On February 2, Robert Whitaker published an article on Mad in America. The title is Disability and Mood Disorders in the Age of Prozac. The article echoes and updates one of the themes of his 2010 book “Anatomy of an Epidemic”: that the steady increase in the numbers of people receiving disability benefits for depression and mania is driven largely by the corresponding increase in the use of antidepressant drugs.
Robert provides some up-to-date statistics from the US Department of Social Security, and his paper is cogent and compelling. He ends on a sad but realistic note:
“And so the disability numbers march on.”
This general issue has received a good deal of attention in the literature, but for those not familiar with the matter, there are two essential factors. Firstly, there is the well-established fact that some people who take antidepressants become floridly manic, which in many cases leads to a diagnosis of bipolar disorder, and a subsequent disability award. Secondly, a great many people who take antidepressants for an extended period develop a kind of drug-induced anhedonia, and a correspondingly increased rate of being adjudged disabled.
Robert’s post generated about 120 comments, the majority of which were positive, but a few days later (February 14), Timothy Kelly put up a post, also on Mad in America, challenging the validity and/or appropriateness of Robert’s article. Tim’s paper is titled Robert Whitaker Missed the Mark on Drugs and Disability: A Call for a Focus on Structural Violence.
Here are some quotes from Tim’s article, intermingled with my thoughts and comments:
So essentially, what Tim is saying is that we should spend less time and energy on contentious issues like the “role of psychiatric treatment in recovery”, and focus instead on areas where we can find agreement, and on the role of poverty and injustice in the genesis of counterproductive thoughts, feelings, and/or behavior.
On the face of it, this seems a reasonable stance – put aside our differences, and pool our resources – but as is often the case, there are problems in the details. Tim encourages us to refocus our “reform efforts” through collaboration, but what will these reform efforts look like, if the parties concerned are fundamentally divided on the validity/usefulness of psychiatric care.
The kind of compromise and accommodation that Tim advocates can only succeed if in fact there is more agreement than disagreement between the various parties, or if the areas of contention are a relatively minor part of the whole. Neither of these conditions is true in the present context. Psychiatry, with its spurious diseases and toxic treatments, is the proverbial elephant in the living room of the present debate. Those who support psychiatry and those who oppose it might be able to agree on what to order for lunch, but not, I suggest, on much else. The pretense that we can find common ground and “work with” psychiatrists has been the great error of the past fifty years, during which psychiatry, with the help of its pharma allies, has consolidated its turf, and successfully marginalized and ridiculed all opposing viewpoints.
Psychiatry’s fundamental tenet, embodied unambiguously in all editions of the DSM since DSM-III, is that every significant problem of thinking, feeling, and/or behaving is an illness, that can only be addressed successfully through medical intervention – specifically drugs and electric shocks to the brain.
Psychiatry has expended, and continues to expend, enormous sums of, mostly pharma, money in their attempts to establish the validity of this spurious tenet. So far, all of these efforts have been in vain, and it is extremely unlikely that the core tenet will ever be validated. Nevertheless, psychiatrists, at both leadership and rank and file levels, continue to promote this self-serving and deceptive notion with undiminished ardor and enthusiasm.
Nor is the matter academic. Psychiatry’s application of its core tenet is damaging and destructive. Firstly, and perhaps most profoundly, persuading people that they have a disabling illness, when in fact they don’t, is inherently disempowering, and encourages people to think of themselves as incapable of living a normal life. Secondly, all psychiatric treatment disrupts normal brain functioning, and in many cases this disruption, especially when used for extended periods, causes permanent impairment.
The fact that psychiatric drugs produce a transient desired effect is irrelevant to the medicalization issue. Crack cocaine produces a transient desired effect, but nobody is suggesting that street corner dealers are performing a medical function. In fact, apart from the legality of their respective activities, there is no essential distinction between psychiatrists and street corner drug dealers.
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“In this discussion of disability I intentionally leave aside questions of whether the experiences classified in the DSM5 are most usefully characterized as medical problems, even if they have a biological basis. In my view, the ‘body’ and the ‘mind’ are mutually entangled, and so of course there are physiological processes involved in all human experiences, as well as considerable variability among bodies. The extent to which a biomedical approach is useful or resonant for any given person is contingent on the particularity of that person within their sociocultural surround. How persons negotiate the meaning(s) of their (our) own experience in relation to different explanatory models is highly contextually specific. For instance, using medication does not necessarily imply agreement with a biomedical model, just as the efficacy of yoga or mindfulness may be characterized in more biological, rather than spiritual terms depending on context. I’d like to see us shift our attention from debates about medications, loosening up polarizations that hamper our ability to work effectively on these issues, towards careful thinking and contextual grounding in fields such as mad studies, survivor research, medical anthropology, the medical humanities, and social and cultural psychiatry.”
This passage is not entirely clear, but in general what Tim seems to be saying is a variation of the old 60’s phrase: “different strokes for different folks”. Some people find it “useful or resonant” to conceptualize their problems as “illnesses” that call for “medication”; others don’t. Either way it’s not that important, so let’s move on to other issues on which we can agree.
This kind of conceptual relativism is fine as far as it goes. We have freedom of speech, so we certainly have freedom of thought. But it is still the case that some conceptual frameworks are more valid and more accurate than others. In the long run, comfort, or “resonance” bought at the expense of truth usually proves a bad bargain.
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“That psychiatric diagnoses do not index discreet disease processes with clearly identified etiologies has also been acknowledged by leading proponents of otherwise mainstream psychiatric treatment like Thomas Insel (Director of the National Institute of Mental Health). This is also clearly inscribed in the DSM5 which acknowledges that current psychiatric categories do not map onto discrete disease processes with homogenous ‘biomarkers,’ that knowledge is therefore provisional, and the state of the science still limited. In this post, I have therefore opted to sidestep issues that are already relatively well-accepted across academic and activist contexts (such as the scientific and philosophical limitations of psychiatry).”
Thomas Insel, MD, has indeed stated unambiguously that the various DSM entities (which, incidentally, Dr. Insel calls “labels“) do not correspond in any systematic fashion with specific neural pathologies. With regards to DSM-5, Tim does not provide a page number, but I’m not aware of an acknowledgement in that text that “current psychiatric categories do not map onto discrete disease processes with homogenous ‘biomarkers’.” But in any event, the matter is moot, because the contrary notion is still very much alive and well in psychiatric circles. Most psychiatrists are still telling their clients that they have “chemical imbalances”, though some are moving with the times and substituting the equally nebulous and equally unproven “neural circuitry anomalies”, and are promoting the impression that the various DSM labels are indeed discrete disease entities with scientifically proven etiologies. A great many psychiatric clients actually believe, erroneously, that a brain scan would show this pathology clearly and unambiguously.
So, Tim’s statement that he decided to sidestep these controversial topics because they’re “already relatively well-accepted” is, I suggest, premature. He is, of course, free to sidestep them if he wishes, but, in so doing, he is working with a very limited canvas. He is focusing on some, admittedly interesting, and important, trees at the edge of the woods, but has turned his back on the dark and forbidding forest. And in particular, he has missed the fact that the forest is literally shading and starving those trees on which he pins so much hope.
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Then Tim takes us into really deep waters:
My Merriam-Webster dictionary (2000) gives the following definition of the word “dogma”:
b. a code of such tenets
c. a point of view or tenet put forth as authoritative without adequate grounds
Now I am very proud to describe myself as antipsychiatry. I am unambiguously opposed to psychiatry because it is based on false and spurious premises, and is destructive, disempowering, and stigmatizing in its practices. But I am emphatically not dogmatic. In fact, one of my arguments against psychiatry is that its core principles are ultimately statements of belief, vigorously and authoritatively promoted, without any kind of supportive evidence. And I have written on many occasions that all psychiatry has to do to silence me is produce evidence in support of their tenets, at which point I will fold my tent and enjoy my retirement.
In addition, I can’t think of a single antipsychiatry advocate whose pronouncements could even remotely be described as dogma, in any ordinary sense of the term.
But Tim is taking this rhetoric even further. He tells us that the expression of these “dogmatic anti-psychiatry positions” is actually being used “at the federal level” to promote the infamous Tim Murphy (Helping Families in Mental Health Crisis) Bill. I’m certainly not aware of any such dynamic. In fact, my reading of recent events is that the Tim Murphy bill has been derailed largely because of the protests from the antipsychiatry faction.
With regards to his manifesto, obviously I respect Tim’s personal convictions, but there are some matters that, in my view, warrant clarification. Firstly, I have never encountered or read any critic of psychiatry who adopted the position that clients’ experiences or distress weren’t real. The issue for most of us is that the various labels catalogued in the DSM are not illnesses. In this regard, those of us on this side of the debate recognize the reality of these problems far more clearly than psychiatrists who bundle them neatly into spurious “diagnostic categories” without ever taking the time to understand or appreciate their very real human significance.
The notion that we in the anti-psychiatry camp dismiss clients’ problems as “not real” is a common ploy that adherents of psychiatry often use to discredit us, and for this reason it is particularly disappointing that Tim would come at us with this particularly facile and groundless attack.
Secondly, Tim asserts that “…medication is helpful for many people. The question is: for whom, for how long, and how best to weigh the benefits against the risks.” This is also a fairly standard psychiatric formula, though in practice, the pills are dished out a good deal more liberally than the formula would suggest. But the question that comes to my mind is: how does Tim know that “medication” is helpful for many people? What standards are being used to assess helpfulness, and where are the randomized controlled studies that provide the evidence? The point of Robert’s original article was that the drugs are actually doing a great deal of harm in the long run, a contention that is receiving a good deal of support from research studies in recent years.
Tim tells us that he reached the conclusion quoted above from:
- his own personal experience;
- the experience of others;
- years of formal academic research
Lived experience, obviously, is the bedrock of all our knowledge and skills, and our personal assessments and reactions are generally excellent guides with regards to the costs and benefits of various activities and substances. But there are certain substances which, through their action on brain chemistry, routinely deceive us in this regard. Alcohol, nicotine, heroin, cocaine, etc., all have in common that, through direct action on the brain, they induce a false sense of well-being, which often blinds the ingestor to their long-term toxic effects. It is this accident of biology that underlies and drives the phenomenon that we call chemical addiction.
Most users of nicotine find the experience pleasant and rewarding. Many also report that this substance improves their ability to study and concentrate. Alcohol induces a sense of well-being and relaxation. And so on.
Pharmaceutical antidepressants are specifically designed through their action on brain chemistry, to induce a transient and false sense of well-being. And this sense of well-being also has the effect of blinding the user to their long-term toxicity and adverse effects.
The point here is that lived experience, valuable as it is in most matters, is generally a poor guide when it comes to evaluating the efficacy or helpfulness of brain-altering chemicals.
There are also problems with regards to “formal academic study and research.” Most of this has been conducted by pharma-psychiatry, focuses on short-term outcomes, suppresses negative results, and is an unreliable guide to long-term effects.
Tim mentions the need “to weigh the benefits against the risks”, and this advice is attached to virtually every psychiatric drug in the PDR. But in reality, it’s a hollow formula. How can one weigh the benefits of a transient and false sense of well-being against the longer term risk of chronic, and more or less permanent, damage? There is not, and never can be, any kind of calculus for making such comparisons. And the issue is compounded by the fact that the risks vs. benefits question is usually presented as if the drug were the only option. In fact, there are a great many ways to resolve feelings of depression that entail no particular risks at all – principally: by dealing with the problems that precipitated the depression in the first place.
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Tim tells us that “…there would be a lot more space to develop psychosocial approaches and address broader systemic issues if we decentered medication in these discussions…”. To which I can only disagree. Prior to about the year 2000, the antipsychiatry movement was virtually non-existent. Those few of us who did speak out were ridiculed, marginalized, and at times vilified. There was virtually no discussion on the downside of what Tim euphemistically calls “medication”. By Tim’s argument, there should therefore have been lots of “space” to develop psychosocial approaches, and address broader systemic issues. But in fact these things didn’t happen. The spurious illness philosophy, and the ubiquitous drugs, held the field. Other concepts and practices were effectively suppressed, and truly millions of lives were destroyed.
Today, when the antipsychiatry movement is growing in leaps and bounds, we are actually seeing a great deal more discussion of psychosocial approaches and broader issues than at any time in the past fifty years.
Today, the antipsychiatry issues are being heard, and progress is evident on all fronts. But psychiatry, unconvinced and unrepentant, continues to resist. There is some receptiveness, on the part of a very few psychiatrists, to alternative perspectives. But for the most part, the leadership and the rank and file are redoubling their efforts to promote their medicalization agenda. The APA has even engaged the services of a PR firm to improve their image and sell their philosophy.
But the facts have not changed. Depression is not an illness. Outbursts of temper are not an illness. Academic inattentiveness is not an illness. Painful memories are not an illness. Bereavement is not an illness.
But in the looking-glass world of psychiatry, these age-old human problems – and hundred more besides – are all illnesses that need to be “treated” with psychiatry’s so-called medication.
So for all of these reasons, I, for one, will continue to critique psychiatry and its destructive “treatments” with all the vigor at my disposal. And I will do this because psychiatry is not something good that just needs to be expanded to embrace psychosocial and other broader issues. Rather it is something fundamentally spurious and destructive; a wrong turning in human history. It not only destroys individuals, but saps our cultural resilience with its self-serving insistence that virtually every significant human problem is an illness which needs a pill. Psychiatry is not a healing force in the world. Rather, it is a disabling force, and the pills are the most visible facet of its destructiveness.