On March 19, a new article was posted on Aeon Magazine. It’s titled A Mad World, and was written by Joseph Pierre, MD, who works in Log Angeles as a psychiatric practitioner and professor. Dr. Pierre has authored more than fifty papers, and has received several awards. He has lectured nationally and internationally, and would, I think, be considered an eminent psychiatrist. I am grateful to several readers for the link to the article.
The paper is written in a collegial, reassuring manner, but there are some very profound and disturbing implications which I feel ought to be identified and elucidated.
Dr. Pierre opens his discussion with some chatty remarks concerning the reluctance of people to disclose information about themselves to psychiatrists for fear that they might be “.. labelled crazy, locked up in an asylum, medicated into oblivion, or put into a straitjacket.” He then continues:
“Of course, such fears are the accompaniment of the very idiosyncrasies, foibles, and life struggles that keep us from unattainably perfect mental health.”
What he’s saying here, or at least what I think is implied, is that “idiosyncrasies, foibles, and life struggles” are what stands between us and “perfect mental health.” In other words, idiosyncrasies, foibles, and life struggles are illnesses or symptoms of illnesses. This, of course, has been psychiatry’s implied message for decades, but it is unusual to see it articulated so clearly.
Dr. Pierre continues:
“As a psychiatrist, I see this as the biggest challenge facing psychiatry today. A large part of the population – perhaps even the majority – might benefit from some form of mental health care, but too many fear that modern psychiatry is on a mission to pathologise normal individuals with some dystopian plan fuelled by the greed of the pharmaceutical industry, all in order to put the populace on mind-numbing medications.”
So the biggest challenge facing psychiatry today is to rope even more people (“the majority” of the population) into psychiatric “treatment.” But psychiatry is thwarted in this noble and altruistic challenge because people are fearful that the psychiatric-pharma alliance is on a “mission” to pathologize normality and sell more drugs. Wherever could we have gotten such a notion? Perhaps from the inexorable expansion of the DSM catalog? Perhaps from psychiatry’s long-standing corrupt relationships with pharma? Perhaps from psychiatry’s willing and active involvement in the fraudulent research? Perhaps from the pharmaceutical infomercials that posed as, and were avidly accepted by psychiatry as, continuing education? Perhaps from pharma ads to the general public? Perhaps from the ghost-writing scandals? Perhaps from the self-serving fabrication of childhood bipolar disorder by an “eminent” psychiatrist and the consequent widespread prescribing of mind-numbing neurotoxic drugs to children as young as two years for temper tantrums? Perhaps from the medicalization of bereavement? Etc.? So perhaps our fears and concerns with regards to psychiatry’s mission are founded.
Dr. Pierre then gives us a brief historical account of the expansion of psychiatry’s scope including:
“From the first DSM through to the most recent revision, inclusiveness and clinical usefulness have been guiding principles, with the profession erring on the side of capturing all of the conditions that bring people to psychiatric care in order to facilitate evaluation and treatment.”
It is clear that he approves of this widening of psychiatry’s net and of the general blurring of the distinction between psychiatric “illness” and normality. One of the putative advantages of this development is that
“… newer medications with fewer side effects are more likely to be offered to people with less clear-cut psychiatric illnesses.”
“Viewed through the lens of the DSM, it is easy to see how extending psychiatry’s helping hand deeper into the population is often interpreted as evidence that psychiatrists think more and more people are mentally ill.”
Actually, it isn’t just interpreted as evidence, it is evidence. Psychiatrists do indeed promote the notion that more and more people are “mentally ill.” They have promoted this spurious notion in three ways: firstly, by increasing the number of their so-called diagnoses, secondly, by progressively lowering the criteria thresholds, and thirdly, by routinely telling their clients that they have chemical imbalances in their brains.
“To many, the idea that it might be normal to have a mental illness sounds oxymoronic at best and conspiratorially threatening at worst. Yet the widening scope of psychiatry has been driven by a belief – on the parts of both mental health consumers and clinicians alike – that psychiatry can help with an increasingly large range of issues.”
So, there it is! All this time we thought that psychiatry was expanding its scope for self-serving purposes like turf expansion and increased business, when in reality they were just responding dutifully and responsibly to requests for help with an “increasingly large range of issues”!
The fact is that people go to psychiatrists for an increasing range of non-medical human problems, because psychiatrists have developed and promoted the false notions that these problems are illnesses, and that these illnesses are best treated by drugs. They have also downplayed the adverse effects. In these endeavors they have been ably assisted by their pharmaceutical allies. They have also promoted the notion that failure to “treat” these spurious illnesses inevitably leads to dire consequences, particularly in the case of children. Pharma’s ad campaigns, including ads in psychiatric journals, have been a major driving force in this area for at least the last 40 years. If psychiatrists had had any qualms about pharma’s excessive rhetoric, shouldn’t they have spoken out? Shouldn’t they have refused to run the ads? Is it not reasonable – given the absence of any such protest – to conclude that psychiatry approved of, and was even complicit in this promotion?
To state, at this advanced stage of the proceedings, that psychiatric expansion is simply a reflection of increased confidence on the part of the consumer is at least disingenuous and perhaps blatantly deceptive.
Dr. Pierre continues by telling us that psychiatry’s ” diagnostic creep…becomes more understandable by conceptualizing mental illness, like most things in nature, on a continuum.” (Note in passing the phrase “like most things in nature,” which conveys the impression that the DSM catalog actually identifies real entities, in the manner, say, of the Periodic Table, when in fact the only ontological status that these “illnesses” have is the fact that they were voted into existence by the APA.)
He then uses the continuum concept to justify the “diagnosing” and drugging of almost anyone.
“For example, someone with mild depression might not be on the verge of suicide, but could really be struggling with work due to anxiety and poor concentration. Many people might experience sub-clinical conditions that fall short of the threshold for a mental disorder, but still might benefit from intervention.”
This is a level of psychiatric spin that I have not encountered before. Psychiatry has received a good deal of criticism in recent years for expanding their “diagnoses” and for prescribing drugs to more and more people. There have been some half-hearted and unconvincing rebuttals from psychiatry, but for the most part their response has been: deny, deflect, and keep your head down till it blows over. These are the standard tactics of politicians. But Dr. Pierre has taken us to a new level: diagnostic expansion and increased drugging are good things. Imagine a politician confronted with a charge of taking bribes arguing that bribes are a form of economic activity and, as such, should be encouraged in a free market context!
Then Dr. Pierre points out that the DSM, with its fussy little polythetic criteria sets, isn’t really such a big deal.
“The truth is that while psychiatric diagnosis is helpful in understanding what ails a patient and formulating a treatment plan, psychiatrists don’t waste a lot of time fretting over whether a patient can be neatly categorised in DSM, or even whether or not that patient truly has a mental disorder at all. A patient comes in with a complaint of suffering, and the clinician tries to relieve that suffering independent of such exacting distinctions. If anything, such details become most important for insurance billing, where clinicians might err on the side of making a diagnosis to obtain reimbursement for a patient who might not otherwise be able to receive care.”
This is drug-pushing without even the semblance of a medical veneer. He might as well hang out a shingle: Whatever ails you, get your drugs here. I also imagine that, like the street dealer, he gets a lot of repeat customers.
He concedes that he may have to fabricate something to get the insurance company to pay for his services, a practice which incidentally constitutes fraud, but he’s not going to “waste a lot of time” fretting over “such exacting distinctions.”
Then Dr. Pierre treats us to the standard psychiatry-is-just-like-general-medicine claim.
“Though many object to psychiatry’s perceived encroachment into normality, we rarely hear such complaints about the rest of medicine.”
Why, he asks, if we accept that we can have a wide range of physical illnesses during our lives, are we so reluctant to accept “…that it might also be normal to be psychiatrically ill at various points in our lives?”
And that’s a terrific question. My answer is: because “mental illness” is a spurious concept with no explanatory or ontological validity – that the problems embraced by the term are actually not illnesses at all, and that the various “diagnoses” listed in DSM are nothing more than rewording of the presenting problems. If Dr. Pierre were to spend an hour browsing the anti-psychiatry websites or even reading a few books such as The Myth of The Chemical Cure by Joanna Moncrieff or Anatomy of An Epidemic by Robert Whitaker, he would get lots of other answers. But alas, his question was rhetorical. He already knows the answer.
“The answer seems to be that psychiatric disorders carry a much greater degree of stigma compared with medical conditions.”
There is it – the Jeffrey Lieberman argument: people won’t accept our concepts because of the stigma. The big, bad, stigma. It’s got nothing to do with the conceptual flaws, or the damage caused by the “treatments.” Just that darned stigma! – to which, incidentally, psychiatry’s medicalization drive has been a major contributor, as Angermeyer et al, 2011, have demonstrated so convincingly.
So how can we get rid of stigma? Well, here again, I could make a few suggestions, but no need. Dr. Pierre has it all figured out.
“To be less stigmatising, psychiatry must support a continuous model of mental health instead of maintaining an exclusive focus on the mental disorders that make up the DSM.”
In other words: forget the DSM; forget the diagnoses (who needs them?). Let’s just acknowledge that everyone can experience suffering and impairment, and offer psychiatric services to all. Then there’ll be no stigma. We’ll bump into each other socially as we come in and out of the psychiatrist’s office, and it’ll be:
“What are you in for today?”
“The grandchildren are coming up for the weekend and we thought we could use a little extra Valium. What about you?”
“Oh, Big Phil has been a bear since we changed over to Daylight Savings Time. I always need a little Celexa for that. It takes the edge off, you know.”
“I haven’t been a bear!”
“Yes you have.”
“Really? Perhaps I should go in and get a little something.”
“Yes, do. Get some Valium.”
See – no stigma at all.
In fairness to Dr. Pierre, he sounds a note of caution in this regard.
“If the scope of psychiatry widens, will psychiatric medications be vastly overprescribed, as is already claimed with stimulants such as methylphenidate (Ritalin) for attention deficit hyperactivity disorder (ADHD)?”
(Note the word “claimed” – but let’s let that go.)
But he reassures us:
“In the end, implementing pharmacotherapy for a given condition requires solid evidence from peer-reviewed research studies. Although by definition the benefit of medications decreases at the healthier end of a mental health continuum (if one isn’t as sick, the degree of improvement will be less), we need not reject all pharmacotherapy at the healthier end of the spectrum, provided medications are safe and effective.”
So, as long as the drugs are “safe and effective,” we can confidently dish them out for “sub-clinical conditions.” But who determines that the drugs are “safe and effective?” The same chronically-flawed, short-term, industry-sponsored trials that we have at present. Every psychiatric drug on the market today is “safe and effective” by that standard.
And here, dear readers, it really goes downhill.
“…the shift to medicating the healthier end of the continuum paves a path towards not only maximising wellness but enhancing normal functioning through ‘cosmetic’ intervention. Ultimately, availability of medications that enhance brain function or make us feel better than normal will be driven by consumer demand, not the Machiavellian plans of psychiatrists.”
“Maximizing wellness”; “enhancing normal functioning”; “cosmetic intervention”; “make us feel better than normal”?
And then it goes further downhill.
“The legal use of drugs to alter our moods is already nearly ubiquitous. We take Ritalin, modafinil (Provigil), or just our daily cup of caffeine to help us focus, stay awake, and make that deadline at work; then we reach for our diazepam (Valium), alcohol, or marijuana to unwind at the end of the day. If a kind of anabolic steroid for the brain were created, say a pill that could increase IQ by an average of 10 points with a minimum of side effects, is there any question that the public would clamour for it? Cosmetic psychiatry is a very real prospect for the future, with myriad moral and ethical implications involved.”
Note the slick juxtaposition of caffeine, on the one hand, with Ritalin and diazepam on the other: routine aids to daily living. And what are we to make of likening a pill that could increase IQ by 10 points to the present array of psychiatric drugs?
Dr. Pierre assures us that psychiatrists are just trying to help.
“In the final analysis, psychiatrists don’t think that everyone is crazy, nor are we necessarily guilty of pathologising normal existence and foisting medications upon the populace as pawns of the drug companies. Instead, we are just doing what we can to relieve the suffering of those coming for help, rather than turning those people away.”
“A good psychiatrist draws upon clinical experience to gain empathic understanding of each patient’s story, and then offers a tailored range of interventions to ease the suffering, whether it represents a disorder or is part of normal life.”
On March 22, Psycritic, another psychiatrist, posted a critique of Dr. Pierre’s article. In this article, psycritic makes some interesting points. He/she ultimately attributes Dr. Pierre’s enthusiasm for increased drugging to misguided consumerism. The idea is that while consumerism (sell the customer whatever he wants) is OK with regards to everyday products and services, it can create problems when applied uncritically to medicine.
There is merit to this argument, of course. But there is another, more fundamental, issue: that it has been pharma-psychiatry’s objective for decades to expand, without any indication of limits, the use of psychiatric drugs. Pharma has pursued this objective through advertizing and through the distribution of largesse to psychiatrists. Psychiatrists, meanwhile, have played their part by creating new “diagnoses,” lowering thresholds for existing diagnoses, making widespread use of their NOS categories, pretending that the drugs are medications, and through active political lobbying, such as the present drive to expand coerced administration of psychiatric drugs.
The reality is that Dr. Pierre is not just an overly-enthusiastic consumerist. Rather, he is the perfect psychiatrist: the flag-carrier for all that the APA stands for which is: that every human problem is the legitimate concern of psychiatry, and for every problem there’s a pill.