Wednesday, November 29, 2023

Letters to the Editor: Is MIA Doing More Harm Than Good?

From Miranda Spencer

I appreciate Dr. Phelps’ willingness to engage with MIA’s well-documented critiques of the institution of psychiatry and the careful, often non-drug approach he takes to helping his patients/clients. Other writers have already articulated many of my concerns with his arguments in their rebuttals. Two issues, though, still haven’t fully been raised in this discussion, and those are power and accountability.

“Drop the disparaging, blaming, and diminishing of psychiatry,” he pleads. As someone who has edited scores of personal essays for MIA, some of which have literally brought me to tears, I’m actually offended that he would ask us to silence or tamp down the sometimes-agonized voices of people who truly can be called victims of psychiatry’s current Standard Operating Procedures.

To me, these essays validate the truism that one story is an anecdote, many stories are data. People who have been “disparaged, blamed, and diminished” by psychiatrists—especially those who’ve been involuntarily subjected to polypharmacy, lifelong labeling, and authoritarian attitudes—may understandably wish to hold these people and the field itself accountable.

Dr. Phelps also expresses concern that harm may come if “a person who’s severely depressed hearing about Mad in America and reading some of the posts here…become[s] less inclined than they might have been, before that, to seek help from medical professionals.” While acknowledging this actually might be a good thing, he also fears it could have a terrible outcome.

Let’s get real about the relative power of institutional psychiatry (and its sister, the pharmaceutical industry) to shape the dominant narrative versus a small nonprofit news outlet like MIA. While we are no longer a “voice in the wilderness,” as proven by the fact that Dr. Phelps took the time to write, the media messaging from the mainstream model of mental healthcare is currently far louder (and far better funded). That is why the counter-narratives MIA provides are so important: They serve as a counter-weight to help balance the scales unfairly tipped in conventional psychiatry’s favor.

Miranda Spencer
MIA Staff Editor

 

From Rob Wipond

Let’s not neglect this discussion’s proverbial “elephant in the room”: Forced psychiatric treatment.

As a journalist who researches and writes frequently about civil rights in the mental health system, including for Mad in America, I’m always grateful to psychiatrists who are willing to engage in honest, respectful public dialogue, even with their critics. So I read psychiatrist Jim Phelps’ views with interest, and considered his strong belief that some people express “too much certainty” when discussing the apparent serious harms and dubious effectiveness of many common psychotropics. And I certainly share his desire that everyone work together to “keep wondering, keep asking questions, keep studying.”

However, I’ve recently completed a book that explores patients’ experiences amid the rising rates of psychiatric detention and forced psychiatric treatment currently going on across the US and Canada. So I feel compelled to point out that there’s arguably no single act that more epitomizes the overpowering scientific and moral “certainty” that many psychiatric institutions and psychiatric professionals claim to have than their routine, daily practice of stripping people of their basic rights and treating them with psychotropic drugs against their will—all questions and respectful dialogue be damned.

Many former and current psychiatry residents frankly admitted to me that, as part of their training, they at times routinely ignored their own genuine concerns about a drug’s serious harms and weak effectiveness—and forcibly drugged people, simply because their supervisor believed it was the correct decision.

I attended or reviewed records of hundreds of civil commitment hearings and talked with many legal and psychiatric experts, and it was consistently clear that refusal of psychiatric medications is the single most probative evidence typically used to commit people—because psychiatrists regularly testify to judges with persuasive certainty that psychotropics are extremely safe and very effective and that any claims otherwise are merely indicative of patients’ “lack of insight,” while any apparent harms are purportedly caused by patients’ own “treatment-resistant illness.”

And in recent years hardly a month goes by where there isn’t, somewhere in North America, an expansion of the laws determining whom can be forcibly treated—as a direct consequence of psychiatrists assuring legislators, with strong certainty, that psychiatric drug treatments are extremely safe and very effective. This, though in my research I found very little evidence of outcomes of forced treatment ever even being formally studied.

If anyone who works in the psychiatric field cannot imagine why some people, sometimes with intense passion, “disparage” or “blame” psychiatry or seek to “diminish” its social influence, then they can appear to others to be unconsciously sitting inside a fortified bunker of conviction, privilege, and power. It becomes all the more vital to start really listening—respectfully—to the voices and perspectives of the countless people who feel that their lives have been ravaged by psychiatrists’ acting with “too much certainty.”

Rob Wipond
Author of Your Consent Is Not Required: The Rise in Psychiatric Detentions, Forced Treatment, and Abusive Guardianships

 

From Michael Sturman

Reading the exchange of points-of-view between Robert Whitaker and Jim Phelps in “Is Mad in American Doing More Harm Than Good?” reminded me of the time when I interviewed for Medical School back in the 1960s. My science grades weren’t that good, which is what counted in getting in. But I really wanted to go and sent my application in anyways. And for whatever reason, they decided to interview me. I talked to one of their top psychiatrists and told him I was interested in psychiatry and being a psychotherapist. He promptly told me that they were moving away from that in their training programs and towards bringing psychiatry closer to medicine.

That meant only one thing to me—more drugs and more shock—and I didn’t like it at all. I’d had my own experience with psychiatric drugs and shock treatment at sixteen when I was in the state hospital. I’ll never forget how difficult it was to stay awake and do anything on Thorazine, the brutality of shock treatment, and having to struggle to go back home when I was better despite their having little to offer except somatic treatment. Later, as an outpatient I was on small doses of less sedating drugs which helped take away some of my anxiety and sleep better, but I still felt I was being overly sedated.

Everywhere I turned in those days, it was the same old story of severe mental illness, heredity, and incurability. I had a very hard time convincing anyone that psychotherapy was right for me.  Our family doctor, for instance, had strong beliefs on mental illness and heredity and lectured me at length. I was not easily convinced, however, because of the many things I learned on my long trips to the library downtown, my university studies, and my believing that the abusive treatment I received at the state hospital was terribly wrong. In the long run it turned out I was right, and therapy did help!

I’m glad to see now that more dissident voices are being heard. Recently, in Robert Whitaker’s and Jim Phelps’ exchange, Dr. Phelps, a psychiatrist and pharmacologist, admitted that psychiatry has placed too much emphasis on medications by overestimating their effectiveness and minimizing their side-effects, and too little emphasis on psychotherapy. At the same time, he pointed out, that a number have benefitted greatly from psychiatric medication. I agree with him on all points.

Robert Whitaker continued with his account of how he discovered the false narrative of biological psychiatry when he was a reporter for the Boston Globe and his founding of Mad in America. He makes the case that too often the medical model has been blindly accepted despite evidence of poor outcomes, the harm it may do, and a deemphasis on alternatives.

One such possible alternative for those hearing hallucinatory voices was described by Daniel Bergner in The New York Times (May 17, 2022). He tells of the struggles of Caroline Mazel-Carlton who heard voices from an early age but only responded marginally to medication. Following a tumultuous period in her life, she became a peer support specialist working alongside professional practitioners in the treatment of the mentally ill. Later, she went on to become a leader in the Hearing Voices Network (HVN), a peer support program for those who hear voices which does not depend on medication.

Yet, despite criticisms of psychiatry’s overreliance on medication, they do not appear to have translated into fewer prescriptions being written. London psychotherapist Jonathan Coppin writes that antidepressant use in the UK has doubled in the last 13 years.  I would expect a similar trend in the US, especially with the increase in individuals seeking mental health care during the pandemic.

Michael E. Sturman, MA  

 

From Keith Hoeller

Psychiatrist Jim Phelps believes that the Mad in America webzine may be doing more harm than good by “paint[ing] all of psychiatry as dishonest, corrupted by money, and ignorant of social effects of human experience.” He also mentions that some “psychiatric treatment lead[s] to better outcomes than no treatment.”

I do not believe that Mad in America routinely paints all of psychiatry in this way, or that the site routinely argues that people should do nothing at all to solve their personal problems.

What Mad in America does do is raise the question as to whether or not psychiatric theories and treatments are scientifically valid and reliable, safe and effective.

In his new book Sickening: How Big Pharma Broke American Health Care and How We Can Repair It, John Abramson makes a strong case that our health care system is broken and that the drug companies have broken it. The drug firms conduct 80% of the research; manipulate the experimental design; only publish positive results; massage the data; employ ghost writers for articles; pay specialist MDs who decide the practice guidelines; subsidize professional and lay organizations; subsidize and manipulate the FDA drug approval process; run false advertisements to both doctors and the public; and employ more lobbyists than members of Congress. Most importantly, the drug companies do not release raw data from experiments even to those doctors who set the prescribing guidelines.

While most people believe that the first principle of medical ethics is “first, do no harm” (primum non nocere), many medical treatments are in fact harmful. So in the 20th century the principle of “informed consent” was developed and became enshrined as the first of ten principles in the Nuremberg Code following Nazi experiments: “The voluntary consent of the human subject is absolutely essential.”

In short, doctors are supposed to tell their patients of the potential benefits, and the potential harms, of a medication and/or treatment they are prescribing. They are also supposed to discuss the potential benefits and harms of alternative therapies.

Abramson’s book Sickening explains in detail why informed consent may be missing from all of medicine thanks to the drug company monopoly on medication information. But at least medicine has a reasonable hope of treating bone fide diseases verifiable through laboratory tests and making an argument that lack of medical intervention can in fact be fatal with certain illnesses.

But whether psychiatry treats bona fide illnesses and has safe and effective treatments is precisely what Mad in America is designed to question. Informed consent remains even more problematic for psychiatry, as numerous articles in MIA have documented.

As I wrote twenty years ago, there is still “No Proof ‘Mental Illness’ Rooted in Biology.” Mental health workers do not diagnose diseases; they diagnose “disorders” from a relatively recent series of books called the Diagnostic and Statistical Manual of Mental Disorders, published by the American Psychiatric Association. Psychiatric diagnoses are often made by practitioners with no medical training. The DSM has been shown to have interrater reliability little better than chance. It has never been tested for validity since there are no lab tests to confirm whether anyone diagnosed with a mental illness actually has it. See “The Myth of Reliability of DSM,” by Stuart Kirk and Herb Kutchins” and “How Reliable is the DSM-5?” by Rachel Cooper.

It has been thirty years since David Cohen, co-author of Your Drug May Be Your Problem, first developed “A Model Consent Form for Psychiatric Drug Treatment,” and twenty years since he originally published it in an article with psychologist David Jacobs.

Virtually all of the statements in the consent form still remain unknown not only to patients, but to practitioners as well. Here is just one example: I understand that although my doctor says that I am sick or that I have a treatable illness or disease, he or she is just using a figure of speech and cannot establish, with any test or procedure known to medical science that I in fact “have” the “illness” implied by the diagnostic label.”

Cohen and Jacobs conclude: “We are inclined to think that no one who was so informed would consent.”

Has anything changed in psychiatry in the last thirty years? I wrote to David Cohen, who is currently traveling in Europe. He has given me permission to publish his response:

In thirty years, much has changed and much remains the same. When routine prescription meets routine hazard, truth usually loses. Most antidepressant prescriptions are written by GPs [General Practitioners] who can choose from 20 different brands, inspiring confidence that it’s all safe and flexible and already individualized for the patient in the pill. In a typical 10-15 minute consultation, what to expect? While consumers have more access now to real information on their own, this is counteracted by the tsunami of marketing, indoctrination and social pressure to feel diseased and to take drugs now and anticipate better drugs later. As regards antipsychotics, I can’t quite imagine how informed consent is obtained today, given that tardive dyskinesia is marketed as a kind of sexy treatable condition with hot new drugs. (May 16, 2022)

As the Nuremberg Code makes clear, consent must be voluntary. And here is where psychiatry has another ethical problem. While non-psychiatric doctors may treat unconscious patients in an emergency, psychiatrists are still the only ones who can routinely force involuntary treatment on conscious adults who reject it. Informed consent depends on patient autonomy, which may be missing in many patient encounters and can lead to coercion even when outright force is eschewed.

Phelps and Whitaker debate the question of whether or not MIA may be doing more harm than good. Perhaps the question would be easier to answer if it were reframed: Is informed consent helpful or harmful to patients?

Keith Hoeller, PhD
Editor, Studies in Existential Psychology & Psychiatry, Seattle, WA

 

From Jill Leslie Littrell

Last week I attended the three-day convention of the Society for Biological Psychiatry.  I had been to their conventions in the past, which had always been very good.  What surprised me about this event was that most of the presenters were neuroscientists and psychologists.  Judy Ford and Suzanne Haber, both psychologists, had been planning this conference for over a year.  The theme of the conference was “Positivity in a worrisome world”.  They had been collaborating with Richie Davidson about whom to invite and which topics to include.

Richie Davidson, a social psychologist, began his career using EEG to investigate which side of the brain was more active in infants.  He found that infants in whom the right cortex predominated predicted being more distress as toddlers.  For years now, Richie has been imaging the brains of Tibetan monks, including the Dalai Lama, and asking how meditating changes the brain.  He has also asked about the behaviors and attitudes adopted by resilient people, that is, those who operate well under stress.  Currently he operates “The Center for Healthy Minds” at the University of Wisconsin, Madison.  He has developed exercises and apps, which can be downloaded to one’s phone for free and can be accessed through “tryhealthyminds.org”.  I have downloaded the app and am quite impressed with all the types of instructions for meditation.  He also has instructions for developing the pillars of positive mental health:  Awareness/Staying Focused, Connection to others, Insight, Purpose.  Richie’s talk was entitled “Well being is a skill”.  One can learn how to do it and one can get better with practice.

Perhaps my favorite sessions were the four people who spoke at the symposium entitled “The bright side of life: positive psychology interventions for depression and their mechanisms of action”.  Each presenter had developed ways to increase happiness.  In the first presentation, Alicia Meuret indicated that for clients, positive affect is more important than decreasing distress. Alicia Meuret acknowledged that whereas therapies such as cognitive behavior therapy and pharmacological treatments might decrease distress, none of conventional therapies increase happiness.  However, Meuret and her colleagues found that interventions that target increasing happiness not only increase happiness but decrease distress as well, despite the fact that none of the interventions involves talking about traumas or problems. 

All of the interventions employed novel approaches.  For example, Charles Taylor of University of California at San Diego uses the increasingly more intimate series of questions to which partners take turns responding designed by Aron et al. (1997) to increase emotional closeness among dyads. Taylor also focuses on gratitude and kindness.  Kymberly Young used neural feedback to increase feelings of pleasure.  Kymberly explained that although the amygdala is best known for its role in fear, however, in fact, it is a salience detector.  Those with diagnoses of depression not only exhibit more activity in the amygdala in response to fearful memories, but they exhibit less activity in the amygdala when anticipating or recalling positive experiences.  In terms of intervention, Kymberly placed research participants in the scanner while she imaged their amygdala as they thought about pleasurable experiences.  Kymberly gave research participants a thermometer which provided her research participants with information about the level of activity occurring in their amygdale.  Kymberly told participants to increase the value in the thermometer as they thought about pleasurable events.  This procedure reliably increased positive mood.

At the conference, there was almost no mention of traditional psychiatric medications.  There were sessions on transcranial magnetic stimulation.  There was also much discussion of hallucinogens, LSD, peyote, etc.  In the first plenary session, Yale’s Molly Crockett presented her investigation of the use of hallucinogens at festivals to establish closer connections among people.  Many people presented research on increasing empathy between people.  I concluded that when an organization is not under the influence of the pharmaceutical houses, all of a sudden they come up with ways to provide innovative approaches for improving well-being.

There were many people at the convention whose work I have been following for years.  Some were psychiatrists, but I know they spend most of their time doing research.  Kerry Ressler, now at Harvard, but who started the Grady Trauma Project when he was at Emory, is a researcher.  David Lewis, who is on the Society’s Council, did the research in the primates showing that antipsychotics can shrink the brain.  It was so nice to see novel approaches both in terms of treatments and about foregoing diagnoses while instead focusing on happiness. 

For me one of the most damning evaluations of our current system was the study published by Matthew Nock et al. (2013).  It was a retrospective study in which Nock et al. obtained data on 6,483 adolescents.  Of these, 12.0% reported suicidal ideation, 4.0% planned a suicide, and 4.0% had attempted suicide.  The shock was that, according to Nock et al., “These analyses reveal that most suicidal adolescents (55.3-73.2% across outcomes) receive some form of treatment before the onset of their suicidal behavior—most often mental health or school-based services” (p. 306).  These data suggest the current system is not working.  The studies presented at this biological psychiatry conference made a strong case for focusing on increasing positive mood, because, when one does so, positive feelings increase and distress dissipates.

Jill Leslie Littrell, PhD
Professor, Georgia State University

 

From Allan Leventhal

I found the dialogue between Robert Whitaker and Jim Phelps very interesting. Perhaps what struck me most was the contrast between the basis for their conclusions regarding the outcome of the prescription of anti-psychotic and antidepressant drugs. In Whitaker’s case, it is data, in Phelps’ case it is anecdote.

Insel, too, depends on anecdote in his book, “Healing” (a strikingly odd title for his book given his acknowledgment of worsening of just about every measure of mental health during his tenure at the NIMH). As director of the NIMH, Insel spent 20 billion dollars on research, the great bulk of it on neurological research, very little on psychological research. He admits this enormous expenditure has had no beneficial effect on patients. The absence of science behind the prescription of antidepressant drugs clearly doesn’t count for much to him. He is certain that psychotherapy must be an adjunct to psychiatry’s medicalization, despite the abundance of data favoring psychotherapy as more effective and safer than drugs.

The dialogue in Mad in America well illustrates Whitaker’s thesis about psychiatry’s failure as a responsible medical science, which also is the subject of my book, “Grifting Depression: Psychiatry’s Failure as a Medical Science,” where I show how psychiatry has repeatedly failed testing of the three pillars of the science of health care: diagnosis, explanation, and treatment. The data show that conflict of interest, not science, is driving psychiatry’s medicalization.

Although economic interests are a problem throughout medical care, by contrast, medical care applied to the care of physical illness is data driven. It is this insistence on science, of course, that explains the contrast between the great advances that have been made over the last hundred years in physical health care that are absent from the treatment of mental disorder.

With respect to depression, which has become without justification the #1 psychiatric diagnosis, Kirsch’s research on the placebo effect explains the value of antidepressant drugs in psychological, not medical terms. And Fava’s review of the damaging effects of the chemicals in these drugs on brain function gives ample warning of their harmfulness. Psychiatry rejects these data despite their objectivity.

We need to be wary of anecdote, whether from a researcher, doctor, or patient. This is not to deny the importance of listening carefully to patients, but patient insight is very rarely of value in establishing cause and effect relationships.

On a personal note, in my practice, I saw many people who had been prescribed antidepressant drugs after having been misdiagnosed as depressed and others as bi-polar despite their never having experienced a manic episode. Their mania was regarded as “incipient.” Diagnosis has been monetized, serving as a justification for prescribing medications that benefit psychiatry and the drug companies, not patients. That’s what the data tells us.

Allan M. Leventhal, PhD
Professor Emeritus, American University

 

From Robert Nikkel

A fundamental question comes to mind when I think about the dialogue Bob Whitaker has created in response to Jim Phelps and that is this:  how can one actually measure “doing more harm than good?”  I see nothing in either of Dr Phelps’ statements and analysis that help me evaluate this question.  I do see assertions that people may read Mad in America and because of this go off meds.  The data shows however that if done carefully most will do better off than on.  I don’t see any data to back up the claim of MIA doing more harm than good.

I do question how many actually decide to reduce or go off meds simply because of reading Anatomy of an Epidemic or MIA.  A comparative measurement would have to take into account how many of us go off them simply because they make us feel worse or do not make us feel better.  I would venture to guess the comparison would show far more of the latter personal experiences of unwanted outcomes than of the former.

I think this kind of analysis would also have to look at the harm reflected in poor outcomes or worsening health as a result of doctors’ prescribing the drugs.  I venture to say that this is responsible for a massive amount of harm.  Shouldn’t that be counted in the equation?

Another reaction I have is that in the years I spent working for MIA directing its continuing education program, I didn’t experience within the organization the kind of certainty it is being accused of. I do see Bob looking at the research,  telling us about the relative validity of those studies relating to outcomes and then telling us, from his perspective as a medical journalist, what they mean.  His job isn’t to tell us how that should change psychiatry other than pay attention and do the right things.  That’s ours.

I have tried to do my part which has been to organize quite a number continuing education presentations over the past 6 or 7 years to get this kind of information out there.  We need help to expand the scope of learners into medical schools and all forums where these sorts of courses get into in-service training.  Unfortunately our continuing education accreditation service repeatedly told us we were one of a kind.

Robert Nikkel
Former MIA Continuing Education Director

 

From Maria Mangicaro

The dialogue between Dr. Phelps and Robert Whitaker certainly deserves careful consideration. In his post, The Baby in the Psychiatric Bathwater, Dr. Phelps makes these assertions:

  • In agreement with Robert Whitaker, “psychiatry has come to place far too much emphasis on medications and too little on psychotherapy.”
  • Mania is an example of a symptom that is not a “social construct” and psychiatric treatment of mania leads to better outcomes than no treatment.

As someone who experienced manic symptoms and psychiatric treatment, I believe psychiatry places too much emphasis on medications and too little on the actual practice of medicine.  Individuals who suffer states of mania, psychosis or other symptoms considered to be psychiatric disorders, deserve to know these symptoms could be caused by a wide variety of underlying medical conditions, including some that could be life-threatening.  Recognizing and treating underlying medical conditions that manifest as psychiatric disorders would also help family members better understand what their loved ones are going through and reduce the stigma associated with “mental illness”.

I feel the effort of Robert Whitaker and Mad in America are helping to advance best practice standards within our mental health care system.

Kind Regards,
Maria Mangicaro