Understanding psychiatry's resistance to change
Good morning, ladies and gentlemen. It is a great honour for me to speak with you today. I guess I am here today primarily because of my book, Beyond Prozac: Healing Mental Suffering Without Drugs. Published in Ireland just over two years ago, it has sold 6000 copies to date in Ireland, a country whose population matches that of Manchester. ‘Beyond Prozac’ was short-listed for the MIND Book of the Year award in 2002, and will be published in the United Kingdom by PCCS Books within the next twelve months – Dorothy Rowe has agreed to write the foreword. I have been a fully registered GP, based in Limerick, Ireland, for over twenty years. I have re-trained as a psychotherapist, in an attempt to fill the gaping holes in my medical training regarding how to deal with emotional and mental distress.
For generations, the medical profession has been given prime responsibility for mental health care. Governments throughout the world see no need to independently assess the validity of the claims, the practices, of psychiatry. This, I believe, is a serious error on the part of governments worldwide. Are psychiatrists and GPs truly the independent-thinking, objective scientists they portray themselves to be? Lets look for a moment at what doctors say, and compare that to what they do.
The predominant belief within the medical profession regarding mental health problems such as depression, bipolar disorder, and schizophrenia, is that these so-called ‘mental illnesses’ are physical, biological conditions requiring physical, biological treatments. Doctors frequently compare these so-called ‘mental illnesses’ to biochemical conditions such as diabetes.
What doctors do, however, is another matter entirely. Neither GPs nor psychiatrists ever confirm any psychiatric diagnosis with laboratory tests. Why? Because no such tests exist. If such tests did exist, they would immediately become widely publicised and widely available.
Such tests would enormously vindicate the biomedical approach, and those who support the biomedical approach would ensure that they became widely available. Compare this to what doctors do regarding known biochemical conditions such as diabetes. Biochemical tests are an essential part of the diagnosis and ongoing management of diabetes, and of all known biochemical conditions such as hypothyroidism, pernicious anemia, iron deficiency anemia.
How can it be that there is such a vast discrepancy between what doctors say, and what they do? This leads me directly into two related topics; the limitations of psychiatry, and psychiatry’s resistance to change. Doctors are human. While psychiatrists publicly project an air of science and authority, to understand the vast discrepancy between what doctors say and what doctors do, one must look at the human side of the medical profession. Doctors are prone to the same insecurities, vulnerabilities, self-interest, biases, limited vision, external influences, defence mechanisms, and wishful thinking which can and do occur in any area of life.
This point came forcefully home to me five years ago. I had been asked to give a three hour talk with recently qualified doctors. During this talk, I expressed my concerns about mental health care, and about the major inadequacies in the training which these young doctors had experienced. At the end of the talk, most of these young doctors were visibly unsettled. Never before had their faith in the medical system been questioned in such a manner. After the meeting, one doctor wryly commented – ‘Great! – now we don’t know who we are!’
Those words helped me to see the role played by the human aspects of doctors in maintaining the status quo within mental health. Psychiatrists and to a lesser extent GPs have an enormous investment in the current medical approach to mental health care.
In reality, the biology of mental health problems is a belief system. It is a belief system because doctors have such faith in it, even though their patients never, ever have their supposed biochemical imbalance confirmed by biochemical or other tests.
Three characteristics of belief systems are:
1. an investment in the continuation of the belief system by those who run and believe in the system;
2. a resistance from within the belief system to question the fundamentals of their belief system and to resist such questioning from others;
3. a resistance to the exploration and development of other beliefs, beliefs which might challenge or reduce the power and influence of the said belief system. The preservation of the belief system and of those who propagate it becomes paramount.
It can be said of some belief systems that they are not based on logic, more on desire and wish fulfilment. This is true of psychiatry. Belief systems frequently aspire to a future salvation or redemption. With regard to psychiatry, the future salvation is the hoped-for biochemical and biological proof - at some time in the future - of causation for mental health problems. This hoped-for future salvation would lead to the redemption of psychiatry, allowing psychiatry to finally take its place as the respected medical specialty it desperately seeks to be.
Who has most to lose if the current drug-dominated and biologically-focused psychiatric system were to be expanded to a truly bio-psycho-social model of mental health care? Not service users. Service users want help to overcome the distress they are experiencing, to get their lives back on track. They do not have an enormous vested interest in the type of help provided within the services.
It is the service providers who have most to lose, psychiatrists, GPs, and of course the pharmaceutical industry. Groups or individuals, who have a lot to lose, tend to resist changes which may diminish their power, influence, status, earning power, sense of identity, regardless of whether such changes might benefit the community generally.
The path of psychiatric research over the past 100 years confirms this. Filled with a passionate desire to establish psychiatry as a scientific, respectable branch of medicine, for more than 100 years psychiatrists have made a major error of judgement. They first arrived at their conclusion, the outcome which most excited and validated them, and set up their research to prove that their conclusion was the correct one.
Having decided that mental illness was caused by a physical brain defect, psychiatry has in the main designed research to establish that this is the case. Thus, the cart was put before the horse. Wishful thinking becomes presented as scientific thinking. This approach is grossly unscientific. Science demands, of those who purport to be scientists, an open and enquiring mind; rigorous, regular self-examination to ensure that one’s own biases are not influencing one’s conclusions; and sufficient honesty and humility to acknowledge the possible validity of views contrary to one’s own. Science does require us to be open to the possibility that at some future time, perhaps biochemical and/or genetic imbalances may be identified for mental health problems. Science also requires that we do not come to premature conclusions; that is precisely what the medical profession has done for decades, unfortunately.
A British Professor of Psychiatry wrote in Medical Dialogue, December 1997 that ‘For more than 30 years the dominant hypothesis of the biological basis for depression have been related to noradrenaline and serotonin’.
Common sense – not to mention science – suggests that to focus so intensely on one hypothesis for over thirty years, to the virtual exclusion of equally valid psycho-social hypotheses, is a questionable practice. This pre-occupation with serotonin typifies the blindness which is a regular occurrence within psychiatry. The underlying purpose of this blindness is to preserve the biological belief system, to maintain bio-psychiatry at the pedestal of the mental health care hierarchy. A pitfall for any belief system is that its faith can be blind; blind to its own limitations and to the value of other possibilities which do not fall within its own belief system. This blindness perhpas psychiatry’s greatest limitation, the ultimate losers being the mental health service users.
It is no coincidence that what psychiatrists value – medication, for example – is widely available to patients, while what psychiatry does not value – counselling, self-esteem-, self-confidence, empowerment-building programmes, step-by-step programmes to help people get their life back on track, for example – are thin on the ground within the mainstream mental health services.
Here are some further examples of psychiatry’s blindness; psychiatry’s reliance on antidepressants as the primary treatment for depression, despite considerable evidence that counselling can be as effective as antidepressants and considerable evidence that antidepressants may only be marginally more effective than placebo.
Then there is psychiatry’s dogged insistence that antidepressants are definitely not addictive, despite the fact that SSRI antidepressants were never systematically tested for their addictive potential. In contrast to the stubborn medical insistence that antidepressants are not addictive, for years the public have not been convinced. A 1995 British MORI poll found that 78% of the public believed that antidepressants were addictive.
I expect that the people surveyed based their opinion on their own experiences, or on the experiences of people around them. In my opinion, the public are a reliable source, since the public have nothing to lose if it were established that antidepressants were addictive. The recent removal from the Seroxat information leaflet of the words ‘remember, you cannot become addicted to Seroxat’, is a remarkable milestone in the unfolding history of SSRI antidepressants.
Regarding the SSRI antidepressants, I believe we are currently watching the unfolding of a debacle similar to the benzodiezepines, the amphetamines, the barbiturates, all of which were enthusiastically and widely prescribed by a medical profession which did not want to hear about people’s enormous difficulty coming off these drugs until belatedly forced to do so by growing public anger and concern. It is sobering to recall that in 1967, 23.3 million prescriptions were written for amphetamines in the US alone. Over 12 million Americans took amphetamines on medical advice that year.
Regarding what is called schizophrenia, psychiatry has preoccupied itself with certain aspects, such as hearing voices, so-called delusions, and paranoia, seeing these as meaningless and purposeless evidence of psychosis. Hence, psychiatrists rarely explore or validate these experiences. However, I and others have come to see so-called hallucinations, delusions, paranoia and many other such experiences in a very different light.
These experiences frequently reveal something very important about the person, about their life. I have found that exploring these experiences can be extremely worthwhile. Talking about them is frequently very important to the person, since it is not everywhere that they can talk candidly about these experiences.
I have also learned that through exploring these experiences, both I and the person experiencing them can come to an understanding of them, can see the sense in them, so to speak. This can be quite beneficial for a person who up to now has been told that these experiences are meaningless, symptoms of their illness.
But I wont be holding my breath waiting for mainstream psychiatry to enthusiastically develop this possibility further. Because to do so might threaten the belief system, might produce results which question the fixation with biology and which might suggest that approaches other than medication may have real potential. This is directly against the beliefs of the psychiatric belief system. Such ideas will not be fully developed as long as biopsychiatry dominates mental health care, regardless of any potential benefit for the user of the mental health services.
Research sometimes appears in medical journals which runs contrary to the biopsychiatry belief system. One such study, published in the Irish Journal of Psychological Medicine in 2001, looked at childhood risk characteristics in children who go on to develop schizophrenia-type problems later in life. The researchers found a significantly higher incidence of social maladjustment in school; a strong preference for solitary play; self-reported social anxiety at age 13; teacher-reported anxiety at age 15; passivity; social withdrawal; social anxiety; hypersensitiveness to criticism; disciplinary problems; antisocial behaviour; flat affect – that is, seldom laugh or smile, no reaction when praised or encouraged.
Very significantly in my opinion, the study found that the more anxious children were, the more likely they were to develop schizophrenia. This is a pattern I have repeatedly observed in people who have been diagnosed as having schizophrenia. These features suggest that a psychosocial hypothesis regarding the causation of schizophrenia is at least as valid as the hypothesised biochemical theory.
However, such a psychosocial hypothesis runs contrary to the belief system, the blind faith in biology. Consequently, there is little interest or enthusiasm within mainstream psychiatry for psychosocial hypotheses, or indeed for psychosocial interventions.
Schizophrenia Ireland, a major service user group in Ireland, carried out a survey of service users in 2002. Many interesting findings emerged from that survey. The survey asked respondents about a range of non-medical interventions. The most commonly experienced non-medical interventions included employment training, counselling/psychotherapy, peer group support, and Art/Music/other creative therapy. In each of these areas, an average of over 75% found the intervention to be very helpful, or helpful. Yet, the vast majority of psychiatrists insist that counselling and psychotherapy are a waste of time in the treatment of schizophrenia, bipolar disorder, and, to a considerable degree, depression.
Service users are saying they want these services and find them helpful. Psychiatry, however, is telling service users - and governments - that doctor knows best, that service users own experiences regarding what helps them cannot be relied upon. Hardly a democratic way to provide services. Psychiatry continues to insist that counselling and psychotherapy and other psycho-social interventions have little role in the management of enduring mental health problems.
Its not as if drug treatment of schizophrenia is so successful that we can be complacent about the possible value of other treatment options. According to a London psychiatrist, quoted in the Summer 1998 edition of Community Mental Health, ‘Sedation, rather than any genuine antipsychotic effect, is often the main role of standard anti-psychotics’. Recovery rates from schizophrenia have not improved over the past 70 years.
World Health organisation studies suggest that recovery rates from schizophrenia are significantly higher in underdeveloped countries than in developed countries. In order to maintain the belief system, psychiatry needs to remain blind to the possibility that psychosocial approaches have real potential. This situation is hardly in the interests of the users of the mental health services.
Similar limitations apply to psychiatry’s treatment of what is called bi-polar disorder. Widely presumed by psychiatry to be caused by a biochemical imbalance, patients so diagnosed never have their supposed biochemical problem confirmed by any test. Medication is the sole treatment offered to the vast majority of those so diagnosed, and medication certainly does have its place.
I repeatedly observe that there is a strong psycho-social element to this condition. The ‘highs’ are frequently triggered by stress, overwhelm, emotional distress and pain. Yet psychiatry offers these people nothing to help them deal with stress and overwhelm. Many of those attending me, diagnosed with bipolar disorder, tell me the work they are doing with me is far more relevant to their experience and their recovery than the medication-based approach of their psychiatrists.
And so it is that issues highly relevant to the person’s daily experience, their life and their distress, including the distress of depression, so-called schizophrenia, and so-called bipolar disorder, remain un-noticed and unresolved. Issues such as fear, terror, anxiety, stress, powerlessness, overwhelm, hurts; insecurity, identity issues, relationship issues, life changes; unresolved losses and grief, self-esteem, self-confidence, unresolved and unexpressed feelings, lack of assertiveness; abuse, abandonment, rejection, humiliation, ridicule, bullying, losing face, loneliness; lack of and fear of love and intimacy, difficult life decisions, self-image issues;
fear of failure, fear of success, fear of being invisible to others and for some people, fear of being visible; one’s own expectations, hopes and dreams and those of others; the gradual accumulation of self-doubt, the angst of having so many choices; the human need to belong, to have purpose; sexuality; financial issues; the need to find various ways of escaping and withdrawing from the difficulties and challenges of life and indeed from the intensity of one’s own feelings; the perceived demands of society that one should pretend, wear a mask, that one should hide one’s distress;
the anxiety associated with risk-taking in life especially if one’s self-esteem is low; peer pressures; the human need for acceptance, affirmation and reassurance; the human instinctual reaction to protect oneself from overwhelm; the human need for a sense of equilibrium and how this equilibrium gets rocked by various shocks in life, performance anxiety, comparisons between self and others, hopelessness, the human need to trust but fearing being let down if one does trust in people, the challenge of taking responsibility for oneself, counterproductive habits and patterns such as procrastination, fear of being with or around other people yet not really wanting to be alone either, ostracisation of various types, isolation, life events, the double-edged sword of wanting to get on with ones life but being terrified to do so.
These are some of the real issues which the users of mental health services have to deal with on a daily basis, issues which psychiatry has decided are of little relevance to people’s mental health problems and their recovery.
The medical approach focuses on maintenance, on symptom control rather than on recovery. Far more attention and research should be devoted to those who have recovered, to identify what factors were important in their recovery.
Such research would contribute to a far more proactive mental health care policy than currently exists, but isn’t happening to any great extent because it is fundamentally challenging to the biomedical belief system.
Any theory which might potentially enhance our understanding and our approaches to the condition should receive appropriate attention. Because of medical tunnel vision in favour of biological theories and against psycho/socio/emotional aspects of mental health, such exploration is currently not happening. Even in the top psychiatric hospitals, patients regularly report that there is little for them to do during the day. The day revolves around the drugs trolley.
Steps need to be taken towards the creation of preventative policies within mental health care, something which is currently virtually nonexistent, due in no small part to psychiatry’s focus on biology at the expense of psychosocial issues.
Thus, the limitations of psychiatry permeate all aspects of mental health. I urge you to do all you can to bring this to an end. Only then can we create a truly bio-psycho-social model of mental health care.
Thank you very much.