Tag Archives: antipsychiatry

12/22/20

Psychiatry Is Different, Not Irrelevant

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The Vice article, The Movement Against Psychiatry, opened with a disturbing story about two women who sought help from the mental health system, but received very different and ultimately harmful results. One woman refused to take medication or see her therapist and her condition deteriorated until she was eventually psychotic and incarcerated. The second woman served as a sergeant in the Army and sought psychiatric help while she was receiving medical care in Germany when she learned her convoy hit a roadside bomb in Iraq. “I walked straight down the hallway to the psychiatry office because I thought that’s what you do when you need help.” That began 13 years of being treated with 45 different medications, up to 18 at the same time until she said enough.

“The Movement Against Psychiatry” by Shayla Love used these two women to illustrate the contrasting position at the center of the debate of how to fix—or to do away with—the way we treat mental illness: over and under medication. At the core of this issue are the differences between psychiatry and what is called anti-psychiatry or critical psychiatry. But Love does not give a very fair presentation of the so-called anti-psychiatry position. This assessment is shared by Robert Whitaker, the journalist, author, and founder of madinamerica.com, which Love said was probably “the most active and legitimate critical psychiatry platform that exists today.”

Whitaker wrote a response to the Love’s article, “Vice, MIA and The Movement Against Psychiatry,” in which he presented a three-pronged assessment of what Love wrote. First, he gave an explanation of the mission of Mad in America. Then he addressed a common criticism made against himself and the Mad in America website that Love repeated, namely that Whitaker and his webzine distort the scientific record of psychiatry. Lastly, he saw the article as an opportunity to illustrate how the media, represented by Vice, perpetuated the conventional narrative about psychiatry.

In a section of his article titled: “Understanding Mad in America,” Whitaker gave a description of how the webzine seeks to be a forum for developing a new narrative to guide society’s thinking and care about psychiatry and its drug treatments. He then went on in “Deconstructing the Vice Article,” to describe some surprising details about what seems to be Love’s failure to remain unbiased. Love did not interview Whitaker for her article, instead she contacted him by email one week before her article was to be published. Whitaker also invited her to contact the researchers whose work he was said to have misinterpreted in order to see whether they thought his reporting of their work was inaccurate.

It seems she also failed to do that as well. Whitaker said, “All she needed to do was read the studies, call Harrow or Jobe, and she could have had a blockbuster article, anchored by research that revealed there was a scientific rationale for a “movement against psychiatry.”

Martin Harrow and Thomas Jobe had investigated long-term outcomes of patients diagnosed with psychotic disorders. They found at the 15-year mark that the recovery rate for schizophrenia patients off medication was eight times better than those who were medication compliant. Whitaker noticed in their data that even patients with milder psychotic disorders who stayed on antipsychotics had worse long-term outcomes than those with schizophrenia who got off medications. Harrow and Jobe later published further analysis of their long-term data and cited him and Joanna Moncrieff among those who questioned the received narrative for long-term outcomes for those who were using antipsychotics. Harrow and Jobe said:

Overall, the longitudinal studies cited do not provide conclusive proof of a causal relationship between being off medications and being psychosis free. They do clearly indicate that not all schizophrenia patients need continuous antipsychotics for a prolonged period, providing extensive evidence of samples of medication-free schizophrenia patients with favorable outcomes.

Whitaker’s deconstruction of “The Movement Against Psychiatry” illustrates how the article reinforces the conventional narrative of psychiatry. Read an op-ed article for MedPage Today, “Why Anti-Psychiatry Now Fails and Harms,” if you want an example of what is meant by the conventional narrative. Coincidentally, two of the three authors of the MedPage Today article were cited or quoted by Love as supporting the conventional narrative.

The Vice article was presented as an exploration of the “movement against psychiatry,” and yet you can see, once it is deconstructed, how it told a story that surely pleased the promoters of the conventional narrative, and put the “critics” on the defensive at almost every turn.

The concluding comments in Whitaker’s article appear to invite further dialogue between psychiatry and so-called “anti-psychiatry,” but he seems to be frustrated with the way many media outlets—Vice being the example here—protect and perpetuate the conventional narrative of psychiatry:

I hope that deconstructing this article—and revealing the journalistic standards that are on display—helps reveal the depth of the challenge for those who would like to see “psychiatry reimagined.” Unfortunately, this struggle is regularly hindered by the fact that media are often poised to report in ways that protect the conventional narrative, and look askance at those who would challenge it. But as is the case in any struggle, it’s always good to know what you are up against.

It also seems that Love may have misrepresented more than just Whitaker and Mad in America. Awais Aftab, a psychiatrist and author of an interview series for Psychiatric Times,” was prompted to clarify the context surrounding Love’s quotes of him the day after “The Movement Against Psychiatry” was published in: “The VICE Story: Beyond Anti-psychiatry.” Dr. Aftab appeared to be attempting a corrective against the potential for “the VICE Story” to lead too far into a “polarizing discourse.” He said he does not identify as a “critical psychiatrist,” because he does not think “critical” serves well as an identity function. He also said “anti-psychiatry” is an imperfect term because very few individuals today self-identify their views as being anti-psychiatry. Nevertheless, “one can still recognize the tremendous need for reform, and acknowledge the valid ways in which an exclusive emphasis on medical conceptualization can be harmful.”

This is a delicate and qualified position and navigating a dialogue from such a position is subject to the constant pressure for the dialogue to collapse into one polar position or another. I do not always succeed in that, but I try. That has precisely been the function of my interview series for Psychiatric Times, “Conversations in Critical Psychiatry”, where I try to engage with various critical and philosophical perspectives.

Attempting to maintain that dialogue, he noted how Love recognized the need to resist a polarizing discourse in her article. He pointed out that Love said it was nearly as useless to be steadfastly pro-psychiatry as it was to be anti-psychiatry. He concluded by saying: “One can recognize the need for meaningful criticisms and structural reform without delegitimizing the medical basis of psychiatry.”

Although Shayla Love did not interview Robert Whitaker for her article, John Horgan did interview him for an opinion piece published online for Scientific American, “Has the Drug-Based Approach to Mental Illness Failed?” When asked if he saw himself as a journalist or an activist, Whitaker said he didn’t see himself as an activist at all. He then quoted the mission statement for Mad in America, which said its mission was to serve as a catalyst for rethinking psychiatry. The current psychiatric paradigm has failed. Scientific research and the lived experience of those who have been diagnosed with a psychiatric disorder both call for a profound change.

The usual practice in “science journalism” is to look to the “experts” in the field and report on what they tell about their findings and practices. However, while reporting and writing Mad in America, I came to understand that when “experts” in psychiatry spoke to journalists they regularly hewed to a story that they were expected to tell, which was a story of how their field was making great progress in understanding the biology of disorders and of drug treatments that—as I was told over and over when I co-wrote the series for the Boston Globe—fixed chemical imbalances in the brain. But their own science, I discovered, regularly belied the story they were telling to the media. That’s why I turned to focusing on the story that could be dug out from a critical look at their own scientific literature.

Dr. Aftab’s comment above, about doing meaningful criticism and structural reform without delegitimizing the medical basis of psychiatry, may have captured the essence of the struggle between psychiatry and “anti-psychiatry.” Psychiatry wants to hold on to its identity as a medical specialty and sees the critique of Whitaker and others as a distinct threat to that identity. Perhaps the way forward lies with Lisa Cosgrove’s remarks quoted in “The Movement Against Psychiatry.” She said the fact that there are not any biomarkers doesn’t make psychiatry irrelevant as a medical discipline. “It just makes it different from other subspecialties in medicine.” Psychiatry needs to embrace its difference.

11/10/20

Does ‘Medical’ Mental Illness Exist?

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A recent article in Vice, “The Movement Against Psychiatry,” wrestled with the ongoing debate between mainstream, institutional psychiatry and what has been called “anti-psychiatry” or critical psychiatry. The subtitle to the article was “The contentious debate of whether to fix—or completely overthrow—the way we treat mental illness.” Around the same time Mad in America highlighted an article published in the American Journal of Physical Anthropology, “Mental health is biological health.” The authors noted that while the biomedical sciences have rapidly reduced the global burden of infectious disease, mental disorders are emerging as major contributors to the global burden of disease. However, “the causes of most mental disorders … remain a mystery, and there has been little progress in reducing the prevalence of any of them.”

You get a condensed, but ultimately biased, picture of the debate, and are introduced to several of the individuals and institutions associated with anti-psychiatry in “The Movement Against Psychiatry,” whose author said anti-psychiatry should not be dismissed as a fringe movement. Issues like over-medication, and problems tapering off of meds are being seriously discussed within mainstream psychiatry. An interview series published in Psychiatric Times called “Conversations in Critical Psychiatry” seeks to engage “prominent individuals who have made meaningful criticisms of psychiatry and have offered constructive alternatives.” Awais Aftab, the author and interviewer for “Conversations in Critical Psychiatry”has interviewed several of the same individuals quoted and referred to in “The Movement Against Psychiatry”: Allen Frances, Sandra Steingard, Lisa Cosgrove, and Lucy Johnstone. Other individuals interviewed for “Conversations in Critical Psychiatry” include Joanna Moncrieff, Giovanni Fava, and Ronald Pies—names I recognized from my own journey and reading articles for and against “anti-psychiatry.”

In “Mental health is biological health,” you find a persuasive argument for a “re-thinking” of psychiatry from the ground up, including psychopharmacology and diagnosis. The authors said scientists understand little about the etiology of mental disorders and noted popular treatments like antidepressants and antipsychotics “have only moderate-to-weak efficacy in treating symptoms” and do not target biological systems that correspond to discrete psychiatric syndromes. The track record of biological psychiatry was said to be poor. “So far, there are no diagnostic tests, and treatments have limited efficacy.” Many critics believe this is due to fundamental flaws in the DSM classification system and that it is impeding research.

Unlike the natural classifications of plants, animals, infectious diseases, and inorganic substances, which all played key roles in the discovery of underlying causal principles, such as the theory of evolution, the atomic theory of matter, and the germ theory of disease, the various classifications of mental disorders have failed, so far, to uncover their underlying causes. The current system has little claim to be a “natural” classification, and is instead deeply contingent on the specific history of psychiatry.

Both articles are long, but worth reading and digesting, if you are interested in the topic. But first let’s push through some of the rhetoric. “The Movement Against Psychiatry” made a distinction between “anti-psychiatry” and “critical psychiatry” seeing anti-psychiatry as having more of an abolitionist sense—a movement of people who feel psychiatry is harmful and needs to be eradicated. Critical psychiatry may be a good lens to see how a biological paradigm has captured our cultural and medical understanding of mental distress. Lucy Johnstone said she agrees with many of the points made by critical psychiatry and opposes what she sees as the medical model of mental illness. She added the term anti-psychiatry is used in the U.K. as an insult.

Challenging the medical model of mental illness seems to be at the heart of the current debate over “anti-psychiatry.” Psychiatrists see their position as a medical specialty being attacked by so-called “anti-psychiatrists.” Aftab, who is a psychiatrist, warned that anti-psychiatry positions run the risk of encouraging distrust of the medical system and available treatment options. This leads people to be wary of seeking help. “For individuals who are on psychiatric medications, they can abruptly discontinue their medications with very serious consequences.”

On the other hand, “Critical psychiatry is more of a reformist movement, attempting to address psychiatry’s issues while maintaining some semblance of its infrastructure.” Lisa Cosgrove, a clinical psychologist and professor at the University of Massachusetts Boston, has a more nuanced view of psychiatry as a medical discipline. She said the fact that we don’t have biomarkers does not make psychiatry irrelevant as a medical discipline. “It just makes it different from other subspecialties in medicine.”

The failure to identify biomarkers for psychiatric illnesses under the auspicious of the medical model of mental illness, despite decades of research and millions of research dollars, stands in direct contrast to the progress with other medical specialties over the past 150 years. Psychiatry seems to feel uncomfortable or self-conscious of this difference.

In her article “Does ‘Mental Illness’ Exist?”, Lucy Johnstone said it obviously does exist, but the idea that the experiences subsumed under the term ‘mental illness’ are best explained as medical disorders “has never had any evidence to support it.” She said that despite decades of research, no so-called symptoms have been causally linked to established patterns of chemical imbalances, genetic flaws or other bodily malfunctions. “Any science – in this case medicine – needs to be able to demonstrate that it is based on a reliable and valid classification system, in order to develop testable hypotheses and hence the general laws that constitute a body of scientific knowledge.” If this cannot be established, she said the whole model breaks down and all psychiatry’s functions are fundamentally undermined. “In the words of Peter Breggin, psychiatry would then become ‘something that is very hard to justify or defend – a medical specialty that does not treat medical illnesses.’”

Johnstone said a psychiatric diagnosis turns ‘people with problems’ into ‘patients with illnesses.’ Psychiatry itself is a failed paradigm. While we have made extraordinary advances in what she called legitimate branches of medicine, “we have made no comparable progress in the illegitimate branch of medicine that calls itself psychiatry.” Her suggested starting point for understanding  these problems was ‘formulation,’ the process in psychology of making sense of a person’s difficulties in the context of their social circumstances and life events. “The professional contributes their clinical experience and their knowledge of the evidence—for example, about the impact of trauma. The client or service user brings their personal experience and the sense they have made of it.”

In “Moving Beyond Psychiatric Diagnosis,” Awais Aftab interviewed Lucy Johnstone for his series, “Conversations in Critical Psychiatry.” He said he was intrigued by her envisioning formulation as an alternative to psychiatric diagnosis. He thought most people in psychiatry and psychology don’t see diagnosis and formulation as mutually exclusive, but rather as complementary and synergistic. “In fact, many would argue good diagnostic practice requires diagnosis to be made in the context of a formulation. Why should we see diagnosis and formulation as competitors rather than allies?” Johnstone replied:

The argument for psychological formulation—or formulation as an alternative to diagnosis—is simple. A formulation is a hypothesis, drawing on the best evidence, and tailored for the particular client. If you have a reasonably complete hypothesis, based on someone’s life experiences and the sense they have made of them, about why they are having mood swings or feeling suicidal or self-injuring, then you don’t need another, competing hypothesis that says, “And it is also because you have bipolar disorder/clinical depression/borderline personality disorder.” Even if we think these are valid categories, the diagnosis is now redundant. 

Aftab disagreed that a diagnosis could be conceived as a causal hypothesis. He later asked her if she advocated for the abolition of psychiatric diagnosis. Johnstone said she did not think “abolition” was the right word. She believed they should use concepts that were evidence-based and jettison those that weren’t. Aftab responded by saying he thought it was disingenuous to argue that psychiatric diagnoses were not valid with respect to a certain scientific standard and then not apply the same standard to psychological formulations. But Johnstone was not distracted from her point.

She replied that in science, it was understood that constructs routinely had to be revised and then abandoned in favor of more accurate ones. She noted that in Biblical times, people believed madness was caused by evil spirits. No one could see them, but everyone was certain they existed. Diagnoses like schizophrenia were based on the same logic. “There are no bodily signs to confirm or disconfirm their presence, but we are convinced we’ll find them someday. This is purely a matter of faith, and it flies in the face of the mountain of evidence for psychosocial causal factors in all forms of mental distress.”

We may be able to come up with all kinds of cleverly nuanced perspectives on how we, as professionals and philosophers, understand psychiatric diagnosis, but the fact remains that people are being told they have mental illnesses and disorders, with all the usual connotations of those terms in Western societies. Moreover, they are heavily encouraged to take on the particular narrow understanding that you refer to—we are all bombarded with messages about “mental illness” being “as real as a broken arm”, and needing to be managed by drugs “just like diabetes.” Even the dubious compromise that is the “biopsychosocial” model—a way of acknowledging some role for psychosocial factors while at the same time instantly relegating them to “triggers” of a disease process—is not much in evidence on the ground. And furthermore, the biomedical message is reinforced by the fact that these labels are applied by doctors and nurses, working in hospitals and clinics, who use not just the labels themselves but the whole medicalized discourse of symptom, patient, prognosis, treatment, relapse, and so. The “stereotypical biomedical understanding of diagnosis” as you put it, is absolutely everywhere.

Aftab said clearly there was a lot wrong with the popular perception of what a diagnosis entails and he thought they needed tremendous effort to counter that. But he thought she was engaging in a certain sense with a strawman—a widespread stereotype of psychiatric diagnosis. If she was only trying to convince the public or professionals who did not have a nuanced understanding, her arguments worked well. But if her goal was to engage with thoughtful psychiatrists and psychologists, they were not sufficient.

Johnstone replied that her primary goal was to work towards a non-medical understanding of emotional suffering, which was what “mental illness” actually meant. She and her colleagues decided this was necessary because “there is not and never has been” any hard evidence that experiences that are now called “mental illness/disorder” were best understood in that way. There is an overwhelming amount of evidence that they arise from within the person and can be understood as a response to psychosocial adversities. “The dominance of the diagnostic viewpoint blinds us to the extent to which non-medical alternatives are already flourishing.”

In summary, it doesn’t matter whether you think I am putting forward a caricature of diagnosis. Diagnosis—however we choose to understand it—has no place in this field, and nor does the diagnostic thinking that it supports and perpetuates. All human experience has biological aspects, but not all forms of suffering are medical illnesses. We are dealing with people with problems, not patients with illnesses, and the whole paradigm—the “DSM mindset” as clinical psychologist Mary Boyle puts it—needs to change.

Notice another piece of rhetoric here: diagnosis itself is a medical term. So, the critique of psychiatric diagnosis has a medical nuance from the start.

Returning to “The Movement Against Psychiatry,” I agree that whether we are pro-psychiatry or anti-psychiatry resolving disagreements over the medicalization of ‘problems in living’ is complicated. After millions of dollars in research funding, biological psychiatry still finds the human brain to be an enigma. As Allen Frances said, “The human brain is the most complicated thing in the known universe and keeps its secrets well hidden.” Yet he thought the next right thing in care for the severely mentally ill was simple: decent housing; easily accessible treatment; social clubs; vocational rehab. The top priority was to get people out of prison and off the streets; and provide them with proper community housing and care. “How can it be that the richest country in the world is most neglectful of its most vulnerable citizens?”

It’s nearly as useless to be steadfastly pro-psychiatry as it is to be anti-psychiatry. Psychiatry is not a monolith, but an entire field and history, with some practices that are more helpful than others, and a huge range of diversity in terms of the kinds of people it treats.

Can’t we start with a critical psychiatry approach and see where it leads us? Calling for the abolition of psychiatry or diagnosis only results in the further entrenchment of psychiatry and supporters of the medical model with no real change to the existing system. Attempts at dialogue, as with Dr. Aftab’s interviews for “Conversations in Critical Psychiatry” and the formation of groups like CEP, Council for Evidence-Based Psychiatry, and the Critical Psychiatry Network are a good start.

10/15/14

Psychiatry’s Mythical Phoenix

Prominent research psychiatrists are beginning to sound like their “antipsychiatric” critics. They are saying the current DSM diagnostic system isn’t valid; that something new, something scientifically sound and useful for treating patients is needed. One of these research psychiatrists is Thomas Insel, the Director of the Director of the National Institute of Mental Health (NIMH). He dropped a bombshell last year when he announced that the NIMH would be “re-orienting its research away from DSM categories.” The New York Times quoted Insel as saying: “As long as the research community takes the D.S.M. to be a bible, we’ll never make progress. . . . People think that everything has to match D.S.M. criteria, but you know what? Biology never read that book.”

So the NIMH has developed a new research strategy to classify mental disorders based upon “dimensions of observable behavior and neurobiological measures.” This strategic plan is known as: Research Domain Criteria (RDoC), a framework for collecting data needed for a new nosology. The goal is for RDoC to “transform diagnosis by incorporating genetics, imaging, cognitive science, and other levels of information to lay the foundation for a new classification system.” It was not meant to be a useful clinical tool.

RDoC is in search of the holy grail of psychiatry: reliable biomarkers (measurable indicators of a biological state or condition) for mental disorders. This search for biomarkers has been going on for decades. David Kupfer, the chair of the DSM-5 Task Force said: “We’ve been telling patients for several decades that we are waiting for biomarkers. We’re still waiting.” Susan Kamens suggested that the imminent discovery of biomarkers has been “the driving expectation of psychiatry since its birth in the 18th century.” But there are some problems with the RDoC quest.

What RDoC proposes is to replace the DSM diagnoses used currently to frame mental health research with broad categories based upon cognitive, behavioral and neural mechanisms. This means that the NIMH will be supporting research projects that look across or sub-divide existing DSM categories. But this very same DSM is what is used to assess the potential of future NIMH-funded research under RDoC.

In an article found in Nature, “Psychiatry Framework Seeks to Reform Diagnostic Doctrine,” Nassir Ghaemi said: “It is very hard for people who have been following the DSM their entire professional lives to suddenly give it up.” Ghaemi has felt shackled by the DSM. He wanted to do some research that cut across DSM categories. But his colleagues warned him against straying too far from the DSM structure when he applied for funding from the NIMH, because peer reviewers tended to insist on research structured by the DSM. So he held off from applying.

Steven Hyman, a former NIMH director, blames the DSM for hampering research into the biological or genetic basis of psychiatric illness. He said it was “a fool’s errand” to use symptom-based DSM diagnosis with little basis in nature to try and find a biomarker. Hyman urged the NIMH to think about how biomarkers identified by RDoC would be incorporated into mental health practice with the DSM. “It would be very problematic for the research and clinical enterprises to wake up in a decade to a yawning gulf.”

But Susan Kamens sees a deeper problem with blaming the DSM for hampering the search for biomarkers—it takes for granted that the biomarkers exist. In other words, it presumes what it seeks to find. According to Kamens:

“The main difference is belief versus doubt in the hypothesis that what we call mental disorder is primarily a disorder of biology. We treat that hypothesis as unfalsifiable, as if the proof [that mental disorder is biological] arrived before the evidence. We don’t test whether the hypothesis holds; we test whether and how to make the data fit it. When critics raise doubts, they’re often accused of ignoring the very same evidence that psychiatric researchers have recently declared to be utterly insufficient.”

Kamens noted that the RDoC “blueprint” is no less theoretical that the DSM-5. While the RDoC constructs are more measurable than the categories listed in the DSM, they are “essentially no more than basic human emotions and behaviors.”  She asked how RDoC would make clinically meaningful determinations into its “domains” and “constructs”? How would the research reveal anything beyond the coordinates of normal psychological processes? “In other words, how is RDoC anything beyond basic (nonclinical) neuroscience?”

RDoC is developing a new research model that will undoubtedly yield unprecedented data, but it focuses on the biogenetic correlates and normative mapping of basic psychological processes like visual perception, language, fear responses, and circadian rhythms. The idea is to create interventions for psychological and physiological processes that deviate from the norm. For this reason, RDoC is less likely to save psychiatry than it is to resurrect eugenics.

The quest for biomarkers in psychiatry can be likened to the legend of the phoenix, a mythological bird that repeatedly rises out of the ashes of its predecessor. The DSM seems to be near end of its life-cycle. Now psychiatry is building an RDoC “nest” that it will eventually ignite, reducing both the DSM and RDoC to ashes. And from these ashes, it is hoped, a new diagnostic system—a new phoenix—will arise.

Also see my blog post, “Psychiatry Has No Clothes.”