Illusions of Psychiatric Progress -selected sections
Introduction
NOTE: My comments in red. Important parts of the text in orange.
Madness poses fundamental problems for every society, past and present. The terms used to describe it—lunacy, insanity, mental disease, mental illness, nervous breakdown, emotional or psychological distress, mental disorder—carry a cargo of cultural meanings and spawn countless social reactions....
Madness also safely subsumes and “explains” behavioral strangeness and violence that threaten social order, such as, for example, apparently unprovoked mass shootings by solitary individuals harboring deep grudges. The word madness represents some reality that triggers images for everyone, but hardly any two individuals would agree about its essence. Perhaps madness has no essence; perhaps it is only a linguistic black hole. Psychiatric historians and others, however, relying on their own personal histories and presumptions (often unacknowledged), have usually attempted to tell coherent and optimistic tales affirming the belief that medicine has virtually solved the mystery of madness and has validated it as yet another affliction of nature—a disease.
The current psychiatric establishment, exemplified by the US National Institute of Mental Health (NIMH) and the American Psychiatric Association (APA), wants the public to believe that disturbing behaviors result from brain diseases, that scientific research moves ever closer to finding causes and cures for these diseases, and that patients should be treated by approved, expertly-trained therapists applying certified, evidence-based treatments. This medical language and medicalized apparatus is a bid for authority over a long-disputed territory of distresses and misbehaviors. The language implies that errors of the past have given way to steady progress in understanding madness and treating it effectively. The claim for authority covers an immense range of human emotion, suffering, and behavior, including experiences that can severely frighten a person or those around them, such as panic, immobilizing despondency, having unusual perceptions, or acting violently in response to (possibly imagined) threats. But the bulk of the behavioral territory claimed by the modern professions addressing madness—including psychiatry, psychology, and social work—covers more common experiences, such as feeling irritable, sad, or very sensitive; having difficulty concentrating; feeling inept; working too much or too little; sleeping too much or too little; eating too much or too little; or feeling discomfort in ordinary social situations. Contemporary psychiatry claims that these diverse feelings and behaviors—from the rare and extreme to the common and mild—are symptoms of mental disorder, signs of underlying physiological dysfunction, requiring medical treatment.
In contrast, we will argue that the fundamental claims of modern American psychiatry are not based on well-tested research but on science that is itself a bit mad: misconceived, flawed, erroneous, misinterpreted, and often misreported. Using the cover of scientific medicine, psychiatry has managed to become the leading legally chartered profession for the management of misery and misbehavior reframed as an illness (i.e., mental illness). We will demonstrate that the touted achievements of psychiatry in the past half century—keeping disturbed people out of psychiatric hospitals for extended periods, developing a novel and easily applied diagnostic approach embodied in the modern Diagnostic and Statistical Manual of Mental Disorders (DSM), and using “safe and effective” drugs as the first-line intervention for every ill and misfortune—are little more than a recycled mishmash of coercion of the mad and misbehaving, mystification of the process of labeling people, and medical-sounding justifications for people’s desires to use, and professionals’ desires to give, psychoactive chemicals. Obviously, then, this book questions the notion that these psychiatric achievements constitute progress. We argue that until society come to grips with the unscientific nature of the management of madness, it will perpetuate a “mental health” system that serves the interests of professional and corporate elites while it exacerbates the very problems it claims to tackle.
Mental health professionals and the public have been well apprised of the notable achievements of psychiatry this past half century: the near-closing of state asylums in order to provide “evidence-based” care in the community, the expansion of the category mental illness via the renovation of the Diagnostic Manual of Mental Disorders (especially since DSM-III), and the invention and marketing of new psychoactive drugs. These achievements have often been described as paradigm shifts that have shaped the current mental health system. Undoubtedly, their role in shaping this system cannot be taken lightly. However, we argue that these achievements constitute a trio of illusions, spawned more by the misuse than the progress of science.
And, as illusions often do, they have unleashed a torrent of unanticipated adverse consequences, even as they have benefited organized psychiatry, pharmaceutical companies, and the proponents of the “mental health movement.”
As with the “unexpected” collapse of Wall Street in 2008, Americans may yet again, much to their consternation, come to realize that a huge social institution is not as sound as its best and brightest continually claim. The mental health enterprise, like some banks, is continually propped up by government, the profession, and the media because it has become too big to fail. Yet there is no question to us that it has failed and continues to fail daily. Our hope in this book is that society may yet learn to minimize psychiatric coercion and excuses, to offer help to those who need it, and to minimize the manipulation and distortion of science.
On the Language of Madness
"Social scientists have to decide, every time they do research, what to call the things they study. If they choose the terms decided on by the interested and powerful parties already involved in the situations they are studying, they accept all the presuppositions built into that language."
(Becker, 2007)
This is an enormously important part of the problem and it relates directly back to the logic of operationism, CV theory and ordinary language philosophy. That is, the role of language in science.
As the sociologist Howard Becker reminds us in the quotation above, we should be skeptical about the rhetoric used by powerful parties and the assumptions that they may bootleg into public discourse. It is advice that we intend to follow throughout this book. Let’s begin by examining how the National Institute of Mental Health (NIMH), the federal government’s leading mental health agency, speaks of madness. Here is a typical excerpt from its website in 2008:
"The mission of NIMH is to reduce the burden of mental and behavioral disorders through research on mind, brain, and behavior. Mental disorders are brain disorders and that means that achieving progress requires a deeper understanding of the brain and behavior."
"Since our inception in 1946, NIMH has been the lead agency for research on mental disorders. Through our research, enormous gains have been made over the decades, including: establishing that mental disorders are complex brain diseases and demonstrating that medications and behavioral therapies can relieve suffering and improve daily functioning for many people. Recent groundbreaking discoveries from mapping of the human genome, sophisticated studies of the brain, and investigations of cognition and behavior have provided powerful new insights and approaches."
"Science now provides opportunities that promise to deliver for each of these needs. Success will require an understanding of the underlying processes in brain and behavior—from neurons to neighborhoods—to make the discoveries that point the way to new diagnostics and interventions and, eventually to recovery, prevention, and cure." (From Strategic Planning Reports, NIMH website, 2/15/08)
NIMH is explicit about madness: the behaviors are “brain diseases” managed by “therapies” while science moves closer to finding a “cure.” The language of biomedicine pervades today’s official views: disease, genetics, medications, behavioral therapies, rehabilitation, cure, recovery. It is as if none of these terms are contested or misleading. And yet great confusion exists at NIMH and throughout the scientific establishment about what behaviors express brain disorders, how they come about, how they should be managed, and by whom. As we will see, many experts believe that no scientific evidence exists to describe the vast array of behaviors corralled in the rubric of mental disorders as “brain diseases.” What NIMH presents as a simple equation is a political, not a scientific, pronouncement. For fifty years, the bureaucratic language about madness has contained many convoluted, vague, or tautological attempts at definition, as exemplified by the definition of “serious emotional disturbances” in children taken from the President’s New Freedom Commission on Mental Health (2002):
"A serious emotional disturbance is defined as a mental, behavioral, or emotional disorder of sufficient duration to meet diagnostic criteria specified in the DSM-III-R that results in functional impairment that substantially interferes with or limits one or more major life activities in an individual up to 18 years of age. Examples of functional impairment that adversely affect educational performance include an inability to learn that cannot be explained by intellectual, sensory, or health factors; an inability to build or maintain satisfactory interpersonal relationships with peers and teachers; inappropriate types of behavior or feelings under normal circumstances; a general pervasive mood of unhappiness or depression; or a tendency to develop physical symptoms or fears associated with personal or school problems." (Retrieved 10-17-12 from: http://govinfo.library.unt.edu/mental- healthcommission/reports/FinalReport/FullReport.htm)
The President’s Commission appears to eschew the terms brain disorder or brain disease in describing children’s behaviors. It opts to use “serious emotional disturbance” instead, admittedly a more neutral term, but its meaning is itself obscure. For example, the passage leads to confusion by defining serious emotional disturbance “as a mental, behavioral, or emotional disorder,” suggesting that three distinct types of “disorders” constitute emotional disturbance, without a wisp of explanation about the nature of the distinctions. To shore up the ambiguities, the passage borrows language from the DSM and elsewhere regarding “duration” and “functional impairment” that lead to various inabilities and inappropriate behaviors, feelings, fears, or unhappiness—plunging the reader into the depths of current psychiatric diagnostic murkiness. This type of descriptive obscurity would be unacceptable, for example, to cancer researchers trying to distinguish pathological from normal cells, suggesting that despite the official modern vocabulary of madness, we are leagues away from the logic of medicine. In fact, the more ambiguous the terms used to demarcate mental disorder from no mental disorder, or emotional disturbance from emotional stability, the more behavioral territory can be annexed under the jurisdiction of the mental health professions.
Here we see a direct consequence of vagueness of defintion and meaning in science. That is, a consequence of a logical principle that follows from CV theory. This is one attraction to operationism....the principle that vagueness of defintion in science should be avoided.
In 1980 the APA published its first serious official attempt to grapple with a definition of mental disorder, the current popular term. This occurred in the third edition and all subsequent editions of what is regularly referred to as the psychiatric Bible, the Diagnostic and Statistical Manual of Mental Disorders (DSM), readying itself for its seventh face-lift, DSM-5, scheduled for release in 2013. Admitting that “there is no satisfactory definition that specifies precise boundaries” (p. 5) for mental disorder, the DSM (APA, 1980) offered the following guidance:
"In DSM each of the mental disorders is conceptualized as a clinically significant behavioral or psychological syndrome or pattern that occurs in an individual and that is typically associated with either a painful symptom (distress) or impairment in one or more important areas of functioning (disability). In addition, there is an inference that there is a behavioral, psychological, or biological dysfunction, and that the disturbance is not only in the relationship between the individual and society. (When the disturbance is limited to a conflict between an individual and society, this may represent social deviance, which may or may not be commendable, but is not by itself a mental disorder.)" (p. 6)
Almost every phrase in this cumbersome definition has been criticized (Kutchins & Kirk, 1997). One critic (Wakefield, 1992) noted in a widely cited article that the DSM defined disorder as a dysfunction, but without any attempt to suggest what a dysfunction is. Wakefield’s subsequent attempts to define dysfunction have, in turn, also been questioned as constituting speculative hypotheses about the functions of human evolution (Bolton, 2008; Boyle, 2002; Lilienfeld & Marino, 1995; McNally, 2011). More recently, a group of psychiatric researchers (Rounsaville et al., 2002), working under the auspices of the APA in preparation for DSM-5, concluded that mental disorder as defined in DSM is not an exact term and “is not cast in a way that allows it to be used as a criterion for deciding what is and is not a mental disorder” (p. 3), and that there is a “contentious” debate about “whether disease, illness, and disorder are scientific biomedical terms or are sociopolitical terms that necessarily involve a value judgment” (p. 3, emphasis in original). And finally, they report that the current DSM “...is based on a falsely optimistic assumption: that psychiatric disorders are discrete biomedical entities with clear . . . boundaries” (p. 8). In other words, even these prominent psychiatric researchers, trying to improve or fine-tune diagnosis of the presumed entities that make up the very subject matter of psychiatry, disagree not only with DSM but with the professed certainties of NIMH’s “brain diseases.”
The definition of madness remains in disarray. This dilemma has become abundantly clear as the American Psychiatric Association struggles to produce DSM-5, which will be discussed in greater detail in chapter 5. Particularly revealing is an article titled “What Is a Mental/Psychiatric Disorder: From DSM-IV to DSM-V,” written to guide DSM-5 (Stein et al., 2010). The authors concede the following: there are disagreements about the term mental disorder; the “clinically significant” DSM criterion for mental disorders is tautological and difficult to operationalize; the boundaries between normal and pathological are complex and contentious; and the concept of dysfunction is controversial and involves speculative theoretical assumptions about human evolution. Undeterred, the authors suggest adding additional criteria that are themselves problematic. First, “any disorder in DSM should have diagnostic validity” on the basis of a number of key validators, which they admit are variable and may not be readily available, but “in their absence . . . other evidence of diagnostic validity is helpful.” Second, any disorder in DSM “ should have clinical utility,” another potentially tautological or meaningless criterion that would exclude almost no human distress, because someone somewhere can always claim that an effective treatment for it exists. Allen Frances, the chairperson of the DSM-IV Task Force (who presided over an enormous expansion of the mental disorder vocabulary and population), surprisingly summarized the definitional difficulties in the plainest terms: “There is no definition of a mental disorder. It’s bullshit. I mean, you just can’t define it” (Greenberg, 2011)....
Remember Watson....Consciousness is undefined and undefinable! This EXACTLY the same problem 80 years later with mental disorder. A true operationist would never say this and a community of operationist scientists would never give in to such a problem. To an operationist, mental disorder can be defined and must be defined in order for science to progress in a coherent way. The community would recognize the importance of a definition and so would get together and create one. It turns out that defining a meter is a rather difficult thing to do. But it has been done and an international agreement has been signed by over 100 countries about what a meter is. And interestingly....the definition decided upon has nothing to do with ordinary, everyday, non-technical tape measures or meter sticks.
What Is Meant by Madness?
The process of transmogrifying the notion of madness into a medical disease has been essentially linguistic: it has involved verbally funneling an exceedingly heterogeneous group of individuals needing complex, individualized management or assistance into one category describing people burdened with a medical illness and requiring technical attention from mental health professionals. The pedagogic effort has been hugely successful (everyone seems to know what mental illness looks like and that it requires treatment), whereas the scientific effort to validate madness as a medical entity far less so (no one knows what a mental illness is). For example, a leading contemporary biological researcher of schizophrenia, psychiatrist Nancy Andreasen (1999), thus commented:
"At present the most important problem in schizophrenia research is not finding the gene or localizing it in the brain and understanding its neural circuits. Our most important problem is identifying the correct target at which to aim our powerful new scientific weapons. Our most pressing problem is at the clinical level: defining what schizophrenia is." (p. 781)
Given this obvious definitional uncertainty, here is our own view of what is subsumed by the term mental illness. It is a label used to characterize and organize the many different behaviors that have become the targets of a “biomedical industrial complex” (Gomory et al., 2011). They include at least two broad types of problems that should be distinguished, although people may experience or manifest both. On the one hand, there is personally perceived distress: usually situational, life stage-related difficulties in coping with life’s and society’s demands that often appear as inability or unwillingness to pursue personal goals or to interact smoothly with other people. When people experience personal distress, they typically seek or accept help voluntarily from whatever sources they believe will best address these difficulties. Personal distress usually directly burdens no one outside of friends, peers, immediate family, and co-workers and causes little public notice, nor does it trigger formal public intervention, although when people fail to meet various personal and social obligations while they are distressed, there are indirect social and economic consequences.
On the other hand, there is misbehavior: visibly deviant, uncooperative, morally offensive or socially disruptive behaviors. These behaviors threaten and therefore mobilize the immediate interpersonal network or the larger society to forcefully restrain and then exclude (and perhaps re-educate) the offending individual (who may be acting from a variety of possible motives, or from no discernable motive). Although many people who so misbehave may cross over into frankly criminal activities, and may therefore also experience simultaneous or successive management by the criminal justice system, many do not.
Both these categories of behavior fall into what sociologist Andrew Abbott (1988) described as the personal problems jurisdiction, an arena vigorously competed for by several helping professions in the late nineteenth and early twentieth centuries. These professions included psychiatry, social work, neurology, the clergy, and a nascent clinical psychology. The struggle for professional supremacy over this jurisdiction was won by psychiatry. Abbott pointedly thinks that psychiatry’s success rested particularly on its ability to construct a persuasive medicalized rhetoric....
People Seeking Help
Scholars can afford to be skeptical about the pronouncements of experts and authorities on mental illness, but the general public often becomes engaged with the psychiatric establishment when struggling to contend with personal and family distress. When individuals and families are in crisis, they must make a series of judgments: How unpleasant is the difficulty to me or others I care about? If I ignore it or wait, will it resolve itself over time or get worse? Is the difficulty due to my own mistakes or inadequacies or to challenges thrust on me by circumstances or the actions of others? Can I rectify the difficulty through diligence, self-control, and perseverance? Would I benefit from asking friends or family for advice, or should I seek professional advice? If I seek professional advice, whom should I turn to first—a member of the clergy, attorney, nurse, social worker, psychologist, family counselor, or medical doctor? Should I first speak to someone who experienced a similar difficulty and found a way to resolve it?
These questions raise complicated issues that involve assessments of self, guesses about what is likely to happen if no action is taken, and estimates of the future consequences of taking different courses of action. These issues, in turn, are heavily constrained by the options available in one’s community, society, and culture. People with similar troubles may handle them in very different ways. Although scientific knowledge cannot indicate the best way for people to proceed when troubled, those who enter the current mental health system seeking help are likely to face a bewildering array of professional beliefs, theories, treatments, and controversies—and may also find themselves completely removed from decision making about their lives or the lives of their relatives.
Let us explore [an] example of how people who seek help for themselves or for their children become involved with the mental health system and the consequences their actions bring.....
“Bipolar Is a Lifetime Diagnosis”
Diana was anguished in trying to understand what was happening to her sixteen-year-old son Benjamin, who was sad, afraid, not sleeping, and doing poorly in school. Where could she turn for help? She contacted Benjamin’s teachers for their observations of his class performance; then she turned to his pediatrician and to mental health professionals for advice. A psychologist recommended by the school’s principal concluded that the boy was “deeply depressed” and referred them to a psychiatrist for a medication evaluation. “The psychiatrist was another nice man, young, in an attractive office,” she reported. The psychiatrist asked them to fill out questionnaires. When she mentioned to the doctor that her own mother had been hospitalized once with a “nervous breakdown,” had seen a therapist and seemed to recover, the psychiatrist showed great interest in this family history. After forty-five minutes, the psychiatrist looked at Benjamin and said: “You’re bipolar. It will only get worse over time unless we begin to medicate you now. I’m prescribing Abilify.” When asked, the doctor said that Benjamin would have to take the medication for “the rest of his life. Bipolar is a lifetime diagnosis.” ....
Let us provide an illustration of our approach to examining the mental health system and how institutional actors, such as professional groups, federal research institutes, the pharmaceutical industry, and established family lobbies operate together to shape individuals’ experiences when they seek psychiatric help. Let us explore the expanded institutional context of Wagman’s saga about Benjamin.
Prescription for Insanity
The day after Wagman’s distressing story appeared in the Los Angeles Times, a full-page, multicolored advertisement was displayed in the Health section of the same paper (November 6, 2006, section F10). The two-inch banner headline read: “Treating Bipolar Disorder Takes Understanding.” The top half of the ad, in large print, offered a purported diagnosis: “You’ve been up and down with mood swings. You want to move forward.” The ad continued: “Maybe ABILIFY can help: control your symptoms of bipolar mania; stabilize your mood; reduce your risk of manic relapse.” The ad implied that if you experience distinct mood changes and want to move forward—and who doesn’t?—you are likely to suffer from something called bipolar mania.
The ad then claims that some scientific consensus exists about how ABILIFY “works” in the body: “ABILIFY may work by adjusting dopamine activity, instead of completely blocking it and by adjusting serotonin activity. However, the exact way any medicine for bipolar disorder works is unknown.” Why dopamine or serotonin might need adjusting because one’s mood changes, however, can be left unsaid. What specific sort of adjusting would actually be done by the chemical also need not be stated. The ad does not indicate that this drug is not approved by the Federal government’s drug- approval agency for children or adolescents. Then, before presenting a half page of small-print warnings about possible adverse effects, including death, it makes the perfunctory pitch: “Ask your healthcare professional if once-a- week ABILIFY is right for you.” In the smallest of print, one learns that the ad was placed by two multinational pharmaceutical companies: Bristol-Myers Squibb and Otsuka Pharmaceutical. Of course, seeking advice from health- care professionals was exactly what Diana Wagman tried exhaustively to do, but the experienced professionals sharply disagreed on how to help.
Why would a drug company make a pitch to the lay public about a presumable psychiatric disease, one that even baffles the experts? And why would a company advertise to the public a drug that no layperson could legally obtain without the permission and prescription of a physician? As the ad admits, no one has any evidence regarding how or why Abilify “works”—even here it is implied that it does work, though what this means is left to the copywriters. Moreover, ... professionals do not agree on how to define mental illnesses, on exactly what kind of phenomena they are, on what causes them, or on how they should be treated—or even if they exist as entities at all. And certainly, professionals, including the makers of Abilify, don’t understand the pharmacology of these drugs. (To be more precise, the makers of Abilify have an exquisitely honed understanding of the pharmacology of their drug, but no understanding of how that pharmacology influences the hypothesized entity bipolar mania.) Lay and professional ignorance about these matters is the norm, not the exception. But it is precisely this level of ignorance that the pharmaceutical industry exploits to make billions of dollars. The federal regulatory agency, the Food and Drug Administration (FDA), rather than protect the public from the marketing campaigns of pharmaceutical firms, is seen by many critics (Angell, 2004; D. Healy, 2012) as ineffectual, for example, approving Abilify for use with children in February 2008. In addition, in 2007 Bristol-Myers paid $515 million to settle a lawsuit filed by the federal government over accusations of fraud in which the drug company employed a kickback scheme to defraud Medicare and Medicaid. Several years later California regulators filed suit, accusing Bristol-Myers of bribing doctors and pharmacists to use its products, including Abilify (Helfand & Lifsher, 2011).
One week after Wagman told her story, the New York Times’ mental health reporter, Benedict Carey, wrote a long article, “What’s Wrong with a Child? Psychiatrists Often Disagree” (2006). He reported that many other families echo Wagman’s laments. Parents seeking help for their children receive shifting and confusing diagnoses accompanied by different regimens of drug treatment; mental health professionals acknowledge that there is confusion in the field; and advice given to parents is subject to diagnostic and treatment fads. Bipolar disorder, in particular, was described as being “wildly overdiagnosed.” Carey reports that Jane Costello, a psychiatry professor at Duke University, stated that “the system of diagnosis in psychiatry was 200 to 300 years behind other branches of medicine” and that “on an individual level, for many parents and families, the experience can be a disaster.”
One year later, the American Medical Association’s leading psychiatric journal, the Archives of General Psychiatry, published a report that confirmed what many clinicians and journalists had already discovered: namely, that there has been an explosion of diagnoses of bipolar disorder for youth and adults. The report, however, offered no conclusive judgments from acknowledged experts as to why this had occurred (Moreno et al., 2007). In fact, the increase in the use of the bipolar diagnosis was so astounding that the national press immediately reported it (Carey, 2007; Gellene, 2007). In a survey of outpatient office visits to physicians, a team of researchers at Columbia University found that youth received bipolar disorder diagnoses forty times more frequently in 2002–2003 than ten years prior, 1994–1995. The number of adults receiving bipolar diagnoses doubled during the same period. Nine out of ten children and adults diagnosed received psychotropic medications. This was a staggering increase in bipolar disorder diagnoses, and yet the researchers stumbled in offering possible explanations: the disorder had been seriously under-diagnosed before; the disorder is over-diagnosed currently; bipolar overlaps symptomatically with other common disorders such as ADHD; clinicians and researchers do not agree on how to recognize bipolar disorder in children, or recognize it better and earlier in a child’s life; and so on. The most plausible explanation for the explosion of the use of bipolar diagnoses was not mentioned by the research team: the generously funded and well-crafted marketing campaigns by drug companies providing financial incentives to psychiatrists and the public to make bipolar diagnoses among children and to prescribe psychotropic medications such as Abilify (D. Healy & Le Noury, 2007).
Only two days after media reports of the epidemic of bipolar disorder among children, the Business section of the Los Angeles Times (“Sales of Anti-psychotic Drugs for Kids Surge,”September 6, 2007, section C6) reported that sales of antipsychotic drugs for children had exploded. Johnson & Johnson, AstraZeneca, and Pfizer were the beneficiaries of the doubling of prescriptions for children from 2003 to 2006, making children the fastest-growing segment of the $11.5 billion US market for antipsychotic drugs, which were not then even approved by the FDA for children. Joseph Woolston, chief of child psychiatry at Yale University Hospital, was quoted by the Los Angeles Times calling the trend “the juvenile bipolar juggernaut” and a “big problem.”
Remarkably, twenty years ago children were never diagnosed with bipolar disorder (or its prior DSM-II moniker: manic depressive illness/psychosis). Bipolar disorder was only reserved for adults and, even then, to very few. Manic depression/bipolar was viewed as an exceedingly rare affliction. By 2006, however, the experiences of young Benjamin Wagman were common. What we suggest actually occurred is not an illness epidemic, but rather what the British describe as disease mongering—the manufacturing of diseases and disease explanations by those with a financial interest in opening new markets for their medical products (Moynihan, Heath, & Henry, 2002). The explosion in the psychiatric labeling of children, many younger than five years, has been so dramatic that it is now routinely the subject of media comment (Groopman, 2007; M. Healy, 2007). These exposés typically review the rapid spread of labeling children and youth as mentally ill, the confusion among psychiatrists about what these labels represent, and the trial and error prescription of powerful drugs pushed by Big Pharma without anyone knowing whether they truly help children or what the lifetime negative consequences may be. John March, a child psychiatrist at Duke University, offers a partial defense of the increase: “I think the increase shows that the field is maturing when it comes to recognizing pediatric bipolar disorder,” but acknowledges that the controversies reflect “that we haven’t matured enough” and that bipolar diagnosis for young children “may or may not reflect reality” (Carey, 2007). Is such ambiguity from a professional leader truly an informed opinion? Does Dr. March display any more insight into the prescribing situation than anyone else?
Gabrielle Carlson, a professor of psychiatry at Stony Brook University School of Medicine, describes plainly how the drug companies pressure psychiatrists: “We are just inundated with stuff from drug companies, publications, throwaways, that tell us six ways from Sunday that . . . we’re missing bipolar” and encouraging parents with difficult children to seek relief in that diagnosis (Carey, 2007). She estimated that only one out of five children referred to her with bipolar diagnoses actually had it (a seemingly finer-grained critical judgment, but one which ignores that the bipolar disorder diagnosis cannot be validated), and in some cases the diagnosis was given in order to obtain insurance reimbursement (Gellene, 2007).
In an extensive analysis of how drug companies can “create a culture that legitimizes practices that would otherwise appear extraordinary,” David Healy and Gabrielle Le Noury (2007) suggest, using the medical language of psychiatry, that we may have witnessed “a variation on Munchausen’s syndrome, where some significant other wants the individual to be ill and these significant others derive some gain from these proxy illnesses” (p. 219)....
It is noteworthy that during the decades in which these three momentous changes were implemented, psychiatry did not lack critics from within and from without. Indeed, the major challenge to the validity of the central psychiatric notion, mental illness—against which psychiatry was forced to respond over the next decades by “remedicalizing” itself—was published in 1961: The Myth of Mental Illness (Szasz, 1961). It was followed by numerous critiques of psychiatric philosophies and practices and their harmful effects on people and social institutions (Armstrong, 1993; Breggin, 1991; Cohen, 1990; Conrad & Schneider, 1980; Fisher & Greenberg, 1997; Goffman, 1961; Kirk & Kutchins, 1992; Kittrie, 1973; Modrow, 1992; Robitscher, 1980; Ross & Pam, 1995; Scheff, 1966; Torrey, 1974; Wilson, 1997). How psychiatry actually dealt with (or ignored) the issues raised by these and many other scholars and practitioners is described in the rest of this book.
What Is Science?
Since much of our book is devoted to discussions involving science as if it were the best approach to devise better understandings and explanations of the workings of our physical and human world, it is fitting to offer briefly our own view of what proper science is. To begin with, science is a human enterprise and therefore highly fallible. Scientists are not a special class of individuals free from error, able to set biases aside, able to be completely objective, or concerned mostly with searching for the truth. As the sociologist of science Thomas Kuhn suggested, most scientists are “normal scientists,”a phrase by which he meant scientists who do not question the current assumptions of the reigning theoretical paradigm and are mostly not interested in getting at fundamental truths, but rather who less ambitiously try to solve smaller-scale everyday problems (which he called puzzles) within the current paradigm. Normal scientists leave the bigger questions to an elite group of scientific authorities recognized by their peers. One of these bigger questions is the question of when a shift in the scientific paradigm should occur. Usually the shift happens, according to Kuhn, when members of the old elite die out or retire and are replaced by young Turks; when a consensus is reached among them that a shift is called for; or when observations from the everyday puzzles that are directly at odds with expected findings accumulate to such an extent that these contradictory observations can no longer be ignored. But any of these factors succeed only if an alternative paradigm is readily available to take its place.
One of Kuhn’s main contributions to the history and sociology of science has been to draw attention and scholarship to the personal nature of activities of scientists: that is, the extent to which the work of scientists is like the work of all humans: shaped by personal beliefs, commitments, capabilities, skills, and social and cultural expectations. But as the authors of this book we are not Kuhnians in any strict sense. We are more in line with those who might call themselves falsificationists (exemplified by the work of Karl Popper). That is, we see all theories (explanations, which include proposed solutions, interventions, programs, and policies) regarding the world and human behavior as tentative efforts to explain or predict that world, that must be rigorously criticized (through vigorous debate) and evaluated (by means of logical and transparent experimental tests) before being offered more generally. And even after being implemented, stringent evaluations should be regularly conducted on these theories and interventions, keeping in mind that future application of apparently successful theories or treatments and solutions may turn out ultimately to be more harmful than helpful.
The social science methodologist Donald Campbell suggested that:
"[s]cience requires a disputatious community of “truth seekers.” The ideology of the scientific revolution agrees with Popper’s . . . epistemological sociology of science. . . . Truth is yet to be discovered. Old beliefs are to be systematically doubted . . . The community of scientists is to stay together in focused disputation, attending to each others’ arguments . . . mutually monitoring and “keeping each other honest.” (Campbell, 1988, p. 290)
Psychiatric Coercion, Diagnosis, and Drugs
We will begin with a brief history of attempts to understand and treat mental disease and the claims about the effectiveness of community treatment. We then turn to an analysis of the revolution in defining mental disorders that began with the publication of the third edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM) in 1980. Finally, we review the puzzling scientific terrain of psychoactive drugs.
Coercion and Deinstitutionalization
The movement of people out of state psychiatric hospitals and into various forms of care and control in the community or into other institutions, called deinstitutionalization, was the most important policy and institutional change in psychiatry in the twentieth century. Community care consisted of a potpourri of services (e.g., coordination of health and welfare benefits by a case manager), treatments (crisis intervention, medication monitoring, brief hospitalizations, counseling), and facilities (group homes, board and care residences, nursing homes, jails and prisons). During the 1960s and 1970s there was a sizeable emptying of state asylums for the mad, which had many determinants—exposés in the media about inhumane confinement in massive facilities, skepticism about the effectiveness of custodial treatment, misgivings about involuntary commitment, growing cost of hospital care, and the shift to federal funding for community treatments, as well as new hopes spurred by the introduction of newer psychoactive drugs. Whereas coercion had been a major component of psychiatric practice in state asylums, there was hope that community treatment, by using the new psychoactive drugs to control the mad and misbehaving, could operate without obvious coercion. Proponents of deinstitutionalization justified it as a method of providing more efficient, effective, and humane treatment for the “chronically mentally ill” than warehousing them in large, oppressive facilities. The stated goals of deinstitutionalization were to reintegrate the mad into their communities, normalize their circumstances, and improve their quality of life.
In chapter 2 we provide a succinct history of the rise of community treatment and public psychiatry in America and how private troubles for individuals and families have become concerns, first of communities, then states, and, finally, the federal government. But throughout that evolution in responsibility, the language of madness has also changed decisively into a language of medical disease. In reviewing the history of madness in America, it is notable that the major historians have trapped themselves in a medical vocabulary that, while it arguably shapes or reflects professional and public views, impairs their ability to provide an objective account of this history.
We extend this story in chapter 3, where we will examine what we believe is the mainstay of psychiatry—coercion—and its community-based use that often goes by the persuasive-sounding moniker of evidence-based practice (EBP). EBP is derived from a currently popular but seemingly already fading movement in medicine called evidence-based medicine (EBM). EBM claims to identify the most effective medical treatments through a series of workgroups that evaluate the research literature on treatments and rank them based on their effectiveness through a methodological protocol that includes the use of statistical methods. In selecting effective medical treatments, EBM is argued to be superior to the traditional reliance on the expertise of individual doctors and the wishes of their patients. We examine the evidence regarding both EBM’s and EBP’s claimed superiority and find it wanting. To demonstrate EBP’s failure, we include a close review of the evidence on assertive community treatment (ACT), touted and promoted enthusiastically by a coterie of academic experts as one of only six evidence-based, gold-standard psychosocial interventions in mental health. Our analysis shows how the claim for the benefits of community treatment over state mental institutions rests on the use of administrative tactics and medically and socially sanctioned coercion (currently renamed “leverage”). Exaggerating the presumed effectiveness of a heavily marketed ACT helped to divert attention from the sorry plight ofthose supposedly reintegrated into the community. Jails, inhumane group facilities, and the streets have been the major community environments for the chronically mad for the past few decades. Community treatment’s failure to deliver on its promises can be seen by the increasing efforts of psychiatric experts to justify and legitimize coercion as treatment.
Diagnosis
The second major psychiatric development, discussed in chapters 4 and 5, was a response to criticisms that psychiatric diagnoses lacked validity and were unreliably used by clinicians: in layman’s language, they were inaccurate. These flaws were potentially ominous for psychiatry as a respected medical profession but were for years rarely discussed because providing scientific evidence was not necessary for psychiatry to carry out its functions. Nevertheless, in the interest of improving the scientific and political standing of their profession and to counteract psychiatric critics, a handful of psychiatrists in the mid-1970s strategically used the vulnerability of the diagnostic system to revolutionize psychiatric diagnosing, culminating in the 1980 publication of the third revision of the DSM, which provided what appeared to be more scientific detail and guidance for clinicians in making diagnoses.
Unlike the shift to community care, no one had clamored for change in the DSM, and few laypeople even knew it existed. The new DSM promised a descriptive diagnosis—using symptoms alone, without the need to understand any presumed underlying causes or dynamics—to defining mental illness. Although fully aware of the limitations of descriptive diagnosis, its proponents continually affirmed its advantages and their belief that its adoption was a necessary step in investigating and then discovering the biological bases of madness and misbehavior and in “remedicalizing” psychiatry. The heralded DSM-III hugely enhanced psychiatric authority, as it formalized a vast expansion of the behaviors, states, circumstances, and emotions indicating mental disorder. This expansion, in turn, was used to create a manufactured epidemic of mental illness in the United States.
All interested parties relentlessly exploited the new DSM—the pharmaceutical industry for economic gain; related professional and consumer groups (e.g., National Alliance for the Mentally Ill, Children and Adults with Attention Deficit Hyperactivity Disorder) vying to share in the reborn power and prestige of psychiatry; and the public, seduced by the ease and appeal of wielding diagnoses on themselves, just like the experts. The territory of madness thus was greatly enlarged, and many mental disorders became banal, even normal. When psychiatric experts (Kessler et al., 1994; US Dept. of Health and Human Services, 2011) declared that half the US population would qualify for a psychiatric diagnosis in their lifetime, validly distinguishing disorder from normality became largely irrelevant, since practically everyone could be viewed as potentially “in need of treatment.” The popular fascination with the DSM-III hid the fact that any evidence for its superiority over any previous diagnostic approaches was seriously flawed, as DSM-III barely made a dent in the acknowledged reliability and validity problems of diagnoses. Today, as the fifth edition of DSM is being prepared for publication in 2013, a firestorm of criticism has erupted (from, among others, the former chief architects of DSM-III and DSM-IV) about the continuing expansion of the concept of mental disorder, its extremely flimsy scientific and medical basis, and the disastrous consequences that widespread use of this medical concept has had on understanding the troubles of real people seeking help from mental health experts.
Drugs
The third fateful illusion regarding modern madness concerns psychoactive drugs, which we discuss in chapters 6 and 7. While deinstitutionalization and the DSM brought images of mental disorder into every neighborhood, the promotion of modern psychoactive drugs capitalized on the public’s desire for medicalized yet familiar solutions to life’s difficulties. Psychoactive drug cultures are nothing new, given that vast numbers of people have always used drugs to relieve their personal distress, to work more efficiently, to enhance pleasure, and to find meaning in life. The novelty lies in the successful campaign by the mental health establishment to convince people that their appreciation of psychoactive drugs proved that their unwanted emotions and behaviors were symptoms of mental disorders and, moreover, that whatever psychoactive drugs their physicians prescribed were specific treatments for these disorders.
The campaigns began with the industry promotion of amphetamines (such as Benzedrine) to physicians as antidepressants in the 1940s, closely followed by the marketing success of the benzodiazepines in the 1960s (such as Librium and Valium). In parallel, the arrival of the stuporproducing antipsychotics in the 1950s (led by Thorazine) radically changed the insane asylums and wedded psychiatry (then still largely operating and viewed as a custodial enterprise) to a future with drugs. Waves of new-and-improved “selective serotonin reuptake inhibitors” (led by Prozac and Paxil), “atypical antipsychotics” (led by Risperdal and Zyprexa), “mood stabilizers” (led by Depakote and Neurontin), and the resurgence of stimulants (led by Ritalin and Adderall) expanded and strengthened convictions that solving the problem of mental illness (now seen as affecting large segments of the populations of post-industrialized nations) meant making the drug du jour as widely available as possible. It did not seem to matter that the promoted drugs differed little—as substances affecting feeling, thinking, and behaving and regularly inflicting physical harm—from the banished and forbidden drugs on which authorities simultaneously waged a century-long war.
The misuse of science and research in the pursuit of profits from drug sales has been phenomenal, with no stakeholder guiltless. While the new drugs changed expectations and perceptions, the documented helpfulness of psychiatric treatment has remained unchanged, despite fifty years of widespread psychiatric drug prescriptions. In comparison with the pre-modern drug era, no significant improvements on any indicator of any major mental disorder, including depression, schizophrenia, and bipolar disorder have been demonstrated in studies that have been conducted relatively free of industry design or funding, as we will document in later chapters (and as the director of the NIMH states explicitly). Still, the marketing of medications has resulted in the daily drugging of an unprecedented number of children, youths, and adults, converting every mental health practitioner into a potential or actual drug dispenser. At the same time, the power of placebo, which could account for most of what passes as treatment “effectiveness,” and the stupendous failings of clinical drug trials to inform about the actual, genuine effects of psychoactive drugs remain barely acknowledged. Moreover, producing and recycling drugs created new opportunities to invent DSM-style diseases and to market more drugs, making diagnoses more important to Big Pharma than they had ever been to clinicians or patients.
In chapter 8, we recapitulate our arguments and attempt to discern a way ahead. First, we reflect on our potential biases and how we attempted to counter them. Next, we identify what we think are the crucial characteristics of mad science. We then call for a deemphasis of the current biomedical control over the understanding and management of the mentally ill in favor of a broad nonmedical system of personal assistance and supports to those seeking help, along with an essential decoupling of coercion from services. The helping enterprise does not need to pretend that coercion is treatment or that people must be treated against their wishes, and society must cease expecting those it considers healers to police and sequester the distressed and misbehaving. We also call for a decoupling of diagnosis from the eligibility and provision for services. There is no inherent need for diagnosing people as medically defective or pathological with hollow diagnoses in order to offer and to fund information, help, advice, counseling, support, and other personal, vocational, or housing services (that is, the bulk of what are called mental health services). There is also no meaningful empirical or rational distinction between (currently) legal and (currently) illicit psychoactive drugs, and no self-evident justification for allowing any group that claims unique expertise or responsibility to control how people use drugs to relieve their distress or reduce their misbehavior. We think that psychiatric practitioners have demonstrated—especially over the past half-century—that they regularly fail to exercise independent, informed judgment about the worth and usefulness of the various psychoactive medications under their purview.
Although rampant conflicts of interest among psychiatric leaders and institutions make it extremely difficult to disentangle knowledge from propaganda, this has always been so in the history of psychiatry and of the helping professions. We will suggest that the monopolistic reign of psychiatric experts over therapeutic resources for troubled and misbehaving people should be abolished. This will require clear-headedness about the illusions that have encouraged us to believe that the sometimes tragic challenges and troubles of human life—of living with our self and with other people—are symptoms of eradicable brain diseases falling under the jurisdiction of medicine. This does not mean that human existence cannot be improved or made more palatable. Moreover, medicine certainly has a place in a more truly humane system of services for people in need. But we question whether the current system, dominated by state-sanctioned psychiatric definitions, coercion, and prescription psychoactive drugs and distorted by financial conflicts of interest, is serving the public very well. This book is a hard-headed examination of the mad science that has created these psychiatric illusions and failures of the past and present, so that we might begin to move in new directions in the future.
Notes
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It’s far beyond the scope of this book to examine psychiatry from an international comparative perspective. Nonetheless, the peculiar form of American psychiatric thinking that we describe in the book—which views distress and misbehavior as symptoms of conventional medical diseases, the discovery of their (unknown) etiologies requiring first and foremost the categorization of their presenting problems, and their treatment requiring the medical prescription of centrally active chemicals—has had a major influence on psychiatric thinking and practice throughout the world. The publication of DSM-III in 1980 (the third edition of the Diagnostic and Statistical Manual of Mental Disorders of the American Psychiatric Association), and its widespread dissemination and translations, fostered and in turn was fostered by globalization, including the expansion of mar- kets for psychiatric drugs by multinational pharmaceutical companies. As it continues to become exported far and wide, this style of American psychiatry undoubtedly contributes to reducing the number of different existing vocabularies and models of madness, much like opening roads and transforming forests into farms in the Amazon Basin undoubtedly reduces biodiversity. A similar thesis is made by Watters, 2010.
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A similar but more elaborate recent statement from NIMH (April 24, 2012) may be found at: http://wwwapps.nimh.nih.gov/about/strategic-planning- reports/index.shtml.
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Personal distress becomes of public concern when people seek “health” insurance to cover the costs of treatment for personal difficulty (which currently requires them to receive a clinical diagnosis of a psychiatric disorder), or when chronic or unacknowledged personal distress leads to misbehaviors that physically or emotionally damage other people.
4. Writings critical of psychiatric thinking and practice run in the hundreds if not thousands. Two bibliographies displaying the breadth and varieties of critiques are available at the following websites: Philosophy of Psychiatry Bibliography (http://www.uky.edu/~cperring/PPB2.HTM) and Critical Psychiatry Website (http://www.mentalhealth.freeuk.com/article.htm). But we caution that the mainstream psychiatric literature is considerably larger.
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