Wednesday, November 3, 2010

Psychiatry Bashing

Anyone who follows this blog or who has read my new book is well aware that I am highly critical of many of my colleagues in the mental health professions. Drugs are prescribed inappropriately and dangerously, diagnoses are made cavalierly and without considering all the evidence, relationship problems and family dysfunction are ignored, and some therapists think that an unresoved Oedipus Complex is the final common pathway for all mental and behavioral problems, or that food pellets and electric shocks are more important than relationships in shaping human behavior.

Furthermore, I have written about how many so-called psychiatric "experts" are in bed with the pharmaceutical companies and how managed care insurance has done its best to devalue all psychiatric treatments.

My own brother-in-law stated, after he read my book, that on the basis of what I had written he would be reluctant to consult any mental health provider.

Nonetheless, I know that there are a lot of ethical and competent psychopharmacologists and psychotherapists doing fine work out there.  They have just become a bit harder to find.  In my book I tell the reader what to look for when they first visit a new clinician.

Folks, there is more than enough blame to go around for the current troublesome trends in the mental health field.  Another party also worthy of blame is the American public.  In fact, none of the horrible practices in mental health could have taken root without the American public's enthusiastic support and participation.

Consider the following: a lot of people these days seem to be looking for a quick cure for everything. For all the anti-drug hysteria in this country, people want to be medicated for everything. Do the hard work of therapy on your relationships? It's too much work!

Distracted at home or at work?  Taken an Adderal.  Doctors will hand them out like water.

As one psychiatry blogger, FunPsych, pointed out, "...many Americans, if given a choice between exercising for an hour a week versus taking a weight-loss pill, would choose the pill...Furthermore, Americans are already overworked and feel pressured to work even more. At least half the patients that I've seen that I want to do therapy with just don't have time for it."  Or so they say. 

Kids out of control? Do most parents want to look at their own parenting practices to see if they are contributing to their children's behavior problems? Some may write to get free advice from the Supernanny and get on TV, but I've already placed several posts about the answer to this question.  Rampant child abuse and neglect?  Nothing but implanted memories and false accusations, according to many.

A psychiatrist who wants to do the right thing can go bankrupt.  If a resident fresh out of training is looking for a job, he or she will find this situation as described by another psychiatry blogger, Pacificpsych: 

"Show me one [psychiatry] job in the entire US ... that entails psychiatrists doing therapy. The entire system consists of psychiatrists being forced to medicate, as well as them being controlled by insurance, UR people, nurse admin, non nurse admin...Show me the clinics or hospitals where you can get a job doing anything else but medicating patients." 

Rehabilitation for schizophrenic patients instead of just meds?  The public will not pay for it, and therefore it has become nearly non-existant in the public sector, and almost as rare privately.

Mental health is the first thing that is cut when state finances get tight?   Why?  I'll tell you why.  Because the mentally ill do not vote, and most of the public does not give a sh*t.  Because many politicians seem to think the mentally ill are all slackers, agreeing with the rabid antipsychiatry zealots (more on them shortly) that all mental illness is a myth. (How ironic that Ronald Reagan suffered from a mental illness - Alzheimer's disease - for the last part of his life).

And then we have the antipsychiatry lot who seem to be incapable of making any distinctions at all. All psychiatric drugs damage people and do nothing else, according to these people.

Apparently they believe there is some vast worldwide conspiracy to ignore the supposed horrific dangers of, say, antidepressants (which have been in use since the 1950's), and that the FDA as well as legitimate FDA watchdog groups like Public Citizen (not to be confused with Scientology's Citizens Commission on Human Rights) have somehow completely missed the millions and millions of patients around the world who have been destroyed by these widely-used and popular drugs.

But we know the FDA is completely in the hip pocket of the pharmaceutical companies.  (Of course, the FDA put a "black box" label on antidepressants on the basis of rather minimal evidence warning of potential suicidal ideation caused in teens and children.  How did that ever happen?)

I received a few comments on one of my blog posts by one reader that I decided not to post. I'd like to share some of them here: 

"Psychiatry is an evil profession, and you know it...Psychiatry has changed very little since 1938, when it was the training ground for the SS - exterminating up to 100,000 German citizens who were deemed "mentally ill" with 'special treatment'...Is psychiatry an evil profession? Absolutely...

I looked [at your blog]. What I found was the writing of a guy who wants to be different from his peers, but isn't. You have very little respect for people who suffer. One minute, describing how their condition is related to past trauma, the next minute ridiculing their behavior. You wrote the book on personality disorders, it appears. Yet your own personality is about as twisted as any person I've ever read...You seem to be a very miserable person, an abusive person...Your arrogance leaves me nauseated...You are an abuser, and YOU KNOW IT !!!!!!!!!!!!!!!!!!!!!!!!!!!!!"

Let's see. If I use a little snarky humor or exaggeration in a blog in order to make a point and to entertain readers (guilty as charged!), then of course I surely must consistently and abusively ridicule my own patients. I suppose I should never see any black humor in my patients' horrible predicaments; if I had any empathy at all I would be depressed along with them. (That's what patients really need: a doctor who is as depressed as they are).

This guy says I am a knowing participant in an evil profession. Psychiatrists like me who have committed people who are a danger to themselves or others are no better than the Nazi psychiatrists who helped exterminate the mentally ill during WWII.  Yes, I know all about Ernst Rudin and the eugenics movement - you will find an interesting discussion of it in Chapter One of my new book.   I guess that makes me a Nazi. There will undoubtedly be a picture of me with a Hitler mustache on some placard someday.

He accuses me of all these horrible things and yet he tells me I am abusive? That's rich! Pot, meet kettle.

Are patients who are terrified by persecutory delusions and hallucinations and who are found running nude on the freeway by the police better off in jail, where many of them in fact are now, or on Skid Row, than in a hospital? 

Pacificpsych also said, "...even psychiatrists who are completely opposed to the current system have no power to change it. They are trapped, unless they are in private practice and doing well there. YOU, yes YOU need to help us. Go to the administrator of the clinic, call the health insurance/medicare/medicaid administrator, call your senator and congressman. Demand that you get proper treatment. That means spending as much time with your psychiatrist as you and your psychiatrist feel is necessary..."


  1. How exactly is Alzheimers (I'm assuming you would also include dementia)classified as a mental illness? We know that schizophrenia used to be called dementia praecox, until it was decided it was not the same thing at all. Most adults if they live long enough develop dementia. Are most people then mentally ill?

    While I also tend to agree with many of the points you raise, the system as it has developed particularly in the USA is perverted by lobbying and financial incentives. People who criticize the system are demonized as crackpots by, yes, the American Pychiatric Association.

    The problem with many of the people who feel most strongly is that they demean their cause by not self-censoring their outbursts. They could advance their cause a lot further if they figured this out.

    That being said, I think you are being rather sensitive. There is a give and take here.

  2. 1. Many of us do vote, as it happens. I realize you're making a generalization that includes highly disabled people, but as you know, nuance tends to get lost on the Web, where Everything Is Literal--and which leads, not coincidentally, to a second point:

    2. As for this comment--"One minute, describing how their condition is related to past trauma, the next minute ridiculing their behavior"--I too have had that reaction to some of your posts. Again, given the Everything Is Literal bind that can follow the problem of tone online, sometimes it's difficult to determine whether the humor is of the heaven-help-all-mortals variety or the borderlines-are-a-completely-homogenous-group-of-users-out-to-destroy-you variety.

    These are observations, not criticisms. Most people probably wouldn't keep reading if they weren't also learning.

  3. "Moderation in all things," I think, "including how we perceive a profession, and how we practice it ..."

    I've "sat in both chairs" --> been in the roles of both therapist and person seeking help. The range of behaviour in both practitioners and patients covers the entire range of human possibilities ...

    It is a terrible waste of practitioners' learning, wisdom, skills and gifts to expect them to dispense pills and nothing else -- the quick-fix mentality is ruinous to any chance of lasting change and deep healing; they only occur, if they can, through authentic presence and relation ... This is my bottom line in all things, not only in therapy ...

    It must be a constant stress for any practitioner who wants to fully practice his profession to be hounded by the powers that be to scribble out prescriptions, rather than to actually engage with another person ... and for those of us who seek genuine *care* in our therapists, it is devastating to be seen and treated only as a complex of symptoms or as a "disorder" ...

    I imagine that until the powers-that-be are no longer solely invested in profit, the imperatives for practitioners won't change ... and many therapists who are in private practice charge too much for most people who need their skills.

    Yes, all our experience runs the entire gamut ... I've had a couple of therapists who were literal life-savers and who lived as proof that healing is possible, and a few mind-blowing, huge-hearted clinical supervisors ... and I've had my share of (forgive me) idiots who kept one eye on the clock and whose fingers were itching to pull out the Rx pad. One man, during a one-time, mandated psych consult, dismissed me after 14 minutes. He told me, "You don't qualify for PTSD," and simply shrugged when I replied, "My physician of 20 years would disagree with you." What a waste of my time, my intention to be well again, and of money that could have been better spent in actual care. I've ended up doing a great deal of self-care, moment by moment ... and when all's said and done, it's my intimate relations with cherished family and friends that make the deepest difference. We're all in this together ...

  4. I have not long found your blog and am heartened by your honesty; it is a rare thing for a psychiatrist to acknowledge that many in his profession are medicalising normal human emotions and 'bad behaviour'.

    Bad parenting leading to bad behaviour - medicalise it - make it a disorder. Sadly, many parents would rather accept an ADHD dx for their child than offer their child guidance, routine, boundaries and instil in them respect for others. Gross generalisation the aforementioned is not meant to be.

    Mental health loses out the world over, and as you rightly say - if you don't suffer from a problem - you don't give a shit. It seems to me that for an adult to have a mental health problem - the stigma attached is enormous; but for junior to be given a label - that's okay if it excuses lax parenting.

    I must state that I work in mental health and am proud to do so. Those suffering from mental ill health do get a raw deal - it is the Cinderella of medicine.

    Rant over!

    Anna :o]

  5. Thanks for the comments, everyone.

    Rossa, yes dementia is classified as a mental disorder, and Alzheimer's is one cause of it. It is a disease of the elderly. Just like cancer and cardiovascular disease, the longer you live the more likely you are to get it. You are not mentally ill, however, until you do get it.

    I agree with you that the APA, like most trade organizations, tends to demonize any opposition.

    Anonymous: very well put! I must admit I am tired, when making generalizations, of constantly having to include the usual caveats that not all the people I am talking about do what I describe, nor are the ones who do do it doing it all the time, that of course there are other people who do the same things, and there are always a lot of other factors that contribute to the behavior I'm generalizing about. So I tend to leave all that out.

    Just using the DSM criteria, there are almost 200 different combinations of character traits that qualify for the diagnosis of borderline personality disorder, so obviously they're not all clones.

    Thank you for giving me the benefit of the doubt about the snarky comments. Believe it or don't, but the comments are all of the "heaven help all mortals" variety. (Sometimes, however, one does need to get people's attention by hitting them over the head with the truth).

  6. My problems with psychiatry.
    The religious belief that the psych meds-drugs can only do "good" things to a patient. Psychiatry only does "good". There are never mistakes in psychiatry.

    All of the patients are willing patients.

    Before a prison term, the person is proven guilty of a crime from some kind of evidence and a trial with both con and pro voices.
    If in a hospital psych ward the person is locked up on a single persons ( the psychiatrist) judgement of sanity. This judgment is supposedly scientific and medical in nature and stays with the patient-person for their life.

    40 billion dollars a year of profit from antipsychotic sales is nothing to laugh at.

    Lastly the magical psychiatric medication has no withdrawal effects like any other mind altering drug in existence.

    and don't take the comments you get too seriously pro or con.
    This blog , like my blog or any other blog is just entertainment.

  7. Mark, I have some of those exact same problems with some psychiatrists, but who exactly is saying that the drugs are perfect, have no potentially severe side effects, no withdrawal symptoms, and that no psychiatrist ever makes a mistake?

    Even the worst psychiatrists I know don't believe any of those things. Other stupid things, yes, but not those.

  8. Over the years, I've educated my doctor in some ways ... I've alerted him to side-, cumulative and withdrawal effects of an SSRI that I take, and done a small part to keep him current on innovative thinking and treatment in the trauma field (I used to work as a therapist and social worker, and part of my own self-treatment for C-PTSD is to study, research and apply the new understandings as best I can ... I also would have probably become a physician myself were it not for that C-PTSD ...). My doctor is willing to listen, and he respects my understanding of things, as I do his. While we sometimes disagree, we fasten ourselves to that respect and our willingness to learn.

    My doc and I had a wee giggle, too, over that psychiatrist I saw who decided he knew all there was to know about me after 14 minutes. My cherished physician actually rolled his eyes ;-D

    I imagine that doctors who love their work and honour their patients and profession (and the patience their profession requires) are feeling terrible pressure to conform to increasingly rigid directives ... My doctor alludes briefly on occasion to his own struggles. I feel for him ... I imagine he'd be, if he could, a small-town, home-visit, angel-at-the-bedside kind of practitioner. He is *kind* ... and that is what has made me come to love him as a person over the 20 years we have worked together. He is also practical and prudent -- he doesn't make mountains out of molehills or v.v.

    I imagine, too, that there must be some real agony for psychiatrists who have studied deeply and conducted their quiet, compelling profession for years -- I think of psychiatrists as the most scholarly of doctors; the internists of mental health -- who are mandated now (as I see it) to basically toss aside all they have learned, except for the pharmacology and memorized updates from the latest DSM, in order to pill up their patients with all the drugs they, the doctors, are pressured to prescribe ... Physicians who are reading, does your experience feel anything like this?

  9. Aren't you turning an economic issue into a moral one, or at least tying to? Many non-physician psychotherapists are excellent clinicians, more plentiful than psychiatrists, therefor cheaper. If MD, DO psychiatrists focus more on biological treatments where their medical skills are needed, maybe it's just a better use of limited resources, keeping costs down, and making more of us available to the people who really do need meds, ECT, VNS or rTMS. And what's with a systemic thinker engaging in all this blaming?

  10. Moviedoc,

    Sure, that might make sense for psychiatrists who do not like to do psychotherapy, although I personally find doing nothing but writing scripts all day rather boring and soul-crushing.

    Also, one-stop shopping is cheaper and more convenient for patients, so it's not always cheaper to do split treatment, but I do realize there is a labor shortage.

    The trouble is, I see a lot of psychiatrists medicating things they should not be medicating, and not even referring their patients for essential psychotherapy to non-medical therapists.

    Not surprising, some of these patients fire their psychiatrist and come to me because they are not getting any better, due to the lack of attention to their relationships.

    I refer most of my patients that I do not do therapy with myself to psychologists and social workers. When I was in California, I also worked with a lot of MFT's.

    I limit my psychotherapy sessions to those patients with borderline personality disorder, since that's my academic interest.

    It also helps that we have a great psychologist in our office with us so that both "providers" (I hate that word) can communicate to avoid splitting. It's almost impossible to keep up communication between a bunch of different clinicians not in the same office for a whole caseload of patients.

    Ever try calling a therapist? I try to call at 10 minutes to the hour but that doesn't work either. And I am just as hard to connect with.

    As to blaming, the point of the post was actually that blaming is non-productive. I should have made that clearer; thanks for pointing that out.

    Just like in a family system, every adult involved shares responsibility for what is going on, although not always equally by any means.

    If everyone is to "blame," then noone is to blame. Moralistic blaming makes people defensive and therefore interferes with problem solving. Let's just get that out of our systems and blame Adam and Eve for starting the whole mess if we have to blame someone.

    Leave administering justice to the legal system, not the mental health system.

    1. "Leave administering justice to the legal system, not the mental health system." How glib!! It has a rhythm to it, sorta like "If it doesn't fit, you must acquit!!" However, reality check:Psychiatry is all through the legal system, has perverted it as much as it has perverted the very concepts of mental health and mental illness and destroyed all meaningful civil rights in its arbitrary coercive behaviors and tactics--all fully protected by state laws, sufficiently vague to allow the worst abuses imaginable, which regularly do occur.

    2. Abuses occur in all walks of life, unfortunately. That's no excuse for people with schizophrenia, being jailed for minor offenses instead of being sent to hospitals. I bet if one showed up unannounced in your yard naked and frightened your kids, you'd call the cops.

      Cops are all through the legal system too, come to think of it, and some of them abuse their power all the time.

      Maybe we should we let all the patients with severe Alzheimer's disease wander the streets to protect their civil rights? After all, according to the anti-psychiatry folks, brain diseases do not exist.

  11. If we stop playing the blame game, what kind of solution can you propose? For example, if you're the one handing out the $, how much do you want to pay me for a psychotherapy session? I charge ~$800/hr as an expert witness for time on the witness stand. Phil Towle, therapist/performance enhancement coach, was said to get $40,000/month for helping Metallica (according to the film) with interpersonal conflict and creativity(?), probably doing the same thing you do with families, but maybe not quite as well. Where will you get that money? Who gets treated and who doesn't? Even if we can do away with the insurance companies we have to deal with rationing, fraud, etc. We need solutions.

    As for your question "Ever try calling a therapist?" Email often works better, but you should probably ask a a psychotherapist, "Ever try calling a psychiatrist?" If independent practitioners refuse to communicate, they shouldn't work together.

  12. If I knew the solution to the health care crisis in this country, I might run for president myself.

    What should be a priority? How much do some of your patients spend on cigarettes every month? Why are we paying for non-defensive wars and not healthcare? Many many questions to think about.

    I admitted in my post that I am just as hard to reach as a psychologist if I am not able to return a call. Telephone tag is a professional hazard. E-mail is not secure. One psychologist and I fax our notes back and forth. That usually works.

  13. I know you can't solve the crisis, and I agree about the $ patients spend on cigarettes, both kinds. But what do you think we're worth? $300/hour, more? Pick a number and tell us how you arrive at it and whether you believe non-physician psychotherapists should be paid the same.

    If you don't identify the patient, it doesn't matter that email isn't secure.

  14. Moviedoc,

    I liked the old days when we could negotiate a fee with patients based on their ability to pay, and the insurance companies reimbursed whatever they reimbursed.

    It's hard for me to pick a number because I'm already partly retired and fairly well set, so I'm willing to work for less than I think highly trained professionals should get, and see people who have more limited means. Also, where I am office space is a lot cheaper than it is in other parts of the country.

    I do think managed care rates here are somewhat insulting. The best psychologists here do not even join managed care panels.

    Since as psychiatrists we are also the psychopharmacologist and can monitor the interaction of medical conditions with psychological problems, I do think we should be paid more per hour than non-medical therapists.

  15. I did not read the above comments, but in regards to the original posy, you really B-slapped em'....and i loved it! I feel like I have been giving in on some issues I used to stand against, professional and personally but you have given me the inspiration I needed to reflect on my mentality and make some changes. I agree with what you said about America and this quick fix. I think a lot of over medicating has a lot to do with the average person's knowledge of disorders, or lack of. I talk to people all the time that are told, and believe it's just a chemical imbalance. Ignorance keeps one in bondage.