Friday, March 24, 2023

Comments by Stevie

Showing 64 of 64 comments.

  • As I’ve tried to say, my fellow Steve, most psychiatrists try to do their best under pretty oppressive work situations over the last decade or two, resulting in an epidemic of our burning out. No, I’m not asking for any sympathy, just trying to point out again the system problems surrounding us all.

    In view of these system problems, most clinical psychiatrists try to do what they can under very limited time, and that is medication. The serotonin issue is a red herring here. That same time pressure produces a need on both sides – us and patients – to try to make some sense, even the powerful placebo sense, of whatever practical steps are taken. I can assure you that most psychiatrists would like to have more time to do more psychotherapy. As to the uproar, most everyday psychiatrists couldn’t care less about this controversy; they just want to plug away and help wherever they can.

    DSM 5 is a major problem and surely misleading. One growing alternative is a network perspective on psychological symptoms, pioneered by the Dutch psychometrician Denny Borsboom and colleagues. Depression in this viewpoint arises from a network of interactions among its constituent elements. Treatment then addresses those elements.

  • Let me put aside what some would think to be just the innocent mistakes that Mr. Whitaker made in his August 13th article about Psychiatric Times and the spelling of my name. Though perhaps irrelevant for his points, they point out carelessness with the truth.

    I think what is important to discuss is the real life clinical work of many psychiatrists because even the best quality studies are not the same as everyday clinical work. When I was seeing patients, I never used the chemical imbalance theory, but instead that serotonin seemed to be increased in the brain with SSRIs. I was never all that enamored with the results overall, but many individual patients did well. Almost always, joint treatment with psychotherapy enhanced the results. The truth is: we don’t really know what is going on in the brain in the deepest and most important ways with depression, probably because the brain is so well protected, making usually research very difficult.

    What we also keep forgetting are the for-profit systems that greatly influence treatment settings. These are the for-profit insurance companies, managed care companies, and Pharma. In many meetings, only 10-15 minutes are left to see each patient. That is absurd. (See my book The Ethical Way: Challenges & Solutions for Managed Behavioral Healthcare, 1997). They are our real mutual enemies. No wonder mental health workers from Kaiser Northern California are on strike.

    I once write for this publication, but the animosity towards any psychiatrist that didn’t fall in line with the going criticisms of psychiatry made it worthless to continue. Not much is liable to improve unless we can work together more and improve the systems care care and future research.

  • In commenting about Dr. Pies,Mr. Whitaker states that Psychiatric Times is the trade publication of the American Psychiatric Association (APA). That couldn’t be further from the truth. It is a separate publication, often publishing articles much different than that of Psychiatric News, which is the trade publication of the APA. I hope there aren’t other untruths in this article.

    -Steven Moffic, MD

  • And even this psychiatrist has used music for its therapeutic effects. Since I was an adolescent, that has been jazz music, as well as blues, both of were healing and enhancing. Jazz was also antiracist, a gift of Black Americans to the world, and one of the earliest social situations that was integrated. Along the way, I reviewed records a bit and named “Dr. Jazz”.

    A landmark series. Thanks you.

  • Long ago I wrote some blogs for MIA, and ever since I stopped, occasionally view what’s being written. As a psychiatrist who has long valued music and the arts for mental health, including my own, I read this article with some “chills” of myself. In my opinion, this is the best article on music (and with a suggestion towards the expressive arts and sports being of similar value) that I have ever read. As I was starting to prepare my notes for giving my weekly video on Society & Psychiatry, this one on The Arts and The Inauguration, this article is invaluable.

    Looking forward to the third in the series and hope you branch out into all the expressive arts and sports in your analyses.


  • I fear our mental health concerns are much wider and broader than just focusing on “mental illness”. We are a society that is burning up, not only climate-wise, but psychologically. The “burnout” rates of all kinds of workers is rising, as well as parental burnout. The highest rates, perhaps because of systemic issues, is that of human and animal physicians. I suppose this is some sort of offshoot of not only the biological model, but how even that is blocked from whatever efficacy it can provide. Then there is the rising xenophobia and all the related discriminated against groups. We need a much broader mental health mission as far as I can tell.


  • Mr. Whitaker, did you ever think that societal problems were causing the escalation of mental health problems? Or, the the corporatization of health and mental healthcare were handcuffing psychiatrists so that psychiatrists are burning out at epidemic rates and suiciding at the highest professional rate?

  • Bob, wish your considerable journalistic talents would now turn toward the societal issues causing so much increasing psychological distress, including the overuse of medications:

    – inadequate drug testing and misleading PR by Pharma;
    – inadequate insurance coverage that limits psychotherapy;
    – the control of psychiatry and medicine by the payers, causing over a 50% burnout rate in physicians;
    – rapid changes in society and technology leaving many more insecure;
    – a President that is increasing conflict, divisiveness and scapegoating;

    Please consider leaving this “dead horse” for a time and look at what’s causing so many of us to have our souls die.

  • Dr. Levine, maybe you want to take a look at the expanded edition of The Dangerous Case of Donald Trump, released a week ago and edited by Bandy Lee. The book in both its editions has elicited the condemnation of the American Psychiatric Association due to the “Goldwater Rule”, which some psychiatrists feel is secondary to the ethical risks from this Presidency.

    Someone on this site should review the book.



  • I’m heartened by this blog. Yes, it is a much bigger issue. That medical care has become a big business has thwarted and limited physicians in having enough time to listen to patients and provide compassionate care. Meds become a time-saver. This will get worse as ObamaCare is getting dismantled. It does no good, really, to scapegoat psychiatrists when we are burning out due to our systems. We should be in this challenge together.


  • Maybe if he and many here would be more optimistic about psychiatry, he would have recovered more. It is also crucial to know that appearing much better, as Kermit Cole wrote, can be a clue that someone has decided to commit suicide and is relieved by that. This is a tragedy that perhaps could have had a different outcome with a different view of psychiatry.


  • It is difficult to accept the points by Dr. Hickey when he uses Dr. Carlat to support his criticism of Dr. Pies. Dr. Carlat was a notorious well-paid spokesperson for Pharma for many years, until his conversion to something else. Dr. Hickey took Dr. Carlat’s points out of his contradictory history.


  • Well, maybe we have something in common, Steve, besides our name. And, I appreciate your kind and respectful reply. It is this kind of interaction that can move all of us back in the same direction, not the blanket scapegoating of psychiatrists.

    I think many social changes contributed to the transition: the limited success of talk therapy with certain conditions; the promise and marketing of medications (including “thought leader” psychiatrists paid a lot to talk them up); the power of for-profit managed care to influence what care gets provided and paid for; and competition among the different mental health professionals (including psychologists who still want to be able to prescribe medications).

    But, believe it or not, younger psychiatrists seem to realize what they have missed and want to learn about more than medications. They do want to know what is wrong with medications. The older ones like me are retiring (and I know there will be some applause out there), though we still try and try to have constructive conversations about what needs to change. All sides have valuable perspectives, if we listen respectively to them. Many have been chased away or stay away from this site.

    -Dr. Moffic

  • Gee. Richard. I check in now and then to see if anything has changed. Guess not. The “good ole days” are still here at MIA.

    But the “good ole days” of the 1960s in psychiatry are gone. In fact, I found it fascinating and helpful to talk to people no matter how unusual their words were. Often, if you empathized and looked for symbolic messages, much could be learned. But it took much time and patience.

    Glad to know I was missed.

    Dr. Moffic

  • Laura,

    You make good points and I’m loath to respond too much, given some of the reactions. All I’ll about managed care is that most psychiatrists (other than those who are in private practice and have self-pay patients) hate managed care and feel managed care has used and distorted the field (say with “medical necessity”) for the financial gains of the companies (which are immense). Personally, I have a more mixed view of managed care, including supporting the need to reduce hospitalizations (and time in the hospital) and unnecessary treatment, which I tried to present in the book “The Ethical Way: Challenges and Solutions for Managed Behavioral Healthcare” (1997). Most systems of mental healthcare nowadays are run explicitly or implicitly by business people; what makes money and keeps the system afloat tends to rule the day.

  • Duane,

    People don’t have to read my comments or blogs at all. I don’t think I’ve been disrespectful and actually, in contrary to your viewpoint, I don’t think anybody needs to earn respect. I try to convey respect and dignity as much as I can as a principle of being a human being who lives in an interdependent society.

  • I think I answered Laura’s first question fully. I respond to the situation at hand here. Have I learned here? Yes. Have I don a 180? Nowhere close. Of course, Duane would say I’ve gone in circles, but I’ve enjoyed the recent interactions with Laura and Nathan.

  • He was already on an outpatient commitment and I didn’t know him that well. Actually, we psychiatrists don’t recommend whether to extend that or not, just send them our treatment view. As far as I could tell so far, he hadn’t changed from when he came in.

  • Thanks for sharing information on this book. The title jives with what most physicians should strive for: the variation of the “do no harm” ethical principle attributed to Hippocrates, which really is “do as little harm as possible”. Do you know what is recommended in this book is similar to other strategies that have been relayed in this to getting off medication?

  • Nathan,

    As I think I’ve said elsewhere, I and many psychiatrists have done the last thing you’ve said. I’ve also worked in a low-paying prison. My principle was to focus on those in most need who also wanted care. I can’t remember the last time I played any role whatsoever in forced treatment of any sort. My main question in an evaluation was always “what gives your life the most meaning and let’s see if I can help you achieve that”. Of course, at times I might disagree or say I couldn’t help, i.e., get or prescribe certain drugs. That question I found to be the best inroad into one’s inner world. I don’t think it is of much use here to state it, but a psychiatrist has (or at had) the broadest training of any mental health clinician, including anthropology and the humanities. The training of folk healers is different, but valid and valuable in itself. There is just so, so much we don’t know about the brain and mind (which may be different than the brain).

  • Laura,

    By cultural, I meant just one influence on our subjectivity.

    For your first question, I’d answer no. Certainly, many of our leaders in politics, new movements, and religion had intense emotions and/or thoughts outside of the norm. I suppose we could also add the recent example of Steve Jobs in his inventiveness and leadership. Of course, many everyday people too. Different on a spectrum, perhaps, but surely not necessarily abnormal.

    The answer to the second for me would be no also.

    I think psychiatry has whatever power it does from a societal political decision akin to what Nathan wrote. As I answered Nathan, I would add that psychiatrists, when they are trying to work with people, would like to have more power to have the time to get to understand the subjectivity you mention. Although this is being eroded, we always talked more about the “art” of psychiatry than the “science”. I know others will say, well, just take the day and take whatever pay you can. That is one solution, but for now the demand to see us is great and when insurance is involved (and that will only increase under Obama’s plan), those companies have more power in many ways (? like the real power behind the throne??


  • Nathan, I agree with you just about with everything you said. However, I would add that “psychiatry”, generally led organizationally by those in private practice, gave up the power of leadership in institutions (state hospitals, community mental health centers, etc.) long ago. As individual psychiatrists, most of us wanted to have enough power to do more than just med checks, a quest most of us have lost.

  • Why would you assume that others who do not respond are not hurt? I believe it is impossible to have an on-line dialogue with someone who feels “disgust” toward me. So, I’ll close my responses with this passage (and, if offensive and necessary, take out the religious references):
    “O God, help me avoid every abuse of speech. Let no untrue word escape my lips. I pray that I may never speak badly of others, or speak empty words of flattery. Help me stay away from profanity. Teach me, dear God, when to keep silent and when to speak; and when I speak, O God, save me from using Your wonderful gift of speech to humiliate or hurt others”.
    -Reb Nachman of Bratzlav

  • OK, Laura, let me try to respond as a “cultural” psychiatrist (and I never use the word primitive because I think it is derogatory, but others do so I put it in quotes). A cultural psychiatrist is interested in how the cultural values of other people influence how they view variations in emotional expression and thinking. Of course, this can verge on stereotypes and needs to consider individual variations. Cultures can include ethnic groups, religious groups, economic groups, countries, tribes, refugees, etc. We know that in some cultures around the world historically and currently, such variations are much more accepted into the wider society and medication is much less used. In a so-called Western or industrialized society, Gheel is the best example I know. One could say that we would need less professionals if there was better societal acceptance of variation in emotional expression, thinking, and some behavior. Many cultures have there own “healers” to go to first; I talked about some of that in my last blog, ranging from shamans to curanderos to clergy. Sometimes these within-cultures healers will refer onto cultural psychiatrists. There is an organization called the Society for the Study of Culture and Psychiatry that focuses on all of this, mainly from a research perspective.

    I greatly appreciate the tone of the discussion and questions. It makes me think we can learn from each other.

  • I put the politicians up there because ultimately if you want some human and civil rights laws to change, they will need to cooperate.

    Supporting your view may be how so-called “primitive” and historical cultures and societies do so much more to accept, support, and value the more extreme emotions and thoughts you mention. “Cultural psychiatrists” understand this.

  • Malene,

    I’m sorry I did not answer all your questions. They are good ones, but would take a long time to consider and answer properly, and right now there is not enough time for me to do so, so I just made the brief comment I did.

    I’m not sure how our interaction here is at all like China and Tibet. Personally, I’ve been a strong and clear advocate for a “free” Tibet. I’ve even written a blog on China for PT, but you may not like it since I advocated for the development of some more psychiatry there. I also think there is a time and place for angry, vehement protest and criticism; when that is and how that is directed we seem to disagree about.

  • Duane,

    I would now say I essentially believe in what Dr. Steingard recently blogged about Anogosognosia, though I have also been informed by other commenters here. I probably should not have used the word “many” in the blog, but if psychiatrists work with upwards of a million patients, maybe a small percentage of that would still be “many”.

    For most situations, I would say that people diagnosed with severe mental illness do have the right to decide on their treatment, even if they have that “condition”, unless (and this is the very difficult decision) they seem to be of imminent danger to themselves or others without an obviously known good reason to be so. Another exception might be those who have conveyed in advance that they want a certain kind of help if they are ever is a condition where they can not decide as usual for themselves (including the much different Alzheimer’s).

  • Thank you for the comment about the Joseph blog. It was not meant to be a call for a cease fire, but for what we might have in common as far as a healing approach. Feeling like this is a war or battle will make me feel too much on edge and defensive.

  • I’m here for a dialogue where I can learn as well. If it seems like I am interested in defending psychiatry, I am not. I am not even practicing psychiatry anymore. However, I may not have the same conclusions and recommendations as others.

  • Thanks, Laura, and of course we disagree to some degree on some things. As to power, or at least potential power, I would put the politicians on top, and they are ultimately crucial for any human rights advancement. They influence everything from medication approvals to new laws.

  • Well, then, tell me how to make that distinction in a critic that does not identify themselves, or decides not to be truthful, or even might be paid to say something? I am not claiming or suggesting that would fit anybody on this site, but it could. When critics make blanket criticism of psychiatry and psychiatrists, it is hard for me to completely have “good faith”. If my wording in Psychiatric Times conflated the two unintentionally, I apologize.

  • Duane,

    I don’t know any psychiatrists who are so “simpleminded”. No sense being a doctor or psychiatrist if we will automatically taper someone off meds whenever that is desired without discussion and providing our opinion. I guess that is one reason to get rid of psychiatrists, or at least the education of psychiatrists. This is the same reason most psychiatrists will not – and should not – put someone on the medication in the television advertisement when the patient wants what they saw on TV (now there’s another area that should be addressed – the misleading ads on TV). For some people, “autonomous decision-making” is essential for mental health; for many others (especially from certain ethnic cultures), they would prefer expert advise. When – and if – we can get some agreement on this complexity of tapering, and get more points of view, then those psychiatrists might come out of the woodwork and even participate in this site.

  • I apologize for the delay in responding as our computer needed fixing and then I was away. When someone says “it is totally irresponsible of Dr. Moffic”, then we lose the ability to dialogue. I am just giving my opinion; if I am wrong, that is not necessarily being irresponsible. To me, being irresponsible is not incorporating all the information and data one can obtain, and then proceeding as best as possible in action. It seems to me that this site, as valuable as it is for criticizing psychiatry, is missing any other consumer/public point of view. Let’s say there are 50,000 psychiatrists, as Duane says, and perhaps we average 200 patients each (I had more than 400 when in practice). So, we have maybe a million patients. Do we know and hear from those who are satisfied? Those who have mixed feelings? In stopping meds, some may need very slow titration off and some can stop easily cold turkey after chronic use, and many other in-between. To do so the best way possible, I think one needs detailed discussion with each individual. Alternative “certification” may be a great idea, but not if the criteria are too narrow. Again, just my opinion.

    Maybe this needs repeating, but I write for what I think is useful for a particular audience. This is akin to how I worked with patients; I would never try to shove something down their throats (meds) that they did not want to try or when there were other alternatives. If you consider all my blogs for three different sites, here, PT, and Behavioral Healthcare, you’ll have a much better idea of how I really view things, if that matters.

    Lastly, I think it is indeed of utmost importance to distance Scientology from this site. I just don’t know if that is possible, given how what is behind one’s moniker or stated beliefs can not readily be checked.

  • No, Duane, I am not defending psychiatry, like you I am only giving my opinion about the state of emotional care or whatever we decide to call it. If you want to keep labeling me in another way, that is up to you, but just as I can learn from others here, perhaps others can learn something from me. If this site is just to bash psychiatry in any way possible, that is up to this site.

    Yes, I know way over 50 who would meet much or all of your criteria. How do I know these people so that it is more towards a fact than opinion. I have had – and had – leadership roles in many of the more fringe psychiatric groups that tend to be more critical of psychiatry: the Group for the Advancement of Psychiatry (where Mr. Whitaker was invited to speak last April, and where he was not tarred and feathered, Past President and current Board member of the American Association for Social Psychiatry, Founding Board member of the American Association of Community Psychiatry, ethics chair of many committees. Would I recommend any of them to become involved with this site right now? No, but I do know that some are watching and reading some of the stuff. When we are more welcome, I’ll let them know.

    What revolutions are you using as a model? The USA? Great for certain populations, not for the Natives. South Africa? Political freedom for the oppressed, but the political leaders that came out of the oppressed have shown much corruption. Revolutions, as exciting are they are, like any attempt to make things better, have very serious potential side effects and aftermath.

    “Tough skin”. Yes, I have it, but I am continually saddened by words that hurt others unnecessarily.

  • Duane,

    I think you are missing the point I am trying to make. We can not answer your question unless we agreed on your criteria, then did a survey of all psychiatrists, and tried some way to verify their responses. In other words, the same kind of “scientific” study we want for other issues. Just throwing out stats to make a point can be very misleading; one could say the same was done to push medications. All I’ll say again is that there are many other psychiatrists who feel horrible for the injustices we know of, desperately want our field to improve and would participate more if they felt welcome. Does this site just mainly want “like-minded” points of view, or to my mind, more hopefully, the “like-intended” that Kermit Cole relayed? “Like-intended” would include different points of view with the hope for some consensus and improvement in certain causes.

  • I guess I didn’t see MIA as heavily populated with academics and mental health professionals, but maybe you can cross me off of that list now that I am retired.

    If the “movement” is open enough, there will be the support of the likes of me, if that is wanted. Maybe we will even have some useful ideas and suggestions. I think all of the “rights” movements had some crucial support of those not directly in need of those rights.