the treatment causes the illness, psychiatrists may interpret this as the treatment “unmasking” a secret illness that was there all along. I see this all the time. Here are two examples (of many more) from my experience in the psychiatry practice:
-Client is a man in his 20s who recently became depressed in the context of severe stress and was prescribed fluoxetine (Prozac) by his psychiatrist. He soon developed “severe agitation and insomnia” (quote from medical chart), which are common adverse effects of this drug. After these “symptoms” didn’t improve on a benzo, discontinued Prozac, another antidepressant, and an antipsychotic, he was referred to a highly biomedically-oriented psychiatry clinic called the Black Dog Institute where he was diagnosed with bipolar disorder. From the chart: “In hindsight, he had experienced an irritable hypomania associated with the antidepressant which unmasked a latent BAD (bipolar affective disorder). This is colloquially referred to as BAD III, and is a useful diagnostic indicator of bipolarity.” He now believes, based on what he has been told by psychiatrists, that he is mentally ill due to a malfunctioning brain with a chemical imbalance, and will need to be on medication for the rest of his life. He feels hopeless and was recently suicidal while thinking his life was over and he could never attain his longtime goals. He now takes a “mood stabiliser” and an “antipsychotic” and has been told he will need to do so for the rest of his life. He was referred to me to learn some “skills” to manage his bipolar disorder.
-Client is a woman in her 50s who recently became depressed in the context of major life stressors. Last year she was given an SSRI antidepressant. Shortly after the dose was doubled, she experienced mild mania (increased energy, goal-directed behaviour, decreased need for sleep) for the first time in her life. Her psychiatrist diagnosed this as the emergence of latent bipolar disorder unmasked by the antidepressant. The client now takes lithium, an antidepressant, and an antipsychotic. She recently switched psychiatrists with the goal of going off her medications. Instead, her new psychiatrist doubled the dose of each drug to “stabilize” her. She did not protest but was disappointed. She complains now of weight gain (30 pounds), fatigue, and being in a fog. Her psychiatrist assured her these are not adverse drug effects despite each being a well-known effect of the drugs she is taking. She was referred to me to learn some “psychological tools” to cope with her “bipolar symptoms.”
These cases are not outliers. I saw clients with similar experiences on a daily basis working in a psychiatry clinic. Needless to say, I am very, very glad to be working now in my own private practice.
Someone Else, you may be interested to know that the DSM-5 (2013) quietly changed its tune on antidepressant-induced mania. As you noted, DSM-IV stated that manic episodes caused by antidepressants should not count as bipolar disorder. As described in this Psychiatric Times article (http://www.psychiatrictimes.com/major-depressive-disorder/switching-mood-depression-mania-antidepressants), “DSM-5 now considers that mood elevation with antidepressants justifies the diagnosis of bipolar disorder, whereas earlier editions considered it a drug-induced reaction.” I wasn’t aware of this change until I started seeing clients with clear antidepressant-induced mania being diagnosed by psychiatrists with bipolar disorder and given drug cocktails consisting of a “mood stabiliser” and “antipsychotic” as a result.
Auntie, your common sense suggestion seems totally reasonable. In my view, there are any number of things a knowledge non-psychiatrist professional should be able to convey to clients about psychiatric drugs, that are well-established scientific facts that are important to know for informed consent. Certainly the information in the patient information leaflet is an example. Another example is what credible clinical practice guidelines recommend for the “treatment” of various problems. So, one answer to the question “under what circumstances can a psychologist convey information to a client about their psychiatric drugs,” might be when this information is scientifically bulletproof, relevant to the client’s concerns, and has not been shared by/discussed with the prescriber.
A different answer to this question was given to me by my psychiatrist colleagues and government regulatory agency: never. This answer was based on a different consideration than the common sense one mentioned above. According to these sources, the wellbeing of the client takes a backseat to a more important consideration, namely the possibility that a medical doctor might be upset at the psychologist for undermining their “treatment.” In their view, saying anything at all to a client about their drugs, under any circumstances, risks undermining medical treatment, upsetting the prescriber, having a complaint filed, and severe penalties against that psychologist. I reiterate that this was the advice given to me by the governmental regulatory agency that handles complaints against healthcare providers. In such an environment, doctors (like the child psychiatrist I described above) can routinely violate clinical practice guidelines, unethically withhold informed consent, and distribute drug cocktails of questionable safety and no established efficacy without any concern about negative consequences. And clients, their families, and well-informed non-physician professionals are helpless to do anything about it. This is the healthcare system in which I work.
When I worked at the psychiatry practice mentioned above, I sometimes provided accurate information to my clients about the psychiatric drugs they took that I deemed important for informed consent given the client’s concerns. Examples included information that “antidepressants” can cause emotional blunting and mania (in cases where this had obviously occurred), and that antidepressants aren’t necessary to correct a chemical imbalance that causes depression and need to be taken for life like insulin for diabetes (in case where this rationale had been given by the prescriber). In each case, I was careful that the information I provided was scientifically bulletproof, was conveyed in a respectful manner that did not disparage the prescriber, and was conveyed *not* as advice but as information for the client to consider and discuss with their prescriber if they wished so they could make an informed decision about their care.
When word reached my psychiatrist colleagues that I was occasionally conveying such information, I was told to stop, was threatened with being reported to the regulatory body, and told that this would likely result in the loss of my license and would destroy my career. I subsequently spoke to the regulatory agency directly and asked what information a well-informed psychologist can convey to clients about their psychiatric drugs they have been prescribed. I was strongly advised not to provide *any* information about drugs to clients. Better to refer the client back to the prescriber, or to contact the prescriber myself to discuss concerns. If the prescriber learned I was providing information about drugs to clients, they might make an official complaint that I’m operating beyond the scope of my practice, and this could result in loss of my license. I asked the government official a question: “are you saying there is literally no scenario in which any psychologist can provide a client with any information about medication they have been prescribed by a doctor?” He said, “yes.”
Marilyn, thank you for this excellent post. I feel compelled to reply because of the idea that it is surprising that a psychiatrist would prescribe an “antipsychotic” to an 8-year-old. I think most people have no idea what the practice of psychiatry involves in the real world, where 8-year-olds are routinely given drug cocktails including neuroleptics. This idea should be surprising, but it is not to those familiar with real-world practice.
I worked in a psychiatry and psychology clinic last year. The clinic employed an experienced psychiatrist who specialised in working with children and adolescents. Families from all over the area sought out this psychiatrist as there are few child specialists and they are in great demand.
The clinic used an electronic medical record that showed what psychiatric drugs clients were prescribed. Out of interest, I kept track of the psychiatrist’s prescribing habits in the medical record. Here is a list of drugs prescribed to clients of this psychiatrist seen during a specific, representative week:
-9-year-old girl on fluoxetine
-12-year-old boy on sertraline
-13-year-old girl on methylphenidate, fluvoxamine, and quetiapine
-13-year-old boy on methylphenidate, fluvoxamine, and quetiapine
-14-year-old boy on methylphenidate, dexamphetamine, sodium valproate, risperidone, and quetiapine
-14-year-old girl on fluoxetine and quetiapine
-15-year-old boy on fluoxetine and quetiapine
-16-year-old boy on olanzapine, risperidone, and quetiapine
-16-year-old girl on fluoxetine, quetiapine, and methylphenidate
-17-year-old boy on dexamphetamine and lisdexamfetamine
-17-year-old girl on aripiprazole, risperidone, and sertraline
-17-year-old girl on diazepam and escitalopram
-17-year-old girl on lorazepam and quetiapine
-17-year-old girl on aripiprazole, risperidone, venlafaxine, and sertraline
-18-year-old boy on fluoxetine and quetiapine
-19-year-old girl on lorazepam, sertraline, and quetiapine
-(note: all clients were on one or more psychiatric drugs)
The list above reflects a typical week in the practice of a highly experienced and qualified specialist in child psychiatry. Based on my experience, this psychiatrist’s clients and their families were not adequately informed about adverse effects, or the lack of scientific evidence for these drug cocktails, or the existence of alternative evidence-based psychological therapies for the problems these drugs were used to “treat.” In other words, there was no informed consent, which is an ethical violation. None of these clients were referred to a psychologist for help with the issues (mostly stress, anxiety, depression, and family problems) that prompted them to come to the clinic.
I realise I am not capable of meeting the purity test requirements of those who dominate the comments section here. This is true despite my rejection of the biomedical model, which I describe on my own professional website (http://www.illawarraanxietyclinic.com.au/values-and-philosophy.html). I’ve said as much in many blog posts and published articles (e.g., https://www.madinamerica.com/2017/08/house-fire-mental-health-literacy-parable/). I have given dozens of free copies of Anatomy of an Epidemic to my clients in the past year. I reject the notion of “mental health,” as opposed to “mental illness,” and I talk to my clients all the time about this. I could go on and on, but what’s the point? I do not belong here, according to the culture of the comments section at MIA, and I’ve finally come to understand that. People who share my scientific values do not belong here. This helps to explain why MIA has made basically no inroads, and indeed has no chance of making inroads, in the world of non-biomedically-oriented “mental health” professionals who care about science, as long as the present culture remains intact. I’m sure I will get flamed for saying this but I’m also sure this is true, and I have a very educated opinion about this based on extensive personal experience. And that is why I have come to recognise the futility of being an active member in the comments section of this website. And so, with respect, I am bowing out of discussions here. I wasn’t planning on writing this but felt compelled to do so to respond to some recent posts. That’s it for me, thank you.
To oldhead, Steve, dragonslayer, I appreciate our dialogue but I’m going to respectfully step away from it, for the reasons mentioned in my last post. Thank you.
Steve, did you read my comment that I didn’t say it was possibly to *objectively* measure emotions, behaviours, and beliefs? Nobody here is claiming this. But we can often measure them in a scientifically adequate manner. I’ve published many studies on self-report measures of psychological constructs. Here is an example: http://www.uw-anxietylab.com/uploads/7/6/0/4/7604142/tbes_validation_jad.pdf. Turns out we can strongly predict the therapy practitioners provide to their clients by measuring their negative beliefs about exposure therapy. From this research, we can give an individual practitioner our measure of negative beliefs about exposure therapy and, knowing his/her score, have a probability estimate of how he/she might work with anxious clients. And we can be pretty confident in our probability estimate because of how strongly scores on our measure predict therapist behaviour. This is solid science and I’m proud of it.
I’ve been reflecting on my presence at MIA, more specifically why I am an active commenter here. I totally support MIA’s criticism of the biomedical paradigm, but beyond that, what I encounter at MIA is often an affront to what I stand for as a psychologist with strong scientific values. This perception is regularly reinforced in my discussions here and often enough in what MIA staff post, like the article that started this discussion. Mental health professionals who share my scientific values are all but absent here; some used to be around but have long since left. I’ve mentioned this before – MIA has had basically zero apparent reach/impact in the world of science-based clinical psychology. And that is too bad, because I believe there could be a natural alliance to be built. For example, a massive global trend in psychotherapy is toward acceptance and mindfulness-based approaches, like Acceptance and Commitment Therapy (ACT), that explicitly reject the biomedical paradigm. Find a way to connect MIA with ACBS, the Association for Contextual Behavioral Science, and the game would change overnight. But a cultural shift would have to occur at MIA for that to happen. At present, most ACBS members wouldn’t last long here, not because they have thin skin, but because MIA doesn’t reflect their values.
For my part, I don’t want to have to continually defend why scientific knowledge is important as a mental health professional, why I advocate therapies that have a great deal of scientific support over those that do not, why it makes sense to apply the results of group-level research in a probabilistic manner to individuals, how psychological phenomena like beliefs and behaviour can be adequately measured, etc. I’m tired of it. And I look around and notice there is nobody else here like me and I wonder what in the hell I am doing here. And I don’t have a good answer. And so, I think I need to stick to only reading articles here, at least for a while. Thanks Steve and others for the discussions of late, I have genuinely enjoyed them.
For the record, I’m not saying I’m right and others are wrong, that’s not at all the point of this post. What I am saying is that MIA, for all its awesomeness, is a lonely and contentious place for someone like me who is both a fierce opponent of the biomedical model and a staunch advocate of rigorous science and useful psychosocial approaches derived from it. When it comes to biomedical paradigm criticism, I think MIA nails it, hands down best resource in the world. But this site is all over the shop when it comes to identifying and encouraging useful science-based alternatives to psychiatry’s drug-based paradigm of care. And the antagonism toward all things science-based and brought to you by mental health professionals, no matter how well-established and useful, gets old after a while, at least to me. Alright, I’ve said what I wanted to say, thanks for reading. Catch ya’ll later. -Brett
Dragonslayer, I just said what I consider science to be. Psychology is the realm of thoughts/feelings/behaviours, so a psychological phenomenon would be something in that realm. oldhead, I didn’t say we can *objectively* measure subjective phenomena – you accused me of saying this and critiqued me for it. I said we can adequately measure (many) psychological phenomena like behaviours, beliefs, and subjective experiences with the use of instruments like questionnaires, rating scales, etc. If you are claiming that we cannot adequately measure any psychological phenomena like behaviours and beliefs, then well, I can’t believe you believe that. The snark level in this comment thread is unnecessary.
Gerard, you wrote, “Too many variables when it comes to studying people and then generalising those results to everyone, Brett. If one does that, then it smacks of arrogance (as Steve said) and looks and sounds like psychiatry.” Can I assume, from what you’re saying here, that you reject the entire science of psychology, based as it is on the study of groups of people? Or that you reject the notion that what we learn from the scientific study of groups of people is at all relevant to the experience of individual people (of which groups consist)? Or both? If it is arrogant to conclude otherwise, what adjective would you use to describe the rejections I noted above?
oldhead, as I see it, science is a method of inquiry, not the product of this method. Some questions are beyond the scope of science, such as those that pertain to philosophy or spirituality whose validity cannot be revealed through scientific study. But if we can adequately measure a variable and study it using the scientific method, it is within the scope of science. We can adequately measure psychological phenomena like behaviours, beliefs, subjective experiences, quality of life, etc. And we can examine the impact of various manipulations/interventions of these phenomena using the scientific method. “Therapy” is one such intervention, and we have a massive amount of well-conducted scientific studies that speak to its effects on different types of problems of thinking/feeling/behaving, as measured with psychometrically sound instruments. This is science, in my book. Now, this science is done by people, which means it is often misinterpreted, suppressed, inappropriately manipulated, etc., but that is another topic.
Steve, you’ll get no argument from me that the relationship is critically important, and without it it doesn’t much matter what “techniques” the therapist uses. But beyond the relationship, its also clear from our available science that for certain problems, some approaches (not “techniques,” but “approaches” that have a unified philosophy/theory/strategy, like exposure therapy for anxiety) are more effective than others. I don’t remotely see technique/type of therapy and relationship as antithetical, and debates of the merits of one vs. the other miss the point to me. It’s great to have the right relationship factors in place, but those alone aren’t always enough, and the research is clear that for some problems – like the ones I help my clients address – the relationship alone (in the context of non-exposure-based therapy) isn’t optimal. That’s not the case for everyone, but the data are the data, and they show that people in general who seek help for anxiety problems tend to benefit more from exposure-based therapy. Yes, they are all unique individuals with their own complex histories and contexts, but still, isn’t it best to start as a default by using the approach science shows to work best, and modify as needed from there?
I’ll end by quoting from the great psychologist/philosopher Paul Meehl, whose words on this topic speak to me (http://www.dgapractice.com/documents/meehl_case_conferences_adapted.pdf). “The vulgar error is the cliché that “We aren’t dealing with groups, we are dealing with this individual case.” It is doubtful that one can profitably debate this cliché in a case conference, since anyone who puts it quite this way is not educable in ten minutes. He who wishes to reform the thinking in case conferences must constantly reiterate the elementary truth that if you depart in your clinical decision making from a well- established or even moderately well-supported) empirical frequency— whether it is based upon psychometrics, life-history material, rating scales or whatever—your departure may save a particular case from being misclassified predictively or therapeutically; but that such departures are, prima facie, counterinductive, so that a decision policy of this kind is almost certain to have a cost that exceeds its benefits. The research evidence strongly suggests that a policy of making such departures, except very sparingly, will result in the misclassifying of other cases that would have been correctly classified had such nonactuarial departures been forbidden; it also suggests that more of this second kind of misclassification will occur than will be compensated for by the improvement in the first kind (Meehl, 1957—reprinted here as Chapter 4). That there are occasions when you should use your head instead of the formula is perfectly clear. But which occasions they are is most emphatically not clear. What is clear on the available empirical data is that these occasions are much rarer than most clinicians suppose.”
Gerard, when an opinion can be cast in the form of a testable hypothesis, and that hypothesis can be studied scientifically, and scientific research has converged on a clear result, we have the equivalent of scientific fact that can be used to examine the validity of an opinion.
The idea that what appears to be a clear phobia of something specific (like needles) reflects a deeper, perhaps unconscious fear of something else, is a psychoanalytic idea that has no empirical support. A corollary is the doctrine of “symptom substitution,” which says treating the “superficial” fear without address its underlying “root cause” won’t work, and symptoms will pop up in other areas because the root cause remains unaddressed. This myth is debunked here, among many places: https://www.ukhypnosis.com/2009/08/30/evidence-against-the-doctrine-of-symptom-substitution/.
Does the fact that a problem like the fear of needles can’t be defined according to a biological test mean that it does not exist? That it cannot be measured, even with psychometrically high-quality self-report measures, or behavioural measures? That there is no point in investigating which strategies best help people overcome the fear of needles? That such research, when it exists and produces clear conclusions, can be entirely ignored because the fear of needles is not a bona fide medical disease that can be shown to exist with objective measures? That everyone with a fear of needles is such a unique individual that they have nothing in common that could allow us to understand what contributes generally speaking to a fear of needles, and what helps people generally speaking to overcome it? My answer to these questions is no, and that about sums up my rejection of the idea you and Steve have noted here.
Chris, thanks for sending these links. There is a lot of bad science in the field, baseless claims, and fraudulent marketing, and I have been an outspoken critic of pseudoscience in psychology for a long time. For example, I co-authored this book chapter, published in “Science and Pseudoscience in Clinical Psychology,” on therapies for trauma (http://www.uw-anxietylab.com/uploads/7/6/0/4/7604142/lohr_gist_deacon_devilly_and_varker_2014.pdf) in which I called out EMDR for its pseudoscientific nature. I’ve written about the pseudoscientific nature of “antidepressants” as well (http://www.illawarraanxietyclinic.com.au/uploads/7/6/0/4/7604142/are_antidepressants_overrated_deacon___spielmans_2017.pdf). I value science, appreciate good science, and am a fierce critic of pseudoscience anywhere it shows up.
There is actually a lot of good science to support the safety, tolerability, and effectiveness of exposure therapy for anxiety. It’s probably the most clearly science-based approach of any kind, for any type of psychological problem. I’ve written about this quite a bit (e.g., http://www.uw-anxietylab.com/uploads/7/6/0/4/7604142/exposure_and_ethics_cbp.pdf). Your claim that a “significant majority” can’t tolerate exposure is empirically false, according to a large body of science on this topic. Meta-analyses indicate that exposure-based therapies do not have higher dropout rates than non-exposure-based therapies for anxiety (e.g., https://www.ncbi.nlm.nih.gov/m/pubmed/26375387/; https://www.ncbi.nlm.nih.gov/pubmed/17663606). Notably, dropout rates are very low to non-existent in the kind of highly intensive exposure-based therapies critics might expect to be especially intolerable. To illustrate, Hansen et al. (https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5943612/) reported no dropouts among 65 clients diagnosed with OCD who initiated their highly effective, four-day intensive exposure treatment. Similarly, Foa and colleagues (https://www.ncbi.nlm.nih.gov/pubmed/29362795) obtained fewer dropouts (14%) in 2 weeks of massed exposure (10 daily sessions) for PTSD than in 8 weeks of exposure therapy (25%). I could go on and on, there is a large scientific literature here and it unequivocally does not show that most clients cannot tolerate exposure.
But what is certainly true is that many therapists believe, incorrectly, that most clients cannot tolerate exposure. I have studied this as well (http://www.uw-anxietylab.com/uploads/7/6/0/4/7604142/tbes_validation_jad.pdf). Therapists who believe this have been shown in many studies to eschew exposure in favor of “gentler” approaches like relaxation, mindfulness, and so on that are less effective, but less distressing – to the therapist (e.g., http://www.uw-anxietylab.com/uploads/7/6/0/4/7604142/why_do_clinicians_exclude_clients_from_exposure.pdf; http://www.uw-anxietylab.com/uploads/7/6/0/4/7604142/exposure_for_child_anxiety_jad.pdf). Exposure is the most powerful therapy we have for anxiety, and it as safe and tolerable as other therapies, but most therapists don’t provide it and most clients can’t access it, and this is a big problem. If anything, MIA worsens this problem fostering cynicism about anything and everything on offer in the mental health system, even the approaches that work well and are not aligned with psychiatry’s biomedical model. This continues to be a thorn in my side as a participant here and I’m sure is the major reason why science-based (clinical) psychology has basically no presence here.
rasselas.redux, I appreciate your comments and I’m glad to hear you have experienced mental health professionals who listened to you and respected you. I think it’s important we here at MIA fight the tendency to lump in all mental health professionals with the worst, biomedicaly-obsessed, dehumanising psychiatrists.
Gerard, I understand your perspective, but it is a scientific fact that some therapies are more effective than others for certain types of psychological problems. I happen to specialise in a type of therapy that even staunch proponents of the “all therapies are equally effective” camp acknowledge to be specifically effective (e.g., http://citeseerx.ist.psu.edu/viewdoc/download?doi=10.1.1.536.6948&rep=rep1&type=pdf): exposure therapy for anxiety. When people are seeking help for, say, a specific phobia (e.g., of needles, like a client I saw today), exposure therapy is more effective in improving the problem than other therapy approaches without regard to the many aspects that make that person a unique individual. What I generally experience on this site is rejection of the idea that the kind of therapy a practitioner provides for any type of client issue is of any importance whatsoever, because it’s all about the relationship. Bullshit. I have a practice full of clients who have seen many therapists whom they describe as kind, well-meaning, and unhelpful because they weren’t equipped with a scientific understanding of their clients’ particular type of problem and an approach to intervention based on our best available science. My needle phobic client today has seen numerous therapists who taught him to breathe deeply and relax when he gets an injection, which is precisely the opposite of what he should do (based on a scientific understanding of the problem) as this makes him more likely to pass out, which is precisely the problem. “Evidence-based” absolutely can be a hoax intended to make money, but it can also be a well-informed description of the kind of therapy that clients are desperate to find – and clearly prefer – but have great difficulty accessing, in part because of the belief among many therapists that whatever therapy they happen to be providing to their clients is as good as anything else because “technique” is irrelevant.
Quick follow-up: quote from above: “[Shedler] writes that the newfound meaning behind the “evidence-based” hype discounts patient values and perspectives as well as clinician judgment. When patients are not appropriately informed about the potential drawbacks and benefits to different forms of treatment, they cannot exercise informed choice. Further, clinicians encouraged to adhere to manuals rather than exercise clinical judgment are limited in the degree to which they can respond to client needs.”
Shedler obviously believes clients (or in his words, “patients”) do not value or prefer evidence-based therapies. He is wrong, according to research that has examined this issue. Turns out people want their therapy to be scientifically credible and shown to be effective in clinical studies, in addition to wanting a good relationship with their therapist. And therapists (like Shedler) tend to fail to appreciate this, and assume their clients share their own biases, which they appear not to share.
Here we go again. I’m not sure why MIA deems it useful to provide a platform for an outspoken psychodynamic therapist who argues that our most scientifically supported approach to therapy is not as good as his preferred long-term psychodynamic therapy which has far less evidence to support it. Within the field, Shedler is a hero to psychodynamic therapists who resent having their unscientific approach usurped by more evidence-based approaches. He is also not taken seriously by science-based psychologists who favor CBT because he misrepresents the state of the science and refuses to engage with his critics and counter-arguments to his ideas, of which there are many.
Interested readers can check out two of his blog posts at Psychology Today and in particular the comments sections, in which Shedler oddly fails to respond to any of his many critics who presented thoughtful rebuttals of his claim. Missing from the comments at the first link is a comment where I pointed out with some concern his failure to engage thoughtful critics – a comment he deleted.
Politifact posted an article titled, “No links between Ritalin and school shootings, as NRA’s Oliver North claimed” (http://www.politifact.com/truth-o-meter/statements/2018/may/22/oliver-north/no-connection-ritalin-school-shootings-nra/). It made it to the top page of Reddit politics (https://www.reddit.com/r/liberalgunowners/comments/8ldxls/no_links_between_ritalin_and_school_shootings/). Some quotes from the Politico article:
“The short answer is that this is nonsense,” said Katherine S. Newman, Torrey Little professor of sociology at the University of Massachusetts and author of Rampage: The Social Roots of School Shootings.
For Rampage, Newman and her fellow researchers studied medication as a precipitating factor in the school shootings that took place between 1970 and 2000. They found no evidence drugs played a role.”
“A minor percentage of school shooters studied had been medicated, not “many.” The notion that many have specifically been on the drug Ritalin since kindergarten has no factual basis. More broadly, causation has never been established between the medication and violence. We found no specific ties between ADHD medication and school shootings, either.”
When I worked at the Mayo Clinic, drug reps were everywhere, and they were invariably young, female, and attractive. I later read this article in the New York Times: https://www.nytimes.com/2005/11/28/business/gimme-an-rx-cheerleaders-pep-up-drug-sales.html. From the article:
“Anyone who has seen the parade of sales representatives through a doctor’s waiting room has probably noticed that they are frequently female and invariably good looking. Less recognized is the fact that a good many are recruited from the cheerleading ranks.
Known for their athleticism, postage-stamp skirts and persuasive enthusiasm, cheerleaders have many qualities the drug industry looks for in its sales force. Some keep their pompoms active, like Onya, a sculptured former college cheerleader. On Sundays she works the sidelines for the Washington Redskins. But weekdays find her urging gynecologists to prescribe a treatment for vaginal yeast infection.”
Institutional corruption in psychiatry helps to explain why Niall’s paper was rejected from Australasian Psychiatry; why David Nutt was trotted out to publicly defend the chemical imbalance theory following bad press for “antidepressants” in a New Zealand newspaper in the wake of the Mental Health in Crisis tour; and why the RANZCP promotes the mythical chemical imbalance theory in its public “education” materials. Psychiatry as an institution cannot be counted on for integrity (honesty) despite this being one of its core “values.” In reality, it has only one core value: self-defence. That’s why Psychiatry says psychiatrists always provide informed consent despite strong evidence to the contrary. That is what psychiatrists do because, well, that is what they must be doing if they have integrity. To acknowledge otherwise means psychiatrists do not practice ethically, and that can’t be true. Psychiatry says the chemical imbalance theory is accurate, despite a mountain of scientific evidence to the contrary, because it must be true. To acknowledge otherwise means psychiatry has been lying to society for decades, and that can’t be true. Antidepressants work because they must work. To acknowledge otherwise means 1 in 10 people have been convinced to take a drug that does more harm than good, and that can’t be true if Psychiatry has integrity. And so the bullshit continues, brought to you by an institution incapable of honestly examining itself, happy to peddle obvious untruths, and unwilling to acknowledge its shortcomings and act to correct them.
Niall, thank you for this great post! I attended the Mental Health in Crisis workshop in Sydney and it was fantastic. And given the institutional corruption you noted, the response was predictable. One response showed up here in this New Zealand newspaper story: https://www.stuff.co.nz/the-press/news/101845845/claims-antidepressants-dont-work-dangerous-doctors-say. In it, famous UK psychiatrist David Nutt had some interesting and provocative things to say. And so I took the liberty of trying to engage him in a discussion about his remarks. I’m copying and pasting our email exchange below in case anyone is interested. Like you Niall, I don’t like bullshit, especially the kind that does great harm to society. Keep up the great work. -Cheers, Brett
(Email to Dr. David Nutt from Brett Deacon)
Dear Dr. Nutt:
I read with interest this article from the Press (Christchurch, New Zealand): https://www.stuff.co.nz/the-press/news/101845845/claims-antidepressants-dont-work-dangerous-doctors-say. The article quotes your views on antidepressants and depression, and includes the following passage:
“There was “overwhelming evidence” supporting the view that mental health problems were caused by chemical imbalances in the brain…”It’s like the climate change debate. Some people do not want it to be true but there is a biological element. It’s not a myth. We know the chemistry of depression.”
I am a fellow scientist and practitioner with an interest in this topic. I am very interested in hearing from you what overwhelming scientific evidence shows depression and/or other mental health problems to be caused by a chemical imbalance in the brain. I’d appreciate any citations to specific studies you can provide that substantiate such a claim. Thanks very much for your time and consideration.
(Reply from Dr. David Nutt)
Maybe start with this book?
Dr. Nutt, thank you for your prompt response. I have not read that book, but I am a student of the literature in this area and have read numerous summaries of the research pertinent to chemical imbalance theories of depression and schizophrenia. My understanding from these reviews is that there does not exist clear evidence that a chemical imbalance is an established cause of any mental disorder. But I may be mistaken and was wondering if you were aware of specific studies that I am not that have established this finding. Is that the case?
(Email to Dr. David Nutt from Brett Deacon)
Dear Dr. Nutt:
It has recently come to my attention that Dr. Patrick McGorry, psychiatrist and former Australian of the year, has a different view of the chemical imbalance theory from the one you expressed. In an interview (http://www.abc.net.au/radionational/programs/lifematters/depression,-anxiety-and-the-pros-and-cons-of-antidepressants/9391218), he stated that the chemical imbalance theory was attributable to the “drug companies, the DSM, the FDA … American psychiatrists … 40 years ago … now no one believes that any more. If you talk to any modern researcher in neuroscience or psychiatry no one would say that is the explanation. But when you go to a GP or even some psychiatrists they will still trot out that very simplistic explanation to people.”
You claimed there exists “overwhelming evidence” that mental health problems are caused by a chemical imbalance in the brain, and that failure to acknowledge this is akin to denying the reality of climate change. Yet the esteemed Dr. McGorry expressed in no uncertain terms his opinion that the chemical imbalance theory is a scientific myth that is not taken seriously by researchers in this area. Dr. McGorry’s opinion is consistent with my understanding of the available scientific evidence, as summarised in the following articles:
In the United States where I am from, top psychiatrists have distanced themselves from the chemical imbalance theory, claiming that it was never taken seriously by thoughtful psychiatrists and scientists or promoted to clients. Here are some examples:
I am also aware that the media frequently and uncritically promotes the chemical imbalance theory (https://link.springer.com/article/10.1007/s12115-007-9047-3). This appears to have been the case in Cecile Meier’s The Press article in which you were quoted as claiming overwhelming evidence supports a chemical imbalance cause of mental disorders, a claim whose veracity was not questioned (https://www.stuff.co.nz/the-press/news/101845845/claims-antidepressants-dont-work-dangerous-doctors-say).
I have made an effort to promote thoughtful, scientific, and public discourse about topics like the chemical imbalance story of mental disorders (for example, see http://www.uw-anxietylab.com/uploads/7/6/0/4/7604142/biomedical_model_commentary.pdf and http://www.abct.org/docs/PastIssue/38n7.pdf). I believe this is important because misinformation abounds, and patients require access to accurate information in order to make informed decisions about their healthcare. I am concerned that your comments about the chemical imbalance theory in The Press article hinder this important dialogue through your promotion of a scientifically unfounded theory as established fact. But, as I noted in my previous email, you may know of scientific studies of which I and other experts in this area are unaware that do in fact establish that a chemical imbalance is a specific, sensitive, and replicable cause of one or more DSM-defined mental disorders, particularly depression which was the subject of your recent comments. In that case, I would be grateful if you could alert me to such studies. If not, I would appreciate hearing whatever justification you can provide for your claim, in contravention to the consensus of scientific experts on this topic, that the chemical imbalance theory is supported by overwhelming evidence.
I’ve copied Cecile Meier on this message (Hi Cecile!) as she may be interested in your reply. Thank you for your time and consideration.
(I never heard back from Dr. Nutt)
My observations from working with psychiatrists for years is that the typical sequence of “treatment” for depression looks like this:
1. Start the client on a SSRI, selected based on which company’s attractive young female drug rep has been the most influential lately.
2. When that doesn’t work, increase the dose. Repeat 2-3 times.
3. When that doesn’t work, add another drug, most likely an “antipsychotic” or “mood stabiliser.” If the client develops akathisia, add a benzo.
4. Indefinitely maintain the client on an experimental drug cocktail that can expand but not contract.
Steve, to answer your last question, I think the answer is usually “no.”
Steve, we are largely in agreement. Regarding “techniques,” they can be simply tools in a toolbox, or can be part of a unified approach that includes philosophy, theory, and strategy, and these two versions are very different. When I use exposure to help a client, I’m not thinking of it as a technique but as an entire therapy. A legitimate complaint about CBT as it is commonly practiced is that it involves a lot of techniques that might not be chosen that thoughtfully, sometimes contradict each other (e.g., simultaneously encouraging a client to face a feared situation while using controlling breathing to suppress anxiety), and are not clearly tied to a defensible theory that suggests the chosen techniques are necessary and effective. Anyway, my experience is that discussions of the value of “technique” vs. the relationship, when engaged in by people who prefer opposite sides, quickly become contentious and never get anywhere, so I think it best I bow out of this thread at this point.
Gerard, if you can’t agree that people can have the same *type of problem* then I’m afraid we’re so far apart there’s not much use trying to find common ground.
Don’t different people (each of whom is unique) sometimes have the same type of problem? And if so, isn’t it possible that this same type of problem can have specific causes/influences, and be addressed using a specific approach, that can benefit most who have the problem despite the fact that each of them is a unique individual? That’s not one size fits all in my book.
I agree therapy should always be individually tailored to each client. But I’m not reinventing therapy from scratch for each person, with no guiding theoretical assumptions to understand human psychological experience or familiarity with types of strategies that are useful for types of problems. Any therapist who does so has no business being credentialed.
I have seen far too many cases where therapists believed every client is a unique individual, rejected one size fits all therapies, had no theory or principles for making sense of their client’s experience, had no knowledge or strategies to convey, and tried to “relationship” their client out of a severe and chronic anxiety problem. That approach is what most clients on my caseload have tried time and time again only to find it make little to no dent on their concerns.
littleturtle, I have some resources that might help answer your questions about panic. Feel free to email me (http://www.illawarraanxietyclinic.com.au/contact.html) if you’d like me to pass them along to you.
I agree the relationship is critical, that people are different, and that therapy is more than a bag of tricks. I do also believe that for some types of problems, some therapy approaches are better than others. To illustrate, I’m currently seeing numerous clients who for years have been tormented by unwanted, intrusive thoughts of things like killing others, molesting children, etc. They find these thoughts abhorrent and are terrified they might one day act on them. All of these clients have seen numerous therapists in the past, who are described as generally nice, well-meaning, but also unhelpful. These therapists taught my clients mindfulness, breathing and relaxation techniques, and other superficial “skills” for managing their anxiety. In no case did a previous therapist directly address the core concern that the client might act on the thoughts. In our work, I use exposure therapy to address this concern and help clients learn through their own experience that thoughts are just thoughts, and that they will not act on their unacceptable thoughts even if they drop the safety-seeking behaviours they think are preventing them from doing so. Exposure in this case isn’t a skill or technique, it’s an approach that includes a specific way of understanding the problem and a specific way of addressing it. And there is good research to show that this approach is specifically and uniquely effective for this type of problem. So, I generally agree with the sentiments expressed in this comments section, but I will reiterate that context matters. There are circumstances where an empathic, well-meaning, intelligent therapist who genuinely tries to understand the problem and otherwise does most things right can utterly fail to help clients because they are using an approach that doesn’t adequately address the problem.
I don’t disagree with the general sentiment here but I will say that, for some types of issues, which approach a therapist uses matters above and beyond the characteristics of the therapist and client.
I’ve never understood how it makes sense to compare the effectiveness of different therapies across many different types of problems. This is like comparing the relative benefits of surgery and medication for medical problems. Which approach to treating medical problems works best? Surely the answer is, at least to some extent, it depends on the type of problem. I have no trouble believing there are psychological issues for which standard CBT is no better than one or more alternative approaches. But I’ll take CBT over psychoanalysis any day for phobias. Context matters.
Kristina, thank you for this excellent article! Your final point is so important – research like this benefits scientists but not society. The longstanding enterprise of studying the genetics of “mental disorders,” engaged in by thousands of scientists and funded by billions of dollars, has not benefitted a single “patient” through the development of innovative tests or interventions. Indeed, this research has principally affected society by contributing to the idea that psychological struggles are medical diseases with genetic causes, which creates stigma and discrimination and diminishes the lives of many. But the scientists who work in this area are richly rewarded with tenured professorships, grants, and prestige. The fact that their work has no societal benefit, and indeed will never have any (barring a miraculous discovery), is apparently irrelevant. It must be nice to work in the complete absence of accountability.
This study can be viewed as part of UCLA’s $500 million dollar “Grand Challenge” to rid the world of depression: https://grandchallenges.ucla.edu/depression/. This effort views depression as a disease, emphasises biomedical research to discover its “cause,” promptes biomedical treatments like ECT and ketamine, and seeks to reduce the “stigma” surrounding this “disease.” A press release (http://newsroom.ucla.edu/releases/combating-depression-is-uclas-second-grand-challenge) quotes a UCLA scientist: “Advances in technology for genetic research have now made it possible for us to discover the causes of depression,” Freimer said. “We know a genetics-based strategy will be successful, just as it has been with heart disease, diabetes and cancer. But finding the causes of depression is just the first step.”
Looks like we are once again on the verge/on the cusp/on the brink/on the threshold/facing a tipping point of transformative breakthroughs that will blah blah blah, you know the rest.
Oldhead, this is the most important point of all. The entire enterprise is based on the false premise that DSM diagnoses are medical diseases. Most people who work in this enterprise are incapable of questioning this premise or viewing psychological issues through an alternative lens. To them, there is simply nothing else they could be but diseases. No amount of fruitless scientific studies, or prolonged failure to develop more effective “treatments,” or wasted billions of taxpayer dollars, or worsening societal outcomes, is capable of giving rise to the thought that the entire paradigm might be based on a false premise. Excuses show up and protect the belief system, such as “we don’t have the scientific tools yet to find the causes we know exist,” and “mental disorders like schizophrenia are probably many different diseases with different causes.” In this way, the paradigm is self-perpetuating. Its failure to succeed is taken as evidence that it needs further resources in order to succeed.
From the article: “The identification of shared structural variants underlying the five neuropsychiatric disorders helps to refine the genetic basis for co-morbidity and co-occurrence of neuropsychiatric diseases among individuals or families has the potential to help in the development of common therapeutics of shared genetic targets across different diseases.”
I’d LOVE to hear how identifying a gene variation found in 0.5% of these “disorders” can lead to the development of effective “treatments” for them. Such claims frequently appear in articles like this, always without any explanation as to how this might actually happen. Decades of genetic research has got us basically nowhere in identifying causes, but even if causal genes were found, this wouldn’t mean we could successfully treat them. For many conditions (Huntington’s disease), longstanding knowledge of a genetic cause has not produced curative treatment.
Peter, thank you for this excellent critical review! Seriously, great work, I’d love to see more posts like this at MIA. Your analysis highlights the absurdity of what passes for the highest level of genetic research into “mental disorders.” It seems clear the entire genetic research enterprise as it relates to “mental disorders” is incapable of benefitting society or anyone in it other than the scientists who receive resources (jobs, grants, prestige) for doing this work. It amazes me that the scientific community takes this stuff seriously anymore.
I can see this conversation is going nowhere as you are apparently unable or unwilling to address the issue I raised and seem intent on mischaracterising my position and attacking my logic. Goodbye.
Au Valencia, you are wrong, I do not in fact “believe that any difference from the norm is an illness, injury, or otherwise.” And back to my original post, the label “neurodiverse” suggests the autistic brain is different from the non-autistic brain. How is it different from the norm? Does reliable scientific evidence indicate that autism is associated with or caused by reliable, specific, and large-enough-to-be-meaningful brain differences? If so, I’d be very interested to learn about this research. If not, why describe autism as a different brain? This was my original question and I’d appreciate hearing your answer.
Frank, DSM-5’s rebranding of “mental disorders” as “neuropsychiatric disorders” comes to mind as a prototypical example.
Au Valencia, how does labeling autism as a brain difference (neurodiversity) not an example of biomedical language? I suspect I am not the only one who reads “neurodiverse” and hears “associated with or caused by an abnormal brain.” I appreciate you may not view it to mean or even imply this, but I imagine such an implication would be clear to many others.
This has been an interesting discussion to follow. One question I have concerns the label of “neurodiverse.” I understand that people diagnosed with autism could be said to have different “minds” (thoughts, feelings, and behaviours) than those not so diagnosed. But as I understand it, autism is not associated with reliable, specific, and large-enough-to-be-meaningful brain/genetic differences, as recently described by Sami Timimi. Given this, my question is, why advertise autism as brain difference (neurodiversity)? A major theme here at MIA is criticism of the central assumption of the biomedical paradigm, namely that psychiatric diagnoses are medical diseases, and the ways in which this assumption manifests via the use of biomedical language to describe psychological experiences. Isn’t describing autism in terms of “neurodiversity” an example of this? Thanks for considering my comment, I look forward to any feedback on these issues.
I am pleased to learn of this Washington Post article highlighting the off-label use of seroquel/quetiapine, particularly for sleep. I see it all the time in the clinic. I know a child psychiatrist who hands out quetiapine like candy to young teenagers. About 1/3 of the clients referred to me by psychiatrists are taking this drug and have not been informed about the possible adverse effects, lack of scientifically established benefits for sleep, and expert recommendations not to use it for sleep (http://www.ndshp.org/Resources/Documents/Quetiapine.pdf). My clients typically say the drug knocks them out at night and that they awake feeling tired, groggy, and cognitively impaired, and that these effects take hours to wear off. Failure to provide even basic information to clients about established risks and benefits of a drug is an ethical violation yet appears to be standard practice. My experience in the clinic is consistent with Chaya Grossberg’s lesson learned #1 (https://www.madinamerica.com/2018/03/10-things-learned-people-coming-off-psych-drugs/): “No one gets on psychiatric drugs with informed consent.”
The myths are alive and well. The functions they serve are too valuable to allow a lack of scientific support to usher them away. Better to dismiss the lack of scientific support or pretend it doesn’t exist.
Rob, I couldn’t help myself from spending some time on the RANZCP’s Your Health in Mind website. Here are some things I learned in addition to the quote you posted stating that psychiatric drugs “work by rebalancing the chemicals in the brain.” The quotes below struck me as the most egregious contradictions between the flattering picture painted in the website and scientific/clinical reality. I offer them below without commentary:
1. Psychiatrists provide fully informed consent (https://www.yourhealthinmind.org/psychiatry-explained/whats-a-psychiatrist). For example, they “will only suggest treatments that are proven to be safe and effective.” For treatments they choose, they will explain: “why they recommend this treatment…how it works…what the side-effects are…any risks of the treatment…how much it costs. It’s up to you whether you agree to have the treatment.”
2. “In people with ADHD, there are differences in the parts of the brain that control our ability to plan, organise and focus” (https://www.yourhealthinmind.org/mental-illnesses-disorders/adhd-in-adults)/
3. “We know that bipolar disorder changes how the brain works, and this causes symptoms of mental illness.” (https://www.yourhealthinmind.org/mental-illnesses-disorders/bipolar-disorder)
4. “Newer antidepressant medications work by altering the amounts of natural chemicals in your brain, such as serotonin or noradrenaline.” (https://www.yourhealthinmind.org/treatments-and-medication/antidepressant-medication)
5. “ECT is safe, painless and very effective in treating depression” (https://www.yourhealthinmind.org/treatments-medication/ect). “It’s safe and there are few side effects…The risks are similar to any minor medical procedure given under general anaesthetic.” Adrian, an ECT patient, is quoted: “I’ve had severe depression for 16 years. Any short term memories I lose to get rid of that never-ending, crushing feeling of hopelessness and sadness are worth it, in my opinion.”
6. Regarding psychiatric hospitals (https://www.yourhealthinmind.org/treatments-medication/psychiatric-hospitals): “Sometimes a mental illness can become so severe that the person with the illness may not even realise they are unwell. If someone is so sick they don’t understand they need treatment, and if not having the treatment would put them (or others) in danger, the law allows that person to be treated involuntarily. This means they can be kept in hospital (if necessary) and treated, even though they say they don’t agree to it. To make sure this only happens when it’s absolutely necessary, the law requires that doctors present a case for this in front of a tribunal (or, in New Zealand, a judge)…Seclusion and restraint are a last resort where all other options to keep people safe have been tried or considered. Both should be very rare. The RANZCP’s position is that the use of seclusion and restraint should be reduced and where possible removed entirely.”
According to this study (https://www.ncbi.nlm.nih.gov/pubmed/23357658), changes of three points or less on the HAM-D correspond to ratings of “no change” on clinician‐rated global symptom severity.
I’m sure the World Psychiatric Association’s statement banning psychiatrists from torture will comfort Garth Daniels (https://www.madinamerica.com/2016/05/psychiatry_garth_daniels/), who for years has been secluded, restrained to a hospital bed for months at a time, forcibly injected with psychiatric drugs, and forcibly given ECT. According to the WPA’s statement, psychiatrists can torture clients like Garth to their heart’s content provided it is “intended for therapeutic benefit.” As long as psychiatry defines torture according to the intent of behavior (tying a non-violent client to a hospital bed for 6 months and repeatedly shocking his brain without consent “for his own benefit”), as opposed to actual behavior that grossly violates a client’s civil rights regardless of its therapeutic intent, torture will continue to be endemic in the mental health system.
In response to the petition described above, a new petition has been launched by those who support the APA’s PTSD treatment guidelines: https://www.thepetitionsite.com/en-au/takeaction/780/537/970/. I signed it and wrote the following:
I support the APA’s PTSD treatment guidelines. Our most science-based, demonstrably effective therapies for PTSD should be the standard of care. It is impossible to publish science-based guidelines without upsetting those whose favored therapies are not recommended. This is the price we must pay to claim scientific credibility as mental health professionals. The alternative petition is titled, “Protect PTSD Treatments That Work!” That title is ironic given that this alternative petition seeks to retain the favored status of therapies that lack sufficient scientific evidence, while the APA’s guideline advocates science-based therapies with proven effectiveness. I support the APA’s guideline because I wish to protect treatments that work!
This article notes, again and again, that “antidepressants” induce mania. At least the psychiatric establishment now openly admits this. But it’s fascinating, in a pathetic and frightening way, to see where the profession takes this observation. Antidepressant-induced mania, a toxic drug effect, is viewed by psychiatrists paid to act as spokespersons for drug companies as evidence of “mental illness” that should be treated with “antipsychotics” that produce additional, worse adverse effects. This is a brilliant strategy from the perspective of pharmaceutical company shareholders seeking to maximise their investment, and for the guild interests of psychiatry. But for the poor people whose antidepressant-induced mania leads to the use of additional and more toxic psychiatric drugs…well, the whole clinical guideline enterprise isn’t really about them, is it? The authors can add another line on their CV, confident that their publication will be highly cited and they will be viewed by their peers as key opinion leaders.
Zoe, may I ask how your iatrogenic “bipolar” came about?
Robert, thank you for this excellent and provocative article. What passes for “integrated care” is generally pathetic. My experience has been that integrated care means psychiatrists make decisions that “allied health professionals” (such as psychologists, social workers, peer support workers) are required to support. The latter can occasionally say a few words that offer a different perspective, but they are generally of little relevance or impact, and often only have an opportunity to be expressed after the psychiatrists’ decisions have been implemented as when “medication,” ECT, and so on have already begun. Such care is “integrated” only in the sense that multiple professionals are theoretically able to chat to each other about it. That is a superficial and fairly meaningless way of operationalizing “integrated care.” Though I imagine this version of integrated care is held in high esteem by psychiatrists who can use it as evidence of their commitment to teamwork, patient-centered care, holistic treatment, or (insert your own meaningless buzzword or phrase here).
When I was a professor, the introductory psychology students would complete a series of online screening questionnaires at the beginning of the semester for course credit. Their responses were sometimes used by researchers to select students who scored above a certain threshold on a particular questionnaire and invite them to participate in a study. For example, students who scored above the “clinical cutoff” on a depression questionnaire might be invited to take part in a depression study a few weeks later.
But there was a recurring, significant problem for the researchers. Many who scored above the clinical cutoff during the initial screening scored in the normal range when they showed up for the study a few weeks later. Maybe half were no longer eligible to participate. Their initially extreme scores had normalized. Perhaps they were having a bad day when they completed the screening measure. Perhaps they were distressed due to a transient stressor that had improved. In any case, it’s a well-known empirical fact that extreme scores tend to be less extreme when measured later. It’s called regression to the mean.
Imagine if we took everyone who scored above a clinical cutoff score on a depression questionnaire at an initial screening, ignored what was happening in their life, concluded they were “mentally ill” based on their score, and “treated” them with “antidepressants”? How many people who would have otherwise naturally improved would be prevented from doing so? Perhaps the massive increase in chronic, disabling, “treatment-resistant” depression during the antidepressant era provides a clue?
Robert, thank you for this provocative article. If the entire mental health system is to be abolished, to the steps you listed, one would have to similar steps for the other mental health professions beyond psychiatry. This would mean closing all training programs, de-registering all practitioners, abolishing all organisations, etc. in fields such as psychology, social work, counselling, marriage and family therapy, and even (paid) peer support work. If it seems likely such steps would not happen with psychiatry, it is even more likely they would not happen with all mental health professions combined. I understand how those who wish to abolish the entire mental health system might react negatively to the tone of Robert’s article. At the same time, I think his analysis can provide some insight into how those with a different agenda might react to calls for the abolition of the entire mental health system and all who practice within it (such as the quote Robert listed by Tireless Fighter), even those whose work does not follow psychiatry’s biomedical paradigm.
Thanks, Sera. Here is a recent example (of many) of how it can be difficult to be in a clinical role and oppose the biomedical paradigm. I was recently informed by a psychiatrist that because I am not a medical doctor, lack their medical knowledge and expertise in psychopharmacology, and lack their clinical experience using psychiatric drugs with clients, I am not qualified to say anything to clients about their drugs. For example, I am not to point out the possibility that their experiences (e.g., sexual dysfunction, blunted emotions) might be drug effects or inform clients about what the science shows regarding the safety and effectiveness of the drugs they take. I am not to say anything that could possibly be construed as “undermining medical treatment.” In theory, this could lead to a complaint being filed by an offended medical doctor, an investigation, and disastrous consequences for my career.
It’s all well and good for me to be knowledgeable about psychiatric drugs and even to publish scientific articles on them, but I cannot share this knowledge with my clients because, as a non-physician, I am not qualified to “interpret” how to apply scientific knowledge about psychiatric drugs to individual clients. Only medical doctors, by virtue of their expertise and experience, can do so. The basic idea here is that a treatment is a good treatment – by definition, and regardless of what that treatment entails – if it is provided by a medical doctor.
If I understand there to be a potential problem with a client’s psychiatric treatment – such as clear “antidepressant”-induced mania being diagnosed as “bipolar disorder” leading to a drug cocktail the client hates – I’m told I should encourage the client to talk to their doctor. This would be the same doctor who thought it was good medical practice, in the example above, to interpret antidepressant-induced mania as the unmasking of latent bipolar disorder, prescribe an “antipsychotic” and “mood stabilizer” in addition to the “antidepressant,” inform the client he is mentally ill and will need to remain on these drugs for the rest of his life, and dismiss the client’s reservations about the diagnosis and treatment. I’m pretty sure I know how such a conversation would go.
Richard’s quote resonates with me: “So in the final analysis, it does not fundamentally matter how much we expose the faulty science and oppressive forms of treatment and build resistance in numbers, Psychiatry and their Medical Model has become TOO BIG AND IMPORTANT to be allowed to fail in the current order of things.” In the clinic, it’s difficult to even expose clients to accurate information in the first place, let alone build any sort of momentum for resistance to the biomedical paradigm. Only medical doctors are apparently able to communicate with clients about their medical treatment. Psychiatry polices its members carefully and doesn’t tolerate dissent, so this ensures faith in the biomedical paradigm will remain strong without regard to the science reviewed in Anatomy of an Epidemic.
Sera, I have missed your writing and am glad to hear from you again. I’m not sure what to say other than thank you for the work you do, both in your peer work and as a writer here. I’ve always found your writing inspirational, and it’s clear your clients (as a peer worker) and family (as an informed person who knows what’s what regarding “mental health” information taught to your kids) are lucky to have you. I am sorry to hear of your exasperating experiences, but I am not surprised given their familiarity to me as a psychologist who opposes the biomedical model. I want to thank you for the inspiration you have provided to me, and I hope I can translate your influence into helping others. Thank you, Sera!
Lawrence, thank you for another thoughtful contribution. I enjoy your writing and always appreciate what you have to say. As you noted, there is no definition of “mental illness” or “mental disorder” that can withstand even mild scrutiny. No explanation of “mental illness” or “mental disorder” as a syndrome, illness, or disease holds up on either logical or scientific grounds. If we abandon the notion that psychological issues are medical illnesses, then how are we to think about them? I appreciate your take on this. I understand how conflicts between the individual and society, compounded by capitalism, can fuel psychological struggles. But I also think psychological struggles are so varied and sometimes so unique to the individual that there’s no grand theory that can be reasonably applied in any general way to the kinds of psychological issues that can be diagnosed using the DSM. For example, I have clients who pull their hair and pick blackheads on their skin, and are seeking help because they are distressed by the negative effects on their appearance. I have clients who are afraid of panic attacks that they think will cause them to have a heart attack and die. I have clients who have been catastrophically injured in car accidents who now cannot work or play with their kids. There are some social conflicts there, but also a lot of individual psychological concerns.
You wrote that “mental illness” is “nothing more than a concept that evolved to serve a specific societal purpose/function.” Totally agree. And I agree that it’s important to understand what that function is, and we can use different lenses to do it. To me, there are two obvious functions served by promoting the concept of “mental illness.” First, by construing diagnoses in the DSM (published by the APA) as mental illnesses, psychiatry appears credible as a medical specialty and can claim domain over “mental health” and the drugs used to “treat mental illness.” Second, construing psychological issues as “mental illness” provides a rationale for the use of psychiatric drugs to “treat” them, which funnels billions of dollars to the pharmaceutical industry. Personally, I don’t think we need to look much beyond these two functions to explain the popularity of the “mental illness” concept today.
Gotcha, thanks for clarifying.
That is the main point of the blog, yes. I took Stephen’s main point to be that it’s not just psychiatrists, general practitioners also hand out psychiatric drugs or you prefer neurotoxins as if they’re candy. I’m not aware that I said anything against of these points. I initially posted to clarify that with a few highly circumscribed exceptions, psychologists/psychotherapists are not doing the prescribing.
Many GP’s here do indeed hand out antidepressants and other psychiatric drugs (like benzos) easily and often. In the Australian healthcare system, a referral from a GP or psychiatrist is required for people to have Medicare pay for their sessions with a psychologist. Almost every client who sees me sees a prescriber first. Many of them are prescribed psychiatric drugs by their GP as part of the handoff to a psychologist. An even higher percentage referred by psychiatrists are given drugs, often drug cocktails. The price many Australians pay to access a psychologist is to first meet with a medical doctor who unnecessarily prescribes one or more psychiatric drugs. I can’t even imagine the societal cost, financial and otherwise, of organising a healthcare system this way.
Quick point of clarification regarding your comment, “Most neurotoxin prescriptions are being given out by psychologists and psychotherapists, not psychiatrists. These psychologists and psychotherapists want this prescription capability because it adds to their professional status, and to their fees.”
Exceptionally few psychiatric drugs are prescribed by psychologists/psychotherapists. Prescriptive authority for psychologists is legal only in New Mexico, Louisiana, and Illinois, and only for specially trained psychologists in those states. The Illinois statute requires so much training that it’s likely no psychologist will ever bother to complete it. Although the American Psychological Association has been aggressively lobbying for prescriptive authority for decades, their campaign has been a spectacular failure, and many psychologists are opposed to prescriptive authority.
It’s certainly true that “These psychologists and psychotherapists want this prescription capability because it adds to their professional status, and to their fees.” But > 99% of prescriptions for psychiatric drugs in the US are not written by psychologists/psychotherapists. Here in Australia where I live now, no psychologists/psychotherapists can prescribe and I would be shocked if that ever changes.
Danielle, thank you for this excellent article! There is much to be disturbed about here. I read the study abstract (http://www.thelancet.com/journals/lanpsy/article/PIIS2215-0366(17)30371-1/fulltext) and noted the authors concluded “This study confirmed the safety and feasibility of subcallosal cingulate DBS as a treatment for treatment-resistant depression,” in the very sentence after observing “28 patients experienced 40 serious adverse events; eight of these (in seven patients) were deemed to be related to the study device or surgery.” This is troubling given that the abstract is the most read and most influential part of scientific articles.
What I find most troubling is that, as you chronicled, it appears the study investigators have either incompetently measured or fraudulently modified the data regarding adverse effects of DBS. This means the raw data themselves are inaccurate. Therefore, the statistical analyses and conclusions based upon these data are necessarily inaccurate. This includes the analyses and conclusions in this study, and in all subsequent systematic reviews and meta-analyses that include data from this study. It also includes the clinical guidelines that will be drawn up based in part on findings from this study. Inaccurate data such as these have the potential to eventually affect the lives of thousands in society.
We have seen this before in studies of SSRIs in depressed children and it has poisoned the literature and prevented society from accurately understanding the true effects of the drugs. It’s incredible how deep this scientific problem cuts. It’s not just that positive studies are published and negative studies are not (publication bias), or that authors spin their interpretation of the findings to make the results appear more positive, it’s that the very data themselves are fudged. I think it’s time scientific journals seriously consider whether industry-funded trials of medical products are sufficiently trustworthy to merit publication.
I ran a quick news search and found this article on DBS for depression that describes results of the trial: http://nationalpost.com/news/canada/could-an-experimental-brain-surgery-make-you-happier. I’ll end by posting the last three paragraphs, which speak to how these findings have been spun and fit the broader biomedical narrative (FYI, Kathryn is a client who received DBS). In this narrative, a demonstrably ineffective and somewhat harmful surgical treatment for depression is cause for hope, helps destigmatize mental illness, and is part of the march of progress toward revolutionary new medical treatments. Sound familiar?
“For now, DBS remains an experimental surgery. While it is reserved for the most severe cases of depression, Kathryn refers to the power that comes from just knowing that something like DBS is out there, and that other potential new solutions are emerging, such as genetic testing and new medications inspired by the drug ketamine.
DBS, because it’s a surgery, also has the opportunity to further destigmatize mental illness, said Dr. Giacobbe, “by showing people that a physical intervention can help an emotional disorder.”
In the meantime, while we wait, we have hope. And for those struggling, hope remains a most powerful medicine.”
Steve, you’ve changed the subject. This is an interesting topic though and I imagine we have similar perspectives on it. For my benefit, I’d be interested in seeing the studies you noted that show similar or better outcomes with para-professionals or untrained peer counsellors compared to professionals.
If a person who is struggling psychologically seeks the help of a credentialed psychologist, and visits that psychologist at his or her office, is this an inherently medical paradigm? Does calling the office a “clinic” make it so? Perhaps the answer depends on what we mean by medical paradigm. If by medical paradigm we’re simply referring to a person seeing a credentialed member of a helping profession in a professional setting and paying that professional for services, then sure, clinical psychology is part of a medical paradigm along with every other profession associated with the healthcare system. But to me, there is a critical difference between this general medical paradigm and the biomedical paradigm of psychological struggles, in which they are diagnosed with a DSM label, framed as mental illnesses, assumed to be the products of biological dysfunction, and treated with psychiatric drugs. The authors referenced in this blog post reject this biomedical paradigm. But yes, they are part of the general medical paradigm described above. If you reject the notion that it is acceptable for people who experience psychological struggles to voluntarily seek help from a credentialed professional like a clinical psychologist who is paid for services rendered, I’d be interested in learning why.
The clinical is there to distinguish this type of psychology from other varieties such as social, developmental, industrial/organizational, and the like. I take “clinical” to denote applied work in “clinical” settings like hospitals, community clinics, etc.
I think “clinical psychologists” don’t necessarily come with a “medicine/disease/treatment” framework. People like Lucy Johnstone and Peter Kinderman, who contributed to this approach, don’t operate from this framework. Of course, they do work in a system in which they work with people who are seeking help for psychological problems, and get paid for doing so, but it’s possible to do this work in my view without operating from oppressive principles and assumptions. It can be difficult because of the rules of the system, but it is possible.
Richard, I really appreciate your response. I agree with you that “scientism” is a problematic term. You’ve helped clarify my thinking about this. I’ll stick to more clear terms like “pseudoscience.” On that note, I also think it makes more sense to apply a term like pseudoscience to specific ideas and practices rather than professions. It makes no sense to say psychology is a pseudoscience, for example, because much of what counts as psychological knowledge is in fact scientifically established via credible and replicable research. But psychology, particularly its clinical practice, is also chalked full of bullshit, and it is useful to call it out as pseudoscience.
Hi Richard. Great comments. Although I greatly admire Dr. Timimi and his blog post, I share your concerns about the term “scientism.”
For me, this term is complicated. My own history with it is that this term has been used by psychoanalysts, with whom I’ve previously attempted a friendly but critical dialogue, to complain that science-based criticisms of their approach, which is scientifically unsupported, is a product of scientism. Their argument was that their approach was good because their “clinical judgment” said it was good, and that science-based critiques of their approach were unfairly biased due to the false belief that scientific evidence is a uniquely useful source of information (i.e., “scientism”). Those making this argument demonstrated little awareness of the limitations of clinical judgment, including its historical use as the primary source of “evidence” supporting discredited “treatments” like bloodletting, lobotomy, insulin coma therapy, and so on. Science, when used properly, is an effective tool for cutting through bias and revealing the truth regarding matters of objective reality, such as the effects of pharmaceutical interventions. This makes science essential, and I agree with you that we need more science, not less. You said it well, “And you can’t be “too scientific” when trying to understand and transform the world into a more humane place to live.”
The flip side is that it’s difficult to be a staunch proponent of science given the many ways in which the enterprise has been corrupted. A great deal of our science isn’t worth the paper it’s printed on. Guild interests, financial interests, and perverse incentives that encourage scientists to publish biased results have corrupted the scientific literature. This is unacceptable on many levels and is good reason to mistrust science, which as a scientist myself I do a great deal. Personally, this corruption of science infuriates me, because not only does it do society a disservice, but it gives those who wish to discredit faith in science as “scientism” good reason to do so.
I suppose it comes down to the need to conduct a critical analysis of science, and to subscribe to scientific findings that are credible, to expose those that are not as pseudoscientific, and to call out the promotion of bad science as fact as scientism. And on that note, I fully agree with Dr. Timimi that much of what is currently considered by society, professionals, and clients as valid psychiatric theory and practice is based on scientism. I could say the same for much of what is currently practiced in psychology, social work, counselling, and other non-psychiatric mental health professions.
Scott wrote, “In short, this MDMA study has the far-reaching implications that will transform mental health care and our view of the human psyche.”
That would be a truly incredible development. But as we all know, near-identical statements have been offered time and again about novel somatic “treatments” in the history of psychiatry (e.g., lobotomy, insulin coma therapy, ECT, neuroleptics, benzos, SSRIs, etc.) Near-identical statements are now being offered regarding ketamine for depression. Given the 100% historical failure rate for such statements to come to fruition, Scott, you can surely understand skepticism of your expansive claims about MDMA and trauma.
As a scientist, you of all people should know not to make statements about the revolutionary, transformational effects of a treatment until one has data to support such an assertion. Such data do not exist in the case of MDMA and PTSD. Some promising data has been published from small sample size, uncontrolled pilot studies. I agree with you these data are encouraging and warrant a larger randomised controlled trial. I look forward to seeing the results.
Until the results are available and properly vetted by the scientific community, I will have an attitude of open-minded skepticism toward MDMA for PTSD. I remain open to the possibility that MDMA will “transform mental health care and our view of the human psyche.” But I am extremely skeptical of this claim, and rightly so, and I am under no obligation to take your claims seriously until you have data to back them up. This is how scientists are meant to think – the burden of proof rests on the claimant.
By the way, how will you possibly conduct an adequately blinded trial of a drug whose effects are immediately and extremely obvious to those who take it? Will you be measuring the blind by asking clients and assessors to guess which pill the client is taking? If not, how is this methodological choice justifiable? If you do assess the blind and fail to show your study is adequately blinded, isn’t this a fatal confound that renders the results uninterpretable?
Frank, I couldn’t agree more.
Steve, I must admit that I took my definition from Wikipedia, which seems to capture what most sources say about what defines a syndrome: https://en.wikipedia.org/wiki/Syndrome. I’d always thought of a syndrome as a collection of signs/symptoms, but it turns out that’s apparently the first half of the definition. I think it’s also important to put “symptoms” in quotes as you did because a lot of what we call “symptoms” constitute normal experiences and, unlike a fever or sore throat, don’t represent a departure from normal, healthy functioning. I never use the word “symptom” in my practice unless I am specifically critiquing the misguided notion that unwanted psychological experiences constitute “symptoms” caused by an underlying “illness” (or syndrome).
Frank, I get where you’re coming from and share your disdain for forced treatment and related human rights violations, and the role non-psychiatric “mental health” professions have played and continue to play in a system that allows such violations to occur.
Frank, I am a psychologist. Can you clarify what you are saying regarding my role? Am I a partner in the same business as psychiatry? Should we abolish psychology?
A syndrome refers to a collection of signs or symptoms that consistently occur together and represent a disease process or medical condition. Obviously, no DSM mental disorder represents a scientifically established disease process. Regarding signs and symptoms, a valid syndrome is one where a given collection of signs and symptoms can be shown empirically to reliably occur together, and to be distinct from other syndromes. As far as I know, schizophrenia (like other DSM diagnoses) is not a valid syndrome in the scientific sense and thus represents a “presumed syndrome.” I think by referring to DSM diagnoses as syndromes that are implicitly assumed to be scientifically valid, we give them undue credit as scientifically legitimate.
Steve, I agree that it is indeed incredible. I understand how this is possible if one holds 2 assumptions: (1) benzos (and other psychiatric drugs) produce few if any real adverse effects, and (2) any “symptoms” that emerge following starting a drug, changing its dose, or discontinuing it represent latent “mental illness” that has been “unmasked.”
I recently saw a young man who became depressed and was prescribed fluoxetine (Prozac). He immediately experienced “severe agitation and insomnia,” which are well-known adverse effects of this drug. After these “symptoms” didn’t improve on Xanax, discontinued Prozac, another antidepressant, and an antipsychotic, he was referred to a highly biomedically-oriented psychiatry clinic where he was diagnosed with bipolar disorder. The psychiatrists’ report reads, “In hindsight, he had experienced an irritable hypomania associated with the antidepressant which unmasked a latent bipolar disorder.” The client now believes, based on what he has been told by psychiatrists, that he is mentally ill due to a malfunctioning brain with a chemical imbalance, and will need to be on medication for the rest of his life. He is hopeless and suicidal due to the belief that his life is basically over and that his former goals are not unattainable.
Hi Igor. Good question. To me, credible psychological approaches are based on scientifically supported theories about the problems they address and have evidence of effectiveness in well-designed clinical studies. I’m well aware that science is not perfect, but despite its flaws there are a number of approaches that are clearly credible and effective, like the one I specialise in (exposure therapy for anxiety). Science-based therapies are described in further detail at the links below, the first one for adults and the second for youth.
Dear Eve: Thank you for writing this courageous post. I’m glad to have you with us.
You’ve received a lot of good responses already, some supportive, some critical. I do question your version of psychiatry’s “good old days,” as others have done, and add the observation that psychoanalysis deserves rich criticism for many reasons including its basis in pseudoscientific ideas and dearth of evidence to support its effectiveness. You wrote, “Not that long ago, our work involved stepping into the deepest recesses of our patients’ worlds, and partnering with them to find healing and transformation.” That may be true, but it must be said the psychoanalytic approach to healing and transformation was fundamentally misguided, which helps to explain why it has faded away. In the latter half of the 20th century, psychiatry transitioned from pseudoscientific psychotherapy to pseudoscientific polypharmacy while largely ignoring credible psychological approaches to understanding and alleviating psychological problems.
You wrote: “I never expected to have to worry that the tool bag I was being given to do my job would be full of rusty implements and ineffective potions. I never thought I would be pushed to do things that had the potential to harm, or even kill people. But today I know that our drugs can do that. As the curtain has been pulled back, and the ghoulish nature of the pharmaceutical universe revealed, I have felt completely overwhelmed and personally challenged.”
I’m pleased you now see what is behind the curtain. As you know, the evidence described by Robert Whitaker in Anatomy of an Epidemic (and detailed in many other places) has been available for decades. Given this, I’m curious how you have only recently come to the realization that your tool bag is full of “rusty implements and ineffective potions.” How is it possible that you were not aware of this all along? Wasn’t it important to you to understand the scientific evidence regarding the “treatments” you provide every day?
You wrote, “One’s professional organization should be the bulwark against which we can all stand for support of our best efforts. But the whole field has gone mad. And we psychiatrists, and our patients, have been the victims.”
I implore you not to cast yourself, and your fellow psychiatrists, as victims in the same breath where you acknowledge providing “treatments” that have “the potential to harm, or even kill people.” I understand where you’re coming from, but the real victims here are those in society who have been harmed by psychiatry’s biomedical paradigm (and before that, psychoanalysis and a host of barbaric somatic treatments).
Peter, thank you for your amazing work and this insightful blog post. I agree with the proposed strategy articulated in your final paragraph and am working on it in my professional of psychology. It occurs to me that if psychiatry were to abandon the assumption that psychological struggles are brain diseases, its identity and reason for existence would dramatically change. This leads me to a question for you: if we somehow succeeded in convincing psychiatry that psychological struggles are part of the human condition and not brain disease, what would that mean for psychiatry? It’s not clear to me that psychiatry would have a role to play or reason to exist. And I imagine many psychiatrists would recognize this possibility and as a result remain closed to even the most compelling arguments and data we might offer. As you know as well as anybody, this seems to have been the case for the past 4 decades. Do you truly believe your proposed strategy – to persuade psychiatry to abandon its biomedical model by arguing that psychological struggles are part of the human condition and not the product of brain disease – can work?
Steve, I had this same thought, and I’m embarrassed it took so long into my career to appreciate this reality. Overdiagnosis presumably means diagnosing people as having a given condition who do not actually have it. But mental disorders are purely subjective as you say, and are not “things” people “have” but labels they are given that say more about the professionals who give them than the people who receive the labels. There is no overdiagnosis of “mental disorders,” just diagnosis. Use of the term “overdiagnosis” implicitly protects the validity of the mental disorder concept by making it appear that they are valid conditions that some people actually “have,” and that good practice involves skill in discriminating those who do and do not have these conditions. I have heard psychiatrists like Allen Frances and Jeffrey Lieberman make this point many times. I will do my part to vigorously question the notion of “overdiagnosis” to combat this false narrative.
“I can’t unsee it and i can’t hear anything else she has to say.” Well said, couldn’t agree more.
Phil, thanks for yet another fantastic, critical, and devastating post!
I have been following the evolution of the “bereavement exception” over time as well as was particularly interested to see how it was treated in DSM-5. During the lead-up to DSM-5, the APA’s website had documents describing rationales for proposed revisions. The mood disorders group clearly wanted to get rid of the bereavement exclusion so grieving people could be diagnosed with “Major Depressive Disorder” and treated with psychiatric drugs. Speaking for the group, psychiatrist Kenneth Kendler wrote, “The DSM-IV position is not logically defensible. Either the grief exclusion criterion needs to be eliminated or extended so that no depression that arises in the setting of adversity would be diagnosable.” As you noted, for a variety of reasons (political, ideological, financial), they could not acknowledge that psychological struggles can be caused by adversity. And so they concluded, once again, that context is irrelevant. If you’re depressed, you should be diagnosed regardless of what has happened to you. If there were any doubt left about the reality that psychiatric diagnoses are context-free, removal of the bereavement exclusion in DSM-5 has dispelled it.
You noted that all the DSM-IV mood disorders work group members had financial ties to drug companies. For DSM-5, 8 of 11 had financial ties, including 6 whose conflicts were ongoing during the time the committee met. Importantly, some of them had conducted industry-funded research on antidepressants for bereavement.
In the UK, it has become popular practice to “screen” for clinical depression using the PHQ9, which is a DSM symptom tick box questionnaire. Like the DSM, it counts “symptoms” and ignores their context. Doctors are encouraged to diagnose and treat people who score above the clinical cutoff. As this article describes, antidepressant prescriptions have doubled in the past decade: http://www.dailymail.co.uk/health/article-3674994/England-s-depression-crisis-Antidepressant-prescriptions-double-decade-costing-NHS-780-000-DAY.html.
Lastly, I’m pleased to see you critique the words of Dr. Pies, which are always seemingly intended to warmly justify whatever it is psychiatrists do. His message here seems to be this: “Patients are too stupid to understand why they are depressed. Psychiatrists know best.” From this condescending position, cloaked in the veneer of science, Pies and his ilk feel free to deem their “patients” mentally ill by counting “symptom” checkboxes and ignoring their psychosocial context.
Wow. BetterLife, thanks for this excellent peer review of the article. I hadn’t read the entire thing, but your post lays bare the obvious fact that its publication was a failure of peer review. It’s incredible that a study with such obvious methodological flaws was published in a peer reviewed scientific journal.
I am so sorry to hear about this tragedy. My sincere condolences to Matt’s family on your loss. He was brilliant, informed, eloquent, and passionate, and will be missed dearly. This community will do its part to see to it that his death will not be in vain.
After reading this post, I flipped through my copy of the DSM-5. There is a brief section (pp. 19-24) titled “Use of the Manual” in which context is briefly mentioned. The manual states that a “case formulation” (which is distinct from a diagnosis) should include assessment of the broader context, and that a diagnosis should not just involve checking off symptoms but requires clinical judgment about the “relative severity and valence of individual criteria and their contribution to a diagnosis”. But this section has no language that supports the researchers’ contention, noted by Peter, that “In the DSM, context is to be considered as providing alternative explanations for distress—that is, diagnoses should be ruled out if a negative context could explain the symptoms.” I found this statement surprising because my well-informed understanding of the DSM indicates that diagnoses are in fact *context-free by design.*
I had a look at the article Peter reviewed to see what the authors had to say about the supposed contextual basis of DSM diagnoses. Here is the relevant quote:
“The Diagnostic and Statistical Manual of Mental Disorders (DSM; American Psychiatric Association [APA], 2013) provides some guidance for several specific disorders on how contextual information may inform diagnostic decision making. For example, the DSM suggests that a diagnosis of conduct disorder should not be provided if a symptom displayed by a child could serve as an adaptive reaction to the environment in which the child is living. In this way, if a child lives in a violent neighborhood, the disorder symptom of “getting into fights” could be explained away as a normative reaction to his environment. Likewise, previous DSM editions suggested a diagnosis of major depressive disorder was not warranted if symptoms were in reaction to the loss of a loved one (e.g., APA, 2000). What these examples have in common is a focus on context as a causal explanation for clinical presentations. That is, if a person displays symptoms that appear to be explained by a reaction to a contextual trigger, then a diagnosis is unwarranted.”
The paragraph above is incredible, for several reasons. First, I’ve just read the entire conduct disorder section in the DSM-5 and the only relevant language is this: “Conduct disorder diagnoses may at times be potentially misapplied to individuals in settings where patterns of disruptive behavior are viewed as near-normative (e.g., in very threatening, high crime areas or war zones). Therefore, the context in which the undesirable behaviors have occurred should be considered.” This is obviously very different from the authors claim that the DSM-5 says the diagnosis should not be given if the behavior in question is an adaptive response to the environment. The DSM-5 in fact says no such thing. It doesn’t even say the diagnosis should not be given, just that the context should be “considered,” whatever that means.
Second, the authors chose DSM-4 major depressive disorder as an example of the DSM’s sensible use of context because bereavement was included as an exception. Incredibly, the authors didn’t mention the fact that in DSM-5, this exception was eliminated and a top-level decision was made to make the diagnosis context-free!
The authors of this article, building on the paragraph I quoted above, added this gem:
“An underlying theme in the approach of the DSM is that a person will think about a diagnostic conclusion and then alter that diagnosis depending on how context could be used to causally explain those symptoms. In these types of cases the use of context seems to be an active choice made in the final steps of diagnosis.”
I can only presume that the authors don’t actually understand the DSM and simply assumed based on common sense that it must work this way, or deliberately cast it as working this way to create a nice narrative for their study. But in reality, it most emphatically does not work this way. The context-free nature of nearly all DSM diagnoses is ludicrous and studies like this one shouldn’t obscure this important reality.
Registeredforthissite, thank you for your thoughtful comments. Your question – what have I done – is more than fair. My full answer would take a long time to write, and I’m proud of that fact because there is a lot I could write about (http://www.illawarraanxietyclinic.com.au)/. Many of my efforts have been devoted toward fellow professionals, as well as students and supervisees, and my efforts continue now in my capacity as a private practice clinical psychologist. I have a great deal more to understand about the relevant issues and to figure out how to address them. For now, I note that one important thing I have done is to have written this blog post, and to have done the research and acquired the knowledge necessary to have written it, and to have the courage to publish it here when doing so threatens the status quo in my profession. I hope to be able to make meaningful contributions to my profession and society and am continually working on how to do so.
To all who have commented, thank you very much for your thoughtful remarks and kind words. Among the many issues critiqued in my post is the modern-day practice of “mental health literacy” education, which I suspect does not mean what most people think it means. Of particular concern to me are initiatives to “educate” children to have high “mental health literacy” in the name of reducing stigma and increasing help-seeking. Such initiatives are becoming popular and are heartily endorsed by the mental health establishment. We seem headed toward the day where a generation of young people will learn to construe their psychological experience through a biomedical lens. In a future blog post, I will deconstruct and critically analyze a “mental health literacy” program being rolled out in Canada (and other countries) that is now part of teacher training at some Canadian universities. Similar “mental health literacy” initiatives can be found around the world. In my hometown, mental health professionals have partnered with high schools to identify signs of “emerging borderline personality disorder” in students. At-risk students are encouraged to receive therapy that asks them to accept this highly stigmatising “personality disorder,” which is presented as a valid “mental illness,” into their long-term identity. I’d like to see more public critical discussion of the “mental health literacy” enterprise and its biomedical philosophy and hope that blog posts like this one will be disseminated far and wide and stimulate such discussion. Thanks for your support and stay tuned for a future post on this topic.
These authors appear to assume that (a) antidepressants “work,” (b) that they do so for biological reasons, and (c) these reasons explain the “therapeutic delay” in which symptom reduction takes several weeks to kick in. The scientific evidence does not support any of these assumptions.
“Antidepressants” work almost entirely due to the placebo effect. The pharmacological action of different drugs on serotonin has no relationship to their effects on depression. To the extent a biological explanation is necessary to explain their effects, Joanna Moncrieff’s drug-centered model does the job quite nicely. The therapeutic delay concept is a myth. Week-by-week scores on depression measures during drug trials shows a steady, linear decrease in symptoms that begins in the first week. But it takes a few weeks for that increase to become large enough to be clinically meaningful, hence the misperception that the drugs take a few weeks to “kick in.”
It’s good that researchers have come around to caring about what antidepressants do to the brain, but this work needs to be based on accurate assumptions, and it usually is not. Case in point: the authors’ closing statement, “Understanding the true relationship between serotonin and depressed states will be important in understanding the etiology of those states and developing effective treatments.” This statement assumes serotonin is important to the etiology of depression. It seems the “chemical imbalance” myth is still alive and well despite Ronald Pies’ premature eulogy for it.
Hi Bob. Thank you for this excellent article! You will not receive a direct response from Ronald Pies, which is unfortunate as I’d enjoy seeing him attempt to engage with your strong data-based argument, as well as the serious ethical issues you raised regarding these two studies. I don’t understand how either of those “quality of life” studies could have been approved by a non-corrupt institutional review board.
You’ve covered a lot of territory in your response and have done a nice job of critically analyzing the relevant science and justifying why it is credible and important for a journalist like you to analyze it. But you didn’t address an issue that I suspect Pies would say is critical, so much so that it justifies his simply dismissing anything you say without the need to even consider it. I’m speaking of the view that practicing clinicians are uniquely qualified to understand the nature of “clinical reality.” According to this view, clinicians have access to a uniquely valuable source of information that people like you don’t – clinical judgment and experience – and as a result, they better understand the nature of “mental illness,” the effectiveness of psychiatric drugs, and how to interpret the meaning of scientific articles. No amount of thoughtful critical analysis by a person like you will ever be compelling enough to be taken seriously by someone like Pies, because you don’t understand what he has seen (or thinks he has seen) with his own eyes in the clinic.
A quick anecdote: In 2004, as a Mayo Clinic postdoc, I was able to arrange for Irving Kirsch to present a grand rounds talk to the Department of Psychiatry and Psychology. His talk was titled, “Antidepressant medications: The emperor’s new drugs.” You can guess how popular it was with the psychiatrists in attendance. The next week’s speaker was a psychiatrist who studied the biological aspects of depression. In introducing the speaker, the department chair (a psychiatrist) noted that given his extensive clinical experience with depressed patients, the speaker was in a better position that Kirsch to understand the “true effectiveness” of antidepressant medications.
The same thing happened to me when I debated the president of the European Psychiatric Association on the efficacy of antidepressants (https://www.madinamerica.com/2013/09/united-states-biomedical-model-five-anecdotes/). My opponent, a “scientist” with 600+ publications, invoked his clinical experience to trump findings from the clinical trials literature on antidepressants.
Bob, you and I encountered the same problem: when faced with contradictory evidence from well-conducted scientific studies, some psychiatrists invoke clinical experience to dismiss it. As I see it, the issue for Pies isn’t so much that you have mischaracterized the nature of clinical reality, as it is that you are not qualified to comment on it because you are not a clinician. I doubt he will take your critical analysis seriously, compelling as it is, because you are a non-clinician and thus do not have access to his privileged reality.
In my view, the best response to Pies is to vigorously critique the accuracy of clinical judgment. That is breathtakingly easy to do. There is a massive literature on the fallibility of clinical judgment and the superior accuracy of controlled scientific research (at least when it’s not being manipulated by pharma or to promote guild interests). Clinicians are lousy at judging the effectiveness of drugs and psychotherapies, and the nature of psychological problems, through subjective observation. Reasons for this are obvious (e.g., clinicians see an unrepresentative sample of clients, don’t receive accurate feedback, don’t see people who improved without treatment, don’t know what would have happened if their clients received a different treatment, etc.). “Clinical experience” led psychiatrists to believe that lobotomy and insulin coma therapy were safe and high effective therapies, led physicians to believe that leeches and bloodletting were effective, and led psychotherapists to believe that recovered memory techniques were helpful. An excellent, recent summary of why clinical judgment is often wrong can be found here: http://pps.sagepub.com/content/9/4/355.short (brief blog: https://digest.bps.org.uk/2014/07/28/the-mistakes-that-lead-therapists-to-infer-psychotherapy-was-effective-when-it-wasnt/).
A truly scientifically-minded clinician would never invoke clinical experience to trump scientific research, and would understand that one should be embarrassed for doing so. Yet Pies prides himself in smugly dismissing you in favor of his clinical experience. I submit that if you wish to do real damage to Pies, call him out for engaging in the kind of shoddy clinical reasoning that first-year psychology students know to be fallacious.
Noel and William, congratulations on authoring an excellent article! I would like to speak with you about it. I’d appreciate it if you could email me at [email protected]. Thank you very much.